'Closing the loop': re-audit of the diagnosis and management of vitamin B12 deficiency in general practice.

INTRODUCTION: Vitamin B12 deficiency is common in Ireland, The Irish Longitudinal Study on Aging (TILDA) survey indicates 12% of over 50s in Ireland are low or deficient. The condition is commonly managed exclusively in general practice. AIM: The intention of this audit was to establish whether B12 deficiency is diagnosed correctly and whether there was over-treatment of patients. METHODS: The audit was conducted in an urban general practice in midwest Ireland. The primary limitation was the low number of patients. Thirty-five patients were included after practice database searches. An initial audit was performed which compared with the standard, Royal University of Bath: 'Guidelines for the Investigation & Management of B12 deficiency'. RESULTS: The recommendations from this audit were to complete follow-on investigations and to switch over patients from IM to oral replacement. Twenty-one patients were then recalled, and investigations were performed. Ten patients were then switched from IM replacement to oral therapy. A re-audit was then completed. The re-audit showed marked improvement in compliance, from 17% (n = 6) to 83% (n = 29). The reduction in patients on IM therapy will decrease practice burden, with an annual reduction of nurse consultations by 46, representing a 30% decrease in nurse consultations for IM vitamin B12. This equates to an annual cost reduction of €1,340. CONCLUSION: This closed loop audit demonstrated that there was over treatment and under investigation of patients with B12 deficiency in general practice and that auditing of this process could both reduce risk for patients and save money and time.

Reduction and alkylation of proteins in preparation of two-dimensional map analysis: why, when, and how?

The standard procedure adopted up to the present in proteome analysis calls for just reduction prior to the isoelectric focusing/immobilized pH gradient (IEF/IPG) step, followed by a second reduction/alkylation step in between the first and second dimension, in preparation for the sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) step. This protocol is far from being optimal. It is here demonstrated, by matrix assisted laser desorption/ionization-time of flight (MALDI-TOF)-mass spectrometry, that failure to reduce and alkylate proteins prior to any electrophoretic step (including the first dimension) results in a large number of spurious spots in the alkaline pH region, due to "scrambled" disulfide bridges among like and unlike chains. This series of artefactual spots comprises not only dimers, but an impressive series of oligomers (up to nonamers) in the case of simple polypeptides such as the human alpha- and beta-globin chains, which possess only one (alpha-) or two (beta-) -SH groups. As a result, misplaced spots are to be found in the resulting two-dimensional (2-D) map, if performed with the wrong protocol. The number of such artefactual spots can be impressively large. In the case of analysis of complex samples, such as human plasma, it is additionally shown that failure to alkylate proteins results in a substantial loss of spots in the alkaline gel region, possibly due to the fact that these proteins, at their pI, regenerate their disulfide bridges with concomitant formation of macroaggregates which become entangled with and trapped within the polyacrylamide gel fibers. This strongly quenches their transfer in the subsequent SDS-PAGE step.

Two cases of thyroid cancer in a small workforce.

In 1994, in a large parcel depot in the north of England employing 600 staff and 24 electrical and mechanical engineers, two engineers developed papillary cell carcinoma of the thyroid in the same year. A comprehensive review of the literature revealed that ionizing radiation is the only known direct cause of this disease. There was speculation that air filter changing undertaken by the two men affected, shortly after the Chernobyl accident in 1986, may have exposed them to concentrated radioactive fallout. A radiation survey of the parcel depot was undertaken and revealed no evidence of abnormal radioactivity. A total of 27 past and present engineering staff were screened for thyroid cancer. No cases of thyroid cancer were found. Investigation of clusters of rare disease in the occupational setting is indicated mainly in order to address the concerns of the workforce. Nevertheless, investigation is warranted, especially when the aetiology of a disease is poorly understood. It would be prudent for doctors, in whatever speciality, to take an occupational history from individuals who develop thyroid cancer.

Variations between rheumatologists in using sulphasalazine.

The increased use of audit and resource management within the health service will focus attention on variations in clinical practice. We have looked at one rheumatological example; the extent rheumatologists vary in their clinical use of a slow-acting anti-inflammatory drug. We studied a single drug - sulphasalazine. In a prospective study sulphasalazine was given to 298 rheumatoid patients at 24 rheumatology centres in South East England. They were followed for 6 months. There were large differences between centres in: the types of patient started on therapy; the numbers of patients remaining on treatment; the responses after 6 months. The difference between some centres was more marked than the expected improvement in clinical and laboratory variables given by sulphasalazine. The use of a slow acting anti-rheumatic drug like sulphasalazine in rheumatoid arthritis is agreed by most rheumatologists in the UK and yet there are wide variations in its use. Our results question the validity of comparing clinical practice and associated costs between centres for even a simple clinical procedure.

Tolerability of enteric-coated sulphasalazine in rheumatoid arthritis: results of a co-operating clinics study.

