Growth and Cyclin-E Expression in the Stony Coral Species Orbicella faveolata Post-Microfragmentation

AbstractCoral growth is critical to reef health, resilience under rapidly changing environmental conditions, and restoration efforts. Although fragmenting coral has been occurring for many years in an effort to restore reefs, recently it was discovered that microfragmenting, the process of cutting one piece of coral into many small pieces (about three to five polyps), induces exponential growth. Our study investigates the process by which microfragments of nine different genotypes from the stony coral species Orbicella faveolata grow and exhibit Cyclin-E expression. Microfragments were examined by using a high-powered dissecting microscope with a camera to document the precise areas of tissue exhibiting exponential growth. We found that new polyp formation occurs only on the microfragment edges and that edge polyp growth rates varied between different genotypes. We then extracted tissue from both the edge and the center of five genotypes for genetic analysis. We chose to analyze Cyclin-E expression because it is involved with stimulating mitotic division and is a conserved signaling pathway that is known to exist in Drosophila, mammals, and Cnidaria. Two primers for Cyclin-E were utilized to examine the level of expression for center and edge tissue. We found that Cyclin-E is expressed differentially between O. faveolata polyps, with a tendency for increased expression of the Cyclin-E in edge versus center tissue in each of five genotypes, although this result was not significant. Despite consistently higher levels of Cyclin-E expression within an organism's edge tissue, genotypes varied significantly in the degree of increased expression. This variation positively correlated with growth rate, suggesting the potential for molecular selection in aid of more rapid reef restoration. Future work will focus on deciphering the specific growth pathways involved in microfragmented coral growth and analyzing expression patterns in injured tissues.

1600 Assessing Necessity and Cost-Effectiveness of Routine Pre-Thyroidectomy Group and Save Tests

Aim

To determine the necessity and cost effectiveness of routine blood group and save tests (G&S) before thyroidectomy

Background

Sub-total or total thyroidectomy is the mainstay of treatment for several thyroid disorders. The incidence of post-thyroidectomy haemorrhage has been reported between 0.36% and 4.3% in the literature. Many patients undergo routine G&S testing in anticipation of a peri-operative haemorrhage requiring blood transfusion.

Method

Retrospective review identified 276 patients undergoing an elective total or sub-total thyroidectomy at a London University Teaching Hospital between February 2018 and August 2020. Electronic medical and transfusion department records were audited to identify patients who had pre-operative G&S tests, pre-operatively reserved blood products and peri-operative transfusions.

Results

261 (94.6%) patients had a valid pre-operative group and save test. 17 (6.16%) patients had a total of 61 units of blood products ordered pre-operatively. Only 2 patients required transfusion.

Conclusions

The blood transfusion rate for elective thyroidectomies at this centre was 0.72%. Routine G&S tests cost the trust thousands of pounds and create unnecessary burden on healthcare providers’ time and hospital resources. We propose that routine pre-operative G&S tests are unnecessary for elective thyroidectomies.

Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high‐quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post‐tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.

Identifying hospital-acquired infections using retrospective record review from the Irish National Adverse Events Study (INAES) and European point prevalence survey case definitions

BACKGROUND

Point prevalence surveys (PPSs) collect data on hospital-acquired infections (HAIs) at one point in time but do not provide information on incidence over the entire admission or impact on patients or healthcare resources. Retrospective record review examines the entire admission to determine adverse event prevalence, incidence, preventability, physical impairment and additional length of stay.

AIM

To establish whether European HAI surveillance definitions can be applied to the Irish National Adverse Events Study (INAES) retrospective record review data to determine HAI burden.

METHODS

In the INAES, 1574 admissions were reviewed using a two-stage methodology and 247 adverse events were found. These were examined against European HAI case definitions to determine whether the event was an HAI. Results were compared with the 2011/12 European PPS data for Ireland.

FINDINGS

The prevalence of HAI adverse events in INAES was 4.4% (95% confidence interval (CI) 3.1-6.1%) with an incidence of 3.8 (95% CI 2.5-5.2) HAI adverse events per 100 admissions. The PPS HAI prevalence for Ireland was 5.2%. HAI types and micro-organisms were similar in INAES and the PPS. Approximately three-quarters of INAES HAI adverse events were preventable, 7% caused permanent impairment and 7% contributed to death. A mean of 10 additional bed days were attributed to HAI adverse events, equivalent to €9400 per event.

