DNA sequencing demonstrates the importance of jellyfish in life cycles of lepocreadiid trematodes.

Sequence data were combined with morphological analyses to identify two lepocreadiid trematode species from jellyfishes and fishes. Three species of jellyfish were captured within Port Phillip Bay, Australia, and three species of fish that feed on jellyfish were obtained from Moreton Bay (Queensland) and Port Phillip Bay and Portland (Victoria). The digeneans were distributed throughout most parts of the jellyfish. Opechona cf. kahawai Bray & Cribb, 2003 parasitized the scyphozoan jellyfish Aequorea eurodina and the scombrid fish Scomber australasicus. Cephalolepidapedon warehou Bray & Cribb, 2003 parasitized the scyphozoans Pseudorhiza haeckeli and Cyanea annaskala, and the centrolophid fishes Seriolella brama and Seriolella punctata. Intensities ranged from four to 96 in the jellyfish, and one to 30 in the fish. For both trematode species, internal transcribed spacer 2 of ribosomal DNA sequences from mature adults in the fishes matched those from metacercariae from the jellyfish. This is the first record of larval stages of C. warehou and O. cf. kahawai, and the first use of DNA sequencing to identify digenean trematode metacercariae from jellyfish. Three new host records are reported for C. warehou and two for O. cf. kahawai.

Impact of outcomes data on the management of postoperative hypocalcemia in head and neck endocrine surgery patients.

Postoperative hypocalcemia is a well-described outcome following thyroid and parathyroid surgery with symptoms ranging from clinically insignificant laboratory findings to tetany and seizures. The aims of this study were 1. To identify the characteristics and management patterns of postoperative hypocalcemia in head and neck endocrine surgery patients and 2. To compare outcomes between patients treated with empiric calcium and patients treated using a biochemically driven calcium replacement algorithm. Clinical electronic medical record (EMR) data was collected from patients who had undergone total thyroidectomy, completion thyroidectomy, and/or parathyroidectomy at Wake Forest Baptist Medical Center (WFBMC), a tertiary referral and academic institution. Between July 1, 2016, and June 30, 2017, 298 adult patients underwent surgery by a WFBMC Head & Neck (H&N) endocrine surgeon. Objective calcium and parathyroid hormone levels, postoperative supplementation with calcium and Vitamin D, 30-day physician access line (PAL) phone call utilization, emergency department (ED) encounters, and readmission rates were queried. The overall rate of hypocalcemia was 17.4%. No statistically significant difference in PAL utilization, ED visits, or readmissions was found between the empiric supplementation group and those whose supplementation was biochemically directed (PAL 5.0% vs. 5.0% [p = 0.983], ED visit 3.3% vs. 2.5% [p = 0.744], Readmission 1.7% vs. 0% [p = 0.276]). The overall postoperative rates of hypocalcemia and hypoparathyroidism following H&N endocrine surgery were consistent with the reported literature. Neither method of calcium supplementation was superior in reducing PAL utilization, ED encounters, or readmission.

A multistage mixed methods study protocol to evaluate the implementation and impact of a reconfiguration of acute medicine in Ireland's hospitals.

BACKGROUND: To address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation. METHODS: We will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme's outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme's implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme's outcomes can be explained by the level of implementation. DISCUSSION: This formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.

Iodine supplementation of the pregnant dam alters intestinal gene expression and immunoglobulin uptake in the newborn lamb.

