Visual assessment of the timing of bruising by forensic experts

INTRODUCTION

Forensic experts are frequently asked to comment on the age of injuries and interpretation may have significant medico-legal consequences. The purpose of this study is to determine the accuracy with which forensic experts can visually age a bruise from photographs produced under standard conditions.

METHODS

Bruises were produced on the upper arms of 11 subjects by a suction pump. Sequential photographs were taken daily until they were no longer visible to the naked eye. Fifteen forensic experts who did not know the age of the bruises were asked to estimate their ages and also to place them in chronological order.

RESULTS

Hundred and thirty-two images of 25 bruises were produced, ranging from 0 to 209h in age. There was considerable inter- and intra-observer variability in accuracy (median difference between the estimated age and the real age=26.0h (95% C.I. 24.0-31.0h). There was greatest accuracy for bruises photographed between 0 and 12h. No significant differences were seen between male and female observers (p=0.553) and performance was also unaffected by the age of the observer (p=0.160). Of the bruise images placed in chronological order >80% of the observers made between 0 and 2 errors.

CONCLUSION

Bruise age estimates by forensic experts, from photographs, are unreliable. However, it appears that the vast majority of observers are better able to place bruises from the same subjects in their chronological order.

Efficacy of combination anthelmintics against multiple resistant strains of sheep nematodes

Broad-spectrum anthelmintics were tested for their efficacy in either single active or combination formulations against multiple anthelmintic-resistant strains of Haemonchus contortus, Teladorsagia circumcincta and Trichostrongylus colubriformis. Three efficacy trials based on post mortem worm counts showed that the triple and quadruple combinations of benzimidazoles, levamisole, macrocyclic lactones and closantel were effective against most strains that were resistant to each of the components when drenched individually. Consequently, use of any one of these classes of anthelmintics by itself against multiple-resistant strains would lead to a rapid increase in the level of resistance. When used in combinations, the anthelmintics reduced the survival rate of most strains to <5%. However, because some strains of T. circumcincta and T. colubriformis were found to be resistant to all combinations currently marketed in Australia, it is clear that combinations should be used before resistance levels become too high.

Pilot study to evaluate the efficacy and tolerability of levetiracetam (Keppra) in treatment of patients with trigeminal neuralgia

BACKGROUND AND PURPOSE

The objective of this study was to determine whether levetiracetam (LEV) is an effective drug for treatment of trigeminal neuralgia (TN).

METHODS

Ten patients with TN were enrolled in a 10-week, prospective, open-label pilot study. The primary outcome measure was the visual analogue scale on daily pain diary and side effects. Serum levels of LEV were measured to assess correlation between drug levels and pain control.

RESULTS

There was a significant tendency towards improvement in pain severity compared with baseline in four patients with higher doses of 4,000 mg/day. The four treatment responders had less pain compared with baseline (50-90% improvement) and three subjects continued the drug after study completion. All patients rated themselves on the global evaluation scale as much improved (n = 2), minimally improved (n = 3), no change (n = 1), minimally worse (n = 2), much worse (n = 1) and very much worse (n = 1). LEV was very well tolerated and there was no difference in side effects between the low and high doses of LEV evaluations.

CONCLUSION

Given its established safety profile, a randomized, placebo-controlled, double-blind trial of LEV using enhancement enrollment design is needed to confirm these open-labelled findings using a wide variety of outcome measures.

Evaluation of iron ochre from mine drainage treatment for removal of phosphorus from wastewater

Treatment of polluting discharges from abandoned coal mines in the UK currently produces ca 30,000 t y(-1) of hydrous iron oxides ("ochre"), for which there is no major end-use, but which has previously been shown to have potential for removing P from wastewater and agricultural runoff. The efficiency of ochre for P removal from wastewater was investigated in experiments at two sites in the UK: Leitholm in Scotland and Windlestone in England. The three-year experiment at Leitholm involved diverting secondary-treated wastewater effluent through a trough which contained granular and pelletized ochre at different times. In the nine-month experiment at Windlestone, beds of ochre pellets in horizontal and vertical flow configurations were tested. The ochre treatment systems at Leitholm reduced influent concentrations of total P (TP) and TP mass by ca 80% and 50%, respectively, during optimal flow conditions, and achieved a removal rate of up to 65+/-48 mg TP kg(-1) ochre d(-1). There was no detectable release of potentially toxic metals from the ochre during the experiments. P removal rates by concentration were inversely related to flow and declined during the different phases of the experiments, probably due to clogging. At Windlestone, higher removal rates up to 195 mg TP kg(-1) ochre d(-1) were achieved for short periods of time following cleaning of the experimental system. Ochre has considerable potential to remove P from wastewater in a multi-stage treatment system and has a lifetime estimated to be 10 times longer than other substrates tested for P removal.

