The emerging specialty of perioperative medicine: a UK survey of the attitudes and behaviours of anaesthetists.

BACKGROUND: In 2014, the Royal College of Anaesthetists (RCoA) launched the Perioperative Medicine Programme to facilitate the delivery of best preoperative, intraoperative and postoperative care through implementation of evidence-based medicine to reduce variation and improve postoperative outcomes. However, variation exists in the establishment of perioperative medicine services in the UK. This survey explored attitudes and behaviours of anaesthetists towards perioperative medicine, described current anaesthetic-led perioperative medicine services across the UK and explored barriers to anaesthetic involvement in perioperative medicine. METHODS: Survey content based on the RCoA vision document was refined and validated using an expert panel. An anonymous electronic survey was then sent by email to the members of the RCoA. RESULTS: Seven hundred fifty-eight UK anaesthetists (4.5% of the RCoA mailing list) responded to the survey. Of these, 64% considered themselves a perioperative doctor, with 65% having changed local services in response to the RCoA vision. Barriers to developing perioperative medicine included insufficient time (75%) and inadequate training (51%). Three quarters of respondents advocate anaesthetists leading the development of perioperative medicine. CONCLUSIONS: Despite evidence of emerging services, this survey describes barriers to ongoing development of perioperative medicine. Facilitators may include increased clinical exposure, targeted education and training and collaborative working with other specialties.

A Foundation Programme educational placement in peri-operative medicine for older people: mixed methods evaluation.

We established an innovative Foundation placement in peri-operative medicine for older patients in response to the need for training in 'whole patient' medicine and the challenge of fewer Foundation doctors in acute surgical roles. The placement and underpinning curriculum were co-designed with junior doctors and other clinical stakeholders. This resulted in a modular design offering acute and community experience and dedicated quality improvement project time. To evaluate the placement we used a mixed methods study based on Kirkpatrick's model of workplace learning. Level 1 (trainee reaction) was evaluated using Job Evaluation Study Tool questionnaires and nominal group technique. Levels 2 and 3 (trainee learning/behaviour) were assessed using a Likert-style survey mapped to curriculum objectives, e-portfolio completion, nominal group technique and documentation of completed quality improvement projects and oral/poster presentations. Sixty-eight foundation trainees underwent the new placement. A similar-sized 'control' sample (n = 57) of surgical Foundation trainees within the same Trust was recruited. The trainees in the peri-operative placement attained both generic Foundation and specific peri-operative curriculum competencies, and gave higher job satisfaction scores than trainees in standard surgical placements. The top three ranked advantages from the nominal group sessions were senior support, clinical variety and project opportunities. Universal project completion resulted in high rates of poster and platform presentations, and in sustained service changes at hospital level.

Survival trends of Staphylococcus aureus, Pseudomonas aeruginosa, and Clostridium perfringens in a sandy South Florida beach.

The search for alternative indicators of disease-risk from non-enteric pathogens at the beach revealed high densities of targeted bacteria. To explain the high numbers of potential non-enteric pathogens, Staphylococcus aureus and Pseudomonas aeruginosa, in beach sand, we investigated factors affecting their survival and distribution, as well as those of a potential fecal indicator, Clostridium perfringens. Results indicated greater S. aureus and P. aeruginosa survival and proliferation in sterile beach sand, than seawater, with diminished numbers upon exposure to natural micro-predators. C. perfringens remained relatively consistent with initial numbers. Intermediate sand particles (850 µm-2 mm) constituted the major micro-niche; creating implications for beach classification programs. Colonization of sterile sand boxes at the beach by S. aureus and P. aeruginosa confirmed the filtering action (>100×) of beach sand. The use of these potential pathogens in periodic sanitary evaluation of beach sand quality is indicated, regardless of the factors influencing their abundance.

Survival potential of Escherichia coli and Enterococci in subtropical beach sand: implications for water quality managers.

