Screening for asymptomatic deep vein thrombosis in COVID-19 patients admitted to the medical ward: a cross-sectional study.

PURPOSE: Patients with COVID-19 have an increased risk for venous thrombo-embolism (VTE), especially pulmonary embolism. The exact prevalence of asymptomatic DVT is not known, as is the usefulness of screening for DVT in patients admitted to ward with COVID-19. We have studied the prevalence of asymptomatic DVT. METHODS: We performed a cross-sectional observational multi-center study at four university medical centers in The Netherlands. All adult patients admitted with COVID-19 to a medical ward were eligible for inclusion, including patients who were transferred back from the ICU to the ward. The study protocol consisted of weekly cross-sectional rounds of compression ultrasound. RESULTS: In total, 125 patients were included in the study. A significant proportion of patients (N = 34 (27%)) had developed a VTE during their admission for COVID-19 before the study ultrasound was performed. In most VTE cases (N = 27 (79%)) this concerned pulmonary embolism. A new asymptomatic DVT was found in 5 of 125 patients (4.0%; 95% CI 1.3-9.1%) (Table 2). Nine patients (7.2%; 95% CI 3.3-13.2%) developed a VTE (all PE) diagnosed within 28 days after the screening US was performed. CONCLUSION: We have shown a low prevalence (4%) of newly discovered asymptomatic DVT outside the ICU-setting in COVID-19 patients. Despite this low prevalence, nine patients developed PE (7%) within 28 days after ultrasound. This favors the hypothesis of local thrombus formation in the lungs. Based on our findings and literature, we do not recommend US-screening of asymptomatic patients with COVID-19 admitted to the ward.

Changes in body composition and energetic efficiency in response to growth curve and dietary energy-to-protein ratio in broiler breeders.

Body composition plays an important role in reproduction in broiler breeders. The aim of this study was to evaluate the dynamics in body composition and energetic efficiency in broiler breeders, using different dietary strategies. About 1,536-day-old pullets were randomly allotted to 24 pens in a 2 × 4 factorial design with 2 growth curves (standard or elevated (+15%)) and 4 diets, with a step-wise increment in energy (96, 100, 104, and 108% apparent metabolizable energy nitrogen corrected [AMEn]) fed on a pair-gain basis. Body composition was determined at 10 time points from 0 to 60 wk of age. Body protein mass was linearly related to body weight (BW) in growing breeders, which can be expressed as -6.4+0.184*BW (R2 = 0.99; P < 0.001). Body fat mass was exponentially related to BW in growing breeders, which can be expressed as -42.2+50.8*1.0006BW (R2 = 0.98; P < 0.001). A higher energy-to-protein ratio resulted in higher body fat mass at the same BW (P < 0.001). Sexual maturation was related to body protein mass at 21 wk of age, where each 100 g of body protein mass extra advanced sexual maturation by 5.4 d (R2 = 0.83). Estimates of energetic efficiency for growth (kg) and egg production (ke) appeared not constant, but varied with age in a quadratic manner between 0.27 and 0.54 for kg and between 0.28 and 0.56 for ke. The quadratic relationship could be expressed as kg=0.408-0.0319*Age+0.00181*Age2 (R2 = 0.72; P < 0.001) and ke=-0.211+0.034*Age-0.00042*Age2 (R2 = 0.46; P < 0.001). Body protein mass in broiler breeders is tightly regulated and mainly depended on BW and seems to be the main determinant for sexual maturation. Body fat mass is exponentially related to BW, where an increase in dietary energy-to-protein ratio results in a higher body fat mass. Treatments had minimal effects on estimated energetic efficiencies in breeders.

The Dutch Working Party on Antibiotic Policy (SWAB) Recommendations for the Diagnosis and Management of Febrile Neutropenia in Patients with Cancer.

