Infrared thermography and ulcer prevention in the high-risk diabetic foot: data from a single-blind multicentre controlled clinical trial

AIM

To assess the usefulness of monthly thermography and standard foot care to reduce diabetic foot ulcer recurrence.

METHODS

People with diabetes (n = 110), neuropathy and history of ≥ 1 foot ulcer participated in a single-blind multicentre clinical trial. Feet were imaged with a novel thermal imaging device (Diabetic Foot Ulcer Prevention System). Participants were randomized to intervention (active thermography + standard foot care) or control (blinded thermography + standard foot care) and were followed up monthly until ulcer recurrence or for 12 months. Foot thermograms of participants from the intervention group were assessed for hot spots (areas with temperature ≥ 2.2°C higher than the corresponding contralateral site) and acted upon as per local standards.

RESULTS

After 12 months, 62% of participants were ulcer-free in the intervention group and 56% in the control group. The odds ratios of ulcer recurrence (intervention vs control) were 0.82 (95% CI 0.38, 1.8; P = 0.62) and 0.55 (95% CI 0.21, 1.4; P = 0.22) in univariate and multivariate logistic regression analyses, respectively. The hazard ratios for the time to ulcer recurrence (intervention vs control) were 0.84 (95% CI 0.45, 1.6; P = 0.58) and 0.67 (95% CI 0.34, 1.3; P = 0.24) in univariate and multivariate Cox regression analyses, respectively.

CONCLUSIONS

Monthly intervention with thermal imaging did not result in a significant reduction in ulcer recurrence rate or increased ulcer-free survival in this cohort at high risk of foot ulcers. This trial has, however, informed the design of a refined study with longer follow-up and group stratification, further aiming to assess the efficacy of thermography to reduce ulcer recurrence.

Cornelius Celsus--ancient encyclopedist, surgeon-scientist, or master of surgery?

PURPOSE

The Roman nobleman Cornelius Celsus (25 BC-AD 50) wrote a general encyclopedia (De Artibus) dealing with several subjects, among which some had medical content (De Medicina), an eight-volume compendium, including two books about surgery (VII + VIII). It is the most significant medical document following the Hippocratic writings. In 1443, Pope Nicolas V rediscovered the work of Cornelius Celsus, despite it having been forgotten for several centuries, and it was the first medical and surgical book to be printed (AD 1478). Up until the nineteenth century, 60 editions were published in Latin as well as numerous translations in European languages, the last of which was a French translation in 1876. While Celsus' work is the best account of Roman medicine as practiced in the first century of the Christian era and its influence persisted until the nineteenth century, there is controversy as to whether Cornelius Celsus himself actually practiced as a surgeon or was only an encyclopedist who collected in the Latin language the medical knowledge available at that time.

METHODS

The detailed analysis of the surgical techniques described by Celsus, the modifications tailored to the findings, possible complications, detailed description of pre- and postsurgical activities, give the general impression that he himself practiced surgery at least within his family and among his dependents. In addition, his descriptions give a clear insight into the astonishingly high standard of surgical knowledge available at the time of Celsus.

RESULTS

His work thus reflects the state of knowledge of his time, which is why he also assumed the role of teacher and scientist. As such, his meets the modern criteria addressed to a surgeon-scientist, who apart from the practical surgical activity, also had a role as teacher of surgery and scientist. Whether Cornelius Celsus had inaugurated a new surgical technique and was the first to describe that, and as such can be described as a master of surgery, cannot be corroborated.

CONCLUSION

Cornelius Celsus deserves a firm place in the history of surgery because with his publication De Medicina, Book VII + VIII, he has preserved Roman surgical knowledge in the first century of the Christian era and, thanks to the use of Latin in medicine and surgery, this continues to be retained up till the present day.

Effectiveness of chlorine washing disinfection and effects on the appearance of artichoke and borage

AIM

Optimal conditions for chlorine application to obtain a reasonable decrease in the microbial counts without damaging the appearance of artichoke and borage have been established.

