Correction to Effect of vitamin K on bone mineral density and fractures in adults: an updated systematic review and meta-analysis of randomised controlled trials.

Following the work of Avenell et al. that has raised concerns about the integrity of the Yamaguchi Osteoporosis Prevention Study (YOPS) conducted by Ishida and Kawai we issue here an adjustment to all meta-analysis estimates that contained this work within our systematic review.

Effect of vitamin K on bone mineral density and fractures in adults: an updated systematic review and meta-analysis of randomised controlled trials.

Vitamin K may affect bone mineral density and fracture incidence. Since publication of a previous systematic review the integrity of some of the previous evidence has been questioned and further trials have been published. Therefore an update to the systematic review was required. INTRODUCTION: This systematic review was designed to assess the effectiveness of oral vitamin K supplementation for increasing bone mineral density and reducing fractures in adults. METHODS: MEDLINE, EMBASE, CENTRAL, CINAHL, clinicaltrials.gov, and WHO-ICTRP were searched for eligible trials. Randomised controlled trials assessing oral vitamin K supplementation that assessed bone mineral density or fractures in adult populations were included. A total of 36 studies were identified. Two independent reviewers extracted data using a piloted extraction form. RESULTS: For post-menopausal or osteoporotic patients, meta-analysis showed that the odds of any clinical fracture were lower for vitamin K compared to controls (OR, 0.72, 95%CI 0.55 to 0.95). Restricting the analysis to low risk of bias trials reduced the OR to 0.76 (95%CI, 0.58 to 1.01). There was no difference in vertebral fractures between the groups (OR 0.96, 95%CI 0.83 to 1.11). In the bone mineral density meta-analysis, percentage change from baseline at the lumbar spine was higher at 1 year (MD 0.93, 95%, CI - 0.02 to 1.89) and 2 years (MD 1.63%, 95%CI 0.10 to 3.16) for vitamin K compared to controls; however, removing trials at high risk of bias tended to result in smaller differences that were not statistically significant. At 6 months, it was higher in the hip (MD 0.42%, 95%CI 0.01 to 0.83) and femur (MD 0.29%, 95%CI 0.17 to 0.42). There was no significant difference at other anatomical sites. CONCLUSIONS: For post-menopausal or osteoporotic patients, there is no evidence that vitamin K affects bone mineral density or vertebral fractures; it may reduce clinical fractures; however, the evidence is insufficient to confirm this. There are too few trials to draw conclusions for other patient groups.

Fast calculation of the infrared spectra of large biomolecules.

Vibrational spectra of proteins potentially give insight into biologically significant molecular motion and the proportions of different types of secondary structure. Vibrational spectra can be calculated either from normal modes obtained by diagonalizing the mass-weighted Hessian or from the time autocorrelation function derived from molecular dynamics trajectories. The Hessian matrix is calculated from force fields because it is not practical to calculate the Hessian from quantum mechanics for large molecules. As an alternative to molecular dynamics the spectral response can be calculated from a time autocorrelation derived from numerical solution of the harmonic equations of motion, resulting in calculations at least 4 times faster. Because the calculation also scales linearly with number of atoms, N, it is faster than normal-mode calculations that scale as N (3) for proteins with more then 4,700 atoms. Using this method it is practical to perform all-atom calculations for large biological systems, for example viral capsids, with the order of 10(5) atoms.

Efficiency of RAPD versus SSR markers for determining genetic diversity among popcorn lines.

Using only one type of marker to quantify genetic diversity generates results that have been questioned in terms of reliability, when compared to the combined use of different markers. To compare the efficiency of the use of single versus multiple markers, we quantified genetic diversity among 10 S(7) inbred popcorn lines using both RAPD and SSR markers, and we evaluated how well these two types of markers discriminated the popcorn genotypes. These popcorn genotypes: "Yellow Pearl Popcorn" (P1-1 and P1-5), "Zélia" (P1-2 and P1-4), "Curagua" (P1-3), "IAC 112" (P9-1 and P9-2), "Avati Pichinga" (P9-3 and P9-5), and "Pisankalla" (P9-4) have different soil and climate adaptations. Using RAPD marker analysis, each primer yielded bands of variable intensities that were easily detected, as well as non-specific bands, which were discarded from the analysis. The nine primers used yielded 126 bands, of which 104 were classified as polymorphic, giving an average of 11.6 polymorphisms per primer. Using SSR procedures, the number of alleles per locus ranged from two to five, giving a total of 47 alleles for the 14 SSR loci. When comparing the groups formed using SSR and RAPD markers, there were similarities in the combinations of genotypes from the same genealogy. Correlation between genetic distances obtained through RAPD and SSR markers was relatively high (0.5453), indicating that both techniques are efficient for evaluating genetic diversity in the genotypes of popcorn that we evaluated, though RAPDs yielded more polymorphisms.

