Four years of monitoring for viral haemorrhagic septicaemia virus in marine waters around the United Kingdom.

Between 1995 and 1998, marine fish from around the coast of the UK were collected and samples analysed for viral haemorrhagic septicaemia virus (VHSV) using cell culture isolation methods. In 1997 and 1998 the samples were also analysed for VHSV by reverse transcription PCR (RT-PCR). A total of 1867 fish of 11 species were tested, but VHSV was isolated on only 1 occasion, from herring Clupea harengus, in 1996. However, despite VHSV not being isolated in 1997 and 1998, in both years samples of herring from the west and south coasts of England produced positive signals in the RT-PCR, and in 1997 cod from the east coast of England also produced positive signals in the RT-PCR. These results are believed to be true indications of the presence of VHSV nucleic acid in the fish. In 1997, birnaviruses from Serogroup B1 were isolated from herring (a previously unrecorded host for the virus) and cod Gadus morhua, and a birnavirus from Serogroup A2 was also isolated from cod. In 1998, an aquareovirus was isolated from haddock Melanogrammus aeglefinus, a previously unrecorded host for the virus.

Remifentanil by patient-controlled analgesia compared with intramuscular meperidine for pain relief in labour.

BACKGROUND: The pharmacokinetics of remifentanil suggests that it may be suitable for analgesia during labour. METHODS: In an open pilot study, 36 women requesting meperidine for analgesia were recruited early in labour and randomized to receive either meperidine i.m. or remifentanil given as patient-controlled analgesia (PCA). Pain severity, sedation and anxiety were assessed with visual analogue scales and overall effective analgesia was assessed by the woman and midwife. RESULTS: The pain scores were lower in the remifentanil group: median pain score at 60 min was 72 mm for meperidine and 48 mm for remifentanil (P=0.004) and median maximum pain score during the first 2 h was 82.5 mm for the meperidine group and 66.5 mm for the remifentanil group (P=0.009). Both the midwives' and the women's assessments of overall effective analgesia were higher in the remifentanil group [Likert scale (5 = excellent to 1 = poor): chi2=12.10, P=0.002 for mothers' assessment; chi2=12.80, P=0.002 for midwives' assessment]. CONCLUSION: In this pilot study, remifentanil by PCA gave better pain relief to mothers in labour than intramuscular meperidine. However, remifentanil is a potent respiratory depressant and adequate continuous monitoring is necessary.

Maternal cardiovascular consequences of positioning after spinal anaesthesia for Caesarean section: left 15 degree table tilt vs. left lateral.

Sixty healthy women undergoing elective Caesarean section were randomly allocated to either a measured 15 degrees left table tilt position (n = 31) or full left lateral position (n = 29) for a 15-min period after spinal blockade. Arm and leg blood pressure, ephedrine requirements, symptoms, fetal heart rate, cord gases and Apgar scores were recorded. Mean ephedrine requirements and incidence of hypotension were similar in the two groups. Arm systolic arterial pressure over time was similar in both groups, but leg systolic arterial pressure over time was significantly lower in the tilt group (p < 0.001); the mean leg systolic arterial pressure was lower for all 15 sequential recordings in the tilt group, reaching statistical significance (p < 0.05) at 4, 5, 6 and 8 min. Differences in maternal nausea, vomiting and bradycardia and fetal outcome were not statistically significant. Following spinal anaesthesia, even a true 15 degrees left table tilt position is associated with aortic compression.

Intrauterine resuscitation: active management of fetal distress.

Acute fetal distress in labour is a condition of progressive fetal asphyxia with hypoxia and acidosis. It is usually diagnosed by finding characteristic features in the fetal heart rate pattern, wherever possible supported by fetal scalp pH measurement. Intrauterine resuscitation consists of applying specific measures with the aim of increasing oxygen delivery to the placenta and umbilical blood flow, in order to reverse hypoxia and acidosis. These measures include initial left lateral recumbent positioning followed by right lateral or knee-elbow if necessary, rapid intravenous infusion of a litre of non-glucose crystalloid, maternal oxygen administration at the highest practical inspired percentage, inhibition of uterine contractions usually with subcutaneous or intravenous terbutaline 250 microg, and intra-amniotic infusion of warmed crystalloid solution. Specific manoeuvres for umbilical cord prolapse are also described. Intrauterine resuscitation may be used as part of the obstetric management of labour, while preparing for caesarean delivery for fetal distress, or at the time of establishment of regional analgesia during labour in the compromised fetus. The principles may also be applied during inter-hospital transfers of sick or labouring parturients.

