Wetting of a Stepped Platinum (211) Surface.

Steps stabilize water adsorption on metal surfaces, providing favorable binding sites for water during wetting or ice nucleation, but there is limited understanding of the local water arrangements formed on such surfaces. Here we describe the structural evolution of water on the stepped Pt(211) surface using thermal desorption, low-energy electron diffraction, and scanning tunneling microscopy to probe the water structure. At low coverage water forms linear structures comprising zigzag chains along the steps that are decorated by H-bonded rings every one or two units along the terrace. Simple 2-coordinate H-bonded chains are not observed, indicating the Pt step binds too weakly to compensate entirely for a low water H-bond coordination number. As the coverage increases, water chains assemble into a disordered (2 × 1) structure, likely made up of the same narrow water chains along the steps with little or no H-bonding between adjacent structures. The chain structure disappears as water adsorption saturates the surface to form an incommensurate, disordered network of water rings of different size. Although the steps on Pt(211) clearly stabilize water adsorption and direct growth, the surface does not support the simple 1D chains previously proposed or an ordered 2D network such as seen on other surfaces. We discuss reasons for this and the factors that determine the behavior of the first water layer on stepped metal surfaces.

Merkel cell carcinoma.

Merkel cell carcinoma (MCC) is a rare neuroendocrine carcinoma. The cellular origin of MCC may include Merkel cell precursors. The incidence of MCC has increased significantly however trends may have been confounded by evolving diagnostic criteria. The two key aetiologies of MCC are ultraviolet radiation and Merkel cell polyoma virus (MCPyV). Both have unique mechanisms of carcinogenesis. MCC presents non-specifically as a rapidly growing, red-to-violet nodule on sun-exposed areas. Diagnostic accuracy has improved through immunohistochemical markers such as CK-20. Lymph nodes should be evaluated in MCC through examination and sentinel biopsy. USS, CT, MRI and CT-PET may be useful in staging. Management depends on tumour location, stage and comorbidities. MCPyV status may guide treatment strategy in the future. Treatment for the primary MCC is commonly wide local excision followed by radiotherapy, guided by anatomical constraints. There is uncertainty about surgical margins. Treatments for nodal disease have not been determined through trials. They include nodal dissection or radiotherapy for clinically or radiologically apparent disease, and adjuvant nodal irradiation for negative nodes, microscopic disease or following nodal dissection for definite disease. Patients with loco-regional advanced inoperable disease should be considered for combination therapy including chemotherapy, radiotherapy, surgery and immunotherapy. Systemic therapy for advanced disease includes immune checkpoint inhibitors targeting the PD-1/PD-L1 pathway. Avelumab can improve survival in metastatic MCC. Immunotherapy may result in longer disease control. Various other immunotherapeutic and molecular agents are undergoing trials. MCC continues to have a high mortality characterized by high recurrence and early metastases.

Clinical response to antibiotic regimens in lower limb cellulitis: a systematic review.

There is variation in the treatment of lower limb cellulitis (LLC) with no agreement on the most effective antibiotic regimen. Many patients with cellulitis fail to respond to first-line antibiotics. This can negatively affect patient care and result in unnecessary hospital admissions. The aim of this systematic review was to determine the clinical response and safety of antibiotic regimens for the management of LLC. A systematic review for randomized controlled trials (RCTs) was conducted using OVID MEDLINE, Ovid Embase and Cochrane Central Register of Controlled Trials in January 2019. Outcomes of interest included the clinical response to antibiotic regimens (type, dose, route, duration) and the safety of antibiotics in LLC. Trial quality was identified using the Cochrane Risk of Bias tool. Four RCTs were included. All included studies showed no significant differences between the clinical response to different antibiotic type, administration route, treatment duration or dose. LLC may be overtreated and shorter courses of oral antibiotics, possibly with lower doses, may be more suitable. There is a lack of published data on the clinical response and safety of antibiotics in LLC. Three studies were high risk for bias overall. Further high-quality studies may help determine whether less intensive antibiotic regimens can effectively treat LLC.

Potentiating cutaneous wound healing in young and aged skin with nutraceutical collagen peptides.

