Tracking of thermal microbial shock proteins and genomic variation of Bacillus cereus due to some abiotic stresses.

Bacillus cereus is considered the most potent bacterial strain in terms of the increment in induced proteins during thermal treatment at 52 °C for 90 min. Protein production in food-born microorganism (Bacillus cereus) recovered from contaminated food was investigated in response to heat shock treatment. Bacterial tolerance towards pH, salinity, and temperature at various levels was also investigated. Heat-shock proteins (HSPs) produced when exposed to 52 °C for up to 60 minutes led to significant differences (30%) above the untreated control (37 °C), and the maximum difference was recorded at 52°C at 90 minutes. ISSR detected a higher number of bands/primer than RAPD (13.7 vs. 12.7, respectively), and more polymorphic bands (10.7 vs. 8.4 bands/primer, respectively). The untreated bacterial strain did not grow at pH levels lower than 3, whereas the thermally treated strain grew significantly at pH two. A consistent increase in HSPs was observed, with a gradual increase in salinity of less than 16%. Surprisingly, the gradual increase in temperature did not induce tolerance against higher temperatures. However, a significant growth rate was noticed in response to heat-shocked treatments. The untreated Bacillus cereus demonstrated antibiotic resistance to gentamycin and clindamycin (1.54 and 1.65 cm, respectively), much lower than the corresponding inhibition areas with preheat-treated test pathogen which were recorded (2.37 and 2.49 cm, respectively).

Factors Affecting the Psychological Well-Being of Health Care Workers During the COVID-19 Crisis.

Background: Health care workers (HCWs) are a group that especially suffered during the COVID-19 pandemic. In addition to facing the stress of dealing with patients and social isolation, they had to worry about being infected themselves and transmitting the infection to their families. This study evaluated the fear, anxiety, and depression experienced by HCWs during the COVID-19 crisis. Subjects and Methods: The sample size was 541 HCWs. Data collection was done using an online validated questionnaire through Google Docs, sent to HCWs by email and WhatsApp groups. We assessed depression and anxiety with the 4-item Patient Health Questionnaire-4 (PHQ-4), while evaluating fear with the Fear of COVID-19 Scale (FCV-19S). Results: A statistically significant difference was found in the perception of fear between married and unmarried people, and between those with colleagues who had died from COVID-19 infection and those without. There was a significant relation between HCWs' anxiety and a history of death from COVID-19 infection, either of friends or of close relatives. The prevalence of depression was 18.48% in the tested sample of HCWs. Participants who had close relatives or friends infected with COVID-19 showed a significantly higher degree of depression. The age group <30 and those working 20 to 30 hours weekly showed higher degrees of anxiety and depression. Conclusion: Sociodemographic variables such as age, marital status, and working area had a significant impact on the mental and psychological health of HCWs during the COVID-19 crisis. HCWs who lost patients due to COVID-19 had a significantly higher prevalence of fear, depression, and anxiety.

Impact of Plant Spacing and Nitrogen Rates on Growth Characteristics and Yield Attributes of Egyptian Cotton (Gossypium barbadense L.).

This current study was performed to determine the influences of plant spacing, Nitrogen (N) fertilization rate and their effect, on growth traits, yield, and yield components of cotton (Gossypium barbadense L.) cv. Giza 97 during the 2019 and 2020 seasons. A split plot experiment in three replicates was utilized whereas the cotton seeds were planted at 20, 30, and 40 cm, as main plots and nitrogen at 75, 100, and 125%, was in subplots. The results revealed that the planting spacing at 40 cm significantly (p ≤ 0.01) increased plant height, number of fruiting branches per plant, number of bolls per plant, boll weight (BW), lint percentage (L%), seed cotton yield (SCY), lint cotton yield (LCY), seed index and lint index by 165.68 cm, 20.92, 23.93, 3.75 g, 42.01%, 4.24 ton/ha, 5.16 ton/ha, 12.05, 7.86, respectively, as average in both seasons. The application of N fertilizer rate at 125% caused a maximum increase in growth and yield parameters i.e., plant height (169.08 cm), number of vegetative branches (2.67), number of fruiting branches per plant (20.82), number bolls per fruiting branch (1.39), number of bolls per plant (23.73), boll weight (4.1 g), lint percent (41.9%), seed index (11.8 g), and lint index (8.2), while the plants treated with 100% N rates exhibited highest seed cotton yield (4.3 ton/ha) and lint cotton yield (5.6 ton/ha), as average in both seasons. Combining plant spacing at 40 cm between plants with a 100% N fertilizer rate recorded the highest lint cotton yield (5.67 ton/ha), while the highest seed cotton yield (4.43 and 4.50 ton/ha) was obtained from 125% N fertilizer rate under planting spacing 20 and 40 cm, respectively. Conclusively, a wide density (40 cm) with 125% N is a promising option for improved biomass, cotton growth, yield, physiological traits, and fiber quality.

