Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study

OBJECTIVES

Children with trisomy 21 often have anatomic and physiologic features that may complicate tracheal intubation (TI). TI in critically ill children with trisomy 21 is not well described. We hypothesize that in children with trisomy 21, TI is associated with greater odds of adverse airway outcomes (AAOs), including TI-associated events (TIAEs), and peri-intubation hypoxemia (defined as > 20% decrease in pulse oximetry saturation [Sp o2 ]).

DESIGN

Retrospective database study using the National Emergency Airway Registry for Children (NEAR4KIDS).

SETTING

Registry data from 16 North American PICUs and cardiac ICUs (CICUs), from January 2014 to December 2020.

PATIENTS

A cohort of children under 18 years old who underwent TI in the PICU or CICU from in a NEAR4KIDS center. We identified patients with trisomy 21 and selected matched cohorts within the registry.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We included 8401 TIs in the registry dataset. Children with trisomy 21 accounted for 274 (3.3%) TIs. Among those with trisomy 21, 84% had congenital heart disease and 4% had atlantoaxial instability. Cervical spine protection was used in 6%. The diagnosis of trisomy 21 (vs. without) was associated with lower median weight 7.8 (interquartile range [IQR] 4.5-14.7) kg versus 10.6 (IQR 5.2-25) kg ( p < 0.001), and more higher percentage undergoing TI for oxygenation (46% vs. 32%, p < 0.001) and ventilation failure (41% vs. 35%, p = 0.04). Trisomy 21 patients had more difficult airway features (35% vs. 25%, p = 0.001), including upper airway obstruction (14% vs. 8%, p = 0.001). In addition, a greater percentage of trisomy 21 patients received atropine (34% vs. 26%, p = 0.004); and, lower percentage were intubated with video laryngoscopy (30% vs. 37%, p = 0.023). After 1:10 (trisomy 21:controls) propensity-score matching, we failed to identify an association difference in AAO rates (absolute risk difference -0.6% [95% CI -6.1 to 4.9], p = 0.822).

CONCLUSIONS

Despite differences in airway risks and TI approaches, we have not identified an association between the diagnosis of trisomy 21 and higher AAOs.

Using Fractal Iconography to Emulate Nature's Aesthetics

This year's cover artists are members of a team of physicists and psy-chologists who create human-centered designs based on psychology experiments that investigate the positive impacts of viewing fractal patterns. These positive impacts include reduced physiological stress levels and enhanced cognitive skills. Here, the team explores the concept of 'fractal iconography' as an approach to employing computers to generate naturalistic art. Adopting this approach, three forms of fractal patterning ('fractal icons') are combined in a variety of ways to generate the rich complexity of nature's scenery. These composite fractals are remarkably effective at conveying nature's aesthetic power.

Patients' experience of necrotising otitis externa: a qualitative study

BACKGROUND

Necrotising otitis externa is a serious infective condition. Patients are typically frail, diagnostic delay is common and severe pain is a key feature. This study aimed to qualitatively analyse patient-centred data to identify key themes in the patient's experience.

METHODS

Open-ended questionnaires were sent to 28 patients. Responses were qualitatively analysed using a grounded theory approach. Iterative cycles were used to develop codes using a constant comparison technique. Emerging categories were refined to identify core themes.

RESULTS

Four main themes emerged: severe pain, mental health, quality of life and diagnostic delays.

CONCLUSION

This is the first study to explore patients' perspectives in necrotising otitis externa. It indicates a need to raise awareness of necrotising otitis externa, and to improve symptom management, pain control and quality of life. This valuable information can be used to identify research priorities, guide service improvements, improve clinical care and feed into the development of a Core Outcome Set for necrotising otitis externa.

Food Insecurity Is Common in the Orthopedic Trauma Population at a Rural Academic Trauma Center

Background

Food insecurity is an increasingly recognized public health issue. Identifying risk factors for food insecurity would support public health initiatives to provide targeted nutrition interventions to high-risk individuals. Food insecurity has not been investigated in the orthopedic trauma population.

