HIV and Pneumocystis Jiroveci Pneumonia (PJP) Managed With Extracorporeal Membrane Oxygenation (ECMO).

Presentation A 40-year-old Irish female presented with a new diagnosis of HIV, advanced immunosuppression and severe respiratory failure. Diagnosis Patient was subsequently diagnosed with Pneumocystis jiroveci Pneumonia (PJP). Treatment The patient was treated for HIV and PJP and required mechanical ventilation. She continued to deteriorate and veno-venous Extracorporeal Membrane Oxygenation (V-V ECMO) was deployed in her management after 18 days of mechanical ventilation. Conclusion HIV presenting with extensive pneumonia secondary to PJP and advanced immunosuppression is still a treatable condition. All available respiratory support including ECMO should be considered for patients even if they have been on mechanical ventilation for more than 7 days.

Injuries in youth track and field are perceived to have multiple-level causes that call for ecological (holistic-developmental) interventions: A national sporting community perceptions and experiences.

Engaging in competitive sports as a youth can have many health benefits, but recent studies also report a high risk for injury. The long-term purpose of this Swedish research program is to develop a framework for safe track and field training for young athletes (aged 12-15 years). The aim of this study was to establish what is perceived to contribute and cause injuries in youth track and field by compiling the best available experiential knowledge about the underlying factors and use this knowledge to identify appropriate areas to handle these in practical ways. Nine focus group interviews with in total 74 participants and confirming interviews with five individuals were performed in seven Swedish regions. Qualitative research methods were used for data analysis. Injuries in youth athletes were not considered to be strictly the result of individual factors but rather the result of the interactions between factors at different levels. Three major factors emerged as follows: Insufficient knowledge for athletic development in daily practice; shortsighted communities of practice and sports policies not adjusted to youth; and societal health behaviors. The experiential knowledge in the national sporting community suggests that if effective and sustainable injury prevention processes are to be implemented for youth track and field, an ecological (holistic-developmental) approach to injury prevention is needed. Such an approach allows a longitudinal development-focused strategy for prevention that spans an athlete's entire career.

Role of vascular channels as a novel mechanism for subchondral bone damage at cruciate ligament entheses in osteoarthritis and inflammatory arthritis.

OBJECTIVES: The purpose of this work was to test whether normal peri-entheseal vascular anatomy at anterior and posterior cruciate ligaments (ACL and PCL) was associated with distribution of peri-entheseal bone erosion/bone marrow lesions (BMLs) in inflammatory arthritis (IA) and osteoarthritis (OA). METHODS: Normal microanatomy was defined histologically in mice and by 3 T MRI and histology in 21 cadaveric knees. MRI of 89 patients from the Osteoarthritis Initiative and 27 patients with IA was evaluated for BMLs at ACL and PCL entheses. Antigen-induced arthritis (AIA) in mice was evaluated to ascertain whether putative peri-entheseal vascular regions influenced osteitis and bone erosion. RESULTS: Vascular channels penetrating cortical bone were identified in knees of non-arthritic mice adjacent to the cruciate ligaments. On MRI of normal cadavers, vascular channels adjacent to the ACL (64% of cases) and PCL (71%) entheses were observed. Histology of 10 macroscopically normal cadaveric specimens confirmed the location of vascular channels and associated subclinical changes including subchondral bone damage (80% of cases) and micro-cyst formation (50%). In the AIA model, vascular channels clearly provided a site for inflammatory tissue entry and osteoclast activation. MRI showed BMLs in the same topographic locations in both patients with early OA (41% ACL, 59% PCL) and IA (44%, 33%). CONCLUSION: The findings show that normal ACL and PCL entheses have immediately adjacent vascular channels which are common sites of subtle bone marrow pathology in non-arthritic joints. These channels appear to be key determinants in bone damage in inflammatory and degenerative arthritis.

Flexor digitorum accessorius causing tarsal tunnel syndrome in a paediatric patient: A case report and review of the literature.

The flexor digitorium accessorius muscle is an unusual anatomical variant found in the posteromedial aspect of the hindfoot and ankle. As previously described, its location predisposes patients to developing tarsal tunnel syndrome. This case illustrates the diagnosis, treatment and resolution of tarsal tunnel syndrome in a paediatric patient, secondary to the presence of flexor digitorium accessorius muscle.

Potential role of the posterior cruciate ligament synovio-entheseal complex in joint effusion in early osteoarthritis: a magnetic resonance imaging and histological evaluation of cadaveric tissue and data from the Osteoarthritis Initiative.

