Variations in assessment and certification in postgraduate anaesthesia training: a European survey.

BACKGROUND: Postgraduate specialty training has traditionally been based on a time- and rotation-based model, but competency-based models are emerging. Because anaesthesia training evolves differently across Europe, variations in assessment and certification processes are expected, but the extent of similarities and differences is unknown. The aim of this study was to compare anaesthesia training programmes in Europe, focusing on assessment and certification processes. METHODS: We performed an online survey among national representatives of the Union of European Medical Specialists/European Board of Anaesthesiology. RESULTS: All 36 countries participated. Duration of training had a median of 5 yr (range 2.75-7). Mean number of different assessment tools was 7.45 (range 4-13), with more tools being used in competency-based programmes [mean 9.1 (sd 2.97) vs 7.0 (sd 1.97); P=0.03]. Most countries had a nationally uniform certification process. Based on a qualitative analysis of the survey findings, a categorization of countries emerged, reflecting the approach to assessment and certification. We observed two main streams of countries with an underlying knowledge or procedural focus within a time- and rotation-based apprenticeship model. These main streams are evolving, to different extents, towards a third orientation, competency-based training. CONCLUSIONS: Assessment and certification processes in European anaesthesia training are diverse. In many countries, a time-based apprenticeship model is evolving towards a competency-based certification process. This diversity precludes comparison of competence of graduating anaesthetists across Europe.

Concentrations of calcium and 25-hydroxycholecalciferol (vitamin D3) in plasma of wild kakapo (Strigops habroptilus) living on two islands in New Zealand.

AIMS This preliminary study had the objectives of describing the concentrations of ionised calcium and 25-hydroxycholecalciferol (25(OH)D3) in the blood of wild kakapo (Strigops habroptilus) living on two islands in New Zealand, and to determine the effects of supplementary feeding on these blood parameters. METHODS Blood samples were obtained from 33 kakapo living on two offshore islands during routine health checks in 2015. Birds on Hauturu were sampled in May (n=5) and birds on Whenua Hou were sampled in July (n=15) and November (n=26). Of the birds sampled on Whenua Hou in November, 15 received supplementary food prior to sampling. Samples were analysed for pH, and concentrations of ionised calcium, total calcium, phosphorous, total protein, albumin, globulin, uric acid and 25(OH)D3. RESULTS Concentrations of ionised calcium did not differ between unsupplemented birds on the two islands, nor between supplemented (median 1.17 (95% CI=1.12-1.20) mmol/L) and unsupplemented (median 1.09 (95% CI=1.08-1.14) mmol/L) birds sampled in November on Whenua Hou (p>0.05), and were comparable with published normal ranges for other psittacines. Concentrations of 25(OH)D3 did not differ between unsupplemented birds on the two islands (p>0.05), but were higher in supplemented (median 8.00 (95% CI=4.76-8.45) nmol/L) than unsupplemented (median 0.00 (95% CI=-0.16-0.48) nmol/L) birds on Whenua Hou (p<0.001). All values were much lower than published ranges for healthy psittacines. There was no difference between male and female birds on Whenua Hou for any parameter measured (p>0.05). CONCLUSIONS AND CLINICAL RELEVANCE The calcium status of the kakapo in this study was comparable to other wild psittacines, however concentrations of 25(OH)D3 were much lower. The concentrations of 25(OH)D3 may be within the normal range for the species, however further data are required to confirm this. The significant increase in concentrations of 25(OH)D3 in supplementary fed birds suggests that this food was providing more of the nutrient than the wild diet at that time of year, although the effects of this are unknown. Further investigation is required into the calcium and vitamin D3 status of kakapo, across a wider range of locations, seasons and ages. This would help define normal ranges for these parameters, allow interpretation in clinically abnormal individuals, and guide the refinement of supplementary foods. This information would, therefore, assist the future conservation management of this critically endangered species.

