An investigation of the effects of procalcitonin testing on antimicrobial prescribing in respiratory tract infections in an Irish university hospital setting: a feasibility study

BACKGROUND

Diagnostic uncertainty and a high prevalence of viral infections present unique challenges for antimicrobial prescribing for respiratory tract infections (RTIs). Procalcitonin (PCT) has been shown to support prescribing decisions and reduce antimicrobial use safely in patients with RTIs, but recent study results have been variable.

METHODS

We conducted a feasibility study of the introduction of PCT testing in patients admitted to hospital with a lower RTI to determine if PCT testing is an effective and worthwhile intervention to introduce to support the existing antimicrobial stewardship (AMS) programme and safely decrease antimicrobial prescribing in patients admitted with RTIs.

RESULTS

A total of 79 patients were randomized to the intervention PCT-guided treatment group and 40 patients to the standard care respiratory control group. The addition of PCT testing led to a significant decrease in duration of antimicrobial prescriptions (mean 6.8 versus 8.9 days, P = 0.012) and decreased length of hospital stay (median 7 versus 8 days, P = 0.009) between the PCT and respiratory control group. PCT did not demonstrate a significant reduction in antimicrobial consumption when measured as DDDs and days of therapy.

CONCLUSIONS

PCT testing had a positive effect on antimicrobial prescribing during this feasibility study. The successful implementation of PCT testing in a randomized controlled trial requires an ongoing comprehensive education programme, greater integration into the AMS programme and delivery of PCT results in a timely manner. This feasibility study has shown that a larger randomized controlled trial would be beneficial to further explore the positive aspects of these findings.

NWChem: Past, present, and future

Specialized computational chemistry packages have permanently reshaped the landscape of chemical and materials science by providing tools to support and guide experimental efforts and for the prediction of atomistic and electronic properties. In this regard, electronic structure packages have played a special role by using first-principle-driven methodologies to model complex chemical and materials processes. Over the past few decades, the rapid development of computing technologies and the tremendous increase in computational power have offered a unique chance to study complex transformations using sophisticated and predictive many-body techniques that describe correlated behavior of electrons in molecular and condensed phase systems at different levels of theory. In enabling these simulations, novel parallel algorithms have been able to take advantage of computational resources to address the polynomial scaling of electronic structure methods. In this paper, we briefly review the NWChem computational chemistry suite, including its history, design principles, parallel tools, current capabilities, outreach, and outlook.

Intracranial haemorrhage in children with inherited bleeding disorders in the UK 2003-2015: A national cohort study

INTRODUCTION

Intracranial haemorrhage in children with inherited bleeding disorders is a potentially life-threatening complication and presents a significant therapeutic challenge.

AIM

To define the characteristics, management and outcomes of intracranial haemorrhage presenting in UK children ≤16 years of age with inherited bleeding disorders from 2003 to 2015.

METHOD

Retrospective analysis of children treated at UK haemophilia centres.

RESULTS

Of 66 children presenting with Intracranial haemorrhage (ICH), 82% had haemophilia A or B, 3% VWD and 15% a rare IBD. The IBD was a severe phenotype in 91%. The rates of ICH were 6.4 and 4.2 per 1000 patient years for haemophilia A and B, respectively. Median age at presentation was 4 months (33% neonates; 91% children <2 years of age). In neonates, delivery was spontaneous vaginal (SV) in 11, instrumental in 6, caesarean in 4 and unknown in 1. In children with haemophilia, the risk of ICH after instrumental delivery was 10.6 times greater than after SV delivery. Trauma was more common in children >2 years (67%) than in children 1 month to 2 years (18%; P = .027). Prior to ICH, only 4.5% of children were on prophylaxis. 6% of haemophiliacs had an inhibitor. The median duration of initial replacement therapy was 15 days. Mortality was 13.5%. Neurological sequelae occurred in 39% of survivors, being more common following intracerebral bleeding. In haemophilia survivors, 52% subsequently developed a FVIII inhibitor.

CONCLUSION

Intracranial haemorrhage occurs most frequently in children with severe IBDs, during the first 2 years of life and in children not receiving prophylaxis. Intracranial haemorrhage often occurs without documented trauma.

Preliminary report: Surgical outcomes following genitoplasty in children with moderate to severe genital atypia

INTRODUCTION

Prior studies of outcomes following genitoplasty have reported high rates of surgical complications among children with atypical genitalia. Few studies have prospectively assessed outcomes after contemporary surgical approaches.

OBJECTIVE

The current study reported the occurrence of early postoperative complications and of cosmetic outcomes (as rated by surgeons and parents) at 12 months following contemporary genitoplasty procedures in children born with atypical genitalia.

STUDY DESIGN

This 11-site, prospective study included children aged ≤2 years, with Prader 3-5 or Quigley 3-6 external genitalia, with no prior genitoplasty and non-urogenital malformations at the time of enrollment. Genital appearance was rated on a 4-point Likert scale. Paired t-tests evaluated differences in cosmesis ratings.