METHODS AND RESULTS

The influence of chlorine concentration (0-200 mg l(-1)), pH, addition of organic acids, contact time and presence of protective structures on the microflora and vegetal appearance were studied. When pH was not controlled the effect of chlorine depended on its concentration until the pH increase caused by addition of chlorine reached 8.8. Any further increase in chlorine concentration was nullified by the pH increase. When pH was adjusted to 4.5 with acetic acid, the effectiveness increased with concentration. However, the use of citric acid to control pH caused a sharp decrease in effectiveness at concentration about 250 mg l(-1). The higher effectiveness of chlorine on homogenized plant extracts compared with the whole plant showed the impact of the vegetal structures on the resistance of the microorganisms. For artichoke, a relationship between the effectiveness of chlorine disinfection and its structures was also found. Extended washing times did not affect the total counts. However, in both vegetables, the appearance was affected by the extended contact times.

CONCLUSIONS

The solutions rendering the highest microbial reduction with minimum damages were: 50 mg l(-1) free chlorine without pH control for artichoke and 100 mg l(-1) free chlorine at pH 7.0 for borage.

SIGNIFICANCE AND IMPACT OF THE STUDY

Specific conditions for chlorine disinfection of artichoke and borage were determined to reduce the microorganisms in minimally processed artichoke and borage without damaging their appearance.

Working With Women in Secure Environments

1. Women's adverse experiences as patients in secure and other mental health services appear to reflect sexism in wider social and historical contexts. 2. A Women's Service Development Group in a medium secure unit in the United Kingdom has made improvements in services for female patients, including an independent advocacy and befriending service, a Well-Woman Clinic, and other gender-sensitive activities. 3. In general, services were evaluated positively by women. Some dissatisfaction primarily was related to activities, issues concerning seclusion, and the lack of a day area for women only. 4. Women had mixed views about their contact with male staff and patients. Because of this, policies and services in this and related areas should account for individual needs.

FPTT is a low-incidence Rh antigen associated with a "new" partial Rh D phenotype, DFR

BACKGROUND

Several Rh D phenotypes with partial D antigens are recognized. Some partial D antigens are associated with low-incidence Rh antigens. New partial D antigens are revealed by an atypical pattern of reactions with anti-D.

STUDY DESIGN AND METHODS

The reactions of D variant cells with panels of monoclonal anti-D and with antibodies to low-incidence antigens were compared to those of known D categories to identify a new Rh D phenotype. The inheritance of partial D antigens was studied by Rh phenotyping of the families of the probands. Standard serologic methods were used and family data were analyzed.

RESULTS

A new Rh D phenotype, to be called DFR, was identified in 17 probands, two of whom had made anti-D. The partial D antigen carries epD3, epD4, and epD9 and lacks epD8. The presence of other D epitopes is ambiguous; different answers were obtained for the same sample with different monoclonal anti-D of the same apparent epitope specificity. The immunoglobulin class of the anti-D was important: IgG were more successful than IgM monoclonal anti-D in detecting the partial D of DFR. Family studies showed that DFR traveled with Ce more frequently than with cE. The low-incidence antigen FPTT (International Society of Blood Transfusion number 700048) was found on all DFR samples. Family studies demonstrated that FPTT is, as suspected, part of the complex Rh system.

CONCLUSION

The partial D of the Rh D phenotype, DFR, is recognized by its pattern of reactions with monoclonal anti-D and its association with the low-incidence antigen FPTT, FPTT has now been numbered Rh50.

Glycophorin He(Sta) of the human red blood cell membrane is encoded by a complex hybrid gene resulting from two recombinational events

