The PTS(Ntr) system globally regulates ATP-dependent transporters in Rhizobium leguminosarum.

Mutation of ptsP encoding EI(Ntr) of the PTS(Ntr) system in Rhizobium leguminosarum strain Rlv3841 caused a pleiotropic phenotype as observed with many bacteria. The mutant formed dry colonies and grew poorly on organic nitrogen or dicarboxylates. Most strikingly the ptsP mutant had low activity of a broad range of ATP-dependent ABC transporters. This lack of activation, which occurred post-translationally, may explain many of the pleiotropic effects. In contrast proton-coupled transport systems were not inhibited in a ptsP mutant. Regulation by PtsP also involves two copies of ptsN that code for EIIA(Ntr) , resulting in a phosphorylation cascade. As in Escherichia coli, the Rlv3841 PTS(Ntr) system also regulates K(+) homeostasis by transcriptional activation of the high-affinity ATP-dependent K(+) transporter KdpABC. This involves direct interaction of a two-component sensor regulator pair KdpDE with unphosphorylated EIIA(Ntr) . Critically, ptsP mutants, which cannot phosphorylate PtsN1 or PtsN2, had a fully activated KdpABC transporter. This is the opposite pattern from that observed with ABC transporters which apparently require phosphorylation of PtsN. These results suggest that ATP-dependent transport might be regulated via PTS(Ntr) responding to the cellular energy charge. ABC transport may be inactivated at low energy charge, conserving ATP for essential processes including K(+) homeostasis.

Mutation of GOGAT prevents pea bacteroid formation and N2 fixation by globally downregulating transport of organic nitrogen sources.

Mutation of gltB (encoding glutamate oxoglutarate amidotransferase or GOGAT) in RU2307 increased the intracellular Gln:Glu ratio and inhibited amino acid transport via Aap and Bra. The mechanism probably involves global post-translational inhibition independent of Ntr. Transport was separately restored by increased gene expression of Aap or heterologous transporters. Likewise, second site suppressor mutations in the RNA chaperone Hfq elevated transport by Aap and Bra by increasing mRNA levels. Microarrays showed Hfq regulates 34 ABC transporter genes, including aap, bra and opp. The genes coding for integral membrane proteins and ABC subunits aapQMP braDEFGC were more strongly elevated in the hfq mutants than solute-binding proteins (aapJ braC). aapQMP and braDEFG are immediately downstream of stem-loops, indicating Hfq attenuates downstream translation and stability of mRNA, explaining differential expression of ABC genes. RU2307 nodulated peas and bacteria grew down infection threads, but bacteroid development was arrested and N(2) was not fixed. This probably results from an inability to synthesize or transport amino acids. However, GOGAT and GOGAT/AldA double mutants carrying suppressor mutations that increased amino acid uptake fixed N(2) on pea plants. Thus de novo ammonium assimilation into amino acids is unnecessary in bacteroids demonstrating sufficient amino acids are supplied by plants.

Psychological distress and concerns of elderly patients treated with palliative radiotherapy for lung cancer.

We conducted a prospective observational cohort study of 83 elderly patients (aged 75 and above) being treated with palliative radiotherapy for lung cancer, with a comparison group of 49 younger patients (aged 65 and under). Psychological distress and concerns were measured before and after treatment using the Hospital Anxiety and Depression Scale (HADS) and a Concerns Checklist. Psychosocial morbidity was common, however, prevalence was similar in both age groups. There was a trend towards worsening of both anxiety and depression scores after treatment, but this did not reach statistical significance. Younger patients reported more concerns than the older group (median 12 vs 10) but this too was not statistically significant. Concerns about the illness and symptoms were more likely to have been addressed by the care team than were concerns about psychosocial issues such as the family and the future. People of all ages have similar concerns and levels of anxiety and depression whilst receiving palliative radiotherapy for lung cancer. Further research is needed to explore the use of screening tools, like those used in this study, to identify patients' difficulties and target interventions to improve their quality of life.

Do elderly people with lung cancer benefit from palliative radiotherapy?

The median age at diagnosis of patients with lung cancer is currently around 70 and is rising, yet the trials on which treatment is based included few elderly people. We conducted a prospective observational cohort study of 83 elderly patients (aged 75 and above) being treated with palliative radiotherapy for lung cancer, with a comparison group of 49 younger patients (aged 65 and under). Response to treatment was evaluated by patient-assessed symptom and quality of life scores using the EORTC QLQ-C30 and its companion lung module LC17. This is to date the largest prospective study of elderly lung cancer patients in routine practice. We found no significant differences in response or toxicity between the two groups. Elderly people with lung cancer should be offered palliative radiotherapy the same as younger patients, with the same expectation of benefit.

A migrating pacemaker.

A deceased 79 year old man with a permanent cardiac pacemaker was due to be cremated, but the pacemaker generator was not detectable by palpation. A hand held metal detector to locate the device so that it could be extracted before cremation.

History of the development of geriatric medicine in the UK.

In this review the development of the specialty of geriatric medicine in the UK is traced from its humble beginnings. Elderly medicine is now thriving and represents the largest group of physician members of the Royal Colleges of Physicians. Geriatric medicine is essentially about optimising the care and wellbeing of older people. A key component of this is teamwork. A successful service for old people depends on the skills of many people, including nurses, therapists, social workers, and others. The contributions made by nurses and other professionals have been immense, but space does not permit a historical review of their important role.

The development of a method for functional assessment of dentures.

