Reliably colonising broiler chickens with Campylobacter spp. using a litter-based method.

1. Chicken-associated Campylobacter spp. are the cause of most food poisoning cases in Europe. In order to study the host-pathogen interactions, a reliable and reproducible method of colonising chickens with the bacteria is required. 2. This study aimed to identify a more appropriate and less invasive method of colonisation (cf. gavaging) by seeding bedding material (litter) that commercial chickens are kept on with a mixture of Campylobacter spp., broth and faeces. 3. The first phase of the study tested the longevity of Campylobacter spp. recovery in seeded litter over 24 h: significantly more Campylobacter spp. was recovered at 0 or 3 h post-seeding than at 6 and 24 h post-seeding, indicating that the pathogen can survive to detectable levels for at least 3 h in this environment. 4. In the second phase, three groups of 10 broiler chickens (negative for Campylobacter spp. prior to exposure) were exposed at 21 days of age to one of three different Campylobacter jejuni and C. coli mixes (A, B, C), using the method above. At 28 days of age, birds were euthanised by overdose of barbiturate or cervical dislocation, and livers and caeca removed for Campylobacter spp. assessment. 5. All liver and 28/30 caeca samples tested positive for Campylobacter spp., with mix A and C giving higher counts in the caeca than mix B. The method of euthanasia did not affect Campylobacter spp. counts. 6. In conclusion, a successful method for reliably colonising broiler chickens with Campylobacter spp. has been developed which negates the need for gavaging and is more representative of how contamination occurs in the field.

Combined dysfunctions of immune cells predict nosocomial infection in critically ill patients.

BACKGROUND: Nosocomial infection occurs commonly in intensive care units (ICUs). Although critical illness is associated with immune activation, the prevalence of nosocomial infections suggests concomitant immune suppression. This study examined the temporal occurrence of immune dysfunction across three immune cell types, and their relationship with the development of nosocomial infection. METHODS: A prospective observational cohort study was undertaken in a teaching hospital general ICU. Critically ill patients were recruited and underwent serial examination of immune status, namely percentage regulatory T-cells (Tregs), monocyte deactivation (by expression) and neutrophil dysfunction (by CD88 expression). The occurrence of nosocomial infection was determined using pre-defined, objective criteria. RESULTS: Ninety-six patients were recruited, of whom 95 had data available for analysis. Relative to healthy controls, percentage Tregs were elevated 6-10 days after admission, while monocyte HLA-DR and neutrophil CD88 showed broader depression across time points measured. Thirty-three patients (35%) developed nosocomial infection, and patients developing nosocomial infection showed significantly greater immune dysfunction by the measures used. Tregs and neutrophil dysfunction remained significantly predictive of infection in a Cox hazards model correcting for time effects and clinical confounders {hazard ratio (HR) 2.4 [95% confidence interval (CI) 1.1-5.4] and 6.9 (95% CI 1.6-30), respectively, P=0.001}. Cumulative immune dysfunction resulted in a progressive risk of infection, rising from no cases in patients with no dysfunction to 75% of patients with dysfunction of all three cell types (P=0.0004). CONCLUSIONS: Dysfunctions of T-cells, monocytes, and neutrophils predict acquisition of nosocomial infection, and combine additively to stratify risk of nosocomial infection in the critically ill.

Evaluation of the effect of diagnostic methodology on the reported incidence of ventilator-associated pneumonia.

