Development of a next generation SNP genotyping array for wheat

High-throughput genotyping arrays have provided a cost-effective, reliable and interoperable system for genotyping hexaploid wheat and its relatives. Existing, highly cited arrays including our 35K Wheat Breeder's array and the Illumina 90K array were designed based on a limited amount of varietal sequence diversity and with imperfect knowledge of SNP positions. Recent progress in wheat sequencing has given us access to a vast pool of SNP diversity, whilst technological improvements have allowed us to fit significantly more probes onto a 384-well format Axiom array than previously possible. Here we describe a novel Axiom genotyping array, the 'Triticum aestivum Next Generation' array (TaNG), largely derived from whole genome skim sequencing of 204 elite wheat lines and 111 wheat landraces taken from the Watkins 'Core Collection'. We used a novel haplotype optimization approach to select SNPs with the highest combined varietal discrimination and a design iteration step to test and replace SNPs which failed to convert to reliable markers. The final design with 43 372 SNPs contains a combination of haplotype-optimized novel SNPs and legacy cross-platform markers. We show that this design has an improved distribution of SNPs compared to previous arrays and can be used to generate genetic maps with a significantly higher number of distinct bins than our previous array. We also demonstrate the improved performance of TaNGv1.1 for Genome-wide association studies (GWAS) and its utility for Copy Number Variation (CNV) analysis. The array is commercially available with supporting marker annotations and initial genotyping results freely available.

116 Patient Long Stay in the Manchester Centre for Clinical Neurosciences Complex Spines Department: Numbers, Reasons, and Recommendations

Patient long-stay is one of the main causes of inefficient resource management in the National Health Service. Similarly, delays in treatment and access to social care contributes to the trust’s economic burden but also causes a significant delay in care for society's most vulnerable.

A single-centre evaluation of patient long stay was performed in a tertiary spinal unit in Greater Manchester. The top 50 patients who stayed the longest in an acute spinal bed between 2018 and 2019 were selected for analysis. Demographics, indication for transfer from another trust, overall length of stay, and the main reasons for such were evaluated.

Of the 50 assessed, there was an average length of stay of 46.9 days and the majority were comprised of patients with metastatic spinal cord compression. 74% had delays to surgery due to poor medical optimisation pre-transfer.

41% remained as an inpatient longer than necessary due to non-medical concerns. The main reasons included awaiting placement in a rehabilitation facility, social care issues and delays in repatriation back to their referring trust for ongoing care.

Delays in treatment and length of stay were found to be increased in patients who were poorly optimised pre-operatively and who required complex social and medical care post-operatively.

Phytochemical management of root knot nematode (Meloidogyne incognita) kofoid and white chitwood by Artemisia spp. in tomato (Lycopersicon esculentum L.)

In vitro and screen house experiments were conducted to investigate the effectiveness of thirteen phytochemicals from Artemisia elegantissimia and A. incisa on root knot nematode, Meloidogyne incognita in tomato (Lycopersicon esculentum L.) cv. Rio Grande. A positive control (Carbofuran) and negative control (H2O) were also used for comparison. Effectiveness of phytochemicals against juveniles (J2s) mortality and egg hatch inhibition were evaluated after 24, 48 and 72 hours of incubation at three concentrations viz; 0.1, 0.2 and 0.3 mg/mL in vitro conditions. Amongst thirteen phytochemicals, Isoscopletin (Coumarin), Carbofuran and Apigenin (Flavonoid) showed the highest mortality and egg hatch inhibition of M. incognita at all intervals. Inhibition of eggs and J2s mortality were the greatest (90.0%) and (96.0%) at 0.3 mg/mL concentration. Application of phytochemicals caused reduction in number of galls, galling index, and egg masses on tomato plant and enhanced plant growth parameters under screen house conditions. Gall numbers (1.50), galling index (1.00), number of juveniles (4.83) and egg masses (4.00) were greatly reduced and plant growth parameters such as; plant height (28.48 cm), fresh (72.13 g) and dry shoot weights (35.99 g), and root fresh (6.58 g) and dry weights (1.43 g) were increased significantly by using Isoscopletin. In structure activity relationship, juveniles of M. incognita, exhibited variations in their shape and postures upon death when exposed to different concentrations of phytochemicals of Artemisia spp. The present study suggests that Artemisia based phytochemicals possess strong nematicidal effects and can be used effectively in an integrated disease management program against root knot nematodes.