A complex glycophorin (GP) variant of the human red blood cell membrane exhibiting both He and Sta antigens was characterized at the molecular level. Restriction mapping identified two novel Msp I fragments derived from the 5' and 3' portions of the GPHe(Sta) gene, respectively. Genomic DNA, including exons II-V and their splice junctions, was amplified by polymerase chain reaction, and the nucleotide sequences were determined. Comparison with the GPA and GPB sequences showed the presence in GPHe(Sta) of multiple recombinational breakpoints. In the 5' region of the variant gene, a sequence covering a portion of exon II to intron 2 had been transferred from GPA to GPB, resulting in a B-A-B hybrid structure. Such a gene conversion-like event introduced a number of templated and untemplated nucleotide replacements and was the direct cause for the expression of the He antigen. In the 3' region of the variant gene, an unequal crossover from GPB to GPA took place in the third intron at a recombination site apparently identical to that observed in the B-A hybrid GPSta type A gene. These results indicated that GPHe(Sta) occurs as a B-A-B-A hybrid gene, most likely originating from a two-step mechanism of homologous recombination. Transcript analysis showed the maturation from the GPHe(Sta) pre-mRNA of two shortened mRNAs of which the exon III-deleted species encodes both the He and Sta antigens.

Autoimmune hemolysis following transfusion: a mimicking autoanti-D in a D- patient with alloanti-D

An 80-year-old group O, D- (rr) female with anti-C, -D, -E, and -Fya received four units of crossmatch-compatible red blood cells (RBCs). The direct antiglobulin test (DAT) was negative. Two weeks later, jaundice, dark urine, a 16% drop in hematocrit (Hct), a 20% reticulocyte count, and absent haptoglobin occurred. During the next month, her DAT was positive with anti-IgG and -C3d. Acid eluates, which repeatedly showed anti-D specificity, were nonreactive with enzyme-treated D- RBCs. Adsorption with D- RBCs reduced reactivity. An eluate from the adsorbing D- RBCs was nonreactive with D+ KBCs. These findings suggest an autoantibody mimicking alloanti-D. The patient was treated with prednisone and was transfused with group O, D- (rr), K-, Fy(a-) RBCs. Four months later, the Hct was stable. One year later, the DAT remained positive and the eluate demonstrated a panagglutinin.

Further complexities of the Rh antigen D disclosed by testing category DII cells with monoclonal anti-D

The reaction pattern of monoclonal anti-D with category DII cells differed from those of other category D cells. DII cells express epD1, epD2, epD3, epD5, epD6/7 and epD8 but lack epD4 and a new epitope epD9. The new epitope, epD9, is proposed to explain the failure of some monoclonal anti-D (previously considered to be anti-epD3) to react with DII cells.

Adenovirus infection inhibits the phosphorylation of major histocompatibility complex class I proteins

Major histocompatibility complex (MHC) class I molecules act as peptide receptors to direct the recognition of foreign antigens by cytolytic T cells. The cell surface expression and trafficking of these peptide receptors is thought to be controlled by the conformation of the MHC molecule and possibly by the phosphorylation of the cytoplasmic portion of the heavy chain protein. It is of some interest that adenoviruses (Ads) have evolved proteins that interfere with the expression of MHC molecules. One of these proteins, called E3/19k, binds to newly synthesized MHC molecules in the rough endoplasmic reticulum (RER) and inhibits their trafficking to the cell surface. Here we show that during the infection of a human cell line with Ad2, the phosphorylation of the endogenous MHC molecules is inhibited. We also observe that the phosphorylation of the endogenous HLA molecules is grossly impaired in a human cell line transfected with the Ad2 EcoRI D fragment containing the E3/19k gene. We conclude that the E3/19k protein inhibits the phosphorylation of the MHC heavy chains and that this may be one of the important functions of this protein in infected cells. In addition, we show that a mutant of the E3/19k protein, which lacks an RER retention signal but which retains its ability to bind to HLA molecules, does not inhibit the phosphorylation of HLA molecules and that phosphorylated molecules are not Endo H sensitive. This suggests that HLA molecules are phosphorylated after leaving the medial-Golgi compartment, thus providing the most compelling evidence yet that HLA molecules are phosphorylated at or near the cell surface. Finally, to our knowledge, this is the first study under which the phosphorylation of MHC molecules is shown to be altered and may have some relevance for other pathogenic conditions.

Rh immunization by the partial D antigen of category DVa

Reported here is the first example of a partial D antigen stimulating the production of anti-D: stimulation was of fetal origin. During her second pregnancy, anti-D developed in the serum of a D-negative mother who had received Rh immunoglobulin after the birth of her first D-positive child. Her second baby had moderate neonatal jaundice and was successfully treated by phototherapy. Subsequently the red cells of the father and of the first child were shown to carry a partial D antigen of category DVa type. Six available batches of Rh immunoglobulin reacted with DVa cells.

