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A case of metastasising colonic carcinoma associated with Peutz-Jeghers syndrome in a 39 year old man is described. The caecal adenocarcinoma had metastasised widely to regional lymph nodes and was associated with several other colonic Peutz-Jeghers polyps, showing no evidence of dysplasia or malignancy. It was not possible to determine whether the carcinoma had arisen from a Peutz-Jeghers polyp. The patient also had gastric and small intestinal polyps. The serum carcinoembryonic antigen (CEA) was normal at presentation in this patient and in one other reported case. The use of this determination as a screening test for so-called high risk groups is, therefore, not supported by this report. The risk of malignancy is not known. It will only be determined by careful follow up of a defined Peutz-Jeghers syndrome population and comparison of carcinoma incidence with a matched sample of the general population. A national registry of Peutz-Jeghers syndrome patients in the United Kingdom would help to resolve this question. [ABSTRACT FROM PUBLISHER]

A letter to the editor is presented in response to an article about the outpatient treatment of ingrowing toenails.

Objective This paper presents a brief description of an activity to redesign a nursing assessment followed by a critique of the practice development process used. Setting Adult acute care general hospital wards. Primary argument Practice development can address shortfalls in clinical practice by using a systematic process to change practice so improving health care. Through the application of a professional development activity addressing assessment the described process provides the basis for a critique that gives directions for ongoing similar activities. Conclusions Directions identified for ongoing practice development activities are: engage all staff in the change process who own the practice; appoint alternative persons with delegated authority for key facilitators; build professional development into the practice change; provide service users (eg patient representatives) with mentoring; develop transformational strategies that address not only the dominant organisational culture but also existing subcultures; and employ an emancipatory practice development process. The main recommendation for practice development in bureaucratic organisations is to develop and establish the evidence base necessary to ensure the process is effective. [ABSTRACT FROM AUTHOR]

The membrane spanning enzyme γ-glutamyl transpeptidase (γ-GT; EC 2.3.2.2) catalyses the breakdown of the tripeptide glutathione and uses free amino acids (AA) to form γ-glutamyl transpeptidase (GT) AA that become transported into cells and converted back into free AA. γ-Glutamyl transpeptidase activity has been shown to be important for mammary AA uptake in rodent systems, and while γ-GT activity is high in lactating bovine mammary tissue, the role of this enzyme in milk protein synthesis of the ruminant has not been defined. The present study shows that γ-GT activity in the ovine mammary gland, like that of rodents, increases during pregnancy and peaks early in lactation. Acivicin, a well-known inhibitor of γ-GT, decreased γGT activity in acini isolated from the ovine mammary gland and did not have secondary toxicity effects on cell viability or the uptake of radiolabeled amino-isobutyric acid. Isolated ovine acini were incubated in the presence of radiolabeled leucine, and incorporation of label into secreted protein increased during incubation. Incubation of acini with acivicin decreased milk protein secretion by 75%, indicating that γ-GT plays an important role in milk protein production in the ruminant. Acivicin did not inhibit secretion of specific caseins but caused a global decrease in individual proteins suggesting that γ-GT may be responsible for providing a complement of AA for milk protein synthesis. [ABSTRACT FROM AUTHOR]

Abstract: The prevalence of ageism in health care prevents nurses from providing the best care to older adults. Nursing education can prepare nurses to proactively dismantle their own ageist views as well as ageist practices within health care settings. Active learning strategies, such as role-play and case studies, can be used to teach nurses how to become anti-ageism advocates and improve the quality of health care for older adults., Competing Interests: The author has declared no conflict of interest., (Copyright © 2023 National League for Nursing.)

Transthoracic echocardiography (TTE) is widely utilised within many aspects of clinical practice, as such the demand placed on echocardiography services is ever increasing. In an attempt to provide incremental value for patients and standardise patient care, the British Society of Echocardiography in collaboration with the British Heart Valve Society have devised updated guidance for the indications and triaging of adult TTE requests for TTE services to implement into clinical practice., (© 2022. The Author(s).)

Introduction: Optimal management of people with advanced NSCLC depends on accurate identification of predictive markers. Yet, real-world data in this setting are limited. We describe the impact, timeliness, and outcomes of molecular testing for patients with advanced NSCLC and good performance status in England., Methods: In collaboration with Public Health England, patients with stages IIIB to IV NSCLC, with an Eastern Cooperative Oncology Group performance status of 0 to 2, in England, between June 2017 and December 2017, were identified. All English hospitals were invited to record information., Results: A total of 60 of 142 invited hospitals in England participated in this study and submitted data on 1157 patients. During the study period, 83% of patients with advanced adenocarcinoma underwent molecular testing for three recommended predictive biomarkers (EGFR, ALK, and programmed death-ligand 1). A total of 80% of patients with nonsquamous carcinomas on whom biomarker testing was performed had adequate tissue for analysis on initial sampling. First-line treatment with a tyrosine kinase inhibitor was received by 71% of patients with adenocarcinoma and a sensitizing EGFR mutation and by 59% of those with an ALK translocation. Of patients with no driver mutation and a programmed death-ligand 1 expression of greater than or equal to 50%, 47% received immunotherapy., Conclusions: We present a comprehensive data set for molecular testing in England. Although molecular testing is well established in England, timeliness and uptake of targeted therapies should be improved., (© 2021 The Authors.)