The 2020 Beirut Explosion: A Healthcare Perspective.

On August 4th, 2020, at 6:07pm local time, an explosion took place in Beirut's port near the central district. This tragic event reportedly left more than 204 victims dead, more than 6,500 wounded, and displaced around 300,000 from their homes. Patients were transported to several hospitals, which became quickly overwhelmed within minutes by the large number of patient admissions. This is a retrospective chart review conducted on 292 patients, who presented to the American University of Beirut Medical Center (AUBMC) after sustaining blast-related injuries during the Beirut port explosion on August 4th, 2020. Measures including age, gender, location of the injury, mechanism of blast injury (primary, secondary, tertiary, and quaternary) and outcomes were collected. Time of arrival of the first victim was 10 minutes after the explosion. Patients across all ages presented to the medical center (age range from 3 months to 86 years) and the majority of injuries were in the upper extremity (45.6%), and head and neck region (43.2%). Most blast-related injuries were due to secondary and tertiary types, 78.4% and 24.1% respectively. This study aims to expand the literature and widen the knowledge regarding the mechanism of injury associated with the Beirut port explosion. Moreover, it could be helpful in preparing medical staff, healthcare centers and other communities to work under difficult conditions in similar disasters and improve the global response to devastating events.

Le 4 août 2020 à 18 h 07 locales, une explosion s'est produite dans le port de Beyrouth, à proximité du centre- ville. Cette explosion a tué 204 personnes, en a blessé plus de 6 500 et en a laissé environ 300 000 sans abri. Les blessés ont été acheminés dans plusieurs hôpitaux, vite débordés par cet afflux massif. Cet article est une revue sur dossier de 292 cas de patients blastés lors de cette catastrophe pris en charge à l'Hôpital Universitaire Américain de Beyrouth, la première étant arrivée 10 mn après l'explosion. Nous avons répertorié l'âge, le sexe, la localisation des blessure et le type de lésions de blast (primaire, secondaire, tertiaire ou quaternaire), les plus fréquents étant les blasts secondaires (78,4%) et tertiaires (24,1%) et l'évolution. Les patients étaient âgés de 3 mois à 86 ans et leurs blessures se situaient plus fréquemment au niveau de la partie supérieure du corps (45,6%) ou de la région cervico- céphalique (43,2%). Cette étude permet d'abonder la littérature sur les mécanismes lésionnels après une explosion comme celle du port de Beyrouth. Elle pourrait en outre permettre d'améliorer les réponses médicale, hospitalière et générale après une catastrophe.

The use of the alt perforator flap for reconstruction of severe pediatric burn scar contractures.

Pediatric burn injuries are frequently complicated by burn scar contractures that often create functional limitations. Usually release followed by skin grafts, local flaps or tissue expansion is adequate. In rare instances, when the contracture is severe and simpler forms of reconstruction have failed, microsurgical free tissue transfer becomes essential. Even though in pediatric patients it can be technically more demanding and there is a reported risk of vasospasm, free tissue transfer has proven to be a good alternative. It is a one-stage procedure that guarantees decent functional outcomes. The perforator anterolateral thigh flap is a workhorse flap in microsurgery. The versatility of this flap allows it to be used in various anatomic locations. In this paper we report its use in neck, wrist, foot and face reconstructions. Flap success rates were 100%, with no cases of partial or complete flap loss. No acute or chronic complications were noted. Only one patient required reoperation for thinning of the flap to allow proper shoe fitting. All patients had good functional outcomes and the contractures were fully released. Joint function was regained in all patients except one that required wrist fusion. When indicated, the free perforator ALT flap is an excellent option for challenging reconstructions.

