An in vitro study of the susceptibility of mobile and cystic forms of Borrelia burgdorferi to tinidazole

The susceptibility of mobile and cystic forms of Borrelia burgdorferi to tinidazole (TZ) was examined. The minimal bactericidal concentration (MBC) of TZ against the mobile spirochetes was >128 μg/ml at 37°C in micro-oxic atmosphere when incubated for 14 days. TZ significantly reduced the conversion of mobile spirochetes to cystic forms during incubation. The MBC for older (10- months-old) cysts at 37°C in a micro-oxic atmosphere was >0.5 μg/ml, but >0.125 μg/ml for young (1-day-old) cysts. Acridine orange staining, dark-field microscopy and transmission electron microscopy revealed that, when the concentration of TZ was ≥ MBC, the contents of the cysts were partly degraded, core structures did not develop inside the young cysts, and the amount of RNA in these cysts decreased significantly. When cysts were exposed to TZ, both the spirochetal structures and core structures inside the cysts dissolved, and the production of blebs was significantly reduced. These observations may be valuable in the treatment of resistant infections caused by B. burgdorferi, and suggest that a combination of TZ and a macrolide antibiotic could eradicate both cystic and mobile forms of B. burgdorferi. [Int Microbiol 2004; 7(2):139–142

An in vitro study of the susceptibility of mobile and cystic forms of Borrelia burgdorferi to hydroxychloroquine

In this work the susceptibility of mobile and cystic forms of Borrelia burgdorferi to hydroxychloroquine (HCQ) was studied. The minimalba ctericidal concentration (MBC) of HCQ against the mobile spirochetes was >32 μg/mlat 37°C, and >128 μg/ml at 30°C. Incubation with HCQ significantly reduced the conversion of mobile spirochetes to cystic forms. When incubated at 37°C, the MBC for young biologically active cysts (1-day old) was >8 μg/ml, but it was >32 μg/ml for old cysts (1-week old). Acridine orange staining, dark-field microscopy and transmission electron microscopy revealed that the contents of the cysts were partly degraded when the concentration of HCQ was ≥MBC. At high concentrations of HCQ (256 lg/ml) about 95% of the cysts were ruptured. When the concentration of HCQ was ≥MBC, core structures did not develop inside the cysts, and the amount of RNA in these cysts decreased significantly. Spirochetal structures inside the cysts dissolved in the presence of high concentrations of HCQ. When the concentration of HCQ was ≥MBC, the core structures inside the cysts were eliminated. These observations may be valuable in the treatment of resistant infections caused by B. burgdorferi, and suggest that a combination of HCQ and a macrolide antibiotic could eradicate both cystic and mobile forms of B. burgdorferi

Susceptibility of motile and cystic forms of Borrelia burgdorferi to ranitidine bismuth citrate

Gastrointestinal symptoms accompanying Lyme disease have not been considered in the treatment of Lyme patients yet. Here we examine the effect of ranitidine bismuthcitr ate (RBC) on motile and cystic forms of Borrelia burgdorferi in vitro, to determine whether it could cure this bacterial infection in the gastrointestinal tract. When motile forms of B. burgdorferi were exposed to RBC for 1 week at 37°C, the minimal bactericidal concentration (MBC) was >64 mg/ml. At 30°C, the MBC was >256 mg/ml. When the incubation lasted for 2 weeks at 37°C, the MBC dropped to >2 mg/ml. Bismuth aggregates were present on the surface of B. burgdorferi when RBC ≥ MBC, as shown by transmission electron microscopy (TEM). Cystic forms of B. burgdorferi, exposed to RBC for 2 weeks at 37°C, were examined by cultivation in BSK-H medium (Sigma B3528). They were stained with acridine orange (pH 6.4, pH 7.4) and studied by TEM. The MBC for RBC for young cystic forms (1 day old) and old cysts (8 months old) was estimated to be >0.125 mg/ml and >2 mg/ml, respectively. Bismuth aggregates were attached to the cysts and, in some, the pin-shaped aggregates penetrated the cyst wall. The bismuth aggregates also bound strongly to blebs and granules of B. burgdorferi when RBC ≥ MBC. When B. burgdorferi is responsible for gastrointestinal symptoms, bismuth compounds may be candidates for eradication of the bacterium from the gastrointestinal tract

A 28-year Single Institutional Experience of Complete Reduction of Extremity Lymphedema Using Suction Assisted Lipectomy.