RESULTS

Out of 27 children, 10 were 46,XY patients with the following diagnoses: gonadal dysgenesis, PAIS or testosterone biosynthetic defect, severe hypospadias and microphallus, who were reared male. Sixteen 46,XX congenital adrenal hyperplasia patients were reared female and one child with sex chromosome mosaicism was reared male. Eleven children had masculinizing genitoplasty for penoscrotal or perineal hypospadias (one-stage, three; two-stage, eight). Among one-stage surgeries, one child had meatal stenosis (minor) and one developed both urinary retention (minor) and urethrocutaneous fistula (major) (Summary Figure). Among two-stage surgeries, three children developed a major complication: penoscrotal fistula, glans dehiscence or urethral dehiscence. Among 16 children who had feminizing genitoplasty, vaginoplasty was performed in all, clitoroplasty in nine, external genitoplasty in 13, urethroplasty in four, perineoplasty in five, and total urogenital sinus mobilization in two. Two children had minor complications: one had a UTI, and one had both a mucosal skin tag and vaginal mucosal polyp. Two additional children developed a major complication: vaginal stenosis. Cosmesis scores revealed sustained improvements from 6 months post-genitoplasty, as previously reported, with all scores reported as good or satisfied.

DISCUSSION

In these preliminary data from a multi-site, observational study, parents and surgeons were equally satisfied with the cosmetic outcomes 12 months after genitoplasty. A small number of patients had major complications in both feminizing and masculinizing surgeries; two-stage hypospadias repair had the most major complications. Long-term follow-up of patients at post-puberty will provide a better assessment of outcomes in this population.

CONCLUSION

In this cohort of children with moderate to severe atypical genitalia, preliminary data on both surgical and cosmetic outcomes were presented. Findings from this study, and from following these children in long-term studies, will help guide practitioners in their discussions with families about surgical management.

Prospective assessment of cosmesis before and after genital surgery

INTRODUCTION

Little data exist about the surgical interventions taking place for children with disorders of sex development (DSD). Most studies that have evaluated cosmetic outcomes after genitoplasty have included retrospective ratings by a physician at a single center.

OBJECTIVE

The present study aimed to: 1) describe frequency of sex assignment, and types of surgery performed in a cohort of patients with moderate-to-severe genital ambiguity; and 2) prospectively determine cosmesis ratings by parents and surgeons before and after genital surgery.

STUDY DESIGN

This prospective, observational study included children aged <2 years of age, with no prior genitoplasty at the time of enrollment, moderate-to-severe genital atypia, and being treated at one of 11 children's hospitals in the United States of America (USA). Clinical information was collected, including type of surgery performed. Parents and the local pediatric urologist rated the cosmetic appearance of the child's genitalia prior to and 6 months after genitoplasty.

RESULTS

Of the 37 children meeting eligibility criteria, 20 (54%) had a 46,XX karyotype, 15 (40%) had a 46,XY karyotype, and two (5%) had sex chromosome mosaicism. The most common diagnosis overall was congenital adrenal hyperplasia (54%). Thirty-five children had surgery; 21 received feminizing genitoplasty, and 14 had masculinizing genitoplasty. Two families decided against surgery. At baseline, 22 mothers (63%), 14 fathers (48%), and 35 surgeons (100%) stated that they were dissatisfied or very dissatisfied with the appearance of the child's genitalia. Surgeons rated the appearance of the genitalia significantly worse than mothers (P < 0.001) and fathers (P ≤ 0.001) at baseline. At the 6-month postoperative visit, cosmesis ratings improved significantly for all groups (P < 0.001 for all groups). Thirty-two mothers (94%), 26 fathers (92%), and 31 surgeons (88%) reported either a good outcome, or they were satisfied (see Summary Figure); there were no significant between-group differences in ratings.

DISCUSSION

This multicenter, observational study showed surgical interventions being performed at DSD centers in the USA. While parent and surgeon ratings were discordant pre-operatively, they were generally concordant postoperatively. Satisfaction with postoperative cosmesis does not necessarily equate with satisfaction with the functional outcome later in life.

CONCLUSION

In this cohort of children with genital atypia, the majority had surgery. Parents and surgeons all rated the appearance of the genitalia unfavorably before surgery, with surgeons giving worse ratings than parents. Cosmesis ratings improved significantly after surgery, with no between-group differences.

[Primary interdisciplinary reconstruction of perineal defects to reduce wound complications after abdominoperineal resection]

BACKGROUND

Multimodal treatment options for ultra-low neoplasms of the rectum or anal cancer include chemotherapy, radical abdominoperineal resection and/or radiation. Primary wound closure increases the risk of perineal wound complications that require secondary revision. Perineal wound complications may trigger delay of adjacent tumor therapy and thus have an impact on rate of local recurrence and long-term survival for rectal cancer. Simultaneous primary reconstruction of the perineal defect has been shown to reduce the incidence of perineal wound complications as well as hospital stay which enables timely adjacent therapy and may improve prognosis.

