Evaluating the Feasibility and Acceptability of a Psychosexual Intervention for Couples Post-allogeneic Hematopoietic Stem Cell Transplantation

PURPOSE

Allogeneic hematopoietic stem cell transplantation (HSCT) can have a long-term impact on patients' sexual functioning and consequently, their relationship satisfaction. This study aimed to examine the feasibility and acceptability of a 5-session psychosexual intervention for HSCT survivors and their partners.

METHODS

To be eligible patients were required to be more than 3 months post-allogeneic HSCT. The intervention comprised 2 components: (1) A psychosexual education session exploring medical/behavioral treatment options for sexual dysfunction, delivered by a specialist nurse; (2) A 4-session Emotionally-Focused Therapy-based relationship education program for couples delivered by a clinical psychologist. Measures assessing relationship quality, sexual functioning, anxiety, and depression were administered pre- and post-intervention. Feasibility was measured via participation rate, adherence and compliance with completing main measures. Acceptability of the intervention was assessed via patient/partner satisfaction surveys.

RESULTS

Eight of 85 (9.4%) eligible patients and their partners participated in the study. Reasons for declining participation included: feeling uncomfortable due to sensitive nature of intervention; did not have any relationship/sexual function issues; and experiencing ongoing medical issues. Six of 8 couples (75%) attended at least 4 intervention sessions and 5 of 8 (62.5%) completed the main study measures post-intervention. Four couples reported that sexual satisfaction and relationship satisfaction was somewhat or much better post-intervention; 1 reported no change.

CONCLUSION

Feasibility criteria were not met, with low enrolment rate, however the intervention was deemed acceptable. Couples who participated adhered to the intervention and considered it beneficial. Further strategies to identify and manage sexual concerns are required.

Exploring the experiences of staff conducting psychology consultations via telehealth in an oncology hospital

PURPOSE

During the COVID-19 pandemic, telehealth delivery of psychological care services expanded to meet the needs of people with cancer. This study examined psychologists' attitudes toward using telehealth during the pandemic peak in a tertiary oncology hospital.

METHODS

Semi-structured interviews were conducted with ten psychologists who used telehealth to deliver psychological services. Thematic analysis was conducted to identify themes in the interview data.

RESULTS

Themes identified: (1) increased uptake and attendance of psychology sessions was due to greater accessibility of services; (2) clinicians reported ease of communication and building of rapport when using telehealth; and (3) clinicians perceived differences in the psychotherapeutic process when sessions were delivered via telehealth compared to in-person.

CONCLUSIONS

Clinicians expressed high satisfaction with delivering telehealth psychological support for oncology patients. Implications for Psychosocial Providers: Oncology services that are considering developing or expanding a telehealth psychology service can facilitate this by ensuring a reliable technological platform and providing training and/or support to staff and patients. Clinicians should also use their clinical judgment to decide if a patient is appropriate for telehealth-delivered psychological care or if a mix of modalities is more ideal.

Efficacy and cost-effectiveness of an online mindfulness program (MindOnLine) to reduce fear of recurrence among people with cancer: study protocol for a randomised controlled trial

INTRODUCTION

Fear of cancer recurrence (FCR) is a common condition among cancer survivors that can lead to significant levels of distress, anxiety and depression. Online mindfulness programmes may provide the mechanism to support cancer survivors manage FCR and distress, and improve people's well-being over the short, medium and long term. The primary aim of this study is to determine the potential efficacy of MindOnLine, a 9 session mindfulness-based programme for survivors of breast, prostate and colorectal cancer. A formal economic programme will also be conducted.

METHODS AND ANALYSIS

A single-blind randomised controlled trial to determine the efficacy and cost-efficacy of a MindOnLine programme for cancer survivors. A total of 400 people living with cancer will be recruited via online advertisements on social media platforms, peak consumer advocacy groups or through outpatient services at healthcare providers across Victoria, Australia. People will be randomly allocated to either the MindOnLine programme (n=200) or waitlist control (n=200). Participant assessments will occur at baseline, at 9 weeks and 9-month follow-up. The primary outcome is change in Fear of Recurrence Index Score total score between baseline and 9 weeks; secondary outcomes are changes in depression and anxiety, quality of life and mindfulness. The economic analysis comprises a cost-consequences analysis where all outcomes will be compared with costs.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Peter MacCallum Cancer Centre (20-53) and Deakin University (2020-284). All participants will be required to provide written informed consent. Findings will be disseminated in peer reviewed journals and among key stakeholder organisations including hospitals, cancer and community organisations and Government. If successful the project will be rolled out nationally with a formal implementation plan.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (12620000645954); Pre-results. Registered 6 June 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379520&isReview=true.

Study protocol of a pilot study evaluating feasibility and acceptability of a psychosexual intervention for couples postallogeneic haematopoietic stem cell transplantation

INTRODUCTION

Sexual dysfunction is one of the most common side effects of allogeneic haematopoietic stem cell transplantation (HSCT) for haematological cancers. Problems can persist between 5 and 10 years post-transplant and impact mood, couple intimacy and relationship satisfaction. Few intervention studies, however, target sexual dysfunction in patients post-HSCT. This pilot study aims to examine the feasibility and acceptability of implementing a psychosexual intervention for HSCT survivors and their partners post-transplantation.

METHODS AND ANALYSIS

Fifteen allogeneic HSCT survivors and their partners will be recruited. Patients who are more than 3 months post-transplantation will be sent invitation letters describing the couples' psychosexual intervention that will be offered through this study. The intervention will comprise two components: (1) psychosexual education about medical and behavioural treatment options for sexual dysfunction delivered by a haematology nurse consultant; (2) emotionally focused therapy-based relationship education programme for couples delivered by a clinical psychologist (four sessions of 1.5 hours each). Couples who consent to participate will be administered a series of measures assessing mood, relationship satisfaction and sexual dysfunction preintervention and post-intervention, as well as satisfaction with the intervention postintervention. Feasibility of the intervention will be examined via recording enrolment rate, adherence, compliance with completing outcome measures and fidelity of intervention delivery.

