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Background:The scale of the 2022 global mpox (formerly known as monkeypox) outbreak has been unprecedented. In less than 6 months, non-endemic countries have reported more than 67 000 cases of a disease that had previously been rare outside of Africa. Mortality has been reported as rare but hospital admission has been relatively common. We aimed to describe the clinical and laboratory characteristics and outcomes of individuals admitted to hospital with mpox and associated complications, including tecovirimat recipients. Methods:In this cohort study, we undertook retrospective review of electronic clinical records and pathology data for all individuals admitted between May 6, and Aug 3, 2022, to 16 hospitals from the Specialist and High Consequence Infectious Diseases Network for Monkeypox. The hospitals were located in ten cities in England and Northern Ireland. Inclusion criteria were clinical signs consistent with mpox and MPXV DNA detected from at least one clinical sample by PCR testing. Patients admitted solely for isolation purposes were excluded from the study. Key outcomes included admission indication, complications (including pain, secondary infection, and mortality) and use of antibiotic and anti-viral treatments. Routine biochemistry, haematology, microbiology, and virology data were also collected. Outcomes were assessed in all patients with available data. Findings:156 individuals were admitted to hospital with complicated mpox during the study period. 153 (98%) were male and three (2%) were female, with a median age of 35 years (IQR 30–44). Gender data were collected from electronic patient records, which encompassed full formal review of clincian notes. The prespecified options for data collection for gender were male, female, trans, non-binary, or unknown. 105 (71%) of 148 participants with available ethnicity data were of White ethnicity and 47 (30%) of 155 were living with HIV with a median CD4 count of 510 cells per mm3(IQR 349–828). Rectal or perianal pain (including proctitis) was the most common indication for hospital admission (44 [28%] of 156). Severe pain was reported in 89 (57%) of 156, and secondary bacterial infection in 82 (58%) of 142 individuals with available data. Median admission duration was 5 days (IQR 2–9). Ten individuals required surgery and two cases of encephalitis were reported. 38 (24%) of the 156 individuals received tecovirimat with early cessation in four cases (two owing to hepatic transaminitis, one to rapid treatment response, and one to patient choice). No deaths occurred during the study period. Interpretation:Although life-threatening mpox appears rare in hospitalised populations during the current outbreak, severe mpox and associated complications can occur in immunocompetent individuals. Analgesia and management of superimposed bacterial infection are priorities for patients admitted to hospital.

It is unknown whether rectus sheath catheter (RSC) continuous infusion of local anaesthetic is superior to standard post-operative opiate analgesia following major abdominal surgery. Previous audit in our Trust had suggested RSC was very effective and reduced opiate analgesia use. We aimed to see if this was maintained as the technique became more widespread comparing clinical outcomes and post-operative opiate analgesia requirements between patients who had RSCs and those that did not following major abdominal surgery over a 32-month period.A retrospective observational study investigated patients who had major abdominal surgery at a single centre in the UK between January 2018 and August 2020. Placement of RSCs was at the discretion of the surgical team according to their own personal choice. All patients having the procedure in both an elective and non-elective setting have been included in this study, including patients requiring higher level care after emergency surgery. Clinical outcomes and post-operative opiate analgesia requirements (oral and intravenous) were analysed using multivariate logistic regression models adjusting for American Association of Anesthesiologists (ASA) grade and type of surgery (emergency vs elective and open vs laparoscopic).There were 911 patients; 276/911 (30.3%) RSC and 635/911 (69.7%) non-RSC. Median age was 64 (52-74) years; 51.6% were male. In the adjusted models, RSC was associated with a reduced likelihood of serious complications (OR 0.49 (95% CI 0.33, 0.72); p 0.001) and lower length of stay in ICU (OR 0.95 (95% CI 0.91, 0.99); p = 0.029). RSC was not associated with reduced post-operative opiate analgesia use. There were 3/276 (1.1%) adverse events following RSC placement during the period of data collection.Clinical outcomes may be superior for patients following major abdominal surgery when RSCs are placed for post-operative analgesia but uncertainty remains. This paper highlights the difficulty with retrospective non-selected data in answering this question. High quality prospective randomised data are required to determine the effects on clinical outcomes and post-operative opiate analgesia requirements.

