Prevention of Staphylococcus aureus biofilm formation and reduction in established biofilm density using a combination of phage K and modified derivatives

AIMS

To investigate the ability of a mixture of phage K and six of its modified derivatives to prevent biofilm formation by Staphylococcus aureus and also to reduce the established biofilm density.

METHODS AND RESULTS

The bioluminescence-producing Staph. aureus Xen29 strain was used in the study, and incubation of this strain in static microtitre plates at 37°C for 48 h confirmed its strong biofilm-forming capacity. Subsequently, removal of established biofilms of Staph. aureus Xen29 with the high-titre phage combination was investigated over time periods of 24 h, 48 h and 72 h. Results suggested that these biofilms were eliminated in a time-dependent manner, with biofilm biomass reduction significantly greater after 72 h than after 24-48 h. In addition, initial challenge of Staph. aureus Xen29 with the phage cocktail resulted in the complete inhibition of biofilm formation over a 48-h period with no appearance of phage resistance.

CONCLUSIONS

In general, our findings demonstrate the potential use of a modified phage combination for the prevention and successful treatment of Staph. aureus biofilms, which are implicated in several antibiotic-resistant infections.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study highlights the first use of phage K for the successful removal and prevention of biofilms of Staph. aureus.

Staged abdominal closure after small bowel or multivisceral transplantation

Following paediatric SBMT, size discrepancy between the recipient's abdomen and the graft may lead to ACS, graft dysfunction, and death. We report our experience with SAC in these patients. Between 04/1993 and 03/2009, 57 children underwent 62 SBMTs. When abdominal wall tension seemed excessive for safe PAC, SAC was performed, using a Silastic® sheet and a vacuum occlusive dressing. Transplantations with SAC (23 combined liver and small bowel [CLB]) were compared with those with PAC [14 ISB and 25 CLB]. Indications for transplantation, preoperative status (after stratification for ISB/CLB transplants), age at transplantation, donor-to-recipient weight ratio, reduction in bowel and/or liver, and incidence of wound complications were not different in both groups. Post-operative intubation, stay in intensive care unit, and hospital stay were prolonged after SAC. Two deaths were related to ACS after PAC, none after SAC. Since 2000, one-yr patient survival is 73% after ISB transplantation and 57% vs. 75% after CLB transplantation with PAC vs. SAC, respectively (NS). SAC safely reduces severe ACS after paediatric SBMT and can be combined with graft reduction for transplantation of small recipients.

How children die: classifying child deaths

AIM

To validate a descriptive tool for the causes of child death, which was designed to circumvent problems posed by the analysis of a confidential enquiry.

METHOD

3 participants from different healthcare backgrounds used clinical data, including the entries on the medical certificate of the cause of death, to classify the root cause of 783 deaths from the Confidential Enquiry into Maternal and Child Health child death review. A bespoke hierarchical system was used. Unanimity of allocation within categories and inter-rater and intra-rater agreement were assessed. Two methods for treating disagreements were compared by assessing their effect upon the apparent incidence of different causes of death.

RESULTS

The participants were most consistent in grouping deaths due to trauma, malignancy and sudden infant death. Each was highly consistent in allocating cases to groups (κ 0.85-0.99), but the agreement between participants, although "good", was worse (κ 0.66-0.78). The greatest number of discrepancies was between diseases identified as congenital by the doctor and as chronic medical conditions by others. The method for treating disagreement between participants does not affect the commonest cause of death (trauma) but alters the ranking of the subordinate causes.

CONCLUSION

Agreement within diagnostic categories might be improved by greater training of assessors in the use of the technique. This level of performance compares well with that of other coding systems upon their target groups.

Why children die: avoidable factors associated with child deaths

AIM

To describe the avoidable factors associated with child deaths identified by a confidential enquiry.

METHOD

In the Centre for Maternal and Child Enquiries confidential enquiry, a sample (13%) of cases was subjected to case note review by multidisciplinary panels attempting to identify avoidable factors associated with the deaths. Cases were selected blindly but in equal numbers from predetermined age bands and participating regions. The anonymised records were reviewed in regions remote to where the child lived and died. Panel composition, conduct and reporting were standardised.