ETHICS AND DISSEMINATION

Ethics approval has been obtained at the Peter MacCallum Cancer Centre in Melbourne, Australia. Results will be presented at national and international conferences and published in a peer-reviewed journal so that in can be accessed by clinicians involved in the care of allogeneic HSCT patients. If this intervention is found to be feasible and acceptable, its impact will be examined in a future randomised controlled trial and subsequently implemented as part of routine care in the allogeneic HSCT population.

Mycobacterium tuberculosis curli pili (MTP) is associated with significant host metabolic pathways in an A549 epithelial cell infection model and contributes to the pathogenicity of Mycobacterium tuberculosis

INTRODUCTION

A clear understanding of the metabolome of Mycobacterium tuberculosis and its target host cell during infection is fundamental for the development of novel diagnostic tools, effective drugs and vaccines required to combat tuberculosis. The surface-located Mycobacterium tuberculosis curli pili (MTP) adhesin forms initial contact with the host cell and is therefore important for the establishment of infection.

OBJECTIVE

The aim of this investigation was to determine the role of MTP in modulating pathogen and host metabolic pathways in A549 epithelial cells infected with MTP proficient and deficient strains of M. tuberculosis.

METHODS

Uninfected A549 epithelial cells, and those infected with M. tuberculosis V9124 wild-type strain, Δmtp and the mtp-complemented strains, were subjected to metabolite extraction, two-dimensional gas chromatography time-of-flight mass spectrometry (GCxGC-TOFMS) and bioinformatic analyses. Univariate and multivariate statistical tests were used to identify metabolites that were significantly differentially produced in the WT-infected and ∆mtp-infected A549 epithelial cell models, comparatively.

RESULTS

A total of 46 metabolites occurred in significantly lower relative concentrations in the Δmtp-infected cells, indicating a reduction in nucleic acid synthesis, amino acid metabolism, glutathione metabolism, oxidative stress, lipid metabolism and peptidoglycan, compared to those cells infected with the WT strain.

CONCLUSION

The absence of MTP was associated with significant changes to the host metabolome, suggesting that this adhesin is an important contributor to the pathogenicity of M. tuberculosis, and supports previous findings of its potential as a suitable drug, vaccine and diagnostic target.

Mycobacterium tuberculosis curli pili (MTP) deficiency is associated with alterations in cell wall biogenesis, fatty acid metabolism and amino acid synthesis

INTRODUCTION

In an effort to find alternative therapeutic interventions to combat tuberculosis, a better understanding of the pathophysiology of Mycobacterium tuberculosis is required. The Mycobacterium tuberculosis curli pili (MTP) adhesin, present on the surface of this pathogen, has previously been shown using functional genomics and global transcriptomics, to play an important role in establishing infection, bacterial aggregation, and modulating host response in vitro and in vivo.

OBJECTIVE

This investigation aimed to determine the role of MTP in modulating the metabolism of M. tuberculosis, using mtp gene-knockout mutant and complemented strains.

METHODS

Untargeted two-dimensional gas chromatography time-of-flight mass spectrometry, and bioinformatic analyses, were used to identify significant differences in the metabolite profiles among the wild-type, ∆mtp mutant and mtp-complemented strains, and validated with results generated by real-time quantitative PCR.

RESULTS

A total of 28 metabolites were found to be significantly altered when comparing the ∆mtp mutant and the wild-type strains indicating a decreased utilisation of metabolites in cell wall biogenesis, a reduced efficiency in the breakdown of fatty acids, and decreased amino acid biosynthesis in the former strain. Comparison of the wild-type to mtp-complement, and ∆mtp to mtp-complemented strains revealed 10 and 16 metabolite differences, respectively. Real-time quantitative PCR results supported the metabolomics findings. Complementation of the ∆mtp mutant resulted in a partial restoration of MTP function.

CONCLUSION

The lack of the MTP adhesin resulted in various bacterial cell wall alterations and related metabolic changes. This study highlights the importance of MTP as a virulence factor and further substantiates its potential use as a suitable biomarker for the development of diagnostic tools and intervention therapeutics against TB.

Experiences of Unmet Need and Access to Supportive Care for Men Receiving Androgen Deprivation Therapy for Prostate Cancer: A Bi-national Study

OBJECTIVE

The number of men affected by incurable prostate cancer is expected to increase worldwide. Research is needed to enable men to share their experiences of unmet supportive care needs in current care delivery. We aimed to identify the most frequently reported domains of unmet supportive care needs, levels of anxiety, depression, distress, health-related quality of life, and to identify any perceived barriers to receiving supportive care.

DATA SOURCES

Men diagnosed with prostate cancer who had received a minimum of 6 months of ADT were recruited into a cross-sectional study. Participants completed standardised questionnaires; clinical and demographic data was also collected.

CONCLUSION

Two hundred seventy-two patients were invited, and 102 participated. No statistically significant differences were found between participant scores from Australia and UK in relation to anxiety and depression, exercise, health-related quality of life, or distress scores. Perceived barriers include service delivery related to information provision and difficulties in the navigation of complex care systems.

IMPLICATIONS FOR NURSING PRACTICE

Men affected by prostate cancer receiving ADT reported unmet supportive care needs, specifically related to sexual, informational, and psychological aspects of care. Mapping future trajectories of needs and identifying men at high risk can significantly improve timely and tailored interventions.

Exploring the impact of providing men with information about potential prostate cancer treatment options prior to receiving biopsy results

PURPOSE

There is little research assessing the impact of providing men with information about prostate cancer (PCa) treatment options at the time of referral for a prostate biopsy. Study objectives were to determine whether receiving an information booklet about PCa treatment options prior to receiving biopsy results was acceptable to patients, and if receiving this information influenced levels of anxiety, depression, distress, and treatment decisional conflict.

METHODS

Between June 2016 and September 2017, a randomised block design was used to allocate patients from an Australian urology practice into the intervention or control group. Patients in the intervention group were provided with written information about treatment options for localised PCa prior to their biopsy. Outcome measures including the Distress Thermometer, Generalised Anxiety Disorder-7, Patient Health Questionnaire-9, and Decisional Conflict Scale were completed pre-biopsy and 2-3 weeks post-biopsy. Ninety-eight patients referred for an initial prostate biopsy for an elevated PSA test or suspicious digital rectal exam participated in the study (response rate = 78%).