Correcting endogenous concentrations of testosterone influences bioequivalence and shows the superiority of TDS(R)-testosterone versus Androgel(R)

AIM

Circulating concentrations of endogenous compounds such as testosterone, complicate the analysis of pharmacokinetic parameters when these compounds are administered exogenously. This study examines the influence of three correction methods of accounting for endogenous concentrations on the determination of bioequivalence between two testosterone formulations.

METHODS

12 healthy males received 50 mg TDS-testosterone, TDS-placebo, and 50 mg Androgel in a randomized placebo controlled study. Three correction methods (1,2 and 3) to remove the influence of endogenous testosterone from the exogenous blood concentrations data were carried out before the calculation of the AUC and Cmax. The relative bioavailabilities between two treatments were then performed for the AUC and Cmax for all the corrected and uncorrected data. Correction 4 was performed on the AUC and the Cmax values and the average values were calculated for both active treatments.

RESULTS

The relative bioavailability comparison of the AUC and Cmax, showed that the TDS-testosterone and Androgel was bioequivalent by using uncorrected data (CI: 93 - 120%; AUC0-12 and 88 - 117%; Cmax). However, they were not bioequivalent when using all the corrections data ((Corr. 1; CI: 52 - 106%; AUC0-12 and 50 - 258%; Cmax), (Corr. 2; CI: 71 - 655%; AUC0-12 and 87 - 286%; Cmax), (Corr. 3; CI: 67 - 315%; AUC0-12 and 88 - 157%; Cmax)). TDS-testosterone also showed the higher AUC0-12 and Cmax compared to Androgel for uncorrected and all the Corrections 1, 2, 3 and 4.

CONCLUSIONS

Different results obtained in the relative bioavailability between TDS-testosterone and Androgel for uncorrected data and corrected data, suggests that correcting endogenous concentrations is important for the proper determination of bioequivalent for endogenous compounds such as testosterone.

Provision of forensic medical services to police custody suites in England and Wales: current practice

INTRODUCTION

Police services within England and Wales are required under the Police and Criminal Evidence Act 1984 to ensure appropriate healthcare to those detained in police custody (forensic medical services). Traditionally doctors have been used by police services to provide an appropriate level of care. Changes within the Act allowed other healthcare professionals (nurses and paramedics and emergency care practitioners) to be included in the provision of such services. The aim of this appears at least in part to have been to reduce the costs of providing such a service. In recent years police services within England and Wales have been outsourced to assorted commercial providers. There are now several different modes of delivery of forensic medical services, which are determined locally by separate police services.

AIMS

This study aimed (a) to determine the different modes of delivery of forensic medical services in England and Wales; (b) to determine the healthcare workload caused by Police and Criminal Evidence Act 1984 Codes of Practice; (c) to determine the relative costs of different service models and (d) to determine availability of such information from the police services.

METHODS

The study was undertaken in two parts--(a) a telephone survey of all police services, and (b) an application to each police service utilising the Freedom of Information Act 2000.

RESULTS

All police services (n=43) in England and Wales were contacted. Of the 41 forces that furnished detailed information; 13/41 had a doctor only service; 20/41 had a doctor/nurse service; 6/41 had a doctor/nurse/paramedic service; 1/41 had a doctor/emergency care practitioner service (who may be nurses or paramedic); 1/41 had a doctor/paramedic service. 23/43 services were outsourced to private commercial providers. Mean cost per patient contact (in 17/43 services which supplied data) was GBP 97.25. The cheapest cost per patient contact was the Metropolitan Police Service - a doctor only service (GBP 56.4), the highest Lincolnshire--a doctor only service (GBP 151.1). Mean cost for a doctor only service was GBP 97.1; for a doctor/nurse service--GBP 91.56 and for a doctor/nurse/paramedic service--GBP 115.76. There was no significant difference in costs per patient contact between a doctor only versus mixed HCP delivery of service. Relative costs and 95% confidence intervals expressed as a percentage show that a doctor only model was on average 3.4% lower than a mixed HCP provision, and that a non-outsourced service was on average 9.9% less than an outsourced service. No outsourced service in this study uses a doctor only model.