PATIENTS AND METHODS

This study was designed to retrospectively evaluate wound complications after abdominoperineal resection by comparing a group with and one without primary perineal reconstruction. Between 2005 and 2011, patients were analysed and divided into cohorts 1 and 2. Cohort 1 included n = 33 patients without primary perineal reconstruction. Cohort 2 included n = 4 patients with primary perineal reconstruction. Risk factors were identified for increased wound complications and delay of adjacent therapy.

RESULTS

Subgroup analysis revealed that 18 out of 33 patients of cohort 1 had wound complications. In five cases, prolonged wound healing resulted in a delay of adjacent therapies. Four patients suffered from progression of tumour, 2 out of these 4 patients had a history of delayed adjacent therapy. The main risk factor for prolonged wound healing due to postoperative complications was a history of neoadjuvant treatment resulting in a rate of 64.7 %. Cohort 2 undergoing primary reconstruction presented without wound complications or delay in adjuvant therapy.

DISCUSSION

A primary perineal reconstruction after APRE can reduce the rate of perineal wound complications. Furthermore, neoadjuvant treatment was shown to carry a major risk for wound complications. Patients after radio-/chemotherapy should undergo a primary reconstruction to prevent procedure-related perioperative morbidity. Subsequently, delays in adjuvant therapy, and prolonged hospital stay can be inhibited. Moreover, quality of life can be increased. The interdisciplinary approach aims at identifying high-risk patients for perineal wound complications who may benefit from primary reconstruction in order to reduce rate of wound complications with potential impact on rate of local recurrence. All these measures contribute to an optimized surgical standard.

Survival of the rumen bacterium Synergistes jonesii in a herd of Droughtmaster cattle in north Queensland

Droughtmaster steers from the CSIRO Research Station at Lansdown, 50 km south of Townsville, Queensland, were assessed at slaughter for indications of leucaena toxicity and the presence of the 3,4 dihydroxypyridine (DHP)-degrading bacterium Synergistes jonesii. This bacterium had been introduced to the herd 25 years earlier. Absence of clinical signs of ulceration of the oesophagus, absence of DHP in the urine, the presence of normal thyroid glands and the ability of rumen fluid to degrade high levels of mimosine from leucaena shoot tips in vitro all confirmed that these steers had an active bacterial culture capable of degrading mimosine and its degradation products 3,4 and 2,3 DHP. Steers had been away from the Research Station and away from leucaena pastures for long periods but had clearly not lost the bacteria or if they had, they had regained them on return to leucaena pastures on Lansdown. It is postulated that the bacteria may spread via the faeces in cattle yards and remain in the rumen for long periods, even at low levels, in the absence of leucaena in the diet. Reasons other than the effectiveness of the bacterium should be explored to explain the failure of cattle in some Queensland herds to fully degrade 3,4 and 2,3 DHP.

Decreased risk of complications with bilateral thoracoscopy and left-to-right mediastinal dissection during minimally invasive repair of pectus excavatum

INTRODUCTION

The repair of pectus excavatum using minimally invasive surgery is widely gaining acceptance as an equal if not superior technique to the traditional open approach. A number of modifications to the original Nuss procedure have been proposed to avoid complications.

PURPOSE OF THE STUDY

The aim of the study was to confirm the efficacy and safety of left-to-right mediastinal dissection during a Nuss procedure.

METHODS

A retrospective review of modified thoracoscopic Nuss repairs of pectus excavatum done at the Children's Hospital Oakland over approximately a 5-year period with subsequent data analysis was performed.

RESULTS

Thirty-two patients between the ages of 3 and 19 underwent a modified Nuss procedure using bilateral thoracoscopy and left-to-right mediastinal dissection. No intra- or postoperative complications were noted in any of the patients, which included but were not limited to mediastinal injury, bleeding, or chest tube insertion for pneumothorax.

CONCLUSIONS

Bilateral thoracoscopic repair of pectus excavatum with left-to-right mediastinal dissection is a safe alternative to the traditional approach, as it allows a more complete visualization of the mediastinum and eliminates the need for additional safety measures such as subxiphoid dissection and elevation.

Acculturation and the prevalence of pain amongst South Asian minority ethnic groups in the UK

BACKGROUND

Musculoskeletal pain is reported more commonly by South Asians in the UK than by white Europeans. This may result from a variety of factors, including cultural differences, and thus we investigated the extent to which differences in the prevalence of pain within the South Asian population could be explained by differences in acculturation (the extent to which immigrants take on the culture of their host population).

METHODS

Nine hundred and thirty-three Europeans and 1914 South Asian (1165 Indian, 401 Pakistani and 348 Bangladeshi) subjects were recruited from the age-sex registers of 13 general practices in areas with high densities of South Asian populations (Bolton, Oldham, Ashton-under-Lyne and Birmingham). A 28-item acculturation scale was developed, based, on aspects including use of language, clothing style, and use of own-culture media. Principle component analysis generated a score (range 0-100), which was validated against constructs expected to relate to acculturation, such as years of full time education and time spent in the UK. The presence of widespread pain was assessed by the answer to the question 'Have you suffered from pain all over the body in the past month?'

