Are postoperative antibiotics required after orthognathic surgery?

The aim of this study was to investigate and compare the frequency of surgical site infection (SSI) between orthognathic patients who received only intraoperative antibiotics and patients who received intraoperative antibiotics plus postoperative antibiotics. A retrospective study was performed of patients treated by a single surgeon over the years 2006-2012 and 2016-2019. The primary predictor variable was antibiotic exposure. The control group received no postoperative prophylactic antibiotics. The study group received postoperative antibiotics. Both groups received prophylactic intraoperative antibiotics and performed postoperative chlorhexidine rinses. The primary outcome was SSI frequency. Univariate, bivariate, and multiple logistic regression analyses were performed; statistical significance was set at P ≤ 0.05. The sample comprised 333 patients. Their mean age was 30.7 ± 11.8 years. The study group included 129 patients (38.7%); the control group included 204 patients (61.3%). The frequency of SSI was 17.1% in the study group and 26.5% in the control group (P = 0.048). In the multivariable logistic regression, only alcohol consumption was significantly associated with an increased risk of SSI (odds ratio 2.46, 95% confidence interval 1.36-4.44; P = 0.003). In patients undergoing orthognathic surgery, postoperative antibiotic exposure in addition to intraoperative prophylaxis approached but was not statistically significant for a decreased risk of SSI (P = 0.067).

309 A FRAILTY CENSUS OF INPATIENTS AGED 65 AND OVER ADMITTED TO A MODEL 4 HOSPITAL

Background

Frailty is a risk factor for in-hospital mortality, long hospital stay and functional decline at discharge. Profiling the prevalence and level of frailty within the acute hospital setting is vital to ensure evidence-based practice and service development within the construct of frailty.

Methods

All patients aged ≥65 years and admitted to a medical or surgical inpatient setting, were screened over a 12-hour period (08:00-20:00) using validated frailty and co-morbidity scales. Age and Gender Demographics, Clinical Frailty Scale (CFS), Charlson Co-morbidity Index (CHI) and admitting specialty (Medical/Surgical) were collected. The data was fully anonymised and ethical approval was granted. Descriptive statistics were used to profile the cohort and Chi-squared tests applied for comparisons.

Results

Within a sample of 413 patients, 291(70%) were ≥65yrs. Of this cohort, 202(70%) were ≥75yrs. 207(71%) utilised in-patient medical services and 121(41%) surgical services while 37(12%) used both. The mean CFS was 6 indicating moderate frailty levels and the mean CCI score was 4 denoting moderate co-morbidity. Overall: 195(67%) had moderate-severe frailty (CSF ≥6) while 218 (75%) had moderate-severe co-morbidity (CCI Mod 3-4, Severe ≥5). Associations with age >75 and frailty (p=0.001) and medical service usage and frailty (p=0.004) were established. No significant differences were observed across genders for CFS (p=0.110) and CCI (p=0.465).

Conclusion

There is a high prevalence of frailty and co-morbidity within the admitted patient cohort ≥65yrs. Overcrowding across the hospital system and higher levels of frailty and comorbidity will contribute to increased lengths of stay and the need for specialist intervention, particularly for those ≥75yrs who represented 70% of patients screened. With an increased focus on the integration of care for older adults across care transitions, there is a clear need for expansion of frailty-based services and staff training in frailty care across the hospital and community setting.

Early outcome of cardiac surgery in dialysis-dependent end-stage renal failure patients

INTRODUCTION

Preoperative dialysis-dependent renal failure is a strong independent risk factor for in-hospital mortality and morbidity after open heart surgery. This retrospective study analyses the early outcome in dialysis-dependent renal failure patients who underwent elective open-heart surgery in the Institut Jantung Negara (IJN).

METHODS

We retrospectively analyse a series of 228 consecutive postoperative patients with dialysis-dependent (end stage renal failure (ESRF)) admitted to the adult cardiothoracic ICU in IJN between January 2012 and December 2016.

RESULTS

The overall early mortality rate included 34 patients (15.8%). Patients with ESRF underwent combined procedure recorded a very high mortality rate at 56.3%. Twenty-four patients (11.2%) needed resternotomy for postoperative bleeding or cardiac temponade. Postoperative mediastinitis rate was high, involving 13 patients (6%). The neurological and gastrointestinal complications rate were recorded at 2.3% (5 patients) and 6% (13 patients) respectively. In the group of patients (n=199) with sinus rhythm during the preoperative period, 100 patients (50.3%) developed postoperative AF. 77 patients (35.8%) stayed in hospital for more than 14 days.

CONCLUSIONS

dialysis-dependent patients undergoing cardiac surgery poses higher perioperative risk of mortality and morbidity of 3-4 times higher compared to those patients with normal renal function. IJN shows acceptable perioperative risk of mortality and morbidity which is comparable to other centres.