Climate conditions associated with the occurrence of antimicrobial and macrocyclic lactone residues in bulk tank milk / Condições climáticas associadas à ocorrência de resíduos de antimicrobianos e lactonas macrocíclicas em amostras de leite de tanque

The present study aimed to identify the climate condition parameters that are associated with the occurrence of antimicrobial and macrocyclic lactone residues in bulk tank milk using a multivariate principal components analysis (PCA). A total of 132 raw milk samples were collected at dairy farms in Minas Gerais State in Brazil and analyzed for 35 analytes, comprising macrocyclic lactones and antibacterials, using liquid chromatography coupled with mass spectrometry in tandem mode spectrometry. Of the 132 samples, 34 (25.76%) bulk tank milk samples were positive for at least one analyte. PCA showed that antimicrobial residues in bulk tank milk occurred less frequently on days with a higher average temperature, maximum temperature and temperature-humidity index. In contrast, relative humidity was inversely associated with antimicrobial residues in raw milk. The PCA showed that daily milk production was also related to macrocyclic lactone residues, while rainfall showed an inverse association. Thus, some climate conditions, such as average temperature, maximum temperature and temperature-humidity index, can predict the moments with lower risk of occurrence of antimicrobial residues in bulk tank milk, in contrast to relative humidity. Furthermore, the risk of macrocyclic lactone residues in bulk tank milk was higher in months with less rainfall.(AU)

O presente trabalho objetivou identificar fatores climáticos associados à ocorrência de resíduos de antimicrobianos e lactonas macrocíclicas em amostras de leite de tanque por análise multivariada de componentes principais (ACP). Para o presente trabalho, 132 amostras de leite cru foram coletadas em fazendas leiteiras localizadas no estado de Minas Gerais (Brasil) e analisadas por cromatografia líquida de alta eficiência e espectrometria de massas in tandem para detecção de 35 analitos, incluindo antimicrobianos e lactonas macrocíclicas. Das 132 amostras de leite analisadas, detectou-se pelo menos um analito em 34 (25,76%) amostras. A ACP demonstrou que a presença de resíduos de antimicrobianos no leite de tanque ocorreu menos frequentemente nos dias com maior temperatura média, temperatura máxima e índice de temperatura e umidade. Por outro lado, a umidade relativa foi inversamente associada à presença de resíduos antimicrobianos no leite. A ACP demonstrou associação entre a presença de resíduos de lactonas macrocíclicas no leite e a produção diária de leite, e a presença de resíduos de lactonas macrocíclicas ocorreu menos frequentemente nos meses com maiores índices pluviométricos. Dessa forma, conclui-se que alguns índices climáticos, como temperatura média, temperatura máxima e índice de temperatura e umidade, podem predizer períodos com maior risco de ocorrência de resíduos de antimicrobianos, em contraste com a umidade relativa. Além disso, o risco de resíduos de lactonas macrocíclicas no leite de tanque foi maior nos meses com menores índices pluviométricos.(AU)

Climate conditions associated with the occurrence of pyrethroid residues in bulk milk tank / Condições climáticas associadas à ocorrência de resíduos de piretroides em amostras de leite de tanque

The present study attempted to identify climate conditions that are associated with the occurrence of pyrethroid residues using a multivariate principal component analysis (PCA). A total of 132 raw milk samples were collected from dairy farms in Minas Gerais State - Brazil and analyzed for seven analytes using gas chromatography with electron capture detection. Of the 132 milk samples, pyrethroid residues were identified in 14 (10.6%) milk samples, of which 12 (9.1%) and two (1.5%) milk samples had the identification of cypermethrin and deltamethrin, respectively. From those samples, nine (6.8%) milk samples were regarded as non-compliant for cypermethrin with this analyte concentration above the maximum residue limits set by Brazilian legislation. A PCA assessing pyrethroid residues in bulk tank milk demonstrated that the average temperature and the Temperature-Humidity Index were associated with pyrethroids residues in bulk milk tank, although the relative humidity was inversely correlated. Thus, the data analysis indicated that the pyrethrid residues associated with some climate conditions can predict the moments with higher risk of occurrence of pyrethroid residues in bulk tank milk.(AU)

