241 IMPLEMENTATION OF AN INTRACEREBRAL CEREBRAL HAEMORRHAGE CARE BUNDLE

Background

Mortality for Intracerebral haemorrhage (ICH) is 31% (Irish National Audit Stroke, 2019). An ICH care bundle focusing on acute anticoagulation reversal, blood pressure lowering, and a neurosurgical care pathway was associated with improved survival. Translating evidence-based medicine into clinical practice is challenging. The aim of this study was to determine feasibility and outcomes of implementation of a care bundle.

Methods

An ICH care bundle was developed using an iterative process involving expert stakeholder review of the evidence-based literature. A pre-and-post quasi-experimental research design was employed to evaluate this intervention. Baseline data were collected before implementation (January 2016-June 2018). Implementation took place in a staged manner in a single university teaching hospital with multiple ‘Plan Do Study Act cycles’ (June 2018 to January 2021). Data on compliance, process measures and outcomes were collected.

Results

Systolic blood pressure (first 24-hours) and anticoagulant reversal were significantly better controlled post-implementation (χ2 (1, N = 91) = 5.34, P = 0.02), (χ2 (1, N = 25) = 5.85, P = 0.016), respectively. DNAR orders were significantly lower in the post-implementation group (χ2 (1, N = 25) = 5.85, P = 0.029). However, ‘Do Not Actively Resuscitate’ status did not significantly differ when accounting for low GCS as a surrogate measure for poor prognosis (χ2 (1, N = 34) = 0.00, P = 0.966). Modified Rankin Scale on discharge did not differ significantly pre-and-post-implementation (z = −0.075, P = 0.94). A greater proportion of patients survived in the post-implementation group; however, this was not statistically significant (χ2 (1, N = 133) = 0.77, P = 0.38). Length of stay significantly increased post implementation.

Conclusion

An ICH care bundle was developed based on expert stakeholder feedback. The feasibility of implementing this bundle of care was demonstrated in a real-world clinical practice setting. A cluster-randomized trial or a large registry study is the next step to evaluate the overall impact of this care bundle on patient outcomes.

Crude Fat, Diethyl Ether Extraction, in Feed, Cereal Grain, and Forage (Randall/Soxtec/Submersion Method): Collaborative Study

A method for determining crude fat in animal feed, cereal grain, and forage (plant tissue) was collaboratively studied. Crude fat was extracted from the animal feed, cereal grain, or forage material with diethyl ether by the Randall method, also called the Soxtec method or the submersion method. The proposed submersion method considerably decreases the extraction time required to complete a batch of samples. The increase in throughput is very desirable in the quest for faster turnaround times and the greater efficiency in the use of labor. In addition, this method provides for reclamation of the solvent as a step of the method. The submersion method for fat extraction was previously studied for meat and meat products and was accepted as AOAC Official Method 991.36. Fourteen blind samples were sent to 12 collaborators in the United States, Sweden, Canada, and Germany. The within-laboratory relative standard deviation (repeatability) ranged from 1.09 to 9.26% for crude fat. Among-laboratory (including within) relative standard deviation (reproducibility) ranged from 1.0 to 21.0%. The method is recommended for Official First Action.

Crude Fat, Hexanes Extraction, in Feed, Cereal Grain, and Forage (Randall/Soxtec/Submersion Method): Collaborative Study

A method for determining crude fat in animal feed, cereal grain, and forage (plant tissue) was collaboratively studied. Crude fat was extracted from the animal feed, cereal grain, or forage material with hexanes by the Randall method, also called the Soxtec method or the submersion method. The use of hexanes provides for an alternative to diethyl ether for fat extractions. The proposed submersion method considerably decreases the extraction time required to complete a batch of samples compared to Soxhlet. The increase in throughput is very desirable in the quest for faster turnaround times and the greater efficiency in the use of labor. In addition, this method provides for reclamation of the solvent as a step of the method. The submersion method for fat extraction was previously studied for meat and meat products and was accepted as AOAC Official Method 991.36. Fourteen blind samples were sent to 14 collaborators in the United States, Sweden, Canada, and Germany. The within-laboratory relative standard deviation (repeatability) ranged from 1.23 to 5.80% for crude fat. Among-laboratory (including within) relative standard deviation (reproducibility) ranged from 1.88 to 14.1%. The method is recommended for Official First Action.