Background: It has been documented that the mortality rate in diabetic persons can reach 10%. In addition, it has been shown that the rate of mortality and the need for respiratory support are higher among newly diagnosed cases of diabetes mellitus compared with patients known to have diabetes mellitus for a relatively long duration. In the setting of the pandemic of COVID-19, glycemic control for the patients admitted to hospitals is critical, as is diabetes screening to uncover undiagnosed cases.Aim of the study: To explore the possible link between diabetes mellitus and COVID-19 in Iraq Patients and methods: The current research was carried out in Al-Diwaniyah Province, Iraq, in Al-Diwaniyah Teaching Hospital, including the word of medicine, respiratory unit, and intensive care unit. The study started on Sept 15, 2021 and ended on Apr 15, 2022. The study was cross-sectional and included 100 patients with a diagnosis of COVID-19 evidenced by polymerase chain reaction (PCR) test and CT-scan “computed tomography scan of the chest. Those patients were chosen randomly from the pool of patients visiting the teaching hospital. The age range of patients was between 18 and 94 years, with 45 males and 55 females. Laboratory investigation results were retrieved from patients’ records and included random blood sugar, lactate dehydrogenase, d-dimer, HbA1c%, and “C-reactive protein (CRP).” Results: The mean values of age, random blood sugar (RBS), lactate dehydrogenase (LDH), d-dimer, HbA1c, and HS-CRP were comparable between males and females (p > 0.05). Patients with high HbA1c levels (HbA1c ≥ 6.5%) were older and had significantly higher levels of random blood sugar and d-dimer than patients with HbA1c is less than 6.5%. The d-dimer level showed a significant positive correlation to RBS, LDH, HbA1c, and HS-CRP (p is less than 0.05). Conclusion: Higher levels of markers of inflammation were associated with HbA1c levels in the diabetic range, indicating a bi-directional relation between diabetes mellitus and the severity of COVID-19.

Multi-walled carbon nanotubes (MWCNTs) are composed of multiple coaxially arranged graphene cylinders. MWCNTs range in diameter from 1 to over 100 nm depending on the number of constituting graphene cylinders. MWCNTs can be divided into two general subtypes, straight and tangled: increasing the number of constituent graphene cylinders increases the number of layers that compose the carbon nanotube wall, and as the number of wall layers increase, the wall thickness increases and the MWCNT becomes more rigid and straight. MWCNTs with a low number of wall layers are flexible and can assemble into tangled agglomerates. We initially showed MWCNT-N, a straight-type MWCNT with 30-40 walls, induced lung tumors and mesotheliomas after administration by intra-tracheal intra-pulmonary spraying (TIPS): rats were administered a total dose of 1mg/rat during the initial 2 weeks of the study, and animals were observed for 2 years without any further treatments. Using this short-term dosing and 2-year observation method we conducted carcinogenicity tests for other MWCNTs with different cylinder wall layers. We found that both straight type MWCNTs, MWCNT-7 (40 layers), MWCNT-A (150 layers), and tangled type MWCNTs, MWCNT-B (15 layers) and double-walled CNT (DWCNT) (2 layers) induced lung tumors and/or pleural mesotheliomas. In contrast to these results, we found carbon nanohorns, carbon nanostructures composed of single-walled carbon nanotubes (SWCNT), and carbon nanobrushes, a fibrous aggregate of carbon nanohorns, were not carcinogenic. Data on foreign body radical production, microarray and mutational signature analyses, and gene alterations will be presented.

A number of studies have highlighted physiological data from the first surge in critically unwell Covid-19 patients but there is a paucity of data describing emerging variants of SARS-CoV-2, such as B.1.1.7. We compared ventilatory parameters, biochemical and physiological data and mortality between the first and second COVID-19 surges in the United Kingdom, where distinct variants of SARS-CoV-2 were the dominant stain. We performed a retrospective cohort study investigating critically unwell patients admitted with COVID-19 across three tertiary regional ICUs in London, UK. Of 1782 adult ICU patients screened, 330 intubated and ventilated patients diagnosed with COVID-19 were included. In the second wave where B.1.1.7 variant was the dominant strain, patients were had increased severity of ARDS whilst compliance was greater (p

Plant growth-promoting rhizobacteria (PGPR) are associated with plant roots and use organic compounds that are secreted from root exudates as food and energy source. Root exudates can chemoattract and help bacteria to colonize the surface of plant roots by inducing chemotactic responses of rhizospheric bacteria. In this study, we show that root colonization of Brachypodium distachyon by Bacillus velezensis strain B26 depends on several factors. These include root exudates, organic acids, and their biosynthetic genes, chemotaxis, biofilm formation and the induction of biofilm encoding genes. Analysis of root exudates by GC-MS identified five intermediates of the TCA cycle; malic, fumaric, citric, succinic, oxaloacetic acids, and were subsequently evaluated. The strongest chemotactic responses were induced by malic, succinic, citric, and fumaric acids. In comparison, the biofilm formation was induced by all organic acids with maximal induction by citric acid. Relative to the control, the individual organic acids, succinic and citric acids activated the epsD gene related to EPS biofilm, and also the genes encoding membrane protein (yqXM) and hydrophobin component (bslA) of the biofilm of strain B26. Whereas epsA and epsB genes were highly induced genes by succinic acid. Similarly, concentrated exudates released from inoculated roots after 48 h post-inoculation also induced all biofilm-associated genes. The addition of strain B26 to wild type and to icdh mutant line led to a slight induction but not biologically significant relative to their respective controls. Thus, B26 has no effect on the expression of the ICDH gene, both in the wild type and the mutant backgrounds. Our results indicate that root exudates and individual organic acids play an important role in selective recruitment and colonization of PGPR and inducing biofilm. The current study increases the understanding of molecular mechanisms behind biofilm induction by organic acids.

