Incorporating non-equilibrium dynamics into demographic history inferences of a migratory marine species.

Understanding how dispersal and gene flow link geographically separated the populations over evolutionary history is challenging, particularly in migratory marine species. In southern right whales (SRWs, Eubalaena australis), patterns of genetic diversity are likely influenced by the glacial climate cycle and recent history of whaling. Here we use a dataset of mitochondrial DNA (mtDNA) sequences (n = 1327) and nuclear markers (17 microsatellite loci, n = 222) from major wintering grounds to investigate circumpolar population structure, historical demography and effective population size. Analyses of nuclear genetic variation identify two population clusters that correspond to the South Atlantic and Indo-Pacific ocean basins that have similar effective breeder estimates. In contrast, all wintering grounds show significant differentiation for mtDNA, but no sex-biased dispersal was detected using the microsatellite genotypes. An approximate Bayesian computation (ABC) approach with microsatellite markers compared the scenarios with gene flow through time, or isolation and secondary contact between ocean basins, while modelling declines in abundance linked to whaling. Secondary-contact scenarios yield the highest posterior probabilities, implying that populations in different ocean basins were largely isolated and came into secondary contact within the last 25,000 years, but the role of whaling in changes in genetic diversity and gene flow over recent generations could not be resolved. We hypothesise that these findings are driven by factors that promote isolation, such as female philopatry, and factors that could promote dispersal, such as oceanographic changes. These findings highlight the application of ABC approaches to infer the connectivity in mobile species with complex population histories and, currently, low levels of differentiation.

Cultural traditions across a migratory network shape the genetic structure of southern right whales around Australia and New Zealand.

Fidelity to migratory destinations is an important driver of connectivity in marine and avian species. Here we assess the role of maternally directed learning of migratory habitats, or migratory culture, on the population structure of the endangered Australian and New Zealand southern right whale. Using DNA profiles, comprising mitochondrial DNA (mtDNA) haplotypes (500 bp), microsatellite genotypes (17 loci) and sex from 128 individually-identified whales, we find significant differentiation among winter calving grounds based on both mtDNA haplotype (FST = 0.048, ΦST = 0.109, p < 0.01) and microsatellite allele frequencies (FST = 0.008, p < 0.01), consistent with long-term fidelity to calving areas. However, most genetic comparisons of calving grounds and migratory corridors were not significant, supporting the idea that whales from different calving grounds mix in migratory corridors. Furthermore, we find a significant relationship between δ(13)C stable isotope profiles of 66 Australian southern right whales, a proxy for feeding ground location, and both mtDNA haplotypes and kinship inferred from microsatellite-based estimators of relatedness. This indicates migratory culture may influence genetic structure on feeding grounds. This fidelity to migratory destinations is likely to influence population recovery, as long-term estimates of historical abundance derived from estimates of genetic diversity indicate the South Pacific calving grounds remain at <10% of pre-whaling abundance.

Interleukin-17 Expression in the Barrett's Metaplasia-Dysplasia-Adenocarcinoma Sequence.

Introduction. This pilot study evaluated the expression of the proinflammatory cytokine IL-17 along the Barrett's metaplasia-dysplasia-adenocarcinoma sequence by establishing the expression levels of IL-17 in columnar epithelium, intestinal metaplastic cells, and dysplastic/glandular neoplastic cells. Immunohistochemical techniques were used to examine the accumulation of the proinflammatory cytokine IL-17 in forty (n = 40) formalin-fixed, paraffin-embedded oesophageal archived specimens across a range of endoscopic diagnostic categories, and a highly significant difference was found, where P ≤ 0.001, in IL-17 expression (Kruskall Wallis and Mann-Whitney U) between all the cell types examined. There was also a strong positive correlation (Spearman's rank correlation) between disease progression and IL-17 expression (r s = 0.883, P < 0.001, n = 29), IL-17 expression was absent or absent/weak in columnar epithelium, weak to moderate in columnar metaplastic cells, and moderate to strong in dysplastic/neoplastic cells, which demonstrated that the elevation of IL-17 expression occurs in the progression of the disease. Understanding the differential expression of IL-17 between benign and malignant tissue potentially has a significant diagnostic, prognostic, and therapeutic value. Ultimately, this selective biomarker may be employed in routine clinical practice for the screening of oesophageal adenocarcinoma.

Challenge of improving postoperative pain management: case studies of three acute pain services in the UK National Health Service.