Effect of Continuous Digital Hypothermia on Lamellar Inflammatory Signaling When Applied at a Clinically-Relevant Timepoint in the Oligofructose Laminitis Model

BACKGROUND

Although continuous digital hypothermia (CDH) protects lamellae from injury in the oligofructose (OF) model of sepsis-related laminitis (SRL), conflicting results exist from these studies regarding effects of CDH on lamellar inflammatory events.

HYPOTHESIS/OBJECTIVES

To determine the effect of CDH on lamellar inflammatory events in normal and OF-treated horses when instituted at a clinically relevant time point (onset of clinical signs of sepsis in this model).

ANIMALS

Standardbred geldings (n = 15) aged 3-11 years were used.

METHODS

In a randomized, controlled discovery study, animals were administered either OF (OF group, n = 8) or water (CON group, n = 8) by nasogastric tube and CDH was initiated in one forelimb (ICE) 12 hours later. Lamellar tissue samples were collected 24 hours after initiation of CDH (ICE and ambient [AMB] forelimbs). Lamellar mRNA concentrations of inflammatory mediators and lamellar leukocyte numbers were assessed using qPCR and immunohistochemistry, respectively; values from four sample groups (CON AMB, OF AMB, CON ICE, and OF ICE) were analyzed using mixed model linear regression.

RESULTS

Although lamellar mRNA concentrations of multiple inflammatory mediators (IL-1β, IL-6, CXCL1, MCP2, COX-2) were increased after OF administration (OF AMB group versus CON AMB; P < 0.05), only 2 inflammatory mediators (IL-6 and COX-2) and lamellar leukocyte numbers were decreased with CDH (OF ICE versus OF AMB; P < 0.05).

CONCLUSIONS AND CLINICAL IMPORTANCE

Continuous digital hypothermia initiated at a time point similar to that commonly used clinically (clinical onset of sepsis) resulted in a more focused inhibition of inflammatory signaling.

Not Another ACS Rule Out

CASE

A 50 year old African-American woman with diabetes, hypertension, and hyperlipidemia presented with progressively worsening retro-sternal chest pain, exacerbated by activity and relieved by rest. She also endorsed a thirty-pound unintentional weight loss, and dysphagia. She was dysarthric with left-sided Bell's Palsy and a palpable left axillary lymph node. She had been evaluated at several hospitals in the previous months for similar typical chest pain. Her troponin values were normal, and an EKG showed T-wave inversions in leads I and aVL. On echocardiography, her ejection fraction was 45 percent with anterolateral hypokinesis. She was treated for NSTEMI, and an angiogram showed 95 percent stenosis of the right coronary artery. A modified barium swallow study revealed weakened swallowing with aspiration of thin liquids. An MRI Brain demonstrated scattered T2/ FLAIR hyper-intense foci in the subcortical white matter and focal meningeal thickening. ANA, dsDNA, ANCA, and Lyme antibodies were all negative, and a chest CT showed hilar lymphadenopathy. Cardiac MRI demonstrated scattered foci of delayed enhancement in the mid-myocardium and sub-epicardium without infarction. An endobronchial biopsy of hilar lymph nodes showed two small epithelioid granulomas, consistent with Sarcoidosis. She was started on high-dose corticosteroids with rapid improvement. A repeat modified barium swallow study was normal and a repeat echocardiogram demonstrated recovered ejection fraction of 55 percent with improved wall motion in the septum and apex. Additionally, her left-sided Bell's Palsy and dysarthria improved after several days of therapy.

DISCUSSION

To our knowledge, this report is the third case of multi-organ Sarcoidosis presenting as ACS. This case depicts the simultaneous presentation of neurologic, pharyngeal, pulmonary, and cardiac Sarcoidosis. Myocardial involvement in Sarcoidosis is rare and usually presents as conduction abnormalities with arrhythmia rather than ACS. Though her symptoms were consistent with Sarcoidosis, she had multiple risk factors for coronary atherosclerosis including diabetes, hypertension, and hyperlipidemia. This case highlights the importance of including Sarcoidosis in the differential diagnosis for patients with recurrent typical chest pain of uncertain etiology.

Effect of Delayed Digital Hypothermia on Lamellar Inflammatory Signaling in the Oligofructose Laminitis Model

Background

In the oligofructose (OF) model of sepsis‐related laminitis (SRL), digital hypothermia (“cryotherapy”) initiated before the onset of clinical signs is reported not only to limit lamellar injury, but also to cause marked inhibition of lamellar inflammatory signaling.

