Point of Care Ultrasound in Geriatric Patients: Prospective Evaluation of a Portable Handheld Ultrasound Device.

PURPOSE: The aim of the current study was to evaluate point of care ultrasound (POCUS) in geriatric patients by echoscopy using a handheld ultrasound device (HHUSD, VScan) at bedside in comparison to a high-end ultrasound system (HEUS) as the gold standard. MATERIALS AND METHODS: Prospective observational study with a total of 112 geriatric patients. The ultrasound examinations were independently performed by two experienced blinded examiners with a portable handheld device and a high-end ultrasound device. The findings were compared with respect to diagnostic findings and therapeutic implications. RESULTS: The main indications for the ultrasound examinations were dyspnea (44.6 %), fall (frailty) (24.1 %) and fever (21.4 %). The most frequently found diagnoses were cystic lesions 32.1 % (35/109), hepatic vein congestion 19.3 % (21/109) and ascites 13.6 % (15/110). HHUSD delivered 13 false-negative findings in the abdomen resulting in an "overall sensitivity" of 89.5 %. The respective "overall specificity" was 99.6 % (7 false-positive diagnoses). HHUSD (versus HEUS data) resulted in 13.6 % (17.3 %) diagnostically relevant procedures in the abdomen and 0.9 % (0.9 %) in the thorax. Without HHUSD (HEUS) 95.7 % (100 %) of important pathological findings would have been missed. CONCLUSION: The small HHUSD tool improves clinical decision-making in immobile geriatric patients at the point of care (geriatric ward). In most cases, HHUSD allows sufficiently accurate yes/no diagnoses already at the bedside, thereby clarifying the leading symptoms for early clinical decision-making.

Low proportions of folic acid deficiency after introduction of mandatory folic acid fortification in remote areas of northern Queensland, Australia: a secondary health data analysis.

Background: Australia implemented mandatory folic acid fortification of bread-making flour in 2009. Objective: To assess the impact of folic acid fortification in remote vs. regional urban areas and Indigenous vs. non-Indigenous populations in northern Queensland. Methods: Routinely collected data on folic acid measurements in remote areas and two regional urban centres in northern Queensland between 2004 and 2015 were analysed (n = 13,929) dichotomously (folic deficient vs. non-deficient). Results: Overall prevalence of folic acid deficiency was 3.2% (235/7282) in urban centres compared with 7.2% (480/6647) in remote areas (p < 0.001), and 9.3% (393/4240) in the Indigenous population compared with 3.2% (273/8451) in the non-Indigenous population (p < 0.001). Prevalence of folic acid deficiency dropped from 12.2% (n = 481) in 2004-2008 to 1.5% (n = 126) in 2010-2015 (p < 0.001). This translates into a relative risk reduction (RRR) of 88%. RRR was 79% (7.2% vs. 1.5%) in urban centres, 91% (17.3% vs. 1.5%) in remote areas, 92% (20.5% vs. 1.6%) in the Indigenous population and 80% (7.4% vs. 1.5%) in the non-Indigenous population (p < 0.001 for all). Conclusions: Substantial declines of folic acid deficiency to low and comparable proportions in former high-risk populations indicate that mandatory folic acid fortification of flour has had a population-wide benefit in northern Queensland.

Folic acid deficiency declined substantially after introduction of the mandatory fortification programme in Queensland, Australia: a secondary health data analysis.

