Topical treatment: which dressing to choose

Wounds have existed since the beginning of time. The interest in this subject has been stimulated in the main by conflict and war that have necessitated the development of new ways of managing wounds. In the 1960s the development of new materials that maintained a moist environment in the wound area encouraged a number of commercial companies to produce a wide variety of new materials with physical and chemical properties that might provide a moist environment. However the data to support the use of such materials are limited if one requires evidence that they have produced more rapid healing in chronic wounds kept moist as to those kept dry. Is this due to a problem with the outcome measure rather than a problem with the materials themselves? Rather than seeing this as justification for not using such materials, it should instead lead clinicians to question the validity of endpoint studies in wound healing experiments. There is a lack of evidence regarding the ability of such materials to improve the speed of healing in chronic wounds. Nevertheless considerable clinical experience, obtained from treating many patients, has indicated that not only are such new treatments cost effective, but that they are also proving to be extremely beneficial and acceptable to patients, on account of their ability to reduce pain, odour or leakage from a wound.

Properties of HLA class II molecules divergently associated with Goodpasture's disease

Goodpasture's disease provides an opportunity to analyse molecular mechanisms that may underlie MHC class II associations with autoimmune disease because it is caused by autoimmunity to a defined antigen [the 230 amino acid NC1 domain of the alpha3 chain of type IV collagen (alpha3(IV)NC1)] and has strong HLA class II associations. We compared the alpha3(IV)NC1 peptide binding of class II molecules with strong positive (DR15) and dominant negative (DR7/1) associations using an inhibition binding assay and short synthetic peptides spanning the sequence of alpha3(IV)NC1. DR15 in general bound the peptides with low affinity (three of 23 < 100 nM) compared to DR1 and DR7 (12 and 10 < 100 nM respectively), and no peptide bound DR15 with much higher affinity (>10-fold) than both DR1 and DR7. Thus DR15 molecules are unlikely to increase susceptibility to Goodpasture's disease by presenting a particular alpha3(IV)NC1-derived peptide uniquely well and DR1/7 are unlikely to protect by their inability to present particular peptides. However DR1/7 could protect by capturing alpha3(IV)NC1 peptides and preventing their display bound to DR15; the binding data suggest that all the major (biochemically detectable) alpha3(IV)NC1 peptides presented bound to DR15 by DR15 homozygous antigen-presenting cells (APC) would bind preferentially to DR1/7 in DR15, 1/7 heterozygote APC.

A comparison of large volume spacer, breath-activated and dry powder inhalers in older people

AIMS

To see if elderly people can use the breath-activated (Easi-breathe) and dry powder (Turbohaler) inhalers as effectively as the metered-dose inhaler and Volumatic system.

METHODS

102 inhaler-naive patients (aged 75-101, mean 84 years), without cognitive impairment, were randomly allocated one of Easi-breathe, Turbohaler or metered-dose inhaler and Volumatic placebo inhalers. Standardized tuition was done on enrolment and at 6 h review. Inhaler technique was assessed immediately after enrolment tuition and at 6 and 24 h. Assessment was by scoring (0 = poor, 1 = moderate, 2 = perfect) five aspects of technique.

RESULTS

Mean total scores were significantly (P < 0.005) higher for Turbohaler and Easi-breathe than metered-dose inhaler and Volumatic on enrolment and 6 h and at 24 h (P < 0.045). Fewer patients achieved excellent scores of 9 or 10 when using metered-dose inhaler and Volumatic. The main difficulties were in assembling the metered-dose inhaler and Volumatic and detecting when the metered-dose inhaler and Volumatic or Easi-breathe was empty.

CONCLUSIONS

Breath-activated and dry powder inhalers were more likely to be used correctly than metered-dose inhalers with large volume spacers.

Memories are made of this: the effects of time on stored visual knowledge in a case of visual agnosia

We report the effects of the passage of time on the longterm visual knowledge for objects in a patient with visual agnosia (H.J.A.). The naming of real objects was found to have improved, although this was not associated with any change in H.J.A.'s basic perceptual abilities which were stable over a 16-year period. The improvement in object naming was attributed to better use of non-contour-based visual information (such as surface detail and depth cues). In addition, we demonstrate a deterioration in H.J.A.'s long-term memory for the visual properties of objects, and argue that this has occurred as a result of his having impaired perceptual input. The deterioration was only apparent in drawing from memory and in the verbal descriptions of items; with forced-choice testing, H.J.A. operated at ceiling; we propose that current tests of visual imagery may not be sufficiently sensitive to detect subtle impairments of visual memory. Our findings can be taken to indicate that perceptual and memorial processes are not functionally independent, but are linked in an interactive manner.

