HIV and Pneumocystis Jiroveci Pneumonia (PJP) Managed With Extracorporeal Membrane Oxygenation (ECMO).

Presentation A 40-year-old Irish female presented with a new diagnosis of HIV, advanced immunosuppression and severe respiratory failure. Diagnosis Patient was subsequently diagnosed with Pneumocystis jiroveci Pneumonia (PJP). Treatment The patient was treated for HIV and PJP and required mechanical ventilation. She continued to deteriorate and veno-venous Extracorporeal Membrane Oxygenation (V-V ECMO) was deployed in her management after 18 days of mechanical ventilation. Conclusion HIV presenting with extensive pneumonia secondary to PJP and advanced immunosuppression is still a treatable condition. All available respiratory support including ECMO should be considered for patients even if they have been on mechanical ventilation for more than 7 days.

Altered plasma arginine metabolome precedes behavioural and brain arginine metabolomic profile changes in the APPswe/PS1ΔE9 mouse model of Alzheimer's disease.

While amyloid-beta (Aß) peptides play a central role in the development of Alzheimer's disease (AD), recent evidence also implicates altered metabolism of L-arginine in the pathogenesis of AD. The present study systematically investigated how behavioural function and the brain and plasma arginine metabolic profiles changed in a chronic Aß accumulation model using male APPswe/PS1ΔE9 transgenic (Tg) mice at 7 and 13 months of age. As compared to their wild-type (WT) littermates, Tg mice displayed age-related deficits in spatial water maze tasks and alterations in brain arginine metabolism. Interestingly, the plasma arginine metabolic profile was markedly altered in 7-month Tg mice prior to major behavioural impairment. Receiver operating characteristic curve analysis revealed that plasma putrescine and spermine significantly differentiated between Tg and WT mice. These results demonstrate the parallel development of altered brain arginine metabolism and behavioural deficits in Tg mice. The altered plasma arginine metabolic profile that preceded the behavioural and brain profile changes suggests that there may be merit in an arginine-centric set of ante-mortem biomarkers for AD.

Injuries in youth track and field are perceived to have multiple-level causes that call for ecological (holistic-developmental) interventions: A national sporting community perceptions and experiences.

Engaging in competitive sports as a youth can have many health benefits, but recent studies also report a high risk for injury. The long-term purpose of this Swedish research program is to develop a framework for safe track and field training for young athletes (aged 12-15 years). The aim of this study was to establish what is perceived to contribute and cause injuries in youth track and field by compiling the best available experiential knowledge about the underlying factors and use this knowledge to identify appropriate areas to handle these in practical ways. Nine focus group interviews with in total 74 participants and confirming interviews with five individuals were performed in seven Swedish regions. Qualitative research methods were used for data analysis. Injuries in youth athletes were not considered to be strictly the result of individual factors but rather the result of the interactions between factors at different levels. Three major factors emerged as follows: Insufficient knowledge for athletic development in daily practice; shortsighted communities of practice and sports policies not adjusted to youth; and societal health behaviors. The experiential knowledge in the national sporting community suggests that if effective and sustainable injury prevention processes are to be implemented for youth track and field, an ecological (holistic-developmental) approach to injury prevention is needed. Such an approach allows a longitudinal development-focused strategy for prevention that spans an athlete's entire career.

Medium term review of the ASR implant system: A single surgeon series.

INTRODUCTION: Both ASR hip resurfacings and stemmed ASR XL arthroplasties have failed at high rates in several published series. We assessed a single surgeon series of these arthroplasties looking to identify factors associated with their failure. METHODS: All surgeries were performed by one surgeon. Patients were evaluated clinically, radiologically and with serial cobalt and chromium ion analysis. RESULTS: 274 implants were analysed - 152 ASR resurfacings and 122 ASR XL implants. Thirty revisions were performed. CONCLUSION: The failure rate of the ASR implant in our series is unacceptably high - its use in routine hip arthroplasty cannot be supported.

Flexor digitorum accessorius causing tarsal tunnel syndrome in a paediatric patient: A case report and review of the literature.

