Aortic dissection associated with Campylobacter aortitis

Infective aortitis and associated mycotic aneurysms are uncommon clinical entities and most reported cases are associated with Salmonella species. We report successful surgical and medical treatment of a mycotic aneurysm of the aorta which presented as acute pericarditis and may have been caused by Camplyobacter jejuni.

Subsoil constraints in Vertosols: crop water use, nutrient concentration, and grain yields of bread wheat, durum wheat, barley, chickpea, and canola

Single or multiple factors implicated in subsoil constraints including salinity, sodicity, and phytotoxic concentrations of chloride (Cl) are present in many Vertosols including those occurring in Queensland, Australia. The variable distribution and the complex interactions that exist between these constraints limit the agronomic or management options available to manage the soil with these subsoil constraints. The identification of crops and cultivars adapted to these adverse subsoil conditions and/or able to exploit subsoil water may be an option to maintain productivity of these soils. We evaluated relative performance of 5 winter crop species, in terms of grain yields, nutrient concentration, and ability to extract soil water, grown on soils with various levels and combinations of subsoil constraints in 19 field experiments over 2 years. Subsoil constraints were measured by levels of soil Cl, electrical conductivity of the saturation extract (ECse), and exchangeable sodium percentage (ESP). Increasing levels of subsoil constraints significantly decreased maximum depth of water extraction, grain yield, and plant-available water capacity for all the 5 crops and more so for chickpea and durum wheat than bread wheat, barley, or canola. Increasing soil Cl levels had a greater restricting effect on water availability than did ECse and ESP. We developed empirical relationships between soil Cl, ECse, and ESP and crop lower limit (CLL) for estimating subsoil water extraction by 5 winter crops. However, the presence of gypsum influenced the ability to predict CLL based on the levels of ECse. Stronger relationships between apparent unused plant-available water (CLL – LL15; LL15 is lower limit at –1.5 MPa) and soil Cl concentrations than ESP or ECse suggested that the presence of high Cl in these soils most likely inhibited the subsoil water extraction by the crops. This was supported by increased sodium (Na) and Cl concentration with a corresponding decrease in calcium (Ca) and potassium (K) in young mature leaf of bread wheat, durum wheat, and chickpea with increasing levels of subsoil constraints. Of the 2 ions, Na and Cl, the latter appears to be more damaging than the former, resulting in plant dieback and reduced grain yields.

Analysis of the SAGES outcomes initiative cholecystectomy registry

BACKGROUND

In 1999, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) introduced the SAGES Outcomes Initiative as a method for its members to use for tracking their own outcomes. This report provides a descriptive analysis of the cholecystectomy database.

METHODS

The SAGES Outcome Initiative database was accessed for all gallbladder cases from September 1999 to February 2005. The data from the preoperative, intraoperative, and postoperative entries were summarized. These data are purely descriptive, and no statistical analysis was performed.

RESULTS

The gallbladder registry contained 3,285 cases, with 2,005 follow-up cases. Most patients were employed women with some comorbidities who had elective surgery under general anesthesia. Most of the operating surgeons were attending surgeons and surgical assistants. Most of the patients had biliary colic, and symptoms were improved for more than 95% of the patients. More than 90% of the cases were managed laparoscopically, with a conversion rate of 3%. Biliary imaging was used in the vast majority of cases, with most shown to be normal. Intraoperative gallbladder perforation was common, with bile duct injury occurring in 0.25% of cases. The most frequently cited postoperative event was wound infection, with most complications classified as class 1. More than 95% of the patients were able to return to work.

CONCLUSIONS

The SAGES Outcomes Initiative database demonstrates that most participating SAGES members perform laparoscopic cholecystectomies themselves using intraoperative cholangiograms. Adverse outcomes are few, with most patients able to return to normal activity. Importantly, there were relatively few missing data points, implying that when surgeons enter data, the information is relatively complete.

