A survey of the contribution made by UK orchestras to the health and well-being sectors.

OBJECTIVE: To provide a comprehensive picture of the contribution that orchestras currently make in the public health sector. STUDY DESIGN: An online survey of member orchestras of the Association of British Orchestras. METHODS: Data gathered covered geographical, financial and musical aspects, the type of healthcare settings in which the work takes place, orchestras' motivation for their involvement in the healthcare sector, the role health and well-being delivery plays in their business models, and finally, the impact of COVID-19 on orchestras' current and future plans. RESULTS: Approximately half of UK orchestras are engaged significantly in the area of health and well-being in all four UK nations and a wide range of healthcare settings. There is a strong appetite to develop this work among those orchestras not yet involved. At the same time, the extent of this work is not formally recognised or paid for by the healthcare sector. CONCLUSIONS: While there is considerable unevenness in the provision, it is clear that UK professional orchestras made a significant contribution to the health and well-being sectors in hospitals and other healthcare settings. There is scope for a greater contribution by orchestras to the healthcare sector, which will require more formal recognition of the value of this work.

Improving transfusion practice: ongoing education and audit at two tertiary speciality hospitals in Western Australia.

BACKGROUND: Institutions undertaking transfusion have a responsibility to ensure safe and appropriate practice. The hospital transfusion committee (HTC) plays a major role in monitoring all aspects of transfusion. Dedicated staff with the responsibility of undertaking transfusion education and audit have been employed at many hospitals. The question is 'Do these positions improve practice?'. STUDY DESIGN AND METHODS: In 2005, a transfusion coordinator was employed by the King Edward Memorial Hospital (KEMH) and Princess Margaret Hospital (PMH) in Perth, Western Australia. After an initial audit to collect baseline data on transfusion documentation and compliance with national guidelines, a series of interventions was undertaken. In addition, the transfusion protocols were rewritten and published electronically. Further audits were undertaken in 2006, 2007 and 2009. RESULTS: Sequential audits show measured improvements in transfusion documentation. Baseline, hourly and completion observations are now correctly recorded in >94% of records at KEMH and >96% of records at PMH. Compliance with recording of 15 min observations has shown a 23% magnitude increase at KEMH and 36% at PMH. Compliance with recording of consent has increased by 20% at KEMH and 31% at PMH. Promotion of positive patient identification, when collecting specimens and administering blood, has been undertaken. CONCLUSION: The initiatives implemented by the transfusion coordinator and endorsed by the HTCs have improved the standard of transfusion documentation and practice at both institutions.

The development and implementation of an obstetric cell salvage service.

Cell salvage in obstetric haemorrhage is now endorsed by a number of organisations. Most of the literature has focused on isolated case series and safety. We describe how cell salvage, including a quality assurance process conducted prior to clinical implementation, was introduced to our stand-alone obstetric hospital which had no previous experience of this technique. An implementation committee was established and 25 quality assurance and familiarisation cases were initially conducted. As part of this process the alpha fetoprotein, haematocrit, free plasma haemoglobin, potassium and Kleihauer tests were performed when enough blood was available for processing. Our guidelines for clinical use included women at greatly increased risk of obstetric haemorrhage and women at increased risk of haemorrhage who refused traditional transfusion. After the successful completion of this process, cell salvage was signed off for clinical use in March 2007 and was used on 51 occasions between March 2007 and July 2009. Twenty-one patients had salvaged blood re-transfused and for seven patients this was their only red blood cell replacement. The median blood loss in patients re-transfused was 3000 ml (range <500 to 8500 ml), with the median volume re-transfused 359 mi (range 60 to 1300 ml). There was one episode of unexplained hypotension associated with administration of salvaged blood. We have successfully introduced obstetric cell salvage into clinical practice. A quality assurance process prior to implementation was beneficial for the staff involved. Despite targeting a high-risk obstetric population, our re-transfusion rates are approximately 40%. No serious adverse events have been recorded. We recommend that in units that already provide intraoperative cell salvage in a non-obstetric setting, extending the service into obstetric situations should be considered. Units that routinely care for high-risk obstetric patients should also consider the introduction of such a service. Post transfusion Kleihauer testing should be performed as soon as possible in Rhesus-negative mothers who deliver a Rhesus-positive foetus, so that appropriate anti-D prophylaxis can be administered.