Abstract 1344: Simultaneous mRNA, protein, and immune repertoire profiling of antigen-specific T cells by single cell sequencing

High-throughput single cell RNA-seq (scRNA-seq) has transformed our understanding of complex and heterogenous immune populations. New advances in scRNA-seq are expanding the molecules that can be profiled at the single cell level, such as oligo-conjugated antibody technologies that enable protein expression profiling alongside mRNA. Although the ability to sequence the immune repertoire can provide crucial insights into understanding the complexities of the adaptive immune system and advancing discoveries in immuno-oncology, the ability to extract this information from single cells requires new technology to profile regions of the mRNA that are missed by conventional 3' scRNA-seq. In this study we utilized an ex vivo antigen stimulation system to measure antigen-specific T-cell activation and clonal amplification. Stimulated T cells from two donors were loaded onto the BD Rhapsody™ Single-Cell Analysis System to extract immune repertoire information in addition to gene and protein expression information from the same cells. In a single workflow, we profiled a panel of 400 mRNA targets, 20 BD® AbSeq protein markers associated with different status of T-cell activation, and the hypervariable region of T-cell receptors at the single cell resolution. The study is a proof of concept of combining mRNA, protein and immune repertoire analysis at the single cell level to deconvolute the heterogeneity and different activation of stimulated T cells.

For Research Use Only. Not for use in diagnostic or therapeutic procedures.

BD, the BD Logo, and Rhapsody are trademarks of Becton, Dickinson and Company or its affiliates. © 2019 BD. All rights reserved.

Citation Format: Imteaz Siddique, Xiaoshan Shi, Margaret Nakamoto, Stefanie Mortimer. Simultaneous mRNA, protein, and immune repertoire profiling of antigen-specific T cells by single cell sequencing [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1344.

Simultaneous mRNA, protein, and immune repertoire profiling of antigen-specific T cells by single cell sequencing

High-throughput single cell RNA-seq (scRNA-seq) has transformed our understanding of complex and heterogenous immune populations. New advances in scRNA-seq are expanding the molecules that can be profiled at the single cell level, such as oligo-conjugated antibody technologies that enable protein expression profiling alongside mRNA. Although the ability to sequence the immune repertoire can provide crucial insights into understanding the complexities of the adaptive immune system and advancing discoveries in immuno-oncology, the ability to extract this information from single cells requires new technology to profile regions of the mRNA that are missed by conventional 3′ scRNA-seq. In this study we utilized an ex vivo antigen stimulation system to measure antigen-specific T-cell activation and clonal amplification. Stimulated T cells from two donors were loaded onto the BD Rhapsody™ Single-Cell Analysis System to extract immune repertoire information in addition to gene and protein expression information from the same cells. In a single workflow, we profiled a panel of 400 mRNA targets, 20 BD® AbSeq protein markers associated with different status of T-cell activation, and the hypervariable region of T-cell receptors at the single cell resolution. The study is a proof of concept of combining mRNA, protein and immune repertoire analysis at the single cell level to deconvolute the heterogeneity and different activation of stimulated T cells.

For Research Use Only. Not for use in diagnostic or therapeutic procedures.

BD, the BD Logo, and Rhapsody are trademarks of Becton, Dickinson and Company or its affiliates. © 2019 BD. All rights reserved.

Antiplatelet drugs: a review of pharmacology and the perioperative management of patients in oral and maxillofacial surgery

INTRODUCTION

An increasing number of patients are taking oral antiplatelet agents. As a result, there is an important patient safety concern in relation to the potential risk of bleeding complications following major oral and maxillofacial surgery. Surgeons are increasingly likely to be faced with a dilemma of either continuing antiplatelet therapy and risking serious haemorrhage or withholding therapy and risking fatal thromboembolic complications. While there are national recommendations for patients taking oral antiplatelet drugs undergoing invasive minor oral surgery, there are still no evidence-based guidelines for the management of these patients undergoing major oral and maxillofacial surgery.

METHODS

MEDLINE and EMBASE databases were searched to retrieve all relevant articles published to 31 December 2017.

FINDINGS

A brief outline of the commonly used antiplatelet agents including their pharmacology and therapeutic indications is discussed, together with the haemorrhagic and thromboembolic risks of continuing or altering the antiplatelet regimen in the perioperative period. Finally, a protocol for the management of oral and maxillofacial patients on antiplatelet agents is presented.

CONCLUSIONS

Most current evidence to guide decision making is based upon non-randomised observational studies, which attempts to provide the safest possible management of patients on antiplatelet therapy. Large randomised clinical trials are lacking.

Concomitant back pain as a predictor of outcome after single level lumbar micro-decompressive surgery - A study of 995 patients

Objective

To determine if preoperative leg pain and low back pain severity affected postoperative outcome.

Method

Prospectively collected Spine-Tango data was analysed for 995 consecutive patients who underwent a primary, single level, lumbar micro-decompression/microdiscectomy at a single tertiary spinal centre.

Result

At 3 months, 72% of patients were satisfied with the outcome of surgery. Pre-operative low back pain was a significant predictor of poor outcome (P < 0.01).

Conclusion

Our study has shown that patients with a low back pain VAS of 6 or more have a significantly greater chance of a poor outcome following primary lumbar microdecompressive/microdiscectomy surgery.

