Experiences of mpox illness and case management among cis and trans gay, bisexual and other men who have sex with men in England: a qualitative study

Background

The 2022-2024 global mpox outbreak, occurring primarily in the sexual networks of gay, bisexual and other men who have sex with men (GBMSM), has not been accompanied by a focus on patient perspectives of illness. We explore the experiences of GBMSM diagnosed with mpox in England to understand needs for social and clinical support.

Methods

In-depth interviews (March/July 2023) were conducted with 22 GBMSM diagnosed with mpox in 2022, randomly selected from a national mpox surveillance database, and 4 stakeholders from clinical/community-based organisations. Interviews covered experiences of illness, testing, diagnosis, treatment and contact tracing, and were recorded, transcribed and analysed with a thematic framework.

Findings

Media coverage drawing on homophobic stereotypes around sex between men contributed to feelings of stigma and shame. GBMSM living with HIV appeared to cope better with mpox stigma, drawing on their experiences of being diagnosed with HIV for resilience. Younger GBMSM with less experience of stigmatising illness found mpox diagnosis more traumatic and sometimes required support beyond what was provided. Accessing testing could be complicated when healthcare professionals did not recognise mpox symptoms. Men felt information on course of illness, isolation and vaccination after recovery was often inconsistent and contradictory. GBMSM described that care from sexual health and infectious disease units usually better met their emotional and medical needs. This was frequently linked by men to these services having skills in working with the GBMSM community and managing infection risk sensitively. General hospital services and centralised contact tracing could increase feelings and experiences of stigma as some staff were perceived to lack skills in supporting GBMSM and, sometimes, clinical knowledge. Long-term impacts described by men included mental health challenges, urethral/rectal symptoms and life-changing disability.

Interpretation

In this study stigma was a central feature of mpox illness among GBMSM and could be exacerbated or lessened depending on the clinical and social support provided. Involving communities affected by outbreaks in co-producing, planning and delivering care (including contact-tracing) may help improve support provided.

Funding

TCW, AJR, AS and FMB received support from the National Institute for Health and Care Research (NIHR) under its Programme Grants for Applied Research Programme (Ref: NIHR202038). CS and JS receive support from the National Institute for Health and Care Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in partnership with UKHSA; RV receives support from the NIHR HPRU in Emerging and Zoonotic Infections and NIHR HPRU in Gastrointestinal Infections. The views expressed are those of the author(s) and not necessarily those of the NIHR, UK Health Security Agency, World Health Organization or the Department of Health and Social Care.

Rebound of Gonorrhea after Lifting of COVID-19 Preventive Measures, England

After lifting of all COVID-19 preventive measures in England in July 2021, marked, widespread increases in gonorrhea diagnoses, but not testing numbers, were observed, particularly in persons 15-24 years of age. Continued close surveillance and public health messaging to young persons are needed to control and prevent gonorrhea transmission.

Retrospective testing for mpox virus in routine STI screens from men who have sex with men in England, August-October 2022

OBJECTIVES

A global outbreak of mpox (monkeypox) has been ongoing since 2022, with most cases in the UK detected in gay, bisexual and other men who have sex with men (GBMSM). Asymptomatic and pauci-symptomatic mpox infection has been reported outside of the UK. We aimed to investigate whether mpox could be detected in specimens from GBMSM in England who were attending sexual health services (SHSs) for asymptomatic sexually transmitted infection screening.

METHODS

Anonymised, residual clinical specimens from GBMSM undertaking routine asymptomatic screening for gonorrhoea (Neisseria gonorrhoeae (NG)) and chlamydia (Chlamydia trachomatis (CT)) infection were tested for the presence of mpox virus. Specimens were collected between 1 August and 7 October 2022 from three SHSs in high-mpox incidence areas in England. Testing was performed using a dual-clade, mpox virus-specific real-time PCR.

RESULTS

During the collection period, 2927 clinical specimens (951 pharyngeal swabs, 1022 urine specimens and 954 rectal swabs) were obtained from 1159 GBMSM. Mpox virus was detected in four specimens from two participants who attended the same SHS at different times (the first during the week 8-12 of August, the second during the week 19-23 of September). One participant was positive in the urine specimen only, while the other tested positive at all three sites.

CONCLUSIONS

A very low prevalence (2 of 1159, 0.17%) of mpox infection was detected in GBMSM attending SHS in England for asymptomatic NG/CT screening, suggesting that undetected infection in this population was unlikely to be a main driver of transmission. Confirmed mpox cases in the UK declined from over 1100 per month in June and July to 764 cumulatively during the collection period. These data give reassurance that the observed reduction in cases during the collection period was not due to undetected infection or changes in presentation among SHS attendees. Currently, there is insufficient evidence to support routine testing of asymptomatic GBMSM for mpox infection in England.

