Contemporary epidemiology of infective endocarditis in patients with congenital heart disease: A UK prospective study.

OBJECTIVES: Infective endocarditis is a life-threatening complication of congenital heart disease (CHD), but there are few studies concerning the contemporary risk profile, preceding invasive procedures and outcomes in this patient population. The aim of this study was to investigate the epidemiology of infective endocarditis (IE) in patients with CHD. METHODS: Cases of IE in children and adults with CHD were prospectively recorded as part of the UK National Institute for Cardiovascular Outcomes Research (NICOR) National Congenital Heart Disease Audit. Patients were entered into the database between April 2008 and March 2016. RESULTS: Eight hundred episodes of IE were recorded in 736 patients with CHD. Sixty-five patients (9%) were infants (aged <1 year), 235 (32%) were children (aged 1-15 years), and 436 (59%) were adults (aged >15 years). The most common diagnoses were Tetralogy of Fallot (n = 150, 22.8%), ventricular septal defect (n = 129, 19.6%) and bicuspid aortic valve (n = 70, 10.7%). Dental procedures preceded 67 of 635 episodes (11%) of IE, and non-dental invasive procedures preceded 177 of 644 episodes (27.4%). The most common causative organisms were streptococci, accounting for 40% of cases. Overall in-hospital mortality was 6.7%. On multivariable analysis, adverse factors associated with in-hospital mortality were staphylococcal infection and presence of an underlying atrioventricular septal defect. CONCLUSIONS: Infective endocarditis in patients with CHD is an ongoing clinical challenge. In contemporary practice in tertiary congenital centers, 1 of 15 patients do not survive to hospital discharge. Streptococci remain the most common causative organism, and antecedent dental or medical procedures were undertaken in a significant minority in the 3 months before diagnosis. The presence of an atrioventricular septal defect or staphylococcal infection is associated with significantly increased risk of early mortality.

Transcatheter aortic valve implantation: current status and future perspectives.

In the 16 years since the first pioneering procedure, transcatheter aortic valve implantation (TAVI) has come of age and become a routine strategy for aortic valve replacement, increasingly performed under conscious sedation via transfemoral access. Simplification of the procedure, accumulation of clinical experience, and improvements in valve design and delivery systems have led to a dramatic reduction in complication rates. These advances have allowed transition to lower risk populations, and outcome data from the PARTNER 2A and SURTAVI trials have established a clear evidence base for use in intermediate risk patients. Ongoing studies with an expanding portfolio of devices seem destined to expand indications for TAVI towards lower risk, younger and asymptomatic populations. In this article, we outline recent advances, new devices and current guidelines informing the use of TAVI, and describe remaining uncertainties that need to be addressed.

Measurements of the stratospheric plume from the mount st. Helens eruption: radioactivity and chemical composition.

Gas measurements made in the stratospheric plume from the eruption of Mount St. Helens on 18 May 1980 were not consistent with a reported large injection of radon-222 into the atmosphere. No enrichment in the volatile element polonium was found in filter samples, and the ratio of polonium-210 to lead-210 was not different from background values. Data obtained with an experimental impactor, flown shortly after the eruption, showed an increase of 10(3) in the stratospheric number concentration of submicrometer sulfate particles compared to concentrations before the eruption.

Cation-ratio and accelerator radiocarbon dating of rock varnish on mojave artifacts and landforms.

The first accelerator radiocarbon dates of rock varnishes are reported along with potassium/argon ages of lava flows and conventional radiocarbon dates of pluvial lake shorelines, in an empirical calibration of rock varnish K(+) + Ca(2+)/Ti(4+) ratios with age in the Mojave Desert, eastern California. This calibration was used to determine the cation-ratio dates of 167 artifacts. Although cation-ratio dating is an experimental method, some dates suggest human occupation of the Mojave Desert in the late Pleistocene.

Laser microsurgery in cell and developmental biology.

New applications of laser microbeam irradiation to cell and developmental biology include a new instrument with a tunable wavelength (217- to 800-nanometer) laser microbeam and a wide range of energies and exposure durations (down to 25 X 10(-12) second). Laser microbeams can be used for microirradiation of selected nucleolar genetic regions and for laser microdissection of mitotic and cytoplasmic organelles. They are also used to disrupt the developing neurosensory appendages of the cricket and the imaginal discs of Drosophila.

