Peri-Operative Impact of Cannabis Use in Conjunction With Elective Primary Breast Augmentation in a Private Practice

Background The consumption of recreational and medicinal cannabis in the United States continues to increase. Understanding the effects of cannabis in patients undergoing elective primary breast augmentation (EPBA) is of paramount importance with the expanding rates of reported cannabis consumption. Objectives This study aims to analyze the peri-operative impact of cannabis use in conjunction with EPBA in a single-surgeon practice in San Francisco, California. Methods A retrospective chart review was performed of 134 adult female patients undergoing EPBA from August 2018 to January 2022 within a single-surgeon practice plastic surgery office. Cannabis use was self-reported as current use or former use. Cohorts were grouped as cannabis users and cannabis non-users. Results Of the 134 patient charts identified for analysis, 58 (43.3%) reported cannabis use. Cannabis users were significantly younger than cannabis non-users (26.8 years versus 31.5 years, P<0.001). No significant differences were found between groups among intra-operative blood loss, post-operative complication rates, post-operative narcotic use, or intra-operative anesthetic requirements. The incidence of adverse events, including wound breakdown, skin necrosis, and capsular contracture requiring reoperation, did not differ significantly between cannabis users and cannabis non-user groups. Ninety-six percent of patients had their implants placed subpectorally, and all procedures were done using a Keller funnel. Eighty-three percent of patients had Sientra implants, and 96% of all implants were silicone gel implants. All procedures were done under general anesthesia. Patients were followed for up to two years. Discussion This review found no significant differences in peri-operative and post-operative outcomes between cannabis users and cannabis non-users.

Examining Trends in Implantable Arterial Doppler Usage Among North American Head and Neck Microsurgeons: A Survey Study

BACKGROUND

There are variations in implantable arterial Doppler usage for microvascular free tissue monitoring among North American surgeons. Identifying utilization trends among the microvascular community may elucidate practice patterns that may be useful in determining protocols. Furthermore, study of this information may yield novel and unique applications in other disciplines such as vascular surgery.

METHODS

Electronically disseminated survey study shared with a large database of North American head and neck microsurgeons.

RESULTS

Seventy four percent of respondents use the implantable arterial Doppler; 69% report use in all cases. Ninety five percent remove the Doppler by the seventh postoperative day. All respondents felt that the Doppler did not impede care progression. Any implication of flap compromise was followed with a clinical assessment in 100% of respondents. If viable, 89% would continue monitoring after clinical examination, while 11% would take the patient for exploration regardless of clinical examination.

CONCLUSIONS

The efficacy of the implantable arterial Doppler has been established in the literature and is supported by the results of this study. Further investigation is required to establish a consensus on use guidelines. The implantable Doppler is more often used in conjunction with rather than substitution for clinical examination.

Alternative Abdominal Wall Plication Techniques: A Review of Current Literature

Abdominoplasty is one of the most common procedures performed in plastic surgery. By removing redundant skin and fat tissue, body contouring narrows the waist and achieves a naturally flattened appearance. To achieve this, one technique frequently utilized is plication of the abdominal rectus sheath. Although abdominal wall plication is commonly performed during abdominoplasty, there is a lack of consensus regarding which plication method provides the best outcomes. Each variation addresses some of the common intraoperative and postoperative complications of abdominoplasty. These include extended operating time, rupture of the plication, epigastric bulging, and patient postoperative dissatisfaction. Many plication techniques have been described in the literature, but no single technique has been adopted by plastic surgeons as the gold standard. Here we present a narrative comparison of current published literature reporting novel or modified abdominoplasty plication techniques. This includes diagrams of each procedure, sutures utilized, and key concepts of each plication technique. Discussion regarding how these modifications change operating time, alter epigastric bulging, and improve the ability to narrow the waist is provided. The purpose of this paper is to provide a concise source document for plastic surgeons to reference when choosing a plication method to use during abdominoplasty.

LEVEL OF EVIDENCE: 4

The Potential Role of Exosomes in Aesthetic Plastic Surgery: A Review of Current Literature

Despite an increasing surge of exosome use throughout the aesthetic arena, a paucity of published exosome-based literature exists. Exosomes are membrane-bound extracellular vesicles derived from various cell types, exerting effects via intercellular communication and regulation of several signaling pathways. The purpose of this review was to summarize published articles elucidating mechanisms and potential applications, report available products and clinical techniques, and prompt further investigation of this emerging treatment within the plastic surgery community.

Methods

A literature review was performed using PubMed with keywords exosomes, secretomes, extracellular vesicles, plastic surgery, skin rejuvenation, scar revision, hair growth, body contouring, and breast augmentation. Publications from 2010 to 2021 were analyzed for relevance and level of evidence. A Google search identified exosome distributors, where manufacturing/procurement details, price, efficacy, and clinical indications for use were obtained by direct contact and summarized in table format.