Les brûlures de l'enfant se compliquent souvent de rétractions cicatricielles entraînant des limitations fonctionnelles. Le plus souvent, la libération suivie de greffes, de lambeaux locaux, de lambeaux expansés est une solution efficace. Dans de rares cas, lorsque la rétraction est importante et que les techniques simples ont échoué, l'utilisation de transferts tissulaires micro-anastomosés devient nécessaire. Même si chez l'enfant la technique peut être plus difficile et que l'on rapporte des risques de spasmes vasculaires, les transferts tissulaires micro-anastomosés se sont montrés être une alternative utile. Il s'agit d'une procédure en un temps qui assure un résultat fonctionnel satisfaisant. Le lambeau perforant antérolatéral de cuisse est le lambeau favori en microchirurgie. La polyvalence de ce lambeau permet son utilisation dans des localisations anatomiques très diverses. Dans cet article, nous rapportons son utilisation au niveau du cou, du poignet, du pied et de la face. Le taux de réussite du lambeau était de 100 %, sans aucun cas de perte partielle ou complète du lambeau. Aucune complication immédiate ou secondaire n'a été notée. Un seul patient a nécessité une reprise du lambeau pour l'affiner, afin de permettre un chaussage correct. Tous les patients ont eu un bon résultat fonctionnel et les rétractions ont été complètement libérées. La mobilité articulaire a été récupérée pour tous les patients sauf pour un qui a nécessité une arthrodèse au niveau du poignet. Le lambeau perforant antérolatéral de cuisse libre est une excellente solution pour les reconstructions difficiles.

Microsurgery in the burn population - a review of the literature.

The management of patients suffering from burn injury poses unique challenges for the reconstructive surgeon, both in the acute and delayed settings. Once resuscitative measures are optimized and hemodynamic stability is achieved, early burn debridement and coverage is performed. Traditionally, this consists of excision of devitalized tissue and subsequent coverage using split thickness skin grafts. However, in certain instances, and depending on the extent and nature of the burn injury, skin grafting (or even local tissue rearrangement) may not be a reasonable option. in these cases, free tissue transfer may provide a viable reconstructive alternative. While free flap reconstruction is rare in burn surgery, particularly in the acute setting, burn injuries that expose vital structures, such as tendon, nerve, bone, or deep vessels, require robust flap coverage. in the delayed setting, unsightly scar formation and contracture often occurs secondary to skin graft coverage. These significant patient morbidities are often amenable to free tissue transfer as well. This review article discusses the indications, applications, and problems with free flap surgery for burn injuries in both the acute and delayed setting, and summarizes the available literature on microsurgical free tissue transfer for burn management.

La prise en charge des patients atteints de brûlures pose des défis uniques pour le chirurgien de reconstruction, à la fois dans les cadres aigus et retardés. Une fois les mesures de réanimation sont optimisés et la stabilité hémodynamique est obtenue, il faut faire le débridement précoce et la couverture de la brûlure. Traditionnellement, il s'agit de l'excision des tissus dévitalisés et la couverture par division ultérieure en utilisant des greffes de peau partielle épaisse. Cependant, dans certains cas, et en fonction des dimensions et la nature de la brûlure, une greffe de peau n'est pas toujours une option raisonnable. Dans ces cas, le transfert de tissu libre peut fournir une alternative viable. Alors que la reconstruction de lambeau libre est rare dans la chirurgie des brûlures, en particulier dans le cadre aiguë, les brûlures qui exposent les structures vitales, telles que les tendons, nerfs, os, ou les vaisseaux profonds, nécessitent une couverture robuste. Dans le cadre retardé, la formation de cicatrices inesthétiques et de contractures se produit fréquemment secondaire à une couverture de greffe de peau. Souvent ces morbidités importantes sont aussi prêtent au transfert de tissu libre. Cet article de revue discute les indications, les applications, et des problèmes avec la chirurgie de lambeau libre pour des brûlures dans les cadres aigus et retardés. Cet article résume aussi la littérature disponible sur la microchirurgie du transfert de tissu libre pour la prise en charge des brûlures.

