A novel neurotropic microsporidium from the swamp guppy Micropoecilia picta from Grenada, West Indies.

A novel microsporidium was observed in wild swamp guppies Micropoecilia picta from Levera Pond within Levera National Park Grenada, West Indies. Initial observations indicated similarity with Pseudoloma neurophilia, an important pathogen in zebrafish Danio rerio. P. neurophilia exhibit broad host specifity, including members of the family Poecillidae, and both parasites infect the central nervous system. However, spore morphology and molecular phylogeny based on rDNA showed that the swamp guppy microsporidium (SGM) is distinct from P. neurophilia and related microsporidia (Microsporidium cerebralis and M. luceopercae). Spores of the SGM were smaller than others in the clade (3.6 µm long). Differences were also noted in histology; the SGM formed large aggregates of spores within neural tissues along with a high incidence of numerous smaller aggregates and single spores within the surface tissue along the ventricular spaces that extended submeninx, whereas P. neurophilia and M. cerebralis infect deep into the neuropile and cause associated lesions. Analysis of small subunit ribosomal DNA sequences showed that the SGM was <93% similar to these related microsporidia. Nevertheless, one of 2 commonly used PCR tests for P. neurophilia cross reacted with tissues infected with SGM. These data suggest that there could be other related microsporidia capable of infecting zebrafish and other laboratory fishes that are not being detected by these highly specific assays. Consequently, exclusive use of these PCR tests may not accurately diagnose other related microsporidia infecting animals in laboratory and ornamental fish facilities.

Implementing core NICE guidelines for osteoarthritis in primary care with a model consultation (MOSAICS): a cluster randomised controlled trial.

OBJECTIVE: To determine the effectiveness of a model osteoarthritis consultation, compared with usual care, on physical function and uptake of National Institute for Health and Care Excellence (NICE) osteoarthritis recommendations, in adults ≥45 years consulting with peripheral joint pain in UK general practice. METHOD: Two-arm cluster-randomised controlled trial with baseline health survey. Eight general practices in England. PARTICIPANTS: 525 adults ≥45 years consulting for peripheral joint pain, amongst 28,443 population survey recipients. Four intervention practices delivered the model osteoarthritis consultation to patients consulting with peripheral joint pain; four control practices continued usual care. The primary clinical outcome of the trial was the SF-12 physical component score (PCS) at 6 months; the main secondary outcome was uptake of NICE core recommendations by 6 months, measured by osteoarthritis quality indicators. A Linear Mixed Model was used to analyse clinical outcome data (SF-12 PCS). Differences in quality indicator outcomes were assessed using logistic regression. RESULTS: 525 eligible participants were enrolled (mean age 67.3 years, SD 10.5; 59.6% female): 288 from intervention and 237 from control practices. There were no statistically significant differences in SF-12 PCS: mean difference at the 6-month primary endpoint was -0.37 (95% CI -2.32, 1.57). Uptake of core NICE recommendations by 6 months was statistically significantly higher in the intervention arm compared with control: e.g., increased written exercise information, 20.5% (7.9, 28.3). CONCLUSION: Whilst uptake of core NICE recommendations was increased, there was no evidence of benefit of this intervention, as delivered in this pragmatic randomised trial, on the primary outcome of physical functioning at 6 months. TRIAL REGISTRATION: ISRCTN06984617.

Effect of a model consultation informed by guidelines on recorded quality of care of osteoarthritis (MOSAICS): a cluster randomised controlled trial in primary care.

OBJECTIVE: To determine the effect of a model osteoarthritis (OA) consultation (MOAC) informed by National Institute for Health and Care Excellence (NICE) recommendations compared with usual care on recorded quality of care of clinical OA in general practice. DESIGN: Two-arm cluster randomised controlled trial. SETTING: Eight general practices in Cheshire, Shropshire, or Staffordshire UK. PARTICIPANTS: General practitioners and nurses with patients consulting with clinical OA. INTERVENTION: Following six-month baseline period practices were randomised to intervention (n = 4) or usual care (n = 4). Intervention practices delivered MOAC (enhanced initial GP consultation, nurse-led clinic, OA guidebook) to patients aged ≥45 years consulting with clinical OA. An electronic (e-)template for consultations was used in all practices to record OA quality care indicators. OUTCOMES: Quality of OA care over six months recorded in the medical record. RESULTS: 1851 patients consulted in baseline period (1015 intervention; 836 control); 1960 consulted following randomisation (1118 intervention; 842 control). At baseline wide variations in quality of care were noted. Post-randomisation increases were found for written advice on OA (4-28%), exercise (4-22%) and weight loss (1-15%) in intervention practices but not controls (1-3%). Intervention practices were more likely to refer to physiotherapy (10% vs 2%, odds ratio 5.30; 95% CI 2.11, 13.34), and prescribe paracetamol (22% vs 14%, 1.74; 95% CI 1.27, 2.38). CONCLUSIONS: The intervention did not improve all aspects of care but increased core NICE recommendations of written advice on OA, exercise and weight management. There remains a need to reduce variation and uniformly enhance improvement in recorded OA care. TRIAL REGISTRATION NUMBER: ISRCTN06984617.

