The management of animal bites in the United kingdom

OBJECTIVE

Animal bites represent a significant global health issue. The evidence in the literature regarding their management in many areas is conflicting and unclear. This project attempts to identify current evidence in the literature on the management of animal bites and assess if current practice in the United Kingdom is evidence based.

MATERIALS AND METHODS

A literature review on the management of animal bites was performed, and a national UK survey was contacted using a questionnaire based on the available evidence in the literature.

RESULTS

The results from this survey show that 98% of plastic surgery units routinely use prophylactic antibiotics in all animal bite wounds; 58% close low-risk injuries primarily after initial washout, and there are conflicting opinions regarding the management of associated fractures and soft tissue injuries. The available data in the literature suggest that appropriate wound management is the most important factor for prevention of infection in animal bites. Antibiotic prophylaxis should only be given in high-risk wounds and primary closure should be performed in low-risk wounds.

CONCLUSIONS

The management protocols of many plastic surgery units often diverge from the available evidence within the literature. On the basis of a thorough literature review, a guideline for the management of animal bites is presented. Future studies should investigate the management of associated fractures and soft tissue injuries.

Abstract P3-04-08: Expression of hormone-responsive genes in benign breast tissue varies with menstrual cycle phase and menopausal status

Background: The expression of many genes is known to be regulated by ambient hormone levels. In a preliminary study of random fine-needle aspirate (rFNA) samples from benign breast tissue, we found several genes that were highly correlated with the serum levels of progesterone (P4) and estradiol (E2). We now present data to further validate these genes as markers of menstrual cycle phase (MCP) and menopausal status (MPS) in benign breast tissue which may allow retrospective classification of archived breast samples with respect to MCP and MPS at the time of sampling.

Methods: 240 rFNA samples from healthy women with recorded hormonal data at the time of sampling were analyzed. We divided these subjects by menstrual cycle phase (MCP) and menopausal status (MPS): 41 early follicular: (low circulating E2 and P4); 48 mid-cycle (high E2 and low P4); 31 luteal (moderate E2 and high P4). 120 post-menopausal (low E2 and low P4). 100 ng of RNA from rFNA samples of the breast was reverse transcribed. Amplicons of interest were linearly amplified to 14 cycles for 35 genes related to hormone responsiveness. qPCR reactions were carried out using the TaqMan OpenArray (Applied Biosystems). For each gene of interest, expression levels were normalized to the average expression of GAPDH. Gene expression difference between groups were conducted using the Mann-Whitney Test. P-values from gene expression difference were adjusted via the Benjamini-Hochberg (1995) approach.

Results: The mean value of TNFSF11 expression level was 13.19 fold higher in luteal phase subjects than in post-menopausal subjects (p = 0.0003) where there was also the biggest difference of serum P4 level between groups. The expression of DIO2 and MYBPC1 was also significantly higher in luteal phase group than in the post-menopausal group (p = 0.005, p = 0.02, respectively). These 3 genes also demonstrated a higher expression pattern in luteal phase than mid-cycle and follicular phase but analysis is still ongoing. All comparisons between these groups will be presented at the meeting.

Conclusion: The expression levels of TNFSF11, DIO2 and MYBPC1 vary with MCP and MPS. These hormone-responsive genes are candidate MCP classifiers which could be applied to archived breast samples to assess whether biomarkers of breast cancer risk are stable across the menstrual cycle, since MCP and MPS variation is likely an important source of biological noise in studies of archived breast biopsy material.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-04-08.

Gemella haemolysans spondylodiscitis: a report of two cases

We report on two cases of infective spondylodiscitis caused by Gemella haemolysans in otherwise healthy patients. This organism has only rarely been identified as a cause of bone and joint infection, with only two previous reports of infective spondylodiscitis. We describe the clinical features, investigations and treatment options.

Mitochondrial gene replacement in human pluripotent stem cell-derived neural progenitors