Results

Exosomes are currently derived from bone marrow, placental, adipose, and umbilical cord tissue. Laboratory-based exosome studies demonstrate enhanced outcomes in skin rejuvenation, scar revision, hair restoration, and fat graft survival on the macro and micro levels. Clinical studies are limited to anecdotal results. Prices vary considerably from $60 to nearly $5000 based on company, source tissue, and exosome concentration. No exosome-based products are currently Food and Drug Administration-approved.

Conclusions

Administered alone or as an adjunct, current reports show promise in several areas of aesthetic plastic surgery. However, ongoing investigation is warranted to further delineate concentration, application, safety profile, and overall outcome efficacy.

Analysis of vein grafting versus arteriovenous loop in microvascular head and neck reconstruction: Multicenter series of 36 patients

BACKGROUND

The utilization of an arteriovenous loop is an underreported technique that affords the creation of reliable vascular options. Understanding the efficacy and impacting variables of microvascular reconstruction with an arteriovenous loop can be critical to its use.

METHODS

Multi-institutional study of 36 patients who underwent vein grafting or AV loop with free tissue transfer.

RESULTS

58.3% of patients received prior radiation and 38.9% prior flap reconstruction. Flap success for vein grafting was 76% and AV loop was 100% (p = 0.16). Success for the radiated cohort was 90.5% and non-radiated 80% (p = 0.63). Flap success for the radiated, vein grafted patient was 83.3% and 100% flap success rate for radiated, AV loop patient (p = 0.49). Overall flap survival was 83.3% versus 97% overall success rate in the United States.

CONCLUSION

The AV loop is a viable modality for vessel-depleted free tissue reconstruction. Radiation and previous surgery do not significantly impact flap success rates.

Reconstructing a chronic, malunited Galeazzi fracture with distal radial ulnar joint instability: a simple, modified technique

A male in his 70s presented with a chronic malunited comminuted Galeazzi fracture dislocation, including angular malunion, radial shortening (1.3 cm ulnar-plus variance) and distal radioulnar joint (DRUJ) instability secondary to chronic dislocation with mechanical rotation block. A modified, single-stage radius corrective osteotomy with bone grafting technique to overcorrect radius length was employed, restoring normal DRUJ motion and stability by engaging the secondary DRUJ stabilisers without triangular fibrocartilage complex repair. DRUJ stability was restored via radius lengthening, engaging the DRUJ’s secondary stabilisers, bypassing the need for complex ligamentous reconstruction. The patient returned to full activity. We recommend our simple yet effective approach to treat chronic, malunited Galeazzi fractures with DRUJ instability.

Disruption of targeted muscle reinnervation due to heterotopic ossification in an amputated lower extremity

A patient in his late 40s presented after 1-year following below knee amputation and targeted muscle reinnervation (TMR) with new prosthesis intolerance and pinpoint pain, suspicious for neuroma. X-ray confirmed fibular heterotopic ossification (HO). Operative revision identified HO encompassing a TMR construct with a large neuroma requiring excision and neuroplasty revision. Now approximately 1-year post procedure, the patient remains active, pain-free and ambulating with a prosthetic. Amputated extremities can be at risk for development of HO. Although described in literature, the pathophysiology and timeline for HO development is not well understood. Preventative measures for HO have been described, yet results remain variable. The gold standard for existing HO remains to be operative excision. Due to the unpredictable nature and debilitating presentation, risk of HO should be incorporated into patient-physician discussions. Additionally, new prosthetic intolerance absent of prior trauma should raise suspicion for possible HO development.

Multi-staged management of a mangled, exploded hand crush injury with long-term outcome: the critical link between surgery and therapy

A 38-year-old right-hand dominant man sustained a severe, work-related left-hand crushing injury. A multi-staged approach to salvage was employed in conjunction with aggressive hand therapy involvement for a successful, functional outcome. Now at approximately 5 years postinjury, the patient can perform daily activities, coaches sports and has returned to and maintained his full-time work position. Mangled, severe hand crush injuries warrant immediate treatment to debride non-salvageable tissues, stabilise and revascularise the hand in an effort to maximise reconstructive potential and functional capacity. It is critical to recognise that these cases require multiple stages of operative reconstruction with direct and ongoing involvement of hand therapy and pending degree of injury, rehabilitation often lasting months to years.

Multiple simultaneous venous flow-through free flap salvage for multifinger revascularisations

A 22-year-old man presented with traumatic crush-avulsion injuries to the left index, ring and small fingers resulting in complex soft tissue loss and acute three-finger ischaemia. The patient underwent immediate revascularisation and soft tissue resurfacing of the three digits using three separate venous flow-through free flaps performed in a single-stage operation. Continued follow-up after 9 months confirmed successful salvage of these three digits. Multiple simultaneous venous flow-through free flaps can be considered as a viable alternative reconstructive modality for traumatic multi-digit ischaemia where both graft-based digital artery reconstruction and soft tissue coverage are required for multiple digits.

