The Impact of Body Mass Index on Fluoroscopy Time During Lumbar Epidural Steroid Injection; A Multicenter Cohort Study.

Objective: This study aimed to assess the relationship between BMI and fluoroscopy time during lumbar epidural steroid injections (LESIs) performed for lumbosacral radicular pain. Design: Multicenter retrospective cohort study. Setting: Three academic, outpatient pain treatment centers. Subjects: Patients who underwent fluoroscopically guided LESI. Methods: Mean and standard deviation (SD) fluoroscopy time were compared between patients with normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2) BMI. Statistical significance was set at P=0.01 due to multiple comparisons. Results: A total of 2,930 procedure encounters were included, consisting of 598 interlaminar LESIs and 2,332 transforaminal LESIs. Fluoroscopy time was significantly longer in the obese patients compared to normal and overweight patients during interlaminar LESI (P < 0.01). Fluoroscopy time was significantly longer with each increasing BMI category in during transforaminal LESI (P < 0.01). These relationships remained when a trainee was involved (P < 0.01; P<0.01), during repeat injections (P < 0.01; P < 0.01), and during bilateral transforaminal LESIs (P < 0.01). While longer fluoroscopy times were required in high BMI categories during L5-S1 transforaminal LESI (P < 0.01), there was no relationship between fluoroscopy time and BMI during L4-L5 and S1 transforaminal LESI (P = 0.02; P = 0.13). Fluoroscopy time during interlaminar LESI compared to transforaminal LESI was significantly lower within all BMI categories (all P<0.01). Conclusions: The findings of this study indicate that fluoroscopy time is increased during interlaminar LESIs and during L5-S1 transforaminal LESIs in patients who are obese. These relationships are not affected by injection number, performance of bilateral injections, or trainee involvement. Further study is needed to determine if this increase in fluoroscopy time is indicative of a clinically significant associated increase in radiation dose.

Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Cervical Interlaminar Epidural Steroid Injections?

BACKGROUND: The challenge of obtaining medical imaging in individuals with higher body mass index (BMI) is described, but there is minimal data regarding the relationship between BMI and fluoroscopy time during cervical interlaminar epidural steroid injection (CIESI). OBJECTIVE: To determine the relationship between BMI and fluoroscopy time during CIESI. METHODS: Retrospective cohort study of patients who underwent fluoroscopically guided CIESI between January 2014 and February 2015 at an academic pain medicine center. Fluoroscopy time data were collected. Comparisons based on analysis of variance were made between patients with normal (<25.0 kg/m 2 ), overweight (25.0-29.9 kg/m 2 ), and obese (≥30.0 kg/m 2 ) BMI. RESULTS: Of 399 procedure encounters, 366 had documented BMI and fluoroscopy time data and were included for analysis. Mean age (± SD) in this cohort was 53 ± 13 years, including 189 females (52%) and 205 first-time injections. Mean fluoroscopy time for all injections was 18 ± 10 seconds. Separated by categorical BMI class, the mean fluoroscopy time was 18 ± 9 seconds for normal weight patients, 17 ± 10 seconds for overweight patients, and 20 ± 11 seconds for obese patients, respectively. Post hoc analysis showed that fluoroscopy time was significantly longer only in obese compared with overweight patients ( P = 0.02). Trainee involvement and first-time vs repeat injection did not significantly alter fluoroscopy time ( P = 0.17 and P = 0.12, respectively). CONCLUSIONS: The findings of this study indicate that BMI does not appear to have a clinically significant impact on fluoroscopy time during cervical interlaminar epidural steroid injection procedures. Future study is needed to directly quantify radiation exposure in patients and practitioners, as well as the associated health risk.

Investigation of Johne's disease in Tasmanian fallow deer (Dama dama).

In 2012 when many sheep flocks in northern-central Tasmania were experiencing a high prevalence of ovine Johne's disease, 34 wild adult fallow deer shot on or near infected properties were negative to microscopic Mptb lesions of the ileo-caecal valve, terminal ileum and ileo-caecal lymph nodes. This study demonstrated 95% confidence of detecting Johne's disease in this fallow deer population if ≥10% of animals were shedding Mycobacterium avium subsp. paratuberculosis in their faeces, or if ≥21% of animals were sub-clinically infected.

Molecular insights into uremic cardiomyopathy: cardiotonic steroids and Na/K ATPase signaling.