Anti-MUC1 class I restricted CTLs in metastatic breast cancer patients immunized with a synthetic MUC1 peptide

Sixteen metastatic breast cancer patients were immunized with a low dose (5 micrograms) of a 16 amino acid MUC1 peptide (GVTSAPDTRPAPGSTA) conjugated to KLH (BP16-KLH) plus DETOX adjuvant and evaluated for antibody titers against MUC1 peptide and KLH and for cytotoxic lymphocyte (CTL) activity using class 1 HLA-matched MUC1-positive tumor targets. All patients generated strong anti-KLH IgG responses. Only 3 patients developed an anti-MUC1 IgG response, which was weak in magnitude. As it is controversial whether human cancer patients generate class-1-restricted CTL against MUC1, we examined anti-MUC1 CTL activity of PBLs following 4 immunizations with BP16-KLH. The generation of MUC1-specific CTLs required only a 6-day in vitro stimulation of patients' T-cells with synthetic MUC1-peptide-pulsed autologous APCs. The assay for CTL activity was a 4 hour 51Cr release from labeled adenocarcinoma target cells. Eleven of the 16 immunized patients were tested for CTL activity using class-1-matched adenocarcinoma target cell lines. Evidence for class-1-restricted killing of MUC1-expressing tumor cell lines was obtained in 7 of these 11 patients.

Phase I trial of retinoic acid and cis-platinum for advanced squamous cell cancer of the head and neck based on experimental evidence of drug synergism

OBJECTIVE

Cis-platinum and 13-cis-retinoic acid have received much attention in the treatment of head and neck squamous cell cancer. Even though they have different mechanisms of action, little information is available on their interaction. This paper reviews experimental evidence for retinoic acid-cis-platinum synergy and presents toxicity data from patients with stage IV head and neck squamous cell cancer participating in a phase I trial combining 13-cis-retinoic acid and cis-platinum.

METHODS

Patients were given 13-cis-retinoic acid orally daily for 7 days before and daily during high-dose (150 mg/m2 per week for 4 weeks) intraarterial cis-platinum treatment with concurrent radiation. Toxicity was scored with use of the cancer and leukemia group B scale.

RESULTS

In the phase I clinical trial, 15 patients were treated to determine a maximum tolerated dosage for 13-cis-retinoic acid of 20 mg/day. Grade 4 hematologic toxicity was dose limiting in 3 of 8 patients treated with 40 mg/day and in 1 patient treated with 60 mg/day. There were no deaths caused by toxicity; 12 of the 15 patients received all four weekly doses and the remaining 3 received three doses. Of 10 patients with fully evaluable data, all achieved a complete response at the primary site and 9 had a complete response in the neck. One patient had persistent neck disease after chemoradiation, and this tumor was removed with neck dissection.

CONCLUSIONS

13-Cis-retinoic acid and cis-platinum are strongly synergistic against head and neck squamous cell cancer in vitro. Pretreatment with retinoic acid results in stronger synergy than concurrent drug exposure alone. Preliminary clinical experience with combined retinoic acid and cis-platinum in a design that parallels the in vitro study indicates that toxicity is acceptable with 13-cis-retinoic acid dosages of 20 mg/day in a high-dose-intensity intraarterial chemoradiation regimen.

Protein markers in cerebrospinal fluid from BSE-affected cattle

Two-dimensional gel electrophoresis was used to analyse cerebrospinal fluid (CSF) from 75 suspect cases of bovine spongiform encephalopathy (BSE), 61 of which were confirmed by post mortem brain histopathology, and 38 normal cattle. CSF samples were also examined from cattle killed at periodic intervals through the incubation period following experimental challenge. Consistent changes were recorded in all CSF samples from the confirmed cases of natural BSE and also from cattle showing early signs of experimental disease. The changes consisted of an increased intensity of staining of apolipoprotein E and the presence of two protein spots, as yet unidentified, of molecular weights 35 and 36 kDa, both with a pI of 5.5. These changes were absent in the CSF samples from the normal cattle, from the clinically suspect cattle which were not confirmed as BSE and from the experimentally challenged cattle in the preclinical phase of infection.

Caring for children with wounds

An update on the problems associated with managing children with wounds and their families

Levels of substance P and IgE decapeptide in nasal polyp fluid and matching sera: a preliminary study

Sixteen unselected patients with nasal polyps had the levels of substance P and IgE decapeptide measured by ELISA in the oedema fluids and their matched sera. All 16 samples had low levels of substance P in their sera and had high level of substance P in eight samples of nasal polyp oedema. There was a considerable variation in the values of IgE decapeptide found in the sera but 14 polyp oedema fluids had high levels of IgE decapeptide. This study supports the idea that there is a linkage between the cellular and neurovascular responses. High levels of IgE decapeptide suggest that mast cell reactions occur in the majority of cases and that IgE may be implicated in the process of mast cell degranulation.