O presente trabalho objetivou identificar fatores climáticos associados à ocorrência de resíduos de piretroides em amostras de leite de tanque por análise multivariada de componentes principais (ACP). Para o presente trabalho, 132 amostras de leite cru foram coletadas em fazendas leiteiras localizadas no estado de Minas Gerais (Brasil) e analisadas por sete analitos por cromatografia gasosa com detector por captura de eletróns para detecção de resíduos de piretroides. Das 132 amostras de leite analisadas, a presença de resíduos de piretroides foi detectada em 14 amostras (10,6%), e em 12 (9,1%) e duas (1,5%) foram detectados cipermetrina e deltametrina, respectivamente. Destas amostras, em nove (6,8%) a concentração de cipermetrina encontrada foi maior que a permitida pela legislação brasileira. A ACP demonstrou que a presença de resíduos de piretroides no leite de tanque ocorreu menos frequentemente nos dias com maior umidade relativa, embora a presença desses resíduos estivesse associada a maior temperatura média e a maior índice de temperatura e umidade. Dessa forma, conclui-se que alguns índices climáticos podem predizer períodos com maior risco de ocorrência de resíduos de piretroides no leite de tanque.(AU)

Dermatomycosis caused by Paranannizziopsis australasiensis in five tuatara (Sphenodon punctatus) and a coastal bearded dragon (Pogona barbata) in a zoological collection in New Zealand.

CASE HISTORY: Health monitoring of tuatara (Sphenodon punctatus) at Auckland Zoo between 2001 and 2009 showed that 58/93 tuatara had been affected by dermatitis of unknown origin. From 2011 onwards, cases of suspected fungal dermatitis underwent extensive diagnostic investigations. CLINCAL FINDINGS: Six cases of dermatomycosis were attributed to Paranannizziopsis australasiensis, five in tuatara and one in a coastal bearded dragon (Pogona barbata). Cases presented typically as raised, yellow to brown encrustations on the skin. Severe cases progressed to necrotising ulcerative dermatitis, and in the bearded dragon to fatal systemic mycosis. Following topical and systemic treatments, lesions resolved in all five tuatara. LABORATORY FINDINGS: Histopathological examination of skin biopsy samples revealed dermatitis with intralesional septate branching hyphae. Fungal culture yielded isolates morphologically resembling Chrysosporium species, and isolates were submitted for molecular confirmation and sequencing of DNA. DIAGNOSIS: All six cases were confirmed as dermatitis due to infection with P. australasiensis, on the basis of fungal culture and DNA sequencing of isolates. CLINICAL RELEVANCE: These are the first reported cases of dermatomycosis associated with P. australasiensis infection in tuatara, and the first cases in which systemic therapeutic agents have been used in the treatment of such disease. Tuatara at the Auckland Zoo are now routinely examined every 3 months and tissue samples from any lesions sent for histopathology and fungal culture. Further work to elucidate the epidemiology and significance of P. australasiensis infections in reptiles in New Zealand is important for both welfare and conservation purposes.

Cosinor modelling of seasonal variation in 25-hydroxyvitamin D concentrations in cardiovascular patients in Norway.