Human pluripotent stem cell-derived neural progenitor (hNP) cells are an excellent resource for understanding early neural development and neurodegenerative disorders. Given that many neurodegenerative disorders can be correlated with defects in the mitochondrial genome, optimal utilization of hNP cells requires an ability to manipulate and monitor changes in the mitochondria. Here, we describe a novel approach that uses recombinant human mitochondrial transcription factor A (rhTFAM) protein to transfect and express a pathogenic mitochondrial genome (mtDNA) carrying the G11778A mutation associated with Leber's hereditary optic neuropathy (LHON) disease, into dideoxycytidine (ddC)-treated hNPs. Treatment with ddC reduced endogenous mtDNA and gene expression, without loss of hNP phenotypic markers. Entry of G11778A mtDNA complexed with the rhTFAM was observed in mitochondria of ddC-hNPs. Expression of the pathogenic RNA was confirmed by restriction enzyme analysis of the SfaN1-digested cDNA. On the basis of the expression of neuron-specific class III beta-tubulin, neuronal differentiation occurred. Our results show for the first time that pathogenic mtDNA can be introduced and expressed into hNPs without loss of phenotype or neuronal differentiation potential. This mitochondrial gene replacement technology allows for creation of in vitro stem cell-based models useful for understanding neuronal development and treatment of neurodegenerative disorders.

Klebsiella pneumoniae producing KPC carbapenemase in a district general hospital in the UK

We report two patients with multidrug-resistant KPC-carbapenemase-producing Klebsiella pneumoniae urinary tract infections. A bla(KPC-2) gene was detected in both of the isolates by polymerase chain reaction and sequencing. The isolates had identical pulsed-field gel electrophoresis patterns and belonged to sequence type ST11. The index patient probably acquired the KPC-producing strain while in hospital in Curaçao, with subsequent nosocomial transmission to the second patient occurring in our hospital. We describe the interventions that were taken to prevent its further spread within the acute Trust and the community.

A humanized monoclonal antibody targeting the β7 integrin selectively blocks intestinal homing of T lymphocytes

BACKGROUND AND PURPOSE

rhuMAb Beta7 is a humanized anti-human β7 monoclonal antibody currently in phase I in inflammatory bowel disease. rhuMAb Beta7 binds the β7 subunit of the integrins α4β7 and αEβ7, blocking interaction with their ligands. These integrins play key roles in immune cell homing to and retention in mucosal sites, and are associated with chronic inflammatory diseases of the gastrointestinal tract. The goal of this study was to evaluate the mucosal specificity of rhuMAb Beta7.

EXPERIMENTAL APPROACH

We assessed the effect of murine anti-Beta7 on lymphocyte homing in mouse models of autoimmune disease. We also compared the effect of rhuMAb Beta7 on circulating mucosal-homing versus peripheral-homing T cells in naïve non-human primates.

KEY RESULTS

In cynomolgus monkeys, occupancy of β7 integrin receptors by rhuMAb Beta7 correlated with an increase in circulating β7(+) mucosal-homing lymphocytes, with no apparent effect on levels of circulating β7(-) peripheral-homing lymphocytes. rhuMAb Beta7 also inhibited lymphocyte homing to the inflamed colons of severe combined immunodeficient mice in CD45RB(high) CD4(+) T-cell transfer models. Consistent with a lack of effect on peripheral homing, in a mouse model of experimental autoimmune encephalomyelitis, anti-β7 treatment resulted in no amelioration of CNS inflammation.

CONCLUSIONS AND IMPLICATIONS

The results presented here suggest that rhuMAb Beta7 selectively blocks lymphocyte homing to the gastrointestinal tract without affecting lymphocyte trafficking to non-mucosal tissues. rhuMAb Beta7 provides a targeted therapeutic approach with the potential for a more attractive benefit:risk ratio than currently available inflammatory bowel disease therapies.

Increased maternal Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) associated with older age at diagnosis of Type 1 diabetes in offspring

AIMS

Obesity and insulin resistance have been linked to rising incidence and earlier onset of Type 1 diabetes. Inherited differences in insulin action might also influence the evolution of Type 1 diabetes.Our aim was to determine whether parental BMI and insulin resistance influences age of onset of Type 1 diabetes in their offspring.

METHODS

BMI standard deviation score and age at diagnosis of Type 1 diabetes was examined in 227 children, and in 206 of these was compared with local matched control subjects. Non-diabetic parents of a subgroup of 80 children with Type 1 diabetes were recruited. Parental BMI was compared with local adult control subjects. The relationship between parental BMI, waist-hip ratio, homeostasis model assessment of insulin resistance (HOMA-IR), leptin and adiponectin levels and age at diagnosis of Type 1 diabetes in offspring was examined.

RESULTS

We found no relationship between age at diagnosis of Type 1 diabetes in children and BMI standard deviation score (P = 0.5). Children with Type 1 diabetes and their parents were heavier than matched control subjects (mean BMI standard deviation score sd in children = 0.66 1.06 vs. 0.32 1.16 in control subjects, P = 0.002; mean parental BMI sd 27.7 0.4 vs. 25.5 0.4 kg ⁄m2 in control subjects; P < 0.0001). Maternal HOMA-IR accounted for 20% of variation in age at diagnosis (P < 0.001) with increasing maternal insulin resistance associated with later age at diagnosis of Type 1 diabetes.