Hypothesis/Objectives

Because hypothermia also has been reported to be protective when not initiated until the onset of lameness in the OF model of SRL, we hypothesized that the lamellar protection conferred by hypothermia is caused by local lamellar inhibition of inflammatory signaling as described when hypothermia was initiated earlier in the disease process.

Animals

Eight Standardbred geldings aged 3–11 years with no lameness and no abnormalities of the feet detectable by gross or radiographic examination.

Methods

Using the OF model of SRL, lamellar mRNA concentrations of proinflammatory cytokines, chemokines, and endothelial adhesion proteins were compared between samples from treated limbs (CRYO, submerged in ice water for 36 hour starting at the onset of lameness), untreated limbs (NON‐CRYO, opposite limb from CRYO limbs maintained at ambient temperature), and untreated limbs from normal horses in which laminitis was not induced (CON).

Results

Although OF administration resulted in increases in lamellar mRNA concentrations of several inflammatory mediators in NON‐CRYO limbs (vs CON), digital hypothermia had no significant effect on these increases.

Conclusions and Clinical Importance

The lack of inflammatory inhibition in lamellar tissue samples in our study indicates that the protective effects of digital hypothermia instituted at the onset of clinical signs of laminitis do not arise from inhibition of inflammatory pathways.

Informing etiologic research priorities for squamous cell esophageal cancer in Africa: A review of setting-specific exposures to known and putative risk factors

Esophageal squamous cell carcinoma (ESCC) is one of the most common cancers in most Eastern and Southern African countries, but its etiology has been understudied to date. To inform its research agenda, we undertook a review to identify, of the ESCC risk factors which have been established or strongly suggested worldwide, those with a high prevalence or high exposure levels in any ESCC-affected African setting and the sources thereof. We found that for almost all ESCC risk factors known to date, including tobacco, alcohol, hot beverage consumption, nitrosamines and both inhaled and ingested PAHs, there is evidence of population groups with raised exposures, the sources of which vary greatly between cultures across the ESCC corridor. Research encompassing these risk factors is warranted and is likely to identify primary prevention strategies.

A Direct Oral Anticoagulant as a Cost Effective Alternative to Warfarin for Treatment of Provoked Venous Thrombosis

In Ireland, Warfarin is the primary anticoagulant prescribed in the secondary prevention of provoked DVT. We completed a comprehensive cost analysis of a trial group of 24 patients treated with Rivaroxaban (between November 2013 and December 2014), versus a control group treated with Warfarin (between January 2008 and November 2013). The groups were matched for gender (3/7 M/F ratio), DVT type (5 proximal, 19 distal DVTs), provoking factor (20 traumatic, 4 atraumatc), and age. We calculated the cost for each group based on drug administration and clinic costs (labour, sample analysis, and additional costs). Warfarin patients attended clinic 14.58 times; Rivaroxaban patients attended 2.92 times. Overall, the cost per patient on Rivaroxaban is €273.30 versus €260.68 with warfarin. This excludes patient costs which would further increase cost of Warfarin therapy.

What are the risks and knowledge deficits for prescribing and administering opioids in the ward environment? A quality project on assessing and improving knowledge

Investigations into Medical Emergency Team (MET) calls and related clinical incident reviews at a large district teaching hospital provided evidence that over sedation can be a significant issue post opioid administration and that safe and effective pain management requires accurate opioid knowledge and patient assessment skills. The aim of the study was to develop education that was directed at identified knowledge deficits, and to evaluate the impact of this tailored education program on knowledge of safe prescribing and administration of opioids. Knowledge levels were explored using a structured questionnaire in a pre and post-test design. A convenience sample of 34 nurses and 5 junior medical officers across three surgical wards in a tertiary referral hospital had their knowledge assessed. Results showed significant improvement when repeat questionnaires were given two weeks post-delivery of education. Mean scores were 68% at baseline and 89% two weeks post completion of the education program. The greatest improvement in scores was recorded for drug knowledge including dose, half-life and administration. The findings from this study suggest that the opioid education program is effective in improving the knowledge of safe prescribing and administration of opioids, however further studies are required.

Delayed seizure-like activity following analytically confirmed use of previously unreported synthetic cannabinoid analogues

Synthetic cannabinoid use has become widespread, leading to increased burdens on health care providers. Symptoms range from agitation and psychosis to seizures and acute kidney injury. We report a case where a patient was assessed and treated twice within 12 h for seizures following synthetic cannabinoid intoxication. Blood sample determinations showed low concentrations of analogues not previously reported, some of which are legal. Clinicians should be aware that synthetic cannabinoids may cause an array of severe health consequences. Given the ever evolving structure of available analogues, clinicians must also be prepared for other unexpected adverse effects.