BACKGROUND: Previous national survey research has shown significant deficits in routine postoperative pain management in the UK. This study used an organizational change perspective to explore in detail the organizational challenges faced by three acute pain services in improving postoperative pain management. METHODS: Case studies were conducted comprising documentary review and semi-structured interviews (71) with anaesthetists, surgeons, nurses, other health professionals, and managers working in and around three broadly typical acute pain services. RESULTS: Although the precise details differed to some degree, the three acute pain services all faced the same broad range of inter-related challenges identified in the organizational change literature (i.e. structural, political, cultural, educational, emotional, and physical/technological challenges). The services were largely isolated from wider organizational objectives and activities and struggled to engage other health professionals in improving postoperative pain management against a background of limited resources, turbulent organizational change, and inter- and intra-professional politics. Despite considerable efforts they struggled to address these challenges effectively. CONCLUSIONS: The literature on organizational change and quality improvement in health care suggests that it is only by addressing the multiple challenges in a comprehensive way across all levels of the organization and health-care system that sustained improvements in patient care can be secured. This helps to explain why the hard work and commitment of acute pain services over the years have not always resulted in significant improvements in routine postoperative pain management for all surgical patients. Using this literature and adopting a whole-organization quality improvement approach tailored to local circumstances may produce a step-change in the quality of routine postoperative pain management.

Understanding the challenges of service change - learning from acute pain services in the UK.

OBJECTIVES: To explore organizational difficulties faced when implementing national policy recommendations in local contexts. DESIGN: Qualitative case study involving semi-structured interviews with health professionals and managers working in and around acute pain services. SETTING: Three UK acute hospital organizations. MAIN OUTCOME MEASURES: Identification of the content, context and process factors impacting on the implementation of the national policy recommendations on acute pain services; insights into and deeper understanding of the generic obstacles to change facing service improvements. RESULTS: The process of implementing policy recommendations and improving services in each of the three organizations was undermined by multiple factors relating to: doubts and disagreements about the nature of the change; challenging local organizational contexts; and the beliefs, attitudes and responses of health professionals and managers. The impact of these factors was compounded by the interaction between them. CONCLUSIONS: Local implementation of national policies aimed at service improvement can be undermined by multiple interacting factors. Particularly important are the pre-existing local organizational contexts and histories, and the deeply-ingrained attitudes, beliefs and assumptions of diverse staff groups. Without close attention to all of these underlying issues and how they interact in individual organizations against the background of local and national contexts, more resources or further structural change are unlikely to deliver the intended improvements in patient care.

Peristomal varices--life threatening or luminal?

Bleeding from the edge of an ileostomy site is a common problem. In those who have undergone a proctocolectomy with ileostomy formation in conjunction with a risk of chronic liver disease (even with normal liver function tests), this may be due to peristomal varices. If this is the case, significant, difficult-to-control and potentially life-threatening bleeding is likely in the future and may require transfusion. Improvements in radiological imaging techniques can give quick, sensitive and specific information to diagnose and guide management in this group. In those patients with major bleeding episodes, an initial conservative management policy should be adopted with the knowledge that, if bleeding persists, propanolol therapy, portosystemic shunt insertion or even liver transplantation may be indicated.

Disparity of autonomic control in type 2 diabetes mellitus.

AIMS/HYPOTHESIS: Acute insulinaemia activates the sympathetic drive in a nonuniform manner. The extent and nature of such activation in type 2 diabetic patients who do not have neuropathy have not yet been addressed despite evidence relating sympathetic activation to cardiovascular risk. We planned to determine the magnitude and extent of the sympathetic drive and its reflex responses in patients with type 2 diabetes and fasting hyperinsulinaemia. METHODS: We measured resting muscle sympathetic nerve activity (MSNA) as the mean frequency of multi-unit bursts and single unit muscle sympathetic nerve activity (s-MSNA) in 17 overweight patients with type 2 diabetes and two matched normal control groups comprising 17 overweight and 16 normal-weight subjects. We also tested the MSNA and s-MSNA responses to cold pressor and isometric hand-grip tests, along with the effect of sympatho-vagal balance on heart period variability. RESULTS: Both MSNA and s-MSNA in the group with type 2 diabetes (66+/-3.5 bursts/100 beats and 78+/-4.5 impulses/100 beats) were greater (at least p<0.0001) than in the overweight control group (42+/-2.6 bursts/100 beats and 48+/-3.4 impulses/100 beats) and normal-weight control group (43+/-6.2 bursts/100 beats and 51+/-7.1 impulses/100 beats), though the three groups had similar reflex responses, baroreflex sensitivity and sympatho-vagal balance controlling the heart period. CONCLUSIONS/INTERPRETATION: The patients with type 2 diabetes had no evidence of impaired reflex or autonomic control of heart period variability at a time when there was central sympathetic activation to the periphery. Furthermore, being overweight itself was not associated with sympathetic activation.

