Eculizumab Therapy for Chronic Antibody-Mediated Injury in Kidney Transplant Recipients: A Pilot Randomized Controlled Trial.

We hypothesized that de novo donor-specific antibody (DSA) causes complement-dependent endothelial cell injury in kidney transplants, as assessed by expression of endothelial cell-associated transcripts (ENDATs), that may be attenuated through complement inhibition. In total, 15 participants (five control, 10 treatment) with DSA and deteriorating renal function were enrolled. The treatment group received 6 mo of eculizumab followed by 6 mo of observation, whereas controls were observed. The primary end point was percentage change in estimated GFR (eGFR) trajectory over the treatment period. The treatment group had an improved eGFR trajectory versus control, based on our predetermined two-sided 0.10 significance level (p = 0.09). Within-subject analysis of treated participants at 6-mo intervals did not show significant change (p = 0.60). Modeling C1q status showed that C1q-positive patients had significantly higher mean eGFR than patients with negative C1q (p = 0.04). Biopsies revealed elevated renal ENDATs in most participants, but ENDATs were not reduced with complement inhibition. Our data suggest that eculizumab treatment may stabilize kidney function in patients with chronic persistent DSA based on our pilot a priori significance threshold. ENDAT expression predicative of acute humoral injury is not reduced with complement inhibition in this chronic setting. Further studies will be necessary to determine which patients may benefit from eculizumab.

Preoperative renal dysfunction and mortality after non-cardiac surgery.

BACKGROUND: Chronic kidney disease is an important preoperative risk factor. However, the association between renal dysfunction and risk of death has not been well explored in non-cardiac surgery. METHODS: Two prospective observational studies in non-cardiac surgery were analysed: the European Surgical Outcomes Study (EuSOS) and the UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD). The relationship between preoperative estimated glomerular filtration rate (eGFR) and postoperative mortality was examined using multivariable Cox proportional hazards models. RESULTS: In EuSOS, 1580 (4·3 per cent) of 36 779 patients died in hospital; in NCEPOD, 298 (2·8 per cent) of 10 466 patients had died by 60 days after surgery. Chronic kidney disease (eGFR below 60·0 ml per min per 1·73 m(2) ) was present in 6415 patients (17·4 per cent) in EuSOS and 2262 (21·6 per cent) in NCEPOD. Preoperative chronic kidney disease was associated with older age, men, diagnosis of diabetes, cardiovascular or respiratory disease, and non-elective surgery. Preoperative eGFR categories below 60·0 ml per min per 1·73 m(2) were associated with increasing adjusted hazard ratios (HRs) for death compared with a value of 90·0 ml per min per 1·73 m(2) and above. In EuSOS, the risk of death increased with lower eGFR category, to a maximum with eGFR 15·0-29·9 ml per min per 1·73 m(2) (HR 3·37, 95 per cent c.i. 2·70 to 4·22). In NCEPOD, the risk of death also increased with declining eGFR and was maximal for eGFR below 15·0 ml per min per 1·73 m(2) (HR 3·40, 1·78 to 6·50). CONCLUSION: Renal dysfunction is an important risk factor for death after non-cardiac surgery and the risk increases steeply for patients with moderate to severe kidney dysfunction.

Development and validation of the Surgical Outcome Risk Tool (SORT).