PURPOSE: Absent lymph flow and chronic inflammationleads to excess subcutaneous adipose tissue deposition.Chronic non-pitting lymphedema does not respond to conservativetreatment or microsurgical procedures becausethey do not target the adipose tissue. Removing the adiposetissue using suction assisted lipectomy (SAL) seems thus tobe a logic treatment strategy.METHODS: Arms: 190 women, mean±SEM age of 62±0.8years, with a duration of arm swelling of 8.6±0.5 yearsunderwent SAL. Age at breast cancer operation, intervalbetween breast cancer operation and lymphedema start, andduration of lymphedema were 51±0.8 years, 2.8±0.4 years,and 8.6±0.5 years respectively. Legs: 128 patients with amean age of 49±1.4 years and with a duration of leg swellingof 13±0.9 years underwent SAL. There were 64 primary(PL) and 64 secondary lymphedemas (SL) following cancertherapy. Age at cancer treatment and interval between cancertreatment and lymphedema start were 2.5±0.7 years and42±1.7 years respectively. Age at onset of PL was 10 years.RESULTS: Arms: Preoperative mean excess volume was1404±52 ml. Postoperative reduction was 104±2.0% at 3months and 117±2.1% at 1 year, and more than 100% during28 years’ follow-up. Legs: Preoperative excess volumewas 3580±153 ml. Postoperative reduction was 82%±2.3%at 3 months and 101±2.3% at 1 year, and more than 100%during 23 years’ follow-up.CONCLUSION: SAL is effective for treatment of chroniclymphedema in patients who do not respond to conservativetreatment. Removal of the hypertrophied adipose tissueleads to complete reduction. Constant use of compressiongarments maintains outcome

Liposuction and Controlled Compression Therapy in the Treatment of Arm Lymphedema following Breast Cancer

Liposuction and controlled compression therapy in the treatment of arm lymphedema following breast cancer About one-third of all women treated for breast cancer develop arm lymphedema. The cancer itself is a worry, but the swollen and heavy arm is an additional handicap for the patients, both physical and psychosocial. Previous surgical and conservative treatments have not always given satisfactory and permanent results, conceivably because lymphedema causes hypertrophy of the subcutaneous adipose tissue. From this point of view, liposuction (LS) combined with Controlled Compression Therapy (CCT) is an interesting approach as the hypertrophied adipose tissue is effectively removed and the outcome sustained by wearing a compression garment. Altogether 51 women participated in the present investigations. All, except one had received radiotherapy after the breast cancer operation which included the excision of axillary lymphnodes in all cases. Thirty-six patients were treated with LS and postoperative CCT, whereas 15 received CCT only. Pre- and postoperative arm edema volumes were measured using water displacement technique. Skin blood flow was recorded using laser Doppler imaging. Lymph transport in the arm was assessed with indirect lymphoscintigraphy. Rage of motion in the shoulder joint was measured using a protractor. Effects on quality of life were estimated using the Visual Analogue Scale, Nottingham Health Profile, Psychological General Well-Being index, and the Hospital Anxiety Depression scale. Results were monitored for up to one year after treatment. LS+CCT reduced the arm edema volume completely, compared with a 50% decrease following CCT alone. The use of a compression garment after liposuction is necessary to maintain the normalized arm volume. LS+CCT did not affect the already impaired lymph transport; it merely increased skin microcirculation. A reduced incidence of cellulitis was noted. The treatment improved range of motion in the shoulder joint and patients' quality of life, particularly qualities directly related to the volume reduction and thereby qualities associated with everyday activities. As could be expected from the volume measurements, the more favorable outcomes were recorded mostly in the LS+CCT group

Liposuction Normalizes - in Contrast to Other Therapies - Lymphedema-Induced Adipose Tissue Hypertrophy