Treatment of a paediatric patient with a distal lower extremity traumatic wound using a dermal regeneration template and NPWT.

Degloving injuries are common in trauma and represent a spectrum of complex wounds, the management of which may be highly challenging especially in the paediatric population. In severe injuries leading to wounds reaching tendon and bone, vascularity is compromised precluding traditional wound management, and sometimes necessitating amputation. This report highlights the use of a dermal regeneration template combined with vacuum-assisted closure (VAC) in the treatment of complex traumatic degloving wounds. Here, we present a case of a five-year-old boy who sustained a high-energy shear injury to his lower extremity that resulted in an extensive degloving wound involving the distal third of his leg and the dorsum of his foot. After debridement, the patient underwent VAC combined with a dermal skin substitute placement, followed by split-thickness skin grafting. The extremity healed with no complications and without the need for amputation or flap reconstruction, achieving satisfactory recovery of range of motion and favourable cosmetic results.

Salvage of shoulder joint through simplification of wound management.

Infection is a common sequela of open dislocation of the shoulder joint. This typically leads to joint surface and humeral head necrosis, resulting in severe limitation of motion. Few cases of open and infected glenohumeral joints have been reported, and none had a good functional outcome with pain-free, near-full range of motion. Here we report the case of a 24-year-old man, who sustained a severe degloving injury of his left shoulder with an open glenohumeral joint, in a road traffic accident. We describe a treatment plan that salvaged near-full range of shoulder motion and resulted in pain-free active and passive movements.

Renal dysfunction in burns: a review.

Acute kidney injury (AKI), although rare, is a major complication of burn injury that commonly leads to mortality. It results from a complex interplay of various cellular and neuro-humoral changes affecting burn patients. Guidelines for the treatment of this entity are still not well defined; therefore, prevention and early diagnosis are key to avoid the unfavorable prognosis of AKI. These entail a comprehensive understanding of the global physiologic changes underlying the condition of burn patients and a judicious interpretation of their continuous homeostatic alterations. The aim of this review is to present the salient features in burn patient physiology that contribute to AKI. Strategies for identifying early AKI are presented. Finally, the different treatment modalities are revisited.

Les lésions rénales aiguës (LRA) sont rares, mais elles constituent une complication majeure des brûlures qui mène souvent à la mortalité. Ces lésions sont provoquées par une interaction complexe de divers changements cellulaires et neurohumoraux qui affectent les patients brûlés. Les directives pour le traitement de ces patients ne sont pas encore bien définies et, par conséquent, la prévention et le diagnostic précoce sont essentiels pour éviter le pronostic défavorable des LRA. Cela nécessite une compréhension complète des changements physiologiques présents dans ces patients et une interprétation judicieuse de leurs continuelles altérations homéostatiques. Les Auteurs se sont proposé de présenter les principales caractéristiques de la physiologie du patient brûlé qui contribuent à ce type de lésion. Apres avoir discuté les stratégies pour identifier ces lésions en phase précoce, ils concluent avec une description des différentes modalités de traitement.

The role of a dedicated staff psychiatrist in modern burn centers.

Psychiatric disorders may be more common in burn-injured subjects than in the general population, and oftentimes contribute to the injury itself. Even in the absence of underlying psychiatric illnesses, burn patients may still benefit from a psychiatric evaluation during and after their hospitalization. In this regard, we included a dedicated psychiatry service in our multidisciplinary burn team. We review herein the course of burn patients that were offered psychiatric evaluation and highlight the benefits of such a program. We conducted an IRB-approved retrospective chart review of burn subjects admitted to our institution between June 15, 2009 and April 30, 2010 and identified 83 patients that were examined by our psychiatrist. Indications for consultation, history of psychiatric illness and substance abuse, as well as administered drugs, were recorded. Among the 83 evaluated patients, 48 (57.8%) had a preexisting psychiatric disorder and 36 (43.4%) suffered from substance abuse. The most common indications for consultation were pain (28.1%), alcohol dependence (25.8%), anxiety (24.7%), illicit drug abuse (16.8%), depression (15.7%), post-traumatic stress disorder (8.9%), and sleep disturbances (8.9%). Pharmacotherapy was initiated in 75 patients (90.3%). 31 (37.3%) had neither a psychiatric disorder nor a history of substance abuse, although 26 of them (83.9%) still received drugs for psychiatric conditions. The inclusion of a dedicated psychiatrist as part of our burn team has improved our comprehensive burn care. In the overwhelming majority of cases, even in the absence of preexisting psychiatric illnesses, consultation resulted in pharmacologic intervention and enhanced patient care.