Fecal bacteria have traditionally been used as indicator organisms to monitor the quality of recreational waters. Recent work has questioned the robustness of traditional indicators, particularly at seawater bathing beaches. For example, a study of Florida beaches found unexpectedly high abundances of Escherichia coli, fecal coliforms, and enterococci in beach sand. The aim of the present study was to explain these abundances by assessing the survival of E. coli and enterococci in beach sand relative to seawater. We used a combination of quantitative laboratory mesocosm experiments and field observations. Results suggested that E. coli and enterococci exhibited increased survivability and growth in sand relative to seawater. Because fecal bacteria are capable of replicating in sand, at least under controlled laboratory conditions, the results suggest that sand may be an important reservoir of metabolically active fecal organisms. Experiments with "natural" mesocosms (i.e., unsterilized sand or water rich in micropredators and native bacteria) failed to show the same increases in fecal indicators as was found in sterile sand. It is postulated that this was due to predation and competition with indigenous bacteria in these "natural" systems. Nonetheless, high populations of indicators were maintained and recovered from sand over the duration of the experiment as opposed to the die-off noted in water. Indicator bacteria may wash out of sand into shoreline waters during weather and tidal events, thereby decreasing the effectiveness of these indicators as predictors of health risk and complicating the interpretations for water quality managers.

Prevalence of Acanthamoeba and other naked amoebae in South Florida domestic water.

The purpose was to identify the prevalence of naked amoebae in tap water in south Florida to ascertain the risk of amoebal infections of the cornea in contact lens wearers. Over the course of a 2-year period, water samples were collected from sites throughout Broward, Palm Beach, and Dade counties, Florida. The presence of amoebae in samples was based on an enrichment cultivation method appropriate for Acanthamoeba. Amoebae were identified using diagnostic features discernable by light microscopy. A total of 283 water samples were processed and amoebae were noted in 80 of these. Acanthamoeba were found on 8 occasions (2.8%). The genera Hartmannella and Vahlkampfia, rarely involved in keratitis cases, were found in 3.5% and 2.8% of samples, respectively. A total of 19 different naked amoebae were recorded and amoebae (regardless of genus) were present in 19.4% of all samples. Previous surveys in England and Korea have shown that acanthamoebae are found in 15 to 30% of tap water samples in the home and have been associated with corneal infection in contact lens wearers. The incidence of acanthamoebae infection in the USA (2.8%) has been found to be lower than that in the UK and it has been postulated that this is related to the lack of a storage water tank in the roof loft space. However, the level of treatment of municipal water is clearly not effective at killing amoebal cysts (or trophozoites) as evidenced by the high occurrence of amoebae (19.4%) in this study.

Prevalence of yeasts in beach sand at three bathing beaches in South Florida.

The abundance and types of yeasts in the wet and dry sand of three recreational beaches in South Florida were determined. Samples were collected on 17 occasions between August 2001 and July 2002. After analyzing 102 sand samples, a total of 21 yeast species were identified by molecular methods. These isolates comprised four Basidiomycetes and 17 Ascomycetes and included eight species that had previously been reported from humans. The most frequently encountered yeasts were Candida tropicalis and Rhodotorula mucilaginosa. A greater diversity of species (16 species) was found in the dry sand above the high tide mark compared with the wet sand in the intertidal zone (11 species). Densities were also highest in the dry sand relative to wet sand (20-fold higher at Hobie beach, 6-fold higher at Fort Lauderdale Beach and 1.3-fold higher at Hollywood beach). There were no clear temporal patterns in the data and overall densities were greatest at the busiest bathing beach (Hobie Beach) where total yeasts averaged 37,720 cfu 100g(-1) dry sand and 1852 cfu 100 g(-1) in the wet sand. This concentration of yeast was significantly higher than populations at the less populated beaches. Fort Lauderdale beach had a mean count of 4130 cfu 100 g(-1) dry sand and 705 cfu 100g(-1) in the wet sand while the least populated beach, Hollywood Beach averaged 1945 cfu 100g(-1) dry sand and 1483 cfu 100g(-1) wet sand. While definitive statements cannot be made, high levels of yeasts may have a deleterious bearing on human health and the presence of such a diverse aggregation of species suggests that yeasts could have a role as indicators of beach health.