Plant growth-promoting rhizobacteria (PGPR) are associated with plant roots and use organic compounds that are secreted from root exudates as food and energy source. Root exudates can chemoattract and help bacteria to colonize the surface of plant roots by inducing chemotactic responses of rhizospheric bacteria. In this study, we show that root colonization of Brachypodium distachyon by Bacillus velezensis strain B26 depends on several factors. These include root exudates, organic acids, and their biosynthetic genes, chemotaxis, biofilm formation and the induction of biofilm encoding genes. Analysis of root exudates by GC-MS identified five intermediates of the TCA cycle; malic, fumaric, citric, succinic, oxaloacetic acids, and were subsequently evaluated. The strongest chemotactic responses were induced by malic, succinic, citric, and fumaric acids. In comparison, the biofilm formation was induced by all organic acids with maximal induction by citric acid. Relative to the control, the individual organic acids, succinic and citric acids activated the epsD gene related to EPS biofilm, and also the genes encoding membrane protein (yqXM) and hydrophobin component (bslA) of the biofilm of strain B26. Whereas epsA and epsB genes were highly induced genes by succinic acid. Similarly, concentrated exudates released from inoculated roots after 48 h post-inoculation also induced all biofilm-associated genes. The addition of strain B26 to wild type and to icdh mutant line led to a slight induction but not biologically significant relative to their respective controls. Thus, B26 has no effect on the expression of the ICDH gene, both in the wild type and the mutant backgrounds. Our results indicate that root exudates and individual organic acids play an important role in selective recruitment and colonization of PGPR and inducing biofilm. The current study increases the understanding of molecular mechanisms behind biofilm induction by organic acids.

Root colonization by plant-growth-promoting bacteria could not be useful without the beneficial properties of the bacterium itself. Thus, it is necessary to evaluate the bacterial capacity to form biofilms and establish a successful interaction with the plant roots. We assessed the ability of growth-promoting bacterial strains to form biofilm and display chemotactic behaviour in response to organic acids and (or) root exudates of the model plant

Introduction: Diagnosis of pheochromocytoma/paraganglioma (PPGL) can be challenging. Plasma metanephrines have highest sensitivity (96-99%) yet lowest specificity (85%)1 whereas 24-hour urinary metanephrines have 87.5% sensitivity and 99.7% specificity. Diagnostic accuracy depends on factors such as patient positioning and medications, questioning its potential value in a hospital setting. Methods: The audit was performed in a hospital which caters to a population of 400,000. Data was collected retrospectively on patients who had a request for plasma or urine metanephrines from March 2018 – September 2018. Results: A total of 85 patient order requests (58% male, 42% female) were reviewed; only 2 patients were ultimately diagnosed with a pheochromocytoma. The mean age of patients was 48 years. The most common indication for requests was hypertension (64 patients). Locations of order requests included 42% from outpatient clinics, 32% inpatient requests, 18% from Ambulatory Care, 6% by A&E and 2% by GP. Of the 27 (32%) inpatient requests, 10 had positive results: 1 diagnosed with primary aldosteronism, 1 with hypercortisolism and the others had no definite diagnosis. 8/10 patients with positive results did not have a repeat test. Focusing on plasma metanephrines, 52% plasma metanephrines samples were negative, 22% were positive and 26% were not processed due to laboratory error. From the 19 positive plasma metanephrines, adrenal adenoma was present in 7 patients (from this group, 1 was referred for surgery with confirmed diagnosis of pheochromocytoma), 1 patient’s MIBG scan was negative and 1 diagnosis of stress-related raised metanephrines was made. The remaining 10 patients did not undergo an adrenal scan. 9 out of 18 cases with positive urine metanephrines had an adrenal adenoma. In 7/9, plasma metanephrines were positive, the remaining 2 had negative plasma metanephrines. 34 cases with initial negative test still had another urine/plasma metanephrines performed with similar negative result. Furthermore Discussion: This audit highlights the potential pitfalls of investigating PPGL with plasma and urinary metanephrines, and in fact raises the question of its accuracy as an inpatient diagnostic tool as none of the positive inpatient tests resulted in a diagnosis of PPGL. Inappropriate urine and plasma metanephrines requests cause financial burden and patient anxiety. Even with outpatient requests, few positive results led to a PPGL diagnosis. Patient selection and conditions of testing must be more rigorously scrutinised and threshold for positive result must be raised for specificity of the test to be improved in ‘real world’ conditions. References: 1. Lenders JW al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA. 2002.

