Prediction of a time-sensitive condition among patients with dizziness assessed by the emergency medical services.

BACKGROUND: Dizziness is a relatively common symptom among patients who call for the emergency medical services (EMS). AIM: To identify factors of importance for the early identification of a time-sensitive condition behind the symptom of dizziness among patients assessed by the EMS. METHODS: All patients assessed by the EMS and triaged using Rapid Emergency Triage and Treatment (RETTS) for adults code 11 (=dizziness) in the 660,000 inhabitants in the Municipality of Gothenburg, Sweden, in 2016, were considered for inclusion. The patients were divided into two groups according to the final diagnosis (a time-sensitive condition, yes or no). RESULTS: There were 1536 patients who fulfilled the inclusion criteria, of which 96 (6.2%) had a time-sensitive condition. The majority of these had a stroke/transitory ischaemic attack (TIA). Eight predictors of a time-sensitive condition were identified. Three were associated with a reduced risk: 1) the dizziness was of a rotatory type, 2) the dizziness had a sudden onset and 3) increasing body temperature. Five were associated with an increased risk: 1) sudden onset of headache, 2) a history of head trauma, 3) symptoms of nausea or vomiting, 4) on treatment with anticoagulants and 5) increasing systolic blood pressure. CONCLUSION: Among 1536 patients who were triaged by the EMS for dizziness, 6.2% had a time-sensitive condition. On the arrival of the EMS, eight factors were associated with the risk of having a time-sensitive condition. All these factors were linked to the type of symptoms or to clinical findings on the arrival of the EMS or to the recent clinical history.

Using volatile organic compounds to enhance atrazine biodegradation in a biobed system.

The effect of the terpenes α-pinene, eucalyptol, and limonene, individually and as mixtures, on atrazine (ATZ) biodegradation and on biological activity in a biobed biomixture was evaluated. Additionally, terpenes emitted from the biomixture were captured using solid-phase microextraction. Terpenes added individually at relatively low concentrations (50 µg kg(-1)) significantly enhanced ATZ degradation and biological activity during the first incubation days. No significant effect on ATZ degradation was found from adding the terpene mixture, and, interestingly, an inhibitory effect on phenoloxidase activity was found during the first 20 days of incubation when mixed terpenes were present at 100 µg kg(-1). Capturing terpenes demonstrated that during the first hour of incubation a significant fraction of the terpenes was volatilized. These results are the first to demonstrate the feasibility of using terpenes to enhance the degradation of a pesticide. However, successive applications of terpenes or the addition of materials that slowly release terpenes could sustain the ATZ degradation enhancement.

Measurements and modeling of pesticide persistence in soil at the catchment scale.

Degradation of pesticides in soils is both spatially variable and also one of the most sensitive factors determining losses to surface water and groundwater. To date, no general guidance is available on suitable approaches for dealing with spatial variation in pesticide degradation in catchment or regional scale modeling applications. The purpose of the study was therefore to study the influence of various soil physical, chemical and microbiological characteristics on pesticide persistence in the contrasting cultivated soils found in a small (13 km(2)) agricultural catchment in Sweden and to develop and test a simple model approach that could support catchment scale modeling. Persistence of bentazone, glyphosate and isoproturon was investigated in laboratory incubation experiments. Degradation rate constants were highly variable with coefficients of variation ranging between 42 and 64% for the three herbicides. Multiple linear regression analysis and Mallows Cp statistic were employed to select the best set of independent parameters accounting for the variation in degradation. Soil pH and the proportion of active microorganisms (r) together explained 69% of the variation in the bentazone degradation rate constant; the Freundlich sorption co-efficient (K(f)) and soil laccase activity together explained 88% of the variation in degradation rate of glyphosate, while soil pH was a significant predictor (p<0.05) for isoproturon persistence. However, correlations between many potential predictor variables made clear interpretations of the statistical analysis difficult. Multiplicative models based on two predictors chosen 'a priori', one accounting for microbial activity (e.g. microbial respiration, laccase activity or the surrogate variable soil organic carbon, SOC) and one accounting for the effects of sorption on bioavailability, showed promise to support predictions of degradation for large-scale modeling applications, explaining up to 50% of the variation in herbicide persistence.

Reversible transition between active and dormant microbial states in soil.

