Surgical delay in the management of dog bite injuries in children, does it increase the risk of infection?

Dog bites are contaminated wounds and convention dictates that any surgical treatment should be performed at the earliest opportunity. This practice, however, may be in direct conflict with NCEPOD guidelines to reduce night time operating. We audited our treatment of dog bite injuries in children over a 5-year period (1998-2002) to determine whether delaying surgery to conform to operating guidelines increased the incidence of infection. A retrospective case note study identified 118 patients admitted to Sheffield Children's Hospital with dog bite injuries. Details of their injury, treatment and outcome were recorded. There were 70 males and 48 females and an average age of 6.6 years (range 1-15 years). The most common type of injury was a single laceration (32%) and the most frequent site of injury was the face (59%). The majority of wounds (68%) were cleaned and dressed before theatre and 89% were closed directly after minimal debridement. All patients received prophylactic antibiotics. Of the 114 patients that required surgery, 57 (50%) were operated on within 12 h of their injury and 57 (50%) after 12 h. There were three cases of infection in the early group (<12 h) and none in the delayed group (>12 h). We suggest that delaying the surgical treatment of dog bites in children to avoid operating at night does not increase the infection rate.

Bicyclic and tricyclic thiophenes as protein tyrosine phosphatase 1B inhibitors

A novel pyridothiophene inhibitor of PTP1B was discovered by rational screening of phosphotyrosine mimics at high micromolar concentrations. The potency of this lead compound has been improved significantly by medicinal chemistry guided by X-ray crystallography and molecular modeling. Excellent consistency has been observed between structure-activity relationships and structural information from PTP1B-inhibitor complexes.

DNA methylation in lysogens of pathogenic Burkholderia spp. requires prophage induction and is restricted to excised phage DNA

Burkholderia mallei-specific phage PhiE125 encodes DNA methyltransferases in both the lysogenic and replication modules within its genome. Characterization of DNA methylation in recombinant systems, specifically in PhiE125 lysogenic strains of B. mallei and Burkholderia thailandensis, revealed that, upon induction, cytosine methylation was targeted specifically to the phage episome but not the phage provirus or the host chromosome.

Evolution of duplicated growth hormone genes in autotetraploid salmonid fishes

A defining character of the piscine family Salmonidae is autotetraploidy resulting from a genome-doubling event some 25-100 million years ago. Initially, duplicated genes may have undergone concerted evolution and tetrasomic inheritance. Homeologous chromosomes eventually diverged and the resulting reduction in recombination and gene conversion between paralogous genes allowed the re-establishment of disomic inheritance. Among extant salmonine fishes (e.g. salmon, trout, char) the growth hormone (GH) gene is generally represented by two functional paralogs, GH1 and GH2. Sequence analyses of salmonid GH genes from species of subfamilies Coregoninae (whitefish, ciscos) and Salmoninae were used to examine the evolutionary history of the duplicated GH genes. Two divergent GH gene paralogs were also identified in Coregoninae, but they were not assignable to the GH1 and GH2 categories. The average sequence divergence between the coregonine GH genes was more than twofold lower than the corresponding divergence between the salmonine GH1 and GH2. Phylogenetic analysis of the coregonine GH paralogs did not resolve their relationship to the salmonine paralogs. These findings suggest that disomic inheritance of two GH genes was established by different mechanisms in these two subfamilies.

Gonadotropin-releasing hormone-stimulated gonadotropin levels in women with premenstrual dysphoria