Methods

From April 27, 2021 to June 23, 2021, we surveyed patients within six months of operative pelvic and/or extremity fracture fixation at a single institution. Food insecurity was assessed using the validated United States Department of Agriculture Household Food Insecurity questionnaire generating a food security score of 0 to 10. Patients with a food security score ≥ 3 were classified as Food Insecure (FI) and patients with a food security score < 3 were classified as Food Secure (FS). Patients also completed surveys for demographic information and food consumption. Differences between FI and FS for continuous and categorical variables were evaluated using the Wilcoxon sum rank test and Fisher's exact test, respectively. Spearman's correlation was used to describe the relationship between food security score and participant characteristics. Logistic regression was used to determine the relationship between patient demographics and odds of FI.

Results

We enrolled 158 patients (48% female) with a mean age of 45.5 ± 20.3 years. Twenty-one patients (13.3%) screened positive for food insecurity (High security: n=124, 78.5%; Marginal security: n=13, 8.2%; Low security: n=12, 7.6%; Very Low security: n=9, 5.7%). Those with a household income level of ≤ $15,000 were 5.7 times more likely to be FI (95% CI 1.8-18.1). Widowed/single/divorced patients were 10.2 times more likely to be FI (95% CI 2.3-45.6). Median time to the nearest full-service grocery store was significantly longer for FI patients (t=10 minutes) than for FS patients (t=7 minutes, p=0.0202). Age (r= -0.08, p=0.327) and hours working (r= -0.10, p=0.429) demonstrated weak to no correlation with food security score.

Conclusion

Food insecurity is common in the orthopedic trauma population at our rural academic trauma center. Those with lower household income and those living alone are more likely to be FI. Multicenter studies are warranted to evaluate the incidence and risk factors for food insecurity in a more diverse trauma population and to better understand its impact on patient outcomes. Level of Evidence: III.

Food Insecurity Is Common in the Orthopedic Trauma Population: A Multicenter Cross-Sectional Study

Objectives

Malnutrition increases the risk for adverse outcomes after musculoskeletal trauma. Food insecurity is an increasingly recognized risk factor for malnutrition. The purpose of this investigation is to evaluate the prevalence and risk factors for food insecurity in a diverse population treated for operative fracture fixation.

Methods

A two-center study (Midwest and Pacific Northwest) enrolled participants of any age within 6 months of operative fixation of pelvis or extremity fractures. Food insecurity was assessed using the USDA Household Food Insecurity questionnaire. A score ≥3 indicated food insecurity, 1 or 2 indicated marginal food security, and 0 indicated high food security. Subgroup analysis was performed for participants with available demographic, income, and food access data. Differences between food insecure and food secure participants in continuous and categorical variables were evaluated using the Wilcoxon sum rank test and Fisher's exact test, respectively. Spearman's correlation was used to describe associations between food security scores and participant characteristics. Logistic regression was used to relate patient demographics and odds of food insecurity.

Results

Of the 476 participants enrolled, 53 (11%) were food insecure, 48 (10%) had marginal food security, and 375 (79%) were food secure. Those with food insecurity were more commonly female (p &lt; 0.0001). Participants with a household income ≤$15,000 were 5.7 times more likely to be food insecure (95% CI 1.8–18.1). Widowed/single/divorced participants were 10.2 times more likely to experience food insecurity than married/partnered participants (95% CI 2.3–45.6). Median time to the nearest full-service grocery store was significantly longer for food insecure (t = 10 minutes) than for food secure participants (t = 7 minutes, p = 0.0202). Time to store demonstrated a weak correlation with food security score (r = 0.23, p = 0.0041). Age (r = −0.08, p = 0.327) and hours working (r = −0.10, p = 0.429) demonstrated no correlation with food security score.

Conclusions

Food insecurity is common in the musculoskeletal trauma population. Those with lower household incomes and living alone are more likely to experience food insecurity. Food insecurity is a potentially modifiable risk factor for malnutrition-related complications after operative fracture fixation.

Funding Sources

None.

Significant Loss of Skeletal Muscle Mass Occurs After Femoral Fragility Fracture

Objectives

Femoral fragility fractures in the elderly result in devastating loss of physical function and muscle mass, which is a direct result of immobilization and nutrient deficiencies during healing. A better understanding of how muscle mass responds to injury is needed to critically evaluate nutrition interventions designed to prevent muscle loss and optimize function. The purpose of this study was to document sarcopenia, nutrition status, and changes in muscle mass after femoral fragility fractures.