Surveillance of Mpox Cases Attending Sexual Health Services in England (SOMASS): design, implementation and initial findings from the SOMASS data collection tool, 2022

OBJECTIVES

We aimed to design and implement a data collection tool to support the 2022 mpox (monkeypox) outbreak, and to describe clinical and epidemiological data from individuals with mpox attending sexual health services (SHSs) in England.

METHODS

The UK Health Security Agency and the British Association for Sexual Health and HIV established the Surveillance of Mpox Cases Attending Sexual Health Services in England (SOMASS) system.Descriptive data were collected via a secure web-based data collection tool, completed by SHS clinicians following consultation with individuals with suspected mpox. Data were collected on patient demographics, clinical presentation and severity, exposures and behavioural characteristics.

RESULTS

As of 17 November 2022, 276 SOMASS responses were submitted from 31 SHSs in England.Where recorded, most (245 of 261; 94%) individuals identified as gay, bisexual or men who have sex with men (GBMSM), of whom two-thirds were HIV negative (170 of 257; 66%) and taking HIV pre-exposure prophylaxis (87 of 140; 62%), with a median age of 37 years (IQR: 30-43). Where known, thirty-nine per cent (63 of 161) had a concurrent sexually transmitted infection (STI) at the time of their mpox diagnosis.For 46% of individuals (127 of 276), dermatological lesions were the initial symptom. Lesions were mostly asymmetrical and polymorphic, predominately affecting the genital area and perianal areas.Nine per cent (24 of 276) of individuals were hospitalised. We report an association between receptive anal intercourse among GBMSM and proctitis (27 of 115; 24% vs 7 of 130; 5%; p<0.0001), and the presence of perianal lesions as the primary lesion site (46 of 115; 40% vs 25 of 130; 19%; p=0.0003).

CONCLUSIONS

We demonstrate multidisciplinary and responsive working to develop a robust data collection tool, which improved surveillance and strengthened the knowledge base. The SOMASS tool will allow data collection if mpox resurges in England. The model for developing the tool can be adapted to facilitate the preparedness and response to future STI outbreaks.

Genomic epidemiology of syphilis in England: a population-based study

BACKGROUND

Syphilis is a sexually transmitted bacterial infection caused by Treponema pallidum subspecies pallidum. Since 2012, syphilis rates have risen dramatically in many high-income countries, including England. Although this increase in syphilis prevalence is known to be associated with high-risk sexual activity in gay, bisexual, and other men who have sex with men (GBMSM), cases are rising in heterosexual men and women. The transmission dynamics within and between sexual networks of GBMSM and heterosexual people are not well understood. We aimed to investigate if whole genome sequencing could be used to supplement or enhance epidemiological insights around syphilis transmission.

METHODS

We linked national patient demographic, geospatial, and behavioural metadata to whole T pallidum genome sequences previously generated from patient samples collected from across England between Jan 1, 2012, and Oct 31, 2018, and performed detailed phylogenomic analyses.

FINDINGS

Of 497 English samples submitted for sequencing, we recovered 240 genomes (198 from the UK Health Security Agency reference laboratory and 42 from other laboratories). Three duplicate samples (same patient and collection date) were included in the main phylogenies, but removed from further analyses of English populations, leaving 237 genomes. 220 (92·8%) of 237 samples were from men, nine (3·8%) were from women, and eight (3·4%) were of unknown gender. Samples were mostly from London (n=118 [49·8%]), followed by southeast England (n=29 [12·2%]), northeast England (n=24 [10·1%]), and southwest England (n=15 [6·3%]). 180 (76·0%) of 237 genomes came from GBMSM, compared with 25 (10·5%) from those identifying as men who have sex with women, 15 (6·3%) from men with unrecorded sexual orientation, nine (3·8%) from those identifying as women who have sex with men, and eight (3·4%) from people of unknown gender and sexual orientation. Phylogenomic analysis and clustering revealed two dominant T pallidum sublineages in England. Sublineage 1 was found throughout England and across all patient groups, whereas sublineage 14 occurred predominantly in GBMSM older than 34 years and was absent from samples sequenced from the north of England. These different spatiotemporal trends, linked to demography or behaviour in the dominant sublineages, suggest they represent different sexual networks. By focusing on different regions of England we were able to distinguish a local heterosexual transmission cluster from a background of transmission in GBMSM.

INTERPRETATION

These findings show that, despite extremely close genetic relationships between T pallidum genomes globally, genomics can still be used to identify putative transmission clusters for epidemiological follow-up. This could be of value for deconvoluting putative outbreaks and for informing public health interventions.

FUNDING

Wellcome funding to the Sanger Institute, UK Research and Innovation, National Institute for Health and Care Research, European and Developing Countries Clinical Trials Partnership, and UK Health Security Agency.