Doha, the capital of the State of Qatar, has faced enormous economic growth and rapid urban transformation over the last few decades. More recently, this has been accentuated by the construction of major urban public transit systems in the State and a desire to implement the Transit-Oriented Development (TOD) model in new developments and/or urban regeneration projects along the new ‘Doha Metro’ rail network. A TOD is a mixed-use area planned to maximize access to public transport and encourage transit ridership. Scholars argue that TODs encourage sustainable urbanism via enhancement of livability by better integrating transportation and land-use strategies in urban form. This makes it critical to better understand the challenges and benefits that TODs offer for models of urbanism in formulating strategies and guidelines for the planning of sustainable settlements. This study focuses on one major new transit hubs in Qatar: West Bay, the waterfront business district of Doha, and its surrounding neighborhood. The aim of the research study is to evaluate the extent to which the new West Bay TOD will impact livability in the district and surrounding neighborhood. The findings provide a guide for the design and implementation of the TOD model in other districts of Doha to enhance livability for residents and citizens. Keywords: Sustainable Urbanism, Urban Sociology, Urban Regeneration, TODs, Urban Fabric

Quality improvement project (QUIP) concepts are becoming embedded into medical school curricula, with many students now expected to conduct a QUIP as part of their progression. This study aimed to assess whether student-led QUIPs can be effective and sustainable. A systematic literature search was conducted using 5 databases: MEDLINE, Embase, Ovid, CINAHL, and PsycINFO. The authors searched for articles published between January 28, 1978, and January 28, 2018. In all, 3965 articles were identified through database searching, and an additional 9 articles through hand searches. After screening and full-text analysis, 12 articles were included. Greater than 50% of QUIPs described a statistically significant improvement in the primary outcome. However, effective student-led QUIPs were not necessarily sustainable, with a mean final audit at 4.4 months. Medical students have the potential to produce effective QUIPs. There now needs to be a structured approach to give medical students the freedom to test and validate more unique interventions.

Introduction: Podocalyxin-like 1 (PODXL) is an anti-adhesive transmembrane sialomucin whose expression on the membrane of tumor cells, indicates an integral role in tumor progression. Objectives: To evaluate prognostic value of PODXL expression in colorectal carcinoma (CRC). Materials and Methods: Fifty CRC cases were collected randomly from colectomy specimens. Sections were prepared from paraffin blocks and the slides immunohistochemically stained with PODXL. Correlations of PODXL expression with other clinicopathological variables and survival analysis were done. Results: Fourteen percent of cases showed negative expression for PODXL and 86% showed positive expression. A statistically significant relationship was detected between high expression (+3, +4) and patients with stage IV CRC (P = 0.001), positive circumferential margin (P = 0.006), and patients with increased CEA after 6 cycles of chemotherapy (P = 0.002). No statistically significant relationship was detected between PODXL expression and lymph node metastasis (P = 0.30) or T stage (P = 0.60). A higher median overall survival among cases with negative or +1 PODXL was obtained compared to lower median survival among cases with +3 and +4 and the difference is highly significant statistically (P < 0.0001). Conclusion: PODXL was a poor prognostic factor in CRC. PODXL can act as an attractive target for new strategies in treatment, and predicting prognosis in CRC.

Dear editor We read with great interest the expert opinion of Singagireson et al and agree with the key points raised.1 However, this can be seen to be only one part of the multidimensional foundation program application. It is important to add that we feel there are multiple inequitable components that impact on UK medical students’ foundation program application. The author emphasizes that the situational judgment test (SJT) and medical school performance make up two points of the application performance; however, there are two factors that have a larger-than appreciated impact on the foundation program application – “PubMed-referenced publications” and additional degrees (eg, an intercalated BSc or PhD).2 The author raises the question of significant disparities between the opportunities available at medical schools across the UK. This is clearly shown in the national variability in intercalation opportunities – some medical schools offer compulsory BSc-intercalated programs, whereas some schools offer only intercalated degrees to up to a maximum of one-fifth of their students.3,4 Similarly, the foundation program accepts applications from postgraduate medical students who may have previous masters or even PhDs. There are up to five points available for an extra degree in the foundation program application, out of 100; the presence of a PhD adds five application points, with a Master’s or Bachelor’s degree contributing up to four points.2 In addition, publications are valued at up to two points in the foundation program application where one point is available for each PubMed-referenced publication a student has authored, up to a maximum of two points.2 It can be argued that the skills learnt from extra degrees give medical students a far greater opportunity to do research and publish work in a particular field.5 Thus, individuals who have been given an opportunity to study for an extra degree are at an advantage in more than one way when approaching their foundation program application.