BACKGROUND: Existing risk stratification tools have limitations and clinical experience suggests they are not used routinely. The aim of this study was to develop and validate a preoperative risk stratification tool to predict 30-day mortality after non-cardiac surgery in adults by analysis of data from the observational National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Knowing the Risk study. METHODS: The data set was split into derivation and validation cohorts. Logistic regression was used to construct a model in the derivation cohort to create the Surgical Outcome Risk Tool (SORT), which was tested in the validation cohort. RESULTS: Prospective data for 19 097 cases in 326 hospitals were obtained from the NCEPOD study. Following exclusion of 2309, details of 16 788 patients were analysed (derivation cohort 11 219, validation cohort 5569). A model of 45 risk factors was refined on repeated regression analyses to develop a model comprising six variables: American Society of Anesthesiologists Physical Status (ASA-PS) grade, urgency of surgery (expedited, urgent, immediate), high-risk surgical specialty (gastrointestinal, thoracic, vascular), surgical severity (from minor to complex major), cancer and age 65 years or over. In the validation cohort, the SORT was well calibrated and demonstrated better discrimination than the ASA-PS and Surgical Risk Scale; areas under the receiver operating characteristic (ROC) curve were 0·91 (95 per cent c.i. 0·88 to 0·94), 0·87 (0·84 to 0·91) and 0·88 (0·84 to 0·92) respectively (P < 0·001). CONCLUSION: The SORT allows rapid and simple data entry of six preoperative variables, and provides a percentage mortality risk for individuals undergoing surgery.

The management of trauma victims with head injury: a study by the National Confidential Enquiry into Patient Outcome and Death.

INTRODUCTION: In 2006 the National Confidential Enquiry into Patient Outcome and Death undertook a large prospective study of trauma care, which revealed several findings pertaining to the management of head injuries in a sample of 493 patients. METHODS: Case note data were collected for all trauma patients admitted to all hospitals accepting emergencies in england, wales, Northern Ireland and the Channel Islands over a three-month period. severely injured patients with an injury severity score (iss) of ≥16 were included in the study. the case notes for these patients were peer reviewed by a multidisciplinary group of clinicians, who rated the overall level of care the patient received. RESULTS: Of the 795 patients who met the inclusion criteria for the study, 493 were admitted with a head injury. Room for improvement in the level of care was found in a substantial number of patients (265/493). Good practice was found to be highest in high volume centres. The overall head injury management was found to be satisfactory in 84% of cases (319/381). CONCLUSIONS: This study has shown that care for trauma patients with head injury is frequently rated as less than good and suggests potential long-term remedies for the problem, including a reconfiguration of trauma services and better provision of neurocritical care facilities.

Community-acquired pneumonia due to Panton-Valentine leukocidin-producing Staphylococcus aureus in an HIV-2-infected patient.

Pneumonia caused by Panton-Valentine leukocidin-producing Staphylococcus aureus is associated with a high fatality rate. There have been few reported cases in HIV-1-co-infected patients. Here we report a fatal case of severe community-acquired pneumonia caused by Panton-Valentine leukocidin-producing S. aureus in a 45-year-old woman with HIV-2 infection.

Chasing the golden egg: vaccination against poultry coccidiosis.

Eimeria species, of the Phylum Apicomplexa, cause the disease coccidiosis in poultry, resulting in severe economic losses every year. Transmission of the disease is via the faecal-oral route, and is facilitated by intensive rearing conditions in the poultry industry. Additionally, Eimeria has developed drug resistance against most anticoccidials used today, which, along with the public demand for chemical free meat, has lead to the requirement for an effective vaccine strategy. This review focuses on the history and current status of anticoccidial vaccines, and our work in developing the transmission-blocking vaccine, CoxAbic (Netanya, Israel). The vaccine is composed of affinity-purified antigens from the wall-forming bodies of macrogametocytes of Eimeria maxima, which are proteolytically processed and cross-linked via tyrosine residues to form the environmentally resistant oocyst wall. The vaccine is delivered via maternal immunization, where vaccination of laying hens leads to protection of broiler offspring. It has been extensively tested for efficacy and safety in field trials conducted in five countries and involving over 60 million offspring chickens from immunized hens and is currently the only subunit vaccine against any protozoan parasite to reach the marketplace.

Evidence for associations between the purinergic receptor P2X(7) (P2RX7) and toxoplasmosis.

