Standardizing the classification of skin tears: validity and reliability testing of the International Skin Tear Advisory Panel Classification System in 44 countries.

BACKGROUND: Skin tears are acute wounds that are frequently misdiagnosed and under-reported. A standardized and globally adopted skin tear classification system with supporting evidence for diagnostic validity and reliability is required to allow assessment and reporting in a consistent way. OBJECTIVES: To measure the validity and reliability of the International Skin Tear Advisory Panel (ISTAP) Classification System internationally. METHODS: A multicountry study was set up to validate the content of the ISTAP Classification System through expert consultation in a two-round Delphi procedure involving 17 experts from 11 countries. An online survey including 24 skin tear photographs was conducted in a convenience sample of 1601 healthcare professionals from 44 countries to measure diagnostic accuracy, agreement, inter-rater reliability and intrarater reliability of the instrument. RESULTS: A definition for the concept of a 'skin flap' in the area of skin tears was developed and added to the initial ISTAP Classification System consisting of three skin tear types. The overall agreement with the reference standard was 0·79 [95% confidence interval (CI) 0·79-0·80] and sensitivity ranged from 0·74 (95% CI 0·73-0·75) to 0·88 (95% CI 0·87-0·88). The inter-rater reliability was 0·57 (95% CI 0·57-0·57). The Cohen's Kappa measuring intrarater reliability was 0·74 (95% CI 0·73-0·75). CONCLUSIONS: The ISTAP Classification System is supported by evidence for validity and reliability. The ISTAP Classification System should be used for systematic assessment and reporting of skin tears in clinical practice and research globally. What's already known about this topic? Skin tears are common acute wounds that are misdiagnosed and under-reported too often. A skin tear classification system is needed to standardize documentation and description for clinical practice, audit and research. What does this study add? The International Skin Tear Advisory Panel Classification System was psychometrically tested in 1601 healthcare professionals from 44 countries. Diagnostic accuracy was high when differentiating between type 1, 2 and 3 skin tears using a set of validated photographs.

Outcomes after foot surgery in people with a diabetic foot ulcer and a 12-month follow-up.

OBJECTIVE: The aim of this study was to retrospectively measure the outcomes of foot-sparing surgery at one year follow-up for patients with diabetic foot ulcers (DFUs). We assessed wound healing and the need for further surgery in relation to the variables that influence healing. METHOD: Data were retrospectively collected by reviewing the electronic files of patients attending the Wound Expert Clinic (WEC). Outcomes of surgical debridement, toe, ray and transmetatarsal amputations were assessed. RESULTS: A total of 129 cases in 121 patients were identified for inclusion. The results demonstrated that complete wound healing was reached in 52% (61/117) of the patients within 12 months. The need for additional surgery or for major amputation was 56% (n=72/129) and 30% (n=39/129) respectively. The need for an additional procedure was particularly high after surgical debridement (75%, 33/44) and transmetatarsal amputation (64%, 7/11). Risk factors for non-healing or for a major amputation were: infection (p=0.01), ischaemia (p=0.01), a history of peripheral arterial occlusive disease (p<0.01) and smoking (p=0.01). Additional findings were that not all patients underwent vascular assessment and in half of the patients there was a delay in undergoing revascularisation. CONCLUSION: The results of the study reveal some areas for improvement including timely revascularisation and performance of multiple debridement procedures if needed in order to save a limb.

Receiving or believing in family support? Contributors to the life quality of Latino and non-Latino families of children with intellectual disability.

BACKGROUND: Previous studies have identified the role of family support in mitigating the stress of parents caring for a child with intellectual disability. Less is known about families whose members are willing but unable to support each other because of geographical, structural and economic barriers. Our study examined the contribution to family quality of life (FQL) of family support beliefs, actual assistance from family members, as well as the moderating effects of ethnicity and household income. METHOD: We conducted telephone interviews with 84 Latino and 61 non-Latino mothers. RESULTS: Mothers who received more emotional support from partners and other family members reported a higher FQL, controlling for family characteristics. Familism beliefs were also associated with FQL, particularly for Latino mothers. Income was not a significant moderator. CONCLUSIONS: These findings suggest that some predictors of FQL are partially moderated by ethnicity, while others may be powerful across diverse communities.

