Incidence of candidaemia in prolonged venovenous extracorporeal membrane oxygenation.

This single-centre retrospective study reports the dynamics of the incidence of candida bloodstream infection (CBSI) in 145 patients receiving venovenous extracorporeal membrane oxygenation (ECMO) for respiratory support between January 2014 and December 2018. The incidence rate and odds ratio (OR) of CBSI were calculated, stratified by week of ECMO exposure. Weekly incidence increased throughout the ECMO run, with an increasing trend in OR (P=0.005), and a window of continued risk after decannulation was observed. Of the 13 patients who developed CBSI, five (38%) received empirical micafungin treatment before positive culture due to clinical suspicion. There is a need for prospective studies aiming to improve ECMO diagnostic stewardship practices and discourage unnecessary antifungal prophylaxis or empiric management.

Factors affecting tuberculosis health message recall 2 years after active case finding in Blantyre, Malawi.

SETTING: Urban slums, Blantyre, Malawi. OBJECTIVE: To explore tuberculosis (TB) community-wide active case finding (cwACF) recall and accompanying messaging 2 years after the intervention. DESIGN: This mixed-methods study used population-weighted random cluster sampling to select three cwACF-receiving and three non-cwACF-receiving neighbourhoods in Blantyre. Qualitative data were collected using 12 focus group discussions (community peer-group members) and five in-depth interviews (TB officers) with script guides based on the concepts of the Health Belief Model (HBM). Thematic analysis was used to explore transcripts employing deductive coding. Questionnaires completed by focus group participants were used to collect quantitative data, providing a 'knowledge score' evaluated through univariate/multivariate analysis, analysis of variance and multiple linear regression. RESULTS: Community peer-group participants (n = 118) retained high awareness and positive opinions of cwACF and recognised the relationship between early diagnosis and reduced transmission, considering cwACF to have prompted subsequent health-seeking behaviour. TB-affected individuals (personal/family: 47.5%) had significantly higher knowledge scores than unaffected individuals (P = 0.039), but only if resident in cwACF-receiving neighbourhoods (P = 0.005 vs. P = 0.582), implying effect modification between exposures, albeit statistically under-powered (P = 0.229). CONCLUSION: Consistent with epidemiological evidence and HBM theory, cwACF may have a permanent impact on knowledge and behaviour, particularly in communities with a high prevalence of TB-affected individuals. Behaviour change strategies should be explicitly included in cwACF planning and evaluation.

Consistency of performance of robot-assisted surgical tasks in virtual reality.

The purpose of this study was to investigate consistency of performance of robot-assisted surgical tasks in a virtual reality environment. Eight subjects performed two surgical tasks, bimanual carrying and needle passing, with both the da Vinci surgical robot and a virtual reality equivalent environment. Nonlinear analysis was utilized to evaluate consistency of performance by calculating the regularity and the amount of divergence in the movement trajectories of the surgical instrument tips. Our results revealed that movement patterns for both training tasks were statistically similar between the two environments. Consistency of performance as measured by nonlinear analysis could be an appropriate methodology to evaluate the complexity of the training tasks between actual and virtual environments and assist in developing better surgical training programs.

How common is hearing impairment in osteogenesis imperfecta?

Hearing impairment has long been recognized as a common feature in osteogenesis imperfecta. The figures in some publications could be taken to imply that, with increasing age, the proportion of osteogenesis imperfecta patients with hearing impairment approaches 100 per cent. The incidence of hearing loss in a large survey of 1394 patients with osteogenesis imperfecta was examined. It was found that the most common age of onset was in the second, third and fourth decades of life. At the age of 50 approximately 50 per cent of the patients had symptoms of hearing impairment; over the next 20 years there was little further increase. Differences were shown between patients with different clinical types of osteogenesis imperfecta as delineated in the Sillence classification; hearing loss was significantly less common in the type IV disease than in the type I disorder. Among the 29 families with osteogenesis imperfecta type IA there were distinct differences in the likelihood of hearing loss. These findings provide insights which will be valuable in giving patients advice on the likelihood of developing hearing loss in the future.

Ruptured abdominal aortic aneurysms--prognostic indicators and complications affecting mortality. A local experience.

Although elective abdominal aortic aneurysm (AAA) repair can be done with a less than 5% mortality rate, ruptured AAAs have a 32-85% mortality rate. The aims of this study were: (i) to identify prognostic factors affecting mortality; (ii) to identify and assess the impact of postoperative complications on mortality; and (iii) to try to identify a subgroup of patients who would not benefit from surgery. The records of 54 patients presenting with ruptured AAAs were reviewed; 49 of these patients were operated on, 43 of them males and 6 females (mean age 67 years). The operative mortality rate was 44%, most patients who died doing so in the intensive care unit. In 14 cases AAA was diagnosed before rupture--6 of these patients died. Factors that had a significant effect on mortality were: (i) associated ischaemic heart disease--83% of these patients died postoperatively; (ii) the degree of shock on admission--66% of patients with a blood pressure on admission of 85 mmHg or less died; and (iii) the number of postoperative complications per patients--those with 2 or more complications had an 83% mortality rate. Factors that did not correlate statistically with mortality were age, time interval to surgery, volume and composition of intra-operative fluid therapy, and length of surgery. The most important correctable error was failure to operate electively. From the factors assessed it was not possible clearly to identify a subgroup of patients in this study who should have been excluded from surgery.

[Partial ileal bypass for familial hypercholesterolemia]. / Gedeeltelike ileale omleiding vir familiële hipercholesterolemie.