BACKGROUND: Chronic wounds continue to be a burden to healthcare systems, with ageing linked to increased prevalence of chronic wound development. Nutraceutical collagen peptides have been shown to reduce signs of skin ageing, but their therapeutic potential for cutaneous wound healing remains undefined. AIM: To determine the potential for nutraceutical collagen peptides to promote cutaneous wound healing in vitro in the context of age. METHODS: The potential for bovine- or porcine-derived nutraceutical collagen peptides to promote wound healing of primary cutaneous fibroblasts and keratinocytes derived from young and aged individuals in vitro was assessed by two-dimensional scratch and cell-viability assays and by immunofluorescence for the cell proliferation marker, Ki67. The achievement of peptide concentrations in vivo, equivalent to those exerting a beneficial effect on wound healing in vitro, was confirmed by pharmacokinetic studies of hydroxyproline, a biomarker for collagen peptide absorption, following peptide ingestion by healthy individuals over a wide age range. RESULTS: Results demonstrated significant nutraceutical collagen peptide-induced wound closure of both young and aged fibroblasts and keratinocytes, mediated by enhanced cellular proliferation and migration. Analysis of blood levels of hydroxyproline in young and aged individuals following porcine collagen peptide ingestion revealed peak serum/plasma levels after 2 h at similar concentrations to those exerting beneficial effects on wound healing in vitro. CONCLUSION: These data demonstrate the capacity for nutraceutical collagen peptides to promote cutaneous wound closure in vitro, at pharmacologically achievable concentrations in vivo, thereby offering a potential novel therapeutic strategy for the management of cutaneous wounds in young and aged individuals.

A review of trench foot: a disease of the past in the present.

From the French Invasion of Russia in 1812, to Glastonbury festival in 2007, trench foot has been reported, yet the exact nature of the condition remains unclear. This review explores the pathogenesis and treatment of trench foot. Trench foot is considered to be a nonfreezing cold injury often complicated by infection, in which exposure to cold temperatures just above freezing, combined with moisture, results in a peripheral vasoneuropathy. The presence of physical trauma, bacterial or fungal infections, malnutrition, venous hypertension and lymphoedema mean that some individuals are at greater risk of trench foot. Trench foot may be prevented by warming the feet, changing socks, staying active, rubbing the skin with oil and regularly inspecting the feet. Avoiding risk factors may help prevent the condition. The management of trench foot is less clear. Vasodilators such as iloprost and nicotinyl tartrate or sympathectomy may help. Trench foot may lead to necrosis, cellulitis, sepsis and amputation. It remains a poorly understood condition.

Lower limb cellulitis: low diagnostic accuracy and underdiagnosis of risk factors.

Accurate diagnosis and recognition of predisposing factors has been shown to be challenging in lower limb cellulitis (LLC). Assessment of 1746 consecutive patients with cellulitis presenting to a UK university hospital showed increasing overdiagnosis, with only 31.9% of patients referred during the period 2015-2018 having the diagnosis of LLC confirmed. Recognition of at least one predisposing factor increased from 61% to 89% following introduction of more specific screening questions. This identified a need for better primary care dermatology education and the benefit of a proforma with specific screening questions for reversible predisposing factors for LLC.

A new urethral catheterisation device (UCD) to manage difficult urethral catheterisation.

The cost of urethral catheterisation injury (UCI) is significant, but the true incidence of patient care error is difficult to establish in the absence of specific hospital codes recording difficult urethral catheterisation (DUC) and UCI. For many years urologists are familiar passing a non-traumatic hydrophilic guidewire blindly into the bladder to aid urethral catheter insertion in difficult circumstances. However, so far, no purpose-built regulated medical device was available on the market and clinicians had to improvise. Urethrotech filled that gap and developed the Urethral Catheterisation Device (UCD®), which integrates a standard hydrophilic Nitinol guidewire into a 3-way 16F Silicone urethral catheter design to enable safe second-line urethral catheterisation when first-line catheterisation with a standard urethral catheter is unsuccessful. The safety and efficacy of UCD® catheterisation were evaluated in consecutive cohorts of men undergoing cardiac surgery and compared to the incidence of DUC and UCI with standard Foley catheterisation. A simple new Male Catheterisation Algorithm is proposed that can deliver a safe male urethral catheterisation treatment protocol for all clinical settings of healthcare services, which is easy to implement and integrate into standard catheterisation training programs to manage DUC and avoid UCI, empowering a frontline workforce to deliver better patient care.

Continuous Paravertebral Infusions as an Effective Adjunct for Postoperative Pain Management in Living Liver Donors: A Retrospective Observational Study.