Beta-lactamase-mediated beta-lactam resistance in Campylobacter species: prevalence of Cj0299 (bla OXA-61) and evidence for a novel beta-Lactamase in C. jejuni.

Fifty-two percent of 1,288 poultry isolates of campylobacters were ampicillin resistant, and resistance was more common among Campylobacter coli isolates (67.4%) than among Campylobacter jejuni isolates (47.5%). Production of beta-lactamase was typically associated with resistance to ampicillin, amoxicillin (amoxicilline), penicillin, and ticarcillin. Regardless of beta-lactamase production, all isolates were resistant to piperacillin (MICs >or= 256 microg/ml), and most were resistant to carbenicillin, cloxacillin, and cephalosporins. Of all ampicillin-resistant campylobacters tested, 91% (347/380) carried the bla(OXA-61) gene, and 77% (136/175) of those tested with nitrocefin produced a beta-lactamase, presumably OXA-61. The isoelectric point (pI) of OXA-61 was 8.7, and the molecular mass was 31.0 kDa. Insertional inactivation of bla(OXA-61) in C. jejuni NCTC 11168 and two ampicillin-resistant isolates resulted in increased susceptibility to ampicillin, co-amoxiclav (amoxicillin and clavulanic acid), penicillin, carbenicillin, oxacillin, and piperacillin, but the effects on MICs of cephalosporins and imipenem were negligible. Some C. jejuni isolates that lacked bla(OXA-61) produced a beta-lactamase, CjBla2, with a pI of 9.2 and molecular mass of 32.4 kDa. Mass spectrometry confirmed that the most prevalent beta-lactamase was the product of bla(OXA-61), but CjBla2 was not identified. OXA-61 is prevalent among Campylobacter spp. of veterinary origin and is similar to the beta-lactamase previously reported in human isolates. Production of OXA-61 was associated with resistance to penams but not cephalosporins. Co-amoxiclav remained active against all isolates tested.

Commonly used farm disinfectants can select for mutant Salmonella enterica serovar Typhimurium with decreased susceptibility to biocides and antibiotics without compromising virulence.

OBJECTIVES: To determine if one passage of Salmonella enterica serovar Typhimurium in the presence of farm disinfectants selected for mutants with decreased susceptibility to disinfectants and/or antibiotics. METHODS: Eight Salmonella Typhimurium strains including field isolates and laboratory mutants were exposed to either a tar oil phenol (PFD) disinfectant, an oxidizing compound disinfectant (OXC), an aldehyde based disinfectant (ABD) or a dairy sterilizer disinfectant (based on quaternary ammonium biocide) in agar. The susceptibility of mutants obtained after disinfectant exposure to antibiotics and disinfectants was determined as was the accumulation of norfloxacin. The proteome of SL1344 after exposure to PFD and OXC was analysed using two-dimensional liquid chromatography mass spectrometry. RESULTS: Strains with either acrB or tolC inactivated were more susceptible to most disinfectants than other strains. The majority (3/5) of mutants recovered after disinfectant exposure required statistically significantly longer exposure times to disinfectants than their parent strains to generate a 5 log kill. Small decreases in antibiotic susceptibility were observed but no mutants were multiply antibiotic-resistant (MAR). Notably exposure to ABD decreased susceptibility to ciprofloxacin in some strains. Mutants with increased disinfectant tolerance were able to survive and persist in chicks as well as in parent strains. Analysis of proteomes revealed significantly increased expression of the AcrAB-TolC efflux system after PFD exposure. CONCLUSIONS: Data presented demonstrate that efflux pumps are required for intrinsic resistance to some disinfectants and that exposure to disinfectants can induce expression of the AcrAB-TolC efflux system, but that single exposure was insufficient to select for MAR strains.

