Tranexamic acid in life-threatening military injury and the associated risk of infective complications.

BACKGROUND: Tranexamic acid (TXA) has been shown to reduce mortality from severe haemorrhage. Although recent data suggest that TXA has anti-inflammatory properties, few analyses have investigated the impact of TXA on infectious complications in injured patients. The aim was to examine the association between TXA administration and infection risk among injured military personnel. METHODS: Patients who received TXA were matched by Injury Severity Score with patients who did not receive TXA. Conditional logistic regression was used to examine risk factors associated with infections within 30 days. A Cox proportional analysis evaluated risk factors in a time-to-first-infection model. RESULTS: A total of 335 TXA recipients were matched with 626 patients who did not receive TXA. A greater proportion of TXA recipients had an infection compared with the comparator group (P < 0·001). Univariable analysis estimated an unadjusted odds ratio (OR) of 2·47 (95 per cent c.i. 1·81 to 3·36) for the association between TXA and infection risk; however, TXA administration was not significant in multivariable analysis (OR 1·27, 0·85 to 1·91). Blast injuries, intensive care unit (ICU) admission, and receipt of 10 units or more of blood within 24 h after injury were independently associated with infection risk. The Cox proportional model confirmed the association with ICU admission and blood transfusion. Traumatic amputations were also significantly associated with a reduced time to first infection. CONCLUSION: In life-threatening military injuries matched for injury severity, TXA recipients did not have a higher risk of having infections nor was the time to develop infections shorter than in non-recipients. Extent of blood loss, blast injuries, extremity amputations and ICU stay were associated with infection.

Subjectively perceived personality and mood changes associated with subthalamic stimulation in patients with Parkinson's disease.

BACKGROUND: Clinical and ethical implications of personality and mood changes in Parkinson's disease (PD) patients treated with subthalamic deep brain stimulation (STN-DBS) are under debate. Although subjectively perceived personality changes are often mentioned by patients and caregivers, few empirical studies concerning these changes exist. Therefore, we analysed subjectively perceived personality and mood changes in STN-DBS PD patients. METHOD: In this prospective study of the ELSA-DBS group, 27 PD patients were assessed preoperatively and 1 year after STN-DBS surgery. Two categories, personality and mood changes, were analysed with semi-structured interviews. Patients were grouped into personality change yes/no, as well as positive/negative mood change groups. Caregivers were additionally interviewed about patients' personality changes. Characteristics of each group were assessed with standard neurological and psychiatric measurements. Predictors for changes were analysed. RESULTS: Personality changes were perceived by six of 27 (22%) patients and by 10 of 23 caregivers (44%). The preoperative hypomania trait was a significant predictor for personality change perceived by patients. Of 21 patients, 12 (57%) perceived mood as positively changed. Higher apathy and anxiety ratings were found in the negative change group. CONCLUSIONS: Our results show that a high proportion of PD patients and caregivers perceived personality changes under STN-DBS, emphasizing the relevance of this topic. Mood changed in positive and negative directions. Standard measurement scales failed to adequately reflect personality or mood changes subjectively perceived by patients. A more individualized preoperative screening and preparation for patients and caregivers, as well as postoperative support, could therefore be useful.

Stem cell application in acute burn care and reconstruction.

Burn injuries have a consistently high rate of mortality and morbidity, principally due to sepsis and systemic inflammation. Furthermore, wound closure is often troubled by a limited supply of autologous skin graft availability. Researchers are now looking at augmenting alternative sources for tissues engineering, including stem cells in the bone marrow, fat and hair follicles. Many studies suggest that the ability of stem cells to augment the clinical care of thermally-injured patients shows great potential; however, while our understanding of stem-cell biology has expanded dramatically over the last two decades, significant insight is still required so the full potential of these cells can be safely harnessed and transferred to patient care. This article provides a commentary on the evidence supporting a role for stem-cell therapy in acute burn care and tissue reconstruction, with particular reference to those in the bone marrow, adipose tissue and hair follicle.

