Bite injuries to the hand: microbiology, virology and management

Bites to the human hand, be it from a pet, a stray animal or even a fellow human, may often have dire consequences for the person suffering the insult. Bites by mammals are a common problem and they account for up to 1% of all visits to hospital emergency rooms, in the UK. Clenched fist injuries to the mouth ('fight bite') are notorious for being the worst human bites. Bite injuries of the hand and their related infections must be monitored vigilantly and managed proactively, by experts in this field of surgery. In this review article we discuss the associated microbiology and virology of these injuries as well as their management.

Comparison of antimicrobial resistance phenotypes and genotypes in enterotoxigenic Escherichia coli isolated from Australian and Vietnamese pigs

This study aimed to compare the antibiogram phenotype and carriage of antimicrobial resistance genes (ARGs) of 97 porcine multidrug-resistant (MDR) enterotoxigenic Escherichia coli (ETEC) isolates obtained from Vietnam and 117 porcine MDR-ETEC obtained from Australia, two countries with different antimicrobial regulation systems. An antimicrobial resistance index (ARI) was calculated to quantify their potential significance to public health. Both Vietnamese and Australian isolates had moderate to high levels of resistance to commonly used antibiotics (ampicillin, tetracycline and sulphonamides). None of the Australian isolates were resistant to fluoroquinolones or third-generation cephalosporins and none possessed associated plasmid-mediated ARGs. However, 23.1% of Australian isolates were resistant to gentamicin owing to ARGs associated with apramycin or neomycin resistance [e.g. aac(3)-IV] that impart cross-resistance to gentamicin. Whilst Vietnamese isolates carried aminoglycoside ARGs, 44.4% of commercial pig isolates were resistant to gentamicin in comparison with 0% of village pig isolates. The plasmid-mediated fluoroquinolone ARG qnrB was commonly detected in Vietnamese isolates (52.3% commercial, 44.1% village), but phenotypic resistance was low (3.2% and 11.8%, respectively). The mean ARI for Vietnamese isolates (26.0) was significantly different (P<0.001) from the mean ARI for Australian isolates (19.8), primarily reflecting fluoroquinolone resistance in the former collection. This comparison suggests the effectiveness of regulations that slow the dissemination of 'critical' resistance by restricting the availability of important classes of antimicrobials.

New antineutrino energy spectra predictions from the summation of beta decay branches of the fission products

In this Letter, we study the impact of the inclusion of the recently measured beta decay properties of the (102;104;105;106;107)Tc, (105)Mo, and (101)Nb nuclei in an updated calculation of the antineutrino energy spectra of the four fissible isotopes (235,238)U and (239,241)Pu. These actinides are the main contributors to the fission processes in pressurized water reactors. The beta feeding probabilities of the above-mentioned Tc, Mo, and Nb isotopes have been found to play a major role in the γ component of the decay heat of (239)Pu, solving a large part of the γ discrepancy in the 4-3000 s range. They have been measured by using the total absorption technique, insensitive to the pandemonium effect. The calculations are performed by using the information available nowadays in the nuclear databases, summing all the contributions of the beta decay branches of the fission products. Our results provide a new prediction of the antineutrino energy spectra of (235)U, (239,241)Pu, and, in particular, (238)U for which no measurement has been published yet. We conclude that new total absorption technique measurements are mandatory to improve the reliability of the predicted spectra.

TU-G-213AB-01: Organization and Productivity Strategies for Practicing Medical Physicists

Medical physicists face numerous challenges that create stress in the professional workplace. The modern work environment contains multiple communications channels, such as email, smart phones, text and instant messaging, voice mail, pagers, and more. These media make it difficult to organize incoming information, set priorities, and move important work forward in the face of rapid change and the requirement to fulfill multiple responsibilities. Medical physicists in particular are likely to feel acute stress due to off-peak work hour requirements, varied responsibilities including clinical duties, research, teaching, and regulatory matters, and the complexity of supervising other staff members. Many medical physicists also work in multiple physical locations, adding complexity to the task of organizing information and resources. Another common difficulty is that medical physicists' responsibilities typically include some duties that render them subject to frequent and urgent interruption, such as emergency response coverage for radiation safety. The real challenges in the current medical physics work environment differ from those encountered while taking courses and conducting research, as well as from earlier periods when medical physicists faced fewer varied responsibilities, slower-paced change, or both. Today's practicing physicist can benefit greatly from developing a formal framework and skill set to manage their personal workflow. This greatly increases the individual's effectiveness and reduces feelings of stress, while improving the effectiveness of teams or groups in which they participate. In this session, participants will learn about a number of techniques and strategies to manage their own personal workflow. Examples familiar to the medical physicist will be provided to illustrate methods to capture, organize, and act on important information, to delegate effectively, and to handle inevitable interruptions.

LEARNING OBJECTIVES

1. Describe the use of a personal workflow in managing ongoing or routine clinical physics duties. 2. Select an appropriate method for filing various documents and records commonly encountered in medical physics. 3. Implement strategies for minimizing the impact of interruptions on the physicist's daily work.

