Long-term outcomes of autologous vein bypass for repair of upper and lower extremity major arterial trauma

OBJECTIVE

Autologous vein is the preferred bypass conduit for extremity arterial injuries owing to superior patency and low infection risk; however, long-term data on outcomes in civilians are limited. Our goal was to assess short- and long-term outcomes of autologous vein bypass for upper and lower extremity arterial trauma.

METHODS

A retrospective review was performed of patients with major extremity arterial injuries (2001-2019) at a level I trauma center. Demographics, injury and intervention details, and outcomes were recorded. Primary outcomes were primary patency at 1 year and 3 years. Secondary outcomes were limb function at 6 months, major amputation, and mortality. Multivariable analysis determined risk factors for functional impairment.

RESULTS

There were 107 extremity arterial injuries (31.8% upper and 68.2% lower) treated with autologous vein bypass. Mechanism was penetrating in 77% of cases, of which 79.3% were due to firearms. The most frequently injured vessels were the common and superficial femoral (38%), popliteal (30%), and brachial arteries (29%). For upper extremity trauma, concomitant nerve and orthopedic injuries were found in 15 (44.1%) and 11 (32.4%) cases, respectively. For lower extremities, concomitant nerve injuries were found in 10 (13.7%) cases, and orthopedic injuries in 31 (42.5%). Great saphenous vein was the conduit in 96% of cases. Immediate intraoperative bypass revision occurred in 9.3% of patients, most commonly for graft thrombosis. The in-hospital return to operating room rate was 15.9%, with graft thrombosis (47.1%) and wound infections (23.5%) being the most common reasons. The median follow-up was 3.6 years. Kaplan-Meier analysis showed 92% primary patency at 1 year and 90% at 3 years. At 6 months, 36.1% of patients had functional impairment. Of patients with functional impairment at 6 months, 62.9% had concomitant nerve and 60% concomitant orthopedic injuries. Of those with nerve injury, 91.7% had functional impairment, compared with 17.8% without nerve injury (P < .001). Of patients with orthopedic injuries, 51.2% had functional impairment, vs 25% of those without orthopedic injuries (P = .01). On multivariable analysis, concomitant nerve injury (odds ratio, 127.4; 95% confidence interval, 17-957; P <. 001) and immediate intraoperative revision (odds ratio, 11.03; 95% confidence interval, 1.27-95.55; P = .029) were associated with functional impairment.

CONCLUSIONS

Autologous vein bypass for major extremity arterial trauma is durable; however, many patients have long-term limb dysfunction associated with concomitant nerve injury and immediate intraoperative bypass revision. These factors may allow clinicians to identify patients at higher risk for functional impairment, to outline patient expectations and direct rehabilitation efforts toward improving functional outcomes.

Outcomes following ipsilateral great saphenous vein bypass for lower extremity arterial injuries

OBJECTIVE

Use of autologous great saphenous vein (GSV) grafts for repair of extremity arterial injuries is well established. Contralateral great saphenous vein (cGSV) is traditionally used in the setting of lower extremity vascular injury given the risk of occult ipsilateral superficial and deep venous injury. We evaluated outcomes of ipsilateral GSV (iGSV) bypass in patients with lower extremity vascular trauma.

METHODS

Patient records at an ACS verified Level I urban trauma center between 2001 and 2019 were retrospectively reviewed. Patients who sustained lower extremity arterial injuries managed with autologous GSV bypass were included. Propensity-matched analysis compared the iGSV and cGSV groups. Primary graft patency was assessed via Kaplan-Meier analysis at 1-year and 3-years following the index operation.

RESULTS

A total of 76 patients underwent autologous GSV bypass for lower extremity vascular injuries. 61 cases (80%) were secondary to penetrating trauma, and 15 patients (20%) underwent repair with iGSV bypass. Arteries injured in the iGSV group included popliteal (33.3%), common femoral (6.7%), superficial femoral (33.3%), and tibial (26.7%), while those in the cGSV group included common femoral (3.3%), superficial femoral (54.1%), and popliteal (42.6%). Reasons for using iGSV included trauma to the contralateral leg (26.7%), relative accessibility (33.3%), and other/unknown (40%). On unadjusted analysis, iGSV patients had a higher rate of 1-year amputation than cGSV patients (20% vs. 4.9%), but this was not statistically significant (P = 0.09). Propensity matched analysis also found no significant difference in 1-year major amputation (8.3% vs. 4.8%, P = 0.99). Regarding ambulatory status, iGSV patients had similar rates of independent ambulation (33.3% vs. 38.1%), need for assistive devices (58.3% vs. 57.1%), and use of a wheelchair (8.3% vs. 4.8%) compared cGSV patients at subsequent follow-up (P = 0.90). Kaplan-Meier analysis of bypass grafts revealed comparable primary patency rates for iGSV versus cGSV bypasses at 1-year (84% vs. 91%) and 3-years post-intervention (83% vs. 90%, P = 0.364).