Influences on the decision to use an osteoarthritis diagnosis in primary care: a cohort study with linked survey and electronic health record data.

OBJECTIVE: Clinicians may record patients presenting with osteoarthritis (OA) symptoms with joint pain rather than an OA diagnosis. This may have implications for OA research studies and patient care. The objective was to assess whether older adults recorded with joint pain are similar to those with a recorded OA diagnosis. METHOD: A study of adults aged ≥50 years in eight United Kingdom general practices, with electronic health records linked to survey data. Patients with a recorded regional OA diagnosis were compared to those with a recorded joint pain symptom on socio-demographics, risk factors, body region, pain severity, prescribed analgesia, and potential differential diagnoses. A sub-group was compared on radiographic knee OA. RESULTS: Thirteen thousand eight hundred and thirty-one survey responders consented to record review. One thousand four hundred and twenty-seven (10%) received an OA (n = 616) or joint pain (n = 811) code with wide practice variation. Receiving an OA diagnosis was associated with age (75+ compared to 50-64 OR 3.25; 95% Credible intervals (CrI) 2.36, 4.53), obesity (1.72; 1.22, 2.33), and pain interference (1.45; 1.09, 1.92). Analgesia management was similar. Radiographic OA was common in both groups. A quarter of those with a joint pain record received an OA diagnosis in the following 6 years. CONCLUSION: Recording OA diagnoses are less common than recording a joint pain symptom and associated with risk factors and severity. OA studies in primary care need to consider joint pain symptoms to understand the burden and quality of care across the spectrum of OA. Patients recorded with joint pain may represent early cases of OA with need for early intervention.

Quality indicators for the primary care of osteoarthritis: a systematic review.

OBJECTIVE: To identify valid and feasible quality indicators for the primary care of osteoarthritis (OA). DESIGN: Systematic review and narrative synthesis. DATA SOURCES: Electronic reference databases (MEDLINE, EMBASE, CINAHL, HMIC, PsychINFO), quality indicator repositories, subject experts. ELIGIBILITY CRITERIA: Eligible articles referred to adults with OA, focused on development or implementation of quality indicators, and relevant to UK primary care. An English language restriction was used. The date range for the search was January 2000 to August 2013. The majority of OA management guidance has been published within this time frame. DATA EXTRACTION: Relevant studies were quality assessed using previous quality indicator methodology. Two reviewers independently extracted data. Articles were assessed through the Outcome Measures in Rheumatology filter; indicators were mapped to management guidance for OA in adults. A narrative synthesis was used to combine the indicators within themes. RESULTS: 10,853 articles were identified from the search; 32 were included in the review. Fifteen indicators were considered valid and feasible for implementation in primary care; these related to assessment non-pharmacological and pharmacological management. Another 10 indicators were considered less feasible, in various aspects of assessment and management. A small number of recommendations had no published corresponding quality indicator, such as use of topical non-steroidal anti-inflammatory drugs. No negative ('do not do') indicators were identified. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: There are well-developed, feasible indicators of quality of care for OA which could be implemented in primary care. Their use would assist the audit and quality improvement for this common and frequently disabling condition.

The value of cardiopulmonary exercise testing and stress echocardiography in the prediction of all-cause mortality in adults with end-stage renal disease.