INTRODUCTION: This guideline was written by a multidisciplinary committee with mandated members of the Dutch Society for Infectious Diseases, Dutch Society for Hematology, Dutch Society for Medical Oncology, Dutch Association of Hospital Pharmacists, Dutch Society for Medical Microbiology, and Dutch Society for Pediatrics. The guideline is written for adults and pediatric patients. METHOD: The recommendations are based on the answers to nine questions formulated by the guideline committee. To provide evidence-based recommendations we used all relevant clinical guidelines published since 2010 as a source, supplemented with systematic searches and evaluation of the recent literature (2010-2020) and, where necessary, supplemented by expert-based advice. RESULTS: For adults the guideline distinguishes between high- and standard-risk neutropenia based on expected duration of neutropenia (> 7 days versus ≤ 7 days). Where possible a distinction has been made between pediatric and adult patients. CONCLUSION: This guideline was written to aid diagnosis and management of patients with febrile neutropenia due to chemotherapy in the Netherlands. The guideline provides recommendation for children and adults. Adults patient are subdivided as having a standard- or high-risk neutropenic episode based on estimated duration of neutropenia. The most important recommendations are as follows. In adults with high-risk neutropenia (duration of neutropenia > 7 days) and in children with neutropenia, ceftazidime, cefepime, and piperacillin-tazobactam are all first-choice options for empirical antibiotic therapy in case of fever. In adults with standard-risk neutropenia (duration of neutropenia ≤ 7 days) the MASCC score can be used to assess the individual risk of infectious complications. For patients with a low risk of infectious complications (high MASCC score) oral antibiotic therapy in an outpatient setting is recommended. For patients with a high risk of infectious complications (low MASCC score) antibiotic therapy per protocol sepsis of unknown origin is recommended.

Impact of growth curve and dietary energy-to-protein ratio of broiler breeders on offspring quality and performance.

The impact of growth curve (GC) and dietary energy-to-protein ratio of broiler breeder hens on chick quality and broiler performance was investigated. Pullets (n = 1,536) were randomly allotted to 24 pens and assigned to 1 of 8 treatments from hatch onwards, according to a 2 × 4 factorial arrangement with 2 GC (standard growth curve = SGC or elevated growth curve = EGC, +15%) and 4 diets, differing in energy-to-protein ratio (96%, 100%, 104%, and 108% AMEn diet). At 28 and 36 wk of age, 60 hatching eggs per maternal pen were selected for incubation and 768-day-old broilers were assigned to 32 pens according to maternal treatment. Broilers from EGC breeders were 1.9 g heavier at hatch (P < 0.001) and 36 g heavier at slaughter (P = 0.001) than broilers from SGC breeders due to a 1.0 g/d higher growth rate (P = 0.003) and 1.5 g/d higher feed intake (P = 0.006) from hatch to 32 d of age. An increase in breeder dietary energy-to-protein ratio resulted in a linear decrease in embryonic mortality in the first 3 d of incubation (ß = -0.2% per % AMEn; P = 0.05). At hatch, broiler BW decreased with an increasing breeder dietary energy-to-protein ratio (ß = -0.1 g per % AMEn; P = 0.001), whereas at slaughter broiler BW increased with an increasing breeder dietary energy-to-protein ratio (ß = 3.2 g per % AMEn; P = 0.02). This was due to a linear increase in growth rate (ß = 0.1 g/d per % AMEn; P = 0.004) and feed intake (ß = 0.1 g/d per % AMEn; P = 0.02). Additionally, an increase in breeder dietary energy-to-protein ratio resulted in a linear decrease in body weight corrected feed conversion ratio (ß = -0.002 per % AMEn; P = 0.002). Overall, it can be concluded that a higher GC of breeders and an increase in breeder dietary energy-to-protein ratio enhances offspring performance.

Impact of growth curve and dietary energy-to-protein ratio of broiler breeders on egg quality and egg composition.

