A human donor (cadaveric) observation study of three needle placements in the piriformis muscle

OBJECTIVE

To compare the safety and accuracy of three dry needling locations in the piriformis muscle using human donors.

DESIGN

Observational dissection study of embalmed human donors.

METHODS

A licensed physical therapist of 17 years clinical experience and 5 years teaching dry needling placed three needles in a medial, midpoint, and lateral location of 14 piriformis muscles of seven embalmed human donors. Block dissection allowed for observation of tissues the needles traversed and recording of the structures that the needles pierced.

RESULTS

The lateral needle pierced piriformis in 3/14 trials, and contacted sciatic nerve in 0/14 trials. The medial needle pierced both piriformis and sciatic nerve in 11/14 trials. The midpoint needle pierced the piriformis in 11/14 trials, and contacted sciatic nerve in 3/14 trials. Fisher's Exact test (p < 0.001) found a nonrandom association between dry needle placement, and dry needle contact.

CONCLUSIONS

When dry needling the piriformis, a lateral approach can avoid the sciatic nerve, but cannot accurately pierce the piriformis tendon. Furthermore, while a midpoint and medial approach finds the piriformis muscle with the same accuracy, the midpoint location avoided the sciatic nerve more often.

Characteristics Associated with Adults Remembering to Wash Hands in Multiple Situations Before and During the COVID-19 Pandemic - United States, October 2019 and June 2020

Washing hands often, especially during times when one is likely to acquire and spread pathogens,* is one important measure to help prevent the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), as well as other pathogens spread by respiratory or fecal-oral transmission (1,2). Studies have reported moderate to high levels of self-reported handwashing among adults worldwide during the COVID-19 pandemic (3-5)^†; however, little is known about how handwashing behavior among U.S. adults has changed since the start of the pandemic. For this study, survey data from October 2019 (prepandemic) and June 2020 (during pandemic) were compared to assess changes in adults' remembering to wash their hands in six situations.^§ Statistically significant increases in reported handwashing were seen in June 2020 compared with October 2019 in four of the six situations; the odds of remembering to wash hands was 2.3 times higher among respondents after coughing, sneezing, or blowing their nose, 2.0 times higher before eating at a restaurant, and 1.7 times higher before eating at home. Men, young adults aged 18-24 years, and non-Hispanic White (White) adults were less likely to remember to wash hands in multiple situations. Strategies to help persons remember to wash their hands frequently and at important times should be identified and implemented, especially among groups reporting low prevalence of remembering to wash their hands.

COVID-19 recovery: tackling the 2-week wait colorectal pathway backlog by optimising CT colonography utilisation

AIM

To review the indications for computed tomography colonography (CTC) performed on patients referred via the 2-week wait colorectal pathway (2WWCP).

MATERIALS AND METHODS

A retrospective study was performed on all patients referred through the 2WWCP between October 2018 and September 2019. The referrals were audited against the National Institute for Health and Care Excellence (NICE) NG12/DG30 guidelines for referral to the 2WWCP, and against the Royal College of Radiologists (RCR) 2017 guidelines for CTC.

RESULTS

Over the study period, there were 1,707 2WWCP referrals, and 362 (21.2%) of these patients underwent CTC. The median age was 66 years, and 55% were female. Forty-six patients did not meet the NICE NG12/DG30 guidelines for referral to the 2WWCP, and a further 268, although meeting the NICE guidelines, did not meet the RCR 2017 guidelines for CTC. In total, only 13% of CTCs performed complied with both guidelines.

CONCLUSION

This audit demonstrated a significant opportunity to reallocate CTC resources in the recovery stage of the COVID-19 pandemic. To improve outcomes for colorectal cancer (CRC) in the UK, establishing a selective straight-to-test CTC 2WWCP should be considered. Documented consent detailing the risks and benefits of CTC versus colonoscopy should take place in order to assist the patient in making an informed choice.

