Noninvasive ventilation immediately after extubation improves weaning outcome after acute respiratory failure: a randomized controlled trial.

INTRODUCTION: Noninvasive ventilation (NIV), as a weaning-facilitating strategy in predominantly chronic obstructive pulmonary disease (COPD) mechanically ventilated patients, is associated with reduced ventilator-associated pneumonia, total duration of mechanical ventilation, length of intensive care unit (ICU) and hospital stay, and mortality. However, this benefit after planned extubation in patients with acute respiratory failure of various etiologies remains to be elucidated. The aim of this study was to determine the efficacy of NIV applied immediately after planned extubation in contrast to oxygen mask (OM) in patients with acute respiratory failure (ARF). METHODS: A randomized, prospective, controlled, unblinded clinical study in a single center of a 24-bed adult general ICU in a university hospital was carried out in a 12-month period. Included patients met extubation criteria with at least 72 hours of mechanical ventilation due to acute respiratory failure, after following the ICU weaning protocol. Patients were randomized immediately before elective extubation, being randomly allocated to one of the study groups: NIV or OM. We compared both groups regarding gas exchange 15 minutes, 2 hours, and 24 hours after extubation, reintubation rate after 48 hours, duration of mechanical ventilation, ICU length of stay, and hospital mortality. RESULTS: Forty patients were randomized to receive NIV (20 patients) or OM (20 patients) after the following extubation criteria were met: pressure support (PSV) of 7 cm H2O, positive end-expiratory pressure (PEEP) of 5 cm H2O, oxygen inspiratory fraction (FiO2)≤40%, arterial oxygen saturation (SaO2)≥90%, and ratio of respiratory rate and tidal volume in liters (f/TV)<105. Comparing the 20 patients (NIV) with the 18 patients (OM) that finished the study 48 hours after extubation, the rate of reintubation in NIV group was 5% and 39% in OM group (P=0.016). Relative risk for reintubation was 0.13 (CI=0.017 to 0.946). Absolute risk reduction for reintubation showed a decrease of 33.9%, and analysis of the number needed to treat was three. No difference was found in the length of ICU stay (P=0.681). Hospital mortality was zero in NIV group and 22.2% in OM group (P=0.041). CONCLUSIONS: In this study population, NIV prevented 48 hours reintubation if applied immediately after elective extubation in patients with more than 3 days of ARF when compared with the OM group. TRIAL REGISTRATION NUMBER ISRCTN: 41524441.

Treatment Considerations in an HIV Elite Controller.

HIV elite controllers naturally suppress viral loads below limits of detection and evidence lack of evolution of infection for prolonged periods. The role of antiretroviral therapy (ART) in these individuals is controversial. Though recent data suggest that ART may decrease immune activation and prevent complications such as development of accelerated cardiovascular disease (CVD); treatment has not clearly demonstrated a benefit on clinical outcomes (e.g., HIV disease progression, CVD events, mortality). We describe a 49-year-old female HIV elite controller who presented with asymptomatic HIV infection for 26 years and review recent literature on the role of ART in this population.

Ketamine induction of p53-dependent apoptosis and oxidative stress in zebrafish (Danio rerio) embryos.

Ketamine is a widely used pharmaceutical that has been detected in water sources worldwide. Zebrafish embryos were used in this study to investigate the oxidative stress and apoptotic signals following a 24h exposure to different ketamine concentrations (0, 50, 70 and 90 mg L-1). Early blastula embryos (∼2 h post fertilisation-hpf) were exposed for 24 h and analysed at 8 and 26 hpf. Reactive oxygen species and apoptotic cells were identified in vivo, at 26 hpf. Enzymatic activities (superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), lactate dehydrogenase (LDH) and acetylcholinesterase (AChE)), glutathione levels (oxidised (GSSG) and reduced (GSH)), oxidative damage (lipid peroxidation (LPO) and protein carbonyls (CO)) as well as oxidative stress (gclc, gstp1, sod1 and cat), apoptosis (casp3a, casp6, casp8, casp9, aifm1 and tp53) and cell proliferation (pcna) related-genes were evaluated at 8 and 26 hpf. Caspase (3 and 9) activity was also determined at both time-points by colorimetric methods. Superoxide dismutase (SOD), catalase (CAT), glutathione levels (GSSG), caspase-9 and reactive oxygen species (ROS) were shown to be affected by ketamine exposure while in vivo analysis showed no difference in ROS. A significant up-regulation of superoxide dismutase (sod1) and catalase (cat) genes expression was also perceived. Ketamine-induced apoptosis was observed in vivo and confirmed by the apoptotic-related genes up-regulation. The overall results suggest that ketamine induced oxidative stress and apoptosis through the involvement of p53-dependent pathways in zebrafish embryos which could be important for the evaluation of the overall risk of ketamine in aquatic environments.

