Anaerobic Soil Disinfestation and Vermicompost to Manage Bottom Rot in Organic Lettuce

Rhizoctonia solani Kühn (teleomorph: Thanatephorus cucumeris [Frank] Donk) is an aggressive soilborne pathogen with a wide host range, survives saprophytically between crops presenting a challenge for organic vegetable farmers that lack effective management tools. A two-year field experiment was conducted at two organic farms to compare anaerobic soil disinfestation (ASD) and worm-cured compost (vermicompost) to manage bottom rot caused by R. solani subspecies AG1-IB in field-grown organic lettuce (Lactuca sativa). At each farm, four replicate plots of seven treatments were arranged in a randomized complete block design. Randomization was restricted by grouping treatments to evaluate ASD, and treatments to evaluate vermicompost in starter plugs. ASD experiment treatments were three different ASD carbon sources that are commonly used and widely available to local farmers in Vermont: compost, cover crop residues, and poultry manure fertilizer, and a tarped control. Vermicompost experimental treatments were vermicompost compared to two types of controls: a commercial biocontrol product (RootShield® PLUS+G), and unamended (untarped control). This study demonstrated that the ASD method is achievable in a field setting on Vermont farms. However, neither ASD nor vermicompost produced significant disease suppression or resulted in higher marketable yields than standard growing practices. Given the laborious nature of ASD, it is likely more appropriate in a greenhouse setting with high value crops that could especially benefit from being grown in plastic tarped beds (e.g., tomatoes, strawberries). This study is the first known attempt of field-implemented ASD for soil pathogen control in the northeastern USA.

Early and late preterm birth rates in participants adherent to randomly assigned high dose docosahexaenoic acid (DHA) supplementation in pregnancy

BACKGROUND

Intention-to-treat analyses do not address adherence. Per protocol analyses treat nonadherence as a protocol deviation and assess if the intervention is effective if followed.

OBJECTIVE

To determine the rate of early preterm birth (EPTB, <34 weeks gestation) and preterm birth (PTB, <37 weeks gestation) in participants who adhered to a randomly assigned docosahexaenoic acid (DHA) dose of 1000 mg/day.

STUDY DESIGN

Eleven hundred women with a singleton pregnancy were enrolled before 20-weeks' gestation, provided a capsule with 200 mg/day DHA and randomly assigned to two additional capsules containing a placebo or 800 mg of DHA. In the Bayesian Adaptive Design, new randomization schedules were determined at prespecified intervals. In each randomization, the group with the most EPTB was assigned fewer participants than the other group. Adherence was defined a priori as a postpartum red blood cell phospholipid DHA (RBC-PL-DHA) ≥5.5%.and post hoc as ≥8.0% RBC-PL-DHA, the latter after examination of postpartum RBC-PL-DHA. Bayesian mixture models were fitted for gestational age and dichotomized for EPTB and PTB as a function of baseline RBC-PL-DHA and dose-adherence. Bayesian hierarchical models were also fitted for EPTB by dose adherence and quartiles of baseline RBC-PL-DHA.

RESULTS

Adherence to the high dose using both RBC-PL-DHA cut points resulted in less EPTB compared to 200 mg [Bayesian posterior probability (pp) = 0.93 and 0.92, respectively]. For participants in the two lowest quartiles of baseline DHA status, adherence to the higher dose resulted in lower EPTB (≥5.5% RBC-PL-DHA, quartiles 1 and 2, pp = 0.95 and 0.96; ≥8% RBC-PL-DHA, quartiles 1 and 2, pp = 0.94 and 0.95). Using the Bayesian model, EPTB was reduced by 65%, from 3.45% to 1.2%, using both cut points. Adherence also reduced PTB before 35, 36 and 37 weeks using both cut points (pp ≥ 0.95). In general, performance of the nonadherent subgroup mirrored that of participants assigned to 200 mg.

CONCLUSION

Adherence to high dose DHA reduced EPTB and PTB. The largest effect of adherence on reducing EPTB was observed in women with low baseline DHA levels.

CLINICALTRIALS

gov (NCT02626299).

Docosahexaenoic acid (DHA) intake estimated from a 7-question survey identifies pregnancies most likely to benefit from high-dose DHA supplementation

BACKGROUND

Two randomized trials found women with low blood docosahexaenoic acid (DHA; an omega 3 fatty acid) had fewer early preterm births (<34 weeks gestation) if they were assigned to high dose DHA supplementation, however, there is currently no capacity for clinicians who care for pregnancies to obtain a blood assessment of DHA. Determining a way to identify women with low DHA intake whose risk could be lowered by high dose DHA supplementation is desired.

OBJECTIVE

To determine if assessing DHA intake can identify pregnancies that benefit from high dose DHA supplementation.

STUDY DESIGN

This secondary analysis used birth data from 1310 pregnant women who completed a 7-question food frequency questionnaire (DHA-FFQ) at 16.8 ± 2.5 weeks gestation that is validated to assess DHA status. They were then randomly assigned to a standard (200 mg/day) or high dose (800 or 1000 mg/day) DHA supplement for the remainder of pregnancy. Bayesian logistic regressions were fitted for early preterm birth and preterm birth as a function of DHA intake and assigned DHA dose.

RESULTS

Participants who consumed less than 150 mg/day DHA prior to 20 weeks' gestation (n = 810/1310, 58.1%) had a lower Bayesian posterior probability (pp) of early preterm birth if they were assigned to high dose DHA supplementation (1.4% vs 3.9%, pp = 0.99). The effect on preterm birth (<37 weeks) was also significant (11.3% vs 14.8%, pp = 0.97).

CONCLUSION

The DHA-FFQ can identify pregnancies that will benefit most from high dose DHA supplementation and reduce the risk of preterm birth. The DHA-FFQ is low burden to providers and patients and could be easily implemented in obstetrical practice.

Identifying ecological production functions for use in ecosystem services-based environmental risk assessment of chemicals

There is increasing research interest in the application of the ecosystem services (ES) concept in the environmental risk assessment of chemicals to support formulating and operationalising regulatory environmental protection goals and making environmental risk assessment more policy- and value-relevant. This requires connecting ecosystem structure and processes to ecosystem function and henceforth to provision of ecosystem goods and services and their economic valuation. Ecological production functions (EPFs) may help to quantify these connections in a transparent manner and to predict ES provision based on function-related descriptors for service providing species, communities, ecosystems or habitats. We review scientific literature for EPFs to evaluate availability across provisioning and regulation and maintenance services (CICES v5.1 classification). We found quantitative production functions for nearly all ES, often complemented with economic valuation of physical or monetary flows. We studied the service providing units in these EPFs to evaluate the potential for extrapolation of toxicity data for test species obtained from standardised testing to ES provision. A broad taxonomic representation of service providers was established, but quantitative models directly linking standard test species to ES provision were extremely scarce. A pragmatic way to deal with this data gap would be the use of proxies for related taxa and stepwise functional extrapolation to ES provision and valuation, which we conclude possible for most ES. We suggest that EPFs may be used in defining specific protection goals (SPGs), and illustrate, using pollination as an example, the availability of information for the ecological entity and attribute dimensions of SPGs. Twenty-five pollination EPFs were compiled from the literature for biological entities ranging from 'colony' to 'habitat', with 75% referring to 'functional group'. With about equal representation of the attributes 'function', 'abundance' and 'diversity', SPGs for pollination therefore would seem best substantiated by EPFs at the level of functional group.

