Metal ion levels in a triathlete with a metal-on-metal resurfacing arthroplasty of the hip

A prospective study of serum and urinary ion levels was undertaken in a triathlete who had undergone a metal-on-metal resurfacing arthroplasty of the hip four years previously. The one month study period included the final two weeks of training, the day of the triathlon, and the two weeks immediately post-race. Serum cobalt and chromium levels did not vary significantly throughout this period, including levels recorded on the day after the 11-hour triathlon. Urinary excretion of chromium increased immediately after the race and had returned to pre-race levels six days later. The clinical implications are discussed.

14th International HLA and Immunogenetics Workshop: Report on the Prospective Chronic Rejection Project

An international collaborative study of 45 transplant centers was undertaken at the 14th International HLA (human leukocyte antigen) and Immunogenetics Workshop to see if HLA antibodies detected posttransplant are predictive of chronic graft failure. With the newly developed assay, MICA (major histocompatibility complex class I-related chain A) antibodies were also measured and their effect analyzed. Total of 5219 sera from patients who were more than 6 months posttransplant with functioning graft were tested for HLA antibodies by enzyme-linked immunosorbent assay, flow cytometry, or Luminex. HLA antibodies were found in 27.2% of kidney patients, 23.6% in the liver, 52.7% in the heart, and 21.7% in the lung. The method of antibody testing did not have a marked influence on the frequency of antibodies detected. MICA antibodies were detected in 15% of kidney patients, 30% of heart patients, and 31% of liver patients. Among 948 kidney patients who had HLA antibodies, 7.3% had rejected their graft within 1 year of testing, compared with 1.7% in 2615 patients without HLA antibodies (P= 0.8 x 10(-17)). Death occurred in 1.4% of total kidney patients and did not correlate to the presence of antibodies. We conclude that patients with posttransplant HLA antibodies indeed have a higher rate of chronic graft failure and that posttransplant antibodies are predictive of chronic rejection.

Thermographic investigation of the heating effect of high intensity focused ultrasound

The purpose of this study was to use thermal imaging camera to investigate the localised heating effect of High intensity focused ultrasound (HIFU), to monitor temperature rise in real time and accurately. In order to visualise thermally induced protein coagulation, a phantom of Polyacrylamide (PAA) gel containing fresh egg albumin was used as tissue mimicking material. A high resolution thermal camera was positioned directly over the samples to record thermal fluctuations. Two modes of ultrasound were investigated, i.e. continuous wave and pulsed wave. Through imaging processing and thermal analysis, the temperature profile of the phantoms during HIFU heating was obtained, and the optimised parameters for protein coagulation were identified. The experiments have shown that thermal imaging is an effective way to measure the bioheating effect of HIFU.

14th International HLA and Immunogenetics Workshop Prospective Chronic Rejection Project: a three-year follow-up analysis

The three-year follow-up of 4,144 patients of the 14th International Workshop Prospective Chronic Rejection study has reinforced the evidence that post-transplant HLA antibodies are predictive of long-term graft loss. Three years after a single testing for HLA antibodies, 10% of kidney recipients who were antibody-positive had lost their grafts, in contrast to only 5% of antibody-negative patients (p<0.0001). The adverse effect of post-transplant antibodies on graft survival was also observed in lung, heart, and liver transplants. Donor-specific antibodies and 'strong' non-DSA had stronger association with graft loss than 'moderate' non-DSA. Periodic antibody monitoring, combined with specificity and strength analysis, would help in the early identification of allograft recipients who are at high risk of graft failure.

Inadvertent tracheal perforation during thyroidectomy

Valuable advice for thyroid surgeons

A randomized trial comparing the efficacy of four treatment regimens for uncomplicated falciparum malaria in Assam state, India

A four-arm drug sensitivity study compared chloroquine, sulfadoxine-pyrimethamine (SP), mefloquine and mefloquine-artesunate in Sonitpur and Karbi Anglong districts in Assam state, India. Two criteria were used to ascertain outcome: success of clinical treatment and parasitologic cure. In Sonitpur, at 14 days, there were 36/56 early and late treatment failures plus late parasitologic failures to chloroquine and 16/56 for SP. In Karbi Anglong, combined treatment failure at 14 days was 16/56 to chloroquine and 8/60 to SP. Mefloquine and mefloquine-artesunate demonstrated 93.9% and 93.6% sustained responses respectively at 42 days. High failure rates to both chloroquine and SP preclude the use of these drugs as first-line treatment for uncomplicated falciparum malaria in this region. A mefloquine-artesunate combination presents an effective alternative utilizing the currently recommended higher dose of mefloquine.

