Guidelines for the peri-operative care of people with dementia: Guidelines from the Association of Anaesthetists.

Ageing populations have greater incidences of dementia. People with dementia present for emergency and, increasingly, elective surgery, but are poorly served by the lack of available guidance on their peri-operative management, particularly relating to pharmacological, medico-legal, environmental and attitudinal considerations. These guidelines seek to deliver such guidance, by providing information for peri-operative care providers about dementia pathophysiology, specific difficulties anaesthetising patients with dementia, medication interactions, organisational and medico-legal factors, pre-, intra- and postoperative care considerations, training, sources of further information and care quality improvement tools.

Evaluation of Metered Dose Inhaler Use Technique and Response to Educational Training.

BACKGROUND: Prescribing inhalers without imparting adequate education regarding proper technique of their usage may result in suboptimal clinical improvement and wastage of medication. Training interventions using a standard check-list may help improve faulty techniques and enhance drug efficacy. METHODS: Patients using metered dose inhaler (MDI) were included in the study. Inhaler technique was first evaluated at baseline using a standard check-list of recommended steps (National Institute of Health guidelines; see Table) and scores were given for each step correctly performed. Those who could not perform all steps correctly were given training intervention. The patients were assigned to two methods of educational intervention; one group was trained by providing written material giving step-wise instructions while the other group was given an actual physical demonstration using a placebo device. The technique was re-evaluated and scored following each educational session, and continued till the patient achieved a full score, or for a maximum of 3 sessions, whichever occurred earlier. Median score was calculated after each session and was compared between the two groups. Each patient was followed up after two months and the re-evaluated the same way. RESULTS: One hundred and seventeen subjects were enrolled in the study (59 in the written group and 57 in the practical demonstration group). At baseline, only 1 of the 117 subjects could perform all the steps of inhaler usage correctly. This patient was, therefore, not provided the inhaler technique education. The overall median (range) score of the whole group was 3 (range 1-8). This score rose to 6, 7 and 8 after each of the three subsequent educational intervention sessions. At one-month follow-up, the median score dropped to 7 and improved with a repeat educational session as previously done. A significant difference was observed in the median score improvement achieved in the practical demonstration group compared with the written instruction group (3.0 versus 2.0 respectively, p < 0.001). CONCLUSIONS: Inhalation technique of patients improves after imparting systematic educational intervention. A practical demonstration of all the steps proved more effective than simple verbal/written advice. In view of increasing errors being committed over a period of time, repeated demonstration of the proper technique using a standard check-list significantly improves the errors committed during inhaler use.

[High-flow nasal oxygen therapy and hypercapnic acute respiratory failure]. / Oxygénothérapie nasale à haut débit et insuffisance respiratoire aiguë hypercapnique.

Humidified high-flow nasal oxygen therapy (HFNO) has, in recent years, come to assume a key role in the management of hypoxemic acute respiratory failure (ARF). While non-invasive ventilation (NIV) currently represents the first-line ventilatory strategy in patients exhibiting hypercapnic ARF, the operating principles and physiological effects of HFNO could be interesting and useful in the initial management of hypercapnic ARF and/or after extubation, particularly in acute exacerbations of chronic obstructive pulmonary disease. Under these conditions, HFNO could be used either alone continuously or in combination with NIV during breaks in spontaneous breathing, depending on the severity and etiology of the underlying hypercapnic ARF.

Medical education in India: time to make some changes.

India is in need of well-trained doctors. We highlight and analyse some of the problems affecting medical education in India and their possible solutions. The medical education system can be reviewed under four heads: selection of students, medical training, evaluation, and the development and accreditation of faculty. In India, students enter medical colleges without receiving sufficient orientation about the profession. If students were given some exposure to various professions in the final years of school, it would help address this issue. Medical students are selected on the basis of pre-medical tests consisting of multiple-choice questions, the validity of which is being questioned increasingly. There is no coordination between the scheduling of lectures on various diseases and their management and the clinical exposure of the students. Active involvement in treatment is limited to the final year, called internship, which is hampered by preparation for postgraduate entrance examinations. Efforts should be made to provide hands-on experience at an earlier time in the course. A systematic and reliable programme for evaluation is a must. There is a need for a shift in the focus of evaluation, which should assess the application of knowledge rather than the ability to recall facts. The replacement of the traditional long-/short-case examinations with more valid and reliable instruments for the assessment of clinical skills should be considered. 'Vision 2015', a document developed by the Medical Council of India, contains many notable recommendations for the improvement of the current system. If these are implemented effectively, the impact of improvement in Indian medical education will be felt globally.

