The Scottish Brain Health Service Model: Rationale and Scientific Basis for a National Care Pathway of Brain Health Services in Scotland.

In order to address the oft-cited societal, economic, and health and social care impacts of neurodegenerative diseases, such as Alzheimer's disease, we must move decisively from reactive to proactive clinical practice and to embed evidence-based brain health education throughout society. Most disease processes can be at least partially prevented, slowed, or reversed. We have long neglected to intervene in neurodegenerative disease processes, largely due to a misconception that their predominant symptom - cognitive decline - is a normal, age-related process, but also due to a lack of multi-disciplinary collaboration. We now understand that there are modifiable risk factors for neurodegenerative diseases, that successful management of common comorbidities (such as diabetes and hypertension) can reduce the incidence of neurodegenerative disease, and that disease processes begin (and, crucially, can be detected, reduced, and delayed, prevented, or treated) decades earlier in life than had previously been appreciated. Brain Health Scotland, established by Scottish Government and working in partnership with Alzheimer Scotland, propose far-reaching public health and clinical practice approaches to reduce neurodegenerative disease incidence. Focusing here on Brain Health Scotland's clinical offerings, we present the Scottish Model for Brain Health Services. To our knowledge, the Scottish Model for Brain Health, built on foundations of personalised risk profiling, targeted risk reduction and prevention, early disease detection, equity of access, and harnessing comprehensive data to assist in clinical decision-making, marks the first example of a nationwide approach to overhauling clinical, societal, and political approaches to the prevention, assessment, and treatment of neurodegenerative disease.

The effect of bed roughness uncertainty on tidal stream power estimates for the Pentland Firth.

Uncertainty affects estimates of the power potential of tidal currents, resulting in large ranges in values reported for sites such as the Pentland Firth, UK. Kreitmair et al. (2019, R. Soc. open sci. 6, 180941. (doi:10.1098/rsos.191127)) have examined the effect of uncertainty in bottom friction on tidal power estimates by considering idealized theoretical models. The present paper considers the role of bottom friction uncertainty in a realistic numerical model of the Pentland Firth spanned by different fence configurations. We find that uncertainty in removable power estimates resulting from bed roughness uncertainty depends on the case considered, with relative uncertainty between 2% (for a fully spanned channel with small values of mean roughness and input uncertainty) and 44% (for an asymmetrically confined channel with high values of bed roughness and input uncertainty). Relative uncertainty in power estimates is generally smaller than (input) relative uncertainty in bottom friction by a factor of between 0.2 and 0.7, except for low turbine deployments and very high mean values of friction. This paper makes a start at quantifying uncertainty in tidal stream power estimates, and motivates further work for proper characterization of the resource, accounting for uncertainty inherent in resource modelling.

The effect of uncertain bottom friction on estimates of tidal current power.

Uncertainty affects estimates of the power potential of tidal currents, resulting in large ranges in values reported for a given site, such as the Pentland Firth, UK. We examine the role of bottom friction, one of the most important sources of uncertainty. We do so by using perturbation methods to find the leading-order effect of bottom friction uncertainty in theoretical models by Garrett & Cummins (2005 Proc. R. Soc. A 461, 2563-2572. (doi:10.1098/rspa.2005.1494); 2013 J. Fluid Mech. 714, 634-643. (doi:10.1017/jfm.2012.515)) and Vennell (2010 J. Fluid Mech. 671, 587-604. (doi:10.1017/S0022112010006191)), which consider quasi-steady flow in a channel completely spanned by tidal turbines, a similar channel but retaining the inertial term, and a circular turbine farm in laterally unconfined flow. We find that bottom friction uncertainty acts to increase estimates of expected power in a fully spanned channel, but generally has the reverse effect in laterally unconfined farms. The optimal number of turbines, accounting for bottom friction uncertainty, is lower for a fully spanned channel and higher in laterally unconfined farms. We estimate the typical magnitude of bottom friction uncertainty, which suggests that the effect on estimates of expected power lies in the range -5 to +30%, but is probably small for deep channels such as the Pentland Firth (5-10%). In such a channel, the uncertainty in power estimates due to bottom friction uncertainty remains considerable, and we estimate a relative standard deviation of 30%, increasing to 50% for small channels.

