A prospective study of systemic sclerosis-related digital ulcers: prevalence, location, and functional impact.

OBJECTIVES: Although digital ulcers (DUs) are common in patients with systemic sclerosis (SSc), prevalence estimates vary, and functional impact and pathophysiology have been relatively little studied. We investigated the point prevalence of all DUs (both digital-tip and extensor) in a cohort of patients with SSc, testing the hypothesis that both digital-tip and extensor ulcers are associated with functional impairment. METHOD: Over a 12-month period, patients attending an SSc clinic for annual review were assessed by specialist nurses: active DUs were documented and the Hand Mobility in Scleroderma (HAMIS) test performed. Patients also completed the Scleroderma Health Assessment Questionnaire (SHAQ), the Scleroderma Functional Index (SFI), and the Cochin Hand Function Scale (CHFS). RESULTS: A total of 25 active DUs (nine digital-tip and 16 extensor surface) were found in 15 of the 148 patients recruited, giving a prevalence for each ulcer type of 6% and an overall point prevalence of 10%. HAMIS scores were higher (indicating greater impairment) in those with active DUs than in those without: left hand difference 8.8 points [95% confidence interval (CI) 3.2-14.5], p = 0.002; difference significant for extensor as well as digital-tip ulcers. Active DUs were associated with higher visual analogue scale (VAS) scores for pain (p = 0.04), DUs (p < 0.001), and 'overall' assessment (p = 0.03). CONCLUSIONS: Extensor surface ulcers have the same prevalence as digital-tip ulcers in patients with SSc, and are equally disabling. Clinical trials should therefore include both categories of DUs.

Pilot evaluation of anterior dynamic ultrasound screening for developmental dysplasia of the hip in an Australian regional hospital.

INTRODUCTION: Developmental Dysplasia of the Hip (DDH) is the most common notifiable musculoskeletal birth defect in South Australia (SA). Despite routine screening by physical examination of the hips in the neonatal period and at 6 weeks of age, the risk of late diagnosis is increased in rural areas. It is assumed this is due to the examining doctors' reduced clinical expertise. Introducing Anterior Dynamic Ultrasound (ADUS) has reduced the late detection rates in Sweden to almost zero, and may benefit Australian infants in rural areas if routine screening was introduced. This study reports on a small implementation pilot in a SA regional hospital where volunteer postnatal mothers consented to their babies having ADUS examinations. METHODS: The pilot was evaluated by collecting results of physical examination, ADUS, and surveying parental impressions of the screening test. RESULTS: Hips of 86 infants underwent ADUS during the implementation pilot. Parents' perceptions were mainly very positive and indicated ADUS was an accessible and acceptable screening test. Of the hips scanned, three were found to have maximum movement of the femoral head of >3 mm and were deemed to demonstrate increased laxity. Four hips described as loose or mobile on clinical examination were found to be within normal limits of maximum mobility on ADUS. CONCLUSIONS: This study has demonstrated that a larger scale implementation project would be feasible in regional Australia, and would enable researchers to better understand how to reduce the late diagnosis rate of DDH in rural areas.

Hand function after high dose rate brachytherapy for squamous cell carcinoma of the skin of the hand.

AIMS: Current recommendations for the treatment of squamous cell carcinoma of the hand are almost unanimously in favour of ablative surgery. However, many of the patients are frail and elderly, and surgical techniques frequently involve skin grafts or amputation of digits. A non-invasive method of treatment is, therefore, often preferred. Radiotherapy using a brachytherapy technique is a well-established option. This study investigated whether patients found the treatment acceptable and assessed the outcome of treatment in terms of local control, cosmesis and hand function. MATERIALS AND METHODS: Twenty-five patients who underwent mould brachytherapy using a microselectron high dose rate radiotherapy device were available for assessment. We assessed the functional status of the hand and fingers by means of the Disability of Arm, Shoulder and Hand and Michigan Hand Outcomes questionnaires. We examined the hand to assess the severity of post-radiation stigmata. We enquired as to patient acceptability of treatment and outcome. RESULTS: Of 25 patients who agreed to participate, the fingers were affected in 15 and the dorsum of the hand in 10. The mean age at the time of radiotherapy was 69 years (range 50-87). There were no significant differences in parameters, such as range of motion of fingers and wrist, hand/finger grip strength, between the treated and opposite sides. Sensation, including two-point discrimination, was not significantly different from the untreated hand. Seventeen patients had minor skin changes. No patient found the treatment painful or unacceptable. Twenty patients were very satisfied and five patients were moderately satisfied with the cosmetic result. CONCLUSIONS: We conclude that high dose rate brachytherapy is a safe and simple alternative to surgical treatment for squamous cell carcinoma of the hand, as it is not only successful in eradicating tumour, but also preserves hand function.