Congenital Toxoplasma gondii infection can result in intracranial calcification, hydrocephalus and retinochoroiditis. Acquired infection is commonly associated with ocular disease. Pathology is characterized by strong proinflammatory responses. Ligation of ATP by purinergic receptor P2X(7), encoded by P2RX7, stimulates proinflammatory cytokines and can lead directly to killing of intracellular pathogens. To determine whether P2X(7) has a role in susceptibility to congenital toxoplasmosis, we examined polymorphisms at P2RX7 in 149 child/parent trios from North America. We found association (FBAT Z-scores +/-2.429; P=0.015) between the derived C(+)G(-) allele (f=0.68; OR=2.06; 95% CI: 1.14-3.75) at single-nucleotide polymorphism (SNP) rs1718119 (1068T>C; Thr-348-Ala), and a second synonymous variant rs1621388 in linkage disequilibrium with it, and clinical signs of disease per se. Analysis of clinical subgroups showed no association with hydrocephalus, with effect sizes for associations with retinal disease and brain calcifications enhanced (OR=3.0-4.25; 0.004

Non-archetypal Type II-like and atypical strains of Toxoplasma gondii infecting marsupials of Australia.

Australia is geographically isolated and possesses a remarkable diversity of wildlife species. Marsupials are highly susceptible to infection with the cosmopolitan parasite Toxoplasma gondii. Of 46 marsupials screened for T. gondii by multilocus PCR-DNA sequencing at polymorphic genes (B1, SAG3, GRA6, GRA7), 12 were PCR-positive; the majority (67%; 9/12) were infected by non-archetypal Type II-like or atypical strains. Six novel alleles were detected at B1, indicating greater diversity of genotypes than previously envisaged. Two isolates lethal to marsupials, were avirulent to mice. The data support the conclusion that Australia's isolation may have favoured the persistence of non-archetypal ancestral genotypes.

Manual vacuum aspiration: a safe alternative for the surgical management of early pregnancy loss.

Manual vacuum aspiration (MVA) is an alternative to the standard surgical curettage, performed under local anaesthetic in the setting of a treatment room. The aim of our study was to assess the efficacy of MVA in the management of first trimester early fetal demise and first- and mid-trimester incomplete miscarriage. This was a retrospective study of 246 patients who were scheduled to undergo MVA for first trimester early fetal demise and first- and mid-trimester incomplete miscarriage. One woman was excluded in the analysis because of the procedure being abandoned prior to MVA. Efficacy of the procedure was 94.7% (232/245). Incomplete uterine evacuation was seen in 5.3% (13/245) patients. Although not widely used in the UK, MVA could be considered routinely, thus avoiding general anaesthesia and the need for access to theatre.

Muscle moment arms of pelvic limb muscles of the ostrich (Struthio camelus).

Muscle moment arms were measured for major muscles of the pelvic limb of the ostrich (Struthio camelus) in order to assess specific functional behaviour and to apply this to locomotor performance. Pelvic limbs of six juvenile ostriches were used for this study. The tendon travel technique was used to measure moment arms of 21 muscles at the hip, knee, ankle and metatarsophalangeal joints throughout the ranges of motion observed during level running. Six of the 21 muscles measured were found to have moment arms that did not change with joint angle, whilst the remainder all demonstrated angle-dependent changes for at least one of the joints crossed. Moment arm lengths tended to be longest for the large proximal muscles, whilst the largest relative changes were found for the moment arms of the distal muscles. For muscles where moment arm varied with joint angle: all hip muscles were found to have increasing moment arms with extension of the joint, knee flexors were found to have moment arms that increased with extension, knee extensor moment arms were found to increase with flexion and ankle extensor moment arms increased with extension. The greatest relative changes were observed in the flexors of the metatarsophalangeal joint, for which a three-fold increase in moment arm was observed from flexion to full extension. Changes in muscle moment arm through the range of motion studied appear to optimize muscle function during stance phase, increasing the effective mechanical advantage of these muscles.

Muscle architecture and functional anatomy of the pelvic limb of the ostrich (Struthio camelus).

