Performance of non-invasive stroke volume variation during passive leg raising as a predictor of hypotension following induction of spinal anesthesia for elective cesarean delivery: a single cohort study.

BACKGROUND: Spinal anesthesia for cesarean delivery is accompanied by hypotension in up to 70% of cases. To date, there is no gold standard for predicting hypotension after spinal anesthesia for cesarean delivery. The Clearsight™ device is a non-invasive system that uses a digital cuff to calculate stroke volume. We hypothesized that stroke volume variation induced with passive leg raising before spinal anesthesia for elective cesarean delivery could predict the occurrence of hypotension. METHODS: We conducted a prospective observational study, including third trimester parturients undergoing elective cesarean delivery with spinal anesthesia. We analyzed the stroke volume variation performance for predicting hypotension. Stroke volume was collected in the semi-recumbent position (baseline) and during passive leg raising before spinal anesthesia. Systolic arterial blood pressure measurement was followed for 15 min after spinal anesthesia. Hypotension was defined as a ≥20% decrease from the baseline measurement. All parturients received appropriate hypotension prophylaxis. RESULTS: Data from 42 parturients were analyzed. Hypotension occurred in 45%. The area-under-the curve for predicting hypotension using the stroke volume variation was 0.83 (95% CI 0.68 to 0.98; P=0.001). The best cut-off value for predicting hypotension was 7%, having a sensitivity of 87% (95% CI 0.70 to 0.99) and a specificity of 83% (95% CI 0.69 to 0.97). CONCLUSION: In our study of third trimester parturients undergoing cesarean delivery and receiving appropriate hypotension prophylaxis, a digital non-invasive monitoring device of stroke volume variation analysis was useful for predicting the occurrence of hypotension after spinal anesthesia.

MACVIA-LR (Fighting Chronic Diseases for Active and Healthy Ageing in Languedoc-Roussillon): A Success Story of the European Innovation Partnership on Active and Healthy Ageing.

The Région Languedoc Roussillon is the umbrella organisation for an interconnected and integrated project on active and healthy ageing (AHA). It covers the 3 pillars of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA): (A) Prevention and health promotion, (B) Care and cure, (C) and (D) Active and independent living of elderly people. All sub-activities (poly-pharmacy, falls prevention initiative, prevention of frailty, chronic respiratory diseases, chronic diseases with multimorbidities, chronic infectious diseases, active and independent living and disability) have been included in MACVIA-LR which has a strong political commitment and involves all stakeholders (public, private, patients, policy makers) including CARSAT-LR and the Eurobiomed cluster. It is a Reference Site of the EIP on AHA. The framework of MACVIA-LR has the vision that the prevention and management of chronic diseases is essential for the promotion of AHA and for the reduction of handicap. The main objectives of MACVIA-LR are: (i) to develop innovative solutions for a network of Living labs in order to reduce avoidable hospitalisations and loss of autonomy while improving quality of life, (ii) to disseminate the innovation. The three years of MACVIA-LR activities are reported in this paper.

Do endoflip assessments of anal sphincter distensibility provide more information on patients with fecal incontinence than high-resolution anal manometry?

BACKGROUND: Anal manometry is the standard technique for evaluating anal sphincter function. However, the functional lumen imaging probe (EndoFLIP(®) ) can be used to measure sphincter distensibility during volume-controlled distensions. Our aims were (i) to assess anal distensibility in patients with fecal incontinence (FI) and in healthy subjects using the EndoFLIP(®) and (ii) to compare the results with anal pressures measured by 3D high-resolution manometry (3D-HRM) to determine whether the EndoFLIP(®) was more sensitive and specific for diagnosing FI than 3D-HRM. METHODS: EndoFLIP(®) and 3D-HRM assessments of 34 female FI patients and 40 healthy female subjects were performed. Anal distensibility was measured as the median cross-sectional area at the narrowest point divided by the corresponding intra-bag pressure at rest and during peak voluntary contraction and was expressed in mm(2) /mmHg. KEY RESULTS: A 40-mL anal distensibility index was selected for further comparisons as it provided the best discrimination between the FI patients and the healthy subjects. The index was significantly higher in the FI patients than in the healthy subjects at rest (p = 1.10(-4) ) and during voluntary contraction (p = 1.10(-4) ). The index at rest and during voluntary contraction appeared to be more appropriate than anal pressures for discriminating between FI patients and healthy subjects. CONCLUSIONS & INFERENCES: The present study confirmed that FI is associated with an abnormally high distensibility index at rest and during voluntary contraction. The ability of the distensibility index to discriminate between FI patients and healthy subjects was significantly better than anal pressure.