Intracardiac thrombi in pediatric patients: presentation profiles and clinical outcomes.

We document the presentation profiles, treatment strategies, and clinical outcomes in a relatively large cohort of pediatric patients with intracardiac thrombi (ICT). We performed a retrospective review of patients diagnosed with ICT by echocardiography at a tertiary pediatric hospital during a 10-year period. These patients received medical therapy or thrombectomy. We provided echocardiographic descriptions of the ICT-size, chamber location, and mobility/morphology. The outcome measures were ICT (persistence, resolution, or embolization), effectiveness of therapy, and patient morbidity and mortality. There were 40 ICT diagnosed in 31 patients (22 males and 9 females). Mean age at diagnosis was 8.8 years (range, 15 days to 18 years). Overall mortality was 12/31 patients (39%); only one death was attributed to ICT embolization. Embolic events occurred in 4/31 patients (13%). The most common initial therapies included heparin infusion (n = 15), warfarin (n = 7), and aspirin (n = 7). The ICT resolved with medical therapy alone in 19/30 patients (63%). One patient required surgical thrombectomy. The cohort was divided into group 1 (dilated cardiomyopathy), group 2 (status post Fontan operation), and group 3 (other diagnoses). In group 1 (n = 11), there were 8 deaths. Embolization occurred in 2/5 large ICT, resulting in cerebral infarction and death (n = 1) and renal infarction (n = 1). The most common ICT location was the left ventricle (n = 10). Severe ventricular systolic dysfunction was present in 10/11 patients (91%). In group 2 (n = 9), there was 1 death. Embolization occurred in 1/7 large ICT, resulting in seizures and temporary paresis. All ICT were located in the Fontan pathway. Severe ventricular systolic dysfunction was present in 2/9 patients (22%). In group 3 (n = 11), there were 3 deaths. Embolization occurred in 1/9 small ICT, resulting in coronary emboli. ICT are most commonly diagnosed in pediatric patients with dilated cardiomyopathy or patients status post Fontan operation. The majority of ICT resolve with medical therapy. Larger ICT tend to embolize more frequently, and the morbidity secondary to embolization is significant. Rarely is mortality due to ICT embolization. The prognosis is poor for patients with left ventricular ICT or ICT in the presence of ventricular systolic dysfunction.

Oral anticoagulation in a pediatric hospital: impact of a quality improvement initiative on warfarin management strategies.

BACKGROUND: There are potential risks associated with the use of warfarin in children, particularly as the dosing requirements may decrease as patients get older. CONTEXT: Our facility is a 715-bed freestanding pediatric tertiary care center with a large cardiac surgery center. A significant number of patients receive warfarin for treatment or prophylaxis of thromboembolic events while in hospital. KEY MEASURES FOR IMPROVEMENT: Initial dose of warfarin and time taken to achieve goal therapeutic international normalized ratio (INR). STRATEGIES FOR CHANGE: The intervention included: (1) revision of hospital drug formulary so that warfarin dosing was in accordance with the most recent guidelines; (2) warfarin administration restricted to one time of the day (12.00 noon); (3) target therapeutic INR level documented with each warfarin order; and (4) pharmacy computer system mandated that the pharmacist confirmed the target INR, documented the most current INR, and compared the dose with the formulary guidelines. If the warfarin dose was not in accordance with the formulary guidelines, the pharmacist contacted the physician and made dosing recommendations according to the guidelines. EFFECTS OF CHANGE: The number of patients with supratherapeutic INR values during the hospital admission was decreased by more than 50% and goal INR values were documented more frequently in the medical record. There was also an increase in subtherapeutic INR values. The intervention had no effect on the time taken to achieve the goal therapeutic INR. LESSONS LEARNED: Instituting changes in a number of aspects of anticoagulation management and incorporating an intensive educational effort across a breadth of healthcare providers can improve anticoagulation management with warfarin in challenging patient populations such as children. Similar methods could possibly improve anticoagulation with other agents such as unfractionated heparin or low molecular weight heparin.