Epidemiology of Early Monkeypox Virus Transmission in Sexual Networks of Gay and Bisexual Men, England, 2022

After community transmission of monkeypox virus was identified in Europe, interviews of 45 case-patients from England indicated transmission in international sexual networks of gay and bisexual men since April 2022. Interventions targeting sex-on-premises venues, geospatial dating applications, and sexual health services are likely to be critical for outbreak control.

Emergence of novel strains of Shigella flexneri associated with sexual transmission in adult men in England, 2019-2020

National surveillance of shigellosis in England revealed an increase in sexually transmitted Shigella flexneri in adult males in 2019 that persisted throughout 2020. We observed a resurgence of azithromycin-resistant S. flexneri serotype 3a, and the emergence of two novel multidrug-resistant clades of S. flexneri 2a and S. flexneri 1b.

Rapid Increase in Lymphogranuloma Venereum among HIV-Negative Men Who Have Sex with Men, England, 2019

Incidence of lymphogranuloma venereum increased in England during 2018–2019, after a period of decline. Our retrospective analysis of national surveillance data identified a rapid increase in diagnoses among HIV-negative men who have sex with men. These findings indicate a need for sustained surveillance and targeted public health action.

Testing the validity of national drug surveys: comparison between a general population cohort and household surveys

BACKGROUND AND AIMS

There are concerns that national population-based estimates of illicit drug use are underestimated. We investigated this by comparing estimates of illicit substance use at age 24 from the Crime Survey for England and Wales (CSEW) with a birth cohort (Avon Longitudinal Study of Parents and Children, ALSPAC) and by comparing the Smoking and Alcohol Toolkit Studies (STS/ATS) to ALSPAC.

DESIGN

Cross-sectional household survey and cross-sectional data from one wave of a longitudinal birth cohort.

SETTING

England and Wales.

PARTICIPANTS

Young adults aged 23-25 reporting on substance use in 2017 to CSEW (n = 1165), ALSPAC (n = 3389) and STS/ATS (n = 950).

MEASUREMENTS

Lifetime and past-year illicit drug use, smoking status and hazardous drinking at age 24.

FINDINGS

The 2017 CSEW estimate of lifetime illicit drug use was 40.6%, compared with 62.8% in ALSPAC (risk difference % [RD%] = 22.2%; 95% CI = 18.9-25.5%; P ≤ 0.001). The RD in lifetime use between ALSPAC and the CSEW was 23.2% (95% CI = 20.0-26.4%) for cannabis, 16.9% (95% CI = 14.4-19.4%) for powder cocaine and 24.8% (95% CI = 22.6-27.0%) for amphetamine. Past-year drug use was 16.4% in CSEW, compared with 36.7% in ALSPAC (RD% = 20.3%; 95% CI = 17.6-23.0%; P ≤ 0.001). For past-year substance use, the RD between ALSPAC and the CSEW was 15.4% (95% CI = 12.9-17.9%) for cannabis, 14.8% (95% CI = 13.0%-16.6%) for powder cocaine and 15.9% (95% CI = 14.5-17.4%) for amphetamine. Levels of current smoking were similar between STS (27.4%) and ALSPAC (29.4%). Hazardous drinking was substantially higher in ALSPAC (60.3%) than the ATS (32.1%; RD% = 28.2%; 95% CI = 24.8-31.6%; P ≤ 0.001).

CONCLUSIONS

The Avon Longitudinal Study of Parents and Children provides one source of validation for measurements of drug use in government household surveys and indicates that illicit drug use may be underestimated in the Crime Survey for England and Wales.

iLIR@viral: A web resource for LIR motif-containing proteins in viruses

Macroautophagy/autophagy has been shown to mediate the selective lysosomal degradation of pathogenic bacteria and viruses (xenophagy), and to contribute to the activation of innate and adaptative immune responses. Autophagy can serve as an antiviral defense mechanism but also as a proviral process during infection. Atg8-family proteins play a central role in the autophagy process due to their ability to interact with components of the autophagy machinery as well as selective autophagy receptors and adaptor proteins. Such interactions are usually mediated through LC3-interacting region (LIR) motifs. So far, only one viral protein has been experimentally shown to have a functional LIR motif, leaving open a vast field for investigation. Here, we have developed the iLIR@viral database ( http://ilir.uk/virus/ ) as a freely accessible web resource listing all the putative canonical LIR motifs identified in viral proteins. Additionally, we used a curated text-mining analysis of the literature to identify novel putative LIR motif-containing proteins (LIRCPs) in viruses. We anticipate that iLIR@viral will assist with elucidating the full complement of LIRCPs in viruses.