[Clinical management of patients and deceased during the Ebola outbreak from October to December 2003 in Republic of Congo]

Outbreaks of Ebola virus hemorrhagic fever (EVHF) have been reported since 2001 in the Cuvette Ouest department, a forested area located in the Western North of Congo. At the end of October 2003 a new alarm came from this department which was quickly confirmed as being an epidemic of EVHF. The outbreak response was organized by the ministry of health with the assistance of an international team under the aegis of WHO. The case management of suspect cases was done in an isolation ward set up at the hospital; when patients refused to go to the ward for care they were isolated in their house according to a protocol "transmission risks reduction at home". Safe burials were performed by specialized teams which respected the major aspects of the funeral to allow the process of mourning of the families. An active surveillance system was set up in order to organize the detection of new cases and the follow-up of their contacts. A case definition was adopted. From October 11 to December 2, 2003, 35 cases including 29 deaths were reported, 16 cases were laboratory confirmed. The first four cases had been exposed to monkey meat (Cercopithecus nictitans). The epidemic spread was due to family transmission. The population interpretation of the disease, in particular questions around wizards and evil-minded persons, is a factor which must be taken into account by the medical teams during communication meetings for behavioral change of the populations. The case management of patient in isolation wards to prevent the transmission of the virus in the community remains the most effective means to dam up Ebola virus hemorrhagic fever outbreaks. The good perception by the community of the safe funerary procedures is an important aspect in the establishment of confidence relations with the local population.

Heterogeneity of treatment response to azithromycin in patients with cystic fibrosis

RATIONALE

We recently reported a randomized, placebo-controlled trial of azithromycin in patients with cystic fibrosis (CF) that demonstrated a 6.2% improvement in the 168-d relative change in FEV1 among azithromycin participants compared with placebo participants.

OBJECTIVES

In the current analyses, heterogeneity of treatment response and the association between FEV1 and the risk of pulmonary exacerbations were investigated.

METHODS

The time to first pulmonary exacerbation, hospitalization rates, and antibiotic use were compared between participants categorized by their relative change in FEV1 % predicted (>or= 5 vs. < 5% improvement) at Day 168. Pulmonary function and exacerbation responses were compared in subgroups of participants characterized by long-term concomitant medications and baseline lung function.

MEASUREMENTS

All available data from the 185 randomized participants in the azithromycin trial were included in these analyses.

MAIN RESULTS

Compared with placebo participants, a reduced risk of pulmonary exacerbations was observed both among azithromycin participants with >or= 5% and those with < 5% relative improvement in FEV1. Similarly, decreased hospitalization rates and decreased use of oral quinolone and nonquinolone antibiotics were observed in azithromycin participants regardless of improvement in FEV1. Subgroup analyses demonstrated that overall, participants on long-term aerosolized tobramycin and/or rhDNase had worse baseline lung function, but still benefited from azithromycin, as evidenced by a lower risk of exacerbations.

CONCLUSIONS

Azithromycin participants experienced benefits in exacerbation parameters regardless of FEV1 response or subgroup. These data have implications for clinical practice and the design of clinical trials.

Mutation and methylation analysis of TP53 in adrenal carcinogenesis

AIM

To investigate the role of coding region mutation and promoter hypermethylation of TP53 in adrenocortical cancer formation.

METHODS

Twenty sporadic adrenocortical cancers (ACCs) and five normal adrenal tissue samples were available for analysis. Coding region mutation of TP53 in 20 ACCs was examined by polymerase chain amplification using intronic primers for exons 2-11 and direct sequencing of the product. In 10 ACCs and five normal adrenal tissue specimens, methylation of the 16 CpG sites within the TP53 promoter was examined using bisulphite methylation sequencing.

RESULTS

Coding region mutation in TP53 was demonstrated in 5 of 20 ACCs. There were four mis-sense mutations and one frameshift mutation. Four of 5 patients with a TP53 mutation had metastases at diagnosis or detected soon thereafter and 3 of 4 died of disease within 12 months of surgical resection. No methylation was seen in the TP53 promoter in 10 ACC and the five normal adrenal tissues examined.

CONCLUSION

Coding region mutation in TP53 occurs in 25% of ACCs with a trend toward a poorer prognosis. Promoter methylation of TP53 is not present in ACC as a mechanism for tumour suppressor gene (TSG) inactivation and, therefore, other genes in the 17p13 region are implicated in adrenal carcinogenesis.