Patients with chronic renal failure develop a "uremic" cardiomyopathy characterized by diastolic dysfunction, left ventricular hypertrophy, fibrosis, and systemic oxidant stress. Patients with chronic renal failure also are known to have increases in the circulating concentrations of endogenous cardiotonic steroids (also referred to as endogenous digitalis-like substances.) Endogenous cardiotonic steroids produce reactive oxygen species as part of the signal cascade induced by binding to the plasmalemmal Na/K-ATPase in patients, and this signal cascade appears capable of inducing several key pathophysiologic features of uremic cardiomyopathy. In addition, these patients develop both fibrosis and oxidant stress without a known mechanism. In this review we highlight data supporting the hypothesis that endogenous cardiotonic steroids are a key molecular component involved in the diastolic dysfunction, left ventricular hypertrophy, fibrosis, and systemic oxidant stress associated with chronic kidney disease.

Hypokalemia potentiates ouabain's effect on calcium cycling and cardiac growth.

We have previously noted that in neonatal myocytes grown in culture, reductions in extracellular K+ concentration produced a hypertrophic response as assessed by induction of early response genes, atrial natriuretic peptide and skeletal actin and repression of the alpha 3 isoform of the sodium pump in a dose dependent manner. Similarly, decreases in media K+ concentration caused increases in cytosolic calcium concentration in a dose dependent manner, which correlated with repression of alpha 3 expression. In the current study we demonstrate that decreases in media K+ concentration caused increases in cytosolic calcium concentration in isolated adult rat cardiac myocytes. These increases are potentiated by the addition of the cardiotonic steroid, ouabain and blocked by the addition of the Src kinase inhibitor Herbimycin A. In parallel studies performed in vivo, when rats subjected to dietary K+ restriction were subsequently subjected to partial (5/6th) nephrectomy for 4 weeks, cardiac growth was greater than in rats fed a control diet. These data suggest that hypokalemia may produce phenotypic alterations consistent with cardiac hypertrophy as well as potentiate the cardiovascular effects of cardiotonic steroids.

Yield of bronchoscopy for the diagnosis of tuberculosis in patients with human immunodeficiency virus infection.

The efficacy of bronchoscopy for the diagnosis of tuberculosis in patients infected with human immunodeficiency virus (HIV) has not been systematically evaluated. We therefore compared the diagnostic yield of bronchoscopy in 67 HIV-infected and 45 non-HIV-infected patients with culture-proven pulmonary tuberculosis. In all cases, acid-fast smears of sputum were negative or not obtained prior to bronchoscopy. Prebronchoscopic sputum culture yielded Mycobacterium tuberculosis in 34 (89 percent) of 38 HIV-infected patients and 26 (93 percent) of 28 non-HIV-infected patients from whom specimens were obtained. Bronchoscopy provided an early diagnosis of tuberculosis (positive acid-fast smear or granulomata on biopsy) in 23 (34 percent) of the HIV-infected patients and 20 (44 percent) of the patients without HIV infection. The sensitivities of the acid-fast smear and of mycobacterial culture of bronchoscopic specimens and postbronchoscopic sputum were similar in patients with or without HIV infection. In HIV-infected patients, granulomatous inflammation was noted on transbronchial biopsy in 11 (19 percent) of 59 patients with HIV infection, compared to 16 (43 percent) of 37 patients without HIV infection (p = 0.01). Nevertheless, transbronchial biopsy provided the exclusive means for an early diagnosis of tuberculosis in six (10 percent) of 59 HIV-infected patients. We conclude that the yield of bronchoscopy for the diagnosis of pulmonary tuberculosis in HIV-infected patients is similar to that in patients without HIV infection, and that transbronchial biopsy provides incremental diagnostic information not available from evaluation of sputum or bronchoalveolar lavage fluid.

Renal dose dopamine does not alter the response to beta-adrenergic stimulation by isoproterenol in healthy human volunteers.

OBJECTIVES: To determine if renal dose dopamine (3 microg/kg/min) alters the heart rate (HR) by itself, or if a dopamine infusion alters the HR response to bolus doses of the beta-adrenergic agonist isoproterenol in healthy human subjects. DESIGN: Prospective study. SETTING: Clinical laboratory of a university-affiliated academic medical center. SUBJECTS: A total of 15 healthy nonpregnant women and men aged 21 to 44 years. INTERVENTIONS: Subjects were monitored continuously with bedside ECG, pulse oximetry, and ambulatory ECG recording to measure the maximal HR response to separate injections of 10, 20, and 30 ng/kg of isoproterenol, given before, during, and after the infusion of 3 microg/kg/min of dopamine. MEASUREMENTS AND MAIN RESULTS: Dopamine in the absence of isoproterenol did not alter baseline HR significantly (62.7+/-2.2 beats/min without dopamine; 65.4+/-2.2 with dopamine; p=0.15). All three doses of isoproterenol increased HR significantly above baseline, both in the presence and absence of dopamine (p<0.001). Dopamine infusion resulted in a higher HR following isoproterenol only for the 20-ng/kg dose. The incremental increases in HR, defined as the difference between peak HR following isoproterenol and baseline HR, were not increased during dopamine infusion for any of the doses of isoproterenol. Nausea was reported by 5 of the 15 subjects during the dopamine infusion. CONCLUSIONS: In healthy human subjects, infusion of 3 microg/kg/min of dopamine does not significantly increase the HR when combined with beta-adrenergic stimulation using isoproterenol, suggesting neither an additive nor antagonistic interaction between the two drugs. While our study did not demonstrate an increase in HR in healthy subjects, the risk of increasing the chronotropic response to beta-adrenergic inotropic medications with "renal dose" dopamine in critically ill patients needs to be investigated. The frequency of nausea during dopamine infusion also may influence consideration of using dopamine to augment splanchnic blood flow and renal function in conscious patients.