Pulmonary venous stenosis as an associated manifestation of left-sided obstructive lesions in an infant with partial atrioventricular canal defect.

Patients with partial atrioventricular canal defect (PAVC) who present with congestive heart failure within the first year of life are usually found to have associated left-sided obstructive lesions. We present a case of a child with PAVC who subsequently developed progressive pulmonary venous stenosis as a manifestation of her disease.

Captopril-induced pulmonary infiltrates with eosinophilia in an infant with congenital heart disease.

We report a case of an infant with complex congenital heart disease who was placed on captopril for afterload reduction following cardiac surgery and subsequently developed pulmonary infiltrates with eosinophilia. The patient was readmitted with symptoms of rhinorrhea, poor feeding, and decreased activity level. She was found to have diffuse pulmonary infiltrates on chest radiograph and a marked peripheral eosinophilia without leukocytosis. After discontinuing captopril and starting systemic steroids, her symptomatology rapidly improved, and her eosinophilia and radiographic abnormalities both resolved.

Severe coronary sinus dilatation after a modification of the classic Fontan operation: successful resolution with a revision Fontan operation.

Two patients with functional single ventricle and a left superior vena cava, which drained to the coronary sinus, are presented. Each had undergone a Fontan modification that incorporated the coronary sinus into the Fontan pathway. Each developed severe right atrial and coronary sinus dilatation. Revision of a Fontan with an intraatrial lateral tunnel and an extracardiac conduit resulted in improved functional capacity of the patients.

Perioperative care of the adult with congenital heart disease in a free-standing tertiary pediatric facility.

Adult patients with congenital heart disease are presenting more frequently for cardiac surgery. Frequently, pediatric congenital heart surgeons perform these procedures at pediatric hospitals. Between July 1995 and June 2000, a retrospective review of adult patients (> or = 18 years old) who had undergone cardiothoracic operations was performed. A total of 112 operations were performed and divided into two groups--81 cardiac operations in 79 patients and 31 noncardiac operations in 23 patients. One patient had a cardiac and noncardiac operation performed. The overall early operative mortality was 6% (6/101). There were 3 late deaths. New-onset cardiac arrhythmias requiring treatment were diagnosed after 5/81 (6%) cardiac operations. Six of 79 (7%) patients were diagnosed with postoperative clinical depression. An acceptable mortality can be achieved when adult patients undergo cardiothoracic operations at a pediatric facility. New-onset arrhythmias necessitating treatment are relatively common, and postoperative clinical depression should be anticipated.

The effect of short-term prophylactic methylprednisolone on the incidence and severity of postpericardiotomy syndrome in children undergoing cardiac surgery with cardiopulmonary bypass.

OBJECTIVE: The aim of this study was to determine the effect of prophylactic immune suppression on the incidence and severity ofpostpericardiotomy syndrome (PPS) in children after cardiac surgery with cardiopulmonary bypass (CPB). BACKGROUND: Prophylactic suppression of the inflammatory response has an unknown effect on the incidence and severity of PPS in children undergoing surgery with CPB. METHODS: This randomized double-blind placebo controlled trial included two study groups. Group A received pre-CPB intravenous methylprednisolone (1 mg/kg) plus four additional intravenous doses over 24 h, and Group B received intravenous saline placebo at identical intervals. Data included patient demographics, cardiac diagnosis/operation, CPB time, incidence and severity of PPS. Noncomplicated PPS--temperature >100.5 degrees F, pericardial friction rub, patient irritability, small pericardial +/- pleural effusion. Complicated PPS--noncomplicated PPS plus hospital readmission +/- pericardiocentesis or thoracentesis. RESULTS: We randomized 266 children: 20 exclusions (6 perioperative deaths, 14 reasons unrelated to treatment) leaving Group A (n = 126) and Group B (n = 120). There were no significant group differences in gender, cardiac diagnosis or CPB time. Group mean age differed (p = 0.05) and was treated as a covariate with no substantive outcome effect. In total, 39/246 children (16%) developed PPS (noncomplicated: n = 30, complicated: n = 9). There was no inter-group difference in overall PPS incidence (p = 0.73). However, Group A had a marginally significant increase in complicated PPS (p = 0.05). CONCLUSIONS: Intravenous methylprednisolone at a standard anti-inflammatory dose administered pre-CPB and early post-CPB neither prevents nor attenuates PPS in children. Short-term pre-CPB and post-CPB methylprednisolone treatment may complicate PPS.