RESULTS

Multimodal repeated-measures analyses showed no significant differences between control and intervention groups in changes in distress, anxiety, or depression from pre- to post-biopsy, and in decisional conflict post-diagnosis (all p > .05). Thirty-five (87%) patients believed that the resource made it easier to understand subsequent explanation of treatment options, and 51 patients (98%) who received the intervention preferred to be given information at that time.

CONCLUSIONS

Providing patients with information about treatment options prior to biopsy did not impact on changes in psychological distress and decisional conflict post-biopsy. However, the majority of patients preferred to be given such information at this time point.

Spectrum of disease and outcome of primary amputation for diabetic foot sepsis in rural KwaZulu-Natal

BACKGROUND

Primary amputation (stump closure) for diabetic foot sepsis is perceived to have a higher re-amputation rate due to stump sepsis. A guillotine amputation with elective stump closure is widely practised due to the lower risk of stump sepsis and re-amputation.

AIMS

To provide an epidemiological analysis of the spectrum of disease and outcomes of primary amputation for diabetic foot sepsis in a regional rural hospital.

METHODS

A prospective cohort study of 100 patients who underwent surgery for diabetic foot sepsis over a 5-year period was undertaken at Madadeni Provincial Hospital, in northern KwaZulu-Natal. Demographic data, co-morbid profile, radiographic features, anatomical level of vascular occlusion and type of surgery performed were recorded. The Wagner classification (Wag) was used to classify disease severity. Outcome measures included length of hospital stay, in-hospital mortality and re-amputation rates.

RESULTS

Of the 100 patients, females (n = 50) accounted for 50% of admissions. The median age was 61 years (range: 29 to 80 years). Most patients presented with advanced disease: Wag 5, n = 71 (71%); Wag 4, n = 20 (20%); Wag 3, n = 7 (7%); Wag 2, n = 2 (2%). The anatomic levels of vascular occlusion comprised: aortoiliac disease n = 2 (2%), femoropopliteal n=21(21%) and tibioperoneal disease n = 77 (77%). The following surgical procedures were undertaken: above knee amputation (AKA), n = 35 (35%); below knee amputation (BKA), n = 46 (46%); transmetatarsal amputation (TMA), n = 8 (8%); toe ectomy, n = 8 (8%) and debridement, n = 3 (3%). The re-amputation rate to above knee amputation was n = 2/46 (4.3%). All AKA stumps healed completely. The overall in-hospital mortality was n = 7 (7%) and median length of hospital stay was 7.8 ± 3.83 days.

CONCLUSION

Most patients present with advanced disease requiring a major amputation. A definitive one stage primary amputation is a safe and effective procedure for diabetic foot sepsis with distinct advantages of a short hospital stay, low reamputation rates and mortality. A guillotine amputation should be reserved for physiologically unstable patients.

Quality of Life, Psychological Functioning, and Treatment Satisfaction of Men Who Have Undergone Penile Prosthesis Surgery Following Robot-Assisted Radical Prostatectomy

BACKGROUND

Penile prosthesis surgery is last-line treatment to regaining erectile function after radical prostatectomy (RP) for localized prostate cancer.

AIMS

To assess quality of life, psychological functioning, and treatment satisfaction of men who underwent penile implantation after RP; the psychosocial correlates of treatment satisfaction and sexual function after surgery; and the relation between patients' and partners' ratings of treatment satisfaction.

METHODS

98 consecutive patients who underwent penile implantation after RP from 2010 and 2015 and their partners were invited to complete a series of measures at a single time point. Of these, 71 patients and 43 partners completed measures assessing sexual function, psychological functioning, and treatment satisfaction. Proportions of patients who demonstrated good sexual function and satisfaction with treatment and clinical levels of anxiety and depression were calculated. Hierarchical regression analyses were conducted to determine psychosocial factors associated with patient treatment satisfaction and sexual function and patient-partner differences in treatment satisfaction.

OUTCOMES

Patients completed the Expanded Prostate Cancer Index Composite Short Form (EPIC-26), Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS), Prostate Cancer-Related Quality of Life Scale, Self-Esteem and Relationship Questionnaire (SEAR), Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). Partners completed the GAD-7, PHQ-9, EDITS (partner version), and SEAR.

RESULTS

94% of men reported satisfaction with treatment (EDITS score > 50). 77% of men reported good sexual function (EPIC-26 score > 60). Lower depression scores were associated with higher sexual confidence and sexual intimacy, and these were correlated with better treatment satisfaction and sexual function. Patients experienced higher sexual relationship satisfaction (median score = 90.6) than their partners (median score = 81.2), but there was no difference in treatment satisfaction between groups. Higher patient treatment satisfaction was more likely to be reported for couples whose depression scores were more similar.

CLINICAL IMPLICATIONS

It is important to provide preoperative penile implant counseling and encourage patients to seek postoperative counseling if needed.

STRENGTHS AND LIMITATIONS

This is one of the first Australian-based studies comprehensively assessing treatment satisfaction and psychosocial health of men after penile prosthesis surgery after RP. This was a retrospective cross-sectional study, so there is a possibility of recall bias, and causal associations could not be determined.

CONCLUSION

Men in this Australian series who underwent penile prosthesis surgery after RP generally reported good sexual function and treatment satisfaction. Nevertheless, patient and partner mental health influenced their reported experience of the treatment. Pillay B, Moon D, Love C, et al. Quality of Life, Psychological Functioning, and Treatment Satisfaction of Men Who Have Undergone Penile Prosthesis Surgery Following Robot-Assisted Radical Prostatectomy. J Sex Med 2017;14:1612-1620.

Endovascular Therapy for Large Vessel Vasculopathy in HIV-infected Patients

OBJECTIVES

To evaluate outcomes after endovascular treatment of patients with aneurysmal or occlusive vasculopathy in HIV-infected patients.