OBJECTIVE: To investigate the prevalence of folic acid deficiency in Queensland-wide data of routine laboratory measurements, especially in high-risk sub-populations. DESIGN: Secondary health data analysis. SETTING: Analysis of routine folic acid tests conducted by Pathology Queensland (AUSLAB). PARTICIPANTS: Female and male persons aged 0-117 years with routine folic acid testing between 1 January 2004 and 31 December 2015. If repeat tests on the same person were conducted, only the initial test was analysed (n 291 908). RESULTS: Overall the prevalence of folic acid deficiency declined from 7·5 % before (2004-2008) to 1·1 % after mandatory folic acid fortification (2010-2015; P < 0·001) reflecting a relative reduction of 85 %. Levels of erythrocyte folate increased significantly from a median (interquartile range) of 820 (580-1180) nmol/l in 2008 before fortification to 1020 (780-1350) nmol/l in 2010 (P < 0·001) after fortification. The prevalence of folic acid deficiency in the Indigenous population (14 792 samples) declined by 93 % (17·4 v. 1·3 %; P < 0·001); and by 84 % in non-Indigenous residents (7·0 v. 1·1 %; P < 0·001). In a logistic regression model the observed decrease of folic acid deficiency between 2008 and 2010 was found independent of gender, age and ethnicity (ORcrude = 0·20; 95 % CI 0·18, 0·23; P < 0·001; ORadjusted = 0·21; 95 % CI 0·18, 0·23; P < 0·001). CONCLUSIONS: While voluntary folic acid fortification, introduced in 1995, failed especially in high-risk subgroups, the 2009 mandatory folic acid fortification programme coincided with a substantial decrease of folic acid deficiency in the entire population.

Outcomes of three different ways to train medical students as ultrasound tutors.

BACKGROUND: In order to provide faculty-wide undergraduate ultrasound training in times of scarce resources, many medical faculties employ trained peer-student tutors to oversee the hands-on training. However, data to guide the training of ultrasound peer-student tutors are scarce. We conducted a prospective quasi-randomized study to assess the gain in theoretical knowledge and practical scanning skills of peer-student tutors who were trained with a course only, an internship only, or the combination of a course and an internship. METHODS: A total of 44 peer-student tutors were trained by a one-week course only (C-Group, n = 21), by an internship only (I-Group, n = 10) or by a course and an internship (CI-Group, n = 13). Prior to and after the completion of the training the peer-student tutors completed an MC-test (theoretical knowledge) and an OSCE (practical scanning skills). RESULTS: With all three education concepts, the peer-student tutors had significant and comparable gains in theoretical knowledge (C-group + 90%, I-group + 61.5%, CI-group + 114.0%) and practical scanning skills (C-group + 112.0%, I-group + 155.0% and CI-group + 123.5%), all p < 0.001. CONCLUSION: Peer-student tutors, who were trained with a course or an internship or a course and internship improved their theoretical knowledge and their practical scanning skills significantly and to a comparable degree.

Development and implementation of a comprehensive ultrasound curriculum for undergraduate medical students - a feasibility study.

BACKGROUND: Ultrasound is one of the most important imaging techniques in clinical medicine with unique advantages. Skills in ultrasound imaging are very usefull for physicians including novices and thus also mandated by the Task Force "National Competence-Based Learning Objectives for Undergraduate Medical Education" (NKLM) in Germany and as well as by the German Ultrasound Society (Deutsche Gesellschaft für Ultraschall in der Medizin, DEGUM). Since ultrasound is best learned hands-on in very small supervised groups, we developed and implemented a comprehensive ultrasound-curriculum for all undergraduate medical students of our faculty using a peer-teaching concept. METHODS: We used Kern's six-step model of curricular development comprising (1) problem identification and general needs assessment, (2) needs assessment of the targeted learners, (3) goals and objectives, (4) educational stategies, (5) implementation, and (6) evaluation and feedback. RESULTS: The developed curriculum covers basic ultrasound of the abdomen and the throat, eFAST (Extended Focused Assessment with Sonography for Trauma), lung-ultrasound, FEEL (Focused Echocardiography in Emergency Life Support) and compression duplex sonography of the thigh deep vein system. All 5th year medical students receive a 90 min lecture on ultrasound basics by a faculty member and then a 12.5 h hands-on course divided into three sessions with one student tutor for every 4 students. The students are provided with a script (PDF-File) that covers all the learning goals, including example images of pathologies. The student tutors are trained during a 1 week ultrasound course and a 21-day rotation through seven different ultrasound laboratories. In addition, they undergo a standardized 1.5 day didactical training. Prior to the implementation for all students, the overall course was tested on 27 volunteer students. These students rated (on a 6-point Likert scale from 1 = excellent to 6 = very poor) the satisfaction with the student tutors and the faculty members as 1.4 ± .9 (mean ± stddev) and 1.3 ± .5 respectively. CONCLUSION: A comprehensive ultrasound curriculum for all undergraduate medical students using a peer-teaching concept is feasible. Further studies are needed to evaluate in detail the learning outcomes for students and student tutors.