Shigella sonnei Outbreak Investigation During a Municipal Water Crisis-Genesee and Saginaw Counties, Michigan, 2016

Objectives. To investigate a shigellosis outbreak in Genesee County, Michigan (including the City of Flint), and Saginaw County, Michigan, in 2016 and address community concerns about the role of the Flint water system.Methods. We met frequently with community members to understand concerns and develop the investigation. We surveyed households affected by the outbreak, analyzed Shigella isolate data, examined the geospatial distribution of cases, and reviewed available water quality data.Results. We surveyed 83 households containing 158 cases; median age was 10 years. Index case-patients from 55 of 83 households (66%) reported contact with a person outside their household who wore diapers or who had diarrhea in the week before becoming ill; results were similar regardless of household drinking water source. Genomic diversity was not consistent with a point source. In Flint, no space-time clustering was identified, and average free chlorine residual values remained above recommended levels throughout the outbreak period.Conclusions. The outbreak was most likely caused by person-to-person contact and not by the Flint water system. Consistent community engagement was essential to the design and implementation of the investigation.

865. Acanthamoeba Disease Associated With the Practice of Nasal Rinsing in Immunocompromised Patients

Background

The genus Acanthamoeba are free-living amebae found worldwide in water, including tap water, and soil that can cause rare but severe infections of the eye, skin, and central nervous system. Acanthamoeba spp. generally cause disease in immunocompromised persons, including those with HIV, hematologic malignancies, and solid organ transplants. The route of transmission and incubation period are not well known in humans, but animal studies have shown that disease can be produced via the intranasal, intrathecal, and intravenous routes. We describe 5 cases of Acanthamoeba disease among immunocompromised patients who practiced nasal rinsing prior to becoming ill.

Methods

The Centers for Disease Control and Prevention (CDC) offers a clinical consultation service for free-living ameba infections and maintains a Free-living Ameba laboratory with confirmatory diagnostic testing capabilities. When an Acanthamoeba case is confirmed in the United States, details about the case are collected on a standardized case report form which includes questions about the case–patient’s water and soil exposure prior to becoming ill. Questions about nasal rinsing were added to the form in 2011.

Results

Five Acanthamoeba case patients in CDC’s free-living ameba database were reported to have performed nasal rinsing prior to becoming ill. The median age was 60 years (range 36–73 years) and 3 of 5 patients were female. Two were solid-organ transplant patients (heart and kidney), 2 had chronic lymphocytic leukemia, and 1 had HIV. Three patients presented only with encephalitis and died. The 2-organ transplant patients had a combination of rhinosinusitis, osteomyelitis, and skin lesions. One survived and the other died, the cause of which was unrelated to Acanthamoeba. All reported using tap water to perform nasal rinsing, most for sinus congestion using a neti pot or similar device and one for religious purposes.

Conclusion

Acanthamoeba is an inhabitant of water, including treated tap water. Immunocompromised patients, like those presented here, might be at risk for infections caused by Acanthamoeba transmitted via tap water used for nasal rinsing. Clinicians caring for immunocompromised patients should advise their patients not to use tap water for nasal or sinus rinsing.

Disclosures

All authors: No reported disclosures.

A Primary Amebic Meningoencephalitis Case Associated with Rafting on an Artificial Whitewater River

Background

Naegleria fowleri is a climate-sensitive thermophilic ameba found in freshwater that causes primary amebic meningoencephalitis (PAM; 0–8 infections per year in the U.S.) when it enters the nose and migrates to the brain. Patient exposure to water containing the ameba typically occurs in warm freshwater lakes and ponds during recreational water activities. In June 2016, an 18-year-old woman died of PAM after traveling to North Carolina, where she participated in whitewater rafting on an artificial whitewater river.

Methods

To determine water exposures, we reviewed medical records and conducted interviews with family and individuals who had traveled with the case-patient. To further investigate the artificial whitewater river as a possible exposure source, we visited the whitewater facility and collected water, biofilm, and sediment samples from the facility and from the nearby natural river. We performed select water quality tests onsite and tested for the presence of N. fowleri by culture and real-time PCR in the laboratory.

Results

Interviews revealed that the case-patient’s most probable water exposure in the 10 days before becoming ill occurred while rafting on an artificial whitewater river during which she was thrown out of the raft and submerged underwater. The ~11.5 million gallons of water in the whitewater facility were filtered, subjected to UV light, and occasionally chlorinated. Heavy algal growth was noted. The free chlorine residual was 0.05 mg/L, turbidity was 6.7 NTU, and water temperature was 30°C in the whitewater facility during the site visit. All 11 water-related samples taken from the facility were positive for N. fowleri. Of 5 samples taken from the natural river, 1 sediment sample was positive for N. fowleri.

