Clinical comparison between glucose and sucrose additions to a basic electrolyte mixture in the outpatient management of acute gastroenteritis in children

In a double-blind trial in 94 children attending outpatients the value of glucose or a sucrose addition to a basic electrolyte mixture for the management of acute gastroenteritis was compared. Of the children treated with added sucrose 10% failed to respond compared with 27% of those treated with added glucose. This difference was significant (P=0-05), but the time to recovery in those in the two groups who responded to treatment was not significantly different. Thus, despite theoretical advantages, there was no practical advantage in using glucose rather than sucrose. A 5% sucrose electrolyte solution with its relatively low osmolality, ready availability, and ease of preparation is recommended as the treatment of choice in the outpatient management of acute gastroenteritis in infancy.     

Symphysis-fundal height growth chart of an obstetric cohort of 817 Mozambican women with ultrasound-dated singleton pregnancies

Our aim was to construct a new symphysis-fundus height (SFH) growth chart, based on Mozambican women with ultrasound-dated singleton pregnancy, who represent the largest obstetric cohort in a developing country followed for this purpose. Two antenatal clinics were chosen in the suburban area of Maputo City. A cohort of 904 consecutively recruited antenatal clients was followed until delivery. The growth of the SFH was measured every second to third week. Gestational age was determined by ultrasound at enrolment. Women with multiple pregnancy or with gestational age > 21 weeks at enrolment were excluded. The average number of antenatal SFH measurements per woman was 7.8 (SD 2.4). The drop out rate was 9.6%. Mean birthweight was 2909 g. Pre-term deliveries occurred in 15% and low birthweight deliveries (< 2500 g) in 16%. Using proper longitudinal methods, we constructed an FH growth chart and compared it with various previously published SFH charts, which showed the Mozambican chart to be 0-3 cm below the others. Nulliparous women were 0.5 cm below multiparous women. We did not find any difference in the SFH growth charts between women with or without overt morbidity. Women with a body mass index (BMI) < 19 and women with a BMI > 27 had approximately 1 cm lower and 1 cm higher readings, respectively, than women with normal BMI. The Mozambican SFH growth chart is an example of an elaborated growth chart for a well-defined population in a low-income country. It constitutes the basis for further studies to predict the small-for-gestational age newborn from anthropometrical data obtained by use of appropriate technology.     

Care management, dementia care and specialist mental health services: an evaluation

OBJECTIVE: To evaluate a model of intensive case management for people with dementia based in a community-based mental health service for older people. METHOD: Quasi-experimental design. Individuals in one community team setting received case management and were compared with those in a similar team without such a service. Forty-three matched pairs were identified. Eligible older people and their carers were interviewed at uptake and again at 6 and 12 months. RESULTS: The impact of the scheme upon placement occurred in the second year at the end of which 51% of the experimental group remained at home compared with 33% of the comparison group. For the experimental group significant improvements in the social contacts of older people were noted; a decrease in the stress of their carers was observed, together with a reduction in their input to the care of the client; and there were significant improvements on ratings of overall need reduction, aspects of daily living and level of risk. Differences between the two groups based on service receipt showed higher costs for the experimental group. DISCUSSION: The benefits to older people and their carers confirms previous findings that the most effective case management interventions are those targeted on a highly specific client group. Issues which influence the cost-effectiveness of intensive case management are discussed. The benefits of locating this service within a specialist mental health team are explored in the context of current initiatives to promote greater service integration between health and social services.     

Repeated maternal glucocorticoid administration and the developing liver in fetal sheep

Prenatal glucocorticoid exposure has been associated with a reduction in birth weight and postnatal alterations in glucose homeostasis and hypothalamic-pituitary-adrenal (HPA) axis function. The mechanisms underlying these responses are unknown, although changes in fetal hepatic development may play an important role. The fetal liver produces key regulators of fuel metabolism and of the developing HPA axis that are altered by glucocorticoids. The local availability of glucocorticoids is regulated, in part, by corticosteroid-binding protein (CBG), glucocorticoid receptors (GR) and by the enzyme 11beta-hydroxysteroid dehydrogenase (11betaHSD), but the effects of maternal glucocorticoid administration on the expression of these genes in the fetal liver are unknown. 11betaHSD1 is the predominant form of this enzyme present in the liver and is responsible for the conversion of cortisone to cortisol. To determine if prenatal glucocorticoid exposure alters fetal hepatic regulation of CBG, 11betaHSD1 and GRs, we treated pregnant ewes with betamethasone (0.5 mg/kg) intramuscularly at 104, 111 and 118 days of gestation (term 150 days). Animals were killed at 125 or 146 days of gestation. Maternal betamethasone administration did not alter mean cord plasma glucose but significantly decreased cord plasma insulin levels (P<0.05) at 125 days of gestation. At 146 days of gestation, cord plasma glucose levels were significantly increased without alterations in insulin levels following maternal betamethasone treatment (P<0.05). Maternal betamethasone administration resulted in a significant increase in fetal hepatic 11betaHSD1 mRNA and protein levels at 125 days of gestation (P<0.05). CBG mRNA levels were significantly elevated over control at 125 days although levels of CBG protein were not significantly different. GR protein levels were not statistically different at either 125 or 146 days of gestation following glucocorticoid administration. These data suggest that prenatal betamethasone exposure in the ovine fetus results in alterations in cord glucose and insulin levels as well as alterations in hepatic 11betaHSD1 mRNA and protein expression. These changes in 11betaHSD1 increase the potential to generate local cortisol from circulating cortisone. We speculate that this could affect expression of glucocorticoid-dependent hepatic enzymes involved with the regulation of glucose production and HPA responsiveness.     