BACKGROUND: The optimal method for diagnosing ventilator-associated pneumonia (VAP) is controversial and its effect on reported incidence uncertain. This study aimed to model the impact of using either endotracheal aspirate or bronchoalveolar lavage on the reported incidence of pneumonia and then to test effects suggested from theoretical modelling in clinical practice. METHODS: A three-part single-centre study was undertaken. First, diagnostic performance of aspirate and lavage were compared using paired samples from 53 patients with suspected VAP. Secondly, infection surveillance data were used to model the potential effect on pneumonia incidence and antibiotic use of using exclusively aspirate or lavage to investigate suspected pneumonia (643 patients; 110 clinically suspected pneumonia episodes). Thirdly, a practice change initiative was undertaken to increase lavage use; pneumonia incidence and antibiotic use were compared for the 12 months before and after the change. RESULTS: Aspirate overdiagnosed VAP compared with lavage (89% vs 21% of clinically suspected cases, p<0.0001). Modelling suggested that changing from exclusive aspirate to lavage diagnosis would decrease reported pneumonia incidence by 76% (95% CI 67% to 87%) and antibiotic use by 30% (95% CI 20% to 42%). After the practice change initiative, lavage use increased from 37% to 58%. Although clinically suspected pneumonia incidence was unchanged, microbiologically confirmed VAP decreased from 18 to 9 cases per 1000 ventilator days (p = 0.001; relative risk reduction 0.61 (95% CI 0.46 to 0.82)), and mean antibiotic use fell from 9.1 to 7.2 antibiotic days (21% decrease, p = 0.08). CONCLUSIONS: Diagnostic technique impacts significantly on reported VAP incidence and potentially on antibiotic use.

New perspectives in facial contouring using external ultrasonography.

The use of XUAL ultrasonic energy to "fractionate" and redistribute facial fat is a valuable adjunct in facial plastic surgery. The 59 patients enrolled in the author's preliminary evaluation of XUAL under the auspices of the American Society of Aesthetic Plastic Surgery Innovative Procedures Committee had in addition to the body liposculpture external ultrasonography application to "superwet" anesthetized face and neck with or without physical removal of fat or skin. When no excisions or liposuctioning were performed, there was visible and photographic improvement in facial contouring. Interview comments ranged from "I can see my cheek bones now" to questions as to whether or not a facelift had indeed been performed. Individuals who had submental resculpturing ("submental tuck") or simple "safe zone" liposuction in the submental area, jowl, and nasolabial zones also showed a remarkable degree of skin tightening and contouring beyond the area of actual fat removal. Those individuals who have been observed closely for more than 12 months still have the improvement. Redistribution of fat and skin tightening initially noted between the second and eighth weeks have persisted unchanged, often in spite of fat accumulation elsewhere from weight gain.

Differential regulation of chemokine production in human peritoneal mesothelial cells: IFN-gamma controls neutrophil migration across the mesothelium in vitro and in vivo.

Leukocyte recruitment into the infected peritoneal cavity consists of an early, predominant polymorphonuclear leukocyte (PMN) influx and subsequent, prolonged mononuclear cell migration phase. Although chemokine secretion by resident peritoneal cells plays a primary role in mediating this migration, the mechanisms involved in controlling the switch in phenotype of cell infiltrate remain unclear. The present study investigates a potential role for the Th1-type cytokine IFN-gamma in the process of leukocyte recruitment into the peritoneal cavity. Stimulation of cultured human peritoneal mesothelial cells with IFN-gamma (1-100 U/ml) alone or in combination with IL-1beta (100 pg/ml) or TNF-alpha (1000 pg/ml) resulted in significant up-regulation of monocyte chemoattractant protein-1 and RANTES protein secretion. In contrast, IFN-gamma inhibited basal and IL-1beta-, and TNF-alpha-induced production of IL-8. The modulating effects of IFN-gamma on chemokine production occurred at the level of gene expression, and the degree of regulation observed was dependent on the doses of IL-1beta and TNF-alpha used. Analysis of the functional effects of IFN-gamma on IL-1beta-induced transmesothelial PMN migration with an in vitro human transmigration system and an in vivo murine model of peritoneal inflammation demonstrated that IFN-gamma was able to down-regulate PMN migration induced by optimal doses of IL-1beta. These effects were mediated in vivo via down-regulation of CXC chemokine synthesis. These findings suggest that IFN-gamma may play a role in controlling the phenotype of infiltrating leukocyte during the course of an inflammatory response, in part via regulation of resident cell chemokine synthesis.

Il-6 and its soluble receptor orchestrate a temporal switch in the pattern of leukocyte recruitment seen during acute inflammation.

