Fragility fractures in the elderly: Evolving approaches in the NHS

Fragility fractures account for a significant proportion of trauma admissions and clinic attendances in the UK. Hip fractures constitute a major part of these fractures followed by wrist, spine and humerus. With the increasing elderly population and increasing life expectancy, incidences of these fractures have increased proportionately. Hip fractures cause significant morbidity and mortality because of existing medical co-morbidities or perioperative complications. In order to decrease the overall incidence of osteoporotic fractures and improve outcome of surgical treatment, different approaches to prevention and treatment are currently evolving throughout the NHS. These include primary prevention through management of osteoporosis and secondary prevention aimed at treating osteoporosis and reducing further fractures. In this article, we highlight the different care pathways that could effectively decrease the incidence of fragility fractures as well as the morbidity and mortality in these patients.

Immunogenicity of MHC Class I Peptides Derived from Leishmania mexicana Gp63 in HLA-A2.1 Transgenic (HHDII) and BALB/C Mouse Models

BACKGROUND

Leishmania is an intracellular parasite infecting humans and many wild and domestic animals. Recent studies have suggested an important role for cytotoxic T cells against Leishmania. Peptide-based vaccines targeting short sequences derived from known immunogenic proteins have been shown to elicit cellular immune responses against disparate pathogens.

METHODS

We predicted four HLA-A2 peptides derived from L. mexican/major gp63 and tested these in HHD II mice, as well as four peptides for mouse MHC class I from the same proteins tested in BALB/ mice.

RESULTS

The results revealed immunogenicity for three of the four peptides predicted for HLA-A2. Immunisation with these peptides, along with IFA, induced CTL responses detected by standard 4-hour cytotoxicity assay and significantly upregulated the production of IFN-γ. When HHDII mice were injected IM with L. mexicana gp63 cDNA and splenocytes were restimulated with blasts loaded with the immunogenic peptides, two of the peptides were able to induce significant level of IFN-γ detected by ELISA. None of the peptides predicted for Balb/c mouse MHC class I elicited CTL activity or significantly upregulated the IFN-γ.

CONCLUSION

The results may help in developing a peptide-based vaccine, which can be applied alone or in combination with drugs against Leishmania.

Leishmania mexicana Gp63 cDNA Using Gene Gun Induced Higher Immunity to L. mexicana Infection Compared to Soluble Leishmania Antigen in BALB/C

BACKGROUND

Leishmaniasis is a worldwide disease prevalent in tropical and sub tropical countries. Many attempts have been made and different strategies have been approached to develop a potent vaccine against Leishmania. DNA immunisation is a method, which is shown to be effective in Leishmania vaccination. Leishmania Soluble Antigen (SLA) has also recently been used Leishmania vaccination.

METHODS

The immunity generated by SLA and L. mexicana gp63 cDNA was compared in groups of 6 mice, which were statistically analysed by student t- test with the P-value of 0.05. SLA was administered by two different methods; intramuscular injection and injection of dendritic cells (DCs) loaded with SLA. L. mexicana gp63 cDNA was administered by the gene gun.

RESULTS

Immunisation of BALB/c mice with L. mexicana gp63 resulted in high levels of Th1-type immune response and cytotoxic T lymphocytes (CTL) activity, which were accompanied with protection induced by the immunisation against L. mexicana infection. In contrast, administration of SLA, produced a mixed Th1/Th2-type immune responses as well as a high level of CTL activity but did not protect mice from the infection.

CONCLUSION

The results indicate higher protection by DNA immunisation using L. mexicana gp63 cDNA compared to SLA, which is accompanied by a high level of Th1 immune response. However, the CTL activity does not necessarily correlate with the protection induced by the vaccine. Also, gene gun immunisation is a potential approach in Leishmania vaccination. These findings would be helpful in opening new windows in Leishmania vaccine research.

Evaluation of the syndesmotic-only fixation for Weber-C ankle fractures with syndesmotic injury

BACKGROUND

With the length of the fibula restored and the syndesmosis reduced anatomically, internal fixation using a plating device may not be necessary for supra-syndesmotic fibular fractures combined with diastasis of inferior tibio-fibular joint. A retrospective observational study was performed in patients who had this injury pattern treated with syndesmosis-only fixation.