Histidine nutrition and genotype affect cataract development in Atlantic salmon, Salmo salar L

The aim of this study was to investigate effects of dietary levels of histidine (His) and iron (Fe) on cataract development in two strains of Atlantic salmon monitored through parr-smolt transformation. Three experimental diets were fed: (i) a control diet (CD) with 110 mg kg(-1) Fe and 11.7 g kg(-1) His; (ii) CD supplemented with crystalline His to a level of 18 g kg(-1) (HD); and (iii) HD with added iron up to 220 mg kg(-1) (HID). A cross-over design, with two feeding periods was used. A 6-week freshwater (FW) period was followed by a 20-week period, of which the first three were in FW and the following 17 weeks in sea water (SW). Fish were sampled for weighing, cataract assessment and tissue analysis at five time points. Cataracts developed in all groups in SW, but scores were lower in those fed high His diets (P < 0.05). This effect was most pronounced when HD or HID was given in SW, but was also observed when these diets were given in FW only. Histidine supplementation had a positive effect on growth performance and feed conversion ratio (P < 0.05), whereas this did not occur when iron was added. Groups fed HD or HID had higher lens levels of His and N-acetyl histidine (NAH), the latter showing a marked increase post-smoltification (P < 0.05). The HD or HID groups also showed higher muscle concentrations of the His dipeptide anserine (P < 0.05). There was a strong genetic influence on cataract development in the CD groups (P < 0.001), not associated with tissue levels of His or NAH. The role of His and His-related compounds in cataractogenesis is discussed in relation to tissue buffering, osmoregulation and antioxidation.

Releasing the therapeutic potential of the psychiatric nurse: a human relations perspective of the nurse-patient relationship

In psychiatry mental health nurses form the largest professional discipline providing care on an everyday basis for sustained periods. Mental health nurses therefore are in a pivotal position to establish valued therapeutic alliances. In practice, however, a disproportionate amount of nursing time is taken up by administration, time spent talking to patients is minimal and when interactions do occur they remain notionally therapeutic and often are not theoretically informed. This noted paucity of therapeutic contact is antithetical to the aspirations of service users who increasingly are asking for a more skilled approach to the talking-listening that occurs in the therapeutic encounter. It is hypothesized by the present authors that an object-relations perspective of the nurse-patient relationship could release the largely untapped therapeutic potential of the psychiatric nurse by (1) bridging the gap between theory and practice and (2) providing a professional identity from within which nurses can begin to 'get to know' and understand the predicament of the patient with severe mental illness.

Pancreatitis in hispanic patients with cystic fibrosis carrying the R334W mutation

BACKGROUND & AIMS

Cystic fibrosis (CF) results from abnormal production of sticky mucus, which obstructs many organs. In most cases, the pancreas is severely compromised, but 10%-15% of patients with CF have pancreas sufficiency (PS) and are subject to develop pancreatitis. The aim of this study is to determine which specific genotypes lead to the development of pancreatitis in patients with CF.

METHODS

We used prospective data collected by the Cystic Fibrosis Foundation and performed a nested case-control study with all patients who reported at least 1 episode of pancreatitis constituting the cases. We used logistic regression to assess the association between pancreatitis and genotype and the Kaplan-Meier method to estimate the cumulative incidence of pancreatitis for selected genotypes.

RESULTS

Three hundred sixty-four of 17,871 genotyped patients with CF (2.0%) reported at least 1 episode of pancreatitis. Only 0.9% of 12,997 patients with genotypes generally associated with pancreas insufficiency reported pancreatitis against 11.9% of 868 patients carrying at least 1 mild CF mutation generally associated with PS. The greatest rate of pancreatitis (19.0%) was observed for patients carrying an R334W mutation: 48% of these 79 patients were Hispanic and 13 patients were living in Puerto Rico.

CONCLUSIONS

Of all patients with CF, those carrying an R334W mutation have the greatest risk for developing pancreatitis. This mutation is found mostly in Hispanic patients with CF living in Puerto Rico. There are no current data to determine whether asymptomatic carriers of the R334W mutation are at greater risk for developing pancreatitis or whether this mutation is frequent in Hispanics with idiopathic pancreatitis.

Implementation of videoconferencing to support a managed clinical network in Scotland: lessons learned during the first 18 months

Managed clinical networks (MCNs) are usually built on established groups of health professionals from both acute and primary care sectors. We have used videoconferencing to support the gynaecological oncology MCN in the west of Scotland. Videoconferencing was implemented simultaneously at five sites in 2001 and DICOM image-capture software was added in 2003. Videoconferencing and live PC links allowed the multidisciplinary teams to discuss individual cancer diagnoses without the extensive travelling previously required. Our experience of the implementation suggests that local ownership is crucial. In the present project, each of the stakeholders had an important role in the delivery of a successful system. High-quality project management is required during implementation and for some time thereafter to achieve sustainability.

Manipulation and filtration of low index particles with holographic Laguerre-Gaussian optical trap arrays

Multiple low index particles (micrometer-sized ultrasound contrast agent), have been optically trapped using a 4 x 4 Laguerre- Gaussian trap array. The trapping efficiency of the Laguerre-Gaussian arrangement was measured using a Stokes' flow approach whereby the critical relative fluid velocity required to remove particles from the optical trap was measured. The dependence of trapping efficiency on beam power was also explored and the optimum beam parameters were identified. Finally, the utility of the array as a selective filter was demonstrated by tweezing multiple low-index particles from a population exhibiting an inherent distribution in size. This procedure represents a unique remote non-contact process that may have significant applicability throughout the fields of biophysics and biotechnology.