Rhetoric and reality on acute pain services in the UK: a national postal questionnaire survey.

BACKGROUND: The study aimed to explore the extent to which NHS acute pain services (APSs) have been established in accordance with national guidance, and to assess the degree to which clinicians in acute pain management believe that these services are fulfilling their role. METHODS: A postal questionnaire survey addressed to the head of the acute pain service was sent to 403 National Health Service hospitals each carrying out more than 1000 operative procedures a year. RESULTS: Completed questionnaires were received from 81% (325) of the hospitals, of which 83% (270) had an established acute pain service. Most of these (86%) described their service as Monday-Friday with a reduced service at other times; only 5% described their service as covering 24 hours, 7 days a week. In the majority of hospitals (68%), the on-call anaesthetist was the sole provider of out of hours services. Services were categorized by respondents as thriving (30%), struggling to manage (52%) or non-existent (17%). There was widespread agreement (> or =85%) on the principles that should underpin acute pain services, and similar agreement on the need for better organizational approaches (95%) rather than new treatments and delivery techniques (19%). CONCLUSIONS: More than a decade since the 1990 report Pain after Surgery, national coverage of comprehensive acute pain services is still far from being achieved. Despite wide consensus about the problems, concrete solutions are proving hard to implement. There is strong support for a two-fold response: securing greater political commitment to pain services and using organizational approaches to address current deficits.

Beta-oxidation of linoleate in obese men undergoing weight loss.

BACKGROUND: In animals, the whole-body content and accumulation of linoleate can be measured and compared with its intake to determine linoleate beta-oxidation. This method can also provide quantitative information about the beta-oxidation of linoleate in humans. OBJECTIVES: The objectives of the study were to 1) use the wholebody fatty acid balance method to quantify whole-body concentrations of linoleate in humans, 2) estimate the distribution of linoleate between adipose and lean tissue, and 3) assess the effect of weight loss on linoleate stores and beta-oxidation in obese humans. DESIGN: Nine healthy obese men underwent supervised weight loss for 112 d (16 wk). Magnetic resonance imaging data and fatty acid profiles from fat biopsies were both used to determine linoleate stores in adipose and lean tissue and in the whole body. Linoleate beta-oxidation was calculated as intake - (accumulation + excretion). RESULTS: Mean weight loss was 13 kg and linoleate intake was 24 +/- 6 mmol/d over the study period. Whole-body loss of linoleate was 37 +/- 18 mmol/d, or 28% of the level before weight loss. Combining the intake and whole-body loss of linoleate resulted in linoleate beta-oxidation exceeding intake by 2.5-fold during the weight-loss period. CONCLUSIONS: All dietary linoleate is beta-oxidized and at least an equivalent amount of linoleate is lost from the body during moderate weight loss in obese men. The method studied permits the assessment of long-term changes in linoleate homeostasis in obese humans and may be useful in determining the risk of linoleate deficiency in other conditions.

Postoperative pain relief using thoracic epidural analgesia: outstanding success and disappointing failures.

Six hundred and forty patients received epidural analgesia for postoperative pain relief following major surgery in the 6-year period 1993-1998. Although satisfactory pain relief was achieved in over two-thirds of patients for a median duration of 44 h after surgery, one-fifth of patients (133 individuals) still experienced poor pain relief. Almost one out of three patients (194 individuals) had a problem with their epidural. Eighty-three patients (13%) suffered a technical failure and 84 (13%) patients had their epidurals removed at night time when pain-free because of pressure on beds. Seven patients had their epidural replaced and subsequently experienced excellent pain relief for a median of 77 h. Lack of resources prevented a further 480 patients from receiving the potential benefits of epidural analgesia. These results would suggest that the practical problems of delivering an epidural service far outweigh any differences in drug regimens or modes of delivery of epidural solutions.

Skin blood flow changes in response to intradermal injection of bupivacaine and levobupivacaine, assessed by laser Doppler imaging.

