Orthopaedic triage at a physiotherapist-led 'Musculoskeletal Assessment Clinic': a seven-month service evaluation of outcomes.

BACKGROUND: A number of clinical specialist physiotherapist (CSP)-led musculoskeletal triage clinics have been established in the Republic of Ireland as a means of managing patients referred for an outpatient orthopaedic consultation. AIMS: The purpose of this study was to evaluate the outcomes of a recently established 'Musculoskeletal Assessment Clinic' (MAC) in St Vincent's University Hospital (SVUH) Dublin. We identified the (a) number of patients independently managed by the CSPs and (b) conversion rate to orthopaedic intervention as a useful measure of this. METHODS: University College Dublin Research Ethics Committee granted ethical exemption and the Clinical Audit Department of SVUH approved the study. A retrospective service evaluation was carried out on all orthopaedic patients who attended the MAC between January and July 2012. Data were analysed using SPSS v20 using descriptive statistics. RESULTS: Seven-hundred and fourteen patients attended the MAC, 54 % of whom were female; mean age 50 years (range 12-89). The majority of patients were diagnosed with low back pain (35 %) and knee osteoarthritis (16 %). The majority of patients who attended the MAC (76 %) were independently managed by the CSPs without need for orthopaedic consultation; from a valid sample (n = 110), 80 patients required orthopaedic intervention, a conversion rate of 73 %. The most common interventions were arthroplasty (22 %) and arthroscopy (16 %). CONCLUSIONS: The findings of this service evaluation indicate that a significant number of patients referred for an orthopaedic consultation may be managed independently by a CSP and that onward referrals for orthopaedic consultation were highly appropriate.

Dietary polyunsaturated fatty acids, vitamin E and hypoxia/reoxygenation-induced damage to cardiac tissue.

Polyunsaturated fatty acids (PUFA), in the form of marine oils, contain a large proportion of n-3 long chain fatty acids and have been recommended as a dietary supplement for patients with ischaemic heart disease. It has also been suggested that consumption of diets rich in polyunsaturated fatty acids renders tissues more susceptible to free radical-mediated lipid peroxidation, a process which has been implicated in the mechanisms by which tissues may become damaged following hypoxia and subsequent reoxygenation. We have examined the effect of supplementation of diets with oils of different PUFA composition and different vitamin E content on the accumulation of fatty acids by rat hearts in comparison with the effects on tissue lipid peroxidation and the response of the heart to a standardised form of oxidative stress. Groups of Wistar rats were fed a vitamin E supplemented (100 mg alpha-tocopherol acetate/kg) diet containing either 10% corn oil, 10% menhaden oil or 10% lard, or a low vitamin E diet (2.5 mg alpha-tocopherol acetate/kg) containing either 10% corn oil, 10% menhaden oil or 10% lard for 82 +/- 3 days. Diets supplemented with menhaden oil had a dramatic effect on the incorporation of n-3 fatty acids into the cardiac tissue and increased the susceptibility of this tissue to lipid peroxidation in vitro. The effect of these changes on damage to isolated hearts subjected to 60 min hypoxia and reoxygenation was examined using a modified Langendorff system. Nutritional manipulation of the tissue fatty acids and vitamin E content had no influence on the release of creatine kinase activity from rat hearts subjected to hypoxia/reoxygenation. Thus these data do not support the hypothesis that consumption of diets rich in polyunsaturated fatty acids renders tissues more susceptible to free radical damage induced by hypoxia/reoxygenation.

Dietary fish-oil supplementation in humans reduces UVB-erythemal sensitivity but increases epidermal lipid peroxidation.

Ultraviolet radiation (UVR)-induced erythema may be mediated in part by free radical-generated tissue damage, including lipid peroxidation. We have examined the effect of dietary fish oil rich in omega-3 fatty acids upon susceptibility to UVB-induced erythema and epidermal lipid peroxidation. Fifteen volunteers took 10 g fish oil, containing 18% eicosapentaenoic acid and 12% docosahexaenoic acid, daily for 3 or 6 months. Sensitivity to UVB was assessed at intervals on fish oil, and 2.5 months after stopping treatment. Paired skin shave biopsies were taken from six subjects, at baseline and 3 months, from both irradiated and control skin. Fatty acid composition was analyzed and thiobarbituric acid-reactive substances measured as an index of lipid peroxidation. With increasing time on fish oil the minimal erythema dose rose progressively, from 18.9 +/- 13.9 mJ/cm2 (mean +/- SD) at baseline to 41.1 +/- 16.6 mJ/cm2 at 6 months, p < 0.01. Ten weeks after stopping fish oil the minimal erythema dose fell to 23.1 +/- 4.9 mJ/cm2, p < 0.05. Epidermal total omega-3 fatty acids rose from 1.8 +/- 0.4% total fatty acids (mean +/- SEM) to 24.2 +/- 3.9% at 3 months, p < 0.01. This was accompanied by a rise in thiobarbituric acid-reactive substances in irradiated skin from 6 +/- 0.3 (mean +/- SEM) to 18.5 +/- 2.6 A532/g skin, p < 0.01. Hence dietary omega-3 fatty acids produce a pronounced reduction in UVB-erythemal sensitivity, although susceptibility of skin to lipid peroxidation is increased. Thus, omega-3 fatty acids may act as an oxidizable buffer, protecting more vital structures from free radical damage.