From the Journals

Inflammatory skin disease and tumour necrosis factor-alpha Surgical maggots for wound treatment Older people and pressure sores Chronic venous leg ulcers Body temperature during dressing changes Wound microbiology and infection.

Educational initiatives in wound care

A review of the educational activities developed at the Wound Healing Research Unit in Cardiff

From the Journals

Standardised assessment and evaluation of wounds

Nutritional support in wound healing

Pressure sores, a review of the literature

Gene therapy in skin grafts

Surgical techniques in pilonidal disease

Prognostic usefulness of serum albumin for pressure ulcer healing

From the Journals

Factors associated with wound infection in elderly people The effects of intravenous iloprost on below-knee amputations Management of peripheral artery occlusive disease.

Letters

ANTIBIOTICS AND OLDER PEOPLE PATIENT CONFIDENTIALITY RESEARCH ON LEG ULCERS INFECTION AND SOCIAL HAND-WASHING WATER, WATER EVERYWHERE.

From the Journals

Pressure sore prevention model

Assessing mattress durability

Wound care in an ageing population

An examination of the implications for wound care of demographic projections showing a significant growth in the older population over the next 40 years.

Clinical syndrome and diagnosis of hyperkalaemic periodic paralysis in quarter horses

Of the 16 horses studied, 14 belonged to a family previously shown to be susceptible to hyperkalaemic periodic paralysis (HPP), and 8 were shown to have HPP. Diagnosis of HPP by electromyographic detection of myotonic discharges or by oral administration of KCl to induce clinical signs and hyperkalaemia had similar reliability and gave the same result in 80% of cases. KCl had to be administered at doses up to 0.2 g/kg bodyweight to produce signs in some horses. KCl challenge testing was more time consuming than EMG and resulted in one fatality. Overall, electromyography and potassium challenge testing together gave the most accurate diagnosis. Horses were more likely to manifest signs of HPP if they were immature. There was no sex predisposition. The most frequent sign of HPP was muscle fasciculation. Other signs were sweating, muscle spasm, and weakness. Respiratory rate increased greatly during some attacks. Attacks of muscle fasciculation without hyperkalaemia were observed in 2 HPP-affected horses. Affected horses had a greater frequency of spontaneous clinical abnormalities, due mainly to trailering problems, traumatic abrasions and episodes of continuous muscle fasciculation. Hyperkalaemia was confirmed in only one of these instances.

Reviews

WOUND MANAGEMENT GUIDELINES A HANDBOOK OF SURGICAL DRESSINGS 1992 edition VIDEO A SORE POINT Managing the stages of pressure sores (Series No. 21).

From the Journals

Using growth factor PDGF-BB to treat chronic pressure sores

Controlling scarring in adult wounds

Paget's legacy to pressure area care

Surveying the Pegasus Airwave System

The use of transcutaneous electrical nerve stimulation during the biliary lithotripsy procedure

Transcutaneous electrical nerve stimulation (TENS) has been suggested as a means to reduce the amount of intravenous analgesia/sedation in patients undergoing extracorporeal shock wave lithotripsy (ESWL). A retrospective analysis of 79 ESWL procedures on 73 consecutive unselected patients was done in an attempt to determine the effectiveness of TENS in reducing the amount of intravenous fentanyl citrate and/or midazolam HCl needed to control pain and anxiety during the ESWL procedure. The study was divided into two parts: (1) all patients receiving TENS (n = 44) versus a non-TENS group (n = 35), and (2) comparison of the early (n = 22) and late non-TENS (n = 22) groups against each other; separately the late non-TENS group was compared to the entire TENS group. In the study, TENS reduce the amount of fentanyl citrate needed to control anxiety by 22.9% (P less than 0.025). No difference was noted when the early and late non-TENS group of patients were compared to each other. A gender difference was noted with a significant reduction in the dose of fentanyl citrate only in female patients receiving TENS (45.4%). Likewise, there was a significant reduction in the dose of midazolam HCl only in males who had TENS (38.9%). The data suggests that TENS may be a useful addition to reduce the amount of sedation and analgesia during ESWL.

Judgement of mood in music following right hemisphere damage

Evidence on hemispheric specialization has implicated the right hemisphere as having a special role in the mediation of emotion. Since music is an area in which both cognitive and affective aspects of perception can be assessed, the aim of this study was to investigate the effect of right hemisphere damage on perception of emotional meaning or mood in music. An initial pilot study was conducted to select music on which normal subjects were consistent in their judgement of musical mood. The musical stimuli consisted of extracts of classical piano music. The technique used as a measure of musical mood was the Semantic Differential. Tracks of music and adjectival scales were selected for the experimental study in which 15 right hemisphere lesioned patients and normal controls were compared in their response to music. The right hemisphere group demonstrated a characteristic response in their judgement of mood in music. The results are discussed in terms of the role of pitch in judgement of mood in music and in terms of the relationship between music and language.