BACKGROUND AND OBJECTIVES: The vascular effects of local anesthetics are important determinants of their therapeutic activity. Drugs that vasoconstrict have the potential clinical advantages of limited systemic uptake and prolonged duration of effect. The aim of this study was to assess quantitatively the cutaneous vasoactivity of racemic bupivacaine and one of its enantiomers, levobupivacaine. METHODS: Four concentrations of each drug (0.1 mL each of 0.125%, 0.25%, 0.5%, and 0.75%), as well as normal saline, were injected intradermally into randomly assigned sites on the forearms of 10 volunteers. We measured skin blood perfusion using laser Doppler imaging before injection and at 2.5, 10, 20, 40, 60, and 90 minutes thereafter. RESULTS: Both drugs produced a rapid, dose-dependent increase in skin perfusion (P <.001). Saline also caused an increase in perfusion, although less sustained. By 40 minutes, most responses had returned to baseline levels. However, after this time, perfusion continued to decrease, below baseline, for both bupivacaine and levobupivacaine. The exception to this was 0.75% bupivacaine, the response to which was significantly higher than the same concentration of levobupivacaine over this later period (P <.05). CONCLUSIONS: Bupivacaine and levobupivacaine both have a biphasic effect on skin microvessels. The vasoconstriction observed after 40 minutes may occur when the quantity of drug remaining at the administration site has decreased to a lower level. The continued vasodilatation caused by bupivacaine is more difficult to interpret. The results suggest that these local anesthetics cause vasodilatation at high doses and vasoconstriction at lower, subclinical doses. This hypothesis and the clinical relevance of these effects warrant further investigation.

World-wide genetic differentiation of Eubalaena: questioning the number of right whale species.

Few studies have examined systematic relationships of right whales (Eubalaena spp.) since the original species descriptions, even though they are one of the most endangered large whales. Little morphological evidence exists to support the current species designations for Eubalaena glacialis in the northern hemisphere and E. australis in the southern hemisphere. Differences in migratory behaviour or antitropical distribution between right whales in each hemisphere are considered a barrier to gene flow and maintain the current species distinctions and geographical populations. However, these distinctions between populations have remained controversial and no study has included an analysis of all right whales from the three major ocean basins. To address issues of genetic differentiation and relationships among right whales, we have compiled a database of mitochondrial DNA control region sequences from right whales representing populations in all three ocean basins that consist of: western North Atlantic E. glacialis, multiple geographically distributed populations of E. australis and the first molecular analysis of historical and recent samples of E. glacialis from the western and eastern North Pacific Ocean. Diagnostic characters, as well as phylogenetic and phylogeographic analyses, support the possibility that three distinct maternal lineages exist in right whales, with North Pacific E. glacialis being more closely related to E. australis than to North Atlantic E. glacialis. Our genetic results provide unequivocal character support for the two usually recognized species and a third distinct genetic lineage in the North Pacific under the Phylogenetic Species Concept, as well as levels of genetic diversity among right whales world-wide.

Antiarrhythmic management and implantable defibrillator use in survivors of prehospital cardiac arrest without myocardial infarction in West Yorkshire.

OBJECTIVE: To explore the current use of secondary preventive treatment in survivors of out of hospital cardiac arrest without myocardial infarction (primary ventricular tachycardia/ventricular fibrillation (VT/VF)) in West Yorkshire, and assess the implications of recent studies on the benefits of implantable cardioverter-defibrillators (AICD) in this context. DESIGN: Retrospective analysis of an ambulance service based database of outcome after resuscitation of out of hospital cardiac arrest and the Leeds AICD implantation database. MAIN OUTCOME MEASURES: Mortality, rate of referral for specialist investigation, antiarrhythmic treatment. RESULTS: Twelve month mortality following successful discharge after primary VF arrest was 15%. Of 53 patients with primary VF/VT, 29 apparently did not see a cardiologist during the initial admission. Amiodarone was the most widely used antiarrhythmic agent. Six patients (15%) received an AICD. During the same period 22 patients from the same catchment area received an AICD following an in-hospital cardiac arrest. CONCLUSIONS: Mortality among survivors of non-infarct related prehospital cardiac arrest remains significant, with few patients being referred for specialist investigation. The implementation of recent guidelines on AICD use in cardiac arrest survivors would have resulted in an approximate 60% increase in the total numbers of defibrillators implanted in the West Yorkshire area.