Method Extension Study to Validate Applicability of AOAC Official Method 996.14 Assurance® Polyclonal Enzyme Immunoassay for Detection of Listeria monocytogenes and Related Listeria spp. from Environmental Surfaces: Collaborative Study

Test portions from 3 environmental surface types, representative of typical surfaces found in a food production facility, were analyzed by the Assurance®Listeria Polyclonal Enzyme Immunoassay (EIA) and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) culture method for Listeria monocytogenes and related Listeria species. In all cases, naturally contaminated environmental test samples were collected from an actual food production facility by sponge or swab. Test samples from concrete surfaces were collected by both swab and sponge; sponge test samples were collected from rubber surfaces, and swabs were used to sample steel surfaces. Test portions from each surface type were simultaneously analyzed by both methods. A total of 23 collaborators, representing government agencies, as well as private industry in both the United States and Canada, participated in the study. During this study, a total of 550 test portions and controls was analyzed and confirmed, of which 207 were positive and 336 were negative by both methods. Six test portions were positive by culture, but negative by the EIA. Three test portions were negative by culture, but positive by the EIA. Two test portions were negative by EIA and by culture, but confirmed positive when EIA enrichment broths were subcultured to selective agars. The data reported here indicate that the Assurance®Listeria EIA method and the USDA/FSIS culture method are statistically equivalent for detection of L. monocytogenes and related Listeria species from environmental surfaces taken by sponges or swabs.

Visual Immunoprecipitate Assay Eight Hour Method for Detection of Enterohemorrhagic Escherichia coli O157:H7 in Raw and Cooked Beef (Modification of AOAC Official Method 996.09): Collaborative Study

AOAC Official Method 996.09, Visual Immunoprecipitate Assay (VIP®) for Escherichia coli O157:H7, was modified to incorporate a new enrichment protocol using BioControl EHEC8™ medium for testing raw and cooked beef. Foods were tested by VIP assay and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) enrichment procedure and the FDA Bacteriological Analytical Manual (BAM) isolation and confirmation techniques. A total of 15 collaborators participated. Raw and cooked ground beef were inoculated with E. coli O157:H7 at 2 different levels: a high level, where predominantly positive results were expect d, and a low level where fractional recovery was anticipated. Collaborators tested 396 test portions and controls by both methods, for a total of 792 test portions. Of the 396 paired test portions, 75 were positive and 230 were negative by both the VIP and culture methods. Eleven test portions were presumptively positive by VIP and could not be confirmed culturally; 32 were negative by VIP, but confirmed positive by culture; and 65 were negative by the culture method, but confirmed positive by the VIP method. There was no statistical difference between results obtained with the VIP for EHEC 8 h method and the culture method except for cooked beef, where the VIP had significantly higher recovery for one inoculation level.

Assurance® Enzyme Immunoassay Eight Hour Method for Detection of Enterohemorrhagic Escherichia coli O157:H7 in Raw and Cooked Beef (Modification of AOAC Official Method 996.10): Collaborative Study

AOAC Official Method 996.10, Assurance® Enzyme Immunoassay (EIA) for Escherichia coli O157:H7 (EHEC), was modified to incorporate a new enrichment protocol using BioControl EHEC8™ medium for testing raw and cooked beef. Foods were tested by EIA and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) enrichment conditions and the FDA Bacteriological Analytical Manual (BAM) isolation and confirmation techniques. A total of 14 collaborators participated. Raw and cooked ground beef were inoculated with E. coli O157:H7 at 2 different levels: a high level where predominantly positive results were expected, and a low level where fractional recovery was anticipated. Collaborators tested 378 test portions and controls by both the 8 h EIA and the USDA/FSIS enrichment methods, for a total of 756 test portions. Of the 378 paired test portions, 75 were positive and 212 were negative by both methods. Thirteen test portions were presumptively positive by EIA and could not be confirmed culturally; 30 were negative by EIA, but confirmed positive by culture; and 65 were negative by the culture method, but confirmed positive by the EIA method. There was no statistical difference between results obtained with the Assurance EIA for EHEC 8 h method and the culture method for raw ground beef. The Assurance EIA had a significantly higher recovery for cooked beef.

Method Extension Study to Validate Applicability of AOAC Official Method 997.03 Visual Immunoprecipitate Assay (VIP®) for Listeria monocytogenes and Related Listeria spp. from Environmental Surfaces: Collaborative Study

Test portions from 3 environmental surface types, representative of typical surfaces found in a food production facility, were analyzed by the Visual Immunoprecipitate assay (VIP®) and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) culture method for Listeria monocytogenes and related Listeria species. In all cases, naturally contaminated environmental test samples were collected from an actual food production facility by sponge or swab. Test samples from concrete surfaces were collected by both swab and sponge; sponge test samples were collected from rubber surfaces, and swabs were used to sample steel surfaces. Test portions from each surface type were simultaneously analyzed by both methods. A total of 27 laboratories, representing government agencies as well as private industry in both the United States and Canada, participated in the study. During this study, a total of 615 test portions and controls was analyzed and confirmed, of which 227 were positive and 378 were negative by both methods. Nine test portions were positive by culture, but negative by the VIP. Five test portions were negative by culture, but positive by the VIP. Four test portions were negative by VIP and by culture, but confirmed positive when VIP enrichment broths were subcultured to selective agars. The data reported here indicate that the VIP method and the USDA/FSIS culture method are statistically equivalent for detection of L. monocytogenes and related Listeria species from environmental surfaces taken by sponges or swabs.