Reconstruction of Congenital Arhinia With Stereolithographic Modeling: Case Correlate and Literature Review

Complete congenital arhinia is a rare defect of embryogenesis leading to the absence of the external nose and airway. We report our novel multistaged reconstructive approach and literature review. Nasal methyl methacrylate prosthesis was created from a stereolithographic model for use as a temporary prosthesis and tissue expander. Lefort 1 with cannulization was utilized for midface advancement and airway formation. External framework was reconstructed with bilateral conchal bowl cartilage and rib osteocartilagenous grafts. Patient was pleased with the aesthetics and had safe decannulation with the ability to breathe through the nose and airway.

Hospital-based, acute care within 30 days following discharge for acute burn injury

BACKGROUND

While the acute management of burn injury has received substantial attention, patients may undergo additional hospital based, acute care following initial management. We conducted this study to quantify and describe patients' full hospital based, acute care needs within 30 days following an acute burn injury.

METHODS

Using Florida, Nebraska, and New York state inpatient and emergency department databases, we identified adult patients discharged for an acute burn injury from January 1, 2010-November 30, 2014. The primary outcome was the frequency of hospital based, acute care (ED visit or hospital admission) within 30 days of initial discharge. Multivariable logistic regression modeling was used to identify patient factors associated with more frequent hospital based, acute care in the overall population.

RESULTS

The final sample included 126,685 patients who sustained an acute burn injury and were initially managed through the ED (88.3%) or by hospital admission (11.7%). Overall, 16.5% of patients experienced at least one hospital based, acute care encounter within 30 days of discharge of their initial encounter. Most commonly, these were ED visits not undergoing hospital admission for wound care, ongoing burn care, or infectious complications. Patient-level factors associated with more frequent encounters included a history of opioid misuse or abuse (Adjusted Odds Ratio = 2.23, [95% Confidence Interval 2.01-2.47]), chronic obstructive pulmonary disease (AOR = 1.25, [1.12-1.38]), diabetes mellitus (AOR = 1.13, [1.04-1.23]), and mental health diagnoses (AOR = 1.22, [1.11-1.34]).

CONCLUSIONS

Hospital based, acute care encounters are common after initial burn management. Further efforts are needed to improve the transition to outpatient care.

Reconstruction of the Mandibular Condyle

The mandibular condyle is an integral structure in the temporomandibular joint (TMJ) serving not only as the hinge point for mandibular opening, but also facilitating mandibular growth and contributing to facial aesthetics. Significant compromise of the TMJ can be debilitating functionally, psychologically, and aesthetically. Reconstruction of the mandibular condyle is rarely straightforward. Multiple considerations must be accounted for when preparing for condylar reconstruction such as ensuring eradication of all chronically diseased or infected bone, proving clear oncologic margins following tumor resection, or achieving stability of the surrounding architecture in the setting of a traumatic injury. Today, there is not one single gold-standard reconstructive method or material; ongoing investigation and innovation continue to improve and transform condylar reconstruction. Herein, we review methods of condylar reconstruction focusing on autologous and alloplastic materials, surgical techniques, and recent technological advances.

Snapping Extensor Pollicis Longus Tendon Subluxation Secondary to Trapeziometacarpal Instability: Case Report and Technique

CASE

A 20-year-old woman presented with painful, snapping extensor pollicis longus (EPL) tendon subluxation and trapeziometacarpal (TMC) joint instability. Hemi-extensor carpi radialis longus (ECRL) tendon autograft stabilized the TMC joint, reconstructing the 1-2 intermetacarpal ligament. The subluxed EPL tendon was centralized over the dorsal first metacarpal by tightening the metacarpophalangeal radial sagittal band and creating a dorsal first metacarpal "neosheath" pulley using ECRL graft remnant. Postoperative rehabilitation included Spica bracing and immediate thumb interphalangeal joint exercises.

CONCLUSION

The patient's pain due to EPL tendon subluxation and TMC joint instability completely resolved. Postoperative thumb range of motion and function were equivalent to the nonaffected side.

Reconstructing Complex Open Back Wounds with a Modified Minimal-Access Keystone Flap: A Case Report

CASE

A 61-year-old patient was referred 12 days postoperative with complex, infected, and dehisced paraspinal wound. After debridement and revision of hardware, deep dead space was eliminated through bilateral paraspinal muscle flap advancement. After hardware coverage, a large skin and tissue defect remained. The defect was reconstructed using a modified Keystone flap, eliminating the lateral cutaneous incision. Our patient healed without complication.

CONCLUSION

The modified Keystone flap is an option for reconstructing spinal wound defects, yielding excellent tissue coverage and advancement, grants additional flap advancement if necessary because of elimination of the lateral cutaneous incision, and an overall pleasing aesthetic result.

Avoiding Complications in Functional and Aesthetic Rhinoplasty

Historically, nasoseptal surgery favoring functional considerations has compromised aesthetic ones, and vice versa, but modern techniques have evolved that allow symbiotic achievement of both goals. Nasoseptal surgery is among the most commonly performed plastic surgical procedures in the United States, and while it is generally well tolerated, there are a few surgical and aesthetic complications of which to be aware. Herein, we review surgical techniques that improve the nasal airway and nasal aesthetics in a top-down approach with a discussion of possible ensuing complications.

