The Scottish doctor--learning outcomes for the medical undergraduate in Scotland: a foundation for competent and reflective practitioners.

This paper describes a set of learning outcomes that clearly define the abilities of medical graduates from any of the five Scottish medical schools. The outcomes are divided into 12 domains that fit into one of three essential elements for the competent and reflective medical practitioner.

Five years of anticonvulsant monitoring on site at the epilepsy clinic.

The influence of antiepileptic drug monitoring on site at the epilepsy clinic was assessed in a prospective way by recording physicians' decisions before and after the drug concentration became available over the five-year period including 1986 to 1990. A total of 2,857 assays (1,121 carbamazepine, 798 phenytoin, 622 sodium valproate, and 72 phenobarbital) were performed during 2,696 hospital attendances on 618 epileptic patients. A gradual reduction in the proportion of visits monitored annually was observed (1986: 42%; 1987: 51%; 1988: 44%; 1989: 39%; 1990: 28%; p < 0.01). In 481 (17.8%) visits a change in management resulted from knowledge of the drug concentration. This was not an automatic response, as a large minority of unexpected results did not produce such an alteration. The proportion of decisions to adjust the drug dose after an unexpected result, however, tended to increase over the years of the study (1986: 43%; 1987: 70%; 1988: 60%; 1989: 78%; 1990: 54%; p < 0.01). Changes in anticonvulsant dose following an unexpected result were observed in "low" (59%), "therapeutic" (61%), and "high" (52%) concentration categories. Possible benefit for patients can be inferred from the observation that more assay results fell within the target range in the last (61%) compared with the first (33%) year of monitoring (p < 0.01).

Antiepileptic drug monitoring at the epilepsy clinic: a prospective evaluation.

To assess the value of on site therapeutic drug monitoring at the epilepsy clinic, management decisions were recorded before and immediately after antiepileptic drug (AED) concentrations became available. In the first year of this prospective study, 632 [277 carbamazepine (CBZ), 170 phenytoin (PHT), 113 valproate (VPA), and 72 phenobarbital (PB)] assays were performed during 488 clinic attendances in 182 actively managed epileptic patients. The results of drug analysis led to alterations in management at 114 patients visits, i.e., 23% of those monitored. Dosage was increased in response to the circulating AED concentration in 12% of consultations and decreased in another 7.5%. Unsuspected poor compliance was uncovered in eight patients, and in three others an AED was added or discontinued on the basis of the assay result. The time of the next appointment was rearranged in 58 attendances. Only 50% of results were in the "therapeutic" ranges for the four major AEDs. Dosage was adjusted (50 up, 16 down) after 54% of low results. "Therapeutic" levels were followed by a change in AED dose (52 up, 31 down) in 26%. Only 29% of concentrations above the "therapeutic" range persuaded the doctor to alter the dosage regimen, and in 20% of these an increase in dose was recommended. On-site AED monitoring had an immediate impact on clinical decision-making in greater than 23% of consultations but in a form more subtle than the simple quest for a therapeutic result.

Increased collagen-linked fluorescence in skin of young patients with type I diabetes mellitus.

Our objective was to determine whether the fluorescence of skin collagen, which may reflect the accumulation of advanced glycosylation end products, is increased in young patients with type I (insulin-dependent) diabetes. Our study design was a cross-sectional case-control study in a referral-based diabetic clinic in an academic hospital. Study subjects comprised a convenience sample of 18 type I diabetic patients aged 17-30 yr and 8 age-matched healthy control subjects. The fluorescence of collagen was measured in skin biopsy material. Collagen-linked fluorescence (CLF) was increased in diabetic patients (mean 10.5 [range 5.8-15.8] U/mg) compared with control subjects (7.6 [5.6-10.1] U/mg, P less than 0.02). In diabetic patients, CLF was related to age (r = 0.581) and duration of diabetes (r = 0.697) but not concentration of glycosylated hemoglobin (r = 0.082). Partial correlation analysis demonstrated that duration of diabetes is the main factor determining the fluorescence of collagen in these patients. There was a relationship between CLF and presence of diabetic retinopathy after the data were adjusted for patient age and duration of diabetes (P = 0.023). Increased fluorescence of skin collagen can be detected in young type I diabetic patients and is primarily related to duration of diabetes.

