Effects of Academic Detailing, Panel Management and Mailed Multi-Target Stool-DNA Testing on Colorectal Cancer Screening

INTRODUCTION

Academic detailing, patient-panel management, and mailed, stool-based testing have each been utilized to increase colorectal cancer (CRC) screening in rural clinics. The effectiveness of combining these interventions to increase CRC screening during COVID-19 restrictions was unclear.

METHODS

We explored the effects of a multi-component intervention including academic detailing, active patient panel management, and mailed MT-sDNA testing on colorectal cancer screening in our rural family medicine clinic. Baseline interventions included EMR-based provider alerts and mailed patient reminders. Our intervention (March-May 2020) and follow-up periods (June-August 2020) coincided with the initial COVID-19 surge, giving us the opportunity to observe the effects of our intervention during COVID-19 restrictions.

RESULTS

A total of 407 patients were eligible and overdue for colorectal cancer screening. Our clinic's CRC screening rate increased significantly after intervention (69.7%) as compared with before (64.3%) (P = <0.01; 95%CI = 5.39-5.4). Our clinic's CRC screening rates increased significantly during the initial 3 months of the COVID-19 surge (67.8%) compared with the same period the prior year. (62.3%) (P = .003; 95%CI = 3.4-7.6). Our CRC screening rates increased after intervention (69.7%) compared with our regional health system (67%) (P = <0.01; 95%CI = 2.6-2.77). Our weekly stool-based CRC screening increased (94% increase) compared with other health systems nationally (61 to 83% decrease).

DISCUSSION

A multi-component intervention, including academic detailing, panel management, and mailed MT-sDNA testing, can lead to significant increases in CRC screening in a rural family medicine clinic, empowering providers to maintain an effective CRC screening outreach during COVID-19 related restrictions.

Magic shotgun approach to anti-inflammatory pharmacotherapy: Synthesis of novel thienopyrimidine monomers/heterodimer as dual COX-2 and 15-LOX inhibitors endowed with potent antioxidant activity

Emerging evidence points to the intertwining framework of inflammation and oxidative stress in various ailments. We speculate on the potential impact of the magic shotgun approach in these ailments as an attempt to mitigate the drawbacks of current NSAIDs. Hence, we rationally designed and synthesized new tetrahydrobenzo[4,5]thieno[2,3-d]pyrimidine monomers/heterodimer as dual selective COX-2/15-LOX inhibitors with potent antioxidant activity. The synthesized compounds were challenged with diverse in vitro biological assays. Regarding the monomeric series, compound 5k exerted the highest COX-2 inhibitory activity (IC50 = 0.068 μM, SI = 160.441), while compound 5i showed the highest 15-LOX inhibitory activity (IC50 = 1.97 μM). Surpassing the most active monomeric members, the heterodimer 11 stemmed as the most potent and selective one in the whole study (COX-2 IC50 = 0.065 μM, SI = 173.846, 15-LOX IC50 = 1.86 μM). Heterodimer design was inspired by the cross-talk between the partner monomers of the COX-2 isoform. Moreover, some of our synthesized compounds could significantly reverse the LPS-enhanced production of ROS and proinflammatory cytokines (IL-6, TNF-α, and NO) in RAW 264.7 macrophages. Again, the heterodimer showed the strongest suppressor activity against ROS (IC50 = 18.79 μM) and IL-6 (IC50 = 4.15 μM) production outperforming the two references, celecoxib and diclofenac. Regarding NO suppressor activity, compound 5j (IC50 = 18.62 μM) surpassed the two references. Only compound 5a significantly suppressed TNF-α production (IC50 = 19.68 μM). Finally, molecular modeling simulated the possible binding scenarios of our synthesized thienopyrimidines within the active sites of COX-2 and 15-LOX. These findings suggest that those novel thienopyrimidines are promising leads showing pharmacodynamics synergy against the selected targets.

Exiled at home: British Muslims' experiences of integration

This article takes up the question of Muslim integration in the United Kingdom with one main argument: British Muslims, including those who are UK-born, endure wider exilic narratives that stand in clear contradiction to a rooted sense of belonging and equal citizenship. Referring to data from 12 months of ethnographic research, this article argues that integration as a lived experience for this community is ironically characterised by a range of exilic narratives entailing stereotyping, misrecognition, misrepresentation, and inequalities that put their sense of Britian as 'home' at stake. While these conditions do not necessarily work in the same way for all Muslims across their differences, they generally shape-in many different ways-their perceptions and understandings of belonging, home, and integration. Exploring everyday integration practices and dynamics in a local community, this paper discusses Muslims' sense of belonging and the barriers they encounter in achieving a sense of home. It investigates the roles of fear and citizenship built in inequalities in creating an exilic space that impinges on Muslims' sense of belonging. The analysis at the end extends this to highlight the responses and approaches Muslims adopt in their efforts to construct belonging in an exilic context.

