When fasted is not empty: a retrospective cohort study of gastric content in fasted surgical patients†.

Background: Perioperative aspiration leads to significant morbidity and mortality. Point-of-care gastric ultrasound is an emerging tool to assess gastric content at the bedside. Methods: We performed a retrospective cohort study of baseline gastric content on fasted elective surgical patients. The primary outcome was the incidence of full stomach (solid content or >1.5 ml kg−1 of clear fluid). Secondary outcomes included: gastric volume distribution (entire cohort, each antral grade); the association between gastric fullness, fasting intervals, and co-morbidities; anaesthetic management changes and incidence of aspiration. Results: We identified 538 patients. Thirty-two patients (6.2%) presented with a full stomach. Nine of these (1.7%) had solid content and 23 (4.5%) had clear fluid >1.5 ml kg−1. An empty stomach was documented in 480 (89.8%) patients. The examination was inconclusive in the remaining 20 patients (5.0%). As expected, increasing antral grade was correlated with larger antral cross-sectional area and higher gastric volume (P<0.001). Of the 32 patients with a full stomach, only six had a documented risk factor for prolonged gastric emptying. The anaesthetic management was changed in all nine patients with solid content. No aspiration was reported. Conclusions: This retrospective cohort study suggests that a small proportion of elective surgical patients may present with a full stomach despite the recommended duration of fasting. Further research is needed to establish the clinical implications of these findings in the elective setting. At present, the clinical role of gastric ultrasound continues to be for the evaluation of gastric contents to guide management when the risk of aspiration is uncertain or unknown.

Predictors of influenza in the adult population during seasonal and A(H1N1)pdm09 pandemic influenza periods.

We aimed to assess whether the characteristics of influenza-like illness (ILI) cases in the general population were similar during the seasonal and pandemic A(H1N1)pdm09 influenza periods. We conducted a study using a general population database, which included demographic (sex, age) and clinical (underlying medical conditions, influenza vaccination status) information on more than 80 000 subjects. We assessed the most important predictors of ILI during each season by using multiple logistic regression. We descriptively compared whether they were similar during different seasons. The model, including all demographic and clinical characteristics, showed that age ⩾60 years decreased the odds for ILI by 52% and 81% during the seasonal and A(H1N1)pdm09 pandemic periods, respectively. Being vaccinated decreased the odds of ILI for seasonal influenza by 32%, while suffering from the comorbidities other than lung or cardiovascular diseases doubled the odds of ILI during the A(H1N1)pdm09 pandemic.

Torsade de pointes during sevoflurane anesthesia and fluconazole infusion in a patient with long QT syndrome. A case report.

We present the occurrence of 'torsade de pointes' induced by the combination of peroperative fluconazole administration and sevoflurane anesthesia in a patient with 'long QT syndrome' (LQTS) scheduled for resection of a sacral abscess. Eight minutes following uneventful induction of anesthesia 'torsade de pointes' occurred, terminated by a counter shock. At this time the end-tidal concentration of sevoflurane was 2%. The fluconazole infusion was disconnected and the operation was continued. Post-operatively the patient awakened uneventfully. The direct postoperative ECG showed a QTc of 531 ms (preoperative QTc of 442 ms.) and remained prolonged afterwards. A long QT syndrome was the most likely diagnosis. LQTS is classified as either congenital or acquired. Patients with acquired LQTS may have an underlying predisposition for QT prolongation. Many drugs have shown to be associated with a prolonged QT interval (1). The syndrome in this particular patient was unmasked by sevoflurane. Concomitant administration of fluconazole might have further predisposed the patient to the development of 'torsade des pointes'. Although LQTS is relatively rare, it is important for the anesthesiologist to be familiar with the disease because of the associated morbidity and mortality and the potential for anesthesia to induce malignant arrhythmias in asymptomatic carriers.

Exercise prescription for patients with a Fontan circulation: current evidence and future directions.