Simultaneous mRNA, protein, and immune-repertoire profiling of thousands of single cells

High-throughput single cell RNA-seq (scRNA-seq) has transformed our understanding of heterogenous immune populations. Advances in scRNA-seq, such as oligo-conjugated antibody technologies that enable protein expression profiling alongside mRNA, are expanding the range of molecules that can be profiled at the single cell level. Although sequencing the T-cell and B-cell immune repertoire can provide crucial insights into the complexities of the adaptive immune system, thus advancing discoveries in immunology and immune-oncology, the ability to extract this information from single cells requires new technology to profile regions of the mRNA missed by conventional 3′ scRNA-seq. Here we demonstrate a novel approach using the BD Rhapsody™ system to extract immune-repertoire information in addition to gene-expression information from the same cells. In a single workflow, we profiled a panel of 400 mRNA targets and 40 protein markers as well as the CDR3 region of T- and B-cell receptors in thousands of human PBMCs. After using the mRNA and protein information to robustly annotate different lymphocyte populations, we examined the T- and B-cell repertoires for differences in their clonal diversity. We were able to identify clonally expanded T cells and B cells and examine how their gene-expression profiles differ from that of non-expanded cells. This study demonstrates the power of combining mRNA, protein, and immune repertoire analysis at the single cell level to answer complex and important biological and clinical questions.

For Research Use Only. Not for use in diagnostic or therapeutic procedures.

BD, the BD Logo, and Rhapsody are trademarks of Becton, Dickinson and Company. © 2019 BD and its subsidiaries. All rights reserved.

Magnetically controlled growing rods in the treatment of early-onset scoliosis

The MAGnetic Expansion Control (MAGEC) system is used increasingly in the management of early-onset scoliosis. Good results have been published, but there have been recent reports identifying implant failures that may be associated with significant metallosis surrounding the implants. This article aims to present the current knowledge regarding the performance of this implant, and the potential implications and strategies that may be employed to identify and limit any problems.

We urge surgeons to apply caution to patient and construct selection; engage in prospective patient registration using a spine registry; ensure close clinical monitoring until growth has ceased; and send all explanted MAGEC rods for independent analysis.

The MAGEC system may be a good instrumentation system for the treatment of early-onset scoliosis. However, it is innovative and like all new technology, especially when deployed in a paediatric population, robust systems to assess long-term outcome are required to ensure that patient safety is maintained.

Cite this article: Bone Joint J 2017;99-B:708–13.

Occupational exposure to bodily fluids in oral and maxillofacial surgery: an evaluation of reporting practices and attitudes among staff at a major teaching hospital in the UK

Our aim was to evaluate experience, practice, and beliefs about reporting of occupational exposures to blood and other body fluids among a sample of 88 healthcare providers working in oral and maxillofacial surgery at Sheffield Teaching Hospitals. We used a cross-sectional survey to evaluate awareness of the Trust's policy for reporting occupational exposure, recent incidence of exposure, and current reporting practices. Beliefs were measured using questions derived from the theory of planned behaviour. Fifty-five people responded, 14 of whom had been exposed to bodily fluids in the previous 12 months. Of those, 10 did not report it. Fifty-three respondents were certain that the Trust had a protocol in place for reporting sharps injuries to staff. Most (n=51) said the Trust had a protocol for reporting mucocutaneous exposure to blood. Respondents placed equal importance on reporting exposures that affected both themselves and patients, but intention to report exposure of patients was significantly higher than for themselves (z score -3.18, p<0.0001). We conclude that OMFS healthcare workers generally think that occupational exposures should be reported, but there are shortcomings in practice.

Pre-culturing of nodal explants in thidiazuron supplemented liquid medium improves in vitro shoot multiplication of Cassia angustifolia

An in vitro propagation system for Cassia angustifolia Vahl. has been developed. Due to the presence of sennosides, the demand of this plant has increased manyfold in global market. Multiple shoots were induced by culturing nodal explants excised from mature plants on a liquid Murashige and Skoog [8] medium supplemented with 5-100 μM of thidiazuron (TDZ) for different treatment duration (4, 8, 12 and 16 d). The optimal level of TDZ supplemented to the culture medium was 75 μM for 12 d induction period followed by subculturing in MS medium devoid of TDZ as it produced maximum regeneration frequency (87%), mean number of shoots (9.6 ± 0.33) and shoot length (4.4 ± 0.46 cm) per explant. A culture period longer than 12 d with TDZ resulted in the formation of fasciated or distorted shoots. Ex vitro rooting was achieved when the basal cut end of regenerated shoots was dipped in 200 μM indole-3-butyric acid (IBA) for half an hour followed by their transplantation in plastic pots filled with sterile soilrite where 85% plantlets grew well and all exhibited normal development. The present findings describe an efficient and rapid plant regeneration protocol that can further be used for genetic transformation studies.

Improving osteoporosis assessment in the fracture clinic

INTRODUCTION

The aim of this study was to compare the effectiveness of different ways of referring patients to an osteoporosis assessment service at an orthopaedic fracture clinic of a hospital in the UK.

