The use of surgeon-performed ultrasound assessment in a foot and ankle clinic.

BACKGROUND: We describe the first reported use of ultrasound examination performed by an orthopaedic surgeon in the setting of a foot and ankle clinic. METHODS: The senior author attended a course in musculoskeletal ultrasound and performed 100 examinations each checked against the results from a consultant radiologist. Records were kept of all examinations performed in the clinic over a 6-month period with results. RESULTS: Of the 622 patients seen, 91 had an ultrasound scan and 36 had guided injections. All patients had one hospital attendance spared, for most two. Time saved on the treatment pathway per patient was on average 6 weeks. CONCLUSION: Ultrasound assessment performed by a clinician during an outpatient clinic appointment reduces delay in treatment and cuts costs by reducing patient episodes.

Localization, growth, and inactivation of Salmonella Saintpaul on jalapeño peppers.

Consumption of Salmonella-contaminated jalapeño peppers has been implicated in one of the largest foodborne illness outbreaks in the summer of 2008. The objective of this study was to investigate representative groups of native microflora and the distribution, growth, and inactivation of experimentally-inoculated Salmonella Saintpaul on jalapeño peppers. Two genetically modified strains of Salm. Saintpaul producing either green- or red-fluorescent protein were constructed and used in the study. Microbiological analyses showed that jalapeño peppers contained an average of 5.6 log units of total aerobic count and 3.5, 1.8, and 1.9 log units, respectively, of enterobacteriaceae, lactic acid bacteria, and yeast/mold per gram of tissue. Strains typical of Pseudomonas accounted for 8.3% of total aerobic count, and 0.2% of which exhibited pectolytic activity. On inoculated peppers, a vast majority (>90%) of Salm. Saintpaul was recovered from stem/calyx and only a small proportion recovered from fleshy pods. Growth of Salm. Saintpaul on peppers was indicated by an increase in the population of 3 log units after incubation of samples at 20 degrees C for 48 h. Fluorescent Salm. Saintpaul aggregates could be readily detected on stem/calyx using stereofluorescence imaging microscopy and scanning electron microscopy. Data presented showed that Salm. Saintpaul could survive for at least 8 wk on peppers stored at 4 degrees C. Immersion of inoculated peppers in 200 ppm of sodium hypochlorite, acidified sodium chlorite, or peroxy acetic acid for 10 min could reduce the number of Salm. Saintpaul on stem/calyx by 1.5 to 1.7 and that on flesh by 2.1 to 2.4 log units. Practical Application: Consumption of Salmonella-contaminated jalapeño peppers has been implicated in foodborne illness outbreaks. The vast majority of Salmonella Saintpaul recovered from inoculated jalapeño peppers (>90%) was from stem/calyx. Salmonella increased by 3 log units during storage at 68 degrees F (20 degrees C) for 48 h. Salmonella could survive for at least 8 wk on peppers stored at 4 degrees C. Immersion of inoculated peppers in 200 ppm of sodium hypochlorite, acidified sodium chlorite, or peroxyacetic acid for 10 min reduced Salmonella on stem/calyx by 1.5 to 1.7 log units, compared with reductions of 2.1 to 2.4 log units on flesh. These results highlight the need to consider the stem/calyx as the most likely area for contamination of jalapeño peppers, and to process this commodity accordingly to minimize exposure and cross-contaminations.

The advantages gained by the use of modern materials in the post operative casting procedure for foot and ankle surgery.

BACKGROUND: In June 2006, the post operative plaster immobilisation protocol for patients undergoing hindfoot and ankle surgery, at our institution, changed from multiple plaster changes to the immediate application of a definitive removable and reusable split synthetic cast. This study aims to assess the savings to the hospital and patient, following this change in practice. METHODS: A retrospective analysis of plaster room records from June 2005 to June 2007 was performed. The difference in cost to the hospital of the two different post operative journeys was then calculated. RESULTS: Two-hundred and twenty-two patients from 2005 to 2006 were managed at a total cost of 97,125 euro. From 2006 to 2007, 203 patients were managed with the new technique at a total cost of 37,860 euro. The net saving to the hospital of this change in practice was 251 euro per patient and 50,953 euro in total, while 203 patient visits and costs associated therewith were also saved. CONCLUSIONS: This study demonstrates how small changes in local practice can result in significant financial and temporal savings for hospitals and patients.

Ultraviolet light (254 nm) inactivation of Listeria monocytogenes on frankfurters that contain potassium lactate and sodium diacetate.