Applying a mechanistic model to predict interacting effects of chemical exposure and food availability on fish populations

The potential environmental impacts of chemical exposures on wildlife are of growing concern. Freshwater ecosystems are vulnerable to chemical effects and wildlife populations, including fish, can be exposed to concentrations known to cause adverse effects at the individual level. Wild fish populations are also often subjected to numerous other stressors simultaneously which in temperate climates often include sustained periods of food limitation. The potential interactive effects of chemical exposures and food limitation on fish populations are however difficult to establish in the field. Mechanistic modelling approaches can be employed to help predict how the physiological effects of chemicals and food limitation on individuals may translate to population-level effects. Here an energy budget-individual-based model was developed and the control (no chemical) model was validated for the three-spined stickleback. Findings from two endocrine active chemical (EAC) case studies, (ethinyloestradiol and trenbolone) were then used to investigate how effects on individual fecundity translated into predicted population-level effects for environmentally relevant exposures. The cumulative effects of chemical exposure and food limitation were included in these analyses. Results show that effects of each EAC on the population were dependent on energy availability, and effects on population abundance were exacerbated by food limitation. Findings suggest that chemical effects and density dependent food competition interact to determine population responses to chemical exposures. Our study illustrates how mechanistic modelling approaches might usefully be applied to account for specific chemical effects, energy budgets and density-dependent competition, to provide a more integrated evaluation of population outcomes in chemical risk assessments.

Endogenous neurosteroids influence synaptic GABAA receptors during postnatal development

GABA plays a key role in both embryonic and neonatal brain development. For example, during early neonatal nervous system maturation, synaptic transmission, mediated by GABA_A receptors (GABA_A Rs), undergoes a temporally specific form of synaptic plasticity to accommodate the changing requirements of maturing neural networks. Specifically, the duration of miniature inhibitory postsynaptic currents (mIPSCs), resulting from vesicular GABA activating synaptic GABA_A Rs, is reduced, permitting neurones to appropriately influence the window for postsynaptic excitation. Conventionally, programmed expression changes to the subtype of synaptic GABA_A R are primarily implicated in this plasticity. However, it is now evident that, in developing thalamic and cortical principal- and inter-neurones, an endogenous neurosteroid tone (eg, allopregnanolone) enhances synaptic GABA_A R function. Furthermore, a cessation of steroidogenesis, as a result of a lack of substrate, or a co-factor, appears to be primarily responsible for early neonatal changes to GABAergic synaptic transmission, followed by further refinement, which results from subsequent alterations of the GABA_A R subtype. The timing of this cessation of neurosteroid influence is neurone-specific, occurring by postnatal day (P)10 in the thalamus but approximately 1 week later in the cortex. Neurosteroid levels are not static and change dynamically in a variety of physiological and pathophysiological scenarios. Given that GABA plays an important role in brain development, abnormal perturbations of neonatal GABA_A R-active neurosteroids may have not only a considerable immediate, but also a longer-term impact upon neural network activity. Here, we review recent evidence indicating that changes in neurosteroidogenesis substantially influence neonatal GABAergic synaptic transmission. We discuss the physiological relevance of these findings and how the interference of neurosteroid-GABA_A R interaction early in life may contribute to psychiatric conditions later in life.

Abstract P6-11-08: Safety and efficacy results from phase I study of BYL 719 plus nab-paclitaxel in HER 2 negative metastatic breast cancer

Introduction

Mutations/deregulations in the phosphatidylinositol-3-kinase (PI3K) pathway are common in breast cancer, Inhibition of the PI3K pathway is recognized as a promising target for the treatment of breast cancer. Although taxanes are effective early on in advanced stage breast cancer, resistance often develops. It has been demonstrated that activation of the PI3K/AKT pathway confers resistance to paclitaxel, and in preclinical models, concomitant inhibition of the PI3K pathway enhances the efficacy of taxanes. BYL719 is a potent oral, class I PI3K inhibitor which strongly inhibits the PI3K alpha isoforms and is significantly less active against the other class I isoforms. Targeting the alpha isoform of PI3K is expected to improve the therapeutic window over inhibitors with less isoform specificity. Nab-Paclitaxel is a solvent-free, nanoparticle, albumin-based paclitaxel which takes advantage of the antitumor activity of paclitaxel while decreasing the toxicities typically associated with the solvent (Cremophor) used to administer the most common formulation of paclitaxel.

Methods

A 3+3 dose-escalation design evaluated three dose levels of BYL719 (250mg, 300mg, and 350mg) administered PO once daily (D1-28) with nab-Paclitaxel (100 mg/m2 intravenously D 1, 8, 15) every 28 days in patients with metastatic HER 2 negative breast cancer. The aims of the study were to 1) determine the recommended phase II dose (RPTD) of BYL719 + nab-Paclitaxel, 2) assess pharmacokinetics of BYL and nab-paclitaxel, and 3) assess preliminary efficacy.

Results

10 patients were enrolled at 3 dose levels of BYL719 and 3 patients were enrolled in expansion cohort at the RPTD of BYL719 of 350 mg PO daily plus nab-paclitaxel 100mg/m2 (D 1, 8, 15). Median age was 61years; 54% (7/13) of patients were hormone receptor positive and 46% (6/13) triple negative. 85% (11/13) had visceral disease, 69% (9/13) had received prior chemotherapy for metastatic disease and 85% (11/13) had received prior taxane in adjuvant/metastatic setting. There were no DLTs in the three cohorts and the MTD of BYL was not reached. Hyperglycemia (G3:31%, G4:0%) and neutropenia (G3:15%, G4:8%), were the most common grade 3/4 adverse events. There were no Grade 3/4 diarrhea or rash. Best overall response for 12 patients was 58% (7/12) (complete response=1, partial response=6), and an additional 33% (4/12) demonstrated stable disease. Objective responses were noted in both hormone positive and triple negative disease. Median duration of response is 6.5 months (range 2-14 months). No pharmacokinetic interactions were detected when BYL and nab-paclitaxel were co-administered.

Discussion:

This phase I study demonstrates that combination of BYL719 and nab-paclitaxel was well tolerated and shows encouraging efficacy in metastatic HER2 negative breast cancer. Enrollment in the phase II portion of the trial at the RPTD (BYL719 350mg PO daily plus nab-paclitaxel 100mg/m2 D1,8,15 every 28 days) continues. Ongoing analysis of PI3K pathway alterations in tumor and cfDNA will be correlated with clinical response.