Measurement of conformational changes in the structure of transglutaminase on binding calcium ions using optical evanescent dual polarisation interferometry.

The conformational changes occurring when the protein transglutaminase binds calcium ions have been studied using the optical evanescent technique of dual polarization interferometry (DPI) implemented via a dual slab waveguide structure. Immobilized transglutaminase layers of 4-5 nm in thickness were obtained, which when challenged with calcium ions underwent a contraction of approximately 0.5 nm (depending on the concentration of calcium) and an increase in refractive index of approximately 1 x 10-2. The affinity constant for the calcium binding was found to be in the range of 0.95 +/- 0.2 mM. The results reported are in good agreement with those found in the literature obtained by other techniques. It has also been shown that the structural changes occurring during the binding event are considerably larger than the mass changes that take place; thus, DPI offers a potentially valuable method to study real-time structural changes occurring to proteins when they bind metal ions.

Quantifying the effects of melittin on liposomes.

Melittin, the soluble peptide of bee venom, has been demonstrated to induce lysis of phospholipid liposomes. We have investigated the dependence of the lytic activity of melittin on lipid composition. The lysis of liposomes, measured by following their mass and dimensions when immobilised on a solid substrate, was close to zero when the negatively charged lipids phosphatidyl glycerol or phosphatidyl serine were used as the phospholipid component of the liposome. Whilst there was significant binding of melittin to the liposomes, there was little net change in their diameter with melittin binding reversed upon salt injection. For the zwitterionic phosphatidyl choline the lytic ability of melittin is dependent on the degree of acyl chain unsaturation, with melittin able to induce lysis of liposomes in the liquid crystalline state, whilst those in the gel state showed strong resistance to lysis. By directly measuring the dimensions and mass changes of liposomes on exposure to melittin using Dual Polarisation Interferometry, rather than following the florescence of entrapped dyes we attained further information about the initial stages of melittin binding to liposomes.

Temporal and spatial profiling of the modification of an electroactive polymeric interface using neutron reflectivity.

Electropolymerized films of the functionalized pyrrole, pentafluorophenyl-3-(pyrrol-1-yl)propionate (PFP), were reacted with a solution-phase nucleophile, ferrocene ethylamine. This reaction was chosen as a model representative of a postdeposition modification of the polymer membrane's properties. For the first time, a nondestructive method for direct chemical analysis of the reaction profile within the electrodeposited polymer membrane after nucleophilic substitution is presented. This was achieved through the application of in situ neutron reflectivity with supplementary analytical information concerning the film's chemical composition obtained from XPS, FT-IR, and electrochemical measurements. The results presented illustrate how, for a partially reacted film resulting from a short reaction time, the extent of reaction with ferrocene ethylamine is not homogeneous throughout the thickness of the film, but occurs predominantly at the polymer/solution interface. We show that the progress of the reaction within the polymer film is limited by the transport of reacting species in the dense regions of the membrane that are furthest from the solution interface. The data do not fit an alternative model in which there is spatially homogeneous progression of the reaction front throughout the bulk of the thin film polymer. Guided by the neutron reflectivity measurements, suitable modifications were made to the electrodeposition method to prepare films whose architecture resulted in faster rates of reaction.

Refractometric discrimination of void-space filling and swelling during vapour sorption in polymer films.

Thin polymeric films have been deposited as upper cladding layers on a new integrated optical interferometer fabricated from layers of silicon oxynitride on a silicon wafer. The evanescent field of the probing waveguide mode transduces refractive index changes in the polymer layer into the measured phase changes in the device. Real-time measurement of index change and its sign is obtained. Upon exposure to humid air, we record water sorption by films of poly(vinyl pyrrolidone) by a rapid positive index change for void-space filling followed by a slow negative index change for swelling. Sorption of water vapor into a thin film of the viscous liquid polymer polyethylenimine shows only swelling mode behaviour and a simple constitutive model can be applied to give the fractional water occupied volume.