CONCLUSION

Ipsilateral GSV may be used as a durable conduit for bypass in cases of lower extremity arterial trauma where use of contralateral GSV is not feasible, with comparable long-term primary graft patency rates and ambulatory status.

Late Type III Endoleaks Are Common in Early Generation Endologix AFX Stent Grafts

INTRODUCTION

Early generation Endologix AFX Endovascular AAA Stent Graft devices are at risk of developing type IIIa (intercomponent/overlap-related) as well as type IIIb (fabric tear) endoleaks over time. Current follow-up studies are limited to short (<24 months) and midterm (24-48 months) reports. The purpose of this study was to identify the incidence of type III endoleaks associated with these endografts over a long-term follow-up (>4 years) period and discuss current management strategies.

METHODS

A retrospective single institution cohort analysis of all Endologix AFX endografts implanted 10/2011-10/2016 was performed. Patient characteristics, imaging and follow-up were obtained via chart review. Type III endoleaks were characterized based on Computed tomography (CT) angiogram/operative findings and confirmed by 2 surgeons. Statistical Analysis was performed with SAS v9.4.

RESULTS

Sixty-three patients underwent AFX stent graft implantation for aneurysmal disease. 47 patients comprised the final cohort for analysis after exclusions were made for primary iliac aneurysms as well as off label use of the device (e.g., hypogastric snorkel) or primary occlusive indications. Average age was 73.3 years with longest follow-up 8.7 years (median 5.2). Most AAA (89.2%) were fusiform with initial median diameter 5.5cm. Initial 30-day mortality was 0%. Of the initial cohort, 10 (21.3%) type III endoleaks were treated, of which 6 (60%) were type IIIa and 4 (40%) were type IIIb. By time to event analysis at latest follow-up freedom from type 3 intervention was 48% at 8 years. Median time to type III endoleak discovery was 4.7 years (range 1.1 -7.2 years) an interval that was similar for type IIIa and type IIIb leak types, p=0.73. Patients with type III endoleaks had average sac growth of 1.3cm over the follow-up interval compared to a net decrease for patients without type III endoleaks, p<.0001. Of the 10 patients treated for type III leaks, 7 (70%) underwent complete endovascular re-lining, one (10%) had partial re-lining while 2 (20.0%) underwent open endograft explant with aortic graft reconstruction. Reintervention 30-day mortality was 0% for all approaches.

CONCLUSION

Early generation Endologix AFX stent grafts have a high rate of type III endoleaks, with freedom from type III leak <50% at 8-year follow-up. Most of these are not detected until several years (>4.5) after initial implantation, beyond the range of the follow-up interval of most published reports. Long-term imaging surveillance is critical and a low threshold for complete relining should be considered with any sign of sac enlargement, even if endoleak is not clearly demonstrated in patients with early generation Endologix AFX grafts.

How does muscularity assessed by bedside methods compare to computed tomography muscle area at intensive care unit admission? A pilot prospective cross-sectional study

BACKGROUND

Low muscularity and malnutrition at intensive care unit (ICU) admission have been associated with negative clinical outcomes. There are limited data available evaluating the validity of bedside techniques to measure muscle mass in critically ill adults. We aimed to compare bedside methods for muscle mass assessment [bioimpedance spectroscopy (BIS), arm anthropometry and subjective physical assessment] against reference technology [computed tomography (CT)] at ICU admission.

METHODS

Adults who had CT scanning at the third lumbar area <72 h after ICU admission were prospectively recruited. Bedside methods were performed within 48 h of the CT scan. Pearson's correlation compared CT muscle area with BIS-derived fat-free mass (FFM) (kg) and FFM-Chamney (kg) (adjusted for overhydration), mid-upper arm circumference (cm) and mid-arm muscle circumference (cm). Depleted muscle stores were determined using published thresholds for each method. Cohen's kappa (κ) was used to evaluate the agreement between bedside and CT assessment of muscularity status (normal or low).

RESULTS

Fifty participants were enrolled. There were strong correlations between CT muscle area and FFM values and mid-arm muscle circumference (P < 0.001). Using FFM-Chamney, all six (100%) participants with low CT muscle area were detected (κ = 0.723). FFM-BIS, arm anthropometry and subjective physical assessment methods detected 28%-38% of participants with low CT muscle area.

CONCLUSIONS

BIS-derived FFM using an adjustment algorithm for overhydration was correlated with CT muscle area and had good agreement with muscularity status assessed by CT image analysis. Arm anthropometry and subjective physical assessment techniques were not able to reliably detect participants with low CT muscle area.