A low-incidence red cell antigen JAL associated with two unusual Rh gene complexes

A multilaboratory investigation during several years has identified a low incidence antigen JAL on the red cells of 7 propositi. JAL appears to be associated with two unusual Rh complexes, one of which produces a depressed C antigen and the other a depressed c antigen. Family studies strongly suggest that the JAL antigen is encoded by the RH locus. Anti-JAL has been implicated in haemolytic disease of the newborn and is thus considered to be a clinically significant antibody.

The red cell antigen JAL in the Swiss population: family studies showing that JAL is an Rh antigen (RH48)

The JAL antigen was found to have an overall frequency of 0.004% in the Swiss population and 0.06% in French-speaking Swiss. Family studies of 5 JAL+ individuals have shown that the JAL antigen is not part of the ABO, MNSs, Fy, Jk and Co blood group systems, or the Se system, nor is it X- or Y-linked. JAL is encoded by the RH locus or by a very closely linked locus. The number RH48 (4.48) has been assigned for JAL by the International Society of Blood Transfusion Working Party on Terminology for Red Cell Surface Antigens.

Murine monoclonal antibodies against a unique determinant of erythrocytes, related to Rh and U antigens: expression on normal and malignant erythrocyte precursors and Rhnull red cells

Three murine monoclonal antibodies (Mabs) MB-2D10, LA-18.18 and LA-23.40 were prepared. They reacted with red cells of all common and most rare blood-group phenotypes, with the exception of those of the RhnullU negative and RhmodU negative phenotypes. So far, only a single example of an alloantibody (Duclos or anti-Rh38) of a similar specificity has been found. Serological studies indicated that the Mabs were probably not directed against an antigenic determinant of Rh polypeptides, the LWab glycoprotein or glycophorin B, all structures absent from or aberrantly expressed on Rhnull red cells. The antigen was found to be erythrocyte-specific, and was also present on pro-erythroblasts, erythroblasts and malignant erythroblastoid cells but not on erythroid progenitors in the bone marrow. The Mabs were found to block each other in an immune rosette method and are thus probably directed against the same epitope or against neighbouring epitopes on the same structure. In immunochemical studies, MB-2D10 precipitated the 30-32 kDa Rh polypeptides from red cell membranes and a protein or proteins which formed diffuse and overlapping bands in SDS-polyacrylamide gel electrophoresis, with Mrs of 40-200 kDa (probably the Rh-related glycoproteins). Under certain experimental conditions glycophorin B appeared to be coprecipitated. The 2D10 structure, detected by the Mabs, seems to be part of a complex of proteins and/or glycoproteins, which includes Rh polypeptides, the LWab glycoprotein and glycoproteins recognized by various Mabs with Rh-related specificities. In the red cell membrane, the complex may be associated with glycophorin B.

Ten homozygous-D-individuals in one Italian village

A large inbred Italian kindred with 10 members homozygous for the rare Rh gene complex-D-is described. The propositus has immune antibody to a high-incidence Rh antigen: her baby required exchange transfusion. None of the other 9-D-/-D- individuals has made antibody even though 2 were women with children. This kindred supports previous observations of the excess of consanguinity among the parents of -D-homozygotes. 40.9% (instead of the 25% expected) of the offspring of -D-heterozygous parents are -D-homozygotes.

Demonstration of seven epitopes on the Rh antigen D using human monoclonal anti-D antibodies and red cells from D categories

The agglutination patterns have been established for the reaction between 29 monoclonal antibodies with specificity for the Rh antigen D and red cells of D categories IIIa, IIIc, IVa, IVb, Va, Vc, VI and VII, which are known to lack certain epitopes on the D polypeptide. Six different agglutination patterns were recognized and interpreted to indicate the recognition of seven different epitopes. These epitopes are termed epD1 through to epD7. The separate existence of epD6 and epD7 is deduced from previous observations in inhibition studies using purified 125I-labelled antibodies; they cannot yet be distinguished in agglutination tests. The number of epitopes lacking from cells of each category varied between two and five. As all the antibodies agglutinated cells of categories IIIa, IIIc and VII and cells of categories II, IIIb and Vb were not available, it is probable that there are epitopes other than the seven presently recognized. Eighteen out of the 29 antibodies which were examined recognized epitopes epD6/7 and it is suggested either that antibodies recognizing these epitopes predominate in polyclonal anti-D sera, or that the lymphocytes producing these antibodies are preferentially selected during establishment of cell lines.