Targeted muscle reinnervation following external hemipelvectomy or hip disarticulation: An anatomic description of technique and clinical case correlates

BACKGROUND

Targeted muscle reinnervation (TMR) has been shown to decrease or prevent neuropathic pain, including phantom and residual limb pain, after extremity amputation. Currently, a paucity of data and lack of anatomical description exists regarding TMR in the setting of hemipelvectomy and/or hip disarticulations. We elaborate on the technique of TMR, illustrated through cadaveric and clinical correlates.

METHODS

Cadaveric dissections of multiple transpelvic exposures were performed. The major mixed motor and sensory nerve branches were identified, dissected, and tagged. Amputated peripheral nerves were transferred to identified, labeled target motor nerves via direct end-to-end nerve coaptations per traditional TMR technique. A retrospective review was completed by our multi-institutional teams to include examples of clinical correlates for TMR performed in the setting of hemipelvectomies and hip disarticulations.

RESULTS

A total of 12 TMR hemipelvectomy/hip disarticulation cases were performed over a 2 to 3-year period (2018-2020). Of these 12 cases, 9 were oncologic in nature, 2 were secondary to traumatic injury, and 1 was a failed limb salvage in the setting of chronic refractory osteomyelitis of the femoral shaft.

CONCLUSIONS

This manuscript outlines the technical considerations for TMR in the setting of hemipelvectomy and hip disarticulation with supporting clinical case correlates.

Preserving the Knee in the Setting of High Segmental Tibial Bone and Massive Soft-Tissue Loss Using Vascularized Distal Tibial Bone Docking and a Foot Fillet Flap: A Case Report

CASE

We discuss our reconstructive approach to avoid an above-knee amputation in a 33-year-old man presenting after lower extremity crush injury. We used a vascularized tibial bone flap and a foot fillet flap to restore length and joint functionality to the residual limb. The patient ambulates with good prosthetic fit on durable heel pad skin and 100° active knee motion.

CONCLUSION

This pairing of intramedullary nail with vascularized bone flap and fillet flap to address soft-tissue coverage and retain limb length is a useful tool in traumatic lower extremity injury management, providing an alternative technique for tibial bone graft stabilization with robust, sensate tissue coverage.

Cannabis Abuse or Dependence and Post-operative Outcomes After Appendectomy and Cholecystectomy

BACKGROUND

Though cannabis is gaining broader acceptance among society and a noted increase in legalization, little is known regarding its impact on post-operative outcomes. We conducted this study to quantify the relationship between cannabis abuse or dependence (CbAD) on post-operative outcomes after cholecystectomy and appendectomy.

METHODS

Using the 2013-2015 Nationwide Readmissions Database, we identified discharges associated with cholecystectomy or appendectomy from January 2013-August 2015. Patients were grouped by CbAD history. The primary outcomes were length of stay, serious adverse events, home discharge, and 30-day readmission. Propensity-score matching was used to account for differences between groups and all statistics accounted for the matched sample.

RESULTS

The final sample included 3288 patients with a CbAD history matched 1:1 to patients without a CbAD history (total sample = 6576). After matching, acceptable balance was achieved in clinical characteristics between groups. In the cholecystectomy cohort (n = 1707 pairs), CbAD patients had longer hospitalizations (3.5 versus 3.2 d, P 0.003) and similar rates of serious adverse events (6.1 versus 4.8, P 0.092), home discharge (96.1 vs 96.2, P 0.855), and readmission (8.3 versus 6.9, P 0.137). In the appendectomy cohort (n = 1581 pairs), CbAD patients had longer hospital stays (2.7 versus 2.5 d, P 0.024); more frequent serious adverse events (5.0 versus 3.5, P 0.041); and similar home discharge (96.8 vs 97.3, P 0.404) and readmission (5.4 versus 5.1, P 0.639) rates.

CONCLUSIONS

Patients with a history of CbAD in the cholecystectomy and appendectomy cohorts had slightly longer hospital stays, and patients with a history of CbAD in the appendectomy group displayed a slight increase in adverse events, but otherwise similar clinical outcomes without clinically significant increases in complications compared to patients without this history.

Outcome of Early Motion Protocol for Total Hand Replantation: 1- and 2-Year Postoperative Results

Introduction  We review the benefits of early motion protocols following replantation of a total right hand amputation at 1 and 2 years after replantation, and provide recommendations for postoperative management. Materials and Methods  Replantation of the entire right hand in zone-4 was performed and supported by rigid external fixation spanning the forearm and hand. An early active "place-and-hold" motion protocol was initiated within the first 3 postoperative days. Metacarpophalangeal joint extensors were tethered by the pins, limiting full excursion. This resulted in stiffness and extensor adhesions that required a staged extensor tenolysis; however, all joints remained supple. The early motion protocol prevented the need for significant flexor tenolysis and joint releases. Results  Early motion rehabilitation protocols can produce very successful results in complex replantation. The enhanced stability afforded by external fixation of the wrist allowed us to perform aggressive early rehabilitation. Conclusion  This case highlights the benefits of early active motion (limiting the need for complex joint and flexor tendon releases) and demonstrates the degree of extensor adhesions caused by even minor extensor tendon tethering. This aggressive rehabilitation approach can produce excellent range of motion, and likely limit the need for secondary tenolysis and joint release procedures.