RESULTS

119 of 126 cases reviewed by enquiry panels had sufficient information to determine avoidable factors. These cases were comparable with the whole dataset in terms of sex and causes of death. 31 (26%) of 119 had avoidable factors that were predominantly related to individuals or agencies with a direct responsibility to the child. 51 (43%) of 119 were defined as potentially avoidable. In all, 130 factors were considered in relation to these 82 cases, and 64% of the factors were healthcare related. Avoidable factors were more likely where life-limiting illness was not present. Recurring avoidable factors included failure to recognise serious illness at the point of presentation and death occurring in children who had been lost to follow-up.

CONCLUSION

Child Death Overview Panels now have the responsibility to review child deaths using similar methods but relying upon data forms rather than the case record. Analysis of contributory factors on a national scale has the potential to improve understanding of why children die and indicate strategies to reduce child mortality.

Practice development in community nursing: opportunities and challenges

Practice development has evolved as an activity in health care that is committed to supporting evidence-based practice, person-centered care and quality care. This article seeks to place the emerging evidence for the need for new approaches to practice development in the context of primary care and current health policy. The literature related to community practice development is reviewed and potential opportunities and challenges are discussed. An overview of some work from a practice development unit based in a primary care trust setting is highlighted.

Transition to adult services for children and young people with palliative care needs: a systematic review

OBJECTIVE

To evaluate the evidence on the transition process from child to adult services for young people with palliative care needs.

DESIGN

Systematic review.

SETTING

Child and adult services and interface between healthcare providers.

PATIENTS

Young people aged 13-24 years with palliative care conditions in the process of transition.

MAIN OUTCOME MEASURES

Young people and their families' experiences of transition, the process of transition between services and its impact on continuity of care and models of good practice.

RESULTS

92 studies included. Papers on transition services were of variable quality when applied to palliative care contexts. Most focussed on common life-threatening and life-limiting conditions. No standardised transition program identified and most guidelines used to develop transition services were not evidence-based. Most studies on transition programs were predominantly condition-specific (eg, cystic fibrosis (CF), cancer) services. CF services offered high-quality transition with the most robust empirical evaluation. There were differing condition-dependent viewpoints on when transition should occur but agreement on major principles guiding transition planning and probable barriers. There was evidence of poor continuity between child and adult providers with most originating from within child settings.

CONCLUSIONS

Palliative care was not, in itself, a useful concept for locating transition-related evidence. It is not possible to evaluate the merits of the various transition models for palliative care contexts, or their effects on continuity of care, as there are no long-term outcome data to measure their effectiveness. Use of validated outcome measures would facilitate research and service development.

Epidemiology of biliary atresia in England and Wales (1999-2006)

OBJECTIVE

To identify the epidemiological characteristics of infants with biliary atresia in England and Wales, since centralisation of its management in 1999.

METHODS

The care of infants with biliary atresia (BA) in England and Wales is centralised to only three centres. All infants (treated from January 1999 to December 2006) were identified from a prospective national database; demographic details were ascertained from medical records and compared between two groups based on presumed aetiology (isolated biliary atresia (IBA) and developmental biliary atresia (DBA) (for example, syndromic infants, biliary atresia splenic malformation, cystic biliary atresia)).

RESULTS

There were 302 (133 male (44%)) infants with BA that could be divided into IBA (n = 219, 73%) and DBA (n = 76, 25%). The overall incidence was 0.58/10 000 (1 in 17,049) live births with marked regional differences along a north-west/south-east axis varying from 0.38 (north-west England) to 0.78 (south-east England)/10,000 live births (OR 2.05 (95% CI 1.26-3.41); p = 0.002). The commonest month of birth was September with December being the least common, although there was no evidence for significant seasonal variation (p = 0.2). Infants with DBA were more likely to be female (p<0.001), of white background (p = 0.01), first-born (p = 0.04) and to be formula-fed (p = 0.07). Infants of south Asian origin came to surgery at an older age (59 (IQ 45-75) versus 52 (IQ 42-65) days; p = 0.03).

CONCLUSIONS

There is a remarkable variation of incidence of biliary atresia within England and Wales, some of which may have been caused by factors related to a different aetiological and racial background.