Methods

A two-center prospective observational study enrolled individuals ≥65 years old admitted for operative fixation of a low-energy femoral fracture. Body composition was assessed within 72 hours of admission using bioelectrical impedance and repeated 6 and 12 weeks after injury. Sarcopenia was defined by gender-specific cutoffs for appendicular skeletal muscle mass index. Malnutrition was defined by Mini Nutritional Assessment®. Wilcoxon Signed Rank test was used to assess 6 and 12-week change from baseline in skeletal muscle mass (SMM). Wilcoxon Rank Sum test was used to compare the change in SMM in those with vs without malnutrition and sarcopenia. SMM results are presented as median (interquartile range).

Results

Thirty participants (27% male) age 76.9 ± 8.9 years were enrolled. At baseline, 11 (37%) were sarcopenic, and 17 (59%) were at risk of malnutrition. SMM decreased 1.75kg (−3.30 to −0.40, p < 0.001) by 6 weeks post-injury. By 12 weeks, participants lost 3.04 kg of SMM (−4.49 to −1.45), p < 0.001). Participants with adequate baseline nutrition status lost more SMM at 6 weeks compared to those with at risk of malnutrition (−3.56 kg (−4.65 to −1.60) versus −1.22 kg (−2.00 to −0.20), P = 0.01). No difference was observed in SMM loss between those with vs without sarcopenia at baseline.

Conclusions

Femoral fragility fractures result in devastating losses of skeletal muscle mass. Most were at risk of malnutrition, but participants with adequate baseline nutrition lost more muscle mass, indicating that future investigations of interventions to prevent muscle loss should focus on all fragility fracture patients regardless of nutrition status. These results highlight the need for further investigation into interventions to mitigate muscle loss after injury.

Funding Sources

Orthopedic Trauma Association.

Reliability of Multifrequency Bioelectrical Impedance Analysis to Quantify Body Composition in Patients After Musculoskeletal Trauma

BACKGROUND

Changes in body composition, especially loss of lean mass, commonly occur in the orthopedic trauma population due to physical inactivity and inadequate nutrition. The purpose of this study was to assess inter-rater and intra-rater reliability of a portable bioelectrical impedance analysis (BIA) device to measure body composition in an orthopedic trauma population after operative fracture fixation. BIA uses a weak electric current to measure impedance (resistance) in the body and uses this to calculate the components of body composition using extensively studied formulas.

METHODS

Twenty subjects were enrolled, up to 72 hours after operative fixation of musculoskeletal injuries and underwent body composition measurements by two independent raters. One measurement was obtained by each rater at the time of enrollment and again between 1-4 hours after the initial measurement. Reliability was assessed using intraclass correlation coefficients (ICC) and minimum detectable change (MDC) values were calculated from these results.

RESULTS

Inter-rater reliability was excellent with ICC values for body fat mass (BFM), lean body mass (LBM), skeletal muscle mass (SMM), dry lean mass (DLM), and percent body fat (PBF) of 0.993, 0.984, 0.984, 0.979, and 0.986 respectively. Intra-rater reliability was also high for BFM, LBM, SMM, DLM, and PBF, at 0.994, 0.989, 0.990, 0.983, 0.987 (rater 1) and 0.994, 0.988, 0.989, 0.985, 0.989 (rater 2). MDC values were calculated to be 4.05 kg for BFM, 4.10 kg for LBM, 2.45 kg for SMM, 1.21 kg for DLM, and 4.83% for PBF.

CONCLUSION

Portable BIA devices are a versatile and attractive option that can reliably be used to assess body composition and changes in lean body mass in the orthopedic trauma population for both research and clinical endeavors. Level of Evidence: III.

What is in? What is out? Updating the British Society for Cutaneous Allergy facial series

BACKGROUND

Allergic contact dermatitis (ACD) to cosmetics is widely reported. To ensure we are accurately diagnosing ACD, patch test series should be continually reviewed to identify relevant and emerging allergens and highlight those that are outdated. The current British Society for Cutaneous Allergy (BSCA) facial series recommends 26 allergens and was last modified in 2012.

OBJECTIVES

To review and update the BSCA facial series.