ObjectivesTo explore the barriers and facilitators to patients achieving death at home.MethodsIn-depth, semistructured interviews with end-of-life care experts were conducted to develop an insight into the barriers and facilitators to achieving death at home. Thirty-three interviews were conducted compromising of a mixture of face-to-face and tele interviews. Experts included healthcare professionals working in the community, hospital and policy/academic settings. Thematic analysis was undertaken on interview transcripts.ResultsThree overarching themes, further divided into a total of 12 subthemes were identified. The three themes were ‘managing people’, ‘education' and ‘planning’. The ‘managing people’ theme included subthemes of patient preferences and family influences; the ‘education’ theme encompassed knowledge and training, perceptions of death and communication and the ‘planning’ theme contained seven subthemes including ‘coordination’, ‘resources’ and ‘cost’.ConclusionsMultiple barriers and facilitators to achieving death at home were identified in this study. Of particular significance was the identification of the fear and stigma associated with death among doctors, patients and their families serving as a barrier to home death, not previously identified in the literature. Additionally, the importance of social networks and resource provision were highlighted as key in influencing patient death at home.

Evidence suggests that the majority of patients wish to die at home. However, this is attainable for few.

Despite a growing desire amongst patients to spend their last days at home, many are unable to do so, leaving a lasting effect on both patients and families. We undertook a qualitative study with in- depth, semi-structured interviews in England, UK. A combination of face-to face and telephone interviews were conducted with 33 experts in the field of end-of-life care. These included policy makers, academics and hospital and community healthcare professionals from leading UK organisations. Interviews were transcribed and thematically analysed. As a result, three overarching themes were identified: ‘education’; ‘planning’ and ‘managing people’. These were further divided into a total of 12 sub themes containing practical guidance on enabling better end-of-life care. The theme of ‘planning’ contained seven subthemes including ‘policy’, ‘cost’ and ‘coordination’. The ‘education’ theme included ‘communication’ and ‘perceptions of death’. Of particular significance was the identification of the growing stigma and fear surrounding end-of-life amongst patients and healthcare professionals alike. ‘Managing people’ as a theme included the impact of ‘patient preferences’ and ‘family influences’ on enabling comfortable death at home. In conclusion, multiple barriers and facilitators to achieving death at home were identified in this study. The lack of training, education and funding within the National Health Service was highlighted, as was the importance of sociopolitical factors. These include the lack of social networks amongst elderly patients and the inequality of resource provision in hospitals and communities. We offer a list of recommendations to combat these barriers, paying specific attention to UK end-of-life policy and education.

Idiopathic pulmonary fibrosis (IPF) is characterized by an alveolitis with epithelial and endothelial damage progressing to fibrosis. Numerous mediators have been implicated in this complex process. Studies in humans have shown that endothelin-1 (ET-1), a vasoconstrictor and mitogenic peptide, is a mediator in IPF. To determine the role of ET-1 and endothelin-converting enzyme (ECE)-1 and the effect of Bosentan, an ET receptor antagonist, in an animal model of IPF, we studied three groups of rats (n = 6 each): Group 1, control, received saline; Group 2, fibrosis, received 1.5 U bleomycin intratracheally; Group 3, fibrosis-Bosentan treated, received bleomycin and Bosentan daily by gavage. After 28 d, right upper lobes were fixed for immunohistochemistry (IHC) and sections were stained with antisera to ET-1 and ECE-1 and graded semiquantitatively. Sections from left lungs were embedded in paraffin and stained for light microscopic morphometry to quantitate the fibrosis. By IHC, we found increased ET-1 immunoreactivity (ir) in airway epithelium and inflammatory cells, and ECE-1-ir in airway epithelium, type II pneumocytes and endothelial cells (p < 0.05). By morphometry, the volume fraction (Vv) of connective tissue (CT) increased and the Vv of air decreased in the fibrosis group compared with that in the control group. Bosentan reduced the Vv of CT and increased the Vv of air compared with that in the fibrosis group (p < 0.05). These results indicate that ET-1 is involved in the pathogenesis of pulmonary fibrosis in the rodent model and that blockage of its receptors reduces the fibrosis.

