An exploration of the cognitive and affective processes for anaesthetists when performing an emergency front of neck airway.

Emergency front of neck airway (eFONA) is a potentially lifesaving but very high-stress procedure. We explored the cognitive and affective processes involved via semi-structured interviews with 17 UK anaesthetists who had attempted eFONA within the previous two years. Thematic analyses generated two meta-themes: 'Making the decision is the hardest part; the doing is easier' and 'What helps make the decision?'. We found concerns around scrutiny, lack of a flat hierarchy, unfamiliarity with the situation and the lack of a model for transitioning to eFONA. Culture change, using a shared mental model, priming and emotional disengagement, assisted with eFONA decision-making. Conclusions and implications for practice are presented.

The genetic characterisation of stripe rust resistance in the German wheat cultivar Alcedo.

Stripe rust resistance in the German winter wheat cv. Alcedo has been described as durable, the resistance having remained effective when grown extensively in Germany and Eastern Europe between 1975 and 1989. Genetic characterisation of field resistance in a cross between Alcedo and the stripe rust susceptible UK winter wheat cv. Brigadier identified two major QTL in Alcedo located on the long arms of chromosomes 2D (QPst.jic-2D) and 4B (QPst.jic-4B). Stripe rust resistance was evaluated by measuring the extent of fungal growth, percentage infection (Pi) and the necrotic/chlorotic response of the plant to infection, infection type (IT). Both QPst.jic-2D and QPst.jic-4B contributed significantly to the reduction in stripe rust infection (Pi), with QPst.jic-2D explaining up to 36.20% and QPst.jic-4B 28.90% of the phenotypic variation measured for Pi. Both QTL were identified by the IT phenotypic scores, with QPst.jic-2D in particular being associated with a strong necrotic phenotype (low IT), QPst.jic-2D explaining up to 53.10% of IT phenotypic variation and QPst.jic-4B 22.30%. In addition, two small effect QTL for field stripe rust resistance were identified in Brigadier, QPst.jic-1B on the long arm of chromosome 1B and QPst.jic-5A on the short arm of chromosome 5A. The influence of QPst.jic-1B was primarily seen with the Pi phenotype, contributing up to 13.10% of the explained phenotypic variation. QPst.jic-5A was only detected using an approximate multiple-QTL model and selecting markers linked to the major effect QTL, QPst.jic-2D and QPst.jic-4B as co-factors. Seedling stripe rust resistance was also mapped in the cross, which confirmed the location of Yr17 from Brigadier to the short arm of chromosome 2A. A seedling expressed QTL was also located in Alcedo that mapped to the same location as the field stripe rust resistance QPst.jic-2D.

Case report: spontaneous coronary artery dissection during elective caesarean section under spinal anaesthesia.

A 37-year-old woman, otherwise healthy, had an acute myocardial infarction associated with acute left ventricular failure during an elective caesarean section under spinal anaesthesia. Emergency coronary catheterisation postoperatively revealed a probable dissection distally in the D1 branch of the left anterior descending artery. We review the recent literature and case reports on spontaneous coronary artery dissection, and discuss its recommended management.

Characterising the nutritional status of children with primary ciliary dyskinesia.

INTRODUCTION: Primary ciliary dyskinesia (PCD) is a rare, heterogeneous genetic disorder where impaired mucociliary clearance is caused by dysfunctional motile cilia leading to bronchiectasis. There is limited evidence characterising the nutritional status of children with PCD, although lower body mass index (BMI) z-score has been associated with worse lung function (FEV1). METHODS: All children (n = 43) with PCD, aged <16 years, from a single tertiary centre were prospectively enrolled. Information on clinical phenotype and nutritional status including bioelectrical impedance spectroscopy (BIS) phase-angle was collected. RESULTS: There was a weak positive association between height-for-age z-score (HAZ) and FEV1 z-score (n = 28, r = 0.4, p = 0.049). Those with a low fat free mass index (<-2 z scores) had a lower BMI z score (-1.3 ± 1.2 vs. 0.8 ± 0.7, p = 0.0002). BIS phase angle identified more patients at nutritional risk than using moderate malnutrition cut-offs of either HAZ or BMI ≤ -2 z scores alone (21% vs. 4.6% vs. 6.9% respectively). PCD patients had a higher incidence of vitamin D insufficiency (<50 nmoL/L) (54%) and deficiency (<30 nmoL/L) (26%) than healthy children. CONCLUSIONS: We have characterised the nutritional phenotype of a cohort of children with PCD. Monitoring vitamin D levels is important in PCD patients. There is a weak association between lung function and nutritional status, and measures of BIS phase-angle. The use of BIS phase-angle may allow for early identification of at risk children and may therefore be of benefit for nutritional assessments in the clinical setting. These findings will help inform a future nutritional intervention strategy in children with PCD.