Despite consistent evidence that premenstrual dysphoria (PMD) is not characterized by abnormalities in basal ovarian hormone secretion, the possibility remains that PMD is associated with an abnormality in the regulation of the hypothalamic-pituitary-ovarian (HPO) axis. We studied HPO axis regulation in 11 women with prospectively confirmed PMD and 20 asymptomatic controls, during both the follicular and luteal phases of the menstrual cycle. Plasma levels of the gonadotropins, luteinizing hormone (LH) and follicle-stimulating hormone (FSH), were obtained before and after stimulation with gonadotropin-releasing hormone (GnRH) (100 microg intravenously). Potential diagnostic- and menstrual cycle phase-related diferences in basal and plasma hormone levels were analyzed by repeated-measures analysis of variance. No significant differences were observed between women with PMD and controls in either basal or stimulated levels of FSH and LH. Stimulated FSH was significantly increased and stimulated LH was significantly decreased during the follicular compared with the luteal phase in both women with PMD and controls. These data are consistent with prior findings of normal basal reproductive hormone levels in women with PMD. Our data suggest the absence in women with PMD of an abnormality of dynamic ovarian function as measured by GnRH stimulation.

The SIS extracellular matrix scaffold-preliminary results of use in congenital diaphragmatic hernia (CDH) repair

There is no ideal bio-tensile material for tissue replacement in paediatric surgical conditions. A variety of materials have been described to replace or reinforce tissue deficits in congenital diaphragmatic hernia (CDH). The problems with these materials range from extensive surgery to body wall deformity and hernia recurrence. The ideal graft would be safe, strong, have the potential to grow and not require replacement, not affect chest wall development or produce deformity, and have minimal risk of recurrence. Surgisis is a biomaterial composed of porcine intestinal submucosa that provides inherent tensile strength as a collagen lattice and is ultimately replaced by native collagen tissue. Our objective was to prospectively assess the utility of Surgisis as a replacement graft in a cohort of 10 children undergoing primary or recurrent CDH repair. The graft was well tolerated, and there was no recurrence of herniation. We conclude that Surgisis collagen mesh may be a useful alternative for tissue replacement or reinforcement in difficult cases of CDH and diaphragmatic agenesis. The biological framework of Surgisis may also prove useful in other situations of complex tissue loss in children.

Physicochemical Evolution and Molecular Adaptation of the Cetacean and Artiodactyl Cytochrome b Proteins

Cetaceans have most likely experienced metabolic shifts since evolutionarily diverging from their terrestrial ancestors, shifts that may be reflected in the proteins such as cytochrome b that are responsible for metabolic efficiency. However, accepted statistical methods for detecting molecular adaptation are largely biased against even moderately conservative proteins because the primary criterion involves a comparison of nonsynonymous and synonymous substitution rates (dN/dS); they do not allow for the possibility that adaptation may come in the form of very few amino acid changes. We apply the MM01 model to the possible molecular adaptation of cytochrome b among cetaceans because it does not rely on a dN/dS ratio, instead evaluating positive selection in terms of the amino acid properties that comprise protein phenotypes that selection at the molecular level may act upon. We also apply the codon-degeneracy model (CDM), which focuses on evaluating overall patterns of nucleotide substitution in terms of base exchange, codon position, and synonymy to estimate the overall effect of selection. Using these relatively new models, we characterize the molecular adaptation that has occurred in the cetacean cytochrome b protein by comparing revealed amino acid replacement patterns to those found among artiodactyls, the modern terrestrial mammals found to be most closely related to cetaceans. Our findings suggest that several regions of the cetacean cytochrome b protein have experienced molecular adaptation. Also, these adaptations are spatially associated with domain structure, protein function, and the structure and function of the cytochrome bc(1) complex and its constituents. We also have found a general correlation between the results of the analytical software programs TreeSAAP (which implements the MM01 model) and CDM (which implements the codon-degeneracy model).

Glutamic acid decarboxylase 67 (GAD67) gene expression in discrete regions of the rostral preoptic area change during the oestrous cycle and with age

Gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter, is important to the timing and amplitude of the gonadotrophin-releasing hormone (GnRH)-induced luteinizing hormone (LH) surge on pro-oestrus. Data suggest that GABA input in the preoptic area must decrease for a normal LH surge to occur in young rats. We have previously found that ageing alters the timing and amplitude of the LH surge. Therefore, this study focused on changes in GAD(67) gene expression, a reflection of GABA synthesis, in two regions of the rostral preoptic area, the organum vasculosum of the lamina terminalis (OVLT) and the anteroventral periventricular nucleus (AVPV) during the oestrous cycle and with age. We assessed the possibility that the expression of GAD(67) mRNA in these regions displays time-related and age-dependent changes on pro-oestrus. Our results demonstrate that, with age, overall expression of GAD(67) mRNA decreases in the area surrounding the OVLT and in the AVPV. Young rats display a diurnal rhythm in GAD(67) mRNA in both regions. GAD(67) mRNA expression is high during the early morning hours of pro-oestrus and then declines around the time of the GnRH-induced LH surge. In addition, the diurnal rhythm disappears in the AVPV and is attenuated in the area surrounding the OVLT of middle-aged proestrous rats. These findings suggest that a loss of rhythmicity in GAD(67) gene expression and maintenance of inhibitory tone on proestrous afternoon may alter the timing and amplitude of the LH surge, as previously observed in middle-aged rats.

Access to health care in South Africa--the influence of race and class

OBJECTIVES

The first democratic government elected in South Africa in 1994 inherited huge inequities in health status and health provision across all sections of the population. This study set out to assess the impact of the new government's commitment to address these inequities and implement policies to improve population health in general and address inequalities in health care in particular.

DESIGN

A 1998 household survey assessed many aspects of health delivery, including their own perceived and actual access to health care among different segments of South African society.

RESULTS

Race was the main predictor of perceived changes in access to health care, with black, coloured-and Indian respondents significantly more likely to feel that access had improved since 1994, compared with white respondents. Socio-economic status (SES) was the main predictor of actual access to health care, with low and middle SES classes significantly less likely to access care when ill.

CONCLUSIONS

One-third of respondents perceived health care access to have improved between 1994 and 1998, and this response was partially determined along racial lines. About one-quarter reported an inability to access health care when they required it, and this response was partially determined along socio-economic lines. This set of contrasting responses suggests that at a political level perceptions are largely influenced by race, but at the operational level actual access is influenced by SES.

Critical parameters influencing hyperthermia-induced apoptosis in human lymphoid cell lines

Brief mild hyperthermia is sufficient to induce apoptosis (programmed cell death) in many cell lines. Here we describe the effects of a number of factors modulating heat shock induced apoptosis outcomes. We report the effects of cell type, heat load, recovery times, cellular growth phase, and protein synthesis on the levels of apoptoses seen in heat stressed cell populations. We observe that a number of cell lines are competent to undergo heat stress induced apoptosis using both the comet assay and cellular and nuclear morphologies. Of the cell lines tested we saw a wide spectrum of sensitivities, ranging from resistant (less than 1% apoptotic after 12 h) to exquisitely sensitive (>95%). By incrementally increasing the heat load from 37-49 degrees C, we observed a gradual increase in apoptosis with a significant change from apoptotic to necrotic death at temperatures beyond 45 degrees C. The kinetics of the apoptotic response to heat shock were also examined. A time dependent increase in apoptotic cell death was seen after initial hyperthermic treatment with most cell types reaching a 'plateau' at 18 h. In addition to these parameters we report that growth phase has a strong influence on the number of apoptoses induced as a result of heat stress. Cultured cells, grown to a plateau, undergo apoptosis at a much higher level than similarly treated cells taken during an exponential phase of growth. Finally, we determined the necessity of protein synthesis for apoptotic competency.

Release studies of benzalkonium chloride from hydrogel in a freshwater environment

The use of underwater optical sensors to monitor pollution and climate change processes has led to the development of robust instruments able to be deployed in lakes and seas for months at a time. However, despite this improvement in their durability they are subject to biofouling on their optical ports resulting in erroneous readings. The use of hydrogel coatings containing the cationic surfactant benzalkonium chloride (BAC) has been shown to prevent the development of biofouling for up to 12 weeks in the marine environment. In this study the use of hydrogel coatings in the freshwater environment was less successful with fouling visible at 2 weeks. In both field and laboratory studies a rapid initial loss of BAC from the hydrogel film was observed. The loss is a combination of diffusive and mass flow but the period from 12 to 50 h appeared to fit to diffusion kinetics and a diffusion coefficient of 7.3 x 10(-8) cm2 s(-1) (13 degrees C) was calculated, an order of 10 times greater than that found in seawater. Subsequently the rate of loss of the residual BAC, for which a diffusion coefficient of 5.7 x 10(-10) cm2 s(-1) (15 degrees C) was measured, was too low to prevent the early stages of biofouling.

