Surfactants and their role in wound cleansing and biofilm management.

Surfactants are widely used as detergents, emulsifiers, wetting agents, foaming agents and dispersants in the cosmetics, hygiene, food and oil industries. Their use in a clinical setting is also common, particularly within the field of wound care. Many wound cleansers contain surfactants and subsequently there is available data that shows the growing potential of these wound cleansers in the enhancement of wound closure. The presence of microorganisms in wounds has been recognised as a significant factor that delay healing. In complex or chronic wounds that are complicated by biofilms, persistent inflammation or the production of non-viable tissue and slough, the use of surfactants has been shown to aid in the removal of these barriers to wound healing. The use of concentrated surfactant(poloxamer) based wound dressings represent an important component of wound management. Consequently, this article will discuss the effect of clinically used surfactants, with specific focus on a concentrated poloxamer for use against wound biofilm.

Concordance and acceptability of electric stimulation therapy: a randomised controlled trial.

OBJECTIVE: A pilot single-blinded randomised controlled trial (RCT) was conducted to examine concordance with and acceptability of electric stimulation therapy (EST) in patients with venous leg ulcers (VLUs) who had not tolerated moderate to high compression. METHOD: Participants were randomised to the intervention group (n=15) or a placebo control group (n=8) in which EST was used four times daily for 20 minutes per session. Participants were monitored for eight weeks during which time concordance with the treatment and perceptions of the treatment were assessed. RESULTS: Concordance with the total recommended treatment time was 71.4% for the intervention group and 82.9% for the control group; a difference that was not statistically significant. Participants rated EST as acceptable (84.6% intervention; 83.3% control), only two participants, both from the placebo control group, would not be willing to use EST again. The majority considered EST easier to use than compression (68.4%). CONCLUSION: EST was a practical and acceptable treatment among people who have been unable to tolerate moderate to high compression therapy.

Understanding biofilm in practice: a global survey of health professionals.

OBJECTIVE: The aim of this survey was to examine health professionals' views and practices relating to biofilm in chronic wounds. METHOD: A global online survey was conducted to assess the current understanding of biofilm and wound management practices. The survey consisted of 20 questions designed to evaluate health professional knowledge of biofilm, perception and understanding of biofilm behaviour, detection and diagnosis, and treatment. Respondents were classified as 'specialists' if wounds were their primary focus and they developed protocols and determined formularies. Respondents were classified as 'generalists' if wounds were part of multiple indications they treat and they were able to choose wound care products from a restricted list of products. The Pearson's chi-square or Fisher's exact test was used to assess whether the responses were independent of the clinician role, health-care setting and country. RESULTS: Overall, 3011 health professionals took part in the survey, of which 397 were excluded or disqualified. Of the remaining 2614 respondents, 1223 (46.8%) completed the entire survey. Although the majority of health professionals were aware of biofilm, knowledge gaps regarding its prevalence in chronic wounds were evident. In general, the majority indicated that they understood that biofilm is detrimental to wound healing. With the exception of wound stalling, there was a lack of consensus on other clinical signs in the detection and diagnosis of biofilm. Knowledge gaps were also evident over the treatment of biofilm and the efficacy of antimicrobial treatments, debridement and wound dressing. CONCLUSION: Our results show that though there is a broad recognition of biofilm and its possible role in chronic wounds, there is still a need to educate and increase knowledge on recognition and treatment of biofilm.

Venous leg ulcer healing with electric stimulation therapy: a pilot randomised controlled trial.

OBJECTIVE: Compression therapy is a gold standard treatment to promote venous leg ulcer (VLU) healing. Concordance with compression therapy is, however, often sub-optimal. The aim of this study was to evaluate the effectiveness of electric stimulation therapy (EST) to facilitate healing of VLUs among people who do not use moderate-to-high levels of compression (>25 mmHg). METHOD: A pilot multicentre, single-blinded randomised controlled trial was conducted. Participants were randomised (2:1) to the intervention group or a control group where EST or a sham device was used 4 times daily for 20 minutes per session. Participants were monitored fortnightly for eight weeks. The primary outcome measure was percentage of area (wound size) change. RESULTS: In the 23 patients recruited, an average redution in wound size of 23.15% (standard deviation [SD]: 61.23) was observed for the control group compared with 32.67 % (SD: 42.54) for the intervention. A moderate effect size favouring the intervention group was detected from univariate [F(1,18)=1.588, p=0.224, partial eta squared=0.081] and multivariate repeated measures [F(1,18)=2.053, p=0.169, partial eta squared=0.102] analyses. CONCLUSION: The pilot study was not powered to detect statistical significance, however, the difference in healing outcomes are encouraging. EST may be an effective adjunct treatment among patients who have experienced difficulty adhering to moderate-to-high levels of compression therapy.

