Audit of hemostatic clip use after colorectal polyp resection in an academic endoscopy unit.

Background and study aims Prophylactic closure of endoscopic resection defects reduces delayed hemorrhage after resection of non-pedunculated colorectal lesions ≥ 20 mm that are located proximal to the splenic flexure and removed by electrocautery. The risk of delayed hemorrhage after cold (without electrocautery) resection is much lower, and prophylactic clip closure after cold resection is generally unnecessary. The aim of this study was to audit clip use after colorectal polyp resection in routine outpatient colonoscopies at two outpatient centers within an academic medical center. Patients referred for resection of known lesions were excluded. Patients and methods Retrospective chart analysis was performed as part of a quality review of physician adherence to screening and post-polypectomy surveillance intervals. Results Among 3784 total lesions resected cold by 29 physicians, clips were placed after cold resection on 41.7% of 12 lesions ≥ 20 mm, 19.3% of 207 lesions 10 to 19 mm in size, and 2.8% of 3565 lesions 1 to 9 mm in size. Three physicians placed clips after cold resection of lesions 1 to 9 mm in 18.8%, 25.5%, and 45.0% of cases. These physicians accounted for 8.1% of 1- to 9-mm resections, but 69.7% of clips placed in this size range. Electrocautery was used for 3.1% of all resections. Clip placement overall after cold resection (3.9%) was much lower than after resection with electrocautery (71.1%), but 62.4% of all clips placed were after cold resection. Conclusions Audits of clip use in an endoscopy practice can reveal surprising findings, including high and variable rates of unnecessary use after cold resection. Audit can potentially reduce unnecessary costs, carbon emissions, and plastic waste.

Prevalence and drug use correlates of inadvertent fentanyl exposure among individuals misusing drugs in seven U.S. states.

Fentanyl has emerged as the leading cause of fatal drug overdoses in the U.S. Individuals misusing drugs may not always be aware of exposure to fentanyl.To determine the prevalence of fentanyl use and extent of awareness of fentanyl exposure among a national sample of treatment-seeking individuals with opioid use disorder (n = 1098).Participants provided oral fluid and urine specimens, which were tested for drugs by liquid chromatography/tandem mass spectrometry. Participants also provided self-reports of fentanyl use.49.5% tested positive for fentanyl in oral fluid, urine, or both. Of those testing positive for fentanyl, 29.8% were unaware that they had been exposed to fentanyl. Participants testing positive for opioids methadone, and specifically 6-monoacetylmorphine (6-MAM), a unique metabolite of heroin, were significantly more likely to be unaware of fentanyl exposure than participants testing negative for these substances, with a similar trend for oxycodone and tramadol.These findings may be due to fentanyl's effect being difficult to distinguish from that of other opioids, whereas when other types of drugs are adulterated with fentanyl, the differences in effects are likely to be readily discernable. These results support the importance of expanded drug-checking services.

Acute disseminated encephalomyelitis and routine childhood vaccinations - a self-controlled case series.

Acute disseminated encephalomyelitis (ADEM) is an autoimmune, central nervous system demyelinating disorder that follows antecedent immunologic challenges, such as infection or vaccination. This study aimed to investigate the potential association between routine childhood vaccinations and ADEM. Children under 7 years of age admitted to the two tertiary level pediatric hospitals in Victoria, Australia with ADEM from 2000-2015 had their clinical information linked to vaccination records from the Australian Childhood Immunization Register. Chart review was undertaken utilizing the Brighton Collaboration ADEM criteria. The self-controlled case-series (SCCS) methodology was employed to determine the relative incidences of ADEM post-vaccination in two risk intervals: 5-28 days and 2-42 days. Forty-six cases were eligible for SCCS analysis with a median age of 3.2 years. Of the forty-six cases, three were vaccine proximate cases and received vaccinations 23, 25 and 28 days before ADEM onset. Two vaccine proximate cases received their 4-year-old scheduled vaccinations (MMR and DTPa-IPV) and one vaccine proximate case the 1-year old scheduled vaccinations (MMR and Hib-MenC). The relative incidence of ADEM during the narrow and broad risk intervals were 1.041 (95% CI 0.323-3.356, p = 0.946) and 0.585 (95% CI 0.182-1.886, p = 0.370) respectively. Sensitivity analyses did not yield any substantial deviations. These results do not provide evidence of an association between vaccinations routinely provided to children aged under 7 years in Australia and the incidence of ADEM. However, these results should be interpreted with caution as the number of ADEM cases identified was limited and further research is warranted.

Grain structure control during metal 3D printing by high-intensity ultrasound.

