A traditional Ugandan Ficus natalensis bark cloth exhibits antimicrobial activity against methicillin-resistant Staphylococcus aureus.

AIMS: Surgical site, soft tissue and wound infections are some of the most prominent causes of healthcare-associated infections (HCAIs). Developing novel antimicrobial textiles and wound dressings may help alleviate the risk of developing HCAIs. We aimed to determine the antimicrobial efficacy of natural Ugandan bark cloth derived exclusively from the Ficus natalensis tree. METHODS AND RESULTS: Antimicrobial contact and disc diffusion assays, coupled with time-kill kinetic assays, demonstrated that bark cloth inhibited the growth of a clinically relevant methicillin-resistant Staphylococcus aureus (MRSA) strain and acted as a bactericidal agent causing a seven-log reduction in bacterial viability. Scanning electron microscopy was used to reveal morphological changes in the bacterial cell ultrastructure when exposed to bark cloth, which supported a proposed mechanism of antimicrobial activity. CONCLUSIONS: The observed antimicrobial properties, combined with the physical characteristics elicited by bark cloth, suggest this product is ideally suited for wound and other skin care applications. SIGNIFICANCE AND IMPACT OF THE STUDY: This is the first report where a whole bark cloth product made by traditional methods has been employed as an antimicrobial fabric against MRSA. Bark cloth is a highly sustainable and renewable product and this study presents a major advance in the search for natural fabrics which could be deployed for healthcare applications.

Impact of Introduction of a Clinical Pathway for the Management of Pyelonephritis on Obstetric Patients: a Quality Improvement Project

Aim To determine whether the introduction of a clinical pathway for the treatment of pyelonephritis in obstetric patients would improve outcomes. Methods This was a retrospective study conducted in a maternity hospital using quantitative analysis methods. Patients who met laboratory and clinical criteria for pyelonephritis during data collection were included. Results The study included analysis of 23 patients pre-intervention and 19 post-intervention. Baseline and patient characteristics were similar for both groups. A statistically significant difference was seen in 3 of 7 outcome measures. Increased use of gentamicin (13% Vs 52% p=0.006), Increased number of renal ultrasounds (17% Vs 47%, p=0.04) and increased use of prophylaxis (21% Vs 68%, p=0.003). The proportion of patients receiving ≥ 10 days of IV antimicrobials decreased from 48% to 21% post-intervention (p=0.07). Discussion This study has shown that the introduction of a pathway for the treatment of pyelonephritis in pregnancy had a positive impact on several important clinical outcomes.

Ivacaftor for cystic fibrosis: An evaluation of real world utilisation and expenditure in the Irish Healthcare Setting.

In Ireland, Ivacaftor is reimbursed, on the High-Tech Drug Scheme, for the treatment of cystic fibrosis in patients age 6 years and older who have the G551D mutation. The aim of this study was to analyse the utilisation and expenditure of Ivacaftor on this scheme in the 12 month period post-reimbursement. All patients who had received Ivacaftor (regardless of General Medical Services Scheme eligibility/ineligibility) were included. A total of 140 individuals (male=74; 53%) received Ivacaftor over the defined 12 month study period (from January 2015 to December 2015 inclusive). The cohort ranged in age from 6 years to 61 years. The mean age was 22 years; a positive skew in age distribution indicated that a greater number of the cohort were in the younger age groups. No statistically significant difference was detected in the mean ages of the male and female subgroups. Drug acquisition expenditure by the Health Services Executive on Ivacaftor over the 12 month study period was €29.81 million.

Diagnostic accuracy of a brief screening tool for attention deficit hyperactivity disorder in UK prison inmates.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is overrepresented in prison, making it imperative to identify a screening tool that can be quickly applied to efficiently detect the disorder. We explored the discrimination ability of a widely used ADHD screen, the Barkley Adult ADHD Rating Scale (BAARS-IV), against a clinical diagnostic interview. A brief version of the screen was then developed in order to simplify its use in the prison context, and maximize its diagnostic properties. METHOD: A cross-sectional study of 390 male prison inmates was performed in the UK, all participants were screened and interviewed via the Diagnostic Interview for ADHD in Adults 2.0 (DIVA-2). RESULTS: A total of 47 (12.1%) inmates screened positive for ADHD using the full BAARS-IV, and 96 (24.6%) were clinically diagnosed, for a sensitivity of 37.9 and a specificity of 96.3. Our models identified the six items that most predicted ADHD diagnosis, with adjusted odds ratios ranging from 2.66 to 4.58. Sensitivity, specificity and accuracy were 0.82, 0.84 and 0.84, respectively, for the developed brief scale, and 0.71, 0.85 and 0.81 for its validation. Weighted probability scores produced an area under the curve of 0.89 for development, and 0.82 for validation of the brief scale. CONCLUSIONS: The original BAARS-IV performed poorly at identifying prison inmates with ADHD. Our developed brief scale substantially improved diagnostic accuracy. The brief screening instrument has great potential to be used as an accurate and resource-effective tool to screen young people and adults for likely ADHD in the criminal justice system.