BACKGROUND/OBJECTIVES: Seasonal variation may reduce the validity of 25-hydroxyvitamin D (25OHD) as a biomarker of vitamin D status. Here we aimed to identify potential determinants of seasonal variation in 25OHD concentrations and to evaluate cosinor modelling as a method to adjust single 25OHD measurements for seasonal variation. SUBJECTS/METHODS: In Caucasian cardiovascular patients (1999-2004), we measured 25OHD by liquid chromatography tandem mass spectrometry in 4116 baseline and 528 follow-up samples. To baseline values, we fitted a cosinor model for monthly concentrations of 25OHD. Using the model, we estimated each patient's adjusted annual 25OHD value. Further, we studied how covariates affected the annual mean 25OHD concentration and seasonal variation of the study cohort. To evaluate the model, we predicted follow-up measurements with and without covariates and compared accuracy with carrying forward baseline values and linear regression adjusting for season, common approaches in research and clinical practice, respectively. RESULTS: The annual mean (59.6 nmol/l) was associated with participants' age, gender, smoking status, body mass, physical activity level, diabetes diagnosis, vitamin D supplement use and study site (adjusted models, P<0.05). Seasonal 25OHD variation was 15.8 nmol/l, and older age (>62 years) was associated with less variation (adjusted model, P=0.025). Prediction of follow-up measurements was more accurate with the cosinor model compared with the other approaches (P<0.05). Adding covariates to cosinor models did not improve prediction (P>0.05). CONCLUSIONS: We find cosinor models suitable and flexible for analysing and adjusting for seasonal variation in 25OHD concentrations, which is influenced by age.

Ovariectomy as treatment for ovarian bacterial granulomas in a Duvaucel's gecko (Hoplodactylus duvaucelii).

CASE HISTORY: An adult female Duvaucel's gecko (Hoplodactylus duvaucelii) from a threatened species breeding programme presented due to a prolonged gestation period and distended abdomen. CLINICAL AND PATHOLOGICAL FINDINGS: The gecko was in lean body condition with an irregularly shaped, firm mass in the coelomic cavity. Radiographically there was a diffuse radio-opacity within the coelomic cavity with cranial displacement of the right lung field. Ultrasonography revealed a round homogenous abdominal mass of medium echogenicity with an echogenic capsule. Haematology showed a leucocytosis with a moderate left shift in heterophils and toxic changes. Bilateral ovariectomy was performed to remove two ovarian granulomas and Salmonella enterica subspecies houtenae (IV) was cultured from the ovarian tissue. The gecko recovered well from the surgery, regained weight and remained in good health 3 years following the surgery. DIAGNOSIS: Pre-ovulatory stasis and ovarian granulomas associated with infection with Salmonella enterica subsp. houtenae. CLINICAL RELEVANCE: The surgery described in this case resulted in recovery of the gecko, which despite its loss of reproductive capability is of value as an education animal. This is the first report of pre-ovulatory stasis and ovarian granulomas associated with infection with Salmonella enterica in a Duvaucel's gecko and is also the first reported case of pre-ovulatory stasis in a viviparous lizard species. The case adds to knowledge regarding potential reproductive pathology in lizards, which is particularly important information for managers of captive lizard breeding programmes.

Exudative cloacitis in the kakapo (Strigops habroptilus) potentially linked to Escherichia coli infection.

AIM: To investigate the initiating causes of cloacitis (inflammation of the cloaca) in kakapo (Strigops habroptilus). METHODS: Metagenomics using unbiased RNA or DNA sequencing was applied to faecal material from an 11-year-old female kakapo with exudative cloacitis, and a pool of eight birds (male and female aged 1-20 years) with no current signs or history of the disease. Faecal material from the diseased bird was collected pre- and post-treatment. For RNA sequencing, extracted RNA/DNA was subject to DNase, and the remaining RNA reverse transcribed to cDNA and subject to multiple displacement amplification prior to sequencing. RESULTS: No significant alignment to any known avian virus sequence was obtained from any faecal samples. However significant BLAST alignments to five bacteriophages known to infect enterobacteria were obtained. Strong evidence was obtained for the presence of the bacteriophage Escherichia phage TL-2011b, a bacteriophage known to occur in Escherichia coli causing outbreaks of foodborne disease in humans, in the sample from the diseased bird, but not the non-diseased pool. Differences in E. coli community structure between the diseased bird and the non-diseased pool were also apparent. CONCLUSIONS: Escherichia coli infection of human origin is suggested as a possible cause of exudative cloacitis, although confirmatory work is required to test this hypothesis.

