Usefulness of non-invasive spectrophotometric haemoglobin estimation for detecting low haemoglobin levels when compared with a standard laboratory assay for preoperative assessment.

BACKGROUND: Delay in diagnosis of anaemia during preoperative assessment poses logistic problems, leading to multiple clinic visits, inadequate preoperative management, and unnecessary delay of surgery. Therefore, we tested an instant spectrophotometric haemoglobin (SpHb) measurement technique to facilitate this assessment. METHODS: We evaluated portable instant SpHb vs standard laboratory screening of anaemia between March 2012 and December 2013. Paired Hb measurements were performed on 726 patients using SpHb (Pronto-7, Masimo Corporation, Irvine, CA, USA) and Hb measured on the same day using an automated analyser. The results were obtained from a group of 638 patients from the pre-anaesthetic clinic with expected normal Hb values, and 88 patients from the oncology clinic with known low Hb. RESULTS: Median (range) SpHb was 129.5 (67-171) compared with 136 g litre(-1) (63-178) Hb measured using the automated system. Identifying Hb below a threshold of 130 g litre(-1) for males had a high sensitivity (93%), while identifying a threshold of 120 g litre(-1) for females had lower sensitivity (75%). The specificity for males (77%) and females (81%) was similar. Mean measurement bias and agreement: tolerability interval ratio was -8.1 g litre(-1) and 2.78 for men and -3.1 g litre(-1) and 2.44 for women. CONCLUSIONS: SpHb was sensitive as a preliminary screening tool for detecting true low Hb values in males, but less sensitive in females. Instant SpHb measurement may enable prompt routine preoperative anaemia management, but its precision was lower than expected. CLINICAL TRIAL REGISTRATION: This study is approved by the Tasmanian Human Ethics Committee, Australia and was registered prospectively in the Australian and New Zealand Clinical Trials Registry (http://www.ANZCTR.org.au/ ACTRN12611001256965) and the World Health Organization Clinical Trials Registry (http://apps.who.int/trialsearch/trial.aspx?trialid=ACTRN12611001256965).

Antimicrobial susceptibilities and resistance genes in Campylobacter strains isolated from poultry and pigs in Australia.

AIMS: To evaluate the phenotypic and genotypic profiles of Campylobacter spp. from poultry faecal samples from free range or intensively raised meat chickens and free range egg layers. In addition, a case-comparison study of antibiotic resistance genes from different groups of poultry and some pig strains previously collected was carried out. METHODS: Resistance to different antibiotics was assessed using the agar dilution method. In addition, all the strains were tested for ampicillin (bla(OXA-61) ), erythromycin (aph-3-1), tetracycline tet(O), streptomycin (aadE), and the energy-dependent multi-drug efflux pump (cmeB) resistance genes using multiplex polymerase chain reaction. RESULTS: The evaluation of phenotypic resistance revealed all of the strains from poultry were sensitive to ciprofloxacin, gentamicin, erythromycin or tylosin. But, widespread resistance to lincomycin (51-100%), extensive resistance to ampicillin (33·3-60·2%) and less resistance to tetracycline (5·6-40·7%) were observed in the different groups of chickens. Antibiotic resistance genes bla(OXA-61,) cmeB and tet(O) were found in 82·6-92·7%, 80·3-89% and 22·3-30·9% Camp. coli isolates from pigs, whilst 59-65·4% and 19·2-40·7% Camp. jejuni from chickens were found to encode bla(OXA-61) and tet(O), respectively. CONCLUSION: No significant difference between isolates from free range egg layers and meat chickens (P < 0·05) was found. However, there were significant differences between the pig strains and all the groups of poultry strains (P < 0·05) with regard to carriage of resistance genes. In addition, pulsed field gel electrophoresis of selected resistant isolates from the poultry and pig revealed closely related clonal groups. SIGNIFICANCE AND IMPACT OF THE STUDY: Our results suggest the resistant strains are persisting environmental isolates that have been acquired by the different livestock species. Furthermore, the different treatment practices in poultry and pigs have resulted in differences in resistance profiles in Campylobacter isolates.

Improving the improvisational pelvic circumferential compression technique for open-book pelvic fractures using a simulation model and a sphygmomanometer.