Balancing inflammatory, lipid, and xenobiotic signaling pathways by VSL#3, a biotherapeutic agent, in the treatment of inflammatory bowel disease

BACKGROUND

The interleukin 10 knockout mouse (IL10-KO) is a model of human inflammatory bowel disease (IBD) used to study host microbial interactions and the action of potential therapeutics. Using Affymetrix data analysis, important signaling pathways and transcription factors relevant to gut inflammation and antiinflammatory probiotics were identified.

METHODS

Affymetrix microarray analysis on both wildtype (WT) and IL10-KO mice orally administered with and without the probiotic VSL#3 was performed and the results validated by real-time polymerase chain reaction (PCR), immunocytochemistry, proteomics, and histopathology. Changes in metabolically active bacteria were assessed with denaturing gradient gel electrophoresis (DGGE).

RESULTS

Inflammation in IL10-KO mice was characterized by differential regulation of inflammatory, nuclear receptor, lipid, and xenobiotic signaling pathways. Probiotic intervention resulted in downregulation of CXCL9 (fold change [FC] = -3.98, false discovery rate [FDR] = 0.019), CXCL10 (FC = -4.83, FDR = 0.0008), CCL5 (FC = -3.47, FDR = 0.017), T-cell activation (Itgal [FC = -4.72, FDR = 0.00009], Itgae [FC = -2.54 FDR = 0.0044]) and the autophagy gene IRGM (FC = -1.94, FDR = 0.01), a recently identified susceptibility gene in human IBD. Consistent with a marked reduction in integrins, probiotic treatment decreased the number of CCL5+ CD3+ double-positive T cells and upregulated galectin2, which triggers apoptosis of activated T cells. Importantly, genes associated with lipid and PPAR signaling (PPARalpha [FC = 2.36, FDR = 0.043], PPARGC1alpha [FC = 2.58, FDR = 0.016], Nr1d2 [FC = 3.11, FDR = 0.0067]) were also upregulated. Altered microbial diversity was noted in probiotic-treated mice.

CONCLUSIONS

Bioinformatics analysis revealed important immune response, phagocytic and inflammatory pathways dominated by elevation of T-helper cell 1 type (TH1) transcription factors in IL10-KO mice. Probiotic intervention resulted in a site-specific reduction of these pathways but importantly upregulated PPAR, xenobiotic, and lipid signaling genes, potential antagonists of NF-kappaB inflammatory pathways.

The effect of naturopathic and nutritional supplement treatment on tumor response, control, and survival in prostate cancer patients treated with radiation therapy

e16088

Background: Potential antagonism of clinical response to cancer treatment by naturopathic/nutritional supplements (NNS) with anti-oxidant activity has been suggested. This study assessed effects of NNS on tumor response to radiation therapy (RT) in prostate cancer patients (PCpts). Methods: Of 134 RT-treated PCpts with localized tumors, 69 received NNS (+NNS; median age=62.0 yrs) and 65 did not (-NNS; median age=61.5 yrs). Based on pre-RT PSA, 52low (4–10 ng); 13 intermediate (10–20 ng); and 4 high risk (> 20 ng) PCpts were +NNS and 50, 10, and 5 low, intermediate & high risk PCpts were -NNS. Tumor stages for +NNS were T1c (39%); T2a (44%); T2b (10%); T2c (5%) with 1 T3b tumor and were T1b (3%); T1c (46%); T2a (32%); T2b (12%); and, T2c (5%) with 1 T3a tumor for -NNS cohorts. RT consisted of external beam therapy (4500–5000 cGy) + HDR brachytherapy (600–650 cGy/fraction x 2–3 fractions) administered over 6–8 weeks. NNS regimens (range 1–7 antioxidants) included Green Tea Extract, Melatonin, high-potency multivitamins, vitamin C, and vitamin E. All pts were monitored ≥ 24 months post RT. Hormonal therapy (HT; oral bicalutamide (50 mg/day) ±leuprolide depot (22.5 mg IM q 3 months) as neoadjuvant or adjuvant HT was given to 39 (57%) and 38 (58%) PCpts in the +NNS and -NNS cohorts respectively. Results: For the +NNS cohort that did not receive HT, PSA levels were 5.05; 0.285; and 0.356 ng at pretreatment, nadir and ≥ 24 months followup respectively with PSA nadir at 27 months and median followup of 36 months. The corresponding values for the -NNS cohort were 5.6, 0.54, and 0.585 ng with PSA nadir at 25 months and median followup of 29.6 months. Differences were not statistically significant. For the +NNS cohort that did receive HT, PSA levels were 6.8, 0.03 and 0.12 ng at pretreatment, nadir and ≥ 24 months followup with median time to nadir = 4.3 months and median followup = 29.2 months. Corresponding values for -NNS cohort were 6.9, 0.03, and 0.11 with median time to nadir = 3.6 months and median followup = 30.5 months. Differences were also not statistically significant. Conclusions: This study shows that NNS with antioxidant activity do not interfere with clinical response to RT ± HT as definitive treatment for limited stage prostate cancer.