METHODS

Retrospective analysis of a prospective database of treatment outcomes in patients with HIV related vasculopathies between April 2005 and September 2015.

RESULTS

Sixty HIV patients presented with post-traumatic pseudoaneurysm formation (n = 7), aneurysmal disease (n = 24) or occlusive disease (n = 29 (48%)). The majority were male (42/60 (70%)), with a mean age of 43.9 years (SD ± 12.6). All seven patients with a post-traumatic pseudoaneurysm were treated by insertion of a covered stent (n = 6) or coiling (n = 1). All were successfully treated at 30 days, but only one patient returned for late surveillance. 23/24 patients who underwent insertion of a stent graft/covered stent for aneurysmal disease returned for 30 day review (one asymptomatic stent graft occlusion). Only 11 patients attended for late surveillance; 9/11 were asymptomatic with patent stent grafts. Late stent occlusion occurred in two (no further action (n = 1), major limb amputation (n = 1). In the 29 patients who underwent endovascular treatment for occlusive disease, 9 (31%) had immediate treatment failure (including 8 amputations (28%)). Of the sixteen who returned for serial review, 8 (50%) suffered further complications including 4 amputations. Overall, 12/29 treated patients (41%) ultimately underwent amputation.

CONCLUSIONS

In the immediate short term, an 'endovascular first' strategy was associated with good outcomes in HIV patients with aneurysmal disease. By contrast, outcomes were poor in HIV patients with occlusive disease. Whether this relates to the underlying natural history of HIV occlusive vasculopathies remains unclear. One major problem in trying to formulate meaningful management strategies is a generalised reluctance for HIV patients to return for surveillance.

A prospective study of the relationship between sense of coherence, depression, anxiety, and quality of life of haematopoietic stem cell transplant patients over time

OBJECTIVES

The primary aim of this study was to examine the impact of patient sense of coherence (SOC) on anxiety and depressive symptoms, and quality of life (QoL) dimensions in the acute phase of haematopoietic stem cell transplantation (HSCT). A secondary aim was to determine if SOC measured pre-transplant was predictive of psychological distress and QoL post-transplantation, after controlling for physical wellbeing.

METHOD

A series of measures was completed by 60 HSCT patients prior to transplantation. Follow-up data were collected at 2-3 weeks and 3 months post-transplantation. Measures administered included the Brief Symptom Inventory-18, Orientation to Life Questionnaire, and Functional Assessment of Cancer Therapy-Bone Marrow Transplantation.

RESULTS

When compared across the three time points, depression levels, and physical and functional wellbeing were worst at 2-3 weeks post-transplantation. SOC was positively associated with physical wellbeing prior to HSCT but not after transplantation. Weaker SOC predicted higher levels of depression, and poorer social, emotional, and functional wellbeing at both follow-up points, after accounting for physical wellbeing.

CONCLUSIONS

Given that SOC was related to depression and QoL dimensions post-transplantation, it may be important for health care professionals to conduct psychosocial assessments to determine patient SOC. This would enable provision of tailored psychological support prior to and following stem cell transplantation.

Psychosocial factors predicting survival after allogeneic stem cell transplant

PURPOSE

A primary aim was to assess the relative contribution of psychological factors, such as anxiety, depression and mental adjustment to cancer, to overall survival outcomes at a median follow-up of 2 years following allogeneic haematopoietic stem cell transplant (HSCT). A secondary aim was to ascertain if demographic, medical and psychosocial factors assessed prior to transplantation were predictors of survival for patients after accounting for post-transplant events.

METHOD

Between 2005 and 2011, 130 allograft patients completed the Mental Adjustment to Cancer Scale and Brief Symptom Inventory-18 as part of routine psychological assessment before undergoing transplantation. Survival status data were obtained, and predictors of survival status assessed and analysed using Cox-regression models.

RESULTS

Thirteen percent experienced clinical levels of distress pre-transplant. None of the psychological factors predicted post-HSCT survival. In contrast, hierarchical multivariate analysis indicated that post-transplant factors (acute graft-versus-host disease and relapse post-transplant) predicted survival (Chi-square change, p < 0.001). The addition of a series of pre-transplant psychosocial and medical variables further improved the prediction of survival (Chi-square change, p = 0.01). In particular, relationship status (being single) (p = 0.04) and increased somatic symptoms (p = 0.02) pre-transplant were associated with shorter survival. Both variables were not associated with medical factors but were related to increased severity of anxiety and depressive symptoms as well as greater use of helpless-hopelessness and reduced fighting spirit adjustment response.

CONCLUSIONS

Despite the significant influence of acute post-transplant factors in predicting survival following allogeneic HSCT, multidisciplinary pre-transplant assessments are important in identifying patients who are likely to experience poorer survival outcomes.

Psychosocial factors associated with quality of life in allogeneic stem cell transplant patients prior to transplant

OBJECTIVES

The primary aim of this retrospective study was to determine levels of psychological distress and quality of life (QoL) immediately prior to allogeneic stem cell transplantation. The secondary aim was to examine the demographic, medical and psychosocial factors that were correlated with various QoL domains at this stage of treatment.

METHODS

A series of measures was completed by 122 allograft patients as part of routine psychological assessment at the treating hospital prior to undergoing the transplant. These included the Mental Adjustment to Cancer Scale, the Brief Symptom Inventory-18 and the World Health Organisation Quality of Life-BREF. Demographic and medical data were also extracted.

RESULTS

In this study, 12% and 14% of the sample experienced significant levels of depressive and anxiety symptoms, respectively. Half of the sample reported impaired physical QoL, whereas approximately 40% reported poor psychological and social QoL. Besides relationship status, the limited number of demographic (age and gender) and medical factors (disease status) tested did not contribute significantly to reported QoL. After controlling for medical and demographic factors, weaker Fighting Spirit and higher levels of depression (trend towards significance) were associated with poorer physical and social QoL.