Fetal microchimerism by mode of delivery: a prospective cohort study

OBJECTIVE

To compare fetal microchimerism (FMc) in pregnancies with uncomplicated vaginal delivery (VD) versus caesarean delivery (CD).

DESIGN

Prospective cohort study.

SETTING

University of Washington and Fred Hutchinson Cancer Research Center, USA.

POPULATION

Women delivering singleton pregnancies without pertinent antenatal complications with uncomplicated deliveries (n = 36).

METHODS

We collected maternal predelivery, postdelivery and umbilical cord blood for each mother-baby pair. Following maternal and fetal genotyping, FMc was measured with quantitative polymerase chain reaction assays targeting fetus-specific polymorphisms. Quantification of FMc is expressed as genome equivalents (gEq) of fetal DNA/100 000 total gEq tested. FMc detection was evaluated by logistic regression while controlling for total number of cell equivalents tested and clinically relevant covariates. FMc concentrations were compared using negative binomial regression while controlling for the same covariates and predelivery FMc positivity.

MAIN OUTCOME MEASURE

Detection and concentration of FMc by mode of delivery.

RESULTS

Twenty-four mother-baby pairs had a VD and 12 had a CD. Postdelivery FMc detection was higher following CD than after VD (58.3% versus 16.7%, P = 0.02). After controlling for covariates, the likelihood of postdelivery FMc detection was almost nine-fold higher after CD than VD (odds ratio 8.8, 95% CI 1.6-47.6; P = 0.01). With respect to postdelivery FMc concentration, the detection rate ratio for CD versus VD in the adjusted negative binomial regression model was 14.7 (95% CI 3.2-66.8; P = 0.001).

CONCLUSION

Postdelivery peripheral FMc detection and concentration are significantly higher after CD than after VD. As FMc is associated with long-term maternal health, our findings suggest that the mode of delivery may impact this risk.

TWEETABLE ABSTRACT

Greater fetal microchimerism found in maternal blood following caesarean delivery compared with vaginal delivery.

Recommendations on multidisciplinary management of elective surgery in people with haemophilia

Planning and undertaking elective surgery in people with haemophilia (PWH) is most effective with the involvement of a specialist and experienced multidisciplinary team (MDT) at a haemophilia treatment centre. However, despite extensive best practice guidelines for surgery in PWH, there may exist a gap between guidelines and practical application. For this consensus review, an expert multidisciplinary panel comprising surgeons, haematologists, nurses, physiotherapists and a dental expert was assembled to develop practical approaches to implement the principles of multidisciplinary management of elective surgery for PWH. Careful preoperative planning is paramount for successful elective surgery, including dental examinations, physical assessment and prehabilitation, laboratory testing and the development of haemostasis and pain management plans. A coordinator may be appointed from the MDT to ensure that critical tasks are performed and milestones met to enable surgery to proceed. At all stages, the patient and their parent/caregiver, where appropriate, should be consulted to ensure that their expectations and functional goals are realistic and can be achieved. The planning phase should ensure that surgery proceeds without incident, but the surgical team should be ready to handle unanticipated events. Similarly, the broader MDT must be made aware of events in surgery that may require postoperative plans to be changed. Postoperative rehabilitation should begin soon after surgery, with attention paid to management of haemostasis and pain. Surgery in patients with inhibitors requires even more careful preparation and should only be undertaken by an MDT experienced in this area, at a specialized haemophilia treatment centre with a comprehensive care model.

Physical activity, but not fitness level, is associated with depression in Australian adults

AIM

The objective of this study was to evaluate the fitness and physical activity levels of people referred to a nutrition and physical activity program for the management of mental health in general practice.

METHODS

General practitioners referred 109 patients being treated for depression and/or anxiety to a lifestyle intervention program. All participants completed anthropometric measurements and questionnaires including the Depression, Anxiety and Stress Scale (DASS) and the Active Australia Survey. Aerobic fitness was measured with the YMCA step test and muscular fitness was measured with repeated chair stands and arm curls. Fitness scores were compared to population norms, and physical activity levels were compared to population norms and national recommendations.

RESULTS

Eighty percent of participants were overweight or obese. A greater proportion of study participants (51%) than the general Australian population (38%) met the recommended 150 minutes per week spent in moderate physical activity. However, participants demonstrated lower than average levels of fitness and participated in low levels of vigorous physical activity.

CONCLUSION

Levels of physical activity, but not fitness, were inversely correlated with DASS scores. Patients presenting with depression and/or anxiety should be screened for physical activity behaviours and encouraged to meet the National Physical Activity Guidelines.