Modification of Enrichment Protocols for TECRA Listeria Visual Immunoassay Method 995.22: Collaborative Study

A collaborative study was conducted to validate new enrichment methods for the TECRA Listeria Visual Immunoassay (TLVIA). These new methods incorporate a newly formulated medium, TECRA Listeria Enrichment Broth, which does not contain the highly toxic antifungal agent, cycloheximide. The new procedures will provide an alternative to the enrichment procedures described in AOAC Method 995.22. Three food types (raw ground beef, lettuce, and ice cream) were analyzed in the United States, and 2 food types (cooked turkey and cooked fish fillets) were analyzed in Australasia. Thirty collaborators participated in the study, 16 in Australasia and 14 in the United States. With the exception of one batch of ground beef, comparison of the proportion of positive test portions (p ≥ 0.05) showed no significant difference between the TLVIA and the reference method for the 5 foods at 3 inoculation levels. For the one batch of naturally contaminated raw ground beef, the TLVIA gave significantly more confirmed positive results than the reference method.

Comparison of hyperspectral classification methods for the analysis of cerium oxide nanoparticles in histological and aqueous samples

Hyperspectral imaging (HSI) and classification are established methods that are being applied in new ways to the analysis of nanoscale materials in a variety of matrices. Typically, enhanced darkfield microscopy (EDFM)-based HSI data (also known as image datacubes) are collected in the wavelength range of 400-1000 nm for each pixel in a datacube. Utilising different spectral library (SL) creation methods, spectra from pixels in the datacube corresponding to known materials can be collected into reference spectral libraries (RSLs), which can be used to classify materials in datacubes of experimental samples using existing classification algorithms. In this study, EDFM-HSI was used to visualise and analyse industrial cerium oxide (CeO₂ ; ceria) nanoparticles (NPs) in rat lung tissues and in aqueous suspension. Rats were exposed to ceria NPs via inhalation, mimicking potential real-world occupational exposures. The lung tissues were histologically prepared: some tissues were stained with hematoxylin and eosin (H&E) and some were left unstained. The goal of this study was to determine how HSI and classification results for ceria NPs were influenced by (1) the use of different RSL creation and classification methods and (2) the application of those methods to samples in different matrices (stained tissue, unstained tissue, or aqueous solution). Three different RSL creation methods - particle filtering (PF), manual selection, and spectral hourglass wizard (SHW) - were utilised to create the RSLs of known materials in unstained and stained tissue, and aqueous suspensions, which were then used to classify the NPs in the different matrices. Two classification algorithms - spectral angle mapper (SAM) and spectral feature fitting (SFF) - were utilised to determine the presence or absence of ceria NPs in each sample. The results from the classification algorithms were compared to determine how each influenced the classification results for samples in different matrices. The results showed that sample matrix and sample preparation significantly influenced the NP classification thresholds in the complex matrices. Moreover, considerable differences were observed in the classification results when utilising each RSL creation and classification method for each type of sample. Results from this study illustrate the importance of appropriately selecting HSI algorithms based on specific material and matrix characteristics in order to obtain optimal classification results. As HSI is increasingly utilised for NP characterisation for clinical, environmental and health and safety applications, this investigation is important for further refining HSI protocols while ensuring appropriate data collection and analysis.

Bespoke video vignettes - an approach to enhancing reflective learning developed by dental undergraduates and their clinical teachers

This study explores the selective use of video as a medium to support reflective processes as related to dental undergraduate learning. With the objective of developing and enhancing high-quality adult dental care, the use of compiled video materials created in an undergraduate clinical setting was investigated. Video cameras were used to capture elements of reflection-in-action and reflection-on-action typically found during everyday clinical practice. 'Gold standard' or 'textbook outcomes' are rarely, if ever, fully achieved in dental practice. Real-life clinical experiences offer challenges and opportunities for both teachers and students to engage with reflective learning processes. The materials generated allowed for an experience of individual reflective learning and the creation of a data bank or archive with potential use for the benefit of a wider student cohort. Various aspects of the students' views and comments on the process of reflection were reported and explored by means of a semi-structured focus group moderated by a linked educational advisor.

