Impact of obesity on arteriovenous fistula outcomes in dialysis patients

Fistula use for dialysis is less frequent among obese than non-obese patients. This discrepancy may be due to a lower rate of fistula placement in obese patients, a higher primary failure rate (fistulas that are never usable for dialysis), or a higher secondary failure rate (fistulas that fail after being used successfully for dialysis). Using a prospective, computerized vascular access database, we identified all patients receiving a first fistula or graft at our institution during a 2-year period. The access outcomes were compared between obese (body mass index (BMI) >or=30 kg/m2) and non-obese (BMI<30 kg/m2) patients. Fistula placement was equally likely between obese and non-obese patients (47.4 vs 47.1%). The primary failure rate of fistulas was similar in both groups (46 vs 41%, P=0.45). Among those fistulas that were usable for dialysis, the secondary survival was worse in obese patients (hazard ratio 2.74; 95% confidence interval (CI), 1.48-7.90; P=0.004). Secondary fistula survival in obese vs non-obese patients was 68 vs 92% at 1 year, 59 vs 78% at 2 years, and 47 vs 70% at 3 years. On multiple variable survival analysis with age, sex, race, diabetes, coronary artery disease, peripheral vascular disease, fistula location, surgeon, and obesity in the model, obesity was the only significant factor predicting secondary fistula failure (hazards ratio 2.93; 95% CI, 1.44-5.93; P=0.004). In conclusion, long-term fistula survival is worse in obese than non-obese patients, owing to a higher secondary failure rate.

Recommendations for the use of etanercept in psoriasis: a European dermatology expert group consensus

BACKGROUND

Psoriasis is a chronic, inflammatory skin disorder that has a significant impact on quality of life and, particularly in moderate to severe cases, adversely affects the patient's overall health and well-being. Biological treatments, such as etanercept, are being widely adopted across Europe for treatment of moderate to severe psoriasis due to favourable safety and efficacy profiles. The increase in usage, combined with a growing body of clinical evidence, has identified a need to clarify the best use of etanercept within its current treatment label.

OBJECTIVE

To prepare a series of recommendations agreed by an expert group of dermatologists, relating to the most effective use of etanercept for psoriasis in Europe, within the product license.

METHODS

An expert panel of dermatologists from across Europe completed a Delphi survey to address the current use of etanercept in psoriasis in Europe. In June 2005 the results were presented to the expert panel at their nominal group meeting, and a consensus was agreed.

RESULTS

It was recommended that, where possible, patients are initiated on the 50 mg twice-weekly (BIW) dose. Etanercept should be given until remission is achieved (maximum 24 weeks) and retreatment should be initiated according to the physician's judgement. Before commencing treatment, contraindications, such as infection or previous malignancy (within 5 years), should be ruled out.

CONCLUSIONS

The consensus presented herein provides valuable clarification of use of etanercept according to the label, which may have wider implications relating to the use of all biological therapies in psoriasis.

Elevated expression and genetic association links the SOCS3 gene to atopic dermatitis

In a systematic analysis of global gene-expression patterns, we found that SOCS3 messenger RNA was significantly more highly expressed in skin from patients with atopic dermatitis than in skin from healthy controls, and immunohistochemical analysis confirmed a similar elevation of SOCS3 protein. Furthermore, we found a genetic association between atopic dermatitis and a haplotype in the SOCS3 gene in two independent groups of patients (P<.02 and P<.03). These results strongly suggest that SOCS3, located in a chromosomal region previously linked to the disease (17q25), is a susceptibility gene for atopic dermatitis.

Review of the potential photo-cocarcinogenicity of topical calcineurin inhibitors. Position statement of the European Dermatology Forum

Topical Calcineurin Inhibitors (TCIs) used for the treatment of atopic eczema modify the immune regulatory function of the skin and may have the potential to enhance immunosuppressive ultraviolet (UV) effects. Current recommendations on UV protection in eczema patients treated with PCIs are inconsistent and have given rise to uncertainty and anxiety in patients. Therefore, the European Dermatology Forum (EDF) developed a position statement which reviews critically the available data with regard to the problem, especially analysing and commenting the limitations of rodent models for the human situation. There is no conclusive evidence from rodent trials to indicate that long-term application of TCIs is photococarcinogenic. There is a need for further studies to investigate the validity of mouse models as well as long-term cohort studies in patients using TCIs. Available data suggest that long-term application of TCIs is safe, that there is no evidence of increased skin cancer risk and that it is ethical to treat patients with TCIs when indicated.