CONCLUSION

Retrospective record review is an accurate source of information on HAI incidence, preventability and impact that complements PPS prevalence rates. HAI adverse events result in higher costs to the healthcare system than other adverse events.

Adverse events in healthcare: learning from mistakes

Large national reviews of patient charts estimate that approximately 10% of hospital admissions are associated with an adverse event (defined as an injury resulting in prolonged hospitalization, disability or death, caused by healthcare management). Apart from having a significant impact on patient morbidity and mortality, adverse events also result in increased healthcare costs due to longer hospital stays. Furthermore, a substantial proportion of adverse events are preventable. Through identifying the nature and rate of adverse events, initiatives to improve care can be developed. A variety of methods exist to gather adverse event data both retrospectively and prospectively but these do not necessarily capture the same events and there is variability in the definition of an adverse event. For example, hospital incident reporting collects only a very small fraction of the adverse events found in retrospective chart reviews. Until there are systematic methods to identify adverse events, progress in patient safety cannot be reliably measured. This review aims to discuss the need for a safety culture that can learn from adverse events, describe ways to measure adverse events, and comment on why current adverse event monitoring is unable to demonstrate trends in patient safety.

Confronting evidence: individualised care and the case for shared decision-making

In many clinical scenarios there exists more than one clinically appropriate intervention strategy. When these involve subjective trade-offs between potential benefits and harms, patients' preferences should inform decision-making. Shared decision-making is a collaborative process, where clinician and patient reconcile the best available evidence with respect for patients' individualized care preferences. In practice, clinicians may be poorly equipped to participate in this process. Shared decision-making is applicable to many conditions including stable coronary artery disease, end-of-life care, and numerous small decisions in chronic disease management. There is evidence of more clinically appropriate care patterns, improved patient understanding and sense of empowerment. Many trials reported a 20% reduction in major surgery in favour of conservative treatment, although demand tends to increase for some interventions. The generalizability of international evidence to Ireland is unclear. Considering the potential benefits, there is a case for implementing and evaluating shared decision-making pilot projects in Ireland.

Opportunistic and interventional salpingectomy in women at risk: a strategy for preventing pelvic serous cancer (PSC)

OBJECTIVE

Salpingectomy is proposed as a prophylactic measure to reduce the incidence of tubo-ovarian/pelvic serous cancers. We surveyed the attitudes of obstetrician/gynecologists to incorporating salpingectomy opportunistically into surgery for benign conditions, and electively for young BRCA mutation carriers.

STUDY DESIGN

A questionnaire, designed to assess current standard clinical practice and willingness to perform salpingectomy for female sterilization at abdominal hysterectomy for benign disease (ABH), vaginal benign hysterectomy (VBH) and electively for women with BRCA mutations who wish to postpone oophorectomy was mailed to obstetrician/gynecologists working in Irish hospitals.

RESULTS

In their current practice of interval female sterilization 96% of gynecologists applied clips at laparoscopy and 4% performed salpingectomy, and 73% were willing to consider salpingectomy. Eighty-one percent were willing to consider salpingectomy for sterilization at cesarean section. Gynecologists performing hysterectomy (without oophorectomy) for benign conditions did salpingectomy in 26% at ABH and 5.4% at VBH, and now 90% would consider salpingectomy at ABH and 66% at VBH. Two-thirds of respondents would consider salpingectomy for women at genetic risk of ovarian cancer who want to postpone oophorectomy.

CONCLUSION

Changing general gynecological practice to include more opportunistic salpingectomy has the potential to reduce the incidence of serous cancers. The majority of gynecologists are willing to incorporate more salpingectomies into their surgical practices and consider elective salpingectomy as an interim measure for women with defined genetic risk of pelvic serous cancer.

Identification of the Transmembrane Glucose Regulated Protein 78 as a Biomarker for the Brain Cancer Glioblastoma Multiforme by Gene Expression and Proteomic Studies

The prognosis of patients with Glioblastoma Multiforme (GBM), the most malignant adult glial brain tumor, remains poor in spite of advances in treatment procedures, including surgical resection, irradiation and chemotherapy. Genetic heterogeneity of GBM warrants extensive studies to gain a thorough understanding of the biology of this tumor. While there have been several studies of global transcript profiling of glioma with the identification of gene signatures for diagnosis and disease management, translation into clinics is yet to happen. In the present study, we report a novel proteomic approach by using two-dimensional difference gel electrophoresis (2D-DIGE) followed by spot picking and analysis of proteins/peptides by Mass Spectrometry. We report Glucose Regulated Protein 78 (GRP78) as a differentially expressed protein in the GBM cell line compared to human normal Astrocyte cells.