The flexor digitorium accessorius muscle is an unusual anatomical variant found in the posteromedial aspect of the hindfoot and ankle. As previously described, its location predisposes patients to developing tarsal tunnel syndrome. This case illustrates the diagnosis, treatment and resolution of tarsal tunnel syndrome in a paediatric patient, secondary to the presence of flexor digitorium accessorius muscle.

A single intracerebroventricular Aß25-35 infusion leads to prolonged alterations in arginine metabolism in the rat hippocampus and prefrontal cortex.

While amyloid beta (Aß) plays a central role in the development of Alzheimer's disease (AD), recent evidence suggests the involvement of arginine metabolism in AD pathogenesis. Earlier research has shown that a single intracerebroventricular (i.c.v.) infusion of pre-aggregated Aß25-35 (the neurotoxic domain of the full-length Aß) altered arginine metabolism in the rat hippocampus (particularly the CA2/3 and dentate gyrus (DG) sub-regions) and prefrontal cortex (PFC) at the time point of 8 days post-infusion. The present study measured the levels of L-arginine and its nine downstream metabolites (L-citrulline, L-ornithine, agmatine, putrescine, spermidine, spermine, glutamate, GABA and glutamine) in the hippocampus and PFC at the time points of 42 and 97 days following a single bilateral i.c.v. infusion of Aß25-35 (30 nmol/rat) or Aß35-25 (reverse peptide; 30 nmol/rat). At the 42-day time point, Aß25-35 resulted in decreased levels of glutamate, glutamine and spermine in the CA2/3 sub-region of the hippocampus. At the 97-day time point, however, there were decreased L-ornithine, GABA and putrescine levels, but increased glutamate/GABA ratio, in the PFC and increased spermine levels in the DG sub-region. Cluster analyses showed that L-arginine and its three main metabolites L-citrulline, L-ornithine and agmatine formed distinct groups, which changed as a function of Aß25-35 at the 42-day and 97-day time points, particularly in the CA2/3 and PFC regions respectively. This study, for the first time, demonstrates that a single i.c.v. infusion of pre-aggregated Aß25-35 leads to prolonged alterations in arginine metabolism in a region-specific and time-dependent manner, which further supports the involvement of arginine metabolism in AD pathogenesis.

Role of vascular channels as a novel mechanism for subchondral bone damage at cruciate ligament entheses in osteoarthritis and inflammatory arthritis.

OBJECTIVES: The purpose of this work was to test whether normal peri-entheseal vascular anatomy at anterior and posterior cruciate ligaments (ACL and PCL) was associated with distribution of peri-entheseal bone erosion/bone marrow lesions (BMLs) in inflammatory arthritis (IA) and osteoarthritis (OA). METHODS: Normal microanatomy was defined histologically in mice and by 3 T MRI and histology in 21 cadaveric knees. MRI of 89 patients from the Osteoarthritis Initiative and 27 patients with IA was evaluated for BMLs at ACL and PCL entheses. Antigen-induced arthritis (AIA) in mice was evaluated to ascertain whether putative peri-entheseal vascular regions influenced osteitis and bone erosion. RESULTS: Vascular channels penetrating cortical bone were identified in knees of non-arthritic mice adjacent to the cruciate ligaments. On MRI of normal cadavers, vascular channels adjacent to the ACL (64% of cases) and PCL (71%) entheses were observed. Histology of 10 macroscopically normal cadaveric specimens confirmed the location of vascular channels and associated subclinical changes including subchondral bone damage (80% of cases) and micro-cyst formation (50%). In the AIA model, vascular channels clearly provided a site for inflammatory tissue entry and osteoclast activation. MRI showed BMLs in the same topographic locations in both patients with early OA (41% ACL, 59% PCL) and IA (44%, 33%). CONCLUSION: The findings show that normal ACL and PCL entheses have immediately adjacent vascular channels which are common sites of subtle bone marrow pathology in non-arthritic joints. These channels appear to be key determinants in bone damage in inflammatory and degenerative arthritis.

