Aspirin deprescribing in primary prevention of cardiovascular disease: a prospective risk-benefit approach

BACKGROUND

Current evidence and practice guidelines do not recommend aspirin for primary prevention of cardiovascular disease (CVD). Insufficient all-cause mortality benefits juxtaposed to increased gastrointestinal bleeding rates are well established. Pharmacists are well placed to assess the clinical appropriateness of aspirin in CVD and initiate deprescribing as required with medical colleagues.

AIM

The aim of this study was to identify medical inpatients taking aspirin for primary prevention of CVD and initiate deprescribing utilising a risk-benefit approach.

METHODS

A single-arm prospective feasibility study of general medicine patients admitted to a major tertiary hospital over 5 weeks (July-August 2020) was conducted. Screened patients were categorised as either taking aspirin for primary or secondary prevention. A 5-year benefit-risk analysis of bleeding and cardiovascular risk was calculated using a validated tool from the Cardiac Society of Australia and New Zealand to guide recommendations.

RESULTS

This study screened 277 patients, of which 71 patients were identified as taking aspirin. Ten of these patients (14%) were categorised as taking aspirin for primary prevention and thus were deemed suitable for deprescribing. The analysis showed that aspirin continuance would, on average, increase major bleeding events by 39%, whilst reducing major cardiovascular events by 13.4%. Pharmacists recommended aspirin cessation in seven of the cases identified, and deprescribing was successful in five cases.

CONCLUSIONS

This study described an impactful pharmacist-led initiative utilising a validated aspirin-specific tool to conduct risk-benefit analysis to reduce potential major bleeding associated with inappropriate aspirin use.

A 12-month audit of clozapine associated myocarditis in a South Australian Local Health Network: The importance of screening and personalised titration

Clozapine is effective in up to 50 % of patients resistant to other antipsychotics. Its use is restricted to third-line due to adverse effects which include myocarditis. Australia reports the highest incidence of clozapine-associated myocarditis (CAM) in the context of pharmacovigilance and relatively rapid titration. An audit of patients commenced on clozapine within the Central Adelaide Local Health Network (CALHN) between 2012 and 2015 found an incidence of 8.6 %. We present here a case series from a follow up audit considering titration relevant risk factors for CAM. We reviewed anecdotal cases and data from all hospital-based commencements of clozapine across CALHN for the period July 2021 to June 2022 using pharmacy and medical record databases. We identified 5 cases of CAM and all had risk factors impacting on clozapine metabolism, including rapid titration, elevated baseline CRP, Asian ethnicity and concomitant treatment with inhibitors of clozapine metabolism. While personalisation of clozapine treatment needs further investigation in prospective trials, slower titration to lower targets for risk groups may not impact on hospital length of stay and has the potential to significantly reduce the burden of adverse events. Australian manufacturer approved titration rates exceed those recommended for personalised dosing and may not be safe for patients with risk factors. Early clozapine levels at week two could identify slow metabolisers for dose adjustment. Closer ties between psychiatrists and cardiologists are critical for the development of protocols for safely maintaining clozapine treatment during low level cardiac inflammation and to support safe rechallenge.

Fat mass: a novel digital biomarker for remote monitoring that may indicate risk for malnutrition and new complications in decompensated cirrhosis

BACKGROUND

Cirrhosis is associated with sarcopaenia and fat wasting, which drive decompensation and mortality. Currently, nutritional status, through body composition assessment, is not routinely monitored in outpatients. Given the deleterious outcomes associated with poor nutrition in decompensated cirrhosis, there is a need for remotely monitoring this to optimise community care.

METHODS

A retrospective analysis was conducted on patients monitored remotely with digital sensors post hospital discharge, to assess outcomes and indicators of new cirrhosis complications. 15 patients had daily fat mass measurements as part of monitoring over a median 10 weeks, using a Withing's bioimpedance scale. The Clinical Frailty Score (CFS) was used to assess frailty and several liver disease severity scores were assessed.

RESULTS

73.3% (11/15) patients were male with a median age of 63 (52-68). There was a trend towards more severe liver disease based on CLIF-Consortium Acute Decompensation (CLIF-C AD) scores in frail patients vs. those not frail (53 vs 46, p = 0.072). When the cohort was split into patients who gained fat mass over 8 weeks vs. those that lost fat mass, the baseline CLIF-C AD scores and WBC were significantly higher in those that lost fat (58 vs 48, p = 0.048 and 11.2 × 109 vs 4.7 × 109, p = 0.031).