Uncemented total hip arthroplasty in young patients with juvenile chronic arthritis.

The hip joint is commonly affected in juvenile chronic arthritis (JCA) and involvement is usually bilateral. It is well established that the involvement of the hip in JCA is the most important reason that the patient will lose independence and mobility. The positive gains, both in terms of hip function and the overall functional capability, of the patients of JCA after hip replacement have been shown by several studies. There have been many reports regarding cemented total hip replacement in young patients with JCA. The short-term results have been excellent, but failure rates were considerably higher with further follow-up. To our knowledge there have been no other reports to date of the results of cementless arthroplasty of the hip in this condition. We reviewed the results of 25 primary uncemented total hip replacements (THR) in 16 patients with JCA. The mean postoperative follow-up time was 4.5 years (range 1-19 years). The clinical results were evaluated using the modified Harris hip score. The functional outcome was assessed by a scoring system described by Witt et al. The most significant long-term problem was acetabular loosening (12%) in our series.

Brain nucleic acid composition and fractional rates of protein synthesis in response to chronic ethanol feeding: comparison with skeletal muscle.

Brain atrophy is a common feature of chronic alcohol misuse, although the pathogenic mechanisms are unknown. We propose that defects in protein synthesis are contributing events. To test this hypothesis the experimental effects of chronic (i.e., 2 and 3 weeks) ethanol feeding on brain nucleic acid composition and rates of protein synthesis in vivo were investigated. These were compared with those of skeletal muscle (represented by the plantaris). Male Wistar rats, used at mean body weights of either 82 g (first study for 2 weeks ) or 93 g (second study for 3 weeks) were fed a nutritionally complete liquid diet in which ethanol comprised a third of the total calories. Control rats were pair-fed identical amounts of the same diet, in which ethanol was substituted by isoenergetic glucose. At 2 weeks there were small reductions (i.e., approximately 5-10%) in the weight of the whole brain, cortex, and brain stem. Ethanol-induced reductions in the total protein content of the brain stem was found at 2 weeks, although these changes did not achieve significance. At 3 weeks the weights of whole brain were significantly reduced compared to a greater reduction in skeletal muscle weights. Total protein contents were reduced at 3 weeks in the whole brain and skeletal muscle. At 2 weeks there were decreases in the RNA contents of the cortex, brain stem, and entire brain. There were also reductions in cerebellum RNA composition only when expressed relative to DNA. The DNA composition of the brain was relatively unaffected by chronic ethanol feeding. At 3 weeks, total RNA and DNA were reduced in the whole brain and muscle. Fractional rates of protein synthesis (i.e., the percentage of tissue protein pool renewed each day) in the brain were unaltered after 3 weeks of ethanol feeding, but were reduced in skeletal muscles, largely as a consequence of reduced RNA composition. In conclusion, only moderate changes in the brain were found in ethanol feeding. These data can be compared to skeletal muscle, which shows that ethanol induces profound reductions in protein, RNA, and protein synthesis rates.

Lysosomal and nonlysosomal protease activities of the brain in response to ethanol feeding.

The contribution of impaired degradative processes to the cellular changes occurring in the brain as a consequence of chronic ethanol exposure was assessed. Male Wistar rats were fed nutritionally adequate liquid diets containing ethanol as 35% of total dietary calories. Controls were pair-fed identical amounts of the same diet in which ethanol was replaced by isocaloric glucose. The results showed that at the end of 3 weeks the activities of neutral protease (nonlysosomal) and cathepsin D (lysosomal) were unaltered. However, there were significant elevations in the activities of the lysosomal enzyme cathepsin B, regardless of whether the activities were expressed relative to wet weight ( p = 0.005), protein (p = 0.006), or DNA (p = 0.045). In addition, we showed that the activities of cathepsin B were not significantly affected by additions of carnosine or acetaldehyde, in vitro. However, neutral protease activities were increased by carnosine additions in vitro. We conclude that selective alterations in brain protease activities may be contributing factors in the genesis of alcoholic brain disorders.

Hepatitis A immunization in HIV-infected haemophilic patients.