Haemophilia Experiences, Results and Opportunities (HERO) Study: influence of haemophilia on interpersonal relationships as reported by adults with haemophilia and parents of children with haemophilia

Evidence delineating the effects of haemophilia on interpersonal relationships is sparse and largely outdated, failing to reflect the impact of current treatment strategies. HERO (Haemophilia Experiences, Results and Opportunities) was commenced to garner a more comprehensive understanding of psychosocial issues facing persons with haemophilia (PWH). This article describes the findings of the quantitative HERO survey relating to the influence of haemophilia on interpersonal relationships of adult PWH, and parents/caregivers of children with haemophilia. Separate questionnaires were completed by adult PWH and parents of minor children from 10 countries, including satisfaction with support from partners, family, friends and other social contacts; disclosure of haemophilia and carrier status and family dynamics. A total of 675 PWH and 561 parents completed the survey. Over half of PWH (57%) and parents (84%) were married. Most PWH were satisfied with support from partners (94%), family (90%) and friends (85%), with lower percentages reported among those with inhibitors. Most parents were likewise satisfied with support from partners (88%) and family (83%). Whereas PWH were reticent to disclose their diagnosis beyond family and friends, parents were more likely to share their son's diagnosis, and most were satisfied with the support from their son's peers (74%), teachers (83%) and other adults in supervisory roles (85%). PWH and parents surveyed were satisfied overall with the support they received from partners, family, friends and social contacts. Relationships are affected by haemophilia in various ways, and particularly affected in terms of disease burden, age and social life.

Psychosocial aspects of haemophilia: a systematic review of methodologies and findings

Psychosocial factors have a significant impact on quality of life for patients with chronic diseases such as haemophilia. Interventions to support the psychosocial needs of patients and their families, such as offering information and assistance, clarifying doubts, and teaching coping strategies to minimize the impact of disabilities, may help to maximize patient outcomes and improve quality of life for their families. The aim of this study was to evaluate the current literature on psychosocial aspects of haemophilia. Literature searches were performed using the PubMed database to identify studies evaluating psychosocial stressors in persons with haemophilia. Articles pertaining to the HIV epidemic were excluded from the analysis, as were those published before 1997. The literature reviews identified 24 studies, covering a range of different populations, generally with small cohorts (n < 100). Most studies were questionnaire based, with almost no overlap in terms of the instruments used. Only one study combined questionnaire techniques with qualitative methods. Except for two European studies, all publications reported data from a single country. Overall, studies tended to show that quality of life is reduced in persons with haemophilia, with a potential impact on education and employment, particularly when prophylactic treatment is not available. Carrier status in women may have a psychosocial impact and affect reproductive choices. Data on psychosocial aspects of the haemophilia life cycle are lacking in the published literature, along with data from developing countries. There is a need for more international, multifaceted research to explore and quantify the social and psychological aspects of life with haemophilia.

Orthopaedic management of haemophilia arthropathy of the ankle

Joint bleeding, or haemarthrosis, is the most common type of bleeding episode experienced by individuals with haemophilia A and B. This leads to changes within the joints, including synovial proliferation, which results in further bleeding and chronic synovitis. Blood in the joint can also directly damage the cartilage, and with repeated bleeding, there is progressive destruction of both cartilage and bone. The end result is known as haemophilic arthropathy. The joints most commonly affected are the knees, elbows and ankles, although any synovial joint may be involved. In the ankle, both the tibiotalar and subtalar joints may be affected and joint bleeding and arthropathy can lead to a number of deformities. Haemophilic arthropathy can be prevented through regular factor replacement prophylaxis and implementing physiotherapy. However, when necessary, there are multiple surgical and non-surgical options available. In early ankle arthropathy with absent or minimal joint changes, both radioisotopic and chemical synoviorthesis can be used to reduce the hypertrophied synovium. These procedures can decrease the frequency of bleeding episodes, minimizing the risk of articular cartilage damage. Achilles tendon lengthening can be performed, in isolation or in combination with other surgical measures, to correct Achilles tendon contractures. Both arthroscopic and open synovectomies are available as a means to remove the friable villous layer of the synovium and are often indicated when bleeding episodes cannot be properly controlled by factor replacement therapy or synoviorthesis. In the later stages of ankle arthropathy, other surgical options may be considered. Debridement may be indicated when there are loose pieces of cartilage or anterior osteophytes, and can help to improve the joint function, even in the presence of articular cartilage damage. Supramalleolar tibial osteotomy may be indicated in patients with a valgus deformity of the hindfoot without degenerative radiographic findings. Joint fusion, or arthrodesis, is the treatment of choice in the advanced stages of ankle arthropathy although total ankle replacement is currently available. Early ankle replacement components were associated with a poor outcome, but as implant designs have improved, there have been successful outcomes achieved. As the ankle is a commonly affected joint in many individuals with haemophilia, it is important to add to the knowledge base to validate indications and timing of surgical and non-surgical interventions in ankle arthropathy.