CONCLUSIONS

The study shows that there was a complete lack of consistency in the recording and availability of information regarding forensic medical services for police services in England and Wales. The information that was obtained suggested that usage of such services varied greatly between police services and that costs of forensic medical services appear to be increased by the use of mixed healthcare professional service delivery and by using external commercial providers.

Peripheral Blood T-Cell Responses to Keratin Peptides that Share Sequences with M Proteins are Largely Restricted to Skin-Homing CD8+ T Cells

The association of psoriasis with throat infections by streptococcus pyogenes suggests a potential antigenic target for the T cells that are known to infiltrate dermis and epidermis of psoriatic skin. Streptococcal M protein shares an extensive sequence homology with human epidermal keratins. Keratins 16 (K16) and 17 (K17) are mostly absent from uninvolved skin but are upregulated in psoriatic lesions. There is increasing evidence that CD8⁺ T cells play an important effector role in psoriasis and M protein‐primed T cells may recognize these shared epitopes in skin via molecular mimicry. To identify candidate epitopes, peptides with sequences from K17 were selected on the basis of predicted binding to HLA‐Cw6 and sequence similarities with M6 protein. Matched peptides from the sequence of M6 protein and a set of peptides with poor predicted binding were also selected. Cw6⁺ individuals with psoriasis and Cw6⁺ healthy controls, having a family history of psoriasis, were recruited. PBMCs were incubated with the peptide antigens. T‐cell activation in the CD4⁺, CD8⁺ and later the skin‐homing cutaneous lymphocyte‐associated antigen (CLA)‐expressing subset of CD8⁺ T cells was evaluated by CD69 expression and intracellular IFN‐γ accumulation using flow cytometry. We demonstrate that Cw6⁺ psoriasis patients had significant CD8⁺ T‐cell IFN‐γ responses to peptides from K17 and M6 protein selected on the basis of sequence homology and predicted HLA‐Cw*0602 binding. These responses were about 10 times more frequent in the skin‐homing cutaneous lymphocyte‐associated antigen‐expressing (CLA⁺) subset of CD8⁺ T cells. CD4⁺ T cells showed only borderline responses. CD8⁺ T cells from Cw6 + nonpsoriatic individuals responded to some M6 peptides but very rarely to K17 peptides, and this also applied to the CLA⁺CD8⁺ subset. These findings indicate that psoriatic individuals have CD8⁺ T cells that recognize keratin self‐antigens and that epitopes shared by streptococcal M protein and human keratin may be targets for the CD8⁺ T cells that infiltrate psoriatic skin lesions.

Differential Effects of Interleukin-12 and Interleukin-10 on Superantigen-Induced Expression of Cutaneous Lymphocyte-Associated Antigen and αEβ7 Integrin (CD103) by CD8+ T cells

The interaction with adhesion molecules expressed by vascular endothelium is the first step in lymphocyte infiltration into tissues. At both cutaneous and mucosal sites interleukin‐10 (IL‐10), IL‐12 and transforming growth factor (TGF)‐β are important regulators of chronic inflammatory disease, where cutaneous lymphocyte‐associated antigen (CLA) and αE integrin (CD103) may be expressed. Unlike CLA, CD103 is not believed to play a role in tissue‐specific homing but may help to retain T cells within epithelial layers. We have previously shown that IL‐12 alone can together with an unknown cofactor increase the expression of CLA. Stimulation with streptococcal pyrogenic exotoxin C (SpeC) increased the expression of CD103 by CD8⁺ but not CD4⁺ T cells. While IL‐12 increased superantigen‐stimulated expression of CLA, this cytokine strongly inhibited the CD103 expression, and a combination of IL‐12 and TGF‐β completely abrogated the induced CD103 expression. Conversely, IL‐10 suppressed CLA but increased CD103 expression.