Inflammatory bowel disease and thromboembolism. Is inflammation at the centre of the clot?

Thromboembolic events are well recognised in patients with inflammatory bowel disease (IBD). We present three cases which highlight the need for vigilance with respect to this complication. We also propose that consideration be given to re-evaluating disease activity in those patients who develop thromboembolic complications.

Service user involvement in mental health practitioner education in Ireland

In recent years, there is an ever increasing call to involve people who use mental health services in the development, delivery and evaluation of education programmes. Within Ireland, there is very little evidence of the degree of service user involvement in the educational preparation of mental health practitioners. This paper presents the findings on service user involvement in the education and training of professionals working in mental health services in Ireland. Findings from this study indicate that in the vast majority of courses curricula are planned and delivered without consultation or input from service users. Currently the scope of service user involvement is on teaching, with little involvement in curriculum development, student assessment and student selection. However, there is evidence that this is changing, with many respondents indicating an eagerness to move this agenda forward.

Laminar inflammatory gene expression in the carbohydrate overload model of equine laminitis

REASONS FOR PERFORMING STUDY

There is a need to assess the laminar inflammatory response in a laminitis model that more closely resembles clinical cases of sepsis-related laminitis than the black walnut extract (BWE) model.

OBJECTIVES

To determine if a similar pattern of laminar inflammation, characterised by proinflammatory cytokine expression, occurs in the CHO model of laminitis as has been previously reported for the BWE model.

METHODS

Sixteen horses administered 17.6 g of starch (85% corn starch/15% wood flour)/kg bwt via nasogastric (NG) tube were anaesthetised either after developing a temperature>38.9°C (DEV group, n=8) or at onset of Obel grade 1 lameness (OG1 group, n=8). Control horses (CON group, n=8) were anaesthetised 24 h after NG administration of 6 l of deionised water. Laminar tissue was collected from horses while under anaesthesia, followed by humane euthanasia. Real time-quantitative PCR was used to assess laminar mRNA concentrations of genes involved in inflammatory signalling.

RESULTS

Increased mRNA concentrations (P<0.05) for IL-1β, IL-6, IL-12p35, COX-2, E-selectin and ICAM-1 were present in laminae from horses with OG1 lameness but not at the DEV time, when compared to the CON horses. No differences between the groups were found for IL-2, IL-4, IL-10, TNF-α, IFN-γ or COX-1 at either the DEV or OG1 time points.

CONCLUSIONS

There was a notable difference in the temporal pattern of inflammatory events between the BWE and CHO models, with the majority of laminar inflammatory events appearing to occur at or near the onset of lameness in the CHO model, whereas many of these events peak earlier in the developmental stages in the BWE model. This suggests that, in addition to circulating inflammatory molecules, there may be a local phenomenon in the CHO model resulting in the simultaneous onset of multiple laminar events including endothelial activation, leucocyte emigration and proinflammatory cytokine expression.

POTENTIAL RELEVANCE

The similar (although somewhat delayed) inflammatory response in the CHO model of laminitis indicates that inflammatory signalling is a consistent entity in the pathophysiology of laminitis.

Acute medical assessment units: an efficient alternative to in-hospital acute medical care

Acute Medical Assessment Units (AMAUs) are being proposed as an alternative to congested Emergency Departments (EDs for the assessment of patients with a range of acute medical problems. We retrospectively reviewed the discharge destination of patients referred to a newly established AMAU during a six-month period. During the same period we contrasted activity in the ED for a similar group of patients. 1,562 patients were assessed in the AMAU. 196 (12.5%) were admitted to an in-patient bed and 1,148 (73.5%) were entered into specific diagnosis-driven out-patient pathways. 1,465 patients attended the ED and 635 (43.3%) were admitted. Out-patient alternatives to expensive in-patient care need to be provided at the 'coal face" of acute referral. The AMAU provides this, and as a consequence admission rates are relatively low. This is achieved by directly communicating with GPs, accessing senior clinical decision makers, and providing immediate access to diagnostically driven outpatient pathways.