CONCLUSIONS

This proof-of-principle study shows feasibility for remote monitoring of fat mass and nutritional reserve in decompensated cirrhosis. Our results suggest fat mass is associated with greater severity of acute decompensation and may serve as an indicator of systemic inflammatory response. Further prospective studies are required to validate this digital biomarker.

[Evaluation of rule out strategy for patients with non-ST-elevation acute coronary syndrome with single measurement of high-sensitivity cardiac troponin I from one sample tested beetween 3 and 6 hours after chest pain onset]

BACKGROUND

Guidelines recommend to consider excluding non-ST-segment elevation myocardial infarction (NSTEMI) when high-sensitivity cardiac troponin is below the limit of quantification and a single blood sample is taken > 6 h after the onset of chest pain. The aim of our study was to assess such exclusion when a single blood sample was taken 3-6 h after the onset of permanent chest pain.

METHODS

This observational study included consecutive patients admitted into the emergency room of our hospital with chest pain and suspected NSTEMI, with non-contributive electrocardiograms and a single high-sensitivity cardiac troponin I (hs-cTnI) blood sample taken 3-6 h after the onset of chest pain and hs-cTnI < 4 ng/l (Abbott Diagnostic). Clinical follow-up was undertaken 1 month after admission.

RESULTS

The mean age of the 432 patients was 48.5 ± 5.6 years and 51% were male. Based on a clinical algorithm, the pre-test probability of NSTEMI was low in 70%, and intermediate in 21% of patients. Among 419 patients with available 1-month follow-up data, there were no myocardial infarctions or deaths. Thirty-eight patients (9%) were admitted into hospital but none for cardiac reasons.

CONCLUSIONS

Our results suggest that exclusion of NSTEMI in patients with a non-contributive electrocardiogram and a single "negative" troponin test in a blood sample taken 3-6 h after the onset of symptoms is valid.

HuBiogel incorporated fibro-porous hybrid nanomatrix graft for vascular tissue interfaces

Native extracellular matrix (ECM) possesses the biochemical cues to promote cell survival. However, decellularized, the ECM loses its cell supporting mechanical integrity. We report, here, a novel biohybrid vascular graft of polycaprolactone (PCL), poliglecaprone (PGC) incorporated with human biomatrix as functional materials for vascular tissue interfacing by electrospinning, thus harnessing the biochemical cues from the ECM and the mechanical integrity of the polymer blends. The fabricated fibro-porous tubular small diameter graft (i.d. = 4 mm) from polymer blend was coated with a cocktail of collagenous matrix derived from human placenta called HuBiogel™. The compositional, morphological, and mechanical properties of graft were measured and compared with a non-coated tubular PCL/PGC graft using Fourier Transform infrared spectroscopy (FTIR), x-ray photoelectron spectroscopy (XPS), and scanning electron microscopy (SEM). BCA assay was used to calculate the protein content and coating-uniformity throughout the hybrid graft. Mechanical properties such as tensile strength (1.6 MPa), Young's modulus (2.4 MPa), burst pressure (>1900 mmHg), and suture retention strength (2.3 N) of hybrid graft were found to be comparable to native blood vessels. Protein coating has improved the hydrophilicity and the biocompatibility (cell viability and cell-attachment) enhanced with human umbilical vein endothelial cells (HUVECs) seeded in vitro onto the lumen layer of the graft over two weeks. The overall results promise this new biohybrid graft to be a potential candidate for vascular tissue interface and regeneration.

Continuation of Buprenorphine to Facilitate Postoperative Pain Management for Patients on Buprenorphine Opioid Agonist Therapy

BACKGROUND

Acute pain management in patients on buprenorphine opioid agonist therapy (BOAT) can be challenging. It is unclear whether BOAT should be continued or interrupted for optimization of postoperative pain control.

OBJECTIVES

To determine an evidence-based approach for pain management in patients on BOAT in the perioperative setting, particularly whether BOAT should be continued or interrupted with or without bridging to another mu opioid agonist and to identify benefits and harms of either perioperative strategy.

STUDY DESIGN

Systematic literature review with qualitative data synthesis.

SETTING

Hospital, perioperative.

METHODS

The study protocol was registered on PROSPERO (Registration number 9030276355). Medline via OVID, EMBASE, CINAHL, and the Cochrane CENTRAL register of trials were searched for prospective or retrospective observational or controlled studies, case series, and case reports that described perioperative or acute pain care for patients on BOAT. References of narrative and systematic reviews addressing acute pain management in patients on BOAT and references of included articles were hand-searched to identify additional original articles for inclusion. The full text of publications were reviewed for final inclusion, and data were extracted using a standardized data extraction form. Results were summarized qualitatively. Primary outcomes were postoperative pain intensity and total opioid use and identification of benefits and harms of perioperative strategies.