Les troubles psychiatriques peuvent être plus fréquents chez les patients brûlés que dans la population générale, et contribuent souvent à la blessure elle-même. Même en l'absence de maladies psychiatriques sous-jacents, les patients brûlés peuvent encore bénéficier d'une évaluation psychiatrique pendant et après leur hospitalisation. À cet égard, nous avons inclus un service de psychiatrie dédié à notre équipe multidisciplinaire pour la gestion des brûlures. Nous examinons ici les cours de patients brûlés à qui une évaluation psychiatrique a été proposée et nous mettons en évidence les avantages d'un tel programme. Nous avons effectué un examen rétrospectif - approuvé par les CPP - des patients brûlés admis dans notre institution entre le 15 Juin 2009 et le 30 Avril, 2010, à partir de lequel nous avons identifié 83 patients qui ont été examinés par notre psychiatre. Nous avons enregistré les indications pour la consultation, les antécédents de maladie psychiatrique et la toxicomanie, ainsi que les médicaments administrés. Parmi les 83 patients évalués, 48 (57,8 %) avaient un trouble psychiatrique préexistante et 36 (43,4%) a souffert de l'abus de substances. Les indications les plus fréquentes de consultation étaient la douleur (28,1%), la dépendance à l'alcool (25,8%), l'anxiété (24,7%), l'abus de drogues illicites (16,8%), la dépression (15,7%), les troubles de stress post-traumatique (8,9%), et troubles du sommeil (8,9%). La pharmacothérapie a été instaurée dans 75 patients (90,3%). 31 (37,3%) ne présentaient pas de troubles psychiatriques ni une histoire d'abus de substance mais quand même 26 d'entre eux (83,9 %) ont reçu des médicaments pour des troubles psychiatriques. L'inclusion d'un psychiatre spécialisé dans le cadre de notre équipe a amélioré notre système complet de soins aux brulés. Dans l'écrasante majorité des cas, même en l'absence des maladies psychiatriques préexistantes, la consultation a donné lieu à une intervention pharmacologique et a amélioré les soins aux patients.

Acute burn resuscitation and fluid creep: it is time for colloid rehabilitation.

Fluid overloading has become a global phenomenon in acute burn care. The consensus Parkland formula that has excluded colloid use, the impact of goal-directed resuscitation, and the overzealous on the scene crystalloid resuscitation combined with subsequent inefficient titration of fluid administration and lack of timely reduction of infusion rates, have all contributed to this phenomenon of fluid overloading, known as fluid creep and recognized only recently, constituting a landmine in modern burn care. Solid evidence is supportive to the fact that excessive administration of crystalloid and the abandonment of colloid replenishment at some point of resuscitation are the major contributors to fluid creep. With available evidence from the literature, the present is a comprehensive review of literature about fluid creep, trying to determine the etiology behind it as well as to propose strategies to control its magnitude and complications, namely through colloid administration amongst other options.

Reverse tissue expansion by liposuction deflation adopted for harvest of large sheet of full-thickness skin graft.

Full-thickness skingraft is a valid option to release burn scar contractures with the main purpose of correcting the induced limitation in function and improve the disfiguring appearance of the scar. The main pitfall remains the limited availability of these grafts, especially when large sheets are needed. We present an application of a previously described technique known as reverse tissue expansion, which permits the harvesting of a large sheet of full thickness skin graft when needed. This method was adopted to release a burn scar contracture in a 32-yr-old man who sustained a 65% TBSA burn secondary to a gasoline tank explosion at the age of 7 yr followed by multiple reconstructive procedures. The patient presented with a disfiguring anterior neck contracture coupled to limited range of motion. Improvement of neck extension was contemplated using full-thickness skin graft harvested following reverse tissue expansion achieved by deflation liposuction of the donor site.