It is well documented that children with a Fontan circulation have a reduced exercise capacity. One of the modalities to improve exercise capacity might be exercise training. We performed a systematic literature review on the effects of exercise training in patients with a Fontan circulation. Six published studies were included that reported on the effects of exercise training in 40 patients. All studies had a small sample size and/or did not include a control group.Based on the six published studies we can conclude that children who have undergone a Fontan operation and who are in a stable haemodynamic condition can safely participate in an exercise training programme and that exercise training results in an improved exercise capacity. However, more research is needed to establish the optimal exercise mode, dose-response relation, and the effects of exercise training on cardiac function, peripheral muscle function, physical activity, and health-related quality of life. (Neth Heart J 2007;15:142-7.).

Loss to follow-up of cervical smears without endocervical columnar cells is not disturbing.

OBJECTIVE: To investigate the six-month recommended follow-up after mass screening of Pap smears because of the absence of endocervical columnar cells (ECC-) or ECC+ smears with atypical squamous or glandular cells of undetermined origin (ASCUS/AGUS) or low-grade squamous or glandular intraepithelial lesions (LSIL/LGIL) in a Dutch mass screening cervical cancer programme. METHODS: Data were extracted from computerised medical records of national representative Dutch general practices. We have studied the attendance at and the outcome of the subsequent Pap smears after a 6-month recommendation. RESULTS: The six-month follow-up was linked to 8.7% of the Pap smears (n = 1,002); 77.6% were without endocervical columnar cells (ECC-). Clear differences were found between the follow-up of ECC+ and ECC- smears; after 36 weeks of follow-up of 43.5% the women had an ECC- smear and 66.9% had other conditions. For initial ECC- Pap smears, 84.1% had no abnormalities in the subsequent Pap smear; for initial ECC+ Pap smears, in about 64% of the cases no abnormalities were found (p < 0.0001). CONCLUSIONS: Repeating ECC- smears has a low follow-up rate but also lacks evidence-based necessity. However, for the other 6-month recommended Pap smears, one in five women had still not responded within one year, so improvement is necessary.

Mechanism of exercise-induced hypoglycemia during sulfonylurea treatment.

Exercise-induced hypoglycemia in diabetic patients on sulfonylurea treatment is not uncommon. However, its pathophysiology has not been examined. We studied 9 postabsorptive nondiabetic subjects after oral administration of 1.75 mg glyburide (glibenclamide) (protocol A), during 60 min of leg exercise on a bicycle ergometer at a work load of 80 +/- 10 W (protocol B), and during a combination of these conditions (protocol C). Serum glibenclamide levels rose to similar levels (160 ng/ml) with protocols A and C. Heart rate, blood pressure, and blood lactate levels increased immediately after onset of exercise and were comparable under conditions of protocols B and C. Serum insulin levels fell during protocol B from 6.1 +/- 0.6 to 4.0 +/- 0.3 microU/ml (P less than .001) but increased from 6.5 +/- 0.6 to 12.3 +/- 2.8 microU/ml during protocol A and from 6.6 +/- 0.6 to 12.7 +/- 4.3 microU/ml during protocol C, P less than .001. Maximal levels were reached at 80 min under both conditions. Comparable responses were seen for serum C-peptide concentrations. Blood glucose concentrations did not change during exercise alone. Glycemia decreased markedly after administration of the drug reaching a nadir of 49 +/- 3 mg/dl with protocol A and a nadir of 46 +/- 3 mg/dl under protocol C. However, the nadir was reached 80 min after oral ingestion of the drug when exercise and glyburide were combined, compared to 110 min (P less than .01) after ingestion of the drug alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Context effects of facial appearance on attitudes toward mentally handicapped persons.