A comparison of the effects of medical Qigong and standard exercise therapy on symptoms and quality of life in patients with advanced cancer.

PURPOSE: Patients with advanced cancer frequently experience anxiety, depression and poor quality of life (QOL), as well as physical symptoms such as fatigue and weakness. Physical exercise has potential to help control these symptoms but the optimal training prescription is still not clear. We performed a study comparing medical Qigong (QG) and standard endurance and strength training (SET) in patients with advanced stage non-small cell lung (NSCLC) and gastrointestinal (GI) cancers. METHODS: A randomized, cross-over study was performed in patients with advanced NSCLC and GI cancers receiving or eligible for chemotherapy. Patients received supervised QG or SET twice-weekly for 6 weeks. Psychological functioning, QOL, symptoms and physical functioning were assessed before and after each intervention period. RESULTS: Nineteen patients completed both interventions. Comparing interventions revealed no difference between QG and SET on change in anxiety or depression scores or QOL. However, SET treatment was better at improving perceived strength (P = 0.05) and walking distance (P = 0.02). The order in which interventions were performed had a significant impact on the improvement in certain symptoms (sleep quality, breathlessness, P < 0.05), QOL (P = 0.01) and walking distance (P = 0.008). In all cases, the beneficial effects of the exercise interventions were markedly reduced during the second interval. CONCLUSIONS: QG and SET are equivalent in their impact on many aspects of psychological function in cancer patients. However, SET leads to greater improvements in exercise capacity and helps reduce some symptoms. The reduction in beneficial effect of SET on exercise function when offered as the second intervention is a new finding that warrants further study.

The prevalence of biofilms in chronic wounds: a systematic review and meta-analysis of published data.

The presence of biofilms in chronic non-healing wounds, has been identified through in vitro model and in vivo animal data. However, human chronic wound studies are under-represented and generally report low sample sizes. For this reason we sought to ascertain the prevalence of biofilms in human chronic wounds by undertaking a systematic review and meta-analysis. Our initial search identified 554 studies from the literature databases (Cochrane Library, Embase, Medline). After removal of duplicates, and those not meeting the requirements of inclusion, nine studies involving 185 chronic wounds met the inclusion criteria. Prevalence of biofilms in chronic wounds was 78.2 % (confidence interval [CI 61.6-89, p<0.002]). The results of our meta-analysis support our clinical assumptions that biofilms are ubiquitous in human chronic non-healing wounds.

Supplementation of metabolizable protein during late gestation and fetal number impact ewe organ mass, maternal serum hormone and metabolite concentrations, and conceptus measurements.

To examine the effects of maternal metabolizable protein (MP) supplementation during late gestation on serum hormone and metabolites and organ masses, multiparous ewes (n = 45) carrying singletons or twins were allotted randomly (within pregnancy group) to 1 of 3 treatments: 60% (MP60), 80% (MP80), or 100% (MP100) of MP requirements. Blood samples were drawn before the initiation of diets (day 100) and before slaughter (day 130) for chemistry panel analysis and weekly for hormone analysis including progesterone (P4) and estradiol-17ß (E2). At day 130, ewe organ masses were recorded. Despite being fed isocaloric diets, MP60 ewes gained less weight throughout pregnancy compared with MP80 and MP100 ewes which were similar. Although diet did not impact E2 or P4 concentrations, ewes carrying twins had greater (P < 0.05) concentrations of both as gestation advanced. Albumin, aspartate aminotransferase, and total protein were reduced (P < 0.05) in MP60 compared with MP100 ewes near term. There was a diet by fetal number interaction (P = 0.03) for lactate dehydrogenase. Twin-carrying MP80 ewes had greater lactate dehydrogenase compared with all other groups on day 130 of gestation. Ewes that were fed MP80 had greater body weight on day 130 of gestation compared with MP60 ewes. Kidney and heart weights were lighter in MP60 ewes compared with MP80 ewes. There was a maternal diet by fetal number interaction (P = 0.05) on fetal weight per unit empty ewe body weight. In ewes carrying singletons, MP60 ewes supported less fetal weight compared with MP100. In contrast, MP60 ewes supported more fetal mass compared with MP100 ewes when carrying twins. The level of protein, and not just total energy, in the diet appears to impact some aspects of the maternal system. Moreover, it appears some measurements of mobilizing maternal body resources are enhanced in ewes carrying twins.