We analyzed the effectiveness of paravertebral-block for immediate postoperative pain control in living liver donors. Specifically, we sought to determine whether or not the addition of paravertebral catheters with continuous ropivacaine infusion would decrease postoperative opioid use and reduce the incidence of adverse effects and complications. We reviewed the records of 26 patients who underwent right-lobe living donor hepatectomy (RLDH): 16 with and 10 without such catheters. The primary outcome was opioid use on postoperative day (POD) 1 through 3. For each of those 3 days, we calculated each patient's opioid use in morphine equivalents (mg). We also noted pain scores, adverse effects, and complications. The rate of decrease in morphine equivalents was higher in the catheter group (rate of change = -22.72; P = .038) for POD 1 (0-24 hours) and POD 2 (25-48 hours) than in the noncatheter group. For POD 2 alone, the catheter group used, on average, 20.98 mg fewer morphine equivalents than the noncatheter group (P = .023). The catheter group had a markedly reduced pain trajectory postoperatively (P = .014) than the noncatheter group. The catheter placement procedure itself was safe.

Medical students and interns' knowledge about and attitude towards homosexuality.

BACKGROUND AND RATIONALE: Medical professionals' attitude towards homosexuals affects health care offered to such patients with a different sexual orientation. There is absence of literature that explores the attitudes of Indian medical students or physicians towards homosexuality. AIM: This study aimed to evaluate Indian medical students and interns' knowledge about homosexuality and attitude towards homosexuals. MATERIALS AND METHODS: After IEC approval and written informed consent, a cross-sectional study was conducted on a purposive sample of undergraduate medical students and interns studying in one Indian medical college. The response rate was 80.5%. Only completely and validly filled responses (N = 244) were analyzed. The participants filled the Sex Education and Knowledge about Homosexuality Questionnaire (SEKHQ) and the Attitudes towards Homosexuals Questionnaire (AHQ). SEKHQ consisted of 32 statements with response chosen from 'true', 'false', or 'don't know'. AHQ consisted of 20 statements scorable on a 5-point Likert scale. Multiple linear regression was used to find the predictors of knowledge and attitude. RESULTS: Medical students and interns had inadequate knowledge about homosexuality, although they endorsed a neutral stance insofar as their attitude towards homosexuals is concerned. Females had more positive attitudes towards homosexuals. Knowledge emerged as the most significant predictor of attitude; those having higher knowledge had more positive attitudes. CONCLUSION: Enhancing knowledge of medical students by incorporation of homosexuality related health issues in the curriculum could help reduce prejudice towards the sexual minority and thus impact their future clinical practice.

Comparison of tumor markers for predicting outcomes after resection of nonfunctioning pancreatic neuroendocrine tumors.

BACKGROUND: This study compares the predictability of 5 tumor markers for distant metastasis and mortality in pancreatic neuroendocrine tumors (PNETs). METHODS: A total of 128 patients who underwent pancreatectomy for nonfunctioning PNETs between 1998 and 2011 were evaluated. Tumor specimens were stained via immunochemistry for cytoplasmic and nuclear survivin, cytokeratin 19 (CK19), c-KIT, and Ki67. Univariate and multivariate regression analyses and receiver operating characteristics curve were used to evaluate the predictive value of these markers. RESULTS: A total of 116 tumors (91%) were positive for cytoplasmic survivin, 95 (74%) for nuclear survivin, 85 (66.4%) for CK19, 3 for c-KIT, and 41 (32%) for Ki67 >3%. Twelve (9%) tumors expressed none of the markers. Survivin, CK19, and c-KIT had no substantial effect on distant metastasis or mortality. Age >55 years, grade 3 histology, distant metastasis, and Ki67 >3% were associated with mortality (P < .05). A cut-off of Ki67 >3% was the best predictor (83%) of mortality with an area under the curve of 0.85. Ki67 >3% also predicted occurrence of distant metastases with odds ratio of 9.22 and 95% confidence interval of 1.55-54.55 (P < .015). CONCLUSION: Of the 5 markers studied, only Ki67 >3% was greatly associated with distant metastasis and death. Survivin, CK19, and c-KIT had no prognostic value in nonfunctioning PNETs.

MELAS syndrome presenting as an acute surgical abdomen.

