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Objective: Patients with comorbidities can be referred to a physician-led high-risk clinic for medical optimisation prior to elective surgery at the discretion of the surgical consultant, but the factors that influence this referral are not well understood. The aims of this study were to understand the factors that influence a surgeon's decision to refer a patient to the clinic, and how the clinic impacts on the management of complex patients., Design: Qualitative study using theoretical thematic analysis to analyse transcribed semi-structured interviews., Setting: Interviews were held in either the surgical consultant's private office or a quiet office/room in the hospital ward., Participants: Seven surgical consultants who were eligible to refer patients to the clinic., Results: When discussing the factors that influence a referral to the clinic, all participants initially described the optimisation of comorbidities and would then discuss with examples the challenges with managing complex patients and communicating the risks involved with having surgery. When discussing the role of the clinic, two related subthemes were dominant and focused on the management of risk in complex patients. The participants valued the involvement of the clinic in the decision-making and communication of risks to the patient., Conclusions: The integration of the high-risk clinic in this study appears to offer additional value in supporting the decision-making process for the surgical team and patient beyond the clinical outcomes. The factors that influence a surgeon's decision to refer a patient to the clinic appear to be driven by the aim to manage the uncertainty and risk to the patient regarding surgery and it was seen as a strategy for managing difficult and complex cases., Competing Interests: Competing interests: Dr Catherine Gibb is a consultant physician in the High Risk Clinic at the Royal Adelaide Hospital and Queen Elizabeth Hospital. The remaining authors declare no conflict of interest., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Clinics have been established to provide preoperative medical consultations, and enable the anaesthetist and surgeon to deliver the best surgical outcome for patients. However, there is uncertainty regarding the effect of such clinics on surgical, in-hospital and long-term outcomes. A systematic review of the literature was conducted to determine the effectiveness of preoperative medical consultations by internal medicine physicians for patients listed for elective surgery., Design: Systematic searches of MEDLINE, EMBASE, CINAHL, PubMed, Current Contents and the NHS Centre for Reviews and Dissemination were conducted up to 30 April 2017., Setting: Elective surgery., Study Selection: Randomised controlled trials and non-randomised comparative studies conducted in adults., Outcome Measures: Length of hospital stay, perioperative morbidity and mortality, costs and quality of life., Results: The one randomised trial reported that preadmission preoperative assessment was more effective than the option of an inpatient medical assessment in reducing the frequency of unnecessary admissions with significantly fewer surgical cancellations following admission for surgery. A small reduction in length of stay in patients was also observed. The three non-randomised studies reported increased lengths of stay, costs and postoperative complications in patients who received preoperative assessment. The timing and delivery of the preoperative medical consultation in the intervention group differed across the included studies., Conclusion: Further research is required to inform the design and implementation of coordinated involvement of physicians and surgeons in the provision of care for high-risk surgical patients. A standardised approach to perioperative decision-making processes should be developed with a clear protocol or guideline for the assessment and management of surgical patients., Competing Interests: Competing interests: CLG is a consultant physician in the High Risk Clinic at the Royal Adelaide Hospital and Queen Elizabeth Hospital. The remaining authors declare no conflict of interest., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Rationale, Aims and Objectives: A physician-led clinic for the preoperative optimization and management of high-risk surgical patients was implemented in a South Australian public hospital in 2008. This study aimed to estimate the costs and effects of the clinic using a mixed retrospective and prospective observational study design., Method: Alternative propensity score estimation methods were applied to retrospective routinely collected administrative and clinical data, using weighted and matched cohorts. Supplementary survey-based prospective data were collected to inform the analysis of the retrospective data and reduce potential unmeasured confounding., Results: Using weighted cohorts, clinic patients had a significantly longer mean length of stay and higher mean cost. With the matched cohorts, reducing the calliper width resulted in a shorter mean length of stay in the clinic group, but the costs remained significantly higher. The prospective data indicated potential unmeasured confounding in all analyses other than in the most tightly matched cohorts., Conclusions: The application of alternative propensity-based approaches to a large sample of retrospective data, supplemented with a smaller sample of prospective data, informed a pragmatic approach to reducing potential observed and unmeasured confounding in an evaluation of a physician-led preoperative clinic. The need to generate tightly matched cohorts to reduce the potential for unmeasured confounding indicates that significant uncertainty remains around the effects of the clinic. This study illustrates the value of mixed retrospective and prospective observational study designs but also underlines the need to prospectively plan for the evaluation of costs and effects alongside the implementation of significant service innovations., (© 2016 John Wiley & Sons, Ltd.)