A double ring closing metathesis reaction in the rapid, enantioselective synthesis of NK-1 receptor antagonists.

[structure: see text]. The NK-1 receptor antagonist 1 has been prepared in seven steps from phenylglycine methyl ester. The key steps are a double ring closing metathesis reaction of tetraene 7 to prepare spirocycle 6 and a reductive Heck reaction to introduce the aryl moiety. This latter reaction discriminates the olefins of compound 6 and proceeds in a highly regio- and stereoselective manner.

A nomogram for rapid calculation of metabolic requirements on intubated patients.

There is a need for estimating the calorific requirements of patients undergoing or about to undergo total parenteral nutrition (TPN) other than by complicated direct calorimetry or by guesswork. We describe a simple, cheap, indirect calorimetric method for determining energy requirements from the measurement of mixed expired carbon dioxide tension (PECO2) in patients who are intubated, and in whom the breathing circuit characteristics allow collection of pure expired gas. This can be achieved by collection of expired gas from ventilators where an on-demand fresh gas flow rather than a continuous flow occurs during spontaneous or intermittent positive pressure ventilation, such as with the Siemens Servo 900C.

Cefoperazone-sulbactam combination in the treatment of urinary tract infections: efficacy, safety, and effects on coagulation.

Seventy hospitalized patients with upper urinary tract infections were treated with cefoperazone (2 gm) and sulbactam (1 gm) every 12 hours for three or more days. All but six patients also received vitamin K. Forty of the 70 patients (57%) were cured of infection at one week after treatment, 13 relapsed, 11 had reinfections, and six were lost to follow-up. There were no treatment failures. Escherichia coli was the predominant pathogen (62% of isolates). Overall there was 15% resistance to cefoperazone and all resistant isolates were susceptible to the combination of agents. Synergy was demonstrated in 26% of isolates. One uroseptic patient who had an organism resistant to both study agents, but susceptible to the combination, was cured. Two of six patients who did not receive vitamin K demonstrated abnormal coagulation patterns and one had an associated major bleeding complication. Although 12 of 64 (19%) patients who received vitamin K had at least one coagulation abnormality, there were no significant bleeding complications in this group.

Progress in national control and assurance programs for ovine Johne's disease in Australia.

Since the detection of ovine Johne's disease in Australia in 1980, 578 flocks have been diagnosed as infected, with 442 of these still infected. The disease was initially believed to be confined to the central tablelands area of NSW, but has subsequently been shown to be more widely distributed. Sheep strains of M. paratuberculosis are known to infect sheep and goats in south-eastern Australia. Although sheep strains have recently been identified in some cattle in Australia, epidemiological evidence to date supports the distinction between ovine Johne's disease, caused by sheep strains in sheep and goats, and bovine Johne's disease, caused by cattle strains in cattle, goats and alpaca, as a basis for control and eradication strategies. Four national initiatives to control and better understand OJD are outlined. The Australian Johne's Disease Market Assurance Program for sheep was launched in May 1997. By December 1998, 548 flocks had achieved an assessed negative status. Three flocks assigned a flock status have subsequently been found to be infected. National standards for State control of Johne's disease through zoning, movement controls and procedures in infected and suspect flocks have also been developed. In addition, a $40.1 m National Ovine Johne's Disease Control and Evaluation Program was agreed to in August 1998, and is currently being implemented. It is jointly funded by National and State industries, and Commonwealth and State governments. Its objectives are to deliver, through research and surveillance, a solid basis for a future decision on the most appropriate course for dealing with OJD and to maintain control of OJD nationally.

Progress in national control and assurance programs for bovine Johne's disease in Australia.