The rate of respiration obtained in the substrate-induced respiration (SIR) method can be divided into the respiration rate of growing (r) and non-growing (K) microorganisms. The fraction of r is generally small (5-20%) in soils with no recent addition of substrates, but can be 100% in soils with high substrate availability. This suggests that substrate availability determines the proportion of biomass between these groups, and implies that transitions between them can take place reversibly. These hypotheses were tested by adding three different amounts of glucose which induced first-order, zero-order, and growth-associated respiration kinetics to three soils at four pre-incubation times (4, 12, 27, and 46 days) before the SIR measurement. An abiotic flush of CO(2) in the SIR measurement was detected and corrected for before data analysis. Accumulated CO(2)-C over 4 days after glucose addition, corrected for the respiration in unamended controls, corresponded to 41-50% mineralization of the glucose-C, and the relative amount mineralized by each soil was independent of the glucose amount added. The high glucose concentration gave an increased SIR, which reverted to the initial value within 27-46 days. In a specific sample, the maximum respiration rate induced during the pre-incubation, and the amount of organisms transformed from the K to the r state, as quantified in respiration rate units in the SIR measurement, were identical to each other, and these parameters were also highly correlated to the initial glucose concentration. The K-->r transition was very fast, probably concurrent with the instantaneous increase in the respiration rate obtained by the glucose amendment. Thereafter, a slow first-order back-transition from the r to the K state ensued, with half-lives of 12, 23, and 70 days for the three soils. The results suggest the existence of community-level controls by which growth within or of the whole biomass is inhibited until it has been completely transformed into the r state. The data also suggest that the microbial specific activity is not related to the availability of exogenous substrate in a continuous fashion, rather it responds as a sharp transition between dormant and fully active. Furthermore, the inherent physiological state of the microbial biomass is strongly related to its history. It is proposed that the normal dynamics of the soil microbial biomass is an oscillation between active and dormant physiological states, while significant growth occurs only at substantial substrate amendment.

Metabolic cardiovascular syndrome after renal transplantation.

BACKGROUND: Cardiovascular disease (CVD) is the major cause of death in renal transplant recipients. Traditional risk factors like hypertension, dyslipidaemia and diabetes mellitus are common, but cannot completely account for the high prevalence of CVD in this population. The aim of the present study was to assess whether post-transplant glucose intolerance, defined as post-transplant diabetes mellitus, impaired glucose tolerance, or impaired fasting glucose, is associated with metabolic disturbances known to increase risk of cardiovascular disease, similar to what has been observed in the general population. METHODS: One hundred and seventy-three consecutive patients were prospectively examined 10 weeks after transplantation. An oral glucose tolerance test was completed in 167 patients. Questionnaires, medical records, and the results of various blood tests were used to evaluate a number of known cardiovascular risk factors in all patients. RESULTS: Glucose intolerance was present in about one-half the recipients and was associated with age, a positive family history of ischaemic heart disease, acute rejection, higher levels of serum triglycerides, apolipoprotein B and 2-h insulin, and lower levels of serum HDL cholesterol. After adjustment for age and sex, lower HDL cholesterol (P=0.005), higher serum triglycerides (P<0.001), apolipoprotein B (P=0.039) and 2-h insulin (P<0.001) were still associated with post-transplant glucose intolerance. CONCLUSIONS: Ten weeks after renal transplantation glucose intolerance is associated with a clustering of cardiovascular risk factors and metabolic abnormalities, consistent with a post-transplant metabolic cardiovascular syndrome.

Tapering off prednisolone and cyclosporin the first year after renal transplantation: the effect on glucose tolerance.

BACKGROUND: Glucose intolerance is an untoward side effect of some immunosuppressive and anti-hypertensive drugs. The primary aim of the present prospective observational study was to test the hypothesis that tapering off prednisolone and cyclosporin (CsA) the first year after transplantation may have beneficial effects on glucose tolerance in renal transplant recipients. METHODS: Ninety-one non-diabetic recipients were included, and 87 patients underwent a 75 g oral glucose tolerance test both 10 weeks and 1 year after renal transplantation. The change over time in 2-h blood glucose was compared with a number of variables potentially influencing glucose tolerance. RESULTS: The proportion of glucose intolerant recipients was reduced from 55 to 34% during the study. Univariate linear regression analysis showed a significant association between the reduction in daily prednisolone dose down to 5 mg and decline in blood glucose (P=0.001), whereas weight gain was associated with increasing blood glucose (P=0.031). Each 1-mg reduction of prednisolone dose leads to an estimated decline in 2-h blood glucose of 0.12 mmol/l based on the multiple linear regression model (P=0.003). Twelve out of 22 patients with post-transplant diabetes mellitus (PTDM) at baseline improved to normal or impaired glucose tolerance. Ten PTDM-subjects who remained diabetic 1 year after transplantation had lower serum insulin levels during the oral glucose challenge, and five patients treated with anti-diabetic drugs at baseline required hypoglycaemic drugs also at follow up. The decline in CsA level of 100 microg/l and the lower number of patients treated with beta-blockers at follow-up, did not alter glucose tolerance significantly. CONCLUSIONS: Tapering off prednisolone, but not CsA, significantly improves glucose tolerance during the first year after renal transplantation.