In addition to proteomic studies, we performed microarray analysis which further confirmed up regulation of GRP78 in GBM cells compared to human normal Astrocyte cells.

GRP78 has long been recognized as a molecular chaperone in the endoplasmic reticulum (ER) and can be induced by the ER stress response. Besides its location in the ER, GRP78 has been found in cell plasma membrane, cytoplasm, mitochondria, nucleus and other cellular secretions. GRP78 is implicated in tumor cell proliferation, apoptosis resistance, immune escape, metastasis and angiogenesis, and its elevated expression usually correlates with a variety of tumor micro environmental stresses, including hypoxia, glucose deprivation, lactic acidosis and inflammatory response. GRP78 protein acts as a centrally located sensor of stress, which senses and facilitates the adaptation to the tumor microenvironment.

Our findings showed differential expression of this gene in brain cancer GBM and thus confirm similarities in findings in existing transcriptional and translational studies. Thus, these findings could be of further importance for diagnostic, therapeutic and prognostic approaches for dealing with this highly malignant cancer.

Young adults’ preferred options for receiving chlamydia screening test results: a cross-sectional survey of 6085 young adults

Summary

We investigated how young adults aged 18-29 years would like to be notified of chlamydia screening test results, and, when they test positive, their willingness and preferred mechanism for informing their partners. We conducted a cross-sectional survey of 6085 young adults and found that a call to their mobile phone was their preferred way of receiving positive test results (selected by 50%), followed by email. Text messages (short message service [SMS]) and calls to landline phones were unpopular options, selected by between 5 and 10%. Over 75% of respondents stated they would inform their current partner of a positive chlamydia diagnosis, and 50% would inform their previous partners. Most were willing to receive yearly reminders to go for a chlamydia test. Young adults preference for being informed of chlamydia test results by mobile phone call, rather than by email or SMS text, especially if they test positive, suggests they place high value on the security of the communication mechanism. Offering a range of mechanisms for receipt of test results may increase the acceptability and coverage of sexually transmitted infection (STI) control strategies.

The origin and fate of morphological intermediates between wild and cultivated soybeans in their natural habitats in Japan

The spread of transgenes into the genome of wild soybean is a concern when transgenic and wild soybeans are planted sympatrically. The objectives of this study were to investigate the origin and fate of morphological intermediates between wild and cultivated soybeans in their natural habitats in Japan. Twenty nuclear microsatellite and two chloroplast dCAPS markers were used to evaluate genetic variation of 468 wild, 17 intermediate, and 12 cultivated soybean samples collected from six sites between 2003 and 2006. Allelic differentiation of microsatellite markers between wild and cultivated soybeans was sufficient to detect their hybrids. Based on levels of observed heterozygosity, intermediate soybean plants were from two generations: either F(1) or an early segregating generation. Genetic admixture analysis and parentage assignment analysis revealed that the parents of all intermediate soybean plants could be assigned to a particular wild soybean plant and late-maturing cultivar. The chloroplast DNA haplotypes revealed that all intermediate soybean plants originated from gene flow from cultivated to wild soybeans at all sites. Based on monitoring at both the phenotypic and molecular levels, hybrids quickly disappeared from natural habitats, and secondary gene flow from these plants to wild soybean was not detected. Thus, while gene flow from transgenic soybean into wild soybean can occur, gene introgression appears to be rare in natural habitats in Japan. This is the first report on the detection of gene flow from cultivated to wild soybean at the molecular level.

Out of Africa: traveller malaria in paediatric patients presenting to Our Lady of Lourdes Hospital Drogheda

Malaria is one of the world's most important parasitic infections and is endemic in over 100 countries. The number of cases of malaria in Ireland has increased significantly over the last 10 years. The aim of this study was to retrospectively examine cases of paediatric malaria presenting to Our Lady of Lourdes Hospital Drogheda over a one year period to identify the reason for travel to endemic areas, to establish if prophylaxis was received on travelling and to determine the clinical course and post-treatment follow up. Five children presented during the study period, all children were infected with the Plasmodium falciparum, two had evidence of cerebral involvement, all were children travelling to visit family and none of the children received adequate prophylaxis. This study highlights the importance of parental education on the risks associated with non-compliance with malaria prophylaxis and the complications associated with malaria infection in children.