The various types of treatment of lymphedema are under discussion and there has been some controversy regarding liposuction for lymphedema. Although it is clear that conservative therapies such as complex decongestive therapy (CDT) and controlled compression therapy (CCT) should be tried in the first instance, options for the treatment of late-stage lymphedema that is not responding to such treatment is not so clear. Improvements in technique, patient preparation, and patient follow-up have led to a greater and a wider acceptance of liposuction as a treatment for lymphedema. This paper outlines the benefits of using liposuction and presents the evidence to support its use

Defining the fracture population in a pragmatic multicentre randomised controlled trial : PROFHER and the Neer classification of proximal humeral fractures

OBJECTIVES: Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck. METHODS: The trial manual illustrated the Neer classification of proximal humeral fractures. However, in addition to surgical neck displacement, surgeons assessing patient eligibility reported on whether either or both of the tuberosities were involved. Anonymised electronic versions of baseline radiographs were sought for all 250 trial participants. A protocol, data collection tool and training presentation were developed and tested in a pilot study. These were then used in a formal assessment and classification of the trial fractures by two independent senior orthopaedic shoulder trauma surgeons. RESULTS: Two or more baseline radiographic views were obtained for each participant. The independent raters confirmed that all fractures would have been considered for surgery in contemporaneous practice. A full description of the fracture population based on the Neer classification was obtained. The agreement between the categorisation at baseline (tuberosity involvement) and Neer classification as assessed by the two raters was only fair (kappa 0.29). However, this disparity did not appear to affect trial findings, specifically in terms of influencing the effect of treatment on the primary outcome of the trial. CONCLUSIONS: A key reporting requirement, namely the description of the fracture population, was achieved within the context of a pragmatic multicentre randomised clinical trial. This article provides important guidance for researchers designing similar trials on fracture management.Cite this article: H. H. G. Handoll, S. D. Brealey, L. Jefferson, A. Keding, A. J. Brooksbank, A. J. Johnstone, J. J. Candal-Couto, A. Rangan. Defining the fracture population in a pragmatic multicentre randomised controlled trial: PROFHER and the Neer classification of proximal humeral fractures.Bone Joint Res 2016;5:481-489. DOI: 10.1302/2046-3758.510.BJR-2016-0132.R1

CDER\u27s emerging technology team

The newly formed Emerging Technology Team (ETT) draws membership from all CDER quality review, research and inspection functions, including Office of Biotechnology Products. The goal of the ETT is provide a primary point of contact for external inquiries regarding emerging technology in pharmaceutical and biotechnology manufacturing and quality control. The ETT will partner with review offices in a cross-functional manner and identify regulatory strategy and resolve roadblocks to new technologies relating to existing guidance, policy or practices related to review or inspection. The ETT’s initial focus will be innovation on novel products, manufacturing processes, or testing technologies or processes to be submitted in a BLA, NDA or ANDA. This talk will provide an update on ETT’s activities in 2015

Standardised measurements used to order compression garments can be used to calculate arm volumes to evaluate lymphoedema treatment.

Abstract Lymphoedema treatment outcome can be evaluated by calculating estimated limb volumes directly by water displacement (plethysmography; PG), or indirectly by circumference measurements (CM) and using the formula for a truncated cone. This study assessed the correlation between PG and circumference volume measurements to assess whether the correlation is acceptable, and if circumference measurements can be used to accurately assess arm volume. Ten women with unilateral lymphoedema after breast cancer treatment with a mean age of 66 (range 50-83) years volunteered for arm volume estimates by PG and circumference measurements. The coefficient of variation (CV%) for all methods was calculated. Two Excel-based formulae of the truncated cone were developed; one for fixed 4-cm intervals leading to 10 volume segments (CM-10-VS), and one for varying intervals leading to four volume segments (CM-4-VS). The CV% was 0.609% for PG, 0.628% for CM-10-VS, and 0.632% for CM-4-VS. As expected, PG generated a significantly larger volume of both arms because it includes the hand. The difference between CM-10-VS and CM-4-VS measurements was not significant. All three measurement methods showed a high coefficient of correlation (0.813-0.915), and a high coefficient of regression (0.863-1.089). The excess volume, which is used to determine treatment outcome, showed the respective values of 0.932-0.978 and 0.963-1.020, respectively. Using circumference measurements identical to those used when ordering made-to-measure compression garments speeds up volume measurements and can be used safely to evaluate lymphoedema treatment outcome