Immediate and early renal function after living donor transplantation.

BACKGROUND: In order to assess the immediate renal function after living donor transplantation, renal function was compared in eight renal allograft recipients and their living related kidney donors during the first 24 h after transplantation. METHODS: Substantial and comparable intraoperative volume loading with Ringer's acetate and mannitol was performed together with the administration of frusemide. Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were estimated by the clearances of inulin and p-aminohippurane, respectively. Tubular reabsorptive function and injury were estimated from the clearance of lithium, the fractional excretion of sodium and the urinary excretion of N-acetyl-beta-glucosaminidase. RESULTS: One hour after completion of surgery, GFR (54 +/- 7 ml/min) and ERPF (294 +/- 35 ml/min) were only 30% lower in the grafts than in the remaining donor kidneys, increasing to similar levels within 3 h. Only minor tubular dysfunction and injury were revealed in the grafted kidneys, and these tended to normalize within 24 h. CONCLUSIONS: By the present transplantation procedure comprising short ischaemia time and substantial volume expansion combined with mannitol and frusemide administration, kidneys from living donors regain nearly normal function within a few hours after transplantation.

Glucose intolerance after renal transplantation depends upon prednisolone dose and recipient age.

BACKGROUND: Retrospective studies on the prevalence of posttransplant diabetes mellitus (PTDM) in patients on triple-drug immunosuppressive therapy have shown great dispersity, while the incidence of posttransplant impaired glucose tolerance (IGT) is unknown. The aim of our study was to prospectively examine the incidence of posttransplant glucose intolerance and to assess potential risk factors. METHODS: Glucose intolerance was prospectively examined in 173 consecutive kidney transplant recipients by oral glucose tolerance tests (n=167) or the diagnosis of manifest diabetes mellitus (n=6) at 10 weeks after transplant. RESULTS: We found a high incidence of PTDM (18%) and IGT (31%). Univariate analysis revealed that age, family history of diabetes, HLA-B27 phenotype, DR mismatch, rejection, actual prednisolone dose, total methylprednisolone dose, total steroid dose, cytomegalovirus (CMV) infection, and the use of furosemide were associated with PTDM. Age, prednisolone dose, CMV infection, and the use of beta-blockers were associated with IGT. Gender, body mass index, donor source, and cyclosporine level did not influence glucose tolerance. Prednisolone dose, age, family history of diabetes, CMV infection, and HLA-B27 phenotype were independent predictors of PTDM with the use of multiple stepwise logistic regression analysis. Age, prednisolone dose, and the use of a beta-blocker were associated with IGT in the multivariate model. Both univariate and multivariate linear regression analysis revealed a significant relationship between the 2-hr serum glucose and prednisolone dose. The risk of developing PTDM was 5% per 0.01 mg/kg/day of increase in prednisolone dose. CONCLUSIONS: Increased prednisolone dose and older age are strongly associated with the development of posttransplant glucose intolerance.

Effect of fluvastatin for safely lowering atherogenic lipids in renal transplant patients receiving cyclosporine.

The lipophilic 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors have been associated with rhabdomyolysis in cyclosporine-treated treated patients, indicating an interaction of drugs. We therefore studied the safety and efficacy of the hydrophilic HMG-CoA reductase inhibitor fluvastatin in 14 cyclosporine-treated renal transplant patients. To qualify for inclusion, total cholesterol after dietary stabilization had to be > 240 mg/dL. Prior to starting active medication, patients underwent a 4-week placebo period. Fluvastatin was given in a dose of 20 mg once daily for 12 weeks, which was increased to 20 mg twice daily for a further 8 weeks. Fluvastatin reduced total and low density lipoprotein cholesterol in all patients at both dosages whereas no effect on high density lipoprotein cholesterol was observed. Triglyceride levels were lowered at week 20. Incremental dosages of fluvastatin did not affect cyclosporine concentration and no adjustment of cyclosporine dosage was necessary. The higher doses of fluvastatin also had no effect on renal function as judged by serum creatinine levels. Creatine phosphokinase remained unchanged throughout the study. No serious side-effects were observed. In conclusion, the hydrophilic HMG-CoA reductase inhibitor fluvastatin at either 20 or 40 mg/day appears to be both safe and effective in lowering atherogenic lipids in renal transplant patients.