These findings indicate that, in addition to suppressing the development of Th1‐mediated inflammatory responses, IL‐10 may also inhibit the migration of CD8⁺ T cells into the skin while IL‐12 promotes such migration. Thus, the expression of CLA and CD103 may be antagonistically regulated by IL‐10 and IL‐12, and the balance between these cytokines could influence the T‐cell migration of inflammatory cells into epithelial tissues.

Obesity in psoriasis: leptin and resistin as mediators of cutaneous inflammation

BACKGROUND

Obesity is a significant risk factor for psoriasis and body mass index (BMI) correlates with disease severity. Objectives To investigate the relationship between obesity and psoriasis, focusing on the role of adipokines such as leptin and resistin.

PATIENTS/METHODS

Patients with psoriasis (n = 30) were recruited and their BMI, waist circumference and disease severity [Psoriasis Area and Severity Index (PASI)] were recorded. Fasting serum samples were obtained on enrolment and after a course of ultraviolet (UV) B treatment. Age-, sex- and BMI-matched healthy controls were also recruited.

RESULTS

On enrolment, serum leptin and soluble leptin receptor levels were not raised compared with the controls. However, resistin, interleukin (IL)-1beta, IL-6, and chemokines CCL2, CXCL8 and CXCL9 were all significantly elevated in the patient group and serum resistin correlated with disease severity (r = 0.372, P = 0.043). Improvement after UVB treatment was accompanied by decreased serum CXCL8. In vitro, both leptin and resistin could induce CXCL8 and tumour necrosis factor-alpha production by blood monocytes, and leptin could additionally induce IL-1beta and IL-1 receptor antagonist production. Leptin also dose dependently increased secretion of the growth factor amphiregulin by ex vivo-cultured lesional psoriasis skin.

CONCLUSIONS

These data support the view that leptin and resistin may be involved in the pathogenesis of psoriasis in overweight individuals, possibly by augmenting the cytokine expression by the inflammatory infiltrate.

Response to ciclosporin treatment in Ethiopian and Nepali patients with severe leprosy Type 1 reactions

Leprosy type 1 reactions (T1R) are immune-mediated events with inflammation of peripheral nerves and skin. We report the clinical outcomes of a closely monitored open prospective trial in which eight Nepali and 33 Ethiopian patients with T1Rs were treated with an Indian generic formulation of ciclosporin (Cn; 5-7.5 mg/kg/day) for 12 weeks and followed up for 24 weeks after starting treatment. Outcomes were measured using a clinical severity score. Among the Nepalis, 75-100% improved in all acute clinical parameters; 67-100% patients maintained improvement, except for those with acute sensory nerve impairment among whom 67% relapsed after stopping treatment. The skin lesions of all Ethiopians on 5 mg/kg/day of Cn improved and 50-60% had peripheral nerve function improvement. Most Ethiopians needed a higher dose of Cn to improve nerve impairment and neuritis, and 50-78% of them developed worse clinical severity scores when Cn was stopped. Four Ethiopians and two Nepalis developed elevated serum creatinine levels on 7.5 mg/kg/day Cn, and three (9%) Ethiopians developed treatable hypertension. This suggests that Cn monotherapy is an effective treatment for severe T1R with few adverse effects. A dose of 5 mg/kg/day seems efficacious in Nepalis, but a higher dose may be required in Ethiopian patients.

Cyclosporin in idiopathic glomerular disease associated with the nephrotic syndrome : workshop recommendations

