Anaemia in elective orthopaedic surgery - Royal Adelaide Hospital, Australia.

BACKGROUND: An anaemia clinic was established to improve the preoperative management of elective orthopaedic patients scheduled for arthroplasty. This paper is a report on the first 100 patients assessed. AIM: To assess the incidence and causes of anaemia in patients on a waiting list for elective arthroplasty in a public hospital and to assess the impact of anaemia detection in this patient population. METHODS: Patients attending an Anaemia Clinic for elective orthopaedic surgical patients, during March 2010 to June 2013 were studied. Outcome measures included change in haemoglobin preoperative results and perioperative transfusion rates by preoperative haemoglobin. RESULTS: Seventeen per cent of patients scheduled for elective surgery were found to be anaemic. Of the 100 patients who attended, approximately half were found to be iron deficient and the remainder had anaemia of chronic disease. Serum ferritin <30 µg/L alone did not identify iron deficiency in 80% of patients with iron deficiency. Patients with iron deficient anaemia were able to be treated, in all cases, to achieve a significant increase in preoperative haemoglobin. The general unavailability of erythropoietin limited effective intervention for the non-iron-deficient anaemic patients. Seven patients had their surgery cancelled because of the screening programme. CONCLUSIONS: Half of the anaemic patients in a joint replacement screening clinic were iron deficient, and treatment was effective in improving the pre-operative haemoglobin and reducing perioperative transfusion rates. This screening process should improve patient outcome. Another important finding in this group of patients is that ferritin levels cannot be reliably used as the sole indicator in the diagnosis of iron deficiency anaemia in this group of patients undergoing elective arthroplasty.

Mindfulness Meditation, Mental Health, and Health-Related Quality of Life in Chinese Buddhist Monastics.

OBJECTIVE: To determine associations between mindfulness meditation and mental health and health-related quality of life among Buddhist monastics. METHODS: This is a cross-sectional study of Chinese Buddhist monastics aged ≥18 years who practised mindfulness meditation daily. Mental health was assessed by the 12-item General Health Questionnaire (GHQ-12), whereas health-related quality of life was assessed by the 12-item Short Form Health Survey (SF-12). The number of years and the average daily amount of time spent in mindfulness meditation were collected. RESULTS: 47 monastics completed the interview. They practised mindfulness meditation for a mean of 7.3 years, 1.1 hours per day. Both the number of years (ß = -0.48, p = 0.03) and amount of daily practice (ß = -0.53, p < 0.001) of mindfulness meditation were associated with the GHQ-12 score, after adjusting for age, sex, education, and years of being a monastic. Only the amount of daily practice (ß = 0.44, p = 0.004) was associated with the mental component summary of SF-12. Neither was associated with the physical component summary of SF-12. CONCLUSIONS: Among Chinese Buddhist monastics who practise daily mindfulness meditation, spending more time each day and having longer years of practice were associated with better mental health.

Beyond the Chief Complaint: Our Patients' Worries.

Fourth-year medical students at the University of Colorado School of Medicine distributed cards to patients in the emergency department asking, "What Worries You Most?" The patients' responses provided insight about their most pressing concerns, often unrelated to their "chief complaints."

In vitro interaction of some drug combinations to inhibit rapidly growing mycobacteria isolates from cats and dogs and these isolates' susceptibility to cefovecin and clofazimine.

OBJECTIVES: To investigate whether selected drug combinations used to treat rapidly growing mycobacteria (RGM) have drug-drug interactions that affect efficacy and to investigate each isolate's susceptibility to cefovecin and clofazimine, individually. DESIGN: In vitro susceptibility testing of bacterial isolates. METHODS: Initially, five feline isolates and one canine isolate from both Mycobacterium fortuitum and M. smegmatis clusters (n = 12) underwent microbroth susceptibility testing to individual drugs to establish minimum inhibitory concentrations (MIC) of cefovecin, ciprofloxacin, clarithromycin, clofazimine, doxycycline, enrofloxacin, trimethoprim and sulfanilamide (the latter two as a combination). Checkerboard assays were then performed for susceptible M. smegmatis isolates for the following combinations: clarithromycin (one isolate only) versus enrofloxacin, clarithromycin vs doxycycline, clarithromycin vs trimethoprim/sulfanilamide; enrofloxacin vs doxycycline (six isolates); enrofloxacin vs trimethoprim/sulfanilamide (six isolates). Susceptible M. fortuitum isolates were tested against enrofloxacin versus doxycycline (four isolates only). RESULTS: All six M. fortuitum isolates were susceptible to enrofloxacin, but only four of six were susceptible to doxycycline. All six M. smegmatis isolates were susceptible to doxycycline, enrofloxacin and trimethoprim/sulfanilamide. A single isolate from the 12, a M. smegmatis isolate, was susceptible to clarithromycin. The fractional inhibitory concentration of each drug ranged from 0.64 to 1.84, indicating that neither synergism nor antagonism was evident. All 12 isolates were resistant to cefovecin. The clofazimine MIC50 to inhibit isolate growth was approximately 3.3 µg/mL for both strains. CONCLUSION: Drugs commonly used for treatment of RGM, when tested as combinations, do not appear to antagonise one another in vitro. Cefovecin is not efficacious for treatment of RGM infections.