Flow through a very porous obstacle in a shallow channel.

A theoretical model, informed by numerical simulations based on the shallow water equations, is developed to predict the flow passing through and around a uniform porous obstacle in a shallow channel, where background friction is important. This problem is relevant to a number of practical situations, including flow through aquatic vegetation, the performance of arrays of turbines in tidal channels and hydrodynamic forces on offshore structures. To demonstrate this relevance, the theoretical model is used to (i) reinterpret core flow velocities in existing laboratory-based data for an array of emergent cylinders in shallow water emulating aquatic vegetation and (ii) reassess the optimum arrangement of tidal turbines to generate power in a tidal channel. Comparison with laboratory-based data indicates a maximum obstacle resistance (or minimum porosity) for which the present theoretical model is valid. When the obstacle resistance is above this threshold the shallow water equations do not provide an adequate representation of the flow, and the theoretical model over-predicts the core flow passing through the obstacle. The second application of the model confirms that natural bed resistance increases the power extraction potential for a partial tidal fence in a shallow channel and alters the optimum arrangement of turbines within the fence.

Wave directional spreading from point field measurements.

Ocean waves have multidirectional components. Most wave measurements are taken at a single point, and so fail to capture information about the relative directions of the wave components directly. Conventional means of directional estimation require a minimum of three concurrent time series of measurements at different spatial locations in order to derive information on local directional wave spreading. Here, the relationship between wave nonlinearity and directionality is utilized to estimate local spreading without the need for multiple concurrent measurements, following Adcock & Taylor (Adcock & Taylor 2009 Proc. R. Soc. A465, 3361-3381. (doi:10.1098/rspa.2009.0031)), with the assumption that directional spreading is frequency independent. The method is applied to measurements recorded at the North Alwyn platform in the northern North Sea, and the results compared against estimates of wave spreading by conventional measurement methods and hindcast data. Records containing freak waves were excluded. It is found that the method provides accurate estimates of wave spreading over a range of conditions experienced at North Alwyn, despite the noisy chaotic signals that characterize such ocean wave data. The results provide further confirmation that Adcock and Taylor's method is applicable to metocean data and has considerable future promise as a technique to recover estimates of wave spreading from single point wave measurement devices.

Energy potential of a tidal fence deployed near a coastal headland.

Enhanced tidal streams close to coastal headlands appear to present ideal locations for the deployment of tidal energy devices. In this paper, the power potential of tidal streams near an idealized coastal headland with a sloping seabed is investigated using a near-field approximation to represent a tidal fence, i.e. a row of tidal devices, in a two-dimensional depth-averaged numerical model. Simulations indicate that the power extracted by the tidal fence is limited because the flow will bypass the fence, predominantly on the ocean side, as the thrust applied by the devices increases. For the dynamic conditions, fence placements and headland aspect ratios considered, the maximum power extracted at the fence is not related in any obvious way to the local undisturbed kinetic flux or the natural rate of energy dissipation due to bed friction (although both of these have been used in the past to predict the amount of power that may be extracted). The available power (equal to the extracted power net of vertical mixing losses in the immediate wake of devices) is optimized for devices with large area and small centre-to-centre spacing within the fence. The influence of energy extraction on the natural flow field is assessed relative to changes in the M2 component of elevation and velocity, and residual bed shear stress and tidal dispersion.

Extended roles and the dietitian: community adult enteral tube care.