We aimed to assess the prognostic utility of different parameters routinely assessed from cardiopulmonary exercise testing (CPET) and exercise echocardiography in adults with end-stage renal disease (ESRD). Forty-two ESRD (37 male) individuals (age: 58 ± 13 years, height: 169.30 ± 8.30 cm, weight: 81 ± 15 kg, body surface area: 1.92 ± 0.20 m2) underwent a maximal/symptom limited CPET, with a full cross-sectional echocardiogram performed at baseline and peak exercise. All participants were prospectively followed over a 10-year period, with all-cause mortality as the primary endpoint. After the follow-up period, a total of 19 participants (45%) died. Left atrial size (4.70 ± 0.70 vs. 3.65 ± 0.50 cm, P < 0.001) and anteroseptal wall thickness (1.28 ± 0.40 vs. 1.06 ± 0.02 cm, P = 0.002) were significantly greater in those that died, while peak heart rate was significantly lower (108 ± 12 vs. 128 ± 14 bpm, P < 0.001). The prevalence of myocardial ischaemia (13 vs. 8 participants, P = 0.03) was significantly greater, while peak VO2 (9.80 ± 2.10 vs. 15.90 ± 4.30 ml·kg-1·min-1, P < 0.001) was significantly lower in those that died. Following multivariate cox regression, myocardial ischaemia (Hazard Ratio 3.08; 95% Confidence Interval 1.09-8.70; P = 0.03) and peak VO2 (HR 0.73; 95% CI 0.64-0.84; P < 0.001) were significant independent predictors of 10-year all-cause mortality. This is the first study to establish peak VO2 as powerful marker of all-cause mortality when assessed with clinical, resting and stress echocardiography parameters in people with ESRD over a 10-year follow up period. This observation indicates that, in clinical practice, CPET and exercise echocardiography may serve as valuable tools for the risk stratification of individuals with ESRD.HighlightsWe aimed to assess the prognostic utility of cardiopulmonary exercise testing (CPET) and exercise echocardiography in end-stage renal disease (ESRD) with 10-year mortality.Peak aerobic capacity and the presence of ischaemic heart disease were independently associated with all-cause mortality.This observation indicates that, in clinical practice, CPET and exercise echocardiography may serve as valuable tools for the risk stratification of individuals with end-stage renal disease.

Phospholipid-nucleoside conjugates. The aggregational characteristics and morphological aspects of selected 1-beta-D-arabinofuranosylcytosine 5'-diphosphate-L-1,2-diacylglycerols.

1-beta-D-Arabinofuranosylcytosine 5'-diphosphate-1,2-diacylglycerols have previously been shown to be promising candidates as prodrugs of the clinically useful antileukemic agent 1-beta-D-arabinofuranosylcytosine. Because of the amphipathic nature of these liponucleotides and the potential that their morphological state may mediate their biological activity, it was necessary to undertake detailed studies of their aggregational and morphological characteristics. When samples of 1-beta-D-arabinofuranosylcytosine 5'-diphosphate-L-1,2-diacylglycerols (containing either dimyristoyl, dipalmitoyl or distearoyl fatty acid side chains) were prepared in buffered saline solutions using sonication methods, the morphological nature of the resulting aggregate was shown to be related to temperature and the length of the side chain. When sonicated at low temperatures all the above-mentioned derivatives gave turbid solutions containing large bilayer sheets. As the temperature was raised, a transition temperature was reached at which a stable three-dimensional cross-linked network of small interlocking bilayer stacks was formed. This turbidity transition temperature was directly related to the chain length of the fatty acid side chain. Sonication at temperatures close to this turbidity transition temperature produced small disc-shaped micellar structures. These micelles were shown to exist in another aggregational equilibrium consisting of a stacking-destacking process, the position within this equilibrium being dependent upon the concentration. In contrast, a sample of 1-beta-D-arabinofuranosylcytosine 5'-diphosphate-L-1,2-dioleoylglycerol (which contains an unsaturated carbon-carbon bond in each of the fatty acid side chains) was shown to give a multilamellar liposome structure when sonicated in buffered saline at temperatures above its turbidity transition temperature.

Reconstruction by myocutaneous eyelid flaps.

The combined loss of skin and deeper tissues of the eyelids and periorbital regions can frequently be reconstructed with use of an eyelid myocutaneous flap. This technique alone can be used for most eyelid defects not involving the lid margin, or it can be used in conjunction with other procedures when the lid margin is involved. Defects, sometimes quite large, in 37 patients have been reconstructed with good results. The technique provides one-stage reconstruction, avoids volume loss and depressed scars, provides an excellent blood supply to the flap, gives an optimum tissue match, decreases patient morbidity, and increases the likelihood of a good cosmetic result. The generalized applications of this technique make it valuable for reconstructive surgery of the orbital region.

Loxoscelism of the eyelids.