Trophic and spatial patterns of contaminants in fishes from the Republic of the Marshall Islands in the equatorial Pacific.

The Republic of the Marshall Islands (RMI) has been affected by marine pollution from militarization and urbanization. To address concerns raised by the Marshall Islands Marine Resources Authority, this study examined concentrations of dissolved contaminants in reef and pelagic fishes in the RMI and assessed potential associated risks. Metals, organochlorine pesticides, polychlorinated biphenyls (PCBs), and polycyclic aromatic hydrocarbons (PAHs) were examined in reef and pelagic fishes from six atolls: Kwajalein, Majuro, Jaluit, Utirik, Rongelap, and Wotje. Clear trophic patterns emerged for metals. Total arsenic was highest in higher trophic level reef fishes, particularly in the camouflage grouper (Epinephelus polyphekadion) (>100 µg g-1 total As), but inorganic arsenic was negligible in higher trophic levels and showed an inverse trend with the highest percentages present in parrotfishes and herbivores. Copper and mercury were elevated in higher trophic level reef and pelagic fishes, respectively, and the maximum mercury concentrations (6.45 µg g-1 in Gymnosarda unicolor) were among the highest reported in the Pacific. Conversely, cadmium and lead were highest in lower trophic levels, like surgeonfishes and parrotfishes. PCBs were more clearly linked to locations and were highest at two atolls with military history (Kwajalein and Jaluit) (>U.S. EPA Screening Value of 2.5 ppb). PAHs were ubiquitous across taxa (detected in 97% of samples), but the highest concentrations were in lower trophic levels. Organochlorine pesticides were detected at very low concentrations that do not likely pose a risk. We compare concentrations to established thresholds for human health and find that - for specific locations and species - contaminant concentrations may pose a risk to fish and other marine taxa, as well as human consumers. This study provides baseline information that aids the development of marine conservation and public health recommendations and addresses a data gap that persists for marine pollution throughout the Pacific Islands.

Myofunctional therapy. Part 1: Culture, industrialisation and the shrinking human face.

Culture, industrialisation and the shrinking human face: Why is it important? Over the past 300,000 years, not only has the way we consume food from birth through our lifetime changed, there have also been changes related to the methods of food preparation, availability, processing, and storage. These diet-related factors, along with other epigenetic factors, have led to a widespread increase in orofacial myofunctional disorders (OMDs) and resultant human malocclusion phenotypes (HMPs) worldwide. Currently there is an increasing need for resolution of HMPs in early childhood and associated OMDs. This review will include reports of cases and describe the nature of the problem and strategies for effective solutions.

Establishing scald prevention measures in UK maternity units from takeaway drinks.

AIM: To identify policies on the consumption of hot drinks by patients and visitors on all perinatal and postnatal wards in the United Kingdom, and to seek the opinions of members of the wider burns MDT as to whether standardised patient education or regulation of hot drinks around newborn babies is required. METHODS: All maternity units with postnatal wards across the United Kingdom were surveyed to establish availability of hot drinks on site and whether these were permitted on postnatal wards around infants. An online questionnaire was distributed to members of the British Burn Association to ascertain opinions on hot drinks policies. RESULTS: Hot takeaway drinks were permitted around newborn infants in 194 of surveyed postnatal wards and were only banned by two units. The online survey received 49 responses from different members of the British Burn Association. Thirty responders (61%) supported a takeaway hot drink ban, while those against the policy would alternatively encourage patient education, dedicated drinking areas and introduction of safety measures. CONCLUSIONS: Almost every postnatal unit in the UK has access to hot drink retailers on site allowing parents and visitors to bring them into close contact with babies. With varying local regulations, this poses potentially serious consequences during feeding or carrying. We propose a standardised antenatal education be made available, together with standardised designated areas on wards for parents and visitors to consume hot drinks away from infants.

Corrosive attacks in the UK - Psychosocial perspectives and decontamination strategies.