Link Between Clinical Predictors of Heterotopic Ossification and Histological Analysis in Combat-Injured Service Members.

BACKGROUND: Heterotopic ossification (HO) is a debilitating condition that occurs following traumatic injury and may restrict range of motion and delay rehabilitation. The timing and efficacy of surgical resection have varied widely, and there is a gap in knowledge between clinical predictors of HO recurrence and histological analysis. METHODS: Thirty-three service members seen at Walter Reed National Military Medical Center for symptomatic HO were enrolled in an institutional review board-approved study. Participants took oxytetracycline on four scheduled days prior to HO resection to determine the mineral apposition rate (bone growth rate). RESULTS: Detailed histological analyses included scanning electron microscopy with backscattered electron imaging and light microscopy. Data indicated that the mineral apposition rate of trauma-induced HO was approximately 1.7 µm/day at the time of operative intervention, which was 1.7 times higher than the rate in non-pathological human bone. The mineral apposition rate and postoperative alkaline phosphatase values were demonstrated to be positively and significantly related (ρ = 0.509, p = 0.026, n = 19). When the analysis was limited to patients with no more than a two-year period from injury to excision (thereby removing outliers who had a longer time period than their counterparts) and traumatic brain injury and nonsteroidal anti-inflammatory drugs (known correlates with HO development) were controlled for in the statistical analysis, the mineral apposition rate and recurrence severity were significantly related (ρ = -0.572, p = 0.041, n = 11). CONCLUSIONS: Data demonstrated a link between benchtop research and bedside care, with the mineral apposition rate elevated in patients with HO and correlated with recurrence severity; however, a larger sample size and more clinical factors are needed to refine this model. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Maternal metabolizable protein restriction during late gestation on uterine and umbilical blood flows and maternal and fetal amino acid concentrations near term in sheep.

To examine the effects of maternal metabolizable protein (MP) restriction during late gestation on uterine and umbilical blood flows, conceptus size, and amino acid concentrations in the uterine and umbilical vessels, 11 ewes with singleton pregnancies were assigned to one of three isocaloric diets formulated to provide 60% of MP (MP60), 80% of MP (MP80), or 100% of MP (MP100) requirements from days 100 to 130 of gestation. On day 130 of gestation, intraoperative uterine and umbilical blood flows were obtained as well as serum samples from the uterine artery, uterine vein, umbilical artery, and umbilical vein. Ewes on the MP60 diet had lighter (P=0.04) and smaller (P≤0.05) fetuses, but increased (P=0.02) uterine blood flow relative to fetal weight compared with MP100 ewes, with MP80 being intermediate. Umbilical blood flow was similar (P=0.70) across treatments. Glutamine, glycine, isoleucine, leucine, ornithine, serine, and valine concentrations were impacted (P≤0.02) by maternal treatment. While uterine flux of total serum nitrites was greater (P=0.03) in MP60 and MP80 ewes compared with MP100 ewes, fetal flux did not differ. Decreased maternal protein intake resulted in less (P<0.01) maternal cytochrome P450 1A enzyme activity. There were minimal impacts of maternal diet on steroid concentrations. Maternal dietary protein may alter fetal growth by impacting placental vasculature function and nutrient absorptive capabilities.

Development of chitosan-vancomycin antimicrobial coatings on titanium implants.

Techniques for titanium surface modification have been studied for applications in orthopedic implants specifically for local drug delivery. The extensive research in surface modification is driving the development of devices that integrate infection prevention, osseointegration, and functionality in a structural role. In this study, vancomycin was applied to modified titanium surfaces to determine the effect of surface morphology on drug loading and release profiles. The antimicrobial effectiveness of the released vancomycin was evaluated and found to have a similar effect as the standard vancomycin. The engineered surfaces included sandblasted, sandblasted acid etched, electrochemically etched, and sandblasted electrochemically etched. The antibiotic release was observed to be independent of the measured surface parameters of the engineered surfaces. The development of an implantable device in which the surface morphology can be tailored for an application with no effect on the total drug released would be beneficial to more precisely control the biological response while maintaining local drug delivery for infection prevention.

A rapid admission protocol to reduce emergency department boarding times.