RESULTS

Widespread pain was more common in all three South Asian ethnic groups than in the white Europeans [odds ratio (OR) = 3.7, 95% confidence interval (CI) 2.9-4.9], with this increase ranging from 2.7 to 5.8 in the different South Asian subgroups. There was a similar increase in consultation rates for pain. Within the South Asians, pooling all three groups, there was a strong negative association between acculturation score and widespread pain, which remained after adjusting for age and sex: [OR (95% CI) per standard deviation decrease in acculturation score -1.2 (1.0-1.3)]. Adjusting for acculturation accounted for some, but not all, of the differences between the ethnic groups in the prevalence of widespread pain: OR 2.0 (95% CI 1.4-3.0).

CONCLUSIONS

Widespread pain is more commonly reported in South Asians though there are interesting differences within the South Asian community. Lower acculturation has a strong influence on the reporting of pain, but cannot explain all of the difference between South Asian and European populations.

An excess of widespread pain among South Asians: are low levels of vitamin D implicated?

BACKGROUND

Anecdotal reports from rheumatologists in the United Kingdom suggest that patients from South Asian backgrounds are more likely to report widespread body pain.

OBJECTIVE

To confirm the presence of an excess of widespread pain in South Asians, and to evaluate the relationship of their symptoms with levels of 25-OH vitamin D.

METHODS

Two population studies involving over 3135 subjects were carried out in the North West and Midlands areas of England.

RESULTS

The first study confirmed an excess of widespread pain among South Asians (OR = 1.6, 95% CI 1.3 to 2.1). The second smaller study conducted only among young women also showed a similar excess of widespread pain among South Asians (OR = 1.8, 95% CI 0.7 to 4.7) and found that low levels of 25-OH vitamin D (<10 ng/ml) were more common among those with widespread pain (OR = 3.5, 95% CI 0.4 to 31.0).

CONCLUSIONS

Owing to the small numbers, the relationship between 25-OH vitamin D and widespread pain must be considered preliminary and requires further investigation. However, it may be one potentially treatable cause of widespread pain.

Verapamil (VP) improves the outcome after renal transplantation (CRT)

Calcium antagonists (CATs) have a role in the management of certain types of renal insufficiency. These include prophylaxis against post-transplant-associated acute renal failure and cyclosporine A (CsA)-induced renal dysfunction. For the transplanted kidney, CATs may be beneficial in several settings. First, a CAT during organ procurement protects the kidney during ischemic periods. Second, CATs given perioperatively protect the kidney during reperfusion and early after transplantation. Third, CATs also offer protection against CsA nephrotoxicity.

Ovarian responses in gonadotrophin-releasing hormone-treated anoestrous ewes: follicular and endocrine correlates with luteal outcome

The relationships between the development of antral follicles (growing from 3 to > or = 5 mm diameter), hormone secretion (luteinizing hormone (LH), follicle-stimlating hormone (FSH), oestradiol and progesterone), ovulation and the formation of luteal structures in response to gonadotrophin-releasing hormone (GnRH) were examined in 24 anoestrous Western White Face ewes (May-July). Ewes were monitored by transrectal ovarian ultrasonography for 34 days, commencing 15 days before the administration of GnRH. Following treatment with GnRH, 83% (20/24) of ewes ovulated. Twenty-five per cent of all ewes (6/24) subsequently had normal (full-life span) corpora lutea (CL), 37% (9/24) had inadequate CL, 17% (4/24) had both normal and inadequate CL, 17% (including three of four anovular ewes and one ewe with inadequate CL) formed luteinized follicles and only 4% (1/24) did not ovulate or produce any luteal structure. None of the variables of follicular growth (follicles reaching > or = 5 mm diameter) differed between follicles that either ovulated or failed to ovulate and there was no evident correlation between the age or stage of development of ovulatory sized antral follicles and the type of luteal structure formed, except for luteinized unovulated follicles; these follicles all emerged within 3 days of GnRH injection. Mean serum concentrations of FSH and oestradiol before treatment did not differ (P>0.05) between ewes with different ovarian responses, but peaks of fluctuations in serum concentrations of FSH in daily samples were higher in ewes that produced normal CL compared with ewes with inadequate CL. After GnRH treatment, oestradiol secretion was higher in ewes that formed luteinized unovulated follicles than in all ewes with inadequate CL (P<0.05). The peak concentration of the GnRH-induced LH surge was higher and the interval from GnRH to peak LH discharge was shorter in ewes with inadequate CL compared with ewes that had normal CL after ovulation (P<0.05). In conclusion, ovulatory sized antral follicles at a similar stage of their life span can give rise to either normal or inadequate CL and a proportion of these follicles do not ovulate in response to GnRH in seasonally anoestrous ewes. This suggests differences in ovarian follicular responsiveness to gonadotrophic stimuli. Both the amplitude of episodic elevations in daily serum FSH concentrations and the characteristics of the pre-ovulatory LH surge may be important for luteogenesis following ovulation.