Egg characteristics have an impact on embryonic development and post-hatch performance of broilers. The impact of growth curve (GC) and dietary energy-to-protein ratio of broiler breeder hens on egg characteristics was investigated. At hatch, 1,536 pullets were randomly allotted to 24 pens in a 2 × 4 factorial dose-response design with 2 GC (standard growth curve = SGC or elevated growth curve = EGC (+ 15%)) and 4 diets, differing in energy-to-protein ratio (defined as 96%, 100%, 104% and 108% AMEn diet). Feed allocation per treatment was adapted weekly to achieve the targeted GC and to achieve pair-gain of breeders within each GC. Breeders on an EGC produced larger eggs (∆ = 2.3 g; P < 0.001) compared to breeders on a SGC. An exponential regression curve, with age (wk) of the breeders, was fitted to describe the impact of GC and dietary energy-to-protein ratio on egg composition. Yolk weight was 0.8 g higher for eggs from EGC breeders than from SGC breeders (a-108.1*0.907Age, where a was 22.1 and 22.9 for SGC and EGC, respectively; R2 = 0.97; P<0.001). An interaction between GC and dietary energy-to-protein ratio on albumen weight was observed (P = 0.04). Dietary energy-to-protein ratio did not affect albumen weight in SGC breeders (42.7-56.2*0.934Age; R2 = 0.89), but for EGC breeders, a higher dietary energy-to-protein ratio resulted in a 0.9 g lower albumen weight from 96% AMEn to 108% AMEn (a-62.9*0.926Age, where a was 43.4, 43.2, 42.8, and 42.5 for 96% AMEn, 100% AMEn, 104% AMEn, and 108% AMEn, respectively; R2 = 0.86). Albumen DM content decreased linearly with an increased dietary energy-to-protein ratio, but this was more profound in EGC breeders (ß = -0.03 %/% AMEn) than in SGC breeders (ß = -0.01 %/% AMEn; P = 0.03). Overall, it can be concluded that an EGC for breeders led to larger eggs with a more yolk and albumen, whereas dietary energy-to-protein ratio had minor effects on egg composition.

Translation initiation factor eIF2Bε promotes Wnt-mediated clonogenicity and global translation in intestinal epithelial cells.

Modulation of global mRNA translation, which is essential for intestinal stem cell function, is controlled by Wnt signaling. Loss of tumor supressor APC in stem cells drives adenoma formation through hyperactivion of Wnt signaling and dysregulated translational control. It is unclear whether factors that coordinate global translation in the intestinal epithelium are needed for APC-driven malignant transformation. Here we identified nucleotide exchange factor eIF2Bε as a translation initiation factor involved in Wnt-mediated intestinal epithelial stemness. Using eIF2BεArg191His mice with a homozygous point mutation that leads to dysfunction in the enzymatic activity, we demonstrate that eIF2Bε is involved in small intestinal crypt formation, stemness marker expression, and secreted Paneth cell-derived granule formation. Wnt hyperactivation in ex vivo eIF2BεArg191His organoids, using a GSK3ß inhibitor to mimic Apc driven transformation, shows that eIF2Bε is essential for Wnt-mediated clonogenicity and associated increase of the global translational capacity. Finally, we observe high eIF2Bε expression in human colonic adenoma tissues, exposing eIF2Bε as a potential target of CRC stem cells with aberrant Wnt signaling.

Impact of growth curve and dietary energy-to-protein ratio on productive performance of broiler breeders.

The impact of growth curve (GC) and dietary energy-to-protein ratio on productive performance of broiler breeder females was investigated from 0 to 60 wk of age. One-day-old pullets (n = 1,536) were randomly allotted to 24 pens according to a 2 × 4 factorial arrangement, with 2 GC (standard growth curve = SGC or elevated growth curve = EGC, +15%) and 4 diets, differing in energy-to-protein ratio (96%, 100%, 104%, or 108% AMEn). Feed allocation per treatment was adapted weekly based on the desired GC, meaning that breeders fed the different diets within each GC were fed according to a paired-gain strategy. Linear and quadratic contrasts for energy-to-protein ratio for each GC were evaluated. Elevated growth curve breeders had an earlier sexual maturity (∆ = 4.1 d) than SGC breeders. Egg weight was higher for EGC breeders (∆ = 2.3 g) than for SGC breeders over the whole laying phase (22-60 wk). No differences between EGC and SGC breeders were observed on settable egg production. An increase in dietary energy-to-protein, at a similar BW, led to a linear increase in age at sexual maturity (ß = 0.14 d/% AMEn). From 22 to 40 wk of age, an increase in dietary energy-to-protein ratio led to a linear decrease in egg weight (ß = -0.06 g/% AMEn), regardless of GC. An interaction between GC and dietary energy-to-protein ratio was observed on settable egg production in this phase. An increase in dietary energy-to-protein ratio led to a linear decrease on settable egg production, which was more profound in EGC breeders (ß = -0.70 eggs/% AMEn) than in SGC breeders (ß = -0.19 eggs/% AMEn). From 41 to 60 wk of age, an interaction between GC and dietary energy-to-protein ratio was observed on egg weight. In the EGC, an increase in dietary energy-to-protein ratio led to a linear decrease in egg weight (ß = -0.13 g/% AMEn), whereas in the SGC, a linear increase in egg weight was observed (ß = 0.03 g/% AMEn). From 41 to 60 wk of age, no differences between diets were observed on settable egg production. It can be concluded that a higher GC of breeders has beneficial effects on egg weight, while maintaining settable egg production. Feeding breeders a lower dietary energy-to-protein ratio stimulated productive performance of broiler breeder hens, mainly during the first phase of lay. This effect was more profound when breeders were fed according to a higher GC.