Listeria monocytogenes, a psychrotrophic foodborne pathogen, is an occasional postprocess contaminant on ready-to-eat meat (RTE) products including frankfurters. Ultraviolet C light (UVC) is an FDA-approved technology for the decontamination of food surfaces. In this study, the ability of UVC to inactivate L. monocytogenes on frankfurters that contained potassium lactate (PL) and sodium diacetate (SDA), either before or after packaging, was investigated. UVC irradiation of frankfurters that were surface-inoculated with L. monocytogenes resulted in a 1.31, 1.49, and 1.93 log reduction at doses of 1, 2, and 4 J/cm(2), respectively. UVC treatment had no effect on frankfurter color or texture at UVC doses up to 4 J/cm(2). Frankfurter meat treated with UVC doses up to 16 J/cm(2) did not increase mutagenesis in bacterial or human cells, either with or without exogenous metabolic activation. UVC treatment of single-layer frankfurter packs at a dose of 2 J/cm(2) resulted in a 0.97 (+/- 0.14) log reduction of L. monocytogenes. Following 8 wk of refrigerated storage L. monocytogenes levels decreased by only 0.65 log in non-UVC-treated frankfurter packs compared with 2.5 log in the UVC-treated packs. Because the numbers of L. monocytogenes associated with contaminations of ready-to-eat meats are typically very low, the use of UVC in combination with potassium lactate and sodium diacetate has the potential to reduce the number of frankfurter recalls and foodborne illness outbreaks.

Acquired adult flat foot due to isolated plantar calcaneonavicular (spring) ligament insufficiency with a normal tibialis posterior tendon.

BACKGROUND: We present nine cases of acquired flat foot deformity (AFFD) in adults caused by isolated spring ligament insufficiency. METHODS: We present the clinical sign that allows differentiation of this diagnosis from posterior tibialis tendon (PTT) dysfunction namely the ability to single leg tiptoe, but with persistent forefoot abduction and heel valgus. In addition we illustrate the unique radiological features which allow confirmation of the diagnosis. Only a solitary previous case report has documented this alternative aetiology of AFFD; in that case, diagnosis was made intra-operatively. RESULTS: Six patients have been managed with orthoses. Three patients underwent surgery; one patient who presented early had isolated repair of the spring ligament complex. The remaining two required a calcaneal osteotomy and flexor digitorum longus transfer as for a PTT reconstruction. CONCLUSION: We propose that early diagnosis (with ultrasound confirmation) and management of this condition would offer a better prognosis and allow less interventional surgery.

Arthrodesis of the hindfoot for valgus deformity. An entirely medial approach.

Correction of valgus deformity of the hindfoot using a medial approach for a triple fusion has only recently been described for patients with tight lateral soft tissues which would be compromised using the traditional lateral approach. We present a series of eight patients with fixed valgus deformity of the hindfoot who had correction by hindfoot fusion using this approach. In addition, we further extended the indications to allow concomitant ankle fusion. The medial approach allowed us to excise medial ulcers caused by the prominent medial bony structures, giving simultaneous correction of the deformity and successful internal fixation. We had no problems with primary wound healing and experienced no subsequent infection or wound breakdown. From a mean fixed valgus deformity of 58.8 degrees (45 degrees to 66 degrees) pre-operatively, we achieved a mean post-operative valgus angulation of 13.6 degrees (7 degrees to 23 degrees). All the feet were subsequently accommodated in shoes. The mean time to arthrodesis was 5.25 months (3 to 9). We therefore recommend the medial approach for the correction of severe fixed valgus hindfoot deformities.

The management of failed ankle replacement.

Advances in the design of the components for total ankle replacement have led to a resurgence of interest in this procedure. Between January 1999 and December 2004, 16 patients with a failed total ankle replacement were referred to our unit. In the presence of infection, a two-stage salvage procedure was planned. The first involved the removal of the components and the insertion of a cement spacer. Definitive treatment options included hindfoot fusion with a circular frame or amputation. When there was no infection, a one-stage salvage procedure was planned. Options included hindfoot fusion with an intramedullary nail or revision total ankle replacement. When there was suspicion of infection, a percutaneous biopsy was performed. The patients were followed up for a minimum of 12 months. Of the 16 patients, 14 had aseptic loosening, five of whom underwent a revision total ankle replacement and nine a hindfoot fusion. Of the two with infection, one underwent fusion and the other a below-knee amputation. There were no cases of wound breakdown, nonunion or malunion. Management of the failed total ankle replacement should be performed by experienced surgeons and ideally in units where multidisciplinary support is available. Currently, a hindfoot fusion appears to be preferable to a revision total ankle replacement.