A Cost-effectiveness Analysis of Surgery, Endothermal Ablation, Ultrasound-guided Foam Sclerotherapy and Compression Stockings for Symptomatic Varicose Veins.

OBJECTIVE: The aim was to investigate the cost-effectiveness of interventional treatment for varicose veins (VV) in the UK NHS, and to inform the national clinical guideline on VV, published by the National Institute of Health and Care Excellence. DESIGN: An economic analysis was constructed to compare the cost-effectiveness of surgery, endothermal ablation (ETA), ultrasound-guided foam sclerotherapy (UGFS), and compression stockings (CS). The analysis was based on a Markov decision model, which was developed in consultation with members of the NICE guideline development group (GDG). METHODS: The model had a 5-year time horizon, and took the perspective of the UK National Health Service. Clinical inputs were based on a network meta-analysis (NMA), informed by a systematic review of the clinical literature. Outcomes were expressed as costs and quality-adjusted life years (QALYs). RESULTS: All interventional treatments were found to be cost-effective compared with CS at a cost-effectiveness threshold of £20,000 per QALY gained. ETA was found to be the most cost-effective strategy overall, with an incremental cost-effectiveness ratio of £3,161 per QALY gained compared with UGFS. Surgery and CS were dominated by ETA. CONCLUSIONS: Interventional treatment for VV is cost-effective in the UK NHS. Specifically, based on current data, ETA is the most cost-effective treatment in people for whom it is suitable. The results of this research were used to inform recommendations within the NICE guideline on VV.

Exploring diastolic pressure ratio to fractional flow reserve discordance and a hypothesis on tailoring diastolic pressure ratio cut-off values to improve diagnostic accuracy in the mid- and distal-LAD.

Previous studies have identified a higher rate of discordance between non-hyperaemic pressure ratios and FFR in the LAD when compared to the other two coronary arteries. We hypothesised that in keeping with recently published data, we would identify a higher discordance rate between diastolic pressure ratio (DPR) and FFR in the LAD compared to the RCA or LCx. In our study, 12.7% of LAD lesions had discordant results compared with 2.4% of non-LAD lesions. This represents a statistically significant increased rate of discordance in LAD lesions compared to non-LAD lesions (p = 0.04986). Note was made of a tendency for non-proximal LAD lesions to be associated with false-positive DPR results in the borderline range (0.88 and 0.89). In a speculative, hypothesis generating post-hoc analysis, we found an improved diagnostic accuracy of DPR when the cut-off value for a positive DPR in the non-proximal LAD was changed to ≤0.87. It is fathomable that improvements in the diagnostic accuracy of DPR for FFR may be improved by tailoring DPR cut-offs to the location of the lesion assessed.

Treatment of anal human papillomavirus-associated disease: a long term outcome study.

Treatment for human papillomavirus (HPV)-associated anal canal disease has been unsatisfactory. The objective of our study was to determine the treatment outcome in our cohort with anal HPV disease. Overall, 181 patients were evaluated over a median period of 19.1 months (range = 2.8-125.5). Eighty-eight patients (48.6%) with high-grade anal intraepithelial neoplasia (AIN) and 82 patients (45.3%) with low-grade AIN underwent treatment. One hundred and forty-one patients (77.9%) received laser ablative treatment as an outpatient procedure. The treatment yielded cure, defined as a disease-free state at 12 months after treatment, in 63.0% (114/181). Median time to cure for the cohort was 31.5 months (95% confidence interval: 23.0-40.0). Treatment outcome showed no evidence of being affected by age, sexual preference, history of smoking or presence of high-grade disease. Median time to cure was significantly affected by a positive HIV status (P = 0.02) and the extent (volume) of the disease (P = 0.01). Contrary to the current view that treatment of HPV-related anal disease is difficult, unrewarding due to recurrences and may lead to substantial morbidity, we demonstrate that effective treatment is possible for both low- and high-grade AIN. These findings should help with the general desire to introduce screening for AIN for at-risk groups.

Risk factors and in-hospital course of first episode of myocardial infarction or acute coronary insufficiency in women.

