Urban legends series: oral candidosis

Candida species (spp) are commensal yeast that can only instigate oral infection (oral candidosis – OC) when there is an underlying predisposing condition in the host. We investigated four controversial topics on OC: (i) How can a microbiological determination of OC be made as Candida spp. are commensal yeasts and not all of them form hyphae or pseudohyphae during infection? (ii) Is median rhomboid glossitis (MRG) a manifestation of candidal infection? (iii) Can candidal infection cause palate papillary hyperplasia (PPH)? (iv) What is the best therapeutic treatment for denture‐associated erythematous stomatitis (DAES)? Results from extensive literature searches, including a systematic review, suggested the following: (i) the diagnosis of OC merely on the basis of the presence of yeasts is an oversimplification of a complex process. No convincing evidence of a single test or method better able to discriminate the transition from candidal saprophytism to pathogenicity has been reported in the literature; (ii–iii) conclusive evidence of a direct aetiopathogenic relationship between MRG and PPH and candidal infection has not been found; and (iv) only limited evidence is available for any DAES treatment, thus making it impossible to make strong therapeutic recommendations.     

Challenging boundaries: an enhanced recovery programme for radical cystectomy

Introduction

The implementation of enhanced recovery programmes (ERPs) in colorectal surgery has seen improvements in the length of inpatient stay with no increase in complications. We investigated the role of ERP in radical cystectomy at our institution.

Methods

Prospective data were collected from 26 consecutive patients prior to the introduction of the ERP and 51 patients who underwent open radical cystectomy within an ERP. Individuals in the ERP cohort did not receive bowel preparation or nasogastric drainage but received preoperative carbohydrate drinks, perioperative epidural analgesia and immediate mobilisation on day 1. Primary outcome measures included duration of intensive care unit (ICU) stay and length of hospital stay. Secondary outcome measures included the time to the passage of flatus and faeces, and time to mobilisation. Other measures that were analysed included operation time and complications.

Results

Baseline characteristics for both groups were similar. The median length of hospital stay fell from 11.5 days to 10.4 days and the mean ICU stay dropped from 2.4 days to 1.0 days (p=0.01). Time to removal of nasogastric tube, and time to passage of flatus and faeces were significantly shorter in the ERP group, as was the time to full oral diet. Clavien complication rates and 30-day mortality rates were similar in both groups. There were no readmissions.

Conclusions

ERP in radical cystectomy is safe and not associated with any increase in complications or readmissions. It is associated with reductions in ICU stay, and could also reduce length of hospital stay and duration of postoperative ileus.     

Audiovisual distraction reduces pain perception during aural microsuction

Introduction

Aural microsuction is a common ear, nose and throat procedure used in the outpatient setting. Some patients, however, find it difficult to tolerate owing to discomfort, pain or noise. This study evaluated the effect of audiovisual distraction on patients’ pain perception and overall satisfaction.

Methods

A prospective study was conducted for patients attending our aural care clinic requiring aural toileting of bilateral mastoid cavities over a three-month period. All microsuction was performed by a single clinical nurse specialist. Any patients with active infection were excluded. For each patient, during microsuction of one ear, they watched the procedure on a television screen while for the other ear they did not view the procedure. All patients received the same real time explanations during microsuction of both ears. After the procedure, each patient completed a visual analogue scale (VAS) to rate the pain they experienced for each ear, with and without access to the television screen. They also documented their preference and reasons why.

Results

A total of 37 patients were included in the study. The mean pain score for patients viewing the procedure was 2.43 compared with a mean of 3.48 for patients with no television view. This difference in patients’ pain perception was statistically lower in the group who observed the procedure on the television (p=0.003), consistent with the majority of patients reporting a preference to viewing their procedure (65%).

Conclusions

Audiovisual distraction significantly lowered patients’ VAS pain scores during aural microsuction. This simple intervention can therefore reduce patients’ perceived pain and help improve acceptance of this procedure.     

Functional abnormalities of human neutrophils collected by continuous flow filtration leukopheresis.

Continuous flow filtration leukopheresis (FL) is a relatively simple, inexpensive, and efficient technique of harvesting blood neutrophils from normal donors for transfusion into neutropenic recipients. There has been concern, however, that neutrophils may be functionally altered druing this leukopheresis procedure. Human neutrophils obtained by various FL techniques were studied for in vitro chemotaxis by a 51Cr-radiolabel method and for in vitro killing and phagocytosis of Staphylococcus aureus. We compared their function with neutrophils obtained by the NCI-IBM cell separator and by dextran sedimentation from whole blood. FL neutrophils eluted from nylon filters after 3-hr collection periods were functionally abnormal by all parameters tested, while neutrophils obtained by cell separator after similar collection times were not significantly different from control cells. However, neutrophils from 3-hr FL collections were found to include both normal and abnormal populations of cells. Loosely adherent cells, eluted after tapping the filters, were functionally normal; more adherent cells, eluted after tapping the filters and representing the bulk of cells collected, were progressively more abnormal the less readily they were eluted. Shortened FL collection times (1-2 hr) were found to decrease the functional defects. Also, administration of dexamethasone to donors prior to filtration leukopheresis diminished the functional defects of FL neutrophils perhaps by altering adherence characteristics of the cells. These studies show that neutrophils obtained by filtration leukopheresis are functionally abnormal in relation to the time and extent of adherence to nylon filters.     