Bioimpedance spectroscopy measurements of phase angle and height for age are predictive of outcome in children following surgery for congenital heart disease.

OBJECTIVE: Children with congenital heart disease (CHD) are often growth restricted (low weight- and/or height-for-age) which may increase risk of poor post operative resilience. Bioelectrical impedance spectroscopy (BIS) has been used to determine body composition in different clinical settings and has been shown to mark differences in nutritional state and clinical outcome. In disease conditions were fluid is not normally distributed it is proposed that raw impedance values and BIS derived phase-angle may serve as prognostic indicators of clinical outcome. We sought to describe the relationship between nutritional status, phase-angle and post-operative outcomes in children with congenital heart disease. DESIGN: Single centre prospective cohort study. SETTING: Paediatric Intensive Care Unit (PICU), Southampton Children's Hospital. PATIENTS: 122 children with CHD following cardiac surgery (March 2015-April 2016). Outcome variables included growth, mechanical-ventilation, PICU length of stay (PICU-LOS) and phase-angle at 50 Hz. MEASUREMENTS AND MAIN RESULTS: BIS measurements were taken before and on the day of surgery (day 0), day 2 post-operatively and on discharge from hospital. Pre-operative moderate malnutrition defined as height-for-age-z-score (HAZ) ≤-2 was observed in 28.5% of infants and 20.6% of children. Regression analysis was used to investigate the relationship between phase-angle, HAZ and clinical outcomes. Moderate-malnutrition (HAZ ≤-2) was associated with an increased PICU-LOS (odds ratios (OR) with 95% confidence interval: 1.8; 1.1-2.7, p = 0.008) whilst a low phase-angle (≤2.7° on day 2 was associated with longer PICU-LOS (OR 7.8; 2.7-22.45, p < 0.001)); When the model was adjusted for age, known risk factors and length of surgery, HAZ ≤-2 and phase-angle ≤2.7° on day 2 were associated with longer PICU-LOS (p = 0.001 and p = 0.04 respectively) and together explained 81.7% of the variability in PICU-LOS. CONCLUSIONS: Moderate malnutrition (HAZ ≤-2) in infants and children undergoing cardiac surgery is associated with longer PICU-LOS. Post-operative measures of BIS phase angle may further improve our ability to identifying hose children with an increased risk of prolonged PICU-LOS compared to using pre-operative anthropometry alone.

Expression and characterisation of single-chain antibody fragments produced in transgenic plants against the organic herbicides atrazine and paraquat.

Single-chain antibody fragments (scAbs), which have a human C-kappa constant domain and a hexa-histidine tail attached to the carboxy terminus of the single-chain Fv (ScFv) fragments to facilitate purification, have been raised against the herbicides paraquat and atrazine and expressed in transgenic Nicotiana tabacum cv. Samsun NN. Prior to purification, the anti-atrazine scAb is expressed as up to 0.014% of soluble leaf protein and has a binding profile in ELISA, against an atrazine-bovine serum albumin (BSA) conjugate, similar to that of the scAb produced in Escherichia coli. Competition ELISA has shown that the plant-derived scAb also recognises free atrazine. Following antibody affinity purification to isolate dimers, the affinity for immobilised antigen approaches that of the parental monoclonal antibody. This was confirmed by surface plasmon resonance analysis. The purified scAb also recognises related triazine herbicides. When isolated from cell-suspension cultures, the anti-paraquat scAb binds to a paraquat conjugate in a concentration-dependent manner, with a profile similar to the parental monoclonal antibody. This is the first demonstration that functional scAbs against organic pollutants can be produced in transgenic plants and that the scAbs may be appropriate for the development of immunoassay-based detection systems.

Interaction of nuclear proteins with an AP-1/CRE-like promoter sequence in the human TNF-alpha gene.