CONCLUSIONS

Childrenwith Type 1 diabetes and their parents have an increased BMI at diagnosis.Maternal insulin resistance is associated with later onset of Type 1 diabetes in children.

Loss of ethanol conditioned taste aversion and motor stimulation in knockin mice with ethanol-insensitive α2-containing GABA(A) receptors

GABA type A receptors (GABA(A)-Rs) are potential targets of ethanol. However, there are multiple subtypes of this receptor, and, thus far, individual subunits have not been definitively linked with specific ethanol behavioral actions. Interestingly, though, a chromosomal cluster of four GABA(A)-R subunit genes, including α2 (Gabra2), was associated with human alcoholism (Am J Hum Genet 74:705-714, 2004; Pharmacol Biochem Behav 90:95-104, 2008; J Psychiatr Res 42:184-191, 2008). The goal of our study was to determine the role of receptors containing this subunit in alcohol action. We designed an α2 subunit with serine 270 to histidine and leucine 277 to alanine mutations that was insensitive to potentiation by ethanol yet retained normal GABA sensitivity in a recombinant expression system. Knockin mice containing this mutant subunit were tested in a range of ethanol behavioral tests. These mutant mice did not develop the typical conditioned taste aversion in response to ethanol and showed complete loss of the motor stimulant effects of ethanol. Conversely, they also demonstrated changes in ethanol intake and preference in multiple tests. The knockin mice showed increased ethanol-induced hypnosis but no difference in anxiolytic effects or recovery from acute ethanol-induced motor incoordination. Overall, these studies demonstrate that the effects of ethanol at GABAergic synapses containing the α2 subunit are important for specific behavioral effects of ethanol that may be relevant to the genetic linkage of this subunit with human alcoholism.

Inhaled anesthetic responses of recombinant receptors and knockin mice harboring α2(S270H/L277A) GABA(A) receptor subunits that are resistant to isoflurane

The mechanism by which the inhaled anesthetic isoflurane produces amnesia and immobility is not understood. Isoflurane modulates GABA(A) receptors (GABA(A)-Rs) in a manner that makes them plausible targets. We asked whether GABA(A)-R α2 subunits contribute to a site of anesthetic action in vivo. Previous studies demonstrated that Ser270 in the second transmembrane domain is involved in the modulation of GABA(A)-Rs by volatile anesthetics and alcohol, either as a binding site or a critical allosteric residue. We engineered GABA(A)-Rs with two mutations in the α2 subunit, changing Ser270 to His and Leu277 to Ala. Recombinant receptors with these mutations demonstrated normal affinity for GABA, but substantially reduced responses to isoflurane. We then produced mutant (knockin) mice in which this mutated subunit replaced the wild-type α2 subunit. The adult mutant mice were overtly normal, although there was evidence of enhanced neonatal mortality and fear conditioning. Electrophysiological recordings from dentate granule neurons in brain slices confirmed the decreased actions of isoflurane on mutant receptors contributing to inhibitory synaptic currents. The loss of righting reflex EC(50) for isoflurane did not differ between genotypes, but time to regain the righting reflex was increased in N(2) generation knockins. This effect was not observed at the N(4) generation. Isoflurane produced immobility (as measured by tail clamp) and amnesia (as measured by fear conditioning) in both wild-type and mutant mice, and potencies (EC(50)) did not differ between the strains for these actions of isoflurane. Thus, immobility or amnesia does not require isoflurane potentiation of the α2 subunit.

Invasive group A streptococcal infection: an update on the epidemiology and orthopaedic management

Invasive group A streptococcus (iGAS) is the most common cause of monomicrobial necrotising fasciitis. Necrotising infections of the extremities may present directly to orthopaedic surgeons or by reference from another admitting specialty. Recent epidemiological data from the Health Protection Agency suggest an increasing incidence of iGAS infection in England. Almost 40% of those affected had no predisposing illnesses or risk factors, and the proportion of children presenting with infections has risen. These observations have prompted the Chief Medical Officer for the Central Alerting System in England to write to general practitioners and hospitals, highlighting the need for clinical vigilance, early diagnosis and rapid initiation of treatment in suspected cases. The purpose of this annotation is to summarise the recent epidemiological trends, describe the presenting features and outline the current investigations and treatment of this rare but life-threatening condition.