Extended haplotypes in rheumatoid arthritis and preliminary evidence for an interaction with immunoglobulin genes

The incidence of extended haplotypes of the Major Histocompatibility Complex was compared between 20 probands with RA, their unaffected family members, and 42 controls. One haplotype only, HLA-Bw62 BfS C4A*3 C4B*3 DR4 GLO2, was significantly increased in the patient group, whereas HLA-B7 BfS C4A*3 C4B*1 DR2 GLO1, which was the most common haplotype in the control groups, was absent. The immunoglobulin allotype Glm(2) was significantly increased in frequency in the RA patients, and analysis showed that of the seven patients carrying Bw62-DR4, five were G1m(2) positive. Further, the increase in frequency of the phenotype Gm(1,2,17,21,3,5,23) was also significant and was carried by two of four probands with the extended haplotype HLA-Bw62 BfS C4A*3 C4B*3 DR4 GLO2 and by one proband also bearing this haplotype but with a null allele at the C4A locus. The striking association of G1m(2) and Bw62 with DR4 in our patients suggests that in interaction of immunoglobulin genes with DR4 is stronger when DR4 is associated with particular haplotypes rather than with DR4 in general.

Motor imitation abilities and neurological signs in autistic children

Autistic children were compared with chronological and mental age-matched normal children on two tests of motor imitation and on the Herzig Battery for Non-Focal Neurological Signs. The results indicated that autistic children have significant handicaps in the neurodevelopmental area, with very poor performance on motor imitation tasks and a universal and significant excess of soft signs of neurological dysfunction. Such "dyspraxias" may underlie the failure of these children to learn to use gesture.

Synovial synthesis of rheumatoid factors and immune complex constituents in early arthritis

Synovial synthesis of immune complex constituents and rheumatoid factors has been estimated in rheumatoid arthritis (RA) and in unclassifiable inflammatory arthritis (IA) and related to duration of symptoms. Within 6 months of onset of symptoms both RA and IA patients synthesised (or trapped) immune complexes locally. However, local synthesis of the rheumatoid factors was almost exclusive to RA patients and mainly in patients with symptoms of more than 6 months' duration. Thus all arthritis patients may respond immunologically to an initial trigger in the affected joint but only RA patients develop localised chronic autoimmunity later.

Mortality among young black women using contraceptives

Data on the risk of death associated with various contraceptive methods are incomplete. Therefore, we analyzed the mortality rates for young, black inner-city women who used one of four methods of contraception--oral contraceptives, depomedroxyprogesterone acetate, intrauterine (contraceptive) devices, and barrier methods. The subjects were 30,580 15- to 44-year-old women who enrolled at a family planning clinic between 1967 and 1972 and who were observed by monitoring death certificates through the end of 1977. Forty percent of the 218 deaths observed were from accidents and violence. Use of this family planning clinic greatly reduced the risk of death from childbearing; only two deaths were associated with pregnancy and childbirth, compared with the 24 deaths expected. Overall, users of the four methods died at similar, low rates. Given that this study involves considerable loss to follow-up, possible acute effects of contraceptives (eg, infections or thrombosis) are more accurately estimated than possible long-term effects (eg, cancer).

Risk of breast cancer in women with history of benign disease of the breast

A consecutive series of 791 women who had attended diagnostic breast clinics during 1967-70 and been found to be free of malignant disease were later traced to determine their subsequent incidence of breast cancer. Of the 770 (97%) successfully traced, 22 had developed breast cancer. Based on data from the Welsh Cancer Registry only eight cases of breast cancer had been expected, so that the excess risk for the group was 2.7. The increased risk occurred in all age groups and in women deemed "essentially normal" as well as in those who had had a pathological abnormality. The risk was increased when epithelial hyperplasia was present. No excess mortality from breast cancer was apparent, but follow up was short. More breast symptoms were experienced and more biopsies performed than expected in this group of women. Women with a past history of benign breast disease have a slightly increased risk of breast cancer. Selective screening of these women, however, may be uneconomic and a cause of groundless anxiety.

[Anatomy of the upper abdomen seen by real-time ultrasound]

Ultrasound has made it possible to identify major blood vessels of the abdomen. The identification of these vascular structures has been facilitated with the use of gray's scale ultrasound but more so with real time ultrasound. The identification of these vascular structures as well as the advantages that they present in identifying abdominal viscera will be discussed.