Prediction of crude protein and neutral detergent fibre concentration in residues of in situ ruminal degradation of pasture samples by near-infrared spectroscopy (NIRS)

An important constraint of in situ degradability studies is the need to analyse a high number of samples and often with insufficient amount of residue, especially after the longer incubations of high-quality forages, that impede the study of more than one nutritional component. Near-infrared spectroscopy (NIRS) has been established as a reliable method for predicting composition of many entities, including forages and other animal feedstuffs. The objective of this work was to evaluate the potential of NIRS for predicting the crude protein (CP) and neutral detergent fibre (NDF) concentration in rumen incubation residues of permanent and sown temperate pastures in a vegetative stage. In situ residues (n = 236) from four swards were scanned for their visible-NIR spectra and analysed for CP and NDF. Selected equations developed by partial least-squares multivariate regression presented high coefficients of determination (CP = 0.99, NDF = 0.95) and low standard errors (CP = 4.17 g/kg, NDF = 7.91 g/kg) in cross-validation. These errors compare favourably to the average concentrations of CP and NDF (146.5 and 711.2 g/kg, respectively) and represent a low fraction of their standard deviation (CP = 38.2 g/kg, NDF = 34.4 g/kg). An external validation was not as successful, with R2 of 0.83 and 0.82 and a standard error of prediction of 14.8 and 15.2 g/kg, for CP and NDF, respectively. It is concluded that NIRS has the potential to predict CP and NDF of in situ incubation residues of leafy pastures typical of humid temperate zones, but more robust calibrations should be developed.

Clinical audit of a lymphoedema bandaging system: a foam roll and cohesive short stretch bandages

OBJECTIVE

Late-stage lymphoedema is characterised by chronic swelling, shape distortion, inflammatory processes and tissue fibrosis. Our aim was to perform a clinical audit of a lymphoedema compression bandaging system (Rosidal Soft foam roll layer and figure-of-eight application of Actico cohesive inelastic bandages) specifically designed for patients with late stage lower limb lymphoedema.

METHOD

The audit explored suitability of the bandaging system, benchmarking limb volume changes with research evidence, and reporting patient and practitioner evaluations.

RESULTS

A mean reduction (33%) in excess limb volume was reported for the 11 patients with unilateral lymphoedema who completed a course of bandaging over 12 days. Mean percentage reduction of absolute limb volume after treatment was 8%. Patient and practitioner evaluations indicated the suitability of this bandage system for patients with late stage lymphoedema in terms of comfort and effectiveness.

CONCLUSION

The bandaging system is suitable for patients with late stage chronic swelling. Two parameters for calculating change in limb volume are not interchangeable. Future evaluation of the bandaging system, using validated outcome measures within a comprehensive research study is required.

DECLARATION OF INTEREST

Activa Healthcare provided financial support to the project and supplied the materials.

Failed subacromial decompression. Risk factors

BACKGROUND

Arthroscopic subacromial decompression (acromioplasty) is widely held to be effective, although pain may persist after the procedure. The objective of this study was to evaluate the proportion of patients with residual pain (i.e., the failure rate) after isolated subacromial decompression and to look for predictors of failure.

MATERIAL AND METHOD

We conducted a retrospective multicentre study of 108 patients managed with isolated arthroscopic subacromial decompression between 2007 and 2011, for any reason. We excluded patients in whom surgical procedures on the rotator cuff tendons were performed concomitantly. Data were collected from the medical records, a telephone questionnaire, and radiographs obtained before surgery and at last follow-up. Failure was defined as persistent pain (visual analogue scale score>3) more than 6 months after surgery and at last follow-up.

RESULTS

The failure rate was 29% (31/108). Two factors significantly predicted failure, namely, receiving workers' compensation benefits for the shoulder condition and co-planing. Heterogeneous calcific tendinopathy and deep partial-thickness rotator cuff tears were also associated with poorer outcomes, but the effect was not statistically significant.

DISCUSSION

Co-planing may predict failure of subacromial decompression, although whether this effect is due to an insufficient degree of co-planing or to the technique itself is unclear. Nevertheless, in patients with symptoms from the acromio-clavicular joint, acromio-clavicular resection is probably the best option. Receiving workers' compensation benefits was also associated with treatment failure, as a result of well-known parameters related to the social welfare system.

CONCLUSION

Isolated arthroscopic subacromial decompression is effective in 70% of cases. We recommend the utmost caution if co-planing is considered and/or the patient receives workers' compensation benefits for the shoulder condition, as these two factors are associated with a significant increase in the failure rate.

LEVEL OF EVIDENCE

IV (retrospective study).

Is it time to re-appraise the role of compression in non-healing venous leg ulcers?

OBJECTIVE

To evaluate the role of compression in non-healing venous leg ulcers (VLUs) of > 3 months' duration.

METHOD

Patients' records from three independent data sets of non-healing VLUs of > 3 months'duration were re-analysed.Two data sets were separate audits of clinical practice and the third comprised patients' records from a randomised controlled trial. Some patients in each data set were never treated with compression. The effect of compression on healing at 6 months was tested with logistic regression.