The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet

AIMS

To determine the level of aerosol formation and fallout within a toilet cubicle after flushing a toilet contaminated with indicator organisms at levels required to mimic pathogen shedding during infectious diarrhoea.

METHODS AND RESULTS

A semisolid agar carrier containing either Serratia marcesens or MS2 bacteriophage was used to contaminate the sidewalls and bowl water of a domestic toilet to mimic the effects of soiling after an episode of acute diarrhoea. Viable counts were used to compare the numbers of Serratia adhering to the porcelain surfaces and those present in the bowl water before and after flushing the toilet. Air sampling and settle plates were used to determine the presence of bacteria or virus-laden aerosols within the toilet cubicle. After seeding there was a high level of contamination on the porcelain surfaces both under the rim and on the sides of the bowl. After a single flush there was a reduction of 2.0-3.0 log cycles cm(-2) for surface attached organisms. The number of micro-organisms in the bowl water was reduced by 2.0-3.0 log cycles ml(-1) after the first flush and following a second flush, a further reduction of c. 2.0 log cycles ml(-1) was achieved. Micro-organisms in the air were at the highest level immediately after the first flush (mean values, 1370 CFU m(-3) for Serratia and 2420 PFU m(-3) for MS2 page). Sequential flushing resulted in further distribution of micro-organisms into the air although the numbers declined after each flush. Serratia adhering to the sidewalls, as well as free-floating organisms in the toilet water, were responsible for the formation of bacterial aerosols.

CONCLUSIONS

Although a single flush reduced the level of micro-organisms in the toilet bowl water when contaminated at concentrations reflecting pathogen shedding, large numbers of micro-organisms persisted on the toilet bowl surface and in the bowl water which were disseminated into the air by further flushes.

SIGNIFICANCE AND IMPACT OF THE STUDY

Many individuals may be unaware of the risk of air-borne dissemination of microbes when flushing the toilet and the consequent surface contamination that may spread infection within the household, via direct surface-to-hand-to mouth contact. Some enteric viruses could persist in the air after toilet flushing and infection may be acquired after inhalation and swallowing.

Successful treatment of severe psoriasis and psoriatic arthritis with adalimumab

Adalimumab, a fully human-derived recombinant monoclonal antibody against tumour necrosis factor-alpha, has been shown to be effective for the treatment of patients with moderately to severely active rheumatoid arthritis. We report two patients with long-standing recalcitrant psoriasis and psoriatic arthritis who, after multiple treatment failures with conventional and experimental antipsoriatic medications, both responded to treatment with adalimumab. Significant clinical improvement was noted in both skin and joint disease in the two patients after several weeks of treatment with adalimumab. We are unaware of previous published reports of adalimumab therapy in patients with psoriasis and psoriatic arthritis.

Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces

A reverse transcriptase polymerase chain reaction assay was used to study the transfer of Norovirus (NV) from contaminated faecal material via fingers and cloths to other hand-contact surfaces. The results showed that, where fingers come into contact with virus-contaminated material, NV is consistently transferred via the fingers to melamine surfaces and from there to other typical hand-contact surfaces, such as taps, door handles and telephone receivers. It was found that contaminated fingers could sequentially transfer virus to up to seven clean surfaces. The effectiveness of detergent- and disinfectant-based cleaning regimes typical of those that might be used to decontaminate faecally contaminated surfaces and reduce spread of NV was also compared. It was found that detergent-based cleaning with a cloth to produce a visibly clean surface consistently failed to eliminate NV contamination. Where there was faecal soiling, although a combined hypochlorite/detergent formulation at 5000 ppm of available chlorine produced a significant risk reduction, NV contamination could still be detected on up to 28% of surfaces. In order consistently to achieve good hygiene, it was necessary to wipe the surface clean using a cloth soaked in detergent before applying the combined hypochlorite/detergent. When detergent cleaning alone or combined hypochlorite/detergent treatment failed to eliminate NV contamination from the surface and the cleaning cloth was then used to wipe another surface, the virus was transferred to that surface and to the hands of the person handling the cloth. In contrast, were surfaces where contaminated with NV-infected faecal suspension diluted to 1 in 10 and 1 in 80, intended to simulate surfaces that have become contaminated after secondary transfer, treatment with a combined bleach/detergent formulation, without prior cleaning, was sufficient to decontaminate surfaces and prevent transfer.