Public health outcome of Tuberculosis Cluster Investigations, England 2010-2013

OBJECTIVES

Tuberculosis (TB) is a serious re-emergent public health problem in the UK. In response to rising case incidence a National TB Strain-Typing Service based on molecular strain-typing was established. This facilitates early detection and investigation of clusters, targeted public health action, and prevention of further transmission. We review the added public health value of investigating molecular TB strain-typed (ST) clusters.

METHODS

A structured questionnaire for each ST cluster investigated in England between 1 January 2010 and 30 June 2013 was completed. Questions related to epidemiological links and public health action and the perceived benefits of ST cluster investigation.

RESULTS

There were 278 ST cluster investigations (CIs) involving 1882 TB cases. Cluster size ranged from 2 to 92. CIs identified new epidemiological links in 36% of clusters; in 18% STs were discordant refuting transmission thought to have occurred. Additional public health action was taken following 23% of CI.

CONCLUSIONS

We found positive benefits of TB molecular ST and CI, in identifying new epidemiological links between cases and taking public health action and in refuting transmission and saving resources. This needs to be translated to a decrease in transmission to provide evidence of public health value in this low prevalence high resource setting.

The Adjunctive Use of Biologically Engineered Products in Plastic Surgery Practice

Biologically engineered products are medical devices offer support and structure for wound healing by providing a scaffold for cell growth and proliferation. In the field of plastic surgery, these devices are being used to improve the outcomes of surgical closure in selected patients. The purpose of this article is to provide an overview of the source, indications, mechanisms, and outcomes of commonly used biologic products in wound healing. It will also provide an understanding of how biologics can be of value to patients with significant tissue defects requiring plastic surgery.

In vivo and in vitro ketamine exposure exhibits a dose-dependent induction of activity-dependent neuroprotective protein in rat neurons

Anesthetic doses of ketamine induce apoptosis, as well as gene expression of activity-dependent neuroprotective protein (ADNP), a putative homeodomain transcription factor in rat pups (P7). This study investigated if ketamine induced ADNP protein in a dose-dependent manner in vitro and in vivo using primary cultures of cortical neurons and neonatal pups (P7). In vivo immunohistochemistry demonstrated a sub-anesthetic dose of ketamine increased ADNP in the somatosensory cortex (SCC) which was previously identified to be damaged by repeated exposure to anesthetic doses of ketamine. Administration of low-dose ketamine prior to full sedation prevented caspase-3 activation in the hippocampus and SCC. Primary cultures of cortical neurons treated with ketamine (10 μM-10mM) at 3 days-in vitro (3 DIV) displayed a concentration-dependent decrease in expanded growth cones. Furthermore, neuronal production and localization of ADNP varied as a function of both ketamine concentration and length of exposure. Taken together, these data support the model that ADNP induction may be partially responsible for the efficacy of a low-dose ketamine pre-treatment in preventing ketamine-induced neuronal cell death.

Midwives' influenza vaccine uptake and their views on vaccination of pregnant women

BACKGROUND

Pregnant women in England are now offered seasonal influenza vaccine. Midwives could be influential in promoting this, but specific information on their views on the policy and their role in its implementation is lacking.

METHODS

London midwives were surveyed for their views on the new policy and their own vaccine uptake, using an anonymously self-completed semi-structured online survey via a convenience sampling approach.

RESULTS

In total, 266 midwives responded. Sixty-nine percent agreed with the policy of vaccinating all pregnant women. Seventy-six percent agreed that midwives should routinely advise pregnant women on vaccination, but only 25% felt adequately prepared for this role. Just 28% wished to be vaccinators, due to concerns about increased workload and inadequate training. Forty-three percent received seasonal influenza vaccine themselves. Major reasons for non-uptake were doubts about vaccine necessity (34%), safety (25%) and effectiveness (10%); and poor arrangements for vaccination (11%). Suggested strategies for improving their own uptake included better access to evidence of effectiveness (67%) and improved work-based vaccination (45%).

CONCLUSIONS

London midwives support influenza vaccination of pregnant women, but are more willing to give advice on, than to administer, the vaccine. Midwives' own influenza vaccine uptake could improve with more information and easier access to vaccination in their workplace.