Biochemical and genetic analysis of a child with cystic fibrosis and cystinosis.

We have studied a child with cystic fibrosis (CF), nephropathic cystinosis, and manifestations of Bartter syndrome, a finding reported previously in both of these diseases (CF and cystinosis). The chance of an individual inheriting a mutant allele for both CF and cystinosis from each of his parents by independent segregation is very small. Therefore, other mechanisms of inheritance were investigated, including whether his diseases were caused by a chromosome deletion or rearrangement that caused defects in both genes, whether his phenotype was caused by a new mutation or variant of either disease, or whether both diseases were inherited together due to inheritance of 2 copies of the same chromosome from one of the parents (uniparental disomy). An investigation was made of whether having mutations for both CF and cystinosis resulted in a different phenotype for either disease and whether the child was a heterozygote rather than a homozygote for one of the mutations. The results suggest that neither disease influenced the expression of the defect in the other and that this child inherited a mutant allele for both diseases independently from each parent.

Usage of triptans among migraine patients: an audit in nine GP practices.

A retrospective audit was carried out to investigate triptan usage over a period of one year among 360 adult patients with migraine in nine GP practices in the UK and the Republic of Ireland. Data from patient records were analysed, in conjunction with replies to a questionnaire about patients' perceptions of their migraine and its treatment. The majority of patients included in the audit were women (83%), and most patients (81%) were aged between 35 and 64 years. Most patients in the audit population (60%) were in the lowest band of triptan usage (1-36 tablets prescribed over 12 months); 7% had moderate usage (37-53 tablets). A minority of patients appeared to be taking triptans in higher quantities: about 15% of patients had been prescribed 54-94 triptan tablets over a year, 9% had received prescriptions for 95-149 tablets and 7% had received prescriptions for 150 or more tablets. These results indicated that some migraine patients were using triptans at higher than expected rates, and suggested that some patients might have been using their prescribed triptans inappropriately to treat a headache that they incorrectly perceived as migraine (e.g. chronic daily headache). Analyses were carried out to identify predictors of high usage. Predictors identified included the use of several other (non-triptan) medications to treat conditions other than migraine, one triptan dose being reported as sufficient to treat an attack, patient's perception of all headaches as migraine and lack of concern about taking too much medication. Patients identified as using triptans at a higher than expected rate can be called in for review of migraine diagnosis, identification of possible causes of any increased frequency of attacks, and investigation of suspected non-migrainous headaches, such as chronic daily headache and medication-induced headaches. For GPs, such actions would help achieve and maintain a high standard of care for their migraine patients, thus helping to contribute towards meeting the demands of the clinical governance agenda. Audit of triptan usage may also offer financial benefits for the practice, since helping patients to avoid the inappropriate use of triptans could lead to reductions in the overall costs of triptan prescribing within the practice. The high usage predictors could be developed into a checklist of potential indicators for GPs to identify patients who may become high users if prescribed triptans and who might require closer monitoring. We recommend that patients identified as having a potential for high usage should be routinely reviewed, every 3-6 months, to ensure that they are using triptans appropriately to treat migraine. Although triptans are generally safe and well tolerated, unnecessary use of any medication should be avoided.

Induction of molecular remission by donor peripheral blood leukocyte therapy in patients relapsing with extramedullary blastic phase chronic myeloid leukemia after allogeneic bone marrow transplantation.

Two patients with chronic myeloid leukemia (CML) who relapsed in blastic transformation after allogeneic bone marrow transplantation (BMT) were treated with infusions of leukapheresed peripheral blood mononuclear cells from their original donor. At relapse, their disease was characterized by symptomatic extramedullary deposits of leukemia with minimal (PCR positive, cytologically negative) involvement of bone marrow. Treatment with donor cell infusions was associated with clinical remission, return of full donor chimerism and loss of the BCR-ABL transcript detectable in bone marrow before donor leukocyte infusion (molecular remission). Donor leukocyte infusions should be considered for therapy of relapsed blastic phase CML after allogeneic BMT, especially when the relapse is primarily extramedullary and responsive to local and systemic cytoreductive therapy. However, severe GVHD and CNS relapse remain obstacles to achieving a successful long-term outcome.

Cesarean section: a contemporary assessment.