Cradle-to-farm gate environmental footprints of beef cattle production in Kansas, Oklahoma, and Texas

A comprehensive national assessment of the sustainability of beef is being conducted by the U.S. beef industry. The first of 7 regions to be analyzed is Kansas, Oklahoma, and Texas. A survey and visits conducted throughout the region provided data on common production practices. From these data, representative ranch and feedyard operations were defined and simulated for the varying climate and soil conditions throughout the region using the Integrated Farm System Model. These simulations predicted environmental impacts of each operation including cradle-to-farm gate footprints for greenhouse gas emissions, fossil-based energy use, nonprecipitation water use, and reactive N loss. Individual ranch and feedyard operations were linked to form 28 representative production systems. A weighted average of the production systems was used to determine the environmental footprints for the region where weighting factors were developed based on animal numbers reported in the survey and agricultural statistics data. Along with the traditional beef production systems, Holstein steer and cull cow production from the dairy industry in the region were also modeled and included. The carbon footprint of all beef produced was 18.3 ± 1.7 kg CO2 equivalents (CO2e)/kg carcass weight (CW) with the range in individual production systems being 13 to 25 kg CO2e/kg CW. Energy use, water use, and reactive N loss were 51 ± 4.8 MJ/kg CW, 2,470 ± 455 L/kg CW, and 138 ± 12 g N/kg CW, respectively. The major portion of each footprint except water use was associated with the cow-calf phase; most of the nonprecipitation water use was attributed to producing feed for the finishing phase. These data provide a baseline for comparison as new technologies and strategies are developed and implemented to improve the sustainability of cattle production. Production information also will be combined with processing, marketing, and consumer data to complete a comprehensive life cycle assessment of beef.

Impact of nursing home residence on hospital epidemiology of meticillin-resistant Staphylococcus aureus: a perspective from Asia

In a Singapore hospital practising meticillin-resistant Staphylococcus aureus (MRSA) admission screening, the relative risk for MRSA colonization for those admitted from nursing homes was 6.89 (95% confidence interval: 5.74-8.26; 41% of 190 vs 6.0% of 14,849). However, the MRSA burden on admission attributable to nursing home residence was low (6.9%). Risk factors independently associated with MRSA colonization in patients admitted from nursing homes were previous hospital admissions, broken skin, prior use of antibiotics and Chinese ethnicity. Low rates of nursing home use means that the overall impact of nursing home residence on MRSA in our hospital is low.

An ongoing large outbreak of measles in Merseyside, England, January to June 2012

From 1 January to 30 June 2012, 359 confirmed and 157 probable cases of measles were reported in Merseyside, England. The most affected age groups were children under five years and young adults from 15 years of age. Most cases have been sporadic. There have been few outbreaks in nurseries; however, no outbreaks have been reported in schools. Of the cases eligible for vaccination, only 3% of the confirmed cases were fully immunised.

An ongoing large outbreak of measles in Merseyside, England, January to June 2012

From 1 January to 30 June 2012, 359 confirmed and 157 probable cases of measles were reported in Merseyside, England. The most affected age groups were children under five years and young adults from 15 years of age. Most cases have been sporadic. There have been few outbreaks in nurseries; however, no outbreaks have been reported in schools. Of the cases eligible for vaccination, only 3% of the confirmed cases were fully immunised.

Compositional studies of human RPE lipofuscin: mechanisms of molecular modifications

The accumulation of lipofuscin has previously been implicated in several retinal diseases including Best's macular dystrophy, Stargardt's disease and age-related macular degeneration (AMD). Previously one of the major fluorophores of lipofuscin was identified as a bis-retinoid pyridinium salt called A2E, which is known to photochemically cause damage. In addition to A2E, there are numerous components in RPE lipofuscin that are unidentified. These compounds were determined to be structurally related to A2E by their fragmentation pattern with losses of 106, 190, 174 and/or 150 amu from the parent ion and the formation of fragments of ca 592 amu. The vast majority consists of relatively hydrophobic components corresponding to derivatized A2E with molecular weights in discrete groups of 800-900, 970-1080 and > 1200 m/z regions. In order to determine the mechanism of these modifications, A2E was chemically modified by; (1) the formation of specific esters, (2) reaction with specific aldehydes and (3) spontaneous auto-oxidation. The contribution of ester formation to the naturally occurring components of lipofuscin was discounted since their fragmentation patterns were different to those found in vivo. Alternatively, reactions with specific aldehydes result in nearly identical products as those found in vivo. Artificial aging of RPE lipofuscin gives a complex mixture of structurally related components. This results from the auto- and/or photooxidation of A2E to form aldehydes, which then back react with A2E giving a series of higher molecular weight products. The majority of these modifications result in compounds that are much more hydrophobic than A2E. These higher molecular weight materials have increased values of log P compared to A2E. This increase in hydrophobicity most likely aids in the sequestering of A2E into granules with the concomitant diminution of its reactivity. Therefore, these processes may serve as protective mechanisms for the RPE.