BACKGROUND: Open-book pelvic fractures are associated with significant mortality. Emergency management may require a commercial pelvic circumferential compression device to reduce the fracture and compress haemorrhaging pelvic vasculature. Standard, commercial, twin-sized bedsheets are acceptable should commercial devices be unavailable. However, obese victims or personnel with insufficient body strength may impede successful reduction. OBJECTIVE: To demonstrate the value of an improvisational windlass (intravenous pole) in improving the ability to reduce an open-book pelvic fracture. METHODS: The Institutional Review Board-approved study involved 28 diverse healthcare students and emergency medicine residents. Each participant's demographic information and physical characteristics were recorded. A METIman was prepared with knee and ankle binding and a sphygmomanometer set at 40 mm Hg placed over the symphysis pubis. Two-person teams were randomly selected to place a bedsheet at greater trochanter level and atop the sphygmomanometer. The bedsheet was secured with maximum effort by the pairs and the pressure recorded. Following this, the pairs inserted an intravenous pole in the knot and torqued the pole to maximum effort and a repeat pressure recorded. RESULTS: The mean increase in pressure using only the bedsheet was 106.43 mm Hg per team. With bedsheet and intravenous pole, the mean pressure increase was 351.79 mm Hg per team. The difference was statistically significant (independent samples t-test: t = 17.177, p < 0.001, 95% CI (216.65 to 274.07 mm Hg). There was no correlation between pressure increases and the individual physical characteristics of the subjects (r = - 0.183, p = 0.352). CONCLUSIONS: Regardless of personnel's physical attributes, the addition of an improvisational windlass to a pelvic circumferential compression bedsheet can improve the ability to reduce an open-book fracture, especially in obese victims.

A baseline survey of the microbiological quality of chicken portions and carcasses at retail in two Australian states (2005 to 2006).

Raw poultry products were purchased from the retail market place in two Australian states, New South Wales (n = 549) and South Australia (n = 310). The products sampled on a proportional volume basis were chicken portions with the skin off or skin on, in bulk or tray packs, and whole carcasses. They were collected from butcher shops, supermarkets, and specialty stores from urban areas during the winter (2005) and summer (2006) months. The samples were analyzed to determine the prevalence and concentration of Escherichia coli, Salmonella, and Campylobacter spp. in addition to total viable counts. Salmonella was found in 47.7 and 35.5% of retail chicken samples (35.3 and 21.9% were the less virulent Salmonella Sofia), at mean counts of -1.42 and -1.6 log MPN/cm2 in New South Wales and South Australia, respectively. Campylobacter was found in 87.8 and 93.2% of samples at mean counts of 0.87 and 0.78 log CFU/cm2, respectively. In both states in both seasons, the mean total viable count was 5 log CFU/cm2. On whole birds, E. coli was detected in all winter samples and on 92.9 and 85.7% of summer samples in New South Wales and South Australia, respectively; the log of the geometric mean per square centimeter was 0.5 in winter and slightly lower in summer. On chicken portions, E. coli was detected in around 90% of winter samples in both states, and in summer on 75.1 and 59.6% of samples in New South Wales and South Australia, respectively. The log of the geometric mean CFU per square centimeter for E. coli was 0.75 and 0.91 in winter, and 0.66 and 0.5 in summer in New South Wales and South Australia, respectively.

Effect of diet and Lactobacillus acidophilus supplements on human fecal bacterial enzymes.

The effect of diet and Lactobacillus acidophilus supplements on fecal microflora enzyme activity was studied in humans. The bacterial enzymes that were investigated are known to catalyze reactions that may result in formation of proximal carcinogens. Compared to vegetarians, omnivores eating a "Western-type" diet had higher levels of beta-glucuronidase, nitroreductase, azoreductase, and steroid 7-alpha-dehydroxylase in their fecal microflora. Removal of red meat or addition of fiber in the form of bran or wheat germ to the diet of omnivores for 30 days had no effect on beta-glucuronidase, nitroreductase, or azoreductase activity. However, removal of red meat or addition of fiber reduced fecal steroid 7-alpha-dehydroxylase activity. The addition of viable Lactobacillus acidophilus supplements to the diet of omnivores significantly decreased fecal bacterial beta-glucuronidase and nitroreductase activities. Thirty days after Lactobacillus supplements were curtailed, fecal enzyme levels returned to normal base-line activities. These findings suggested that the metabolic activity of the fecal microflora was influenced by diet and could be altered by Lactobacillus supplements and to a lesser extent by dietary fiber.