A modified method of auxiliary partial liver transplantation in the rat.

BACKGROUND/AIMS: In the animal model of auxiliary partial liver transplantation in the rat, the major problem is high outflow pressure since the direction of vascular outflow of the graft was perpendicular to that of the recipient inferior vena cava (IVC) and the anastomosis was far away from the right atrium. We aimed at developing an animal model that could prevent graft congestion. METHODOLOGY: The graft contained the right lateral lobe and triangulated lobe of rat's liver. The modification of implantation included anatomizing an oblique cuff of IVC of donor graft into the recipient's IVC so that the size of anastomosis was large with an angle of 45 degrees and the resulting vascular outflow was no longer perpendicular to that of the recipient's IVC, and the creation of double grooves on the cuff body of the donor portal vein. Bile drainage was completed by inserting the bile duct (together with a stent) into the recipient's duodenum. RESULTS: Congestion of grafts was not seen in 25 rats undergoing auxiliary partial liver transplantation using an oblique IVC graft. The 1-week and 2-week survival rates were 88% and 80%, respectively. In the group of rats (n = 10) operated on by using a straight IVC graft, graft congestion was seen and only 1 rat could survive over 1 day. CONCLUSIONS: Modification of vascular outflow anastomosis prevented graft congestion and improved animal survival. The model may be useful for studying liver regeneration, transplantation immunology, and gene transfer.

[Enkephalinase activity in the guinea pig model of asthma].

Enkephalinase exists in airway epithelial cells, smooth muscle, and submucosa near glands, and cleaves tachykinins to inactive metabolites, thereby reducing there effects. To study the role of enkephalinase in asthmatic response, we measured its activity in guinea pig model of asthma. When compared with the control values, the enkephalinase activity was reduced during in immediate asthmatic response (IAR) and late asthmatic response (LAR). Compared with the control values (100%), each value was 79.7%, 73.4% in the trachea and 74.3%, 55.7% in the lung respectively. Tracheal muscle preparation taken from the control, IAR, and LAR groups were made and mounted in oxygenated modified Krebs-Ringer solution. The response was monitored by isometric transducer. Concentration response curves to NKA with or without phosphoramidon were obtained. The contractile responses of the LAR groups were enhanced in potency and efficiency. Phosphoramidon potentiated the NKA induced contraction of control and the IAR groups but was less potent in enhancing the contractile response in the LAR group, showing less enkephalinase activity in the LAR. These results suggest that the enkephalinase plays an important role in LAR. In LAR, the enkephalinase activity may be inhibited and the responsiveness of the smooth muscle to some bronchoconstrictor, such as tachykinins, may be increased.

Selective oestrogen receptor modulators differentially potentiate brain mitochondrial function.

The mitochondrial energy-transducing capacity of the brain is important for long-term neurological health and is influenced by endocrine hormone responsiveness. The present study aimed to determine the role of oestrogen receptor (ER) subtypes in regulating mitochondrial function using selective agonists for ERα (propylpyrazoletriol; PPT) and ERß (diarylpropionitrile; DPN). Ovariectomised female rats were treated with 17ß-oestradiol (E(2) ), PPT, DPN or vehicle control. Both ER selective agonists significantly increased the mitochondrial respiratory control ratio and cytochrome oxidase (COX) activity relative to vehicle. Western blots of purified whole brain mitochondria detected ERα and, to a greater extent, ERß localisation. Pre-treatment with DPN, an ERß agonist, significantly increased ERß association with mitochondria. In the hippocampus, DPN activated mitochondrial DNA-encoded COX I expression, whereas PPT was ineffective, indicating that mechanistically ERß, and not ERα, activated mitochondrial transcriptional machinery. Both selective ER agonists increased protein expression of nuclear DNA-encoded COX IV, suggesting that activation of ERß or ERα is sufficient. Selective ER agonists up-regulated a panel of bioenergetic enzymes and antioxidant defence proteins. Up-regulated proteins included pyruvate dehydrogenase, ATP synthase, manganese superoxide dismutase and peroxiredoxin V. In vitro, whole cell metabolism was assessed in live primary cultured hippocampal neurones and mixed glia. The results of analyses conducted in vitro were consistent with data obtained in vivo. Furthermore, lipid peroxides, accumulated as a result of hormone deprivation, were significantly reduced by E(2) , PPT and DPN. These findings suggest that the activation of both ERα and ERß is differentially required to potentiate mitochondrial function in brain. As active components in hormone therapy, synthetically designed oestrogens as well as natural phyto-oestrogen cocktails can be tailored to improve brain mitochondrial endpoints.