MR"I": An "eye" for the preoperative diagnosis of ectopic molar pregnancy, a case report

Hydatidiform mole (complete and partial), invasive mole, choriocarcinoma, placental site trophoblastic disease, and epithelioid trophoblastic tumour constitute the spectrum of benign and malignant gestational trophoblastic disease[1] Invasive mole, choriocarcinoma, placental site trophoblastic disease, and epithelioid trophoblastic tumour also classify under gestational trophoblastic neoplasia.[1] The prevalence of molar pregnancy shows great worldwide variation with reported rates of 12 per 1,000 pregnancies in Indonesia, India, and Turkey; one to two per 1,000 pregnancies in Japan and China; and 0.5 to one per 1,000 pregnancies in North America and Europe.[1] Ectopic pregnancy, which is primarily tubal, is the leading cause of first trimester maternal mortality.[2] Diagnosis of ectopic pregnancy is a combinatorial analysis of clinical signs and symptoms; beta-hCG trends; and ultrasonography.[2] Since ectopic gestations cause maternal deaths, the decisive role of the diagnostic test employed measured by its discriminative potential for a reliable preoperative diagnosis is paramount.[2] Although ultrasonography demonstrates high sensitivity and specificity in diagnosing ectopic gestations, inconsistencies in sonographic identification have been known to occur.[2] Particularly, ultrasonography suffers from limitations such as specifying the exact location of infrequent extrauterine presentations and identifying ectopic gestations with atypical features.[2] Molar pregnancies that are largely known to be placental in location have a known but rare potential for extrauterine proliferation.[3] Ectopic molar gestations are rare with only more than a hundred reported cases in scientific literature.[4] Our case delineates this uncommon entity and the superiority of magnetic resonance imaging in terms of diagnostic performance in characterizing the gestational mass over ultrasonography. This is pertinent considering the need to differentiate an ectopic molar pregnancy from an ectopic pregnancy without molar tissue because the potential for malignancy in the former atypical form is akin to that of an intrauterine molar pregnancy.[4].

Comparative Physicochemical Evaluation of Starch Extracted from Pearl millet seeds grown in Sudan as a Pharmaceutical Excipient against Maize and Potato Starch, using Paracetamol as a model drug

OBJECTIVES

The aim of the current study was to compare the physicochemical and disintegrant properties of pearl millet starch with other starches using paracetamol as model drug.

METHODOLOGY

Determination of percentage yield, Physicochemical, micrometrics characteristics of starch/granules, drug excipients compatibility studies and evaluation of prepared paracetamol tablets were measured using official techniques.

RESULTS

The yield of the millet starch ranged from 30 to 40%. Moisture content 8.77%, pH 5.7, Swelling capacity 1.2, Hydration capacity 1.748, Moisture uptake 11.8%, Amylose 24.6%, with poor flowability and compressibility. No significant difference in hardness, friability% & disintegration times for formulations containing millet starch to that containing potato and maize starch (P>0.05).

CONCLUSION

From the study, Millet seeds locally cultivated in Sudan gave a high yield of starch, has same physicochemical properties as maize and potato starch so can be used as an alternative to those starches.

Effect of intravenous alteplase on ischaemic lesion water homeostasis

BACKGROUND AND PURPOSE

Intravenous (IV) lysis with alteplase is known to increase biomarkers of blood-brain barrier breakdown and has therefore been associated with secondary injuries such as hemorrhagic transformation. The impact of alteplase on brain edema formation, however, has not been investigated yet. The purpose was to examine the effects of IV alteplase on ischaemic lesion water homeostasis differentiated from final tissue infarct in patients with and without successful endovascular therapy (sET).

METHODS

In all, 232 middle cerebral artery stroke patients were analyzed. 147 patients received IV alteplase, of whom 106 patients received subsequent sET. Out of 85 patients without IV alteplase, 50 received sET. Ischaemic brain edema was quantified at admission and follow-up computed tomography using quantitative lesion net water uptake (NWU) and its difference was calculated (ΔNWU). The relationship of alteplase on ΔNWU and edema-corrected final infarct volume was analyzed using univariate and multivariate linear regression models.

RESULTS

The mean ΔNWU was 11.8% (SD 7.9) in patients with alteplase and 11.5% (SD 8.3) in patients without alteplase (P = 0.8). Alteplase was not associated with lowered ΔNWU whilst being associated with reduced edema-corrected tissue infarct volume [-27.4 ml, 95% confidence interval (CI) -49.4 to -5.4 ml; P = 0.02], adjusted for the Alberta Stroke Program Early Computed Tomography Score and recanalization status. In patients with sET, ΔNWU was 10.5% (95% CI 6.3%-10.5%) for patients with IV alteplase and 8.4% (95% CI 9.1%-12.0%) for patients without IV alteplase.

CONCLUSION

The application of IV alteplase did not significantly alter ischaemic lesion water homeostasis but was associated with reduced edema-corrected tissue infarct volume, which might be directly linked to improved functional outcome.

Staged repair of redo and crippled hypospadias: analysis of outcomes and complications

INTRODUCTION

Residual curvature, scarred or absent urethral plate, shortage of skin, and paucity of vascularized tissues and flaps are all obstacles to overcome during repair of redo and cripple hypospadias after failed reconstruction. Limited articles address the outcome of repair of these cases using different grafts.

OBJECTIVE

An analysis of outcomes and complications after the repair of redo and cripple hypospadias in a cohort of children operated by a single surgeon is presented, and data are retrieved from a prospectively designed database.

STUDY DESIGN

Thirty-one children with a median age of 96 months (18-216, interquartile range [IQR]: 78), who underwent previous surgeries three to five times, were operated in the period from late 2011 to August 2017 in a single center by a single surgeon (first author); the first-stage repair was performed by using an inner prepuce graft in three children and oral grafts in 28 children. Penile straightening by degloving and removal of ventral scarred tissues are followed by development of glanular wings and grafting of the ventral surface.