The effect of frictional heating and forced cooling on the serum lubricant and wear of UHMW polyethylene cups against cobalt-chromium and zirconia balls

Hip simulator tests of femoral balls of cobalt-chromium alloy or zirconia against acetabular cups of UHMW polyethylene were run with and without a coolant circulated inside the femoral balls. Without cooling, the wear of polyethylene against zirconia was about 48% lower than with cobalt-chromium alloy, but the steady-state temperature of the zirconia ball was higher (55 degrees C vs. 41 degrees C), and there was more precipitation of protein from the serum, which sometimes formed an adherent layer on the surface of the zirconia. Circulating coolant at 1-20 degrees C markedly reduced the bearing temperatures and the protein precipitation. With coolant at 4 degrees C, wear of the polyethylene against cobalt-chromium alloy was about 26% lower than against zirconia, but the macroscopic and microscopic appearance of the worn polyethylene surfaces were unlike that typically generated in vivo. With or without coolant, the morphology of the polyethylene wear debris was comparable to that generated in vivo, but the ratio of fibrillar to granular debris was higher at the reduced temperature. These results suggested that circulating coolant at an appropriate temperature could avoid overheating (due to non-stop running of the simulator), preventing excessive protein precipitation while providing wear surfaces and wear debris with morphologies closely comparable to those generated in vivo.

Cancer-related fatigue--a difference of opinion? Results of a multicentre survey of healthcare professionals, patients and caregivers

The objective of this study was to investigate the perceptions of patients with cancer, their caregivers and healthcare professionals (HCPs) about fatigue and its impact on quality of life. It was a cross-sectional survey, the respondents were patients with cancer attending three UK regional cancer centres (n = 1,370), their informal caregivers (n = 1,370) and a random selection of HCPs (oncologists/nurses/radiographers/haematologists; n = 1,098). The response rates for patients, caregivers and HCPs were 42%, 33% and 34% respectively. Fatigue was reported to affect 56% of patients and to have a considerable impact on quality of life. Caregivers also recognized that fatigue was a common problem, with significant effects on patients' quality of life and impact on themselves. Healthcare professionals recognized that fatigue was a common problem for their patients but overestimated its impact on some aspects of patients' daily lives. Although most HCPs reported that they prescribed/recommended treatment for over half of their patients, only 14% of patients reported receiving any such treatment. The most common advice was to take more rest and relaxation.

CONCLUSIONS

patients with cancer report that fatigue is a common and distressing symptom and the importance of this symptom is generally recognized by both HCPs and lay-carers. Healthcare professionals need more information about the effectiveness of existing interventions for cancer-related fatigue and further research is required to improve the current management of this debilitating symptom.

Xp22.3 microdeletion in a 19-year-old girl with clinical features of MLS syndrome

We describe a 19-year-old girl who has clinical features of microphthalmia with linear skin defects (MLS) syndrome caused by a microdeletion of Xp22.3. In addition to the classical ocular abnormalities and linear skin defects she has other features not previously described. She was previously reported in this journal in 1990 as poikiloderma congenitale, but her true diagnosis of an Xp22.3 microdeletion was clarified when fluorescent in situ hybridization (FISH) analysis indicated that one of her X chromosomes had a microdeletion including the KAL gene. We describe this patient with an Xp22.3 microdeletion to heighten awareness among dermatologists of this syndrome and to underscore the difficulties in diagnosing MLS syndrome.

Rabbit calvarial wound healing by means of seeded Caprotite scaffolds

Autologous bone is the most successful bone-grafting material; however, limited supply and donor site morbidity are problematic. Synthetic bone substitutes are effective, but healing is slow and unpredictable. Osseous wound healing may be enhanced if bone substitutes are combined with autologous bone marrow cells. To test this hypothesis, we created 40 calvarial defects in 20 12-week-old New Zealand White rabbits, divided into four groups: (1) unrepaired controls, (2) autologous bone grafts, (3) unseeded Caprotite (a polymer-ceramic composite) grafts, and (4) Caprotite grafts seeded with autologous bone marrow stromal cells. CT scans were obtained at 0, 6, and 12 weeks post-operatively, and defects were harvested for histology. Defects repaired with autologous bone had significantly (p < 0.05) more bone than the other three groups, although seeded Caprotite defects showed different wound-healing sequelae. Results suggest that seeded Caprotite scaffolds did not significantly enhance osseous defect healing compared with controls.