Identification and antigenicity of broadly cross-reactive and conserved human immunodeficiency virus type 1-derived helper T-lymphocyte epitopes

Human immunodeficiency virus (HIV)-specific helper T lymphocytes (HTL) play a key role in the immune control of HIV type 1 (HIV-1) infection, and as such are an important target of potential HIV-1 vaccines. In order to identify HTL epitopes in HIV-1 that might serve as vaccine targets, conserved HIV-1-derived peptides bearing an HLA-DR binding supermotif were tested for binding to a panel of the most representative HLA-DR molecules. Eleven highly cross-reactive binding peptides were identified: three in Gag and eight in Pol. Lymphoproliferative responses to this panel of peptides, as well as to the HIV-1 p24 and p66 proteins, were evaluated with a cohort of 31 HIV-1-infected patients. All 11 peptides were recognized by peripheral blood mononuclear cells from multiple HIV-infected donors. Many of the responsive HIV-infected subjects showed recognition of multiple peptides, indicating that HIV-1-specific T-helper responses may be broadly directed in certain individuals. A strong association existed between recognition of the parental recombinant HIV-1 protein and the corresponding HTL peptides, suggesting that these peptides represent epitopes that are processed and presented during the course of HIV-1 infection. Lastly, responses to the supermotif peptides were mediated by CD4(+) T cells and were restricted by major histocompatibility complex class II molecules. The epitopes described herein are potentially important components of HIV-1 therapeutic and prophylactic vaccines.

Effect of preslaughter feed withdrawal period on longissimus tenderness and the expression of calpains in the ovine

The objective was to study the role of calpains in meat tenderness. Lambs were fasted for various periods of time to generate differences in meat tenderness and to determine in tandem the expression of calpain 1, calpain 2, calpain 3, and calpastatin. The assumption has been that increased calpain expression associated with an increase in tenderness indicates a role for calpain in the tenderization process and vice versa. Fasting lambs for 1 day caused a significant improvement in longissimus (LD) tenderness compared to the control. Correlations between the tenderness of the LD and the expression of the calpains and calpastatin were significant for calpains 1 and 3 but not for calpain 2 or calpastatin. Consequently, this study supports a role for calpains 1 and 3, but not for calpain 2, in the tenderization of the LD from fasted lambs during post-mortem aging.

Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms

OBJECTIVES

To compare the efficacy of antidepressant drugs and generic counselling for treating mild to moderate depression in general practice. To determine whether the outcomes were similar for patients with randomly allocated treatment and those expressing a treatment preference.

DESIGN

Randomised controlled trial, with patient preference arms. Follow up at 8 weeks and 12 months and abstraction of GP case notes.

SETTING

31 general practices in Trent region.

PARTICIPANTS

Patients aged 18-70 who met research diagnostic criteria for major depression; 103 patients were randomised and 220 patients were recruited to the preference arms.

MAIN OUTCOME MEASURES

Difference in mean Beck depression inventory score; time to remission; global outcome assessed by a psychiatrist using all data sources; and research diagnostic criteria.

RESULTS

At 12 months there was no difference between the mean Beck scores in the randomised arms. Combining the randomised and patient preference groups, the difference in Beck scores was 0.4 (95% confidence interval -2.7 to 3.5). Patients choosing counselling did better than those randomised to it (mean difference in Beck score 4.6, 0.0 to 9.2). There was no difference in the psychiatrist's overall assessment of outcome between any of the groups. 221/265 (83%) of participants with a known outcome had a remission. Median time to remission was shorter in the group randomised to antidepressants than the other three groups (2 months v 3 months). 33/221 (15%) patients had a relapse.

CONCLUSIONS

Generic counselling seems to be as effective as antidepressant treatment for mild to moderate depressive illness, although patients receiving antidepressants may recover more quickly. General practitioners should allow patients to have their preferred treatment.

Comparison of rumen fluid from South African game species and from sheep to digest tanniniferous browse