RESULTS

Eleven distal penile hypospadias and 20 posterior hypospadias were operated. First-stage repair was revised in three children; 25 children, eight distal and 17 posterior hypospadias, underwent second-stage repair with a median age of 84 months (18-216, IQR: 60). The success rate after the second-stage repair was 56% (14 children), and complications were encountered in 11 children in the form of penoscrotal fistulae in four, complete dehiscence in one, and glanular dehiscence in six children. After closure of fistulae, the overall success rate increased to 72%. Although complications were more common among children with posterior hypospadias (nine children) than children with distal hypospadias (two children), no statistical significance was reached (p = .234), with no effect of age on complications (p = .233), no effect of the position of the meatus on glanular dehiscence (p = .624), and no effect of age on glanular dehiscence (p = .114).

CONCLUSION

Repair of redo and crippled hypospadias using staged graft repair in children could be achieved with a satisfactory overall success rate of 72%. Glanular dehiscence is the main complication; however, it is not considered by parents of children in the series, necessitating intervention. The lowest complication rate is expected among those with a position of the meatus more distal, however, not proven statistically in the series.

Predictors of mortality in the elderly patient with a fracture of the odontoid process

Aims

Fracture of the odontoid process (OP) in the elderly is associated with mortality rates similar to those of hip fracture. The aim of this study was to identify variables that predict mortality in patients with a fracture of the OP, and to assess whether established hip fracture scoring systems such as the Nottingham Hip Fracture Score (NHFS) or Sernbo Score might also be used as predictors of mortality in these patients.

Patients and Methods

We conducted a retrospective review of patients aged 65 and over with an acute fracture of the OP from two hospitals. Data collected included demographics, medical history, residence, mobility status, admission blood tests, abbreviated mental test score, presence of other injuries, and head injury. All patients were treated in a semi-rigid cervical orthosis. Univariate and multivariate analysis were undertaken to identify predictors of mortality at 30 days and one year. A total of 82 patients were identified. There were 32 men and 50 women with a mean age of 83.7 years (67 to 100).

Results

Overall mortality was 14.6% at 30 days and 34.1% at one year. Univariate analysis revealed head injury and the NHFS to be significant predictors of mortality at 30 days and one year. Multivariate analysis showed that head injury is an independent predictor of mortality at 30 days and at one year. The NHFS was an independent predictor of mortality at one year. The presence of other spinal injuries was an independent predictor at 30 days. Following survival analysis, an NHFS score greater than 5 stratified patients into a significantly higher risk group at both 30 days and one year.

Conclusion

The NHFS may be used to identify high-risk patients with a fracture of the OP. Head injury increases the risk of mortality in patients with a fracture of the OP. This may help to guide multidisciplinary management and to inform patients. This paper provides evidence to suggest that frailty rather than age alone may be important as a predictor of mortality in elderly patients with a fracture of the odontoid process. Cite this article: Bone Joint J 2019;101-B:253–259.

Informed consent: the view from the trenches

We review some of the recent literature on consent for surgical procedures and suggest a scheme for obtaining surgical consent.

Adherence to, and outcomes of, a galactomannan screening protocol in high-risk hematology patients

Background

A twice-weekly galactomannan (gm) screening protocol was implemented in high-risk hematology inpatients. Study objectives were to determine adherence to the protocol, use of selected resources, and patient outcomes.

Methods

This retrospective cohort study compared outcomes of interest before and after implementation of gm screening. Adults undergoing matched related allogeneic hematopoietic stem-cell transplantation or induction chemotherapy for acute leukemia were eligible. Patients could be enrolled more than once and were evaluated as episodes. Adherence to the gm protocol was assessed in post-implementation episodes. Use of broad-spectrum antifungals (bsafs), consultations (infectious diseases, respirology), and diagnostic procedures (computed tomography imaging, bronchoalveolar lavage) were compared between phases, as were the patient outcomes of all-cause mortality and clinical success (alive and not taking a bsaf).

Results

Of 182 episodes consecutively screened, 70 per phase were enrolled. Clinical characteristics and duration of assessment were similar for the phases. Full or partial adherence to the protocol was observed in 61 post-implementation episodes (87%), with full adherence in 40 episodes (57%). More episodes in the pre-implementation phase than in the post-implementation phase involved receipt of bsafs, consultations, and diagnostics (27% vs. 7%, p = 0.02; 46% vs. 26%, p = 0.014; and 46% vs. 31%, p = 0.083 respectively). Although mortality was similar in the two phases, clinical success at the final assessment was observed in fewer pre-implementation than post-implementation episodes (79% vs. 98%, p < 0.001).

Conclusions

Implementation of a gm screening protocol was feasible and associated with significantly fewer episodes involving receipt of bsafs and consultations, and with significantly more episodes showing clinical success.

Accuracy of the revised Tokuhashi score in predicting survival in patients with metastatic spinal cord compression (MSCC)

PURPOSE

The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our aim was to analyse the actual survival time of patients treated for metastatic spinal cord compression (MSCC) in comparison with the predicted survival based on the revised Tokuhashi score. This would thereby allow us to determine the overall predictive value of this scoring system.

METHODS

This study was a semi-prospective clinical study of all patients with MSCC presenting to our unit over 8 years-data from October 2003 to December 2009 were collected retrospectively and from December 2009, all data collected prospectively to October 2011. Patients were divided into three groups--Group 1 (Tokuhashi score 0-8, n = 84), Group 2 (Tokuhashi score 9-11, n = 83) and Group 3 (Tokuhashi score 12-15, n = 34). Data collected included demographic data, primary tumour histology, surgery type and complications, neurological outcome (Frankel grade) and survival.

