Extreme eutrophication and salinisation in the Coorong estuarine-lagoon ecosystem of Australia's largest river basin (Murray-Darling).

Estuaries in rainfall poor regions are highly susceptible to climatic and hydrological changes. The Coorong, a Ramsar-listed estuarine-coastal lagoon at the end of the Murray-Darling Basin (Australia), has experienced declining ecological health over recent decades. Twenty years of environmental data were analysed to assess patterns and drivers of water quality changes. Large areas of the Coorong are now persistently hyper-saline (salinity >80 psu) and hypereutrophic (total nitrogen, TN > 4 mg L-1, total phosphorus, TP > 0.2 mg L-1, chlorophyll a > 50 µg L-1) which coincided with reduced flushing due to diminished freshwater inflows and increasing evapo-concentration. Sediment quality also was related to flushing, with higher concentrations of organic carbon, TN, TP and sulfides as salinity increased. While total nutrient levels are very high, dissolved inorganic nutrients are generally low. Increased lagoonal flushing would be beneficial to reduce the hypersalinisation and hypereutrophication and improve ecosystem health.

The trend of percutaneous and open surgical procedures for peripheral arteriovenous malformations in the National Health Service England.

INTRODUCTION: This study aimed to assess the trend of percutaneous and open surgical procedures for peripheral arteriovenous malformations (AVMs) performed in NHS hospitals in England between 2012 and 2018. METHODS: Hospital Episode Statistics (HES) is a freely available data warehouse that represents the whole population of England served by the NHS. Data from the HES database was obtained and analysed for all hospital episodes between 2012 and 2018 for the total number and trend of 'primary diagnosis', and 'primary procedures and interventions' identified for peripheral AVMs. RESULTS: Over the period studied, there was an increase in the total number of admissions for peripheral AVMs; total primary diagnosis increased from 2242 to 2857 per year. Open surgery remained more commonly performed than percutaneous procedures throughout the studied period. However, the overall percentage of primary procedures and interventions being percutaneous in this period increased from 29.8% to 41.0% per year. The increase in the number of percutaneous procedures per year seemed to occur in both children (from 43 to 124) and adults (from 408 to 492) over the course of the study period. CONCLUSIONS: This study concluded that open surgery remained the most commonly performed primary procedure for peripheral AVMs, although there was an increasing trend for percutaneous procedures in NHS hospitals in England. The increase in the number and percentage of percutaneous procedures for peripheral AVMs was likely to have significant resource implications for the provision of care for patients with peripheral AVMs in NHS hospitals.

Paediatric endophthalmitis: a UK retrospective study.

INTRODUCTION: Paediatric endophthalmitis is a severe but rare complication of intraocular surgery, penetrating trauma and far less commonly extra-ocular surgery or endogenous origin. We set out to establish the incidence and risk factors of exogenous endophthalmitis in children, and to develop an evidence-based protocol that can be used for treatment of suspected exogenous endophthalmitis in children. METHODS: Microbiology reports and operation numbers were obtained from two large tertiary referral hospitals sharing 24-h paediatric ophthalmology cover for the period January 2009-December 2016. All cases of aqueous and/or vitreous tap performed on children aged ≤18 years were identified and case notes reviewed for complete information on each case. RESULTS: Sixteen cases were eligible for inclusion as 'postoperative endophthalmitis': complete data was found on 13 cases. The incidence of postoperative endophthalmitis was 0.17% over 7 years. The mean age of presentation was 5.5 years (range from 7 months to 16 years and 9 months), from 3 days-78 months post operatively. In all, 11/13 had at least one glaucoma procedure. Microbiology results showed growth in 8/13. Most isolates were Gram-positive bacteria but Gram-negatives were also isolated and in one case Candida from a conjunctival swab. The antibiotic regime varied depending on age, organism identified and sensitivities. In all, 9/13 had hand movement or worse vision after treatment. CONCLUSION: Paediatric endophthalmitis may present to any paediatric/general ophthalmologist. It is a rare but devastating condition with poor visual prognosis, requiring prompt recognition and aggressive management. Previous glaucoma surgery is a long-term risk factor in our local paediatric population. Based on our study, an evidence-based protocol for management is proposed in order to improve outcomes.