Injuries and alcohol management plans in remote Indigenous communities: a two-community comparison.

To curb high rates of alcohol-related violence and injury in Indigenous communities, alcohol management plans (AMPs) were implemented in 2002-2003 and tightened in 2008. This project compares injury presentations and alcohol involvement from two Indigenous Cape York communities, one that entered full prohibition and one that did not. Aclinical file audit was performed for the period 2006-2011, capturing changes in alcohol availability. Medical files were searched for injury presentation documenting type of injury, cause of injury (including alcohol), date of injury and outcomes of all presenting injuries for the time period 1 January 2006 to 31 December 2011, capturing the major changes of the 2008 AMP restrictions. Findings indicated injury presentation rates were higher in both communities before prohibition than afterwards andreduction was more pronounced in community 2 (prohibition). Ongoing research is imperative, as this area is characterised by a near-absence of evidence.

A longitudinal observation study assessing changes in indicators of serious injury and violence with alcohol controls in four remote indigenous Australian communities in far north Queensland (2000-2015).

BACKGROUND: Legal restrictions on alcohol availability have been used to address violence and injury in the world's remote Indigenous communities. In Australia, alcohol management plans (AMPs) were implemented by the Queensland Government in 2002. This study reports changes in indicators of alcohol-related violence and injury in selected communities. METHODS: Design and setting: A longitudinal observational study was conducted in four Aboriginal and Torres Strait Islander (Indigenous) communities in Cape York, far north Queensland. All communities are similarly-isolated from population centres where alcohol is available. DATA: For 2000 to 2015 inclusive: 1019 Royal Flying Doctor Service aeromedical trauma retrievals; 5641 Queensland Police Service records of unique assault occurrences, including 2936 involving alcohol; and records for 2741 unique assault victims were examined. DATA ANALYSIS: Rates (per 1000 population) of trauma retrievals, assault occurrences and assault victims (per 1000 population) were compared across three policy phases. Phase 1: 2000 to 2008. Initial restrictions on possession and consumption of alcohol in 'restricted areas' were implemented during 2002-2003. Phase 2: 2009 to 2012. All alcohol was prohibited in three study communities and its legal availability limited in the fourth from 2009. Phase 3: 2013 to 2015. Government reviews of AMP policies in light of legal challenges and community responses characterise this phase. RESULTS: Compared with Phase 1, in Phase 2 retrieval rates declined by - 29.4%, assault occurrences by - 34.1% with less than one-third involving alcohol, and assault victims by - 21.1%, reaching historically low levels in 2010-2012. These reductions did not continue consistently. Compared with Phase 1, in Phase 3 retrieval rates, assault occurrence rates and assault victim rates declined by somewhat lesser amounts, - 13.9%, - 15.0% and - 13.4%, respectively. In Phase 3, the proportion of assault occurrences involving alcohol in communities 2, 3 and 4 rose towards pre-2008 levels. CONCLUSIONS: Early successes of these controversial alcohol restrictions are jeopardised. Indicators of violence and injury appear to be rising once more in some AMP communities. Importantly, rates have not generally exceeded the highest levels seen in Phase 1. Fresh policy action is required with rigorous monitoring to prevent erosion of initial important successes.

Incidence of middle ear barotrauma in staged versus linear chamber compression during hyperbaric oxygen therapy: a double blinded, randomized controlled trial.