Conclusion

This investigation documents a novel exposure to an artificial whitewater river as the likely exposure causing PAM in this case. Conditions in the whitewater facility (warm, turbid water with little chlorine and heavy algal growth) rendered the water treatment ineffective and provided an ideal environment for N. fowleri to thrive. The combination of natural and engineered elements at the whitewater facility create a challenging environment to control the growth of N. fowleri.

Disclosures

All authors: No reported disclosures.

A phase II trial of low-dose estradiol in postmenopausal women with advanced breast cancer and acquired resistance to aromatase inhibition

BACKGROUND

High-dose oestrogen (HDE) is effective but toxic in postmenopausal women with advanced breast cancer (ABC). Prolonged oestrogen deprivation sensitises BC cell lines to estrogen and we hypothesised that third-generation aromatase inhibitors (AIs) would sensitise BCs to low-dose estradiol (LDE).

METHODS

A single-arm phase II study of LDE (2 mg estradiol valerate daily) in postmenopausal women with estrogen receptor-positive (ER+) ABC. The primary end-point was clinical benefit (CB) rate. If LDE was ineffective, HDE was offered. If LDE was effective, retreatment with the pre-LDE AI was offered on progression.

RESULTS

Twenty-one patients were recruited before the trial was closed early due to slow accrual; 19 were assessable for efficacy and toxicity. CB was seen in 5 in 19 patients (26%; 95% confidence interval 9.1-51.2%), all with prolonged SD (median duration 16.8 months; range 11.0-29.6). Treatment was discontinued for toxicity in 4 in 19 patients (21%) and 8 in 11 women without hysterectomy experienced vaginal bleeding (VB). After primary LDE failure, three patients received HDE and one achieved a partial response (PR). Following CB on LDE, four patients restarted pre-LDE AI and three achieved CB including one PR. Those with CB to LDE had a significantly longer duration of first-line endocrine therapy for ABC than those without (54.9 versus 16.8 months; p < 0.01) CONCLUSION: LDE is an effective endocrine option in women with evidence of prolonged sensitivity to AI therapy. LDE is reasonably well tolerated although VB is an issue. Re-challenge with the pre-LDE AI following progression confirms re-sensitisation as a true phenomenon.

Notes from the field: outbreak of diarrheal illness caused by Shigella flexneri - American Samoa, May-June 2014

On May 9, 2014, a physician at hospital A in American Samoa noticed an abnormally high number of children presenting to the emergency department with bloody diarrhea. Based on preliminary testing of stool specimens, Entamoeba histolytica infection was suspected as a possible cause. Shigella was also suspected in a subset of samples. On May 22, the American Samoa Department of Health requested assistance from CDC with the outbreak investigation. The goals of the investigation were to establish the presence of an outbreak, characterize its epidemiology and etiology, and recommend control measures. The CDC field team reviewed the emergency department log book for cases of diarrheal illness during April 15-June 13, 2014. During this period, 280 cases of diarrheal illness were recorded, with a peak occurring on May 10. Twice as many cases occurred during this period in 2014 compared with the same period in 2011, the most recent year for which comparable surveillance data were available. Cases were widely distributed across the island. The highest number of cases occurred in children aged 0-9 years. Across age groups, cases were similarly distributed among males and females. These patterns are not consistent with the epidemiology of disease caused by E. histolytica, which tends to cause more cases in males of all ages.

Ocular and systemic side effects of brimonidine 0.2% eye drops (Alphagan®) in children

INTRODUCTION

Brimonidine 0.2% (Alphagan) is a topical alpha-2 agonist widely used as an antihypertensive. There have been occasional reports of systemic adverse effects in children including apparent central nervous system depression. There are few data available on the overall safety of brimonidine 0.2% in children.

METHODS

Computerised pharmacy records were used to identify all children who had been prescribed brimonidine 0.2% in our eye department between August 1999 and June 2001, and their notes were reviewed.