PCR-targeted Streptomyces gene replacement identifies a protein domain needed for biosynthesis of the sesquiterpene soil odor geosmin

Streptomycetes are high G+C Gram-positive, antibiotic-producing, mycelial soil bacteria. The 8.7-Mb Streptomyces coelicolor genome was previously sequenced by using an ordered library of Supercos-1 clones. Here, we describe an efficient procedure for creating precise gene replacements in the cosmid clones by using PCR targeting and lambda-Red-mediated recombination. The cloned Streptomyces genes are replaced with a cassette containing a selectable antibiotic resistance and oriT(RK2) for efficient transfer to Streptomyces by RP4-mediated intergeneric conjugation. Supercos-1 does not replicate in Streptomyces, but the clones readily undergo double-crossover recombination, thus creating gene replacements. The antibiotic resistance cassettes are flanked by yeast FLP recombinase target sequences for removal of the antibiotic resistance and oriT(RK2) to generate unmarked, nonpolar mutations. The technique has been used successfully by >20 researchers to mutate around 100 Streptomyces genes. As an example, we describe its application to the discovery of a gene involved in the production of geosmin, the ubiquitous odor of soil. The gene, Sco6073 (cyc2), codes for a protein with two sesquiterpene synthase domains, only one of which is required for geosmin biosynthesis, probably via a germacra-1 (10) E,5E-dien-11-ol intermediate generated by the sesquiterpene synthase from farnesyl pyrophosphate.     

Estrogen, progesterone, prolactin, prostaglandin E2, prostaglandin F2 alpha, 13,14-dihydro-15-keto-prostaglandin F2 alpha, and 6-keto-prostaglandin F1 alpha gradients across the uterus in women in labor and not in labor

Before or during labor in humans, changes in peripheral levels of estrogen and progesterone are not evident. Local alterations of estrogen, progesterone, and prolactin concentrations may be present and be accompanied by prostaglandin changes. The purpose of this study was to investigate the differences in concentrations of these hormones across the uterus and to evaluate their interrelationships in patients at term gestation with and without labor. Blood samples were obtained from a radial artery and a uterine vein in 22 women without and in 10 with labor. The difference between levels in the two blood vessels was designated as the gradient. Neither levels nor gradients were different between the two groups for estrone, estradiol, estriol, progesterone, or prolactin. The plasma levels of prostaglandin F2 alpha, 13,14-dihydro-15-keto-prostaglandin F2 alpha, and prostaglandin E2 were significantly increased in labor. Prostacyclin levels, as indicated by the 6-keto-prostaglandin F1 alpha metabolite, were not altered. The gradients for prostaglandin F2 alpha and E2 were significantly increased in labor. The results of the study also suggested that, in gestation at term, serum prolactin is produced mainly by the pituitary and that estrone may originate from peripheral conversion of estradiol. We conclude that in humans prostaglandin gradients of the E and F groups are increased in labor. These increases are not associated with changes in sex steroids or prolactin. Prostacyclin metabolite gradients also appear not to be altered in labor, suggesting that some prostaglandins are selectively increased in early labor either by enhanced production or decreased metabolism or both.     

Plasma adrenocorticotropic hormone and cortisol and adrenal blood flow during sustained hypoxemia in fetal sheep

We examined the effect of sustained hypoxemia with progressive acidemia on pituitary-adrenal endocrine function (adrenocorticotropic hormone, cortisol) and on adrenal blood flow in fetal sheep. Hypoxemia was induced by the maternal sheep breathing a gas mixture containing 9% oxygen, with 3% carbon dioxide added. Induced hypoxemia resulted in a progressive fetal metabolic acidosis but with little change in maternal pH. During induced hypoxemia there was little change in maternal plasma adrenocorticotropic hormone or cortisol level. Fetal adrenocorticotropic hormone and cortisol increased to peak values within 2.8 hours of induced hypoxia but by 7.2 hours had begun to fall to values that were not significantly different from those at 1.4 hours. Fetal adrenal blood flow (microsphere technique) also increased significantly and remained elevated throughout the duration (7.2 hours) of hypoxemia. The maximum fetal adrenal blood flow achieved during hypoxemia was significantly correlated with the basal (prehypoxemia) flow to the adrenals. We conclude that the changes in fetal adrenocorticotropic hormone, cortisol, and adrenal blood flow seen in short-term hypoxemia are reproduced during sustained hypoxemia with acidemia. Furthermore, the noted rise in the fetal adrenocorticotropic hormone level may be an important factor contributing to the increase in adrenal blood flow during hypoxemia.     

Perceptions of flexible training in medicine

Most flexible trainees believe that their full-time colleagues perceive flexible training as flawed in some way. However, most consultants and full-time trainees actually view flexible trainees and their posts in a positive light.