No significant financial relationships to disclose.

Intratumoral chemotherapy as an adjunct to endobronchial brachytherapy

7591

Background: NSCLC patients (pts) with clinically significant endobronchial obstruction have a poor prognosis and quality of life in both locally advanced and metastatic stages of disease. Radiation therapy (RTx) in conjunction with chemotherapy (CTx) improves survival compared to either modality alone but produces greater toxicity and morbidity. Significant clinical benefit with respect to disease management and quality of life could be realized with improved methods for controlling obstructing endobronchial lesions. The hypothesis for this study is that optimal clinical control of endobronchial lesions can be achieved by intratumoral injection of a drug with both clinical activity against NSCLC and synergy with RTx. Cisplatin (CPt), an active agent in NSCLC and a known radiosensitizer is an ideal drug for this objective. Thus, the goal of this exploratory study was to determine the clinical efficacy and tolerance to intratumoral CPt injection in combination with HDR brachytherapy (BTx) in NSCLC patients with obstructing endobronchial lesions. Methods: NSCLC pts (n=16) with > 75% endoluminal obstruction of a main or lobar airway were evaluated. Intratumoral CTx consisted of CPt (1 mg/ml; 0.5–2.0 ml/session) injected into the entire visible tumor through a flexible 21 gauge needle through the bronchoscope. BTx was given as 500 cGy/session at one cm diameter for 4 sessions concomitant with CTx. Results: All pts completed the entire 4 sessions of planned local therapy. There was complete resolution of injected lesions in 14/16 pts confirmed bronchoscopically and cytologically. In the other 2 pts, necrotic tissue occupying < 10 and 20% of the airway, cytologically negative for tumor was seen. There were no adverse events or complications related to bronchoscopy or local CTx. Conclusions: The results of this study demonstrate that intratumoral administration of CPt, as an adjunct to endobronchial BTx for the management of endobronchial obstructing lesions in patients with NSCLC is safe and effective. This approach offers the possibility of superior local tumor control while reducing toxicity to normal lung and esophagus as compared to conventional external beam radiation therapy modalities. Further studies evaluating the impact of this approach on survival and quality of life are warranted.

No significant financial relationships to disclose.

Disc calibration for digital templating in hip replacement

Digital radiography is becoming widespread. Accurate pre-operative templating of digital images of the hip traditionally involves positioning a calibration object at its centre. This can be difficult and cause embarrassment. We have devised a method whereby a planar disc placed on the radiographic cassette accounts for the expected magnification. Initial examination of 50 pelvic CT scans showed a mean hip centre distance of 117 mm (79 to 142) above the gluteal skin. Further calculations predicted that a disc of 37.17 mm diameter, placed on the cassette, would appear identical to a 30 mm sphere placed at the level of the centre of the hip as requested by our templating software. We assessed accuracy and reproducibility by 'reverse calibration' of 20 radiographs taken three months after hip replacement using simultaneous sphere and disc methods, and a further 20 with a precision disc of accurate size. Even when variations in patient size were ignored, the disc proved more accurate and reliable than the sphere. The technique is reliable, robust, cost effective and acceptable to patients and radiographers. It can easily be used in any radiography department after a few simple calculations and manufacture of appropriately-sized discs.