BACKGROUND: Role flexibility is considered central to a health policy agenda stressing workforce redesign measures and professional role boundary change. Extensions in health professionals' role boundaries may involve the incorporation of new or 'vacant' roles, as well as the competitive acquisition of others. In the present study, the experiences of dietitians with extended roles in home enteral tube feeding (HETF) were explored and considered within the context of workforce role transition. METHODS: Six semi-structured interviews conducted with dietitians specialising in HETF were undertaken and the emergent role development for dietitians in HETF was explored. RESULTS: Dietetic HETF roles emerged as a form of diversification, occupying a task 'vacancy', commonly on an opportunistic basis. Role overlap in these community based tasks was negotiated with community nurses, privately funded industry nurses and other medical staff. Notably, role conflict was encountered only with nutrition nurse specialists. CONCLUSIONS: To date, a lack of role exclusivity in a small and confined speciality field with multiple potential competitors has resulted in surprisingly little role conflict. Financial constraints within the National Health Service are considered likely to favour a privately funded service model of delivery, and this may have implications for dietitians specialising in this field. Dietitians also perceived an increase in professional status as a result of extended roles.

Mortality within 30 days of chemotherapy: a clinical governance benchmarking issue for oncology patients.

No national benchmark figures exist for early mortality due to chemotherapy unlike for surgical interventions. Deaths within 30 days of chemotherapy during a 6-month period were identified from the Royal Marsden Hospital electronic patient records. Treatment intention--curative or palliative, cause of death and number of previous treatments--were documented. Between April 2005 and September 2005, 1976 patients received chemotherapy with 161 deaths within 30 days of chemotherapy (8.1%). Of these, 124 deaths (77.0%) were due to disease progression. Of the other 37 deaths, 12 (7.5%) were related to chemotherapy, six each for solid tumours and haematological malignancies, of which seven (4.3%) were due to neutropenic sepsis. For the remaining 25 deaths (15.5%) there was insufficient information. There were more deaths after third and subsequent lines of therapy than with first and secondlines of therapy. Only 12 of the 161 deaths occurred in patients who were receiving potentially curative chemotherapy to give a mortality rate in breast and gastrointestinal malignancy of 0.5 and 1.5%, respectively. It is possible to audit mortality within 30 days of chemotherapy and this should become a benchmark for standard practice nationally. Most deaths were due to disease progression in the palliative setting. We practice this form of audit each quarter and feed back to the treating teams so that deaths are discussed and practice monitored.

Design and synthesis of pyrrolidine-5,5-trans-lactams (5-oxo-hexahydro-pyrrolo[3,2-b]pyrroles) as novel mechanism-based inhibitors of human cytomegalovirus protease. 1. The alpha-methyl-trans-lactam template.

Mechanism-based inhibitors of human cytomegalovirus (HCMV) protease have been designed based on the pyrrolidine-5,5-trans-lactam ring system. New routes to the beta-methyl-, desmethyl-, and alpha-methyl-pyrrolidine-5,5-trans-lactam templates have been developed from 2,4-diaminobutyric acid. ESI/MS studies have shown that these inhibitors can bind covalently and reversibly to the viral enzyme in a time-dependent manner by a mechanism which is consistent with acylation of HCMV deltaAla protease at the active site nucleophile Ser 132. SAR in this series of pyrrolidine-5, 5-trans-lactams has defined the relative stereochemisty of the methyl substituent adjacent to the lactam carbonyl, the functionality on the lactam nitrogen, and the mechanism of action of this novel series of serine protease inhibitors against the HCMV deltaAla protease. Activity decreases on moving from the alpha-methyl to the desmethyl to the beta-methyl series. This selectivity is the opposite of that observed for these templates against the elastase and thrombin enzymes. The activity against HCMV deltaAla protease is the greatest with inhibitors based on the Cbz-protected alpha-methyl-5,5-trans-lactam template which have low micromolar activity against the viral enzyme.

Signalling pathways involved in the stimulation of glycogen synthesis by insulin in rat hepatocytes.