Biological therapies in the systemic management of psoriasis: International Consensus Conference

Psoriasis is a chronic, immune-mediated disorder that usually requires long-term treatment for control. Approximately 25% of patients have moderate to severe disease and require phototherapy, systemic therapy or both. Despite the availability of numerous therapeutic options, the long-term management of psoriasis can be complicated by treatment-related limitations. With advances in molecular research and technology, several biological therapies are in various stages of development and approval for psoriasis. Biological therapies are designed to modulate key steps in the pathogenesis of psoriasis. Collectively, biologicals have been evaluated in thousands of patients with psoriasis and have demonstrated significant benefit with favourable safety and tolerability profiles. The limitations of current psoriasis therapies, the value of biological therapies for psoriasis, and guidance regarding the incorporation of biological therapies into clinical practice are discussed.

The effects of cleaning and disinfection in reducing Salmonella contamination in a laboratory model kitchen

AIMS

To establish a laboratory model to compare the effectiveness of detergent-based disinfection procedures for reducing cross-contamination risks during handling of contaminated chicken.

METHODS AND RESULTS

During handling of chickens, artificially contaminated with Salmonella enteritidis PT4, the organism was widely spread to hands, cloths, and hand- and food-contact surfaces. Hygiene procedures were assessed on the basis of their ability to reduce the number of recoverable salmonellas to <1 CFU. Although detergent-based cleaning using a typical bowl-wash routine without rinsing produced some risk reduction (from 100 to 61.4% of contaminated surfaces), it was insufficient to consistently restore surfaces to a hygienic state. By combining detergent-based cleaning with a rinsing step or with hypochlorite at 500 ppm (of available chlorine) some further reduction in microbial risk was achieved, but was not considered satisfactory for food hygiene purposes. By contrast the risk reduction produced by hypochlorite at 5000 ppm was highly significant and was sufficient to reduce the number of contaminated surfaces to 2.9%.

CONCLUSIONS

A key step in achieving a hygienic state through detergent-based cleaning is rinsing but even this will not produce a 'hygienic' result for difficult surfaces such as the chopping board or the dishcloth. Disinfectant compounds should be considered in order to reduce the potential for foodborne cross infection within the home environment.

SIGNIFICANCE AND IMPACT OF THE STUDY

Although tests are available to determine the performance of disinfectants, there are no quantitative procedures available to compare the risk reduction achieved by disinfection with that produced by detergent-based procedures. This study describes a reproducible laboratory method which can be used to differentiate the effectiveness of different hygiene procedures for reducing cross-contamination risks during food handling.

Structure-function analysis of invasion plasmid antigen C (IpaC) from Shigella flexneri

Shigella flexneri causes a self-limiting gastroenteritis in humans, characterized by severe localized inflammation and ulceration of the colonic mucosa. Shigellosis most often targets young children in underdeveloped countries. Invasion plasmid antigen C (IpaC) has been identified as the primary effector protein for Shigella invasion of epithelial cells. Although an initial model of IpaC function has been developed, no detailed structural information is available that could assist in a better understanding of the molecular basis for its interactions with the host cytoskeleton and phospholipid membrane. We have therefore initiated structural studies of IpaC, IpaC I', (residues 101-363 deleted), and IpaC Delta H (residues 63-170 deleted). The secondary and tertiary structure of the protein was examined as a function of temperature, employing circular dichroism and high resolution derivative absorbance techniques. ANS (8-anilino-1-napthalene sulfonic acid) was used to probe the exposure of the hydrophobic surfaces under different conditions. The interaction of IpaC and these mutants with a liposome model (liposomes with entrapped fluorescein) was also examined. Domain III (residues 261-363) was studied using linker-scanning mutagenesis. It was shown that domain III contains periodic, sequence-dependent activity, suggesting helical structure in this section of the protein. In addition to these structural studies, investigation into the actin nucleation properties of IpaC was conducted, and actin nucleation by IpaC and some of the mutants was exhibited. Structure-function relationships of IpaC are discussed.