During acute inflammation, leukocyte recruitment is characterized by an initial infiltration of neutrophils, which are later replaced by a more sustained population of mononuclear cells. Based on both clinical and experimental evidence, we present a role for IL-6 and its soluble receptor (sIL-6R) in controlling this pattern of leukocyte recruitment during peritoneal inflammation. Liberation of sIL-6R from the initial neutrophil infiltrate acts as a regulator of CXC and CC chemokine expression, which contributes to a suppression of neutrophil recruitment and the concurrent attraction of mononuclear leukocytes. Soluble IL-6R-mediated signaling is therefore an important intermediary in the resolution of inflammation and supports transition between the early predominantly neutrophilic stage of an infection and the more sustained mononuclear cell influx.

Limited abdominoplasty techniques applied to complete abdominal repair.

The techniques of umbilical stalk separation, closure of the umbilical site in the midline, and short upturned incision lines define the operation described as limited abdominoplasty. The operation has evolved over the past 17 years into a procedure which is applicable in the majority of patients who have suffered distortion of the entire abdominal wall, with panniculus formation and fatty deposition. The use of liposuction is an essential part of "limited" abdominoplasty and of "complete" abdominoplasty. To protect the flap, techniques once applied only in the lesser procedures are now used for patients requiring a repair of the abdominal wall from the xiphoid to the pubis. These techniques also include advancement of the incision line to the "French line" position for aesthetic reasons. A description of the technical maneuvers required as well as the objectives for correction of the deformity in patients of all abdominoplasty types is presented. Patient selection is no longer an absolute criterion for the type of abdominoplasty repair that is selected.

Use of synthetic discriminant functions for handwritten-signature verification.

Handwritten-signature verification is treated as a two-class synthetic discriminant function (SDF) problem. Images of valid and casually forged signatures are collected and binarized, using an electronic digitizing camera. Performance of this approach with a small number of valid signatures in the training set is examined, and substantial improvement is demonstrated when forgeries are included in the set. In particular, the equal-error rate for the SDF classifier with forgeries included is shown to average approximately 4% across nine different subjects. The effects of image preprocessing on false acceptance and true rejection rates are examined. The use of alternatives to forged signatures in the training matrix is explored. Finally, SDF performance is shown to deteriorate when the tested forgeries are produced with some a priori knowledge of the target signature.

Staff surgery--the inevitable question.

The results of a survey of 450 plastic surgeons regarding the practice of operating on their staff members is presented. An overwhelming majority (85 percent) of responding surgeons do operate on their staff. Whether surgery is a "right" of employment or a "reward" for service was addressed. Seventy-two percent felt surgery was a "reward," while only 8 percent felt it was a "right." The results found complications to be relatively minor but numerous (23.5 percent). The need for an office policy is stressed to help eliminate misunderstandings with other employees, and a model office policy is presented and endorsed.

Individual modifications in body contour surgery: the "limited" abdominoplasty.

Stretching of the abdominal wall and skin following pregnancy or excessive weight gain may be limited to the infraumbilical area. In these patients, abdominal repair may be accomplished with a shorter incision and without the necessity for relocating the umbilicus with its attendant visible scar. Forty patients are presented in whom excellent aesthetic repairs were effected through short curvilinear, low abdominal incisions with removal of a modest amount of excess skin. Fascial plication from pubis to umbilicus or above is facilitated by buried figure-of-eight sutures. Suction-assisted lipectomy may be employed as an adjunct. Recovery is facilitated by the reduced incision line length, reduced undermined area, and absence of tension in the midline skin incision, such as may occur in a standard abdominoplasty in which large amounts of panniculus and skin are removed with a complete repair of the abdominal wall. The limited abdominoplasty may be safely performed with ketamine-diazepam anesthesia in an office surgical center. Major complications are few and generally reflect the unpredictable nature of the elasticity of the abdominal skin.

Resolution of late-developing periprosthetic breast infections without prosthesis removal.

Based on prior experience with implant exposure, an aggressive regimen to eradicate periprosthetic infections has proven successful in delayed gram-positive and gram-negative bacterial infections and in atypical microbacterial infections. The objective of the "salvage" procedure is to retain a prosthesis, to maintain breast contour, and to avoid psychological and physical consequences of prosthesis removal. The "salvage" procedure involves topical antisepsis, contracture release if needed, systemic and topical antibiotics with intermittent or continuous irrigation, and reinforcement of incision lines in selected cases using local tissue flaps.