Prevalence of infections among residents of Residential Care Homes for the Elderly in Hong Kong.

INTRODUCTION: A point prevalence study was conducted to study the epidemiology of common infections among residents in Residential Care Homes for the Elderly in Hong Kong and their associated factors. METHODS: Residential Care Homes for the Elderly in Hong Kong were selected by stratified single-stage cluster random sampling. All residents aged 65 years or above from the recruited homes were surveyed. Infections were identified using standardised definitions. Demographic and health information-including medical history, immunisation record, antibiotic use, and activities of daily living (as measured by Barthel Index)-was collected by a survey team to determine any associated factors. RESULTS: Data were collected from 3857 residents in 46 Residential Care Homes for the Elderly from February to May 2014. A total of 105 residents had at least one type of infection based on the survey definition. The overall prevalence of all infections was 2.7% (95% confidence interval, 2.2%-3.4%). The three most common infections were of the respiratory tract (1.3%; 95% confidence interval, 0.9%-1.9%), skin and soft tissue (0.7%; 95% confidence interval, 0.5%-1.0%), and urinary tract (0.5%; 95% confidence interval, 0.3%-0.9%). Total dependence in activities of daily living, as indicated by low Barthel Index score of 0 to 20 (odds ratio=3.0; 95% confidence interval, 1.4-6.2), and presence of a wound or stoma (odds ratio=2.7; 95% confidence interval, 1.4-4.9) were significantly associated with presence of infection. CONCLUSIONS: This survey provides information about infections among residents in Residential Care Homes for the Elderly in the territory. Local data enable us to understand the burden of infections and formulate targeted measures for prevention.

Heterogeneity and disparities in the use of exception scores in pediatric liver allocation.

Physicians apply for Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease exception points on a case-by-case basis to improve an individual patient's chances of receiving a liver transplant. This retrospective cohort study describes trends in the use of exceptions among the pediatric liver waitlist population with chronic liver disease. The cohort (n = 3728) included all children with a diagnosis of chronic liver disease listed in the United Network for Organ Sharing transplant database for first isolated liver transplant between February 27, 2002 and March 31, 2013. Exception score requests were common (34%); 90% of requests were approved. The rate of exception score requests in 2013 was five times that of 2002 (incident rate ratios [IRR] 5.25, 95% confidence interval [CI] 3.19-8.63, p < 0.01). Patients of non-White race had exception score request rates 13% lower than patients of White race (IRR 0.87, 95% CI 0.77-0.98, p = 0.02). Older patients had lower rates of exception score requests than younger patients (p = 0.03). Request rates varied by region. Time spent at an active exception status nearly tripled the hazard rate for transplantation (hazard ratio = 2.90, 95% CI 2.62-3.21, p < 0.01). There is disparity in use of exceptions by race that is not explained by clinical disease severity, diagnosis, geography or other demographic factors.

Low levels of C-peptide have clinical significance for established Type 1 diabetes.

AIM: To determine whether the low C-peptide levels (< 50 pmol/l) produced by the pancreas for decades after onset of Type 1 diabetes have clinical significance. METHODS: We evaluated fasting C-peptide levels, duration of disease and age of onset in a large cross-sectional series (n = 1272) of people with Type 1 diabetes. We then expanded the scope of the study to include the relationship between C-peptide and HbA1c control (n = 1273), as well as diabetic complications (n = 324) and presence of hypoglycaemia (n = 323). The full range of C-peptide levels was also compared with 1,5-Anhydroglucitol, a glucose responsive marker. RESULTS: C-peptide levels declined for decades after diagnosis, and the rate of decline was significantly related to age of onset (P < 0.0001), after adjusting for disease duration. C-peptide levels > 10 pmol/l were associated with protection from complications (e.g. nephropathy, neuropathy, foot ulcers and retinopathy; P = 0.03). Low C-peptide levels were associated with poor metabolic control measured by HbA1c (P < 0.0001). Severe hypoglycaemia was associated with the lowest C-peptide levels compared with mild (P = 0.049) or moderate (P = 0.04) hypoglycaemia. All levels of measurable C-peptide were responsive to acute fluctuations in blood glucose levels as assessed by 1,5-Anhydroglucitol (P < 0.0001). CONCLUSIONS: Low C-peptide levels have clinical significance and appear helpful in characterizing groups at-risk for faster C-peptide decline, complications, poorer metabolic control and severe hypoglycaemia. Low C-peptide levels may be a biomarker for characterizing at-risk patients with Type 1 diabetes.