The hypothesis that South African game animals that use browse containing condensed tannins (CT) could have rumen microbial populations better able to ferment tanniniferous forages was explored. Rumen fluid (RF) from a range of browsing ruminants was used to ferment tanniniferous forages in vitro and the results were compared with the values obtained with rumen fluid from sheep. Leaves of the shrub legumes Leucaena leucocephala, L. pallida, L. trichandra, Calliandra calothyrsus,Gliricidia sepium, and Acacia boliviana were used as substrates. In vitro digestibility of dry matter (IVDMD) and nitrogen (IVND) was measured in the presence or absence of polyethylene glycol (PEG) 4000 to assess the adverse effects of the CT in the feeds. Rumen fluid from giraffe, greater kudu, eland, duiker, impala, nyala, goat, and gnu was compared with that from sheep. Ability to metabolise or block the adverse effects of CT was expected to result in only a small or no response to PEG in terms of IVDMD and IVND with rumen fluid from browsers, and therefore to result in a significant animal feed and animal PEG interaction. There were no significant (P > 0.05) animal feed interactions. For every animal species there was a response to PEG in terms of IVND, and this response was linearly related to the CT in the feed as measured by PEG binding using 14C-labelled PEG. Rumen fluid from browsers had a lower pH (5.78 0.060 v. 6.68 0.052) and a higher dry matter content (1473 102 mg v. 415 4.3 mg/100 mL RF) than that of grazers (sheep and gnu). However, when measured at 2 pH levels (6.7 and 5.8), IVDMD and IVND of the feeds were not improved at the lower pH with rumen fluid from the browsers. Rather, digestibility was depressed at the lower pH with rumen fluid from all animal species. We conclude from these in vitro studies that rumen microbial populations from browsers are not able to ferment tanniniferous forages better than rumen microbial populations from grazers. It seems likely that these browsers do not have rumen bacteria capable of degrading the CT in these shrub legumes. Production on such tanniniferous feeds may well depend on tannin binding with proline-rich saliva rather than on metabolism of or tolerance to CT by rumen bacteria.

Effect of the tropical forage calliandra on microbial protein synthesis and ecology in the rumen

AIMS

To determine the effect of condensed tannins in Calliandra calothyrsus (calliandra) on rumen microbial function.

METHODS AND RESULTS

Microbial populations, ruminal protein synthesis and fermentation end-products were measured in sheep fed roughage hay supplemented with calliandra (30%), with and without inclusions of polyethylene glycol (PEG) to counteract the effect of tannin. Molecular and conventional enumeration techniques were used to quantify rumen bacteria, fungi and protozoa, and protein synthesis was predicted from estimates of urinary purine excretion. The total number of cellulolytic bacteria, including populations of Fibrobacter succinogenes and Ruminococcus spp., was significantly lower in sheep supplemented with calliandra and these populations increased when animals were treated with PEG. By contrast, protozoa and fungi and the microbial group containing Bacteroides-Porphyromonas-Prevotella bacteria appeared to be less affected. The efficiency of microbial protein synthesis in the rumen was not altered significantly.

CONCLUSION

Calliandra caused significant shifts in rumen microbial populations without changing the efficiency of protein synthesis.

SIGNIFICANCE AND IMPACT OF THE STUDY

The effect of calliandra tannins on rumen digestion may result more from complexing with nutrients than direct inhibition of micro-organisms.

Disposition of a mixed meal by conscious dogs after seven days of treatment with cyclosporine A and prednisone

BACKGROUND

Combination immunosuppressive therapy, that often includes prednisone and cyclosporine A (CyA), is commonly used in the treatment of organ transplant patients. We hypothesized that CyA and prednisone treatment would alter the roles of the liver and peripheral tissues in the disposal of carbohydrates from a meal.

METHODS

Using the arteriovenous difference technique, we examined the disposition of an intragastrically delivered mixed meal in eight 24-hour fasted conscious dogs that had received CyA 15 mg x kg(-1) daily and prednisone 5 mg twice daily for 7 consecutive days before study (CyA-prednisone group). The results were compared with those from a group of 13 dogs (control group) receiving the same meal but no drugs.

RESULTS

Neither arterial blood glucose concentrations nor arterial plasma insulin or glucagon concentrations differed significantly between the groups at any time. Cumulative net gut glucose output was equivalent to 43 +/- 9 vs 57% +/- 7% of the glucose in the meal in CyA-prednisone vs control (p = .12). The CyA-prednisone group exhibited greater (p < .05) mean net hepatic glucose uptakes (15.4 +/- 4.6 vs 4.3 +/- 2.2 micromol x kg(-1) x min(-1) and net hepatic fractional extractions of glucose (7.8 +/- 1.6 and 1.5% +/- 1.0%) than the control group. Arterial blood lactate concentrations and net hepatic lactate output were greater in the CyA-prednisone group than the control group (p < .05). Hepatic glycogen content at the end of the study was 2.5-fold greater in the CyA-prednisone group than in the control group (p < .05). The nonhepatic tissues disposed of approximately 91% of the absorbed glucose in the control group but only approximately 26% in the CyA-prednisone group (p < .05).

CONCLUSIONS

CyA-prednisone treatment caused a marked shift in the carbohydrate disposal from a meal, enhancing the hepatic glucose uptake and decreasing peripheral glucose disposal.