A statistical model for estimating donor postdonation platelet counts after plateletpheresis

BACKGROUND: To avoid the need, in serial apheresis donors, either to delay plateletpheresis until a predonation platelet count is completed or to obtain a postdonation count after each procedure, a statistical model has been developed to predict the postdonation platelet count from the donor predonation platelet count, weight, and hematocrit. STUDY DESIGN AND METHODS: Predonation and postdonation platelet counts were measured in two groups of approximately 100 consecutive donors (Group A to test the model and Group B to validate it), and the postdonation counts were calculated with the model. Using stepwise multiple linear regression from donor data, estimated postdonation platelet counts were found to be comparable to the postdonation platelet counts actually measured. RESULTS: Estimated postdonation platelet counts × 10(9) per L (mean +/− SD) for each group, respectively, were Group A, 195 +/− 35, versus actual platelet counts of 195 +/− 39 (p = 0.43), and Group B, 183 +/− 36, versus actual platelet counts of 189 +/− 34 (p = 0.14). Sensitivity and specificity, respectively, were Group A, 57 and 99 percent and Group B, 62 and 99 percent. CONCLUSION: For most serial apheresis donors, application of this predictor model should preclude the need to obtain an extra postdonation platelet count.     

Resolution of refractory, classic thrombotic thrombocytopenic purpura after staphylococcal protein A immunoadsorption

BACKGROUND: Multiple therapeutic interventions are available for treatment of thrombotic thrombocytopenic purpura. Resolution of thrombotic thrombocytopenic purpura may require use of several of these interventions. CASE REPORT: A patient presenting with classic (non- cancer chemotherapy-associated) thrombotic thrombocytopenic purpura had an initial response to intensive, daily plasma exchange with fresh- frozen plasma and cryosupernatant. Multiple attempts over a period of 2 months to decrease the frequency of plasma exchange resulted in exacerbations of disease activity, indicated by increased schistocytosis, decreased hematocrit, increased serum lactate dehydrogenase, and decreased platelet counts. After a total of 39 plasma exchanges, the patient was begun on immunoadsorption therapy utilizing a staphylococcal protein A immunoadsorption treatment column. After six 2000-mL protein A immunoadsorption treatments, the patient's platelet count, lactate dehydrogenase, and peripheral smear normalized, and they have remained normal over nearly 4 months of follow-up. CONCLUSION: Treatment by protein A immunoadsorption may be of benefit in patients with classic thrombotic thrombocytopenic purpura who are not achieving a sustained remission with conventional plasma exchange therapy.     

Perturbation of red blood cell membrane rigidity by extracellular ligands

It is known that binding of extracellular antibodies against the major sialoglycoprotein, glycophorin A, reduced the deformability of the red blood cell membrane. This has been taken to result from new or altered interactions between the glycophorin A and the membrane skeleton. We have shown by means of the micropipette aspiration technique that antibodies against the preponderant transmembrane protein, band 3, induce similar effects. A definite but much smaller reduction in elasticity of the membrane is engendered by univalent Fab fragments of the anti-band 3 antibodies. By examining cells genetically devoid of glycophorin A or containing a variant of this constituent, truncated at the inner membrane surface, we have shown that the anti-band 3 antibodies do not act through the band 3-associated glycophorin A. We examined the effect of anti-glycophorin A antibodies on homozygous Wr(a+b-) cells, in which an amino acid replacement in band 3 annihilates the Wright b (Wrb) epitope (comprising sequence elements of glycophorin A and band 3) and thus, by implication disrupts or perturbs the band 3-glycophorin A interaction; these cells show a much smaller response to an anti-glycophorin A antibody than do normal controls. We infer that in this case anti-glycophorin A antibodies exert their rigidifying effect through the associated band 3. Another anti- glycophorin A antibody, directed against an epitope remote from the membrane surface, however, increases the rigidity of both Wr(a+b-) and normal cells. This implies that not all antibodies act in the same manner in modifying the membrane mechanical properties. The effect exerted by anti-band 3 antibodies appears not to be transmitted through the band 3-ankyrin-spectrin pathway because the rigidifying effect of the intact antibody persists at alkaline pH, at which there is evidence that the ankyrin-band 3 link is largely dissociated. The large difference between the effects of saturating concentrations of the divalent and univalent anti-band 3 antibodies implies the existence of an overriding effect on rigidity, resulting from the bifunctionality of the intact antigen. Freeze-fracture electron microscopy shows that the anti-band 3 promotes the formation of small clusters of intra-membrane proteins. Extracellular ligands may in general act by promoting strong or transient interactions between integral membrane proteins, thereby impeding local distortion of the membrane skeletal network in response to shear.