Several studies have suggested an important role for endothelin in the pathophysiology of the upper and lower respiratory tract. In the present study, we have investigated the localization of endothelin-1 (ET-1) and endothelin-converting enzyme-1 (ECE-1) messenger RNAs(mRNAs) and immunoreactivities in the human nasal mucosa by immunohistochemistry and in situ hybridization. Inferior turbinates were obtained from 32 patients at surgery. Histopathologic examination of nasal biopsy specimens revealed that 17 patients had chronic inflammation and 15 patients had normal mucosa. Immunostaining for ET-1 and ECE-1 was seen in the surface epithelium, endothelial cells, submucosal glands, and infrequently in vascular smooth muscle cells, in all subjects. There was significantly more staining for ET-1 and ECE-1 in nasal glands and inflammatory cells in patients with chronic inflammation than in those with normal nasal mucosa. In patients with chronic inflammation, strong immunoreactivity for ECE-1 was seen over inflammatory cells. In situ hybridization showed abundant expression of ET-1 and ECE-1 mRNAs over the surface epithelium, glands, vessels, and inflammatory cells. Both immunohistochemistry and in situ hybridization demostrated the expression of ET-1 and ECE-1 immunoreactivities and mRNAs in similar sites, and also independently. The present findings demonstrate the co-expression of ET-1 and its converting enzyme in the human nasal mucosa and suggest a possible role for the endothelin system in the pathogenesis of chronic rhinitis.

The nasal mucosa plays an important role in defense of the lung against harmful agents. It has been suggested that this is partly mediated by the production of nitric oxide (NO). We have investigated the localization of the messenger ribonucleic acids (MRNAs) for human endothelial NO synthase (Type III NOS) and inducible NO synthase (Type II NOS) and the immunoreactivities of these enzymes in human nasal mucosa by immunohistochemistry, in situ hybridization, and reduced nicotinamide adenine diphosphate (NADPH) diaphorase histochemistry. Inferior nasal turbinates were obtained from 27 patients at the time of surgery for local disease. Strong immunostaining for Type III NOS was localized to vascular endothelium, surface epithelium, and submucosal glands in all subjects. Moderate immunostaining for Type II NOS was seen in surface epithelium; glandular, inflammatory, and vascular endothelial cells; and smooth-muscle cells in the specimens from patients with chronic rhinitis only. In situ hybridization showed expression of the mRNA for Type III NOS in similar sites to those shown by immunohistochemistry, whereas the mRNA for Type II NOS was predominantly localized to inflammatory cells. The sites of NOS expression were further confirmed by NADPH histochemical staining. These findings demonstrate the cellular expression of NOS in the human nasal mucosa and suggest a possible role for Types II and III NO synthase in the regulation of blood flow, nasal secretion, and ciliary movement in health and disease.

Introduction Evidence suggests that the majority of patients wish to die at home. However, this is only attainable for few. Aim To identify the barriers and facilitators to being able to die at home in the UK. Methods: A two-step study approach was adopted.1 A systematic literature review (SLR) and2 primary qualitative data collection. In the SLR 3241 papers were retrieved. 72 articles remained after screening and filtering processes. Qualitative articles were analysed using meta-ethnography and quantitative articles were analysed using a descriptive approach. In the primary study, 33 in-depth interviews were conducted with experts in end-of-life care. Thematic Analysis of interview transcripts was conducted. Approval from Imperial College Research Ethics Committee was obtained for the study. The results from the SLR and primary data collection were amalgamated to produce a set of overarching barriers and facilitators. Results Six barriers and four facilitators were identified. The specific barrier of ‘challenges in resource planning’ will be discussed in this paper. This overarching theme included logistical issues in getting both the patient and equipment home, lack of continuity of care and geographic variation in resource provision, including 24/7 care. Conclusions Addressing this barrier could allow more patients to achieve death at home. However, it is important to acknowledge the qualitative nature of results. As a result, further research is required to identify the relative impact this barrier has on patients’ ability to achieve home death when compared to other barriers and facilitators identified.