The United Kingdom public health response to an imported laboratory confirmed case of a novel coronavirus in September 2012

On 22 September 2012, a novel coronavirus, very closely related to that from a fatal case in Saudi Arabia three months previously, was detected in a previously well adult transferred to intensive care in London from Qatar with severe respiratory illness. Strict respiratory isolation was instituted. Ten days after last exposure, none of 64 close contacts had developed severe disease, with 13 of 64 reporting mild respiratory symptoms. The novel coronavirus was not detected in 10 of 10 symptomatic contacts tested.

The United Kingdom public health response to an imported laboratory confirmed case of a novel coronavirus in September 2012

On 22 September 2012, a novel coronavirus, very closely related to that from a fatal case in Saudi Arabia three months previously, was detected in a previously well adult transferred to intensive care in London from Qatar with severe respiratory illness. Strict respiratory isolation was instituted. Ten days after last exposure, none of 64 close contacts had developed severe disease, with 13 of 64 reporting mild respiratory symptoms. The novel coronavirus was not detected in 10 of 10 symptomatic contacts tested.

Clostridium perfringens in London, July 2009: two weddings and an outbreak

Food poisoning outbreaks caused by Clostridium perfringens enterotoxin occur occasionally in Europe but have become less common in recent years. This paper presents the microbiological and epidemiological results of a large C. perfringens outbreak occurring simultaneously at two weddings that used the same caterer. The outbreak involved several London locations and required coordination across multiple agencies. A case-control study (n=134) was carried out to analyse possible associations between the food consumed and becoming ill. Food, environmental and stool samples were tested for common causative agents, including enterotoxigenic C. perfringens. The clinical presentation and the epidemiological findings were compatible with C. perfringens food poisoning and C. perfringens enterotoxin was detected in stool samples from two cases. The case-control study found statistically significant associations between becoming ill and eating either a specific chicken or lamb dish prepared by the same food handler of the implicated catering company. A rapid outbreak investigation with preliminary real-time results and the successful collaboration between the agencies and the caterer led to timely identification and rectification of the failures in the food handling practices.

Surveillance of antenatal infections--HIV, hepatitis B, syphilis and rubella susceptibility in London

London has relatively high rates of HIV, hepatitis B and syphilis, and has the potential for undiagnosed infection in pregnancy. As part of a drive to improve HIV testing in pregnancy, surveillance of a number of antenatal infections has been carried out in London's 30 maternity units since 2000. Infection screening rates rose from 89% in 2000 to 94% in 2002, and HIV screening rates increased from 66% to 86%. During 2002, 115,230 women booked for antenatal care; 998 were HBsAg positive (about ten in 1000), 452 were HIV positive (five in 1,000), 412 tested positive for syphilis (four in 1000), and 3,929 were susceptible to rubella (36 in 1000). The main burden of infection was concentrated in a few geographic areas. Worryingly the majority of women found to be HIV positive were diagnosed by antenatal screening and not before.

Hospital management of adults with severe acute respiratory syndrome (SARS) if SARS re-emerges--updated 10 February 2004

Severe Acute Respiratory Syndrome (SARS) is a potentially severe and highly infectious disease to which healthcare workers involved in the management of cases are particularly vulnerable. These guidelines briefly summarise optimal and safe practice for clinicians involved in the emergency care of patients with probable or confirmed SARS.

Selective production of rat mutant selenoprotein W with and without bound glutathione

Matrix-assisted laser desorption/ionization mass spectrometry (MALDI MS) and electrospray ionization mass spectrometry (ESI MS) analysis of a 6x His-tagged recombinant form of rat mutant selenoprotein W (RMSW) reveals that aerobic growth conditions primarily produce a form of RMSW without bound glutathione (10,305 Da) whereas anaerobic conditions produce a glutathione-bound (305 Da) form (10,610 Da). Purification of RMSW was achieved with a procedure employing acetone precipitation and DEAE-cellulose chromatography, in addition to Ni-NTA agarose chromatography. Additional steps, including polyvalent metal ion binding (PMIB) resin chromatography and CM-cellulose chromatography, were necessary after elution from the Ni-NTA agarose column, in order to maintain solubility of the purified protein.

SARS: UK public health response--past, present and future

The emergence of severe acute respiratory syndrome (SARS) in China, the occurrence of epidemics of SARS in China and a number of Southeast Asian countries, and its spread to countries elsewhere, have presented major challenges to public health systems throughout the world. Although very few true cases of SARS were detected in the United Kingdom, the public health response to the threat of SARS was considerable. The main components of this response were the early detection, isolation and reporting of cases, and the provision of comprehensive information to health professionals, cases, their contacts and the public. The development of the response to SARS raised a number of more general issues relevant to future infectious epidemic threats. Although the World Health Organisation has now declared SARS 'contained', the possibility of re-emergence is ever present. All countries will need to be vigilant and plan their response to the possibility of a renewed SARS epidemic.