MATERIALS AND METHODS

12 patients who had Weber type-C injury pattern were treated with syndesmosis only fixation. The treatment plan was followed only if the fibular length could be restored and if the syndesmosis could be anatomically reduced. Through a percutaneous or mini-open reduction and clamp stabilization of the syndesmosis, all but one patient had a single tricortical screw fixation across the syndesmosis. Patients were kept non-weight-bearing for 6 weeks, followed by screw removal at an average of 8 weeks. Outcomes were assessed using an objective ankle scoring system (Olerud and Molander scale) and by radiographic assessment of the ankle mortise.

RESULTS

At a mean follow-up of 13 months, the functional outcome score was 75. Excellent to good outcomes were noted in 83% of the patients. Ankle mortise was reduced in all cases, and all but one fibular fracture united without loss of fixation. Six patients had more than one malleolar injury, needing either screw or anchor fixations. One patient had late diastasis after removal of the syndesmotic screw and underwent revision surgery with bone grafting of the fibula. This was probably due to early screw removal, before union of the fibular fracture had occurred.

CONCLUSION

We recommend syndesmosis-only fixation as an effective treatment option for a combination of syndesmosis disruption and Weber type-C lateral malleolar fractures.

Management of ruptured amoebic liver abscess: 22-years experience

BACKGROUND

Amoebiasis affects approximately 10% of the population all over the world. Amoebic liver abscess (ALA) is the commonest complication of amoebiasis affecting 3-9% victims. It is an ancient disease as Hippocrates notified large hepatic abscesses likely to be amoebic abscesses. Objective of this study was to see the efficacy of conservative treatment in the management of ruptured amoebic liver abscess.

METHODS

Record of 1,083 patients of amoebic liver abscess, who were treated and managed at Liaquat University Hospital between January 1986 and December 2007, was reviewed retrospectively. Amongst these, 36 (3.32%) patients, found to have intra-peritoneal rupture of the liver abscess were included in this study. The record of these patients was reviewed. The patients were divided into group A and B depending upon the mode of treatment employed. Group A included 16 (44.44%) patients in whom exploratory laparotomy was performed while group B included 20 (55.55%) patients who were treated conservatively.

RESULTS

Group A consisted of 16 (44.4%) patients who underwent laparotomy for acute peritonitis due to non-availability of ultrasound in the initial period of the study. In group B, all twenty patients were treated conservatively after a diagnosis of ruptured amoebic liver abscess made by ultrasound guided percutaneous aspiration of pus. These patients were treated with ultrasound guided aspiration of pus with placement of peritoneal drain under local anaesthesia. Six patients in group A died compared to one patient in group B. the overall mortality of ruptured amoebic liver abscess was 19.4%. It was higher in patients treated surgically (37.5%) compared to patients who were treated conservatively (5%).

CONCLUSION

Conservative treatment is an effective modality of treatment for ruptured liver abscess with minimum mortality and mortality if diagnosis is made early.

CTL responses to Leishmania mexicana gp63-cDNA vaccine in a murine model

Immunity to Leishmania is believed to be strongly dependent upon the activation of Th1 immune responses, although the exact role of cytotoxic T lymphocytes (CTLs) has not yet been determined. The aims of this study were to establish a suitable cytotoxicity assay to measure CTL activity and to compare immunity induced by Leishmania mexicana gp63 cDNA via i.m. injection and gene gun immunization in the BALB/c mouse model. The CTL activity was evaluated by short-term (51)Cr-release cytotoxicity assays against CT26 tumour cells transfected with L. mexicana gp63 cDNA and dendritic cells (DCs) loaded with soluble Leishmania antigen (SLA) as targets. The results clearly demonstrated that higher protection to L. mexicana infection was induced by gene gun DNA-immunization vs. i.m. injection. Cytotoxic T lymphocyte activity of splenocytes was observed in mice immunized either with L. mexicana gp63 cDNA or SLA and long-lived CTL activity was observed in immunized and/or re-challenged mice but not naïve mice infected with the parasite.