Cattle strains of Mycobacterium paratuberculosis are known to infect cattle, goats and alpaca in southeastern Australia, where there are also significant numbers of farmed deer. Although sheep strains have recently been identified in some cattle in Australia, epidemiological evidence to date supports the distinction (between bovine Johne's disease (JD), caused by cattle strains in cattle, goats and alpaca, and ovine JD, caused by sheep strains in sheep and goats) for the purposes of control and assurance programs. The National Johne's Disease Control Program is coordinated by the Australian Animal Health Council, working with the livestock industries and with the Commonwealth, state and territory governments. The council also brokers industry and government funding for the program. The National Johne's Disease Market Assurance Program for Cattle was launched in 1996 as the first of a suite of voluntary national market assurance programs (MAPs) to assess and certify herds as negative for JD. By December 1998, over 550 herds had achieved an assessed negative status. A MAP was also launched for alpaca in 1998 and a program for goats should be finalized in early 1999. National standards for state control of JD through zoning, movement controls and procedures in infected and suspect herds have also been developed. The paper covers factors affecting development and implementation, uptake of and improvements to national control and assurance programs for bovine JD in Australia.

The impact of intraoperative culture on treatment and outcome in children with perforated appendicitis.

BACKGROUND: Most protocols for the operative treatment of perforated appendicitis use a routine culture. Although isolated studies suggest that routine culture may not be necessary, these recommendations generally are not based on objective outcome data. METHODS: The authors reviewed the records of 308 children who underwent operative treatment for perforated appendicitis between 1988 and 1998 to determine if information gained from routine culture changes the management or improves outcome. Inclusion criteria included either gross or microscopic evidence of appendiceal perforation. RESULTS: Mean patient age was 7.5 years, 51% were boys, and there was no mortality. The majority of children (96%) underwent culture that was positive for either aerobes (21%), anaerobes (19%), or both (57%). Antibiotics were changed in only 16% of the patients in response to culture results. The use of empiric antibiotics, as compared with modified antibiotics, was associated with a lower incidence of infectious complication, shorter fever duration, and decreased length of hospitalization. We also investigated the relationship between culture isolates and antibiotic regimens with regard to outcome. The utilization of antibiotics suitable for the respective culture isolate or organism sensitivity was associated with an increased incidence of infectious complication and longer duration of both fever and length of hospitalization. Finally, the initial culture correlated poorly with subsequent intraabdominal culture (positive predictive value, 11%). CONCLUSION: These outcome data strongly suggest that the practice of obtaining routine cultures can be abandoned, and empiric broad spectrum antibiotic coverage directed at likely organisms is completely adequate for treatment of perforated appendicitis in children.

Computer simulation of pigeons' performance on a spatial memory task.

Delayed matching of key location is a useful paradigm for the study of pigeons' short-term memory for a spatial location. On each trial a randomly selected key from a matrix of keys is lit briefly as a sample and followed by a retention interval. During the ensuing choice period the sample and one of the non-sample keys are lit; choice of the sample is correct and rewarded whereas choice of the distractor key is not. The computer simulation of performance on this task is based on a simple model: We assume that the pigeon has knowledge of the location of the keys stored in a map-like reference memory. We also assume that short-term memory involves an attention focus or "pointer" that "drifts" on the surface of this map. The pointer migrates from a randomly determined position during the intertrial interval towards the location of the sample when this stimulus is presented. It wanders randomly from its previous position when this cue is no longer present in the retention interval. During the test for retention the bird selects the location (i.e., sample or distractor) closer to the location of the pointer on the map of the matrix. The simulation successfully reproduced several of the phenomena observed in delayed matching of location experiments and provided an account of some hitherto perplexing results. As well, the model successfully predicted some new empirical data.

Laparoscopy for intrauterine insemination and embryo recovery in superovulated ewes at a commercial embryo transfer unit.

Of 111 variable age, pedigree ewes subjected to a range of superovulatory regimens and then submitted to embryo recovery by laparoscopy, nine had adhesions corresponding to a mid-line laparotomy (presumably from a previous attempt to recover embryos) and could not have their embryos recovered by the laparoscopic technique. Of the remainder, 27 ewes (26.5%) had less than three ovulations or had prematurely regressing corpora lutea at the selected time for embryo recovery (Days 5 to 6 following insemination), and no attempt was made to recover embryos from them. For the 75 ewes subjected to laparoscopic ovum recovery following laparoscopic intrauterine insemination, the average number of ovulations (+/- SEM) was 7.9 +/- 0.6; the average ovum recovery (mean of values for each ewe) was 51.7% +/- 3.5; and the percentage of recovered ova that were fertilized was 87.3%. For a further nine 3-yr-old crossbred ewes the mean values for ovulation and ovum recovery were 7.6 +/- 1.2 and 70.1 +/- 7.7, and were not significantly different for the two insemination methods used (laparoscopic intrauterine vs cervical). In general, ovulation rates for ewes given pregnant mare serum gonadotrophin (PMSG) tended to be lower (5.2 +/- 0.7) than for those given porcine follicle stimulating hormone (pFSH, 7.7 +/- 0.8) or human menopausal gonadotrophin (hMG, 7.7 +/- 2.3). Ova recovery rates were similar on Days 5 and 6 (Day 0 = insemination), and were not affected by method of insemination (laparoscopic intrauterine vs cervical).