Citation Format: Sharma P, Abramson VG, O'Dea A, Lewis S, Scott JN, Ward J, De Jong JA, Lehn C, Brown AR, Williamson SK, Perez RP, Komiya T, Godwin AK, Reed GA, Khan QJ. Safety and efficacy results from phase I study of BYL 719 plus nab-paclitaxel in HER 2 negative metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-11-08.

Assessing variation in the potential susceptibility of fish to pharmaceuticals, considering evolutionary differences in their physiology and ecology

Fish represent the planet's most diverse group of vertebrates and they can be exposed to a wide range of pharmaceuticals. For practical reasons, extrapolation of pharmaceutical effects from 'model' species to other fish species is adopted in risk assessment. Here, we critically assess this approach. First, we show that between 65% and 86% of human drug targets are evolutionarily conserved in 12 diverse fish species. Focusing on nuclear steroid hormone receptors, we further show that the sequence of the ligand binding domain that plays a key role in drug potency is highly conserved, but there is variation between species. This variation for the oestrogen receptor, however, does not obviously account for observed differences in receptor activation. Taking the synthetic oestrogen ethinyloestradiol as a test case, and using life-table-response experiments, we demonstrate significant reductions in population growth in fathead minnow and medaka, but not zebrafish, for environmentally relevant exposures. This finding contrasts with zebrafish being ranked as more ecologically susceptible, according to two independent life-history analyses. We conclude that while most drug targets are conserved in fish, evolutionary divergence in drug-target activation, physiology, behaviour and ecological life history make it difficult to predict population-level effects. This justifies the conventional use of at least a 10× assessment factor in pharmaceutical risk assessment, to account for differences in species susceptibility.

A study of subunit selectivity, mechanism and site of action of the delta selective compound 2 (DS2) at human recombinant and rodent native GABA(A) receptors

BACKGROUND AND PURPOSE

Most GABA(A) receptor subtypes comprise 2α, 2β and 1γ subunit, although for some isoforms, a δ replaces a γ-subunit. Extrasynaptic δ-GABA(A) receptors are important therapeutic targets, but there are few suitable pharmacological tools. We profiled DS2, the purported positive allosteric modulator (PAM) of δ-GABA(A) receptors to better understand subtype selectivity, mechanism/site of action and activity at native δ-GABA(A) receptors.

EXPERIMENTAL APPROACH

Subunit specificity of DS2 was determined using electrophysiological recordings of Xenopus laevis oocytes expressing human recombinant GABA(A) receptor isoforms. Effects of DS2 on GABA concentration-response curves were assessed to define mechanisms of action. Radioligand binding and electrophysiology utilising mutant receptors and pharmacology were used to define site of action. Using brain-slice electrophysiology, we assessed the influence of DS2 on thalamic inhibition in wild-type and δ(0/0) mice.

KEY RESULTS

Actions of DS2 were primarily determined by the δ-subunit but were additionally influenced by the α, but not the β, subunit (α4/6βxδ > α1βxδ >> γ2-GABA(A) receptors > α4β3). For δ-GABA(A) receptors, DS2 enhanced maximum responses to GABA, with minimal influence on GABA potency. (iii) DS2 did not act via the orthosteric, or known modulatory sites on GABA(A) receptors. (iv) DS2 enhanced tonic currents of thalamocortical neurones from wild-type but not δ(0/0) mice.

CONCLUSIONS AND IMPLICATIONS

DS2 is the first PAM selective for α4/6βxδ receptors, providing a novel tool to investigate extrasynaptic δ-GABA(A) receptors. The effects of DS2 are mediated by an unknown site leading to GABA(A) receptor isoform selectivity.

Contaminants in fine sediments and their consequences for biota of the Severn Estuary

When the first MPB special issue was published 25 years ago it was suggested that high body burdens of metals and selected organic pollutants in the Severn Estuary were the result of anthropogenic loadings from a variety of sources. The objective of this synopsis is to illustrate recent trends for contaminants (metals, PAHs, PCBs) in sediments and benthic biota and to consider the evidence for improved environmental quality over the last quarter of a century. Contaminants in sediments and sediment-dwelling fauna such as Hediste(=Nereis)diversicolor are, generally, evenly distributed over the estuary - which is the consequence of extensive re-suspension and redistribution of fine sediment by strong tidal currents. Such dispersal tends to mask the influences of individual discharges and physical characteristics are considered to be the major drivers affecting biodiversity in the Severn Estuary, often overshadowing contaminant concerns. Following the closure of major industries and the introduction of stricter pollution control, many inputs have ceased or been reduced and there are indications that environmental concentrations are now lower. Bioaccumulation of most contaminants has declined accordingly (with the possible exception of Cr). Intuitively, better environmental quality should be linked to ecological improvements. However, due to the dynamic nature of the system (and a lack of biological-effects data) it is difficult to establish direct relationships between inputs, body burdens and biological/ecological consequence. Uniquely, the long-term integrated monitoring program of AstraZeneca (Avonmouth) indicates that recovery of faunal diversity and abundance has occurred in mid-sections of the estuary in recent years implying that contaminants have indeed been a forcing feature for Severn biota. In this context, we highlight contaminant issues and biogeochemical changes which may need to be addressed in connection with the development of proposals for tidal energy schemes.

Large eddy simulation of the atmosphere on various scales

Numerical simulations of the atmosphere are routinely carried out on various scales for purposes ranging from weather forecasts for local areas a few hours ahead to forecasts of climate change over periods of hundreds of years. Almost without exception, these forecasts are made with space/time-averaged versions of the governing Navier-Stokes equations and laws of thermodynamics, together with additional terms representing internal and boundary forcing. The calculations are a form of large eddy modelling, because the subgrid-scale processes have to be modelled. In the global atmospheric models used for long-term predictions, the primary method is implicit large eddy modelling, using discretization to perform the averaging, supplemented by specialized subgrid models, where there is organized small-scale activity, such as in the lower boundary layer and near active convection. Smaller scale models used for local or short-range forecasts can use a much smaller averaging scale. This allows some of the specialized subgrid models to be dropped in favour of direct simulations. In research mode, the same models can be run as a conventional large eddy simulation only a few orders of magnitude away from a direct simulation. These simulations can then be used in the development of the subgrid models for coarser resolution models.

Differential expression of erythroid genes in prion disease

We previously reported reduced expression of erythroid-associated factor (ERAF) within haematopoietic tissues of rodent scrapie models, suggesting an unrecognized role for the erythroid lineage in prion disease. In the present study, we compared the expression of a panel of erythroid genes within four murine scrapie models and five virus infection models with parallels to prion disease pathogenesis. We report that differential expression of erythroid genes is not limited to ERAF, and is a common feature of murine scrapie, dependent on host expression of cellular prion protein. In contrast, erythroid gene expression was not altered following virus infection. Whilst these results further implicate cells of the erythroid lineage in the peripheral pathogenesis of prion disease, analysis of blood from BSE-infected cattle and scrapie-infected sheep reveals that the extent of differential expression of erythroid genes within peripheral blood is not sufficient to provide a discriminatory diagnostic test.