Pulmonary hypertension is characterized by abnormal thickening of the pulmonary arteries and increased pulmonary vascular resistance. Nitric oxide is a potent endothelium-derived vasorelaxant substance and an inhibitor of smooth-muscle-cell growth. Nitric oxide is produced in various cell types by the action of an enzyme, nitric oxide synthase. We compared the expression of endothelial nitric oxide synthase in the lungs of control subjects with that in the lungs of patients with pulmonary hypertension.We investigated the expression of endothelial nitric oxide synthase by histochemical and immunohistochemical analysis, in situ hybridization, and Northern blot analysis in the lungs of 22 patients with plexogenic pulmonary arteriopathy (arteriopathy of grades 4 through 6), 24 patients with secondary pulmonary hypertension (arteriopathy of grades 1 through 3), and 23 control subjects.In the lungs of the control subjects, nitric oxide synthase was expressed at a high level in the vascular endothelium of all types of vessels and in the pulmonary epithelium. In contrast, little or no expression of the enzyme was found in the vascular endothelium of pulmonary arteries with severe histologic abnormalities (i.e., plexiform lesions) in patients with pulmonary hypertension. The intensity of the enzyme immunoreactivity correlated inversely with the severity of histologic changes. There was an inverse correlation between the arterial expression of the enzyme and total pulmonary resistance in patients with plexogenic pulmonary arteriopathy (r = -0.766, P = 0.004).Pulmonary hypertension is associated with diminished expression of endothelial nitric oxide synthase. It is possible that decreased expression of nitric oxide synthase may contribute to pulmonary vasoconstriction and to the excessive growth of the tunica media observed in this disease.

Peroxynitrite is a potent oxidant formed by the rapid reaction of the free radicals nitric oxide (NO) and superoxide. It causes airway hyperresponsiveness and airway epithelial damage, enhances inflammatory cell recruitment, and inhibits pulmonary surfactant. Asthma is characterized by increased airway hyperresponsiveness, airway epithelial shedding, and inflammation. We examined the production of peroxynitrite and the expression of inducible nitric oxide synthase (iNOS) in airways of asthmatic patients compared to normal control subjects. We also performed a double-blind, crossover randomized-order, placebo-controlled study on 10 asthmatic patients to study the effects of inhaled glucocorticoid treatment (Budesonide) on the formation of peroxynitrite and NO. Fiberoptic bronchial biopsies were examined by immunohistochemistry with antiserum to nitrotyrosine, a marker of protein nitration by peroxynitrite. We also examined the expression of iNOS by immunohistochemistry and in situ hybridization, and measured exhaled NO by chemiluminescence. We correlated the airway production of peroxynitrite with pulmonary functions and airway responsiveness. In airway passages of control subjects, there was weak or no nitrotyrosine immunoreactivity. In contrast, there was strong immunoreactivity for nitrotyrosine in the airway epithelium and inflammatory cells in the airways of persons with asthma. Budesonide treatment resulted in a significant reduction in nitrotyrosine immunoreactivity. Expression of iNOS was evident in the airway pithelium of controls and asthmatic patients, but was significantly more abundant in asthmatic patients. The presence of nitrotyrosine in the airway epithelium (r=-0.841, P

Endothelin-1 (ET-1) is a vasoconstrictor, bronchoconstrictor, and mitogenic peptide which is enzymatically converted from a biologically inactive big ET to mature ET (21 amino acid) by the ET-converting enzyme (ECE). Here, we investigate the expression of ECE-1, big ET-1, and ET-1 in the lungs of patients with idiopathic pulmonary fibrosis (IPF) and compare it to those of normal subjects using immunohistochemistry and in situ hybridization. In normal lungs, focal moderate expression of all three molecules is localized to airway epithelium, pulmonary endothelium, and airway and vascular smooth muscle cells. Serous bronchial glands also expressed ET-1 and ECE-1. In IPF, strong diffuse expression of ECE-1 was seen in airway epithelium, proliferating type II pneumocytes, and in endothelial and inflammatory cells. ECE-1 immunostaining was colocalized to big ET-1 and ET-1 immunostaining, and correlated with disease activity (P < 0.05). To study regulatory mechanisms of ET-1 and ECE-1 expression, human normal bronchial epithelial (NBE) cells were treated with cytokines and analyzed by radioimmunoassay and Northern blot. Incubation of human NBE cells with IL-1alpha and -beta or tumor necrosis factor alpha (TNFalpha) resulted in a significant increase in ET-1 release and mRNA expression. TNFalpha resulted in a significant increase in ECE-1 mRNA expression. These findings demonstrated the colocalization of the precursor and active ET-1, and ECE-1 in the same cell, and that ECE-1 expression is elevated in IPF. In addition, increased expression of ET-1 and ECE-1 in IPF may be mediated by proinflammatory cytokines.