Safety and efficacy of total dose infusion of iron dextran in iron deficiency anaemia

AIMS

Intravenous iron is usually reserved for patients in whom oral administration has failed. Typically the calculated total dose is divided in to several fractions. Total dose infusion (TDI) of iron dextran is not commonly used due to the potential for serious side effects such as anaphylactic reactions.

METHODS

We identified 214 patients retrospectively, who were given TDI. Outcomes studied were: immediate side effects, improvement of haemoglobin and haematocrit.

RESULTS

The most frequent side effect of TDI was nausea with a rate of 2.2%. Headache, vomiting, chills and backache were seen in 1.1% of patients and about 0.5% of patients experienced fever and diarrhoea. No anaphylactic reaction was noted. Observed mean elevation of haematocrit was 5.3% and haemoglobin of 2.0 gm/dl (p < 0.0001).

CONCLUSION

TDI of iron dextran is a safe, potentially efficacious and convenient treatment in iron deficiency anaemia, in patients unresponsive or intolerant to oral iron.

Supra dietary levels of vitamins C and E enhance antibody production and immune memory in juvenile milkfish, Chanos chanos (Forsskal) to formalin-killed Vibrio vulnificus

Juveniles of milkfish, Chanos chanos (Forsskal), were fed two independent supra dietary levels of vitamins C (500 and 1500 mg kg(-1) feed, T1 and T2) and E (50 and 150 mg kg(-1), T3 and T4). Milkfish fed diets with supra (in addition to the vitamins present in the control diet) and normal levels (T5 containing 90 and 1.2mg of vitamins C and E, respectively, kg(-1) of feed) of vitamins were immunized (ip) with formalin-killed Vibrio vulnificus (FKVV). Priming and booster antibody responses to the injected bacterin were significantly (P<0.05) better in the milkfish juveniles fed supra dietary levels. Survival response of the experimental fish fed supra dietary levels of vitamins (T1, T2 and T3) was significantly (P<0.01) better than that of the control set. Protective response against virulent bacterial challenge of the vaccinated fish fed vitamin-supplemented diets (T2 and T3) was better than the control (T5) and T1 and T4. Memory factor reflecting immunological memory was superior in the fish fed vitamin-supplemented diets. Diets supplemented with either 1500 mg of Vitamin C or 50mg of Vitamin E kg(-1) produced the best antibody responses, final survival and protective response upon challenge. No conclusive inferences could be drawn on the growth responses from the experiment.

Epidemiological and etiological study of oral submucous fibrosis among gutkha chewers of Patna, Bihar, India

An etiological and epidemiological study of oral submucous fibrosis (OSMF) has been done in Patna, Bihar. Total 157 cases of OSMF and 135 control subjects were selected for study in the period of 2002-2004. It was observed that Male:Female ratio was 2.7:1. The youngest case of OSMF was 11 year old and the oldest one was 54 years of age. Maximum number of cases were belonging to 21-40 years of age and they were belonging to low or middle socioeconomic class. Most of the OSMF cases used heavy spices and chillies, where as control mild spices and chillies. Gutkha was the most commonly used by the OSMF cases only 3 per cent did not use any gutkha or other areca nut product where as 80 per cent control did not have any chewing habit. The OSMF cases used gutkha and other products 2-10 pouches per day and kept in the mouth for 2-10 minutes and they were using since 2-4 years. Most of the OSMF cases kept gutkha in the buccal vestibule or they chewed and swallowed it, only a small number of patients chewed and spitted it out. It was also observed that OSMF developed on one side of the buccal vestibule where they kept the chew and other side was normal.

Prostaglandin EP4 receptor agonist augments fixation of hydroxyapatite-coated implants in a rat model of osteoporosis

The reduced stability of hydroxyapatite (HA)-coated implants in osteopenic conditions is considered to be a major problem. We therefore developed a model of a boosted cementless implantation in osteopenic rats.