Predicting poor outcome in patients with suspected COVID-19 presenting to the Emergency Department (COVERED) - Development, internal and external validation of a prediction model.

BACKGROUND: A recent systematic review recommends against the use of any of the current COVID-19 prediction models in clinical practice. To enable clinicians to appropriately profile and treat suspected COVID-19 patients at the emergency department (ED), externally validated models that predict poor outcome are desperately needed. OBJECTIVE: Our aims were to identify predictors of poor outcome, defined as mortality or ICU admission within 30 days, in patients presenting to the ED with a clinical suspicion of COVID-19, and to develop and externally validate a prediction model for poor outcome. METHODS: In this prospective, multi-center study, we enrolled suspected COVID-19 patients presenting at the EDs of two hospitals in the Netherlands. We used backward logistic regression to develop a prediction model. We used the area under the curve (AUC), Brier score and pseudo-R2 to assess model performance. The model was externally validated in an Italian cohort. RESULTS: We included 1193 patients between March 12 and May 27 2020, of whom 196 (16.4%) had a poor outcome. We identified 10 predictors of poor outcome: current malignancy (OR 2.774; 95%CI 1.682-4.576), systolic blood pressure (OR 0.981; 95%CI 0.964-0.998), heart rate (OR 1.001; 95%CI 0.97-1.028), respiratory rate (OR 1.078; 95%CI 1.046-1.111), oxygen saturation (OR 0.899; 95%CI 0.850-0.952), body temperature (OR 0.505; 95%CI 0.359-0.710), serum urea (OR 1.404; 95%CI 1.198-1.645), C-reactive protein (OR 1.013; 95%CI 1.001-1.024), lactate dehydrogenase (OR 1.007; 95%CI 1.002-1.013) and SARS-CoV-2 PCR result (OR 2.456; 95%CI 1.526-3.953). The AUC was 0.86 (95%CI 0.83-0.89), with a Brier score of 0.32 and, and R2 of 0.41. The AUC in the external validation in 500 patients was 0.70 (95%CI 0.65-0.75). CONCLUSION: The COVERED risk score showed excellent discriminatory ability, also in an external validation. It may aid clinical decision making, and improve triage at the ED in health care environments with high patient throughputs.

Induction of endoplasmic reticulum stress by deletion of Grp78 depletes Apc mutant intestinal epithelial stem cells.

Intestinal epithelial stem cells are highly sensitive to differentiation induced by endoplasmic reticulum (ER) stress. Colorectal cancer develops from mutated intestinal epithelial stem cells. The most frequent initiating mutation occurs in Apc, which results in hyperactivated Wnt signalling. This causes hyperproliferation and reduced sensitivity to chemotherapy, but whether these mutated stem cells are sensitive to ER stress induced differentiation remains unknown. Here we examined this by generating mice in which both Apc and ER stress repressor chaperone Grp78 can be conditionally deleted from the intestinal epithelium. For molecular studies, we used intestinal organoids derived from these mice. Homozygous loss of Apc alone resulted in crypt elongation, activation of the Wnt signature and accumulation of intestinal epithelial stem cells, as expected. This phenotype was however completely rescued on activation of ER stress by additional deletion of Grp78. In these Apc-Grp78 double mutant animals, stem cells were rapidly lost and repopulation occurred by non-mutant cells that had escaped recombination, suggesting that Apc-Grp78 double mutant stem cells had lost self-renewal capacity. Although in Apc-Grp78 double mutant mice the Wnt signature was lost, these intestines exhibited ubiquitous epithelial presence of nuclear ß-catenin. This suggests that ER stress interferes with Wnt signalling downstream of nuclear ß-catenin. In conclusion, our findings indicate that ER stress signalling results in loss of Apc mutated intestinal epithelial stem cells by interference with the Wnt signature. In contrast to many known inhibitors of Wnt signalling, ER stress acts downstream of ß-catenin. Therefore, ER stress poses a promising target in colorectal cancers, which develop as a result of Wnt activating mutations.

