Seroepidemiologic survey for Coxiella burnetii among hospitalized US troops deployed to Iraq.

Q fever is a zoonotic illness which frequently has a non-specific clinical presentation. Cases among deployed US military personnel have been reported in increasing numbers indicating an emerging at-risk occupational group. Banked serum specimens were utilized to estimate seroprevalence and risk factors among military personnel deployed to Iraq. Coxiella burnetii antibody testing was performed and epidemiologic data were analysed from 909 servicemembers. The overall number who seroconverted to Q fever was 88 (10%). The most common ICD-9 code assigned to Q fever cases was fever not otherwise specified (NOS) (45%). A combat occupational specialty was a risk factor for Q fever seroconversion (OR = 1.8, 95% CI: 1.1-2.8) as well as receiving a primary diagnosis of fever NOS (OR = 2.6, 95% CI: 1.6-4.1). These findings indicate that Q fever is a significant infectious disease threat to military personnel deployed to Iraq. A heightened awareness among physicians is necessary to ensure prompt diagnosis and treatment.

Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection.

BACKGROUND: The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing a wide range of colorectal procedures. METHODS: Thirty-nine patients undergoing major elective colonic resection were recruited prospectively. Patients were randomized to receive a ten-point multimodal optimization package or conventional perioperative care. All patients were administered epidural analgesia and opiates were avoided. Outcome measures recorded related to length of hospital stay, physical and mental function, and gut function. RESULTS: Optimization was associated with a significantly shorter median (interquartile range) hospital stay compared with conventional care (5 (4-9) versus 7.5 (6-10) days; P = 0.027). Duration of catheterization (P = 0.022) and duration of intravenous infusion (P = 0.007) were also less. Optimization was associated with a quicker recovery of gut function (P = 0.042). Grip strength was maintained in the postoperative period in the optimized group (P = 0.241) but not in the control group (P = 0.049). There were no differences in morbidity or mortality between the groups. CONCLUSION: Optimization is safe and results in a significant reduction in postoperative stay along with other improved endpoints. This cannot be directly attributed to improvement in any single outcome measure or to the use of epidural analgesia. Improvements are more likely to be multifactorial and may relate to an earlier return of gut function.

A simple method for the analysis of urinary sucralose for use in tests of intestinal permeability.

BACKGROUND: Sucralose is a unique disaccharide probe which is stable in the colon and can be used to assess permeability over the whole gut. Additional information can be gained when sucralose is administered in combination with lactulose and a monosaccharide such as L-rhamnose in the form of a 'triple sugar test.' We describe a simple assay for urinary sucralose by HPLC with refractive index detection (HPLC-RI). METHODS: Phenyl-beta-D-glucopyranoside (internal standard) was added to 10 mL of urine, which was then passed through a 0.45 microm syringe filter. Elution was with 30% methanol (1 mL/min) on a reverse-phase C18 column. Detection was by refractive index, and integration based upon peak areas. Sixty standards of sucralose in human urine were analysed in order to quantify analytical variation. RESULTS: The standard curve for urinary sucralose was linear from 25 to 500 mg/L (r>0.99). The limit of detection was 11 mg/L. Analytical recovery of sucralose at concentrations of 25, 50 and 100 mg/L was 101.5% (CV 7.59%), 102.9% (CV 5.82%) and 105.0% (CV 4.26%), respectively. CONCLUSIONS: The technique described represents a simple assay for urinary sucralose which performed with acceptable accuracy and precision and should facilitate the use of the triple sugar test in clinical research.

Evaluation of a triple sugar test of colonic permeability in humans.

AIM: Conventional dual sugar tests of intestinal permeability assess only the stomach and small intestine. A novel triple sugar method of assessing colonic permeability has recently been described in animals. This utilizes the non-fermented sweetener sucralose, in addition to conventional sugars. It has been postulated that this test enables the simultaneous assessment of small-intestinal and colonic barrier function in humans. The aim of this study was to evaluate the triple sugar test using healthy volunteers and ileostomists. METHODS: Twenty-one healthy volunteers and 18 ileostomists underwent the triple sugar test. After an overnight fast, subjects drank a solution containing lactulose (5 g), rhamnose (1 g) and sucralose (5 g). Urine was collected for 0-5 h and 5-19 h. Urinary sugars were quantified using HPLC, and 5 and 24-h excretion calculated. Nineteen control subjects and 16 ileostomists also underwent a 51Cr-EDTA permeability test. Permeability data were presented as medians (IQR), and differences between groups analysed with Mann-Whitney U-tests. RESULTS: Lactulose excretion and the 5-h lactulose/rhamnose (L/R) ratio were similar in controls and ileostomists [L/R ratio 0.024 (0.022-0.034) vs. 0.025 (0.022-0.035), P = 0.955]. Twenty-four hours excretion of sucralose was significantly higher in control subjects compared with ileostomists [1.41% (1.17-1.68) vs. 0.96% (0.64-1.2), P = 0.003]. The same pattern was seen with 51Cr-EDTA [2.73% (2.06-3.76) vs. 2.06% (1.55-2.71), P = 0.037] and with lactulose [0.52% (0.42-0.60) vs. 0.25% (0.16-0.35), P = 0.002]. CONCLUSIONS: Both sucralose and 51Cr-EDTA underwent significant colonic absorption. A significant amount of lactulose also appeared to be absorbed in the colon. This unexpected finding requires further study.