Creutzfeldt-Jakob disease in Australia 1970-1999

OBJECTIVE

To ascertain all persons who developed a transmissible spongiform encephalopathy (TSE) within Australia during the 30-year period 1970 to 1999 through a comprehensive national surveillance program and subject the group to detailed epidemiologic analysis.

METHODS

Cases were ascertained through reviews of morbidity separation coding data from all university-affiliated tertiary referral hospitals, as well as the centralized data bases of state and territory health departments, regular national death certificate searches, and semiannual mailout questionnaires to all neurologists and pathologists throughout Australia. Prospective monitoring commenced in September 1993.

RESULTS

A total of 387 patients were confirmed as having TSE during this epoch. The majority of cases were sporadic Creutzfeldt-Jakob disease (CJD) (90.7%), with 7.2% heredofamilial and 2.1% iatrogenic. Over this 30-year period, the national average annual sporadic CJD incidence rate per million progressively increased from 0.31 for the decade 1970 through 1979 to 0.77 for 1980 through 1989, reaching 1.03 for 1990 through 1999. Death certificates were found to have a false-positive rate of 11.5% and sensitivity of 83.0% for sporadic CJD.

CONCLUSIONS

Within Australia, there has been a gradual increase in the incidence of transmissible spongiform encephalopathy over the three-decade period 1970 through 1999, peaking in 1999 at 1.4/million/year for sporadic Creutzfeldt-Jakob disease. This increase is believed secondary to improved case ascertainment. Variant Creutzfeldt-Jakob disease was not identified during this period. Age- and sex-adjusted comparisons showed a decline in incidence rates in the elderly in both sexes, usually from age 74 years. Death certificates were a useful but imperfect method of case detection.

Hepatic xenobiotic metabolism of cylindrospermopsin in vivo in the mouse

Cylindrospermopsin (CYN) is a hepatotoxin isolated from the blue-green alga Cylindrospermopsis raciborskii. The role of both glutathione (GSH) and the cytochrome P450 enzyme system (P450) in the mechanism of toxicity of CYN has been previously investigated in in vitro systems. We have investigated the role of GSH and P450 in vivo in mice. Mice pre-treated with buthionine sulphoximine and diethyl maleate to deplete hepatic GSH prior to dosing with 0.2mg/kg CYN showed a seven-day survival rate of 5/13 while the control group rate was 9/14. Dosing mice with 0.2mg/kg CYN produced a small decrease in hepatic GSH with a characteristic rebound effect at 24h. The magnitude of this effect is however small and combined with the non-significant difference in survival rates after GSH depletion suggest depletion of GSH by CYN could not be a primary mechanism for CYN toxicity. Conversely, pre-treatment with piperonyl butoxide, a P450 inhibitor, protected mice against CYN toxicity giving a survival rate of 10/10 compared with 4/10 in the control group (p < 0.05 Chi squared) and was protective at doses up to 0.8 mg/kg, suggesting activation of CYN by P450 is of primary importance in the mechanism of action.

Method for the measurement of the diffusion coefficient of benzalkonium chloride

Biofilm formation on the optical ports of cameras and underwater sensors is the primary cause of their reduced useful deployment time. The use of a transparent hydrogel coating containing the cationic surfactant benzalkonium chloride has been shown to extend the deployment times for up to 12 weeks for these instruments. In order to predict the effective lifetime of these coatings it was necessary to obtain the diffusion coefficient of the benzalkonium chloride used in the coatings. Benzalkonium chloride can have different alkyl chain lengths ranging from C8H17 to C18H37 with chain length greatly affecting its chemical properties. The benzalkonium chloride materials investigated here were mixtures of C12H25 and C14H29 as well as C14H29 on its own. These materials were selected for their proven biofilm resistant qualities. The diaphragm diffusion cell technique was investigated for its applicability to the measurement of diffusion coefficients of molecules with surfactant properties and the ability to form micelles. The method was found to be satisfactory for the cationic surfactant benzalkonium chloride. The average value of the membrane cell integral diffusion coefficient D was 7.78 x 10(-6) cm2 s(-1) at 25 degrees C and there was no significant effect of alkyl chain length on the measured value of D.