METHODS

We retrospectively reviewed the results from 12 UK and Ireland patch test centres' facial series from January 2016 to December 2017. We recorded the number of allergens tested in each centre and the detection rate for each allergen. Using a 0·3% positive rate as the inclusion threshold, we established which allergens in the BSCA facial series had positive patch test rates < 0·3% and > 0·3%. Allergens not in the BSCA facial series that had a positive patch test rate > 0·3% were identified.

RESULTS

Overall, 4224 patients were patch tested to the facial series. The number of allergens included in individual centres' facial series ranged from 24 to 66, with a total of 103 allergens tested across all centres. Twelve of the 26 allergens in the BSCA facial series had a positive patch test rate < 0·3% and 14 had a rate > 0·3%. Twenty-five allergens not recommended in the BSCA facial series had a positive patch test rate > 0·3%.

CONCLUSIONS

This audit has highlighted the significant variation in practice that exists among patch test centres, despite a recommended facial series. The BSCA facial series has been updated and now contains 24 allergens. Fifteen allergens remain, 11 allergens have been dropped and nine new allergens have been added.

The impact of using silver alloy urinary catheters in reducing the incidence of urinary tract infections in the critical care setting

prospective study was undertaken on three critical care units to establish the efficacy of using a silver alloy urinary catheter in reducing the incidence of nosocomial urinary tract infections.

Some 188 patients participated in the evaluation (94 in each group). A urine sample was obtained post insertion and every three days while on the critical care unit to detect bacteriuria. The infection rate was 12.65 in the standard group and 11.32 in the silver alloy group per 1000 catheter days respectively. The mean duration of catheterisation was 16 days (inter-quartile range 13). Gram positive cocci were responsible for 24.5% of the bacteriuria, Gram negatives 64.5% and yeasts accounted for 11%. Based on these results, routine use of silver alloy catheters cannot be justified for all patients, but may be suited to high-risk female patients.

Emergency department visits for nontraumatic dental problems: a mixed-methods study

OBJECTIVES

We documented emergency department (ED) visits for nontraumatic dental problems and identified strategies to reduce ED dental visits.

METHODS

We used mixed methods to analyze claims in 2010 from a purposive sample of 25 Oregon hospitals and Oregon's All Payer All Claims data set and interviewed 51 ED dental visitors and stakeholders from 6 communities.

RESULTS

Dental visits accounted for 2.5% of ED visits and represented the second-most-common discharge diagnosis in adults aged 20 to 39 years, were associated with being uninsured (odds ratio [OR] = 5.2 [reference: commercial insurance]; 95% confidence interval [CI] = 4.8, 5.5) or having Medicaid insurance (OR = 4.0; 95% CI = 3.7, 4.2), resulted in opioid (56%) and antibiotic (56%) prescriptions, and generated $402 (95% CI = $396, $408) in hospital costs per visit. Interviews revealed health system, community, provider, and patient contributors to ED dental visits. Potential solutions provided by interviewees included Medicaid benefit expansion, care coordination, water fluoridation, and patient education.

CONCLUSIONS

Emergency department dental visits are a significant and costly public health problem for vulnerable individuals. Future efforts should focus on implementing multilevel interventions to reduce ED dental visits.

A study to determine whether the use of a preconnect urinary catheter system reduces the incidence of nosocomial urinary tract infections

Nosocomial urinary tract infection (NUTI) is a common problem in the UK and is often related to the use of urinary catheters. In the UK urinary catheters account for approximately 25% of all healthcare associated infections and can have a considerable financial burden on the health service. Bacteria may gain entry into the bladder of a catheterised patient via the intra-luminal route especially if accidental disconnection arises. A prospective study was undertaken to determine the NUTI rates in patients using a preconnected catheter system compared to a traditional bag and catheter system on three medical wards. A total of 205 patients were included in the study. The catheter-associated urinary tract infection rate (CAUTI) in the baseline was 37.8 per 1,000 catheter days and 22.4 per 1,000 catheter days in the intervention group.

The rates of CAUTI were 41% lower in the intervention group. The data in this sample group suggests the use of the preconnected catheter offers some protection against infection. The use of the preconnected system is a new concept in the UK and further studies are required to evaluate its effectiveness. The results from this study suggest their use may help to reduce the risk of CAUTI in certain clinical areas.