Plasma 5-S-cysteinyldopa as an index of melanogenesis.

Plasma 5-S-cysteinyldopa (5-S-CD) concentration measured in healthy volunteers in Edinburgh, Scotland (latitude 56 degrees N) showed only minor changes during the day. However, when measurements were performed over a 12-month period a significant rise in 5-S-CD concentration was found. Skin pigmentation and hair colour were not related to plasma 5-S-CD levels. Patients with psoriasis treated with ultraviolet-B or photochemotherapy (PUVA) developed an almost two fold increase in their plasma 5-S-CD level within the first five treatments, before pigmentation developed, subsequent increments of up to four times the pretreatment level being found in the PUVA group. Dithranol treatment caused an increase in plasma 5-S-CD in some psoriatic patients, suggesting a possible association between skin erythema and elevated 5-S-CD levels. The value of plasma 5-S-CD in the follow-up of patients with malignant melanoma does not seem to be invalidated by unavoidable exposure of the subjects to sunlight in a temperate climate such as that of South East Scotland.

Endogenous digoxin-like immunoreactive substance in patients undergoing coronary surgery. Preliminary report.

Perioperative digoxin concentrations were measured in 20 unselected adult patients undergoing coronary surgery. None of the patients were receiving treatment with digoxin. A digoxin-like immunoreactive substance was found in 16 patients postoperatively. This substance, if pharmacologically active, may have important clinical implications in the management of patients after open heart surgery.

Application of a frame-based computer-aided learning system in clinical chemistry.

A frame-based computer-aided learning system for use on microcomputers has been developed for teaching clinical chemistry. The system presents a case-study model that can be used by students to assess their ability to make a diagnosis, to select patterns of investigations and to institute treatment.

Purification of bile acid-binding proteins from rat hepatic cytosol. Use of a photoaffinity label to detect novel Y' binders.

A 125I-labelled photolabile derivative of cholic acid has been used to investigate the organic anion-binding Y' fraction from rat liver, prepared by the method of Sugiyama, Y., Yamada, T. and Kaplowitz, N. (1982) Biochimica Biophysica Acta, 709, 342-352. The use of this photoaffinity probe led to the discovery of previously undescribed bile acid-binding proteins. A comprehensive purification scheme for the Y' proteins which allows the isolation of these novel binding species is described. Electrophoretic analysis shows that the Y' binders can be divided into two groups. The proteins in group 1 are dimeric and the 5B, 6E and 7F binding species consist of subunits with approximate molecular masses of 19.6, 15.6 and 14.9 kDa, respectively. The group 2 binding proteins, 5C, 5D and 8C, are monomeric and have molecular masses of approximately 36.2, 36.2 and 33 kDa, respectively. Calculation of the incorporation of 125I by these proteins showed that the group 1 proteins displayed a significantly greater specific incorporation of radioactivity than group 2. The specificity of 125I-labelled 3 beta-azidocholylhistamine is further demonstrated by analysis of tryptic digests of photoaffinity labelled Y' binders and glutathione S-transferases AA, A, D and F by reverse-phase high-performance liquid chromatography (HPLC) and thin-layer chromatography (TLC). The majority of the radioactivity was shown to be incorporated into a single component, which was not coincident with the free photoaffinity label.

Plasma 5-S-cysteinyldopa concentrations in oculocutaneous albinism.

5-S-cysteinyldopa concentrations were determined by high-pressure liquid chromatography and electrochemical detection in plasma from normally pigmented patients and patients with oculocutaneous albinism, both tyrosinase-positive and tyrosinase-negative. The plasma 5-S-cysteinyldopa concentrations were similar in all three groups, suggesting that 5-S-cysteinyldopa can be produced by mechanisms which do not involve tyrosinase.

Synthesis and characterisation of an iodinated bile-salt derivative for photoaffinity labelling.