Attribution of the French human Salmonellosis cases to the main food-sources according to the type of surveillance data.

Salmonella are the most common bacterial cause of foodborne infections in France and ubiquitous pathogens present in many animal productions. Assessing the relative contribution of the different food-animal sources to the burden of human cases is a key step towards the conception, prioritization and assessment of efficient control policy measures. For this purpose, we considered a Bayesian microbial subtyping attribution approach based on a previous published model (Hald et al., 2004). It requires quality integrated data on human cases and on the contamination of their food sources, per serotype and microbial subtype, which were retrieved from the French integrated surveillance system for Salmonella. The quality of the data available for such an approach is an issue for many countries in which the surveillance system has not been designed for this purpose. In France, the sources are monitored simultaneously by an active, regulation-based surveillance system that produces representative prevalence data (as ideally required for the approach) and a passive system relying on voluntary laboratories that produces data not meeting the standards set by Hald et al. (2004) but covering a broader range of sources. These data allowed us to study the impact of data quality on the attribution results, globally and focusing on specific features of the data (number of sources and contamination indicator). The microbial subtyping attribution model was run using an adapted parameterization previously proposed (David et al., 2012). A total of 9076 domestic sporadic cases were included in the analyses as well as 9 sources among which 5 were common to the active and the passive datasets. The greatest impact on the attribution results was observed for the number of sources. Thus, especially in the absence of data on imported products, the attribution estimates presented here should be considered with caution. The results were comparable for both types of surveillance, leading to the conclusion that passive data constitute a potential cost-effective complement to active data collection, especially interesting because the former encompass a greater number of sources. The model appeared robust to the type of surveillance, and provided that some methodological aspects of the model can be enhanced, it could also serve as a risk-based guidance tool for active surveillance systems.

Methicillin-resistant Staphylococcus aureus ST398 contamination and transmission in pigs after a low dose inoculation.

AIMS: Methicillin-resistant Staphylococcus aureus (MRSA) ST398 has recently been described as a zoonotic agent. Its transmission between animals seems to be a pivotal factor in its emergence and dissemination. This experimental trial was performed to describe MRSA ST398 contamination and transmission in pigs after a low dose inoculation. METHODS AND RESULTS: Twelve specific pathogen-free (SPF) pigs were randomly divided between two separate pens. Three pigs in each pen received a nasal inoculation of 2 × 10(4) colony-forming units per animal, and three naïve pigs were left in contact with them. Every 2 days and at necropsy, different samples were screened for MRSA. It was detected in nasal swabs from five inoculated and three naïve contact pigs, as early as 1 day after inoculation. MRSA was also found in environmental wipes but never in faecal samples. At necropsy, MRSA was detected in the lymph nodes of two contact pigs and in the tonsils and lymph nodes of three inoculated pigs. Twelve other SPF pigs were included as negative control in a separate room. CONCLUSION: This experiment showed that inoculation of a low dose of MRSA ST398 could lead to the horizontal transmission of the bacterium between pigs, the contamination of mandibular lymph nodes and the contamination of the environment without faecal carriage. SIGNIFICANCE AND IMPACT OF THE STUDY: The minimal inoculated dose via nasal route to observe transmission of MRSA ST398 between pigs is equal or lower to 2 × 10(4) colony-forming units per animal, and faecal excretion seems not to be a necessary condition for horizontal transmission.

Multiresistant Salmonella enterica serovar 4,[5],12:i:- in Europe: a new pandemic strain?