One thousand three hundred and eighty-two patients with rheumatoid arthritis requiring second-line therapy at 108 centres were entered into an open 6-months prospective tolerability study of enteric-coated sulphasalazine 2 g/day (Salazopyrin EN-tabs). Clinical and laboratory variables were measured, any adverse reactions and the reasons for withdrawal of medication were recorded. The outcome of therapy was known in 87.5% of patients entered of whom 65% continued with sulphasalazine beyond the 6-month study period. 3.2% withdrew for reasons unrelated to treatment, 5% for lack of effect and 26.8% due to an adverse event; gastrointestinal/central nervous 66.6%, rash 15.4%, haematological 5.1%, hepatic 4.7% and miscellaneous 8.1%. 1.2% of patients experienced potentially serious reactions: anaphylactic, haematological and hepatic. The majority of adverse events occurred early and were reversible upon cessation of medication. No clear relationship between withdrawal due to an adverse event attributed to sulphasalazine and the nature of the concomitant non-steroidal anti-inflammatory drug was identified.

Intussusception--current trends in management.

Barium enema reductions were attempted in 65 (90%) of 72 intussusceptions, of which 51 (79%) were successful. This represents a success rate of 70% overall. The average hospital stay was 3 1/2 days. There was no mortality and, apart from a recurrence rate of 10%, no morbidity. It is suggested that barium enema reduction should be the treatment of choice provided that there is an emergency service of a paediatric radiologist and the patient is adequately resuscitated, the only absolute contraindication being evidence of pneumatosis intestinalis or peritonitis. Those patients who presented with shock, rectal bleeding, duration of symptoms longer than 48 hours, and pronounced degree of bowel obstruction had a higher rate of unsuccessful reduction. However, only the last two were significant. Further, provided that the clinical condition remains satisfactory and the reduction has been achieved to the caecum a repeat barium enema after some hours may be successful in achieving reflux of contrast into the ileum, confirming complete reduction.

Sexually transmitted diseases as seen by general practitioners in Ireland: use of a telephone survey.

A telephone survey of one of every five general practitioners in the Republic of Ireland was carried out in July 1978 for the purpose of establishing the frequency of diagnosis of venereal diseases during the preceding year. In addition, information was obtained on the subsequent management of the diseases. This type of survey was found to be economical and quick, and the response rate (98.6%) was excellent. The national frequency of diagnosis (per 100,000 population) was estimated from the sample to be 7.7 for syphilis, 97 for gonorrhea, and 2,000 for nonspecific venereal diseases. The rates of reporting of these diseases were less than or equal to 24.3%, 9.8%, and 3.1%, respectively, of the estimated frequencies. Sixty-nine percent of the general practitioners treated the patients themselves; 51% treated on the basis of clinical diagnosis alone.

Incorporation of [2(14)C]malonyl CoA into fatty acids by a cell-free extract of Catharanthus roseus suspension culture cells.

A cell-free extract containing the enzymes for de-novo synthesis, elongation and desaturation of fatty acids was prepared from cultured cells of Catharanthus roseus G. Don. (14)C-Fatty acids synthesized by the extract from [2-(14)C]malonyl CoA substrate were palmitic (16:0), stearic (18:0) and oleic (18:1). Dialyzed extract was active and stable at room temperature and at 4° C, but was inactivated on boiling. There was an absolute requirement for NADPH for incorporation of [2-(14)C]malonyl CoA into total fatty acids. Escherichia coli acyl carrier protein stimulated total fatty-acid synthesis without affecting the relative ratio of individual fatty acids. Total fatty-acid synthesis at a rate of 45 nmol·mg(-1) protein·h(-1) occurred at a substrate level of 73 µM malonyl CoA, cofactor levels of 500 µM NADPH, 30 µg·ml(-1) E. coli ACP, and 1.0 mg·ml(-1) extract protein. Total fatty acid synthesis was also sensitive to cerulenin and CoA levels. Variations in the relative abundance of individual (14)C-fatty acids were regulated by concentrations of [(14)C]malonyl CoA. NADPH and ferredoxin, as well as by pH, temperature and length of incubation. Fatty-acid synthetase enzymes responsible for [(14)C]palmitic acid were rapidly saturated at a low substrate level (0.3 µM malonyl CoA). Increasing the level of [2-(14)C]malonyl CoA permitted further synthesis of [(14)C]stearate and [(14)C]oleate. Desaturation of [(14)C]stearate to [(14)C]oleate was stimulated by increasing the levels of NADPH and ferredoxin. The desaturase and elongase enzymes were sensitive to acidic pH. The desaturase was also unstable at 41° C, although fatty acid synthetase and elongase were unaffected by this temperature.

Fatty-acid composition and biosynthesis in cell suspension cultures of Glycine max (L.) Merr., Catharanthus roseus G. Don and Nicotiana tabacum L.