Adjuvant 5-fluorouracil and folinic acid vs observation for pancreatic cancer: composite data from the ESPAC-1 and -3(v1) trials

The ESPAC-1, ESPAC-1 plus, and early ESPAC-3(v1) results (458 randomized patients; 364 deaths) were used to estimate the effectiveness of adjuvant 5FU/FA vs resection alone for pancreatic cancer using meta-analysis. The pooled hazard ratio of 0.70 (95% CI=0.55-0.88) P=0.003, and the median survival of 23.2 (95% CI=20.1-26.5) months with 5FU/FA vs 16.8 (95% CI=14.3-19.2) months with resection alone supports the use of adjuvant 5FU/FA in pancreatic cancer.

Glucocorticoid receptor haploinsufficiency causes hypertension and attenuates hypothalamic-pituitary-adrenal axis and blood pressure adaptions to high-fat diet

Glucocorticoid hormones are critical to respond and adapt to stress. Genetic variations in the glucocorticoid receptor (GR) gene alter hypothalamic-pituitary-adrenal (HPA) axis activity and associate with hypertension and susceptibility to metabolic disease. Here we test the hypothesis that reduced GR density alters blood pressure and glucose and lipid homeostasis and limits adaption to obesogenic diet. Heterozygous GR^βgeo/+ mice were generated from embryonic stem (ES) cells with a gene trap integration of a β-galactosidase-neomycin phosphotransferase (βgeo) cassette into the GR gene creating a transcriptionally inactive GR fusion protein. Although GR^βgeo/+ mice have 50% less functional GR, they have normal lipid and glucose homeostasis due to compensatory HPA axis activation but are hypertensive due to activation of the renin-angiotensin-aldosterone system (RAAS). When challenged with a high-fat diet, weight gain, adiposity, and glucose intolerance were similarly increased in control and GR^βgeo/+ mice, suggesting preserved control of intermediary metabolism and energy balance. However, whereas a high-fat diet caused HPA activation and increased blood pressure in control mice, these adaptions were attenuated or abolished in GR^βgeo/+ mice. Thus, reduced GR density balanced by HPA activation leaves glucocorticoid functions unaffected but mineralocorticoid functions increased, causing hypertension. Importantly, reduced GR limits HPA and blood pressure adaptions to obesogenic diet.—Michailidou, Z., Carter, R. N., Marshall, E., Sutherland, H. G., Brownstein, D. G., Owen, E., Cockett, K., Kelly, V., Ramage, L., Al-Dujaili, E. A. S., Ross, M., Maraki, I., Newton, K., Holmes, M. C., Seckl, J. R., Morton, N. M., Kenyon, C. J., Chapman, K. E. Glucocorticoid receptor haploinsufficiency causes hypertension and attenuates hypothalamic-pituitary-adrenal axis and blood pressure adaptions to high-fat diet.

Determination of immunological homology between cellulosome subunits and cloned endoglucanases and xylanase of Clostridium thermocellum

Immuno-cross reactivity between the subunits of Clostridium thermocellum cellulosome and cloned endogucanases and xylanase from the same bacterium was studied using the polyclonal antibodies raised against cloned enzymes. Dot blot analysis showed that the cellulosome, S8 and S11 subunits cross-reacted strongly with the antibodies of all cloned enzymes tested except that raised against CelC. Western blot analysis revealed that S8 and S11 subunits cross-reacted with the antibodies of CelA, CelB, CelD, CelG, CelH and XynZ, but the antibodies of CelB and CelG were highly specific for S8 and S11 subunits, respectively. Similar analysis using dissociated cellulosome showed that the antibodies of all cloned enzymes tested cross-reacted with more than one subunit of the cellulosome. Antibodies of CelC showed a very low cross-reactivity against all subunits of the cellulosome. The results indicate that immunological cross-reactivity studies could be useful, not only for demonstrating the similarities between native and cloned enzymes, but also for identifying native enzymes using antibodies of cloned enzymes.