CONTEXT: Middle ear barotrauma (MEB) is common during chamber compression in hyperbaric oxygen therapy. However, little evidence exists on an optimal compression protocol to minimize the incidence and severity of MEB. OBJECTIVE: To compare the incidence of MEB during hyperbaric oxygen therapy using two different chamber compression protocols. DESIGN: Double-blinded, randomized controlled trial. SETTING: Hyperbaric Medicine Unit, The Townsville Hospital, Queensland, Australia, September 2012 to December 2014. PATIENTS: 100 participants undergoing their first hyperbaric oxygen therapy session. INTERVENTION: Random assignment to a staged (n=50) or a linear (n=50) compression protocols. Photographs of tympanic membranes were taken pre- and post-treatment and then graded. Middle ear barotrauma was defined as an increase of at least one grade on a modified TEED scale. RESULTS: The observed MEB incidence under the staged protocol was 48% compared to 62% using the linear protocol (P=0.12, exact one-sided binomial test), and thus the staged protocol did not show a significant improvement in MEB. However, the staged protocol resulted in significantly less severe deteriorations in MEB grades when compared to the linear protocol (P=0.028, exact one-sided Mann-Whitney type test). CONCLUSION: The use of the assessed staged compression protocol for the first hyperbaric oxygen treatment showed no significant effect on the overall incidence of MEB when compared to the gold standard linear protocol but resulted in a significant improvement in the severity of the experienced MEBs. Further studies are needed to elucidate an optimal compression protocol to minimize middle ear barotrauma.

Early discharge using single cardiac troponin and copeptin testing in patients with suspected acute coronary syndrome (ACS): a randomized, controlled clinical process study.

AIMS: This randomized controlled trial (RCT) evaluated whether a process with single combined testing of copeptin and troponin at admission in patients with low-to-intermediate risk and suspected acute coronary syndrome (ACS) does not lead to a higher proportion of major adverse cardiac events (MACE) than the current standard process (non-inferiority design). METHODS AND RESULTS: A total of 902 patients were randomly assigned to either standard care or the copeptin group where patients with negative troponin and copeptin values at admission were eligible for discharge after final clinical assessment. The proportion of MACE (death, survived sudden cardiac death, acute myocardial infarction (AMI), re-hospitalization for ACS, acute unplanned percutaneous coronary intervention, coronary artery bypass grafting, or documented life threatening arrhythmias) was assessed after 30 days. Intention to treat analysis showed a MACE proportion of 5.17% [95% confidence intervals (CI) 3.30-7.65%; 23/445] in the standard group and 5.19% (95% CI 3.32-7.69%; 23/443) in the copeptin group. In the per protocol analysis, the MACE proportion was 5.34% (95% CI 3.38-7.97%) in the standard group, and 3.01% (95% CI 1.51-5.33%) in the copeptin group. These results were also corroborated by sensitivity analyses. In the copeptin group, discharged copeptin negative patients had an event rate of 0.6% (2/362). CONCLUSION: After clinical work-up and single combined testing of troponin and copeptin to rule-out AMI, early discharge of low- to intermediate risk patients with suspected ACS seems to be safe and has the potential to shorten length of stay in the ED. However, our results need to be confirmed in larger clinical trials or registries, before a clinical directive can be propagated.

HIV prevalence is strongly associated with geographical variations in male circumcision and foreskin cutting in Papua New Guinea: an ecological study.

OBJECTIVE: To examine the correlation between HIV prevalence and male circumcision and other foreskin cutting practices across the four regions of Papua New Guinea (PNG). DESIGN: An ecological substudy using unique data from an interdisciplinary research programme to evaluate the acceptability, sociocultural context and public health impact of male circumcision for HIV prevention in PNG. METHODS: Published data describing (a) self-reported circumcision status by region from the 'Acceptability and Feasibility of Male Circumcision for HIV prevention in PNG' study and (b) HIV prevalence by region from PNG National Department of Health were used to correlate male circumcision and other foreskin cutting practices and HIV prevalence. Maps were constructed to visually represent variations across the four regions of PNG. RESULTS: Regions of PNG with the highest HIV prevalence had the lowest prevalence of male circumcision and other forms of foreskin cutting and vice versa. Male circumcision and dorsal longitudinal cuts were strongly associated with HIV prevalence and able to explain 99% of the observed geographical variability in HIV prevalence in PNG (p<0.01). CONCLUSIONS: The regional prevalence of HIV infection in PNG appears to be closely correlated with the regional distribution of male circumcision and dorsal longitudinal foreskin cuts. Further research is warranted to investigate causality of this correlation as well as the potential of dorsal longitudinal cuts to confer protection against HIV acquisition in heterosexual men.