Spinal fusion surgery is a major surgery that results in severe postoperative pain, therefore pain reduction is a primary concern. New strategies for pain management are currently under investigation and include multimodal treatment. A 3-year retrospective analysis of patients with idiopathic scoliosis undergoing spinal fusion surgery was performed at our hospital, assessing patient pain scores, opioid use, and recovery. We evaluated the effect of adding continuous infusion of local anesthetics (CILA) to a postoperative pain management protocol that includes intraoperative intrathecal morphine, as well as postoperative patient-controlled analgesia and oral opioid/acetaminophen combination. The study compared 25 patients treated according to the standard protocol, with 62 patients treated with CILA in addition to the pain management protocol. Patients in the CILA group used nearly 0.5 mg/kg less opioid analgesics during the first 24 hours after surgery.

The membrane spanning enzyme gamma-glutamyl transpeptidase (gamma-GT; EC 2.3.2.2) catalyses the breakdown of the tripeptide glutathione and uses free amino acids (AA) to form gamma-glutamyl transpeptidase (GT) AA that become transported into cells and converted back into free AA. gamma-Glutamyl transpeptidase activity has been shown to be important for mammary AA uptake in rodent systems, and while gamma-GT activity is high in lactating bovine mammary tissue, the role of this enzyme in milk protein synthesis of the ruminant has not been defined. The present study shows that gamma-GT activity in the ovine mammary gland, like that of rodents, increases during pregnancy and peaks early in lactation. Acivicin, a well-known inhibitor of gamma-GT, decreased gamma-GT activity in acini isolated from the ovine mammary gland and did not have secondary toxicity effects on cell viability or the uptake of radiolabeled amino-isobutyric acid. Isolated ovine acini were incubated in the presence of radiolabeled leucine, and incorporation of label into secreted protein increased during incubation. Incubation of acini with acivicin decreased milk protein secretion by 75%, indicating that gamma-GT plays an important role in milk protein production in the ruminant. Acivicin did not inhibit secretion of specific caseins but caused a global decrease in individual proteins suggesting that gamma-GT may be responsible for providing a complement of AA for milk protein synthesis.

Background and Purpose: This study examined whether differences exist about physical therapists' opinions and practices regarding the use of direct access between therapists practicing in Massachusetts, a direct-access state, and therapists practicing in Connecticut, a state that allows only evaluation without referral. A second purpose was to examine direct-access practices of therapists in Massachusetts., Subjects: A sample of 329 therapists in Massachusetts and 179 therapists in Connecticut were surveyed., Methods: A cover letter, questionnaire, and return-reply envelope were mailed to each therapist. Independent group t tests and chi-square analyses were used to determine whether therapists' opinions about direct access differed between states. Frequencies were calculated to examine direct-access practices of therapists in Massachusetts., Results: Adjusted response rates were 65.5% in Massachusetts and 57.9% in Connecticut. Therapists in both states were equally supportive of direct access (74.9%). Therapists in Connecticut were more supportive of three stipulations regulating direct access than therapists in Massachusetts were. In Massachusetts, 34.0% of the respondents stated that they practiced using direct access, and 8.8% of the patients seen by the therapists sampled were treated without physicians' referrals. The therapists indicated that the most common reasons for limited use of direct access were employer policies and lack of insurance reimbursement., Conclusion and Discussion: Therapists in Connecticut favored more stipulation regulating direct access than therapists in Massachusetts did. Although therapists in both states appear to be supportive of direct access, the number of patients in Massachusetts seen through this mode of care appears to be limited because of practice and financial restraints.

Accumulation of lactoferrin mRNA in mammary tissue from virgin, pregnant, lactating, and involuting ewes and cows was localized using 35S-labeled cRNA probes. Expression of lactoferrin was low in the glands of virgin animals. In the glands of animals in early pregnancy, very high expression occurred in the ducts and immature alveoli, but expression tended to decrease as the alveoli matured. In the lactating and involuting gland, expression was generally low or absent in actively secreting alveoli and high in alveoli that had an accumulation of vesicles in the lumen and secretory epithelium, which was indicative of stasis. Occasionally, expression of lactoferrin was seen in cells that appeared to be secretory, particularly in involuting glands. Lactoferrin mRNA was expressed not only at different sites from other milk protein genes, such as alpha-lactalbumin and alpha s1-casein, but also during different stages of mammary development, supporting the view that the expression of lactoferrin is regulated differently from that of other milk proteins. For all ewes and cows, lactoferrin mRNA was detected in the epithelial ducts of the mammary parenchyma and the teat in a gradient that increased in ducts nearer the teats. The expression of lactoferrin in the ductal epithelium close to the teat was consistent with the antibacterial role of lactoferrin.

The factors influencing iron binding and release by lactoferrin have been addressed by comparison of the native full length molecule (Lf) with the N-terminal half of human lactoferrin (LfN) produced from the cloned cDNA expressed in baby hamster kidney (BHK) cells. The coding sequences for LfN were inserted into the expression vector pNUT between the metallothionein promoter and the human growth hormone transcription termination sequences. Transformed BHK cells were grown in roller bottles where concentrations of LfN as high as 35 mg/liter were obtained. The pure protein, produced by the transformed BHK cells, was characterized by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, protein blotting and immunodetection, N-terminal sequence analysis, UV-visible spectroscopy, electron spin resonance spectroscopy, and measurements of metal binding and release. By these criteria LfN was found to be correctly processed, glycosylated, and able to bind iron reversibly. Both UV-visible and electron spin resonance spectra of the half molecule were very similar to those of native lactoferrin and the full length lactoferrin produced in BHK cells, but there were marked differences in the pH at which iron release occurred. Iron release from LfN occurs in the pH range 6.0-4.0, compared with 4.0-2.5 for native lactoferrin and 6.2-4.0 for transferrin. These results suggest that the more facile release of iron from LfN compared with native lactoferrin results from the absence of stabilizing contacts between the N- and C-terminal halves and that the characteristic difference in pH stability between lactoferrins and transferrins is due primarily to differences in these interactions.