Investigation of mortalities associated with Salmonella spp. infection in wildlife on Tiritiri Matangi Island in the Hauraki Gulf of New Zealand.

CASE HISTORY: Salmonellosis was suspected as the cause of death in eight wild animals on Tiritiri Matangi Island, in the Hauraki Gulf of New Zealand, between November and September 2011, including three hihi (Notiomystis cincta), a tuatara (Sphenodon punctatus), a masked lapwing (Vanellus miles novaehollandiae), and a saddleback (Philesturnus carunculatus). An outbreak investigation to identify the source and distribution of infection was undertaken over the summer of 2011-2012. CLINICAL AND LABORATORY FINDINGS: Surveillance of five species of forest bird (n=165) in December 2011 returned a single positive result for Salmonella spp. Environmental sampling of 35 key water sources and hihi supplementary feeding stations conducted in December 2011 and March 2012 returned isolates of S. enterica subspecies houtenae and S. enterica serovar Saintpaul from a stream, a dam and a supplementary feeding station. The same serotypes were identified in tissue samples collected from post mortem specimens of the affected birds, and their similarity was confirmed by pulsed-field gel electrophoresis. DIAGNOSIS: Mortality in wildlife associated with infection with S. enterica subspecies houtenae and S. enterica serovar Saintpaul. CLINICAL RELEVANCE: This is the first detection of these Salmonella spp. from wild birds in New Zealand. Our study highlights how active surveillance in response to observed disease emergence (here mortalities) can provide important insight for risk assessment and management within populations of endangered species and inform risk assessment in translocation planning.

Detection and confirmation of milk adulteration with cheese whey using proteomic-like sample preparation and liquid chromatography-electrospray-tandem mass spectrometry analysis.

Caseinomacropeptide (CMP) is a peptide released by chymosin in cheese production, remaining in whey. Thus, CMP can be used as a biomarker to fluid milk adulteration through whey addition. Commonly, CMP is analyzed by reversed phase (RP-HPLC) or size-exclusion chromatography (SEC). However, some psychrotropic microorganisms - specially Pseudomonas fluorescens - when present in storaged milk, can produce, by enzymatic pathway, a CMP-like peptide generally called pseudo-CMP. These two peptides differ from each other only by one amino acid. RP-HPLC and SEC methods are unable to distinguish these two peptides, which demand development of a confirmatory method with high selectivity. Considering the several degrees of glycosilation and phosphorylation sites in CMP, allied with possible genetic variation (CMP A and CMP B), analytical methods able to differentiate these peptides are extremely complex. In the present work, we developed a proteomic-like technique for separation and characterization of these peptides, using liquid chromatography coupled to mass spectrometry with electrospray ionization able to differentiate and subsequently quantify CMP and pseudo-CMP in milk samples in order to identify adulteration or contamination of these products. The method shows satisfactory precision (<11%) with a detection limit of 1.0 µg mL(-1) and quantification limit of 5.0 µg mL(-1). Specificity, matrix effects and applicability to real samples analysis were also performed and discussed.

Delay to carotid endarterectomy in patients with symptomatic carotid artery stenosis.