Potential role of the posterior cruciate ligament synovio-entheseal complex in joint effusion in early osteoarthritis: a magnetic resonance imaging and histological evaluation of cadaveric tissue and data from the Osteoarthritis Initiative.

OBJECTIVE: This study explored posterior cruciate ligament (PCL) synovio-entheseal complex (SEC) microanatomy to determine whether it may participate in the early osteoarthritis (OA) disease process. METHODS: SEC microanatomy and OA features were evaluated in 14 non-arthritic cadaveric knees (mean age = 69.9) using magnetic resonance imaging (MRI) and histology. MRI images of 49 subjects selected from the progression cohort of the Osteoarthritis Initiative (OAI) were evaluated by a musculoskeletal radiologist using an original semi-quantitative method for features associated with OA at the PCL tibial enthesis. Statistical analysis was performed using chi-square and Wilcoxon signed-rank tests to evaluate associations between SEC configuration and OA features. RESULTS: The PCL formed a SEC-like structure encompassing bone- and ligament-lining intra-articular cartilages to which the posterior root of the medial meniscus contributed. Degenerative features at the PCL-SEC included: neovascularisation (44%), enthesis chondrocyte clustering (44%), collagen matrix fissuring at the enthesis (56%) and in the PCL itself (67%), tidemark duplication (44%), bone remodelling (44%) and microscopic inflammatory changes (33%). In the OAI cohort, SEC-related pathology included bone marrow lesions (BMLs) (69%) and osteophytosis (94%) at locations that corresponded to SEC-related cartilages. Posterior joint recess effusion (49%) was linked to MRI abnormalities at PCL-SEC cartilages (χ2 = 7.27, P = 0.007). CONCLUSIONS: The PCL has a prominent SEC configuration that is associated with microscopic OA changes in aged clinically non-diseased joints. MRI determined knee OA commonly exhibited pathological features at this site which was associated with adjacent joint effusion. Thus, the PCL-SEC could play a hitherto unappreciated role in the early OA disease process.

Demodex-associated bacterial proteins induce neutrophil activation.

BACKGROUND: Patients with rosacea demonstrate a higher density of Demodex mites in their skin than do controls. A bacterium isolated from a Demodex mite from a patient with papulopustular rosacea (PPR) was previously shown to provoke an immune response in patients with PPR or ocular rosacea, thus suggesting a possible role for bacterial proteins in the aetiology of this condition. OBJECTIVES: To examine the response of neutrophils to proteins derived from a bacterium isolated from a Demodex mite. METHODS: Bacterial cells were lysed and proteins were partially purified by ÄKTA fast protein liquid chromatography. Isolated neutrophils were exposed to bacterial proteins and monitored for alterations in migration, degranulation and cytokine production. RESULTS: Neutrophils exposed to proteins from Bacillus cells demonstrated increased levels of migration and elevated release of matrix metalloprotease 9, an enzyme known to degrade collagen, and cathelicidin, an antimicrobial peptide. In addition, neutrophils exposed to the bacterial proteins demonstrated elevated rates of interleukin 8 and tumour necrosis factor-α production. CONCLUSIONS: Proteins produced by a bacterium isolated from a Demodex mite have the ability to increase the migration, degranulation and cytokine production abilities of neutrophils. These results suggest that bacteria may play a role in the inflammatory erythema associated with rosacea.

Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks.