Manipulation of the anabolic and catabolic responses with OP-1 and zoledronic acid in a rat critical defect model

Bone repair involves both anabolic and catabolic responses. We hypothesized that anabolic treatment with OP-1 (BMP-7) and anti-catabolic treatment with zoledronic acid could be synergistic. In a rat critical defect, this combination therapy produced significant increases in new bone volume and strength.

INTRODUCTION

When used to augment bone healing, osteogenic protein 1 (OP-1/BMP-7) and other BMPs stimulate the anabolic response, inducing osteoblast recruitment, differentiation, and bone production. However, BMPs can also upregulate catabolism by direct stimulation of osteoclasts and indirectly by osteoblasts through RANKL/RANK. We hypothesized that if such osteoclastic upregulation were modulated by zoledronic acid (ZA), the combination of OP-1 and ZA should produce increased new bone over OP-1 alone.

MATERIALS AND METHODS

Rats with a surgically induced 6-mm femoral critical size defect were separated into five dosing groups: Carrier, Carrier + ZA, OP-1, OP-1 + ZA, and OP-1 + ZA administered 2 weeks after surgery (2W). Carrier +/- 50 microg OP-1 was placed in the defect, and 0.1 mg/kg ZA or saline was administered subcutaneously. Bone repair was analyzed by radiographs, QCT, mechanical testing, histology, and histomorphometry.

RESULTS

Carrier alone and Carrier ZA groups did not unite by 8 weeks. Radiological union occurred in all OP-1 groups but was tenuous in some animals treated with OP-1 alone. BMC was increased by 45% in the OP-1 ZA group and 96% in the OP-1 ZA 2W group over OP-1 alone (p < 0.01). Callus volume increased over OP-1 alone by 45% and 86% in the OP-1 ZA and OP-1 ZA 2W groups, respectively (p < 0.01). The increased callus volume in the OP-1 ZA 2W group translated to increases in strength of 107% and stiffness of 148% (p < 0.05). BFR was not significantly different between OP-1 groups regardless of ZA treatment.

CONCLUSIONS

ZA treatment significantly increased the BMC, volume, and strength of OP-1-mediated callus in a critical size defect in rats at 8 weeks. Thus, modulation of both anabolic and catabolic responses may optimize the amount and mineral content of callus produced, which could be of clinical benefit in obtaining bone union.

Preventing recurrent rheumatic fever: the role of register based programmes

Despite dramatic gains of the last century, acute rheumatic fever and rheumatic heart disease remain major preventable causes of morbidity and mortality in many parts of the world.

Falls in an acute hospital and their relationship to restraint use

BACKGROUND

Patient falls are a common complication of hospitalisation. Use of restraints in patients who are perceived to be at risk for falling may lead to injury and even death.

AIMS

To determine the frequency of falls and fall-related injuries and the contribution of restraints in a hospital population.

METHODS

We analysed incident reports of falls for a single year from a large teaching hospital. Results The fall rate per 10,000 patient days was 13.2 (95%CI 11.6-14.8). Fall rate increased dramatically with increased age. Eighty-two (30.7%) falls resulted in injury, of which 6 (7.3%) were serious. Injuries occurred in 71/247 (29%) unrestrained falls and in 11/20 (55%) falls in patients who were restrained. Injuries were more severe in falls with restraints in place (p < 0.0001).

CONCLUSIONS

Restraint use is associated with increased severity of injury in hospital patients who fall.

Zoledronic acid improves femoral head sphericity in a rat model of perthes disease