OBJECTIVE: In patients with recently symptomatic carotid artery stenosis, guidelines recommend carotid revascularization within 2 weeks of the index event. The "index event" may be defined as either the first or the most recent event. The delay between the index event and carotid endarterectomy (CEA) over a period of 6 years in a single centre was evaluated and the effect of defining the index event as either the first or the most recent event was assessed. DESIGN: Observational study. METHODS: 555 consecutive patients with symptomatic carotid stenosis ≥ 50% treated with CEA between 2007 and 2012 were assessed. In 2010, changes to the in-hospital process of care to reduce delays in referral and CEA were introduced. These changes included, for example, improving access to physicians, imaging, and operating rooms. The delay from symptoms to surgery was expressed in days. RESULTS: The median time between the first event and surgery was reduced from 53 days (interquartile range [IQR] 30-78) in 2007 to 21 days (IQR 12-45) in 2012, and between the most recent event and CEA from 45 days (IQR 28-67) to 17 days (IQR 9-28). Patients referred directly by their general practitioner more often underwent CEA within 2 weeks than patients referred by specialists from other hospitals. Compared to patients with transient ischaemic attack or ocular symptoms, patients with ischaemic stroke more often underwent CEA within 2 weeks. CONCLUSIONS: A small change in the process of care significantly reduced the delay from the index event to CEA, but in 2012 it still exceeded 14 days in the majority of patients. The definition of the "index event" has a large impact on the total duration of delay, and should therefore be uniform across studies.

A systematic review of the effect of thermal processing on the allergenicity of tree nuts.

BACKGROUND: Allergenicity of foods can be influenced by processing. Tree nuts are an important source of nutrition and increasingly consumed; however, processing methods are quite variable and data are currently lacking on the effects of processing on allergenicity. OBJECTIVE: To perform a systematic literature review on the effects of food processing on the allergenicity of tree nuts. METHODS: A systematic literature search of PubMed and Embase databases was performed, with screening of references, related articles and citations. Studies were included if they assessed the allergenicity or immunogenicity of processed nuts. RESULTS: The search resulted in 32 articles suitable for analysis. Clinical studies indicate that roasting reduces the allergenicity of hazelnut in individuals with a birch pollen allergy and reactivity to raw hazelnut. Thermal processing may reduce the allergenicity of the PR-10 protein in hazelnut and almond in vitro. The majority of the in vitro studies investigating the allergenicity of nonspecific lipid transfer proteins (nsLTPs) and seed storage proteins in hazelnut, almond, cashew nut, Brazil nut, walnut, pecan nut and pistachio nut show heat stability towards different thermal processing methods. CONCLUSION: Thermal processing may reduce allergenicity of PR-10 proteins in hazelnut and almond, in contrast to nsLTPs and seed storage proteins. This has important implications for source materials used for IgE testing and food challenges and diet advice.

[Off-label prescriptions in acute psychiatry: a practice-based evaluation]. / Off-labelmedicatie in de crisisdienst: een praktijkevaluatie.

BACKGROUND: In acute psychiatry the prescribed medication is frequently off-label. AIM: To investigate the indications for off-label prescriptions described in the literature and to evaluate the use of off-label medication in the emergency service of Altrecht, Utrecht, The Netherlands. METHOD: We performed a systematic search of the PubMed database and we evaluated all the records of patients examined by the emergency service during two assessment periods (April 2009 and November 2010). RESULTS: The literature makes no mention of the prescribing of off-label medication in acute psychiatry. In general psychiatry, however, off-label medication is reported mainly for atypical antipsychotics. In the emergency service 41% of the medication prescribed during first contacts with patients was off-label. These prescriptions were most often for antipsychotics (54%) and benzodiazepines (38%) . The most important indications were aggression, agitation and sleep problems. If the term ‘off-label’ is interpreted in a broader sense with respect to antipsychotics for psychosis and hypomania, then 33% of the prescriptions appeared to be off-label. If benzodiazepines prescribed for aggression/agitation were not taken into account, then the proportion of off-label prescriptions decreased to 21%. CONCLUSION: We consider it advisable that the reason for prescribing off-label medication should be clearly documented. New medical guidelines could help by summarising current views on the use of off-label medication.

ß-lactam antibiotics residues analysis in bovine milk by LC-ESI-MS/MS: a simple and fast liquid-liquid extraction method.