The extent of analgesia provided by transversus abdominis plane blocks depends upon the site of injection and pattern of spread within the plane. There are currently a number of ultrasound-guided approaches in use, including an anterior oblique-subcostal approach, a mid-axillary approach and a more recently proposed posterior approach. We wished to determine whether the site of injection of local anaesthetic into the transversus abdominis plane affects the spread of the local anaesthetic within that plane, by studying the spread of a local anaesthetic and contrast solution in four groups of volunteers. The first group underwent the classical landmark-based transversus abdominis plane block whereby two different volumes of injectate were studied: 0.3 ml.kg(-1) vs 0.6 ml.kg(-1). The second group underwent transversus abdominis plane block using the anterior subcostal approach. The third group underwent transversus abdominis plane block using the mid-axillary approach. The fourth group underwent transversus abdominis plane block using the posterior approach, in which local anaesthetic was deposited close to the antero-lateral border of the quadratus lumborum. All volunteers subsequently underwent magnetic resonance imaging at 1, 2 and 4 h following each block to determine the spread of local anaesthetic over time. The studies demonstrated that the anterior subcostal and mid-axillary ultrasound approaches resulted in a predominantly anterior spread of the contrast solution within the transversus abdominis plane and relatively little posterior spread. There was no spread to the paravertebral space with the anterior subcostal approach. The mid-axillary transversus abdominis plane block gave faint contrast enhancement in the paravertebral space at T12-L2. In contrast, the posterior approaches, using both landmark and ultrasound identifications, resulted in predominantly posterior spread of contrast around the quadratus lumborum to the paravertebral space from T5 to L1 vertebral levels. We concluded that the pattern of spread of local anaesthetic differs depending on the site of injection into the transversus abdominis plane. This may have important implications for the extent of analgesia produced with each approach.

'Ready-access' CT imaging for an orthopaedic trauma clinic.

'Ready-Access' to CT imaging facilities in Orthopaedic Trauma Clinics is not a standard facility. This facility has been available at the regional trauma unit, in Merlin Park Hospital, Galway for the past four years. We reviewed the use of this facility over a 2-year period when 100 patients had CT scans as part of their trauma clinic assessment. The rate of CT scan per clinic was 0.6. The mean waiting time for a CT scan was 30 minutes. 20 (20%) new fractures were confirmed, 33 (33%) fractures were out-ruled, 25 (25%) fractures demonstrated additional information and 8 (8%) had additional fractures. 20 (20%) patients were discharged and 12 (12%) patients were admitted as a result of the CT scan. It adds little time and cost to CT scanning lists.

Agmatine protects against beta-amyloid25-35-induced memory impairments in the rat.

Amyloid beta fragment 25-35 (Abeta(25-35)) is the neurotoxic domain of the full-length Abeta(1-42) and causes memory impairments in rodents. Recent research suggests that agmatine, decarboxylated arginine, has a neuroprotective role. This study investigated the effects of a single bilateral i.c.v. infusion of aggregated Abeta(25-35) (30 nmol) in a battery of behavioural tests conducted during the period 4-6 (Experiment 1) and 4-14 (Experiment 2) weeks post-Abeta(25-35) infusion, and evaluated the protective effect of agmatine (40 mg/kg) administered i.p. 30 min prior to Abeta(25-35) infusion and once daily for a further nine consecutive days. In Experiment 1, Abeta(25-35) rats with saline treatment were not impaired in the elevated plus maze and open field and mildly impaired in the reference memory version of the water maze task, but performed poorly in the working memory version of the water maze task and the object recognition memory task, relative to the control rats that received the i.c.v. infusion of Abeta(35-25) (inactive peptide) and saline treatment. By contrast, Abeta(25-35) rats with agmatine treatment did not show performance impairments in the working memory version of the water maze task and the object recognition memory task. In Experiment 2, Abeta(25-35) rats with saline treatment were significantly impaired in the standard radial arm maze task, but only displayed no or very mild impairments in the delayed non-match to position and reference memory versions of the radial arm maze task, T-maze, object recognition memory task, both the reference and working memory versions of the water maze task, elevated plus maze and open field. By contrast, Abeta(25-35) rats with agmatine treatment were not impaired in the standard radial arm maze and performed even better than the controls in the reference memory version of the task. These results demonstrate that agmatine is able to protect against Abeta(25-35)-induced memory deficits.

Differential effects of i.c.v. microinfusion of agmatine on spatial working and reference memory in the rat.