Upper wide-angle viewing system for ITER.

The Upper Wide Angle Viewing System (UWAVS) will be installed on five upper ports of ITER. This paper shows major requirements, gives an overview of the preliminary design with reasons for some design choices, examines self-emitted IR light from UWAVS optics and its effect on accuracy, and shows calculations of signal-to-noise ratios for the two-color temperature output as a function of integration time and divertor temperature. Accurate temperature output requires correction for vacuum window absorption vs. wavelength and for self-emitted IR, which requires good measurement of the temperature of the optical components. The anticipated signal-to-noise ratio using presently available IR cameras is adequate for the required 500 Hz frame rate.

Rage signalling promotes intestinal tumourigenesis.

Development of colon cancer is a multistep process that is regulated by intrinsic and extrinsic cellular signals. Extrinsic factors include molecular patterns that are derived from either pathogens (PAMPs) or cellular damage (DAMPs). These molecules can promote tumourigenesis by activation of the innate immune system, but the individual contribution of ligands and their receptors remains elusive. The receptor for advanced glycation end products (Rage) is a pattern recognition receptor that binds multiple ligands derived from a damaged cell environment such as Hmgb1 and S100 protein. Here we show that Rage signalling has a critical role in sporadic development of intestinal adenomas, as Apc(Min/+) Rage(-/-) mice are protected against tumourigenesis.

Role of mast cells in colorectal cancer development, the jury is still out.

The link between inflammation and colorectal cancer development is becoming increasingly clear. It had long been recognized that patients with inflammatory bowel disease are at an increased risk of colon cancer. Evidence from experimental animals now also implicates the innate immune system in the development of sporadically occurring intestinal adenomas, the precursors to colorectal cancer. Here we discuss the interaction between the immune system and the adenoma to carcinoma sequence with a special emphasis on the role of mast cells which may play a key role in adenoma development. This article is part of a Special Issue entitled: Mast cells in inflammation.

Retrograde autologous priming reduces transfusion requirements in coronary artery bypass surgery.

The hypothesis was tested whether retrograde autologous priming (RAP) of the cardiopulmonary bypass system, compared to a standard primed system (NON-RAP group), results in less haemodilution and less transfusion of packed red blood cells. Retrospectively, data was collected from the medical charts of one hundred patients undergoing elective coronary artery bypass grafting using cardiopulmonary bypass. Fifty patients where RAP was used have been compared to fifty patients using NON-RAP. The prime volume in the NON-RAP group was 1,627±108 mL versus 782±96 mL in the RAP group (p<0.001). The lowest haematocrit during perfusion was 22% in the NON-RAP group versus 26% when the RAP technique was used (p<0.001). In the NON-RAP group, 26% of the patients received packed red cells in contrast to 6% in the RAP group (p<0.012). A positive association was found between RAP and less transfusion of packed red blood cells (p<0.012). In conclusion, retrograde autologous priming, reducing the prime volume of the cardiopulmonary bypass system, causes less haemodilution and reduces intraoperative transfusion of packed red blood cells.

Predictors of cardiac responsiveness to fluid therapy after cardiac surgery.

OBJECTIVES: Central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) are insensitive preload markers and sometimes misleading. The introduction of the pulse contour method for monitoring of continuous cardiac output enabled the real-time quantification of stroke volume variation (SVV). Studies evaluating the accuracy of this parameter as a measure of preload responsiveness are still limited and conflicting results have been published in cardiac surgical patients. The aim of this study was to reevaluate the predictive value of SVV regarding cardiac responsiveness to fluid therapy and to compare it with the standard preload variables in a clinical setting in the ICU after cardiac surgery. METHODS: The assessment of cardiac responsiveness to fluid therapy (HAES-steril 6% 10 mL * Body Mass Index) was performed in 92 ventilated coronary artery surgical patients after arrival in the ICU. After the fluid load, detailed hemodynamic measurements were performed. A 'responder' was defined as a patient with a gain in stroke volume index (SVI) of 5% or more from baseline value to the volume challenge. RESULTS: Post hoc analysis showed that there were 47 responders to the fluid challenge and 45 non-responders. Hemodynamic data before the fluid therapy show that stroke volume variation in the responders group was significantly higher than in the non-responders groups (9.7 +/- 4.3% versus 7.6 +/- 3.0%, P = 0.01). The receiver operating characteristic curves for the baseline values of CVP, PCWP and SVV were constructed for illustrative purposes. The area under the curve for baseline values of SVV was significantly higher than random guess (area = 0.65, p < 0.05), indicative for the value of SVV as a marker of cardiac responsiveness to fluid therapy. The static preload parameters CVP and PCWP had no predictive value. CONCLUSION: SVV as measured with the LiDCO system is a better functional marker of cardiac responsiveness to fluid therapy than the static parameters CVP and PCWP.