PATIENTS AND METHODS

Three methods of identifying and referring to an osteoporosis assessment service were evaluated.

RESULTS

Relying on doctors for such a referral gave a catchment rate of only 1.6%. Involving patients themselves, asking them to self-refer, increased the catchment rate to 63% (P < 0.0001). Having a specialist osteoporosis and fracture liaison nurse present in clinic and reviewing the notes of patients checking in, to see if they match criteria for osteoporosis assessment, further increased catchment to 77% (P = 0.036).

CONCLUSIONS

Simply having an osteoporosis assessment service and strict criteria to identify which patients should be referred to such a service will not necessarily increase catchment rate for osteoporosis patients. A nurse physically present in the clinic provided the best result, and supports the need of investing in an osteoporosis and fracture liaison nurse.

Posterolateral rotatory laxity following surgery to the head of the radius: biomechanical comparison of two surgical approaches

The lateral ligament complex is the primary constraint to posterolateral rotatory laxity of the elbow, and if it is disrupted during surgery, posterolateral instability may ensue. The Wrightington approach to the head of the radius involves osteotomising the ulnar insertion of this ligament, rather than incising through it as in the classic posterolateral (Kocher) approach. In this biomechanical study of 17 human cadaver elbows, we demonstrate that the surgical approach to the head can influence posterolateral laxity, with the Wrightington approach producing less posterolateral rotatory laxity than the posterolateral approach.

Proximal humeral internal locking system (PHILOS) for the treatment of proximal humeral fractures

INTRODUCTION

The aim of this study was to describe early results of a new internal locking system, PHILOS, used for the treatment of proximal humeral fractures.

MATERIALS AND METHODS

A chart and radiographic review of 25 cases that had proximal humeral internal locking system (PHILOS) plate for the treatment of proximal humeral fractures was performed.

RESULTS

Of the 25 cases, 20 went to union with a mean neck/shaft angle of 127.2 degrees . Five cases required or were considered for revision surgery for non-union or implant failure. Of the 25 implants, 4 had screw protrusion into the gleno-humeral joint, 4 had screw loosening and backing out, and 1 plate broke without further trauma.

CONCLUSIONS

Our results suggest that PHILOS is an effective system for providing fracture stabilisation to bony union but awareness of potential hardware complications is essential.

Casting versus surgical fixation for grade IIIA open tibial diaphysial fractures in children: effect on the rate of infection and the need for secondary surgical procedures to promote bone union

We evaluated 39 grade IIIA open tibial fractures presenting in children younger than 13 years of age, to determine if the mode of fracture stabilization (casting vs. surgical fixation) was related to the rate of infection or the need for secondary surgical procedures to promote bone union. All fractures had wound debridement in the operating room. Thirty patients had manipulation and casting, and nine surgical internal or external fixation. There were two cases of infection in the cast-treated group and two in the surgical fixation group (P=0.17). None of the fractures required a secondary surgical procedure to promote bone union. Three of the fractures treated by manipulation and casting displaced; two required re-manipulation and casting and one was converted to external fixation. In two cases the applied external fixator had to be re-aligned. Our results suggest that manipulation and casting is a reliable treatment for open tibial fractures in children.

Early versus delayed surgical treatment of open tibial fractures: effect on the rates of infection and need of secondary surgical procedures to promote bone union

The purpose of this study was to evaluate whether there was any significant difference in the rates of infection and of secondary surgical procedures to promote bone union, between early(6 h or less after arrival to hospital) and delayed(more than 6 h) surgical treatment of open tibial fractures. Three hundred and eighty-three open tibial fractures were evaluated. 184 fractures had early and 199 had delayed surgical treatment. The rates of infection and secondary surgical procedures to promote bone union of the two groups were compared with univariate and multivariate statistical methods. There was no statistically significant difference between early and delayed treatment groups with respect to overall infection (53/184 versus 51/199 infection rates, P = 0.96), deep infection (8/184 versus 8/199 infection rates, P = 1.0), and rates of secondary surgical procedures to promote bone union (24/184 versus 20/198, P = 0.77). We were unable to demonstrate any significant difference in infection rates or need of secondary procedures to promote bone union, between early and delayed surgical treatment of open tibial fractures.

Sural nerve pathology in diabetic patients with minimal but progressive neuropathy

AIMS/HYPOTHESIS

The early pathological features of human diabetic neuropathy are not clearly defined. Therefore we quantified nerve fibre and microvascular pathology in sural nerve biopsies from diabetic patients with minimal neuropathy.

METHODS

Twelve diabetic patients underwent detailed assessment of neuropathy and fascicular sural nerve biopsy at baseline, with repeat assessment of neuropathy 8.7+/-0.6 years later.