Twelve-week-old rats were either ovariectomised (OVX) or sham-operated (SO), and after 24 weeks plain or HA-coated implants were inserted. They were treated with either a prostaglandin EP4 receptor agonist (ONO-4819) or saline for one month.

The EP4 agonist considerably improved the osteoporosis in the OVX group. Ultrastructural analysis and mechanical testing showed an improvement in the implant-bone attachment in the HA-coated implants, which was further enhanced by the EP4 agonist. Although the stability of the HA-coated implants in the saline-treated OVX rats was less than in the SO normal rats, the administration of the EP4 agonist significantly compensated for this shortage. Our results showed that the osteogenic effect of the EP4 agonist augmented the osteoconductivity of HA and significantly improved the stability of the implant-bone attachment in the osteoporotic rat model.

Role of vitamins B6, B12 and folic acid on hyperhomocysteinemia in a Pakistani population of patients with acute myocardial infarction

BACKGROUND AND AIM

Pakistani people belong to an ethnic group which has the highest rate of coronary artery disease (CAD). We investigated the possible correlation between deficiency of vitamins B6, B12 or folic acid and hyperhomocysteinemia in Pakistani patients with acute myocardial infarction (AMI). A case-control study was carried out involving 224 AMI patients (age 30-70 years; 55 females and 169 males) and 126 normal healthy subjects (age 31-70 years; 35 females and 91 males).

METHODS AND RESULTS

Fasting venous blood was obtained from cases and controls. Serum was analyzed for folic acid and B12 using radioassays. Plasma was analyzed for pyridoxal phosphate (PLP; coenzymic form of B6) using a radioenzymatic assay and for total homocysteine using a fluorescence polarization immunoassay. Mean serum B12 concentration in AMI patients was found to be significantly lower than the mean for controls (241+/-185 pg/ml vs 608+/-341 pg/ml; p < 0.001). Mean serum folate level in patients was also found to be lower than controls (3.35+/-3.78 ng/ml vs 4.93+/-2.93 ng/ml), however, the differences were not statistically significant. Similarly, mean PLP concentration in plasma of cases (19.4+/-24.4 nmol/l) was lower than the concentration in controls (23.2+/-17.6 nmol/l), but the difference was not statistically significant. Mean plasma homocysteine level in AMI cases (18+/-8.36 micromol/l) was higher than the mean level in controls (16.4+/-4.9 micromol/l), but not to a significant extent. However, this mean homocysteine concentration in normal healthy subjects was among the highest reported in the literature and was significantly more than mean values reported in most Eastern and Western studies. Compared to controls, there was significantly greater deficiency of folate (32.5% vs 67.1%), B12 (3.2% vs 63.4%) and PLP (49.2% vs 74.1%) in AMI patients. Deficiencies of folate, B12 and PLP were defined as serum folate levels less than 3.5 ng/ml, serum levels of B12 less than 200 pg/ml and plasma PLP levels less than 20 nmol/l. Mean plasma homocysteine levels in smokers were found to be significantly higher in both cases and controls. Similarly, mean serum folate levels in smokers (compared to nonsmokers) were significantly lower in both cases and controls.

CONCLUSIONS

Substantial nutritional deficiencies of these three vitamins along with mild hyperhomocysteinemia, perhaps through an interplay with the classical cardiovascular risk factors (highly prevalent in this population), could be further aggravating the risk of CAD in the Pakistani population.

Nodavirus infection causes mortalities in hatchery produced larvae of Lates calcarifer: first report from India

Larvae (15 to 21 d post hatch, dph) of the Asian sea bass Lates calcarifer (Bloch) suffered heavy mortalities (60 to 90%) during the hatchery-rearing phase. Darkened and moribund larvae showed no evidence of bacterial or parasitic infections. Tissue sections of brain and spinal cord showed clear necrotic vacuolation. Electron microscopy revealed membrane-bound viral particles in the cytoplasm of the nerve cells. The viral particles measured 28 to 30 nm in diameter. Primer sets, designed for the amplification of the RNA2 segment of the piscine nodavirus coat protein gene, were used in the RT-PCR analysis of moribund larvae of 20 and 21 dph which produced the amplified product of 430 bp. The clinical manifestations, pathology and electron microscopy observations supported by the RT-PCR analysis suggest that the nerve necrosis was due to nodavirus infection in the larvae. This is the first report of piscine nodavirus infection from the Indian sub-continent.