AIMS: To design and validate a method of assessing complete dentures from a functional standpoint. SUBJECTS: A random sample of 40 complete denture wearers took part in the study. SETTING: A university clinical department of prosthetic dentistry. INTERVENTION: We undertook a pilot study to refine the protocol and criteria. All participants and their dentures were examined by two authors independently, with no prior knowledge of the patients' complaints. DESIGN: We defined nine clinical factors of functional quality and applied criteria with binary scoring. We analysed the scores for these factors for inter-rater reliability. RESULTS: The method proved simple to apply and took less than 5 minutes to complete. The inter-examiner agreement for all factors was 86% to 100% giving Kappa scores of 0.64 to 1.00 (all Good or Very Good). CONCLUSIONS: This study successfully demonstrates that the technique, which we call the Functional Assessment of Dentures (FAD), can give good inter-examiner reliability. It can therefore be used separately as a routine diagnostic tool and to investigate the relationship between denture qualities and functional 'outcome' such as difficulty eating or dietary selection.

The palmomental reflex: a useful clinical sign?

The palmomental reflex, an involuntary contraction of the mentalis muscle of the chin caused by stimulation of the thenar eminence, can be tested easily and rapidly. Its presence may alert the clinician to the possibility of cerebral pathology. However, the reflex is often present in normal people and may be absent in disease states. Testing merely for the presence or absence of the reflex therefore lacks both specificity and sensitivity. A strong, sustained, and easily repeatable contraction of the mentalis muscle, which can be elicited by stimulation of areas other than the palm, is more likely to indicate cerebral damage.

Too many pre-discharge home assessment visits for older patients? A postal questionnaire survey.

OBJECTIVE: To investigate current practice of pre-discharge home assessment visits for older patients. DESIGN: Postal questionnaire survey. SETTING: NHS Trust hospitals in the United Kingdom. SUBJECTS: Occupational therapy departments in 265 NHS Trust hospitals which admit acutely ill older patients. MAIN OUTCOME MEASURES: The number of pre-discharge home visits done, who went, and therapy time spent on home visits. RESULTS: Of 265 NHS Trusts contacted, 239 (90%) replied. Of 238 units, 155 (65%) do between 11 and 40 visits per month, with 25 (11%) doing more than 60. The equivalent of one day per week or more is spent doing home visits by Senior I occupational therapists in 107 (45%) units and by Senior II staff in 126 (53%) units. Carers or relatives, unqualified occupational therapists, social workers and home care managers accompany the patient and occupational therapist on most home visits. CONCLUSION: Therapy perception is that pre-discharge home assessment visits are increasing in number, complexity and involvement of professional time despite little evidence for their effectiveness. Controlled trials are required to assess which patients are likely to benefit.

Why do so few older people with aortic stenosis have valve replacement surgery?

BACKGROUND: Many older patients with severe aortic stenosis do not have valve replacement surgery. OBJECTIVE: To determine the proportion of older people with symptomatic aortic stenosis referred for specialist assessment and the reasons for non-referral. METHODS: Retrospective study of all patients over 75 attending the geriatric department of an English teaching hospital. Confirmation was by reviewing all echocardiographic reports. RESULTS: Of 40 patients with symptomatic aortic stenosis, only four had undergone surgery. Seven patients refused operation; five were medically unfit (for reasons other than heart failure) and reasons for not referring could not be found in 13 casenotes. Of the 15 patients referred to a cardiologist, eight were considered suitable for surgery. CONCLUSION: Only one in five patients over 75 with echocardiographically-confirmed aortic stenosis was considered for surgery. Prospective studies are needed to determine why patients and geriatricians do not seek specialist assessment for this treatable condition.

The effectiveness of predischarge home assessment visits: a systematic review.

OBJECTIVE: To evaluate the effectiveness of predischarge home assessment visits for elderly patients. DESIGN: Systematic review. METHODS: A computer-aided search was conducted using the databases of Medline and Cinahl. Any studies investigating predischarge home assessment visits were included in the analysis. RESULTS: No randomized controlled trials were found. Only five studies (two retrospective surveys, three observational surveys) were identified. In four of these, a possible benefit for home visiting was suggested. CONCLUSIONS: Little evidence exists for the effectiveness of predischarge home assessment visits. Further research is needed to establish their value.

Now wash your hands? A survey of hospital handwashing facilities.

We studied the adequacy of handwashing facilities on elderly-care wards in seven UK hospitals. We found 10.9% of sinks were inaccessible, 12% of sinks did not have any cleansing agent, 93.2% of ward sinks and 79% of treatment room sinks had no antiseptic agent. We conclude that in our survey, handwashing facilities were inadequate and have suggested a standard checklist for hospital sinks.

Is the Barthel Scale appropriate in non-industrialized countries? A view of rural Pakistan.

PURPOSE: To determine if the Barthel Index, a conventional scale for assessing disability, is appropriate for stroke patients in rural Pakistan, rather than an observational study by visiting stroke patients in their homes. METHOD: Stroke patients attending hospital out patient clinics in Islamabad, together with others identified in local villages, were assessed to test the validity of the Barthel Activities of Daily Living Scale. RESULT: For each item on the disability scale, differences in local customs, lifestyle and architecture meant that the Barthel Scale was not appropriate in rural Pakistan. CONCLUSIONS: There is unlikely to be a disability scale which can be applicable universally. Care must be taken when standard scales are used for international comparisons of stroke disability.