The synthesis and characterisation of a novel iodinated bile salt derivative, 125I-labelled 3 beta-azidocholylhistamine, is described. The derivative is handled by rat liver in a similar manner to taurocholate and binding to bovine serum albumin, a well-characterised bile acid-binding protein, is demonstrated. The suitability of the derivative for photoaffinity labelling is assessed.

Bile salt transport in intestinal lymph of the rat.

The concentrations of conjugated cholate and chenodeoxycholate have been measured in samples of rat thoracic duct lymph, portal and systemic blood. Both these bile salts were present in lymph. After administration of a corn oil meal the flux of both these bile salts in lymph increased significantly (P less than 0.001; Student's t test), the cholate flux rising from 0.9 +/- 0.6 nmol/h (mean +/- SD) to 3.5 +/- 1.1 nmol/h postprandially and the chenodeoxycholate flux rising from 2.5 +/- 0.8 to 4.6 +/- 1.6 nmol/h. This postprandial increase in bile salt flux was due to both an increase in bile salt concentration and an increased lymph flow which rose significantly (P=0.007) from 0.5 +/- 0.2 to 0.7 +/- 0.2 ml/h. Biliary drainage significantly (P less than 0.001) reduced the flux of cholate and chenodeoxycholate in lymph to 0.08 +/- 0.05 and 0.17 +/- 0.10 nmol/h respectively. These biliary drained animals produced no significant rise (P greater than 0.1) in bile salt flux when fed the corn oil meal. The ratio of the concentrations of conjugated cholate to chenodeoxycholate in systemic and portal blood was 1.9:1 and 3.3:1 respectively. In contrast, this bile salt ratio was only 0.44:1 in lymph. These studies show that bile salts, in particular chenodeoxycholate, can pass directly from the intestine into lymphatics thus establishing an enterolymphatic circulation of bile salts.

A study of the structures of the YaYa and YaYc glutathione S-transferases from rat liver cytosol. Evidence that the Ya monomer is responsible for lithocholate-binding activity.

The two dimeric lithocholic acid-binding proteins previously identified as ligandin (YaYa) and glutathione S-transferase B (YaYc) were isolated from rat liver cytosol. These proteins have molecular weights of 44000 and 47000 respectively. The recovery of these two proteins from liver was not affected by the addition of the proteinase inhibitor Trasylol. No spontaneous interconversion between these two proteins was observed on storage. YaYa and YaYc proteins yielded peptides of identical molecular weight after limited digestion with Staphylococcus aureus V8 proteinase. Analytical and preparative tryptic-digest peptide 'maps' showed that all the soluble peptides obtained from YaYa protein were also recovered from YaYc protein. Approximately six extra soluble peptides, which were not recovered from YaYa protein, were obtained from the tryptic digest of YaYc protein. Subdigests of the insoluble tryptic-digest 'cores' also resulted in the recovery of identical peptides from both proteins. Evidence is presented that the Ya subunit possessed by both proteins is identical; glutathione S transferase B is a hybrid of ligandin and glutathione S-transferase AA. The Ya monomer is responsible for lithocholate binding.

Portal blood concentrations of conjugated cholic and chenodeoxycholic acids. Relationships to bile salt synthesis in liver cells.

1. Rats were maintained in a strictly controlled environment of 12 h illumination and 12 h darkness. At regular intervals during the light/dark cycle the portal blood conjugated cholic acid and conjugated chenodeoxycholic acid concentrations were measured. The bile salt concentrations exhibited similar diurnal rhythms, the highest concentrations occurring in the middle of the dark phase. 2. The concentrations of conjugated cholic and chenodeoxycholic acids in the portal blood of rats fed a diet containing the bile salt sequestrant, cholestyramine, were significantly lower than those found in rats given a control diet. 3. During total biliary drainage the portal blood concentrations of conjugated cholic and chenodeoxycholic acids fell to a minimum 6--8 h after the start of the experiment, whereas bile salt synthesis in hepatocytes isolated from the rats was not increased until the least 13 h after the commencement of total biliary drainage. 4. These results suggest that the concentrations of bile salts in the portal blood do not affect directly the diurnal fluctuation in rates of bile salt synthesis, as the response of synthesis to a change in portal blood bile salt concentrations is too slow. 5. When the rats were given a small supplement of cholesterol in the diet to suppress hepatic cholesterologenesis prior to being subjected to total biliary drainage, the changes in the portal blood concentrations of conjugated cholic and chenodeoxycholic acids and the synthesis of the two bile salts by isolated hepatocytes were similar to those found in rats given the control diet. 6. The rise in bile salt production seen during biliary drainage may not be dependent exclusively on a preceding increase in cholesterol synthesis.