Excess iodine intake by the pregnant dam reduces lamb serum antibody concentration, specifically immunoglobulin G (IgG). An experiment was conducted to investigate the mechanisms under pinning the reduced serum IgG concentration at 24 h postpartum in the progeny of iodine supplemented dams. Forty-five mature twin bearing ewes (n=15/treatment) were allocated to one of three dietary treatments as follows: basal diet (Control); basal diet plus 26.6 mg of iodine per ewe per day as calcium iodate (CaIO3); or potassium iodide (KI). Ewes were individually housed and fed from d 119 of gestation until parturition. All lambs received colostrum at 1, 10 and 18 h postpartum via stomach tube. At 1 h postpartum lambs from the control and an iodine supplemented treatment (n=10 per treatment from control and CaIO3) were euthanised before colostrum consumption and ileal segments isolated to determine the gene expression profile of a panel of genes identified as having a role in antibody transfer. Preceding euthanasia, lambs were blood sampled for determination of serum IgG, total thyroxine and free tri-iodothyronine concentrations. Progeny of CaIO3 supplemented dams had lower tri-iodothyronine concentrations (P<0.01) at 1 h postpartum and lower serum IgG concentrations (P<0.001) at 24 h postpartum when compared with the progeny of control dams. Iodine (CaIO3) supplementation of the dam increased the relative expression (P<0.05) of the B2M, PIGR and MYC genes in the ileum of the lamb, before colostrum consumption; while the expression of THRB declined when compared with the progeny of C dams (P<0.01). In conclusion, the results of this study show that it is the actual inclusion of excess iodine in the diet of the ewe, regardless of the carrier element, that negatively affects passive transfer in the newborn lamb. This study presents novel data describing the relationship between maternal iodine nutrition and its effect on the thyroid hormone status and subsequent gene expression in the newborn lamb; which results in a failure of passive transfer and a decline in serum IgG concentration.

Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England.

AIMS: English national guidelines recommend that breast reconstruction is made available to women with breast cancer undergoing mastectomy. We examined the use of immediate reconstruction (IR) across English Cancer Networks, who are responsible for the regional organisation of cancer services and ensuring equitable access to treatment. METHODS: We analysed Hospital Episodes Statistics data for all women with breast cancer who underwent mastectomy in the English NHS between April 2006 and February 2009. IR rates were calculated for the 30 Networks. Multivariable logistic regression was used to adjust the rates for patient age, comorbidity, ethnicity and socioeconomic deprivation. RESULTS: Of 44 837 mastectomy patients, 7375 (16.5%) underwent IR. The IR rate was highest in women under 50 years (32.7%) and lowest in women aged 70 years or over (1.5%), and was lower in women with more comorbidities. Unadjusted IR rates varied from 8.4% to 31.9% among the 30 Networks (p<0.001). Adjusting for their patient characteristics did not appreciably reduce Network-level variation, with adjusted IR rates still ranging from 8.0% to 29.4% (p<0.001). The risk-model also suggested that non-white women and those from more deprived areas were less likely to undergo immediate reconstruction. CONCLUSIONS: There is substantial regional variation in immediate reconstruction use in England that is not explained by the characteristics of the local patient population. English Cancer Networks should act to reduce this variation. They should also examine why rates of reconstruction differ between particular patient groups.

Facet joint injection: a rare form cause of epidural abscess formation.

The posterior zygo-apophyseal joints (facet joints) may be a significant source of back pain. Invasive treatment typically consists of injecting the joints with local anaesthetic and steroid or by radiofrequency ablation of the nerve supply to the joint. Facet joint injection is generally considered to be a very safe procedure with few significant side effects reported. Epidural abscess is a rare but potentially very serious occurrence. Most cases occur spontaneously but the condition may complicate epidural anaesthesia, spinal anaesthesia or epidural steroid injection. We report a case in which facet joint injections resulted in epidural abscess formation. To our knowledge this has not previously been reported.

Development and characterization of novel erythropoiesis stimulating protein (NESP).

Studies on human erythropoietin (EPO) demonstrated that there is a direct relationship between the sialic acid-containing carbohydrate content of the molecule and its serum half-life and in vivo biological activity, but an inverse relationship with its receptor-binding affinity. These observations led to the hypothesis that increasing the carbohydrate content, beyond that found naturally, would lead to a molecule with enhanced biological activity. Hyperglycosylated recombinant human EPO (rHuEPO) analogues were developed to test this hypothesis. Darbepoetin alfa (novel erythropoiesis stimulating protein, NESP, ARANESP, Amgen Inc, Thousand Oaks, CA), which was engineered to contain 5 N-linked carbohydrate chains (two more than rHuEPO), has been evaluated in preclinical animal studies. Due to its increased sialic acid-containing carbohydrate content, NESP is biochemically distinct from rHuEPO, having an increased molecular weight and greater negative charge. Compared with rHuEPO, it has an approximate 3-fold longer serum half-life, greater in vivo potency, and can be administered less frequently to obtain the same biological response. NESP is currently being evaluated in human clinical trials for treatment of anaemia and reduction in its incidence.