The effect of tourniquet padding on the efficiency of tourniquets of the upper limb.

We report the effect of padding on the efficiency of the pneumatic tourniquet for the upper limb. Varying thicknesses of two commercially-available types of orthopaedic padding (Cellona and Velband) were applied to the arms of 20 volunteers, with three pressure transducers placed directly beneath the padding. A tourniquet was positioned over the padding and inflated to 220 mmHg. Significant reductions in the transmitted pressure were recorded from the transducers with both padding materials. With eight layers of padding, reductions in pressure of 13% (1% to 26%) and 18% (7% to 35%) were seen with Cellona and Velband, respectively. The reduction in pressure with Velband padding correlated with increasing arm circumference (Pearson's correlation coefficient 0.711, p < 0.001). Studies to date have examined how arm circumference affects the required tourniquet inflation pressure. Our study is the first to investigate the effect of the padding and the findings suggest that using more than two layers results in a significant reduction in the transmitted pressure.

A change of culture: reducing blood culture contamination rates in an Emergency Department.

Blood cultures are an important investigation to help tailor effective management for patients with severe sepsis. Frequent contaminated samples increase laboratory workload and can delay or cause incorrect changes to patient management. This can prolong patient hospitalisation, increase the risk of harm and increase cost to health boards. Current guidelines advocate a contamination rate of 2-3%. From January 2013 to November 2014 inclusive, the contamination rate was 4.74% in our Emergency Department, responsible for initial management and investigation of over 40 cases of sepsis per month. A Quality Improvement team was created to try to reduce contamination rates to the recommended target. An initial baseline survey of local staff showed good understanding of when to obtain a blood culture but there was variability in the methods and equipment used. A project was then conducted which focused on rationalising and standardising equipment and technique for blood culture sampling along with staff education to support this change. A simple department target of 30 days free from a contaminated blood culture was created which, if achieved, would ensure a contamination rate of less than 3%. This was supported by ongoing surveillance of contamination rates and investigation of contaminated sample cases. We were able to then identify high risk patients and factors which increased the chance of blood culture contamination. This allowed us to formulate solutions to help reduce the risks of contamination. Department achievements and learning points to help prevent further contamination were fed back positively to all staff. This project operated for 12-months and successfully reduced local contamination rates to 2.0%.

A review of the classification of Dupuytren's disease.

Although much has been published about the treatment of Dupuytren's disease, there is no clear consensus regarding the most effective form of treatment. Part of this uncertainty may result from the absence of a universal method of assessing this condition. We undertook a review of the literature in order to summarize the various methods by which Dupuytren's disease has been measured and quantified. We included all articles that offered a classification or assessment system for the disease. We excluded articles that dealt solely with surgical technique (although inevitably there was some overlap). We conclude that there are many methods of assessment, but that none of them is perfect and that further work is needed in the field.

Antibody-dependent cell-mediated cytotoxicity: comparison between HTLV-I and HIV-1 assays.

This study confirms the presence of detectable antibody-dependent cell-mediated cytotoxicity (ADCC) towards both HTLV-I- and HIV-1-infected cell lines, mediated by normal donor peripheral blood mononuclear cells and either by antibody from adult T-cell lymphoma and tropical spastic paraparesis patients (HTLV-I) or by antibody from sera of patients with persistent generalized lymphadenopathy, AIDS-related complex, AIDS and asymptomatic patients seropositive for HIV-1 infection. A comparison of ADCC towards these two retroviruses, under carefully controlled laboratory conditions, indicates major differences between the capacity of HTLV-I-seropositive sera and HIV-1-seropositive sera to mediate ADCC. In all cases, HIV sera showed low-titre ADCC, in contrast to the high titre (greater than 1:800,000) ADCC mediated by HTLV-I-positive sera. Both sets of sera showed the prozone phenomenon, and heat inactivation may abolish ADCC towards HIV-1-infected cells. Quantitation of surface antigen expression on HTLV-I- and HIV-1-infected cell lines indicated the presence of easily detectable amounts of virus-specific antigen. We conclude that, in contrast to some previous reports, ADCC mediated by HIV-1-specific immunoglobulin G (IgG) antibody is rather weak and of low titre when compared with HTLV-I ADCC. This is true for all cell lines and HIV-1 virus isolate combinations tested.