Loxoscelism is a reaction to the bite of spiders of the genus Loxosceles. Several species have been found in the United States; the most commonly encountered is L reclusus, the small brown recluse spider. Two types of reactions occur from the bite. In the localized type, necrotic loxoscelism, a cutaneous lesion with extensive gangrene develops. About 25% of patients have systemic manifestations of viscerocutaneous loxoscelism. There is the same local reaction, but, in addition, fever, chills, vomiting, joint pain, and hematologic abnormalities occur. Hemoglobinemia and hemoglobinuria suggest severe involvement. Deaths are believed to be caused by massive intravascular hemolysis. We describe a 61-year-old man who was bitten on the periorbital region; viscerocutaneous loxoscelism with gangrenous involvement of the eyelids developed. Severe laryngeal edema from regional, massive swelling of his neck was life threatening.

Bispectral Index values are higher during halothane vs. sevoflurane anesthesia in children, but not in infants.

BACKGROUND: Previously, we have shown in adult patients that bispectral index score (BIS) values are significantly higher during halothane anesthesia (53-61 units) as compared with those observed during equipotent concentrations of sevoflurane (39-43 units). Because halothane is frequently used in the pediatric setting, we tested the hypothesis that BIS values observed in children might also be higher during general anesthesia with halothane than with sevoflurane. METHODS: Forty-one healthy, unpremedicated pediatric patients scheduled for elective operations received either halothane or sevoflurane titrated as appropriate for surgical stimulation. RESULTS: During maintenance sevoflurane anesthesia (n=20), the mean BIS values and percent end-tidal concentrations were 44+/-14 and 2.1+/-0.6, respectively, whereas for the halothane group (n=21) the corresponding values were 61+/-7 and 1.1+/-0.4, respectively. CONCLUSION: These findings suggest that BIS values are higher during halothane vs. sevoflurane anesthesia in children, but not in infants.

Bilateral visual loss after blepharoplasty.

Blindness following blepharoplasty is a well-documented complication. Removal of orbital fat is common to most cases in which such blindness occurs. We present a patient who was referred to us following blepharoplasty involving orbital fat removal in all four lids with subsequent onset of bilateral visual loss. Visual acuity in the right eye has remained no light perception and in the left eye improved from 20/400 to 20/20 following bilateral orbital decompression. An electroretinogram was within normal limits in both eyes. A normal response from the visual evoked response in the left eye and an abnormal response from the visual evoked response in the right eye indicate ganglion cell damage or visual pathway disruption in the right eye, probably secondary to optic nerve ischemia. We conclude that the small nutrient vessels to the optic nerve are more easily compromised than the central retinal artery and are responsible for the visual loss in many of these cases. We believe this to be the first documented case of bilateral visual loss following blepharoplasty and the first electrophysiological study demonstrating the pathophysiology of blindness following blepharoplasty. We advocate rapid orbital decompression to treat this catastrophic complication.

Indications, complications and results with silicone stents.

Fifty-two patients with complicated lacrimal problems were treated with silicone stents. Our overall success rate, judging from a minimum 6-month follow-up, was 40% in these complicated cases, accepting only positive dye tests as our criteria for success. We divided these cases into six groups with successes ranging from 0--68%. Twenty-nine percent of patients had complications related to their stents. While silicone stents are probably the most important recent advance in lacrimal surgery, one must be aware of their indications, limitations and complications.

Isolated subscapularis tear from minimal trauma in a recreational athlete: a case report.

A 49-year-old male recreational weight lifter suffered an isolated partial tear of the subscapularis muscle after minimal trauma. His history was atypical for development of a subscapularis tear, which made his case more difficult to evaluate and subsequently treat. His recovery was uncomplicated and was facilitated by a physical therapy program to enhance rotator cuff strength and proprioception. This report includes a brief review of the literature on the etiology and management of these tears. This case emphasizes the importance of an appropriate physical examination and judicious use of imaging techniques so that uncommon disorders, even those with unusual presentations, can be diagnosed and managed to obtain good outcomes.

Proteins of human urine. III. Identification and two-dimensional electrophoretic map positions of some major urinary proteins.

We mapped the proteins of human urine by high-resolution two-dimensional electrophoresis, utilizing the ISO-DALT system. Wide-range pH gradients and narrow-range acid gradients were both used in the first-dimension separations. The patterns revealed proteins ranging in relative molecular mass from 10 000 to 90 000. Proteins identified in the map included transferrin, albumin, hemopexin, alpha 2-HS glycoprotein, alpha 1-antitrypsin. Gc globulin, alpha 1-acid glycoprotein, Zn alpha 2-glycoprotein, retinol binding protein, beta 2-microglobulin, the immunoglobulin light chains, and MAUP (most acid urinary protein). The use and utility of internal-charge and molecular-mass standards are described. We used electrophoretic transfer of proteins to nitrocellulose sheets and subsequent detection by immunological methods to identify some proteins.