RESULTS

In all, 23 patients were identified from pharmacy records and 22 sets of notes were recovered and reviewed. The mean age at commencement of treatment was 8 years (range 0-14 years). In all, 10 (46%) were treated in one eye and 12 (54%) in both. Brimonidine 0.2% was taken for a mean 14 months (range 1 day-75 months). A total of 14 (64%) patients were already taking a topical beta-blocker when brimonidine 0.2% was commenced and a further four (18%) were being treated with another topical hypotensive agent. Of the 22 patients, six (27%) had to stop brimonidine 0.2% because of adverse side effects (two because of local irritation/allergy, two because of tiredness, and two because of fainting attacks).

DISCUSSION

Many topical hypotensive agents are not licensed for use in children and few safety data are available. In this study, 18% of children had systemic adverse effects sufficient to necessitate stopping the drug. It is possible that educational impairment may have passed unnoticed in others. Larger studies are required to investigate this further.

'Get it on' in the millennium

Over the Christmas and New Year period the Health Education Authority launched a sexual health promotion campaign aimed at increasing the awareness of and reducing the incidence of sexually transmitted infections (STIs) and unwanted pregnancy. We undertook a study to assess the effect of this campaign locally in 2 genitourinary medicine (GUM) clinics. From our study we concluded the following: (1) Although rarely performed, it is possible to assess the effectiveness of health promotion campaigns. (2) Genitourinary medicine clinics provide a good forum for the assessment of such campaigns. (3) The information obtained from such assessments can be valuable for effective targeting of future campaigns.

Fluctuating silicate:nitrate ratios and coastal plankton food webs

Marine diatoms require dissolved silicate to form an external shell, and their growth becomes Si-limited when the atomic ratio of silicate to dissolved inorganic nitrogen (Si:DIN) approaches 1:1, also known as the "Redfield ratio." Fundamental changes in the diatom-to-zooplankton-to-higher trophic level food web should occur when this ratio falls below 1:1 and the proportion of diatoms in the phytoplankton community is reduced. We quantitatively substantiate these predictions by using a variety of data from the Mississippi River continental shelf, a system in which the Si:DIN loading ratio has declined from around 3:1 to 1:1 during this century because of land-use practices in the watershed. We suggest that, on this shelf, when the Si:DIN ratio in the river decreases to less than 1:1, then (i) copepod abundance changes from >75% to <30% of the total mesozooplankton, (ii) zooplankton fecal pellets become a minor component of the in situ primary production consumed, and (iii) bottom-water oxygen consumption rates become less dependent on relatively fast-sinking (diatom-rich) organic matter packaged mostly as zooplankton fecal pellets. This coastal ecosystem appears to be a pelagic food web dynamically poised to be either a food web composed of diatoms and copepods or one with potentially disruptive harmful algal blooms. The system is directed between these two ecosystem states by Mississippi River water quality, which is determined by land-use practices far inland.

Early lesion of mystacial vibrissae in rats results in an increase of somatostatin-labelled cells in the somatosensory cortex

Recent studies in the developing cortex have shown that during the first 2 postnatal weeks somatostatin (SRIF)-containing neurons appear in greater numbers. After this time their numbers decline significantly probably due to cell death (Cavanagh and Parnavelas 1988). In this study we report changes in the distribution of SRIF-labelled cells in the somatosensory cortex of adult rats following unilateral lesions of mystacial vibrissae at birth. Specifically, we observed that the side contralateral to the lesion contained a significantly greater number of labelled cells compared to the ipsilateral side. We suggest that the decline in cell numbers observed during normal development is reduced following early deafferentation.

The stellate layer and rhythmic contractions of the Oryzias latipes embryo

The objective of this study was to determine which cells in the medaka (Oryzias latipes) embryo participate in the rhythmic contraction waves that propagate slowly across the yolk sac throughout most of embryonic development. To facilitate observation of the cells, we inhibited the contractions temporarily by incubating the embryos with o-nitrobenzylacetate, n-heptanol, or n-octanol. After we washed out the inhibitor, isolated cells in a subepithelial layer (similar to the stellate layer in Fundulus heteroclitus) began to pulse. Stellate cells are much smaller than cells in the surface epithelium (enveloping layer) and are present throughout the developmental period during which the contractions occur, stage 14 to stage 26. We conclude that the active force for the rhythmic contraction waves is provided by cells in the stellate layer and that cells in the enveloping layer are passively deformed by the contraction of cells in the closely apposed stellate layer.