Auberger red cell antigens are not part of the Kell, Colton, or Dornbrock blood group systems

Since 1981, red cell samples from families were tested with anti-Aua and, since 1986, with both anti-Aua and anti-Aub in an attempt to elevate Auberger to a blood group system status. The results show that Auberger is not pan of the Kell (five families), Colton (three Families), or Dombrock (two families) blood group systems. Exclusion from four more systems (Di, Yt, LW, Ch:Rg) is required before system status may be claimed.

An antiserum identifying a red cell determinant expressed by Rh:33 and by some "new" depressed Rh phenotypes

An antibody detecting a determinant on Rh:33 cells and cells with depressed C and/or e antigens was separated by the absorption and elution technique from a serum with antibodies to several low-frequency antigens. The determinant, tentatively named FPTT, has a frequency of about 0.0094 percent in the South of France.

Chimeric twins. T.S. and M.R. reexamined

A pair of chimeric twins, T.S. (male) and M.R. (female), were examined. The amounts of 'foreign' blood cells in each twin found on three occasions were compared. The percentages of M.R. cells found in the blood of T.S. in 1977 and in 1982 were similar and about 1/5 of that found in 1970. The amount of T.S.-blood cells found in M.R. was declining slowly from about 31% in 1970 to about 25% in 1982.

Third example of anti-Tar and segregation of the Tar (Targett, Rh 40) antigen in a Danish family

The third example of anti-Tar and a large Danish pedigree in which Tar antigen is segregating with the Rh haplotype CDTe are reported.

The Rh antigen Tar (Rh40) causing haemolytic disease of the newborn

Haemolytic disease of the newborn (HDN), in the fifth child of an Israeli of Moroccan origin, disclosed anti-Tar in the serum of the mother. This anti-Tar, the second reported example, is the first to cause HDN and was stimulated by previous pregnancies. Tests on blood from the family show that the Tar antigen in this family is associated with a CDe complex which gives rise to a weak expression of the D antigen. A study of 1327 donors in Jerusalem revealed one Tar + propositus.

Long oesophageal myotomy for diffuse spasm of the oesophagus

The symptoms of chest pain and dysphagia together with the typical radiological features of non-peristaltic segmental oesophageal contractions allowed the diagnosis of diffuse oesophageal spasm to be made in ten patients at The Prince Charles Hospital over the last six years. Eight patients have undergone long oesophageal myotomy with sparing of the lower oesophageal sphincter. All patients had immediate postoperative relief of symptoms, with postoperative cine radiographic examination in all patients demonstrating an inert oesophagus with adequate drainage and no gastro-oesophageal reflux. Two patients subsequently developed progressive dysphagia, one requiring a modified Heller's procedure. Because of the good result in six patients, sparing of the lower oesophageal sphincter with long oesophageal myotomy is recommended.

Bronchobiliary fistula due to hydatid disease: a case report

A case of bronchobiliary fistula due to transdiaphragmatic rupture of hepatic echinococcal cyst is described. The importance of excluding associated extrahepatic biliary obstruction is emphasized. Successful treatment involves relief of this obstruction as well as management of both the pleural space and pulmonary complications.

Mediastinoscopy

A series of 150 mediastinoscopic examinations, performed at The Prince Charles Hospital, Brisbane, is reported. The procedure was employed as a diagnostic aid in the care of patients known to be suffering from disease processes involving the superior mediastinum, and as a preoperative assessment in a group of patients known to have, or suspected of having, bronchogenic carcinoma, There was no mortality. The morbidity rate was 2%.