Reference 1D and 2D electrophoresis maps for potential disease related proteins in milk whey from lactating buffaloes and blood serum from buffalo calves (Water buffalo, Bubalus bubalis).

The aim of this study was to identify potential disease related proteins in milk whey of lactating buffaloes and blood serum of buffalo calves, in order to define a reference electrophoresis map for 1-DE and 2-DE. Additionally, changes in some protein patterns from buffalo calves during salmonellosis and lactating buffaloes during mastitis are presented. Milk samples were collected and distributed into groups: Milk samples from healthy buffaloes (SCC < 100.000 cells/ml, negative microbiology and CMT) (G1, n = 5) and buffaloes with subclinical mastitis (SCC > 500.000 cells/ml, positive microbiology and CMT) (G2, n = 5). Blood samples from buffalo calves (n = 6) were collected, and three calves were experimentally infected with Salmonella Dublin and samples analyzed before (M0) and 72 h after inoculation (M1). 1-DE was accomplished by loading 10 µg of TP into SDS-PAGE, stained with Coomassie blue. 2-DE was accomplished by loading 200 µg of TP into 11 cm, pH 3-10 non-linear IPG strips, followed by SDS-PAGE, stained with Coomassie blue. Protein bands/spots were excised, subjected to tryptic in-gel digestion and analyzed by LC/ESI-MS/MS. Protein identity was assigned using NCBI databases. After bands/spots from 1-DE and 2-DE were analyzed, a protein map with 35 and 40 different identified proteins in blood serum and milk whey, respectively, was generated. Significant changes in patterns of haptoglobin were observed in buffalo calves with salmonellosis and in patterns of IgLC, ß-lactoglobulin and α-lactalbumin of lactating buffaloes during mastitis. The establishment of a protein map for 1-DE and 2-DE, identifying potential disease related proteins, can help to address alterations during diseases in buffaloes.

Candida glabrata endophthalmitis treated successfully with caspofungin.

A 39-year-old man with Candida glabrata endophthalmitis was successfully treated with a 28-day course of intravenous caspofungin. Presence of underlying renal insufficiency and infection with a drug-resistant strain precluded use of amphotericin B or fluconazole. Intravitreal administration of antifungals and vitrectomy were not required. The role of caspofungin in Candida endophthalmitis is discussed.

The ectopic overexpression of a citrus gibberellin 20-oxidase enhances the non-13-hydroxylation pathway of gibberellin biosynthesis and induces an extremely elongated phenotype in tobacco.

Transgenic plants of Nicotiana tabacum overexpressing a gibberellin (GA) 20-oxidase cDNA (CcGA20ox1) from citrus, under the control of the 35S promoter, were taller (up to twice) and had larger inflorescences and longer flower peduncles than those of control plants. Hypocotyls of transgenic seedlings were also longer (up to 4 times), and neither the seedlings nor the growing plants elongated further after application of GA3. Hypocotyl and stem lengths were reduced by application of paclobutrazol, and this inhibition was reversed by exogenous GA3. The ectopic overexpression of CcGA20ox1 enhanced the non-13-hydroxylation pathway of GA biosynthesis leading to GA4, apparently at the expense of the early-13-hydroxylation pathway. The level of GA4 (the active GA from the non-13-hydroxylation pathway) in the shoot of transgenic plants was 3-4 times higher than in control plants, whereas that of GA1, formed via the early-13-hydroxylation pathway (the main GA biosynthesis pathway in tobacco), decreased or was not affected. GA4 applied to the culture medium or to the expanding leaves was found to be at least equally active as GA1 on stimulating hypocotyl and stem elongation of tobacco plants. The results suggest that the tall phenotype of tobacco transgenic plants was due to their higher content of GA4, and that the GA response was saturated by the presence of the transgene.

Deep sternal wound infection caused by group g streptococcus after open-heart surgery.

We report the first case of deep sternal wound infection caused by group G Streptococcus after open-heart surgery. The patient's clinical presentation was nonspecific and his diagnosis was delayed. Surgical debridement and a 4-week course of intravenous antibiotics consisting of sequential penicillin plus gentamicin/ceftriaxone led to recovery. Group G Streptococcus should be suspected as an important postoperative pathogen.