RESULTS

In each data set, patients in the compression and no-compression groups were matched according to ulcer size and duration; there were no differences in comorbidities. Comparing the no-compression with the compression groups, the healing rate at 6 months was 68% vs 48% in study 1, 12% vs 6% in study 2, and 26% vs 11% in study 3. Use of compression was found to be an independent predictor of not healing with an odds ratio of 0.422, 0.456 and 0.408 in studies 1, 2 and 3 respectively.

CONCLUSION

The healing rate of non-healing VLUs of > 3 months' duration in the no-compression groups was double that of VLUs in the compression groups. These findings have the potential for treatment modification if confirmed in a prospective trial.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interest that are directly relevant to the content of this manuscript, which remains their sole responsibility.

Duocentric® reversed shoulder prosthesis and Personal Fit® templates: innovative strategies to optimize prosthesis positioning and prevent scapular notching

We describe our experience with a new system of patient-specific template called Personal Fit(®), which is unique in shoulder surgery and used in combination with Duocentric(®) prosthesis. The reverse prosthesis's concept is the invention of Paul Grammont, developed with Grammont's team of Dijon University as from 1981, which led to the first reversed total shoulder prosthesis called Trumpet in 1985. The Duocentric(®) prosthesis developed in 2001 is the third-generation prosthesis, coming from the Trumpet and the second-generation prosthesis Delta(®) (DePuy). This prosthesis provides a novel solution to the notching problem with an inferior overhang integrated onto the glenoid baseplate. Personal Fit(®) system is based on reconstructing the shoulder joint bones in three dimensions using CT scan data, placing a landmark on the scapula and locating points on the glenoid and humerus. That will be used as a reference for the patient-specific templates. We study the glenoid position planned with Personal Fit(®) software relative to native glenoid position in 30 cases. On average, the difference between the planned retroversion (or anteversion in one case) and native retroversion was 8.6°.

Post-partum depression in the community: a qualitative study from rural South India

BACKGROUND

Post-partum depression, although heterogeneous, is often considered a medical disease when viewed from the biomedical perspective. However, recent reports from the Indian subcontinent have documented psychosocial causal factors.

METHOD

This study employed qualitative methodology in a representative sample of women in rural South India. Women in the post-partum period were assessed using the Tamil versions of the Short Explanatory Model Interview, the Edinburgh Postnatal Depression Scale and a semi-structured interview to diagnose ICD 10 depression. Socio-demographic and clinical details were also recorded.

RESULTS

Some 137 women were recruited and assessed, of these, 26.3% were diagnosed to have post-partum depression. The following factors were associated with post-partum depression after adjusting for age and education: age less than 20 or over 30 years, schooling less than five years, thoughts of aborting current pregnancy, unhappy marriage, physical abuse during current pregnancy and after childbirth, husband's use of alcohol, girl child delivered in the absence of living boys and a preference for a boy, low birth weight, and a family history of depression. Post-partum depression was also associated with an increased number of causal models of illness, a number of non-medical models, treatment models and non-medical treatment models.

CONCLUSION

Many social and cultural factors have a major impact on post-partum depression. Post-partum depression, when viewed from a biomedical framework, fails to acknowledge the role of context in the production of emotional distress in the post-partum period.

Does leg ulcer treatment improve patients' quality of life?

OBJECTIVE

To investigate the impact of 'disease' and treatment on quality of life in patients with venous leg ulceration.

METHOD

Sixty-five patients with venous leg ulcers were recruited and treated. At study entry and exit or following complete wound closure, whichever occurred first, each patient was assessed using the SF-36 quality-of-life questionnaire. Data analysis included an investigation of the study population as whole, differences between patients whose ulcers did and did not heal and between gender and age. Health domain means for all patients were compared with age equivalent norms (AENs) at both entry and exit.

RESULTS

There was a significant improvement in the SF-36 domains of bodily pain, health transition, mental health and social functioning for all 65 patients. Patients whose ulcers healed also showed a statistically significant improvement in the vitality domain. Patients whose ulcers did not heal had statistically significant improved scores for bodily pain and health transition. At entry all SF-36 values, except for general health, were lower than the AENs. On exit, scores for bodily pain, general health and mental health were comparable with the AEN; values for the remaining five domains increased at exit.

CONCLUSION

The results highlight that good wound management and effective compression therapy can improve quality of life in patients with venous leg ulceration, whether or not the patient's leg ulcer healed following treatment.

A non-adhesive foam dressing for exuding venous leg ulcers and pressure ulcers: six case studies

Six patients had their wounds dressed with 3M Foam Dressing, a highly absorbent polyurethane foam covered with a breathable layer, for up to four weeks. The dressing was assessed for its effect on the wound and patient comfort, with promising results.