Excimer laser assisted complex inferior vena cava filter retrieval: a single institution's experience over 6 years.

AIM: To investigate inferior vena cava (IVC) filter retrievals and the use of the excimer laser sheath to assist in complex cases. MATERIALS AND METHODS: Retrospective analysis was undertaken of 181 attempted filter retrievals over a 6 year period. Pre- and perioperative imaging was analysed from both standard retrieval and complex retrieval techniques. RESULTS: One hundred and eighty-one IVC filter retrievals were attempted: 130 (72%) standard retrievals were successful and 51 (28%) failed due to device endothelialisation. Forty (23%) cases then had subsequent successful complex retrieval under general anaesthetic. Eighteen (45%) cases were removed with the sling technique and 22 (55%) cases using the excimer laser dissection technique. Where preoperative venography/computed tomography (CT) demonstrated embedding of the filter feet versus filter apex, this was predictive of requiring dissection techniques versus sling technique (13/18 patients; p<0.05 chi-squared test). The difference in device indwelling time was statistically significant between the successful standard retrieval group (134 days) versus patients who failed standard retrieval and required complex techniques (243 days; p=0.00018). CONCLUSION: Standard retrieval techniques failed in 28% of cases. This correlated with devices that were indwelling for longer. When imaging demonstrated filter-feet endothelisation/perforation, this was predictive of requiring dissection techniques with the excimer laser.

A technician-delivered 'virtual clinic' for triaging low-risk glaucoma referrals.

PurposeThe purpose of this study is to describe the outcomes of a technician-delivered glaucoma referral triaging service with 'virtual review' of resultant data by a consultant ophthalmologist.Patients and methodsThe Glaucoma Screening Clinic reviewed new optometrist or GP-initiated glaucoma suspect referrals into a specialist ophthalmic hospital. Patients underwent testing by three ophthalmic technicians in a dedicated clinical facility. Data were reviewed at a different time and date by a consultant glaucoma ophthalmologist. Approximately 10% of discharged patients were reviewed in a face-to-face consultant-led clinic to examine the false-negative rate of the service.ResultsBetween 1 March 2014 and 31 March 2016, 1380 patients were seen in the clinic. The number of patients discharged following consultant virtual review was 855 (62%). The positive predictive value of onward referrals was 84%. Three of the 82 patients brought back for face-to-face review were deemed to require treatment, equating to negative predictive value of 96%.ConclusionsOur technician-delivered glaucoma referral triaging clinic incorporates consultant 'virtual review' to provide a service model that significantly reduces the number of onward referrals into the glaucoma outpatient department. This model may be an alternative to departments where there are difficulties in implementing optometrist-led community-based referral refinement schemes.

Quality of life and functional vision in children treated for cataract-a cross-sectional study.

PurposeChildren with cataract and their families face intensive medical and surgical management, with numerous hospital attendances, topical medications, and surgical procedures, as well as uncertainty about the child's future visual ability, education, and independence. Little is known about the impact on functional visual ability, vision-, and health-related quality of life (VR-, HR-QoL).Patients and methodsSeventy two children aged 2-16 years (mean 8.45, SD 4.1) treated for developmental or secondary cataract and their parents/carers completed three validated instruments measuring functional visual ability, VR-, and HR-QoL: the Cardiff Visual Ability Questionnaire for Children (CVAQC), Impact of Vision Impairment for Children (IVI-C), and PedsQL V 4.0.ResultsAll scores are markedly reduced: median (interquartile range (IQR)) CVAQC score -1.42 (-2.28 to -0.03), mean (SD) IVI-C score 65.67 (16.91), median (IQR) PedsQL family impact score 75 (56.94-88.19), parent report 71.74 (51.98-88.5), self-report 76.09 (61.96-89.13). Psychosocial PedsQL subscores are lower than physical subscores. Parent-completed tools (PedsQL family and parent report) state greater impact on HR-QoL than tools completed by children/young people, particularly in teenagers. Older children/young people have higher functional visual ability scores than younger children.ConclusionsCataract has a marked a long-term impact on functional visual ability and quality of life of children and young people, with HR-QoL affected to degrees reported in children with severe congenital cardiac defects or liver transplants.