Endothelin-1 (ET-1) is a 21-residue peptide produced by endothelial cells and possesses a wide range of biological activities, including vasoconstriction, mitogenesis, and inotropic effects on the heart. The aim of the present study was to determine the cellular localization of ET-1 immunoreactivity and mRNA in routine endomyocardial biopsy specimens of transplanted human hearts, and to correlate the findings with the associated histological changes. Multiple-step paraffin sections of 72 biopsy samples were immunostained with antiserum to ET-1 and von Willebrand factor (factor VIII) using the avidin-biotin-peroxidase complex method. ET-1 immunoreactivity was localized to vascular and endocardial endothelial cells, as well as to cardiomyocytes. The pattern of endothelial cell immunostaining with the ET-1 antiserum was similar to that of factor VIII. Previous biopsy sites and areas of granulation tissue appeared to have greater ET-1 immunoreactivity, particularly in sections immunostained with the ET-1 antiserum. There was a significant correlation between the presence of ET-1 immunoreactivity and fibrosis or granulation tissue in the biopsy specimens (P < 0.03). There was no correlation between ET-1 immunoreactivity and the presence of cellular infiltrate, definitive rejection, or Quilty effect. In situ hybridization with radiolabeled RNA probes revealed expression of ET-1 mRNA in endothelial cells and myocytes, also in association with granulation tissue and fibrosis. No cellular reactivity was present in control sections stained with the ET-1 antiserum preadsorped with its synthetic peptide. The findings suggests a possible role for ET-1 in vascular regeneration and angiogenesis following myocardial injury.

Abstract Circulating levels of the endothelium-derived vasoconstrictor peptide endothelin-1 (ET-1) are increased in association with myocardial ischemia and infarction. The present study investigates whether ET-1 is synthesized and produced locally in the ischemic heart. Sixteen pigs were divided into three groups. In the first group, the left anterior descending coronary artery was occluded for 90 minutes, followed by 150 minutes of reperfusion (group A, n=8). Two additional groups were subjected to 90 minutes (group B, n=4) or 240 minutes (group C, n=4) of ischemia without reperfusion. Biopsies from the nonischemic and ischemic myocardium were rapidly obtained from the beating heart and subsequently examined by Northern blot, in situ hybridization, and immunohistochemistry. Arterial plasma ET-1 was measured before ischemia and at the end of the experiments. Northern blot revealed a twofold increase in ET-1 mRNA in the ischemic myocardium compared with the nonischemic myocardium. In situ hybridization showed a considerable increase in ET-1 mRNA over the ischemic cardiomyocytes. Substantial ET-1–like immunoreactivity (ET-1-ir) was detected in cardiomyocytes in the ischemic region. In contrast, little or no ET-1-ir or mRNA was detected in nonischemic cardiomyocytes. Both in the ischemic and nonischemic regions, little ET-1-ir was detected in vascular endothelial cells or vascular smooth muscle cells. There was no difference in the intensity and distribution of ET-1 mRNA expression or ET-1-ir among experimental groups A, B, and C. Arterial plasma ET-1 was increased only in group A, the reperfused group. In conclusion, these findings provide a definitive evidence for a de novo synthesis of ET-1 by cardiomyocytes subjected to ischemia in vivo.

A temporary increase in pulmonary vascular resistance is observed during the first 24 hr following lung allotransplantation. We hypothesized that such early vascular changes are secondary to endothelial injury by ischemia-reperfusion, and that this may be mediated by an increased pulmonary endothelin-1 production/release. To test this hypothesis, radioimmunoassay was used to analyze endothelin-1 levels in bronchoalveolar lavage and plasma taken before surgery and at 1 hr, 4 hr, 24 hr, and 1 week after transplantation. The study was carried out on 2 groups of mongrel dogs. One group was subjected to left single-lung allotransplantation and the other to autotransplantation. Endothelin-1 levels in the bronchoalveolar lavage samples from the lung allografts were significantly increased at 1 (0.70 +/- 0.18 pg/ml) and 4 (1.84 +/- 0.65 pg/ml) hr after transplantation compared with the preoperative value (0.14 +/- 0.05 pg/ml), and declined at 24 (0.85 +/- 0.84 pg/ml) hr after transplantation. Similarly, plasma endothelin-1 levels in the allografts were significantly increased at 1 (2.0 +/- 0.80 pg/ml) and 4 (2.0 +/- 0.71 pg/ml) hr after transplant when compared with preoperative levels (0.54 +/- 0.09 pg/ml). Plasma endothelin-1 levels, however, remained significantly high after 24 hr (1.4 +/- 0.4 pg/ml; P < 0.007) and decreased after 1 week after transplant (0.89 +/- 0.32 pg/ml). On the other hand, endothelin-1 levels in bronchoalveolar lavage from the autograft group remained relatively unchanged; however, plasma levels showed a significant increase at 4 hr (6.6 +/- 1.8 pg/ml) after transplantation compared with preoperative levels (2.8 +/- 0.38 pg/ml). Elevation of endothelin-1 levels early after lung transplantation may play an important role in early high pulmonary vascular resistance and temporary graft dysfunction.