Validation of the Routine Assessment of Patient Progress (RAPP) in patients with psychosis in South India

The aim of the study was to validate the Routine Assessment of Patient Progress (RAPP), an instrument for assessment by nurses, among patients with psychosis in South India. One hundred consecutive patients with psychosis admitted to the Department of Psychiatry, Christian Medical College, Vellore, India, were assessed on day five and day 19 using the RAPP, the PANSS, and the CGI scales. The correlation of the RAPP with the other scales, its change over time, the inter-rater reliability, and factor structure were assessed. The subscales of RAPP correlated significantly with those of the other scales at intake and at follow-up. The RAPP scores changed significantly after treatment. Its inter-rater reliability as measured by the intra-class correlation coefficient was 0.98. The Cronbach's alpha, used to measure the internal consistency of the scale, was 0.87. The split-half reliability (Spearman-Brown) was 0.89. Principal component analysis with varimax rotation revealed six factors, which explained 67.4% of the variance. Items related to life skills explained a major proportion of the variance. The good psychometric properties, concurrent validity, high inter-rater reliability and sensitivity to change make it a useful instrument for nurses to employ to assess patients with psychoses.

Randomised, comparative study of three primary dressings for the treatment of venous ulcers

In this article, we describe a randomised trial in which two established primary dressings - Comfeel (Coloplast, UK) and Granuflex improved formulation (Convatec, UK) - were compared to Cutinova foam (Beiersdorf Medical, UK) in the management of venous leg ulcers. Patients that met the study trial criteria were randomised to receive one of the three primary dressings. All ulcers were secondarily bandaged with Comprilan (Beiersdorf Medical, UK) short-stretch compression. The three dressings were compared in terms of their ability to promote ulcer healing (closure rate and healing rate) and reduce the prevalence and severity of ulcer-associated pain, over a 12-week period. The ease with which dressings could be used in a busy outpatient clinic setting was also considered. On enrollment, groups were well matched in terms of all of the patient and ulcer parameters studies. Six patients were withdrawn for reasons unrelated to study dressings or trial procedures. Following non-parametric analysis of the study data, the three dressings were found to be equally effective at promoting ulcer healing and alleviating ulcer-associated pain. Study personnel rated Cutinova Foam as easy, if not easier, to use than Comfeel or Granuflex. This study suggests that Cutinova Foam is as safe and effective as both Comfeel and Granuflex, in the treatment of venous leg ulcers.

Using compression bandages in the treatment of venous leg ulceration

Community nurses may be required to bandage venous leg ulcers and there are a number of methods of doing so. This article will review evidence of the benefits of using short-stretch bandages and various techniques that have been developed for applying them, which have resulted in improved levels of healing.

Intracellular bacterial symbiosis in the genus Sitophilus: the 'biological individual' concept revisited

Eukaryotic cells, as genetic entities, most often involve several physically associated genomes that direct the metabolic cell equilibrium. In the coleopteran insects of the genus Sitophilus, in addition to the nucleus and the mitochondrial genomes, two other intracellular bacterial genomes belonging to the alpha and the gamma groups of Proteobacteria are also present. Coexisting with the eukaryotic host cell genomes, they intervene in the physiology and reproduction of the host. They are both transmitted vertically to the progeny and exhibit different levels of symbiont integration in insects. Their coexistence within a eukaryotic cell system illustrates the genetic complexity of animal tissue and questions the concept of the 'biological individual'.

A putative insect intracellular endosymbiont stem clade, within the Enterobacteriaceae, infered from phylogenetic analysis based on a heterogeneous model of DNA evolution

Insect intracellular symbiotic bacteria (intracellular endosymbionts, or endocytobionts) were positioned within the gamma 3-Proteobacteria using a non-homogeneous model of DNA evolution, allowing for rate variability among sites, for GC content heterogeneity among sequences, and applied to a maximum likelihood framework. Most of them were found to be closely related within the Enterobacteriaceae family, located between Proteus and Yersinia. These results suggest that such a bacterial group might possess several traits allowing for insect infection and the stable establishment of symbiotic relationships and that this could represent a stem clade for numerous insect endocytobionts. Based on the estimations of the equilibrium GC content and branch lengths in the phylogenetic tree, we have made comparisons of the relative ages of these different symbioses.