A marked increase in the prevalence of S. enterica serovar 4,[5],12:i:- with resistance to ampicillin, streptomycin, sulphonamides and tetracyclines (R-type ASSuT) has been noted in food-borne infections and in pigs/pig meat in several European countries in the last ten years. One hundred and sixteen strains of S. enterica serovar 4,[5],12:i:- from humans, pigs and pig meat isolated in England and Wales, France, Germany, Italy, Poland, Spain and the Netherlands were further subtyped by phage typing, pulsed-field gel electrophoresis and multilocus variable number tandem repeat analysis to investigate the genetic relationship among strains. PCR was performed to identify the fljB flagellar gene and the genes encoding resistance to ampicillin, streptomycin, sulphonamides and tetracyclines. Class 1 and 2 integrase genes were also sought. Results indicate that genetically related serovar 4,[5],12:i:- strains of definitive phage types DT193 and DT120 with ampicillin, streptomycin, sulphonamide and tetracycline resistance encoded by blaTEM, strA-strB, sul2 and tet(B) have emerged in several European countries, with pigs the likely reservoir of infection. Control measures are urgently needed to reduce spread of infection to humans via the food chain and thereby prevent the possible pandemic spread of serovar 4,[5],12:i:- of R-type ASSuT as occurred with S. Typhimurium DT104 during the 1990s.

Past, present and future of vasopressin and oxytocin receptor oligomers, prototypical GPCR models to study dimerization processes.

The G protein-coupled receptors (GPCRs) play a major role in the regulation of physiological function. The emergence of the concept of GPCR oligomerization deeply modifies our understanding of their functioning. Much more than a simple association leading to an independent functioning, the GPCR oligomerization affects various steps such as membrane targeting of the receptors, binding of ligands, coupling to the intracellular pathways and internalization. Although significant advances have been performed in proving the existence of GPCR oligomers, its physiological impact remains to be established. Vasopressin and oxytocin receptors have constituted interesting experimental models in oligomer analysis. Because of the pharmacological tools available regarding these receptors and their expression at a high level in various tissues they can constitute very promising models to study the consequences of oligomerization in physiology.

Characteristics of Salmonella contamination of broilers and slaughterhouses in the region of Constantine (Algeria).

The present study provides the first data about the prevalence of Salmonella contamination of broilers and slaughterhouses in the region of Constantine, Algeria. The serotypes and anti-microbial resistance phenotypes of the isolates were determined, and risk factors contributing to the contamination were evaluated. A total of 2490 samples, 1800 originating from 30 broiler farms and 690 from 15 slaughterhouses, were taken during two periods: March 2005-June 2006 and September 2006-March 2007. Salmonella contamination concerned 37% of the broiler farms and 53% of the slaughterhouses. Among the 55 isolates recovered, 10 different serotypes were identified. The most frequently recovered serotypes in both slaughterhouses and breeder farms were S. Hadar (36%, n = 20), S. Virchow (16%, n = 9), S. Infantis (10.9%, n = 6), S. Albany (11%, n = 6) and S. Carnac (7%, n = 4). Isolates belonging to S. Heidelberg (2%, n = 1) and S. Rissen (2%, n = 1) were found only in farms, while those belonging to S. Typhimurium (9%, n = 5), S. Enteritidis (4%, n = 2) and S. Montevideo (2%, n = 1) were recovered only from slaughterhouses. Thirty-nine isolates (80%) were resistant to at least one anti-microbial and 51% were multi-resistant, i.e. resistant to two or more anti-microbial molecules. About 58% (n = 32) were resistant to streptomycin, 36% (n = 20) to tetracyclines, 27% (n = 15) to nalidixic acid, 13% (n = 7) to ofloxacin and one isolate to enrofloxacin. Finally, seven distinct anti-microbial resistance profiles were identified. In parallel, four risk factors were found to be significantly associated with Salmonella contamination. Together with the huge spread of Salmonella in the broiler production chain in Constantine, Algeria, these risk factors highlight the hazards of the broiler channels, particularly linked to poor technical and hygiene practices.

Recognizing meningococcal disease: the case for further research in primary care.