The functional anatomy of the pelvic limb of the ostrich (Struthio camelus) was investigated in order to assess musculoskeletal specialization related to locomotor performance. The pelvic limbs of ten ostriches were dissected and detailed measurements of all muscle tendon units of the pelvic limb were made, including muscle mass, muscle length, fascicle length, pennation angle, tendon mass and tendon length. From these measurements other muscle properties such as muscle volume, physiological cross-sectional area (PCSA), tendon cross-sectional area, maximum isometric muscle force and tendon stress were derived, using standard relationships and published muscle data. Larger muscles tended to be located more proximally and had longer fascicle lengths and lower pennation angles. This led to an expected proximal to distal reduction in total muscle mass. An exception to this trend was the gastrocnemius muscle, which was found to have the largest volume and PCSA and also had the highest capacity for both force and power production. Generally high-power muscles were located more proximally in the limb, while some small distal muscles (tibialis cranialis and flexor perforatus digiti III), with short fibres, were found to have very high force generation capacities. The greatest proportion of pelvic muscle volume was for the hip extensors, while the highest capacity for force generation was observed in the extensors of the ankle, many of which were also in series with long tendons and thus were functionally suited to elastic energy storage.

Comparison of the antioxidant status in tracheal and bronchoalveolar epithelial lining fluids in recurrent airway obstruction.

REASONS FOR PERFORMING STUDY: Following a period of airway inflammation the clearance of inflammatory cells along the mucociliary escalator may impose a considerable oxidant load on the trachea. OBJECTIVES: To determine the degree of oxidative stress in tracheal epithelial lining fluid (ELF) in comparison to that present in peripheral airways after an acute exposure to organic dust. METHODS: Tracheal wash fluid and bronchoalveolar lavage fluid (BALF) were collected for cytology and antioxidant analyses from 6 recurrent airway obstruction (RAO)-affected horses and 6 healthy control horses before and after stabling on straw bedding for 24 h. RESULTS: In RAO-affected horses, organic dust exposure resulted in a significant decrease in ascorbic acid concentration in tracheal ELF (P<0.0001), which was greater than the decrease in bronchoalveolar ELF (P = 0.0003). The percentage decrease in tracheal ELF ascorbic acid correlated with the percentage decrease in bronchoalveolar ELF ascorbic acid (r = 0.76; P = 0.004) following exposure. CONCLUSIONS: Acute organic dust exposure results in significant antioxidant depletion in the trachea, which may reflect inflammation and oxidative processes in peripheral airways. POTENTIAL RELEVANCE: Further work is required to evaluate the role of ascorbic acid depletion in the pathogenesis of RAO.

Functional specialisation of pelvic limb anatomy in horses (Equus caballus).

We provide quantitative anatomical data on the muscle-tendon units of the equine pelvic limb. Specifically, we recorded muscle mass, fascicle length, pennation angle, tendon mass and tendon rest length. Physiological cross sectional area was then determined and maximum isometric force estimated. There was proximal-to-distal reduction in muscle volume and fascicle length. Proximal limb tendons were few and, where present, were relatively short. By contrast, distal limb tendons were numerous and long in comparison to mean muscle fascicle length, increasing potential for elastic energy storage. When compared with published data on thoracic limb muscles, proximal pelvic limb muscles were larger in volume and had shorter fascicles. Distal limb muscle architecture was similar in thoracic and pelvic limbs with the exception of flexor digitorum lateralis (lateral head of the deep digital flexor), the architecture of which was similar to that of the pelvic and thoracic limb superficial digital flexors, suggesting a functional similarity.

Antioxidant and inflammatory responses of healthy horses and horses affected by recurrent airway obstruction to inhaled ozone.