A one-year retrospective study of cesarean section (CS) at Women and Infants Hospital of Rhode Island is reported. There were 5,467 women delivered, including 1,011 who delivered by CS, yielding a total CS rate of 18.5% and a primary rate of 13.4%. The four leading indications for primary CS were: dystocia (38.8%), breech presentation (14.9%), malposition (11.9%) and fetal distress (11.3%). Sepsis was responsible for 75% of the complications. The incidence of low-birth-weight infants was 14.2% for primary CS and 6.7% for repeat CS. The perinatal death rate was 21.2% per 1,000. The relationship of these findings to changing obstetric practice is discussed.

A prospective, randomized comparison of the Volume Diffusive Respirator vs conventional ventilation for ventilation of burned children. 2001 ABA paper.

UNLABELLED: The Volume Diffusive Respirator (VDR) is a high-frequency time cycled pressure ventilator that can ventilate, oxygenate, and promote secretion removal. The VDR provides ventilation at lower airway pressures than those required for conventional ventilation in the pressure control mode (PCV). A prospective, randomized, institutional review board-approved study was conducted comparing the VDR to PCV in burned children with respiratory failure from all causes. METHODS: Pediatric burn patients requiring ventilation were stratified by presence of inhalation injury and ventilated by VDR or PCV to achieve predefined arterial blood gases. RESULTS: Sixty-four patients were prospectively assigned ventilator type; 32 to VDR, 32 to PCV. Data are reported as mean + SEM. Patient age was 7.4 + 0.7 years, TBSA was 56 + 3%, and number of patients with inhalation injuries was 55 (86%). Maximum peak inspiratory pressure with the VDR was significantly less than with PCV (30.9 + 0.8 cm H2O vs 39.5 + 1.8 cm H2O,P < 0.05) and the best PaO2 /FIO2 ratio was significantly higher with the VDR compared with PCV (563 + 15 vs 507 + 13, P < 0.05). No patient in the VDR group had evidence of barotrauma compared with two in the PCV group. Five patients in the PCV group died compared with two in the VDR group. CONCLUSION: Patients ventilated with the VDR required significantly lower peak inspiratory pressure and achieved a significantly higher PaO2 /FIO2 ratio compared with PCV. This demonstrates the VDR is a safe and effective method of ventilation for pediatric burn patients and it offers advantages when compared with conventional ventilation.

Comparison of real-time instruments used to monitor airborne particulate matter.

Measurements collected using five real-time continuous airborne particle monitors were compared to measurements made using reference filter-based samplers at Bakersfield, CA, between December 2, 1998, and January 31, 1999. The purpose of this analysis was to evaluate the suitability of each instrument for use in a real-time continuous monitoring network designed to measure the mass of airborne particles with an aerodynamic diam less than 2.5 microns (PM2.5) under wintertime conditions in the southern San Joaquin Valley. Measurements of airborne particulate mass made with a beta attenuation monitor (BAM), an integrating nephelometer, and a continuous aerosol mass monitor (CAMM) were found to correlate well with reference measurements made with a filter-based sampler. A Dusttrak aerosol sampler overestimated airborne particle concentrations by a factor of approximately 3 throughout the study. Measurements of airborne particulate matter made with a tapered element oscillating microbalance (TEOM) were found to be lower than the reference filter-based measurements by an amount approximately equal to the concentration of NH4NO3 observed to be present in the airborne particles. The performance of the Dusttrak sampler and the integrating nephelometer was affected by the size distribution of airborne particulate matter. The performance of the BAM, the integrating nephelometer, the CAMM, the Dusttrak sampler, and the TEOM was not strongly affected by temperature, relative humidity, wind speed, or wind direction within the range of conditions encountered in the current study. Based on instrument performance, the BAM, the integrating nephelometer, and the CAMM appear to be suitable candidates for deployment in a real-time continuous PM2.5 monitoring network in central California for the range of winter conditions and aerosol composition encountered during the study.

'Cold lesions' on bone scan. A case of metastatic squamous cell carcinoma of the penis.

Photopenic osseous lesions are a well-recognized but unusual manifestation of metastatic disease on bone scintigraphy. Common primary tumors giving rise to such lesions include lung, breast, renal, and thyroid. This case report illustrates multiple "cold" osseous metastases from aggressive penile squamous cell carcinoma without radiographic destruction.