Surface characterization of precious alloys treated with thione metal primers

OBJECTIVES

To characterize the effect of two thione metal primers with phosphate groups on the surface morphology and composition of two noble prosthodontic alloys.

METHODS

Cast specimens from Argen 81(Au-Pd) and Argipal (Hi-Pd) alloys which were ground, polished and ultrasonicated in water, were divided in two groups (2 x 3) and treated with single layers of Alloy Primer (AP) and Metal Primer II (MP) primers respectively. The treated alloy surfaces were washed off with acetone and then examined by polarized light microscopy (PLM), reflection FTIR microspectroscopy (FTIRM) and X-ray photoelectron spectroscopy (XPS).

RESULTS

After AP treatment, PLM revealed a crystalline phase (VBATDT) dispersed in an amorphous phase (MDP plus soluble VBATDT) on both the alloys tested. MP demonstrated a fibrial arrangement with the most dense structure found on the Hi-Pd alloy. FTIRM failed to clearly resolve the presence of SH peaks on alloy surfaces. Moreover, NH and PS peaks were identified denoting the presence of original thione tautomers. In both primers, phosphates were detected in a dissociative state (-PO(3)(2-)). FTIR molecular mapping confirmed separation of VBATDT from MDP and MEPS from residual MMA. XPS showed that on alloy surfaces approximately 50% of sulphur was in the sulphide state, the rest being organic sulphur. AP showed higher sulphide percentage than MP on both alloys and higher sulphide percentage on the Au-Pd alloy (p<0.05).

CLINICAL SIGNIFICANCE

Phase separation of the primer components on alloy surfaces may adversely affect their clinical performance. Sulphide formation on alloy surfaces was confirmed only by XPS under ultra-high vacuum and not by environmental techniques like FTIR; this poses serious questions on the chemical bonding capacity of these primers with the noble alloys tested under environmental conditions.

A new guide to mandibular resection for oral squamous cell carcinoma based on the Cawood and Howell classification of the mandible

A new guide for mandibular resection in the management of oral squamous cell carcinoma based on the Cawood and Howell classification of the jaws is suggested. This was a retrospective review of case records and pre-operative orthopantomograms (OPG), bone scintigraphy and magnetic resonance imaging (MRI). The classification of the mandible was based on the residual bone height as measured in the molar region of the OPG to be equivalent to the Cawood and Howell classification of the mandible (Class I-II dentate or immediate post-extraction), Class III-IV >20mm well-rounded or knife-edge ridge, and Class V-VI <20mm (flat or depressed ridge form). Of the 77 patients, 58% (22/38) of Class I-II, 43% (9/23) of Class III-IV and 6% (1/16) of Class V-VI were treated with a marginal (rim) resection of the mandible. The predictability of the pre-operative investigations was more accurate in the edentulous mandible (Class III-VI). A simple guide is suggested for mandibular resection taking into account the pre-operative investigations, the estimation of invasion clinically, and the Cawood and Howell classification of ridge resorption.

Fear of recurrence and possible cases of anxiety and depression in orofacial cancer patients

Recurrence risk in orofacial cancer patients is relatively high in comparison to other cancers. Little information exists on whether patients are unduly concerned over the possibility of recurrence and the association of this concern with psychological morbidity. Aim of study was to assess fear of recurrence and psychological morbidity in orofacial cancer patients. Two samples of patients with orofacial cancer were followed prospectively. First sample (n = 87) were consecutively drawn 3 months and 7 months following initial treatment. Second sample (n = 100) were cross-sectionally drawn from out-patient list and followed 2 years later. A single question item was employed to assess fear of recurrence used in previous work. Hospital Anxiety and Depression Scale was adopted as the measure of psychological morbidity. A prospective survey design was employed. Over 80% of patients expressed concern over the possibility of recurrence at 3 months post treatment. This level reduced to 72% at 7 months (P=0.06). Approximately two-thirds of patients sampled cross-sectionally were concerned at both assessment occasions. Psychological morbidity was greatest at 3 months post treatment (possible cases: anxiety 37% and depression 28%). Women were more likely to report anxiety (at possible case level) than men 3 months following treatment (P<0.05). Patients aged 65 or more years were less concerned about recurrence. This effect was significant on both occasions that sample two patients were assessed (P's<0.002). Very few patients who expressed no concern about recurrence, at 3 months, were found to report anxiety or depression sufficient to be recognized as a possible case (3 and 0% respectively). The positive association between psychological morbidity and fears of recurrence was significant at the majority of data collection points, with the exception that depression was more independent of these concerns.