INTRODUCTION: Prolonged emergency department boarding times (EDBT) are associated with adverse clinical outcomes and longer hospital stays. A rapid admission protocol was designed at our institution to reduce both EDBT and time to admission orders (EDTAO) for patients admitted to the internal medicine service. METHODS: The existing admission process was examined by a team of clinical and administrative leaders who focused on developing a change management architecture, narrowing clinical roles, mandating direct communication, establishing clear boundaries for patient responsibility and instituting carefully constructed holding orders. The number of steps in the admission process was reduced from 50 to 10. We collected EDBT and EDTAO for all patients admitted to the internal medicine service before and after intervention using a simple interrupted time-series design. RESULTS: The study involved a total of 9604 admissions to one of three inpatient destinations (general medicine ward, telemetry or intensive care unit). The overall EDBT decreased from 360 min in the preintervention period to 270 min in phase 4 (p<0.001). The overall time to admission orders decreased from 210 min in the preintervention period to 75 min in phase 4 (p<0.001) overall. However, no improvements were noted in EDBT for telemetry or ICU patients. CONCLUSIONS: Institution of a rapid admission protocol successfully reduced overall EDBT at our institution, although few gains were noted for patients with a telemetry or ICU destination. In total, the intervention saved 27 884 h, or 1161 emergency department patient-days, over the course of a single year.

Effect of adhesive systems and bevel on enamel margin integrity in primary and permanent teeth.

PURPOSE: This study compared the effectiveness of self-etch and total-etch adhesive systems in bonding to the beveled and nonbeveled margins of primary and permanent teeth. METHODS: This in vitro, factorial-designed study allowed evaluation of 3 factors: (1) tooth type; (2) presence of a bevel; and (3) adhesive type. Two preparations, each including a beveled and nonbeveled margin, were completed on buccal surfaces of 60 extracted molars (30 primary and 30 permanent). Preparations were randomly assigned to self-etch or a total-etch adhesive system and restored with resin composite. After thermocycling, teeth were stained with silver nitrate, sectioned, and measured for microleakage. Statistical analysis used a repeated measures analysis of variance. RESULTS: Beveled margins had less microleakage than nonbeveled margins for primary and permanent teeth (P < .001). Total-etch had less microleakage than self-etch adhesives on primary (53% less, P < .001) and on permanent teeth (22% less, P = .01). Self-etch had considerably more microleakage when enamel margins were not beveled. Comparably less microleakage, however, was found for total-etch and self-etch in restorations with beveled margins. CONCLUSIONS: Total-etch adhesive and beveled margins resulted in the least microleakage. Margin beveling has a greater effect in minimizing microleakage than the type of adhesive used.

Effects of gestational plane of nutrition and selenium supplementation on mammary development and colostrum quality in pregnant ewe lambs.

To examine effects of nutritional plane and Se supplementation on colostrum quality and mammary development, individually fed, pregnant Rambouillet ewe lambs were allotted randomly to 1 of 6 treatments in a 2 x 3 factorial arrangement. Main effects included dietary Se level, which began at breeding (d = 0) [adequate Se (9.5 mug/kg of BW) vs. high Se (81.8 mug/kg of BW)], and plane of nutrition, which began at d 50 of gestation [60% (RES), 100% (CON), and 140% (HIGH) of requirements]. Upon parturition, lambs were immediately separated from dams and weighed. Three hours after lambing, colostrum yield was determined, and samples were obtained for components and immunoglobulin G (IgG) analysis. Ewes were slaughtered within 24 h of parturition, and mammary tissues were collected for determination of alveolar secretory epithelial cell proliferation index and luminal area. Gestation length was reduced (P < 0.01) in HIGH ewes compared with RES and CON ewes. Although birth weights were reduced (P < 0.01) in RES and HIGH compared with CON ewes, there was little effect of diet on placental size. Mammary gland weight was reduced (P /= 0.15) on mammary gland weight, colostrum quantity, or IgG concentration in pregnant ewe lambs. Improper nutrition from mid to late pregnancy in ewe lambs altered colostrum quality and quantity and reduced offspring birth weight, which may have negative implications for lamb health and survival during the early postnatal period.

Posterior single-incision approach to minimally invasive total hip arthroplasty.