Phase I trial of concurrent tirapazamine, cisplatin, and radiotherapy in patients with advanced head and neck cancer.

PURPOSE: To determine the maximum-tolerated dose of tirapazamine when combined with cisplatin and radiation in patients with T3/4 and/or N2/3 squamous cell carcinoma of the head and neck. PATIENTS AND METHODS: The starting schedule was conventionally fractionated radiotherapy (70 Gy in 7 weeks) with concomitant cisplatin 75 mg/m2 and tirapazamine 290 mg/m2 (before cisplatin) in weeks 1, 4, and 7 and tirapazamine alone 160 mg/m2 three times a week in weeks 2, 3, 5, and 6. Positron emission tomography scans for tumor hypoxia (18F misonidazole) were performed before and during radiotherapy. RESULTS: We treated 16 patients with predominantly oropharyngeal primary tumors, including 10 patients with T4 or N3 disease. Febrile neutropenia occurred toward the end of radiotherapy in three out of six patients treated on the initial dose level. Two of these patients also developed grade 4 acute radiation reactions. Another 10 patients were treated with the same doses, but the week 5 and week 6 tirapazamine doses were omitted. This resulted in less neutropenia and only one dose-limiting toxicity (DLT) (febrile neutropenia), and eight out of 10 patients completed treatment without any dose omissions. In these 10 patients, the acute radiation toxicities were not obviously enhanced compared with chemoradiotherapy regimens using concurrent platinum and fluorouracil. 18F misonidazole scans detected hypoxia in 14 of 15 patients at baseline, with only one patient having detectable hypoxia at the end of treatment. With a median follow-up of 2.7 years, the 3-year failure-free survival rate was 69% (SE, 12%), the 3-year local progression-free rate was 88% (SE, 8%), and the 3-year overall survival rate was 69% (SE, 12%). CONCLUSION: DLT was due unexpectedly to febrile neutropenia, which could be overcome by omitting tirapazamine in weeks 5 and 6. The combination of tirapazamine, cisplatin, and radiotherapy resulted in remarkably good and durable clinical responses in patients with very advanced head and neck cancers. It warrants further investigation.

Radical radiation therapy for carcinoma of the vagina--impact of treatment modalities on outcome: Peter MacCallum Cancer Institute experience 1970-1990.

To determine the outcome of radical radiation therapy for carcinoma of the vagina, a retrospective analysis has been made of 103 patients referred with this diagnosis to the Peter MacCallum Cancer Institute from 1970 to 1989. Eighty-four patients were treated for cure, seventy-four patients with definitive radical radiotherapy and 10 patients with adjuvant post-operative radiotherapy. Results were analyzed from two eras--before and after 1985--reflecting changes in referral pattern, treatment policy, and outcome. Forty-eight patients were treated before 1985 (Stage I--24, Stage II--6, Stage III--15, Stage IV--3) and 36 patients after 1985 (Stage I--20, Stage II--3, Stage III--6, Stage IV--7). After 1985 more patients were treated with combined beam radiation and brachytherapy (23/36 vs. 16/48 prior to 1985). More extensive tumors were systematically implanted (Ir 192). (No implants before 1985; 15 implants and 8 intracavitary applications post 1985). Fewer were treated with external beam alone after 1985; 11/36 (31%) vs. 27/48 (55%) before 1985. A small number (7/84-8%) were treated with brachytherapy alone. Survival results were markedly improved after 1985 (22/36-61% vs 16/48-33%) due partly to the shorter period of follow-up, but due also to marked improvement in local control particularly in early stage disease. (1/23 vs. 12/30 recurrences in Stage I, II disease). Results indicate optimal results with radical radiation therapy occur only with adequate dose delivery best achieved with a judicious combination of external beam radiotherapy and brachytherapy. Interstitial implantation plays a crucial role.

Prediction of developmental outcome using a perinatal risk inventory.