We hypothesized that the bisphosphonate zoledronic acid (ZA) could improve femoral head sphericity in Perthes disease by changing the balance between bone resorption and new bone formation. This study tests the effect of ZA in an established model of Perthes disease, the spontaneously hypertensive rat (SHR). One hundred and twenty 4-week old SHR rats were divided into three groups of 40: saline monthly, 0.015 mg/kg ZA weekly, or 0.05 mg/kg ZA monthly. At 15 weeks DXA measurements documented that femoral head BMD was increased by 18% in ZA weekly and 21% in ZA monthly compared to controls (p<0.01). Femoral head sphericity in animals with osteonecrosis was improved in ZA-treatment groups (p<0.01) as measured by epiphyseal quotient (EQ). The proportion of "flat" heads (EQ0.40) was significantly reduced from 32% in saline-treated animals to 12% in weekly ZA and 3% in monthly ZA (p<0.01). Histologically there was a similar prevalence of osteonecrosis in all groups. The prevalence of ossification delay was significantly reduced by ZA treatment (p<0.01). Zoledronic acid favorably altered femoral head shape in this spontaneous model of osteonecrosis in growing rats. Translation of these results to Perthes disease could mean that deformity of the femoral head may be modified in children, perhaps reducing the need for surgical intervention in childhood and adult life.

Control of endemic MRSA-what is the evidence? A personal view

Although there is extensive literature on the control of MRSA, when that concerning epidemics is excluded, only a limited amount remains regarding the control of endemic MRSA. Several guidelines have been recently published recommending stringent control measures, which are often suggested based on their success in controlling MRSA outbreaks in hospitals with few MRSA or in containing MRSA cases introduced into a hospital with no MRSA. In these settings, multiple measures are usually introduced with apparently successful results. However, results may not be generalizable to other settings and we do not know the minimum effective measures required for MRSA containment. This paper aims critically to review the literature to determine whether evidence exists for the value of the infection control measures that are widely recommended in the endemic setting. Much of this literature is based on observational studies, with few randomized, controlled trials having been conducted. More well-designed studies are required before many of the principles on which we build infection control programmes can be regarded as evidence based.

Peptidoglycan and lipoteichoic acid in gram-positive bacterial sepsis: receptors, signal transduction, biological effects, and synergism

In sepsis and multiple organ dysfunction syndrome (MODS) caused by gram-negative bacteria, lipopolysaccharide (LPS) initiates the early signaling events leading to the deleterious inflammatory response. However, it has become clear that LPS can not reproduce all of the clinical features of sepsis, which emphasize the roles of other contributing factors. Gram-positive bacteria, which lack LPS, are today responsible for a substantial part of the incidents of sepsis with MODS. The major wall components of gram-positive bacteria, peptidoglycan and lipoteichoic acid, are thought to contribute to the development of sepsis and MODS. In this review, the literature underlying our current understanding of how peptidoglycan and lipoteichoic acid activate inflammatory responses will be presented, with a focus on recent advances in this field.

Tyrphostin reduces the organ injury in haemorrhagic shock: role of inducible nitric oxide synthase

We investigate the effects of the tyrosine kinase inhibitor, tyrphostin AG126 on the organ injury and dysfunction (kidney, liver, pancreas, muscle and or brain) associated with haemorrhagic shock in the anaesthetised rat. Haemorrhage (sufficient to lower mean arterial blood pressure to 45 mmHg for 90 min) and subsequent resuscitation with the shed blood resulted (within 4 h after resuscitation) in expression of inducible nitric oxide synthase inhibitor (iNOS), positive staining for nitrotyrosine (liver), renal, liver and pancreatic injury, and injury to the muscle and brain. Pre-treatment (30 min prior to the onset of haemorrhage) with the tyrosine kinase inhibitor tyrphostin AG126 reduced the iNOS expression, nitrotyrosine formation, hepatic, brain or muscular injury, and to a lesser extent, the renal injury caused by haemorrhage and resuscitation. Selective inhibition of iNOS activity with N-(3-(aminomethyl)benzyl) acetamidine (1400 W, 10 mg kg(-1) i.v., 5 min prior to the onset of resuscitation), also attenuated nitrotyrosine formation, renal dysfunction, liver injury and brain or muscular injury associated with haemorrhagic shock. The expression of iNOS protein was unaffected by 1400 W. We propose that the activation of tyrosine kinases and the induction of iNOS contribute to the multiple organ injury caused by severe haemorrhage and resuscitation.