Management of idiopathic glomerular disease associated with nephrotic syndrome (INS) remains controversial and one of the most complex areas relates to utilization of the drug cyclosporin. This is despite its demonstrated effectiveness in several histologic types of the INS in randomized controlled trials. Cyclosporin is effective in inducing remission of proteinuria in approximately 80% of steroid-sensitive cases of minimal change disease (MCD). Cyclosporin is also effective in both the induction of remission and long-term preservation of renal function in steroid-dependent/-resistant MCD and steroid-resistant focal segmental glomerulosclerosis (FSGS). The overall response rate in FSGS is lower than in MCD, and long-term therapy (>12 months) may be required to both achieve remission and sustain it. Cyclosporin therapy is also of benefit in reducing proteinuria in 70-80% of patients with steroid-resistant membranous nephropathy (MGN). In MGN, the maximum benefit is often delayed compared to MCD (>12 weeks). Cyclosporin is generally well tolerated and safe. The major concern remains the nephrotoxicity, but with careful monitoring of the patient's renal function; minimizing the maintenance dose and utilizing repeat renal biopsy in those receiving long-term therapy, this risk can be minimized. The algorithms have been developed derived from the best evidence in the literature in each of the histologic types to help provide a guide to the integration of cyclosporin into the management of INS for the practicing nephrologist.

Validation of high-performance liquid chromatographic-mass spectrometric method for the analysis of lidocaine in human plasma

A sensitive and simple liquid chromatography-tandem mass spectrometry method is developed and validated for the determination of lidocaine in human plasma. Bupivacaine is used as an internal standard, and the plasma extraction is performed by a simple liquid-liquid extraction. The limit of quantitation (LOQ) is 0.5 ng/mL with a signal-to-noise ratio greater than 5. The calibration curve is linear from 0.5 to 250 ng/mL with an r2 greater than 0.99. The coefficients of variation for within- and between-assay imprecision, including LOQ, are < or = 13% and < or = 8%, respectively. The percentage of inaccuracy for within- and between-assay, including LOQ, are < or = 9% and < or = 5%, respectively. The absolute recovery of lidocaine and bupivacaine are greater than 84% and 82%, respectively. The higher sensitivity and accuracy of this method allow the measurement of low concentrations of lidocaine in plasma from a clinical study of topically applied lidocaine in healthy subjects.

Intravenous Parecoxib Rapidly Leads to COX-2 Inhibitory Concentration of Valdecoxib in the Central Nervous System

Evidence in animal studies supports widespread induction of cyclooxygenase-2 (COX-2) in the central nervous system (CNS) following tissue injury, probably mediated by cytokines, transducing the signal across the blood-brain barrier. CNS COX-2 blockade is a possible therapeutic target for drugs that are able to reach adequate CNS levels and abolish the prostaglandin E2-induced central sensitization. This human pharmacokinetic study investigated valdecoxib cerebrospinal fluid (CSF) and plasma concentrations over time in 37 patients following 40 mg of single-dose intravenous parecoxib. High-performance liquid chromatography/tandem mass spectrometry analysis was performed. Valdecoxib was first detectable in the CSF at 15 min postdosing, increased rapidly until 50 min, and thereafter remained between 6 and 14 ng/ml. This is the first human study demonstrating CNS COX-2 inhibitor penetration as early as 15 min. CSF valdecoxib concentration rapidly reached in vitro IC50 (inhibitory concentration 50) (1.57 ng/ml) by 17 min and remained consistently higher thereafter.

Paradoxical response to tacrolimus assessed by interleukin-2 gene expression

BACKGROUND

The calcineurin inhibitors cyclosporine and tacrolimus are potent immunosuppressive drugs, used mainly after organ transplantation. Methods to monitor their pharmacodynamic effects are not well established.

METHODS

Whole blood samples from healthy volunteers (n = 16) were incubated for 24 hours in culture medium; each sample was preincubated for 2 hours with or without tacrolimus. An identical procedure was performed for 7 samples using blood from renal transplant patients before transplantation. Following the culture period, total RNA was isolated and quantitative reverse transcriptase polymerase chain reaction, using TaqMan probes, was employed to quantify interleukin-2 (IL-2) mRNA expression, and IL-2 mRNA copy number was reported by reference to a standard curve.

RESULTS

IL-2 mRNA synthesis was suppressed by the presence of tacrolimus in most cases, compared with a control sample. However, some samples demonstrated up-regulation of mRNA expression. In the patient samples, there was up-regulation of IL-2 mRNA in two samples and, after transplantation, these patients developed acute rejection.

CONCLUSION

Quantitative measurement of cytokine IL-2 regulated gene expression may represent a method to assess the efficacy of calcineurin inhibitor drugs.