Lateral Compression Manipulation: A Simple Approach for Sizing Taller-Than-Wide Intracranial Aneurysms with the Woven EndoBridge (WEB) Device.

BACKGROUND AND PURPOSE: The Woven EndoBridge (WEB) system (MicroVention in Tustin, CA, USA) has established itself as a safe and effective option for managing wide-necked bifurcation aneurysms. Addressing aneurysms with a greater height than width using conventional WEB sizing methods has proven ineffective due to the inherent configuration of the devices. To overcome this limitation, we propose an intuitive approach which involves swapping the width and height dimensions of the aneurysm to determine the appropriate WEB size. MATERIALS AND METHODS: A retrospective analysis was conducted on patients undergoing WEB embolization treatment at a single neuroscience center from March 2013 to February 2023. RESULTS: Twenty-five eligible aneurysms were identified, with the height dimension exceeding the width by an average of 2.33 mm (ranging from 1.4 to 4.5 mm). Out of these, twenty cases adhered to the recommended sizing technique, resulting in a 100% success rate of adequate occlusion (14/20 complete occlusion, 6/20 proximal recess filling). In contrast, the outcomes for the remaining five cases that did not follow the proposed sizing method were less favorable (p<0.05). Among these, four cases treated with undersized WEBs showed neck remnants during follow-up, and one patient who received an oversized WEB required device replacement during the same procedure. CONCLUSIONS: The simple sizing method we proposed for treating taller-than-wide aneurysms has demonstrated promising results, allowing the WEB system to address twice the original size range of treatable aneurysms. Further research with a larger sample size is recommended. ABBREVIATIONS: WEB = Woven EndoBridge; SL = Single Layer; SLS = Single Layer Sphere.

Use of multi-strain probiotics in linseed meal based diet for Labeo rohita fingerlings / Uso de probióticos multi-cepas na dieta à base de farinha de linhaça para alevinos de Labeo rohita

Unavailability of probiotics in fish digestive system fingerlings is unable to digest and absorb their food properly. The current research was conducted to investigate the influence of probiotics added Linseed meal based (LMB) diet on hematology and carcass composition of Labeo rohita juveniles. Hematological parameters are essential diagnostics used to estimate the health status of fish. The usage of probiotics for fish health improvement is becoming common due to the higher demand for environment-friendly culture system in water. Linseed meal was used as a test ingredient to prepare six experimental test diets by adding probiotics (0, 1, 2, 3, 4 and 5 g/kg) and 1% indigestible chromic oxide for seventy days. According to their live wet weight, five percent feed was given to fingerlings twice a day. Fish blood and carcass samples (Whole body) were taken for hematological and carcass analysis at the end of the experiment. The highest carcass composition (crude protein; 18.72%, crude fat; 8.80% and gross energy; 2.31 kcal/g) was observed in fish fed with test diet II supplemented with probiotics (2 g/kg). Moreover, maximum RBCs number (2.62× 106mm-3), WBCs (7.84×103mm-3), PCV (24.61), platelets (63.85) and hemoglobin (7.87) had also been reported in the fish fingerlings fed on 2 g/kg of probiotics supplemented diet. Results indicated that probiotics supplementation has a critical role in improvement of fingerlings' body composition and hematological indices. Present findings showed that probiotics supplementation at 2 g/kg level in linseed by-product-based diet was very useful for enhancing the overall performance of L. rohita fingerlings.