REASONS FOR PERFORMING STUDY: Inhaled ozone can induce oxidative injury and airway inflammation. Horses affected by recurrent airway obstruction (RAO) have a decreased pulmonary antioxidant capacity, which may render them more susceptible to oxidative challenge. It is currently unknown whether RAO-affected horses are more susceptible to oxidative stress than those unaffected by RAO. OBJECTIVES: To determine whether ozone exposure induces greater oxidative stress and airway inflammation in RAO-affected horses in remission than in healthy horses. METHODS: Seven healthy control horses and 7 RAO-affected horses were exposed to 0.8 ppm ozone for 2 h at rest. RESULTS: At baseline, bronchoalveolar lavage fluid (BALF) ascorbic acid concentrations were lower in RAO-affected horses than healthy controls. Ozone appeared to preferentially oxidise glutathione rather than ascorbic acid 6 h after exposure. Individual healthy and RAO-affected horses demonstrated oxidation of BALF glutathione after ozone exposure. Overall, RAO-affected horses did not demonstrate increased oxidative stress following ozone exposure, compared with healthy horses. Ozone did not induce significant airway inflammation in either group. CONCLUSIONS: RAO-affected horses in remission are not more sensitive to ozone despite a decreased pulmonary antioxidant capacity. Sensitivity to ozone appears to be independent of initial pulmonary antioxidant status. POTENTIAL RELEVANCE: Horses with high susceptibility to oxidative stress may benefit from antioxidant supplementation.

Ultrasonic measurement of biparietal diameter and femur in foetal age determination.

Our objective was to verify ultrasonic measurement of biparietal diameter and femur in foetal age determination in the second and third trimester of pregnancy. The prospective cross sectional study was carried out at the ultrasound department of Aberdeen Maternity Hospital Scotland. The study population consisted of 716 pregnant Scottish (Caucasian) women who were certain of their gestational ages and had their gestational ages confirmed in the first trimester by ultrasound. The findings revealed: (1) Linearity through out pregnancy using the femur length measurements while that of the biparietal diameter demonstrated poor correlation after 32 weeks of gestation. (2) The standard deviation and the correlation coefficient of the femur length measurements were 0.0042 and 0.9920 respectively while the corresponding values for biparietal diameter were 0.0045 and 0.9850 respectively. (3) The standard error for femur length estimate was 0.2251 as against 0.3009 for biparietal diameter estimate. The results suggest that femur length measurement is a more reliable index of late third trimester gestational age prediction than biparietal diameter.

The development of the macrogamete and oocyst wall in Eimeria maxima: immuno-light and electron microscopy.

We have identified, and followed the development of three macrogamete organelles involved in the formation of the oocyst wall of Eimeria maxima. The first were small lucent vacuoles that cross-reacted with antibodies to the apple domains of the Toxoplasma gondii microneme protein 4. They appeared early in development and were secreted during macrogamete maturation to form an outer veil and were termed veil forming bodies. The second were the wall forming bodies type 1, large, electron dense vacuoles that stained positively only with antibodies raised to an enriched preparation of the native forms of 56 (gam56), 82 (gam82) and 230 kDa (gam230) gametocyte antigens (termed anti-APGA). The third were the wall forming bodies type 2, which appeared before the wall forming bodies type 1 but remain enclosed within the rough endoplasmic reticulum and stained positively with antibodies raised to recombinant versions of gam56 (anti-gam56), gam82 (anti-gam82) and gam230 (anti-gam230) plus anti-APGA. At the initiation of oocyst wall formation, the anti-T. gondii microneme protein 4 positive outer veil detached from the surface. The outer layer of the oocyst wall was formed by the release of the contents of wall forming bodies type 1 at the surface to form an electron dense, anti-APGA positive layer. The wall forming bodies type 2 appeared, subsequently, to give rise to the electron lucent inner layer. Thus, oocyst wall formation in E. maxima represents a sequential release of the contents of the veil forming bodies, wall forming bodies types 1 and 2 and this may be controlled at the level of the rough endoplasmic reticulum/Golgi body.

Pseudorotation of the little finger metacarpal.

Fractures of the little finger metacarpal are common, and are often associated with significant soft-tissue swelling and the appearance of rotational malalignment when the fingers are flexed. Our hypothesis is that soft-tissue swelling causes this apparent rotational deformity of the flexed little finger. The fourth intermetacarpal spaces of three of the authors' non-dominant hands were injected with saline. Following injection, all the hands exhibited the appearance of internal rotation of the little finger. The mean change in rotation was 16 degrees and the maximum was 25 degrees. There was no change in the plane of the nail plate in extension in any hand. We conclude that soft-tissue swelling can cause the appearance of internal rotation of the flexed little finger in the absence of fracture.