An efficient, four-step synthesis of a range of water-soluble, deep-cavity cavitands is presented. Key to this approach are octahalide derivatives (4, X = Cl or Br) that allow a range of water-solubilizing groups to be added to the outer surface of the core host structure. In many cases, the conversion of the starting dodecol (1) resorcinarene to the different cavitands avoids any chromatographic procedures.

Isothermal titration calorimetry was used to probe how salts influence the thermodynamics of binding of guests to cavitand 1. Studies involved six Hofmeister salts covering the range of salting-in to strongly salting-out. The latter were found to reduce affinity. The cause of this was competitive binding of the weakly solvated anion to the hydrophobic pocket of the host. At the other extreme of the Hofmeister series, salts increased guest affinity. Two factors for this were evident. At low concentrations the data fitted a previously reported model that accounts for cation condensation to the outer carboxylates of the host (Carnagie, R.; Gibb, C. L. D.; Gibb, B. C., Angew. Chem., Int. Ed. 2014, 53 (43), 11498-11500). At higher concentrations, an as of yet unidentified contribution was observed that was noted to be guest dependent. Midcontinuum salts such as NaClO3 were found to enhance affinity at low concentrations, but weaken it at high concentrations; a nonmonotonic trend attributed to the aforementioned competing phenomena. In combination with previous work, the data presented here reveal that the Hofmeister effect evident in this system can be mostly attributed to solute-salt interactions.

The (1)H NMR spectroscopic analysis of the binding of the ClO4(-) anion to the hydrophobic, concave binding site of a deep-cavity cavitand is presented. The strength of association between the host and the ClO4(-) anion is controlled by both the nature and concentration of co-salts in a manner that follows the Hofmeister series. A model that partitions this trend into the competitive binding of the co-salt anion to the hydrophobic pocket of the host and counterion binding to its external carboxylate groups successfully accounts for the observed changes in ClO4(-) affinity., (© 2014 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

As part of the fourth statistical assessment of modeling of proteins and ligands (sampl.eyesopen.com) prediction challenge, the strength of association of nine guests (1-9) binding to octa-acid host was determined by a combination of (1)H NMR and isothermal titration calorimetry. Association constants in sodium tetraborate buffered (pH 9.2) aqueous solution ranged from 5.39 × 10(2) M(-1) in the case of benzoate 1, up to 3.82 × 10(5) M(-1) for trans-4-methylcyclohexanoate 7. Overall, the free energy difference between the free energies of complexation of these weakest and strongest binding guests was ΔΔG° = 3.88 kcal mol(-1). Based on a multitude of previous studies, the anticipated order of strength of binding was close to that which was actually obtained. However, the binding of guest 3 (4-ethylbenzoate) was considerably stronger than initially estimated.

Water-soluble octaacid cavitands (OAs) form dimeric capsules suitable for guest incorporation. Our studies reveal that the mechanism of pyrene (Py) binding involves the rapid (<1 ms) formation of the Py·OA complex followed by slower binding with the second OA. The dissociation of the capsular OA·Py·OA complex occurs with a lifetime of 2.7 s, which is 5 orders of magnitude slower than the microsecond opening/closing ("breathing") previously observed to provide access of small molecules to the encapsulated guest. These different dynamics of the capsules have a potential impact on how the chemistry of included guests could be altered.