A passive haemagglutination test for the detection of anti-nicotinic acetylcholine receptor antibodies.

A detergent-solubilised membrane protein (the nicotinic acetylcholine receptor) was coupled to red blood cells by the chromic chloride method. The bound receptor retained both antigenic activity and the ability to bind alpha neurotoxins. Coated cells were successfully used in a haemagglutination test to determine antibody titre and cross-reactivity of polyclonal and monoclonal anti-acetylcholine receptor antisera.

Aedes aegypti survival and dispersal estimated by mark-release-recapture in northern Australia.

The survival and dispersal of adult Aedes aegypti were estimated in northern Australia where sporadic outbreaks of Ae. aegypti-borne dengue viruses have occurred in recent years. Standard mark-release-recapture methods were used. In addition, a new sticky trap was used to capture the mosquitoes. Prior to the field study, the survival and effect of marking Ae. aegypti with fluorescent powder were determined in the laboratory. Mortality was age-dependent and the marked cohorts had higher survival rates than the untreated cohorts. Recapture rates of 13.0% and 3.6% over a seven-day period were achieved for two batches of marked Ae. aegypti released simultaneously at the field site. More males than females were recaptured although the proportion of females increased with time. The probability of daily survival was 0.91 and 0.86 for the blue- and pink-marked females, respectively, and 0.57 and 0.70 for the blue- and pink-marked and males, respectively. The mean distance traveled of recaptured Ae. aegypti was 56 m and 35 m for females and males, respectively. The maximum observed distance traveled of 160 m was the same for both sexes. The warm to hot and dry climatic conditions may have restricted the dispersal of released mosquitoes in this study. The frequency of recaptures at certain trap locations suggested that shade, wind, and the availability of hosts affected the distribution of Ae. aegypti within the study site.

Aedes aegypti (Diptera: Culicidae) vision: response to stimuli from the optical environment.

Although Aedes aegypti (L.) are capable of some wavelength discrimination, behavioral experiments demonstrated that color was not a stimulus to which they responded. Optical stimuli that did affect Ae. aegypti behavior were luminous reflectance, vertical contrast, and movement. Stationary objects of low reflectance and solid color were the most attractive to males and females.

Aedes aegypti (Diptera: Culicidae) vision: spectral sensitivity and other perceptual parameters of the female eye.

From measurements of the mean ommatidial diameter (17.2 microns) and mean interommatidial angle (6.2 degrees) of the eye of female Ae. aegypti (L.), a minimum resolvable angle of 12.3 degrees and an eye parameter of 1.6 microns were calculated. The eye had relatively poor acuity but high overall sensitivity to light. Electroretinographs revealed spectral sensitivity ranging from ultraviolet (323 nm) to orange-red (621 nm), with sensitivity peaks in the ultraviolet (lambda max323-345 nm) and green (lambda max523 nm) wavelengths. The retina is capable of some wavelength discrimination.

Absence of the dorsalis pedis pulse in the parents of children with club foot.

There is some evidence that the anterior tibial vascular tree is poorly developed in children with club foot. We have found a significantly greater prevalence of absence of the dorsalis pedis pulse in the parents of such children. We also found significantly more tobacco smokers among the club-foot parents than in the control group.

Effects of thyrotropin-releasing hormone and a thyrotropin releasing hormone analog on growth and selected plasma hormones in lambs.

An 8-wk growth trial was conducted to assess the effects of continuous infusion of thyrotropin-releasing hormone (TRH) and an active TRH analog less than Aad-His-Pro-NH2 (the less than Aad is L-pyro-alpha-aminoadipic acid) on growth trial performance, carcass composition and hormone profiles of growing lambs. Both drugs were infused at 600 micrograms X lamb -1 X d -1 with 16 lambs/treatment. Both TRH and less than Aad-His-Pro-NH2 decreased average daily gain (ADG; P less than .01) and increased feed conversion (FC; P less than .01) compared with saline infused controls. Average daily feed intake was not altered. Carcasses of lambs given TRH or less than Aad-His-Pro-NH2 contained fewer kilograms of moisture (P less than .05) and appeared to contain fewer kilograms of protein. Thyrotropin-releasing hormone and less than Aad-His-Pro-NH2 increased thyroid gland weights (P less than .05), but pituitary gland weights were not different. Plasma thyrotropin (TSH) concentrations were increased by both drugs compared with control lambs, peaking at 4 to 7 d after initiating infusion. However, by 14 d, TSH concentrations returned to control levels. Triiodothyronine (T3) and thyroxine (T4) were elevated by both drugs over the entire 8-wk trial, with peak levels reached at 10 d and maintained for the duration of the study. Both TRH and less than Aad-His-Pro-NH2 increased prolactin over the entire period. Growth hormone levels were not altered by either drug. The effects of less than Aad-His-Pro-NH2 infusion on growth trial performance, carcass composition and hormone profiles of growing lambs were very similar to TRH. The negative effects of TRH and less than Aad-His-Pro-NH2 infusion on ADG, FC and carcass protein appear to be the result of elevated T3 and T4 levels.