Pulmonary function and inflammatory markers in patients undergoing coronary revascularisation with or without cardiopulmonary bypass.

Lung injury after cardiac surgery is believed to result from cardiopulmonary bypass and its pro-inflammatory effects. To test this hypothesis, we compared the oxygenation ratios, extravascular lung water indices and systemic and pulmonary tumour necrosis factor alpha (TNF-alpha) and interleukin (IL)-8 at predetermined intervals in coronary artery surgery patients with or without cardiopulmonary bypass. No differences in oxygenation ratios or extravascular lung water indices were found. Serum values of TNF-alpha and IL-8 increased in both groups but were higher in the cardiopulmonary bypass group (end of surgery: mean (SD) TNF-alpha 3.68 (2.5) vs 2.20 (1.2) pg.ml(-1) (p = 0.043 (CI 0.05-2.9)) and mean (SD) IL-8 19.45 (10.8) vs 6.31 (5.3) pg.ml(-1) (p = 0.001 (CI 6.9-19.3)). In broncho-alveolar lavage fluid, TNF-alpha and IL-8 increased in both groups with no differences between the groups.

PEG 3350 (Transipeg) versus lactulose in the treatment of childhood functional constipation: a double blind, randomised, controlled, multicentre trial.

BACKGROUND: Recently, polyethylene glycol (PEG 3350) has been suggested as a good alternative laxative to lactulose as a treatment option in paediatric constipation. However, no large randomised controlled trials exist evaluating the efficacy of either laxative. AIMS: To compare PEG 3350 (Transipeg: polyethylene glycol with electrolytes) with lactulose in paediatric constipation and evaluate clinical efficacy/side effects. PATIENTS: One hundred patients (aged 6 months-15 years) with paediatric constipation were included in an eight week double blinded, randomised, controlled trial. METHODS: After faecal disimpaction, patients <6 years of age received PEG 3350 (2.95 g/sachet) or lactulose (6 g/sachet) while children > or =6 years started with 2 sachets/day. Primary outcome measures were: defecation and encopresis frequency/week and successful treatment after eight weeks. Success was defined as a defecation frequency > or =3/week and encopresis < or =1 every two weeks. Secondary outcome measures were side effects after eight weeks of treatment. RESULTS: A total of 91 patients (49 male) completed the study. A significant increase in defecation frequency (PEG 3350: 3 pre v 7 post treatment/week; lactulose: 3 pre v 6 post/week) and a significant decrease in encopresis frequency (PEG 3350: 10 pre v 3 post/week; lactulose: 8 pre v 3 post/week) was found in both groups (NS). However, success was significantly higher in the PEG group (56%) compared with the lactulose group (29%). PEG 3350 patients reported less abdominal pain, straining, and pain at defecation than children using lactulose. However, bad taste was reported significantly more often in the PEG group. CONCLUSIONS: PEG 3350 (0.26 (0.11) g/kg), compared with lactulose (0.66 (0.32) g/kg), provided a higher success rate with fewer side effects. PEG 3350 should be the laxative of first choice in childhood constipation.

Remifentanil provides better protection against noxious stimuli during cardiac surgery than alfentanil.