The extent of reduction in cholesterol levels, the maintenance of low levels in the long-term, the morbidity and mortality as well as the acceptance of side-effects of the partial ileal bypass (PIB) is reviewed. The mean reduction in cholesterol levels following PIB was 35.2% in males and 35.8% in female patients. The reduction is significant and it is maintained over a 10-year period. The morbidity and mortality is low and side-effects are well tolerated. Our results indicate that the PIB may play an important role in the cholesterol-lowering armamentarium.

The diagnosis of abdominal injuries in comatose patients.

The clinical course of 95 comatose trauma patients was prospectively evaluated. The role of clinical findings and diagnostic peritoneal lavage (DPL) combined with computed tomography (CT) were assessed in the diagnosis of abdominal injuries. Seven per cent of the patients were comatose due to hypoperfusion, and did not have a primary brain injury. Of the remaining 88 patients, 28% had an associated abdominal injury. Hypotension predicted an associated abdominal injury with an accuracy of 72%, and a haematocrit less than 30% had an accuracy of 82%. Clinical examination was 50% accurate. DPL was 93% accurate, with a false-positive rate of 10%. No abdominal injuries were present in the group in whom the lavage results were negative, while no unnecessary laparotomies were performed in the group with a 4+ or 5+ positive DPL (calorimetric method). In the group with 1+, 2+ and 3+ positive DPL, 3/15 laparotomies (12%) were done for minor abdominal injuries. Minimising unnecessary laparotomies was achieved by utilising CT to determine the nature and extent of the injury. By using DPL as a screening test, and CT to quantify the injury, unnecessary operations can be avoided, and all injuries can still be diagnosed.

Metabolism of estrogens in the gastrointestinal tract of swine. II. Orally administered estradiol-17 beta-D-glucuronide.

Studies were conducted to determine the absorption and metabolic fate of orally administered 3H-estradiol-17 beta-glucuronide (3H-E2-G) in swine. Xylazine-tranquilized female pigs (5 to 6 wk old) were given .04, .4 or 4 mumol 3H-E2-G via stomach tube, and blood samples were collected from previously implanted jugular cannulas for 12 or 72 h. The entire gastrointestinal tract was removed from gilts euthanatized 12 h post-treatment, and free and conjugated estrogens were isolated from plasma and intestinal chyme by diethyl ether extraction and adsorption to Amberlite XAD-2 resin columns. After preparative thin layer chromatography of the conjugate fractions, the conjugates were cleaved by enzyme hydrolysis, solvolysis or acid hydrolysis. The freed estrogens were identified by thin layer chromatography. Plasma radioactivity peaked between 6 and 8 h after administration of the conjugate. None of the radioactivity in plasma was ether extractable. There was evidence for a decrease in absorption rate of radioactive estrogen in the high dosage group. The pattern of metabolites and urinary excretion or orally administered 3H-E2-G was similar to that reported for 14C-E2, except for the greater proportion of polar metabolites and delayed absorption, probably reflecting the need for the conjugate to be hydrolyzed first. The greater proportion of polar metabolites found in this study may have been due to the longer treatment period rather than the administration of the conjugated form of estradiol.

Hormone induced lactation in the cow. IV. Relationships between lactational performance and hormone concentrations in blood plasma.

Concentrations of progesterone, estrogen, and prolactin in plasma were compared among lactations induced in 29 cows by daily subcutaneous injections of .25 mg progesterone and .1 mg estradiol-17beta per kg body weight for 7 days. Superior, median, and inferior lactations were identified by ranking both weightage adjusted maximum milk yields in 7 consecutive days (average 144 +/- 9 kg) and days for milk yield to increase from 5 to 10 kg/day (15 +/- 3 days). Superior and inferior of the former averaged 189 and 101 kg, and their latter averaged 2 and 42 days. Plasma hormones were measured on day 0 before first treatment (day 1), and on days 7, 14, 17, 21, 24, 28, and 35. Superior lactations were associated with below-average progesterone and estrogen in plasma on day 0, rapid decreases in progesterone after day 7 and in estrogen after day 14, and increased prolactin after 7. In comparison, median lactations were associated with elevated progesterone and estrogen after day 17, but prolactin was similar to that of superior lactations. Inferior lactations were associated with decreased prolactin in plasma from days 21 to 35. We hypothesized that (a) first treatment should start 3 to 8 days after estrus, (b) daily doses of estradiol-17beta should be decreased with progesterone unchanged for the 7 days, and (c) estradiol-17beta alone should be continued for 7 days to improve hormonally induced lactations.

Relationships between immunoreactive estrone and estradiol in milk, blood, and urine of dairy cows.

Quantities of immunoreactive estrone and estradiol in blood plasma, urine, and milk were measured during the estrous cycle and pregnancy of cows. The objectives were to develop a radioimmunoassay procedure for quantifying estrogen in milk and urine and to compare changes in milk estrogen with those in blood plasma and urine. Concentrations of estrone and estradiol in milk varied during the estrous cycle. Relative concentrations of estradiol in blood plasma and milk were not different, but average estrone concentrations in milk were four times greater than those in blood plasma. Concentration of total estrogen (estradiol plus estrone) exceeded 1 ng/ml in colostrum and milk from cows milked prepartum, and was correlated with total estrogen in blood plasma and urine before and after calving. Blood plasma estrone was correlated only with milk estrone whereas blood plasma estradiol was correlated with urinary estradiol, milk estrone, and milk estradiol during the estrous cycle. These results raise possibilities that mammary gland of the lactating cow may concentrate preferentially estrone or convert estradiol to estrone. However, estimated excretion of estrogen through the milk represents no more than a fraction of 1% of the total excreted during the estrous cycle, and the proportion becomes less as gestation progresses up to at least 7 mo.