DNA extraction from benthic Cyanobacteria: comparative assessment and optimization.

AIMS: Benthic Cyanobacteria produce toxic and odorous compounds similar to their planktonic counterparts, challenging the quality of drinking water supplies. The biofilm that benthic algae and other micro-organisms produce is a complex and protective matrix. Monitoring to determine the abundance and identification of Cyanobacteria, therefore, relies on molecular techniques, with the choice of DNA isolation technique critical. This study investigated which DNA extraction method is optimal for DNA recovery in order to guarantee the best DNA yield for PCR-based analysis of benthic Cyanobacteria. METHODS AND RESULTS: The conventional phenol-chloroform extraction method was compared with five commercial kits, with the addition of chemical and physical cell-lysis steps also trialled. The efficacy of the various methods was evaluated by measuring the quantity and quality of DNA by UV spectrophotometry and by quantitative PCR (qPCR) using Cyanobacteria-specific primers. The yield and quality of DNA retrieved with the commercial kits was significantly higher than that of DNA obtained with the phenol-chloroform protocol. CONCLUSIONS: Kits including a physical cell-lysis step, such as the MO BIO Power Soil and Biofilm kits, were the most efficient for DNA isolation from benthic Cyanobacteria. SIGNIFICANCE AND IMPACT OF THE STUDY: These commercial kits allow greater recovery and the elimination of dangerous chemicals for DNA extraction, making them the method of choice for the isolation of DNA from benthic mats. They also facilitate the extraction of DNA from benthic Cyanobacteria, which can help to improve the characterization of Cyanobacteria in environmental studies using qPCRs or population composition analysis using next-generation sequencing.

Comparative evaluation of the visibility and block characteristics of a stimulating needle and catheter vs an echogenic needle and catheter for sciatic nerve block with a low-frequency ultrasound probe.

BACKGROUND: Clear visibility of the needle and catheter tip is desirable to perform safe and successful ultrasound-guided peripheral nerve blocks. This can be challenging with deeper blocks in obese patients. This study compared the visibility of echogenic and non-echogenic block needles and catheters in proximal sciatic blocks when performed with a low-frequency curved probe. METHODS: Seventy-eight patients undergoing total knee joint arthroplasty were randomized to receive an ultrasound-guided continuous sciatic nerve block using either a non-echogenic needle and stimulating catheter or an echogenic needle and echogenic non-stimulating catheter. Block needles in both groups were placed using both neurostimulation and ultrasound guidance, after which the catheter was positioned using either neurostimulation alone (Stimulating group) or imaging alone (Echogenic group). Three anaesthetists blinded to group allocation graded video clips recorded during the blocks for nerve, needle and catheter visibility. Performance characteristics and block parameters were also compared. RESULTS: No significant differences between the two groups were observed with regard to needle or catheter visibility (P=0.516). The Stimulating group required more needle redirections (P=0.009), had a longer procedure time [Echogenic median 274 s vs Stimulating 344 s (P=0.016)], and resulted in greater patient discomfort (P=0.012). There were no significant differences between the two groups in terms of block onset or completion time. CONCLUSIONS: Use of echogenic needles and catheters reduced procedure time and patient discomfort compared with a stimulating catheter system. There were no differences in the visibility scores of the two systems. CLINICAL TRIAL REGISTRATION: CTR Protocol ID: R-11-495, Clinical Trials.Gov ID: NCT 01492660.

Injectate spread following ultrasound-guided lateral to medial approach for dual transversus abdominis plane blocks.