Phospholine iodide toxicity and Jones' tubes.

A 72-year-old man with epiphora secondary to bilateral canalicular stenosis resulting from long-term treatment with 0.125% to 0.25% echothiophate iodide (phospholine iodide) drops for glaucoma underwent bilateral conjunctivodacryocystorhinostomies with Jones' tubes. Within days after undergoing this surgery, he experienced severe unexplained diarrhea, fatigue, weight loss, and prostration. He cancelled his postoperative ophthalmic appointment because of "medical illness." He required admission to his local hospital where extensive studies were done in an attempt to establish the cause of this life-threatening condition. After stopping the echothiophate iodide drops, all symptoms disappeared within two days. Drug toxicity is a previously unreported complication of conjunctivodacryocystorhinostomy, and this case demonstrates that topical medications have enhanced systemic absorption after lacrimal surgery with placement of fistulizing prosthetic devices. One must be aware of this possible complication, not only with long-acting anticholinesterases, but with topical sympathomimetic drugs (especially in cardiac patients) as well as cycloplegic agents in children.

Proteins of human semen. I. Two-dimensional mapping of human seminal fluid.

The proteins in human seminal plasma were mapped by high-resolution two-dimensional electrophoresis (ISO-DALT and BASO-DALT systems). When analyzed under dissociating conditions, samples from normal fertile males revealed a pattern of over 200 proteins, ranging in mass from 10 000 to 100 000 daltons. Comparison of the mapped proteins from these males and those who had undergone vasectomy allowed us to identify one series of glycoproteins as missing from the semen from vasectomized individuals. Glycoproteins isolated by affinity chromatography with use of concanavalin A were also mapped. Some of the protein spots were identified either by co-electrophoresis with purified proteins or by the electrophoretic transfer of proteins to nitrocellulose sheets and subsequent detection by immunological procedures. The proteins identified include a number of serum proteins as well as prostatic acid phosphatase and creatine kinase. Proteolytic events shown to occur during the liquefaction of semen that occurs early after collection indicate the importance of carefully controlled collection and preparation methods for clinical evaluation of seminal plasma. Ethylenediaminetetraacetic acid and phenylmethylsulfonyl fluoride inhibit this proteolysis.

PIP: The proteins in human seminal plasma were mapped by high-resolution 2-dimensional electrophoresis (Iso-Dalt and Baso-Dalt systems). When analyzed under dissociating conditions, samples from normal fertile males revealed a pattern of over 200 proteins, ranging in mass from 10,000-100,000 daltons. Comparisons of the mapped proteins from these males and those who had undergone vasectomy identified 1 series of glycoproteins as missing from the semen of vasectomized individuals. Glycoproteins isolated by affinity fhromatography with the use of concanavalin A were also mapped. Some of the protein spots were identified either by coelectrophoresis with purified proteins or by the electrophoretic transfer of proteins to nitrocellulose shets and subsequent detection by immunological procedures. The proteins identified include a number of serum proteins as well as prostatic acid prosphatase and creatine kinase. Proteolytic events shown to occur during the liquefaction of semen that occurs early after collection indicate the importance of carefully controlled collection and preparation methods for clinical evaluation of seminal plasma. Ethylenediaminetetraacetic acid and phenylmethylsulfonyl fluoride inhibit this proteolysis.

Separation and characterization of fibronectin domains by two-dimensional electrophoresis.

Two-dimensional gel electrophoresis (2DGE) and image processing were used to quantify protein and carbohydrate heterogeneity in human plasma fibronectin (FN) and its enzymatically produced domains. After a 30 minute thermolysin digest of FN, the domains were identified in 2DGE by their known isoelectric points and molecular weights, which were compared to domain standards purified by hydroxyapatite, gel exclusion and heparin-Sepharose chromatography. Three individual species were observed in the cell binding domain which may correspond to the heterogeneity known to result from alternative splicings of the fibronectin gene. In addition, the carbohydrate heterogeneity in the gelatin binding domain was analyzed by 2DGE and isoelectric focusing (IEF) before and after treatment with N-glycanase and neuraminidase to remove selected carbohydrate moieties. Five individual species which differ in carbohydrate structure were observed. The results also indicate a carbohydrate dependent stabilization of the gelatin binding domain with respect to proteolytic digestion.