Improved early results with cavopulmonary connections.

BACKGROUND: We describe the recent results in a large cohort of patients with functionally single ventricle who underwent various modifications of cavopulmonary connections. METHODS: Using the database at our institution, we identified all children who underwent cavopulmonary connection operations between June 1995 and June 1997. Demographic data, surgical history, and perioperative course were reviewed. RESULTS: We performed 130 consecutive operations in 113 patients. The procedures included superior cavopulmonary connections in the form of the HemiFontan procedure in 45 instances, and bidirectional Glenn procedures in 11, and bilateral superior cavopulmonary connections in 7. The median age of these patients was 7.0 months. We completed Fontan operations using a fenestrated lateral tunnel on 47 occasions, and using an extracardiac conduit 9 times, 5 of which were fenestrated. A lateral tunnel without fenestration was constructed in one patient. The median age for these procedures was 19.5 months. In the remaining 10 instances, we revised Fontan procedures at a median age of 8 years. Diagnoses included hypoplastic left heart syndrome in 43 patients, double outlet right ventricle in 22, heterotaxy in 13, tricuspid atresia in 13, and a miscellaneous group accounting for the other 22. One death (0.7%) occurred within 30 days of surgery. Clinical seizures occurred in 7 children (5.3%), 6 had no residual neurologic deficits. Atrial pacing was needed in 14 children (10.7%) because of transient junctional rhythm, and 2 received treatment for supraventricular tachycardia. Pleural effusions were diagnosed radiographically after 31 of 130 (24%) procedures. Diuretic therapy resolved the effusion in 21 of these, with only 6 children requiring thoracostomy catheter drainage, and 4 undergoing thoracentesis alone. The median length of stay on the intensive care unit was 2 days, with a range from 1 to 30 days, and median stay in hospital was 6 days, with a range from 3 to 58 days. CONCLUSION: Mortality and perioperative morbidity after cavopulmonary connections have decreased dramatically in the current era. The long-term results of staged reconstruction for functionally single ventricle, nonetheless, await ongoing study.

Psychologic preparation to decrease anxiety associated with cardiac catheterization.

Undergoing a cardiac catheterization arouses anxiety of most patients. Coronary angiography plays an essential role in the diagnostic evaluation of the patient with suspected or known cardiac disease, and it is an important preoperative cardiac screening protocol for vascular surgery patients. Studies on psychologic preparation have concluded that preparatory techniques--specifically, sensory-perceptual informational and modeling--are beneficial in reducing patients' anxiety in various situations, including cardiac catheterization. The purpose of this study was to compare the preparatory informative (sensory and procedural data) and modeling strategies in reducing anxiety before cardiac catheterization. The research hypothesis that persons (n = 30) given a combination of sensory-perceptual informational preparation and modeling preparation would exhibit less anxiety than persons receiving one preparation alone was not supported. Although no significant difference existed between the postintervention anxiety scores for the 3 different treatment groups, a significant difference existed between the preintervention and postintervention anxiety scores overall. Therefore, this study validates the psychologic and nursing literature that states psychologic preparation is beneficial in reducing patients' anxiety before a stressful experience such as cardiac catheterization. The study findings also revealed an interesting trend for employing a modeling technique. This information contributes to nursing knowledge and may alter and make more effective the nature of standard psychologic preparation for patients undergoing any invasive procedure.

Heart/single-lung transplant for a "failed Fontan" with pulmonary A-V malformation.

Pulmonary arteriovenous malformation can occur in patients with functional single ventricle after a cavopulmonary connection. There is no effective medical treatment for this complication. Pulmonary arteriovenous malformations may regress over time after heart transplantation, but may be a source of significant perioperative morbidity. We report the case of a woman with single ventricle, ventricular dysfunction, and bilateral pulmonary arteriovenous malformations who had successful treatment of both cardiac and pulmonary failure with en bloc heart and right lung transplantation.