Most studies describing the clinical presentation of meningococcal disease use data derived from hospital-based studies. This paper reviews current knowledge on the presentation of meningococcal disease from a primary care perspective. In a small proportion of cases with classical features, making the diagnosis may be relatively simple. In many cases, however, the general practitioner (GP) is faced with the difficulty of discriminating between the rare patient with life-threatening illness and the vast majority who present with similar symptoms secondary to self-limiting viral illness. In the absence of reliable means of excluding the disease, GPs will need to consider the possibility of meningococcal disease in all ill and febrile patients in whom no cause is apparent. Planned follow-up and clearer explanation to patients may increase the chance of identifying earlier those cases that evolve with time. More research is required to identify key clinical and contextual features that help GPs to predict or exclude serious disease, and to describe how this information is used in decision-making. A framework for conceptualizing the problems of researching illness is provided, which takes into account the many factors that influence clinical practice in primary care.

Recognising meningococcal disease in primary care: qualitative study of how general practitioners process clinical and contextual information.

OBJECTIVES: To describe the presentation of meningococcal disease in primary care; to explore how general practitioners process clinical and contextual information in children with meningococcal disease; and to describe how this information affects management. DESIGN: Qualitative analysis of semistructured interviews. SETTING: General practices in South Glamorgan. SUBJECTS: 26 general practitioners who between January 1994 and December 1996 admitted 31 children (under 16 years of age) in whom meningococcal disease was diagnosed. MAIN OUTCOME MEASURES: Categories of clinical rules and techniques used by general practitioners in processing each case. RESULTS: 22 children had rashes; in 16 of them the rashes were non-blanching. When present, a haemorrhagic rash was the most important factor in the doctor's decision to admit a child. 22 children had clinical features not normally expected in children with acute self limiting illnesses--for example, lethargy, poor eye contact, altered mental states, pallor with a high temperature, and an abnormal cry. Contextual information, such as knowledge of parents' consultation patterns and their normal degree of anxiety, played an important part in the management decisions in 15 cases. Use of penicillin was associated with the certainty of diagnosis and the presence and type of haemorrhagic rash. CONCLUSION: The key clinical feature of meningococcal disease--a haemorrhagic rash--was present in only half of the study children. The general practitioners specifically hunted for the rash in some ill children, but doctors should not be deterred from diagnosing meningococcal disease and starting antibiotic treatment if the child is otherwise well, if the rash has an unusual or scanty distribution, or if the rash is non-haemorrhagic.

Evidence-based medicine and general practice.

Evidence-based medicine (EBM) aids clinical decision making in all fields of medicine, including primary care. General practice is characterized by particular emphasis on the doctor-patient relationship and on biomedical, personal and contextual perspectives in diagnosis. Most evidence available to general practitioners (GPs) addresses only the bio-medical perspective and is often not directly applicable to primary care, as it derives from secondary or tertiary care. Emphasis on the biomedical domain and the randomized controlled trial (RCT) alone reflects a reductionist approach that fails to do justice to the philosophy of general practice. The art of medicine is founded on context, anecdote, patient stories of illness and personal experience, and we should continue to blend this with good quality and appropriate research findings in patient care.

Opinions of medical students at the University of Cape Town on emigration, conscription and compulsory community service.

A study was conducted to determine emigration intentions of medical students at the University of Cape Town. Students from 1st to 5th year complete a self-administered questionnaire. A response rate of 86% was achieved. Over half the students (54%) were considering emigration. The most frequently selected motivating factors were moral dissatisfaction with the present government and career opportunities abroad. Men who were eligible for military conscription rated this factor as an important deterrent to remaining in South Africa, and 81% stated objections to national service. However, 71% would be less likely to emigrate were an alternative national service (ANS) instituted. Should a compulsory community service be implemented, 41% of those eligible would be more inclined to emigrate. Recommendations include the implementation of ANS; a re-evaluation of the compulsory community service proposal; and further investigation of emigration trends and of ways to curb emigration. Suggestions offered are a reappraisal of both selection criteria and medical education; and the provision of incentives for doctors to work in rural areas.