Compositional studies of human RPE lipofuscin

Age-related macular degeneration (AMD) is an ocular disease that causes visual loss and legal blindness in the elderly population. The etiology of AMD is complex and may include genetic predispositions, accumulation of lipofuscin and drusen, local inflammation and neovascularization. The accumulation of lipofuscin has been shown to precede the death of photoreceptor cells and the deterioration of the RPE. As a result, the determination of the photosensitive components of lipofuscin has been of major interest. One of these components, previously identified as a bis-retinoid pyridinium compound, is referred to as A2E. A2E has been characterized by mass spectrometry and is known to have a mass of 592 Da. Most remaining chromophores in RPE lipofuscin are structurally related to A2E as determined by their fragmentation pattern with losses of M ± 190, 174 and/or 150 Da. Analysis of lipofuscin from various donors indicated that the extracts consist of as many as 15 of these hydrophobic components, which are also observed to form spontaneously in vitro over extended periods of time. These consist of ca 90% of the A2E-like components in RPE lipofuscin and correspond to derivatized A2E with discrete molecular weights of 800-900 m/z, 970-1080 m/z and above 1200 m/z regions. It was determined that these species are formed from self-reaction of A2E oxidation products or their reaction with A2E itself to form higher molecular weight products. The majority of modifications are much more hydrophobic than A2E and exhibit increasingly higher values of log P. This acts as a driving force for the sequestering of A2E into granules resulting in a concomitant diminution of its reactivity in vivo.

Compositional studies of human RPE lipofuscin

Age-related macular degeneration (AMD) is an ocular disease that causes visual loss and legal blindness in the elderly population. The etiology of AMD is complex and may include genetic predispositions, accumulation of lipofuscin and drusen, local inflammation and neovascularization. The accumulation of lipofuscin has been shown to precede the death of photoreceptor cells and the deterioration of the RPE. As a result, the determination of the photosensitive components of lipofuscin has been of major interest. One of these components, previously identified as a bis-retinoid pyridinium compound, is referred to as A2E. A2E has been characterized by mass spectrometry and is known to have a mass of 592 Da. Most remaining chromophores in RPE lipofuscin are structurally related to A2E as determined by their fragmentation pattern with losses of M ± 190, 174 and/or 150 Da. Analysis of lipofuscin from various donors indicated that the extracts consist of as many as 15 of these hydrophobic components, which are also observed to form spontaneously in vitro over extended periods of time. These consist of ca 90% of the A2E-like components in RPE lipofuscin and correspond to derivatized A2E with discrete molecular weights of 800-900 m/z, 970-1080 m/z and above 1200 m/z regions. It was determined that these species are formed from self-reaction of A2E oxidation products or their reaction with A2E itself to form higher molecular weight products. The majority of modifications are much more hydrophobic than A2E and exhibit increasingly higher values of log P. This acts as a driving force for the sequestering of A2E into granules resulting in a concomitant diminution of its reactivity in vivo.

Age-related accumulation of 3-nitrotyrosine and nitro-A2E in human Bruch's membrane

Age-related macular degeneration (AMD) is a disease leading to severe visual loss and legal blindness in the elderly population. The pathophysiology of AMD is complex and may include genetic predispositions, accumulation of lipofuscin and drusen, local inflammation and neovascularization. Recently four independent research groups have identified a commonly inherited variant (Y402H) of the complement factor H gene in the genome from different groups of AMD patients. The Y402H variant of CFH significantly increases the risk of AMD and links the genetics of the disease with inflammation. During inflammation there is activation of inducible nitric oxide synthase and release of nitric oxide, which in principal could lead to non-enzymatic nitration within extracellular deposits and/or intrinsic extracellular matrix protein components of human Bruch's membrane. We have identified two biomarkers for non-enzymatic nitration in aged human Bruch's membrane, indicative of inflammation, that include 3-nitrotyrosine identified in Bruch's membrane preparations and nitrated A2E from the lipid soluble extract of the Bruch's membrane preparation. Approximately 30-40 times more A2E is observed in samples of the organic soluble extract of lipofuscin compared to the extract of Bruch's membrane. It is of interest to note that although A2E is a major constituent of RPE lipofuscin, nitrated A2E could not be detected in RPE extracts. We show here that nitro-A2E is a specific biomarker of nitrosative stress in Bruch's membrane and its concentration correlates directly with tissue age.

Whipple's procedure for an oligometastasis to the pancreas from a leiomyosarcoma of the thigh

BACKGROUND

Pancreatic tumours are most frequently primary, with lesions secondary to metastasis uncommon.

METHODS

This report describes the case of a 61-year-old man who underwent resection of a right thigh leiomyosarcoma 2 years prior to presentation with obstructive jaundice. Subsequent CT and endoscopic ultrasound (EUS) diagnosed metastatic leiomyosarcoma to the pancreatic head for which he underwent a Whipple's pancreaticoduodenectomy.

CONCLUSION

Metastasis from an extremity leiomyosarcoma to the pancreas is an extremely rare entity, which can be diagnosed by EUS and treated successfully by pancreaticoduodenectomy.

A study of the safety of current gastrointestinal endoscopy (EGD)

BACKGROUND AND STUDY AIMS

Previous attempts at assessing the safety of upper gastrointestinal endoscopy have been hampered by incomplete data collection. We aimed to assess the 30-day mortality associated with esophagogastroduodenoscopy (EGD) and assess the important risk factors.