Displaced intra-articular calcaneal fractures: 15-year follow-up of a randomised controlled trial of conservative versus operative treatment

AIM

To report the 15-year follow-up of displaced intra-articular calcaneal fractures from a randomised controlled trial of conservative versus operative treatment published in 1993.

PATIENTS AND METHODS

Of the initial study, 46 patients (82%) were still alive at a mean of 15 years post injury and 26 patients (57%) agreed to review. The patients had been randomly allocated to either conservative or operative treatment in the original study. Clinical [American orthopaedic foot and ankle society hindfoot scale (AOFAS), foot function index (FFI) and calcaneal fracture score] and radiological (Böhler's angle and calcaneum height) outcome measures were used. The grade of osteoarthritis was also assessed at long-term follow-up.

RESULTS

At long-term follow-up, the clinical outcomes were not different between conservative versus operative treatment. AOFAS hindfoot scale: conservative=78.5 and operative=70, p=0.11; FFI: conservative=24.4 and operative=26.9, p=0.66; calcaneal fracture score: conservative=70.1 and operative=63.5, p=0.41. The radiological outcomes were also not different between both groups. Böhler's angle: conservative=10.4 degrees and operative 16.9 degrees , p=0.07; height of calcaneum: conservative=37.2mm and operative=38.2mm, p=0.57; grade of osteoarthritis of the sub-talar joint: p=0.54. There was no correlation between Böhler's angle and the outcome measures in either group.

CONCLUSION

The results of this 15-year follow-up of displaced intra-articular calcaneal fracture randomised controlled trial were equivalent between conservative and operative treatment and demonstrate similar findings to those at one year follow-up.

Assessment of fluorescent in situ hybridization and PCR-based methods for rapid identification of Burkholderia cepacia complex organisms directly from sputum samples

Several species within the Burkholderia cepacia complex (BCC) have emerged as significant opportunistic pathogens of patients with cystic fibrosis (CF). BCC infection is typically associated with a poor clinical prognosis and decreased survival. These factors, combined with the existence of highly transmissible epidemic strains, have resulted in strict segregation of BCC- and non-BCC-infected patients to minimize cross infection. Accurate and rapid diagnosis of infections is essential to enable appropriate patient management. However, the rapidly evolving taxonomy of BCC poses a considerable challenge to diagnostics. In the present study, we assessed a commercially available fluorescent in situ hybridization (FISH) assay (seaFAST Cystic Fibrosis I kit) and a novel rRNA gene-based PCR assay for the rapid identification of BCC-positive sputa, irrespective of the BCC species. We report that, while the FISH assay fails to identify all BCC species, it does identify the majority of species, including the two most clinically relevant species, B. multivorans and B. cenocepacia. The sensitivity of the assay applied to sputum was limited by nonspecific background fluorescence. While sputum processing was optimized to minimize background, the resulting sensitivity for BCC detection was 8 x 10(5) CFU/ml. In contrast, the novel PCR assay reported herein exhibits 100% sensitivity and specificity for all BCC species and can detect 10(4) CFU/ml when applied to sputum. This novel rRNA gene-based assay is currently the most sensitive BCC-specific PCR assay for the detection of BCC direct from clinical samples and as such is a valuable addition to the field of BCC diagnostics.

Identification of up-regulated genes by array analysis in scrapie-infected mouse brains

The major neuropathological features of the transmissible spongiform encephalopathies (TSEs) are well documented, however, the underlying molecular events are poorly defined. We have applied cDNA expression arrays and quantitative RT-PCR to the study of gene expression in the brain, and more specifically in the hippocampus, of the well-characterized ME7/CV mouse model of scrapie. The number of genes showing consistent, scrapie-associated changes in expression was limited, and was primarily restricted to glial-associated genes. Increased expression of genes encoding glial fibrillary acidic protein, vimentin, complement component 1q (alpha and beta polypeptides), cathepsin D, clusterin and cystatin C was evident in the hippocampus from 170 days after inoculation (dpi), with expression increasing thereafter to terminal disease (225-235 dpi). Elevation of gene expression preceded clinical disease by approximately 30 days, and coincided with a 20-day period in the ME7/CV model during which 50% of the CA1 hippocampal neurones are lost. Increased expression of cystatin C, an inhibitor of lysosomal cysteine proteases, is a novel finding in the context of TSE neuropathology and was confirmed by Western analysis and immunocytochemistry.

Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery

BACKGROUND

A systematic review was conducted to determine which of the methods of obtaining peritoneal access and establishing pneumoperitoneum is the safest and most effective.

METHODS

Studies that met the inclusion criteria were identified from six bibliographic databases up to May 2002, the internet, hand-searches and reference lists. They were critically appraised using a validated checklist and data were extracted using standardized protocols.

RESULTS

Meta-analysis of prospective, non-randomized studies of open versus closed (needle/trocar) access indicated a trend during open access towards a reduced risk of major complications (pooled relative risk (RR(p)) 0.30, 95 per cent confidence interval (c.i.) 0.09 to 1.03). Open access was also associated with a trend towards a reduced risk of access-site herniation (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.03) and, in non-obese patients, a 57 per cent reduced risk of minor complications (RR(p) 0.43, 95 per cent c.i. 0.20 to 0.92) and a trend for fewer conversions to laparotomy (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.17). Data on major complications in studies of direct trocar versus needle/trocar access were inconclusive. Minor complications in randomized controlled trials were fewer with direct trocar access (RR(p) 0.19, 95 per cent c.i. 0.09 to 0.40), predominantly owing to a reduction in extraperitoneal insufflation.

CONCLUSION

The evidence on the comparative safety and effectiveness of the different access methods was not definitive, but there were trends in the data that merit further exploration.

Effects of VOCs on herbaceous plants in an open-top chamber experiment

A selection of herbaceous plants representing the ground flora around a typical chemical installation in the UK was exposed continuously for 7 weeks to a mixture of six VOCs (acetone, acetonitrile, dichloromethane, ethanol, methyl t-butyl ether and toluene) in open-top chambers. Exposure concentrations were based on predictions of atmospheric dispersion from a single source, at a distance of approximately 2 km. The effects of continuous exposure, representing a worst-case, were measured in terms of uncontrolled water loss from leaves, leaf wettability, chlorophyll content and fluorescence, dry matter production and detailed observations of changes in plant growth and phenology. There were significant effects of VOC exposure on seed production, leaf water content and photosynthetic efficiency in some plant species. Such effects may be detectable in vegetation close to major industrial point sources of VOCs, or as a result of an accidental release of material during manufacture or transport. Some of the species tested e.g. birdsfoot trefoil (Lotus corniculatus L.) seem to be promising as potential bioindicators for VOCs, but there may be other even more sensitive species waiting to be discovered. However, the most obvious and conveniently measured response to VOCexposure in the birdsfoot trefoil (premature senescence i.e. advanced timing of seed pod production) could easily be confused in the field with climatic influences. It is also uncertain at this stage whether any of the effects observed would lead to longer term ecological changes in natural plant communities, through biased competition between sensitive and more tolerant species.