Deletion of the N-terminus of murine map2 by gene targeting disrupts hippocampal ca1 neuron architecture and alters contextual memory

Microtubule-associated protein-2 (MAP2) is a brain specific A-kinase anchoring protein that targets the cyclic AMP-dependent protein kinase holoenzyme (PKA) to microtubules. Phosphorylation of MAP2 by different protein kinases is crucial for neuronal growth. The N-terminus of MAP2 contains the binding site for regulatory subunit II of cAMP-dependent protein kinase (PKA-RIIbeta). Using homologous recombination, we created a mutant line of mice (delta1-158) that express truncated MAP2 lacking the N-terminal peptide and the PKA binding site. Deletion of the PKA binding site from the MAP2 gene resulted in decreased efficiency of MAP2 phosphorylation. Biochemical and immunohistochemical studies demonstrate major changes in the morphology of hippocampal neurons in delta1-158 mice. Behavioral tests indicate that delta1-158 mice were impaired (exhibited less conditioned freezing) relative to Wild-Type (WT) controls during a test of contextual, but not during auditory cue, fear conditioning when tested at 8 weeks or 8 months of age. The delta1-158 mice displayed a heightened sensitivity to shock at 8 weeks, but not at 8 months of age. We conclude that PKA binding to MAP2 and MAP2 phosphorylation is essential for the selective development of contextual memory.

Canadian governance of health research involving human subjects: is anybody minding the store?

From an ethical perspective, good governance involves the translation of collective moral intentions into effective and accountable institutional actions. With respect to the use of human subjects in Canadian health research, I contend that there have been many good intentions but very little in the way of appropriate governance arrangements. Hence, the question, "who minds the store?" is especially acute with respect to the protection of vulnerable individuals and groups that are typically recruited as subjects for health research in Canada. Beyond diagnosing failures in governance and their causes, I offer suggestions for significant reforms, including evidence-based ethics assessment, independent oversight, and greater participation of research subjects in governance. I will close with some more general reflections on ethics, law, and governance.

Screening for tuberculosis: the port of arrival scheme compared with screening in general practice and the homeless

BACKGROUND

Tuberculosis is increasing in London, especially in those recently entering the UK from an area of high incidence. Screening through the port of arrival scheme has a poor yield and has been considered discriminatory.

METHODS

A study was undertaken to compare the yield and costs of screening new entrants in a hospital based new entrants' clinic (1262 referrals from the port of arrival), general practice (1311 new registrations), and centres for the homeless (267 individuals) using a symptom questionnaire and tuberculin testing if indicated. Clinical outcome measures were cases of tuberculosis, tuberculin reactors requiring chemoprophylaxis and BCG vaccinations. Cost outcomes were cost per individual screened and cost per individual per case of tuberculosis prevented.

RESULTS

Verbal screening limited tuberculin testing to 16% of those in general practice; most were tested at the other two locations. Intervention (BCG vaccination, chemoprophylaxis or treatment) occurred in 27% of those who received tuberculin testing. Attendance for screening was 17% of the port of arrival notifications (63% had registered with a GP), 54% in primary care, and 67% in the homeless (42% registered with a GP). Costs for screening an individual in general practice, hostels for the homeless, and the new entrants' clinic were 1.26 pounds sterling, 13.17 pounds sterling and 96.36 pounds sterling, respectively, while the cost per person screened per case of tuberculosis prevented was 6.32 pounds sterling, 23.00 pounds sterling, and 10.00 pounds sterling, respectively. The benefit of screening was highly sensitive to the number of cases of tuberculosis identified and case holding during treatment.

CONCLUSION

Screening for tuberculosis in primary care is feasible and could replace hospital screening of new arrivals for those registered with a GP.

Clinical heterogeneity in lymphoedema-distichiasis with FOXC2 truncating mutations

BACKGROUND

Hereditary lymphoedema-distichiasis (LD) is an autosomal dominant disorder that classically presents as lymphoedema of the limbs, with variable age of onset, and extra aberrant growth of eyelashes from the Meibomian gland (distichiasis). Other major reported complications include cardiac defects, cleft palate, and extradural cysts. Photophobia, exotropia, ptosis, congenital ectropion, and congenital cataracts are additional eye findings. Recently, we reported that truncating mutations in the forkhead transcription family member FOXC2 resulted in LD in two families.