Recent evidence suggests that agmatine, the metabolite of arginine by arginine decarboxylase, exists in the mammalian brain and is a novel neurotransmitter. Exogenous agmatine can modulate behaviour function, including learning and memory. The present study investigated the effects of repeated i.c.v. microinfusion of agmatine (once daily) on the reference and working memory versions of the water maze task, as well as the elevated plus maze and open field. Rats with high (100 microg), but not low (10 microg), dose of agmatine displayed reduced exploratory and locomotor activity in the open field relative to the saline controls on day 1 (received three infusions), but not day 12 (received 14 infusions). The three groups performed similarly on both days in the elevated plus maze tested prior to the open field. In the reference memory version of the water maze task, rats with agmatine treatment at both doses performed as well as the saline controls in the cued navigation (day 2), place navigation (days 3-7) and probe test (day 7). In the working memory version of the water maze task (days 8-11), the two agmatine groups generated markedly shorter path length and took significantly less time to reach the platform at the 180 s, but not 30 s, delay as compared to the saline group. These results demonstrate that repeated agmatine treatment produces transient impairments in exploratory and locomotor activity in the open field in a dose-dependent manner. Agmatine significantly facilitates spatial working memory at a longer delay, but not reference memory, suggesting its differential influence on the two types of spatial learning and memory. The underlying mechanisms need to be explored in the future.

MRI detection of a female pelvic arteriovenous fistula after hysterectomy: treatment with superselective coil embolisation.

We present a rare case of acquired pelvic arteriovenous fistula of the uterine vessels in a woman with a remote history of hysterectomy who presented with chronic pelvic and left limb pain. It was successfully treated by coil embolisation of the left uterine artery. The MRI and angiographic features are described, together with the current management and a review of literature.

A meta-analysis study of the effect of chilling on prevalence of Salmonella on pig carcasses.

In the field of food safety, meta-analysis can be used to combine results of prevalence studies of pathogens at critical stages within the food processing chain so that policy makers can access reliable and concise information on the effectiveness of interventions for controlling and preventing foodborne illnesses in humans. The objective of this work was to demonstrate the applicability of a parametric approach of meta-analysis to the specific case of determining the overall effect of chilling on Salmonella prevalence on pig carcasses. A meta-analysis was performed on each of two parameters measuring effect size for binary outcomes (relative risk and risk difference). Both meta-analyses confirmed that the chilling operation has a significant beneficial effect (P < 0.001) on the reduction of Salmonella prevalence on pig carcasses. Because risk difference is a parameter sensitive to the differences across studies in carcass swab areas and Salmonella detection methods, its meta-analysis highly reflected this heterogeneity (P < 0.001). However, parameterization of relative risk, not being biased by the above sources of variability, did not give rise to heterogeneity among studies and produced a fixed-effects meta-analysis solution, which is deemed more suitable for compilations based on a small number of individual studies (n = 9). Because of the systematic approach of meta-analysis (i.e., individual studies are weighed according to precision) and its reliance for actual data, the output distribution of the relative risk effect size (approximately eN(-0.868,0.166)) merits consideration for inclusion in the chilling stage of quantitative risk assessments modeling the prevalence of this pathogen along the pork production chain.

MRI of angiosarcoma associated with chronic lymphoedema: Stewart Treves syndrome.

Cutaneous angiosarcoma is a rare complication of a chronic lymphedematous extremity (Stewart-Treves syndrome). Early recognition of these aggressive tumours is important, as they have a high incidence of local recurrence and metastasis. This report describes the MRI appearance of Stewart-Treves syndrome in a patient with a background of lumpectomy, axillary node dissection and radiotherapy for breast carcinoma. MRI revealed a lobulated cutaneous mass of intermediate signal on T(1) weighted imaging, and low signal on T(2) weighted imaging, with diffuse enhancement following contrast.

Paraovarian adrenal rest with MRI features characteristic of an adrenal adenoma.

We report MR and sonographic imaging features of an incidentally detected paraovarian adrenal rest in a 44-year-old woman who was being evaluated for menorrhagia. This is the first report of chemical shift imaging identifying the presence of lipid within an adrenal rest as well as rapid washout of contrast. Both of these MR characteristics are typically seen with an adrenal adenoma.