Acid attacks, or vitriolage, are defined as violent assaults involving the deliberate throwing of an acid or similarly corrosive substance with the intention to "maim, disfigure, torture or kill" [1]. The Acid Survivors Trust International suggest a prevalence of 1500 attacks reported worldwide per annum, although this is likely to be an underestimate by 40% [2]. The UK is thought to have one of the highest of rates of recorded corrosive attacks, with an increase from 228 attacks in 2012 to 601 in 2016. Most were reported by the London Metropolitan police force followed by Northumbria, Cambridgeshire, Hertfordshire, Greater Manchester and Humberside [[2]]. The chemical agents involved include acids, alkalis, oxidising and reducing agents, alkylating and chelating agents and solvents. They cause injury by producing a chemical interaction which can lead to extensive tissue destruction and extreme pain. Herein, we present a review on the changing epidemiology of corrosive attacks in the UK and currently employed management strategies.

Deformational mass transport and invasive processes in soil evolution.

Soils are differentiated vertically by coupled chemical, mechanical, and biological transport processes. Soil properties vary with depth, depending on the subsurface stresses, the extent of mixing, and the balance between mass removal in solution or suspension and mass accumulation near the surface. Channels left by decayed roots and burrowing animals allow organic and inorganic detritus and precipitates to move through the soil from above. Accumulation occurs at depths where small pores restrict further passage. Consecutive phases of translocation and root growth stir the soil; these processes constitute an invasive dilatational process that leads to positive cumulative strains. In contrast, below the depth of root penetration and mass additions, mineral dissolution by descending organic acids leads to internal collapse under overburden load. This softened and condensed precursor horizon is transformed into soil by biological activity, which stirs and expands the evolving residuum by invasion by roots and macropore networks that allows mixing of materials from above.

Is the etiology of eosinophilic esophagitis in adults a response to allergy or reflux injury? Study of cellular proliferation markers.

Recent research suggests that allergy may be the key factor in the etiology of eosinophilic esophagitis (EE); however, historically, the condition was hypothesized as related to reflux injury to the esophageal mucosa. We studied this hypothesis by comparing markers of inflammation and cellular proliferation in EE and reflux esophagitis. Lower esophageal biopsies of adult patients with EE (n = 10), reflux esophagitis (n = 8), and normal controls (n = 13) were assessed quantitatively for the expression of the cyclooxygenase-2 (COX-2) enzyme, cellular proliferation, and oncogenic resistance to apoptosis using monoclonal antibodies for COX-2, Ki-67, and Bcl-2, respectively. Normal esophageal epithelium demonstrated weak diffuse uptake of COX-2 stain in the basal layer. No COX-2 expression was demonstrated in the EE group, significantly less than the control and reflux groups (P < 0.01 and P < 0.001, respectively). Cellular proliferation measured by Ki-67 expression was higher in EE and reflux compared with control (P < 0.001 and P < 0.01). Ki-67 expression, and thus degree of hyperplasia, appeared greater in EE than reflux, but was not statistically significant (P = 0.228). The degree of apoptosis was similar in all study groups. EE and reflux esophagitis are proliferative conditions expressing Ki-67 in higher concentrations than control. Mucosal proliferation in reflux esophagitis is COX-2 dependent. This novel research in EE has demonstrated downregulation of COX-2 expression compared with reflux esophagitis and control. We hypothesize that the allergy-related cytokine IL-13 known to inhibit COX-2 expression and found in high concentrations in EE as responsible for this. The pathogenesis of EE is likely dependent on allergy rather than reflux injury to the esophagus.

Temperature dissociation of liquids in reusable thermoplastic containers-An eco-friendly scald risk?