Carbohydrate epitopes are immunodominant at the surface of infectious Neoparamoeba spp.

Amoebic gill disease, the main disease of concern to the salmon industry in Tasmania, is caused by the amoeba, Neoparamoeba spp. Experimental infection can only be induced by exposure to wild-type (WT) parasites isolated from the gills of infected fish, as cultured amoebae are non-infective. To characterize the surface antigens of WT parasites, we produced monoclonal antibodies (mAbs) using subtractive immunization. Mice inoculated with non-infective parasites were treated with cyclophosphamide, to deplete reactive lymphocytes, and then immunized with different antigen preparations from infective parasites. When whole parasites were used for boosting, the percentage of WT unique mAbs was very high (86%) as was the percentage of mAbs specific for carbohydrate epitopes (89%). When deglycosylated membranes were used, the numbers of mAbs specific for non-carbohydrate epitopes did not increase, but the total number of WT unique mAbs was reduced (86-40%). Using an untreated membrane preparation, the total number of mAbs to surface molecules was very high, but all recognized carbohydrate epitopes. The total number of mAbs recognizing carbohydrate epitopes on the surface of the WT parasites was 97%, suggesting that the dominant epitopes on the surface molecules unique to WT parasites are carbohydrate in nature.

Evaluation of neurocardiac signals in pediatric patients with cyclic vomiting syndrome through power spectral analysis of heart rate variability.

OBJECTIVE: To investigate autonomic regulation of neurocardiac signals in pediatric patients with cyclic vomiting syndrome (CVS). METHODS: Fourteen patients with CVS, ages 3 to 16 years, were screened to eliminate any underlying cause for their symptoms, although 11 of the 14 patients had a history of migraine in the immediate family. Analysis of autonomic regulation was accomplished through power spectral analysis of the beat-to-beat heart rate variability signal. Data from affected patients were compared with data from 38 control subjects, ages 5 to 16 years, by a one-way analysis of variance. A measure of sympathovagal balance was obtained by computing a ratio of power in the low-frequency band (0. 02-0.15 Hz) to the power in the high-frequency band (0.15-0.4 Hz). RESULTS: Pediatric patients with CVS have an elevated sympathetic modulation of the sinus node as represented by the low frequency/high frequency ratio (1.45 +/- 0.42 in patients vs 0.89 +/- 0.29 in healthy control subjects, P <.001). CONCLUSIONS: The patients with CVS we studied have an autonomic imbalance with enhanced sympathetic and diminished parasympathetic vagal modulation of the heart.

Contributions of femoral fixation methods to the stiffness of anterior cruciate ligament replacements at implantation.

One purpose of this study was to determine the stiffness of three femoral fixation methods used commonly in anterior cruciate ligament (ACL) reconstruction to secure a double-looped semitendinosus and gracilis (DLSTG) graft and then assess how the stiffness of these methods affects the stiffness of the young human femur-fixation method-graft complex at the time of reconstruction. A second purpose was to define principles for adjusting the stiffness of the ACL replacement (defined as the femoral fixation method plus DLSTG graft plus tibial fixation method) to match that of the native ACL. The stiffness of a DLSTG graft and the stiffness of the femur-fixation method-DLSTG graft complex for three endoscopic fixation methods were measured. Fixations of the DLSTG graft to a button, anchor, and post, both with and without compaction of bone, were tested in young, human femur. The stiffness of each fixation was calculated by modeling the DLSTG graft and fixation method as a series of springs. The stiffness of the DLSTG graft averaged 954+/-292 N/mm. The stiffness of the DLSTG graft-fixation complex was lowered fourfold to 40-fold by adding fixation. The method of fixation determined the reduction in stiffness. The stiffness of the femur-button-DLSTG graft complex averaged 23+/-2 N/mm, the femur-anchor-DLSTG graft complex averaged 25+/-3 N/mm, and the femur-post with bone graft-DLSTG graft complex averaged 225+/-23 N/mm (P = .0001). The knot in the suture loop was the least stiff component and determined the stiffness when the DLSTG graft was fixed with both the button and anchor. Compaction of bone significantly increased stiffness by an average of 41+/-14 N/mm (P = .027). Because the stiffness of femoral fixation methods are 4 to 40 times less than the stiffness of the graft, increasing the stiffness of an ACL replacement would be best achieved by selecting fixation methods with higher stiffness and not by either shortening the graft or increasing the cross-sectional area of the graft.