SOX6 binds CtBP2 to repress transcription from the Fgf-3 promoter.

Fgf-3 is expressed in a complex pattern during mouse development. Previously, an essential regulatory element PS4A was identified in the promoter region, and shown to bind at least three factors. To identify the transcription factor(s), we used a yeast one-hybrid screen and obtained a novel Sox6 cDNA (SOX6D). When introduced into cells it strongly repressed activity from both an Fgf-3 reporter gene as well as an artificial promoter containing three PS4A elements. In situ hybridisation analysis showed that Sox6 and Fgf-3 are co-expressed in the otic vesicle of E9.5 mouse embryos in a mutually exclusive pattern, consistent with a repression of Fgf-3 transcription by SOX6. To characterise additional factor(s) involved in Fgf-3 gene repression, a yeast two-hybrid screen was used with the N-terminal portion of SOX6D. Mouse CtBP2 cDNA clones were isolated and shown to bind SOX6 in yeast and mammalian cells. Furthermore, mutational analysis of SOX6 showed that binding to CtBP2, and its responsiveness to this co-repressor, were dependent on a short amino acid sequence motif PLNLSS. Co-expression studies in NIH3T3 cells showed that SOX6 and CtBP2 co-operate to repress activity from the Fgf-3 promoter through the enhancer element PS4A. These results show that SOX6 can recruit CtBP2 to repress transcription from the Fgf-3 promoter.

Patient-controlled analgesia in labour using remifentanil in two parturients with platelet abnormalities.

Two term parturients with documented platelet abnormalities presented to the delivery suite in labour. Because regional analgesic techniques were contraindicated, we elected to use patient-controlled i.v. remifentanil for pain relief. The patient-controlled analgesia (PCA) device was programmed to give a bolus dose of remifentanil 20 micrograms over 20 s with a lockout time of 3 min, and no background infusion. Analgesia was reported as very good by the mothers and by the attending midwives. There were no adverse neonatal sequelae. If there are facilities to monitor the neonate and mother, this method of analgesia may prove useful in those patients where regional techniques are not possible, but further research is needed to ascertain its safety and appropriateness in such circumstances.

Placental oxygen transfer and intrauterine resuscitation: a survey of knowledge in maternity care professionals.

We surveyed 99 maternity care professionals (obstetricians, midwives and anaesthetists in equal numbers) to assess their knowledge of potential treatments during acute intrapartum fetal hypoxia, including maternal oxygen administration. Knowledge of adult arterial oxygen saturation was satisfactory, but few of those surveyed gave a correct figure for fetal oxygenation in terms of umbilical vein oxygen saturation. Only 58% said that maternal oxygen inhalation would affect fetal oxygenation, and 76% of those giving a figure underestimated the potential extent of the increase. Other aspects of intrauterine resuscitation were also not identified. Out of three further factors besides maternal oxygen administration which are commonly considered, 76% suggested none or one, and only 24% noted two or all three. Acute fetal hypoxia during labour and delivery may be amenable to correction by improving oxygen supply to the placenta. We identified deficits in the underlying knowledge of these processes among maternity care professionals. Without this knowledge, correctable causes of fetal hypoxia may go untreated.

Retinoic acid-regulated expression of fibroblast growth factor 3 requires the interaction between a novel transcription factor and GATA-4.

fgf-3 shows a complex spatial-temporal pattern of transcription during mouse development, and the gene product appears to be an important intercellular signaling molecule. Here we show that the major enhancer, which is obligatory for transcription, is composed of three elements with different properties. Both functional analyses in undifferentiated and differentiated F9 cells and characterization of DNA-protein complexes in vitro have identified the sequence motifs GTGACT(C), ATTGT, and GATA as the key transcription factor binding sites. The GTGACT(C) motif, while not essential, is required for full enhancer activity. However, binding at ATTGT is crucial for transcriptional activity and is required for cooperative binding at the proximal GATA site. The GATA binding site mediates the retinoic acid/dibutyryl cyclic AMP stimulation of transcription and correlates with the binding of Gata-4 which is induced by retinoic acid in differentiating F9 cells. The ATTGT and GATA motifs are inactive when placed separately on a minimal thymidine kinase (TK) promoter, but together they act as a strong retinoic acid-regulated enhancer. In undifferentiated F9 cells, gata-4 expression stimulates the fgf-3 promoter, whereas in differentiated F9 cells already expressing gata-4, no further increase in promoter activity was observed.