[Operating principles, physiological effects and practical issues of high-flow nasal oxygen therapy]. / Principes de fonctionnement, effets physiologiques et aspects pratiques de l'oxygénothérapie à haut débit.

First-line symptomatic treatment of acute respiratory failure (ARF) usually requires standard oxygen therapy, of which the limits have nonetheless led to the development of heated and humidified high-flow nasal oxygen therapy (HFNO). HFNO enables the delivery, through simple nasal cannula, of up to 100% of well-heated and humidified fraction of inspired oxygen (FiO2), at a maximum flow rate of 50 to 70 L/min of gas according to the devices chosen (specific or ventilator). The technical characteristics and operating principles of HFNO (coverage of the patient's spontaneous inspiratory flow, improved conditioning of the inspired gases, comfortable nasal cannula) yield a number of interdependent physiological effects that improve not only oxygenation conditions but also ventilatory mechanics. While it could be indicated in many clinical situations, including first-line hypoxemic ARF, the simplicity of HFNO implementation and the respiratory comfort it procures should in no way minimize the clinical monitoring of patients for whom endotracheal intubation may be required, and should not be unduly delayed.

Weight-for-Height Z-score Gain during Inpatient Treatment and Subsequent Linear Growth during Outpatient Treatment of Young Children with Severe Acute Malnutrition: A Prospective Study from Uganda.

BACKGROUND: Linear catch-up growth after treatment of severe acute malnutrition (SAM) is low, and little is known about the association between ponderal and subsequent linear growth. OBJECTIVE: The study assessed the association of weight-for-height z-score (WHZ) gain with subsequent linear growth during SAM treatment and examined its modifiers. METHODS: This was a prospective study, nested in a trial (ISRCTN16454889), among 6-59-mo-old children treated for SAM in Uganda. Weight, total length (TL), and knee-heel length (KHL) were measured at admission, weekly during inpatient therapeutic care (ITC), at discharge, and fortnightly during outpatient therapeutic care (OTC) for 8 wk. Linear regression was used to assess the association between WHZ gain during ITC and linear growth during OTC. RESULTS: Of 400 children, 327 were discharged to OTC and 290 were followed up for 8 wk. Mean WHZ gains were 0.45 in ITC and 1.24 in OTC, whereas mean height-for-age z-score (HAZ) declined by 0.41 during ITC and increased by 0.14 during OTC. WHZ gain during ITC was positively associated with HAZ, TL, and KHL gains during OTC [regression coefficients (ß) (95% CI): 0.12 (0.09, 0.15) z-score; 3.1 (2.4, 3.8) mm and 0.5 (0.1, 0.7) mm, respectively]. The regression coefficients were highest for the middle tertile of WHZ gain with respect to HAZ and TL. Admission diarrhea and low plasma citrulline reduced the association between WHZ gain during ITC and HAZ and TL gain during OTC (P < 0.001). In contrast, pneumonia (P = 0.051) and elevated plasma C-reactive protein (P < 0.001) increased the association with TL gain, but reduced the association with KHL gain (P < 0.001). CONCLUSIONS: Among children admitted with SAM, considerable WHZ gain during ITC was followed by very modest linear catch-up growth during OTC, with no indication of a WHZ gain threshold, above which linear growth was higher. To optimize linear growth in these children, early treatment of infections and conditions affecting the gut may be necessary.

Weight and mid-upper arm circumference gain velocities during treatment of young children with severe acute malnutrition, a prospective study in Uganda.