RESULTS

At baseline, neuropathic symptoms, neurological deficits, quantitative sensory testing, cardiac autonomic function and peripheral nerve electrophysiology showed minimal abnormality, which deteriorated at follow-up. Myelinated fibre density, fibre and axonal area, and g-ratio were normal but teased fibre studies showed paranodal abnormalities (p<0.001), segmental demyelination (p<0.01) and remyelination (p<0.01) without axonal degeneration. Unassociated Schwann cell profile density (p<0.04) and unmyelinated axon density (p<0.001) were increased and axon diameter was decreased (p<0.007). Endoneurial capillaries demonstrated basement membrane thickening (p<0.006), endothelial cell hyperplasia (p<0.004) and a reduction in luminal area (p<0.007).

CONCLUSIONS/INTERPRETATION

The early pathological features of human diabetic neuropathy include an abnormality of the myelinated fibre Schwann cell and unmyelinated fibre degeneration with regeneration. These changes are accompanied by a significant endoneurial microangiopathy.

Distribution of vacA and cagA genotypes of Helicobacter pylori in Kuwait

There is considerable geographical variation in the distribution of allelic types of Helicobacter pylori. This first study from Kuwait determined the prevalence of cagA and vacA genotypes among 117 unselected patients attending a gastroenterology center. We found that whereas vacA s1 and s2 types were equally likely to be present in biopsies obtained from patients of Middle-Eastern origin, African Arabs were predominantly infected with s2 type and South-Asians the s1 type. South Asians most frequently carried the cagA positive genotype with Bangladeshis showing the highest prevalence rate of 87%.

Does the orientation of the distal radioulnar joint influence the force in the joint and the tension in the interosseous membrane?

OBJECTIVE

To investigate the effect of change in the orientation of the distal radioulnar joint on the force in the joint and the strain in the interosseous membrane.

DESIGN

Biomechanical study in fresh frozen cadavers.

BACKGROUND

The articular surfaces of the distal radioulnar joint may be orientated in parallel with the long axis of the forearm (a Type I joint) or at an oblique angle opening distally to the ulnar side (a Type II joint).

METHODS

Three cadaveric upper limbs were held on a custom built frame allowing measured rotation and axial loading across the wrist. Measurements of force in the distal radioulnar joint and strain in the interosseous membrane were taken and repeated after replacement of the distal radioulnar joint with prosthetic Type I and Type II joints.

FINDINGS

The force in the joint and the strain in the interosseous membrane increased with increasing load across the wrist (P < 0.0001). The force in the Type I joint was reduced compared to the normal or Type II joint. This difference was greater with increasing load and was significant at 8 kg (P < 0.001). The strain in the interosseous membrane was maximal at neutral forearm rotation and decreased with increasing pronation and supination.

INTERPRETATION

The force in the joint is greater with the Type II distal radioulnar joint. We believe this compressive force increases joint stability and this orientation of the articular surfaces should be considered in the design of a total distal radioulnar joint arthroplasty.

Regulation of Na/H exchanger-1 in gastroesophageal reflux disease: possible interaction of histamine receptor

Na/H exchanger-1 (NHE-1) isoform regulates intracellular pH and protects the esophageal mucosa. These functions are compromised in gastroesophageal reflux disease (GERD); however, the role and the underlying mechanism of NHE-1 regulation are obscure. To address this issue, NHE-1 protein and mRNA levels were measured by ECL western blot analysis and a semiquantitative RT-PCR using alpha-actin as an internal control. Ouabain-sensitive and K-stimulated p-nitrophenylphosphatase activity was measured as a marker of the sodium pump. The level of NHE-1 protein and mRNA and sodium pump activity was increased in GERD patients with or without esophagitis. Interestingly, myeloperoxidase (MPO) activity and infiltration of inflammatory cells were significantly increased in the GERD patients with esophagitis as compared to the GERD without esophagitis and the normal controls. This induction of NHE-1 and sodium pump was reversed in the GERD patients taking an H2 blocker, but not in those taking antacids. The internal control alpha-actin did not change under these conditions. Yield of total RNA and crude microsomal proteins was also statistically similar in all the test groups. These findings demonstrate that induction of NHE-1 is regulated posttranscriptionally through a possible interaction of histamine receptor. Induction of NHE-1 and sodium pump activity together might be a mechanism underlying the GERD pathogenesis and suggests a significance of NHE-1 inhibition in the treatment of GERD.

Reduced delays in A&E for elderly patients with hip fractures

Published guidelines recommend early transfer of patients with hip fractures to hospital wards and avoidance of unnecessary delays in A&E. We describe a protocol whereby the liaison of an orthopaedic trauma co-ordinator with A&E reduced A&E-to-ward transfer times by 43%. Following introduction of the new protocol, 39% of hip fracture patients were in a ward bed within 3 h of admission to A&E compared to 4% previously. The new protocol also reduces administrative workload for the on-call orthopaedic SHOs.