Mechanisms of chemoprevention by dietary dehydroisoandrosterone. Inhibition of lymphopoiesis

The ingestion of dehydroisoandrosterone (DHA), a naturally occurring steroid, inhibits the development of autoimmunity, neoplasias, and other disorders of rodents. Potential mechanisms of action include (1) the induction of peroxisomal proliferation and (2) the conversion of DHA to androgens. We evaluated the immune system of mice fed DHA. Dietary DHA had no significant effect on antibody responses, cutaneous sensitivity reactions, natural killer activity, or graft-versus-host reactions. However, a decrease in lymphoid organ cellularity and an absence of splenic germinal centers were observed. We assessed progenitor cell activity in irradiated mice by evaluating the repopulation of marrow and lymphoid organs. Dehydroisoandrosterone feeding resulted in an inhibition of lymphopoiesis but not myelopoiesis. Clofibrate, another peroxisomal proliferator, failed to inhibit lymphocyte repopulation after irradiation. Androgen-non-responsive Tfm/Y mice were as susceptible as control mice to the inhibitory effects of DHA on lymphopoiesis. Thus DHA itself may act on lymphoid progenitor cells and/or the microenvironment.

AIDS vaccine research in the UK

The UK Medical Research Council initiated a Directed Programme, aimed at developing vaccines for prevention and drugs for treatment of HIV infection and AIDS, in April 1987. This is a single collaborative research programme encompassing work in about 100 UK laboratories together with a small number in Europe and the USA. The third annual workshop for the programme, held at the University of Sheffield in September 1989, which brought together nearly 400 scientists, technical staff and students, as well as representatives of other national AIDS research programmes, showed that the Directed Programme is now well established and productive, making important contributions to the worldwide effort to control AIDS.

Follicular thyroid tumours: a study of laminin and type IV collagen in basement membrane and endothelium

Immunocytochemical stains for laminin and type IV collagen can be used as markers for basement membrane and vascular endothelium. Thirty four follicular thyroid lesions were examined using these techniques to investigate two aspects: firstly, the relation between the extent of invasion and the integrity of basement membrane; secondly, whether the techniques could enhance the detection of tumour vascular invasion. The results showed that although basement membrane was lost in widely invasive tumours, preservation was seen in most but not all encapsulated tumours. The potential for improved recognition of vascular invasion was also found.

A report of three cases of Yersinia reactive arthritis

Three cases of reactive arthritis associated with Yersinia enterocolitica bowel infection are reported. In one case Y. enterocolitica was cultured from stools while all three exhibited a significant increase in serum antibody titres to Y. enterocolitica. These are believed to be the first reports of Yersinia reactive arthritis in Australia. Synovial membrane biopsy in one case revealed a mixed inflammatory cell infiltrate the appearance of which was quite dissimilar to that of rheumatoid arthritis (RA). Mononuclear cells of the peripheral blood, but not the synovial fluid from another patient had reduced functional activity compared to RA patients as determined by response to phytohemagglutinin stimulation and allogeneic responses. Large numbers of HLA-DR and acid phosphatase positive macrophages were also found in the synovial fluid of this patient. The reason for joint involvement in Y. enterocolitica reactive arthritis is unknown and further work is necessary.

Streptococcal pharyngitis. Evaluation of a new diagnostic kit for clinic and office use

One hundred sixty-eight children with upper respiratory infections were screened for beta-hemolytic streptococcal pharyngitis. A recently developed throat culture kit was processed in comparison with the conventional blood agar plate using a duplicate swab technique. Kits and plates were examined independently. Three individuals with no previous bacteriologic experience were allowed to interpret results of the culture kit after receiving instructions for approximately 15 minutes on three consecutive days. The interpretations of two of these individuals approached 95% accuracy, and those of the third individual surpassed this rate. The kit appears to be at least equal to the conventional blood agar plate in supporting the growth of beta-hemolytic streptococci. Moreover, its selective nature allows the nontechnical office staff to interpret results of the cultures promptly and accurately with a minimum of instruction.