The fatty-acid composition of C. roseus and N. tabacum cell suspension cultures was unaffected by subculture on Wood and Braun, Murashige and Skoog, or Gamborg B5C media. However, placing the cultures - which were normally grown at 25° C - at 15° C reduced growth but resulted in enhanced formation of oleic and linolenic acids in C. roseus cultures and increased levels of linoleic and linolenic acids in cultures of G. max and N. tabacum, respectively. The incorporation of [(14)C]acetate into [(14)C]linoleic acid was more rapid in N. tabacum cells than in G. max cells, but was very poor in C. roseus where the [(14)C] label was distributed mainly between palmitic and oleic acids.

The effect of different temperatures on fatty-acid synthesis and polyunsaturation in cell suspension cultures.

Cell suspension cultures of Catharanthus roseus G. Don, Glycine max (L.) Merr. and Nicotiana tabacum L. were incubated with [(14)C]acetate, [(14)C]oleic acid and [(14)C]linoleic acid at five different temperatures ranging from 15 to 35° C. When the incubation temperature was increased, [(14)C]acetate was incorporated preferentially into [(14)C]palmitate, with a concomitant drop in [(14)C]oleate formation. Between 15 and 20° C, [(14)C]oleic acid accumulated in C. roseus cells. In all cultures, optimum desaturation of [(14)C]oleic acid to [(14)C]linoleic acid occurred between 20 and 25° C, and in G. max this was also the optimal range for desaturation of [(14)C]linoleic acid to [(14)C]linolenic acid. Elongation of [(14)C]palmitic acid was inhibited when cultures grown at 15° C for 25 h were subsequently incubated with [(14)C]acetate at 25° C. [(14)C]oleic acid accumulated in G. max and C. roseus cultures grown at 35° C for 25 h and subsequently incubated at 25° C. Desaturation of [(14)C]oleic acid increased up to 25° C, but then decreased or leveled off depending on the cell line and on the temperature prior to incubation.

Phalangeal microgeodic syndrome of infancy.

A case is described of chilblain-like lesions in the fingers with punched-out erosions in the phalanges on x-ray which appears to be an example of Maroteaux's phalangeal microgeodic syndrome of infancy.

Apparatus for patient-controlled administration of intravenous narcotics during labour.

The intermittent intravenous administration of narcotic analgesics had advantages over intramuscular administration, but is often impracticable. The design of a prototype apparatus is described, from which analgesic, pethidine, can be self-administered intravenously during labour. The apparatus consists of a syringe pump and control system from which the patient can demand an increment of analgesic. The minimum interval between increments and the dose of the increment are preset. A demand for analgesia is only successful when the patient passes a reaction-time test, subsequently modified. The apparatus has been used by forty-two mothers in labour. The mean total dose self-administered (2.2 mg/kg) was well within the prescribed limits, suggesting that mothers regulated their demand. The apparatus appears acceptable and safe in labour. The apparatus will probably be of value in comparative studies of analgesics.

Effects of cation levels of the nutrient medium on the biochemistry of chlorella: I. Concentration series.

The effects of variations in nutrient cation levels on the growth and biochemistry of Chlorella were investigated. This study involved concentration-series experiments in which the levels of Mg(2+), K(+), and Ca(2+) varied from deficiency to toxicity levels for growth. The nutrient sufficiency concentrations of Mg(2+) and K(+) were 0.08 and 0.10 meq/1, respectively. Deficiencies of Mg(2+) or K(+) reduced the growth rate, as well as cellular total nitrogen and unsaturated fatty acid levels. K(+) deficiency increased total lipid levels, while total fatty acids were unaffected. Increasing Mg(2+) or K(+) concentrations in the nutrient media were accompanied by corresponding increases in growth rate and certain biochemical fractions. Calcium was without effect except at a toxicity level. Cellular sufficiency concentrations for Mg(2+) and K(+) were 0.3 and 1.2% of the dry weight, respectively.

Effects of Cation Levels of the Nutrient Medium on the Biochemistry of Chlorella: II. Factorial Experiment.

A factorial experiment was designed to study the effects of Mg(2+), K(+), and Na(+) on the growth and biochemistry of Chlorella sorokiniana. Raising Mg(2+) or K(+) concentration in the nutrient medium increased growth rates as well as total N levels and Mg(2+) and K(+) accumulation by the cells. The total N effect was Mg(2+)-dependent-if Mg(2+) was below a certain level in the medium-increasing the K(+) concentration did not raise the total N level of cells. Low nutrient levels of K(+) decreased the levels of unsaturated fatty acids (especially 18:1 and 18:3), while increasing the levels of palmitic acid (16:0), total fatty acids, and total lipid. Increasing nutrient K(+) concentrations were accompanied by increases in levels of some unsaturated fatty acids, with a concomitant reduction in 16:0, total fatty acids and total lipid. Low Mg(2+) levels in the nutrient medium reduced the cellular levels of palmitic acid, total fatty acids, total lipid, and certain unsaturated fatty acids (though this last effect also depended on the nutrient level of K(+)). These relationships indicate that Mg(2+) may be important in the initial steps of fatty acid synthesis, whereas K(+) may be necessary for the formation of certain unsaturated fatty acids. Variations in Na(+) concentration did not have any significant effect on the growth and biochemistry of C. sorokiniana.