Sampling variability on percutaneous liver biopsy in patients with chronic hepatitis C virus infection

BACKGROUND

Sampling variability on liver biopsy has been demonstrated in a variety of liver diseases. The objective of this study was to determine whether sampling variability exists on percutaneous liver biopsy in patients with chronic HCV infection.

METHODS

Two separate tissue samples were obtained from the right lobe of the liver, through a single skin puncture, in 29 patients (22 M, mean age 43.4 +/- 8.1 years) with chronic HCV infection. The biopsies were assessed using a descriptive histological reporting system and Knodell's Histological Activity Index (HAI) and compared for differences in necroinflammatory activity (grade) and fibrosis (stage).

RESULTS

Thirteen (44.8%) patients had a difference of > or = 1 grade between the 2 biopsies on the descriptive system and 13 differed by > or = 1 stage. On the HAI, 20 (69.0%) patients had a difference of > or = 2 in the necroinflammatory activity score and 10 (34.5%) had a difference of > or = 4; whereas, 11 (38.0%) patients had a difference of > or = 1 in the fibrosis score and 6 (20.7%) had a difference of > or = 2. The mean difference between the two sets of biopsies was 2.4 +/- 2.1 (range 0-7) for the necroinflammatory activity and 0.6 +/- 0.9 (range 0-3) for fibrosis. Spearman's correlation coefficient (r) was moderate for both necroinflammatory activity (r = 0.53, P < 0.01) and fibrosis (r = 0.62, P < 0.0001).

CONCLUSIONS

Sampling variability exists on percutaneous liver biopsy in patients with chronic HCV infection and should be taken into consideration when decisions regarding prognosis and therapy are made based on biopsy, and when defining histological response to antiviral regimens.

Factors delaying surgical treatment of hip fractures in elderly patients

BACKGROUND

Published guidelines recommend early surgical treatment of hip fractures in elderly patients. Understanding the factors that delay surgical intervention is essential in order to introduce changes that will facilitate early treatment.

AIM

To determine the factors delaying surgical treatment of hip fractures in elderly patients for more than 24 h.

PATIENTS AND METHODS

Assessment of 163 consecutive patients undergoing surgery for hip fractures at the trauma unit of Manchester Royal Infirmary.

RESULTS

Only 72/163 (44.2%) patients had their operation within 24 h of presenting to hospital. The remaining 91 patients had a total of 239 days delay (in excess of the initial 24 h) for surgical treatment. Active medical problems (56.5%) and a wait for medical investigations (19.7%) caused most delays. Lack of operating theatre time and Sunday trauma lists caused 23.8% of delays.

CONCLUSIONS

Medical problems account for most delays of surgical treatment of hip fractures. A multidisciplinary approach, with early input by medical and anaesthetic teams, is essential in managing such patients. Established protocols may reduce waiting times for essential investigations.

Comparison of peripheral and central venous pressures in critically Ill patients

We conducted a prospective study to determine the relationship between central (CVP) and peripheral (PVP) venous pressures in critically ill patients. CVP and PVP were measured on five different occasions in 20 critically ill patients in the intensive care unit. Results showed that the mean difference between PVP and CVP was 4.4 mmHg (95% CI = 3.7 to 5.0). However, PVP might be 1.9 mmHg below (95% CI = 0.7 to 3.1) or 10.6 mmHg above (95% CI = 9.4 to 11.8) the CVP. The mean difference between changes in PVP and corresponding changes in CVP was 0.3 mmHg (95% CI = -0.1 to 0.7). The actual change in PVP could be 3.0 mmHg below (95% CI = 2.3 to 3.7) or 3.6 mmHg above (95% CI = 2.9 to 4.3) the change in CVP. Overall, the direction of change in PVP (rise or drop) predicted a same direction of change in CVP with an accuracy of 78%. Changes in PVP > or = 2 mmHg predicted a change in same direction of CVP with an accuracy of 90%. The direction of changes in CVP > or = 2 mmHg were predicted by the direction of change in PVP with an accuracy of 91%. We conclude that PVP measurement does not give an accurate estimate of the absolute value of CVP in individual patients. However, as changes in PVP parallel, in direction, changes in CVP, serial measurements of PVP may have a value in determining volume status and guiding fluid therapy in critically ill patients.

Nerve pathology in the type 1 diabetic dog: effects of treatment with sulindac

The purpose of this study was to define pathological abnormalities in the peripheral nerve of a large animal model of long-duration type 1 diabetes and also to determine the effects of treatment with sulindac. Detailed morphometric studies were performed to define nerve fiber and endoneurial capillary pathology in 6 control dogs, 6 type 1 diabetic dogs treated with insulin, and 6 type 1 diabetic dogs treated with insulin and sulindac for 4 years. Myelinated fiber and regenerative cluster density showed a non-significant trend toward a reduction in diabetic compared to control animals, which was prevented by treatment with sulindac. Unmyelinated fiber density did not differ among groups. However, diabetic animals showed a non-significant trend toward an increase in axon diameter (p < 0.07), with a shift of the size frequency distribution towards larger axons, which was not prevented by treatment with sulindac. Endoneurial capillary density and luminal area showed a non-significant trend toward an increase in diabetic animals, which was prevented with sulindac treatment. Endoneurial capillary basement membrane area was significantly increased (p < 0.05) in diabetic animals, but was not prevented with sulindac treatment. We conclude that the type 1 diabetic dog demonstrates minor structural abnormalities in the nerve fibers and endoneurial capillaries of the sciatic nerve, and treatment with sulindac ameliorates some but not all of these abnormalities.