An effective perinatal developmental screening that predicts developmental outcome of high-risk neonates is currently not available. One hundred twenty-five high-risk infants were evaluated prior to discharge from the neonatal intensive care unit using a newly developed perinatal risk inventory, family status index, and abbreviated neurobehavioral assessment scale. All infants had been evaluated using the Bayley Mental and Motor Scales of the Stanford-Binet. They were also evaluated by a pediatrician, audiologist, and ophthalmologist. Fifteen infants had been evaluated using 9-month Bayley Scales of Infant Development, 74 had been evaluated using the Bayley at 9 and 18 months, and 36 children had been assessed using the Stanford-Binet at 36 months. The total score of the perinatal risk inventory demonstrated a significant correlation with the infants' last score on the Bayley and Stanford-Binet (r = .55, P less than .001). The abbreviated neurobehavioral assessment scale correlated with the infants' IQ and developmental quotient score (r = .3, P less than .001); the family status index did not correlate well with the developmental outcome. Using a score of 10 on the perinatal risk inventory provided a sensitivity of 0.76, specificity of 0.79, positive predictive value of 0.475, and negative predictive value of 0.929. Twelve of the 13 infants with cerebral palsy were identified as being potentially developmentally abnormal prior to discharge. It appears that it is possible to predict the developmental outcome of high-risk neonates using a perinatal risk inventory.

Relationship between blood lead and nutritional factors in preschool children: a cross-sectional study.

OBJECTIVE: The purpose of this study was to assess the relationships between selected nutritional factors and blood lead levels of preschool children. METHODOLOGY: Data on 296 children, aged 9 to 72 months, who were cared for at the University of Maryland at Baltimore Pediatric Ambulatory Center were examined in this cross-sectional study. Nutritional status, socioeconomic aspects, medical history, and potential sources of lead exposure were assessed. Blood samples were evaluated for levels of blood lead, serum iron (ferritin), free erythrocyte photoporphyrin, calcium, and hematocrit. RESULTS: The average blood lead level was 11.4 micrograms/dL. Multicollinearity of nutritional factors was addressed using regression techniques. After adjusting for confounders, significant positive associations with blood lead were found for total caloric intake (P = .01) and dietary fat (P = .05). CONCLUSIONS: The findings of this study suggest that even when behavioral and environmental exposures to lead were statistically controlled, total caloric intake and dietary fat each had an independent and significant association with the level of blood lead.

Radiation with concurrent late chemotherapy intensification ('chemoboost') for locally advanced head and neck cancer.

The aim of this study was to review our experience with a treatment regimen that combined conventionally fractionated radiation therapy (70 Gy over 7 weeks) with chemotherapy (cisplatin and fluorouracil), given concurrently in the last 2 weeks of radiation therapy in patients with previously untreated advanced squamous cell cancer of the head and neck region.Twenty-eight patients, all but two having UICC stage IV disease, were treated at the Peter MacCallum Cancer Institute between November 1995 and April 1998. Planned chemotherapy consisted initially of continuous infusion at 10 mg/m(2) per day of cisplatin and 400 mg/m(2) per day of fluorouracil on days 1-5 of weeks 6 and 7 of a conventionally fractionated course of radiotherapy. After the first 14 patients, the dose of fluorouracil was reduced to 360 mg/m(2) per day because of acute toxicity.36.8 months), with an estimated 50% surviving at 2 years (CI, 29-71%). Sixteen patients (57%) developed confluent mucositis and 11 (39%) developed patchy mucositis. The median duration of mucositis for these 27 patients was 1.5 months. Seventeen patients (61%) required nutritional support for a median duration of 1.4 months. Fourteen patients (50%) had grade three skin reactions, and 12 (43%) had one or more other significant (Grade 3) toxicities, predominantly infective. Grade 3 late toxicity has been observed in three patients to date (three xerostomia, including one with severe depression), and one patient had chronic ulceration of the oral tongue (grade 4). This chemoradiation regimen achieved an excellent complete response rate and good locoregional control at 2 years in patients with a poor initial prognosis. Acute toxicity was significant but manageable. The regimen offers an alternative to surgery and postoperative radiation therapy in locally advanced head and neck cancer.