Properties of whey protein isolates extruded under acidic and alkaline conditions.

Whey proteins have wide acceptance and use in many products due to their beneficial nutritional properties. To further increase the amount of whey protein isolates (WPI) that may be added to products such as extruded snacks and meats, texturization of WPI is necessary. Texturization changes the folding of globular proteins to improve interaction with other ingredients and create new functional ingredients. In this study, WPI pastes (60% solids) were extruded in a twin-screw extruder at 100 degrees C with 4 pH-adjusted water streams: acidic (pH 2.0 +/- 0.2) and alkaline (pH 12.4 +/- 0.4) streams from 2 N HCl and 2 N NaOH, respectively, and acidic (pH 2.5 +/- 0.2) and alkaline (pH 11.5 +/- 0.4) electrolyzed water streams; these were compared with WPI extruded with deionized water. The effects of water acidity on WPI solubility at pH 7, color, microstructure, Rapid Visco Analyzer pasting properties, and physical structure were determined. Alkaline conditions increased insolubility caused yellowing and increased pasting properties significantly. Acidic conditions increased solubility and decreased WPI pasting properties. Subtle structural changes occurred under acidic conditions, but were more pronounced under alkaline conditions. Overall, alkaline conditions increased denaturation in the extruded WPI resulting in stringy texturized WPI products, which could be used in meat applications.

Functionality of extrusion--texturized whey proteins.

Whey, a byproduct of the cheesemaking process, is concentrated by processors to make whey protein concentrates (WPC) and isolates (WPI). Only 50% of whey proteins are used in foods. In order to increase their usage, texturizing WPC, WPI, and whey albumin is proposed to create ingredients with new functionality. Extrusion processing texturizes globular proteins by shearing and stretching them into aligned or entangled fibrous bundles. In this study, WPC, WPI, and whey albumin were extruded in a twin screw extruder at approximately 38% moisture content (15.2 ml/min, feed rate 25 g/min) and, at different extrusion cook temperatures, at the same temperature for the last four zones before the die (35, 50, 75, and 100 degrees C, respectively). Protein solubility, gelation, foaming, and digestibility were determined in extrudates. Degree of extrusion-induced insolubility (denaturation) or texturization, determined by lack of solubility at pH 7 for WPI, increased from 30 to 60, 85, and 95% for the four temperature conditions 35, 50, 75, and 100 degrees C, respectively. Gel strength of extruded isolates increased initially 115% (35 degrees C) and 145% (50 degrees C), but gel strength was lost at 75 and 100 degrees C. Denaturation at these melt temperatures had minimal effect on foaming and digestibility. Varying extrusion cook temperature allowed a new controlled rate of denaturation, indicating that a texturized ingredient with a predetermined functionality based on degree of denaturation can be created.

Giant-cell tumour of the tendon sheath in the foot and ankle.

Giant-cell tumour of the tendon sheath (GCT-TS) is a benign solitary tumour which usually arises in the limbs. It occurs most often in the hand where local recurrence after excision has been reported in up to 45% of cases. It is less common in the foot where the biological behaviour and risk of local recurrence have not been defined. We have studied 17 cases of GCT-TS of the foot and ankle in which treatment was by excision. Fifteen presented as a solitary, painless, slow-growing soft-tissue swelling. One lesion was associated with sensory deficit of a digital nerve and one with pain on walking. Thirteen cases originated from the periarticular tendon-sheath complex of the small joints of the toes and four from the capsule or long tendons of the ankle. A correct preoperative diagnosis was made in only three cases. MRI proved to be the most useful preoperative investigation as GCT-TS has a characteristic appearance which allows planned local excision to be carried out. None of the patients with histologically confirmed GCT-TS required further surgery. There was no local recurrence in 15 patients who were available for follow-up at a mean of 85 months.

Molten globule structures in milk proteins: implications for potential new structure-function relationships.