For over 120 years it has been appreciated that certain salts (kosmotropes) cause the precipitation of proteins, while others (chaotropes) increase their solubility. The cause of this "Hofmeister effect" is still unclear, especially with the original concept that kosmotropic anions "make" water structure and chaotropes "break" it being countered by recent studies suggesting otherwise. Here, we present the first direct evidence that chaotropic anions have an affinity for hydrophobic concavity and that it is competition between a convex hydrophobe and the anion for a binding site that leads to the apparent weakening of the hydrophobic effect by chaotropes. In combination, these results suggest that chaotropes primarily induce protein solubilization by direct binding to concavity in the molten globule state of a protein., (© 2011 American Chemical Society)

An improved synthesis of a water-soluble deep-cavity cavitand (octa-acid, 1) is presented. Previously (Gibb, C. L. D. & Gibb, B. C., J. Am. Chem. Soc., 2004, 126, 11408-11409) we documented access to host 1 in eight (non-linear) steps starting from resorcinol; a synthesis that required four steps involving chromatographic purification. Here we reveal a modified synthesis of host 1. Consisting of seven (non-linear) steps, this new synthesis involves only one chromatographic step, and avoids a minor impurity observed in the original approach. This improved synthesis will therefore be useful for the laboratories that are investigating the properties of these types of host.

Chiral induction during the photoelectrocyclization of pyridones included within octa acid (OA) capsule has been established. Chiral induction is brought about by a chiral auxiliary appended to the reactive pyridone moiety. Importantly, the same chiral auxiliary while ineffective in acetonitrile solution is found to be effective within the confined space of OA capsule. The diastereomeric excess of 92% obtained here is comparable only to that in solid state. OA capsule, we believe, provides restriction to the rotational motions of the reactant pyridone and chiral auxiliary and thus places the chiral auxiliary in a selective conformation with respect to the reactive pyridone part. A correlation between the position of the methyl group on the pyridone ring and diastereoselectivity was noted. Structures of the host-guest complexes were examined by (1)H NMR and the data was used to obtain preliminary information concerning the mechanism of chiral induction within the confined spaces of OA capsule.

Guests covering a range of polarities were examined for their ability to bind to a water-soluble cavitand and trigger its assembly into a supramolecular capsule. Specifically the guests examined were: tridecane 2, 1-dodecanol 3, 2-nonyloxy ethanol (ethylene glycol monononyl ether) 4, 2-(2-hexyloxyethoxy) ethanol (Di(ethylene glycol) hexyl ether) 5, 2-[2-(2 propoxyethoxy)ethoxy] ethanol (Tri(ethylene glycol) propyl ether 6, and bis [2-(2-hydroxyethoxy)ethyl] ether (tetra(ethylene glycol)) 7. In this series, guest 6 proved to signify the boundary between assembly and the formation of 2:1 complexes, and simple 1:1 complexation. Thus, guests 2-5 formed relatively kinetically stable capsules, guest 6 formed a capsule that was unstable relative to the NMR timescale, and guest 7 formed a simple 1:1 complex.

The value of a supramolecular assembly to enforce a closer interaction between a chiral auxiliary and a reaction center has been established using photoreactions of tropolone and cyclohexadienone derivatives. Two probe molecules utilized to establish the concept undergo 4 e- electrocyclization and oxa-di-pi-methane rearrangement from excited singlet and triplet state, respectively. The chiral auxiliaries investigated here has no/little effect in acetonitrile solution during phototransformations of the probe molecules to yield products with new chiral centers. On the other hand the same ones are able to enforce diastereoselectivities to the extent of approximately 30% when the reactions occur within the restricted space of a capsule made up of a synthetic cavitand commonly known as octa acid. Extensive NMR studies have been utilized to characterize the guest-host supramolecular structures. The results presented here should be of value in the overall understanding of chiral induction in photochemical reactions.