Recent global concern regarding the impact of plastic waste on the environment has resulted in efforts to utilise reusable drink containers. Research is lacking regarding temperature dissociation of drinks in reusable thermoplastic cups. This study aimed to compare the cooling time of two common hot drinks sold at a UK retailer, in the three vessels they are sold; ceramic, disposable paper (with and without lid) and reusable thermoplastic cups (with and without lid). All temperatures were collated from 250 ml volumes of black Americano coffee or café latte in the three different containers. The cooling time was measured every sixty seconds using a standardised digital thermocouple thermometer until a threshold liquid temperature of 43 °C was reached. All experiments were performed in triplicate and temperatures converted to a dimensionless logarithmic scale prior to statistical analysis. Cooling time was significantly slower for lidded cups irrespective of material. Unlidded thermoplastic cups significantly slowed cooling times for both black Americano coffee and café latte compared to ceramic and unlidded disposable paper cups. The growing trend in reusable cups does not in itself pose an increased risk of scald injury. However, we consider that the potentially increased ambulatory behaviour associated with using a lidded rather than unlidded cup may increase scald risk. We propose that further consumer guidance should be disseminated regarding the use of any lidded takeaway container to prevent scalds in both adults and children.

Single-stage helical rim reconstruction using a post-auricular bipedicled flap.

BACKGROUND: Middle-third helical rim defects may arise from trauma or oncological resection, and pose a challenging reconstructive problem. Reconstructing defects larger than 2 cm using traditional methods commits patients to the inconvenience of staged procedures. METHOD: This paper describes a single-stage helical rim reconstruction technique using a post-auricular bipedicled flap and ipsilateral conchal cartilage graft for delayed middle-third helical rim reconstruction. RESULTS: Two examples of this technique used in post-trauma and oncological reconstruction cases are presented, with pre- and post-operative photographs provided for demonstration. CONCLUSION: Contralateral graft harvest and staged operations for helical rim reconstruction are associated with donor site morbidity and the inconvenience of multiple operations to achieve the desired reconstructive outcome. Our single-stage helical rim reconstruction technique was well tolerated by patients, and showed satisfactory aesthetic results in terms of size and symmetry.

Is it time for a change in the approach to chemical burns? The role of Diphoterine® in the management of cutaneous and ocular chemical injuries.

A multitude of household and occupational compounds have the potential to induce chemical burns to the eye and skin. Without prompt intervention, irreversible visual loss and disfigurement may prevail. Diphoterine® and Hexafluorine® are amphoteric and hypertonic chelating solutions used in the management of general chemical and hydrofluoric acid burns, respectively. They rapidly neutralise both acid and alkali agents without heat release and limit diffusion, making them superior to water irrigation alone. However, although Diphoterine® and Hexafluorine® uptake is slowly increasing in industrial workplaces, there is a paucity of education and use in both emergency departments and plastic surgery units worldwide. Herein, we present a case report of combined ocular and cutaneous acid burn treated with Diphoterine®, together with a review of the current supporting literature.

Carbon sequestration by Australian tidal marshes.

Australia's tidal marshes have suffered significant losses but their recently recognised importance in CO2 sequestration is creating opportunities for their protection and restoration. We compiled all available data on soil organic carbon (OC) storage in Australia's tidal marshes (323 cores). OC stocks in the surface 1 m averaged 165.41 (SE 6.96) Mg OC ha-1 (range 14-963 Mg OC ha-1). The mean OC accumulation rate was 0.55 ± 0.02 Mg OC ha-1 yr-1. Geomorphology was the most important predictor of OC stocks, with fluvial sites having twice the stock of OC as seaward sites. Australia's 1.4 million hectares of tidal marshes contain an estimated 212 million tonnes of OC in the surface 1 m, with a potential CO2-equivalent value of $USD7.19 billion. Annual sequestration is 0.75 Tg OC yr-1, with a CO2-equivalent value of $USD28.02 million per annum. This study provides the most comprehensive estimates of tidal marsh blue carbon in Australia, and illustrates their importance in climate change mitigation and adaptation, acting as CO2 sinks and buffering the impacts of rising sea level. We outline potential further development of carbon offset schemes to restore the sequestration capacity and other ecosystem services provided by Australia tidal marshes.

Plasma gastrin measurement cannot be used to diagnose a gastrinoma in patients on either proton pump inhibitors or histamine type-2 receptor antagonists.