Septic arthritis in males with haemophilia

We used data collected as part of the Universal Data Collection (UDC) surveillance project in haemophilia treatment centers (HTC) to study the incidence, risk factors and impact of septic arthritis among males with haemophilia. Patients participating in UDC on two or more occasions were included. Cases were defined as patients with documented joint infection. Characteristics of the cases were compared with those of haemophilia patients without infection. Among the 8026 eligible patients with 36 015 person-years of follow-up, 30 (0.37%) had a documented joint infection (incidence rate 83 per 100 000 person-years). In a logistic regression model, only increasing age (OR = 6.1 for age > or =30), race/ethnicity other than white (OR = 3.9), presence of inhibitor (OR = 3.9), invasive procedure in the past year (OR = 2.7) and presence of one or more target joints (OR = 3.2) remained statistically significant. Central venous access devices use and hepatitis C virus and HIV infection were not associated with septic arthritis risk after adjusting for potential confounders. Study limitations include possible underestimation of septic arthritis rate in this population and its retrospective design. We conclude that septic arthritis is an uncommon complication of haemophilia occurring primarily in joints most affected by bleeding and reparative surgical interventions.

The effects of diagnosis and non-compliance attributions on therapeutic alliance processes in adult acute psychiatric settings

To investigate the effects of the diagnoses of borderline personality disorder (BPD) and major depressive disorder (MDD), together with reasons for client non-compliance with therapy tasks, on mental health workers' helping, empathy and anger reactions. Utilizing a 2 x 2 x 2 factorial design, mental health nurses were asked to read a series of vignettes and complete a 15-item rating scale for helping, empathy and anger reactions to each of the vignettes. Eight clinical vignettes were constructed and contained a combination of controllable/uncontrollable and stable/unstable attributional dimensions for service users who failed to complete a therapy task. The diagnoses of BPD and MDD were added to the vignettes to determine whether diagnoses affected alliance factors. A total of 26 mental health workers participated in the study and there were main effects for those workers to be angrier when causes were perceived as due to controllable factors; to be more helpful to service users' with a diagnosis of MDD; and less helpful when causes were perceived to be due to stable factors. Results show some support for Weiner's model of helping behaviour. It is suggested that there is an important role to explore the attributions of mental health workers working with service users with BPD. A role for case conceptualization is discussed to facilitate therapeutic engagement with service users with a diagnosis of BPD.

IHC for Her2 with CBE356 antibody is a more accurate predictor of Her2 gene amplification by FISH than HercepTest in breast carcinoma

BACKGROUND

Her2 (c-erbB-2/neu) overexpression in breast carcinoma predicts response to the anti-Her2 monoclonal antibody, trastuzumab, and is associated with a poor prognosis. When considering patients for trastuzumab treatment, Her2 protein expression is measured by imunohistochemistry (IHC) and, where staining is equivocal, by fluorescence in situ hybridisation (FISH) detection of Her2 gene amplification.

AIMS

To compare IHC using CBE356 with IHC using the Food and Drug Administration approved HercepTesttrade mark.

METHODS

CBE356 and HercepTest were analysed using 167 FISH characterised breast carcinomas. Immunohistochemical expression of Her2 was measured semiquantitatively. Sensitivity, specificity, predictive values, and overall accuracy were calculated for both IHC methods using gene amplification by FISH as the end point, and IHC and FISH assays were tested in Kaplan-Meier survival analysis.

RESULTS

The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CBE356 positive (2+ and 3+) cases were 94%, 89%, 95%, 84%, and 97%, respectively, and of HercepTest positive (2+ and 3+) cases were 91%, 66%, 98%, 92%, and 91%, respectively. A positive result with CBE356, HercepTest, or FISH was associated with significantly decreased overall survival (log rank p = 0.005, p = 0.0017, and p = 0.0005, respectively).

CONCLUSIONS

Positive IHC staining for Her2 using CBE356 is 3% more accurate and 23% more sensitive at predicting Her2 gene amplification by FISH than positive staining with HercepTest. Negative IHC using CBE356 antibody is 6% more likely to represent a truly negative result than negative staining with HercepTest. Overall, CBE356 was a more accurate predictor of Her2 gene amplification by FISH than HercepTest.

Nutritional deficiencies and the skin

Malnutrition states are relatively uncommon in the UK but we have seen two recent cases which have heightened our awareness of both dermatological manifestations of malnutrition and of nutritional sequelae of a dermatological problem. Case 1 is a patient with anorexia nervosa presenting with features of pellagra. This condition is due to deficiency of niacin and responds rapidly to replacement therapy. Classical presentation is an erythematous rash on photoexposed sites, often related to heat or friction. There are three reported cases of pellagra occurring in patients with anorexia nervosa. Case 2 is an adult atopic with sensitizations to multiple foodstuffs. A self-imposed restriction diet caused multiple nutritional deficiencies. Restriction diets in adult atopics are not particularly common in the UK, but there is some evidence to suggest that they may cause significant nutritional deficiency. A nutrition screen may be indicated more frequently than is currently recognized.