Excited-state behavior of eight alpha-alkyl dibenzyl ketones (alkyl = CH3 through n-C8H17) that are capable of undergoing type II and/or type I photoreactions has been explored in isotropic solution and within a water-soluble capsule. The study consisted of two parts: photochemistry that explored the excited-state chemistry and an NMR analysis that revealed the packing of each guest within the capsule. The NMR data (COSY, NOESY, and TOCSY experiments) revealed that ternary complexes between alpha-alkyl dibenzyl ketones and the capsule formed by two cavitands are kinetically stable, and the guests fall into three packing motifs modulated by the length of the alpha-alkyl chain. In essence, the host is acting as an external template to promote the formation of distinct guest conformers. The major products from all eight guests upon irradiation either in hexane or in buffer solution resulted from the well-known Norrish type I reaction. However, within the capsule the excited-state chemistry of the eight ketones was dependent on the alkyl chain length. The first group consisted of alpha-hexyl, alpha-heptyl, and alpha-octyl dibenzyl ketones that yielded large amounts of Norrish type II products within the host, while in solution the major products were from Norrish type I reaction. The second group consists of alpha-butyl and alpha-pentyl dibenzyl ketones that yield equimolar amounts of two rearranged starting ketones within the capsule (combined yield of ca 60%), while in solution no such products were formed. The third group consisted of alpha-methyl, alpha-ethyl, and alpha-propyl dibenzyl ketones that within the capsule yielded only one (not two) rearranged starting ketone in larger amounts (21-35%) while in solution no rearrangement product was obtained. Variation in the photochemistry of the guest within the capsule, with respect to the alpha-alkyl chain length of the guest, highlights the importance of how a small variation in supramolecular structure can influence the selectivity within a confined nanoscale reactor.

In aqueous media the deep-cavity cavitand octaacid 1 forms stable dimeric molecular capsules 1(2), which are stabilized by hydrophobic effects. In this work we investigate the binding interactions in aqueous solution between these capsules and the redox active guests, ferrocene (Fc) and three 4,4'-bipyridinium (viologen) dications: methyl viologen (MV(2+)), ethyl viologen (EV(2+)), and butyl viologen (BV(2+)). Using NMR spectroscopic and electrochemical techniques we clearly show that the hydrophobic Fc guest is encapsulated inside 1(2). An interesting effect of this encapsulation is that the reversible voltammetric response of Fc is completely eliminated when it resides inside the 1(2) capsular assembly, a finding that is attributed to very slow electrochemical kinetics for the oxidation of Fc@1(2). Diffusion coefficient measurements (PGSE NMR spectroscopy) reveal that all three viologen guests are strongly bound to the dimeric capsules. However, the (1)H NMR spectroscopic data are not consistent with encapsulation and the measured diffusion coefficients indicate that two viologen guests can strongly associate with a single dimeric capsule. Furthermore, the (V(2+))(2)*1(2) complex is capable of encapsulating ferrocene, clearly suggesting that the viologen guests are bound externally, via coulombic interactions, to the anionic polar ends of the capsule. The electrochemical kinetic rate constants for the reduction of the viologen residue in the V(2+)*1(2) complexes were measured and found to be substantially lower than those for the free viologen guests.

Cavitand is sufficiently predisposed to form nano-scale capsules in the presence of templating straight-chain hydrocarbons; quaternary complexes are formed when two copies of smaller guests are encapsulated, whilst larger guests form ternary entities.

The water soluble capsule formed by a deep cavity cavitand with eight carboxylic acid groups controls product distribution during photo-Fries rearrangement of naphthyl esters in water by restricting the mobility of primary singlet radical pair.

In aqueous solution, a deep-cavity cavitand was shown to self-assemble into dimeric nano-capsules via the sequestration of gaseous-phase hydrocarbons. The sequestration, assembly, and entrapment process was shown to be dependent on the hydrocarbon. Thus, by way of example, butane could be selectively sequestered from a propane-butane mixture.

A combination of hydrophobic forces and guest templation drive the assembly of cavitands into molecular capsules. Remarkably, anthracene that dimerizes with unit efficiency in solution does not dimerize within the capsule despite forming 2:2 complex. The capsule allows an unprecedented examination of the anthracene excimer.

A combination of hydrophobic forces and guest templation drive the assembly of cavitands into molecular capsules. Encapsulated guests such as dibenzyl ketones reside in an essentially dry environment, and upon irradiation, undergo rearrangement processes that are templated by the shape of the 1 nm x 2 nm cavity.

The synthesis of a water-soluble, deep-cavity cavitand is reported. A blend of molecular curvature and amphiphilicity, this molecule has a hydrophobic concave surface and a hydrophilic convex surface. As a result, in aqueous solution and in the presence of a guest molecule, the host self-assembles to form a capsular assembly with an interior cavity large enough to entrap steroidal guests.

The concept that resorcinarenes can be used as templates for the synthesis of large macrocycles is introduced. By way of example, previously inaccessible, aromatic crown ethers compounds are synthesized.