Investigating cognitive deficits and symptomatology across pre-morbid adjustment patterns in first-episode psychosis

BACKGROUND

Cognitive deficits in schizophrenia are well established and are known to be present during the first episode of a psychotic disorder. In addition, consistent heterogeneity within these impairments remains unexplained. One potential source of variability may be the level of pre-morbid adjustment prior to the onset of first-episode psychosis (FEP).

METHOD

Ninety-four FEP patients and 32 healthy controls were assessed at baseline on several neuropsychological tests comprising six cognitive domains (verbal memory, visual memory, working memory, processing speed, reasoning/problem-solving and attention) and an abbreviated version of the full IQ. A global neurocognitive domain was also computed. Pre-morbid adjustment patterns were divided into three distinct groups: stable-poor, stable-good and deteriorating course.

RESULTS

Based on a cut-off of 0.8 for effect size, the stable-poor pre-morbid adjustment group was significantly more impaired on most cognitive domains and full IQ compared to the deteriorating group, who were more severely impaired on all measures compared to the stable-good group. The type of cognitive deficit within each subgroup did not differ and the results indicate that a global neurocognition measure may reliably reflect the severity of cognitive impairment within each subgroup.

CONCLUSIONS

Pre-morbid adjustment patterns prior to onset of psychosis are associated with severity but not type of cognitive impairment. Patients in the stable-poor group are generally more impaired compared to the deteriorating group, who are, in turn, more impaired than the stable-good group.

Methylnaltrexone bromide for the treatment of opioid-induced constipation in patients with advanced illness--a cost-effectiveness analysis

BACKGROUND

Opioid-induced constipation is a common adverse event in patients with advanced illness and has a significant negative impact on patients' quality of life and costs.

AIM

To examine the cost-effectiveness of treating opioid-induced constipation with methylnaltrexone bromide (MNTX) plus standard care compared with standard care alone in patients with advanced illness who receive long-term opioid therapy from a third-party payer perspective in the Netherlands.

METHODS

A decision-analytical model was created in which advanced-illness patients with constipation were treated with MNTX plus standard care or standard care alone. Clinical efficacy in terms of percentage of patients with rescue-free laxation and time to rescue-free laxation were obtained from a randomized, controlled clinical study. Resource use, costs, utilities and mortality were obtained from published literature and supplemented with data from clinical experts.

RESULTS

Treatment with MNTX plus standard care results in more days without constipation symptoms. Cost of MNTX was mostly offset by reduction in other constipation-related costs. Thus, treating with MNTX plus standard care is cost-effective, with an incremental cost per QALY of 40,865 euro. Results were robust to changes in all parameters.

CONCLUSIONS

Although using MNTX may increase total costs, MNTX plus standard care is cost-effective in treating advanced-illness patients with opioid-induced constipation.

A case of necrotising fasciitis caused by Pseudomonas aeruginosa

Necrotising fasciitis is a rare but severe infection of soft-tissue associated with rapid progression, systemic toxicity and high mortality. Monomicrobial necrotising fasciitis caused by Pseudomonas aeruginosa is exceptionally uncommon with only 12 cases reported in the literature. We describe a fatal case with an atypical presentation in a patient following spinal decompression for a metastasis from prostate cancer.

Atomic force microscopy detects differences in the surface brush of normal and cancerous cells

The atomic force microscope is broadly used to study the morphology of cells, but it can also probe the mechanics of cells. It is now known that cancerous cells may have different mechanical properties to those of normal cells, but the reasons for these differences are poorly understood. Here, we report quantitatively the differences between normal and cancerous human cervical epithelial cells by considering the brush layer on the cell surface. These brush layers, which consist mainly of microvilli, microridges and cilia, are important for interactions with the environment. Deformation force curves obtained from cells in vitro were processed according to the 'brush on soft cell model'. We found that normal cells have brushes of one length, whereas cancerous cells have mostly two brush lengths of significantly different densities. The observed differences suggest that brush layers should be taken into account when characterizing the cell surface by mechanical means.