OBJECTIVE: This study explored posterior cruciate ligament (PCL) synovio-entheseal complex (SEC) microanatomy to determine whether it may participate in the early osteoarthritis (OA) disease process. METHODS: SEC microanatomy and OA features were evaluated in 14 non-arthritic cadaveric knees (mean age = 69.9) using magnetic resonance imaging (MRI) and histology. MRI images of 49 subjects selected from the progression cohort of the Osteoarthritis Initiative (OAI) were evaluated by a musculoskeletal radiologist using an original semi-quantitative method for features associated with OA at the PCL tibial enthesis. Statistical analysis was performed using chi-square and Wilcoxon signed-rank tests to evaluate associations between SEC configuration and OA features. RESULTS: The PCL formed a SEC-like structure encompassing bone- and ligament-lining intra-articular cartilages to which the posterior root of the medial meniscus contributed. Degenerative features at the PCL-SEC included: neovascularisation (44%), enthesis chondrocyte clustering (44%), collagen matrix fissuring at the enthesis (56%) and in the PCL itself (67%), tidemark duplication (44%), bone remodelling (44%) and microscopic inflammatory changes (33%). In the OAI cohort, SEC-related pathology included bone marrow lesions (BMLs) (69%) and osteophytosis (94%) at locations that corresponded to SEC-related cartilages. Posterior joint recess effusion (49%) was linked to MRI abnormalities at PCL-SEC cartilages (χ2 = 7.27, P = 0.007). CONCLUSIONS: The PCL has a prominent SEC configuration that is associated with microscopic OA changes in aged clinically non-diseased joints. MRI determined knee OA commonly exhibited pathological features at this site which was associated with adjacent joint effusion. Thus, the PCL-SEC could play a hitherto unappreciated role in the early OA disease process.

Demodex-associated bacterial proteins induce neutrophil activation.

BACKGROUND: Patients with rosacea demonstrate a higher density of Demodex mites in their skin than do controls. A bacterium isolated from a Demodex mite from a patient with papulopustular rosacea (PPR) was previously shown to provoke an immune response in patients with PPR or ocular rosacea, thus suggesting a possible role for bacterial proteins in the aetiology of this condition. OBJECTIVES: To examine the response of neutrophils to proteins derived from a bacterium isolated from a Demodex mite. METHODS: Bacterial cells were lysed and proteins were partially purified by ÄKTA fast protein liquid chromatography. Isolated neutrophils were exposed to bacterial proteins and monitored for alterations in migration, degranulation and cytokine production. RESULTS: Neutrophils exposed to proteins from Bacillus cells demonstrated increased levels of migration and elevated release of matrix metalloprotease 9, an enzyme known to degrade collagen, and cathelicidin, an antimicrobial peptide. In addition, neutrophils exposed to the bacterial proteins demonstrated elevated rates of interleukin 8 and tumour necrosis factor-α production. CONCLUSIONS: Proteins produced by a bacterium isolated from a Demodex mite have the ability to increase the migration, degranulation and cytokine production abilities of neutrophils. These results suggest that bacteria may play a role in the inflammatory erythema associated with rosacea.

Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks.

The extent of analgesia provided by transversus abdominis plane blocks depends upon the site of injection and pattern of spread within the plane. There are currently a number of ultrasound-guided approaches in use, including an anterior oblique-subcostal approach, a mid-axillary approach and a more recently proposed posterior approach. We wished to determine whether the site of injection of local anaesthetic into the transversus abdominis plane affects the spread of the local anaesthetic within that plane, by studying the spread of a local anaesthetic and contrast solution in four groups of volunteers. The first group underwent the classical landmark-based transversus abdominis plane block whereby two different volumes of injectate were studied: 0.3 ml.kg(-1) vs 0.6 ml.kg(-1). The second group underwent transversus abdominis plane block using the anterior subcostal approach. The third group underwent transversus abdominis plane block using the mid-axillary approach. The fourth group underwent transversus abdominis plane block using the posterior approach, in which local anaesthetic was deposited close to the antero-lateral border of the quadratus lumborum. All volunteers subsequently underwent magnetic resonance imaging at 1, 2 and 4 h following each block to determine the spread of local anaesthetic over time. The studies demonstrated that the anterior subcostal and mid-axillary ultrasound approaches resulted in a predominantly anterior spread of the contrast solution within the transversus abdominis plane and relatively little posterior spread. There was no spread to the paravertebral space with the anterior subcostal approach. The mid-axillary transversus abdominis plane block gave faint contrast enhancement in the paravertebral space at T12-L2. In contrast, the posterior approaches, using both landmark and ultrasound identifications, resulted in predominantly posterior spread of contrast around the quadratus lumborum to the paravertebral space from T5 to L1 vertebral levels. We concluded that the pattern of spread of local anaesthetic differs depending on the site of injection into the transversus abdominis plane. This may have important implications for the extent of analgesia produced with each approach.