Platyamoeba pseudovannellida n. sp., a naked amoeba with wide salt tolerance isolated from the Salton Sea, California.

A new species of naked amoeba, Platyamoeba pseudovannellida n.sp., is described on the basis of light microscopic and fine structural features. The amoeba was isolated from the Salton Sea, California, from water at a salinity of ca. 44%. Locomotive amoebae occasionally had a spatulate outline and floating cells had radiating pseudopodia, sometimes with pointed tips. Both these features are reminiscent of the genus Vannella. However, the surface coat (glycocalyx) as revealed by TEM indicates that this is a species of Platyamoeba. Although salinity was not used as a diagnostic feature, this species was found to have remarkable tolerance to fluctuating salinity levels, even when changes were rapid. Amoebae survived over the range 0 per thousand to 150 per thousand salt and grew within the range 0 per thousand to 138 per thousand salt. The generation time of cells averaged 29 h and was not markedly affected by salt concentration. This is longer than expected for an amoeba of this size and suggests a high energetic cost of coping with salinity changes. The morphology of cells changed with increasing salinity: at 0 per thousand cells were flattened and active and at the other extreme (138 per thousand) amoebae were wrinkled and domed and cell movement was very slow. At the ultrastructural level, the cytoplasm of cells grown at high salinity (98 per thousand was considerably denser than that of cells reared at 0 per thousand.

High numbers of naked amoebae in the planktonic waters of a mangrove stand in southern Florida, USA.

This is the first study to examine the abundance of naked amoebae in the water column of a mangrove stand. A total of 37 different morphotypes was noted and at least 13 of these are probably new species. Over a one-year sampling interval, amoebae averaged 35,400 cells liter(-1) (range 2,000-104,000) by an indirect enrichment cultivation method. Densities in the upper end of this range are the highest ever reported for any planktonic habitat. Variation between samples was related to the quantity of suspended aggregates (flocs) in the water column emphasizing that amoebae are usually floc-associated. The study also showed that it is essential to disrupt floc material prior to withdrawing sample aliquots for the indirect counting method since several amoebae can occupy the interstices of aggregates. There is concern that indirect enumeration methods that require organisms to be cultured in the laboratory seriously underestimate the true count. A direct counting method using acridine orange staining and epifluorescence microscopy was attempted to assess the possible magnitude of the error associated with indirect counting. While this direct method had limitations, notably the difficulty of unambiguously differentiating between small amoebae and nanoflagellates, the results suggested that the indirect method gave estimates that were close to the true count (within a factor of two). Mangrove waters are rich in heterotrophic protozoa (approximately 3 x 10 liter(-1)) and while the heterotrophic flagellates are by far the dominant group, naked amoebae outnumber ciliates some 20-fold. The ecological consequences of high numbers of amoebae, particularly the common small forms less than 10 microm in length, need to be examined for these important coastal sites.

Primary and secondary structure of the small-subunit ribosomal RNA of the naked, marine amoeba Vannella anglica: phylogenetic implications.

The primary and secondary structure of the small-subunit ribosomal RNA (ssrRNA) gene from the naked, marine amoeba, Vannella anglica (subclass Gymnamoebia), was determined. The ssrRNA is 1962 nucleotides in length, with a low G+C content of 37.1%. The ssrRNA is composed of several uncommon secondary structure features including helix E8-1, which may be a useful target for rRNA probes for the direct identification of isolates in mixed culture. Phylogenetic analysis of sequence data showed that V. anglica branched prior to the rapid diversification of the eukaryotes. It did not associate with the other naked, lobose amoebae represented by Acanthamoeba and Hartmannella, indicating that Vannella represents a separate amoeboid lineage and the subclass Gymnamoebia is polyphyletic.

Voice and healing after vocal fold epithelium removal by CO2 laser vs. microlaryngeal stripping.