Additive manufacturing (AM) of metals, also known as metal 3D printing, typically leads to the formation of columnar grain structures along the build direction in most as-built metals and alloys. These long columnar grains can cause property anisotropy, which is usually detrimental to component qualification or targeted applications. Here, without changing alloy chemistry, we demonstrate an AM solidification-control solution to printing metallic alloys with an equiaxed grain structure and improved mechanical properties. Using the titanium alloy Ti-6Al-4V as a model alloy, we employ high-intensity ultrasound to achieve full transition from columnar grains to fine (~100 µm) equiaxed grains in AM Ti-6Al-4V samples by laser powder deposition. This results in a 12% improvement in both the yield stress and tensile strength compared with the conventional AM columnar Ti-6Al-4V. We further demonstrate the generality of our technique by achieving similar grain structure control results in the nickel-based superalloy Inconel 625, and expect that this method may be applicable to other metallic materials that exhibit columnar grain structures during AM.

Carbapenemase-producing Enterobacteriaceae in Australian hospitals: outcome of point-prevalence screening in high-risk wards.

Carbapenemase-producing Enterobacteriaceae (CPE) infections are increasingly reported in Australian hospitals, but prevalence is unknown. In 2016, Victorian hospitals conducted CPE point-prevalence surveys in high-risk wards (intensive care, haematology, transplant). Forty-three hospitals performed 134 surveys, with 1839/2342 (79%) high-risk patients screened. Twenty-four surveys were also performed in other wards. Inability to obtain patient consent was the leading reason for non-participation. In high-risk wards, no CPE cases were detected; three cases were identified in other wards. Since there is low prevalence in high-risk wards, continuous screening is not recommended. Targeted screening may be enhanced by review of patient consent processes.

Role of ultrasonic treatment, inoculation and solute in the grain refinement of commercial purity aluminium.

The present study investigates the influence of ultrasonic treatment on the grain refinement of commercial purity aluminium with a range of Al3Ti1B master alloy additions. When the aluminium contains the smallest amount of added master alloy, ultrasonics caused significant additional grain refinement compared to that provided by the master alloy alone. However, the influence of ultrasonics on grain size reduces with increasing addition of the master alloy which adds additional TiB2 particles and Ti solute with each incremental addition. Applying the Interdependence model to analyse the experimentally measured grain sizes revealed that the results of this study and those from similar experiments on an Al-2Cu alloy were consistent when the alloy compositions are converted to their growth restriction factors (Q) and that increasing Q had a major effect on reducing grain size and increasing grain number density. Compared with the application of ultrasonic treatment where an order of magnitude increase in the grain number density is achieved, an increase in the Ti content over the range of master alloy additions, causes the grain number density to increase by approximately three times.

Controlling initial biodegradation of magnesium by a biocompatible strontium phosphate conversion coating.

A simple strontium phosphate (SrP) conversion coating process was developed to protect magnesium (Mg) from the initial degradation post-implantation. The coating morphology, deposition rate and resultant phases are all dependent on the processing temperature, which determines the protective ability for Mg in minimum essential medium (MEM). Coatings produced at 80 °C are primarily made up of strontium apatite (SrAp) with a granular surface, a high degree of crystallinity and the highest protective ability, which arises from retarding anodic dissolution of Mg in MEM. Following 14 days' immersion in MEM, the SrAp coating maintained its integrity with only a small fraction of the surface corroded. The post-degradation effect of uncoated Mg and Mg coated at 40 and 80 °C on the proliferation and differentiation of human mesenchymal stem cells was also studied, revealing that the SrP coatings are biocompatible and permit proliferation to a level similar to that of pure Mg. The present study suggests that the SrP conversion coating is a promising option for controlling the early rapid degradation rate, and hence hydrogen gas evolution, of Mg implants without adverse effects on surrounding cells and tissues.

Linkage disequilibrium mapping provides further evidence of a gene for reading disability on chromosome 6p21.3-22.