The tumor necrosis factor alpha (TNF-alpha) promoter contains an AP-1/CRE-like binding site, TGAGCTCA. AP-1 elements generally transduce signals involving protein kinase C; the CRE site mediates a cAMP response, involving protein kinase A. Thus, this element has the potential to receive signals through divergent signaling pathways. Nuclear protein binding studies using extracts from THP-1 monocytic cells treated with lipopolysaccharide (LPS), which stimulates, or dexamethasone (Dex) or pentoxifylline (PTX), which inhibit TNF production, respectively, suggest that two low-mobility complexes could be involved in regulation through this promoter region. PTX and Dex increase binding of both these complexes compared with untreated cells; approximately 2 hours after LPS induction, the upper complex becomes undetectable. This upper complex is composed of ATF2 (activating transcription factor 2, a cyclic AMP responsive element binding protein) homodimers; the lower is a heterodimer of jun/ATF2. LPS induces c-jun and thus may enhance formation of jun/ATF2 complexes, which could be activating complexes. In this case, the simultaneous presence of both complexes, which would occur in the presence of Dex or PTX, could reduce the amount of TNF transcription through competitive binding. Through in vitro competitive binding studies comparing the binding affinities of the TNF promoter sequence and a consensus CRE, we further suggest how variation of endogenous binding sequences from consensus may be an important property for regulatory control of particular genes.

Injury of arterial endothelial cells in diabetic, sucrose-fed and aged rats.

The toxicity of elevated levels of very low density lipoproteins (VLDL, d less than 1.006 g/ml) was investigated using porcine aortic endothelial cells in vitro. VLDL isolated from normal rat serum and added at elevated levels was as toxic as VLDL isolated from streptozotocin-induced diabetic rat serum. Injury was detected by scanning electron microscopy in 4-day-old primary cultures of endothelial cells after a 1/2-h exposure to diabetic rat serum. Bleb formation and contraction was seen first in isolated cells (1/2 h), followed by cells at the periphery of the monolayer (1 h) and finally in cells throughout the monolayer (4 h). By 10 h few cells remained attached to the dish. A similar sequence of events occurred in 1-day-old cultures after a 3-h lag period. Serum from sucrose-fed as well as aged rats was also found to be toxic to endothelial cells in vitro. Elevated levels of VLDL were responsible for the toxicities of these sera. Scanning electron microscopy of the aortas from diabetic and sucrose-fed rats revealed endothelial desquamation, platelet and leukocyte attachment, fibrin deposition and the presence of microthrombi. The common occurrence of both micro- and macrovascular disease in diabetic, sucrose-fed, and aged rats and the toxicity of their serum in vitro suggest that elevated levels of VLDL may initiate vascular disease in these models.

T cell depletion increases susceptibility to murine cytomegalovirus retinitis.

To study the effect of immunosuppression on the development of murine cytomegalovirus (MCMV) retinitis, BALB/c mice were immunosuppressed with methylprednisolone (a corticosteroid) and/or with antibodies against CD4+ and CD8+ T cells and inoculated with low-dose MCMV (5 x 10(2) plaque-forming units) by the supraciliary route. Nonimmunosuppressed mice inoculated with low-dose MCMV by the supraciliary route did not develop necrotizing retinitis. By contrast, 78-100% of immunosuppressed mice developed retinitis after inoculation of low-dose MCMV. To study the effect of depletion of individual T cell subsets, mice were depleted of either CD4+ or CD8+ T cells and inoculated with low-dose MCMV by the supraciliary route. The frequency of retinitis in CD4-depleted mice (30%) was not significantly different from that of nonimmunosuppressed control mice (0%). The frequency of retinitis in the CD8-depleted group (80%) was similar to that observed in mice immunosuppressed with corticosteroid alone (90.9%), with antibodies to both T cell subsets (100%), or with steroid and both T cell subset antibodies (100%). These results support the conclusion that the CD8+ T cell subset is responsible for control of ocular MCMV infection. Furthermore, these results suggest that the CD8+ T cell subset may be important in preventing ocular CMV infection in immunosuppressed patients.

Plant transformation technology. Developments and applications.

Plant transformation has its roots in the research on Agrobacterium that was being undertaken in the early 1980s. The last two decades have seen significant developments in plant transformation technology, such that a large number of transgenic crop plants have now been released for commercial production. Advances in the technology have been due to development of a range of Agrobacterium-mediated and direct DNA delivery techniques, along with appropriate tissue culture techniques for regenerating whole plants from plant cells or tissues in a large number of species. In addition, parallel developments in molecular biology have greatly extended the range of investigations to which plant transformation technology can be applied. Research in plant transformation is concentrating now not so much on the introduction of DNA into plant cells, but rather more on the problems associated with stable integration and reliable expression of the DNA once it has been integrated.

Retinitis in euthymic mice following inoculation of murine cytomegalovirus (MCMV) via the supraciliary route.