CONCLUSIONS

The association among psychological distress, coping responses and QoL indicates that poor psychosocial functioning pre-transplant renders an increased likelihood of experiencing impaired QoL across various dimensions. It thus seems important that psychologically vulnerable patients are identified early in the treatment process. If psychosocial adjustment were improved, patients may experience better QoL pre-transplant with a potential subsequent influence on post-transplant outcomes.

A retrospective review of brachial artery injuries and repairs--is it still a "training artery"?

BACKGROUND

A retrospective analysis of operatively managed brachial artery injuries spanning a five-year period from January 2003 to December 2007.

METHODS

The medical records of all patients who had operative management of brachial artery injuries were reviewed. Demographic data, mechanism of injury, pathology of injury, associated injuries, duration of injury, operative management and outcomes were analysed.

RESULTS

A total of 115 patients were included in the review. Twelve patients (10.4%) were female and 103 (89.6%) were male. The mean age was 27.3 years with the oldest patient being 70 years and the youngest 13 years. Most of the injuries were caused by stabs to the brachial artery (53%). 33% were due to gunshot wounds, 11.3% were due to blunt trauma and 2.9% were due to other mechanisms of injury. The majority of injuries (58.3%) were repaired with a reverse saphenous vein graft. Most patients had a pulse restored on discharge with only 4.4% of repairs occluding and of the repairs that occluded only one patient needed an ablation. Four patients (3.5%) had an ablation due to a non-viable limb. 13.9% of patients had a fasciotomy, 54.8% had an associated peripheral nerve injury and 14.8% had an associated venous injury.

CONCLUSION

Brachial artery injuries are still common in our practice, with most being managed operatively. Due to the good collateral circulation in the arm, most brachial artery injuries do not result in limb loss even with a significant time delay and even when the repair occludes. Brachial artery injuries are thus a good vessel for surgical registrars to train on.

Extra-adrenal paraganglioma: presentation in three uncommon locations

Extra-adrenal paragangliomata are uncommon entities. They can be classified into four basic groups according to their anatomical sites, i.e. branchiomeric, intravagal, aorticosympathetic and visceral autonomic. Similar tumours may arise in sites away from the usual distribution of the sympathetic and parasympathetic ganglia, e.g. orbit, nose, small intestine and even in the pancreas. We report three instructive cases of extra-adrenal paraganglioma which were found in unusual sites such as urinary bladder, thyroid gland and on the wall of the inferior vena cava.

Thrombectomy in HIV related peripheral arterial thrombosis: a preliminary report

OBJECTIVES

To evaluate the limb salvage rate in patients undergoing thrombectomy for HIV related peripheral arterial thrombosis.

METHODS

A prospective review of patients with HIV related peripheral arterial thrombosis managed at the Durban Metropolitan Vascular Service in Kwazulu-Natal South Africa over a 5-year (1998-2003) period. All patients underwent thrombectomy.

RESULTS

Twenty-two patients (20 males) with HIV related peripheral arterial thrombosis (two upper limbs, 20 lower limbs) were included in the study. The median age was 36 years (24-46 years). All patients had rest pain and seven patients had gangrene (digital five, forefoot two). Seven patients had a short history of claudication before development of rest pain. Mean duration of symptoms was 30 days (1-120 days) with 10 patients presenting within 24 h. Most patients had a good general state of health and only three had clinical evidence of HIV infection. Ten patients who presented with threatened limbs from acute arterial occlusion were subjected to thrombectomy without any diagnostic investigations. Twelve patients who did not present with critical limb ischaemia had duplex ultrasonography, which showed arterial occlusion by a thrombus with normal proximal arteries. The striking features were the normal proximal vessels and absence of distal run-off. The search for an underlying cause, echocardiography in seven patients and coagulation screening in 10 patients, was always negative. All patients were subjected to thrombectomy with an on-table angiogram and received systemic heparin intra-operatively and deltaparin post-operatively. In 20 patients, duplex ultrasonography confirmed re-thrombosis within 48 h. Two patients remained with patent arteries. Most (16/20) patients who re-thrombosed required a major amputation and thrombectomy did not alter the level of amputation. The other four patients with re-thrombosis had symptomatic relief. Three patients died within 30 days of thrombectomy, all of HIV related complications. Overall the limb salvage rate was 6/22 (27%).

CONCLUSION

Limb salvage rate following thrombectomy in HIV related peripheral arterial thrombosis is very low. Duplex ultrasonography appears to be an adequate radiological diagnostic investigation for these patients.

Transient ischaemic attack: is routine use of computerised cerebral tomography worthwhile?

AIM

To evaluate the role of routine computerised cerebral tomography (CCT) in patients undergoing carotid endarterectomy (CEA) following transient ischaemic attach (TIA).

METHOD

A retrospective review was carried out of data collected on patients with TIA who were managed at the Durban Metropolitan Vascular Service over an 11-year period. All patients underwent carotid duplex scanning and CCT, followed by carotid endarterectomy (CEA) under general anaesthesia.

RESULTS

The records of 140 patients were reviewed. There were 85 (61%) men and 55 (39%) women (F:M = 1:1.6). The mean age was 63 years (range 40-95 years). The presenting symptoms were amaurosis fugax, syncope and speech deficit. Risk factors for arterial disease were smoking (73%), hypertension (55%), diabetes mellitus (28%) and hyperlipidaemia (6%). Duplex ultrasonography showed significant internal carotid artery stenosis in 138 patients and occlusion in two. Arch angiography of the latter two patients showed pre-occlusive carotid stenosis. CCT scans showed abnormalities in 34 (24%) patients. These were lacunar infarcts (56%), old infarcts involving grey and white matter (32%), and cortical infarcts (12%). The findings did not influence management. All patients underwent routine CEA with selective shunting in 51 (36%) patients. Postoperative stroke rate was 2.9%.

CONCLUSION

Routine CCT scanning in patients with TIA did not influence patient management and outcome. It is not cost effective and its routine use is questioned.