FISH mapping of de novo apparently balanced chromosome rearrangements identifies characteristics associated with phenotypic abnormality.

We report fluorescence in situ hybridization (FISH) mapping of 152, mostly de novo, apparently balanced chromosomal rearrangement (ABCR) breakpoints in 76 individuals, 30 of whom had no obvious phenotypic abnormality (control group) and 46 of whom had an associated disease (case group). The aim of this study was to identify breakpoint characteristics that could discriminate between these groups and which might be of predictive value in de novo ABCR (DN-ABCR) cases detected antenatally. We found no difference in the proportion of breakpoints that interrupted a gene, although in three cases, direct interruption or deletion of known autosomal-dominant or X-linked recessive Mendelian disease genes was diagnostic. The only significant predictor of phenotypic abnormality in the group as a whole was the localization of one or both breakpoints to an R-positive (G-negative) band with estimated predictive values of 0.69 (95% CL 0.54-0.81) and 0.90 (95% CL 0.60-0.98), respectively. R-positive bands are known to contain more genes and have a higher guanine-cytosine (GC) content than do G-positive (R-negative) bands; however, whether a gene was interrupted by the breakpoint or the GC content in the 200 kB around the breakpoint had no discriminant ability. Our results suggest that the large-scale genomic context of the breakpoint has prognostic utility and that the pathological mechanism of mapping to an R-band cannot be accounted for by direct gene inactivation.

Paediatric referral and attendance rates for the clinical genetics service in south-east Scotland--a comparison of a regional clinic with satellite clinics.

BACKGROUND AND AIMS: In some studies the establishment of specialist satellite clinics nearer to the homes of patients has resulted in increased referral and attendance rates, particularly amongst populations in lower socio-economic groups. We investigated the effect on these rates of establishing satellite genetic counselling clinics for families with paediatric conditions in South East Scotland. METHODS AND RESULTS: Families offered appointments at a clinic at the regional paediatric hospital were compared with those offered appointments at a satellite clinic at a local district general hospital. Both groups of families were more socially deprived than the general population (regional clinic p < 0.001, satellite clinics p < 0.05), and in both groups attendance rate at first appointment was 88% and inversely related to social deprivation. There was no evidence of greater attendance amongst more deprived patients at the satellite clinics compared to the regional clinic. CONCLUSION: Our study found no evidence that the establishment of satellite clinics for genetic counselling in South East Scotland increases attendance by families with paediatric conditions in lower socio-economic groups. This suggests that factors other than clinic location determine referral and attendance rates, and these may include understanding of the reason for referral and the advantage of attendance.

Molecular characterization of a novel fastidious mycobacterium causing lepromatous lesions of the skin, subcutis, cornea, and conjunctiva of cats living in Victoria, Australia.

Between 1999 and 2006, 15 cats were diagnosed with disease attributable to a novel mycobacterial species. The infections consisted of granulomatous lesions in the skin, subcutis, and ocular or periocular tissues with an indolent but progressive clinical course. Lesions typically were found in facial regions or on the distal limbs. Cats of all ages and both sexes were affected. Infections often were challenging to treat, although they could be cured using surgery in concert with combination antimicrobial therapy. Microscopically, lesions were granulomatous to pyogranulomatous and contained numerous acid-fast bacilli. Scanty cultures of the causal microorganisms occasionally could be obtained in mycobacterial broth, but subculture to solid media failed. When cultures were not available, DNA was extracted from fresh tissue, lyophilized material, and formalin-fixed, paraffin-embedded tissues from lesions. PCR amplification of the 5' end of the 16S rRNA gene and regions within four additional loci (ITS1, hsp65, rpoB, and sodA) was performed with various efficiencies using mycobacterial primers. Nucleotide sequences were unique for each locus tested. Nucleotide sequences obtained from individual cases were identical for each locus for which the amplification was successful. Phylogenetic analysis performed using concatenated partial 16S rRNA and hsp65 gene sequences indicated that this novel mycobacterial species from Victoria is a member of the Mycobacterium simiae-related group, taxonomically related to the mycobacterium causing leproid granulomas in dogs throughout the world. Based on the clustering of cases, we refer to this novel species as Mycobacterium sp. strain Tarwin.