Recent advances in the field of protein chemistry have significantly enhanced our understanding of the possible intermediates that may occur during protein folding and unfolding. In particular, studies on alpha-lactalbumin have led to the theory that the molten globule state may be a possible intermediate in the folding of many proteins. The molten globule state is characterized by a somewhat compact structure, a higher degree of hydration and side chain flexibility, a significant amount of native secondary structure but little tertiary folds, and the ability to react with chaperones. Purified alpha(s1)- and kappa-caseins share many of these same properties; these caseins may thus occur naturally in a molten globule-like state with defined, persistent structures. The caseins appear to have defined secondary structures and to proceed to quaternary structures without tertiary folds. This process may be explained, in part, by comparison with the architectural concepts of tensegrity. By taking advantage of this "new view" of protein folding, and applying these concepts to dairy proteins, it may be possible to generate new and useful forms of proteins for the food ingredient market.

Effects of chilling on sampling of bacteria attached to swine carcasses.

Two microbiological sampling techniques, excision and sponge swabbing, were compared by determining counts of aerobic bacteria, coliforms and injured coliforms from 20 de-haired swine carcasses before and after chilling. Excised jowl skin produced significantly greater counts of the three types of bacteria than sponge swabs. Aerobic bacteria, coliforms and injured coliforms recovered by sponge swabbing carcasses before chilling were 11.6%, 0.9% and 11.0% of excised samples, respectively; the corresponding percentages recovered after chilling were 23.9%, 11.1% and 5.0%. Numbers of all bacteria present on the post-chill carcasses were substantially lower than on the pre-chill carcasses. Excision usually produced more countable plates for coliforms and injured coliforms on chilled carcasses than sponge swabbing and therefore, is more suitable in estimating low numbers of faecal bacteria on chilled carcasses. To explore the possible structural bases for these findings, skin samples were inoculated with 10(2)-10(7) cfu cm(-2) faecal bacteria and examined by scanning electron microscopy. Chilled samples showed bacteria and biofilm embedded in superficial crevices, which underlies a possible reason for the lower recovery of bacterial cells by the sponge swabbing. The study indicates that the differences between sampling techniques may be a result of the chilling process of swine carcasses.

Response to trisodium phosphate treatment of Salmonella Chester attached to fresh-cut green pepper slices.

A laboratory model using green pepper disks was developed to investigate the attachment of Salmonella Chester on plant tissue and to evaluate the effectiveness of sanitizer agents in inactivating attached bacteria on fruits. Pepper disks (14 mm in diam, and 3-4 mm in thickness) were immersed in a bacterial suspension containing 1.5 x 107 cfu x mL(-1) of S. Chester for 30 s and subsequently air-dried at room temperature for 10 min. Approximately 30% of the bacteria retained on the disk after immersion were firmly attached and could not be removed by two washes and agitation. A positive correlation was observed between the number of bacteria attached and the concentration of bacteria in the suspension. Population studies and scanning electron microscopic examinations revealed that attachment of S. Chester on pepper disks occurred mainly on the surfaces of injured (cut) tissue but rarely on the unbroken skin. When inoculated disks were treated with 3% to 12% (w/v) of trisodium phosphate (TSP) at pH 12.3 for 5 min, the population of bacteria on the disk was reduced by 10- to 100-fold. A small portion (0.7% to 7.1%) of bacteria attached to the disk were either resistant to or protected from the TSP treatment. When the pH of TSP solution was reduced from 12.3 to 4.5, the effectiveness of TSP in inactivating S. Chester on pepper disks was reduced by 26%. This study shows that surfaces of injured fruit tissue are the principal sites for bacterial attachment, and a small portion of the bacteria attached to the tissue are resistant to the sanitizer treatment. Avoiding mechanical injuries to fresh fruits during and after harvest would reduce the chance of pathogen attachment and contamination on green pepper and fruits of similar nature.

Enzymatic hydrolysis, grease permeation, and water barrier properties of zein isolate coated paper.

An inexpensive zein-lipid mixture was isolated from yellow dent, dry-milled corn. Grease permeation through zein isolate applied to brown Kraft paper was found to be independent of loading levels at zein isolate levels above 30 mg/16 in.(2). The data shows that water vapor transmission rates depended on the amount of coating applied. Triacylglycerols were the most abundant lipid in milled corn but were absent in the zein isolate (perhaps due to hydrolysis by lipases). Zein from the paper was hydrolyzed enzymatically and the hydrolysis monitored by SDS-capillary electrophoresis. At an E:S ratio of 1:100 no further increase in the hydrolysate peak occurred after 10 and 30 min for alpha-chymotrypsin and pancreatin 8 x; however, zein and lipid were still present 1 h after hydrolysis by pancreatin 1 x.