The influence of facial appearance on social attitudes was examined by exposing participants to the faces of three target persons with or without deviant facial features, posing happy, angry or sad facial expressions, or a mixture of these expressions. When they displayed negative emotional expressions, facially deviant targets were judged more negatively than non-deviant targets. Irrespective of emotional expression and level of personal experience, participants expressed more negative attitudes toward mentally handicapped persons in general after exposure to deviant faces than after exposure to non-deviant faces, or in the absence of exposure. However, correlational analyses suggested that only at low levels of personal experience were attitudes influenced by previously formed impressions of deviant exemplars. Results are discussed in terms of the motivational relevance of physical features in stigmatization, and context and exemplar effects in stereotyping and attitude measurement. Practical implications are also discussed.

Interactions in vivo between the proteins of infectious bursal disease virus: capsid protein VP3 interacts with the RNA-dependent RNA polymerase, VP1.

Little is known about the intermolecular interactions between the viral proteins of infectious bursal disease virus (IBDV). By using the yeast two-hybrid system, which allows the detection of protein-protein interactions in vivo, all possible interactions were tested by fusing the viral proteins to the LexA DNA-binding domain and the B42 transactivation domain. A heterologous interaction between VP1 and VP3, and homologous interactions of pVP2, VP3, VP5 and possibly VP1, were found by co-expression of the fusion proteins in Saccharomyces cerevisiae. The presence of the VP1-VP3 complex in IBDV-infected cells was confirmed by co-immunoprecipitation studies. Kinetic analyses showed that the complex of VP1 and VP3 is formed in the cytoplasm and eventually is released into the cell-culture medium, indicating that VP1-VP3 complexes are present in mature virions. In IBDV-infected cells, VP1 was present in two forms of 90 and 95 kDa. Whereas VP3 initially interacted with both the 90 and 95 kDa proteins, later it interacted exclusively with the 95 kDa protein both in infected cells and in the culture supernatant. These results suggest that the VP1-VP3 complex is involved in replication and packaging of the IBDV genome.

Attendance to cervical cancer screening in family practices in The Netherlands.

BACKGROUND: The effectiveness of three different organizational approaches to cervical cancer screening (community based, family practice based, and a combination) was evaluated in nationally representative family practices. METHOD: We selected 122 family practices with a computerized sex-age register from a database of 1, 251 family practices, representative of all 4,758 family practices in The Netherlands. Approximately 40 practices were linked with each approach. We measured the attendance, the reasons for nonattendance, and the influence of a reminder on the attendance of women invited for cervical screening in September, October, and November 1996. The patients were grouped according to age. A cross-sectional design was used for the study. RESULTS: For younger women, the total attendance rate, coverage (percentage of women "protected" against cervical cancer), and control rate (percentage of women with medical reasons for nonattendance or postponement of the smear) were highest in practices using the family practice-based approach (68, 77, and 90%, respectively) and lowest in practices with the community-based approach (53, 62, and 68%, respectively). For older women, the family practice-based approach and the combination approach were associated with attendance rates significantly higher than those for the community-based approach (approximately 60, 80, and 80% vs 47, 67, and 70%, respectively). A reminder sent by the family physician to women not responding to an initial invitation increased the attendance rate by 7 to 11% in both age categories, depending on who had sent the first invitation. CONCLUSION: A family practice-based cervical screening approach appeared to be the most effective at a national level, achieving the highest attendance rate, coverage, and control rate.

VP1, the RNA-dependent RNA polymerase and genome-linked protein of infectious bursal disease virus, interacts with the carboxy-terminal domain of translational eukaryotic initiation factor 4AII.