The synthesis of three different nanoscale molecular hosts is reported. These cavitands each possess a highly preorganized cavity with an open portal (nearly 1 nm wide), by which guests can enter and egress the cavity. Additionally, these hosts are deep-functionalized with a crown of weakly acidic benzal C-H groups which can form a variety of noncovalent interactions with guest molecules residing within the cavity. Thirty-one guests were examined for their propensity to form complexes with the hosts. Guests that possess halogen atoms were the strongest binders, suggesting the formation of polydentate C-H triplebond X-R hydrogen bonds with the deep crown of benzal hydrogens. Exchange rates between the free and bound states were noted to be dependent on the size of the guest and the solvent used to study complexation. In general, stronger binding and slower exchange were noted for complexations carried out in DMSO with highly complementary guests. The orientation of each guest within the cavity was determined using either EXSY NMR spectroscopy or (1)H NMR shift data. Cumulatively these results showed that the principal factors directing orientation were interactions with the benzal groups and the type of solvent. Van't Hoff analyses of selected complexations were also carried out. As well as revealing that all complexations were entropically unfavorable, these experiments provided support for guest orientation determinations, and gave an estimation that the formation of a C-H triplebond I-R hydrogen bond releases between 1 and 1.5 kcal mol(-1).

Kinetic analysis of the host guest complexation of a large, open molecular basket and a highly complementary adamantoid guest reveals that for these types of systems a dissociative mechanism is in operation. Hence, the resident adamantyl guest must completely vacate the cavity before another guest molecule can move in to replace it. As a result of the rigid nature of the host, the energy barrier to this process is relatively high, about 16 kcal mol(-1) at room temperature. Modifying the cavity of the host by dangling either a methyl group or a hydroxyl group from the portal rim alters the thermodynamic binding profile of these hosts. (1)H NMR shift data analysis also reveals that these functional groups can adjust the orientation that monosubstituted guests adopt within the cavity. Additionally, (1)H NMR studies of the binding of (E)1,4-dibromoadamantane allow the observation of two energetically similar diastereomeric complexes. An examination of this guest binding to the three hosts reveals that the interchange between the isomers is much faster than the entry and egression rates, and that the functional groups at the rim of each cavity influence both the rates of reorientation and the equilibrium relating the isomers.

Tandem repeats of simple doublet and triplet sequences occur with high frequency in the DNA of eucaryotes. Among the most frequent is the repeat of dTG, which has unusual structural properties. We show here that HMG1 (modeled by the second HMG box motif from HMG1 of the rat, HMGb) binds to complexes formed from annealing unequal lengths of dTG x dCA and inhibits the in vitro elongation of these complexes by the Klenow fragment of DNA polymerase I at 37 degrees C. At 46 degrees C, HMGb enhances the elongation. Polylysine inhibits elongation at both temperatures. These results show that the stability of this repeat in vivo can be influenced by the presence of basic proteins in general, and more selectively by the abundant nuclear protein HMG1.

A number of tandemly repeated DNA sequences have the ability to form hairpin structures by forming non-standard base pairs. When (GCC)15 and (GGC)15 strands are annealed together, the expected duplex is the only product. However, when (GCC)15 is annealed with (GCC)10, depending on the relative concentrations, up to five complexes can be detected in native gels. Three of these species are susceptible to limited digestion by Exo VII, suggesting they are duplexes containing single stranded tails. The remaining two bands are resistant to the enzyme, and have low mobility on native gels, consistent with branched structures. The latter complexes bind HMG box proteins, members of a highly abundant class of non-histone proteins of the nucleus. These proteins, modeled in this study by the second box fragment from rat HMG1, HMGb, interact strongly with branched or chemically modified DNA, relative to normal duplexes. The expansion of triplet repeats in genomic DNA is associated with tumor formation as well with a variety of heritable neurologiocal disorders. It is our thesis that the stability of branched intermediate structures that arise in replication of these sequences and promote expansion can be influenced directly by the presence of two highly abundant proteins in the cell nucleus: the HMG box proteins, HMG1/2, and the histone H1, which associates with HMG1/2.