BACKGROUND: Weight gain is routinely monitored to assess hydration and growth during treatment of children with complicated severe acute malnutrition (SAM). However, changes in weight and mid-upper arm circumference (MUAC) gain velocities over time are scarcely described. We assessed weight and MUAC gain velocities in 6-59 mo-old children with complicated SAM by treatment phase and edema status. METHODS: This was a prospective study, nested in a randomized/probiotic trial ( ISRCTN16454889 ). Weight and MUAC gain velocities were assessed by treatment phase and edema at admission using linear mixed-effects models. RESULTS: Among 400 children enrolled, the median (IQR) age was 15.0 (11.2;19.2) months, 58% were males, and 65% presented with edema. During inpatient therapeutic care (ITC), children with edema vs no edema at admission had negative weight gain velocity in the stabilization phase [differences at day 3 and 4 were - 11.26 (95% CI: - 20.73; - 1.79) g/kg/d and - 13.09 (95% CI: - 23.15; - 3.02) g/kg/d, respectively]. This gradually changed into positive weight gain velocity in transition and eventually peaked at 12 g/kg/d early in the rehabilitation phase, with no difference by edema status (P > 0.9). During outpatient therapeutic care (OTC), overall, weight gain velocity showed a decreasing trend over time (from 5 to 2 g/kg/d), [difference between edema and non-edema groups at week 2 was 2.1 (95% CI: 1.0;3.2) g/kg/d]. MUAC gain velocity results mirrored those of weight gain velocity [differences were - 2.30 (95% CI: - 3.6; - 0.97) mm/week at week 1 in ITC and 0.65 (95% CI: - 0.07;1.37) mm/week at week 2 in OTC]. CONCLUSIONS: Weight and MUAC gain velocities among Ugandan children with complicated SAM showed an increasing trend during transition and early in the rehabilitation phase, and a decreasing trend thereafter, but, overall, catch-up growth was prolonged. Further research to establish specific cut-offs to assess weight and MUAC gain velocities during different periods of rehabilitation is needed.

Toxicity of geraniol solution in vitro to the poultry red mite, Dermanyssus galinae.

Geraniol is a bioactive component found in Palmarosa essential oil which has previously demonstrated good repellence to cattle ticks, mosquitoes and sand flies. The toxicity of geraniol to Dermanyssus gallinae, the most economically deleterious ectoparasite of laying hens in Europe, was studied in vitro in the laboratory. Exposure of D. gallinae to 0.5, 1 and 2% concentrations of geraniol (equating approximately to 0.02, 0.04 and 0.07 mg/cm2 geraniol, respectively) over a period of 24 hours resulted in 100% mortality of D. gallinae at all doses used.

Environmental signatures and effects of an oil and gas wastewater spill in the Williston Basin, North Dakota.

Wastewaters from oil and gas development pose largely unknown risks to environmental resources. In January 2015, 11.4ML (million liters) of wastewater (300g/L TDS) from oil production in the Williston Basin was reported to have leaked from a pipeline, spilling into Blacktail Creek, North Dakota. Geochemical and biological samples were collected in February and June 2015 to identify geochemical signatures of spilled wastewaters as well as biological responses along a 44-km river reach. February water samples had elevated chloride (1030mg/L) and bromide (7.8mg/L) downstream from the spill, compared to upstream levels (11mg/L and <0.4mg/L, respectively). Lithium (0.25mg/L), boron (1.75mg/L) and strontium (7.1mg/L) were present downstream at 5-10 times upstream concentrations. Light hydrocarbon measurements indicated a persistent thermogenic source of methane in the stream. Semi-volatile hydrocarbons indicative of oil were not detected in filtered samples but low levels, including tetramethylbenzenes and di-methylnaphthalenes, were detected in unfiltered water samples downstream from the spill. Labile sediment-bound barium and strontium concentrations (June 2015) were higher downstream from the Spill Site. Radium activities in sediment downstream from the Spill Site were up to 15 times the upstream activities and, combined with Sr isotope ratios, suggest contributions from the pipeline fluid and support the conclusion that elevated concentrations in Blacktail Creek water are from the leaking pipeline. Results from June 2015 demonstrate the persistence of wastewater effects in Blacktail Creek several months after remediation efforts started. Aquatic health effects were observed in June 2015; fish bioassays showed only 2.5% survival at 7.1km downstream from the spill compared to 89% at the upstream reference site. Additional potential biological impacts were indicated by estrogenic inhibition in downstream waters. Our findings demonstrate that environmental signatures from wastewater spills are persistent and create the potential for long-term environmental health effects.

Nude mouse model of the melanosis syndrome.

The occurrence of diffuse hyperpigmentation secondary to a xenografted human malignant melanoma was observed in nude mice. The patient from whom this cell line was established developed cutaneous hyperpigmentation after his disease became disseminated. Light and electron microscopy studies were performed on skin and organ biopsy specimens from the hyperpigmented mice. These studies indicated that this melanoma-associated melanosis was secondary to the release of pigment granules from the xenografted tumors and to the uptake of these granules by macrophages throughout the body, including those located in the dermis.

Epithelial characteristics of five subpopulations of a heterogeneous strain BALB/cfC3H mouse mammary tumor.