Fluctuating pulse deficits associated with intimal arterial injury following gunshot wounds of the extremity--a sign not to be missed

Gunshot wounds may result in intimal arterial injury without breach of the arterial wall integrity. Haemorrhage, haematoma and a pulse deficit are therefore not always found. We report on two cases of lower extremity gunshot wounds with temporal variations in the clinical and radiological assessment of the pedal pulses. In both cases surgical exploration revealed intact arterial vessel walls but significant intimal injury with overlying thrombus. We propose that the pulse deficits were due to distal thromboembolism. Subsequent clot lysis led to a return of the original pulse deficit. Variation in the distal pulses in patients with gunshot wounds of the extremities should alert one of the possibility of an intimal arterial injury; imaging of the vessels is therefore advised.

Haloalkane and haloacid dehalogenases from aerobic bacterial isolates indigenous to contaminated sites in Africa demonstrate diverse substrate specificities

Five bacteria were isolated from contaminated sites in Nigeria and South Africa using the culture enrichment technique. They were subjected to standard cultural, biochemical and microbiological techniques and identified to be species of Bacillus, Burkholderia, Corynebacterium, Micrococcus and Pseudomonas. Axenic cultures of the bacterial isolates utilized 1,2-dichloroethane (1,2-DCE) as the sole carbon source up to a final substrate concentration of 10 mM. Their mean generation time in 1,2-DCE ranged significantly (P<0.05) from 9.77 to 15.72 h with the maximum chloride release ranging between 59% and 86%. All the bacterial isolates produced two different dehalogenases, viz. one which is heat labile and specific for halogenated alkanes with optimum activity at a pH of 7.5 and the other which is more heat stable with a higher pH optimum of 9.0 and specific for halogenated alkanoic acids. However, the two enzyme types when tested demonstrated wide substrate specificities. It is therefore adjudged that these organisms may play a vital role in the bioremediation of sites polluted with chlorinated hydrocarbons.

Xylitol production by recombinant Saccharomyces cerevisiae expressing the Pichia stipitis and Candida shehatae XYL1 genes

The xylose reductase gene (XYL1) was isolated from Pichia stipitis and Candida shehatae, cloned into YEp-based vectors under the control of ADH2 and PGK1 promoter/terminator cassettes and introduced into Saccharomyces cerevisiae Y294 by electroporation. Shake-flask fermentations were carried out with 5% xylose and 1% galactose, glucose or maltose as co-substrates. Xylose uptake was similar in both the recombinant strains when different co-substrates were used and slowed once the co-substrate was depleted. The recombinant strains converted xylose to xylitol with yields approaching the theoretical maxima. Xylitol production was most rapid when the co-substrate was still present. Approximately 50% of the xylose was not metabolized due to the depletion of the co-substrate.

The production of hemicellulases by Thermomyces lanuginosus strain SSBP: influence of agitation and dissolved oxygen tension

Shake-flask cultivation of T. lanuginosus strain SSBP on coarse corn cobs yielded beta-xylanase levels of 56,500 nkat/ml at 50 degrees C, whereas other hemicellulases (beta-xylosidase, beta-glucosidase, and alpha-L-arabinofuranosidase) were produced at levels less than 7 nkat/ml. Cultivation on D-xylose yielded much lower levels of xylanase (350 nkat/ml), although other hemicellulase levels were similar to those produced on corn cobs. The influence of agitation rate and dissolved oxygen tension (DOT) on hemicellulase production was studied further in a bioreactor. On xylose, xylanase activities of 4,330 nkat/ml and 4,900 nkat/ml were obtained at stirrer speeds up to 1,400 rpm to control DOT. At a constant stirrer speed of 400 rpm, xylanase activities of 10,930 nkat/ml and 15,630 nkat/ml were obtained when cultivated on xylose and beechwood xylan respectively, despite DOT levels below 5% for the duration of fermentation. The results indicate that there is an interaction between agitation rate and DOT, impacting on xylanase and accessory enzyme production. Higher agitation rates favoured the production of xylosidase, arabinofuranosidase and glucosidase by T. lanuginosus strain SSBP, whereas the lower agitation rates favoured xylanase production. Rheological difficulties precluded cultivation on corn cobs in the bioreactor. Volumetric xylanase productivities of 1,060,000 nkat/l x h and 589,000 nkat/l x h obtained on beechwood xylan and xylose indicate that T. lanuginosus strain SSBP is a hyperxylanase producer with considerable industrial potential.

Relatedness of Thermomyces lanuginosus strains producing a thermostable xylanase

Properties of an endo-beta-xylanase produced by a locally isolated Thermomyces lanuginosus strain SSBP was compared to seven other T. lanuginosus strains isolated from different geographical regions. Strain SSBP produced the highest xylanase activity of 59600 nkat ml(-1) when cultivated on corn cobs (maize) medium, whereas the seven other strains produced xylanase activities ranging from 6000 to 32000 nkat ml(-1). No cellulase activity was produced by the strains. Despite the variability in the production of xylanase, little difference in the other characteristics of the strains could be found. The optimal temperature and pH for xylanase production by the strains was either 40 or 50 degrees C and between pH 6 and 7, respectively. Optimal xylanase activity of the strains was observed at 70 degrees C and at pH 6 or 6.5. Culture supernatant analysis by SDS-PAGE and isoelectric focusing PAGE of all strains revealed the presence of a single 24.7 kDa and pI 3.9 xylanase. Phylogenetic analysis by PCR amplification and sequencing of the internal transcribed spacer of nuclear rRNA repeat units and 5.8S rDNA revealed no strain diversity. However, random amplified polymorphic DNA analysis pointed to greater diversity and with one primer (5'-GCCCGACGCG-3'), a relationship was established between xylanase levels and the RAPD pattern.