PATIENTS AND METHODS

A retrospective cohort study was conducted of patients who underwent endoscopy at Ninewells Hospital in Dundee between 1 June 2000 and 31 May 2003. A total of 11 501 EGDs were performed in 8926 patients. These patients were record-linked to the death registry and the database of hospital admissions in order to calculate the all-cause 30-day mortality. An expert panel judged whether EGD had caused or contributed to the deaths. Logistic regression analysis was performed on outcomes of all-cause and EGD-contributed mortality.

RESULTS

The median age of the patients was 62 years (interquartile range 48 - 74 years), 54 % were women, and 94 % of procedures were diagnostic. A total of 395 patients died within 30 days (all-cause 30-day mortality rate 4.4 %). One patient death was caused directly by the EGD (procedure-caused mortality rate 1 in 9000). EGD was judged to have contributed to patient deaths at a rate of 1 in 182, based on majority agreement of experts: some factors associated with these deaths were percutaneous endoscopic gastrostomy insertion (odds ratio [OR] 18.39, 95 % confidence interval [CI] 5.71 - 59.22), melena or hematemesis indications (OR 9.01, 95 % CI 3.53 - 22.99), and esophageal varices (OR 6.28, 95 % CI 1.54 - 25.60).

CONCLUSIONS

A causal death rate of 1 in 9000 suggests that EGD is very safe. However, certain patient groups have an increased mortality, and the risks and benefits of EGD should be carefully evaluated in each patient.

Molecular characterization of the metabotropic glutamate receptor family in Caenorhabditis elegans

mGluRs (metabotropic glutamate receptors) are G-protein-coupled receptors that play an important neuromodulatory role in the brain. Glutamatergic transmission itself plays a fundamental role in the simple nervous system of the model organism Caenorhabditis elegans, but little is known about the contribution made by mGluR signalling. The sequenced genome of C. elegans predicts three distinct genes, mgl-1, mgl-2 and mgl-3 (designated Y4C6A.2). We have used in silico and cDNA analyses to investigate the genes encoding mgls. Our results indicate that mgl genes constitute a gene family made up of three distinct subclasses of receptor. Our transcript analysis highlights potential for complex gene regulation with respect to both expression and splicing. Further, we identify that the predicted proteins encoded by mgls harbour structural motifs that are likely to regulate function. Taken together, this molecular characterization provides a platform to further investigate mGluR function in the model organism C. elegans.

Antioxidant Properties of Melanin in Retinal Pigment Epithelial Cells

The retinal pigment epithelium (RPE) is a monolayer of highly pigmented cells lining the inner aspect of Bruch's membrane. This pigmentation is due to eumelanin and a possible antioxidant role of melanin is reported here. The photo-oxidation of A2E, a constituent of RPE lipofuscin, leads to the sequential addition of up to nine oxygen atoms and/or the addition or loss of two hydrogen atoms. These photo-oxidations were investigated in the presence and absence of either calf or human RPE melanin in A2E-laden RPE cells. It was found that calf melanin was protective against the photo-oxidation of A2E, with an inhibition of oxidation of up to 50% in the case of the addition of two oxygen atoms. Calf melanin was also protective against blue light-induced damage to RPE cells. In addition this ability appears to decrease in humans as they grow older. With aging, a melanin-lipofuscin complex called melanolipofuscin forms. It is suggested that the oxidation or photo-oxidation of A2E in vivo may contribute to the age-related deterioration of the anti-oxidant role of RPE melanin and lead to various retinal disorders, such as age-related macular degeneration.

Determining calmodulin binding to metabotropic glutamate receptors with distinct protein-interaction methods

mGluRs (metabotropic glutamate receptors) are G-protein-coupled receptors that modulate synaptic transmission. The eight mammalian mGluRs form three groups based on sequence and functional similarities: group I (1 and 5), group II (2 and 3) and group III (4, 6-8) mGluRs. In the present study, we used a Y2H (yeast two hybrid) screen to identify proteins that interact with the C-terminal intracellular tail of mGluR3. Prominent among the candidate receptor interacting proteins was calmodulin, a Ca(2+) sensor known to bind identifiable sequences in group I and III mGluRs. The Y2H method was used to investigate calmodulin binding to mGluRs but failed to confirm the documented interaction with group III mGluRs. Furthermore, subsequent biochemical analysis showed that calmodulin does not interact with group II mGluRs. This illustrates that certain Ca(2+)-dependent interactions are not recapitulated in yeast. Moreover, it highlights the necessity for supporting biochemical data to substantiate interactions identified with Y2H methods.