Sister chromatid separation in vivo and in vitro.

The proteins that are involved in the mechanics of sister chromatid separation and that regulate this process are (as yet) largely unknown. Topoisomerase II activity is known to be essential for sister chromatid separation, probably to decatenate sister chromatids that have remained linked until the metaphase/anaphase transition, but other unidentified proteins are also required. An in vitro sister chromatid separation assay has been developed recently that complements the previously existing techniques used to study the process. This assay had led to some new insights into sister chromatid separation, showing, for example, that the process is regulated by ubiquitin-mediated proteolysis of protein(s) that are not known mitotic cyclins.

Further evidence of the increased risk for malignant peripheral nerve sheath tumour from a Scottish cohort of patients with neurofibromatosis type 1.

A recent study, looking at the lifetime risk of developing malignant peripheral nerve sheath tumour (MPNST) in patients with neurofibromatosis type 1 (NF1), estimated the risk to be 8-13%. Prior to this, longitudinal studies had shown that patients with NF1 had a risk of 4-5% of developing MPNST, and cross-sectional studies had found that only 1-2% of patients with NF1 had MPNST. The aim of this study was to estimate the lifetime risk of MPNST in patients with NF1 in southern Scotland, using patient records obtained from the Edinburgh and Glasgow Genetic Units and Scottish Cancer Register. In the period 1993-2002, 14 patients with NF1 were diagnosed with MPNST in a population of 3.5 million. The lifetime risk of MPNST in the Scottish patients with NF1 was calculated to be 5.9-10.3%. This provides further evidence that patients with NF1 are at greater risk of developing MPNST than was previously estimated, and emphasises the importance of educating patients about suspicious symptoms, which may need an urgent medical opinion. The mean age at diagnosis of MPNST (p<0.05) and 5-year survival (p<0.01) were significantly lower in patients with NF1 than in unaffected individuals. This may be due to patients with NF1 presenting later, because the tumour is mistaken for a neurofibroma, or due to MPNST having a more aggressive course in NF1.

Molecular subtyping of feline immunodeficiency virus from cats in Melbourne.

OBJECTIVE: To determine the subtypes of feline immunodeficiency virus (FIV) present in the domestic cat population in Melbourne. METHODS: Blood samples were collected from 42 cats that had serum antibodies against FIV. DNA was extracted and subjected to polymerase chain reaction (PCR) to amplify variable regions of the envelope (env) and group specific antigen (gag) genes of FIV. PCR products were directly sequenced or sequenced after cloning when direct sequencing yielded ambiguous results. Phylogenetic analysis was performed and comparisons made with representative sequences of different subtypes. RESULTS: The variable region of the env gene was successfully amplified by PCR from 41 of the 42 cats. All 41 were found to cluster with subtype A env sequences. The variable region of the gag gene was successfully amplified by PCR from all 42 cats. Forty-one were found to cluster with subtype A gag genes and one was found to cluster with subtype B sequences, suggesting that it may be derived from a recombinant env A/gag B virus. CONCLUSIONS: Subtype A is the predominant FIV type in Melbourne, although a subtype A/B recombinant was identified in the population of FIV positive cats. These results of env gene analysis were similar to those in a previous Australian study, suggesting that subtype A predominates in Australia. The results of the gag gene analysis show the importance of analysing multiple areas of the FIV genome when assigning FIV subtypes. Comparison with other major urban centres may provide useful information about the phylogenic diversity of FIV in Australia.