Linkage disequilibrium (LD) mapping was used to follow up reports of linkage between reading disability (RD) and an 18 cM region of chromosome 6p21.3-22. Using a two-stage approach, we tested for association between RD and 22 microsatellite markers in two independent samples of 101 (Stage 1) and 77 (Stage 2) parent/proband trios in which RD was rigorously defined. The most significant replicated associations were observed between combinations of markers D6S109/422/1665 (Stage 1, P=0.002 (adjusted for multiple testing); Stage 2, P=0.0001) and D6S506/1029/1660 (Stage 1, P=0.02 (adjusted), Stage 2, P=0.0001). The only two-marker association observed in both samples was with D6S422/1665 (P=0.01, 0.04). No single marker showed replicated association but D6S506 produced values of P=0.01 and 0.08 which were significant when combined (P=0.02). We observed weaker and less consistent evidence of association in a region of confirmed linkage to RD in previous studies. The most consistently significant haplotypic association D6S109/422/1665, showed association with single-word reading, spelling, phonological awareness, phonological decoding, orthographic accuracy and random automised naming, but not with vocabulary or Attention Deficit Hyperactivity Disorder. Our findings strongly support the presence of a gene contributing to RD in a region of chromosome 6 between markers D6S109 and D6S1260, but do not rule out the presence of a gene between D6S1556 and MOG.

Etomoxir-induced oxidative stress in HepG2 cells detected by differential gene expression is confirmed biochemically.

Although they are known to be effective antidiabetic agents, little is published about the toxic effects of carnitine palmitoyltransferase-1 (CPT-1) inhibitors, such as etomoxir (ET). These compounds inhibit mitochondrial fatty acid beta-oxidation by irreversibly binding to CPT-1 and preventing entry of long chain fatty acids into the mitochondrial matrix. Treatment of HepG2 cells with 1 mM etomoxir for 6 h caused significant modulations in the expression of several redox-related and cell cycle mRNAs as measured by microarray analysis. Upregulated mRNAs included heme oxygenase 1 (HO1), 8-oxoguanine DNA glycosylase 1 (OGG1), glutathione reductase (GSR), cyclin-dependent kinase inhibitor 1A (CDKN1 [p21(waf1)]) and Mn+ superoxide dismutase precursor (SOD2); while cytochrome P450 1A1 (CYP1A1) and heat shock 70kD protein 1 (HSPA1A) were downregulated. Real time quantitative PCR (RT-PCR) confirmed the significant changes in 4 of 4 mRNAs assayed (CYP1A1, HO1, GSR, CDKN1), and identified 3 additional mRNA changes; 2 redox-related genes, gamma-glutamate-cysteine ligase modifier subunit (GCLM) and thioredoxin reductase (TXNRD1) and 1 DNA replication gene, topoisomerase IIalpha (TOP2A). Temporal changes in selected mRNA levels were examined by RT-PCR over 11 time points from 15 min to 24 h postdosing. CYP1A1 exhibited a 38-fold decrease by 4 h, which rebounded to a 39-fold increase by 20 h. GCLM and TXNRD1 exhibited 13- and 9-fold increases, respectively at 24 h. Etomoxir-induced oxidative stress and impaired mitochondrial energy metabolism were confirmed by a significant decrease in reduced glutathione (GSH), reduced/oxidized glutathione ratio (GSH/GSSG), mitochondrial membrane potential (MMP), and ATP levels, and by concurrent increase in oxidized glutathione (GSSG) and superoxide generation. This is the first report of oxidative stress caused by etomoxir.

Preliminary examination of contaminant loadings in farmed salmon, wild salmon and commercial salmon feed.

This pilot study examined five commercial salmon feeds, four farmed salmon (one Atlantic, three chinooks) and four wild salmon (one chinook, one chum, two sockeyes) from the Pacific Coast for PCBs (112 congeners), polybrominated diphenylethers (PBDEs - 41 congeners), 25 organochlorine pesticides (OPs), 20 polycyclic aromatic hydrocarbons (PAHs), and methyl and inorganic mercury. The farmed salmon showed consistently higher levels of PCBs, PBDEs, OPs (except toxaphene) than the wild salmon. The mean concentrations in pg/g were 51,216 vs 5302 for total PCBs; 2668 vs 178 for total PBDEs; 41,796 vs 12,164 for total OPs (except toxaphene). The farmed salmon levels are likely a consequence of the elevated level of contamination found in the commercial salmon feed (mean concentrations in pg/g were 65,535 for total PCBs; 1889 for total BPDEs; 48,124 for total OPs except toxaphene). Except for a single high wild chinook value, PAHs were highest in the feed samples followed by the farmed fish and the three other wild fish. The Bio-Oregon-1996 feed of hatchery origin showed a level of PAHs ten times higher than any other feed. The genotoxic implications of such a high PAH level are considered for juvenile chinook salmon. Toxaphene and methyl mercury concentrations were not notably different between the wild and farmed salmon. There was no clear low contaminant brand of salmon feed. The human health implications of eating farmed salmon are considered from the perspective of the current WHO and Health Canada (2000) tolerable daily intake (TDI) values for PCBs. Based on a TDI of 1 pg TEQ/kg bw/day, this analysis indicated a safety concern for individuals who on a regular weekly basis consume farmed salmon produced from contaminated feed.