Pseudomonas spp: contamination sources in bulk tanks of dairy farms / Pseudomonas spp: fontes de contaminação em tanques de expansão em fazendas leiteiras

This study focused on isolating Pseudomonas spp. during milking process in ten dairy farms with manual and mechanical milking systems during dry and rainy seasons, and evaluating DNA homology and patterns of distribution between isolates, in order to identify main sources of milk contamination by Pseudomonas spp. A total of 167 isolates of Pseudomonas spp. were obtained from water, milkers' hands, cows' teats, teat cups, cooling tanks and raw milk. Bacteria of Pseudomonas spp. genus were isolated from 85 and 82 sampling points in dairy farms with manual and mechanical milking system, respectively. A significant difference (p=0.02) on Pseudomonas spp. isolation was observed among samples of surface of cows' teats before and after pre-dipping, but no significant difference (p>0.05) was observed among milking systems or seasons. The possibility of the same Pseudomonas spp. patterns are distributed in different farms and seasons using Amplified Fragment Length Polymorphism (AFLP) technique was demonstrated. Milkers' hands, surface of cows' teats, teat cups and cooling tanks were associated with raw milk contamination with Pseudomonas spp. on farms with manual and mechanical milking system, showing that regardless of the type of milking system and season, proper hygiene procedures of equipment, utensils and workers' hands are essential to avoid contamination of the milk and, therefore, improve milk quality.(AU)

Este estudo se propôs a isolar Pseudomonas spp. durante o processo de ordenha em dez fazendas com sistemas manuais e mecanizados, durante as estações seca e chuvosa, além de avaliar a homologia do DNA e seus padrões de distribuição entre os isolados, a fim de se determinar as principais fontes de contaminação do leite. Cento e sessenta e sete isolados de Pseudomonas spp. foram obtidos a partir de amostras de água, mãos de ordenhadores, tetos, teteiras, tanques de resfriamento e leite cru armazenado, sendo 85 e 82 pontos de amostragem em fazendas com sistemas de ordenha manual e mecânico, respectivamente. Diferença estatisticamente significativa foi encontrada entre os isolados observados entre a superfície dos tetos antes e após o pré-dipping (p=0,02), mas nenhuma diferença foi encontrada entre sistemas de ordenha ou estações (p>0,05). A possibilidade do mesmo padrão de Pseudomonas spp. estar distribuído em diferentes fazendas ou estações foi avaliada pela técnica de Polimorfismo do Tamanho de Fragmento Amplificado (AFLP). As mãos de ordenhadores, superfície dos tetos das vacas, teteiras e tanques de resfriamento foram associados com a contaminação do leite cru, demonstrando que independente do tipo de ordenha e estação, a higiene adequada de equipamentos, utensílios e mãos dos ordenhadores é essencial para evitar contaminação do leite, e consequentemente aumentar sua qualidade.(AU)

Topical intraocular pressure therapy effects on pregnancy.

PURPOSE: To assess the course of intraocular pressure (IOP), visual field progression, and adverse effects of antiglaucoma medication used during pregnancy. METHODS: Thirteen eyes of eight patients with glaucoma were examined. Their clinical records were reviewed to compare IOP, number of medications, and visual field indices (VFI) before, during, and after pregnancy using a two-tailed paired t-test. RESULTS: In seven (87.5%) of the eight patients, no disease progression was observed. IOP (mmHg) remained stable (baseline 17.3 ± 3.6; first trimester 17.4 ± 5.2, P = 0.930; second trimester 18.1 ± 4.7, P = 0.519; third trimester 20.2 ± 8.7, P = 0.344; and postpartum 21.5 ± 7.6, P = 0.136). The mean number of glaucoma treatments fell from 1.7 ± 0.52 before pregnancy to 0.83 ± 0.75 (P = 0.04) in the second and third trimesters. In one patient, IOP increased during pregnancy and there was further visual field loss. In the only patient kept on fixed combination timolol-dorzolamide therapy throughout pregnancy, labor was induced because of delayed intrauterine growth. CONCLUSIONS: No changes in IOP and VFI were detected in most patients despite a reduction in the number of hypotensive agents required. Delayed intrauterine growth in one patient under fixed combination timolol-dorzolamide treatment was observed whereas no other adverse effects were detected.

Reciprocal influence of ethylene and gibberellins on response-gene expression in Arabidopsis thaliana.