Free radicals and muscle damage.

Muscle tissue is unique in its requirement and ability to undertake very rapid and co-ordinated changes in energy supply and oxygen flux during contraction. Several studies have suggested that this renders the tissue particularly prone to oxygen radical-mediated damage. Free radicals have been postulated to play a role in muscle damage induced by different forms of exercise and in various pathological disorders, such as the muscular dystrophies, malignant hyperthermia and alcoholic myopathy. However, conclusive evidence for a fundamental role for free radicals and protective effect of antioxidants remains elusive in all these situations and much further work on the relevant pathogenetic mechanisms is still required.

Genomic structure and alternative splicing of 519, a gene expressed late after T cell activation.

Relatively little is known about the transcriptional control of genes expressed late after T cell activation. We have identified four genes expressed 3 to 5 days after T cell activation by alloantigen or mitogen. Here we report the genomic organization of 519, one of these late T cell activation Ag. Analysis of the genomic clone revealed that 519 consists of six exons. Ribonuclease protection experiments indicated that the most abundant transcript arising from this region is an alternatively spliced form of 519, referred to as 520, which lacks exon 2 and is similar in sequence to NKG5, a cDNA identified in NK cells. These experiments also revealed the existence of two other alternatively spliced RNA transcripts, with heterogeneity in exon 2. Primer extension analysis and ribonuclease protection assays demonstrated that there are two prominent start sites for transcription; however, there is no evidence for the NKG5 transcript in T cells, indicating that NKG5 may represent a NK cell-specific form of 520. The 5' flanking region of this gene contains several previously identified sequences involved in transcriptional regulation, as well as some potentially interesting novel conserved motifs.

Identification and molecular cloning of tactile. A novel human T cell activation antigen that is a member of the Ig gene superfamily.

We have identified and cloned cDNA for a novel cell-surface protein that we have named Tactile for T cell activation, increased late expression. It is expressed on normal T cell lines and clones, and some transformed T cells, but no other cultured cell lines tested. It is expressed at low levels on peripheral T cells and is strongly up-regulated after activation, peaking 6 to 9 days after the activating stimulus. It is also up-regulated on NK cells activated in allogeneic cultures. It is not found on peripheral B cells but is expressed at very low levels on activated B cells. Tactile-specific mAb immunoprecipitates a band of 160 kDa when reduced and bands of 240, 180, and 160 kDa nonreduced. Using an antiserum produced with affinity-purified Tactile protein to screen a lambda gt11 library, we have identified Tactile cDNA. Northern blot analysis shows an expression pattern similar to that of the protein and transfection of COS cells with the full-length 5.2-kb cDNA results in cell-surface expression. Comparison with the sequence databanks show that Tactile is a member of the immunoglobulin gene superfamily, with similarity to Drosophila amalgam, the melanoma Ag MUC-18, members of the carcinoembryonic Ag family, the poliovirus receptor, and the neural cell adhesion molecule. The deduced primary sequence encodes a protein with three Ig domains, a long serine/threonine/proline-rich region typical of an extensively O-glycosylated domain, a transmembrane domain, and a 45 residue cytoplasmic domain. These data suggest that Tactile may be involved in adhesive interactions of activated T and NK cells during the late phase of the immune response.

Isolation and characterization of cDNA from renal tubular epithelium encoding murine Rantes.