Long-term (7 to 8-year) experience with finasteride in men with benign prostatic hyperplasia

OBJECTIVES

To evaluate the effects of finasteride, a specific type II 5-alpha-reductase inhibitor, on symptoms of benign prostatic hyperplasia, prostate volume, and urinary flow during a 7 to 8-year period.

METHODS

A total of 190 men with symptomatic benign prostatic hyperplasia and enlarged prostates entered one of two Phase II double-blind 3 to 6-month studies. Of these, 156 patients continued taking open-label finasteride, and more than 70 patients completed 7 to 8 years of treatment. The symptoms were scored using a patient self-administered modified Boyarsky symptom questionnaire. Prostate volume was measured by magnetic resonance imaging or ultrasonography, and the maximal urinary flow rate was assessed noninvasively.

RESULTS

Treatment with finasteride for 7 to 8 years led to sustained improvement in symptoms, reduction in prostate volume (28% from baseline), and increased urinary flow (median 2.5 mL/s from baseline). Decreases in dihydrotestosterone (86%) and prostate-specific antigen (54%) levels were also maintained. Long-term finasteride treatment was safe and generally well tolerated.

CONCLUSIONS

Long-term treatment with finasteride was well tolerated and resulted in durable symptom relief and improvement in prostate volume and urinary flow.

The relevance of tissue angiotensin-converting enzyme: manifestations in mechanistic and endpoint data

Angiotensin-converting enzyme (ACE) is primarily localized (>90%) in various tissues and organs, most notably on the endothelium but also within parenchyma and inflammatory cells. Tissue ACE is now recognized as a key factor in cardiovascular and renal diseases. Endothelial dysfunction, in response to a number of risk factors or injury such as hypertension, diabetes mellitus, hypercholesteremia, and cigarette smoking, disrupts the balance of vasodilation and vasoconstriction, vascular smooth muscle cell growth, the inflammatory and oxidative state of the vessel wall, and is associated with activation of tissue ACE. Pathologic activation of local ACE can have deleterious effects on the heart, vasculature, and the kidneys. The imbalance resulting from increased local formation of angiotensin II and increased bradykinin degradation favors cardiovascular disease. Indeed, ACE inhibitors effectively reduce high blood pressure and exert cardio- and renoprotective actions. Recent evidence suggests that a principal target of ACE inhibitor action is at the tissue sites. Pharmacokinetic properties of various ACE inhibitors indicate that there are differences in their binding characteristics for tissue ACE. Clinical studies comparing the effects of antihypertensives (especially ACE inhibitors) on endothelial function suggest differences. More comparative experimental and clinical studies should address the significance of these drug differences and their impact on clinical events.

Susceptibility of Canadian isolates of Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae to oral antimicrobial agents