A indisponibilidade de probióticos em alevinos do sistema digestivo de peixes faz com que ele seja incapaz de digerir e absorver seus alimentos adequadamente. A presente pesquisa foi conduzida para investigar a influência de probióticos adicionados à dieta à base de farelo de linhaça (LMB) na hematologia e na composição da carcaça de juvenis de Labeo rohita. Os parâmetros hematológicos são diagnósticos essenciais usados para estimar o estado de saúde dos peixes. O uso de probióticos para a melhoria da saúde dos peixes está se tornando comum devido à maior demanda por sistemas de cultivo em água que não agridam o meio ambiente. Farinha de linhaça foi usada como ingrediente para preparar seis dietas de teste experimentais adicionando probióticos (0, 1, 2, 3, 4 e 5 g/kg) e 1% de óxido crômico indigestível por 70 dias. De acordo com seu peso úmido vivo, 5% de alimento eram dados aos alevinos duas vezes ao dia. Amostras de sangue e carcaça de peixes (corpo inteiro) foram coletadas para análise hematológica e de carcaça no final do experimento. A maior composição da carcaça (proteína bruta, 18,72%; gordura bruta, 8,80%; e energia bruta, 2,31 kcal/g) foi observada em peixes alimentados com a dieta teste II suplementada com probióticos (2 g/kg). Além disso, os números máximos de RBCs (2,62×106 mm-3), WBCs (7,84×103 mm-3), PCV (24,61), plaquetas (63,85) e hemoglobina (7,87) também foram relatados em alevinos alimentados com 2 g/kg de dieta suplementada com probióticos. Os resultados indicaram que a suplementação de probióticos tem um papel crítico na melhoria da composição corporal dos alevinos e índices hematológicos. As descobertas atuais mostraram que a suplementação de probióticos no nível de 2 g/kg em dieta à base de subproduto de linhaça foi muito útil para melhorar o desempenho geral de alevinos de L. rohita.

Use of multi-strain probiotics in linseed meal based diet for Labeo rohita fingerlings

Abstract Unavailability of probiotics in fish digestive system fingerlings is unable to digest and absorb their food properly. The current research was conducted to investigate the influence of probiotics added Linseed meal based (LMB) diet on hematology and carcass composition of Labeo rohita juveniles. Hematological parameters are essential diagnostics used to estimate the health status of fish. The usage of probiotics for fish health improvement is becoming common due to the higher demand for environment-friendly culture system in water. Linseed meal was used as a test ingredient to prepare six experimental test diets by adding probiotics (0, 1, 2, 3, 4 and 5 g/kg) and 1% indigestible chromic oxide for seventy days. According to their live wet weight, five percent feed was given to fingerlings twice a day. Fish blood and carcass samples (Whole body) were taken for hematological and carcass analysis at the end of the experiment. The highest carcass composition (crude protein; 18.72%, crude fat; 8.80% and gross energy; 2.31 kcal/g) was observed in fish fed with test diet II supplemented with probiotics (2 g/kg). Moreover, maximum RBCs number (2.62× 106mm-3), WBCs (7.84×103mm-3), PCV (24.61), platelets (63.85) and hemoglobin (7.87) had also been reported in the fish fingerlings fed on 2 g/kg of probiotics supplemented diet. Results indicated that probiotics supplementation has a critical role in improvement of fingerlings body composition and hematological indices. Present findings showed that probiotics supplementation at 2 g/kg level in linseed by-product-based diet was very useful for enhancing the overall performance of L. rohita fingerlings.

Resumo A indisponibilidade de probióticos em alevinos do sistema digestivo de peixes faz com que ele seja incapaz de digerir e absorver seus alimentos adequadamente. A presente pesquisa foi conduzida para investigar a influência de probióticos adicionados à dieta à base de farelo de linhaça (LMB) na hematologia e na composição da carcaça de juvenis de Labeo rohita. Os parâmetros hematológicos são diagnósticos essenciais usados para estimar o estado de saúde dos peixes. O uso de probióticos para a melhoria da saúde dos peixes está se tornando comum devido à maior demanda por sistemas de cultivo em água que não agridam o meio ambiente. Farinha de linhaça foi usada como ingrediente para preparar seis dietas de teste experimentais adicionando probióticos (0, 1, 2, 3, 4 e 5 g/kg) e 1% de óxido crômico indigestível por 70 dias. De acordo com seu peso úmido vivo, 5% de alimento eram dados aos alevinos duas vezes ao dia. Amostras de sangue e carcaça de peixes (corpo inteiro) foram coletadas para análise hematológica e de carcaça no final do experimento. A maior composição da carcaça (proteína bruta, 18,72%; gordura bruta, 8,80%; e energia bruta, 2,31 kcal/g) foi observada em peixes alimentados com a dieta teste II suplementada com probióticos (2 g/kg). Além disso, os números máximos de RBCs (2,62×106 mm-3), WBCs (7,84×103 mm-3), PCV (24,61), plaquetas (63,85) e hemoglobina (7,87) também foram relatados em alevinos alimentados com 2 g/kg de dieta suplementada com probióticos. Os resultados indicaram que a suplementação de probióticos tem um papel crítico na melhoria da composição corporal dos alevinos e índices hematológicos. As descobertas atuais mostraram que a suplementação de probióticos no nível de 2 g/kg em dieta à base de subproduto de linhaça foi muito útil para melhorar o desempenho geral de alevinos de L. rohita.