The complexity of hormonal responses and their functional overlap support the presence of an intensive cross-talk between hormone signalling pathways. A detailed analysis of responses induced by ethylene and gibberellin (GA) in a GA-insensitive mutant (gai), an ethylene-resistant mutant (etr1-3), the gai etr1-3 double-mutant, and in wild-type Arabidopsis thaliana plants, revealed multiple interactions between ethylene and GA signal transduction pathways. Ethylene insensitive mutants and wild-type plants treated with 1-methylcyclopropene (1-MCP), an ethylene perception inhibitor, displayed a stronger responsiveness of genes differentially regulated by GA. In addition, microarray-analysis showed that the GA-response in an ethylene-insensitive background is different from that in the wild-type, confirming the importance of ethylene in a plant's response towards GA. In this paper, we present a number of genes with an altered response-pattern as a direct consequence of cross-talk between ethylene and GA.

Engineering of gibberellin levels in citrus by sense and antisense overexpression of a GA 20-oxidase gene modifies plant architecture.

Carrizo citrange (Citrus sinensisxPoncirus trifoliata) is a citrus hybrid widely used as a rootstock, whose genetic manipulation to improve different growth characteristics is of high agronomic interest. In this work, transgenic Carrizo citrange plants have been produced overexpressing sense and antisense CcGA20ox1 (a key enzyme of GA biosynthesis) under control of the 35S promoter to modify plant architecture. As expected, taller (sense) and shorter (antisense) phenotypes correlated with higher and lower levels, respectively, of active GA1 in growing shoots. In contrast, other phenotypic characteristics seemed to be specific to citrus, or different from those described for similar transgenics in other species. For instance, thorns, typical organs of citrus at juvenile stages, were much longer in sense and shorter in antisense plants, and xylem tissue was reduced in leaf and internode of sense plants. Antisense plants presented a bushy phenotype, suggesting a possible effect of GAs on auxin biosynthesis and/or transport. The main foliole of sense plants was longer, although total leaf area was reduced. Leaf thickness was smaller in sense and larger in antisense plants due to changes in the spongy parenchyma. Internode cell length was not altered in transgenic plants, indicating that, in citrus, GAs regulate cell division rather than cell elongation. Interestingly, the phenotypes described were not apparent when transgenic plants were grafted on non-transgenic rootstock. This suggests that roots contribute to the GA economy of aerial parts in citrus and opens the possibility of using the antisense plants as dwarfing rootstocks.

Regulation of gibberellin 20-oxidase gene expression and gibberellin content in citrus by temperature and citrus exocortis viroid.

A cDNA clone coding for a gibberellin (GA) 20-oxidase ( CcGA20ox1), an enzyme of GA biosynthesis, which when expressed in vitro catalyzed the conversion of GA(12) to GA(9) and of GA(53) to GA(20), was isolated from the citrus hybrid Carrizo citrange (C itrus sinensis x Poncirus trifoliata). Transcripts of CcGA20ox1 were abundant in the apex and leaves and much less abundant in internodes, nodes and roots. Seedlings of Carrizo citrange cultured under a 32 degrees C/27 degrees C (day/night) regime elongated more than seedlings growing under 17 degrees C/12 degrees C conditions. The effect of higher temperature was associated with more CcGA20ox1 transcripts and with higher content of GA(1), the main active GA in citrus, in the shoot. The infection of Etrog citron ( Citrus medica) plants with citrus exocortis viroid (CEVd), which produces a stunted phenotype, reduced the levels of transcripts in the apical shoot hybridizing to the gene CcGA20ox1 of Carrizo citrange and the content of GA(1). Thus GA(1) content correlated with CcGA20ox1 transcript levels. In contrast, results for gibberellic acid (GA(3)) and paclobutrazol applications to Carrizo citrange showed that CcGA20ox1 expression was subject to feed-back regulation. These observations indicate that the feed-back regulation of GA20ox operates mostly when the levels of active GAs have been dramatically altered. The results also show that the growth reduction induced by environmental (temperature) and biotic (CEVd) factors may be partially due to the modulation of the expression of GA20ox genes.

Endophthalmitis caused by non-perfringens Clostridium species.

The role of other non-perfringens Clostridium species in endophthalmitis infections has not been analyzed. We describe a case of non-perfringens Clostridium endophthalmitis and review prior cases in the literature. Fulminant clinical presentations and poor visual outcomes are the rule, but a combined aggressive medical and surgical approach may conserve vision.