Cytomegalovirus (CMV) retinitis is the most frequent infectious ocular complication of the acquired immune deficiency syndrome (AIDS). Currently, there are few animal models to study the virologic and immunologic factors which contribute to the pathogenesis of CMV retinitis. In these experiments, 1-2 X 10(4) PFU of murine cytomegalovirus (MCMV) was inoculated into the supraciliary space of BALB/c mice. Within three days of inoculation, moderate iridocyclitis was observed which progressed to necrosis of the ciliary body by day 14. Approximately 60% of the mice developed typical retinitis characterized by virus-infected cytomegalic cells in the retina and retinal pigment epithelium, focal retinal infiltrates, transition zones between uninvolved and involved retina, and optic neuritis. The remaining animals exhibited atypical retinitis characterized by non-specific retinal inflammation in the absence of obvious viral infection. This murine model of CMV retinitis shares some features with retinitis observed in AIDS patients with CMV retinitis and may be useful to evaluate the efficacy of immunologic and/or pharmacologic treatment strategies for CMV retinitis.

A follow-up study of patients advised to obtain influenza immunizations.

Computers have been used in general practice to issue reminders to patients overdue for preventive procedures. Although effective, issuing reminders may be inconsistent with the belief that patients should take responsibility for their own health. To assess the effect of a reminder on subsequent use of influenza prevention services, this study examined the three-year immunization behavior of 1,175 patients 65 years or older who were part of a randomized controlled trial. During the middle year only, reminders were issued to patients in the experimental group. A comparison of immunization patterns over the three years in experimental and control groups indicated that the reminder both promoted independent action and engendered dependency on the reminder. The former, favorable effect was more frequent among younger patients; the latter, adverse effect was more common among older patients who visited the practice more frequently.

Prevalence of premilitary adult sexual victimization and aggression in a Navy recruit sample.

U.S. Navy recruits (n = 3,776) were surveyed for premilitary histories of adult sexual assault. They completed a survey designed to estimate rates for experiences as victims (women) and perpetrators (men) of attempted and completed rape since the age of 14. The results show that 45.5% of the women reported being the victim of attempted (9.4%) or completed rape (36.1%) before entering the Navy. Male recruits' self-reports indicated that 14.8% admitted perpetrating attempted (3.5%) or completed rape (11.3%) before entering the Navy. A high percentage of recruits in this study reported histories of sexual assault. Female victims of sexual assault are at high risk of incurring somatic and/or psychological problems that require treatment by health care professionals. Male perpetrators of sexual assault are at high risk of repeating their behavior. The results of this study suggest that it may be cost-effective to develop treatment education, and prevention programs for military recruits.

More realistic soil cleanup standards with dual-equilibrium desorption.

The desorption of contaminants from soils/sediments is one of the most important processes controlling contaminant transport and environmental risks. None of the currently adopted desorption models can accurately quantify desorption at relatively low concentrations; these models often overestimate the desorption and thus the risks of hydrophobic organic chemicals, such as benzene and chlorinated solvents. In reality, desorption is generally found to be biphasic, with two soil-phase compartments. A new dual-equilibrium desorption (DED) model has been developed to account for the biphasic desorption. This model has been tested using a wide range of laboratory and field data and has been used to explain key observations related to underground storage tank plumes. The DED model relates the amount of a chemical sorbed to the aqueous concentration, with simple parameters including octanol-water partition coefficient, solubility, and fractional organic carbon; thus, it is the only biphasic model, to date, that is based on readily available parameters. The DED model can be easily incorporated into standard risk and transport models. According to this model, many regulatory standards of soils and sediments could be increased without increasing the risks.

The CAT-CAM socket and quadrilateral socket: a comparison of energy cost during ambulation.

Twenty unilateral trans-femoral amputees fitted with either the Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM) socket (n = 10) or the quadrilateral (QUAD) socket (n = 10), and a "non-amputee" control group (n = 10) participated in the study. Subjects meeting the following criteria were studied: healthy males between the ages of 18 and 55 years, amputation due to non-vascular pathology, an unaffected sound limb, at least six months use of the test prosthesis, and a minimal stump length of 15 cm. Subjects ambulated in two randomized trials separated by 20 minutes of rest at 2 assigned speeds: a pace reflecting normal walking speed (97 m/min = 2.5 mph) or a slower speed (48.5 m/min = 1.25 mph). Heart rate (HR) and Oxygen uptake (VO2) measured during steady state walking were analyzed via two-way ANOVA. Differences among means were further analyzed using Tukey post hoc and simple effects tests. Significant differences were observed between the control group and CAT-CAM subjects with respect to VO2 (p < 0.05) and HR (p < 0.01) at the slower speed. The control group and subjects using the QUAD socket also differed with respect to VO2 (p < 0.01) and HR (p < 0.01) at the slower pace. Faster pace required more energy expenditure (p < 0.01) and produced higher HR (p < 0.01) than slower speeds. At faster pace, a significantly higher energy expenditure in the QUAD than the CAT-CAM group was observed (p < 0.01). It is concluded that ambulating at normal pace using the CAT-CAM socket design uses less energy than when using a QUAD socket design.