Alpha-tocopherol supplementation decreases the oxidative susceptibility of LDL in renal failure patients on dialysis therapy

Atherosclerotic cardiovascular disease is the leading cause of death in patients with end stage renal disease (ESRD) who have undergone dialysis treatment. The oxidation of low density lipoprotein (LDL) appears to be a crucial step in the pathogenesis of atherosclerosis. The increased oxidative stress and attendant increased oxidizability of lipoproteins, such as LDL could contribute to the accelerated atherosclerosis in dialysis patients. Since alpha-tocopherol (AT) is the major antioxidant in LDL, the aim of the present study was to test the effectiveness of RRR-AT supplementation (800 I.U. per day) for 12 weeks on the susceptibility of LDL to oxidation. The study subjects comprised patients with chronic renal failure on hemodialysis (HD), peritoneal dialysis (PD), and age and sex matched controls (C). Plasma fatty acids, lipoproteins and AT levels were measured in these subjects before and after supplementation. Also, LDL AT and oxidizability was studied. LDL was isolated by ultracentrifugation at baseline and after 12 weeks of supplementation, and subjected to a 5-h time course of copper catalyzed oxidation. Oxidation was measured by the formation of conjugated dienes (CD) and lipid peroxides (LP). Supplementation with AT did not alter the plasma lipid or lipoprotein profile of these subjects. Plasma lipid-standardized AT and LDL AT concentrations were not different among the groups at baseline. AT supplementation significantly increased plasma lipid-standardized AT (C=150%, HD=149%, PD=217%, P<0.001) and LDL AT concentrations (C=94%, HD=94%, PD=135%, P<0.003). AT enrichment of LDL resulted in a significant prolongation in conjugated diene lag phase in all groups (C=34%, HD=21%, PD=54%, P<0.02). Lipid peroxide lag phase was also increased significantly in C (27%,) and PD (40%) groups after AT supplementation (P<0.01). There was a significant positive correlation between plasma lipid standardized AT and lag phase (r=0. 54, P=0.0003). Overall, AT decreased the susceptibility of LDL to oxidation in patients with chronic renal failure but the benefit appears to be greater in patients on PD. Therefore, AT supplementation may also provide a measure of protection against CAD in patients with chronic renal failure on dialysis therapy.

Validation of a new technique to detect malingering of cognitive symptoms: the b Test

We administered the b Test, a new measure to identify malingering requiring recognition of overlearned information, to 34 suspected malingerers and to 161 subjects in various clinical groups (moderate to severe head injury, elderly depressed, learning disability, schizophrenia, right and left CVA, and elderly normals). Comparisons of groups revealed more commission and omission errors in the suspected malingerers relative to all groups except the right stroke patients. In addition, suspected malingerers took longer to complete the task than all groups except right and left stroke patients and normal elderly. A cutoff of >2 commission errors produced a sensitivity of 76.5% and specificity for all comparison groups combined of 82.6%. Lower sensitivity rates were documented for omissions (58.8 using cutoff of >40) and time (57.6% using cutoff of >12 minutes), but specificity remained high at 85.1% and 83.9%, respectively. Thus, the b Test shows considerable potential as a malingering detection tool.

Immediate breast reconstruction after mastectomy for cancer

AIMS

The oncological, surgical and cosmetic results, patient satisfaction and psychological morbidity of immediate breast reconstruction following mastectomy for breast cancer were evaluated.

METHODS

From 1980 to 1994, 79 immediate breast reconstructions were performed in Malmö. From 1985 immediate breast reconstruction was performed in 21% of mastectomies among patients </=65 years. The most common indication for immediate reconstruction was extensive DCIS+/-multifocal invasive growth. In 61 cases permanent implants were used and in 18 expanders. The median volume in the permanent implants was 225 ml, compared with 380 ml in cases where expanders were used.

RESULTS

Post-operative complications requiring re-operation occurred in 13%. After introduction of the expander technique, no necrosis requiring explanation has occurred. Of the patients receiving radiotherapy, 71% developed capsular contracture (10/14). Four patients developed locoregional recurrence. Three-quarters of the patients had an acceptable to very satisfactory cosmetic result. Eight per cent were judged to have a Baker III-IV contracture. Of the patients, 85% were satisfied with the softness of the reconstructed breast and 76% stated the result to be in accordance with their expectations.

CONCLUSIONS

We find immediate breast reconstruction after mastectomy a safe operation with results comparable to those after late reconstruction and without an increased risk of recurrence. Immediate reconstruction with an implant is not recommended in cases where radiotherapy may be necessary.

Isolation and characterization of proteolytic ruminal bacteria from sheep and goats fed the tannin-containing shrub legume Calliandra calothyrsus

Tannins in forages complex with protein and reduce the availability of nitrogen to ruminants. Ruminal bacteria that ferment protein or peptides in the presence of tannins may benefit digestion of these diets. Bacteria from the rumina of sheep and goats fed Calliandra calothyrsus (3.6% N and 6% condensed tannin) were isolated on proteinaceous agar medium overlaid with either condensed (calliandra tannin) or hydrolyzable (tannic acid) tannin. Fifteen genotypes were identified, based on 16S ribosomal DNA-restriction fragment length polymorphism analysis, and all were proteolytic and fermented peptides to ammonia. Ten of the isolates grew to high optical density (OD) on carbohydrates (glucose, cellobiose, xylose, xylan, starch, and maltose), while the other isolates did not utilize or had low growth on these substrates. In pure culture, representative isolates were unable to ferment protein that was present in calliandra or had been complexed with tannin. One isolate, Lp1284, had high protease activity (80 U), a high specific growth rate (0.28), and a high rate of ammonia production (734 nmol/min/ml/OD unit) on Casamino Acids and Trypticase Peptone. Phylogenetic analysis of the 16S ribosomal DNA sequence showed that Lp1284 was related (97. 6%) to Clostridium botulinum NCTC 7273. Purified plant protein and casein also supported growth of Lp1284 and were fermented to ammonia. This is the first report of a proteolytic, ammonia-hyperproducing bacterium from the rumen. In conclusion, a diverse group of proteolytic and peptidolytic bacteria were present in the rumen, but the isolates could not digest protein that was complexed with condensed tannin.