Pharmacological treatments for alcoholism: revisiting lithium and considering buspirone.

OBJECTIVE: Previous research has suggested that both lithium and buspirone could lessen alcoholics' desire to drink as well as reduce the actual amounts of alcohol consumed. The purpose of this study was to compare lithium and buspirone monotherapy with placebo on outcomes of abstinence, alcohol quantity consumed, treatment retention and compliance, and medication side effects. METHODS: We conducted a randomized, double-blind, placebo-controlled, three-arm parallel group, clinical trial that compared lithium and buspirone with placebo in 156 alcohol-dependent men. RESULTS: Study retention rates for the three treatment groups at 3 and 6 months, respectively, were 61% and 46% for lithium, 44% and 27% for buspirone, and 52% and 38% for placebo (p = NS, for 3 and 6 months). Overall abstinence rates were 28% and 19% at 3 and 6 months, respectively. However, mean daily quantities of alcohol consumed and percentage of drinking days decreased significantly (p < 0.0001) over time in all treatment groups. Differential improvement was seen only for the decrement in quantity consumed in the buspirone group, compared with the placebo group, but only at a trend level (p = 0.07). According to pill counts, compliance did not differ significantly among the treatment groups. CONCLUSIONS: These results do not support the hypothesis that either lithium or buspirone, compared with placebo, produces differential reductions in alcohol consumption. The results suggest the need to enhance treatment retention to maximize outcomes.

Family-based association mapping provides evidence for a gene for reading disability on chromosome 15q.

Family-based association mapping was used to follow up reports of linkage between reading disability (RD) and a genomic region on chromosome 15q. Using a two-stage approach, we ascertained 101 (stage 1) and 77 (stage 2) parent-proband trios, in which RD was characterized rigorously. In stage 1, a set of eight microsatellite markers spanning the region of putative linkage was used and a highly significant association was detected between RD and a three-marker haplotype (D15S994/D15S214/D15S146: P and empirical P < 0.001). A significant association with the same three-marker haplotype was also observed in the second-stage sample (P = 0.009, empirical P = 0.006). Our data therefore provide strong evidence for one or more genes contributing to RD being located in the vicinity of the region including D15S146 and D15S994. In addition, our results provide support for association analysis being a useful method to map susceptibility loci for complex disorders.

Comment on analyzing flow cytometric data for comparison of mean values of the coefficient of variation of the G1 peak.

BACKGROUND: The coefficient of variation (CV) is often used to characterize and summarize the flow cytometry analysis of nuclear DNA of the Go/G1 peak in a cell population within an individual organism. CV values are frequently used in subsequent statistical analysis to compare experimental groups of individuals. METHODS: We explain why the conventional analysis of variance, linear comparisons and regressions that employ the F and t-tests are not appropriate for analyzing CV data sets. The weighted least squares procedure which utilizes the chi-square test is presented as an adequate method. We further explain why this type of data needs to be analyzed by this procedure. RESULTS: To illustrate the application of the weighted least squares procedure, we analyzed a real data set that had been previously analyzed by conventional methods. We found that a non-significant result (p = 1) using the latter was significant when re-analyzed with the weighted least squares procedure (p = 0.032). CONCLUSIONS: Significant differences between treatments established by the weighted least squares often go unidentified by the conventional analysis. Use of the weighted least squares procedure is recommended for analyzing CV data sets.

Intrauterine fetal volvulus presenting as fetal distress on cardiotocographic monitoring: a case report.

A rare case of intrauterine fetal midgut volvulus is described. The condition was diagnosed post delivery after the patient presented with markedly decreased fetal movements and fetal distress on cardiotocographic monitoring at 35 weeks' gestation. This baby was delivered and resuscitated before proceeding to laparotomy and bowel resection. The infant has subsequently made a good recovery. Intrauterine volvulus is rare, and presentation in this case was with fetal distress which has not previously been described as a presenting feature.

Infertility treatment: lack of consensus plagues an unregulated field.

Each year, in an attempt to stimulate journalism students' interest in medical writing, CMAJ sponsors the Amy Chouinard Memorial Essay Prize. The $750 award is in memory of Amy Chouinard, a longtime and valued contributor to CMAJ and the Canadian Journal of Surgery. Students from any recognized journalism program at a Canadian college or university are eligible to enter, and the deadline for 1998 entries is June 1. The 1997 winner, Megan Easton, presents a well-written and thorough account of the issues surrounding infertility treatment. Interest in the topic came naturally enough--her father, Dr. William Easton, is a urogynecologist in private practice in Scarborough, Ont.