A New Approach to Measuring the Action Spectrum for Singlet Oxygen Production by Human Retinal Lipofuscin

The human retinal pigment epithelial (RPE) layer contains a complex mixture of components called lipofuscin; this mixture forms with age and with various genetic disorders such as Stargardt's disease. Its presence may contribute to retinal deterioration via several mechanisms including photochemical processes. In the lipofuscin mixture, both type I and II mechanisms have been identified, with the latter consisting of the generation of singlet oxygen. Several components of that mixture have been identified, most notably a bis-retinoid pyridinium compound called A2E and its derivatives. Photooxidative studies on the compound A2E have revealed that its dominant photochemical mechanism is via free radical or type I processes. Because singlet oxygen is an important photooxidative intermediate in tissue, its generation in the RPE may contribute to retinal maculopathies. It is therefore necessary to determine which specific component(s) in the lipofuscin mixture produce singlet oxygen upon excitation with light. This was ascertained by evaluating the action spectrum for singlet oxygen production for the whole lipofuscin mixture using time-resolved spectroscopy. Singlet oxygen was generated by excitation of the sample at different wavelengths while maintaining a constant beam energy, and was directly detected by its phosphorescence decay at 1270 nm using a Ge photodiode. The action spectrum for singlet oxygen sensitization by the organic soluble portion of lipofuscin had an absorption maximum at ca 380 nm, which is to the blue of A2E (maximum at 430 nm). Compounds with a similar absorption maximum eluted in the HPLC earlier than A2E and were detected in human lipofuscin. The concentration of this component apparently increased in concentration in human RPE lipofuscin mixture as a function of age up to 90 years old.

The photochemical oxidation of A2E results in the formation of a 5,8,5′,8′-bis-furanoid oxide

With age and certain diseases, the retinal pigment epithelium (RPE) accumulates a complex mixture of fluorophores generally called lipofuscin. This mixture has been implicated in those diseases via several possible mechanisms including photochemically mediated damage and detergent effects. Recently, a component of that mixture has been identified, a bis-retinoid pyridinium compound called A2E. Furthermore, the photolysis of this compound has been shown to lead to a series of photooxidation products each differing by 16 amu; with the addition of up to a total of nine oxygen atoms to A2E. It has been suggested that these products consist of a series of epoxides forming along the acyclic side chains. The present study reinvestigates this hypothesis and demonstrates that the bis-oxygenated product is in fact a relatively stable 5-8 5'-8'-bis-furanoid oxide. This is in agreement with the oxidation products observed for a homologue of A2E, beta-carotene. In addition, it was found that the bis-oxygenated photoproduct of A2E contained a mixture of symmetrical and unsymmetrical oxidized products where the second oxygen was present in the cyclohexenyl ring structure in the unsymmetrical product. Most importantly, both of these oxidation products of A2E were detected in lipofuscin extracts from human RPE cells, suggesting that these processes occur in vivo.

Fluoxetine improves functional work capacity in women with premenstrual dysphoric disorder

Interference with social and occupational functioning is a key criterion for premenstrual dysphoric disorder (PMDD) and distinguishes it from the less severe premenstrual syndrome (PMS). We conducted a post hoc analysis of the results of a previously reported study evaluating the efficacy of fluoxetine in the management of PMDD, to determine the extent to which women with PMDD perceived impairment in their functional work capacity during the luteal phase of their menstrual cycle. The effects of two doses of fluoxetine vs placebo in alleviating PMDD symptoms and restoring normal work capacity during this period were assessed. We measured baseline follicular vs luteal phase presence of 8 patient-rated functional work capacity-related symptoms on the Premenstrual Tension Scale-Self Rated in 320 women who met diagnostic criteria for late luteal phase dysphoric disorder, now known as PMDD. Women were then randomized to double-blind treatment with either fluoxetine 20 mg/d, fluoxetine 60 mg/d, or placebo daily for 6 menstrual cycles. All 8 work capacity-related symptoms were more likely to be present in the baseline luteal phase than in the baseline follicular phase. A statistically significant improvement from baseline to the average treatment score for the work capacity subscale was detected for both fluoxetine groups compared to the placebo group. This beneficial response to fluoxetine was evident by the first cycle of treatment. Our results demonstrate that fluoxetine at a relatively low dose of 20 mg/d quickly reduced symptoms that negatively affect work capacity and was well tolerated.

Comparison of agar-based media for primary isolation of glycopeptide-resistant enterococci

OBJECTIVE: To compare four vancomycin-containing agar media for the isolation of glycopeptide-resistant enterococci (GRE) from clinical fecal specimens: kanamycin---aesculin---azide (KAA) agar; bile---aesculin---polymixin (BAP) agar; aztreonam---amphotericin blood (CBAA) agar; and neomycin blood (CBN) agar. METHODS: Fecal specimens from 125 patients were inoculated onto each medium. Media were examined for enterococci after incubation for up to 48 h. Enterococci were identified to species level, and glycopeptide phenotypes were determined by measuring minimum inhibitory concentrations of vancomycin and teicoplanin. RESULTS: GRE were isolated from 44/125 samples. Enterococcus faecalis and Enterococcus faecium isolates, expressing glycopeptide resistance of the VanA or VanB phenotypes, were recovered from 27/33 (82%) specimens on BAP medium, 26/33 (79%) on KAA medium, and 21/33 (64%) on CBN and CBAA media. Enterococcus gallinarum and Enterococcus casseliflavus isolates expressing low-level glycopeptide resistance (VanC phenotype) were recovered from 14/15 (93%) specimens on CBAA medium, 7/15 (47%) on KAA and CBN media, and 6/15 (40%) on BAP medium. CONCLUSIONS: The media tested in this study, with the exception of CBN medium, detected at least 75% of patients colonized by GRE. Further development of BAP, CBAA and KAA media is warranted to improve growth and selectivity.