MELAS (mitochondrial cytopathy, encephalomyopathy, lactic acidosis and stroke-like episodes) is a syndrome in which signs and symptoms of gastrointestinal disease are uncommon if not rare. We describe the case of a young woman who presented as an acute surgical emergency, diagnosed as toxic megacolon necessitating an emergency total colectomy. MELAS syndrome was suspected postoperatively owing to persistent lactic acidosis and neurological symptoms. The diagnosis was later confirmed with histological and genetic studies. This case highlights the difficulties in diagnosing MELAS because of its unpredictable presentation and clinical course. We therefore recommend a high index of suspicion in cases of an acute surgical abdomen with additional neurological features or raised lactate.

Prospective analysis of the incidence of metal allergy in patients listed for total replacement of the temporomandibular joint.

We prospectively analysed the incidence of metal allergies in patients listed for total replacement of the temporomandibular joint (TMJ) and the efficacy of patch testing to prevent rejection phenomena. All patients (n=101) that required a prosthetic TMJ between March 2004 and August 2012 were tested preoperatively. A total of 39% had an allergy to one or more metals and they were given all-titanium prostheses. Following the introduction of this protocol no patients have shown signs of an allergic rejection within 6 months of operation. We suggest that all patients listed for total TMJ replacement should have patch tests for metal allergies and that all-titanium prostheses are used when allergy is detected.

Predicting aggressive behavior in nonfunctioning pancreatic neuroendocrine tumors.

PURPOSE: The biologic potential of nonfunctioning pancreatic neuroendocrine tumors (PNETs) is highly variable and difficult to predict before resection. This study was conducted to identify clinical and pathologic factors associated with malignant behavior and death in patients diagnosed with PNETs. METHODS: We used International Classification of Diseases 9th edition codes to identify patients who underwent pancreatectomy for PNETs from 1998 to 2011 in the databases of 4 institutions. Functioning PNETs were excluded. Multivariate regression Cox proportional models were constructed to identify clinical and pathologic factors associated with distant metastasis and survival. RESULTS: The study included 128 patients-57 females and 71 males. The age (mean ± standard deviation) was 55 ± 14 years. The body mass index was 28 ± 5 kg/m(2). Eighty-nine (70%) patients presented with symptoms, and 39 (30%) had tumors discovered incidentally. The tumor size was 3.3 ± 2 cm with 56 (44%) of the tumors measuring ≤2 cm. Seventy-three (57%) patients had grade 1 histology tumors, 37 (29%) had grade 2, and 18 (14%) had grade 3. Peripancreatic lymph node involvement was present in 31 patients (24%), absent in 75 (59%), and unknown in 22 (17%). Distant metastasis occurred in 18 patients (14%). There were 12 deaths, including 1 perioperative, 8 disease related, and 3 of unknown cause. With a median follow-up of 33 months, the overall 5-year survival was 75%. Multivariate Cox regression analysis identified age >55 (hazard ratio [HR], 5.89; 95% confidence interval [CI], 1.64-20.58), grade 3 histology (HR, 6.08; 95% CI, 1.32-30.2), and distant metastasis (HR, 8.79; 95% CI, 2.67-28.9) as risk factors associated with death (P < .05). Gender, race, body mass index, clinical symptoms, lymphovascular and perineural invasion, and tumor size were not related to metastasis or survival (P > .05). Three patients with tumors ≤2 cm developed distant metastasis resulting in 2 disease-related deaths. CONCLUSION: Age >55 years, grade 3 histology, and distant metastasis predict a greater risk of death from nonfunctioning PNETs. Resection or short-term surveillance should be considered regardless of tumor size.

Forgotten ureteral stents: who's at risk?

The sequelae from forgotten stents carry significant morbidity and costs. In this study, we attempt to identify potential risk factors that may make patients less likely to follow up for stent removal so that more effective prevention efforts may be directed at these persons. A single-institution retrospective analysis of 187 consecutive patients who had stents placed between January 2010 and December 2010 was performed. Chart review was conducted to see if patients had undergone stent removal beyond the intended maximal stent life (MSL). Patients who were lost to follow-up were contacted to determine if stents were overdue. Logistic regression was performed to determine risk factors. Of the 187 patients who had stents placed, 147 had the stent removed before MSL and 28 had stents removed after the MSL. Twelve patients could not be contacted and were excluded from the analysis. Within our cohort of 175 patients, 48% were males, 73% were minorities (33% Latino, 30% Black, 8% Asian, and 2% Native American), 39% did not speak English, 79% were unemployed, 73% were uninsured, and 35% were married. Among the patients with forgotten stents, 68% were male, 64% were minorities (32% Latino, 29% Black, 4% Native American, and 0% Asian), 82% were unemployed, 39% did not speak English, 93% were uninsured, and 43% were married. Multivariate regression analysis demonstrated that uninsured patients (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.4-28.2; P value 0.01) and males (OR, 2.8; CI, 1.2-6.8; P=0.02) had statistically significant associations with forgotten stents. Men were 2.8 times more likely to have forgotten stents than females. Patients without health insurance were six times more likely to have forgotten stents than patients with insurance. As efforts are made to prevent forgotten stents, increased attention should be given to these higher-risk patient populations.