BACKGROUND: Bilateral dual transversus abdominis plane (BD-TAP) injections were devised to cover the T7-8 and L1 dermatomes, which are usually spared with classical and mid-axillary TAP injections. The purpose of this study was to delineate the vertical and lateral extent of injectate spread following a lateral to medial approach for TAP injections in embalmed cadavers. METHODS: Ultrasound-guided subcostal and lateral TAP injections were performed on nine embalmed cadavers using 30 ml of 0.5% methylcellulose (20 ml for subcostal and 10 ml for lateral injections) with a 12-cm Tuohy needle in the first six cadavers (nine hemi-abdomens). Vertical extent and the medial to lateral extent of the dye spread were recorded after dissections of the abdominal wall. In a pilot of three cadavers not receiving TAP injections, anatomical impediments to proximal injectate spread were explored separately. RESULTS: The vertical spread of injectate was T7-L1 (n = 2/9), T8-L1 (n = 5/9) and T9-L1 (n = 2/9). None of the TAP injections extended beyond the mid-axillary line. No anatomical impediments for the flow of injectate to the T7 or T8 intercostal nerves were found at the level of the interdigitations of the transversus abdominis muscle and diaphragm. CONCLUSION: A lateral to medial approach for TAP injection resulted in spread of the injectate ranging from T7/8-L1 dermatomes in the majority of the hemi-abdomens. Subcostal and lateral TAP injections do not cover the lateral cutaneous branches of the segmental nerves.

Infantile glaucoma in Rubinstein-Taybi syndrome.

PURPOSE: Long-term follow-up of patients with Rubinstein-Taybi-associated infantile glaucoma. METHODS: Case series. RESULTS: Three cases of infantile glaucoma in association with Rubinstein-Taybi syndrome are presented. DISCUSSION: This report highlights the importance of measuring intraocular pressure in this condition, as glaucoma is one of the major preventable causes of blindness in childhood.

The efficacy of treatment of patients with severe constipation or recurrent pseudo-obstruction with pyridostigmine.

OBJECTIVE: Disorders of colonic motility, such as severe constipation and pseudo-obstruction, remain difficult to treat. The pathophysiology of these conditions is not completely understood, but previous studies suggest a deficiency of cholinergic innervation and an imbalance in autonomic regulation of colonic motor function as contributing factors. Therefore, increasing the availability of acetylcholine in the bowel wall with a cholinesterase inhibitor, such as pyridostigmine, may improve symptoms. METHOD: We studied thirteen patients with severe constipation (slow transit type) or recurrent pseudo-obstruction. The six patients with slow transit constipation had mechanical obstruction and pelvic floor dysfunction excluded, and normal calibre colon and slow transit confirmed. These patients were offered pyridostigmine in an attempt to avoid surgery. The seven patients with pseudo-obstruction had dilated bowel on imaging, and mechanical obstruction was excluded. These patients received pyridostigmine when symptoms recurred, despite previous treatments. Pyridostigmine was initiated at 10 mg b.i.d. and increased if required. RESULTS: One of the six patients with slow transit constipation reported improvement of symptoms and had concurrently weaned anti-psychotic medications. Pyridostigmine was ceased in the remaining five patients due to lack of efficacy and/or side effects. Four patients proceeded to surgery for refractory symptoms. All seven patients with pseudo-obstruction had some improvement of symptoms with few side effects. Of these, two later had surgery for recurrent symptoms. CONCLUSION: In patients with slow transit constipation, treatment with pyridostigmine does not improve symptoms. However, it does improve symptoms in patients with recurrent pseudo-obstruction with few side effects, offering an extra treatment option for these patients.

Effects of enzyme replacement therapy on the cardiomyopathy of Anderson-Fabry disease: a randomised, double-blind, placebo-controlled clinical trial of agalsidase alfa.