RESULTS

A total of 233 patients with MSCC were managed surgically in our unit during this time. Out of these complete data were available on 201 patients for analysis. Mean age of patients was 61 years (range 18-86; 127 M, 74 F). The primary tumour type was Breast (n = 29, 15 %), Haematological (n = 28, 14 %), Renal (n = 26, 13 %), Prostate (n = 26, 13 %), Lung (n = 23, 11 %), Gastro-intestinal (n = 11, 5 %), Sarcoma (n = 9, 4 %) and others (n = 49, 24 %). All patients included in the study had surgical intervention in the form of decompression and stabilisation. Posterior decompression and stabilisation was performed in 171 patients (with vertebrectomy in 31), combined anterior and posterior approaches were used in 18 patients and 12 had an anterior approach only. The overall complication rate was 19 % (39/201)--the most common being wound infection (n = 15, 8 %). There was no difference in the neurological outcome (Frankel grade) between Groups 1 and 2 (p = 0.34) or Groups 2 and 3 (p = 0.70). However, there was a significant difference between Groups 1 and 3 (p = 0.001), with Group 3 having a significantly better neurological outcome. Median survival was 93 days in Group 1, 229 days in Group 2 and 875 days in Group 3 (p = 0.001). The predictive value between the actual and predicted survival was 64 % (Group 1), 64 % (Group 2) and 69 % (Group 3). The overall predictive value of the revised Tokuhashi score using Cox regression for all groups was 66 %.

CONCLUSION

We would conclude that although the predictive value of the Tokuhashi score in terms of survival time is at best modest (66 %), the fact that there were statistically significant differences in survival between the groups looked at in this paper indicates that the scoring system, and the components which it consists of, are important in the evaluation of these patients when considering surgery.

Effect of timing of surgery on neurological outcome and survival in metastatic spinal cord compression

PURPOSE

Metastatic spinal cord compression (MSCC) requires expeditious treatment. While there is no ambiguity in the literature about the urgency of care for patients with MSCC, the effect of timing of surgical intervention has not been investigated in detail. The objective of our study was to investigate whether or not the 'timing of surgery' is an important factor in survival and neurological outcome in patients with MSCC.

METHODS

All patients with MSCC presenting to our unit from October 2005 to March 2010 were included in this study. Patients were divided into three groups-those who underwent surgery within 24 h (Group 1, n = 45), between 24 and 48 h (Group 2, n = 23) and after 48 h (Group 3, n = 53) from acute presentation of neurological symptoms. The outcome measures studied were neurological outcome (change in Frankel grade post-operatively), survival (survival rate and median survival in days), incidence of infection, length of stay and complications.

RESULTS

Patients' age, gender, revised Tokuhashi score, level of spinal metastasis and primary tumour type were not significantly different between the three groups. Greatest improvement in neurology was observed in Group 1, although not significantly when compared against Group 2 (24-48 h; (p = 0.09). When comparisons of neurological outcome were performed for all patients having surgery within 48 h (Groups 1 and 2) versus after 48 h (Group 3), the Frankel grade improvement was significant (p = 0.048) favouring surgery within 48 h of presentation. There was a negative correlation (-0.17) between the delay in surgery and the immediate neurological improvement, suggesting less improvement in those who had delayed surgery. There was no difference in length of hospital stay, incidence of infection, post-operative complications or survival between the groups.

CONCLUSIONS

Our results show that surgery should be performed sooner rather than later. Furthermore, earlier surgical treatment within 48 h in patients with MSCC resulted in significantly better neurological outcome. However, the timing of surgery did not influence length of hospital stay, complication rate or patient survival.

Neuroradiologic manifestations of Loeys-Dietz syndrome type 1

BACKGROUND AND PURPOSE

Loeys-Dietz syndrome (LDS) is a recently described entity that has the triad of arterial tortuosity and aneurysms, hypertelorism, and bifid uvula or cleft palate. Its neuroradiologic manifestations have not been well delineated. We sought to describe the neuroradiologic features of LDS and to assess the manifestations that would warrant follow-up imaging.

MATERIALS AND METHODS

Two neuroradiologists retrospectively reviewed CT angiography (CTA), MR imaging, and plain film studies related to the head and neck in 25 patients ranging from 1 to 55 years of age, all of whom had positive genetic testing and clinical characteristics of LDS. Arterial tortuosity was evaluated by subjective assessment of 2D and 3D volumetric CTA and MR angiography data. Craniosynostosis and spinal manifestations were assessed by using plain films and CT images. MR images mostly of the head were reviewed for associated findings such as hydrocephalus, Chiari malformation, etc. Clinical manifestations were collated from the electronic patient record.

RESULTS

All patients had extreme arterial tortuosity, which is characteristic of this syndrome. Thirteen patients had scoliosis, 12 had craniosynostosis, 8 had intracranial aneurysms, 6 had spinal instability, 3 had dissections of the carotid and vertebrobasilar arteries, 3 had hydrocephalus, 4 had dural ectasia, 2 had a Chiari malformation, and 1 had intracranial hemorrhage as a complication of vascular dissection.

CONCLUSIONS

Significant neuroradiologic manifestations are associated with LDS, predominantly arterial tortuosity. Most of the patients in this series were young and, therefore, may require serial CTA monitoring for development of intra- and extracranial dissections and aneurysms, on the basis of the fact that most of the patients with pseudoaneurysms and dissection were older at the time of imaging. Other findings of LDS such as craniosynostosis, Chiari malformation, and spinal instability may also need to be addressed.