The effects of oxidizing and cysteine-reactive reagents on the inward rectifier potassium channels Kir2.3 and Kir1.1.

The inwardly rectifying potassium channel Kir2.3 possesses extracellular cysteine residues at positions 113, 140, and 145, as well as at position 79 near the outer membrane boundary. In this study, we have investigated the roles of these extracellular cysteine residues in mediating inhibition of the Kir2.3 channel by the cysteine-reactive reagents para-chloromercuribenzenesulphonate (PCMBS) and thimerosal, and the oxidizing agent hydrogen peroxide (H2O2). We have also compared the effects of these reagents with those on Kir1.1 channels (which do not possess cysteine residues equivalent to 140 and 79 in Kir2.3 channels). Mutant channels were made in which cysteine residues were mutated to serine by site-directed mutagenesis. Wild-type or mutant cRNA was injected into Xenopus oocytes and voltage-clamp recordings made 1-2 days later. Wild-type Kir2.3 currents were significantly inhibited by PCMBS, thimerosal and H2O2. Currents for mutants Kir2.3 C79S and C140S were also inhibited by PCMBS, thimerosal and H2O2. These mutations affected the time course of inhibition by all three reagents. For PCMBS, a slow component of inhibition was absent for the C79S mutation, and a fast component was absent for C140S. For the double mutation C79S/C140S, PCMBS no longer had any effect. For thimerosal, there was a slower time course for C140S, a faster time course for C79S, and a delayed onset for C79S/C140S. For H2O2, the main effect was a delayed onset for the double mutant. The reducing agent dithiothreitol (DTT) reversed the inhibition by both PCMBS and thimerosal of wild-type and mutant currents, but not the inhibition due to H2O2. Finally, wild-type Kir1.1 currents were not significantly inhibited by the applications of either PCMBS or thimerosal, while H2O2 produced small inhibition. The results taken together indicate that inhibition by the cysteine-reactive reagent PCMBS is mediated through cysteine residues 79 and 140 in Kir2.3 channels, with C79 mediating a slow component of inhibition and C140 a faster component, and that both residues are extracellularly exposed. The data indicate that these two cysteine residues are also main sites for inhibition by thimerosal and H2O2 but, unlike for PCMBS, an additional non-extracellular inhibitory site(s) must also be involved.

Spinal anesthesia with 0.5% S(-)-bupivacaine for elective lower limb surgery.

BACKGROUND AND OBJECTIVES: This study examines the clinical effects of the subarachnoid administration of levobupivacaine, the S(-)-enantiomer of racemic bupivacaine. METHODS: An open, noncomparative study was performed on 20 patients undergoing elective lower limb surgery. Three milliliters of a plain solution of 0.5% S(-)-bupivacaine ( 15 mg) was administered via the L2 or L3 interspace with the patient in the sitting position. Following injection, the patients were immediately placed supine. Spread of sensory analgesia, degree of motor block, and hemodynamic parameters were recorded. RESULTS: Satisfactory surgical anesthesia was achieved in 18 patients. The median time to onset of analgesia was 2 minutes (ranging 2-10 minutes) and the median duration of analgesia was 388 minutes (range, 295-478 minutes). This group of patients achieved complete motor block, with a median onset time of 5 minutes (2-10 minutes) and duration of 266 minutes (range, 170-415 minutes). Sensory block height was inadequate for surgery in 2 patients, who received supplemental anesthesia. CONCLUSIONS: The results suggest that S(-)-bupivacaine can provide satisfactory surgical anesthesia, but the spread of the plain solution is unpredictable.

Conserved extracellular cysteine residues in the inwardly rectifying potassium channel Kir2.3 are required for function but not expression in the membrane.

The mouse potassium channel Kir2.3 possesses conserved extracellular cysteine residues at positions 113 and 145. We have investigated the role of these cysteines in structure/function and membrane trafficking. Cysteine to serine mutations resulted in the absence of potassium currents in oocytes and co-expression of these mutants with wild-type channel showed a dominant negative inhibition of wild-type currents. FLAG-tagged channels expressed in oocytes were detected in the cell membrane by anti-FLAG antibody for wild-type and mutant channels. In vitro translation using the reticulocyte lysate system showed that mutation of these residues did not affect processing nor insertion into membranes. Cysteine residues at 113 and 145 are therefore required for function of the Kir2.3 channel but not for processing into the cell membrane; disulfide bonds between subunits are unlikely.