Sural nerve fibre pathology in diabetic patients with mild neuropathy: relationship to pain, quantitative sensory testing and peripheral nerve electrophysiology

Nerve fibre pathology is poorly described in diabetic patients with mild neuropathy and has not been adequately related to clinical evaluation, quantitative sensory examination and neurophysiology. Sural nerve myelinated and unmyelinated fibre pathology was morphometrically quantified and related to the presence of pain and conventional measures of neuropathic severity in 15 diabetic patients with mild neuropathy and 14 control subjects. Diabetic patients demonstrated a significant (P < 0.01) reduction in myelinated fibre density, but no change in fibre/axonal area, or g-ratio, compared to control subjects. Unmyelinated fibre degeneration was evidenced by an increase in the percentage of unassociated Schwann cell profiles (P < 0.0001) and a reduction in axon density (P < 0.0008) in diabetic patients. This was associated with a significant reduction in unmyelinated axon diameter (P < 0.001) with a shift of the size frequency distribution to the left (P < 0.02). Neurophysiology, quantitative sensory testing and nerve fibre pathology failed to differentiate diabetic patients with painful and painless neuropathy and failed to correlate with any measure of unmyelinated fibre pathology.

Fecal shedding of Campylobacter and Arcobacter spp. in dairy cattle

Campylobacter jejuni, Campylobacter coli, and Arcobacter spp. were detected in feces of healthy dairy cows by highly specific multiplex-PCR assays. For C. jejuni, at this one-time sampling, cows from 80.6% of farm operations (n = 31) and 37.7% of individual dairy cattle fecal samples (n = 2,085) were positive. Farm management factors were correlated with prevalence in herds in which >25% of cows were positive for C. jejuni. Statistical significance was set at a P of 0.20. Using these criteria, application of manure with broadcast spreaders (P = 0.17), feeding of whole cottonseed or hulls (P = 0.17) or alfalfa (P = 0.15), and accessibility of feed to birds (P = 0.17) were identified as possible risk factors for C. jejuni infection. C. coli was detected in at least one animal in 19.4% of operations and 1.8% of individual cows (n = 2,085). At the herd level, use of broadcaster spreaders was not a risk factor for C. coli infection. For Arcobacter, cows from 71% of dairy operations (n = 31) and 14.3% of individual dairy cattle fecal samples (n = 1,682) were positive. At the herd level, for Arcobacter spp., feeding of alfalfa (P = 0.11) and use of individual waterers (P = 0.19) were protective. This is the first description of Arcobacter spp. in clinically healthy dairy cattle and the first attempt to correlate their presence with C. jejuni.

The role of choledochoscopy in the diagnosis and management of biliary tract diseases

BACKGROUND

The diagnosis and management of biliary tract disorders in certain cases may be incomplete without direct visualization of the bile ducts.

METHODS

We report our experience of 61 choledochoscopies (33 women, 27 men, mean age 44.6 years). Twenty patients had previously undergone orthotopic liver transplantation. All except two choledochoscopies were performed via the transpapillary route. Indications included suspected large bile duct stones in 18 patients, anastomotic strictures in 16, abnormal cholangiograms in 5, elevated liver function tests in 7, suspected cholangiocarcinoma in 4, occluded biliary metallic stent in 4, hemobilia in 4, primary sclerosing cholangitis in 2 and ischemic bile duct injury in 1 patient.

RESULTS

Choledochoscopy confirmed the anticipated diagnosis in 36 of 61 (59%) patients. Importantly, it provided additional unsuspected diagnostic information in 18 of the 61 (29.5%) patients. In addition, for patients in whom standard cholangiography was deemed abnormal, choledochoscopy demonstrated normal results in 7 (11.4%) patients. Fifty-two choledochoscopies were performed with therapeutic intentions, and the procedure was helpful in providing targeted treatment in 27 (44.2%) patients.

CONCLUSIONS

Choledochoscopy is a safe and useful endoscopic modality that can provide specific diagnoses and direct treatment in various biliary tract diseases. The additional information provided by choledochoscopy may change overall patient management and outcome.

Palliation of malignant dysphagia and fistulae with coated expandable metal stents: experience with 101 patients

BACKGROUND

Insertion of coated expandable esophageal stents is the preferred endoscopic palliative treatment for malignant dysphagia and digestive-respiratory fistulae.