The effects of EMLA and a topical formulation of 4% amethocaine (Ametop) on pain associated with retrobulbar injection.

Retrobulbar block is commonly performed to provide anaesthesia for cataract extraction. This technique can cause significant discomfort. A prospective, randomised, placebo-controlled trial was carried out to investigate the efficacy of a eutectic mixture of local anaesthetics (EMLA) and a 4% amethocaine topical formulation (Ametop) in reducing the pain of retrobulbar injection. Ametop and EMLA proved to be of similar efficacy, both being superior to a placebo in alleviating the discomfort of retrobulbar block. No significant side-effects were observed with the use of either formulation.

Enhancement of the amplitude of somatosensory evoked potentials following magnetic pulse stimulation of the human brain.

In this study we have demonstrated an enhancement of cortically generated wave forms of the somatosensory evoked potential (SEP) following magnetic pulse stimulation of the human brain. Subcortically generated activity was unaltered. The enhancement of SEP amplitude was greatest when the median nerve was stimulated 30-70 msec following magnetic pulse stimulation over the contralateral parietal scalp. We posit that the enhancement of the SEP is the result of synchronization of pyramidal cells in the sensorimotor cortex resulting from the magnetic pulse.

Recombinant human erythropoietin and autologous blood donation.

Risks of transfusion are minimized with autologous blood. However, autologous donation programs require 2 to 5 weeks to yield only 2.2 units per patient. Recombinant human erythropoietin (r-HuEPO) has been shown to increase erythropoiesis. This study evaluated the effects of r-HuEPO on an aggressive autologous donation program. Twelve adult male baboons were randomized into two groups of six. All animals were studied three times per week for 5 weeks. A unit of blood was donated when on any study day the hematocrit was greater than 30%. Animals received intravenously either 750 units/kg of r-HuEPO (n = 6) or placebo (n = 6) on each study day. Iron dextran was given intravenously to replace 150% of shed iron. The r-HuEPO group had an earlier onset of reticulocytosis (2.7 vs 5.5 days, p less than 0.01) and donated 35% more blood (13.5 vs 10.0 units, p = 0.01) than the control group. No adverse reactions to r-HuEPO were observed. The data show that an aggressive autologous donation program can yield 10 units of blood over a 5-week period. Further, r-HuEPO increases that yield by an additional 35%. This aggressive autologous donation program with r-HuEPO may significantly reduce the need for homologous transfusion and its attendant risks.

Potential of organic cation-saturated montmorillonite as treatment for poisoning by weak bases.

The preferential adsorption of the protonated form of weak bases by montmorillonite causes an increase in the pKeff of atrazine. The effect on the acid-base equilibrium of atrazine is related to the exchangeable cation on the surface of montmorillonite. The greatest effect was produced by the presence of 3-hydroxypropylammonium-saturated montmorillonite, which caused the pKeff of atrazine to increase 5.3 units to 6.9. This shift in pKeff causes the protonated form of atrazine to be the predominate species in the pH range encountered in the GI tract and should result in a high degree of adsorption of atrazine. Fraction-bound studies confirmed this hypothesis by demonstrating virtually complete absorption of atrazine by 3-hydroxypropylammonium-saturated montmorillonite up to pH 6. The fraction-bound studies also verified that protonated atrazine is adsorbed more completely by 3-hydroxypropylammonium-saturated montmorillonite than by bentonite USP or sodium-saturated montmorillonite. It is believed that saturation of the clay surface by an organic cation alters the surface environment of the clay, which results in enhanced adsorption of the protonated form of atrazine. The potential utility of montmorillonite saturated with an organic cation as an adsorbent for the emergency treatment of poisoning by weak bases is suggested.