RESULTS

Eighteen publications presenting data on the perioperative management of patients on BOAT were identified: 10 case reports, 5 case series, and 3 retrospective cohort studies. Eleven articles reported continuation of BOAT, 2 concerned bridging BOAT, and 4 articles described stopping BOAT without planned bridging. In one retrospective cohort study, BOAT was continued in half and interrupted in half of patients. Patients on BOAT may have pain that is more difficult to treat than those who are not on OAT. There is no clear evidence that one particular strategy provides superior postoperative pain control, but interruption of BOAT may result in harm, including failure to return to baseline BOAT doses, continuing non-BOAT opioid use, or relapse of opioid use disorder.

LIMITATIONS

There were a limited number of articles relevant to the study question consisting of case reports and retrospective observational studies. Some omitted relevant details. No prospective studies were found.

CONCLUSIONS

There is no clear benefit to bridging or stopping BOAT but failure to restart it may pose concerns for relapse. We recommend continuing BOAT in the perioperative period when possible and incorporating an interdisciplinary approach with multimodal analgesia.

KEY WORDS

Opioid use disorder, opiate substitution treatment, buprenorphine, buprenorphine-naloxone, buprenorphine opioid agonist therapy, postoperative pain, acute pain, multimodal analgesia.

A benchmark for Monte Carlo simulation in gamma-ray spectrometry

Monte Carlo (MC) simulation is widely used in gamma-ray spectrometry, however, its implementation is not always easy and can provide erroneous results. The present action provides a benchmark for several MC software for selected cases. The examples are based on simple geometries, two types of germanium detectors and four kinds of sources, to mimic eight typical measurement conditions. The action outputs (input files and efficiency calculation results, including practical recommendations for new users) are made available on a dedicated webpage.

The Mobile Analyzer of Radioactive Gases OuTflows (MARGOT): A promising environmental xenon radionuclides detection system

An ultra-compact and unshielded spectrometer for analysis of atmospheric xenon radionuclides has been developed: the MARGOT system. This system works at ambient temperature and high pressure, and has a 54.3 cm³ inner active volume. Atmospheric xenon radionuclide activities are determined with the electron-photon coincidence technique using both NaI(Tl) detectors and large pixellized Si-PIN detectors. The MARGOT system integrates an enhanced version of the PIPSBox™, Geant4 simulation and first calibration results are discussed.

Effect of cylinder power and axis changes on vision in astigmatic participants

PURPOSE

To ascertain the impact of altering cylinder (cyl) power and axis on vision in astigmatism.

METHODS

In a prospective, randomized, participant-masked, crossover clinical trial, 28 astigmatic participants were tested for the following conditions on different days: full sphero-cyl correction and undercorrection by 0.25, 0.50, and 0.75 DC while maintaining spherical equivalence. Axis was also misaligned between -30° and +30°, in 10° steps. For each configuration, monocular high- and low-contrast visual acuities (HCVA, LCVA) were measured at 6 m, and participants rated vision clarity (1-10), vision satisfaction (1-10), and vision acceptability (yes/no). Linear mixed models were used to compare visual performance in the overall group and in low, medium, and high cyl subgroups.

RESULTS

Undercorrecting cyl power affected all groups equally (P≥0.073). Undercorrection by 0.75 DC was significantly different to full cyl power for all variables (P≤0.007), while 0.25 DC undercorrection did not cause any significant decreases (P>0.05). Undercorrection by 0.50 DC was significantly different to full cyl power for HCVA (P=0.006, however not clinically significant) and vision acceptability (P=0.034). Axis misalignment affected the cyl groups differently (P<0.001), with the greatest impact in the high cyl group, followed by the medium then the low-cyl group. Misalignment by ±30° caused significant decreases in almost all cases (P≤0.003), while misalignments by ±10° or ±20° caused significant decreases for some cyl groups and test variables.

CONCLUSION

Undercorrection of cyl by ≤0.50 DC while maintaining spherical equivalence has no significant effect on HCVA, LCVA, vision clarity, and vision satisfaction, while the amount of axis misalignment that can be tolerated is dependent on the cyl power. These results may have practical ophthalmic applications, such as reducing the total number of stock keeping units of toric contact lenses.