Does solitary morphoea profunda progress?

Solitary morphoea profunda (SMP) is an unusual form of scleroderma and is rarely mentioned in the literature. The back of the trunk is described as the commonest site of involvement by SMP. This disease has been recognized as a nonprogressive condition. We report three cases of SMP seen at our department within a 1-year period. Interestingly, all three patients were females and the lesions were situated on the right upper buttock. In one patient the lesion extended despite using topical tacrolimus but subsequently the lesion was kept under control with topical clobetasol propionate.

Genetic aberrations of c-myc and CCND1 in the development of invasive bladder cancer

Detrusor muscle invasive transitional cell carcinoma is associated with poor prognosis and is responsible for the majority of bladder cancer related deaths. Amplifications of c-myc and CCND1 are associated with detrusor-muscle-invasive transitional cell carcinoma, however, their precise role in driving disease progression is unclear. Fluorescence in situ hybridisation on archival tissue from 16 patients with primary diagnosis of > or = pT2 transitional cell carcinoma and 15 cases with primary pTa/pT1 disease subsequently progressing to detrusor-muscle-invasion was performed, in the latter group both pre and post muscle invasive events were studied. No patients presenting with >/=pT2 had amplification of c-myc, two out of 16 (12.5%) had CCND1 amplification. Of patients who developed > or = pT2, two out of 15 (13.3%) had amplification of c-myc, both in > or = pT2, five out of 15 (33.3%) had CCND1 amplification, two in pTa/pT1 tumours, three in > or = pT2 transitional cell carcinomas. In total, two out of 31 (6.5%) of patients' > or = pT2 TCCs were amplified for c-myc and six out of 31 (19%) were amplified for CCND1. Eighty-seven per cent (40 out of 46) of tumours were polysomic for chromosome 8 and 80% (37 out of 46) were polysomic for chromosome 11 and this reflected the high copy numbers of c-myc and CCND1 observed. In almost all cases an increase in c-myc/CCND1 copy number occurred prior to invasion and persisted in advanced disease. Amplification of CCND1 or alterations in c-myc/CCND1 early in bladder cancer may have clinical relevance in promoting and predicting progression to detrusor-muscle-invasive transitional cell carcinoma.

An investigation of the effect of prolonged glove wearing on the hand skin health of dental healthcare workers

OBJECTIVES

Glove wearing during patient treatment has been central to dental surgery infection control for over 15 years. However, little is known about the cutaneous effects of glove wearing on the hands of dental healthcare workers (DHCWs). The objective of this project was to assess the hand skin health of DHCWs before and after wearing gloves of two types and to compare this with a control group of non-DHCWs.

METHODS

Following a mailing to all dentists in the West of Scotland, 50 DHCWs who wore gloves during dental treatment procedures for a minimum of 8h daily for at least 4 days per week were invited to participate in the project. The control group comprised 25 subjects who did not routinely use surgical or examination gloves. Hands were assessed by clinical examination and by transepidermal water loss at baseline, 1 month and 3 months.

RESULTS

Of the 50 DHCWs, 26 wore a non-powdered latex glove (Microtouch Powder-free: Johnson and Johnson, Arligton, TX, US), and 24 wore a nitrile glove (Hartalega SDN BHD, Malaysia) from the time of the baseline examination until the 3-month examination. No differences were observed in hand skin health between the control group and the DHCWs at baseline, nor between those wearing the latex or nitrile gloves during the 3 month period of the study.

CONCLUSION

It is concluded that the hand skin health of the DHCWs examined were no different from those of a control group of non-DHCWs, and that the wearing of the two types of gloves used in the 3 month study had no significant effect.

Association of the D allele of the angiotensin I converting enzyme polymorphism with malignant vascular injury

AIMS

To determine whether there is an association between the insertion/deletion (I/D) polymorphism of the human angiotensin I converting enzyme (ACE) gene and malignant vascular injury (MVI).

METHODS

The polymerase chain reaction was used to genotype DNA extracted from archival, paraffin wax embedded renal biopsy material from 48 patients with MVI, made up from cases of malignant hypertension (n = 23), scleroderma (n = 10), and haemolytic uraemic syndrome (n = 15), and from whole blood samples from 191 healthy controls.

RESULTS

The D allele was found more frequently in cases of MVI than in healthy controls, (65% v 52%). Both the DD and I/D genotypes occurred significantly more frequently in patients with MVI than did the II genotype (chi(2) = 7.26, p = 0.007; and chi(2) = 4.06, p = 0.04, respectively).