Enhanced surgical techniques and instrumentation enable surgeons to perform total hip arthroplasties through minimally invasive approaches. Using incisions typically less than 10 cm in length, surgeons can achieve adequate visualization of the surgical site while minimizing trauma to deep soft tissues. Associated reductions in morbidity should allow for improved rehabilitation and recovery. Although these techniques have been met with some controversy, a number of recent studies appear to attest to their safety and efficacy. Many of these studies have concentrated on a posterior single-incision technique for total hip arthroplasty. Favorable results for such outcomes as operative times, complication rates, pain, functional recovery, and blood loss have been reported, and patient satisfaction has been high. If surgeons and their patients are to achieve maximum benefit from minimally invasive total hip arthroplasties, it will be necessary to design effective educational tools that address the learning curve associated with these approaches.

The insect homologue of the amyloid precursor protein interacts with the heterotrimeric G protein Go alpha in an identified population of migratory neurons.

The amyloid precursor protein (APP) is the source of Abeta fragments implicated in the formation of senile plaques in Alzheimer's disease (AD). APP-related proteins are also expressed at high levels in the embryonic nervous system and may serve a variety of developmental functions, including the regulation of neuronal migration. To investigate this issue, we have cloned an orthologue of APP (msAPPL) from the moth, Manduca sexta, a preparation that permits in vivo manipulations of an identified set of migratory neurons (EP cells) within the developing enteric nervous system. Previously, we found that EP cell migration is regulated by the heterotrimeric G protein Goalpha: when activated by unknown receptors, Goalpha induces the onset of Ca2+ spiking in these neurons, which in turn down-regulates neuronal motility. We have now shown that msAPPL is first expressed by the EP cells shortly before the onset of migration and that this protein undergoes a sequence of trafficking, processing, and glycosylation events that correspond to discrete phases of neuronal migration and differentiation. We also show that msAPPL interacts with Goalpha in the EP cells, suggesting that msAPPL may serve as a novel G-protein-coupled receptor capable of modulating specific aspects of migration via Goalpha-dependent signal transduction.

Scalar interaction limits from the beta-nu correlation of trapped radioactive atoms.

We have set limits on contributions of scalar interactions to nuclear beta decay. A magneto-optical trap provides a localized source of atoms suspended in space, so the low-energy recoiling nuclei can freely escape and be detected in coincidence with the beta. This allows reconstruction of the neutrino momentum, and the measurement of the beta-nu correlation, in a more direct fashion than previously possible. The beta-nu correlation parameter of the 0(+)-->0(+) pure Fermi decay of (38)K(m) is a =0.9981+/-0.0030+0.0032 / -0.0037, consistent with the standard model prediction a =1.

Novel roles of neuropeptide processing enzymes: EC3.4.24.15 in the neurome.

Neuropeptide processing metalloenzymes, such as angiotensin converting enzyme, neprilysin, endothelin converting enzyme, neurolysin, and EC3.4.24.15 (EP24.15), are central to the formation and degradation of bioactive peptides. We present EP24.15 as a paradigm for novel functions ascribed to these enzymes in the neurome. Although the neurome typically encompasses proteomes of the brain and central nervous system, exciting new roles of these neuropeptidases have been demonstrated in other organ systems. We discuss the involvement of EP24.15 with clinical sequelae involving the use of gonadotropin-releasing hormone (GnRH; LHRH) analogs that act as enzyme inhibitors, in vascular physiology (blood pressure regulation), and in the hematologic system (immune surveillance). Hemodynamic forces, such as cyclic strain and shear stress, on vascular cells, induce an increase in EP24.15 transcription, suggesting that neuropeptidase-mediated hydrolysis of pressor/depressor peptides is likely regulated by changes in hemodynamic force and blood pressure. Lastly, EP24.15 regulates surface expression of major histocompatibility complex Class I proteins in vivo, suggesting that EP24.15 may play an important role in maintenance of immune privilege in sites of increased endogenous expression. In these extraneural systems, regulation of both neuropeptide and other peptide substrates by neuropeptidases indicates that the influence of these enzymes may be more global than was anticipated previously, and suggests that their attributed role as neuropeptidases underestimates their physiologic actions in the neural system.

Novel search for heavy nu mixing from the beta+ decay of 38mK confined in an atom trap.

A new technique, full neutrino momentum reconstruction, is used to set limits on the admixture of heavy neutrinos into the electron neutrino. We measure coincidences between nuclear recoils and positrons from the beta decay of trapped radioactive atoms and deduce the neutrino momentum. A search for peaks in the reconstructed recoil time-of-flight spectrum as a function of positron energy is performed. The admixture upper limits range from 4 x 10(-3) to 2 x 10(-2) and are the best direct limits for neutrinos (as opposed to antineutrinos) for the mass region of 0.7 to 3.5 MeV.