DEGRO practical guidelines for radiotherapy of non-malignant disorders: Part I: physical principles, radiobiological mechanisms, and radiogenic risk.

PURPOSE: Synopsis of the introductory paragraph of the DEGRO consensus S2e-guideline recommendations for the radiotherapy of benign disorders, including physical principles, radiobiological mechanisms, and radiogenic risk. MATERIALS AND METHODS: This work is based on the S2e-guideline recommendations published November 14, 2013. The basic principles of radiation physics and treatment delivery, evaluation of putative underlying radiobiological mechanisms, and the assessment of genetic and cancer risk following low-dose irradiation will be presented. RESULTS: Radiation therapy of benign diseases is performed according to similar physical principles as those governing treatment of malignant diseases in radiation oncology, using the same techniques and workflows. These methods comprise usage of orthovoltage X-ray units, gamma irradiation facilities, linear accelerators (LINACs), and brachytherapy. Experimental in vitro and in vivo models recently confirmed the clinically observed anti-inflammatory effect of low-dose X-irradiation, and implicated a multitude of radiobiological mechanisms. These include modulation of different immunological pathways, as well as the activities of endothelial cells, mono- and polymorphonuclear leukocytes, and macrophages. The use of effective dose for radiogenic risk assessment and the corresponding tumor incidence rate of 5.5%/Sv are currently controversially discussed. Some authors argue that the risk of radiation-induced cancers should be estimated on the basis of epidemiological data. However, such data are rarely available at present and associated with high variability. CONCLUSION: Current radiobiological studies clearly demonstrate a therapeutic effectiveness of radiation therapy used to treat benign diseases and implicate various molecular mechanisms. Radiogenic risks should be taken into account when applying radiation treatment for benign diseases.

Randomized trial of a single incision versus an outside-in transobturator midurethral sling in women with stress urinary incontinence: 12 month results.

OBJECTIVE: The objective of the study was to evaluate objective and subjective outcomes of MiniArc and Monarc (American Medical Systems, Minnetonka, MN) midurethral sling (MUS) in women with stress incontinence at 12 months. STUDY DESIGN: A total of 225 women were randomized to receive MiniArc or Monarc. Women with intrinsic sphincter deficiency, previous MUS, or untreated detrusor overactivity were excluded. Objective cure was defined as negative cough stress test with a comfortably full bladder. Subjective cure was defined as no report of leakage with coughing or exercise on questionnaire. Validated questionnaires, together with urodynamic and clinical cough stress test, were used to evaluate the objective and subjective outcomes following surgery. Participants and clinicians were not masked to treatment allocation. Outcomes were compared with exact binomial tests (eg, Fisher exact test for dichotomous data) for categorical data and Student t tests or exact versions of Wilcoxon tests for numerical data as appropriate. RESULTS: There was no statistically significant difference in the subjective (92.2% vs 94.2%; P = .78; difference, 2.0%; 95% confidence interval, -2.7% to +6.7%) or objective (94.4% vs 96.7%; P = .50; difference, 2.3%; 95% confidence interval, -1.5% to +6.1%) cure rates between MiniArc and Monarc at 12 m, respectively, with a significant improvement in overactive bladder outcomes and incontinence impact from baseline in both arms. CONCLUSION: MiniArc outcomes are not inferior to Monarc MUS outcomes at 12 months' follow-up in women without intrinsic sphincter deficiency.