Dysgonic strain of Microsporum canis pseudomycetoma in a Domestic Long-hair cat.

A 4-year-old Domestic Long-hair cat was presented with two large non-painful, ulcerated and suppurative lesions over the flanks. Histopathology and cytology were consistent with fungal pyogranulomatous inflammation. Culture of tissue yielded a dysgonic strain of Microsporum canis. The cat was treated successfully by staged en bloc resections of the lesions, followed by oral ketoconazole, then oral terbinafine. This is the first reported case of dermatophytic pseudomycetoma in a Domestic Long-hair cat in Australia.

S-phase cyclins are required for a stable arrest at metaphase.

A critical DNA damage checkpoint in Saccharomyces cerevisiae is an arrest at the metaphase stage of mitosis. Here we show that the S-phase cyclins Clb5 and Clb6 are required for this arrest. Strains lacking Clb5 and Clb6 are hypersensitive to DNA damage. Furthermore, in the presence of the DNA alkylating agent methyl methanesulfonate (MMS) over 50% of clb5 clb6 mutants by-passed the metaphase checkpoint and arrested instead with separated sister chromatids. Levels of Pds1, an inhibitor of anaphase that accumulates following DNA damage, were similar in the wild-type and mutant strains following MMS treatment. Furthermore, unlike wild-type cells, clb5 clb6 mutants undergo nuclear division despite the presence of nuclear non-degradable Pds1. Our results suggest a novel role for the S-phase cyclins Clb5 and Clb6 in maintaining sister chromatid cohesion during a metaphase arrest, perhaps by regulating Pds1 activity.

The KEN box regulates Clb2 proteolysis in G1 and at the metaphase-to-anaphase transition.

Clb2 mitotic cyclin inhibits cell cycle progression by preventing mitotic exit and DNA synthesis. To allow cell cycle progression, Clb2 proteolysis is triggered by Cdc20 during the metaphase-to-anaphase (M-A) transition and by Hct1 during mitotic exit and G1 [1-6]. A cis element called the destruction box is required for this proteolysis [7-11]. Recently, an additional cis element called the "KEN box" was also shown to be required for proteolysis of human CDC20 and Securin [3,12]. Using a novel color assay, we show that a Clb2 KEN box is required to target a fusion protein containing the first 124 amino acids of Clb2 for proteolysis. We further show that full-length Clb2 bearing mutations in the KEN box is degraded efficiently during the M-A transition, but poorly during G1. If the destruction box of Clb2 is mutated in combination with mutation of the KEN box, then this form of Clb2 is more stable than Clb2 bearing either mutation by itself during both M-A and G1. Our results show that the KEN box and the destruction box act together during both M-A and G1 to regulate Clb2 proteolysis.

Mobile self-splicing group I introns from the psbA gene of Chlamydomonas reinhardtii: highly efficient homing of an exogenous intron containing its own promoter.

Introns 2 and 4 of the psbA gene of Chlamydomonas reinhardtii chloroplasts (Cr.psbA2 and Cr.psbA4, respectively) contain large free-standing open reading frames (ORFs). We used transformation of an intronless-psbA strain (IL) to test whether these introns undergo homing. Each intron, plus short exon sequences, was cloned into a chloroplast expression vector in both orientations and then cotransformed into IL along with a spectinomycin resistance marker (16S rrn). For Cr.psbA2, the sense construct gave nearly 100% cointegration of the intron whereas the antisense construct gave 0%, consistent with homing. For Cr.psbA4, however, both orientations produced highly efficient cointegration of the intron. Efficient cointegration of Cr.psbA4 also occurred when the intron was introduced as a restriction fragment lacking any known promoter. Deletion of most of the ORF, however, abolished cointegration of the intron, consistent with homing. The Cr.psbA4 constructs also contained a 3-(3,4-dichlorophenyl)-1,1-dimethylurea resistance marker in exon 5, which was always present when the intron integrated, thus demonstrating exon coconversion. Remarkably, primary selection for this marker gave >100-fold more transformants (>10,000/microgram of DNA) than did the spectinomycin resistance marker. A trans homing assay was developed for Cr.psbA4; the ORF-minus intron integrated when the ORF was cotransformed on a separate plasmid. This assay was used to identify an intronic region between bp -88 and -194 (relative to the ORF) that stimulated homing and contained a possible bacterial (-10, -35)-type promoter. Primer extension analysis detected a transcript that could originate from this promoter. Thus, this mobile, self-splicing intron also contains its own promoter for ORF expression. The implications of these results for horizontal intron transfer and organelle transformation are discussed.