The epidemiology, genetics and future management of syndactyly

Syndactyly is a condition well documented in current literature due to it being the most common congenital hand defect, with a large aesthetic and functional significance.There are currently nine types of phenotypically diverse non-syndromic syndactyly, an increase since the original classification by Temtamy and McKusick(1978). Non-syndromic syndactyly is inherited as an autosomal dominant trait, although the more severe presenting types and sub types appear to have autosomal recessive and in some cases X-linked hereditary.Gene research has found that these phenotypes appear to not only be one gene specific, although having individual localised loci, but dependant on a wide range of genes and subsequent signalling pathways involved in limb formation. The principal genes so far defined to be involved in congenital syndactyly concern mainly the Zone of Polarizing Activity and Shh pathway.Research into the individual phenotypes appears to complicate classification as new genes are found both linked, and not linked, to each malformation. Consequently anatomical, phenotypical and genotypical classifications can be used, but are variable in significance, depending on the audience.Currently, management is surgical, with a technique unchanged for several decades, although future development will hopefully bring alternatives in both earlier diagnosis and gene manipulation for therapy.

Management of extensor tendon injuries

Extensor tendon injuries are very common injuries, which inappropriately treated can cause severe lasting impairment for the patient. Assessment and management of flexor tendon injuries has been widely reviewed, unlike extensor injuries. It is clear from the literature that extensor tendon repair should be undertaken immediately but the exact approach depends on the extensor zone. Zone I injuries otherwise known as mallet injuries are often closed and treated with immobilisaton and conservative management where possible. Zone II injuries are again conservatively managed with splinting. Closed Zone III or ‘boutonniere’ injuries are managed conservatively unless there is evidence of displaced avulsion fractures at the base of the middle phalanx, axial and lateral instability of the PIPJ associated with loss of active or passive extension of the joint or failed non-operative treatment. Open zone III injuries are often treated surgically unless splinting enable the tendons to come together. Zone V injuries, are human bites until proven otherwise requires primary tendon repair after irrigation. Zone VI injuries are close to the thin paratendon and thin subcutaneous tissue which strong core type sutures and then splinting should be placed in extension for 4-6 weeks. Complete lacerations to zone IV and VII involve surgical primary repair followed by 6 weeks of splinting in extension. Zone VIII require multiple figure of eight sutures to repair the muscle bellies and static immobilisation of the wrist in 45 degrees of extension. To date there is little literature documenting the quality of repairing extensor tendon injuries however loss of flexion due to extensor tendon shortening, loss of flexion and extension resulting from adhesions and weakened grip can occur after surgery. This review aims to provide a systematic examination method for assessing extensor injuries, presentation and management of all type of extensor tendon injuries as well as guidance on mobilisation pre and post surgery.

Principles of hand fracture management

The hand is essential in humans for physical manipulation of their surrounding environment. Allowing the ability to grasp, and differentiated from other animals by an opposing thumb, the main functions include both fine and gross motor skills as well as being a key tool for sensing and understanding the immediate surroundings of their owner. Hand fractures are the most common fractures presenting at both accident and emergency and within orthopaedic clinics. Appropriate evaluation at first presentation, as well as during their management, can significantly prevent both morbidity and disability to a patient. These decisions are dependant on a wide range of factors including age, hand dominance, occupation and co-morbidities.A fracture is best described as a soft tissue injury with an associated bony injury. Despite this being the case, this paper intends to deal mainly with the bone injury and aims to discuss both the timing, as well as the methods available, of hand fracture management.

An overview of the management of flexor tendon injuries

Flexor tendon injuries still remain a challenging condition to manage to ensure optimal outcome for the patient. Since the first flexor tendon repair was described by Kirchmayr in 1917, several approaches to flexor tendon injury have enabled successful repairs rates of 70-90%. Primary surgical repair results in better functional outcome compared to secondary repair or tendon graft surgery. Flexor tendon injury repair has been extensively researched and the literature demonstrates successful repair requires minimal gapping at the repair site or interference with tendon vascularity, secure suture knots, smooth junction of tendon end and having sufficient strength for healing. However, the exact surgical approach to achieve success being currently used among surgeons is still controversial. Therefore, this review aims to discuss the results of studies demonstrating the current knowledge regarding the optimal approach for flexor tendon repair. Post-operative rehabilitation for flexor tendon surgery is another area, which has caused extensive debate in hand surgery. The trend to more active mobilisation protocols seems to be favoured but further study in this area is needed to find the protocol, which achieves function and gliding but avoids rupture of the tendons. Lastly despite success following surgery complications commonly still occur post surgery, including adhesion formation, tendon rupture and stiffness of the joints. Therefore, this review aims to discuss the appropriate management of these difficulties post surgery. New techniques in management of flexor tendon will also be discussed including external laser devices, addition of growth factors and cytokines.