Macroergonomics and total quality management: how to improve quality of working life?

In this paper, we present a macroergonomic model of work design that is applied and tested to examine Total Quality Management (TQM) in the public sector. According to the model, TQM can influence different aspects of work design and quality of working life (QWL). Questionnaire data collected in 2 public sector organizations in the USA show that TQM can have both positive and negative impact on work design and QWL. The main positive impact of TQM was found on job content, job control and participation, and social relationships. The main negative impact of TQM was on workload, uncertainty, and clarity of job duties. The impact of TQM on QWL was mixed. Our results show that the impact of TQM on work design and QWL varied very much across the 6 participating departments, as well as within the departments. Further research is warranted to assess the human impact of TQM, in particular research on the linkage between various aspects of TQM, on one hand, and work design and QWL, on the other hand.

A sensitive and specific assay for glutathione with potential application to glutathione disulphide, using high-performance liquid chromatography-tandem mass spectrometry

We have utilised the combination of sensitivity and specificity afforded by coupling high-performance liquid chromatography (HPLC) to a tandem mass spectrometer (MS-MS) to produce an assay which is suitable for assaying glutathione (GSH) concentrations in liver tissue. The sensitivity suggests it may also be suitable for extrahepatic tissues. The method has been validated for GSH using mouse liver samples and also allows the assay of GSSG. The stability of GSH under conditions relevant to the assay has been determined. A 20-microl amount of a diluted methanol extract of tissue is injected with detection limits of 0.2 pmol for GSH and 2 pmol for GSSG. The HPLC uses an Altima C18 (150 x 4.6 mm, 5 microm) column at 35 degrees C. Chromatography utilises a linear gradient from 0 to 10% methanol in 0.1% formic acid over 5 min, with a final isocratic stage holding at 10% methanol for 5 min. Total flow rate is 0.8 ml/min. The transition from the M+H ion (308.1 m/z for GSH, and 613.3 m/z for GSSG) to the 162.0 m/z (GSH) and 355.3 m/z (GSSG) fragments are monitored.

Pick's disease associated with the novel Tau gene mutation K369I

Exonic and intronic mutations in Tau cause neurodegenerative syndromes characterized by frontotemporal dementia and filamentous tau protein deposits. We describe a K369I missense mutation in exon 12 of Tau in a patient with a pathology typical of sporadic Pick's disease. The proband presented with severe personality changes, followed by loss of cognitive function. Detailed postmortem examination of the brain showed atrophy, which was most pronounced in the temporal lobes; and numerous tau-immunoreactive Pick bodies and Pick cells in the neocortex and the hippocampal formation, as well as in subcortical brain regions. Their appearance and staining characteristics were indistinguishable from those of sporadic Pick's disease. However, immunoblot analysis of sarkosyl-insoluble tau showed three major bands of 60, 64, and 68 kDa, consistent with the presence of 3- and 4-repeat tau isoforms, as in Alzheimer's disease. Isolated tau filaments were irregularly twisted ribbons, with a small number of Alzheimer-type paired helical filaments. In the presence of heparin, tau proteins with the K369I mutation formed short, slender filaments. Biochemically, recombinant tau proteins with the K369I mutation showed reduced ability to promote microtubule assembly, suggesting that this may be the primary effect of the mutation by providing a pool of aberrant tau for filament assembly. Taken together, results indicate that the K369I mutation in Tau can cause a dementing disease with a neuropathology like that of Pick's disease.