This study examines the risk factor profile, in-hospital course and outcome of 337 women and 643 men admitted with a first episode of acute coronary insufficiency or myocardial infarction. The women were older than the men and had a risk factor profile dominated by hypertension and hypercholesterolemia rather than smoking. Women had a higher rate of unstable angina than did men after adjustment for age distribution. Women with acute infarction showed a higher rate of complications, which was associated with their greater age. They had a higher in-hospital mortality rate (12.6%) than did men (6.6%, p = 0.002). A logistic regression was used to adjust mortality and complication rates for differences in age between the sexes. When this was done, women and men had similar in-hospital prognoses. It is concluded that differences in risk factor profile may result in differences between the sexes in the expression of acute coronary heart disease, but that gender as such does not exert an independent influence on short-term prognosis in this disease.

In-hospital prognosis of patients with fasting hyperglycemia after first myocardial infarction.

OBJECTIVE: To investigate the incidence and prognostic significance of fasting hyperglycemia in a large group of patients with a first myocardial infarction. RESEARCH DESIGN AND METHODS: Blood glucose was measured after an 8-h overnight fast in 752 patients with a first myocardial infarction. Three groups of patients were identified: patients with normal fasting blood glucose (92.5%), patients with fasting hyperglycemia but no prior history of glucose intolerance (3%), and patients previously known to have diabetes mellitus (4.5%). RESULTS: The fasting hyperglycemic patients were significantly older and had significantly more in-hospital complications than the normal blood glucose group. Previously known diabetic subjects tended to be older and had more mechanical complications postinfarction than the group with normal blood glucose but the difference did not reach statistical significance. There was no significant difference between the diabetic subjects and patients with fasting hyperglycemia in mean age and in-hospital prognosis. CONCLUSIONS: Fasting hyperglycemia detected after a first myocardial infarction is associated with a poor in-hospital prognosis that was not due to larger infarct size, as reflected in peak levels of cardiac enzymes. The measurement of a fasting blood glucose level provides additional information in identifying high-risk groups of patients postinfarction.

Comparison of the lipid-lowering effect of clofibrate, and of clofibrate plus beta-pyridylcarbinol.

Forty-eight patients under 65 years were included in a double blind study comparing the lipid-lowering effect of clofibrate with that of beta-pyridylcarbinol combined with clofibrate. Over 4 months there was no significant difference in the lipid-lowering effect of either regime. A mean reduction of triglyceride of approximately 30% and of cholesterol of 18% was observed. Both drugs caused significantly greater reductions than placebo. No serious side-effects were noted.

Unstable angina: natural history and determinants of prognosis.

One hundred one patients with unstable angina were treated conservatively without the routine use of beta receptor blocking agents, calcium antagonist drugs, anticoagulant agents or nitrates. Only two patients underwent arteriography and coronary arterial bypass surgery during hospitalization and one patient during the 1st year of follow-up study. The 28 day mortality rate was 4 percent and the total 1 year cardiac mortality rate 10 percent. Two patients died from carcinoma. The incidence rate of nonfatal myocardial infarction was 9 percent during the first 28 days and a further 3 percent for the 1st year. These results compare favorably with the immediate and 1 year prognosis reported from other studies using different treatment procedures, including modern intensive drug treatment and coronary arterial bypass surgery. Various factors studied during the acute stage of unstable angina were assessed in an effort to predict the immediate and long-term outcome. Only persistence of pain after admission to the hospital was found a significant indicator of an adverse prognosis. Modern medical treatment of unstable angina with beta receptor blocking agents, calcium antagonist drugs, anticoagulant agents, nitrates and antiarrhythmic agents is critically examined. The paucity of proper randomized controlled studies confirming the value of medication is underlined. There is little evidence to show that aggressive or intensive medical or surgical treatment is superior to a conservative approach to management in the coronary care unit. This approach includes bed rest until the pain has resolved, symptomatic drug treatment only, the minimal use of invasive investigations and careful risk factor intervention.

Hoarseness secondary to left atrial myxoma.

A 62-year-old woman presented with a history of hoarseness. Although stable for ten years, she recently showed signs of deterioration. Investigations revealed left vocal cord paralysis and a large left atrial tumor displacing the left pulmonary artery under the arch of the aorta. The lesion was removed and the normal aortopulmonary window on computed tomography (CT) scan was restored. On review of the literature, this case appears to be the first to suggest that myxomas cause recurrent laryngeal nerve palsy through direct effects.

Interobserver variation in the computed tomographic evaluation of mediastinal lymph node size in patients with potentially resectable lung cancer. Canadian Lung Oncology Group.