Dynamic contrast-enhanced ultrasound for quantification of tissue perfusion.

Dynamic contrast-enhanced ultrasound (US) imaging, a technique that uses microbubble contrast agents with diagnostic US, has recently been technically summarized and reviewed by a European Federation of Societies for Ultrasound in Medicine and Biology position paper. However, the practical applications of this imaging technique were not included. This article reviews and discusses the published literature on the clinical use of dynamic contrast-enhanced US. This review finds that dynamic contrast-enhanced US imaging is the most sensitive cross-sectional real-time method for measuring the perfusion of parenchymatous organs noninvasively. It can measure parenchymal perfusion and therefore can differentiate between benign and malignant tumors. The most important routine clinical role of dynamic contrast-enhanced US is the prediction of tumor responses to chemotherapy within a very short time, shorter than using Response Evaluation Criteria in Solid Tumors criteria. Other applications found include quantifying the hepatic transit time, diabetic kidneys, transplant grafts, and Crohn disease. In addition, the problems involved in using dynamic contrast-enhanced US are discussed.

A randomised clinical trial to assess satisfaction with the levonorgestrel- releasing intrauterine system inserted at caesarean section compared to postpartum placement.

BACKGROUND: Insertion of levonorgestrel-releasing intrauterine system (LNG-IUS) at caesarean section (CS) provides contraception prior to resumption of ovulation or sexual activity. Patient satisfaction with insertion at CS has not previously been studied. AIMS: The aim of this study was to compare patient satisfaction with LNG-IUS inserted at the time of lower uterine segment CS to six weeks postpartum. MATERIALS AND METHODS: Open-label randomised controlled trial. Women booked for elective CS were randomised to LNG-IUS insertion either at the time of CS (study group) or at six weeks postpartum (control group). The primary outcome measure was patient satisfaction. Outcomes were measured at six weeks, three months and six months postpartum. RESULTS: Forty-eight women were randomised into two treatment groups. Twenty-five women were randomised to have LNG-IUS inserted at the time of CS, 23 of whom had the planned intervention and two had the LNG-IUS inserted postpartum. Twenty-three women were randomised to the control group, four of whom withdrew prior to treatment. The 44 remaining women contributed to data analysis. Patient satisfaction was high and similar in both groups. At six months postpartum, 90.5% of the study group were very satisfied or somewhat satisfied compared with 88.2% of the control group. CONCLUSIONS: Patient satisfaction is high with LNG-IUS insertion at CS and not different to that with delayed insertion. LNG-IUS insertion may be an option for women who find postpartum contraception difficult to access.

Study Protocol--Alcohol Management Plans (AMPs) in remote indigenous communities in Queensland: their impacts on injury, violence, health and social indicators and their cost-effectiveness.

BACKGROUND: In 2002/03 the Queensland Government responded to high rates of alcohol-related harm in discrete Indigenous communities by implementing alcohol management plans (AMPs), designed to include supply and harm reduction and treatment measures. Tighter alcohol supply and carriage restrictions followed in 2008 following indications of reductions in violence and injury. Despite the plans being in place for over a decade, no comprehensive independent review has assessed to what level the designed aims were achieved and what effect the plans have had on Indigenous community residents and service providers. This study will describe the long-term impacts on important health, economic and social outcomes of Queensland's AMPs. METHODS/DESIGN: The project has two main studies, 1) outcome evaluation using de-identified epidemiological data on injury, violence and other health and social indicators for across Queensland, including de-identified databases compiled from relevant routinely-available administrative data sets, and 2) a process evaluation to map the nature, timing and content of intervention components targeting alcohol. Process evaluation will also be used to assess the fidelity with which the designed intervention components have been implemented, their uptake and community responses to them and their perceived impacts on alcohol supply and consumption, injury, violence and community health. Interviews and focus groups with Indigenous residents and service providers will be used. The study will be conducted in all 24 of Queensland's Indigenous communities affected by alcohol management plans. DISCUSSION: This evaluation will report on the impacts of the original aims for AMPs, what impact they have had on Indigenous residents and service providers. A central outcome will be the establishment of relevant databases describing the parameters of the changes seen. This will permit comprehensive and rigorous surveillance systems to be put in place and provided to communities empowering them with the best credible evidence to judge future policy and program requirements for themselves. The project will inform impending alcohol policy and program adjustments in Queensland and other Australian jurisdictions.The project has been approved by the James Cook University Human Research Ethics Committee (approval number H4967 & H5241).