METHODS

The clinical findings in seven additional families with LD, including the original family described by Falls and Kertesz, were determined and mutational analyses were performed.

RESULTS

Distichiasis was the most common clinical feature followed by age dependent lymphoedema. There is a wide variation of associated secondary features including tetralogy of Fallot and cleft palate. The mutational analyses identified truncating mutations in all of the families studied (two nonsense, one deletion, three insertion, and one insertion-deletion), which most likely result in haploinsufficiency of FOXC2.

CONCLUSIONS

FOXC2 mutations are highly penetrant with variable expressivity which is not explicable by the pattern of mutations.

Plantar pressure differences between obese and non-obese adults: a biomechanical analysis

OBJECTIVE

To investigate plantar pressure differences between obese and non-obese adults during standing and walking protocols using a pressure distribution platform.

SUBJECTS

Thirty-five males (age 42.4+/-10.8 y; 67-179 kg) and 35 females (age 40.0+/-12.6 y; 46-150 kg) divided into obese (body mass index (BMI) 38.75+/-5.97 kg/m2) and non-obese (BMI 24.28+/-3.00 kg/m2) sub-groups, respectively.

MEASUREMENTS

Data collection was performed with a capacitive pressure distribution platform with a resolution of 2 sensors/cm2 (Emed F01, Novel GmbH, München). The measurement protocol included half and full body weight standing on the left, right and both feet, respectively, and walking across the platform, striking with the right foot. Pressures were evaluated for eight anatomical sites under the feet.

RESULTS

For both men and women, the mean pressure values of the obese were higher under all anatomical landmarks during half body weight standing. Significant increases in pressure were found under the heel, mid-foot and metatarsal heads II and IV for men and III and IV for women. Foot width during standing was also significantly increased in obese subjects. For walking, significantly higher peak pressures were also found in both obese males and females.

CONCLUSION

Compared to a non-obese group, obese subjects showed increased forefoot width and higher plantar pressures during standing and walking. The greatest effect of body weight on higher peak pressures in the obese was found under the longitudinal arch of the foot and under the metatarsal heads. The higher pressures for obese women compared to obese men during static weight bearing (standing) may be the result of reduced strength of the ligaments of the foot.

Post-discharge surgical wound infection surveillance in a provincial hospital: follow-up rates, validity of data and review of the literature

BACKGROUND

Numerous studies suggest that many surgical site infections (SSI) come to light only after discharge from hospital. With increasing trends towards shorter length of stay and ambulatory day surgery, post-discharge surveillance may become necessary for all infection control programs, but the methodology has yet to be validated and standardized. The overall aim of the present study was to examine the impact of effective post-discharge SSI follow up on the overall SSI rate.

METHODS

A prospective targeted surveillance programme of 1291 surgical procedures was conducted at St John of God Health Care Geelong using the standardized National Nosocomial Infections Surveillance (NNIS) METHOD: Questionnaires were sent to surgeons and the results rigorously chased up. Factors giving rise to high follow-up rates and the relationship between follow up, attrition bias and validity of data were explored using a literature search.

RESULTS

A post-discharge follow-up rate of 98.7% was achieved. When the post-discharge data were included, the overall SSI rate (6.0% (95% CI: 4.7-7.4)) was more than double that in hospital (2.7% (95% CI: 1.9-3.8)).

CONCLUSIONS

An effective post-discharge follow-up programme significantly increased the SSI rate. From the authors' experience and a literature survey, possible ways to achieve high follow-up rates were suggested. It was also recommended that professional and regulating bodies in Australia be encouraged to standardize methodology and set minimum follow-up rates for post-discharge SSI surveillance. Increasing use of computerized hospital database systems for automated data gathering and processing should make this more practicable.