We measured the susceptibility of Canadian isolates of three respiratory tract pathogens (Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae) to several currently approved antimicrobial agents by two different methods. We also measured the susceptibility of isolates to seven fluoroquinolones. Beta-lactamase was produced by 123/566 (21.7%) of H. influenzae isolates compared with 178/200 (89%) of M. catarrhalis isolates. For S. pneumoniae 83/374 (22.2%) isolates were penicillin resistant and of these 2.1% (8/374) showed high level resistance (MIC > or = 2 mg/l). Regardless of methodology, all fluoroquinolones were highly active against H. influenzae (MIC(90) < or = 0.031 mg/l) and M. catarrhalis (MIC(90) < or = 0.064 mg/l) isolates. Susceptibility of H. influenzae to cefuroxime and amoxycillin/clavulanic acid was 99-100% whereas 84-85.5% were susceptible to cefaclor and cefprozil. Azithromycin susceptibility ranged from 82.6 to 99.2% depending on the method. M. catarrhalis isolates were uniformly susceptible to all agents tested except amoxycillin. Cross-resistance in S. pneumoniae to all non-quinolone agents was concurrent with increasing penicillin resistance as shown by increasing MIC90 values. For the fluoroquinolones tested, the rank order of potency based on MIC(90) values was as follows: gemifloxacin (0.031-0.063 mg/l), trovafloxacin (0.125 mg/l), moxifloxacin (0.125-0.25 mg/l), grepafloxacin (0.125-0.25 mg/l), gatifloxacin (0.5 mg/l), levofloxacin (1 mg/l) and ciprofloxacin (2 mg/l). Our study confirms either a high or increasing prevalence of antimicrobial resistant respiratory pathogens in Canada and also compares the new and old fluoroquinolones and their potential role as therapy for community-acquired infections. The prevalence of beta-lactamase positive H. influenzae may have decreased from levels reported in previous studies.

A review of antimicrobial resistance in Canada

Antimicrobial resistance is a global concern. Over the past 10 years, considerable efforts and resources have been expended to detect, monitor, and understand at the basic level the many different facets of emerging and increasing resistance. This review summarizes our current understanding of bacterial antimicrobial resistance issues in Canada with particular emphasis given to the Enterobacteriaceae, Pseudomonas aeruginosa, Staphylococcus aureus, Enterococcus, Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Streptococcus pyogenes. In addition, future concerns and programs for ongoing surveillance are discussed.

A review of antimicrobial resistance in Canada

Antimicrobial resistance is a global concern. Over the past 10 years, considerable efforts and resources have been expended to detect, monitor, and understand at the basic level the many different facets of emerging and increasing resistance. This review summarizes our current understanding of bacterial antimicrobial resistance issues in Canada with particular emphasis given to the Enterobacteriaceae, Pseudomonas aeruginosa, Staphylococcus aureus, Enterococcus, Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Streptococcus pyogenes. In addition, future concerns and programs for ongoing surveillance are discussed.

The effects of local administration of lactoferrin on inflammation in murine autoimmune and infectious arthritis

OBJECTIVE

To determine whether lactoferrin can modify articular inflammation in murine models of autoimmune and septic arthritis.

METHODS

Collagen arthritis was induced in DBA/1 mice and Staphylococcus aureus septic arthritis in Swiss mice. Joints with established inflammation were injected periarticularly with 0.5 mg or 1 mg of human lactoferrin, and arthritis was monitored for 3 days.

RESULTS

DBA/1 mice injected with lactoferrin showed significantly suppressed local inflammation for up to 3 days, achieving up to 71% of the effect of corticosteroid. Periarticular injection of 125I-lactoferrin confirmed that 25% of lactoferrin was retained in paws after 6 hours. Serum levels of interleukin-6, however, were not significantly reduced, suggesting a predominantly local antiinflammatory effect. Similarly, local, periarticular administration of lactoferrin into S aureus-infected Swiss mice significantly suppressed paw inflammation and did not enhance bacterial survival.

CONCLUSION

Lactoferrin may have clinical utility in reducing articular inflammation, particularly in septic arthritis, in which antiinflammatory effects may be achieved without promoting bacterial survival.

In vitro activity of 19 antimicrobial agents against 3513 nosocomial pathogens collected from 48 Canadian medical centres. The Canadian Antimicrobial Study Group

Antimicrobial resistance is a global concern. Differentiation between susceptibility rates for nosocomial versus community pathogens is important epidemiologically because it impacts on the appropriate empirical selection of antimicrobial therapy for infected patients. We studied resistance rates for 3513 nosocomial pathogens from 48 Canadian medical centres tested against 19 antimicrobial agents. The following are percent susceptibility for ceftazidime, ceftriaxone, ciprofloxacin, imipenem, netilmicin, and ticarcillin/clavulanic acid, respectively: Enterobacteriaceae 95, 95, 97, 99 98, 89; Escherichia coli, all 99 except ticarcillin/clavulanic acid (91); Enterobacter spp. 78, 78, 96, 99, 99, 71; Citrobacter spp. 79, 80, 89, 100, 94, 73; Proteus spp. 99, 88, 99, 88, 99, 98; Pseudomonas aeruginosa 88, 20, 82, 88, 81, 36; Staphylococcus aureus, all > 95; Enterococcus spp. 4, 9, 62, 95, 43, 38. Susceptibility rates for other species of microorganisms and agents tested varied considerably. Some institutions had higher than average resistance rates for some pathogens (i.e. P. aeruginosa) and some agents. Detection and continued surveillance of antimicrobial resistance amongst nosocomial pathogens is vital to patient care and health care resources. The control of antimicrobial resistance can help maintain antibiotic usage and costs associated with the use of ever more potent drugs and the treatment of increasingly resistant infections.