CONCLUSIONS

Possession of at least one copy of the D allele is associated with an increased risk of developing MVI. Our data support a dominant mode of effect for the D allele. Use of the I/D polymorphism as a genetic marker for MVI may be of value clinically in identifying at risk individuals before the development of target end organ damage. Furthermore, those at risk may benefit from early ACE inhibition.

Increased ciprofloxacin resistance in gonococci isolated in Scotland

A review of the susceptibility of Neisseria gonorrhoeae isolated from 4415 episodes of infection in Scotland between 1991 and 1999 showed that the proportion of isolates with lowered susceptibility (ciprofloxacin minimum inhibitory concentration [MIC] > or = 0.05 mg/L) increased from 0.5% in 1991 to 5% in 1999 (p<0.001), whereas the proportion of isolates with clinical resistance (ciprofloxacin MIC > or = 1 mg/L) was significantly higher in 1999 than the average for the preceding 4 years (2.2% vs 0.9%; p=0.02). Ciprofloxacin is a recommended treatment for gonococcal infection in the UK but if resistance continues to increase at the present rate it might not be suitable as a first-line treatment of gonorrhoea for much longer.

Accuracy of questions related to allergic contact dermatitis

BACKGROUND

The ability of a physician to select individuals likely to benefit from patch testing depends on his or her ability to interpret responses to enquiries related to contact allergy. The significance of such responses to questions of nickel, fragrance and colophon allergy is unclear.

OBJECTIVE

The specificity, sensitivity and predictive value of questions relating to nickel, fragrance and colophony allergy were determined.

METHOD

A total of 258 patients attending for routine patch testing were questioned about skin reactions to nickel, fragrances and Elastoplast (Smith and Nephew Healthcare, Hull, England). All subjects were then patch tested to nickel, fragrance mix, and colophony. Responses to questions were compared with patch test results.

RESULTS

The sensitivity of questions relating to nickel, fragrance, and colophony was 82%, 49%, and 71%, respectively. The specificity of the same questions was 77%, 79%, and 90%; the positive predictive value was 54%, 46% and 29%, respectively. After adjustment to include clinical relevance, the sensitivity of nickel questions rose to 100%.

CONCLUSION

These data permit greater understanding of the role of patient history in selection of patients for patch testing.

Functional instability in non-contact ankle ligament injuries

OBJECTIVES

To measure objectively functional standing balance in the acute stages of non-contact ankle sprain, and to compare patients with controls.

METHODS

A Chattanooga balance machine was used to measure postural stability in patients with acute ankle sprain and uninjured controls over a two week period, in one and two legged stance, with eyes open and closed. Participants also completed the Olerud and Molander questionnaire to provide a subjective measure of ankle function.

RESULTS

There was a highly significant improvement in questionnaire scores for the patients during the study period (p<0.0001). Patients appeared to be less stable than controls in all balance tests, although the difference did not reach significance. There was evidence of improvement over time in the number of tests successfully completed on the injured leg in single legged stance with eyes closed (p = 0.043) between visits 1 and 3.

CONCLUSIONS

The patient group showed a subjective improvement, which supports clinical experience of treating acute ankle injuries. There is some evidence that on average the patient group appeared to be less stable than controls in all balance tests, although the difference did not reach statistical significance, even on the uninjured leg. There is a need to carry out further studies to confirm the results found in this pilot study and to investigate the hypotheses generated. It would be useful to evaluate a simple test that could be used clinically to monitor progress after ankle injury, and also to identify athletes with decreased functional stability, who may be more at risk of sustaining ankle injury.

The role of allergy in oral mucosal diseases

We retrospectively assessed the prevalence of positive results to cutaneous patch testing, and the relevance of exclusion of identified allergens in the disease process, in 1252 patients with oral mucosal diseases presenting to the Department of Oral Medicine in Glasgow Dental Hospital and School and referred to the Contact Dermatitis Investigation Unit in Glasgow Royal Infirmary. The prevalence of patch-test positivity in each disease cohort was compared with that in 100 control volunteers. Patients with oral mucosal diseases were significantly more likely to have demonstrable hypersensitivity to food additives, especially benzoic acid, and perfumes and flavourings, especially cinnamaldehyde, than controls, and avoidance therapy caused improvement in the majority. Patch testing and the resultant avoidance therapy are useful adjuncts in the management of oral mucosal diseases.