We have described previously the isolation and characterization of five distinct subpopulations of tumor cells from a single spontaneous strain BALB/cfC3H mouse mammary tumor (Cancer Res., 38: 3174--3181, 3758--3763, 1978). Subpopulations 68H and 4.10 are polygonal and grow in epithelioid patterns in vitro, whereas subpopulations 66, 67, and 168 are fusiform and grow in lattice or fibroblast-like patterns. Line 4.10 produces tumors with distinctly glandular architecture, whereas the other four subpopulations produce poorly differentiated tumors with mixed epithelial-sarcomatous histological patterns. All five lines were evaluated for epithelial characteristics. Dome formation, characteristic of transporting epithelial cells, could be induced by dexamethasone or dimethyl sulfoxide only in line 4.10 cells. Antibodies to cell type-specific mammary epithelial antigens reacted with each of the subpopulations. All five subpopulations had ultrastructural features of epithelial cells, including desmosomes (all five lines), junctional complexes (68H, 4.10, early-passage 66 and 67 only; poorly defined in 168), and growth in cords demonstrating polarity (68H cells). Less definitive myoepithelial characteristics were also seen in four of the lines, including an incomplete reaction for Na+-K+-ATPase (4.10 cells), hemidesmosome-like junctions (168 and early-passage 66 cells), and pinocytotic vesicles at lower than normal frequency (66, 67, and 168 cells). Thus, none of the lines were distinctly myoepithelial. We conclude that the five subpopulations are epithelial cells that express a spectrum of epithelial characteristics.

Establishment and characterization of two human pancreatic cancer cell lines tumorigenic in athymic mice.

Two human pancreatic cancer lines, RWP-1 and RWP-2, have been established from 2 patients with primary pancreatic cancer metastatic to the liver. The patients' tumors, the xenografted tumors, and tumors obtained by inoculation of nude mice with cultured RWP-1 and RWP-2 cells are all moderately-well-differentiated ductal cell adenocarcinomas. Ultrastructural analysis supports the tissue histopathology findings. Xenografts of RWP-1 tumors double every 10 days, whereas the doubling time of RWP-2 xenografts is 22 days. Both tumors contain mucin. RWP-1 and RWP-2 cells have a doubling time in culture of 45 hr and form colonies in soft agar. RWP-1 cultures appear to be morphologically heterogeneous; two distinct epithelial cell types can be identified. RWP-1 and RWP-2 have modal chromosome numbers of 64 and 62, respectively. Appreciable levels of glucose-6-phosphate dehydrogenase and lactic dehydrogenase were found in both cell lines and xenografts. RWP-1 and RWP-2 cells produce appreciable amounts of carcinoembryonic antigen, 1090 and 414 ng/10(6) cells, respectively.

"COLO 357," a human pancreatic adenosquamous carcinoma: growth in artificial capillary culture and in nude mice.

The human pancreatic cancer cell line COLO 357 has been xenografted s.c. in athymic Swiss mice. The xenografts grew well to form typical adenosquamous carcinomas. The cells were placed in a perfused artificial capillary system where they formed a solid tumor mass which survived for 7 weeks. In this system, the cells consumed glucose and released enzymes and carcinoembryonic antigen into the extracapillary space.

Stimulation of experimental endochondral ossification by low-energy pulsing electromagnetic fields.

Pulsed electromagnetic fields (PEMFs) of certain configuration have been shown to be effective clinically in promoting the healing of fracture nonunions and are believed to enhance calcification of extracellular matrix. In vitro studies have suggested that PEMFs may also have the effect of modifying the extracellular matrix by promoting the synthesis of matrix molecules. This study examines the effect of one PEMF upon the extracellular matrix and calcification of endochondral ossification in vivo. The synthesis of cartilage molecules is enhanced by PEMF, and subsequent endochondral calcification is stimulated. Histomorphometric studies indicate that the maturation of bone trabeculae is also promoted by PEMF stimulation. These results indicate that a specific PEMF can change the composition of cartilage extracellular matrix in vivo and raises the possibility that the effects on other processes of endochondral ossification (e.g., fracture healing and growth plates) may occur through a similar mechanism.

Rapid induction of anti-idiotypic responses to unmodified monoclonal antibodies from syngeneic mice following primary immunization.