In hepatocytes glycogen storage is stimulated by insulin and this effect of insulin is counteracted by epidermal growth factor (EGF). The mechanism by which insulin stimulates glycogen synthesis in liver is unknown. We investigated the involvement of candidate protein kinases in insulin signalling in hepatocytes. Both insulin and EGF activated extracellular regulated kinase 2 (ERK-2), p70rsk and protein kinase B (PKB) and inactivated glycogen synthase kinase-3 (GSK-3). Whereas EGF caused a greater activation of ERK-2 than insulin, the converse was true for PKB. The stimulation by insulin of ERK-2 was blocked by a mitogen-activated protein (MEK) inhibitor (PD 98059) and of p70rsk by rapamycin. However, these inhibitors, separately or in combination, did not block the stimulation of glycogen synthesis by insulin, indicating that activation of these kinases is not essential for the stimulation of glycogen synthesis by insulin. Mono Q fractionation of hepatocyte extracts resolved a single myelin basic protein (MBP) kinase peak from extracts of EGF-treated cells (peak 1, eluting at 200 mmol/l NaCl) and two peaks from insulin-treated cells (peak 1 eluting at 200 mmol/l NaCl and peak 2 eluting at 400 mmol/l NaCl). In the combined presence of insulin and EGF, activation of peak 2 was abolished. In situ MBP kinase assays and immunoblotting established that peak 1 coincides with ERK-2 and peak 2 is not an activated form of ERK-1 or ERK-2. It is concluded that PKB, which is activated to a greater extent by insulin than EGF, and peak 2, which is activated by insulin and counteracted by EGF, are possible candidates in mediating the stimulation of glycogen synthesis by insulin.

Investigation of the covalent modification of the catalytic triad of human cytomegalovirus protease by pseudo-reversible beta-lactam inhibitors and a peptide chloromethylketone.

An investigation into the interaction between human cytomegalovirus (HCMV) protease and several beta-lactams, with characterization of the resulting acylenzymes using mass spectrometry, is reported. The time dependence of the inhibitors is highlighted by making comparisons of values obtained for inhibition and acylation. Analysis of inactivated HCMV protease revealed a beta-lactam: protease stoichiometry of 1. Subsequent enzymatic digestion with trypsin, peptide mapping using liquid chromatography coupled with electrospray ionization mass spectrometry and sequencing by nanoelectrospray tandem mass spectrometry (NanoES-MS/MS) allowed the identification of the site of covalent modification and confirmed Ser 132 as the active site hydroxyl nucleophile. Further, treatment of the protease with a peptide chloromethylketone and sequence analysis using NanoES-MS/MS of the alkylated enzyme confirmed His 63 as the active site imidazole nucleophile.

Design and synthesis of monocyclic beta-lactams as mechanism-based inhibitors of human cytomegalovirus protease.

Mechanism based inhibitors of HCMV protease have been designed based on the monocyclic beta-lactam nucleus, which have been shown to acylate the viral enzyme in a time dependent manner. SAR in a series of monocyclic beta-lactam N-ureas, has defined the size and relative stereochemistry of the C-3 substituent producing a low micromolar inhibitor 17b with good aqueous stability and selectivity over the mammalian serine proteases.

Fetal growth and insulin resistance in adult life: role of skeletal muscle morphology.

1. Thinness at birth is associated with insulin resistance in adult life and an apparent delay in activation of glycolysis/glycogenolysis in exercising skeletal muscle. As developmental abnormalities of skeletal muscle histology or metabolism may explain this association we examined muscle histology, biochemistry and blood flow in a group of 27 adult women whose birth details were known. 2. Subjects were examined by near-infrared spectroscopy to determine forearm muscle oxygen supply, and by muscle biopsy and forearm plethysmography. Those with a ponderal index at birth < 23 kg/m3 were insulin resistant (assessed by the short insulin-tolerance test-mean rate constants for glucose disappearance = 4.14 compared with 4.83%/min, P = 0.045) and had significantly more rapid muscle reoxygenation than the remainder of the subjects (13 compared with 22 s, P = 0.004). 3. Thinness at birth did not influence muscle capillary density, muscle glycogen content, glycogen synthase activity, citrate synthase activity or resting forearm blood flow. 4. Insulin resistance seen after fetal malnutrition was not associated with abnormal muscle histology, resting muscle blood flow, mitochondrial volume or glycogen content. 5. The increase in muscle reoxygenation rate in adult subjects who were thin at birth could occur to promote oxidative ATP synthesis in compensation for the delay in activation of glycolysis/glycogenolysis. It suggests altered regulation rather than structure of the muscle microcirculation. These changes appear to antedate the structural and biochemical changes seen in muscle from patients with established diabetes.