Relationship between blood lead and dietary iron intake in preschool children. A cross-sectional study.

The relationship between dietary iron intake and blood lead levels in urban preschool children was investigated in a cross-sectional study of 299 children from 9 months to 5 years old. Mothers of children attending the University of Maryland Pediatric Ambulatory Clinic volunteered for the children and themselves to join the study. The data collected included nutritional status, socioeconomic status, medical history, and potential sources of lead exposure. Blood samples from all participants were evaluated for levels of blood lead, serum iron (ferritin), free erythrocyte protoporphyrin, calcium, and hematocrit. The average blood lead level (standard deviation) in the studied population was 11.4 (7.3) micrograms/dL. With multiple linear and logistic regression analyses to adjust for covariates, a negative association (P = 0.03) between blood lead and dietary iron intake was found. This finding is consistent with similar results from experimental studies. It is concluded that there is evidence that higher dietary iron intake is associated with lower blood lead among urban preschool children in the studied population.

Dose-response of birth weight to various measures of maternal smoking during pregnancy.

Thus far little is known about the dose-response relationship between birth weight and the amount of maternal smoking during pregnancy. The purpose of this report is to describe the effects of smoking intensity, duration, and timing on birth weight with the use of three measures of exposure: self-reported daily consumption, self-reported cumulative consumption, and salivary thiocyanate. Data were obtained on 867 single live-born infants and their mothers who participated in a randomized anti-smoking intervention trial. Smoking was measured for the women at about 15 weeks gestation and again during the eighth month. Although all indicators of dose, as derived from early or late pregnancy smoking measures, were significantly associated with birth weight, whether or not the mother had quit smoking by the time of the 8th month follow-up was almost as predictive as any dose variable. For women who quit smoking before 30 weeks gestation, neither the duration nor the amount of smoking earlier in pregnancy was an important determinant of birth weight.

Prenatal exposure to tobacco: I. Effects on physical growth at age three.

The height and weight of 714 children whose mothers smoked at the beginning of their pregnancies were assessed at three years of age. The children of women who quit smoking during pregnancy were taller and heavier than those of women who continued to smoke throughout pregnancy. Adjustment for maternal postpartum smoking status reduced the difference in weight, but had little effect on height. The differences in both height and weight at three years of age were greatly reduced when adjusted for size at birth and length of gestation. These results suggest that deficits associated with maternal smoking are not overcome by three years of age and that at least some of the observed anthropometric deficits may be extensions of deficits in fetal growth.

Prenatal exposure to tobacco: II. Effects on cognitive functioning at age three.

Three-year-old children, born to women who smoked ten or more cigarettes at the beginning of pregnancy and identified at the time of registration for prenatal care, were assessed by the McCarthy Scales of Children's Abilities and the Minnesota Child Development Inventory. Children whose mothers quit smoking during pregnancy relative to children whose mothers persisted in smoking performed at a statistically significant higher level on the General Cognitive Index of the McCarthy and on each of the three subscales from which the General Cognitive Index is derived. The scores on the Minnesota Child Development Inventory were similar in showing a higher performance in the children of quitters. Statistical adjustment for environmental factors, characteristics of the child, and fetal maturity did not account for the observed differences between children of women who quit smoking and those of women who continued to smoke.

Psychosocial predictors of outcome in a worksite smoking cessation program.

We examined the relationship of smoking history, motivation, social support, and stress to initial cessation and long-term abstinence in a sample of 402 smokers who participated in a worksite smoking cessation program. Compared to nonquitters, smokers who initially stopped smoking expected less difficulty quitting, had previously abstained for longer periods, and had a higher desire to quit. Long-term abstainers were lighter smokers and had more social support and less stress than relapsers. The differences in the predictors of initial cessation and long-term abstinence support the concept of a staged cessation process. The results suggest that intraindividual factors are particularly important early in the process, whereas environmental factors are more important during the later, maintenance stage. These findings are consistent with a biopsychosocial model of cessation and relapse and support multicomponent interventions.

A randomized comparison of Worksite-sponsored smoking cessation programs.