The use of a "reverse" axis (axillary-interscalene) block in a patient presenting with fractures of the left shoulder and elbow

IMPLICATIONS

A patient presented for surgery to repair a fractured left shoulder and elbow and requested regional anesthesia. Most upper extremity operations require a single brachial plexus nerve block. The position of the two fractures however required the use of two separate approaches, an interscalene and an axillary approach.

A comparison of prophylactic antibiotic regimens against airborne orthopaedic wound contamination

Deep infection remains a major complication of joint replacement surgery despite advances in theatre design, surgical technique and antibiotic prophylaxis. Major randomized controlled trials to determine the most effective antibiotic prophylaxis are difficult to construct and interpret. In a conventional theatre, most orthopaedic intra-operative wound contamination arrives by the airborne route. This paper describes a unique method used to compare antibiotics against airborne bacteria. Seven antibiotics were incorporated into blood agar at concentrations equivalent to serum levels. Plates were then exposed to airborne theatre bacteria using a multiple synchronous collection technique. After incubation, the percentage kill was calculated for each antibiotic. At concentrations equivalent to serum level 1h post i.v. dose, all the antibiotics proved highly effective, with kill rates > 95%. Imipenem and co-amoxiclav significantly outperformed the other antibiotics with kill rates of 99.6% and 99.4%, respectively. At trough levels, the antibiotics achieved kill rates from 61% to 97.6%. Future randomized controlled trials comparing large numbers of antibiotics in the setting of an already low infection rate are inappropriate. This technique for comparing antibiotic prophylaxis in quick, inexpensive and repeatable. The superiority of imipenem is not unexpected, but of more interest is the effectiveness of co-amoxiclav over the presently favoured cefuroxime.

Diversity of Tn1546 elements in clinical isolates of glycopeptide-resistant enterococci from Scottish hospitals

The Tn1546-related elements of 48 Van glycopetide-resistant enterococci were compared. Ten distinct Tn1546 types were identified with variation primarily due to IS1542 and IS1216V-like insertions. Clonal isolates frequently differed in their Tn1546 type, indicating instability of Tn1546-related elements. A putative hybrid promoter was identified, generated upstream of vanR by the insertion of IS1542. The presence of this hybrid promoter was associated with constitutive expression of the van genes and elevated teicoplanin resistance.

Effect of sonic and mechanical toothbrushes on subgingival microbial flora: a comparative in vivo scanning electron microscopy study of 8 subjects

OBJECTIVES

The purpose of this initial study was to evaluate the effects of both a sonic and a mechanical toothbrush versus the effects of no treatment on depth of subgingival penetration of epithelial and tooth-associated bacteria.

METHOD AND MATERIALS

Eight adult subjects exhibiting advanced chronic periodontitis with at least 3 single-rooted teeth that were in separate sextants with facial pockets > or = 4 mm and < or = 8 mm and that required extraction constituted the experimental sample. Teeth were either subjected to 15 seconds of brushing with a mechanical toothbrush or a sonic toothbrush or left untreated. The test tooth and the associated soft tissue wall of the periodontal pocket were removed as a single unit. Samples were processed and coded for blind examination by scanning electron microscopy. Distributional and morphologic characteristics of dominant bacteria with specific emphasis on spirochetes were evaluated for both epithelial- and tooth-associated plaque.

RESULTS

No differences were found in morphotypes or distributional and aggregational characteristics of epithelial-associated microbes in the 1- to 3-mm subgingival zone between the mechanical and sonic toothbrush-treated groups and the control group. Both toothbrush groups featured disruption of microbes that extended up to 1 mm subgingivally. Root surfaces on the sonic-treated samples appeared plaque-free at low magnification; however, at 4,700x, a thin layer of mixed morphotypes and intact spirochetes was found subgingivally and slightly subgingivally. In comparison, mechanical brush samples featured incompletely removed plaque, both subgingivally and subgingivally, with intact spirochetes present on subgingival root surfaces.

CONCLUSION

Results suggest similar effects for both sonic and mechanical toothbrushes on epithelial- and tooth-associated bacterial plaque in periodontal pockets and adjacent root surfaces that extend up to 1 mm subgingivally. Further, the presence of intact subgingival spirochetes suggests limited exposure to acoustical or mechanical energy from the toothbrushes evaluated.

Indwelling interscalene catheter anesthesia in the surgical management of stiff shoulder: a report of 100 consecutive cases

One hundred consecutive stiff shoulders in 93 patients resistant to conservative therapy were treated with surgery and intermittent regional anesthesia via indwelling interscalene catheter. Each patient underwent manipulation and one of several operative treatments to release any additional contracture. The indwelling interscalene catheter remained in place and functioned well for an average of 3 days in 87 shoulders. At an average follow-up of 3.0 years, overall clinical results according to Neer's criteria were excellent in 39 shoulders (39%), satisfactory in 28 (28%), and unsatisfactory in 33 (33%). Patients reported no or mild pain in 83 (83%) of the shoulders in the study. At final follow-up, average gains in motion were 44 degrees of elevation (115 degrees to 159 degrees), 31 degrees of external rotation (22 degrees to 53 degrees), and 5 spine segments of internal rotation (L4 to T11). At final follow-up, 95% of the elevation and 79% of the external rotation achieved intraoperatively were maintained. The best results were obtained in those shoulders with idiopathic stiffness (88% excellent or satisfactory results); the worst results were in the postsurgical shoulders (47% excellent or satisfactory results). There were no catheter-related complications. The use of an indwelling interscalene catheter for postoperative pain control is a safe technique that facilitates early physical therapy in a patient population with a high risk of developing recurrent stiffness.

Interscalene block with a nerve stimulator: a deltoid motor response is a satisfactory endpoint for successful block

BACKGROUND AND OBJECTIVES

The interscalene brachial plexus block (ISB) is an effective and well-established anesthetic technique for shoulder surgery. Using nerve stimulation as an aid in block placement, a motor response (twitch) in the biceps or a more distal upper limb muscle has been recommended to indicate accurate needle placement. Our clinical experience, as well as anatomic reasoning, suggests that a deltoid twitch may be just as effective as one in the biceps for predicting successful block. This prospective clinical study was undertaken to compare a deltoid with a biceps twitch with respect to onset and success of motor block.

METHODS

A total of 160 patients scheduled for shoulder surgery were studied prospectively. Interscalene blocks were performed using neurostimulation according to our standard technique. Twitches of the deltoid or biceps or both, whichever appeared first, were accepted and used as the endpoint for needle placement and injection of local anesthetic. Motor block success, i.e., patient inability to lift the arm against gravity, and minutes to motor block onset were recorded.