Clinical characteristics and outcome of lone atrial fibrillation at a tertiary referral centre: the Groote Schuur Hospital experience

INTRODUCTION

Atrial fibrillation (AF) is a relatively common arrhythmia. When AF represents an electrophysiological phenomenon in structurally normal hearts, it is termed lone AF. This study was a retrospective, case-based analysis of patients attending the Cardiac Clinic at Groote Schuur Hospital (GSH) and describes the clinical characteristics and outcomes of patients classified as having lone atrial fibrillation. To the best of our knowledge there are no such studies reported from Africa.

METHODS

This was a retrospective, descriptive study in which 289 medical records of patients with AF at the GSH Cardiac Clinic were reviewed from 1992 to 2006. The clinical data were interrogated to exclude identifiable causes of AF. Information on clinical characteristics and outcomes were entered into a data-entry form. Baseline descriptive statistics were expressed as means and range for continuous variables, and counts with percentages for categorical variables.

RESULTS

Fifteen per cent (n = 42) of patients were identified as having lone AF, with a mean follow-up time of 5.8 years. Males comprised 57% (n = 24) and females 43% (n = 18). Fifty per cent (n = 21) of the patients had paroxysmal AF, 29% (n = 12) had persistent AF, and 12% (n = 5) progressed from paroxysmal to permanent AF. Subsets of lone AF included concomitant atrial flutter (17%) (n = 7) and sick sinus syndrome (21%) (n = 9). Complications were stroke (10%) (n = 4), tachycardia-related cardiomyopathy (17%) (n = 7) and bleeding complications on warfarin (11%) (n = 3).

CONCLUSIONS

Lone AF is not an uncommon arrhythmia, with a preponderance in thin, middle-aged males. The symptoms of lone AF can be debilitating. It has associated morbidity, including tachycardia-related cardiomyopathy and thromboembolism. Rate control and appropriate anticoagulation are the cornerstones of patient management.

Recommendations on diagnostic tools for Batrachochytrium salamandrivorans

Batrachochytrium salamandrivorans (Bsal) poses a major threat to amphibian, and more specifically caudata, diversity. Bsal is currently spreading through Europe, and mitigation measures aimed at stopping its spread and preventing its introduction into naïve environments are urgently needed. Screening for presence of Bsal and diagnosis of Bsal-induced disease in amphibians are essential core components of effective mitigation plans. Therefore, the aim of this study was to present an overview of all Bsal diagnostic tools together with their limitations and to suggest guidelines to allow uniform interpretation. Here, we investigate the use of different diagnostic tools in post-mortem detection of Bsal and whether competition between Bd and Bsal occurs in the species-specific Bd and Bsal duplex real-time PCR. We also investigate the diagnostic sensitivity, diagnostic specificity and reproducibility of the Bsal real-time PCR and show the use of immunohistochemistry in diagnosis of Bsal-induced chytridiomycosis in amphibian samples stored in formaldehyde. Additionally, we have drawn up guidelines for the use and interpretation of the different diagnostic tools for Bsal currently available, to facilitate standardization of execution and interpretation.

GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research

BACKGROUND

While the patient and public involvement (PPI) evidence base has expanded over the past decade, the quality of reporting within papers is often inconsistent, limiting our understanding of how it works, in what context, for whom, and why.

OBJECTIVE

To develop international consensus on the key items to report to enhance the quality, transparency, and consistency of the PPI evidence base. To collaboratively involve patients as research partners at all stages in the development of GRIPP2.

METHODS

The EQUATOR method for developing reporting guidelines was used. The original GRIPP (Guidance for Reporting Involvement of Patients and the Public) checklist was revised, based on updated systematic review evidence. A three round Delphi survey was used to develop consensus on items to be included in the guideline. A subsequent face-to-face meeting produced agreement on items not reaching consensus during the Delphi process.

RESULTS

One hundred forty-three participants agreed to participate in round one, with an 86% (123/143) response for round two and a 78% (112/143) response for round three. The Delphi survey identified the need for long form (LF) and short form (SF) versions. GRIPP2-LF includes 34 items on aims, definitions, concepts and theory, methods, stages and nature of involvement, context, capture or measurement of impact, outcomes, economic assessment, and reflections and is suitable for studies where the main focus is PPI. GRIPP2-SF includes five items on aims, methods, results, outcomes, and critical perspective and is suitable for studies where PPI is a secondary focus.

CONCLUSIONS

GRIPP2-LF and GRIPP2-SF represent the first international evidence based, consensus informed guidance for reporting patient and public involvement in research. Both versions of GRIPP2 aim to improve the quality, transparency, and consistency of the international PPI evidence base, to ensure PPI practice is based on the best evidence. In order to encourage its wide dissemination this article is freely accessible on The BMJ and Research Involvement and Engagement journal websites.

GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research

Background While the patient and public involvement (PPI) evidence base has expanded over the past decade, the quality of reporting within papers is often inconsistent, limiting our understanding of how it works, in what context, for whom, and why.Objective To develop international consensus on the key items to report to enhance the quality, transparency, and consistency of the PPI evidence base. To collaboratively involve patients as research partners at all stages in the development of GRIPP2.Methods The EQUATOR method for developing reporting guidelines was used. The original GRIPP (Guidance for Reporting Involvement of Patients and the Public) checklist was revised, based on updated systematic review evidence. A three round Delphi survey was used to develop consensus on items to be included in the guideline. A subsequent face-to-face meeting produced agreement on items not reaching consensus during the Delphi process.Results 143 participants agreed to participate in round one, with an 86% (123/143) response for round two and a 78% (112/143) response for round three. The Delphi survey identified the need for long form (LF) and short form (SF) versions. GRIPP2-LF includes 34 items on aims, definitions, concepts and theory, methods, stages and nature of involvement, context, capture or measurement of impact, outcomes, economic assessment, and reflections and is suitable for studies where the main focus is PPI. GRIPP2-SF includes five items on aims, methods, results, outcomes, and critical perspective and is suitable for studies where PPI is a secondary focus.Conclusions GRIPP2-LF and GRIPP2-SF represent the first international evidence based, consensus informed guidance for reporting patient and public involvement in research. Both versions of GRIPP2 aim to improve the quality, transparency, and consistency of the international PPI evidence base, to ensure PPI practice is based on the best evidence. In order to encourage its wide dissemination this article is freely accessible on The BMJ and Research Involvement and Engagement journal websites.

Optical analysis of samarium doped sodium bismuth silicate glass

Samarium doped sodium bismuth silicate glass was synthesized using the melt quenching method. Detailed optical spectroscopic studies of the glassy material were carried out in the UV-Vis-NIR spectral range. Using the optical absorption spectra Judd-Ofelt (JO) parameters are derived. The calculated values of the JO parameters are utilized in evaluating the various radiative parameters such as electric dipole line strengths (S_ed), radiative transition probabilities (A_rad), radiative lifetimes (τ_rad), fluorescence branching ratios (β) and the integrated absorption cross- sections (σ_a) for stimulated emission from various excited states of Sm³⁺‡ ion. The principal fluorescence transitions are identified by recording the fluorescence spectrum. Our analysis revealed that the novel glassy system has the optimum values for the key parameters viz. spectroscopic quality factor, optical gain, stimulated emission cross section and quantum efficiency, which are required for a high performance optical amplifier. Calculated chromaticity co-ordinates (0.61, 0.38) also confirm its application potential in display devices.

Spectral and Lensing Characteristics of Gel-Derived Strontium Tartrate Single Crystals Using Dual-Beam Thermal Lens Technique

The Dual Beam mode-matched thermal lens spectrometry is a sensible technique for direct measurements of the thermal properties of tartrate crystalline materials. Here we report the measurement of thermal diffusivity of Strontium Tartrate single crystals incorporated with Rhodamine 6G using the thermal lens experiment. The respective crystals were prepared by solution-gel method at room temperature. The absorption characteristics of three different Strontium Tartrate crystals viz. pure, electric field applied and magnetic field applied were also carried out.

Serratia marcescens Bullous Cellulitis in a Splenectomized Patient: A Case Report and Review of the Literature

Serratia marcescens is a Gram-negative bacillus belonging to the Enterobacteriaceae family. Cutaneous infection with Serratia is rare, and usually occurs in immunocompromised individuals. Primary cutaneous infections are uncommon, but they are typically severe and are associated with significant morbidity and mortality. The pathogenetic factors leading to S. marcescens infection are not fully understood, but contributing virulence factors include proteases, secreted exotoxins, and the formation of biofilm. We report a case of cellulitis occurring in a splenectomized patient, which led to multiple wound debridements and a transmetatarsal amputation. This dramatic case led us to review the published literature on soft tissue infections caused by S. marcescens.

Abstract P2-09-06: Multi-gene panel testing for hereditary cancer risk

Background: Multi-gene panels are widely available for assessing hereditary cancer risk in high risk individuals. Due to the use of these panels, many genetic mutations other than BRCA 1 or 2 can be detected which can potentially affect management. This study presents the results of multi-gene panel testing performed at Beaumont Health System.