A comparison of bile salt binding to lymph and plasma albumin in the rat.

The binding of bile salts to proteins in rat plasma and rat lymph has been investigated. Under the non-equilibrium conditions of gel chromatography no binding of glycochenodeoxycholate or glycocholate to any of the lymph proteins was observed. In contrast, plasma bound a proportion of both bile salts. When lymph was treated with charcoal, binding of glycochenodeoxycholate to a protein with a molecular weight identical to albumin occurred. Equilibrium binding studies showed that the binding of glycocholate to partially purified plasma albumin exhibited saturation kinetics with a dissociation constant of 2 x 10(-4) M. In contrast, the binding of glycocholate to lymph albumin was non-saturable. Potassium oleate, when added to plasma in a free fatty acid : albumin molar ratio of 3.8 : 1, almost completely inhibited the binding of chenodeoxycholate to plasma albumin. The endogenous free fatty acid : albumin ratios found in systemic plasma and lymph were 0.6 : 1 and 9.2 : 1, respectively. It is suggested that the high free fatty acid concentrations found in lymph inhibit the binding of bile salts to albumin.

Clinical value of bile salt tests in anicteric liver disease.

Fasting and postprandial serum bile salt concentrations and intravenous glycocholate disappearance were studied in 20 patients with anicteric liver disease who had only minor abnormalities of conventional liver function tests. Abnormalities in the fasting or two hour postprandial conjugated cholate concentrations were found in all but one of the patients who had an abnormality in bilirubin concentration. In these patients, fasting and postprandial conjugated cholate concentrations were raised on average three and two times respectively above the upper limit of the reference range, while bilirubin concentration was raised only 50%. Postprandial conjugated cholate concentrations were also abnormal in two patients with normal bilirubin concentrations. Measurement of fasting and postprandial conjugated chenodeoxycholate concentration and intravenous glycocholate disappearance proved less informative than the fasting and postprandial conjugated cholate test. These results suggest that, where bilirubin concentrations are normal or only slightly raised, measurement of serum fasting and two hour postprandial conjugated cholate concentrations may prove helpful in the detection of minor abnormalities in hepatic anion transport.

Liver function in Edinburgh haemophiliacs: a five-year follow-up.

Liver function was assessed in 38 Edinburgh haemophiliacs. Results before the introduction of NHS intermediate factor VIII concentrate from 1974 onwards were compared with values in 1979. Measurements of serum bile salts in 16 patients as well as conventional liver function tests gave useful evidence of deranged liver function. Deterioration over the five-year follow-up period was seen only in patients on home treatment using large amounts of factor VIII concentrate, and there was no association between cryoprecipitate usage and derangement of liver function.

Differential timing of maximal postprandial concentrations of plasma chenodeoxycholate and cholate: its variability and implications.

The concentrations of conjugated chenodeoxycholate and cholate in serum have been measured in 26 controls and 19 patients with liver disease before and after taking a fat-containing meal. The times at which maximum bile salt concentrations occurred varied considerably between individuals. In the majority of cases maximal concentrations of the two bile salts occurred simultaneously but in 3 subjects maximal concentrations of chenodeoxycholate were found 15-60 min prior to maximal cholate concentrations. The measurement of bile salt concentration in a single sample taken 2 h after the fatty test meal would have produced two false-negative results in the patients with liver disease. It is concluded that the jejunal absorption of dihydroxylated bile salts may not be significant in the majority of individuals and that the protocol for assessment of liver function by postprandial bile salt analysis should include at least two blood samples collected at 1.5 and 2 h after ingestion of the test meal.