This worksite study assesses the relative effectiveness of three smoking cessation programs. Computerized medical files indicated that 29% of 13,171 employees were current smokers. Of smokers responding to a worksite-wide survey, 79% indicated interest in a smoking cessation program; 402 smokers agreed to participate and were randomly allocated, within their preference for a group or self-help approach, to the three different programs. Overall, 11% of smokers participated, an excellent rate for a large worksite. Participants were followed for 12 months (91% follow-up). Smokers in the group preference had better short-term results than did those following the self-help approach. The Multiple Component Program had 61% who quit, the Relapse Prevention Program had 37%, and the American Cancer Society Quitter's Guide had 12%. Long-term quit rates ranged from 16% to 26%; all groups exceeded the usual spontaneous quit rate of 5%.

Cytomegalovirus diaper dermatitis.

Cytomegalovirus inclusions have been reported in perineal ulcers from immunosuppressed adults. The importance of this finding is unknown. We report the first pediatric case of cutaneous cytomegalovirus infection in an infant with congenital human immunodeficiency virus infection, presenting as a diaper dermatitis. Cytomegalovirus was cultured from the skin biopsy specimen, and characteristic inclusions were seen on hematoxylin-eosin-stained sections. Results of this biopsy specimen analysis prompted further investigation revealing disseminated cytomegalovirus infection, including retinitis. Aggressive pursuit of a pathogen in common conditions such as diaper dermatitis is strongly recommended in immunosuppressed pediatric patients.

Long-term sequelae of childhood sexual abuse: perceived family environment, psychopathology, and dissociation.

In this study, 105 abused and nonabused women were examined for patterns of adult psychopathology associated with childhood sexual abuse and to test the extent to which these patterns are independent of other pathogenic properties of the family environment. Clinical and nonclinical Ss completed the Family Environment Scale, the Minnesota Multiphasic Personality Inventory (MMPI), the Rorschach, and the Stanford Hypnotic Susceptibility Scale. Greater nonspecific impairment among abused women may be a consequence, at least in part, of pathogenic family structure rather than sexual abuse per se. However, MMPI and Rorschach responses suggest sexual abuse may render victims especially vulnerable to specific disturbances i involving soma and self. Abuse was associated with greater use of dissociation, but covariance analysis revealed this effect to be accounted for by family pathology. There was no evidence that sexual trauma is associated with hypnotizability.

Phonological fusion in dichotic monitoring.

Phonological fusion (e.g., BACK + LACK perceived as BLACK) was examined in a dichotic monitoring task that required subjects to press a button whenever they thought a predesignated target (e.g., BLACK) occurred. Fusion rate was determined from incidental response to fusible pairs in this task. It was found that a voluntary strategy of selective attention to one ear reduced fusion rate. However, fusions could not be entirely eliminated using this strategy. A signal detection analysis indicated that strategy did not involve a response bias shift, although individual differences in fusion rates unimodally distributed) could be partly accounted for by differences in response bias and discriminatory ability. Phenomenological data suggested that a fusible stimulus pair may yield more than one percept on a single presentation, but not necessarily that same percept on repeated presentations. Reaction time data supported the view that phonological fusion involves parallel processing of fusible items in the language-dominant hemisphere.

Development of speechreading supplements based on automatic speech recognition.

In manual-cued speech (MCS) a speaker produces hand gestures to resolve ambiguities among speech elements that are often confused by speechreaders. The shape of the hand distinguishes among consonants; the position of the hand relative to the face distinguishes among vowels. Experienced receivers of MCS achieve nearly perfect reception of everyday connected speech. MCS has been taught to very young deaf children and greatly facilitates language learning, communication, and general education. This manuscript describes a system that can produce a form of cued speech automatically in real time and reports on its evaluation by trained receivers of MCS. Cues are derived by a hidden markov models (HMM)-based speaker-dependent phonetic speech recognizer that uses context-dependent phone models and are presented visually by superimposing animated handshapes on the face of the talker. The benefit provided by these cues strongly depends on articulation of hand movements and on precise synchronization of the actions of the hands and the face. Using the system reported here, experienced cue receivers can recognize roughly two-thirds of the keywords in cued low-context sentences correctly, compared to roughly one-third by speechreading alone (SA). The practical significance of these improvements is to support fairly normal rates of reception of conversational speech, a task that is often difficult via SA.