Computerized reminders to encourage cervical screening in family practice.

In a randomized trial three ways of increasing rates of cervical screening were compared for women attending a family medicine center. Working from computerized medical records, 1,587 women aged 18 to 35 years who were overdue for a screening test were included in the study. In a control group, no formal method was used to encourage patients to attend for screening, and 13.7 percent obtained a test within the trial year. In one intervention group the physician was issued a message identifying those women visiting the center for a routine appointment who were due for screening; 16.1 percent were screened. Sending a letter to patients in a second group yielded a 25.9 percent compliance rate. In a third group the practice nurse called patients on the telephone to advise them to obtain the test, and 20.0 percent complied. Reminders issued to the physician provide a low-cost, opportunistic approach to reach women who happen to visit the practice, but this approach should be supplemented by telephoning or sending a letter to those women who do not attend regularly.

Engineering resistance to mixed virus infection in a commercial potato cultivar: resistance to potato virus X and potato virus Y in transgenic Russet Burbank.

Potato virus X (PVX) and potato virus Y (PVY) infection in potato may result in the loss of certification of seed potatoes and affect quality and yield of potatoes in commercial production. We transformed a major commercial cultivar of potato, Russet Burbank, with the coat protein genes of PVX and PVY. Transgenic plants that expressed both CP genes were resistant to infection by PVX and PVY by mechanical inoculation. One line was also resistant when PVY was inoculated with viruliferous green peach aphids. These experiments demonstrate that CP protection is effective against mixed infection by two different viruses and against mechanical and aphid transmission of PVY.

Botulism challenge studies of a modified atmosphere package for fresh mussels: inoculated pack studies.

A series of botulism challenge studies were performed to determine the possibility of production of botulinum toxin in mussels (Mytilus edulis) held under a commercial high-oxygen (60 to 65% O(2)), modified atmosphere packaging (MAP) condition. Spore mixtures of six strains of nonproteolytic Clostridium botulinum were introduced into mussel MAP packages receiving different packaging buffers with or without the addition of lactic acid bacteria. Dye studies and package flipping trials were conducted to ensure internalization of spores by packed mussels. Inoculated mussel packages were stored at normal (4°C) and abusive (12°C) temperatures for 21 and 13 days, respectively, which were beyond the packaged mussels' intended shelf life. Microbiological and chemical analyses were conducted at predetermined intervals (a total of five sampling times at each temperature), including total aerobic plate counts, C. botulinum counts, lactic acid bacterial counts, package headspace gas composition, pH of packaging buffer and mussel meat, and botulinum toxin assays of packaging buffer and mussel meat. Results revealed that C. botulinum inoculated in fresh mussels packed under MAP packaging did not produce toxin, even at an abusive storage temperature and when held beyond their shelf life. No evidence was found that packaging buffers or gas composition influenced the lack of botulinum toxin production in packed mussels.

Total hip replacement for the treatment of acute femoral neck fractures: results from the National Joint Registry of England and Wales at 3-5 years after surgery.

INTRODUCTION: This paper describes, for the first time, the outcomes of patients undergoing total hip replacement for acute fractured neck of femur (#NOF) as recorded by the National Joint Registry of England and Wales (NJR). METHODS: In the NJR we identified 1,302 of 157,232 Hospital Episode Statistics linked patients who had been recorded as having a total hip replacement for acute #NOF between April 2003 and November 2008. RESULTS: The revision rate at five years for fully uncemented components was 4.1% (95% confidence interval [CI]: 2.2-7.3%), for hybrid it was 2.2% (95% CI: 0.9%-5.3%) and for fully cemented components 0.9% (95% CI: 0.4-2.0%). Five-year revision rates were increased for those whose operations were performed via a posterior versus a lateral approach. The Kaplan-Meier estimate of 30-day mortality was 1.4% (95% CI: 1.0-2.4%), which is over double the 30-day mortality rate for total hip replacement identified by the Office for National Statistics. The mean length of stay was also increased for those undergoing total hip replacements for #NOF compared with non-emergency indications. CONCLUSIONS: Our data suggest that total hip replacements for acute #NOF give comparable results with total hip replacements for other indications.