Epidural adhesiolysis: an evidence-based review.

First described over 25 years ago, epidural lysis of adhesions (LOA) involves the mechanical dissolution of epidural scar tissue, which may directly alleviate pain and facilitate the spread of analgesic substances to area(s) of pain generation. Although it most commonly performed for lumbar failed back surgery syndrome, there is a growing body of evidence that suggests it may be effective for spinal stenosis and radicular pain stemming from a herniated disc. There is weak positive evidence that LOA is more effective than conventional caudal epidural steroid injections for failed back surgery syndrome and spinal stenosis, and that LOA is more effective than sham adhesiolysis and conservative management for lumbosacral radiculopathy. For cervical disc herniation and spinal stenosis, there is only anecdotal evidence suggesting effectiveness and safety. Factors that may contribute to the enhanced efficacy compared to traditional epidural steroid administration include the high volume administered, the use of hypertonic saline, and to a lesser extent the use of hyaluronidase and a navigable catheter to mechanically disrupt scar tissue and guide medication administration. Although LOA is widely considered a safe intervention, the complication rates are higher than for conventional epidural steroid injection.

Rearrangement of immunoglobulin genes in shark germ cells.

The variable (V), (diversity [D]), and joining (J) region recombinases (recombination activating genes [RAGs]) can perform like transposases and are thought to have initiated development of the adaptive immune system in early vertebrates by splitting archaic V genes with transposable elements. In cartilaginous fishes, the immunoglobulin (Ig) light chain genes are organized as multiple VJ-constant (C) clusters; some loci are capable of rearrangement while others contain fused VJ. The latter may be key to understanding the evolutionary role of RAG. Are they relics of the archaic genes, or are they results of rearrangement in germ cells? Our data suggest that some fused VJ genes are not only recently rearranged, but also resulted from RAG-like activity involving hairpin intermediates. Expression studies show that these, like some other germline-joined Ig sequences, are expressed at significant levels only early in ontogeny. We suggest that a rejoined Ig gene may not merely be a sequence restricting antibody diversity, but is potentially a novel receptor no longer tied to somatic RAG expression and rearrangement. From the combined data, we arrived at the unexpected conclusion that, in some vertebrates, RAG is still an active force in changing the genome.

Stimulation of all epithelial elements during skin regeneration by keratinocyte growth factor.

Keratinocyte growth factor (KGF), a recently discovered 18.9 kD member of the fibroblast growth factor family has been shown to selectively induce keratinocyte proliferation and differentiation in tissue culture. To explore its potential stimulating keratinocyte growth and differentiation in vivo, we analyzed for the influence of KGF on epithelial derived elements within a wound created through the cartilage on the rabbit ear. KGF accelerated reepithelialization (p = 0.004) and increased the thickness of the epithelium (p = 0.0005) when 4-40 micrograms/cm2 recombinant KGF was added at the time of wounding. The regenerating epidermis showed normal differentiation as detected by cytokeratin immunostaining. Remarkably, however, KGF stimulated proliferation and differentiation of early progenitor cells within hair follicles and sebaceous glands in the wound bed and adjacent dermis. There was a transient but highly significant increase in specific labeling of cycling cells in both basal and suprabasal layers that extended into the spinous layer of the regenerating epidermis. As an indication of specificity, the inflammatory cells and fibroblasts within the wound were not influenced by KGF. The results indicate that KGF is unique in its ability to accelerate reepithelialization and dermal regeneration by targeting multiple epithelial elements within the skin. These results suggest that KGF may induce specific epithelial progenitor cell lineages within the skin to proliferate and differentiate, and thus may be a critical determinant of regeneration of skin. Furthermore, these findings illustrate the potential capacity of this system to analyze epithelial differentiation programs and disorders of epidermis, dermal glandular elements, and hair follicles.

Magnetic resonance imaging for three-dimensional printing of the bony orbit: is clinical use imminent?

