Non-operative management of non-destructive extra-peritoneal rectal injury

This is a case report of extra-peritoneal rectal injury, secondary to a gunshot, that was managed non-operatively. A 57-year old male presented with a single gunshot to the right buttock and had blood per rectum. Extra-peritoneal rectal injuries were seen on proctoscopy and he had no genitourinary injury. He was managed successfully without rectal injury repair orfaecal stream diversion.     

Psychosocial impact of childhood face burns: a multicenter, prospective, longitudinal study of 390 children and adolescents

Introduction

This two-year longitudinal study of the health-related quality of life (HRQoL) of children with face burns was conducted in three regional pediatric burn care centers. Subjects were 390 children less than 18 years old at injury, admitted for burn treatment from September 2001 to December 2004.

Methods

HRQoL was assessed using the age-specific Burn Outcomes Questionnaire (BOQ) administered at scheduled time points following discharge up to 24 months thereafter. A psychosocial score was determined from domains of the BOQ, and these scores from children with both face burns and grafts were compared to those of children with non-face burns or with face burns but no face grafts.

Results

The parents of both the 0-4 year olds and the 5-18 year olds, who had facial burns and grafts, reported decreased BOQ psychosocial scores. When the teenagers (11-18 year olds) with facial burns and grafts filled out the BOQ themselves, they also reported low psychosocial scores compared to those with no facial burns with grafts.

Conclusions

Severe face burn influences HRQoL in children. Additional psychosocial support is suggested to enhance recovery for patients with severe face burns and their families during the years following injury.     

Synergy in microcosms with environmentally realistic concentrations of prochloraz and esfenvalerate

Laboratory experiments have shown that azole fungicides enhance the toxic effect of pyrethroid insecticides towards the aquatic crustacean Daphnia magna. Due to their sorptive properties the pesticides may, however, be less bioavailable in natural environments, possibly rendering them less toxic to aquatic organisms. In the present study, the synergistic potential of azoles on pyrethroids in natural environments was assessed by treating 18 outdoor aquatic microcosms with concentrations of the pyrethroid esfenvalerate at 0.167, 0.333, or 0.833 μg/L either alone or in combination with 90 μg/L of the azole prochloraz. Pesticide concentrations and the zooplankton and phytoplankton communities were assessed prior to pesticide application and at days 0, 1, 2, 4, 7, 14, 21, and 28 after pesticide application. DT₅₀-values for disappearance of the pesticides from the water of 4.7 days and 30 h were observed for prochloraz and esfenvalerate, respectively. The monitored communities showed larger decreases in abundance of cladoceran, copepods, and chironomids in treatments with esfenvalerate in combination with prochloraz compared to treatments with esfenvalerate alone. No systematic effects were observed in populations of Ostracoda. Adverse effects on populations of cladocerans and copepods occurred between day 2 and day 7 and, though copepods in general were less sensitive than cladocerans to both esfenvalerate alone and in combination with prochloraz, the potentiation factors for the two taxa were similar. Thus, comparison of EC₂₀-values estimated on the basis of concentration-response curves for days 2, 4, and 7 showed that prochloraz enhanced the toxicity of esfenvalerate four to sixfold for copepods and three to sevenfold for cladocerans. Rotifers were not significantly affected by any of the treatments, though there was a tendency of a population increase when cladoceran and copepod populations decreased. In all invertebrate populations that showed response to the pesticide treatments, indications of stabilisation or the beginning of recovery occurred between day 7 and day 14 and full recovery was observed in some of the less affected populations of cladocerans, copepods, and chironomids after 28 days. The occurrence of the synergistic interactions between prochloraz and esfenvalerate in the microcosms and at environmentally realistic concentrations implies that the synergistic interactions may also take place in invertebrate communities in natural ponds and ditches being exposed to azoles and pyrethroids via for example runoff or drift. The question of how to deal with synergy between chemicals in the environment from a regulatory perspective is briefly discussed.     