Effects of ovine growth hormone and other anterior pituitary hormones on lipolysis of rat and ovine adipose tissue in vitro.

Ovine growth hormone ( oGH ) was tested for its effects on lipolysis of rat and ovine adipose tissue in vitro. Ovine growth hormone at 1, 5 and 25 micrograms/ml stimulated lipolysis (P less than .05) of chopped rat adipose tissue and isolated rat adipocytes incubated in the presence of 100 mU/ml adenosine deaminase and .2 micrograms/ml dexamethasone, but had no effect on lipolysis of chopped ovine adipose tissue or isolated ovine adipocytes. Isoproterenol, a beta-adrenergic agonist, stimulated lipolysis (P less than .05) of both rat and ovine adipose tissue. Contaminants of the oGH preparation used were examined for lipolytic effects. Thyroid-stimulating hormone (TSH), luteinizing hormone (LH) and adrenocorticotropic hormone (ACTH) content in oGH were measured by radioimmunoassay. When quantities of these hormones contaminating 5 and 25 micrograms oGH were tested for lipolysis in rat adipose tissue, the TSH contamination could account for some (30%) of the lipolysis observed with oGH , while the other hormones had no effect. Also, preincubation of oGH with anti-GH, but not with anti-TSH or anti-LH, removed the principle in oGH responsible for the lipolytic effect on rat adipose tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

Glucose metabolism and effect of acetate in ovine adipocytes.

Isolated ovine adipocytes were incubated in vitro with specifically labeled 14C-glucose in the presence or absence of acetate. The flux patterns of glucose carbon through major metabolic pathways were estimated. When glucose was added as the sole substrate, approximately equal portions of glucose carbon (10%) were oxidized to CO2 in the pentose phosphate pathway, in the pyruvate dehydrogenase reaction and in the citrate cycle. Fifteen percent of the glucose carbon was incorporated into fatty acids and 43% was released as lactate and pyruvate. Addition of acetate to the medium increased glucose carbon uptake by 1.5-fold. Most of this increase was accounted for by a sevenfold increase in the activity of the pentose phosphate pathway. Acetate increased glucose carbon fluxes via pentose phosphate pathway to triose phosphates, from triose phosphate to pyruvate, into glyceride glycerol, into lactate and pyruvate and into pyruvate dehydrogenase and citrate cycle CO2. Glucose carbon incorporated into fatty acids was decreased 50% by acetate while, carbon fluxes through the phosphofructokinase-aldolase reactions were not significantly increased. Results of this study suggest that, when glucose is the sole substrate, the conversion of glucose to fatty acids in ovine adipocytes may not be limited by the maximum capacity of hexokinase, the pentose phosphate pathway or enzymes involved in the conversion of triose phosphates to pyruvate and of pyruvate to fatty acid. Acetate increased glucose utilization apparently by increasing activity of the pentose phosphate pathway as a result of enhanced NADPH utilization for fatty acid synthesis.

Effects of exogenous growth hormone and diethylstilbestrol on growth and carcass composition of growing lambs.

An 8-wk growth trial was conducted to assess the effects of ovine growth hormone (oGH; 7 mg/d, sc) on growth performance and carcass composition of normal, growing wether lambs. Diethylstilbestrol (DES; .1 mg/d, sc) and control lambs were included for comparisons. Plasma oGH levels at 8 wk were 1.9, 5.5 (P less than .05) and 138.1 ng/ml (P less than .001) for controls, DES and oGH lambs, respectively. Diethylstilbestrol did not increase plasma oGH until the fourth week. The oGH improved feed conversion 7.4% (FC; P less than .05), but did not alter average daily gain (ADG) or feed intake (ADF). Diethylstilbestrol increased ADG 15.3% (P less than .05) and improved FC 16.1% (P less than .01), with no effect on ADF. The primary effect of oGH on carcass composition was to decrease the quantity of fat 8.9% (P less than .05). In addition, oGH may have increased protein 6.5% (P less than .10) and moisture 4.0% (not significant). Diethylstilbestrol increased the quantity of carcass protein 10% (P less than .01) and moisture 8.7% (P less than .05), with no effect on fat. In these studies, the primary effect of exogenous oGH on normal, growing lambs was to reduce carcass fat, which may account for the observed improvement in FC. Diethylstilbestrol, at 1/70th of the oGH dose, was superior to oGH for improving FC (P less than .05) and ADG (P less than .10). Improvements in body weight of the lambs given DES were observed 2 wk before an increase in plasma oGH. In addition, DES, unlike exogenous oGH, did not alter the quantity of carcass fat. These observations do not support the concept that the mode of action of DES is through increased GH secretion.