Pharmacology of ACE inhibitors versus AT1 blockers

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type 1 (AT1) receptor blockers share a number of common properties, including their ability to lower blood pressure. However, they can be differentiated based on their individual effects on the renin-angiotensin system, the fibrinolytic system and the actions of bradykinin. They act at different points in the cascade of events that constitute the renin-angiotensin system. In animal models of atherosclerosis, ACE inhibition was associated with a significant reduction in the percentage surface area of lesions, while no similar effect was evident with AT1 receptor blockade. In the fibrinolytic system, both ACE inhibition and AT1 receptor blockade were associated with reduced aldosterone levels, although the effect was greater with ACE inhibition; only ACE inhibition was associated with a significant reduction in plasminogen activation inhibitor-1. By blocking the degradation of bradykinin, ACE inhibitors potentiate the ability of bradykinin to reduce blood pressure and stimulate the release of tissue-type plasminogen activator from the vasculature, an effect not seen with AT1 receptor blockers.

Pancreatic duct stenting as a treatment for hereditary pancreatitis

Hereditary pancreatitis is a genetically transmitted condition usually presenting in childhood or adolescence. The natural history of the condition is that recurrent episodes of pancreatitis may be followed by the development of pancreatic exocrine and endocrine failure. Treatment options are limited, usually consisting of surgical drainage procedures whose efficacy is uncertain and whose effect on disease progression is unknown. We report a child with hereditary pancreatitis treated by means of a pancreatic duct stent placed via endoscopic retrograde cholangiopanctreatography resulting in long-term control of symptoms and speculate that earlier intervention may alter the disease course.

Economic evaluation of ciprofloxacin compared with usual antibacterial care for the treatment of acute exacerbations of chronic bronchitis in patients followed for 1 year

OBJECTIVE

To undertake a 1-year prospective economic evaluation of ciprofloxacin compared with usual antibacterial care (any antibacterial other than a quinolone) for the treatment of acute exacerbations of chronic bronchitis (AECB) in adults presenting with a type I or type II AECB.

DESIGN

Patients entered the study with an initial AECB and were randomised to the ciprofloxacin group or the usual care group. The following measurements were taken at the end of each AECB and every 3 months: resource utilisation, St. George's Respiratory Questionnaire, Nottingham Health Profile and Health Utilities Index (HUI). The following additional measurements were taken after each AECB: AECB-symptom days and willingness to pay to avoid the AECB. Economic evaluations were performed from the societal viewpoint and the viewpoint of a major third-party payer. Cost-effectiveness analysis was based on cost per AECB-symptom day averted; cost-utility analysis (CUA) was based on cost per quality-adjusted life-year (QALY) gained using the HUI as the basis for calculating QALYs. Cost-benefit analysis was based on the willingness-to-pay (WTP) data.

SETTING

This was a study of outpatients enrolled from 46 family physicians and 2 respirologists in Ontario (29 sites) and Québec (19 sites), Canada, between November 1993 and June 1994.

PATIENTS AND PARTICIPANTS

240 adult male and female patients aged > or = 18 years with chronic bronchitis.

MAIN OUTCOME MEASURES AND RESULTS

WTP data did not pass scope tests for reasonableness. Ciprofloxacin was more costly and provided better outcomes compared with usual antibacterial care. The base-case results are as follows (1994/1995 values): the incremental annual cost was 578 Canadian dollars ($Can) from the societal viewpoint and $Can840 for the third-party payer; the cost-effectiveness ratio per AECB-symptom day averted was $Can209 from the societal viewpoint and $Can304 for the third-party payer; the cost-utility ratio per QALY gained was $Can18,600 from the societal viewpoint and $Can27,000 for the third-party payer. According to Laupacis criteria, these CUA results are strong evidence in favour of adoption from the societal viewpoint and moderate evidence in favour from the viewpoint of the third-party payer. A subgroup analysis suggests that ciprofloxacin may be particularly cost effective, even 'win-win', in patients with more severe disease.