Caenorhabditis elegans as a host model for community-associated methicillin-resistant Staphylococcus aureus

The nematode Caenorhabditis elegans has recently been developed as a host model for the study of Staphylococcus aureus virulence and pathogenesis. Here, the toxicity and virulence of representative clinical isolates of our methicillin-resistant S. aureus (MRSA) epidemic strains were studied using this model. The strains USA300 (associated with community infection outbreaks), USA400 (associated with sporadic community infections) and CMRSA2 (associated with both hospital and community infections), as well as the nematocidal reference strain NCTC8325, showed high nematocidal activity, both by killing the majority of the nematodes (> 90%) over 9 days, and by inhibiting second-generation nematode growth. By contrast, the typical hospital-associated MRSA strain CMRSA6, the colonization strain M92, and the non-pathogenic Staphylococcus epidermidis control strain ATCC12228 were non-toxic to the nematode, which behaved normally. The absence of nematocidal activity does not reflect lack of growth or reduced growth of the bacterial inoculum. The two non-nematocidal strains share similar genomic backgrounds, bacterial growth curve patterns and virulence gene profiles. However, the nematocidal strains each showed the same low maximum density growth curve patterns, but possessed distinct genetic profiles; no common virulence gene patterns or specific genes have been elucidated. Our findings demonstrate that community-associated MRSA strains are more pathogenic than hospital-associated MRSA in the C. elegans model and support the use of this model for studying the virulence of S. aureus strains.

Airway inflammation and bronchial remodelling in toluene diisocyanate-exposed BALB/c mouse model

Toluene diisocyanate (TDI), a highly reactive industrial chemical, is one of the leading causes of occupation-related asthma in industrialized countries. The pathogenesis of TDI-induced asthma, however, remains not fully understood, in part due to lack of appropriate animal models. Twenty five female BALB/c mice (age: 8 weeks) were randomly divided into 5 groups: Ovabumin (OVA); OVA peptide amino acid residues No. 323-339 (Pep); TDI; alum and physiological saline. Mice were intraperitoneally injected with 25 microg OVA or pep absorbed on 300 microg alum, 300 microg alum or saline on days 0, 7 and 14. For the TDI group, mice were sensitized subcutaneously with 20 microl neat TDI on day 0; 20 microl of TDI in olive oil (1:10) on days 7 and 14; on days 21-23. Then each group was challenged intranasally with 20 microl of 1% OVA, 1% Pep, 1% TDI, 10% alum and saline respectively. On day 28, mice were killed under pentothal anesthesia. The results demonstrated that neutrophil-dominant inflammation with a few eosinophil infiltration occurred in the peri-bronchial and peri-vascular regions of the lungs. This was accompanied by hyperplasia/hypertrophy of cells lining the airways and mucus production as shown by HE staining. Positive immunohistochemical MBP staining in parenchyma was also shown. Th2 cytokine IL-4 and IgE production were significant increased 5 days after last challenge while IFN-gamma level was below the detection limit.

CONCLUSION

the clear elevation of IL-4 and IgE could allow to conclude a possible Th2-like dominated allergic response in TDI-exposed BALB/c mouse model.

Intrauterine contraceptive device-associated pelvic actinomycosis caused by Actinomyces urogenitalis

We report a case of intrauterine contraceptive device (IUD) associated pelvic actinomycosis due to Actinomyces urogenitalis in a previously healthy young adult woman. Diagnosis was confirmed by 16S ribosomal RNA gene sequencing of bacterial colonies growing from the extracted device. This is the first documented report of human infection caused by this micro-organism.

The practice of out-lying patients is dangerous: a multicentre comparison study of nursing care provided for trauma patients

Pressure for acute hospital beds is a national problem with many acute trauma patients being admitted to non-trauma wards. This prospective multicentre questionnaire study of 220 qualified trauma and non-trauma nurses aims to compare the quality of nursing care that trauma patients receive when admitted to trauma wards and non-trauma wards. The questions included the nursing management of common fractures and post-operative conditions. The completed questionnaires were scored and the results analysed. Hundred percent of the questionnaires were completed and returned. The trauma nurses conveyed the importance of ice (85%) and elevation (97%) in the initial management of limb fractures. This compares with ice (10%) and elevation (50%) on the outlying wards. Trauma nurses correctly monitor for potentially devastating post-operative complications and compartment syndrome 87% of the time compared with 42% on outlying wards. Spinal injuries are managed appropriately 88% of the time on trauma wards compared with 36% on outlying wards. Trauma patients receive better nursing care when admitted to a trauma ward and are nursed by trauma nurses. Many of the out-lying wards provide sub-optimal trauma nursing care and a few are positively dangerous. We suggest that trauma patients should not be nursed on outlying wards.

T cell recognition pattern of bovine milk alphaS1-casein and its peptides

T cell recognition patterns of CAS1_Bovin, its limited hydrolysis, oxidized, reduced/alkylated, cyanogen bromide cleavage fractions and synthetic peptides were examined. Thirteen overlapping peptides covering the intact molecule, with chain lengths varied between 17 and 20 AA, were prepared by f-moc SPPS. In addition, six CNBr-cleavage fragments were obtained and extensively purified using RP/HPLC. Likewise, chemically modified derivatives and limited pepsin hydrolysate, were performed and the specificities were confirmed. Stimulation of PBMC and TCL cultures by the intact CAS1_Bovin molecule, synthetic peptides and modified derivatives were screened by [methyl-3H] thymidine incorporations. PBMC phenotype was performed by flow cytometry and the mean CD4+/CD8+ ratio of freshly prepared PBMC was compared with the ratio following specific CAS1_Bovin stimulation. CD4+ phenotypes (TH1/, TH2 and TH0) were assigned by assay of four marker cytokines IL-4, IL-6, IL-10 and IFN-gamma. Five CNBr fragments and seven of the thirteen tested peptides were recognized by specific TCL. The most reactive epitopes of CAS1_Bovin comprised seven motifs namely: peptides Cas 1-18, Cas 16-35, Cas 67-85, Cas 91-110, Cas 136-155, Cas 152-169 and Cas 166-183. The stimulation range for the seven peptides was 1058-2383 cpm. Stimulation for the CNBr fragments were, respectively, 8670, 5808, 3324, 5465, 2255 and 321 cpm. Cytokine assay showed that CD4+ TH2 phenotype was dominant for half the number of patients, while TH1 solely or combined TH0 were represented in the other four cell culture filtrates. The T cell reactive epitopes described and their antibodies will be useful tools for methods in progress for the detection of masked casein epitopes encompassed in processed food. In conclusion, T cell recognition pattern of CAS1_Bovin was examined using extensively purified synthetic peptides and CNBr fragments. Five large and seven small peptides were clearly recognized. Peptides of chain length less than six AA were left unrecognised. CD4+ TH2 phenotype was the most dominant TCL subpopulations found in atopic patients while CD4+ TH1 was representative in the non-IgE mediated type IV hypersensitivity.