Donor leukocytes combine with immunosuppressive drug therapy to prolong limb allograft survival

Donor leukocytes administered at the time of transplantation may prolong organ allograft survival. This study examined the effectiveness of donor leukocyte injection combined with immunosuppression for limb transplantation across the strong histocompatibility barrier of a Brown Norway donor to a Lewis recipient. Eight animals received 6 x 10(7) donor leukocytes injected on the day of transplantation. From day 1, FK506 (2 mg/kg/d), mycophenolate mofetil (MMF) (15 mg/kg/d), and prednisone (0.5 mg/kg/d) were administered for 2 weeks. After week 2, prednisone and MMF were both tapered by 20% of the initial dosage per week. After week 7, the animals received only FK506 (2 mg/kg/d). From week 8, FK506 was tapered to the maintenance dose of 0.8 mg/kg/d at week 10 and was stopped on week 24. A control group of 8 animals underwent identical treatment except that the leukocyte injection was omitted. Rejection was observed in both groups during FK506 monotherapy; however, the onset of early rejection episodes was significantly later, the period for reversal of the first rejection was significantly shorter, and the dosage of FK506 at the time of rejection was significantly lower among leukocyte-treated recipients. After completion of immunosuppression, survival was modestly prolonged in the leukocyte-treated group. One animal is surviving without immunosuppression on day 234. This trial of donor leukocyte injection combined with immunosuppression in limb transplantation showed a modest, but significant, improvement in outcome.

Nitrogen budgets for three cropping systems fertilised with cattle manure

A field plot experiment was set up on a sandy loam soil of SW England in order to determine the efficiency of nitrogen use from different cattle manures. The manure treatments were low and high dry matter cattle slurries and one farmyard manure applied at a target rate of 200 kg total N ha(-1)year(-1), and an untreated control. There were three different cropping systems: ryegrass/clover mixture, maize/rye and maize/bare soil, which were evaluated during 1998/99 and 1999/00. Measurements were made of N losses, N uptake and herbage DM yields. Result showed that manure type had a significant effect on N utilisation only for maize. N balances were negative in maize (approximately -247 to -10 kg N) compared to grass (approximately 5-158 kg N). Agronomic management was more important than manure type in influencing N losses, where soil cultivation appeared to be a key factor when comparing maize and grass systems.

Bony fragments in the uterus: an association with secondary subfertility

Bone within the uterine cavity is an unusual finding in women with secondary subfertility, and is usually associated with a past history of termination of pregnancy. The etiology is unknown, but theories include retained fetal bone and osseous metaplasia of endometrial tissue. We describe the cases of three subfertility patients, all with a history of surgical termination of pregnancy. Each patient underwent a hysteroscopy after highly echogenic foci were seen in the uterus on transvaginal ultrasound examination. During hysteroscopy, several coral-like bony fragments were seen and removed by sharp curettage. On histological examination, these fragments were found to be mature, necrotic bone. This case report confirms the importance of routine baseline evaluation of the endometrium in subfertile women with a history of termination of pregnancy.

Influence of fibrolytic enzymes on the hydrolysis and fermentation of pure cellulose and xylan by mixed ruminal microorganisms in vitro

A series of in vitro studies was conducted to determine the effects of adding a commercial enzyme product on the hydrolysis and fermentation of cellulose, xylan, and a mixture (1:1 wt/wt) of both. The enzyme product (Liquicell 2500, Specialty Enzymes and Biochemicals, Fresno, CA) was derived from Trichoderma reesei and contained mainly xylanase and cellulase activities. Addition of enzyme (0.5, 2.55 and 5.1 microL/g of DM) in the absence of ruminal fluid increased (P < 0.001) the release of reducing sugars from xylan and the mixture after 20 h of incubation at 20 degrees C. Incubations with ruminal fluid showed that enzyme (0.5 and 2.55 microL/g of DM) increased (P < 0.05) the initial (up to 6 h) xylanase, endoglucanase, and beta-D-glucosidase activities in the liquid fraction by an average of 85%. Xylanase and endoglucanase activities in the solid fraction also were increased (P < 0.05) by enzyme addition, indicating an increase in fibrolytic activity due to ruminal microbes. Gas production over 96 h of incubation was determined using a gas pressure measurement technique. Incremental levels of enzyme increased (P < 0.05) the rate of gas production of all substrates, suggesting that fermentation of cellulose and xylan was enzyme-limited. However, adding the enzyme at levels higher than 2.55 microL/g of DM failed to further increase the rate of gas production, indicating that the maximal level of stimulation was already achieved at lower enzyme concentrations. It was concluded that enzymes enhanced the fermentation of cellulose and xylan by a combination of pre- and postincubation effects (i.e., an increase in the release of reducing sugars during the pretreatment phase and an increase in the hydrolytic activity of the liquid and solid fractions of the ruminal fluid), which was reflected in a higher rate of fermentation.