A method for acquiring random range uncertainty probability distributions in proton therapy.

In treatment planning we depend upon accurate knowledge of geometric and range uncertainties. If the uncertainty model is inaccurate then the plan will produce under-dosing of the target and/or overdosing of OAR. We aim to provide a method for which centre and site-specific population range uncertainty due to inter-fraction motion can be quantified to improve the uncertainty model in proton treatment planning. Daily volumetric MVCT data from previously treated radiotherapy patients has been used to investigate inter-fraction changes to water equivalent path-length (WEPL). Daily image-guidance scans were carried out for each patient and corrected for changes in CTV position (using rigid transformations). An effective depth algorithm was used to determine residual range changes, after corrections had been applied, throughout the treatment by comparing WEPL within the CTV at each fraction for several beam angles. As a proof of principle this method was used to quantify uncertainties for inter-fraction range changes for a sample of head and neck patients of [Formula: see text] mm, [Formula: see text] mm and overall [Formula: see text] mm. For prostate [Formula: see text] mm, [Formula: see text] mm and overall [Formula: see text] mm. The choice of beam angle for head and neck did not affect the inter-fraction range error significantly; however this was not the same for prostate. Greater range changes were seen using a lateral beam compared to an anterior beam for prostate due to relative motion of the prostate and femoral heads. A method has been developed to quantify population range changes due to inter-fraction motion that can be adapted for the clinic. The results of this work highlight the importance of robust planning and analysis in proton therapy. Such information could be used in robust optimisation algorithms or treatment plan robustness analysis. Such knowledge will aid in establishing beam start conditions at planning and for establishing adaptive planning protocols.

Antimicrobial Prescribing in Dogs and Cats in Australia: Results of the Australasian Infectious Disease Advisory Panel Survey.

BACKGROUND: Investigations of antimicrobial use in companion animals are limited. With the growing recognition of the need for improved antimicrobial stewardship, there is urgent need for more detailed understanding of the patterns of antimicrobial use in this sector. OBJECTIVES: To investigate antimicrobial use for medical and surgical conditions in dogs and cats by Australian veterinarians. METHODS: A cross-sectional study was performed over 4 months in 2011. Respondents were asked about their choices of antimicrobials for empirical therapy of diseases in dogs and cats, duration of therapy, and selection based on culture and susceptibility testing, for common conditions framed as case scenarios: 11 medical, 2 surgical, and 8 dermatological. RESULTS: A total of 892 of the 1,029 members of the Australian veterinary profession that completed the survey satisfied the selection criteria. Empirical antimicrobial therapy was more common for acute conditions (76%) than chronic conditions (24%). Overall, the most common antimicrobial classes were potentiated aminopenicillins (36%), fluoroquinolones (15%), first- and second-generation cephalosporins (14%), and tetracyclines (11%). Third-generation cephalosporins were more frequently used in cats (16%) compared to dogs (2%). Agreement with Australasian Infectious Disease Advisory Panel (AIDAP) guidelines (generated subsequently) was variable ranging from 0 to 69% between conditions. CONCLUSIONS AND CLINICAL IMPORTANCE: Choice of antimicrobials by Australian veterinary practitioners was generally appropriate, with relatively low use of drugs of high importance, except for the empirical use of fluoroquinolones in dogs, particularly for otitis externa and 3rd-generation cephalosporins in cats. Future surveys will determine whether introduction of the 2013 AIDAP therapeutic guidelines has influenced prescribing habits.