The trend of nickel allergy from a Scottish tertiary referral centre

The aims of this study were to analyze the change in trend of allergic contact dermatitis (ACD) from nickel in a single tertiary referral centre. In 1982 and 1997, 800 and 860 patients were patch tested, respectively. The frequency of positive reactions to nickel from our centre was 16% in 1982 and 22% in 1997. In both years, the vast majority of patients developed the eruption below 30 years of age. However, the commonest age of onset in 1982 was in the 11-20 year age group, while in 1997, this was 1 decade later, in the 21-30 year age group. In 1997, we noted a much higher female preponderance (F:M=13:1) than in 1982 (F:M=6:1). There was no change in male prevalence but a slight increase in female prevalence in 1997. The rate of atopy in patients with nickel ACD showed an increase from 23% in 1982 to 33% in 1997. Nickel was thought to be a contributory factor in causing occupational dermatitis in 27% of patients in 1982 and 24% patients in 1997. Of these, hairdressing in 1982 and nursing in 1997 were the commonest occupations. In 1982 and 1997, respectively, 40 (5%) and 37 (4%) patients were positive to nickel alone, while 89 (11%) and 150 (18%) patients showed positive reactions to other allergens in addition to nickel. In both the years, the hands were the main sites of involvement. However, in 1997 there was an increase in the number of patients presenting with face and neck involvement.

Survey of patch testing in Scotland

We have surveyed Scottish dermatologists to establish the extent of patch testing, to assess the reasons for referral and to document resources and methods used by dermatologists. 104 questionnaires were sent to members of the Scottish Dermatological Society. 82 questionnaires (79%) were returned. 50% of respondents were consultants, 27% were trainees and 23% held staff grade or clinical assistant positions. The mean waiting time for a patch test appointment was 4.5 months. The most frequent reasons for patch testing were localized eczema, eczema not responding to conventional treatment, occupational eczema, history of contact sensitivity and eczema of uncertain cause. 17 of 82 respondents (21%) were the principal clinicians supervising patch testing in their hospitals. 11 of 17 read reactions at 2 and 4 days. Mean time spent on advising patients was 13 min per patients. 7 of 17 were dissatisfied with resources available for patient education and 16 of 17 felt they would benefit from a central source for patient information. Only 4 of 17 centres recorded patch test results on a database and 3 centres regularly reviewed their patch test results. In conclusion, we have identified areas of patch testing that require further improvement.

Preferred drinking locations of Scottish adolescents

A sample of Scottish schoolchildren (N=1240) were asked a series of questions about their consumption of alcoholic beverages. Those who had consumed alcohol were asked about the circumstances of their last drinking occasion. That is, what alcoholic drink(s) they consumed, how they obtained this alcohol and where they were when they drank it. This was done with the intention of quantifying the extent of under-age drinking in different settings. The results presented in this paper indicate a continuum of drinking styles between what might be regarded as low-risk and high-risk circumstances. At one extreme, much drinking tended to take place within the family home, usually under parental supervision. At the opposite extreme, other alcohol consumption took place in a variety of public or 'hidden' outdoor locations. Consumption in these latter location types more often resulted in intoxication. Also, more dangerous, high alcohol, large volume beverages (e.g. white cider) tended to be consumed in more risky locations. The implications of these findings are discussed in terms of the potential harm and delinquency that can be associated with adolescent drinking.

The genetics of allergic contact hypersensitivity to nickel

We have examined evidence for familial disposition to nickel allergic contact dermatitis (Ni ACD). 258 patients attending for routine patch testing were recruited prospectively. 39 patients were diagnosed with Ni ACD. 31 of 209 1st-degree relatives (15%) of probands had a history of nickel hypersensitivity. 84 patients with no history of nickel hypersensitivity and negative patch tests to nickel were used as controls. 24 of 458 1st degree relatives of controls (5.2%) had a history of Ni ACD. The risk ratio for 1st degree relatives of a patient with Ni ACD is 2.83 (95% confidence intervals are 2.45, 3.27). This is the 1st study to present a statistic to represent risk to relatives of developing ACD. Relatives of patients with Ni ACD have an increased risk of developing the condition, but the genetic basis for this is not yet known. With currently available techniques, this value of relative risk makes a positional cloning approach to gene identification impractical.

Case report--hypersensitivity to denture materials

Hypersensitivity reactions to the commonly used denture base resins are infrequently reported. When they have been reported, most acrylic hypersensitivity reactions have been described as local contact reactions with few reports identifying any significant systemic symptoms. This paper reports a case where the patient suffered extensive systemic symptoms which were strongly linked to denture wear. A variety of alternative dentures of different resin content were constructed over time with varying reactions. The patient was patch-tested and responded with positive reactions to pure dye samples supplied by manufacturers of the resins. She also failed to react to dentures made in a clear acrylic with no dye components. These factors strongly support the hypothesis that the reactions experienced by this patient to some denture resins was the result of the incorporated colouring agents. It is therefore suggested that in cases where a hypersensitivity reaction with systemic manifestations to a denture base resin is suspected, questioning with regard to other reactions to colourants and patch testing for dyestuffs should be considered in addition to the use of a resin with no colouring agents in construction of replacement prostheses.