Dityrosine as a product of oxidative stress and fluorescent probe

Dityrosine can be a natural component of protein structure, a product of environmental stress, or a product of in vitro protein modification. It is both a cross-link and a fluorescent probe that reports structural and functional information on the cross-linked protein molecule. Diverse reactions produce tyrosyl radicals, which in turn may couple to yield dityrosine. Identification and quantitation of dityrosine in protein hydrolysates usually employs reversed phase high pressure liquid chromatography (RP-HPLC) or gas chromatography. RP-HPLC of protein hydrolysates that have been derivatized with dabsyl chloride gives a complete amino acid analysis that includes dityrosine and 3-nitrotyrosine. Calmodulin, which contains a single pair of tyrosyl residues, undergoes both photoactivated and enzyme-catalyzed dityrosine formation. Polarization measurements, employing the intrinsic fluorescence of dityrosine, and catalytic activity determinations show how different patterns of inter- and intramolecular cross-linking affect the interactions of calmodulin with Ca(2+) and enzymes.

Practical limitations of tableting indices

The purpose of this study was to utilize tableting indices to distinguish between materials with varying degrees of compactibility by establishing a quantitative relationship between indices and compactibility. Compactibility in this study is restricted to tablet strength and friability alone. Nine mixtures with varying degrees of compactibility were tableted and the tensile strength and friability of the tablets were determined. The tableting indices of these mixtures were determined using an Instron Universal testing machine. An artificial neural network program was used to establish a quantitative relationship between indices and tablet strength and friability. Six new powders were used to validate the models describing the relationship between indices and tablet strength and friability. These powders were compressed into tablets and their strength and friability were determined. Their indices were also determined. The established models were used to predict tablet strength and friability from index values. The predicted values were compared with the experimentally determined values. There was little correlation between the predicted and experimentally determined values for tablet strength and friability. It was also found that materials or mixtures having almost similar indices had remarkably different compactibilities. It was concluded that models created to predict compactibility using one set of materials may not be able to successfully predict the compactibility of a new material. This calls into question the practicality of indices.

Vertebroplasty

Vertebroplasty is the percutaneous placement of polymethylmethacrylate (PMMA) into vertebral compression fractures for relief of pain. Polymethylmethacrylate is the cement used by orthopedic surgeons for rapid stable fixation of prosthetics in living bone. While the exact mechanism of pain relief is unknown, it is believed that the delivery of the PMMA into the fracture stabilizes the vertebral body, obtaining an analgesic effect. Vertebroplasty is an outpatient procedure that is performed with the aid of fluoroscopy. It has a high benefit/risk ratio with high success rates in comparison to extremely low complication rates. These patients consist of elderly osteoporotic patients that often times have underlying medical conditions or younger patients suffering from steroid or metastatic induced compression fractures. These patients are considered to be poor surgical candidates. In the past, this patient population has been relegated to epidural steroid injections, epidural catheters, or time contingent narcotics to control the pain. These conservative measures often lead to a patient with decreased activities of daily living and uncontrolled pain. Vertebroplasty provides a safe procedure that allows for long-term pain relief, decreased use of medication, and increased activities of daily living. This article is a review of the history, indications, contraindications, and key outcome studies. The technique is described along with complications, preprocedural care, and postprocedural care.

Expedition health and safety: a risk assessment

Little has been published on the risks of participating in an expedition. A questionnaire survey was conducted to quantify those risks and to determine how expedition organizers plan for medical mishaps. 246 expeditions, taking 2381 participants to more than one hundred countries, were studied retrospectively. 65 expeditions (26%) reported no medical incidents; the remaining 181 reported 835 in 130,000 man-days (6.4 per 1000 man-days). 59% of the medical incidents seen on expeditions were preventable, one-third of these being due to gastrointestinal upsets. 78% of medical incidents were classified as minor and only 5% (40) as serious. There was no excess of serious incidents in any particular organizational group or environment. The findings of this survey suggest that the health risks of participating in a well-planned expedition are similar to those encountered during normal active life.

Crystallization challenges in drug development: scale-up from laboratory to pilot plant and beyond

Crystallization is one of the most critical unit operations in the pharmaceutical industry. Pharmaceutical companies invest solid form of the drug substance. Rapid development of a candidate depends on the ability to produce desired drug substance with consistent properties as early as possible. This paper discusses the issues related to crystallization process laboratories at various stages in the drug development cycle. Critical issues at each stage of development, recent advances, and crystallization opportunities and their potential are outlined.

A rationale for the treatment algorithm of failed back surgery syndrome

Failed back surgery syndrome is continued low back pain with or without radicular pain after lumber surgery. The syndrome is difficult to treat due to the variability of pain generators. By examining the anatomy and pathophysiology of the pain mechanisms, a logical progression for an algorithm for treatment is presented.

Discography

Discography is a diagnostic tool that has been used for many years. Although controversial, it provides a physiologic test for evaluation of a disc with a volumetric, manometric, radiographic, and pain-provocative challenge. Although it has a controversial past, when the anatomy and pathophysiology are considered particularly in relation to intradiscal pressure and applied loads (that correlate with daily activities of the patient), the interpretation of the results of discography become more objective and reproducible. As with any procedure, indications for patient selection are an important step in successful outcomes. The equipment and technique used for performing discography using a manometry system are described in this article, as are a review of complications and outcomes. Discography is a safe, accurate, reproducible, objective diagnostic tool when tested for volume, pressure, fluoroscopic changes, and pain provocation.