Evaluating a superabsorbent hydropolymer dressing for exuding venous leg ulcers

A new hydropolymer dressing was compared with an alginate dressing in a multicentre, prospective, controlled, randomised, stratified, open label trial of 113 patients with exuding venous leg ulcers. The study aimed to evaluate the performance of the dressings in terms of their ability to handle exudate, patient and user acceptability and cost-effectiveness. Patients were stratified according to volume of wound exudate (moderate/heavy) and randomised to the hydropolymer dressing or the alginate plus a secondary dressing. A statistically significant difference between treatment groups was observed in mean wear time, with a longer wear time observed in the hydropolymer group (3.91 days) compared with the alginate group (3.09 days, p = 0.001). In terms of patient and user acceptability, all 10 overall evaluations made by both patient and investigator were markedly in favour of the hydropolymer dressing (p < 0.001 to p = 0.020). The use of the hydropolymer dressing for patients with moderate to heavily exuding venous leg ulcers has statistically significant advantages over the alginate dressing in terms of wear time and investigator and patient acceptability. It is anticipated that this reduction in dressing frequency will translate into a cost-effective wound treatment.

Striated muscle preferentially expressed genes alpha and beta are two serine/threonine protein kinases derived from the same gene as the aortic preferentially expressed gene-1

Aortic preferentially expressed gene (APEG)-1 is a 1.4-kilobase pair (kb) mRNA expressed in vascular smooth muscle cells and is down-regulated by vascular injury. An APEG-1 5'-end cDNA probe identified three additional isoforms. The 9-kb striated preferentially expressed gene (SPEG)alpha and the 11-kb SPEGbeta were found in skeletal muscle and heart. The 4-kb brain preferentially expressed gene was detected in the brain and aorta. We report here cloning of the 11-kb SPEGbeta cDNA. SPEGbeta encodes a 355-kDa protein that contains two serine/threonine kinase domains and is homologous to proteins of the myosin light chain kinase family. At least one kinase domain is active and capable of autophosphorylation. In the genome, all four isoforms share the middle three of the five exons of APEG-1, and they differ from each other by using different 5'- and 3'-ends and alternative splicing. We show that the expression of SPEGalpha and SPEGbeta is developmentally regulated in the striated muscle during C2C12 myoblast to myotube differentiation in vitro and cardiomyocyte maturation in vivo. This developmental regulation suggests that both SPEGalpha and SPEGbeta can serve as sensitive markers for striated muscle differentiation and that they may be important for adult striated muscle function.

Addition of wsp sequences to the Wolbachia phylogenetic tree and stability of the classification

Wolbachia are symbiotic bacteria altering reproductive characters of numerous arthropods. Their most recent phylogeny and classification are based on sequences of the wsp gene. We sequenced wsp gene from six Wolbachia strains infecting six Trichogramma species that live as egg parasitoids on many insects. This allows us to test the effect of the addition of sequences on the Wolbachia phylogeny and to check the classification of Wolbachia infecting Trichogramma. The six Wolbachia studied are classified in the B supergroup. They confirm the monophyletic structure of the B Wolbachia in Trichogramma but introduce small differences in the Wolbachia classification. Modifications include the definition of a new group, Sem, for Wolbachia of T. semblidis and the merging of the two closely related groups, Sib and Kay. Specific primers were determined and tested for the Sem group.

Four intracellular genomes direct weevil biology: nuclear, mitochondrial, principal endosymbiont, and Wolbachia

Cell physiology in the weevil Sitophilus oryzae is coordinated by three integrated genomes: nuclear, mitochondrial, and the "S. oryzae principal endosymbiont" (SOPE). SOPE, a cytoplasmic bacterium (2 x 10(3) bacteria per specialized bacteriocyte cell and 3 x 10(6) bacteria per weevil) that belongs to the proteobacteria gamma3-subgroup, is present in all weevils studied. We discovered a fourth prokaryotic genome in somatic and germ tissues of 57% of weevil strains of three species, S. oryzae, Sitophilus zeamais, and Sitophilus granarius, distributed worldwide. We assigned this Gram-negative prokaryote to the Wolbachia group (alpha-proteobacteria), on the basis of 16S rDNA sequence and fluorescence in situ DNA-RNA hybridization (FISH). Both bacteria, SOPE and Wolbachia, were selectively eliminated by combined heat and antibiotic treatments. Study of bacteria involvement in this insect's genetics and physiology revealed that SOPE, which induces the specific differentiation of the bacteriocytes, increases mitochondrial oxidative phosphorylation through the supply of pantothenic acid and riboflavin. Elimination of this gamma3-proteobacterium impairs many physiological traits. By contrast, neither the presence nor the absence of Wolbachia significantly affects the weevil's physiology. Wolbachia, disseminated throughout the body cells, is in particularly high density in the germ cells, where it causes nucleocytoplasmic incompatibility. The coexistence of two distinct types of intracellular proteobacteria at different levels of symbiont integration in insects illustrates the genetic complexity of animal tissue. Furthermore, evolutionary timing can be inferred: first nucleocytoplasm, then mitochondria, then SOPE, and finally Wolbachia. Symbiogenesis, the genetic integration of long-term associated members of different species, in the weevil appears to be a mechanism of speciation (with Wolbachia) and provides a means for animals to acquire new genes that permit better adaptation to the environment (with SOPE).