Methods:All patients who underwent multi-gene panel testing at Beaumont Health System between November 1, 2012 and January 15, 2015 were included in this study. This cohort consisted of patients who met criteria for genetic testing due to personal or family history. All patients received comprehensive pre and post-test genetic counseling. The panels ranged from 5 to 43 genes associated with risk for breast and other cancers.

Results: 653 multi-gene panel tests were performed. The majority of these consisted of either a 5 gene high risk breast panel (25%), an 18 gene moderate to high risk breast panel (21%), or a 9 gene high risk breast and gynecologic panel (17%). 184 variants of undetermined significance (VUS) were identified with a pooled VUS rate of 28%. Among the commonly used panels, there was a positive correlation between VUS rate and the number of genes included in the panel (r = 0.86, p = 0.01, Range 6% to 70%). A pathogenic mutation was identified in one or more genes in 65 (10%) panels for a total of 67 mutations. Of these, 17 mutations were in BRCA1 or BRCA2 gene. Fifty non-BRCA deleterious mutations were identified with the following frequencies: CHEK2(12), MUTYH(7 monoallelic, 1 biallelic), TP53(4), PTEN(4), ATM(4), MSH6(3), PALB2(3), MSH2(2), CDH1(2), APC(2), NF1(2), BARD1(2), MLH1(1) and PMS2(1). Of these non-BRCA mutations, 41(82%) had a significant impact on management.

Conclusions: Our study demonstrates that multi-gene panel testing identifies several genes that can impact management and would likely not have been discovered by pedigree analysis alone. However, this added detection is associated with a higher VUS rate, especially using larger panels. Further research is needed to better define the role of multi-gene panel testing in high risk patients, with a focus on choosing appropriate genes, understanding the magnitude of cancer risk and delineating impact on management.

Citation Format: Yadav S, Ladkany R, Fulbright J, Dreyfuss H, Reeves A, Campian S, Thomas V, Zakalik D. Multi-gene panel testing for hereditary cancer risk. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-09-06.

Epidemiological cut-off values for Flavobacterium psychrophilum MIC data generated by a standard test protocol

Epidemiological cut-off values were developed for application to antibiotic susceptibility data for Flavobacterium psychrophilum generated by standard CLSI test protocols. The MIC values for ten antibiotic agents against Flavobacterium psychrophilum were determined in two laboratories. For five antibiotics, the data sets were of sufficient quality and quantity to allow the setting of valid epidemiological cut-off values. For these agents, the cut-off values, calculated by the application of the statistically based normalized resistance interpretation method, were ≤16 mg L(-1) for erythromycin, ≤2 mg L(-1) for florfenicol, ≤0.025 mg L(-1) for oxolinic acid (OXO), ≤0.125 mg L(-1) for oxytetracycline and ≤20 (1/19) mg L(-1) for trimethoprim/sulphamethoxazole. For ampicillin and amoxicillin, the majority of putative wild-type observations were 'off scale', and therefore, statistically valid cut-off values could not be calculated. For ormetoprim/sulphadimethoxine, the data were excessively diverse and a valid cut-off could not be determined. For flumequine, the putative wild-type data were extremely skewed, and for enrofloxacin, there was inadequate separation in the MIC values for putative wild-type and non-wild-type strains. It is argued that the adoption of OXO as a class representative for the quinolone group would be a valid method of determining susceptibilities to these agents.

Improving medication adherence in rheumatoid arthritis (RA): a pilot study

The aim of this exploratory pilot study was to adapt a psychological intervention to improve adherence to medication for patients with rheumatoid arthritis (RA). The approach draws on cognitive behavioural therapy (CBT) techniques, including motivational interviewing . The current study aimed to (i) adapt the intervention for patients with RA, (ii) assess its effectiveness in improving adherence to medication and (iii) evaluate patients' experience of the intervention. Participants were randomly allocated to either the 'intervention group' (N  =  10), receiving up to six weekly sessions of 'Compliance Therapy', or to the 'wait-list control' group (N  =  8), who received standard care. Data was collected pre intervention (baseline), post intervention and at six weeks post intervention (follow-up). Eighteen female participants with a mean age of 48.78 years (SD 15.12) took part in the study. Comparisons across the two time points for each group found that only those in the 'intervention' group demonstrated significant improvement in mean scores on adherence measures. Between-group comparisons were not significant. The pilot study suggests that an intervention based on CBT may improve adherence in patients with RA, but further research is required.

Cleaning, disinfection and sterilization of surface prion contamination

BACKGROUND

Prion contamination is a risk during device reprocessing, being difficult to remove and inactivate. Little is known of the combined effects of cleaning, disinfection and sterilization during a typical reprocessing cycle in clinical practice.