Occupational exposure of herbicide applicators to herbicides used along electric power transmission line right-of-way.

Occupational exposures to herbicides were measured among 12 applicators in 1979 and 24 applicators in 1980, who were applying the three herbicides, 2,4-D, dichloroprop and picloram to electric power transmission rights of ways. In 1979 only urine was analyzed but in 1980 both breathing-zone air samples and urine were analyzed for herbicide residues. Dermal absorption was found to be the major absorption route being up to 50 times greater than exposure by the inhalation route when using a hand gun sprayer. Even with the mist blower herbicide application method, dermal absorption was 4 and 11 times greater than exposure by the inhalation route. Worker education on hazards of skin contact and improved protective equipment significantly reduced the 1980 urine concentrations of herbicide residues. A model is presented to relate the urinary concentrations to equivalent daily exposure levels.

Selective plasma filtration for treatment of fulminant hepatic failure induced by D-galactosamine in a pig model.

BACKGROUND: Plasma exchange may be useful for treating patients with fulminant hepatic failure but during the procedure growth factors that are important for hepatic regeneration are discarded. Addition of a selective plasma filter to the plasmapheresis circuit could eliminate protein bound toxic substances and retain growth factors for hepatic regeneration. This process is called selective plasma filtration. AIMS: To determine if selective plasma filtration could be a useful treatment modality for fulminant hepatic failure. METHODS: The system was tested in five groups of pigs with fulminant hepatic failure induced by galactosamine: group I, diseased control group (n=5); group II, sham control, (n=6); group III, plasma exchange (n=6); group IV, treatment with AC-1770 selective plasma filter (n=7); and group V, treatment with AC-1730 selective plasma filter which had a smaller pore size than AC-1770 (n=7). Fresh pig plasma was given to replace filtered plasma in pigs of groups III, IV, and V. Treatment was initiated 48 hours after administration of 0.75 g/kg galactosamine. The efficacy of selective plasma filtration was assessed by survival rate and improvement in haematological, biochemical, and immunohistological parameters. RESULTS: Pigs treated with AC-1770 or AC-1730 selective plasma filters survived longer than the other groups (group I: 55 (10) hours; group II: 68 (7) hours; group III: 91 (10) hours; group IV: 269 (156) hours; group V: 950 (555) hours). One pig in group IV survived for 50 days; one pig in group V survived for 77 days and another pig in group V is still alive (>150 days). After treatment, plasma levels of aspartate aminotransferase, bilirubin, bile acid, ammonia, lactate dehydrogenase, and alpha-glutathione-S-transferase decreased. Substantial amounts of tumour necrosis factor alpha (TNF-alpha) and endotoxin were found in the filtrate. The selective plasma filtration groups retained significantly higher amounts of hepatocyte growth factor than plasma exchange alone. Similar TNF-alpha clearance was observed in the selective plasma filtration groups and the plasma exchange group. On day 4, significant improvement in liver function, as measured by the indocyanine green clearance test, was observed in groups IV and V but not in the other groups. A higher regeneration index of hepatocytes was also observed in the groups treated with AC-1770 and AC-1730 selective plasma filters. CONCLUSION: Selective plasma filtration improved survival time and expedited liver regeneration in pigs with fulminant hepatic failure.

Acute thallium poisoning: an evaluation of different forms of treatment.

Hemodialysis, forced potassium diuresis, chelating agents per os, and Dithiocarb given intravenously during short periods of time were used for the treatment of acute thallium poisoning (ingestion of 750 mg of thallium sulfate), and the effectiveness of these different therapeutic procedures was analyzed. Chelating agents per os (Prussian blue, Dithiocarb, and Dithiozone) were ineffective in our patient, since fecal excretion of thallium was very low and unmodified by them. Forced potassium diuresis and hemodialysis were very useful therapeutic measures, especially in the first 12 days following ingestion. Dithiocarb perfusion seems to be the most effective method for enhancing urinary thallium excretion. This method might be most useful in the treatment of thallium poisoning if its deleterious effects could be eliminated.