METHODS

One hundred one patients with malignant dysphagia and digestive-respiratory fistulae, 83 due to esophageal cancer and 18 due to metastatic disease, underwent placement of a coated expandable metal stent. Thirteen patients had a digestive-respiratory fistula. The stricture location (99 patients) was proximal in 11, mid in 29, distal in 37, and at the gastroesophageal junction in 24. The endoscopic appearance was exophytic in 80, infiltrative in 19, single ulcer in 1, and normal in 1. The mean stricture length was 6.7 cm.

RESULTS

Initial stent placement was successful in 100 patients; a second stent was required in 1. The median dysphagia grade improved from 3.6 to 1.4 and sealing-off of the digestive-respiratory fistula was successful in all cases. The overall complication rate was 37.9%. Life-threatening complications occurred in 7.9%. There were no procedure-related deaths. During a mean follow-up of 201 days, 99 patients died-none from stent-related problems.

CONCLUSIONS

This large series confirms the efficacy of the coated metal expandable stent in the palliation of malignant dysphagia and digestive-respiratory fistula with an acceptable complication rate.

Does chemoradiation therapy increase the incidence of complications with self-expanding coated stents in the management of malignant esophageal strictures?

BACKGROUND

Expandable stents offer excellent palliation of malignant dysphagia and digestive-respiratory fistula. There are insufficient data regarding factors that may affect the complication rate of expandable stents, but an association between previous treatment with chemotherapy and/or radiation therapy and stent-related life-threatening complications has been suggested.

METHODS

We retrospectively analyzed our data on 60 patients; in all of them, a coated Wallstent had been successfully placed for malignant dysphagia and/or digestive-respiratory fistula. Our objective in this study was to determine the overall complication rate as well as whether previous or ongoing chemoradiation therapy increased the rate of life-threatening complications.

RESULTS

Among 21 patients with no previous chemotherapy or radiation therapy, two (9.5%) had life-threatening complications (both had bleeding tumors; blood transfusions were required in two and endoscopic hemostasis in one). Among 39 patients who had had either radiation therapy, chemotherapy, or both, life-threatening complications occurred in three (8%). Two of the three had gastrointestinal bleeding (two received blood transfusions, and one had external radiation therapy), and in the third, an esophageal tear was treated with the stent. There was no procedure- or stent-related mortality in either group.

CONCLUSIONS

Palliation of malignant dysphagia or digestive-respiratory fistulas with the coated Wallstent in patients with previous chemotherapy and/or radiation therapy is not associated with an increased risk of life-threatening complications.

Hepatotoxicity of sodium stibogluconate therapy for American cutaneous leishmaniasis

Sodium stibogluconate is the mainstay of treatment for all forms of leishmaniasis. Therapy is associated with an increase in serum aminotransferases. In this study liver damage was assessed during treatment of American cutaneous leishmaniasis with sodium stibogluconate and also in a control group given aminosidine. In addition to standard liver function tests, acute hepatocellular damage was assessed by measuring plasma glutathione S-transferase B1 (GST), and hepatic metabolic capacity was assessed by a caffeine clearance (CCL) test, before, during and after treatment. Thirteen patients were treated; 5 received sodium stibogluconate, 6 received aminosidine and a further 2 patients received aminosidine followed by sodium stibogluconate. Treatment with sodium stibogluconate was associated with an increase in both alanine aminotransferase (ALT) and GST and a fall in the CCL, indicating both hepatocellular damage and functional impairment. Six weeks after treatment had stopped ALT and GST had returned to pre-treatment levels and the CCL remained depressed in only one patient. Patients given aminosidine did not show any evidence of liver damage. Sodium stibogluconate is associated with significant hepatocellular damage and hepatic functional impairment. However, this is rapidly reversible on drug withdrawal. We suggest that liver function is monitored throughout treatment and that patients with pre-existing liver disease receive alternative treatment.

Respiratory symptoms due to Branhamella catarrhalis and other Neisseria species infections--response to erythromycin therapy

Neisseria microorganisms (Neisseria lactamica, Neisseria sicca, and Neisseria mucosa) are regarded as normal respiratory commensals. Branhamella catarrhalis (formerly Neisseria catarrhalis) has also been regarded as a normal respiratory commensal, but reports indicate that it can be pathogenic. The role of Neisseria spp was studied in 160 patients with chest infections and symptoms and signs of obstructive respiratory disease. Group I patients (n = 140) had a history of asthma, bronchitis, and emphysema. Group II patients (n = 20) had an initially responsive pulmonary tuberculosis but presented with fever and obstructive airway disease. Group I patients had disease that was difficult to control despite increased bronchodilator therapy, but they responded dramatically after two to three days of appropriate antibiotic therapy. Patients in group II showed a similar response to erythromycin. Neisseria infection was responsible for precipitating or exacerbating respiratory distress in both groups. Accordingly, it is concluded that Neisseria can be pathogenic and that patients with fever and obstructive respiratory symptoms require treatment.