The effect of physiological concentrations of bile acids on in vitro growth of Mycobacterium tuberculosis.

BACKGROUND: Intestinal tuberculosis occurs mainly in the terminal ileum and caecum, where the concentration of bile acids is lowest, and rarely in the upper digestive tract. OBJECTIVES: We examined the effect of physiological concentrations of bile acids on the in vitro growth of Mycobacterium tuberculosis (MTB). METHODS: The 4 major bile acids, lithocolic acid, cholic acid, deoxycholic acid and chenodeoxycholic acid, were added to individual Lowenstein-Jensen (LJ) culture media at physiological concentrations. A combined LJ medium was also prepared using all 4 bile acids. These were double-diluted 4 times by the addition of LJ media. Each culture medium was inoculated with the H37Rv strain of MTB and incubated at 37°C for 8 weeks. MTB growth was measured at 2 and 8 weeks in a semiquantitative fashion using cut-offs of >5, >10, >20, >100 colony-forming units. RESULTS: All lithocolic acid cultures showed uninhibited TB growth at 2 and 8 weeks. Chenodeoxycholic acid, deoxycholic acid and cholic acid alone, and in combination, showed concentration-dependent inhibition of MTB growth at 2 and 8 weeks. Four cultures were lost to contamination. CONCLUSIONS: Certain bile acids alone and in combination, at physiological concentrations, inhibit the growth of MTB in vitro. This might explain why intestinal TB occurs in the ileocaecum in the majority of cases and why gallbladder TB is very rare.

Salmonella serovars and antimicrobial resistance profiles in beef cattle, slaughterhouse personnel and slaughterhouse environment in ethiopia.

The present study was undertaken to determine the occurrence, distribution and antimicrobial resistance profiles of Salmonella serovars in slaughter beef cattle, slaughterhouse environment and personnel engaged in flaying and evisceration during slaughtering process. A total of 800 samples (each sample type, n = 100) consisting of swabs from hides, slaughterhouse personnel hands at flaying and evisceration, rumen and caecal contents, mesenteric lymph nodes, carcasses and holding pens were collected. Of the total 100 beef cattle examined, 14% were Salmonella positive in caecal content and/or mesenteric lymph nodes. Of the various samples analysed, Salmonella was detected in 31% of hides, 19% of rumen contents, 8% of mesenteric lymph nodes, 6% of caecal contents, 2% of carcass swabs, 9% of palm swabs taken from the hands of personnel in the slaughterhouse during flaying (7%) and evisceration (2%), and in 12% of holding pen swabs. The Salmonella isolates (n = 87) belonged to eight different serovars of which S. Anatum (n = 54) and S. Newport (19) were the major serovars and both serovars were detected in all sample sources except in carcass swabs. Eighteen of the 87 (20.7%) Salmonella serovars consisting of Newport (n = 14), Anatum (n = 3) and Eastbourne (n = 1) were resistant to one or more antimicrobials. Among the antimicrobial resistant Salmonella serovars, S. Newport was multidrug resistant (15.6%) and exhibited resistance to streptomycin, sulphisoxazole and tetracycline.

People with learning disabilities and specialist services.

Valuing people and Valuing people's oral health both advocate choice and inclusion for people with learning disabilities. Research suggests that services and policy and guidance, while prescriptive and available, have not been effective in reducing oral health inequalities for people with learning disabilities. There is a risk that specialist services led by newly created consultants in special care dentistry may have the unintended effect of reducing choice if general dental practitioners are encouraged to refer all those with learning disabilities. A modified model of access is proposed that primary care organisations could use as a commissioning tool for dental contracts to facilitate choice and maximise involvement in oral health care for those with learning disabilities.