Evaluation of Pseudomonas sp. PM 11 and Vibrio fluvialis PM 17 on immune indices of tiger shrimp, Penaeus monodon

Occurrence of widespread epizootics among cultured stock of shrimp has put research programmes on preventive approaches such as application of probiotics on a high priority in aquaculture. In the present study two bacteria, Pseudomonas sp. PM 11 and Vibrio fluvialis PM 17 were selected as candidate probionts from a pool of bacteria isolated from gut of farm reared sub-adult shrimp and tested for their effect on the immunity indicators of tiger shrimp. Sub-adult shrimp, weighing 14 to 22 g were treated in separate experiments with Pseudomonas sp. PM 11 and V. fluvialis PM 17 at 10(3) bacterial cells ml(-1) in the experimental shrimp culture tanks. One set of experimental animals was treated every 3 days and another set of animals every 7 days with each of the candidate probionts. Estimation of immunological indicators such as haemocyte counts, phenol oxidase and antibacterial activity showed declining trends. The haemocyte counts dropped from 31 x 10(3) to 65 x 10(3) ml(-1) on the first day to 4-16 x 10(3) ml(-1) on the 45th day. Similarly, the phenol oxidase activity declined from 12-32 units on the first day to 11-14 units on 45th day of the experiment. Antibacterial activity of haemolymph reduced to 46-67 percent on the 45th day of the experiment. The results of the study suggest that, the criteria used for the selection of putative probiotic strains in the present study, such as predominant growth on primary isolation media, ability to produce extracellular enzymes and siderophores, did not bring about the desired effect in vivo and improve the immune system in shrimp. Hence, new protocols have to be evolved for selection of microbe(s) as putative probiotics and that, detailed understanding of proven probiotics, employed presently on empirical basis may provide a clue on the selection procedure.

Impact of Gemcitabine and Cisplatin with radiotherapy in locally advanced or metastatic transitional cell carcinoma of urinary bladder

OBJECTIVE

The primary object of this study is to evaluate the efficacy and safety of Gemcitabine and Cisplatin along with radiotherapy in transitional cell carcinoma of urinary bladder.

PATIENTS AND METHODS

Twenty patients with locally advanced or metastatic TCC of urinary bladder were enrolled during the 22-months period from January, 1999 to October, 2000 and followed up till March 2002. Three patients received 4 cycles, five patients received 5 cycles and twelve patients received 6 cycles of Gemcitabine 1250 mg/m2 on day 1 and day 8 and Cisplatin 80 mg/m2 on day 1; administered every 3 weeks. No patient received prior chemotherapy, radiotherapy or surgery. However, four patients received prior intravesical chemotherapy. All patients received radiotherapy after completion of chemotherapy regimen.

RESULTS

Nineteen patients achieved complete response at the end of the treatment. The complete response rate was 95%. The confidence interval was at 95%, level of confidence ranged from 85% to 100%. Median duration of clinical benefit was 21 months. Six patients (30%) were documented neutropenia, three patients (15%) documented thrombocytopenia. No life threatening toxicity was observed.

CONCLUSION

Gemcitabine and Cisplatin along with radiotherapy in locally or metastatic Transitional cell carcinoma of urinary bladder, exhibited pronounced response rate among all the patients. The toxicity profile remained extremely low and disease free survival enhanced. The above investigation may further be continued at a larger scale encompassing a wide band of subjects.

Cardiac acceleration as a marker of vagal withdrawal in heart rate control during exercise in humans

OBJECTIVE

To investigate whether the time rate of change in heart rate i.e. cardiac acceleration, during aerobic exercise in human subjects could be used to differentiate vagal withdrawal from sympathetic stimulation.