Production and properties of hemicellulases by a Thermomyces lanuginosus strain

Thermophilic fungi producing extremely high beta-xylanase and their associated hemicellulases have attracted considerable attention because of potential industrial applications. Thermomyces lanuginosus strain SSBP isolated from soil, produced beta-xylanase activity of 59 600 nkat ml-1 when cultivated on a medium containing corn cobs as substrate and yeast extract as nitrogen source. Lower beta-xylanase activities were produced after growth on other xylan substrates, sugars and soluble starch. Other hemicellulases were produced extracellularly at significantly lower levels than the beta-xylanase activity produced on corn cobs. No cellulase activity was observed. The optimal conditions for beta-xylanase production were 50 degrees C and pH 6.5, whereas 70 degrees C and between pH 5. 5 and 9.5 were optimal for beta-xylanase activity. The temperature optima for other hemicellulases were less than the xylanase with the exception of beta-mannosidase. The pH optima of the other hemicellulases were between 5.0 and 6.5. Xylanase was stable up to 70 degrees C and between pH 5.5 and 9.0 for 30 min whereas the other hemicellulase were less stable. These results suggest that the most suitable conditions for hydrolysis of hemicellulose by these enzymes would be at 50 degrees C and pH 6.0.

Purification and biochemical characteristics of beta-D-xylanase from a thermophilic fungus, Thermomyces lanuginosus-SSBP

An extracellular xylanase was purified to homogeneity from the culture filtrate of a thermophilic fungus, Thermomyces lanuginosus-SSBP, and its biochemical characteristics were studied. A yield of 70-80% was achieved through the procedures of 80%-satd. ammonium sulphate precipitation, DEAE-Sephadex A25 and quaternary aminoethyl (QAE)-Sephadex A25 column chromatography. The molecular mass of the purified xylanase was 23.6 kDa, as analysed by SDS/PAGE, with a pI value of 3.8. The molar absorption coefficient of the absorbance at 280 nm was 6.8x10(4) M(-1).cm(-1). The specific activity, calculated using the dinitrosalicylic acid (DNS) method, was 3500 units/mg. The enzyme reactions followed Michaelis-Menten kinetics with K app m and V(max) values of 3.26 mg/ml and 6300 units/ml per mg of protein respectively, as obtained from a Lineweaver-Burk plot. The xylanase contained no other enzyme activity (cellulase, beta-glucosidase, beta-mannosidase, alpha-arabinofuranosidase, or beta-xylosidase) except for the hydrolysis of xylan substrate. The optimal temperature of the enzyme assay was 70-75 degrees C. The enzyme retained full activity after a 60 degrees C incubation for 3 h. The optimal pH of xylanase activity was 6.5 and the enzyme appeared to be stable over a broad pH range (pH 5-12) under the assay conditions. The majority of the metal ions tested had no effect on the enzyme activity, with the exception of Pb(2+) (modest inhibitor) and Hg(2+) (strong inhibitor). The results showed that one or two tryptophan residues oxidized by N-bromosuccinamide per enzyme molecule was sufficient to inhibit the enzyme activity completely, thus indicating that the tryptophan residues play an important role in the catalytical processes of the enzyme reaction. Because of the outstanding properties of the purified xylanase from the SSBP strain, this xylanase has a potential use in biopulping processes and other industrial applications.

Purification and biochemical characteristics of beta-D-glucosidase from a thermophilic fungus, Thermomyces lanuginosus-SSBP

The beta-D-glucosidase produced by Thermomyces lanuginosus-SSBP was purified to apparent homogeneity. The purified enzyme consisted of two identical subunits with a native molecular mass of 200 kDa. The purified beta-D-glucosidase only hydrolysed the glucoside substrates containing a terminal, non-reducing beta-D-glucose residue and was active on both aryl-beta-glucoside and cellobiose. This enzyme also exhibited less, but significant alpha-D-glucosidase activity and was capable of hydrolysing beta-1,6-linked diglucosides and gentiobiose. The Kapp m, V(max) and k(cat) values for p-nitrophenyl-beta-D-glucopyranoside were calculated to be 0.075 mM, 12.12 units/mg of protein and 44.44 glucose molecules released/s respectively. The beta-D-glucosidase retained its full activity after a 30 min incubation at 50 degrees C but was inactive after the same treatment at 70 degrees C. The enzyme appeared to be stable when the pH of the storage buffer was above 5.0. Maximal beta-D-glucosidase activity occurred at 65 degrees C and pH 6.0. This enzyme was competitively inhibited by glucose, cellobiose and salicin with K(i) values of 0.55, 0.52 and 0.81 mM respectively. The presence of Hg(2+) and N-bromosuccinimide inhibited the enzyme activity completely at 2 mM, while cysteine enhanced beta-D-glucosidase activity.

Antibiotic susceptibility patterns and plasmid profiles of penicillinase-producing Neisseria gonorrhoeae strains in Durban, South Africa, 1990-1993

BACKGROUND AND OBJECTIVES

The appearance of strains of Neisseria gonorrhoeae resistant, both chromosomally and plasmid-mediated, to penicillin and other antibiotics makes this versatile pathogen difficult to treat. There is, therefore, a need for surveillance of N. gonorrhoeae strains to determine the efficacy of current therapeutic measures.

GOALS

To survey the antibiotic susceptibilities and plasmid profiles of penicillinase-producing N. gonorrhoeae strains isolated over a 4-year period.

STUDY DESIGN

Penicillinase-producing N. gonorrhoeae strains were detected by the chromogenic cephalosporin test. Minimum inhibitory concentrations to penicillin G, tetracycline, ceftriaxone, and ciprofloxacin were determined using the E-test. Plasmid DNA was obtained by the alkaline lysis method and profiles generated.

RESULTS

Penicillinase-producing N. gonorrhoeae strains increased from 16.4% to 19.0% in the period from 1990 through 1993. Although all strains were resistant to penicillin, strains were susceptible to varying levels of ciprofloxacin, ceftriaxone, and even tetracycline. All penicillinase-producing N. gonorrhoeae strains possessed the 2.6-megadalton cryptic plasmid, and in addition 87.7% contained the 24.5-megadalton conjugative plasmid. Of the six known gonococcal beta-lactamase plasmids, the 4.4-megadalton Asian and 3.2-megadalton African plasmids were predominant. The most prevalent plasmid profile contained the 2.6-megadalton cryptic, 24.5-megadalton conjugative, and 4.4-megadalton Asian plasmids.

CONCLUSIONS

To ensure effective treatment of gonorrhea, continued surveillance of the antimicrobial susceptibilities and plasmid profiles of penicillinase-producing N. gonorrhoeae strains is necessary.