We have been interested in identifying proinflammatory molecules which might play a role in attracting monocytes and T cells to the kidney. Some of the new intercrines are potential candidates. In this report we have isolated cDNA encoding murine Rantes (MuRantes) from renal tubular epithelium (MCT cells). MuRantes is a 91 amino acid member of the -C-C- or intercrine beta subgroup of the Scy superfamily. The amino acid sequence for mature MuRantes was deduced from its coding cDNA and was found to be 90% homologous to its mature human counterpart (HuRantes). MCT epithelium expresses a single mRNA transcript for MuRantes of approximately 1100 bp. The MuRantes protein could be detected in cell lysates of MCT epithelium by western blotting and in the cytoplasm of MCT cells by immunofluorescence using a polyclonal antibody generated against HuRantes fusion protein. A search protocol using MuRantes-specific primers and cDNA amplification revealed that mRNAs for MuRantes are expressed additionally in syngeneic mesangial cells (MMC cells), whole kidney, liver, and spleen, as well as in nephritogenic antigen-specific CD4+ helper and CD8+ effector T cells. cDNA amplification studies also demonstrated a significant elevation in mRNA transcripts encoding MuRantes in response to the stimulation of MCT epithelium with TNF alpha and IL-1 alpha in culture, but not with TGF beta, gamma IFN, or IL-6. Our findings indicate that proximal tubular epithelium is an authentic source of MuRantes, and that transcripts encoding MuRantes are responsive to the modulating influence of paracrine factors having a known role in the development of parenchymal injury.

Delta-crystallin gene expression and patterns of hypomethylation demonstrate two levels of regulation for the delta-crystallin genes in embryonic chick tissues.

In this study we address two questions regarding the control of delta-crystallin gene expression in chick embryos. First we have determined whether delta-crystallin mRNA is found outside of the developing lens, in which it is the predominant mRNA. We find that this mRNA can be detected, although at relatively low levels, in all embryonic tissues we have examined (from the definitive streak stage onward). This low level of transcription may be related to a second function for one or both of the delta-crystallin genes: both genes have a high degree of sequence identity to the enzyme argininosuccinate lyase. This result led us to a second set of experiments in which we reevaluated the possible role of hypomethylation in the expression of the delta-crystallin genes. Previous work showed that particular HhaI and HpaII sites in the crystallin genes undergo hypomethylation early in the process of lens differentiation when there is a burst of delta-crystallin mRNA accumulation. We not find that these sites remain methylated in nonlens tissues, implying that they cannot be required for the delta-crystallin gene activity found in these tissues. Other sites are constitutively hypomethylated, however, and may be functionally linked to this low level of gene activity. From an analysis of the kinetics of the developmentally regulated hypomethylation of HhaI and HpaII sites we also find that complete hypomethylation of these sites is not required for activating high levels of delta-crystallin transcription during lens differentiation. We do find, however, that these sites approach a fully hypomethylated state later in the lens differentiation process. Our analyses of mRNA levels and hypomethylation together lead us to propose that the delta-crystallin genes are regulated by two different mechanisms, one that leads to high levels of expression in the lens and the other which is responsible for low level expression in all other tissues in the chick embryo.

Molecular cloning of syndecan, an integral membrane proteoglycan.

We describe cDNA clones for a cell surface proteoglycan that bears both heparan sulfate and chondroitin sulfate and that links the cytoskeleton to the interstitial matrix. The cDNA encodes a unique core protein of 32,868 D that contains several structural features consistent with its role as a glycosamino-glycan-containing matrix anchor. The sequence shows discrete cytoplasmic, transmembrane, and NH2-terminal extracellular domains, indicating that the molecule is a type I integral membrane protein. The cytoplasmic domain is small and similar in size but not in sequence to that of the beta-chain of various integrins. The extracellular domain contains a single dibasic sequence adjacent to the extracellular face of the transmembrane domain, potentially serving as the protease-susceptible site involved in release of this domain from the cell surface. The extracellular domain contains two distinct types of putative glycosaminoglycan attachment sites; one type shows sequence characteristics of the sites previously described for chondroitin sulfate attachment (Bourdon, M. A., T. Krusius, S. Campbell, N. B. Schwartz, and E. Ruoslahti. 1987. Proc. Natl. Acad. Sci. USA. 84:3194-3198), but the other type has newly identified sequence characteristics that potentially correspond to heparan sulfate attachment sites. The single N-linked sugar recognition sequence is within the putative chondroitin sulfate attachment sequence, suggesting asparagine glycosylation as a mechanism for regulating chondroitin sulfate chain addition. Both 5' and 3' regions of this cDNA have sequences substantially identical to analogous regions of the human insulin receptor cDNA: a 99-bp region spanning the 5' untranslated and initial coding sequences is 67% identical and a 35-bp region in the 3' untranslated region is 81% identical in sequence. mRNA expression is tissue specific; various epithelial tissues show the same two sizes of mRNA (2.6 and 3.4 kb); in the same relative abundance (3:1), the cerebrum shows a single 4.5-kb mRNA. This core protein cDNA describes a new class of molecule, an integral membrane proteoglycan, that we propose to name syndecan (from the Greek syndein, to bind together).

Method for the typing of Clostridium difficile based on polyacrylamide gel electrophoresis of [35S]methionine-labeled proteins.