Indices of apoptosis and proliferation as potential prognostic markers in non-functioning pituitary adenomas.

OBJECTIVE: Non-functioning pituitary adenomas (NFAs) are a distinct group of pituitary adenomas, which comprise approximately 20% of pituitary adenomas. Although most pituitary adenomas are benign, there is a subset of adenomas that behaves in an aggressive fashion, with either invasion of the surrounding structures or recurrence. The aim of this study was to investigate whether the behaviour of NFAs can be predicted using immunohistochemical markers that label proliferating and apoptotic cells, including a new marker for apoptosis (M30 CytoDEATH). This is the first study to analyse both the proliferation labelling index (LI) and the apoptotic index (AI) in NFAs and to correlate the labelling indices of these histological markers with tumor growth rate as measured by 2 postoperative MRI scans. MATERIAL AND METHODS: 40 patients in total were included in the study. 20 patients with high growth rate and percentage change in the pituitary adenoma volume as assessed on 2 postoperative MRI scans were age/sex matched to 20 patients with low growth rate or percentage change. RESULTS: There is no significant statistical difference of the histological and immunohistochemical indices assessed between cases and controls. CONCLUSION: The routine assessment of the proliferation and the apoptotic markers used in this study in NFAs has no prognostic value.

Inflammatory hypophysitis - the spectrum of disease.

BACKGROUND: Inflammatory conditions of the pituitary are rare and consequently there are a number of single case reports of this condition but few reports of series. The condition is often divided into lymphocytic and granulomatous hypophysitis and it has been suggested that these two conditions represent the ends of a spectrum of disease. METHOD: We present our experience with 14 cases of this condition, correlating the presenting symptoms with the neuroradiology, surgical findings and subsequent histology. FINDINGS: The subjects (11 female 3 male) ranged in age from 13 to 64 years. Final histopathological diagnoses included 5 cases of lymphocytic hypophysitis, 4 cases of Rathke's pouch cyst with granulomatous response, 2 cases of granulomatous hypophysitis and 1 case with an inflammatory process that did not fit the current classification. Two subjects did not undergo surgery. Headache was a presenting feature in 11 of 14 cases and fever in 3 of 14 cases. Length of symptoms prior to presentation varied from acute onset to 9 years. One case of lymphocytic hypophysitis was associated with pregnancy. Evidence of hypopituitarism was present in 9 of 10 subjects assessed preoperatively. Preoperative radiology showed three patterns of disease: A cystic appearance was common with low signal content on MRI T1 weighting with an enhancing ring and a thickened enhancing stalk (5 patients). 4 patients showed a solid enhancing mass. A third group (2 patients) showed cysts with high signal content on T1 weighting - both of these were Rathke's cysts on histology. INTERPRETATION: Overall there were no striking features in the clinical presentation to distinguish pituitary inflammation from pituitary adenoma. The prognosis was generally good.

Bispectral index monitoring during sedation with sevoflurane, midazolam, and propofol.

BACKGROUND: Bispectral Index (BIS) has been used to measure sedation depth. Ideally, to guide anesthetic management, range of BIS scores at different sedation levels should not overlap, and BIS should be independent of drug used. This study assessed ability of BIS to predict sedation depth between sevoflurane, propofol, and midazolam. Quality of recovery was also compared. METHODS: Patients undergoing surgery with local or regional anesthesia and sedation were randomized to sevoflurane (n = 23), midazolam (n = 21), or propofol (n = 22). Sedation was titrated to Observers's Assessment of Alertness-Sedation score of 3 (responds slowly to voice). BIS and Observers's Assessment of Alertness-Sedation were measured every 5 min. BIS prediction probability (PK) was compared between drugs. Recovery was assessed by BIS and Digit Symbol Substitution and memory tests. RESULTS: Bispectral Index of responders to voice was significantly different from nonresponders (86 +/- 10 vs. 74 +/- 14, mean +/- SD; P < 0.001) However, wide variability and overlap in BIS were observed (25th-75th percentile, responders vs. non-responders: 79-96 vs. 65-83). BIS of responders was different for sevoflurane versus propofol and midazolam. BIS was a better predictor of propofol sedation than sevoflurane or midazolam (PK = 0.87 +/- 0.11, 0.76 +/- 0.01, and 0.69 +/- 0.02, respectively; P < 0.05). At 10 min after the procedure, 76, 48, and 24% of sevoflurane, propofol, midazolam patients, respectively, returned to baseline Digit Symbol Substitution scores (P < 0.05). Excitement-disinhibition occurred in 70, 36, and 5% of sevoflurane, propofol, and midazolam patients, respectively (P < 0.05). CONCLUSION: Individual BIS scores demonstrate significant variability, making it difficult to predict sedation depth. The relation between BIS and sedation depth may not be independent of anesthetic agent. Quality of recovery was similar between drugs, but excitement occurred frequently with sevoflurane.