A single foot-pad immunization in adjuvant of BALB/c mice with non-modified BALB/c monoclonal antibodies (HyHEL 5, 9 and 10) specific for hen egg lysozyme permitted isolation of anti-idiotypic monoclonal antibodies 10 days later. An evaluation of different screening tests revealed that antibodies were detected more easily by isotype-specific or direct binding assays than by cross-linking ELISA procedures. These results were confirmed by a direct cell-binding assay on B cells transgenic for one of the immunizing antibodies. The use of these cells also permitted an evaluation of the ability of these antibodies to inhibit antigen binding under conditions in which the target antibody, in its cell-surface configuration, is minimally modified by potential artifacts induced by purification or fixation to a solid support. This study demonstrates that anti-idiotypic responses to anti-protein antibodies may be rapidly generated in syngeneic animals.

Increased CD4+ expression and decreased IL-10 in the anterior chamber in idiopathic uveitis.

PURPOSE: To compare cell types and cytokines in aqueous humor from patients with uveitis either occurring in association with a systemic disease or apparently isolated and not associated with a systemic disease. METHODS: Cells were collected by centrifugation of fresh aqueous humor from uveitis and controls, and immunofluorescence techniques were performed with markers for T cells, B cells, and monocytes. Cytokines were measured in the aqueous supernatants, and serum samples were assayed for soluble interleukin-2 receptors. RESULTS: When aqueous samples from idiopathic uveitis were compared with those from uveitis associated with a systemic disease, there were increases in CD3+, CD4+ (p = 0.001), and activated CD4+ T cells (p = 0.02) and a decrease in B cells (p = 0.0013). This was not reflected in the peripheral blood where there were no differences in the cell types or in soluble interleukin-2 receptor levels. No cells were obtainable from control aqueous. Interleukins-10 and -12, interferon-gamma, and transforming growth factor-beta2 were detected in aqueous supernatants. Interleukin-10 was reduced (p = 0.024) in uveitis in comparison with controls. CONCLUSIONS: The results suggest a selective recruitment of CD4+ T cells within aqueous humor but only in idiopathic uveitis. In both disease groups there was a decrease in the immunoregulatory cytokine interleukin-10, which might enable an immune response to occur in an otherwise highly immunosuppressive microenvironment. Increases in activated CD4+ T cells combined with depressed interleukin-10 levels could partially explain why, for example, in acute anterior uveitis, the inflammatory disease is often more severe.

Soft tissue considerations in partial foot amputations.

Success is possible with partial foot amputations even in the diabetic patient population. Many diabetics who in the past would have undergone a major lower extremity amputation now have successful reconstruction of their complex foot wounds. Even though this article presents the levels of amputation and methods of closure for soft tissue defects in a sequential manner, in many instances, different levels and methods are used for different aspects of the same foot defect (i.e., a TMA may require a fillet of toe, STSG, and TAL for successful closure). Familiarity with the principles advocated in this article and the importance of each member of the multispecialty team involved help to ensure that good outcomes in the immediate postoperative period and in the long-term recovery period are achieved.

Mark-recapture models with parameters constant in time.

The Jolly-Seber method, which allows for both death and immigration, is easy to apply but often requires a larger number of parameters to be estimated tha would otherwise be necessary. If (i) survival rate, phi, or (ii) probability of capture, p, or (iii) both phi and p can be assumed constant over the experimental period, models with a reduced number of parameters are desirable. In the present paper, maximum likelihood (ML) solutions for these three situations are derived from the general ML equations of Jolly [1979, in Sampling Biological Populations, R. M. Cormack, G. P. Patil and D. S. Robson (eds), 277-282]. A test is proposed for heterogeneity arising from a breakdown of assumptions in the general Jolly-Seber model. Tests for constancy of phi and p are provided. An example is given, in which these models are fitted to data from a local butterfly population.

Ultrastructure of fallopian tube carcinoma.

Fallopian tube carcinoma is one of the rarest of primary gynecologic malignancies. Normal tubal epithelium is composed of secretory, ciliated, and intercalary cells. To determine the cellular composition and ultrastructural details of this rare neoplasm, a moderately well-differentiated tubal carcinoma was studied with the electron microscope. A prominent feature was the formation of numerous ultramicro alveolar spaces lined by cell surface microvilli. The nuclei of the neoplastic cells demonstrated a variety of fine structural abnormalities. Based on cell size and shape criteria, a possible dual tumor cell population was suggested. However, no cilia were seen in any of the tumor cells and almost all were devoid of secretory granules. These latter observations suggest that this tumor was primarily a proliferation of intercalary cells.