Random-amplified polymorphic DNA (RAPD) analysis shows intraspecies differences among Xanthomonas albilineans strains

Five strains of Xanthomonas albilineans, causal agent of leaf scald disease in sugarcane from various geographical regions, were compared using random amplification of polymorphic DNA (RAPD) to determine whether they could be differentiated at the DNA level. CsCl-purified genomic DNA from these strains were amplified by the polymerase chain reaction (PCR) using arbitrary 10-mer primers according to standard RAPD conditions and the amplification product profiles analysed by conventional agarose gel electrophoresis. Although most RAPD markers were common to all five strains, unique profiles for each strain were discernible using four 10-mer arbitrary primers individually. Reproducible DNA fingerprints indicate that RAPD analysis can be used to identify and differentiate the X. albilineans strains. This technique has the potential for use in monitoring the appearance of foreign strains of X. albilineans in various geographical regions and could be used for the construction of phylogenetic trees.

The distinction of malingering and mental illness in black forensic cases

The ability of twenty items to separate malingering from mental illness is tested. The items were obtained from the literature and clinical experience. The study used an experimental, cross-sectional design which compared fifty malingering African patients and a control group of fifty African State Presidents' Detainees. The chi-square test and the Fisher's exact test were used to assess statistical significance. The effectiveness of these items was assessed by calculating their sensitivity, specificity, false positives and negatives and positive and negative predictive values. Seventeen items showed statistical significance. Eleven items had high positive predictive values mostly above 90% with four items scoring 100%. These diagnosed malingering effectively. Another six items had high negative predictive values mainly above 90%. These diagnosed mental illness directly and excluded malingering effectively. The study proved that seventeen items can scientifically and effectively separate mental illness from malingering.

Cytopathologic changes associated with intrauterine contraceptive devices. A review of cervico-vaginal smears in 350 women

Cervico-vaginal smears from 350 IUCD users were analysed to ascertain the range of abnormalities induced in the genital tract of these women. Alteration of the microbial environment, inflammatory, degenerative, reparative and proplastic epithelial changes were the salient cytological findings. The clinical implications of these are briefly discussed.

Genomic comparisons among parental and fusant strains of Candida shehatae and Pichia stipitis

DNA-DNA binding experiments on selected fusants of Candida shehatae and Pichia stipitis showed that the nucleus of these strains was composed predominantly of Pichia DNA. Electrophoretic karyotyping revealed that the fusants contained four chromosomes, similar to those found in the Pichia parental strain. In addition, the fusants showed only marginal increases in cell DNA content when compared with the parents. Karyogamy was confirmed, however, by the isolation of recombinant phenotypic segregants, induced by meiotic and mitotic segregation. The results suggest that the fusion led to integration of Candida genes, rather than whole chromosomes, with the entire genome of P. stipitis.

Post-menopausal smear patterns--a review of vaginal smears in 480 women

Cytohormonal evaluation was done on the vaginal smears of 480 normal, asymptomatic, post-menopausal women whose ages ranged from 36 to 74 years. About 50% showed atrophic smears consistent with total oestrogen lack. 41% had mild to moderately proliferative smears compatible with sub-optimal oestrogen stimulus. 9% showed a highly proliferative pattern typical of unopposed oestrogen effect and in this group two women had atypical endometrial cells in their smears, which subsequently were found to come from an atypical endometrial hyperplasia and an endometrial adenocarcinoma-in-situ. The clinical relevance of cytohormonal studies in post-menopausal women is briefly discussed.

Linear rate of change in the product of erythrocyte water content and potassium concentration during the 0-120-hour postmortem period in the rat

An accurate and reproducible technique was employed for measurement of water content (RBCH2O) and potassium concentration (RBCK) in rat erythrocytes post mortem. Coefficients of variation for determination of RBCH2O and RBCK, as estimated from the results of duplicate analyses (n = 36), were 1.21% and 1.17%, respectively. Erythrocyte water content and RBCK were directly and linearly related (r = +0.93 (P less than 0.001], while the product of RBCH2O and RBCK varied linearly and inversely (r = -0.89 (P less than 0.001] with postmortem interval (PMI) over the 0-120-h postmortem period. In addition, the standard deviations of the data points for (RBCH2O X RBCK) remained relatively constant and independent of PMI. Attention is drawn to the possibility of determining time elapsed since death from (sequential) measurements of (RBCH2O X RBCK) in individual cadavers.

Evidence for two different gas vesicle proteins and genes in Halobacterium halobium

Most halobacteria produce gas vesicles (GV). The well-characterized species Halobacterium halobium and some GV+ revertants of GV- mutants of H. halobium produce large amounts of GV which have a spindlelike shape. Most other GV+ revertants of H. halobium GV- mutants and other recently characterized halobacterial wild-type strains possess GV with a cylindrical form. The number of intact particles in the latter isolates is only 10 to 30% of that of H. halobium. Analysis of GV envelope proteins (GVPs) by electrophoresis on phenol-acetic acid-urea gels showed that the GVP of the highly efficient GV-producing strains migrated faster than the GVP of the low-GV-producing strains. The relative molecular mass of the GVP was estimated to be 19 kilodaltons (kDa) for high-producing strains (GVP-A) and 20 kDa for low-producing strains (GVP-B). Amino acid sequence analysis of the first 40 amino acids of the N-terminal parts of GVP-A and GVP-B indicated that the two proteins differed in two defined positions. GVP-B, in relation to GVP-A, had Gly-7 and Val-28 always replaced by Ser-7 and Ile-28, respectively. These data suggest that at least two different gvp genes exist in H. halobium NRL. This was directly demonstrated by hybridization experiments with gvp-specific DNA probes. A fragment of plasmid pHH1 and a chromosomal fragment of H. halobium hybridized to the probes. Only a chromosomal fragment hybridized to the same gyp probes when both chromosomal and plasmid DNAs from the low-GV-producing halobacterial wild-type strains SB3 and GN101 were examined. These findings support the assumption that GVP-A is expressed by a pHH1-associated gvp gene and GVP-B by a chromosomal gvp gene.