Abstract P4-11-18: CT Simulation Alone Appears To Be Appropriate for Pre-Operative Partial Breast Radiation

Introduction: Pre-operative radiotherapy is being evaluated at several centers as a method to potentially increase patient eligibility for partialbreast radiotherapy. Theoretically pre-operative radiotherapy will decrease the volume of normal tissue irradiated which could decrease the morbidity. This study was performed to determine whether CT based imaging could be used for radiotherapy planning.

Material and Methods: Between December 2008 and February 2010, 204 breast cancer patients were seen in the breast evaluation and treatment program clinic at the University of Maryland Marlene and Stewart Greenebaum Cancer Center. Patients with a new diagnosis of breast cancer and no prior treatment were included in the study if they underwent MRI of the breast and a CT, including the breast, within 30 days of each other, and images were available for review. Measurements of maximum tumor dimension obtained from CT and MRI were compared. These measurements were also compared to the maximum pathologic tumor dimension, when pathology was available. Measurements were compared using correlative paired t-tests. Associations between these measurements and T stage, tumor diameter, nodal involvement, receptor status and histologic subtype were explored. Specifically, the risk of CT underestimating the size of the tumor in the pre-operative setting was also evaluated, with a 3 mm underestimation of size chosen as significant. Results: CT and MRI images were available for 40 patients. Twelve patients who underwent imaging after receiving induction chemotherapy were excluded, leaving 28 patients for analysis. In 25 patients, CT images were obtained as part of a staging PET/CT. Pathology was available in 19 patients; nine patients received neo-adjuvant chemotherapy after imaging was obtained. The average maximum tumor dimension was 10% smaller on CT than MRI (4.25 cm (range 1.1 — 9.1 cm) versus 4.72 cm (range 1.3 — 9.0 cm)), but this difference was not statistically significant. Tumor measurements obtained by CT and MRI were only statistically different in the presence of lobular carcinoma (p=0.049). The CT underestimated the MRI measurement by greater than 3 mm in 9 out of 28 (32.14%) patients, six of whom had extensive calcifications on mammogram. When the maximum tumor dimension obtained from CT was compared to pathological size, CT underestimated the pathologic tumor size by greater than 3 mm in only 4 out of 19 (21.1%) patients. All 4 patients had pathologic T3 tumors and were node positive. For comparison, the MRI similarly underestimated the tumor size in 3 of these 4 cases. Limiting our analysis to tumors less than 3 cm in diameter, only 1 out of 7 patients had a pathologic tumor size that was 3 mm greater than the maximum tumor dimension obtained from CT imaging.

Conclusions: Measurements of maximum tumor dimension on CT are on average 10% smaller than measurements obtained from MRI, although not statistically different. The risk of underestimating pathologic maximum tumor dimension was similar for CT and MRI. The risk appeared to be less for infiltrating ductal carcinoma and tumors &lt; 3 cm. CT based treatment planning for pre-operative partial breast radiotherapy seems appropriate although additional data is needed to confirm these findings.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-18.

Conserving biodiversity in production landscapes

Alternative land uses make different contributions to the conservation of biodiversity and have different implementation and management costs. Conservation planning analyses to date have generally assumed that land is either protected or unprotected, and that the unprotected portion does not contribute to conservation goals. We develop and apply a new planning approach that explicitly accounts for the contribution of a diverse range of land uses to achieving conservation goals. Using East Kalimantan (Indonesian Borneo) as a case study, we prioritize investments in alternative conservation strategies and account for the relative contribution of land uses ranging from production forest to well-managed protected areas. We employ data on the distribution of mammals and assign species-specific conservation targets to achieve equitable protection by accounting for life history characteristics and home range sizes. The relative sensitivity of each species to forest degradation determines the contribution of each land use to achieving targets. We compare the cost effectiveness of our approach to a plan that considers only the contribution of protected areas to biodiversity conservation, and to a plan that assumes that the cost of conservation is represented by only the opportunity costs of conservation to the timber industry. Our preliminary results will require further development and substantial stakeholder engagement prior to implementation; nonetheless we reveal that, by accounting for the contribution of unprotected land, we can obtain more refined estimates of the costs of conservation. Using traditional planning approaches would overestimate the cost of achieving the conservation targets by an order of magnitude. Our approach reveals not only where to invest, but which strategies to invest in, in order to effectively and efficiently conserve biodiversity.