Hemiplegia following general anaesthesia: an unusual presentation of migraine.

We report the case of a 33-year-old woman who developed a dense hemiplegia immediately after an uncomplicated general anaesthetic for diagnostic laparoscopy. She had a history of recurrent hemiplegic migraine with a strong family history. Her migraine was normally associated with visual disturbances and a unilateral headache followed by a left-sided weakness such that she was unable to walk. Symptoms would last up to 24 h. Her post-operative state was atypical of her normal migraine, in that she had no headache or visual disturbance and initially all four limbs were affected.

Recovery characteristics using single-breath 8% sevoflurane or propofol for induction of anaesthesia in day-case arthroscopy patients.

We studied the induction and recovery characteristics following inhalational induction with 8% sevoflurane in nitrous oxide and oxygen compared with intravenous propofol in 40 patients presenting for arthroscopy of the knee. Patients were randomly allocated to receive either induction agent, and anaesthesia was then maintained with sevoflurane in oxygen and nitrous oxide. A computerised test of hand--eye co-ordination and a p-deletion test were used to measure psychomotor recovery. The sevoflurane group had a faster onset of anaesthesia time. No significant differences between the groups were found in time to eye opening or psychomotor tests. Nausea and vomiting scores were significantly higher at 30 min in the sevoflurane group (p = 0.04); this difference was no longer significant by 90 min. We conclude that inhalational induction with sevoflurane in these patients has no important clinical advantages and causes more nausea and vomiting than propofol.

Laparoscopic peritoneal fenestration and internal drainage of lymphoceles after renal transplantation.

The development of a postoperative lymphocele after renal transplantation is a well-described complication that occurs with relative frequency. Management options have previously included simple aspiration, percutaneous imaging-guided drainage with catheter placement, and operative marsupialization of the cyst into the peritoneal cavity. Because these collections are often multiloculated, catheter drainage may be of limited value, and the recurrence rate is unacceptably high. The operative approach is the most definitive method and is still considered the treatment of choice. This paper describes a laparoscopic approach to peritoneal fenestration and internal drainage of lymphoceles after renal transplant surgery and recommends that this technique be considered the primary mode of therapy for this complication.

Identification of positive and negative regulatory elements involved in the retinoic acid/cAMP induction of Fgf-3 transcription in F9 cells.

The proto-oncogene Fgf-3 has been implicated as an important signalling molecule in vertebrate development. In the mouse, it is expressed for a limited time at a multitude of sites from embryonic day 7 to birth. Transcription of Fgf-3 initiates at three promoter regions resulting in the generation of various mRNAs which nevertheless all encode the same protein products. A 1.7kb DNA fragment which encompasses these regions was joined to the CAT reporter gene and shown to function as a promoter in embryonal carcinoma cells. In stable transfectants the promoter retains its retinoic acid inducibility, initiating transcription at the same cap-sites as the endogenous gene. In differentiated F9 cells, transient transfection of progressive and targeted deletion mutants of the promoter region has revealed at least two positive and three negative regulatory elements. With one exception, loss of these elements was shown to dramatically affect promoter activity in stable transfectants of F9 cells. However the promoter remained inducible by retinoic acid to differing degrees, apart from deletions encompassing PS-4A which essentially abolished promoter activity in both undifferentiated and differentiated cells. The sequences of these potential regulatory regions were further defined using DNase-I footprinting, revealing some similarities to consensus binding sites for known transcription factors.

Acute hantavirus infection presenting as hypersensitivity vasculitis with arthropathy.

Acute hantavirus infection was diagnosed in a young man presenting with a hypersensitivity vasculitis and arthropathy. He has recovered with minimal evidence of residual renal damage.