Controversy exists regarding voice recovery after the use of laser vs. microforceps techniques in the removal of benign vocal fold lesions. The purpose of this study is to compare recovery of voice and healing between groups of cats undergoing vocal fold epithelium removal by CO2 laser and those having vocal fold stripping. Fourteen adult female cats underwent standardized unilateral vocal fold injuries by CO2 laser ablation or stripping. After a 6-week recovery period, phonations were evoked by electrical stimulation of the midbrain periaqueductal gray area. Phonations were recorded for acoustic analysis. The larynges were harvested, fixed, and sectioned for histologic correlation. Acoustic analysis showed the mean signal-to-noise ratios in the laser group (19.72) to be significantly higher than those in the stripped group (13.51) (p = 0.04). The stripped group showed significantly greater amplitude perturbation (8.68% vs. 2.43%, p = 0.02). No between-group difference was found for period perturbation. Histologically, the laser group showed minimal Reinke's space scarring and near-normal epithelial regeneration, and the stripped group showed marked subepithelial scarring, often involving the vocalis muscle. These results demonstrate superior recovery of voice and healing in animals undergoing vocal fold epithelium removal with the CO2 laser. Inferior outcomes seen in the stripped group may be related to difficulty in preserving Reinke's space during epithelium removal.

Evolution of cell adhesion systems: evidence for Arg-Gly-Asp-mediated adhesion in the protozoan Neoparamoeba aestuarina.

Developmental processes in multicellular organisms require structural elements, such as adhesion molecules, to stabilize cells at functional positions. In vertebrates, a series of extracellular matrix proteins, e.g. fibronectin and laminin, are involved in cell adhesion. These proteins contain Arg-Gly-Asp [RGD] at their binding sites. Here we show that at concentrations above 2 mM the peptide GRGDSPK, comprising the tripeptide RGD (Arg-Gly-Asp), prevents the adhesiveness of cells of the marine amoeba Neoparamoeba aestuarina. In addition, elevated levels of GRGDSPK cause cells to alter their shapes from those with digitiform subpseudopodia to rounded cells with small lobed pseudopodia. These cells detach from the substratum. These results are specific for the RGD sequence, because incubation in GRGESPK solution at the same concentrations had no effect on cell attachment or structure. From these data we suggest that the structural adhesion molecules identified in vertebrates show amino acid homologies with those found in unicellular protozoa.

Parvamoeba rugata n. g., n. sp., (Gymnamoebia, Thecamoebidae): An exceptionally small marine naked amoeba.

A small naked marine amoeba isolated from the Cycle Sea area on the west coast of Scotland is described as Parvamoeba rugata n. g., n. sp. It is remarkable in that it is the smallest example of a marine naked amoeba yet to be described and may represent a size class of heterotrophic amoebae worthy of future ecological consideration. It has characters justifying its inclusion in the family Thecamoebidae, notably prominent surface wrinkling obvious with the light microscope, the possession of a Thecamoeba-like glycocalyx, and a nucleus with an electron dense layer similar to the lamella of the Thecamoebidae. However, although its general morphology is compatible with membership in this family, P. rugata has additional features not found in any of the described genera of thecate amoebae. Characters of note include its extremely small size (mean length only 3.9 µm), random surface folds, a raised rather than flattened cell mass and fine subpseudopodia extending from the edge of the hyaloplasm which are not normally associated with Thecamoeba-like amoebae. These features warrant its inclusion in a new genus to be accommodated within the family Thecamoebidae.

Computerized quantitative dynamic analysis of facial motion in the paralyzed and synkinetic face.

Diagnosis, treatment, prognosis, and the neurobiology of recovery of facial paralysis has been impeded by the inability to quantitate facial movement objectively. The purpose of this paper is to report our preliminary results in the study of the paralyzed face using a newly developed computerized quantitative dynamic analysis system. Five normal volunteer subjects, and 17 patients with facial paralysis or paresis, from a wide range of etiologies, were analyzed utilizing the computerized analysis system; eight of these patients had synkinesis. Raw data image-change intensity: duration curves, numeric and graphic displays of curve parameter descriptive statistics, and rank order correlation analyses showed high levels of correlation between the computerized facial motion analysis and the House-Brackmann facial nerve grading system and a clinical grading scale for synkinesis. These data suggest that it is possible to develop a computerized image-difference analysis system that approximates the human ability to access facial movement and, additionally, deliver an equal-interval continuous quantitative data scale dynamic over a spectrum of time during facial motion.