Pediatric bacteremia due to Staphylococcus warneri: microbiological, epidemiological, and clinical features.

Between 1991 and 1995, an apparent high rate of Staphylococcus warneri bacteremias at the Royal Children's Hospital, Melbourne, Victoria, Australia, raised the possibility of a virulent nosocomial strain. In a retrospective review of 30 S. warneri bacteremias in children, organisms were viable and verified in 22 episodes, 12 representing significant bacteremias. Of these 12 episodes, 2 pairs shared chromosomal DNA pulsed-field gel electrophoresis patterns in unconnected patients, dispelling concerns about a single virulent strain.

Specific cleavage of immunoglobulin G by copper ions.

The hinge region of a recombinant-DNA-produced human IgG1 (Campath 1H) is specifically cleavable at a single copper-sensitive peptide bond, yielding a distinct fragment resolved by size-exclusion high-performance liquid chromatography. This novel metal ion-catalysed cleavage at slightly alkaline pH is inhibited by EDTA and its rate is reduced at slightly acidic conditions (pH 5-6) and accelerated by increasing concentrations of cupric ion and higher temperature. Complete cleavage was observed after incubation at pH 8 for 24 h with 1 mM CuCl2. Sequence analysis determined the cleavage site to be the Lys226-Thr227 bond in the hinge-region sequence DKTHT. Cleavage of other IgGs was observed to varying degrees, and specific cleavage of synthetic peptides containing this pentapeptide sequence was also observed.

Cognitive remediation of persons with severe and persistent mental illness.

There is a vast psychiatric literature describing the nature and degree of cognitive deficits present in persons suffering from severe and persistent mental illness, particularly schizophrenic spectrum disorders. A smaller, more recent literature has emerged addressing non-pharmaceutical interventions developed to remediate those deficits. The Cognitive Remediation Program was developed to remediate cognitive deficits in such areas as the ability to sustain attention and concentration, memory processes, concept formation, organizing visual and auditory stimuli into recognizable patterns, and shifting cognitive sets. The program consists of three fifteen minute intervals or "loops" that each contain a different type of task designed to promote remediation of cognitive deficits. The Program also employs behavioral techniques, using a token economy to aid in shaping behavior and motivating patients. The loops consist of: 1) a group that focuses on training in attention, concentration and cognitive flexibility; 2) a computer group utilizing a combination of game software and programs designed for use with a head injured population; 3) a group promoting the generalization of skills learned in the Program to other social arenas. On a ten week pre- and post-measure, participants improved significantly on both a digits forward and digits backward task, both measures of concentration and attention.

Composition and funding. Consultation-liaison psychiatry services.

All of the programs in the Academy of Psychosomatic Medicine directory of U.S. consultation-liaison (C-L) fellowship training (N = 49) responded to a questionnaire to document composition and funding of their staff. The mean annual budget was $324,664 (range $40,000-$550,000), with a mean of 2.4 full-time equivalents and 1.6 fellowship training positions. A significant patient cohort and C-L staff and fellows exist in these programs to launch important hypothesis-generation studies.

Effect of free-radical scavengers and hyperbaric oxygen on random-pattern skin flaps.

OBJECTIVE: To determine whether treatment with the combination of hyperbaric oxygen and free-radical scavengers or inhibitors would result in increased skin-flap survival. DESIGN: An animal model with male Sprague-Dawley rats was used. The flap was a cranial-based dorsal 3 x 12-cm random-pattern skin flap that included the panniculus carnosus. Rats were randomly assigned to one of 10 treatment groups. INTERVENTIONS: The radical scavengers superoxide dismutase, catalase, and alpha-tocopherol acetate and the inhibitor allopurinol were used to combat or scavenge radicals. Oxygen (100%) treatments were for 90 minutes at 2.5 atm absolute daily. MAIN OUTCOME MEASURES: At 7 days, the flaps were examined for survival by fluorescein injection. Lipid peroxidation as a measure of tissue damage was measured by thiobarbituric acid-malondialdehyde analysis. RESULTS: The combination of treatments resulted in significantly increased flap survival compared with untreated controls (P < .05) except in the group treated with allopurinol and hyperbaric oxygen. Lipid peroxidation was inhibited by the superoxide dismutase plus catalase and the alpha-tocopherol treatments but not by treatment with allopurinol. CONCLUSION: Moderate doses of radical scavengers or antioxidants coupled with a conservative hyperoxic exposure regimen can result in the increased survival of random-pattern skin flaps.