Brain-Targeted Nasal Clonazepam Microspheres

Gelatin-chitosan mucoadhesive microspheres of clonazepam were prepared using the emulsion cross linking method. Mirospheres were evaluated using the in vitro and ex vivo drug release patterns. In vivo CNS drug distribution studies were carried out in rats by administering the clonazepam microspheres intra-nasally and clonazepam solution intravenously. From the drug levels in plasma and CSF, drug targeting index and drug targeting efficiency were calculated. Results obtained indicated that intranasally administered clonazepam microspheres resulted in higher brain levels with a drug targeting index of 2.12. Gelatin-chitosan cross linked mucoadhesive microspheres have the potential to be developed as a brain-targeted drug delivery system for clonazepam.

Prognostic factors of concurrent chemo-radiotherapy in head and neck cancers

16527

Background: Concurrent chemo-radiotherapy either as primary or adjuvant treatment is now the standard of care in high- risk head and neck squamous cell carcinomas. This has improved survival rates and chances of organ preservation. Advanced stage, extra- capsular extension, perineural and lympho-vascular invasion and positive surgical margins were considered as poor prognostic factors with radiotherapy alone. Herein we report the significance of these clinical and pathological factors, with concurrent chemo-radiotherapy regimens. Methods:A retrospective analysis of 54 patients with squamous cell carcinoma of head and neck who underwent either primary (21,39 %) or adjuvant (33,61%) concurrent chemoradiation at Amrita Institute of Medical Sciences, Kochi, India, during January 2004 to May 2005 and followed up to Dec 2006. 6 (11%) patients had stage III and 48 (89 %) had stage IV disease. Prognostic significance of clinical and pathological factors was evaluated. Kaplan-Meir curves for survival analysis, log rank test for univariate and Cox proportional method for multivariate analysis were employed. Results: The median follow up was 22 months. Two-year overall (OS) and disease free survival (DFS) rates were 66 % and 52 % respectively. Univariate and multivariate analysis of T stage, nodal stage, radiotherapy interruptions, completion of chemotherapy, schedule of chemotherapy (week 1,4,7 vs weekly), perineural invasion, extra-capsular extension and positive margins showed no significant difference in OS and DFS. However both univariate (p = 0.019 for OS and p = 0.012 for DFS) and multivariate analysis (p = 0.029, HR 0.16,95 %CI - 0.03 to 0.8 for OS and p = 0.017,HR 0.188,95% CI - 0.04 to 0.74 for DFS) revealed lympho-vascular invasion as a significant prognostic factor. Conclusions: Advanced stage, extra capsular invasion and positive margins were conventionally thought to be poor prognostic markers in head and neck cancer. However in our series of patients treated with concurrent chemo radiation lymphovascular invasion was the only significant poor prognostic factor. Other factors were found to be not significant.

No significant financial relationships to disclose.

Methicillin-resistant Staphylococcus aureus infection following arthroscopy of the knee joint

Arthroscopic surgery of the knee is considered to be a safe procedure. We had a microbiologically confirmed infection of methicillin-resistant Staphylococcus aureus (MRSA). Although various rare infective cases are reported following arthroscopy of the knee joint, to the best of our knowledge there is no previous report of MRSA infection following arthroscopy of the knee joint.

Vacuum-assisted closure (VAC) therapy in the management of digital pulp defects

Vacuum-assisted closure (VAC) therapy is a relatively new technique in the field of wound management. It has been increasingly used in treating various types of open wounds with effective results and minimal adverse effects. Digital injuries can occasionally be problematic. We report a new application of vacuum-assisted closure therapy in treating digital pulp defects.

Reducing the risk of peripherally inserted central catheter line complications in the oncology setting

At our institution, a retrospective review of peripherally inserted central catheters (PICCs) in oncology patients had previously demonstrated a complication rate of 40.7%. Since then we have implemented strategies to reduce complications including staff and patient education, insertion technique modification and PICC maintenance utilizing a PICC nurse. The objectives of this study were to evaluate the recent PICC complication rate and to compare it with the previously reported findings. Prospectively collected PICC complication data and medical records from all patients with solid tumours who had PICCs inserted in 2003 were analysed. A historical cohort comparative analysis was performed using our PICC complication rate from 2000 to 2001. Eighty-eight PICC lines were inserted in 73 patients under radiological guidance. The median PICC dwell time was 44 days (1-524 days). The overall complication rate was 15.9% (14/88) or 2.0 complications per 1,000 PICC-days. Infections developed in 5.7% (5/88) and thrombotic events occurred in 4.5% (4 /88) of PICCs. The mean time to complication was 45 days. The complication rate for 2003 was significantly lower than the rate for 2001 (P = 0.006), especially of infective complications (P = 0.004). Strategies introduced to reduce PICC complications may have been the reason for this improvement.