The aim of this study was to examine the accuracy of three dimensionally (3D) printed models of the bony orbit derived from magnetic resonance imaging (MRI) for the purpose of preoperative plate bending in the setting of orbital blowout fracture. Retrospective computed tomography (CT) and MRI data from patients with suspected orbital fractures were used. Virtual models were manually generated and analysed for spatial accuracy of the fracture margins. 3D-printed models were produced and orbital fan plates bent by a single operator. The plates were then digitized and analysed for spatial discrepancy using reverse engineering software. Seven orbital blowout fractures were evident in six orbits. Analysis of the virtual models revealed high congruence between blowout fracture margins on CT and MRI (n=7, average deviation 0.85mm). Three zygomaticomaxillary complex fractures were seen, for which MRI did not demonstrate the same accuracy. For plates bent to the 3D-printed models of blowout fractures (n=6), no significant difference was found between those bent to CT versus those bent to MRI when compared for average surface and average border deviation (Wilcoxon signed rank test). Orbital blowout fractures can be defined on MRI with clinically acceptable accuracy. 3D printing of orbital biomodels from MRI for bending reconstructive plates is an acceptable and accurate technique.

Injury trends in sanctioned mixed martial arts competition: a 5-year review from 2002 to 2007.

BACKGROUND: Professional mixed martial arts (MMA) competition is a full-contact sport that has risen rapidly in popularity in recent years. However, there is limited information regarding the incidence of competition injuries after sanctioning by an athletic commission. METHODS: We conducted a retrospective cohort study to examine MMA injury patterns during a 5 year period after sanctioning in the state of Nevada. Data from all regulated MMA competitions during the study period from March 2002 to September 2007 (1270 fight exposures) was obtained. Injury odds ratios were calculated by conditional logistic regression on match outcome, age, weight, and fight experience, using a pair-matched case-control design (n = 464) and by multiple logistic regression on match outcome, age, fight experience, weight, combat minutes, and scheduled rounds. RESULTS: During the 635 professional MMA matches, 300 of the 1270 athletes sustained documented injuries with an injury rate of 23.6 per 100 fight participations. Most common reported injuries were lacerations and upper limb injuries. Severe concussion rate was 15.4 per 1000 athlete exposures, or 3% of all matches. No deaths or critical sports-related injuries resulted from any of the regulated matches during the study period. Age, weight and fight experience did not statistically increase the likelihood of injuries after controlling for other covariates. CONCLUSIONS: Injury rates in regulated professional MMA competition are similar to other combat sports; the overall risk of critical sports-related injury seems to be low. Additional study is warranted to achieve a better understanding of injury trends and ways to further lower injury risk in MMA.

Effectiveness of irrigation with chlorhexidine after removal of mandibular third molars: a randomised controlled trial.

To evaluate the effect of postoperative irrigation with chlorhexidine on inflammatory complications after the extraction of lower third molars under local anaesthesia, we recruited 100 patients to participate in a controlled, single-blind, randomised clinical trial. They were assigned to one of two groups: the intervention group (postoperative irrigation of the surgical site with chlorhexidine for seven days) or the control group (postoperative chlorhexidine mouth rinse for seven days). The primary outcome variables were pain, swelling, trismus, infection, and alveolar osteitis. The secondary outcome variables were wound dehiscence and food impaction. A total of 95 participants completed the study (47 in the irrigation group and 48 in the rinse group). In the irrigation group, alveolar osteitis and facial swelling had reduced significantly at seven days postoperatively (both p<0.01). Pain scores had also reduced significantly at seven days (p<0.01), but not at 48hours, and patients had lower levels of food impaction (p<0.01) and less severe symptoms (p=0.02). Routine irrigation with chlorhexidine after the extraction of third molars helps to reduce pain and lowers the incidence of alveolar osteitis.

Quantitative Survey of Laypersons' Attitudes Toward Organ Transplantation in Japan.