BACKGROUND: Anderson-Fabry disease is an X-linked glycosphingolipid storage disorder caused by deficient activity of the lysosomal enzyme alpha-galactosidase A. This leads to a progressive accumulation of globotriaosylceramide (Gb(3)) in the lysosomes of cells throughout the body that ultimately results in premature death from renal, cardiac or cerebrovascular complications. Until recently, there was no effective therapy available for this disease. The present study was designed to assess the safety and efficacy of enzyme replacement therapy with agalsidase alfa on the cardiac manifestations of Anderson-Fabry disease. METHOD: The effects of therapy with agalsidase alfa on cardiac structure and function were assessed in a randomised, double-blind, placebo-controlled study of 15 adult male patients with Anderson-Fabry disease. The following parameters were measured at baseline and 6 months: left ventricular mass, QRS duration and levels of Gb(3) in cardiac tissue, urine sediment and plasma. After 6 months of the randomised trial patients were enrolled in a 2-year open-label extension study. RESULTS: Left ventricular mass, as measured by MRI, was significantly reduced following 6 months of treatment with agalsidase alfa compared with placebo (p = 0.041). A mean 20% reduction in myocardial Gb(3) content as assessed by serial transvenous endomyocardial biopsies was demonstrated over the 6 months of enzyme replacement compared to a mean 10% increase in patients receiving placebo (p = 0.42) CONCLUSION: Enzyme replacement therapy with agalsidase alfa resulted in regression of the hypertrophic cardiomyopathy associated with Anderson-Fabry disease.

Mechanism of a plastic phenotypic response: predator-induced shell thickening in the intertidal gastropod Littorina obtusata.

Phenotypic plasticity has been the object of considerable interest over the past several decades, but in few cases are mechanisms underlying plastic responses well understood. For example, it is unclear whether predator-induced changes in gastropod shell morphology represent an active physiological response or a by-product of reduced feeding. We address this question by manipulating feeding and growth of intertidal snails, Littorina obtusata, using two approaches: (i) exposure to predation cues from green crabs Carcinus maenas and (ii) reduced food availability, and quantifying growth in shell length, shell mass, and body mass, as well as production of faecal material and shell micro-structural characteristics (mineralogy and organic fraction) after 96 days. We demonstrate that L. obtusata actively increases calcification rate in response to predation threat, and that this response entails energetic and developmental costs. That this induced response is not strictly tied to the animal's behaviour should enhance its evolutionary potential.

Postmortem magnetic resonance imaging as an adjunct to perinatal autopsy for renal-tract abnormalities.

The aim of this study was to compare postmortem magnetic resonance imaging (MRI) of the renal system with autopsy in perinatal and fetal deaths. 37 deaths were studied and renal abnormalities were found in five of these cases. Postmortem MRI provided information of diagnostic utility comparable to that obtained by autopsy.

Secondary intervention following endovascular repair of abdominal aortic aneurysm: a single centre experience.

AIMS: We aim from a review of our early and late experience of secondary intervention for technical failures, to examine and describe the impact of endovascular and open interventions. METHODS: 108 Abdominal Aortic Aneurysms (AAAs) repaired endoluminally between 1995-2001 were analysed. In our early experience, during 1995/96 home made pre-expanded polytetrafluoroethylene grafts fixed with Palmaz stents were used (n = 26). In our later experience, 1997/2001 Talent (n = 70) or Zenith endografts (n = 12) were used. All cases underwent spiral CT at 5 days and 6 monthly intervals post-op. Angiography was performed when further intervention was intended. All technical failures requiring intervention or not were studied. RESULTS: There were 28 (26%) technical failures identified of which 14 of 26 (54%) occurred in our early experience, and 14 of 86 (16%) occurred in our later experience (p < 0.05). Eleven in all required open conversion at the time of endovascular repair. Our study cohort were the remaining 17 cases requiring secondary intervention, seven were from our early experience and 10 from our later experience. There were 12 endoleaks, including two as a result of graft migration, two graft occlusions, two graft distortions and one graft infection. Overall 10 (66%) technical failures were treated by endoluminal repair and seven (34%) by open methods. However, in our later experience significantly more endoluminal techniques (80%) were used (p < 0.05). CONCLUSIONS: Technical failure rates were significantly higher in our earlier experience. Open repair, which was a feature of our early experience, has been avoided over the final 3 years. Instead, endoluminal techniques were used without further morbidity or mortality. Aneurysm rupture has not so far been experienced in this experience.