CONCLUSIONS

The sensitivity analyses indicate that the results are relatively robust. Nevertheless, the statistical uncertainty in the results is sufficient that the findings cannot be accepted unequivocally. A further study with a larger sample size would be useful to confirm (or deny) the findings of this study.

Low rates of Helicobacter pylori reinfection in children

BACKGROUND & AIMS

Reinfection after treatment for Helicobacter pylori is uncommon in adults. It is more likely to occur in children because they acquire primary infection. The aim of this study was to determine whether children are likely to become reinfected with H. pylori and if there are any risk factors for reinfection.

METHODS

A prospective study of children who had documented evidence of successful treatment for H. pylori infection was performed. Sixty children were eligible for inclusion; results for 52 are presented. Children, parents, and siblings underwent [(13)C]urea breath tests. Details of family size and socioeconomic status were documented. Cox logistic regression analysis was used to determine the risk factors for reinfection.

RESULTS

The duration of follow-up was 103.8 patient-years (mean +/- SD, 24 +/-14.0 months). Forty-six (88.5%) of the index children remained clear of infection, and 6 (11.5%) children were reinfected. The mean age of those who became reinfected was 5.8 +/- 5.6 years compared with 12.3 +/- 3.0 years for those who remained clear of infection (P = 0.00001). Only 2 of 46 (4.3%) children older than 5 years of age were reinfected, although 80.8% had 1 infected parent and 65% of siblings were infected. Reinfection rate was 2.0% per person per year in children older than 5 years. Living with infected parents and siblings and low socioeconomic status were not risk factors for reinfection. In logistic regression analysis, age was the only risk factor for reinfection.

CONCLUSIONS

Reinfection with H. pylori occurs rarely in children older than 5 years of age regardless of socioeconomic group or number of infected family members. These findings also indicate that it is not necessary to treat all family members to achieve long-term eradication of H. pylori.

Oral bioequivalence of three ciprofloxacin formulations following single-dose administration: 500 mg tablet compared with 500 mg/10 mL or 500 mg/5 mL suspension and the effect of food on the absorption of ciprofloxacin oral suspension

The oral bioequivalence and tolerability of two ciprofloxacin formulations (tablet and suspension) and the effect of food on the absorption of ciprofloxacin oral suspension were investigated. Sixty-eight young, healthy male subjects participated in two separate, randomized, crossover studies. In study 1, ciprofloxacin as a single 500 mg tablet or as 500 mg/10 mL oral suspension was administered in a fasted state on day 1. In study 2, subjects participated in a three-way crossover study in which ciprofloxacin suspension was administered as 500 mg/10 mL in a fasted state, or 500 mg/10 mL with food, or 500 mg/5 mL in a fasted state. Plasma ciprofloxacin concentrations were measured by high-performance liquid chromatography. Standard pharmacokinetic parameters were estimated using non-compartmental methods. In study 1, geometric mean Cmax values of ciprofloxacin following the single 500 mg tablet and 500 mg/10 mL suspension doses were 2.36 and 2.18 mg/L, respectively; corresponding geometric mean t(max) values were 1.1 and 1.6 h, respectively. Geometric mean AUC(0-infinity) values were 12.0 and 11.8 mg x h/L, respectively. In study 2, geometric least squares mean Cmax values following ciprofloxacin 500 mg/10 mL and 500 mg/5 mL suspension during fasted conditions were 1.54 and 1.59 mg/L, respectively. Corresponding geometric least squares mean AUC(0-infinity) values were 7.3 and 8.0 mg x h/L. Administration of ciprofloxacin 500 mg/10 mL suspension, in either a fasted or fed state, was not associated with significant changes in Cmax (1.54 mg/L for fasted vs 1.37 mg/L for fed) or AUC(0-infinity) values (7.28 mg x h/L for fasted vs 8.19 mg x h/L for fed). Each ciprofloxacin formulation was well tolerated for the duration of each study. These studies demonstrated bioequivalence between ciprofloxacin 500 mg tablet and two strengths of ciprofloxacin suspension (500 mg/10 mL and 500 mg/5 mL). Bioavailability was unaltered by food.