Infectious bursal disease virus (IBDV), a member of the family Birnaviridae, is a non-enveloped, double-stranded RNA virus. Viral protein 1 (VP1), the putative RNA-dependent RNA polymerase, occurs in virions both as a free polypeptide and as a genome-linked protein, called VPg. To gain more insight in its function, we initiated a yeast two-hybrid screen. With this approach we identified the carboxy-terminal domain of eukaryotic translation initiation factor 4AII (eIF4AII) as an interactor for VP1. The association between these molecules was confirmed by co-immunoprecipitation analyses. eIF4A plays an essential role in the initiation of translation of both capped and uncapped mRNAs. Its association with IBDV VP1 suggests an involvement of this viral protein in IBDV mRNA translation. An interaction between VP1 and full-length eIF4AII was, however, not observed. In view of the known two-domain structure of eIF4AII it is conceivable that the interaction of VP1 with full-length eIF4AII requires collaborating proteins that open up its structure and expose the VP1-binding site in the carboxy-terminal domain. The biological relevance of the potential VP1-eIF4AII interaction is discussed.

Vaccination of high-risk patients against influenza: impact on primary care contact rates during epidemics. Analysis of routinely collected data.

A general practice (GP) based retrospective cohort study was conducted to assess the effects of influenza vaccination on the primary care contact rate during influenza epidemics. Given the rising workload of family physicians, particularly due to ageing of the population, it is very relevant to know to whether influenza vaccination of high-risk patients reduces the contact rate during epidemics. No effect of vaccination was found on the contact rate of GP during a mild epidemic period. During a 'normal' influenza epidemic, the workload was reduced through fewer contacts by patients with cardiovascular or diabetic diseases. Epidemic periods severe enough to show contact rate reduction occurred approximately every other year.

Improving population-based cervical cancer screening in general practice: effects of a national strategy.

OBJECTIVE: To assess the effects of a Dutch national prevention programme, aimed at general practitioners (GPs), on the adherence to organizational guidelines for effective cervical cancer screening in general practice. To identify the characteristics of general practices determining success. DESIGN: A prospective questionnaire study with pre- and post-measurement (before and 15 months after the introduction of the national programme). SETTING AND STUDY PARTICIPANTS: A random sample of one-third of all 4758 Dutch general practices. One GP was asked to participate per practice. INTERVENTION: A national GP prevention programme to improve population-based prevention of cervical cancer combining various methods for quality improvement in general practice, performed on a national, district and practice level. Outreach visitors were a key strategy in bringing about behavioural changes. MAIN OUTCOME MEASURES: The proportion of practices adhering to 10 recommendations (in four guidelines) to organize effective cervical cancer screening. RESULTS: After 15 months, all Dutch practices showed significant improvement in adherence to nine out of 10 recommendations. Two recommendations, in particular 'identifying women who should be medically excluded from screening' and 'sending a reminder to non-compliers' showed the largest absolute increases of 26% and 33%, respectively. Besides more intensive support of outreach visitors, practice characteristics such as 'computerization' and 'delegation of many clinical tasks to the practice assistant' were important in improving the adherence to guidelines. CONCLUSION: The national programme, with a combination of various methods for quality improvement, appeared to be effective in improving the organization of cervical screening in general practice. Computerization and, to a lesser extent, delegation of many clinical tasks to the practice assistant and more intensive support to practices, positively influenced the effectiveness of the national programme.

Design of the Dutch prevention of influenza, surveillance and management (PRISMA) study.

Rationale and design of a study on the cost-effectiveness of the Dutch influenza vaccination campaign are described. During two influenza epidemics, about 75,000 primary care patients recommended for influenza vaccination are included. Cases have fatal or non-fatal influenza, pneumonia, otitis media, acute respiratory disease (ARD), heart failure, myocardial infarction, depression or diabetes dysregulation. Per case four controls are sampled, frequency matched on age and high-risk co-morbidity (<18 years, 18-64, >/=65 healthy, >/=65 with co-morbidity). Baseline and outcome data are retrieved from patient records. During the 1999-2000 influenza A epidemic 5891 (7.9%) high-risk children, 24,848 (33.2%) high-risk adults aged 18-64 years, 18,484 (24.7%) elderly with co-morbidity and 25,527 (34.1%) healthy elderly had been included. The mortality rate was 5.2 per 1000 and 2035 non-fatal outcome events were recorded (incidence rate 27.2/1000).