BACKGROUND AND OBJECTIVE: We hypothesized that remifentanil-propofol cardiac anaesthesia, plus administration of pirinitramide (piritramide) upon cessation of the remifentanil infusion, would be associated with a shorter time to tracheal extubation than alfentanil-propofol anaesthesia, without the occurrence of major haemodynamic instability. METHODS: Haemodynamic stability and recovery characteristics of two remifentanil infusion regimens (0.5 microg kg(-1)min(-1); 0.25 microg kg(-1)min(-1)) were therefore compared with an alfentanil infusion regimen (1 microg kg(-1)min(-1)), in combination with target-controlled infusion of propofol, in a randomized blinded trial in 75 coronary artery surgery patients. RESULTS: Pirinitramide provided good postoperative analgesia without prolonging extubation times: median extubation time in minutes after stopping the opioid-sedative drugs was 300 in the higher-dose remifentanil group and 270 in the lower-dose remifentanil group and alfentanil group (P = 0.606). Significant time-by-treatment interactions were seen for systolic arterial pressure (P = 0.015), mean arterial pressure (P = 0.009) and diastolic arterial pressure (P = 0.006). No significant interaction (P = 0.489) and no constant treatment effect were seen for heart rate (P = 0.288). Time effects were highly significant (P < 0.0001) for all haemodynamic variables. Heart rate remained stable in all groups. In the higher-dose remifentanil group, blood pressure was significantly different and lower during surgery and in this group less bolus doses of the opioid-sedative drugs (P = 0.015) had to be given. CONCLUSION: The higher-dose remifentanil infusion provided superior suppression of haemodynamic responses to noxious stimuli with better haemodynamic stability.

Risk stratification for adverse outcome in cardiac surgery.

Risk-adjusted outcome prediction is mainly important in two separate fields. The first is quality monitoring: measuring actual versus predicted mortality in an institution allows assessment of the clinical surgical and anaesthesia performance while adjusting for the risk profile of the patients. Without risk stratification, surgeons and hospitals treating high-risk patients will appear to have worse results than others. This may prejudice referral patterns, affect the allocation of resources and even discourage the treatment of high-risk patients. The second field is that of informed consent and clinical decision-making. Risk-adjusted predicted mortality should form an important part of patient and surgeon decisions on whether or not to proceed with surgery. Clearly, no 'perfect' model can be produced as some aspects of mortality will always be related to risk factors not included in the model (e.g. the quality of the distal coronary artery vessels in coronary artery surgery) or due to chance happenings not related to preoperative patient characteristics (such as surgical error). An individual patient will either survive or die after cardiac surgery. Clearly, no scoring system will predict the specific outcome for every patient. However, risk stratification will inform patients and clinicians of the likely risk of death for a group of patients with a similar risk profile undergoing the proposed operation. This information is useful and should form part of the basis on which the patient and surgeon decide whether to proceed.

Validation of five commercially available ELISAs for the detection of antibodies against infectious bursal disease virus (serotype 1).

In this study, the results are reported from a validation study of five commercially available enzymelinked immunosorbent assays (ELISAs) for the detection of antibodies against infectious bursal disease virus (IBDV), serotype 1. The specificity of the ELISAs varied from 63.8 to 100%. All ELISAs reached a sensitivity of 100% on sera between 14 and 21 days post-vaccination (d.p.v.) with two classical vaccines and a Delaware variant-E virus. Overall, most birds became positive between 8 and 11 d.p.v. As expected, the ELISA with the lowest specificity showed the highest sensitivity at 5 d.p.v. When the decrease in maternally derived antibodies against IBDV was measured, a highly significant correlation (P < 0.001) was found for all ELISAs and the virus neutralization test (VNT).

[Investigation of the mite fauna content of dust samples collected from pig and poultry farms. Report of the first finding in Western Europe of the house-dust mite Dermatophagoides evansi in dust from poultry houses]. / Een oriënterend onderzoek naar de mijtenfauna in stofmonsters uit varkens- en pluimveestalen in Nederland. Eerste vondst van de huisstofmijt Dermatophagoides evansi in pluimvee-stalstof in West-Europa.

Mites can be important sources of airborne allergens, especially on farms. Two dust samples from pig farms and three dust samples from poultry farms were investigated for mites. House-dust mites were present in the poultry-dust samples, but not in the pig-dust samples. Furthermore, storage mites and predatory mites also were found in the poultry-dust samples. Specifically, the house-dust mite Dermatophagoides evansi was found in the dust samples from two poultry farms. Subsequently, a dust sample was collected from five other poultry farms. Again, D. evansi was present in dust from these farms. This is the first time that D. evansi is reported in dust from poultry farms in Western Europe outside Norway. If D. evansi cross-reacts with other Dermatophagoides spp., then poultry farmers and their families, but also other professionals working in the poultry industry, such as veterinarians, may be exposed to house-dust mites with potential clinical consequences, both domestic and occupational.