Determination of manganese peroxidase activity with 3-methyl-2-benzothiazolinone hydrazone and 3-(dimethylamino)benzoic acid.

This method was proposed earlier for measuring glucose in a peroxidase-glucose oxidase system but has not been studied for determination of manganese peroxidase (MnP) activity. The assay is based on the oxidative coupling of 3-methyl-2-benzothiazolinone hydrazone (MBTH) and 3-(dimethylamino)benzoic acid (DMAB). The reaction of MBTH and DMAB in the presence of H2O2, Mn2+, and MnP gives a deep purple-blue color with a broad absorption band with a peak at 590 nm. The extinction coefficient is high (53,000 M-1 cm-1), so low MnP activities can be detected. Lignin peroxidase and laccase, usually present in cultures of white rot fungi, gave little or no interference at the concentrations tested. However, slight interference from very high LiP activity may occur at very low MnP activity.

Acute physiological changes in canine kidneys following exposure to extracorporeal shock waves.

Nine anesthetized dogs were studied for four to five hours after administration of extracorporeal shock waves to one kidney, the contralateral organ serving as control. Urinary excretion of electrolytes, N-acetyl-beta-glucosaminidase (NAG) and kallikrein, clearances of creatinine, inulin and para-amino-hippuric acid (PAH), serum aldosterone level and plasma renin activity (PRA) were determined. On the exposed side there was a significant increase in urinary flow and urinary NAG excretion, and a significant fall in urinary osmolality. Effective renal plasma flow (ERPF) was reduced and glomerular filtration rate (GFR) unchanged, thus filtration fraction (FF) was increased. Extraction of PAH was significantly reduced compared with the control kidney. On the control side there was a significant increase in urinary flow and excretion of electrolytes, and a significant fall in urinary osmolality. GFR was increased and ERPF unchanged. FF therefore increased also on this side. The mean rise of PRA in the exposed kidney was higher than in the control kidney, the difference being not significant (p = 0.09). Our results may indicate a triggering of the renin-angiotensin system, and an effect on proximal tubular function following exposure of extracorporeal shock waves.

Influence of climatic and edaphic factors on persistence of glyphosate and 2,4-D in forest soils.

Persistence in soil of the two herbicides glyphosate and 2,4-D was investigated after application for brush control in conifer reforestation areas. Field experiments were carried out at five sites in southern Sweden and six in northern Sweden. Initially, glyphosate disappeared faster in northern soils than in southern soils. This was probably a result of the higher biological activity in the northern soils. However, small amounts of glyphosate were detected in the northern area long after all traces had disappeared in the south, presumably because of the long period during which the soil remained frozen in the northern area and because of the slow release of vegetation-bound herbicide. One metabolite of glyphosate, aminomethylphosphonic acid (AMPA), persisted longer than glyphosate itself. After 2 years, 8% of the theoretical amount was found in the northern area and, after 1 year, 1% in the southern area. 2,4-D disappeared rapidly from all sites, although minor amounts persisted for several years, probably because of slow release from vegetation-bound residues.

Long-term blood pressure and renal function in kidney donors.

We have reexamined 68 (92%) of 74 donors accepted at this center nine to 15 years ago. There was a moderate but significant increase in BP, and ten donors (15%) were hypertensive at the follow-up. Twenty-six donors (38%) had albumin excretion over 10 micrograms/min or excretion of total protein over 185 mg/24 hr. In four of 16 with increased excretion of total protein, this exceeded 400 mg/24 hr, and in three donors this could be due to an intercurrent disease. Ccr averaged 78.4% of preoperative values, and was less than 50% (range 32 to 49%) in eight donors. The compensatory increase (median 30.5 mliter/min/1.73m2) was inversely correlated with age and BP. Aspects of tubular function were assessed by the diluting capacity during water diuresis and by urinary excretion of beta 2-microglobulin and N-acetyl-beta-glucosaminidase. No consistent abnormalities were observed. A subgroup of donors (N = 32) was compared with a matched control group. Urinary albumin excretion among the donors was significantly higher compared to the controls, both in absolute terms (5.4 vs. 3.3 micrograms/min, P less than 0.002) and as percent of total protein excretion (7.6 vs. 5.7%, P less than 0.05). Otherwise no consistent differences were observed. The development of BP over time warrants further observations, but there is no evidence that uninephrectomy represents a long-term risk to the donors' health.

Ruptured abdominal aortic aneurysms.

The problems, results and treatment suggestions in regard to ruptured abdominal aortic aneurysms are discussed.