BACKGROUND: In comparison with foreign countries, living-organ transplantations (LOT) have been performed more frequently than dead organ transplants, including brain-dead organ transplantation (BOT) in Japan. This situation has given rise to organ transplantation tourism. Therefore, we clarify laypersons' preferences regarding organ transplantation that are producing the current situation in Japan, to suggest a possible framework for further efforts. METHODS: Voluntary completion of a quantitative and anonymous survey was promoted online (a sample size of 1030). The questionnaire had two types of variables concerning demographic characteristics and organ transplantation-related issues. RESULTS: LOT was favored over BOT. However, for willingness to donate to family members, the participants showed a significantly more positive attitude toward brain-dead organ donors (BODs) than living organ donors (LODs). In the evaluation of each transplantation technology, BOT and LOT were positioned in the middle, between transplantation that does not depend on others and the utilization of animal organs. CONCLUSIONS: Although LOT was favored over BOT, for participants hypothesized to be in a position to donate and receive organs, BODs received a conversely better reputation than LODs. Our survey and discussion suggest that the present conditions of organ transplantation in Japan might be because there is a lack of deliberation on transplantation tourism and LOT. Therefore, more surveys concerning LOT cases and the implications of avoidance of organs from brain-dead bodies, coupled with more discussions based on these surveys, are necessary to formulate a Japanese transplantation policy for the future.

Extended follow-up and impact of high-risk prognostic factors from the phase 3 RESONATE study in patients with previously treated CLL/SLL.

In the phase 3 RESONATE study, ibrutinib demonstrated superior progression-free survival (PFS), overall survival (OS) and overall response rate (ORR) compared with ofatumumab in relapsed/refractory CLL patients with high-risk prognostic factors. We report updated results from RESONATE in these traditionally chemotherapy resistant high-risk genomic subgroups at a median follow-up of 19 months. Mutations were detected by Foundation One Heme Panel. Baseline mutations in the ibrutinib arm included TP53 (51%), SF3B1 (31%), NOTCH1 (28%), ATM (19%) and BIRC3 (14%). Median PFS was not reached, with 74% of patients randomized to ibrutinib alive and progression-free at 24 months. The improved efficacy of ibrutinib vs ofatumumab continues in all prognostic subgroups including del17p and del11q. No significant difference within the ibrutinib arm was observed for PFS across most genomic subtypes, although a subset carrying both TP53 mutation and del17p had reduced PFS compared with patients with neither abnormality. Reduced PFS or OS was not evident in patients with only del17p. PFS was significantly better for ibrutinib-treated patients in second-line vs later lines of therapy. The robust clinical activity of ibrutinib continues to show ongoing efficacy and acceptable safety consistent with prior reports, independent of various known high-risk mutations.

Postoperative interventions to reduce inflammatory complications after third molar surgery: review of the current evidence.

Inflammatory complications such as pain, swelling, trismus, infection and alveolar osteitis have an adverse affect on the quality of life of patients after third molar removal. This review presents the current evidence on postoperative strategies to reduce these complications. A literature search was performed to identify articles published in English between 2000 to 2016 using the following keywords: third molar(s), wisdom tooth/teeth, pain, swelling, trismus, infection, alveolar osteitis and dry socket. In total, 221 papers were reviewed. Methods published included analgesics, antibiotics, corticosteroids, mouthwashes, topical gels, cryotherapy and ozone therapy. This review highlights the variability in evidence available and summarizes the findings from best-quality evidence. In conclusion, paracetamol and ibuprofen are efficacious in managing postoperative pain. Corticosteroids and antibiotics should only be used in selected cases. Chlorhexidine reduces alveolar osteitis. The benefits of cryotherapy, postoperative irrigation and ozone gel are yet to be established.

Cancer Moonshot Data and Technology Team: Enabling a National Learning Healthcare System for Cancer to Unleash the Power of Data.

The Cancer Moonshot emphasizes the need to learn from the experiences of cancer patients to positively impact their outcomes, experiences, and qualities of life. To realize this vision, there has been a concerted effort to identify the fundamental building blocks required to establish a National Learning Healthcare System for Cancer, such that relevant data on all cancer patients is accessible, shareable, and contributing to the current state of knowledge of cancer care and outcomes.

Leptin resistance following over-expression of protein tyrosine phosphatase 1B in liver.

Obesity is typically associated with resistance to leptin, yet the mechanism by which leptin signaling becomes impaired is poorly understood. Here we sought to determine if the development of obesity and leptin resistance correlates with increased expression of protein tyrosine phosphatase 1B (PTP1B) in peripheral tissues and whether over-expression of this phosphatase, specifically in liver, could alter the leptin-mediated effects on feeding and glucose metabolism. Obesity was induced in mice through a high-fat diet that resulted in hyperglycemia, hyperinsulinemia and hyperleptinemia. Resistance to leptin was confirmed as exogenous leptin administration reduced food intake in animals on low-fat, but not high-fat diets. Diet-induced resistance to leptin and insulin was associated with increased hepatic levels of PTP1B. Intriguingly, hepatic adenoviral over-expression of PTP1B in ob/ob mice attenuated the ability of exogenous leptin to reduce both plasma glucose levels and food intake. These findings suggest that leptin reduces both plasma glucose and food intake in part through actions on the liver, and hepatic leptin resistance resulting from over-expression of PTP1B may contribute to the development of both diabetes and obesity.