BACKGROUND: Patients with a gastrinoma are treated with proton pump inhibitors (PPI) and histamine type-2 receptor antagonists (H2). In order to diagnose a gastrinoma these drugs must be discontinued, but this increases the risk of gastrointestinal perforation. We aimed to determine if a gastrinoma could be diagnosed without cessation of PPI/H2 therapy. METHODS: In all, 90 patients (controls and patients diagnosed with a gastrinoma both on and off PPI/H2 therapy) were recruited, and plasma gastrin measured. RESULTS: Patients with a gastrinoma on PPI/H2 medication had a significantly higher fasting plasma gastrin concentration than control patients on PPI/H2 medication (298+/-33 versus 204+/-30 pmol/L, P = 0.01). However, there was substantial overlap between gastrin levels in these two groups. CONCLUSION: This study confirms that a gastrinoma cannot be diagnosed on the basis of a fasting plasma gastrin assay while patients remain on PPI/H2 therapy.

Current approaches to the management of ovine footrot.

Ovine footrot remains the most important cause of lameness in sheep flocks in the UK, despite the existence of proven methods for the control of the disease. Recent research suggests that sheep farmers may be unaware of these methods and may allocate greater resources to treatment of footrot rather than to its prevention. Foot paring, topical treatments, vaccination and parenteral antibiotic therapy all have a role in treating sheep with advanced footrot infections, but prevention of severe infections is best achieved by the timely implementation of control programmes. These are usually based on footbathing and vaccination. For control programmes to be effective it is essential that the pathogenesis and epidemiology of footrot is understood and that control methods are implemented at appropriate times in the season, depending on climatic and pasture conditions. This article reviews these strategies and makes recommendations for steps to reduce the spread of footrot between flocks and to reduce the incidence of footrot within UK flocks.

Deep brain stimulation and cognitive decline in Parkinson's disease: The predictive value of electroencephalography.

Some Parkinson's disease (PD) patients treated with subthalamic nucleus deep brain stimulation (STN-DBS) develop new-onset cognitive decline. We examined whether clinical EEG recordings can be used to predict cognitive deterioration in PD patients undergoing STN-DBS. In this retrospective study, we used the Grand Total EEG (GTE)-score (short and total) to evaluate pre- and postoperative EEGs. In PD patients undergoing STN-DBS (N = 30), cognitive functioning was measured using Mini-Mental State Test and DemTect before and after surgery. Severity of motor impairment was assessed using the Unified Parkinson's Disease Rating Scale-III. Patients were classified into patients with or without cognitive decline after STN-DBS surgery. Epidemiological data, pre- and postoperative EEG recordings as well as neuropsychological and neurological data, electrode positions and the third ventricle width were compared. A logistic regression model was used to identify predictors of cognitive decline. Motor deficits significantly improved from pre- to post-surgery, while the mean GTE-scores increased significantly. Six patients developed cognitive deterioration 4-12 months postoperatively. These patients had significantly higher preoperative GTE-scores than patients without cognitive deterioration, although preoperative cognitive functioning was comparable. Electrode positions, brain atrophy and neurological data did not differ between groups. Logistic regression analysis identified the GTE-score as a significant predictor of postoperative cognitive deterioration. Data suggest that the preoperative GTE-score can be used to identify PD patients that are at high risk for developing cognitive deterioration after STN-DBS surgery even though their preoperative cognitive state was normal.

Health claims and observational human data: relation between dietary fat and cancer.

The US Food and Drug Administration review that provided the basis for authorizing a food-label health claim linking the risk of cancer to dietary fat intake illustrated several considerations in the use of epidemiologic data, and observational data in particular, to support dietary recommendations. The review suggested the need for clear and established criteria for judging the quality of observational human data as well as the importance of making the evaluation process for individual studies transparent and organized. The review, which provided for a claim in the absence of controlled human studies, also suggested that observational data may play a greater role when the nature of the relation to be described by a health-claim statement is broad and general rather than targeted and specific. Of particular importance was the relevance of available data to the questions inherent in showing a diet-disease relation, the need to consider the totality of the evidence, and the key role that existing authoritative reports must play in establishing the basis for relation.