Zoledronic acid improves the mechanical properties of normal and healing bone.

OBJECTIVE: To determine the effects of the bisphosphonate zoledronic acid on the mechanical properties of normal and regenerating bone in a rabbit model of distraction osteogenesis. BACKGROUND: Bisphosphonate therapy is used for treating osteoporosis and, more recently, to enhance bone healing and reduce stress-shielding osteoporosis in distraction osteogenesis. METHODS: Thirty eight rabbits underwent 14 days of distraction osteogenesis on the right rear limb. They received either zero, one or two doses of intravenous zoledronic acid. Four point bending tests were performed to collect mechanical data. RESULTS: The peak load capacity of the regenerating bone was significantly increased by bisphosphonate therapy, but a similar trend in normal bone was not significant. The energy absorbed to failure did not vary significantly in either group. CONCLUSIONS: These data suggest that bisphosphonate therapy has a beneficial effect on the load capacity of regenerating bone, without increasing the brittleness of either new or existing bone. RELEVANCE: Zoledronic acid administration may be a potentially valuable adjunct to distraction osteogenesis treatment, to enhance bone strength, thus reducing refracture complications.

Bisphosphonates and nephrocalcinosis in a rabbit leg lengthening model: a histological and therapeutic comparison.

We performed a comparison of the effects of two bisphosphonates, pamidronate and zoledronic acid, on regenerate bone mineral content in distraction osteogenesis in an immature rabbit model. Single dose zoledronic acid was found to be 18 times more potent at producing an increase in bone mineral content than pamidronate per mg/kg of drug infused at surgery. Histological examination of all rabbit kidneys was performed at trial completion. Nephrocalcinosis was identified in 14 of 20 kidneys of rabbits infused with pamidronate, but was not detected in the 20 kidneys of those rabbits infused with zoledronic acid. A further 20 kidneys from rabbits given a second dose of zoledronic acid were also found to be free of signs of nephrocalcinosis. Three of 40 control kidneys exhibited signs of nephrocalcinosis. The increased potency of zoledronic acid allowed us to give one-tenth the dose of pamidronate, with increased therapeutic efficacy and no evidence of nephrocalcinosis.

Medical management of early fetal demise using a combination of mifepristone and misoprostol.

BACKGROUND: This study aims to assess the efficacy of a combination of mifepristone and misoprostol in the management of missed miscarriage and anembryonic pregnancy. METHODS: Data of 220 consecutive women with miscarriage, undergoing medical evacuation of the uterus were collected prospectively at an early pregnancy assessment unit in a tertiary referral hospital. Each woman received a single oral dose of mifepristone 200 mg and 36-48 h later vaginal misoprostol 800 microg. Three hours following the first dose, two further doses of misoprostol, 400 microg each, were administered vaginally or orally at 3 h intervals. Women who failed to pass products of conception were offered repeat medical regime with misoprostol. Success was defined as complete uterine evacuation within 3 days, without the need for surgical evacuation. RESULTS: The overall success rate of medical management was 84.1%. Mifepristone alone induced natural expulsion of products of conception in 18.1% of women. The median dose of misoprostol required was 1600 microg and the median induction miscarriage interval after first prostaglandin administration was 8.04 h (range: 0.58-50.54 h). Of the 142 women who were symptomatic at presentation the medical regime failed in 30 (21.1%), compared with five (6.4%) failures of the 78 who were asymptomatic (P = 0.007). Of the 35 women who had surgical evacuation, eight required an emergency curettage for bleeding. CONCLUSIONS: The combination of oral mifepristone 200 mg with vaginal or oral misoprostol is an alternative to surgical management of early fetal demise, although it is not as effective as surgery.