Insulin action in cultured human myoblasts: contribution of different signalling pathways to regulation of glycogen synthesis.

A key metabolic action of insulin is the stimulation of non-oxidative glucose utilization in skeletal muscle, by increasing both glucose uptake and glycogen synthesis. The molecular mechanism underlying this process has been investigated using a variety of experimental systems. We report here the use of cultured human myoblasts to study insulin control of glycogen synthesis in humans. In these cells insulin stimulates glycogen synthesis approx. 2.2-fold, associated with a similar activation of glycogen synthase (GS) which occurs within 5-10 min of the addition of insulin. Insulin also causes inactivation of glycogen synthase kinase-3 (GSK-3) and activation of protein kinase B, both processes being sufficiently rapid to account for the effects of insulin on GS. Activation by insulin of the protein kinases p70s6K, p90s6K and extracellular signal-regulated kinase 2 (ERK2) is observed, but is significantly slower than the activation of GS. Selective inhibitors of the p70s6K pathway (rapamycin), the ERK2/p90s6K pathway (PD98059) and phosphatidylinositol 3-kinase (wortmannin) have been used to probe the contribution of these components to insulin signalling in human muscle. Wortmannin blocks activation of both glycogen synthesis and GS and inactivation of GSK-3. PD98059 is without effect on these events, while rapamycin is without effect on inactivation of GSK-3 but partially blocks activation of glycogen synthesis and GS. Taken together, these findings suggest that protein kinase B is responsible for the inactivation of GSK-3, but that an additional rapamycin-sensitive mechanism may contribute to the activation of GS and stimulation of glycogen synthesis.

Intramuscular triglyceride and muscle insulin sensitivity: evidence for a relationship in nondiabetic subjects.

Intracellular triglyceride (TG) is an important energy source for skeletal muscle. However, recent evidence suggests that if muscle contains abnormally high TG stores its sensitivity to insulin may be reduced, and this could predispose to type II diabetes. To test this hypothesis, we measured muscle lipid content in 27 women aged 47 to 55 years (mean, 52) and related it to their glucose tolerance, insulin resistance, and muscle insulin sensitivity as measured by insulin activation of glycogen synthase, an insulin-regulated enzyme that is rate-limiting for insulin action in muscle. Both muscle TG content and intracellular lipid determined by Oil red O staining of muscle fibers were negatively associated with glycogen synthase activation (r = .43, P = .03 and r = -.47, P = .02, respectively). In addition, intracellular lipid correlated with features of the insulin resistance syndrome, including an increased waist to hip ratio (r = .47, P = .01) and fasting nonesterified fatty acids ([NEFA] r = .44, P = .04). These data demonstrate that increased muscle TG stores are associated with decreased insulin-stimulated glycogen synthase activity. Intracellular fat may underlie a major part of the insulin resistance in normal subjects, as well as type II diabetics.

Fetal growth and insulin resistance in adult life: relationship between glycogen synthase activity in adult skeletal muscle and birthweight.

Growth retardation during fetal life is associated with insulin insensitivity and an increased prevalence of impaired glucose tolerance in adult life. Because insulin-mediated stimulation of glycogen synthase may be an important rate-limiting step for insulin action at the cellular level, we have sought to determine whether impaired activation of muscle glycogen synthase is linked with early growth retardation. Postprandial glycogen synthase activity was therefore measured in muscle biopsies from a group of 27 women with normal glucose tolerance aged around 50 who were born in Preston, Lancashire, whose birthweight and body size at birth were recorded. Glycogen synthase activity measured at 0.1 mmol 1(-1) glucose-6-phosphate correlated with insulin sensitivity as measured by a short insulin tolerance test (r = 0.42, p < 0.05) and the waist to hip ratio (r = -0.48, p < 0.01), but not body mass index, body fat percentage or age. Within the group of women with normal glucose tolerance there was no relationship between intra-uterine growth as evidenced by birthweight or body size at birth and the response to insulin of skeletal muscle glycogen synthase in adult life. Thus we found no evidence for a direct link between fetal growth and insulin sensitivity in this pathway.