Randomised clinical trial of elective re-siting of intravenous cannulae.

INTRODUCTION: Peripheral venous thrombophlebitis (PVT) represents a considerable source of iatrogenic morbidity, occurring in about 20% of hospital in-patients. The aim of this prospective randomised study was to investigate the effect of elective change of intravenous cannulae on the incidence of PVT in hospital in-patients. PATIENTS AND METHODS: General medical and surgical inpatients requiring intravenous therapy were randomised into control (n = 26) or study (n = 21) groups. Cannulae in the control group were only removed if the site became painful, the cannula dislodged, or there were signs of PVT. Cannulae in the study group were changed electively every 48 h. All patients were examined daily for signs of PVT. RESULTS: Peripheral venous thrombophlebitis developed in 11/26 patients in the control group and 1/21 patients in the study group (P = 0.003). Elective change of cannulae did not significantly increase the total number of cannulae sited (41 cannulae in the control group versus 43 in the study group). CONCLUSIONS: Elective change of cannulae resulted in a significant reduction in the incidence of infusion phlebitis. The authors recommend that elective re-siting of intravenous cannulae becomes standard practice for all patients requiring intravenous therapy.

Randomised clinical trial of synbiotic therapy in elective surgical patients.

BACKGROUND: It is possible to manipulate the composition of the gastrointestinal microflora by administration of pre- and probiotics. This may help to preserve gut barrier function and reduce the incidence of septic morbidity. AIMS: To assess the effects of a combination of pre- and probiotics (synbiotic) on bacterial translocation, gastric colonisation, systemic inflammation, and septic morbidity in elective surgical patients. PATIENTS: Patients were enrolled two weeks prior to elective abdominal surgery. Seventy two patients were randomised to the synbiotic group and 65 to the placebo group. Patients were well matched regarding age and sex distribution, diagnoses, and POSSUM scores. METHODS: Patients in the synbiotic group received a two week preoperative course of Lactobacillus acidophilus La5, Bifidobacterium lactis Bb-12, Streptococcus thermophilus, and Lactobacillus bulgaricus, together with the prebiotic oligofructose. Patients in the placebo group received placebo capsules and sucrose powder. At surgery, a nasogastric aspirate, mesenteric lymph node, and scrapings of the terminal ileum were harvested for microbiological analysis. Serum was collected preoperatively and on postoperative days 1 and 7 for measurement of C reactive protein, interleukin 6, and antiendotoxin antibodies. Septic morbidity and mortality were recorded. RESULTS: There were no significant differences between the synbiotic and control groups in bacterial translocation (12.1% v 10.7%; p = 0.808, chi(2)), gastric colonisation (41% v 44%; p = 0.719), systemic inflammation, or septic complications (32% v 31%; p = 0.882). CONCLUSIONS: In this study, synbiotics had no measurable effect on gut barrier function in elective surgical patients. Further studies investigating the place of pre- and probiotics in clinical practice are required.

Randomized clinical trial investigating the use of drains and fibrin sealant following surgery for breast cancer.

BACKGROUND: Despite limited evidence, closed suction drainage is often used to reduce the risk of seroma formation after breast cancer surgery. The aim of this study was to evaluate the effect of drains and fibrin sealant on the incidence of seroma formation. METHODS: A total of 116 patients undergoing surgery for breast cancer were randomized to receive suction drainage (group 1; n = 58), or to receive no drain (n = 58). Patients allocated to receive no drain were further randomized to have fibrin sealant applied to the dissected area (group 2; n = 29), or to no intervention (group 3; n = 29). Outcome measures were incidence and volume of postoperative seroma, length of hospital stay and postoperative pain scores. RESULTS: There was no significant difference in the incidence of seroma between group 1 (15 of 58) and either group with no drains (ten of 29 in group 2; 12 of 29 in group 3). There was a significant reduction in hospital stay and postoperative pain scores in patients who did not have a drain. Following mastectomy without a drain, the use of fibrin sealant was associated with a significant reduction in the incidence and total volume of seroma (190 versus 395 ml; P = 0.012). CONCLUSION: Drains did not prevent seroma formation, and were associated with a longer postoperative stay and higher pain scores after surgery for breast cancer. In patients who had mastectomy the use of fibrin sealant reduced the rate of seroma formation.

Randomized clinical trial of multimodal optimization and standard perioperative surgical care.