Pressure for beds--does it put our orthopaedic patients at risk?

INTRODUCTION

High occupancy rates of NHS beds has meant that increasing numbers of trauma patients find themselves on non-orthopaedic wards. Nursing staff on these wards may not have the specialist training to nurse such patients and may not recognise complications should they arise. The failure to recognise compartment syndrome was highlighted in a Clinical Governance meeting, leading to an assessment of nursing awareness of this condition.

METHODS

Fifty orthopaedic trained nurses and a matched cohort of 50 non-orthopaedic trained nurses were asked a series of questions relating to compartment syndrome.

RESULTS

The majority of non-orthopaedic nurses failed to recognise the signs of early compartment syndrome.

CONCLUSION

Compartment syndrome is a limb-threatening condition which requires prompt recognition. Patients at risk should be nursed in an appropriate environment.

Choice of dressing has a major impact on blistering and healing outcomes in orthopaedic patients

OBJECTIVE

To investigate the effect of three postoperative dressings on orthopaedic wound healing.

METHOD

Three hundred orthopaedic patients were divided into three treatment groups and allocated to management with one of three dressings: Primapore, Tegaderm with pad, and OpSite Post-Op. Staff completed a questionnaire to evaluate the wound progression. Outcome measures were the presence of infection, blistering and the number of dressing changes required.

RESULTS

There was a significantly lower incidence of blistering with OpSite Post-Op (6%) than Tegaderm with pad (16%) and Primapore (24%) (p<0.001). Patients in the OpSite Post-Op group had the lowest exudate levels.

CONCLUSION

Dressings that employ a clear film and have a high moisture vapour transmission rate have been shown to reduce both the rate of blistering and wound discharge. The additional expense inherent in using such dressings may, in reality, prove cost-effective because of the reduced need for dressings changes and the subsequent earlier discharge of these patients from hospital with an uncomplicated wound.

New method for laboratory detection of AmpC beta-lactamases in Escherichia coli and Klebsiella pneumoniae

A new cefoxitin-agar medium (CAM)-based assay was compared to the previously published modified three-dimensional (M3D) assay for the detection of AmpC production in Escherichia coli and Klebsiella pneumoniae. Clinical isolates of cefoxitin-resistant E. coli (n = 5) and K. pneumoniae (n = 7) and multiple control strains with and without AmpC enzymes were tested by both methods. The CAM method with 4 microg of cefoxitin/ml was equivalent to the M3D method for detecting AmpC production in E. coli and K. pneumoniae. This new method is easier to perform and interpret and allows for testing of multiple isolates on a single plate.

Evaluation of the Allergenicity and Antigenicity of Bovine-Milk alphas1-Casein Using Extensively Purified Synthetic Peptides

Alphas1-Casein (CAS1_BOVIN), the major allergen of cow's milk (CM), is widely used as hydrolysates in infant diet formulae and additive to other processed food items. To date, most of the reported B-cell epitope mapping were performed on polyethylene pins or cellulose-derivative membrane. We sought to locate the motifs critical for human-specific IgE and rabbit polyclonal IgG binding using extensively purified CAS1_BOVIN, synthetic peptides and derivatives. Thirteen overlapping peptides covering the whole CAS1_BOVIN encompassing 17 : 20 amino acid (AA) were synthesized by f-moc AA solid-phase polyamide peptide synthesis. In addition, six cyanogen bromide (CNBr) cleavage fragments were prepared. Limited hydrolysis, oxidized and reduced/alkylated derivatives were also produced. The preparations were purified by ion exchange, gel filtration chromatography, reversed phase and high-performance liquid chromatography. The homogeneity was visualized by sodium dodecyl sulfate (SDS) and poly acryl amide gel electrophoresis (PAGE) followed by IgE and IgG immunoblotting. IgE binding was measured by Biotin Streptavidin (Bio/strep) fluoro enzyme immuno assay (FEIA) or ELISA-inhibition. Eighteen CM allergy (CMA) sera from 45 clinically examined children (Melbourne) and five adults (Bergen) were selected. Individual sera and pools were used for mapping IgE-binding epitopes. Rabbit IgG sera and pools were used for locating the antigenic sites of the molecule. Results indicated that all the individual CMA sera and pools recognized the intact molecule and three of the CNBr fragments as major antibody-binding allergens. The N- and C-terminal peptides (CAS 16-35; CAS 136-155) showed high IgE-binding affinity. CAS 1-18 and CAS 181-199 showed high IgG bindings. Considering the diversity of the antibody specificities, a reasonable agreement between IgE and IgG epitopes were found at the N- and C-terminals of CAS1_BOVIN. Mapping IgE B-cell epitopes by direct Bio/strep FEIA allowed the development of a sensitive modified technique for detecting unlabelled, casein immune dominant peptides in food products.