The human language faculty as an organ

Developments in the study of language and cognition give increasing credibility to the view that human knowledge of natural language results from--and is made possible by--a biologically determined capacity specific both to this domain and to our species. The functional properties of this capacity develop along a regular maturational path, such that it seems more appropriate to speak of knowledge of our own language as growing rather than as being learned. That our learning of language results from a specific innate capacity rather than by general mechanisms of induction is supported by the extent to which we can be shown to know things that we could not have learned from observation of any plausible available teaching. The domain-specificity of the language faculty is supported by the many dissociations that can be observed between control of language structure and other cognitive functions. Finally, the species-specificity of the human language faculty is supported by the observation that (absent severe pathology) every human child exposed in even limited ways to the triggering experience of linguistic data develops a full, rich capacity that is essentially homogeneous with that of the surrounding community. Efforts to teach human language to other species, however, have uniformly failed. These considerations make it plausible that human language arises in biologically based ways that are quite comparable to those directing other aspects of the structure of the organism. The language organ, in this sense, can be interpreted in a functional sense, and not as implying an anatomical location comparable to that of, say, the kidney.

Evolution of epidural lysis of adhesions

Epidural neuroplasty (lysis of epidural adhesions) is an interventional technique that has emerged over the last 10 years as part of a multidisciplinary approach to treating radiculopathy with low back pain when conservative management has failed. Neuroplasty was at one time performed as a single-catheter technique using the caudal approach. It now has many variations, including placement of the catheter tip in the anterior epidural space. This article will discuss the evolution and refinement of epidural neuroplasty at our institution.

Binding of 9-anthroylcholine monitors the interactions of adenosine cyclic 3',5'-phosphate-dependent protein kinase with MgATP, substrates, and regulatory subunits

The isolated catalytic subunit of cAMP-dependent protein kinase and smooth muscle myosin light chain kinase undergo interactions with the fluorescent dye 9-anthroylcholine (9AC) that are responsive to the two enzymes' associations with substrates and effectors. Additionally, the binding of 9AC is highly sensitive to subtle structural or functional differences among closely related protein kinases. Skeletal muscle myosin light chain kinase and the catalytically active chymotryptic fragment of the gamma-subunit of phosphorylase kinase do not associate with 9AC. The 1:1 fluorescent complex of the isolated catalytic subunit of cAMP-dependent protein kinase with 9AC exhibits a dissociation constant of 21 microM. The association of the catalytic subunit with either of the regulatory subunits, RI and RII, results in decreases in the observed 9AC fluorescence that are reversed upon the addition of cAMP. The effects of MgATP and of polypeptide substrates (Kemptide, troponin I, protamine) on the 9AC-catalytic subunit complex are consistent with a general noncompetitive model in which the interactions of 9AC and the other ligands with the enzyme are mutually antagonistic but not purely competitive.

Flexibility involving the intermolecular dityrosyl cross-links of enzymatically polymerized calmodulin

The role of dityrosine as a fluorescent crossbridge between adjacent calmodulin molecules within the high molecular mass polymers that are generated by Arthromyces peroxidase-catalyzed cross-linking [Malencik, D. A., and Anderson, S. R. (1996) Biochemistry 35, 4375] has been examined in frequency domain fluorescence anisotropy studies. Measurements on a polymer fraction possessing a range of molecular masses > 96 000 in NaDodSO4 polyacrylamide gel electrophoresis demonstrate predominating fast local rotations involving the dityrosyl moieties. Normal distribution analyses of the results show peak rotational correlation times of 0.6 ns (zero Ca2+) and 1.2 ns (+Ca2+), values that are smaller than the principal correlation times determined for the global rotation of the free calmodulin monomer in either the presence or absence of Ca2+. The intermolecularly cross-linked segments of the polymers retain a degree of the mobility that is characteristic of the tyrosine-containing sequences of native calmodulin. The half-widths of the normal distribution curves range from 13 ns (zero Ca2+) to approximately 90 ns (5 mM Ca2+), thus encompassing varying rates of segmental motion within the polymers. When Ca2+ is present, possible contributions from the global rotations of polymer molecules are detected near the operating limits of the method. Experiments with the intramolecularly cross-linked calmodulin monomer give global rotational correlation times of 7.9 ns (zero Ca2+) and 11.4 ns (+Ca2+), which compare to values of 7.2 ns and 9.9 ns found previously in time domain measurements [Small, E. W., and Anderson, S. R. (1988) Biochemistry 27, 419]. Rotations of apparent phi2 = 0.2 to 0.3 ns also are detected, accounting for 31% (-Ca2+) to 23% (+Ca2+) of the anisotropy.