RESULTS

There was 1 failed motor block in the deltoid group and none in the other groups (not a statistically significant difference). When the same local anesthetic was used, there were no statistically significant differences in onset times between the biceps, deltoid, or biceps/deltoid groups.

CONCLUSIONS

A deltoid twitch is as effective as a biceps twitch in determining accurate needle placement for ISB and in predicting successful motor block. Acceptance of a deltoid twitch during ISB eliminates the need for further probing and may translate into better patient acceptance and in a smaller risk of needle-induced nerve damage.

Isolation and characterization of glycopeptide-resistant enterococci from hospitalized patients over a 30-month period

In February 1996, a Hospital Infection Control Practices Advisory Committee-style screening program was commenced to isolate and subsequently characterize glycopeptide-resistant enterococci (GRE) from patients at a hospital trust in Glasgow, Scotland. Over the next 30 months, GRE were isolated from 154 patients. GRE were isolated from patients in traditionally high-risk areas such as the renal unit and intensive care unit and also in areas considered to be lower risk, including medical wards and associated long-stay geriatric hospitals. The majority (90%) of isolates were Enterococcus faecium vanB. The remaining isolates consisted of seven E. faecalis (vanA), three E. gallinarum (vanC), and a further six E. faecium (five vanA, one both vanA and vanB) isolates. Analysis of SmaI-digested DNA by pulsed-field gel electrophoresis revealed that 34 of 40 (85%) VanB E. faecium isolates were identical or closely related, while 11 of 13 (85%) VanA GRE were distinct. High-level aminoglycoside resistance was seen in less than 8% of isolates. VanB E. faecium isolates were almost uniformly resistant to ampicillin and tetracycline. In this study, GRE have been isolated over a prolonged period from a broad range of patients. Glycopeptide resistance within the study hospital trust appeared to be mainly due to the clonal dissemination of a single strain of E. faecium VanB.

The mouse tumor cell lines EL4 and RMA display mosaic expression of NK-related and certain other surface molecules and appear to have a common origin

As a potential means for facilitating studies of NK cell-related molecules, we examined the expression of these molecules on a range of mouse tumor cell lines. Of the lines we initially examined, only EL4 and RMA expressed such molecules, both lines expressing several members of the Ly49 and NKRP1 families. Unexpectedly, several of the NK-related molecules, together with certain other molecules including CD2, CD3, CD4, CD32, and CD44, were often expressed in a mosaic manner, even on freshly derived clones, indicating frequent switching in expression. In each case examined, switching was controlled at the mRNA level, with expression of CD3zeta determining expression of the entire CD3-TCR complex. Each of the variable molecules was expressed independently, with the exception that CD3 was restricted to cells that also expressed CD2. Treatment with drugs that affect DNA methylation and histone acetylation could augment the expression of at least some of the variable molecules. The striking phenotypic similarity between EL4 and RMA led us to examine the state of their TCRbeta genes. Both lines had identical rearrangements on both chromosomes, indicating that RMA is in fact a subline of EL4. Overall, these findings suggest that EL4 is an NK-T cell tumor that may have retained a genetic mechanism that permits the variable expression of a restricted group of molecules involved in recognition and signaling.

Consent to treatment and the mentally incapacitated adult

Doctors are sometimes faced with adult patients who lack the mental capacity to consent to treatment. In a questionnaire, 120 doctors in a district general hospital were asked what action they would take if such a patient had a clear need for elective treatment. Of the 89 who replied, 57 said they would seek consent from relatives or others; 11 of these, nevertheless, stated that treatment could proceed without such consent. These results, and inquiries about other options, pointed to widespread misunderstanding of the law. In English law, no one can give legally valid consent on behalf of another adult. When an individual is unable to give consent, common law allows a doctor to protect a patient's best interests by treating him or her in accordance with a responsible body of medical opinion.

Comparison of outcomes following transhiatal or Ivor Lewis esophagectomy for esophageal carcinoma

Transhiatal esophagectomy (THO) may be a valid alternative to the traditional Ivor Lewis (ILO) procedure, but there have been reservations about procedure mortality, nodal clearance, and survival. ILO is preferred for bulky midesophageal lesions and THO in frail patients, making randomization difficult. This retrospective study compares results of a 10-year period from January 1985 with a minimum follow-up period of 12 months. Four patients were lost to follow-up. Preoperative nutritional markers were similar in the two groups, as were the age and sex distribution. Altogether 33 ILOs and 65 THOs were performed. TNM staging was similar between groups, there being 43% stage II and 45% stage III lesions among the ILO patients and 53% stage II and 32% stage III disease in the THO group. Operating time was shorter for THO (256 +/- 58 minutes vs. 279 +/- 50 minutes) (p = 0.05); if two surgeons operated concurrently, THO could be performed 40 minutes quicker than THO or ILO performed by a single surgeon (p = 0.018). The mean initial intensive care unit stay was 2.9 days for ILO versus 1.7 days for THO (p = 0.014). The 30-day mortality was 5.1%; total in-hospital mortality was 7.1% with no difference for operation type. There were similar morbidity rates for the procedures. Kaplan-Meier survival analysis indicated no significant effect of surgical technique; there were no apparent advantages for either operation when patients were compared by tumor type or matched for stage. Hence THO is a valid alternative to ILO, particularly for stage II and III cancer.

Epidemiology and control of vancomycin-resistant enterococci (VRE) in a renal unit

This study reports an outbreak of infection and colonization caused by vancomycin-resistant enterococci (VRE) in the renal service of a large teaching hospital. The polymerase chain reaction and pulsed-field gel electrophoresis were used to study the epidemiology of 26/34 strains of vancomycin-resistant Enterococcus faecalis and Enterococcus faecium from the outbreak in comparison with five strains from other hospitals in Edinburgh and the Borders, and three from other wards in the Royal Infirmary. The study revealed a heterogeneous population of vancomycin-resistant E. faecalis. Over 60% of E. faecium isolates had matching pulsed-field gel electrophoresis patterns and all of these were of VanA phenotype. These results suggest that clonal spread of VanA phenotype E. faecium within and possibly between hospitals is the major vancomycin-resistant enterococcal problem in Edinburgh. Screening of patients and isolation of colonized and infected patients appear to have been successful in controlling the spread of VRE.

Bacteremia and intraoral suture removal: can an antimicrobial rinse help?

Recent studies have shown that bacteremia can result from the removal of intraoral sutures. The authors found that preprocedural use of an antimicrobial oral rinse (0.12 percent chlorhexidine) did not significantly reduce the incidence of bacteremia when compared with no rinse at all. Similarly, a significant relationship between bleeding and bacteremia was not apparent. Most of the positive cultures yielded low colony counts. The results support the rationale for the American Heart Association's 1997 recommendations for use of antibiotic prophylaxis to prevent bacteremia, as well as the importance of good oral hygiene in prevention efforts.