A Retrospective Study to Determine Whether accessing Frequency Affects the Incidence of Microbial Colonisation in Peripheral Arterial Catheters

Peripheral arterial catheters are used for the continuous monitoring of blood pressure and repeated blood sampling in critically ill patients, but can be a source of catheter-related bloodstream infection. A common assumption is that the more frequently an arterial catheter is accessed, the greater the likelihood of contamination and colonisation to occur. We sought to determine whether the accessing frequency has an influence on the rate of colonisation in a peripheral arterial catheter.

A retrospective, unmatched, nested case control study was conducted in our intensive care unit. The intensive care unit charts of 96 arterial catheters from 83 patients were examined to measure the number of times each respective arterial catheter was accessed. Multivariate Cox proportional hazards regression was used to compare the rate of accessing of arterial catheters and account for varying arterial catheter in situ duration. Arterial catheters which had a high access rate of 8.1 or more times/day (five colonised of 32 patients: hazards ratio 1.69, 95% confidence interval 0.52 to 5.49; P=0.77), or a medium access rate of 6.7 to 8.0 times/day (six colonised of 32 patients: hazards ratio, 1.35, 95% confidence interval, 0.37 to 4.92: P=0.65) were not significantly more colonised when compared to arterial catheters which had a low access rate of 0 to 6.6 times/day (six colonised of 32 patients), adjusted for arterial catheter insertion site and place in hospital where the arterial catheter insertion was performed.

We were unable to demonstrate that the accessing frequency of an arterial catheter was a major predisposing factor for the likelihood of colonisation. Other mechanisms other than hub colonisation should be investigated further.

[Anti-inflammatory effect of enoxolone in an ex-vivo human gingival mucosa model]

INTRODUCTION

Our aim was to assess the modalities of use and the anti-inflammatory activity of enoxolone included in toothpaste and in a mouthwash solution.

MATERIAL AND METHODS

We used gingival fragments kept alive during 3 days at 37 degrees C. To induce inflammation, inflammatory mediators (SP and LPS) were applied to culture medium on contact with corium. The toothpaste versus placebo was applied on epithelium, in double blind. Histological analysis was then performed on hematoxylin and eosin stained slides. Edema was evaluated with semi-quantitative scores. Vasodilatation was studied by counting the percentage of dilated vessels according to scores and the surface of these dilated vessels by morphometrical image analysis. An inflammatory cytokine, IL8, was measured in culture supernatants. Dosing IL1alpha tested the mouth solution.

RESULTS

The toothpaste induced a significant decrease of edema, vasodilatation, and IL8 excretion. The enoxolone solution induced a decrease of IL1alpha.

DISCUSSION

Enoxolone demonstrated an anti-inflammatory property whatever the carrier was.

TLR2 sensing of F. nucleatum and S. sanguinis distinctly triggered gingival innate response

Gingival tissue faces constant exposure to micro-organisms. It functions as part of the host response, an anti-microbial barrier that recognizes and discriminates between commensal and pathogenic bacteria. This study aimed to evaluate and compare the effects of cell wall extracts from different periodontal bacteria, commensals Streptococcus sanguinis and Fusobacterium nucleatum and the pathogen Porphyromonas gingivalis, on the innate immune response of gingival keratinocytes and the role of TLR2 in regulating this. We assayed mRNA levels to determine the expression of human beta-defensins (hbetaD2, hbetaD3), interleukin-1alpha, -1beta, 6 and 8 and matrix metalloproteinase-9. F. nucleatum extracts induced beta-defensin and inflammatory marker mRNA expression at higher levels than P. gingivalis. Extracts from the Gram-positive commensal S. sanguinis did not upregulate the host response. TLR2 extinction inhibited the upregulation of beta-defensin and cytokine transcripts by F. nucleatum extracts but, in contrast, led to a weak induction of hbetaD3 after challenge with S. sanguinis extracts. Although F. nucleatum strongly induces innate immune and inflammatory mediators, S. sanguinis limits their expression through TLR2. Together, our data demonstrate that gingival keratinocytes recognize and discriminate between Gram-positive and Gram-negative commensal extracts, in part through TLR2, to activate different signaling pathways of the innate immune host response.

[Wound healing effect of Eludril in a model of human gingival mucosa]

INTRODUCTION

The aim of this study was to evaluate and to compare the potential for wound healing of the buccal mucosa with the use of two mouth rinses; one containing 0.10% chlorhexidine with alcohol, the second containing 0.12% chlorhexidine without alcohol.