Parenteral peptide formulations: chemical and physical properties of native luteinizing hormone-releasing hormone (LHRH) and hydrophobic analogues in aqueous solution.

The degradation of native LHRH in aqueous buffers of pH approximately 1-10 obeyed the rate equation, kobs = kH + alpha H+ + ko + kHO-(alpha HO-)x, where x at 60-100 degrees C was approximately 0.64 and temperature independent. Extrapolation to 25 degrees C using the Arrhenius equation and secondary rate constants showed that native LHRH is reasonably stable at pH 5.4, giving a shelf life (t90) of approximately 5 years. Regarding physical properties, hydrophobic LHRH analogues nafarelin and detirelix were found to be surface active as demonstrated by a decrease in apparent surface tension with increased peptide concentration. The CMC for detirelix at pH 7.4 was determined to be 5.3 x 10(-4) M (0.88 mg/ml), and that for nafarelin, greater than 2 mg/ml. At higher concentrations (approximately 4-8 mg/ml), nafarelin and detirelix formed nematic liquid crystals of undulose extinction (birefringence, less than 0.001). The thermodynamic stability of these peptide liquid crystals was probed by determining their melting points (Tcm) in the presence of propylene glycol, a solvent which proved to be efficacious at suppressing gelation and at destabilizing liquid crystals as measured by a reduction in Tcm.

There appear to be conserved constraints on the distribution of nucleotide sequences in cellular genomes.

The data from a genomic library can be sorted into the frequencies of every possible tetranucleotide in the sequence. This tabulation, a short sequence distribution, contains the frequency of occurrence of the 256 tetranucleotides and thus seems to serve as a vehicle for averaging sequence information. Two such distributions can be readily compared by correlation. Reported here are correlations (Spearman rs) of the distributions from all of the genomic libraries in GenBank 44.0 with sizes equal to or larger than that of Salmonella typhimurium, except for the data for mouse and humans. All of the organisms examined showed highly significant correlations between the two DNA strands (not the complementarity expected from base pairing). Of 155 comparisons between libraries, 132 showed significant correlations at the 99% confidence level. Application of the correlation coefficients as a similarity matrix clustered most organisms in a phenogram in a pattern consistent with other hypotheses. This suggests a highly conserved pattern underlying all other genetic information in cellular DNA and affecting both DNA strands, perhaps caused by interaction with conserved factors necessary for DNA packaging.

The F pilus of Escherichia coli appears to support stable DNA transfer in the absence of wall-to-wall contact between cells.

Separation of HfrC-F- mating pairs of Escherichia coli by a filter 6 microns thick with straight-through pores 0.01 to 0.1 micron in diameter did not prevent DNA transfer. We conclude that the F pilus alone is capable of acting as a stable conduit for cell-to-cell DNA transfer.

The sequence asymmetry of the Escherichia coli chromosome appears to be independent of strand or function and may be evolutionarily conserved.

I have examined potential determinants of the asymmetric distribution of nucleotide sequences in the genome of Escherichia coli as cataloged in GenBank release 44. I have used the frequency of occurrence of all possible tetranucleotides in a given sequence catalog or derivative as a comparative measure of asymmetry. The GenBank-cataloged strand and its complement show statistically similar (not complementary) distributions. The distribution is statistically similar in comparisons between the protein coding subset and the total genome, the coding subset and selected non-coding genes, the coding subset and the remainder of the DNA, and the coding subset and stable RNA sequences. I have compared the distribution in the genome of E. coli with the distributions found in the cataloged genomes of Salmonella typhimurium, Bacillus subtilis, and of coliphages lambda and T7. The distribution summed in both strands of the cataloged DNA differs statistically only in comparisons with lytic bacteriophage T7 because only the two strands of T7 show statistically dissimilar distributions. Despite similarities in tetranucleotide distribution, the pattern of codon complementarity in B. subtilis is different than that documented for E. coli. Thus, sequence asymmetry does not seem related to specific DNA function or to documented similarities or differences in codon bias. The sequence asymmetry of the E. coli genome may thus reflect a hitherto unsuspected pattern impressed on both strands of DNA which is or can be packaged into bacterial genomes.