Evidence for single origins of 35delG and delE120 mutations in the GJB2 gene in Anatolia

Eighteen different sequence changes, including three novel alterations, were detected in GJB2, encoding connexin 26, in 371 Turkish probands with non-syndromic sensorineural hearing loss. Two frequently detected mutations, 35delG and delE120, were shown to have single origins based on the conserved genotypes of two closely linked microsatellite and five single nucleotide polymorphism markers. Carrier frequencies of 35delG and delE120 in Egypt and Turkic populations of the Near East provide insights about the origin of these two mutations.

Streptococcus equi subspecies equi (Lancefield group C) meningitis in a child

We present a case of Streptococcus equi subsp. equi meningitis in a young boy. This case represents the first report in the literature of meningitis caused by this organism, as far as we know.

Screening for mast cell tryptase and serum IgE antibodies in 18 patients with anaphylactic shock during general anaesthesia

BACKGROUND

In the perioperative setting multiple agents can cause anaphylaxis. Often the reactions are dramatic, and due to their lifethreatening potential it is crucial that the responsible agent is identified in order to avoid future adverse reactions. The aim of the present study was to measure the concentration of serum mast cell tryptase (MCT), to investigate the prevalence of serum IgE antibodies against ammonium groups, choline, morphine, suxamethonium, thiopentone and latex and to perform skin prick tests (SPTs) in 18 patients experiencing an anaphylactic reaction during induction of general anaesthesia.

METHODS

Serum samples from 18 patients with an anaphylactic reaction during general anaesthesia were analyzed for MCT and specific IgE against ammonium groups, choline, morphine, suxamethonium, thiopentone and latex. Skin prick tests were performed in 11 out of 18 patients.

RESULTS

Ten patients had elevated MCT levels and specific IgE against ammonium ion, morphine and (with the exception of patient nos 3, 9 and 10) suxamethonium. Seven of these patients had positive SPTs to suxamethonium. One of the patients tested positive to latex in addition to suxamethonium. Two patients showed elevated MCT, while specific IgE against the drugs tested was not detected. Three patients tested positive to ammonium ion, morphine and suxamethonium, but negative to MCT. Three patients tested negative to both MCT and specific IgE.

CONCLUSIONS

Fifteen out of 18 sera tested positive for MCT and/or specific IgE against neuromuscular blocking drugs (NMBDs). Ten of the 18 patients experienced an IgE-mediated anaphylactic reaction to NMBDs during anaesthesia, verified by detection of specific IgE and elevated levels of MCT.

Novel B and T cell epitopes of chicken ovomucoid (Gal d 1) induce T cell secretion of IL-6, IL-13, and IFN-gamma

BACKGROUND

Chicken ovomucoid (OM, Gal d 1) has an important role in the pathogenesis of IgE-mediated allergic reactions to hen's egg white.

OBJECTIVES

The purpose of this study was to clarify the mechanisms of T cell recognition of ovomucoid using intact OM and chemically modified, characterized and homogeneous solid phase synthetic peptides covering the whole molecule.

METHODS

Eighteen overlapping peptides were prepared by solid phase F-moc polyamide peptide synthesis (SPPS), characterized and high-pressure liquid chromatography (HPLC) purified. The peptides, together with intact, denatured and oxidized OM, were used to stimulate patient-derived cell cultures for mapping T cell epitopes. Proliferation responses, T cell phenotype and cytokine secretion using peripheral blood mononuclear cells (PBMC) from eight individuals and T cell lines (TCL) derived from six hen's egg-allergic patients, were examined. In addition, intact, denatured, oxidized and deglycosylated OM, as well as the peptides solely or with their keyhole limpet haemocyanin (KLH) complexes, were tested. For locating IgE and IgG B cell epitopes, seven egg-allergic patient sera and three OM-polyclonal sera were used. Healthy non-allergic individuals were included as controls.

RESULTS

Seven peptides were recognized by specific IgE, while OM-specific TCL recognized 10 peptides. Six of the OM peptides were commonly recognized both by patient S-IgE and blood-derived TCL. Among those, one novel epitope, peptide OM 61-74, had the ability to bind IgE. Another peptide, OM 101-114, was recognized by IgE and IgG sera, but not by any of the TCLs. In contrast, the peptides OM 41-56, OM 71-84, OM 131-144 and OM 171-186 were exclusively T cell epitopes with no affinity to specific antibodies. Abundant TCL secretion of IFN-gamma, IL-6, IL-4, IL-13, IL-10 and TNF-alpha in response to OM stimulation indicates the contribution of Th2 as well as Th1/Th0 CD4+ cell subsets. For allergic patients moderate amounts of IFN-gamma, IL-13, and high amounts of IL-6, were secreted in response to TCL stimulation by OM peptides. High amounts of IL-6 were secreted in response to all molecular forms of OM (intact-, modified-OM and the peptides 71-84 and 51-64) when TCLs from two non-allergic donors were used.

CONCLUSIONS

One novel B cell epitope (OM 61-74) and 10 T cell epitopes have been identified. The most reactive epitopes of the OM molecule comprise the motifs 1-14 to 71-84, the overlapping peptide-pairs OM 121-134 and OM 131-144 and peptides OM 161-174 and 171-186. Peptides OM 1-14 and 171-186 are the only ones capable of inducing IL-4 secretion. Only one peptide (OM 11-24) induces IL-10 secretion. Those peptides recognized as both T and B cell epitopes or only T cell epitopes, have the potential to induce T cell secretion of moderate to high amounts of IL-13, IFN-gamma and particularly IL-6.