This study presents the development and validation of a simple method for the detection and quantification of six ß-lactam antibiotics residues (ceftiofur, penicillin G, penicillin V, oxacillin, cloxacillin and dicloxacillin) in bovine milk using a fast liquid-liquid extraction (LLE) for sample preparation, followed by liquid chromatography-electrospray-tandem mass spectrometry (LC-MS/MS). LLE consisted of the addition of acetonitrile to the sample, followed by addition of sodium chloride, centrifugation and direct injection of an aliquot into the LC-MS/MS system. Separation was performed in a C(18) column, using acetonitrile and water, both with 0.1% of formic acid, as mobile phase. Method validation was performed according to the criteria of Commission Decision 2002/657/EC. Limits of detection ranged from 0.4 (penicillin G and penicillin V) to 10.0 ng ml(-1) (ceftiofur), and linearity was achieved. The decision limit (CCα), detection capability (CCß), accuracy, inter- and intra-day repeatability of the method are reported.

High-throughput multiclass screening method for antibiotic residue analysis in meat using liquid chromatography-tandem mass spectrometry: a novel minimum sample preparation procedure.

A multiresidue and multiclass method based on liquid chromatography-tandem mass spectrometry for the determination of antibacterials was developed and validated for screening purposes. This method can be applied to commonly used drugs in veterinary medicine such as tetracyclines, quinolones and sulfonamides. Sample preparation consists in cell disruption with sand (previously purified and washed with EDTA 100 mM) followed by protein precipitation with acidified acetonitrile. Validation was conducted in accordance to European Union requirements (2002/657/EC) for qualitative methods covering detection capability (CCß), selectivity, specificity and stability. The method enabled the detection of 21 different drugs and had a false-compliant rate of <5% (ß error) at between 25% and 50% of the maximum residue levels established by legal authorities. The methodology was successfully applied to incurred poultry samples.

Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study.

OBJECTIVE: To evaluate the effect of implementation of the WHO's Surgical Safety Checklist on mortality and to determine to what extent the potential effect was related to checklist compliance. BACKGROUND: Marked reductions in postoperative complications after implementation of a surgical checklist have been reported. As compliance to the checklists was reported to be incomplete, it remains unclear whether the benefits obtained were through actual completion of a checklist or from an increase in overall awareness of patient safety issues. METHODS: This retrospective cohort study included 25,513 adult patients undergoing non-day case surgery in a tertiary university hospital. Hospital administrative data and electronic patient records were used to obtain data. In-hospital mortality within 30 days after surgery was the main outcome and effect estimates were adjusted for patient characteristics, surgical specialty and comorbidity. RESULTS: After checklist implementation, crude mortality decreased from 3.13% to 2.85% (P = 0.19). After adjustment for baseline differences, mortality was significantly decreased after checklist implementation (odds ratio [OR] 0.85; 95% CI, 0.73-0.98). This effect was strongly related to checklist compliance: the OR for the association between full checklist completion and outcome was 0.44 (95% CI, 0.28-0.70), compared to 1.09 (95% CI, 0.78-1.52) and 1.16 (95% CI, 0.86-1.56) for partial or noncompliance, respectively. CONCLUSIONS: Implementation of the WHO Surgical Checklist reduced in-hospital 30-day mortality. Although the impact on outcome was smaller than previously reported, the effect depended crucially upon checklist compliance.

Development of a statewide collaborative to decrease NICU central line-associated bloodstream infections.

OBJECTIVE: To characterize hospital-acquired bloodstream infection rates among New York State's 19 regional referral NICUs (at regional perinatal centers; RPCs) and develop strategies to promote best practices to reduce central line-associated bloodstream infections (CLABSIs). STUDY DESIGN: During 2006 and 2007, RPC NICUs reported bloodstream infections, patient-days and central line-days to the Department of Health, and shared their results. Aiming to improve, participants created a central line-care bundle based on visiting a potentially best performing NICU and reviewing the literature. RESULT: All 19 RPCs participated in this quality initiative, contributing 218,096 patient-days and 56,911 central line-days of observation. Individual RPC nosocomial sepsis infection (NI) rates ranged from 1.0 to 5.8 NIs per 1000 patient-days (2006), and CLABSI rates ranged from 2.6 to 15.1 CLABSIs per 1000 central line-days (2007). A six-fold rate variation among RPC NICUs was observed. Participants unanimously approved a level-1 evidence-based central line-care bundle. CONCLUSION: Individual RPC rates and consequent morbidity and resource use attributable to these infections were substantial and varied greatly. No center was without infections. It is hoped that the cooperation and accountability exhibited by the RPCs will result in a major network for characterizing performance and improving outcomes.