A typing method for Clostridium difficile based on the incorporation of [35S]methionine into cellular proteins, their separation by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and their visualization by autoradiography is described. On analysis of the radiolabeled-protein profiles, nine distinct groups were observed (A to E and W to Z). The method, which is simple, reproducible, and readily expandable, has been applied in epidemiological studies to demonstrate cross-infection and hospital acquisition of C. difficile.

Vaginal carriage and neonatal acquisition of Clostridium difficile.

The relationship between vaginal carriage and subsequent neonatal acquisition of Clostridium difficile was investigated. Vaginal carriage of C. difficile was detected in 11% of women attending the Department of Genital Medicine Clinic. C. difficile was isolated from the vagina in 18% of 50 mothers before delivery, and 8% after delivery; 62% of their babies had positive faecal cultures. Eight of nine of the babies whose mothers had positive cultures before delivery became colonised with C. difficile, while 23 of 41 babies whose mothers had negative cultures became colonised. This suggests that both the vagina and the environment may act as sources of neonatal acquisition of C. difficile. Broth enrichment culture proved a more sensitive method for isolating C. difficile from the vagina than direct plate culture and should be used in such investigations.

Typing scheme for Clostridium difficile: its application in clinical and epidemiological studies.

Epidemiological studies of Clostridium difficile diarrhoeal disease have been hindered by the lack of a typing scheme for this organism. A typing method based on the incorporation of sulphur-35-labelled methionine into cellular proteins and their separation by sodium dodecylsulphate/polyacrylamide gel electrophoresis showed clear pattern differences between strains, and nine distinct groups within the C difficile species were established. 98% of 250 clinical strains derived from four hospitals were typable. Group X was the commonest group and was associated with outbreaks of pseudomembranous colitis and antibiotic-associated colitis in two hospitals. Groups A-D were isolated predominantly from mothers and newborn infants. In outbreaks of antibiotic-associated colitis in oncology and orthopaedic wards the same strains, group X and group E, respectively, were isolated from patients and their environment, providing strong evidence of cross-infection between patients and of hospital acquisition of C difficile.

Isolation of Clostridium difficile from patients and the environment of hospital wards.

Rectal swabs from 122 patients and 497 environmental swabs from several wards were examined for the presence of Clostridium difficile in order to assess the role of the environment in the spread of this organism. Clostridium difficile was isolated from 6/27 (22.2%) oncology patients and from 8/163 (4.9%) environmental specimens obtained from the oncology unit. Items found positive for C difficile were those subjected to faecal contamination such as commode chairs, bed pans, dust pans, discard bins, the sluice and a disposable bed pan machine. Fourteen of 51 (27.4%) asymptomatic neonates yielded mostly toxigenic C difficile in their stools during their first week of life. Five of 156 (3.2%) specimens taken from inanimate objects in the environment of the neonatal units were positive for C difficile. The organism was also isolated from the hands of a nurse. Similar antibiogram patterns were demonstrated in the strains obtained from the patients and their environment indicating the possible occurrence of cross infection. These results indicate that environmental contamination is important in the spread of C difficile in hospitalised patients and the implementation of isolation procedures may limit that spread.

Colonization of the gastric contents in critically ill patients.

In a study of 28 ventilated patients in the ICU, cimetidine was ineffective in maintaining gastric pH above 4. Quantitative and qualitative bacteriological examination of daily gastric aspirates showed that when the pH was above 4, there was rapid colonization with high counts of organisms, predominantly coliforms. Progressive colonization by yeasts, independent of pH, was noted in nearly one-half of the patients. Gastric colonization has possible implications in terms of crossinfection of development of aspiration pneumonia. As these are seriously ill patients with compromised gastrointestinal (GI) barriers and decreased immunity, the large numbers of bacteria or their endotoxins may contribute to the high incidence of septicemia.

Studies on the enterotoxigenicity of environmental Escherichia coli, belonging to serotypes normally considered enterotoxigenic.

Fifteen strains of Escherichia coli which had been collected in previous studies from animals and meat were studied. They belonged to serotypes considered enterotoxigenic and were examined for the production of the heat-labile and heat-stable enterotoxins. Only one of these strains (O8.Hnt) isolated from a cowpat in Cheshire produced heat-labile enterotoxin. Another strain (O8.H9) isolated from a cowpat in another part of Cheshire gave results suggesting production of small amounts of the heat-stable enterotoxin. The ecological aspects of these results are discussed.

Microbial contamination of pharmaceutical products in the home.

One thousand, nine hundred and seventy-seven pharmaceutical products used in the home were examined for microbial contamination. Viable micro-organisms were recovered from 14.0% of samples. Medicines used in the home are apparently not exposed to the same opportunities for contamination as those used in hospital.