Short-stretch bandaging in the treatment of venous leg ulcers

A review of the benefits of short-stretch bandages and techniques that have been developed for their application.

Physical and genetic map of the genome of Buchnera, the primary endosymbiont of the pea aphid Acyrthosiphon pisum

The genome of Buchnera, an endosymbiotic bacterium of the pea aphid Acyrthosiphon pisum, was characterized by pulse-field gel electrophoresis (PFGE) as a circular DNA molecule of 657 kb. The enzymes I-CeuI, CpoI, ApaI, SmaI, NaeI, SacII, MluI, FspI, and NruI were used to cleave the DNA of Buchnera into fragments of suitable size for PFGE analysis. A physical map of the Buchnera genome, including restriction fragments from seven of these enzymes, was constructed using double cutting, partial digestion, and hybridization with linking fragments, and 29 genes and operons were localized on the map. In addition, the genomic map of Buchnera was compared with those of Escherichia coli and Haemophilus influenzae. The gene order in Buchnera is more similar to that of E. coli than to H. influenzae. The dramatic shrinkage of the Buchnera genome compared with those of other members of the closely related Enterobacteriaceae family is discussed in terms of evolution under the influence of the intracellular symbiotic association.

Wound assessment: measuring the area of a leg ulcer

As part of an holistic and systematic assessment, the area of a leg ulcer can be a useful measurement for evaluating the wound repair process. The treatment of a chronic leg ulcer can, if not monitored, become a sequence of dressings and bandaging. Thus, a timely recognition of improvement or deterioration of the wound condition may be overlooked. Area change often depends upon the original size and pathology of the ulcer as well as the treatment method. Perhaps the most important factor which can be derived from area measurements is the rate of area change. Measurements taken at regular intervals give a good indication of a wound's healing progress. Computer technology can be used to assist in accurate area measurement. This information gives the clinician vital information on the treatment's efficacy and the data can be used for further statistical or case study analysis.

Molecular characterization of the principal symbiotic bacteria of the weevil Sitophilus oryzae: a peculiar G + C content of an endocytobiotic DNA

The principal intracellular symbiotic bacteria of the cereal weevil Sitophilus oryzae were characterized using the sequence of the 16S rDNA gene (rrs gene) and G + C content analysis. Polymerase chain reaction amplification with universal eubacterial primers of the rrs gene showed a single expected sequence of 1,501 bp. Comparison of this sequence with the available database sequences placed the intracellular bacteria of S. oryzae as members of the Enterobacteriaceae family, closely related to the free-living bacteria, Erwinia herbicola and Escherichia coli, and the endocytobiotic bacteria of the tsetse fly and aphids. Moreover, by high-performance liquid chromatography, we measured the genomic G + C content of the S. oryzae principal endocytobiotes (SOPE) as 54%, while the known genomic G + C content of most intracellular bacteria is about 39.5%. Furthermore, based on the third codon position G + C content and the rrs gene G + C content, we demonstrated that most intracellular bacteria except SOPE are A + T biased irrespective of their phylogenetic position. Finally, using the hsp60 gene sequence, the codon usage of SOPE was compared with that of two phylogenetically closely related bacteria: E. coli, a free-living bacterium, and Buchnera aphidicola, the intracellular symbiotic bacteria of aphids. Taken together, these results show a peculiar and distinctly different DNA composition of SOPE with respect to the other obligate intracellular bacteria, and, combined with biological and biochemical data, they elucidate the evolution of symbiosis in S. oryzae.

A molecular aspect of symbiotic interactions between the weevil Sitophilus oryzae and its endosymbiotic bacteria: over-expression of a chaperonin

Specific proteins of symbiosis were analyzed by the comparison of two-dimensional electrophoresis protein patterns of symbiotic and aposymbiotic strains of the weevil Sitophilus oryzae. One protein was shown to be exclusively expressed in the aposymbiotic strain and three proteins, including a chaperonin, were characterized in the symbiotic strain pattern. The groE-like operon, encoding the two chaperonins groES and GroEL-like proteins of the endocytobiotes, was sequenced. It was found to be very similar to the groE operon of Escherichia coli (82% identity). In vitro and ex vivo experiments of protein labelling demonstrated that almost 40% of the endocytobiote protein synthesis ex vivo is focused on the GroEL-like protein. Finally, we showed by northern blotting that heat shock at 38 degrees C results in groEL mRNA accumulation inside the endocytobiotes. This work supports the hypothesis that chaperonins could have an essential physiological function in the maintenance of the symbiotic association.

Developing a leg ulcer management programme

Compression therapy is an essential component in the treatment of venous leg ulcers. Comprehensive education and training and support of district nurses in leg ulcer management is essential.