Synthesis and purification of 3-hydroxykynurenine-O-beta-glucoside, a primate lens ultraviolet filter, and its application in a two-step assay for beta-glucosidase activity

3-Hydroxykynurenine-3-O-beta-glucoside (3-HKG) functions in the primate lens as a filter of 295- 400-nm light, thereby protecting the retina from damaging UV radiation. Although extensive studies have been conducted to determine the functional role of 3-HKG in the primate lens, an efficient method for its synthesis and purification has yet to be developed. Several procedures have been reported for the synthesis of 3-HKG; however, these procedures either result in low yields or require numerous sequential reactions and purification steps. In this study, we report a two-step synthesis of 3-HKG with a one-step purification and a two- to eightfold increase in yield over previously reported methods. Additionally, an assay was developed to confirm the presence of a beta-glycosidic linkage in the purified reaction product and we propose a method by which 3-HKG can be used as a general probe of beta-glucosidase activity. The assay consists of adding glucose oxidase to the 3-HKG/glucosidase solution and then allowing the hydrogen peroxide, generated from the interaction of glucose with glucose oxidase, to oxidize 3-hydroxykynurenine to xanthomattin (XAN) and 4,6-dihydroxyquinolinequinone carboxylic acid (DHQCA). Both XAN and DHQCA absorb strongly between 400 and 500 nm and the color change of the solution can be seen by eye. In addition, XAN fluoresces in the visible region with lambda(max) = 527 nm.

Acceptability and patterns of endometrial bleeding in estradiol-based HRT regimens: a comparative study of cyclical sequential combinations of trimegestone or norethisterone acetate

OBJECTIVE

This randomized, double-blind, multicenter study was planned to compare the efficacy and tolerance of a novel oral regimen containing estradiol (2.0 mg) sequentially combined with trimegestone, at a daily dose of either 0.25 mg or 0.5 mg, with a standard hormone replacement therapy containing estradiol and norethisterone acetate (E2 + NETA) in the treatment of climacteric symptoms.

METHODS

The study was conducted over 13 cycles, each of 28 days, and involved 487 subjects, of whom 349 completed the study.

RESULTS

All three treatments were equally effective in alleviating hot flushes and showed a progressive and significant reduction in the value of the Kupperman index. The treatments diminished equally effectively urogenital signs and symptoms. All treatments were well tolerated and the incidences of adverse events associated with each treatment were similar across the treatment groups. The duration of expected withdrawal bleeding was shorter in the estradiol + trimegestone 0.5 mg group than in the estradiol + trimegestone 0.25 mg or E2 + NETA group.

CONCLUSION

All treatments were effective and well tolerated, providing significant relief from climacteric symptoms. Treatment with estradiol + trimegestone 0.5 mg provided the most favorable bleeding pattern.

The nitrite/collagen reaction: non-enzymatic nitration as a model system for age-related damage

The effects of age seen in long-lived connective tissue proteins are thought to be the result of post-translational modifications by reactive molecules. One such molecule is the nitrite ion. Human nitrite exposure results predominately from endogenous production of nitric oxide as well as inhalation of cigarette smoke and ingestion of cured meats. Although nitrite reactions with various proteins have been studied previously with regard to carcinogenesis, the specific reaction with collagen and its role in age-related damage has never been examined. We describe the reaction of nitrite with type I collagen at neutral pH and body temperature. The incubation of collagen with nitrite results in an increase in cross-linking, the accumulation of a yellow chromophore, and a depletion of tyrosine residues. Similar changes also are found in aged human collagen. In addition, 3-nitro-tyrosine, which has recently been used as a marker for peroxynitrite mediated damage, is produced from this reaction. Thus, we propose non-enzymatic nitration as an in vitro model system for human collagen age-related damage.

Community participation in road safety: barriers and enablers

The objectives of the paper were to identify barriers to community participation in road safety activities and to recommend strategies to reduce those barriers. Information was obtained from: a review of relevant literature, from the authors' extensive community-based experiences, from undertaking community-based research, and from interviews with key stakeholders in road safety in Western Australia. Ten significant barriers to community participation were identified. These are classified into two groups: personnel and planning issues. The former includes: reasons why people are often reluctant to become involved in projects in their communities, a lack of leadership, and a lack of skills. The latter includes: inappropriate program foci, inappropriate program evaluation, lack of resources, and a lack of sustainability. It was concluded that the barriers to community involvement in road safety initiatives are similar in many parts of Australia and overseas and apply to a wide range of health promotion interventions besides road safety. Awareness of the barriers and knowledge of their solutions can ensure that appropriate steps are taken to maximise the likelihood of community participation.