MATERIAL AND METHOD

Using a model of human buccal mucosa kept alive ex vivo, an immunohistochemical assessment of the mitotic potential of epithelial cells and a biochemical evaluation of the capacity of the fibroblasts of the gingival mucosa to synthesize collagen was performed.

RESULTS

A mouth rinse containing 0.10% chlorhexidine with alcohol (Eludril) did not alter the potential for epithelial proliferation and for collagen synthesis within the gingival chorion grown in survival conditions. The results revealed a significant difference between the two mouth rinses for each of the parameters studied. The most favourable results were obtained with the mouth rinse containing alcohol.

DISCUSSION

The presence of alcohol in a mouth rinse containing 0.10% chlorhexidine has no deleterious effects on healing capacity. On the contrary, it helps stimulate wound healing. The combination of chlorhexidine plus alcohol is superior for healing, chlorhexidine alone does not show any significant difference compared with the control.

Antimicrobial peptide modulation in a differentiated reconstructed gingival epithelium

Gingival innate immunity has been studied by using biopsies and normal or transformed epithelial cell monolayers. To overcome individual biological variabilities and as a physiological alternative, we have proposed using a reconstructed tissue equivalent. In this study, we investigated the functionality and the stage of differentiation of a reconstructed human gingival epithelium. We also characterized this epithelium at the molecular level to investigate its differentiation stage compared with native human gingival epithelium. The expression levels and localization of markers related to proteins and lipids of well-differentiated stratified epithelium, such as cytokeratins, cornified envelope proteins and enzymes, or to factors in lipid synthesis and trafficking were examined. Immunohistochemistry revealed similar localization patterns in both types of epithelia and mRNA quantification showed a close resemblance of their expression profiles. We further revealed that, like native gingiva, reconstructed gingival epithelium was able to respond to pro-inflammatory or lipopolysaccharide stimuli by producing antimicrobial peptides hbetaD-2, hbetaD-3 or LL-37. Finally, we demonstrated that reconstructed human gingival epithelium, as a model, was good enough to be proposed as a functional equivalent for native human gingival epithelium in order to study the regulation of gingival innate immunity against periodontal infections.

Abnormal haemoglobin levels in acute coronary syndromes

BACKGROUND

Anaemia is an adverse prognostic marker in acute coronary syndromes (ACS), but the epidemiology of abnormal haemoglobin levels in such patients is uncertain.

AIMS

To investigate the prevalence, nature and predictors of abnormal haemoglobin levels in ACS patients at admission.

DESIGN

Observational study.

METHODS

All emergency admissions from January to April 2005 were assessed within 24-48 h of hospital admission. ACS patients (unstable angina, non-ST-elevation or ST-elevation myocardial infarction) were enrolled (n = 320, 190 men). Clinical information was recorded.

RESULTS

Overall, 71% had unstable angina; 18% non-ST-elevation myocardial infarction (MI), and 11% ST-elevation MI. Mean +/- SD haemoglobin was 14.3 +/- 1.7 g/dl in men and 13.2 +/- 1.5 g/dl in women. Abnormal haemoglobin was more common in men (65, 34%) than in women (34, 22%) (p = 0.013). Anaemia (haemoglobin <13 g/dl in men, or <12.0 g/dl in women) was recorded in 35 (18%) men and 24 (18%) women. All had admission haemoglobin >8 g/dl, and anaemia was usually normocytic. Multivariate predictors of anaemia (OR, 95%CI) were age (1.07, 1.04-1.1) and serum albumin (0.90, 0.81-1.00). Elevated haemoglobin (>16 g/dl) was recorded in 30 (16%) men and 4 (3%) women (p < 0.01), and was more common in ST-elevation MI patients (26%) than in unstable angina or non-ST elevation MI patients (9%) (p = 0.005). In patients who underwent invasive management with a post-procedure haemoglobin the following day (n = 85), 15 (18%) new cases of anaemia were detected. Admission duration correlated with haemoglobin (p < 0.01), creatinine (p < 0.01), troponin I (p < 0.01) and C-reactive protein (p < 0.01). Anaemia was more common in those who died in hospital (3, 60%) than in those who survived (56, 18%) (adjusted p = 0.0135).

DISCUSSION

Abnormal haemoglobin levels were common in our ACS admissions. Anaemia was generally mild. Increasing age and interventional management were associated with anaemia, which in turn was associated with adverse in-hospital outcomes. Interventions to prevent and detect anaemia in this setting merit prospective testing.