Forty-seven HIV-infected haemophilic patients were entered into a hepatitis A vaccination programme. 10 patients (21%) were lgG seropositive for hepatitis A consistent with past exposure. Of the 37 patients offered vaccination, one refused and 31 completed the vaccination course, 17/13 (55%) seroconverted, nine after the second and eight after the third injection, and 14 patients failed to seroconvert. The CD4 lymphocyte counts immediately prior to vaccination were significantly higher in the patients who developed immunity compared to the nonresponders (median CD4 count in the immune group 380 × 10(6) /1 (range 170-1290), median CD4 count in nonimmune group 110 × 10(6) /1 (range 10-590), P== 0.003). No patient with a CD4 count < 170 × 10(6) /1 seroconverted and five patients with well-preserved CD4 counts also failed to seroconvert. We conclude that HIV-infected haemophilic patients, especially those with more advanced disease, have an impaired response to hepatitis A vaccination. Due to the likely failure of response in patients with CD4 counts < 150 × 10(6) /1, it is reasonable not to include these patients in a hepatitis A vaccination programme.

Total hip replacement for juvenile chronic arthritis.

We review the results of 96 primary total hip replacements in 54 patients with juvenile chronic arthritis at five years or longer after surgery. The mean age at operation was 16.7 years (range 11.25 to 26.6); the follow-up period averaged 11.5 years. The clinical results in terms of pain, range of movement, mobility and function are presented. A revision procedure was required in 24 hips (25%) in 18 patients at an average of 9.5 years after the primary operation. A further 17 hips had radiographic signs of loosening. The factors thought to contribute to this relatively high failure rate in patients with juvenile chronic arthritis are discussed.

Metal wear and tissue response in failed titanium alloy total hip replacements.

Thirteen total hip replacements with titanium alloy femoral components required revision for loosening at an average of two years after implantation. At revision the soft tissues around the implant were darkly stained and a proliferative membrane had invaded the cement-bone interface. The femoral components showed polishing of parts of their shot-blasted surfaces. Histology showed a fibroblastic reaction with abundant titanium lying free and within histiocytes, and a scanty foreign-body giant-cell reaction. Surface analysis of the removed femoral components and chemical analysis of the excised tissues is described. Tissue reaction in response to the metal-wear debris may have contributed to the early failure of these implants.

A comparison of postoperative analgesia provided by wound infiltration or caudal analgesia.

A prospective randomised study was performed to compare postoperative analgesia produced by caudal block with that of local wound infiltration in 54 children following unilateral inguinal herniotomy. There was no statistically significant difference in the analgesia produced by these two methods. The requirement for additional postoperative analgesia and the incidence of side-effects was similar in the two groups.

The surgery of juvenile chronic arthritis. An overview.

Surgery now has a well-established place in the management of childhood arthritis. However, satisfactory results can only be achieved by a team of medical experts composed of a pediatric rheumatologist, an orthopedic surgeon, an anesthetist, a physiotherapist, and others who are knowledgeable about the particular problems of juvenile chronic arthritis. An aggressive team approach offers the best available help.

Soft-tissue release of the knee in children with juvenile chronic arthritis.

We report the results of 23 soft-tissue release procedures in 15 patients who had juvenile chronic arthritis. The operation, which includes hamstring tenotomies and posterior capsulotomy, is a safe and effective way of eliminating contracture, relieving pain and improving function.

Juvenile chronic arthritis.

Juvenile chronic arthritis is a heterogenous group of diseases in which the common denominator is a persistent arthritis in one or more joints commencing before the age of 16 and lasting three months or more. The care of these patients by a pediatric rheumatologist, an orthopedic surgeon, and a full rehabilitation team must be combined to afford the best treatment. Medication, splintage, and physiotherapy are useful in helping to suppress and reduce the effects of the disease, but in some patients arthritis attacks in acute episodes, while in others arthritis chronically and relentlessly pursues its destructive course. Surgical treatment, particularly of the soft parts, has a considerable part to play in correcting deformity, maintaining movement, and relieving pain. Timely surgical treatment may also serve to prevent deformity and to maintain function as well as muscle strength so that by the time the child becomes an adult he can lead a normal life. The plan of treatment is thus long range.