Immobilized IL-8 triggers progressive activation of neutrophils rolling in vitro on P-selectin and intercellular adhesion molecule-1

The chemokine IL-8 is found on the luminal side of vascular endothelial cells, where it is postulated to be immobilized during inflammation. In this study, we observed that immobilized IL-8 can stimulate neutrophils to firmly adhere to a substrate containing ICAM-1 in a static adhesion assay. Soluble IL-8 was then perfused over neutrophils rolling on P-selectin (P-sel) and ICAM-1, confirming that IL-8 in solution can quickly cause rolling neutrophils to arrest. To mimic a blood vessel wall with IL-8 expressed on the luminal surface of endothelial cells, IL-8 was immobilized along with P-sel and ICAM-1 at defined site densities to a surface. Neutrophils rolled an average of 200 microm on surfaces of P-sel, ICAM-1, and IL-8 before firmly adhering through ICAM-1-beta(2) integrin interactions at 2 dynes/cm(2) wall shear stress. Increasing the density of IL-8 from 60 to 350 sites/microm(2) on the surface decreased by 50% the average distance and time the neutrophils rolled before becoming firmly adherent. Temporal dynamics of ICAM-1-beta(2) integrin interactions of rolling neutrophils following IL-8 exposure suggest the existence of two classes of beta(2) integrin-ICAM-1 interactions, a low avidity interaction with a 65% increase in pause times as compared with P-sel-P-sel glycoprotein ligand-1 interactions, and a high avidity interaction with pause times 400% greater than the selectin interactions. Based on the proportionality between IL-8 site density and time to arrest, it appears that neutrophils may need to sample a critical number of IL-8 molecules presented by the vessel wall before forming a sufficient number of high avidity beta(2) integrin bonds for firm adhesion.

Extraction and purification of the zwitterions cylindrospermopsin and deoxycylindrospermopsin from Cylindrospermopsis raciborskii

The hepatotoxin cylindrospermopsin (CYN) has been isolated from the cyanobacterium Cylindrospermopsis raciborskii (C. raci.). Efforts to study this toxin have been hampered by the time-consuming requirement to extract it from cultures of the organism. It is usually extracted from lyophilized cells collected from a laboratory culture. Our preliminary work suggested far more of the toxin is available in solution in the culture media than in the cells collected. We have therefore investigated the use of commercially available solid phase extraction sorbents to extract CYN from culture media in which C. raci. has been grown. A range of reverse phase and ion-exchange sorbents were tested across a range of pHs for their ability to retain CYN without success. Subsequently, graphitized carbon cartridges were found to retain CYN strongly. Elution with 5% formic acid in methanol allowed the CYN to be regained for final purification by HPLC. Deoxy-CYN, an analog of CYN can also be extracted using this procedure.

Applying quality improvement principles to achieve healthy work organizations

BACKGROUND

Health care has used total quality management (TQM)/quality improvement (QI) methods to improve quality of care and patient safety. Research on healthy work organizations (HWOs) shows that some of the same work organization factors that affect employee outcomes such as quality of life and safety can also affect organizational outcomes such as profits and performance. An HWO is an organization that has both financial success and a healthy workforce. For a health care organization to have financial success it must provide high-quality care with efficient use of scarce resources. To have a healthy workforce, the workplace must be safe, provide good ergonomic design, and provide working conditions that help to mitigate the stress of health care work.

INTEGRATING TQM/QI INTO THE HWO PARADIGM

If properly implemented and institutionalized, TQM/QI can serve as the mechanism by which to transform a health care organization into an HWO. To guide future research, a framework is proposed that links research on QI with research on HWOs in the belief that QI methods and interventions might be an effective means by which to create an HWO. Specific areas of research should focus on identifying the work organization, cultural, technological, and environmental factors that affect care processes; affect patient health, safety, and satisfaction; and indirectly affect patient health, safety, and satisfaction through their effects on staff and care process variables.

SUMMARY

Integrating QI techniques within the paradigm of the HWO paradigm will make it possible to achieve greater improvements in the health of health care organizations and the populations they serve.