Comparison of PCR to histology for the diagnosis of invasive candidiasis in a murine model

The ability of a PCR method to diagnose invasive candidiasis in comparison to histology was determined using a murine model. One hundred and sixty mice were divided into 16 groups of 10 mice each. One group served as a negative control while 15 groups were infected with Candida albicans. Of the infected groups, 14 (A1-A7 and B1-B7) received fluconazole treatment. Surviving animals of group A1 were killed on day 3, and animals of successive groups were sacrificed every other day thereafter. Fluconazole treatment was stopped in the corresponding B group. All surviving mice were killed on day 43. One hundred and thirty-eight mice were evaluable. Yeast were seen in the kidney specimens of 77 mice; 66/77 of these, plus an additional 7 histologically-negative mice, were positive by PCR. The sensitivity and specificity of the PCR test compared with histology were 85.71% and 88.52%, respectively. In combination with blood cultures, PCR could be a useful diagnostic tool for invasive candidiasis in clinical settings.

Evaluation of the Candigen enzyme-linked immunosorbent assay for quantitative detection of Candida species antigen

OBJECTIVE

To assess the clinical utility of an enzyme-linked immunosorbent assay method for the quantitative detection of Candida species antigen (Candigen; Biomerica Inc, Newport Beach, Calif) in patients with suspected disseminated candidiasis.

METHODS

Specimens of blood or cerebrospinal fluid from 75 patients with suspected disseminated candidiasis were analyzed by the Candigen test. Results were compared with those obtained by culture and polymerase chain reaction (PCR) analysis.

RESULTS

Thirty-seven patients had specimens positive for Candida species by either culture or PCR. Of these specimens, 4 were positive by both culture and PCR, 21 were culture positive but PCR negative, and 12 were PCR positive but culture negative. Five specimens were positive by the Candigen test, all of which were PCR positive but culture negative. The sensitivity, specificity, and positive and negative predictive values of the Candigen test compared to culture plus PCR were 13.5%, 100%, 100%, and 54.3%, respectively. Turnaround time for the Candigen test was approximately 3 hours.

CONCLUSION

The Candigen test showed excellent specificity and turnaround time, but its poor sensitivity coupled with its inability to provide species information or susceptibility data make its clinical utility questionable.

Expression and analysis of recombinant salmon parvalbumin, the major allergen in Atlantic salmon (Salmo salar)

The parvalbumin from white muscle of Atlantic salmon was previously found to be a major allergen, and designated Sal s1. Two distinct cDNAs, 14.1 and 24.1, which comprise the entire parvalbumin-encoding regions, were cloned, revealing transcripts from two different parvalbumin genes. In the present study, the protein-coding regions of these cDNAs were subcloned into an Escherichia coli expression vector (pET-19b). Both proteins were expressed and the generated target proteins were localized in both soluble and insoluble fractions of the expression host. The recombinant products in the soluble fraction were purified using the His tag-purification system and analysed on Western blots with anti-salmon parvalbumin polyclonal rabbit sera and sera from patients allergic to fish. Both recombinant products (His10-14.1 and His10-24.1) reacted positively with salmon parvalbumin-specific immunoglobulin G (IgG) from rabbits, and with specific immunoglobulin E (IgE) from the sera of six fish-allergic patients. The allergenicity of His10-14.1 was confirmed using enzyme-linked immunosorbent assay (ELISA). The 14.1 cDNA of salmon parvalbumin was shown to be the dominant type represented in a muscle cDNA library.

Effects of beta2 adrenoceptor agonists on T-cell subpopulations

The aim of the present communication is to determine the effects of beta2 adrenoceptor agonists on growth and cytokine secretion using allergen-specific T cells. Four beta2 adrenoceptor agonists were administered at therapeutically relevant doses (salbutamol 1-2 microM; salmeterol 0.03-0.06 microM; terbutaline 0.56-1.12 microM, and fenoterol 0.7-1.4 microM to: a) Cultures of human peripheral mononuclear cells (PBMC) b) Positively selected CD4+ and CD8+ subsets, c) Allergen-specific T-cell lines (TCL). Drug effects on growth kinetics and the secretion of IL-4, IL-5, INF-gamma and IgE following T-cell stimulation were investigated. Comparing the growth inhibitory effect of the 4 beta2 agonists at 2 different concentrations, using 12 PBMC, 10 CD4+ and CD8+ and 10 TCL cultures, the following patterns were observed: PBMC-, CD4+- and CD8+-cultures: salmeterol, followed by salbutamol and fenoterol, was a more potent inhibitor than terbutaline. In long-term TCL-cultures, salmeterol was the most potent drug, followed by fenoterol. No significant differences were observed between salbutamol and terbutaline. TCL secretion of IL-4 and IL-5 (TH2 cytokines) was also significantly inhibited. In one patient, INF-gamma secretion (TH1/THO cytokine) could be enhanced by drug administration. High IgE secretion, from 1% remaining B cells in one of the patients, following PHA+IL-2 stimulation, could be reduced by the drugs. The results showed that the beta2 agonists could influence T-cell growth and function. The changes regarding cell function were individual and related to T-cell phenotypes secreting TH1/THO or TH2 cytokines. These results suggest that administration of beta2 adrenoceptor agonists could be beneficial, not only for bronchodilation, but also for suppressing the underlying inflammatory process dominated by TH2-like cytokine secretion.