AIM

To investigate the combination of cleaning, disinfection and/or sterilization on reducing the risk of surface prion contamination.

METHODS

In vivo test methods were used to study the impact of cleaning alone and cleaning combined with thermal disinfection and high- or low-temperature sterilization processes. A standardized test method, based on contamination of stainless steel wires with high titres of scrapie-infected brain homogenates, was used to determine infectivity reduction.

FINDINGS

Traditional chemical methods of surface decontamination against prions were confirmed to be effective, but extended steam sterilization was more variable. Steam sterilization alone reduced the risk of prion contamination under normal or extended exposure conditions, but did show significant variation. Thermal disinfection had no impact in these studies. Cleaning with certain defined formulations in combination with steam sterilization can be an effective prion decontamination process, in particular with alkaline formulations. Low-temperature, gaseous hydrogen peroxide sterilization was also confirmed to reduce infectivity in the presence and absence of cleaning.

CONCLUSION

Prion decontamination is affected by the full reprocessing cycle used on contaminated surfaces. The correct use of defined cleaning, disinfection and sterilization methods as tested in this report in the scrapie infectivity assay can provide a standard precaution against prion contamination.

Pan-European resistance monitoring programmes encompassing food-borne bacteria and target pathogens of food-producing and companion animals

Antimicrobial resistance is a concern both for animal and human health. Veterinary programmes monitoring resistance of animal and zoonotic pathogens are therefore essential. Various European countries have implemented national surveillance programmes, particularly for zoonotic and commensal bacteria, and the European Food Safety Authority (EFSA) is compiling the data. However, harmonisation is identified as a weakness and an essential need in order to compare data across countries. Comparisons of resistance monitoring data among national programmes are hampered by differences between programmes, such as sampling and testing methodology, and different epidemiological cut-off values or clinical breakpoints. Moreover, only very few valid data are available regarding target pathogens both of farm and companion animals. The European Animal Health Study Centre (CEESA) attempts to fill these gaps. The resistance monitoring programmes of CEESA have been a collaboration of veterinary pharmaceutical companies for over a decade and include two different projects: the European Antimicrobial Susceptibility Surveillance in Animals (EASSA) programme, which collects food-borne bacteria at slaughter from healthy animals, and the pathogen programmes that collect first-intention target pathogens from acutely diseased animals. The latter comprises three subprogrammes: VetPath; MycoPath; and ComPath. All CEESA projects include uniform sample collection and bacterial identification to species level in various European Union (EU) member states. A central laboratory conducts quantitative susceptibility testing to antimicrobial agents either important in human medicine or commonly used in veterinary medicine. This 'methodology harmonisation' allows easy comparisons among EU member states and makes the CEESA programmes invaluable to address food safety and antibiotic efficacy.

Nanostructured diamond coatings for orthopaedic applications

With increasing numbers of orthopaedic devices being implanted, greater emphasis is being placed on ceramic coating technology to reduce friction and wear in mating total joint replacement components, in order to improve implant function and increase device lifespan. In this chapter, we consider ultra-hard carbon coatings, with emphasis on nanostructured diamond, as alternative bearing surfaces for metallic components. Such coatings have great potential for use in biomedical implants as a result of their extreme hardness, wear resistance, low friction and biocompatibility. These ultra-hard carbon coatings can be deposited by several techniques resulting in a wide variety of structures and properties.

Analysis of K-ras gene mutations in human pancreatic cancer cell lines and in bile samples from patients with pancreatic and biliary cancers

The ras family of oncogenes are the most frequently activated group of dominant transforming genes in both human and experimental cancers. The ras family of genes encode highly similar proteins with molecular weights of 21 kDa which are thought to play a key role in signal transduction. Activation in vivo by point mutations results in the ras p21 protein being maintained in the activated form and stimulating cellular proliferation autonomously. Point mutations at codon 12 of K-ras have been observed in >75% of cases of adenocarcinomas of the exocrine pancreas. The type and frequency of K-ras gene mutations in pancreatic cancer cell lines and in bile samples from patients with cytologically-proven biliary tract malignancies and from patients with non-malignant disorders of the biliary tract were determined. Codons 12, 13 and 61 of the K-ras gene were analysed by using restriction fragment length polymorphisms created through mismatched primers during polymerase chain reaction (PCR) of genomic DNA. A mutation of codon 12 of K-ras was detected in 10 of 13 (77%) human pancreatic cancer cell lines. The amino-acid substitutions were glycine to aspartate (5 samples), arginine (2), valine (2) and cysteine (1). No mutations were found at codons 13 or 61. A mutation at codon 12 of K-ras was detected in 9 of 18 (50%) of bile samples analysed. Eleven bile samples had positive cytology for malignancy of pancreaticobiliary origin, and 4 (36%) of these had a codon 12 mutation. Mutations were detected in 5 of the 7 (71%) cytologically-negative bile samples, although malignancy was subsequently diagnosed in 2 of these patients on further histology, and was suspected in 3 other cases on clinical and radiological criteria. This method provides a rapid determination of K-ras gene mutations in bile samples for patients with pancreatic and biliary tract diseases, which may be useful when considering future therapy directed at inhibition of activated ras-induced signal transduction pathways.