Antitumour activity and pharmacokinetics of niosome encapsulated adriamycin in monolayer, spheroid and xenograft.

Niosomes are multilamellar vesicles formed from nonionic surfactants of the alkyl or dialkyl polyglycerol ether class and cholesterol. Adriamycin has been trapped within vesicles prepared from a monoalkyl triglycerol ether and its activity compared with adriamycin solution in human lung tumour cells grown in monolayer and spheroid culture and in tumour xenografted nude mice. The activity of the encapsulated adriamycin in vitro is maintained with similar clonogenic survival curves following treatment of monolayers and identical growth delays following spheroid exposure. The pharmacokinetics of adriamycin are altered in vivo in human lung tumour-bearing nude mice, when it is administered in niosomal form. There is prolonged release of drug from the plasma compartment with significantly lower peak levels; lower peak cardiac adriamycin concentrations with a shorter tissue half-life and decreased cardiac AUC and a greater degree of hepatic metabolism to inactive 7-deoxyaglycones. The tumour peak drug level and AUC was similar irrespective of the mode of administration of adriamycin. The growth delay (i.e. the time taken for the tumour volume to double) was significantly longer for adriamycin (15 days) and niosomal adriamycin (11 days) than for control (5.8 days). It is possible that the therapeutic ratio of adriamycin could be enhanced by administration in niosomal form.

The distribution of doxorubicin in mice following administration in niosomes.

Large multilamellar non-ionic surfactant vesicles (niosomes) with diameters of around 800-900 nm prepared from a C16 triglyceryl ether with and without cholesterol and containing doxorubicin (Adriamycin) were administered to S180 tumour-bearing NMRI mice by bolus injection. Although in-vitro drug release from cholesterol-containing niosomes is delayed, in-vivo there was little difference between the two preparations when plasma levels were compared. As previously observed, half-lives of the drug were prolonged compared with free solution profiles. Liver uptake was not significantly affected by niosome encapsulation of doxorubicin. There is minor accumulation of drug in the lung, perhaps because of aggregation of the vesicles and their physical entrapment. Tumour levels of drug were higher following administration of cholesterol-containing niosomes and this was reflected in the more effective reduction in tumour growth. Metabolism of doxorubicin is altered by niosomal administration, but more studies are required before the significance of the metabolic data can be assessed.

On the abundance and distribution of protozoa and their food in a productive freshwater pond.

We have examined and quantified the protozoa living in a productive freshwater pond during a 2-day period in June 1987. Over 90 species were recognised. The planktonic and benthic communities were dominated by ciliates and heterotrophic flagellates although the large amoeba Pelomyxa palustris was abundant (102 ml(-1)) in anaerobic sediments. Picoplankton averaged 1.4 × 10(7) ml(-1), phototrophic nanoplankton 0.8 × 10(5) ml(-1), heterotrophic nanoplankton 0.9 × 10(5) ml(-1) and planktonic ciliates 1.3 × 10(2) ml(-1). Numbers were about two orders of magnitude higher in the sediment. Protozoan biomass ranged from 3% to 61% of the total plankton biomass. Heterotrophic flagellates were the principal grazers of the picoplankton. Planktonic ciliates fed mainly on phototrophic nanoplankton but they probably also ingested heterotrophic flagellates. Benthic ciliates were predominantly bactivorous. Competition between ciliate species was minimised by both spatial and food niche separation. Ten species of planktonic ciliates appeared to contain algal symbionts: one species (Strombidium viride) contained structures resembling sequestered chloroplasts. These findings concerning the diversity and abundance of protozoa in a freshwater pond are consistent with the consensus opinion expressed in the marine literature that protozoa play a fundamental role in microbial food webs within aquatic ecosystems.