Transcriptional regulation of the int-2 gene in embryonal carcinoma cells.

The int-2 gene, which encodes a member of the fibroblast growth factor family, is expressed at specific sites and times during mouse development. In certain embryonal carcinoma cell lines, multiple int-2 transcripts accumulate when the cells are induced to differentiate with retinoic acid and dibutyryl cyclic AMP. Nuclear run-on analyses indicate that the apparent induction of int-2 expression results from an increase in the rate of transcription initiation. Six distinct types of RNA have been delineated, originating from three promoters and terminating at either of two polyadenylation sites. Since each transcript appears to encode the same protein, this complexity may reflect the need for lineage-specific or differentiation-dependent control of expression. By comparing the kinetics of induction and turnover of the different RNA species, we show that the choice of promoter or length of the 3'-untranslated region has no significant effect on the half-lives of the various mRNAs. To further evaluate control at the transcriptional level, we have shown that a 1.7-kilobase fragment of int-2 genomic DNA, when fused to the chloramphenicol acetyltransferase gene, can act as a regulated promoter(s) in differentiated versus undifferentiated embryonal carcinoma cells. This segment of DNA encompasses the three promoter regions previously delineated by RNase mapping plus about 900 base pairs of additional upstream sequences.

The development and utilization of patient education videos.

Making and utilizing your own videos can be a great educational addition to any endoscopy department. With the types and numbers of endoscopy procedures increasing daily, new areas of patient education need to be explored to keep the patients ultimately informed. This article is meant to stimulate the imagination about what can be done to improve the effectiveness of a busy endoscopy unit in the area of patient education.

Tools for patient education.

There are many pamphlets, brochures and educational videos available for use in patient teaching. This article is a listing of some of the many items available and where to obtain them.

The mouse homologue of hst/k-FGF: sequence, genome organization and location relative to int-2.

We have located and sequenced the murine homologue of the hst/k-FGF oncogene in genomic DNA clones that extend 3' from int-2 on mouse chromosome 7. The two genes are in the same transcriptional orientation, less than 20 kilobase pairs (kb) apart, and presumably evolved by tandem duplication of a common ancestral gene. RNase mapping and primer extension analyses indicated that the major 3.2 kb hst transcript expressed in undifferentiated embryonal carcinoma (EC) cell lines initiates at a unique cap site downstream from an obvious TATA-box. The 3' end of the transcript as identified in multiple cDNA clones occurs at an appropriate distance from a variant polyadenylation signal, ATTAAA. Translation of the major open reading frame would yield a 202 amino acid protein that is 82% homologous to human HST but lacking 4 residues at the presumed signal peptide cleavage site.

Informed consent: every patient's right.

In order for a patient to give an informed consent for a procedure, he or she needs to understand the risks, benefits and consequences of the procedure explained in layman's terms. It is frequently the responsibility of the gastroenterology nurse or associate to expand on the explanation of the gastroenterologist to be sure the patient fully understands the endoscopic procedure he or she is going to have.

Current techniques of nutritional assessment.

This article has dealt with techniques of nutritional assessment as currently utilized in the hospital setting. Although the techniques are easily mastered and abundant data have been collected, we are only slightly closer to achieving an accurate and clinically meaningful nutritional assessment. Interpretation of data is hampered by reliance on tables of "norms" and by the questionable validity of relating individual tests to the whole patient. The interest stimulated in nutrition by widespread application of these assessment techniques, however, has resulted in a burst of new investigative efforts. Determination of body composition by total body neutron activation and isotope dilution during various states of nutrition, isotope studies of substrate utilization, and evaluation of body function relative to composition are all exciting areas of future investigation. Until an accurate comprehensive technique of nutritional assessment is available, emphasis must be placed on obtaining as much data as possible from the dietary and clinical history, physical examination, and anthropometric and laboratory measurements, with great reliance on clinical impression and judgement. At the current state of the art, in addition to the history and physical examination, we propose as a minimum that a nutritional assessment consist of current weight and recording of recent weight change, determination of serum albumin, transferrin, TLC, and testing for DTHR to common skin test antigens, and an evaluation of muscle function.