METHODS

Fifteen male subjects exercised on a bicycle ergometer at 50 Watts (Step 1), then 100 Watts (Step 2), for 2 minutes each.

RESULTS

Heart rate (HR) was monitored from a resting value (mean +/- SD) of 80.3 +/- 12.9 to 113.8 +/- 13.6 beats min-1 in Step 1. In Step 2 exercise, HR increased from 113.8 +/- 13.6 to 145 +/- 20 beats min-1. At the initiation of Step 1, a rapid acceleration of HR was observed in the form of an overshoot response. In contrast to Step 1, a small overshoot response of cardiac acceleration was observed during Step 2. The difference between the mean cardiac acceleration at 10 seconds in Steps 1 and 2 was significant (2.40 +/- 0.19 and 0.71 +/- 0.12 beats min-1 sec-1, p<0.0001).

CONCLUSION

The initial vagal withdrawal of exercise-induced tachycardia, as a frontline adaptive mechanism, can be indirectly identified from HR transients using cardiac acceleration as a new marker.

Production, purification and some properties of Bac201, a bacteriocin-like inhibitory substance produced by Staphylococcus aureus AB201

Staphylococcus aureus AB201, a clinical isolate from wound pus, produced a bacteriocin-like inhibitory substance termed as Bac201, that was inhibitory to Streptococcus agalactiae, Enterococcus faecalis, Acinetobacter calcoaceticus, Neisseria meningitidis and a number of staphylococcal species. It was purified to homogeneity by ammonium sulfate precipitation, gel filtration (BioSil-SEC-125), and reversed-phase high performance liquid chromatography (Vydac C4). The native Bac201 was sized at approximately 170-kDa as determined by GF HPLC. Fraction-I (native Bac201), having antibacterial activity was also examined by transmission electron microscopy and appeared as globular structure showing resemblance with phage-like objects. The purification of Bac201 resulted in 466-fold increase in specific activity and recovery of 0.94% of total antibacterial activity. The purified Bac201 migrated as single band on SDS-PAGE with an estimated molecular mass of about 41-kDa. Bac201 was sensitive to proteolytic enzymes, resistant to heat and organic solvents, and active over a wide range of pH (2.5-10). The amino acid composition revealed a general resemblance with other reported high molecular mass bacteriocins and predominance of glycine (39%), proline (13%) and alanine (8%) residues. Further results showed that Bac201 has a bactericidal effect on sensitive cells which is not produced by either cell lysis or apparent loss of membrane permeability.

Efficacy of clarithromycin in preventing viridans streptococcal bacteremia following autologous stem cell transplantation

BACKGROUND

In a study involving 200 patients, we previously found that 17.5% of patients developed viridans streptococcal (VS) bacteremia following autologous peripheral blood stem cell transplantation (aPBSCT) when ciprofloxacin or ciprofloxacin plus ampicillin was used for prophylaxis.

PATIENTS AND METHODS

A retrospective evaluation of 100 consecutive recipients of aPBSCT was conducted to ascertain the incidence and outcome of VS bacteremia when a combination of ciprofLoxacin and clarithromycin was utilized for antimicrobiaL prophylaxis following transplantation. The 200 patients from our previous study, in which ciprofloxacin alone or ciprofloxacin with ampicillin was used for prophylaxis, were combined with the current group for the purpose of statistical analysis.

RESULTS

Streptococcus mitis was isolated from the blood of five individuals at a median of 5 days following stem cell infusion. Each of these patients was neutropenic and presented with fever. Three isolates demonstrated intermediate resistance to macrolides in vitro. However, all episodes of bacteremia were treated successfully with systemic antibiotic therapy.

CONCLUSION

Age, duration of neutropenia, type of underlying malignancy and type of conditioning chemotherapy regimen failed to have a significant impact on subsequent VS bacteremia. Only female sex and use of ciprofloxacin without clarithromycin as antimicrobiaL prophyLaxis predicted a significantly increased risk of VS bacteremia in both univariate and Logistic regression analyses.