Characterization of the particles of purified kappa-casein: trypsin as a probe of surface-accessible residues.

kappa-Casein as purified from bovine milk exhibits a rather unique disulfide bonding pattern as revealed by SDS-PAGE. The disulfide-bonded caseins present range from dimer to octamer and above and preparations contain about 10% monomer. All of these heterogeneous polymers, however, self-associate into nearly spherical particles with an average diameter of 13 nm at pH 8.0, as revealed by negatively stained transmission electron micrographs and dynamic light scattering. The weight-average molecular weight of the aggregates at pH 8.0, as judged by analytical ultracentrifugation, is 648,000. Trypsin digestion at pH 8.0 was used to probe the surface groups of the kappa-casein A polymers. The reaction with trypsin was rapid and the peptides liberated were identified by separation with reverse-phase HPLC, amino acid analysis, and protein sequencing. The most rapidly released peptides (t1/2 < 30 sec) were from cleavage at Arg 97 and Lys residues 111 and 112. These results suggest a surface orientation for these residues, and the data are in accord with earlier proposed 3D predictive models for kappa-casein. It is speculated that Arg 97, together with adjacent His residues (98 and 100) and Lys residues 111 and 112, form two positively charged clusters on the surface of the otherwise negatively charged casein. These clusters bracket the neutral chymosin cleavage site (whose hydrolysis triggers a well-known digestive process) and so these clusters may facilitate docking of the substrate caseins with chymosin.

Divot sign: a new observation in anterior impingement of the ankle.

Anterior impingement of the ankle results from osteophyte formation on the anterior edge of the distal tibia. Classically, subsequent degeneration results in an osteophyte forming on the anterior neck of the talus. This results in limited dorsiflexion and impingement seen in the ankles of athletes. Recent clinical observation in high performance soccer players has revealed a previously unrecognized pattern of a localized divot forming in the talar neck in place of the osteophyte. This accepts the tibial osteophyte during dorsiflexion, which is therefore not limited in these patients.

Particle sizes of purified kappa-casein: metal effect and correspondence with predicted three-dimensional molecular models.

kappa-Casein as purified from bovine milk exhibits a rather unique disulfide bonding pattern as revealed by SDS-PAGE. The disulfide-bonded caseins present range from dimer to octamer and above and preparations contain about 10% monomer. All of these heterogenous polymers, however, self-associated into nearly spherical uniform particles with an average radius of 8.9 nm as revealed by negatively stained transmission electron micrographs. Evidence is presented that multivalent cations play a role in the stabilization of these spherical particles. Treatment with EDTA causes disruption of the kappa-casein particles and leads to a broder size distribution as judged by electron microscopy and dynamic light scattering. The size and shape of the particles are in accord with earlier proposed 3D models for kappa-casein that actually predicted participation of divalent cations in the structure.

In situ characterization of Clostridium botulinum neurotoxin synthesis and export.

A monoclonal antitoxin/colloidal gold probe and sequential centrifugation were used to study synthesis, translocation and export of Clostridium botulinum strain 62A neurotoxin (NT). Exponential growth occurred after 5 h of anaerobic incubation of spores and continued for 15-16 h. NT was detected at 15 h using the probe and transmission electron microscopy (TEM), 2 h earlier than the first detection by the mouse bioassay. During exponential growth, the probe localized NT primarily in the cytoplasm, on the inner side of the cytoplasmic membrane and in the cell wall. During stationary and death phases, the NT was located within the cytoplasm, cell wall and extracellularly. NT was released from the cell during cell wall exfoliation. Cells retained NT after repeated gelatin-phosphate washes and sequential centrifugations, consistent with the TEM observation that the NT is bound to the cell wall. These observations indicate that the process of Cl. botulinum type A NT production follows a sequence of synthesis, translocation across the cytoplasmic membrane and export through the cell wall.

Streptococcus bovis-infected total hip arthroplasty.

The case of a 51-year-old man who underwent a total hip arthroplasty following failed AO screw fixation of a subcapital femoral neck fracture is reported. Infection of the prosthesis with Streptococcus bovis type 1 followed a febrile illness. Further investigation revealed an occult premalignant polyp in the proximal colon. Colonic neoplasia and S. bovis bacteremia are associated with endocarditis; however, S. bovis is a rare pathogen infecting joint prostheses and should raise the possibility of a gastrointestinal lesion.