Antibiotic treatment of chronic central venous hemodialysis catheter infection without catheter removal.

Most catheter or shunt infections in hemodialysis patients require the removal of the access before the infection is eradicated. A hemodialysis patient is reported who had multiple previous vascular accesses which failed and thus who had very limited sites for future access placement. When a recurrent Proteus mirabilis catheter infection occurred, a 6-week course of ampicillin intraluminal and tobramycin systematically, eradicated the infection and thus the central venous catheter was salvaged. Serum bactericidal levels with these two antibiotics were obtained early in the course and supported the continued use of antibiotics alone to treat the infection.

Control of Mycobacterium avium subsp. paratuberculosis infection in agricultural species.

Paratuberculosis or Johne's disease is a chronic intestinal disease caused by Mycobacterium avium subsp. paratuberculosis, which continues to spread in agricultural species. Control of paratuberculosis is challenging and should not be underestimated. Due to the long incubation period of the infection, disease is largely subclinical in domesticated livestock. Hence, direct effects on animal productivity and welfare are often masked and may appear insufficient to justify large investments in control programmes by individual farmers, livestock industries or governments. Furthermore, in some countries the main effects of the disease are indirect, resulting from the impact of market discrimination against herds and flocks known to be infected, or from the control measures enforced to reduce transmission. In such circumstances, producers may be unwilling to co-operate with surveillance that may detect infection in herds or flocks. As control programmes are rarely successful in eliminating the infection from a herd or flock in the short term without an aggressive and costly programme, financial and community support assists producers to deal with the challenge. Successful prevention and control depends on animal health authorities and livestock industries acquiring a good understanding of the nature and epidemiology of infection, and of the application of tools for diagnosis and control. Building support for control programmes under the leadership of the affected livestock industries is critical, as programmes are unlikely to be successful without ongoing political will, supported by funding for research, surveillance and control.

An outbreak of rabies in north-western Zimbabwe 1980 to 1983.

The first case of rabies for 25 years was recorded in the Chinhoyi veterinary region of north-western Zimbabwe in September 1980. An epidemic in jackals (86 per cent of cases) with associated cases in cattle (7 per cent) spread rapidly northwestward through the commercial farming areas. Within 18 months the front had moved 180 km from the probable point of entry of the disease. One case was diagnosed a further 30 km to the north-west. Following a comparatively quiet period in 1982 a second epidemic developed in dogs and spread back 100 km south-eastward during the second half of 1983. Epidemiological factors, the behavioural features of cases and the ownership and vaccination status of dogs are reported. Dogs were a more serious threat to human beings than jackals and the only two known human cases occurred in late 1983. Factors contributing to the patterns of the epidemics are illustrated and discussed.

Cerebellar abiotrophy in crossbred cattle.

Cerebellar abiotrophy affected 9 of 74 calves sired by a Poll Hereford bull over 2 successive calving seasons. The disease was characterised by episodes of recumbency and ataxia, with hypermetria and wide base stance. Clinical signs commenced between birth and 8 months of age. Two calves which were affected first at 8 months of age recovered clinically 9 months later. Histological lesions were found in the cerebellar cortex of 7 calves and consisted of segmental degeneration and loss of Purkinje cells, and axonal swellings. The clinical signs and pathological findings were consistent with bovine familial convulsions and ataxia, which has not been described previously in Australia. The clinical signs were not attributable to the lesions observed in the cerebellum and an underlying electrophysiological abnormality is proposed. The aetiology of the condition is probably genetic and appears to have a multifactorial basis.

An association between encephalomyocarditis virus infection and reproductive failure in pigs.

An outbreak of reproductive failure, characterised by mummified foetuses and stillbirths, was investigated in an intensive piggery. Six foetuses that died towards the end of gestation had multifocal myocardial necrosis and encephalomyocarditis virus was recovered from 4 of these foetuses but not from 6 mummified foetuses. There was also a significant increase in failure of conception or early embryonic deaths in sows mated at the same time as sows which produced affected litters.