OBJECTIVE: To measure the reliability of the assessment of mediastinal lymph node size in computed tomographic (CT) scans of the thorax. DESIGN: Observer agreement study in which radiologists, blinded to one anothers' interpretation, were randomized to read 30 scans each. POPULATION: Sixty scans from patients with apparently operable non-small cell carcinoma of the lung were read by radiologists responsible for clinical interpretation (clinical radiologists) and four radiologists with a special interest in thoracic CT (study radiologists). MEASUREMENTS: Radiologists measured the size of left and right superior mediastinal nodes, aortic nodes, and the subcarinal nodes and, on the basis of whether any nodes accessible to mediastinoscopy were greater than 1 cm, recommended whether mediastinoscopy be undertaken. Agreement was quantified using kappa, a measure of chance-corrected agreement. RESULTS: Among all radiologists, agreement on whether there were any nodes larger than 1 cm for right superior mediastinal nodes was 0.68; for left superior mediastinal nodes it was 0.28; for aortic pulmonary nodes it was 0.62; for subcarinal nodes it was 0.58; and for any node greater than 1 cm and accessible to mediastinoscopy it was 0.61. The agreement was very similar when the analysis was restricted to the study radiologists. CONCLUSION: Although the good level of overall agreement suggests that CT provides useful information in the evaluation of mediastinal lymph node size, the disagreement was sufficient that it likely contributes to suboptimal sensitivity and specificity of CT in detecting tumor spread reported in previous studies.

Potential value of digital radiography. Preliminary observations on the use of dual-energy subtraction in the evaluation of pulmonary nodules.

The radiographic demonstration of calcification in a solitary pulmonary nodule renders the possibility of malignancy extremely unlikely, although rare exceptions have been reported. Conventional roentgenograms and tomograms sometimes provide inconclusive evidence although CT can be highly accurate in both identifying and quantifying calcium content. An alternative method is dual-energy subtraction utilizing scanned projection digital radiography. Forty-one patients with solitary (occasionally multiple) pulmonary nodules were examined with the technique, employing second-generation fan-beam equipment: 28 nodules or masses were noncalcified and 13 calcified. Of the former, 20 were pathologically proved, 16 being malignant and 4 benign (2 granulomas, 2 bronchiectasis); in 3 of the remaining 8, a presumptive diagnosis was reasonably certain (1 granuloma, 2 metastases), while in 5 the diagnosis was not made. In 8 of the 13 calcified lesions, the diagnosis can reasonably be regarded as confirmed as granulomas; 5 are being followed up with that presumptive diagnosis.

Reactivation of aged model Pd/Ce0.68Zr0.32O2 three-way catalyst by high temperature oxidising treatment.

A deactivated (aged under redox-cycled model TWC feed-stream) Pd/Ce(0.68)Zr(0.32)O(2) catalyst is remarkably reactivated when subjected to a high temperature oxidising treatment whereas this effect is only marginal for Pd/Al(2)O(3), which indicates the key role of such treatment in restoring the Pd-Ce(0.68)Zr(0.32)O(2) interactions leading to highly active catalysts.

Psychological response to an acute coronary event and its effect on subsequent rehabilitation and lifestyle change.

We assessed anxiety, depression, body image, motivation, and coping ability in 264 patients admitted with a first myocardial infarction. They were followed over 1 year to determine the relationship between psychological factors and subsequent return to work, smoking cessation, weight reduction, and adoption of a leisure exercise program. Females showed a poorer reaction to illness than did males. The better-educated, and patients in white-collar occupations showed less depression and expressed greater motivation. Anxiety and poor body image, however, tended to be least common in the intermediate educational and occupational group. All psychological factors predicted leisure exercise change, and all but anxiety predicted smoking cessation. Poor body image was linked with failure to reduce weight. Low expressed motivation was the only factor predicting delayed return to work.

Integrated radiologic information system: a radiology multimedia communication system.

A multimedia radiologic communication system has been developed that achieves the system design goal of providing a clinical communication service that is an efficient improvement over present methods of communication. The system allows users to access, through a workstation, digitized radiographic images, voice reports, and other patient data. Physicians can consult with each other while simultaneously accessing this information through a shared visual workspace, even though they are in different places. The system was designed by a multidisciplinary team including radiologists, clinicians, engineers, user-interface specialists, and psychologists from hospital, university, and research settings in an effort to maximize system performance and clinical utility.

Acquired diseases of aberrant subclavian arteries.

The anatomic, clinical, and radiologic findings of aberrant subclavian arteries (ASAs) are well known. Acquired diseases such as aneurysms, dissections, or stenosis can complicate these anomalies. We propose that these complications are a result of atherosclerosis caused by abnormal turbulence around the ASA. Comparisons of computed tomographic and angiographic measurements of subclavian arteries in adults with and without arch anomalies and angiographic measurements of ASAs in children show that ASAs dilate in older patients. We describe six patients with acquired diseases of ASAs or the aorta adjacent to the ASA. Aneurysms, aortic dissections, and stenosis were each found in two patients. Problems in the radiologic diagnosis and clinical management of these diseases are emphasized. Radiologists should be cognizant of the significance of ASAs in patients with aortic aneurysms and dissections.