Cardiac surgery in Indigenous Australians--how wide is 'the gap'?

BACKGROUND: Cardiovascular disease remains the leading cause of mortality in the Indigenous Australian population. Limited research exists in regards to cardiac surgery in the Aboriginal and Torres Strait Islander (ATSI) population. We aimed to investigate risk profiles, surgical pathologies, surgical management and short term outcomes in a contemporary group of patients. METHODS: Variables were assessed for 557 consecutive patients who underwent surgery at our institution between August 2008 and March 2010. RESULTS: 19.2% (107/557) of patients were of Indigenous origin. ATSI patients were significantly younger at time of surgery (mean age 54.1±13.23 vs. 63.1±12.46; p=<0.001) with higher rates of preventable risk factors. Rheumatic heart disease (RHD) was the dominant valvular pathology observed in the Indigenous population. Significantly higher rates of left ventricular impairment and more diffuse coronary artery disease were observed in ATSI patients. A non-significant trend towards higher 30-day mortality was observed in the Indigenous population (5.6% vs. 3.1%; p=0.244). CONCLUSIONS: Cardiac surgery is generally required at a younger age in the Indigenous population with patients often presenting with more advanced disease. Despite often more advanced disease, surgical outcomes do not differ significantly from non-Indigenous patients. Continued focus on preventative strategies for coronary artery disease and RHD in the Indigenous population is required.

Anesthesia of tadpoles of the southern brown tree frog (Litoria ewingii) with isoeugenol (Aqui-S).

Because anesthesia of amphibian larvae is currently problematic, the aim of this study was to test if a fish anesthetic containing approximately 500 g/L isoeugenol (Aqui-S) could anesthetize tadpoles. Three concentrations of Aqui-S were tested (of commercial solution 10, 20, and 50 microl/L) with 10 tadpoles of the southern brown tree frog (Litoria ewingii) per concentration. Tadpoles were anesthetized for 15 min in water at 18-20 degrees C. Anesthetic criteria included four time points and two heart rates: time to loss of response to stimulation, loss of righting reflex, and return of spontaneous movement and of righting reflex after removal from Aqui-S, and heart rate after induction and after 15 min of anesthesia. No tadpole showed signs of irritation or excitement, no tadpole died, and all returned to normal behavior. The times for induction of anesthesia (time to loss of righting reflex) decreased significantly (P < 0.001) with increasing concentration: means of 27.5, 16.8, and 5.7 min for 10, 20, and 50 microl/L, respectively. Heart rate after 15 min of anesthesia was significantly lower (P = 0.006) for concentrations of 20 and 50 microl/L compared to 10 microl/L. At the lowest concentration (10 microl/L), anesthesia was light. Recovery times were significantly delayed (P < 0.001) for 50 microl/L, approximately double those for the lower concentrations. Spontaneous movements began at 56.9, 51.4, and 119 min for 10, 20, and 50 microl/L Aqui-S, respectively. Although Aqui-S did anesthetize tadpoles at all three concentrations, with 20 microl/L being the most suitable, additional longer-term toxicity testing is required prior to its adoption as an anesthetic agent for this species. Anesthesia, isoeugenol, Litoria ewingii, southern brown tree frog, tadpoles.

Foreskin cutting beliefs and practices and the acceptability of male circumcision for HIV prevention in Papua New Guinea.