Estimated folate intakes: data updated to reflect food fortification, increased bioavailability, and dietary supplement use.

BACKGROUND: There is a critical need to estimate dietary folate intakes for nutrition monitoring and food safety evaluations, but available intake data are seriously limited by several factors. OBJECTIVE: Our objective was to update 2 national food consumption surveys to reflect folate intakes as a result of the recently initiated food fortification program and to correct folate intakes for the apparently higher bioavailability of synthetic folic acid (SFA; ie, folate added to foods or from dietary supplements) than of naturally occurring folate so as to express intakes as dietary folate equivalents. DESIGN: It was not possible to chemically analyze foods, so adjustments were made to food-composition data by using information about food ingredients and characteristics. Total folate intakes were estimated for several sex and age groups by using the modified data coupled with dietary supplement use. RESULTS: Within the limitations of the data, our findings suggested that 67-95% of the population met or surpassed the new estimated average requirement, depending on the sex and age group and survey. Nonetheless, some subgroups had estimated intakes below these standards. Estimated SFA intakes suggested that approximately 15-25% of children aged 1-8 y, depending on the survey, had intakes above the newly established tolerable upper intake level. We estimated that 68-87% of females of childbearing age had SFA intakes below the recommended intake of 400 microgram/d, depending on the age group and survey. CONCLUSION: There is a need to explore ways to improve folate intakes in targeted subgroups, including females of childbearing age, while not putting other population groups at risk of excessive intakes.

Relationship between age and serum vitamin A in children aged 4-11 y.

The association between age and serum vitamin A concentrations in children was examined by using total serum vitamin A values from the second National Health and Nutrition Examination Survey (NHANES II) and serum retinol values for Mexican Americans from the Hispanic HANES. Analyses included multivariate strategies to identify confounders of serum vitamin A. After the effect of the use of vitamin-mineral supplements on total serum vitamin A values was controlled for, the data indicated that younger children (aged 4-5 y) have lower serum vitamin A concentrations than do older children (aged 9-11 y) regardless of whether the measure was total serum vitamin A or serum retinol. This relationship was systematic across the distribution of values and suggested that the difference may be due to normal physiological events. A different interpretive criterion may be needed for younger and older children when serum vitamin A is used to indicate vitamin A status.

Lack of run-down of smooth muscle P2X receptor currents recorded with the amphotericin permeabilized patch technique, physiological and pharmacological characterization of the properties of mesenteric artery P2X receptor ion channels.

Immunoreactivity for P2X(1), P2X(4) and P2X(5) receptor subtypes was detected in the smooth muscle cell layer of second and third order rat mesenteric arteries immunoreactivity, for P2X(2), P2X(3), P2X(6) and P2X(7) receptors was below the level of detection in the smooth muscle layer. P2X receptor-mediated currents were recorded in patch clamp studies on acutely dissociated mesenteric artery smooth muscle cells. Purinergic agonists evoked transient inward currents that decayed rapidly in the continued presence of agonist (tau approximately 200 ms). Standard whole cell responses to repeated applications of agonist at 5 min intervals ran down. Run-down was unaffected by changes in extracellular calcium concentration, intracellular calcium buffering or the inclusion of ATP and GTP in the pipette solution. Run-down was overcome and reproducible responses to purinergic agonists were recorded using the amphotericin permeabilized patch recording configuration. The rank order of potency at the P2X receptor was ATP=2 methylthio ATP>alpha, beta-methylene ATP>CTP=l-beta,gamma-methylene ATP. Only ATP and 2meSATP were full agonists. The P2 receptor antagonists suramin and PPADS inhibited P2X receptor-mediated currents with IC(50)s of 4 microM and 70 nM respectively. These results provide further characterization of artery P2X receptors and demonstrate that the properties are dominated by a P2X(1)-like receptor phenotype. No evidence could be found for a phenotype corresponding to homomeric P2X(4) or P2X(5) receptors or to heteromeric P2X(1/5) receptors and the functional role of these receptors in arteries remains unclear.