Molecular characterization of Babesia kiwiensis from the brown kiwi (Apteryx mantelli).

To further investigate the recently described avian piroplasm, Babesia kiwiensis, blood samples were collected from 13 wild-caught and 8 zoo-captive brown kiwi (Apteryx mantelli) and screened for the presence of piroplasm DNA using a nested-polymerase chain reaction (PCR) targeting the 18S rRNA gene of most members of Piroplasmida. All captive birds gave a negative PCR result, while 12 wild-caught birds were PCR positive. The nearly full-length 18S rRNA gene for B. kiwiensis was sequenced. Upon phylogenetic analysis, it was found to belong to the babesid group of piroplasms and was ancestral, yet genetically similar, to the Babesia canis-related species. An insight into the current taxonomy of the avian piroplasms is also given. An Ixodes anatis tick collected from 1 of the North Island brown kiwi was also screened using PCR and was found to be positive for B. kiwiensis DNA.

Hypotension in anaesthetized patients during aneurysm clipping: not as bad as expected?

BACKGROUND: Patients with aneurysmal subarachnoid haemorrhage (SAH) often have disturbed autoregulation of cerebral blood flow. A reduction in systemic blood pressure during surgery may therefore lead to delayed cerebral ischaemia (DCI). To assess the incidence and severity of intra-operative hypotension, we performed a retrospective cohort study in 164 patients with recent SAH and surgical clipping of the aneurysm. METHODS: Intra-operative hypotension was defined in three levels of severity, as a decrease in mean arterial pressure (DeltaMAP) of more than 30%, 40% or 50% compared with the pre-operative pressure. For each patient the total amount of time with intra-operative hypotension was retrieved. Logistic regression analysis was performed to study the relation between intra-operative hypotension and the occurrence of DCI and poor outcome. RESULTS: A period with DeltaMAP>30% occurred in 128 patients (78%) with a median duration of this period of 105 min (25-75 per thousand 50-171 min). DeltaMAP>40% occurred in 88 patients (54%) and DeltaMAP>50% occurred in 22 patients (13%). In univariate analysis, DeltaMAP>50% was associated with poor outcome. After adjusting for age and World Federation of Neurological Surgeons grade, the association with poor outcome was no longer statistically significant [odds ratio (OR) 1.018; 95% CI 0.996-1.041]. CONCLUSION: Hypotension during surgical clipping of intracranial aneurysms occurred frequently. In our study population of patients mostly in good clinical condition, hypotension was not confirmed as an independent risk factor for DCI or poor outcome. Anaesthesia may have had a cerebral protective effect.

Tumor necrosis factor-alpha induces changes in mitochondrial cellular distribution in motor neurons.

Motor neuron (MN) mitochondrial abnormalities and elevation in spinal fluid levels of the inflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) have been implicated in the pathogenesis of amyotrophic lateral sclerosis (ALS). The mechanism of neuron death in ALS remains unclear, along with the contributions of mitochondrial dysfunction and inflammation in the process. Cell cultures enriched for MN derived from embryonic rat spinal cords were established and directly exposed in vitro to recombinant TNF-alpha for varying lengths of time. Although cytokine exposure for up to 4 days failed to induce MN death, mitochondrial changes were observed shortly after initiating treatment. Our results demonstrate that TNF-alpha induced mitochondrial redistribution toward the soma in MN. We postulate that inflammation may precede, and in fact cause, the mitochondrial changes observed in ALS tissue.