Incidence of tardive dyskinesia in early stages of low-dose treatment with typical neuroleptics in older patients

OBJECTIVE

The authors studied the risk of tardive dyskinesia for older patients in the early stages of treatment with typical neuroleptics.

METHOD

They examined the cumulative incidence of tardive dyskinesia 1, 3, 6, 9, and 12 months after the institution of neuroleptic therapy among 307 psychiatric outpatients over age 45. The patients' median dose was 68.4 mg/day of chlorpromazine equivalent.

RESULTS

In the patients who had never received neuroleptics at baseline (N = 87), the mean cumulative incidence of tardive dyskinesia was 3.4% and 5.9% at 1 and 3 months, respectively. There was no significant difference in the 12-month cumulative incidence of tardive dyskinesia among patients who had been neuroleptic-naive at baseline (22.3%) and the 89 patients who had received neuroleptics before baseline for 1-30 days (24.6%); however, the 131 patients who had received neuroleptics before baseline for more than 30 days tended to have a greater cumulative 12-month incidence of tardive dyskinesia (36.9%).

CONCLUSIONS

The risk of tardive dyskinesia in older outpatients is high, even with relatively short treatment with low doses of conventional neuroleptics.

In vitro screening of rumen fluid samples from indigenous African ruminants provides evidence for rumen fluid with superior capacities to digest tannin-rich fodders

The capabilities of rumen fluid sources from indigenous African ruminants and hindgut fluid from zebra to ferment leaves of Acacia angustissima, Calliandra calothyrsus, Leucaena diversifolia, Leucaena leucocephala, Leucaena pallida, and Tephrosia bracteolata were evaluated to determine the presence of tannin tolerant or degrading microbes. In vitro gas and ammonia production and loss of neutral detergent fibre were estimated as indices for fermentation. The effect of polyethylene glycol (PEG) on fermentation was tested. The ability of microorganisms in rumen fluid sources to grow in the presence of tannin extracts or tannic acid was also tested and their disappearance was determined by HPLC. There was a significant (P < 0.001) rumen fluid source × fodder type interaction with all variables studied. The highest gas and ammonia production was from samples incubated with rumen fluid from dik-dik and goat. Addition of PEG enhanced fermentation with various rumen fluid sources and from some plant leaves but its effect was greatest (P < 0.001) in A. angustissima. HPLC results showed that tannin and phenolic monomers were hydrolysed by all rumen fluid sources. The conclusion from this work was that rumen fluid from goat, gazelle, Gunther™s dik-dik, and impala effectively fermented tannin-rich fodders and therefore may harbour tannin tolerant or degrading microorganisms.

Primary reconstructive surgery with a sliding flap for carcinoma of the Bartholin gland

Bartholin gland tumours are rare and therefore recommendations concerning management have been based on small series. Although there is a tendency today to perform less radical surgery, meaning hemivulvectomy or a wide local excision, the anatomical position of these tumours often leads to a large postoperative defect. The objective of this report is to present data on three patients but mainly to describe our surgical technique where a sliding flap obtained from the gluteal region is used for primary closure. This surgical procedure offers a functional and cosmetically acceptable vulva which is of importance considering the relative young age of patients with Bartholin gland tumours.

IgE and non-IgE mediated allergic disorders in systemic lupus erythematosus

OBJECTIVE

To ascertain the prevalence of IgE and non-IgE mediated allergic disorders in patients with systemic lupus erythematosus (SLE).

METHODS

49 SLE cases (all satisfying at least four "Revised ARA Criteria") and 98 healthy, age, and sex matched controls (randomly selected through two urban general practices and one rural general practice) were interviewed by telephone to screen for a history of allergy. Subjects with a history of allergic rhinitis, asthma or atopic eczema then underwent skin prick testing to confirm underlying IgE mediated disease.

RESULTS

Analysis of the data by conditional logistic regression revealed no significant difference in frequency of allergic disorders in SLE cases and controls (odds ratio (OR) 0.92, 95% confidence intervals (CI) 0.45, 1.86). In addition a subgroup analysis of subjects with IgE mediated/associated atopic disorders, showed that cases and controls were at a similar risk of having these conditions (OR 0.90, 95% CI 0.41, 1.96).

CONCLUSIONS

This study suggests that people with SLE are not at an increased risk of IgE mediated/associated allergic disorders, in contrast with previous reports.