Content and legibility of outpatient appointment letters

OBJECTIVES

To assess whether outpatient appointment letters can be read by visually impaired people and to examine the information they contain.

DESIGN

Postal survey of hospital outpatient departments in England and Wales.

MAIN OUTCOME MEASURES

Royal National Institute for the Blind (RNIB) guidelines for print size and weight, colour contrast between paper and print and use of capital letters; checklist of items of information contained.

RESULTS

We asked 295 hospital trusts for copies of their outpatient appointment letters, and received 158 samples. In 87% the print size was too small to be read by visually impaired people. All used contrasting paper and print colour, but 13% used too light a print weight. Twelve percent used capital letters throughout which are harder to read than lower case lettering. Information content was variable. Twenty letters specifically designed for low vision clinics were assessed separately; all used adequate print size and weight, but 55% used capitals throughout.

CONCLUSIONS

Most outpatient appointment letters are not easily read by visually impaired people. Important items of information are omitted from some letters.

Tetrafluoroethane (HFC 134A) propellant-driven aerosols of proteins

PURPOSE

Develop metered-dose propellant-driven aerosols of proteins using tetrafluoroethane (HFC 134A) as propellant.

METHODS

Proteins were lyophilized with the propellant-soluble surfactants Triton X-100, Triton X-405, Laureth-9, Brij-30, Nonidet-40, and diethylene glycol monoethylether and then charged with propellants.

RESULTS

Small particle aerosols of the experimental protein bovine gamma globulin were produced. The fraction of aerosolized respirable-sized protein particles (< 4-5 microns) increased after dispersion of particles in propellant with agitation by shaking. Scanning electron microscopy of respirable-sized protein aerosols demonstrated bead-like particles in grape-like clusters. Vigorous shaking of propellant-suspended particles for 2 minutes or more reduced the size of clusters and reduced the diameters of the protein-containing subparticles that constituted the clusters. A 50:50 ratio of HFC 134A and dimethylether (DME) propellants improved the respirability of protein aerosols compared to HFC 134A as the sole propellant. Protein/surfactant particles first dispersed in DME and then diluted in HFC 134A propellant most efficiently produced respirable-sized, propellant-driven, protein aerosols.

Effects of tetracycline hydrochloride and chlorhexidine gluconate on Candida albicans. An in vitro study

This study examined the effects of tetracycline hydrochloride (TCN) and chlorhexidine gluconate (CHX) on the growth and viability of Candida albicans. Subcultures of Candida albicans on Sabouraud's agar, were divided into 5 treatment groups: group 1, untreated control; group 2, 0.12% CHX; group 3, 3.0 mg/ml TCN adjusted to pH 4.5; groups 4 and 5, sodium azide free Tris buffer adjusted to pH 4.5 and pH 7.4, respectively. All groups were incubated for 10 days, and sampled and subcultured daily to determine the viability of each group. Additional samples from group 2 (day 4), group 4 (day 7) and all groups at day 10 were selected for SEM and TEM examination. Visual, SEM and TEM results showed that for groups 1, 3, 4, and 5 there was a heavy and constant uniform growth of Candida albicans throughout the period of the study. However, group 2 (CHX), showed decreasing viability and attachment from day 3 to day 10, with SEM and TEM revealing decreased blastospores and profound changes in the ultrastructural morphology, indicating inhibition of normal cell growth and replication. These results show that TCN even when used at high concentrations, in vitro, will allow uninhibited growth of Candida albicans whereas CHX inhibits cell growth and replication.

Lichen sclerosus et atrophicus of the oral cavity: report of two cases

Lichen sclerosus et atrophicus is a depigmenting mucocutaneous disease most frequently affecting the female genitalia. Genital lesions are symptomatic and may be functionally debilitating. Oral lesions are of little significance other than the esthetic concerns of perioral lesions. In view of the rarity of reported cases, one lesion of the labial mucocutaneous area and a second of the palate are presented along with a description of the disease's clinical and histopathologic findings and a brief review of the literature. The lip lesion was partially resolved with topical corticosteroids and was then fully eliminated with topical testosterone. Histologic verification and examination for the simultaneous occurrence or absence of oral and the more common genital-cutaneous lesions is essential if meaningful information in the medical-dental literature is to be obtained in the future.

Vaccinator device for delivering propellant-driven aerosols of Streptococcus suis bacterin into the respiratory tracts of swine

Metered-dose propellant-driven small particle aerosols of a killed whole bacterium, Streptococcus suis, were produced and characterized for their aerodynamic particle sizes and antigenicity as potential respiratory mucosal vaccines against S. suis infections in swine. To facilitate the efficient delivery of such vaccine aerosols to large animals, an electro-mechanical device was developed to synchronize aerosol release to an animal's inhalation cycles. The device was tested for its capacity to deliver a fluorescein conjugate of this bacterin (FITC-S. suis) into the respiratory tracts of 18 pigs. Results showed that FITC-S. suis could be detected in the lungs of swine as small as 4.5 kg with as few as two aerosol actuations. Metered-dose propellant-driven aerosols of bacterin vaccines delivered by this respiratory vaccinating device are discussed as a new approach for stimulated mucosal immunity against respiratory infections in animals.

Atypical palatal papillomatosis treated by excision and full-thickness grafting

Papillary lesions of the oral cavity are extremely common, and inflammatory palatal hyperplasia is well known to dental practitioners. Advanced sophistication in viral laboratory technologies makes it apparent that various forms of the human papilloma virus are often causative. However, this is not true for inflammatory palatal hyperplasia. This article describes a patient with anatomically well-demarcated, multiple squamous cell papillomas of the palate that could not be classified as inflammatory palatal hyperplasia, nor could a viral etiology be ascertained, despite exhaustive laboratory studies. The lesion recurred despite numerous surgical ablation attempts. Eradication was achieved only after applying free soft-tissue grafts over the areas of excision. The differential diagnosis of papillary lesions with an emphasis on viral etiology, laboratory studies associated with their identification, and a hypothesis that explains why grafting was the only successful means of treatment are also discussed.

An uplifting experience? Hospital passenger lifts and their suitability for disabled people

Hospitals should be welcoming places, and disabled people should not expect difficulties when using a hospital's facilities. For some elderly and disabled people the passenger lift may be the only means of vertical movement within a building. We visited four hospitals and inspected their passenger lifts for use by disabled and elderly people. We compared our findings with those of an "ideal lift' drawn from recommendations by disabled support groups, National Health Services Estates Department and building regulations. We found that most hospital passenger lifts are inadequate for those with mobility, visual and hearing impairments. Consequently, disabled and elderly people might have problems using hospital passenger lifts, with a subsequent loss of independence. The provision of well-designed and accessible passenger lifts is central to imaginative hospital building design.