BACKGROUND: Multimodal optimization of surgical care has been associated with reduced hospital stay and improved physical function. The aim of this randomized trial was to compare multimodal optimization with standard care in patients undergoing colonic resection. METHODS: Twenty-five patients requiring elective right or left hemicolectomy were randomized to receive a ten-point optimization programme (14 patients) or conventional care (11). The groups were similar in terms of age (64 versus 68 years), male : female sex ratio (6 : 8 versus 5 : 6) and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) score (both 26). Outcome measures were recorded before operation and on postoperative days 1, 7 and 30. They included hand grip strength, lung spirometry, and pain and fatigue scores. Further outcome measures included time to achieve a predetermined mobilization target, time to resumption of normal diet, and length of stay. RESULTS: Optimization was associated with maintained grip strength, earlier mobilization (46 versus 69 h; P = 0.043), and significantly lower pain and fatigue scores. Patients in the optimization group tolerated a regular hospital diet significantly earlier than controls (48 versus 76 h; P < 0.001). Optimization significantly reduced the median length of hospital stay (3 versus 7 days; P = 0.002). CONCLUSION: Optimization of surgical care significantly improved patients' physical and psychological function in the early postoperative period and facilitated early hospital discharge.

Peripheral parenteral nutrition.

BACKGROUND: Peripheral parenteral nutrition (PPN) currently accounts for almost 20 per cent of all parenteral nutrition administered in the UK. In the absence of consensus guidelines there is wide variation in practice. Heterogeneity of clinical trials has made direct comparisons difficult and meta-analysis impossible. METHODS: Medline, Embase and Cochrane databases were searched for all clinical trials relating to the use of PPN in adults. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed. RESULTS AND CONCLUSIONS: Effective PPN is possible in about 50 per cent of inpatients requiring parenteral nutrition. Evidence relating to optimal feed composition, choice of cannula, infusion technique and pharmacological manipulation is discussed, along with practical recommendations for the administration of PPN.

Multistate outbreak of Norwalk-like virus gastroenteritis associated with a common caterer.

In February 2000, an outbreak of gastroenteritis occurred among employees of a car dealership in New York. The same meal was also supplied to 52 dealerships nationwide, and 13 states reported illness at dealerships where the banquet was served. A retrospective cohort study was conducted to identify risk factors associated with the illness. Stool samples were collected to detect Norwalk-like virus, and sera were drawn and tested for immunoglobulin A antibodies to the outbreak strain. By univariate analysis, illness was significantly associated with consumption of any of four salads served at the banquet (relative risk = 3.8, 95% confidence interval: 2.5, 5.6). Norwalk-like virus was detected by reverse transcription-polymerase chain reaction assay in 32 of 59 stool samples from eight states. Nucleotide sequences of a 213-base pair fragment from 16 stool specimens collected from cases in eight states were identical, confirming a common source outbreak. Two of 15 workers at caterer A had elevated immunoglobulin A titers to an antigenically related Norwalk-like virus strain. This study highlights the value of molecular techniques to complement classic epidemiologic methods in outbreak investigations and underscores the critical role of food handlers in the spread of foodborne disease associated with Norwalk-like virus.

Hypertensive disorders, diabetes mellitus, and anemia: three common medical complications of pregnancy.

Hypertensive disorders, diabetes mellitus, and anemia are three common medical complications of pregnancy. In many cases, primary care physicians manage them. The understanding of these conditions and recommendations for their treatment are in constant evolution. Care for patients with these problems requires a working knowledge of current information. This article reviews the current knowledge about and treatment of these three disorders.

Differential expression of alpha2-7, alpha9 and beta2-4 nicotinic acetylcholine receptor subunit mRNA in the vestibular end-organs and Scarpa's ganglia of the rat.

To further characterize the pattern of expression of the nicotinic acetylcholine receptor (nAChR) subunits in the peripheral vestibular system, we conducted RT-PCR of all known mammalian nAChR alpha and beta subunits in mRNA extracted from adult rat vestibular primary afferent neurons (Scarpa's ganglia) and vestibular end-organs. Transcripts encoding the alpha2-7 and beta2-4 nAChR subunits were found in the vestibular ganglia, while alpha3, alpha5-7, alpha9 and beta2-4 nAChR subunits were expressed in the vestibular end-organs. These results support previous electrophysiological, immunocytochemical and molecular biological data, and also provide a more complete understanding of the role of nAChRs in the neurochemical transmission subserving the efferent-afferent interaction in the vestibular periphery.

Energy cost of walking and of wheelchair propulsion by children with myelodysplasia: comparison with normal children.

The oxygen consumption of 15 myelodysplastic children during walking and propelling a wheelchair was studied. In comparison to normal children, they walked more slower and consumed more oxygen per meter, but had a similar rate of oxygen consumption. A swing-through gait pattern was 33 per cent more energy-efficient than a four-point gait pattern for these children. Wheelchair propulsion produced velocities and energy efficiencies similar to normal children walking. Oxygen consumption and velocity measurements were found to be significantly related to the clinical factors of level of lesion and strength of hip and knee extension. Regression lines and equations are presented to permit prediction of energy cost and efficiency from heart-rate data of myelodysplastic children.