Development of an algorithm for assessing the risk to food safety posed by a new animal disease

An algorithm was developed as a tool to rapidly assess the potential for a new or emerging disease of livestock to adversely affect humans via consumption or handling of meat product, so that the risks and uncertainties can be understood and appropriate risk management and communication implemented. An algorithm describing the sequence of events from occurrence of the disease in livestock, release of the causative agent from an infected animal, contamination of fresh meat and then possible adverse effects in humans following meat handling and consumption was created. A list of questions complements the algorithm to help the assessors address the issues of concern at each step of the decision pathway. The algorithm was refined and validated through consultation with a panel of experts and a review group of animal health and food safety policy advisors via five case studies of potential emerging diseases of cattle. Tasks for model validation included describing the path taken in the algorithm and stating an outcome. Twenty-nine per cent of the 62 experts commented on the model, and one-third of those responding also completed the tasks required for model validation. The feedback from the panel of experts and the review group was used to further develop the tool and remove redundancies and ambiguities. There was agreement in the pathways and assessments for diseases in which the causative agent was well understood (for example, bovine pneumonia due to Mycoplasma bovis). The stated pathways and assessments of other diseases (for example, bovine Johne's disease) were not as consistent. The framework helps to promote objectivity by requiring questions to be answered sequentially and providing the opportunity to record consensus or differences of opinion. Areas for discussion and future investigation are highlighted by the points of diversion on the pathway taken by different assessors.

Carriage of methicillin-resistant Staphylococcus aureus by veterinarians in Australia

OBJECTIVE

To estimate the prevalence of carriage of methicillin-resistant Staphylococcus aureus (MRSA) among Australian veterinarians.

METHODS

Individuals attending veterinary conferences in Australia in 2009 were recruited to provide nasal swabs and complete a questionnaire about their professional activities. Swabs were processed by standard methods for detecting MRSA and questionnaire responses were used to group veterinarians according to their areas of major work emphasis (species and practice type). Prevalence was estimated for each of these grouping and contingency tables and regression tree analysis used to explain the variation in MRSA carriage.

RESULTS

Among the 771 respondents 'industry and government veterinarians' (controls) had the lowest prevalence of MRSA carriage at 0.9%. Veterinarians with horses as a major area of work emphasis had a prevalence of 11.8% (13-fold that of controls) and those whose only major emphasis was horses had a prevalence of 21.4% (23-fold that of controls). Veterinarians with dogs and cats as a major activity had a 4.9% prevalence (5-fold that of controls). Prevalence rates for other major activities (pigs, dairy and beef cattle, avian and wildlife) were also increased, but were estimated from smaller numbers of respondents. Regression tree analysis clearly isolated equine veterinarians and dog and cat practitioners as groups at increased risk of carriage of MRSA.

CONCLUSION

Carriage of MRSA is a notable occupational health issue for veterinarians in clinical practice in Australia, particularly those who work with horses.

Reactor decay heat in 239Pu: solving the γ discrepancy in the 4-3000-s cooling period

The β feeding probability of (102,104,105,106,107)Tc, 105Mo, and 101Nb nuclei, which are important contributors to the decay heat in nuclear reactors, has been measured using the total absorption technique. We have coupled for the first time a total absorption spectrometer to a Penning trap in order to obtain sources of very high isobaric purity. Our results solve a significant part of a long-standing discrepancy in the γ component of the decay heat for 239Pu in the 4-3000 s range.

Antimicrobial resistance and virulence gene profiles in multi-drug resistant enterotoxigenic Escherichia coli isolated from pigs with post-weaning diarrhoea

This study aimed to characterize antimicrobial resistance and virulence genes in multi-drug resistant enterotoxigenic Escherichia coli (ETEC) isolates (n=117) collected from porcine post-weaning diarrhoea cases in Australia (1999-2005). Isolates were serotyped, antibiogram-phenotyped for 12 antimicrobial agents and genotyped by PCR for 30 plasmid-mediated antimicrobial resistance genes (ARGs), 22 intestinal and 38 extraintestinal E. coli virulence genes (VGs). Nine serogroups were identified, the most prevalent being O149 (46.2%), O141 (11.2%) and Ont (31.6%). None of the isolates showed resistance to ceftiofur or enrofloxacin and 9.4% were resistant to florfenicol. No corresponding extended-spectrum/AmpC β-lactamase, fluoroquinolone or floR ARGs were detected. An antimicrobial resistance index (ARI) was calculated from the combined data with a weighting for each antimicrobial agent dependent upon its significance to human health. Serogroup O141 isolates had a significantly higher ARI due to an elevated prevalence of aminoglycoside ARGs and possession of more virulence genes (VGs), including ExPEC or EHEC adhesins (bmaE, sfa/focDE, fimH, ihA) in toxin-producing strains that lacked the normally associated F4 and F18 fimbriae. Few associations between ARGs and VGs were apparent, apart from tetC, sfa/focDE and ompT which, for a sub-set of O141 isolates, suggest possible plasmid acquisition from ExPEC. The multi-drug resistant ETEC ARG/VG profiles indicate a high probability of considerable strain and plasmid diversity, reflecting various selection pressures at the individual farm level rather than emergence and lateral spread of MDR resistant/virulent clones.