Do it yourself: home-made aids for disabled elderly people

We contacted the caregivers of patients admitted on a hospital respite care scheme and asked them about home-made or modified aids and appliances. Seven home-made devices were discovered and inspected. They were an electric hoist, a builder's plastic skip used as a bath, a wheelchair support and tray made out of chipboard, stair rails made from old steel pipe, an improvised commode and a modified standard commode enabling the user to be cleaned in the sitting position. Several gadgets were innovative; others were dangerous. Two caregivers had injured themselves using the improvised aids. Others were at risk of injury. With an increasing tendency for Community Agencies to charge for equipment, more caregivers may design and build their own aids-some of which may be hazardous. Health professionals who visit elderly people at home should look for home-made gadgets with a view to promoting safety and discovering innovations which may help others.

Injuries sustained by caregivers of disabled elderly people

OBJECTIVE

to investigate the occurrence of physical injury experienced by informal caregivers whilst moving and lifting their disabled elderly dependents at home.

DESIGN

a descriptive study using in-depth interviews.

SETTING

departments of elderly medicine at two teaching hospitals and one district general hospital.

SUBJECTS

46 informal caregivers of elderly patients admitted under a regular hospital respite care scheme, 41 of whom were interviewed.

RESULTS

most caregivers were elderly (median age 70 years), 21 having a medical condition which restricted their physical activity. Thirty one caregivers had injured themselves whilst lifting and handling their dependents. Most sustained back injuries. Eight caregivers were temporarily unable to continue caring as a result of the injuries they sustained. Sixteen patients had been injured whilst being moved by their caregivers. Only 19 caregivers had received instruction in manual handling.

CONCLUSION

informal caregivers are often poorly trained and equipped and at risk of injury. To enable them to continue providing optimal care at home, their physical health should be assessed and they should be trained in safe lifting and handling techniques.

Congestive cardiac failure following laxative withdrawal

We report the case of a 60-year-old woman who presented with weakness and hypokalaemia due to excessive use of laxatives. When the laxatives were withdrawn, she developed severe congestive cardiac failure requiring treatment with a diuretic and angiotensin-converting enzyme inhibitor. There was no underlying cardiac abnormality, and these drugs were eventually stopped with no recurrence of the cardiac failure. The possible mechanisms of heart failure following laxative withdrawal is discussed.

Cellulitis and the occult diabetic

BACKGROUND

Occult diabetes may be an important factor in the development of cellulitis and cellulitis may act as a precipitant to the diagnosis of diabetes mellitus. The present study defines the prevalence of diabetes and glucose tolerance impairment in a group presenting with cellulitis to a teaching hospital. A description of the demographic and pathological presentation of the group is undertaken.

METHODS

Five hundred consecutive admissions for cellulitis to a Sydney teaching hospital were analysed. The cases presented between 1985 and 1994. Precipitating factors, length of stay, site of infection, white cell count, degree of fever, blood sugar estimation, history of diabetes mellitus and microbiological diagnosis were recorded.

RESULTS

Forty-nine patients had a prior diagnosis of diabetes mellitus. Twenty-one percent of patients (56/265) were noted to have abnormal glucose tolerance on routine testing. Thirty-seven per cent of the 1994 cohort (14/38) demonstrated abnormal glucose tolerance. The most common precipitant was trauma (137/500). Mean length of stay was 8.7 days. Microbiological diagnosis was made in 32% of cases.

CONCLUSIONS

Cellulitis requiring admission to hospital is a significant problem in terms of cost and bed occupation. A presentation with cellulitis may be a clinical indicator of impaired glucose tolerance. All patients presenting with cellulitis should have a fasting blood sugar level determined as part of routine workup.

Radiological evaluation of the interfaces after cemented total hip replacement. Interobserver and intraobserver agreement

Three radiological methods are commonly used to assess the outcome of total hip replacement (THR). They aim to record the appearance of lucent areas and migration of the prosthesis in a reproducible manner. Two of them were designed to monitor the implant through time and one to grade the quality of cementing. We have measured the level of inter- and intraobserver agreement in all three systems. We randomised 30 patients to receive either finger packing or retrograde gun cementing during Charnley hip replacements. The postoperative departmental radiographs were evaluated in a blinded study by two orthopaedic trainees, two consultants and two experts in THR. The trainees and consultants repeated the exercise at least two weeks later. We used the unweighted kappa statistic to establish the levels of agreement. In general, intraobserver agreement was moderate but interobserver agreement was poor, with levels similar to or less than those expected by chance. Our results indicate that such systems cannot provide reliable data from centres in different parts of the world, with various levels of surgeon evaluating radiographs at differing time intervals. We discuss the problem and suggest some methods of improvement.

Effectiveness of a prescale gel on subgingival calculus

A prescale gel product, designed to facilitate the removal of calculus, has recently been introduced and marketed to the dental profession. The purpose of this study was to evaluate the effectiveness of this gel on the removal of subgingival calculus. 10 patients, each with 5 periodontally diseased teeth scheduled for extraction, participated in this in vivo/in vitro study. 4 teeth per patient were randomly assigned using a 2-by-2 block design and treated in vivo with either active or placebo gel, with or without scaling, prior to extraction. To assess possible overexposure to the product, 10 selected teeth from the sample were treated with active gel for an extended exposure time. Standardized scaling was performed on a 4x4 mm treated root area in vitro on groups as assigned. Quantification of residual calculus was determined by one examiner blind to treatment group assignment using SEM photomicrograph montages and the Java image analysis computer system. Repeated measures ANOVA showed no statistically significant treatment effect for gel (p > 0.05) in the scaled and no-scaled groups. The 5th group exposed to the prescale gel for an extended time was evaluated descriptively for root surface morphological changes with no noticeable effect. Based on the results of this investigation, treatment of subgingival calculus with prescale gel offers no advantage for calculus removal over scaling alone. The findings suggest no significant clinical impact of product use.

Propellant-driven aerosols for delivery of proteins in the respiratory tract

Metered-dose propellant-driven aerosols of an antigenically reactive protein were produced by combining bovine gammaglobulin (BGG) with one of several surfactants soluble in Freon or dimethylether propellants. Small-particle protein aerosols were most effectively produced by lyophilizing surfactants and proteins prior to the addition of propellants. Up to 26% of the total aerosolized protein was of respirable size. Aerosol metering valves delivering small volumes were most effective in producing respirable-sized (< or = 4 micron median mass aerodynamic diameter) protein aerosols. Proteins were suspended in liquified propellants as both propellant-soluble molecules and visible sedimenting clusters which both contributed to making respirable-sized protein aerosol particles. Electron microscopy showed that respirable-sized protein particles were composed of variable-sized chain aggregates of spherical subunits. Proteins were antigenic after suspension in liquified propellant and release as aerosols, but antigenicity diminished with extended propellant exposure. Local immunity in the respiratory tract is a key factor in resistance to respiratory infections. Metered-dose propellant-driven aerosols offer a potentially attractive method for delivering small-particle aerosols of immunizing antigens or other therapeutic proteins to the respiratory tract.