Synthesis of benzodioxinopyrroles as selective alpha 2-adrenoceptor antagonists.

A novel series of tetrahydrobenzodioxinopyrroles has been identified as potent and selective alpha 2-adrenoceptor antagonists. Convergent syntheses have been developed that allowed the preparation of analogues and their enantiomers. A compound of particular interest is the 5-fluoro substituted analogue (fluparoxan).

The effect of acute (60 minute) insulin stimulation upon human skeletal muscle glycogen synthase and protein phosphatase-1 in non-insulin-dependent diabetic patients and control subjects.

Previous studies have established that activation of muscle glycogen synthase (GS) is abnormal in non-insulin-dependent diabetes mellitus (NIDDM). Insulin-mediated activation of GS depends upon protein phosphatase-1 (PP1), which dephosphorylates the relevant sites of GS. In order to determine whether defects in PP1 activation cause subnormal activation of GS or whether PP1 activation itself is normal, we administered a short insulin infusion to 8 NIDDM subjects and 8 healthy controls matched for gender, age, and body mass index (BMI). GS fractional activity and PP1 activity were determined in biopsies taken from the gastrocnemius muscle before and after 60 min insulin infusion (0.1 U kg h-1). In the NIDDM group, muscle GS fractional activity was 6.8 +/- 1.6 and 10.0 +/- 1.5% (mean +/- SEM) (p = 0.11) before and after insulin infusion. In the control group, muscle GS fractional activity increased from 7.3 +/- 2.0 to 13.3 +/- 2.7% (p < 0.02). PP1 activity had returned towards basal levels after insulin infusion; NIDDM group 156 +/- 24.7 to 184.1 +/- 28.1 U mg-1; control group 220.8 +/- 30.1 to 233.8 +/- 29.8 U mg-1. In the NIDDM group there was a positive correlation between the increases in GS fractional activity and PP1 activity following insulin stimulation r = 0.77; p < 0.025). These data indicate that in vivo insulin-dependent activation of muscle PP1 is transient in normal subjects but is delayed in NIDDM. The defect in GS activation in NIDDM is likely to be proximal to PP1 in the pathway of transmission of the insulin signal.

Inhibition of glycogen synthase kinase-3 by insulin in cultured human skeletal muscle myoblasts.

The acute effects of insulin on the activity of glycogen synthase kinase 3 (GSK-3) have been investigated both in the rat L6 muscle cell line and in cultured human myoblasts. The alpha and beta isoforms of GSK-3 are present in both cell types, with the beta isoform being predominant in the human cells. Insulin causes a rapid inactivation of both isoforms in both cell lines, with 50% inactivation being observed in the human myoblasts.

The protein phosphatases responsible for dephosphorylation of hormone-sensitive lipase in isolated rat adipocytes.

The levels of the cytosolic serine/threonine protein phosphatases (PP) in rat adipocyte extracts have been determined, by using both reference substrates and hormone-sensitive lipase (HSL) as substrates. Adipocytes contain significant levels of both PP1 and 2A (1.6 and 2.0 m-units/ml of packed cells respectively), with lower levels of PP2C and virtually no PP2B activity. PP2A and 2C exhibit similar degrees of activity against HSL phosphorylated at site 1, together accounting for 92% of the total. In contrast, site 2 is dephosphorylated predominantly by PP2A (over 50% of total activity), whereas PP1 and PP2C contribute approx. 20% and 30% respectively to the total phosphatase activity against that site. Total phosphatase activity in the adipocyte extracts was 2-3-fold higher against site 2 than against site 1. The possible significance of these findings to the regulation of HSL activity in adipose tissue in vivo is discussed.