Reliability of pre-operative biopsies in the histological grading of colorectal adenocarcinomas

BACKGROUND

Management of colorectal cancer depends on many patient and tumour variables. Decisions are sometimes based on the histological grade of tumour as assessed by initial biopsy. This retrospective study looked at the reliability of grading colorectal cancer from pre-operative biopsies.

METHODS

118 patients with a diagnosis of colorectal cancer, who had adequate pre-operative biopsies, were included in the study. A single consultant histopathologist re-examined all the preoperative biopsy slides, but was blinded to the final grading of the resection specimen.

RESULTS

Of the 118 resection specimens, 41 were graded well-differentiated, 52 moderately differentiated and 25 poorly differentiated. When compared with postoperative grading, 37 (31%) initial biopsies were undergraded, 49 (43%) were correctly graded and 32 (26%) were overgraded.

CONCLUSIONS

These results suggest that the histological grading of pre-operative specimens is inaccurate and should be used with caution to determine treatment. The difficulty with grading pre-operative biopsies in colorectal cancer may be owing to a lack of specific criteria such as is used in, for example, breast cancer.

Biochemical characterization and mode of action of a thermostable endoglucanase purified from Thermoascus aurantiacus

A major extracellular endoglucanase purified to homogeneity from Thermoascus aurantiacus had a M(r) of 34 kDa and a pI of 3.7 and was optimally active at 70-80 degrees C and pH 4.0-4.4. It was stable at pH 2.8-6.8 at 50 degrees C for 48 h and maintained its secondary structure and folded conformation up to 70 degrees C at pH 5.0 and 2.8, respectively. A 33-amino acid sequence at the N terminus showed considerable homology with 14 microbial endoglucanases having highly conserved 8 amino acids (positions 10-17) and Gly, Pro, Gly, and Pro at positions 8, 22, 23, and 32, respectively. The enzyme is rich in Asp (15%) and Glu (10%) with a carbohydrate content of 2.7%. Polyclonal antibodies of endoglucanase cross-reacted with their own antigen and with other purified cellulases from T. aurantiacus. The endoglucanase was specific for polymeric substrates with highest activity toward carboxymethyl cellulose followed by barley beta-glucan and lichenan. It preferentially cleaved the internal glycosidic bonds of Glc(n) and MeUmbGlc(n) and possessed an extended substrate-binding site with five subsites. The data indicate that the endoglucanase from T. aurantiacus is a member of glycoside hydrolase family 5.

[First transplantation of two hands: results after 18 months]

AIM OF THE STUDY

The previous results achieved in single hand transplantations confirmed the feasibility of this procedure and encouraged us to perform the first human double hand transplantation, which was performed in January 2000. In the present study we reported the results obtained eighteen months after transplantation.

PATIENT AND METHODS

The recipient was a 33-year old man suffering from a traumatic amputation of both hands in 1996. Surgery included procurement of the upper extremities from a 18-year old multiorgan cadaveric donor, preparation of the graft and recipient's stumps, transplantation of the hands, which included bone fixation, arterial and venous anastomoses, nerve suture, joining of tendons and muscles, and skin closure. Immunosuppressive protocol included tacrolimus, prednisone and mycophenolate mofetil. An intensive rehabilitation program was performed. Follow-up included immunological tests, skin biopsies, arteriography, bone scintigraphy, electromyography and brain functional magnetic resonance imaging.

RESULTS

No surgical complications, infectious complications and graft-versus-host-disease occurred. Two episodes of acute skin rejection were demonstrated and they were completely reversed increasing steroid dose. Nerve regeneration and cortical reorganization were shown. Sensorimotor recovery was encouraging and life quality improved.

CONCLUSION

This double hand transplantation showed that conventional immunosuppressive protocol is effective and safe as well as that functional results are at least as good as those achieved in replanted upper extremities.