Central mucoepidermoid carcinoma of maxilla with radiographic appearance of mixed radiopaque-radiolucent lesion: a case report

Mucoepidermoid carcinoma is the most common primary malignancy of the salivary glands. Central mucoepidermoid carcinomas are extremely rare in the jaws. Here we report a case of a 19-year-old central mucoepidermoid carcinoma in a young female patient which was asymptomatic throughout her history and which radiographically simulated a fibro-osseous lesion; both features misled the clinical diagnosis. A radiographic picture of mixed radiopaque-radiolucent appearance in central mucoepidermoid carcinoma is extremely rare. The long duration is also uncommon for a malignant lesion. This case report adds a new dimension to the clinical and radiographic picture a central mucoepidermoid carcinoma can reveal.

Resistance of bacterial biofilms to disinfectants: a review

A biofilm can be defined as a community of microorganisms adhering to a surface and surrounded by a complex matrix of extrapolymeric substances. It is now generally accepted that the biofilm growth mode induces microbial resistance to disinfection that can lead to substantial economic and health concerns. Although the precise origin of such resistance remains unclear, different studies have shown that it is a multifactorial process involving the spatial organization of the biofilm. This review will discuss the mechanisms identified as playing a role in biofilm resistance to disinfectants, as well as novel anti-biofilm strategies that have recently been explored.

Comparative biocidal activity of peracetic acid, benzalkonium chloride and ortho-phthalaldehyde on 77 bacterial strains

Despite numerous reports on biocide activities, it is often difficult to have a reliable and relevant overview of bacterial resistance to disinfectants because each work challenges a limited number of strains and tested methods are often different. The aim of this study was to evaluate the bactericidal activity of three different disinfectants commonly used in industrial or medical environments (peracetic acid, benzalkonium chloride and ortho-phthalaldehyde) against 77 bacterial strains from different origins using one standard test method (NF EN 1040). Results highlight the existence of high interspecific variability of resistance to disinfectants and, contrary to widespread belief, Gram-positive strains generally appeared more resistant than Gram-negative strains. Resistance was also variable among strains of the same species such as Bacillus subtilis to peracetic acid, Pseudomonas aeruginosa to benzalkonium chloride and Staphylococcus aureus to ortho-phthalaldehyde.

In the absence of clinically significant graft vs. host disease, myeloablative conditioning may allow an effective graft vs. leukaemia effect

In AML, prevention of GvHD leads to better tolerance of myeloablative therapy. 66 individuals with AML in CR underwent myeloablative conditioning and transplantation with allogeneic PBPC grafts. Median presentation age was 44.5 years. Karyotyping was intermediate in 48% and of unfavourable risk in 36%. For GvHD prophylaxis, PBPC harvests were incubated ex vivo with anti CD52 antibodies. TRM at day 100 and 1 year was 9% and 17%. At a median of 1018 days 65% are alive. Grade >1 GvHD was seen in 11%. GvHD and adverse karyotype were associated with treatment failure. In younger patients preservation of the dose intensity may improve cure rates.

The biofilm architecture of sixty opportunistic pathogens deciphered using a high throughput CLSM method

This study proposes a high throughput method based on Confocal Laser Scanning Microscopy (CLSM) combined with the use of 96-wells microtiter plates compatible with high resolution imaging for the study of biofilm formation and structure. As an illustration, the three-dimensional structures of biofilms formed by 60 opportunistic pathogens were thus observed and quantified. The results revealed the diversity of biofilm architectures. Specific spatial arrangement such as the mushroom-like structures already described for Pseudomonas aeruginosa was observed. Other features, such as hollow voids in microcolonies of Salmonella enterica strain Agona, were identified for the first time. The combined use of microplates and confocal imaging proved to be a good alternative to the other high throughput methods commonly used as it enables the direct, insitu, qualitative and quantitative characterization of biofilm architecture. This high content method should lead to a clearer understanding of the structure-function relationships implicated in biofilms traits.