WHO Rapid Advice Guidelines for pharmacological management of sporadic human infection with avian influenza A (H5N1) virus

Recent spread of avian influenza A (H5N1) virus to poultry and wild birds has increased the threat of human infections with H5N1 virus worldwide. Despite international agreement to stockpile antivirals, evidence-based guidelines for their use do not exist. WHO assembled an international multidisciplinary panel to develop rapid advice for the pharmacological management of human H5N1 virus infection in the current pandemic alert period. A transparent methodological guideline process on the basis of the Grading Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to develop evidence-based guidelines. Our development of specific recommendations for treatment and chemoprophylaxis of sporadic H5N1 infection resulted from the benefits, harms, burden, and cost of interventions in several patient and exposure groups. Overall, the quality of the underlying evidence for all recommendations was rated as very low because it was based on small case series of H5N1 patients, on extrapolation from preclinical studies, and high quality studies of seasonal influenza. A strong recommendation to treat H5N1 patients with oseltamivir was made in part because of the severity of the disease. Similarly, strong recommendations were made to use neuraminidase inhibitors as chemoprophylaxis in high-risk exposure populations. Emergence of other novel influenza A viral subtypes with pandemic potential, or changes in the pathogenicity of H5N1 virus strains, will require an update of these guidelines and WHO will be monitoring this closely.     

Serum adiponectin is increased in advancing liver fibrosis and declines with reduction in fibrosis in chronic hepatitis B

BACKGROUND/AIMS: Despite the possible role of adiponectin in the pathogenesis of liver cirrhosis, few data have been collected from patients in different stages of liver fibrosis. We studied the role of adiponectin in 2 chronic hepatitis B (CHB)-patient cohorts. METHODS: Serum adiponectin was quantified by enzyme-linked immunosorbent assay. One-hundred liver biopsy specimens from CHB patients with different stages of fibrosis and 38 paired liver biopsies from hepatitis B e antigen-positive patients randomized to lamivudine (n=15), pegylated interferon alfa-2a (n=15) or pegylated interferon alfa-2a plus lamivudine (n=8) therapy for 48 weeks were assessed. RESULTS: Serum adiponectin was detected at levels ranging over fourfold magnitude with advancing fibrosis stage and correlated positively with fibrosis stage [r=0.45, p<0.001]. CHB patients with stage 0-1 fibrosis had higher composition of high molecular weight (HMW) form of adiponectin when compared with CHB patients with liver cirrhosis [mean+/-SEM 51.2+/-2.1% vs. 40.9+/-1.7%, respectively, p=0.001]. After antiviral therapy, patients with fibrosis reduction had marked decline in serum adiponectin level and increase in HMW form of adiponectin [mean+/-SEM 43.5+/-1.2% vs. 37.0+/-3.0%, respectively, p=0.04]. CONCLUSIONS: Serum adiponectin may have a role in fibrosis progression in CHB infection. A marked decline in serum adiponectin after antiviral therapy is associated with fibrosis reduction.     

Outpatient management of survivors of acute coronary syndromes

More patients are both suffering and surviving acute coronary syndromes. After hospital discharge, a host of interventions, including medications, therapeutic lifestyle changes, revascularization, and electrophysiologic devices improve quality of life and survival. Evidence-based management requires the general internist to have a working knowledge of these interventions and to identify patients whose outcomes would benefit from subspecialty referral.     

SGT1 is essential for Nod1 activation

The Nod-like receptor family in man contains proteins that recognize invasive bacteria. Nod1, a member of this family, is activated by specific peptidoglycan-derived muropeptides that contain meso-diaminopimelic acid. Plants contain a large family of proteins known as resistance (R) proteins that have common structural features with the Nod-like receptors and are essential for protection against a variety of plant pathogens. Extensive genetic studies have shown that the R protein function is determined by multiple proteins including SGT1, Rar1, and HSP90. Here we show that SGT1 positively regulates Nod1 activation. Depletion of SGT1 with siRNA did not affect stability of Nod1 protein or of downstream signaling molecules but did prevent multiple cellular responses associated with Nod1 activation. In contrast, depletion of the mammalian orthologue of Rar1, Chp1, had no effect on Nod1-dependent cellular activation. Finally, depletion of HSP90 or addition of a pharmacologic inhibitor of HSP90 resulted in loss of Nod1 protein. Thus, we show common regulatory pathways in plant R protein and human Nod1-dependent pathways and provide the basis for understanding the Nod1 pathway.