Case of the month: Right coronary artery dissection following sports-related blunt trauma.

Coronary artery dissection is a rare life-threatening complication resulting from blunt traumatic injury. Most cases of coronary artery injury, including dissection, involve the left anterior descending artery given its anatomical location relative to the impact. Right coronary artery (RCA) dissection secondary to blunt trauma is a particularly unusual occurrence, and has not previously been reported in the emergency medicine literature. We present a case of RCA dissection following low impact sport-related blunt chest trauma and discuss the pathophysiology, risk factors, diagnosis and current treatment options.

Regulation of renal sulfoglycolipid biosynthesis.

The in vitro activity of the renal galactolipid sulfotransferase and the level of sulfated glycolipids in the rat kidney have been correlated as a function of age. The galactolipid sulfotransferase was found to be greatly reduced in the young as compared with the adult animal. The relatively minor changes in the sulfated glycolipid content of the kidney with age suggests that an increase in sulfoglycolipid turnover occurs during growth. An inhibitory activity was detected in the homogenate supernate of the young animal capable of reducing the in vitro sulfotransferase activity of the adult. Assay of the human renal galactolipid sulfotransferase showed that this enzyme activity is deleted in samples of the blastematous form of Wilm's renal tumor. The results suggest that the rate of synthesis of renal sulfoglycolipids may prove a marker of renal development, perhaps by post translational regulation.

Recycling rates of waste home appliances in Taiwan.

The objective of this study is to provide a calculation of recycling rates of waste home appliances in Taiwan, for the EPA to amend these rates in order to increase the recycling efficiency. The recycling rate is calculated by a formula according to the statistical results obtained through: (1) an estimation of domestic use of home appliances using time series analysis with multiplicative seasonal ARIMA model, (2) a further estimation of generated waste home appliances based upon the estimated domestic use and the corresponding distribution of lifetime span, and (3) a cost analysis of recycling home appliances based on a sampling survey with stratified systematic sampling conducted among collectors and a survey on five recycling plants of waste home appliances. The suggested recycling rates in this study finally used by the EPA show that all of the recycling rates have increased compared with the rates in previous years. This study also implies that amending the recycling rates may only solve some recycling problems temporarily; however, the recycling system of waste home appliances in Taiwan has to be reformed to increase the recycling efficiency for the long term.

Studies on Xenopus immunoglobulins using monoclonal antibodies.

Monoclonal antibodies raised against Xenopus Ig recognize antigenic determinants on IgM and low mol. wt Ig (LMW Ig or IgY ). On SDS-PAGE two forms of mu were distinguished in the supernatant and cell lysate of tunicamycin-treated spleen cell culture. The two bands of v observed in serum appear to be the result of carbohydrate heterogeneity. The light chains resolved into two distinct bands which differed in peptide maps; the more slowly migrating band of light chain was preferentially associated with v. Patterns of cross-reactivity between the immunoglobulins of 11 species of Xenopus and three subspecies of Xenopus laevis were obtained; the polymorphism of mu and v antigenic determinants and its implications for species divergence are discussed.

Junctional diversity in Xenopus immunoglobulin light chains.

Xenopus cDNA sequences encoding the homolog of mammalian kappa (kappa) light (L) chains were isolated from isogenic tadpole and adult individuals to investigate whether there existed stage-specific immunoglobulin L chain expression and somatic diversification. In the course of these studies rearrangements to a sixth J(L) gene segment and a pseudogene (J(L)psi) were found, and it is suggested that the order of these gene segments with respect to the L chain constant (C) region exon is: J(L)6-J(L)1-J(L)2-J(L)3-J(L)4-J(L)5-J(L)psi-C(L). The cDNA junctional diversity was analyzed; few N and P regions were found and almost all the CDR3 were 9 codons in length. There were restricted patterns of recombination site resolution, and this is attributed to some constraint in JL coding end processing.