BACKGROUND: Male circumcision (MC) reduces HIV acquisition and is a key public health intervention in settings with high HIV prevalence, heterosexual transmission and low MC rates. In Papua New Guinea (PNG), where HIV prevalence is 0.8%, there is no medical MC program for HIV prevention. There are however many different foreskin cutting practices across the country's 800 language groups. The major form exposes the glans but does not remove the foreskin. This study aimed to describe and quantify foreskin cutting styles, practices and beliefs. It also aimed to assess the acceptability of MC for HIV prevention in PNG. METHODS: Cross-sectional multicentre study, at two university campuses (Madang Province and National Capital District) and at two 'rural development' sites (mining site Enga Province; palm-oil plantation in Oro Province). Structured questionnaires were completed by participants originating from all regions of PNG who were resident at each site for study or work. RESULTS: Questionnaires were completed by 861 men and 519 women. Of men, 47% reported a longitudinal foreskin cut (cut through the dorsal surface to expose the glans but foreskin not removed); 43% reported no foreskin cut; and 10% a circumferential foreskin cut (complete removal). Frequency and type of cut varied significantly by region of origin (p < .001). Most men (72-82%) were cut between the ages of 10-20 years. Longitudinal cuts were most often done in a village by a friend, with circumferential cuts most often done in a clinic by a health professional. Most uncut men (71%) and longitudinal cut men (84%) stated they would remove their foreskin if it reduced the risk of HIV infection. More than 95% of uncut men and 97% of longitudinal cut men would prefer the procedure in a clinic or hospital. Most men (90%) and women (74%) stated they would remove the foreskin of their son if it reduced the risk of HIV infection. CONCLUSION: Although 57% of men reported some form of foreskin cut only 10% reported the complete removal of the foreskin, the procedure on which international HIV prevention strategies are based. The acceptability of MC (complete foreskin removal) is high among men (for themselves and their sons) and women (for their sons). Potential MC services need to be responsive to the diversity of beliefs and practices and consider health system constraints. A concerted research effort to investigate the potential protective effects of longitudinal cuts for HIV acquisition is essential given the scale of longitudinal cuts in PNG.

Heparin strongly induces soluble fms-like tyrosine kinase 1 release in vivo and in vitro--brief report.

OBJECTIVE: Soluble fms-like tyrosine kinase 1 (sFlt1) is involved in the pathophysiology of preeclampsia and coronary artery disease. Because sFlt1 has a heparin-binding site, we investigated whether or not heparin releases sFlt1 from the extracellular matrix. METHODS AND RESULTS: We measured sFlt1 before and after heparin administration in 135 patients undergoing coronary angiography, percutanous coronary intervention, or both. sFlt1 was increased directly after heparin administration (from 254 to 13,440 pg/mL) and returned to baseline within 10 hours. Umbilical veins and endothelial cells treated with heparin released sFlt1. Heparinase I and III also increased sFlt1. Mice treated with heparin had elevated sFlt1 serum levels. Their serum inhibited endothelial tube formation. CONCLUSIONS: Heparin releases sFlt1 by displacing the sFlt1 heparin-binding site from heparan sulfate proteoglycans. Heparin could induce an antiangiogenic state.

Soluble fms-like tyrosine kinase-1 (sFLT-1) predicts post-percutaneous coronary intervention (PCI) myocardial infarction (MI type 4a).

CONTEXT: Acute myocardial infarction (AMI) related to percutaneous coronary intervention (PCI) (MI type 4a) occurs in up to 26% of elective patients. OBJECTIVE: To evaluate if sFLT-1 helps to predict MI type 4a in troponin negative patients with elective PCI. MATERIALS AND METHODS: We enrolled 135 patients, 106 had a PCI. sFLT-1 levels were assessed at five time points before and after PCI. RESULTS: MI type 4a occurred in 22.1% of patients. sFLT-1 levels at admission above 251 pg/mL indicated a significant relative risk for MI type 4a of 2.83. CONCLUSION AND DISCUSSION: Increased sFLT-1 levels at baseline might indicate unstable atherosclerosis and risk for microembolization and thus be predictive of MI type 4a.