'Ready-access' CT imaging for an orthopaedic trauma clinic.

'Ready-Access' to CT imaging facilities in Orthopaedic Trauma Clinics is not a standard facility. This facility has been available at the regional trauma unit, in Merlin Park Hospital, Galway for the past four years. We reviewed the use of this facility over a 2-year period when 100 patients had CT scans as part of their trauma clinic assessment. The rate of CT scan per clinic was 0.6. The mean waiting time for a CT scan was 30 minutes. 20 (20%) new fractures were confirmed, 33 (33%) fractures were out-ruled, 25 (25%) fractures demonstrated additional information and 8 (8%) had additional fractures. 20 (20%) patients were discharged and 12 (12%) patients were admitted as a result of the CT scan. It adds little time and cost to CT scanning lists.

A meta-analysis study of the effect of chilling on prevalence of Salmonella on pig carcasses.

In the field of food safety, meta-analysis can be used to combine results of prevalence studies of pathogens at critical stages within the food processing chain so that policy makers can access reliable and concise information on the effectiveness of interventions for controlling and preventing foodborne illnesses in humans. The objective of this work was to demonstrate the applicability of a parametric approach of meta-analysis to the specific case of determining the overall effect of chilling on Salmonella prevalence on pig carcasses. A meta-analysis was performed on each of two parameters measuring effect size for binary outcomes (relative risk and risk difference). Both meta-analyses confirmed that the chilling operation has a significant beneficial effect (P < 0.001) on the reduction of Salmonella prevalence on pig carcasses. Because risk difference is a parameter sensitive to the differences across studies in carcass swab areas and Salmonella detection methods, its meta-analysis highly reflected this heterogeneity (P < 0.001). However, parameterization of relative risk, not being biased by the above sources of variability, did not give rise to heterogeneity among studies and produced a fixed-effects meta-analysis solution, which is deemed more suitable for compilations based on a small number of individual studies (n = 9). Because of the systematic approach of meta-analysis (i.e., individual studies are weighed according to precision) and its reliance for actual data, the output distribution of the relative risk effect size (approximately eN(-0.868,0.166)) merits consideration for inclusion in the chilling stage of quantitative risk assessments modeling the prevalence of this pathogen along the pork production chain.

Altered plasma arginine metabolome precedes behavioural and brain arginine metabolomic profile changes in the APPswe/PS1ΔE9 mouse model of Alzheimer's disease.

While amyloid-beta (Aß) peptides play a central role in the development of Alzheimer's disease (AD), recent evidence also implicates altered metabolism of L-arginine in the pathogenesis of AD. The present study systematically investigated how behavioural function and the brain and plasma arginine metabolic profiles changed in a chronic Aß accumulation model using male APPswe/PS1ΔE9 transgenic (Tg) mice at 7 and 13 months of age. As compared to their wild-type (WT) littermates, Tg mice displayed age-related deficits in spatial water maze tasks and alterations in brain arginine metabolism. Interestingly, the plasma arginine metabolic profile was markedly altered in 7-month Tg mice prior to major behavioural impairment. Receiver operating characteristic curve analysis revealed that plasma putrescine and spermine significantly differentiated between Tg and WT mice. These results demonstrate the parallel development of altered brain arginine metabolism and behavioural deficits in Tg mice. The altered plasma arginine metabolic profile that preceded the behavioural and brain profile changes suggests that there may be merit in an arginine-centric set of ante-mortem biomarkers for AD.

Medium term review of the ASR implant system: A single surgeon series.

INTRODUCTION: Both ASR hip resurfacings and stemmed ASR XL arthroplasties have failed at high rates in several published series. We assessed a single surgeon series of these arthroplasties looking to identify factors associated with their failure. METHODS: All surgeries were performed by one surgeon. Patients were evaluated clinically, radiologically and with serial cobalt and chromium ion analysis. RESULTS: 274 implants were analysed - 152 ASR resurfacings and 122 ASR XL implants. Thirty revisions were performed. CONCLUSION: The failure rate of the ASR implant in our series is unacceptably high - its use in routine hip arthroplasty cannot be supported.

A single intracerebroventricular Aß25-35 infusion leads to prolonged alterations in arginine metabolism in the rat hippocampus and prefrontal cortex.