The role and histological classification of needle core biopsy in comparison with fine needle aspiration cytology in the preoperative assessment of impalpable breast lesions.

AIMS: To investigate the role of needle core biopsy (NCB) in the preoperative assessment of impalpable breast lesions, mainly derived from the NHS Breast Screening Programme (NHSBSP) and to assess our own modifications to a suggested system for the classification of breast NCBs. METHODS: The NCB, fine needle aspiration cytology (FNAC), and radiology scores from 298 women with non-palpable breast lesions presenting between January 1997 and December 1998, together with the open biopsy results (where available) were collated and analysed. RESULTS: The mean follow up period was 15.8 months (range, 5-28). The 298 NCB specimens were categorised as follows: unsatisfactory/non-representative (B1; n = 61; 20.5%), benign but uncertain whether representative (B2r; n = 52; 17.4%), benign (B2; n = 103; 34.6%), lesions possibly associated with malignancy but essentially benign (B3a; n = 9; 3.0%), atypical epithelial proliferations (B3b; n = 10; 3.4%), suspicious of malignancy (B4; n = 7; 2.3%), and malignant (B5; n = 56; 18.7%). Excision biopsy was performed in 43 cases within the B1 (n = 19), B2r (n = 8), B2 (n = 8), and the B3a (n = 8; data unavailable in one case) categories, revealing malignancy in 18 (42.8%) cases and in 65 cases within the B3b, B4, and B5 categories, revealing malignancy in 64 cases (98.5%). The sensitivity of NCB for malignancy was 87.7%, with a specificity and positive predictive value of 99.3% and 98.5%, respectively. FNAC had an inadequacy rate of 58.7%, a complete sensitivity of 34.5% and a specificity of 47.6%. CONCLUSIONS: This study confirms the value of NCB in the preoperative assessment of impalpable breast lesions. Two new categories are suggested for the NCB classification; category B2r for benign breast tissue where representativeness is uncertain, and the subdivision of category B3 into B3a for benign lesions potentially associated with malignancy (for example, radial scars and intraduct papillomas) and B3b for more worrisome atypical epithelial proliferations. These will aid the accurate audit of NCB and identify more clearly the intellectual pathway leading to a particular assessment.

Speed of recovery and side-effect profile of sevoflurane sedation compared with midazolam.

BACKGROUND: Sedation for surgical procedures performed with regional or local anesthesia has usually been achieved with intravenous medications, whereas the use of volatile anesthetics has been limited. The use of sevoflurane for sedation has been suggested because of its characteristics of nonpungency, rapid induction, and quick elimination. The purpose of this investigation was to assess the quality, recovery, and side effects of sevoflurane sedation compared with midazolam. METHODS: One hundred seventy-three patients undergoing surgery with local or regional anesthesia were enrolled in a multicenter, open-label, randomized investigation comparing sedation with sevoflurane versus midazolam. Sedation level was titrated to an Observer's Assessment of Alertness--Sedation score of 3 (responds slowly to voice). Recovery was assessed objectively by Observer's Assessment of Alertness--Sedation, Digit Symbol Substitution Test (DSST), and memory scores, and subjectively by visual analog scales. RESULTS: Significantly more patients in the sevoflurane group had to be converted to general anesthesia because of excessive movement (18 sevoflurane and 2 midazolam; P = 0.043). Of remaining patients, 141 were assessable for efficacy and recovery data (93 sevoflurane and 48 midazolam). Sevoflurane and midazolam produced dose-related sedation. Sevoflurane patients had higher DSST and memory scores during recovery. Seventy-six percent (sevoflurane) compared with 35% (midazolam) returned to baseline DSST at 30 min postoperatively (P < 0.05). More frequent excitement-disinhibition was observed with sevoflurane (15 [16%] vs. midazolam; P = 0.008). CONCLUSIONS: Sevoflurane for sedation produces faster recovery of cognitive function as measured by DSST and memory scores compared with midazolam. However, sevoflurane for sedation is complicated by a high incidence of intraoperative excitement.