Thiopeptin for the prevention of ovine lactic acidosis induced by diet change.

Inclusion of thiopeptin, a sulfur-containing peptide antibiotic, at 0, 2.75, 5.5, 8.25, 11 and 22 ppm in the feed was evaluated in 8-week growth trials with 252 lambs. An abrupt diet shift to micronized milo at the start of the trials was used to provide a lactic acidosis challenge. Five of 78 control lambs died within 48 hr after the challenge. In lambs fed diets containing thiopeptin at levels of 11 ppm or more, there was no evidence of lactic acidosis. Lambs given thiopeptin at 11 ppm or more ate 11% more (P less than .05) and gained 20% more (P less than .05) than controls during the 8-week trial. Most of the improvement occurred during the first 2 weeks. Incidence of death was lower among lambs given thiopeptin at 2.75 to 8.25 ppm, but these animals showed no improvement in performance. In another study, abruptly shifting lambs to the micronized milo diet was found to provide an acute lactic acidosis challenge. After the shift, four of eight lambs developed ruminal lactic acidosis, with one dying of systemic lactic acidosis, with one dying of systemic lactic acidosis when plasma lactate exceeded 20 mumoles/ml. In affected lambs, ruminal lactate increased rapidly from an initial level of .2 mumoles/ml to over 130 mumoles/ml within 12 hr of consumption of the milo. Ruminal lactate returned to normal levels of less than 1 mumole/ml by 30 hr in lambs that recovered. High ruminal concentrations of lactate reduced total volatile fatty acids (VFA), and ruminal pH reflected total ruminal acids. Lactic acidosis did not occur in eight lambs after the switch to micronized milo when thiopeptin was included in the feed at 22 ppm. Ruminal lactate was reduced by 68% (P less than .01) and total ruminal VFA increased by 33% (P less than .05) in lambs fed thiopeptin in comparison with average levels in all controls.

Control of wheat-induced lactic acidosis in sheep by thiopeptin and related antibiotics.

Thiopeptin, thiopeptin-like antibiotics and penicillin were shown previously to be highly active in vitro against Streptococcus bovis, the microorganism believed to be responsible for the initiation of ruminal lactic acidosis. The purpose of this work was to determine the efficacy of these antibiotics in preventing lactic acidosis in lambs challenged by intraruminal administration of ground wheat. Lambs, which were fasted and then given ground wheat at 40 g/kg body weight, showed dramatic increases in rumen and plasma lactate over the 30-hr experimental period. Rumen lactate increased from .2 to peak levels of approximately 150 mumoles/ml by 8 to 10 hr after wheat administration. Plasma lactate increased after rumen lactate was elevated and lambs succumbed when plasma levels exceeded 15 mumoles/ml. Ruminal volatile fatty acids were greatly reduced as rumen lactate increased. Over half of the lambs given ground wheat died within 30 hours. Thiopeptin given as a single dose completely prevented lactic acidosis by reducing rumen lactate 80 to 90%. In addition, thiopeptin permitted "normal" rumen fermentation to continue as indicated by a significant increase in volatile fatty acids. The minimum effective dose of thiopeptin to control acute lactic acidosis was .18 mg/kg body weight. Other members of the thiopeptin class, including sulfomycin, sporangiomycin, siomycin and taitomycin, prevented lactic acidosis in a manner similar to thiopeptin. Penicillin, however, inhibited ruminal volatile fatty acid production as well as lactate synthesis. In addition, the effective period for penicillin in the rumen was only 8 to 16 hr, after which lactate fermentation was reestablished. Thus, thiopeptin and thiopeptin-like antibiotics, but not penicillin, appear to provide prophylactic treatment against lactic acidosis in sheep.