CHL1 is a nuclear protein with an essential ATP binding site that exhibits a size-dependent effect on chromosome segregation.

Saccharomyces cerevisiae chl1 mutants have a significant increase in the rate of chromosome missegregation. CHL1 encodes a 99 kDa predicted protein with an ATP binding site consensus, a putative helix-turn-helix DNA binding motif, and homology to helicases. Using site-directed mutagenesis, I show that mutations that are predicted to abolish ATP binding in CHL1 inactivate its function in chromosome segregation. Furthermore, overexpression of these mutations interferes with chromosome transmission of a 125 kb chromosome fragment in a wild-type strain. Polyclonal antibodies against CHL1 show that CHL1 is predominantly in the nuclear fraction of S. CEREVISIAE: CHL1 function is more critical for the segregation of small chromosomes. In chl1Delta1/chl1Delta1 mutants, artificial circular or linear chromosomes <150 kb in size exhibit near random segregation (0.12 per cell division), whereas all chromosomes tested >225 kb were lost at rates (5 x 10(-)(3) per cell division) comparable to that observed for endogenous chromosome III. These results reveal an important role for ATPases/DNA helicases in chromosome segregation. Such enzymes may alter DNA topology to allow loading of proteins involved in maintaining sister chromatid cohesion.

Granulomatous meningoencephalomyelitis with peripheral nervous system involvement in a dog.

A 9-year-old male neutered Labrador Retriever presented with signs consistent with multifocal neurological disease. Cerebrospinal fluid analysis revealed a mononuclear pleocytosis and electromyography revealed abnormal electrical activity in distal appendicular and masticatory muscles. Treatment was declined and necropsy revealed disseminated granulomatous meningoencephalomyelitis with extensive involvement of the peripheral nervous system.

Reference limits for urinary fractional excretion of electrolytes in adult non-racing Greyhound dogs.

OBJECTIVE: To determine reference limits for urinary fractional excretion of electrolytes in Greyhound dogs. METHODS: Urinary fractional excretion was calculated using a spot clearance method preceded by a 16 to 20 hour fast in 48 Greyhound dogs. Raw data analysed using the bootstrap estimate was used to calculate the reference limits. RESULTS: The observed range for urinary fractional excretion in Greyhound dogs was 0.0 to 0.77% for sodium, 0.9 to 14.7% for potassium, 0 to 0.66% for chloride, 0.03 to 0.22% for calcium and 0.4 to 20.1% for phosphate. Expressed as percentages, the suggested reference limits for fractional excretion in Greyhound dogs are as follows: sodium < or = 0.72, potassium < or = 12.2, chloride < or = 0.55, calcium < or = 0.13 and phosphate < or = 16.5. CLINICAL SIGNIFICANCE: Veterinary practitioners may use these reference limits for urinary electrolyte fractional excretion when investigating renal tubular disease in Greyhound dogs.

Evidence based medicine in practice: lessons from a Scottish clinical genetics project.

OBJECTIVE: To establish national clinical guidelines and integrated care pathways for five conditions (tuberous sclerosis (TS), Huntington's disease (HD), myotonic dystrophy (MD), neurofibromatosis type 1 (NF1), and Marfan syndrome (MS)) and audit their use in Scotland. DESIGN: Systematic review of published reports followed by consensus conferences to prepare clinical guidelines and integrated care pathways. Structured review of medical records before and after introduction of integrated care pathways to document changes in practice. Survey of staff views on procedures adopted. SETTING: All four clinical genetics centres in Scotland. RESULTS: Project resulted in reduced variation in practice across centres, improved data recording in medical records, and improved communication with other professional groups. A very poor evidence base for management of patients with the conditions studied was found. CONCLUSIONS: A collaborative structure for undertaking clinical research would improve the evidence base for current practice. National discussion of the boundaries of responsibility of care for the long term management of patients with these disorders is required. The integrated care pathway approach shows promise as a means of facilitating the development of audit within clinical genetics services.