Long-term follow-up of pediatric cardiac patients requiring mechanical circulatory support.

BACKGROUND: The present study examines the long-term outcome of pediatric patients with cardiac disease who required mechanical circulatory support with extracorporeal membrane oxygenation or ventricular assist devices. METHODS: Telephone interviews and questionnaires were administered to parents and physicians of pediatric cardiac patients who were in-hospital survivors after requiring mechanical circulatory support, with either extracorporeal membrane oxygenation or ventricular assist devices. Data was collected regarding these patients' general health, cardiac status, and neurologic outcome, and compared between the two modes of support. RESULTS: Follow-up was available for 26 patients supported with extracorporeal membrane oxygenation (25 survivors, 96%) and 11 patients supported with ventricular assist devices (10 survivors, 91%); median follow-up 42 months, 11 to 92 months). More than 80% of survivors were in New York Heart Association class I or II. Of 31 patients for whom neurologic assessment data was available, moderate to severe neurologic impairment was more common for extracorporeal membrane oxygenation supported patients [13 of 21, 59%) than for ventricular assist device supported patients (2 of 10, 20% p = 0.03). Neurologic impairment was associated with small patient size and the use of circulatory arrest during cardiac surgical repair, but was not associated with in-hospital neurologic complications, carotid cannulation, or presupport cardiac arrest. CONCLUSIONS: The long-term survival and cardiac functional status of pediatric cardiac patients requiring mechanical circulatory support is favorable. Extracorporeal membrane oxygenation supported patients demonstrate higher rates of neurologic impairment than patients supported with ventricular assist devices. Poor neurologic outcomes are associated with institution of support in younger patients with more complex congenital heart disease.

Increased myocardial calcium cycling and reduced myofilament calcium sensitivity in early endotoxemia.

BACKGROUND: Mechanisms of cardiac dysfunction during endotoxemia are multiple and their targets uncertain. This study tested the hypothesis that endotoxin (LPS) induces abnormal calcium-activated contractile force in the heart. METHODS: Adult rabbits were given LPS intravenously; 2 hours later hearts were studied in the Langendorff mode. Measurements included peak developed pressure (PDP), myocardial oxygen consumption (MVO2), high-energy phosphates by 31P-NMR, and beat-to-beat intracellular calcium (Cai) by fluorescence spectroscopy. Myofibrillar calcium sensitivity was assessed from the relationship of PDP to Cai and the rate of diastolic Cai removal (tau Ca) was quantified. RESULTS: Force-calcium relationships were markedly depressed in LPS hearts despite increased Cai. MVO2 was increased in parallel with increased Cai. Taken together, these data denote myofilament calcium insensitivity and mechanical inefficiency. tau Ca was markedly prolonged in LPS hearts, indicating impaired calcium reuptake and/or extrusion. High-energy phosphates and intracellular pH were unaffected by LPS; however, inorganic phosphate (Pi) was significantly increased. Dobutamine further increased Cai and MVO2 in LPS hearts without significantly improving calcium-activated force. Pyruvate, an inotrope that reduces Pi, significantly improved contractility in LPS hearts. CONCLUSIONS: Endotoxemia rapidly induced futile calcium cycling and reduced myofibrillar calcium sensitivity. This state was resistant to beta-agonist inotropic stimulation; inotropes that normalize the calcium-force relationship may be more effective.