While amyloid beta (Aß) plays a central role in the development of Alzheimer's disease (AD), recent evidence suggests the involvement of arginine metabolism in AD pathogenesis. Earlier research has shown that a single intracerebroventricular (i.c.v.) infusion of pre-aggregated Aß25-35 (the neurotoxic domain of the full-length Aß) altered arginine metabolism in the rat hippocampus (particularly the CA2/3 and dentate gyrus (DG) sub-regions) and prefrontal cortex (PFC) at the time point of 8 days post-infusion. The present study measured the levels of L-arginine and its nine downstream metabolites (L-citrulline, L-ornithine, agmatine, putrescine, spermidine, spermine, glutamate, GABA and glutamine) in the hippocampus and PFC at the time points of 42 and 97 days following a single bilateral i.c.v. infusion of Aß25-35 (30 nmol/rat) or Aß35-25 (reverse peptide; 30 nmol/rat). At the 42-day time point, Aß25-35 resulted in decreased levels of glutamate, glutamine and spermine in the CA2/3 sub-region of the hippocampus. At the 97-day time point, however, there were decreased L-ornithine, GABA and putrescine levels, but increased glutamate/GABA ratio, in the PFC and increased spermine levels in the DG sub-region. Cluster analyses showed that L-arginine and its three main metabolites L-citrulline, L-ornithine and agmatine formed distinct groups, which changed as a function of Aß25-35 at the 42-day and 97-day time points, particularly in the CA2/3 and PFC regions respectively. This study, for the first time, demonstrates that a single i.c.v. infusion of pre-aggregated Aß25-35 leads to prolonged alterations in arginine metabolism in a region-specific and time-dependent manner, which further supports the involvement of arginine metabolism in AD pathogenesis.

Congenital lacrimal fistulas.

Twenty-one patients had surgical procedures for symptomatic cogenital lacrimal fistulas. The symptoms were epiphora from birth in 18 patients and late-onset epiphora in three cases. Thirteen patients had nasolacrimal obstruction at the upper duct or sac level. There were 21 dacryocystorhinostomies with fistula excision and canalicular intubation, and one patient had excision of the fistula tract only. The fistulas originated from the tear sac in only four cases and from the common canaliculus in 17; in one, the upper and lower canaliculus and the lacrimal fistula each had a separate opening into the lateral sac wall. The functional success rate was 95%. We recommend dacryocystorhinostomy with common canalicular dissection, fistula excision, and canalicular intubation for all patients with symptomatic congenital lacrimal fistulas to facilitate outflow and to avoid common canalicular obstruction.

Orbital optic nerve glioma in adult life.

In seven cases, optic nerve glioma presented as an expanding orbital mass in previously asymptomatic adults. Clinically and histologically, these tumors were similar to the orbital optic nerve gliomas of childhood; in contrast to the rapidly progressive malignant gliomas of the chiasm well described in adults, the patients with these tumors had a more benign clinical course. Management of optic nerve glioma in adulthood should be conservative in the presence of useful vision.

Ganglioglioma of the optic nerve.

We examined a 15-year-old boy who had a ganglioglioma involving the left optic nerve, which caused proptosis, decreased vision, and optic atrophy. Computed tomography demonstrated an intraconal mass along the course of the orbital portion of the optic nerve. The only evidence of systemic neurofibromatosis was axillary freckling. The patient underwent a combined medial and lateral orbitotomy and excision of the tumor. Histologic examination demonstrated a mass composed of neurons and glial cells characteristic of ganglioglioma. After a one-year follow-up period, we have found no evidence of recurrence.

Orbital cellulitis.

Forty-nine cases of orbital cellulitis were reviewed. The average age of patients at presentation was 31 years. The onset of symptoms varied from seven days or less in 28 patients, one to four weeks in 17 patients, and more than four weeks in four patients. The leucocyte count, available in 33 patients, was greater than 10 X 10(9)/l in only nine. Abnormal sinuses were noted radiographically in 61%. Computed tomography scans, performed on nine patients, revealed non-localised inflammation in three and an orbital mass in six. Cultures, in general, were disappointing. Seventeen surgical procedures were performed on 14 patients. The complications of orbital cellulitis, occurring in five patients, included osteomyelitis of the maxillary bone, strabismus, afferent pupillary defect, chronic draining sinus, and scarred upper eyelid. Usually the treatment of orbital cellulitis requires aggressive parenteral antibiotic therapy and judicious surgical intervention.

Blepharochalasis.

Blepharochalasis is an uncommon disorder distinguished by recurrent episodes of eyelid oedema in young patients. A hypertrophic form, manifested as fat herniation, and an atrophic form, manifested as fat atrophy, have been described. Ptosis with excellent levator function, laxity of the lateral canthal structures with rounding of the lateral canthal angle, nasal fat pad atrophy, and redundant eyelid skin develop after many episodes of eyelid swelling. Fine wrinkling, atrophy, and telangiectasias characterise the excess eyelid skin. We describe four cases of this syndrome in which external levator aponeurosis tuck, blepharoplasty, lateral canthoplasty, and dermis fat grafts were used to correct atrophic blepharochalasis after the syndrome had run its course.