Use of multi-strain probiotics in linseed meal based diet for Labeo rohita fingerlings.

Unavailability of probiotics in fish digestive system fingerlings is unable to digest and absorb their food properly. The current research was conducted to investigate the influence of probiotics added Linseed meal based (LMB) diet on hematology and carcass composition of Labeo rohita juveniles. Hematological parameters are essential diagnostics used to estimate the health status of fish. The usage of probiotics for fish health improvement is becoming common due to the higher demand for environment-friendly culture system in water. Linseed meal was used as a test ingredient to prepare six experimental test diets by adding probiotics (0, 1, 2, 3, 4 and 5 g/kg) and 1% indigestible chromic oxide for seventy days. According to their live wet weight, five percent feed was given to fingerlings twice a day. Fish blood and carcass samples (Whole body) were taken for hematological and carcass analysis at the end of the experiment. The highest carcass composition (crude protein; 18.72%, crude fat; 8.80% and gross energy; 2.31 kcal/g) was observed in fish fed with test diet II supplemented with probiotics (2 g/kg). Moreover, maximum RBCs number (2.62× 106mm-3), WBCs (7.84×103mm-3), PCV (24.61), platelets (63.85) and hemoglobin (7.87) had also been reported in the fish fingerlings fed on 2 g/kg of probiotics supplemented diet. Results indicated that probiotics supplementation has a critical role in improvement of fingerlings' body composition and hematological indices. Present findings showed that probiotics supplementation at 2 g/kg level in linseed by-product-based diet was very useful for enhancing the overall performance of L. rohita fingerlings.

Bacillus Calmette-Guérin vaccination and clinical characteristics and outcomes of COVID-19 in Rhode Island, United States: a cohort study.

Coronavirus disease 2019 (COVID-19) has resulted in a global pandemic, and there is limited data on effective therapies. Bacillus Calmette-Guérin (BCG) vaccine, a live-attenuated strain derived from an isolate of Mycobacterium bovis and originally designed to prevent tuberculosis, has shown some efficacy against infection with unrelated pathogens. In this study, we reviewed 120 consecutive adult patients (≥18 years old) with COVID-19 at a major federally qualified health centre in Rhode Island, United States from 19 March to 29 April 2020. Median age was 39.5 years (interquartile range, 27.0-50.0), 30% were male and 87.5% were Latino/Hispanics. Eighty-two (68.3%) patients had BCG vaccination. Individuals with BCG vaccination were less likely to require hospital admission during the disease course (3.7% vs. 15.8%, P = 0.019). This association remained unchanged after adjusting for demographics and comorbidities (P = 0.017) using multivariate regression analysis. The finding from our study suggests the potential of BCG in preventing more severe COVID-19.

Driving towards malaria elimination in Botswana by 2018: progress on case-based surveillance, 2013-2014.

Background: Reliable information reporting systems ensure that all malaria cases are tested, treated and tracked to avoid further transmission. Botswana aimed to eliminate malaria by 2018, and surveillance is key. This study focused on assessing the uptake of the new malaria case-based surveillance (CBS) system introduced in 2012, which captures information on malaria cases reported in the Integrated Disease Surveillance and Response (IDSR) system. Methods: This was a retrospective descriptive study based on routine data focusing on Ngami, Chobe and Okavango, three high-risk districts in Botswana. Aggregated data variables were extracted from the IDSR and compared with data from the CBS. Results: The IDSR reported 456 malaria cases in 2013 and 1346 in 2014, of which respectively only 305 and 884 were reported by the CBS. The CBS reported 34% fewer cases than the IDSR system, indicating substantial differences between the two systems. The key malaria indicators with the greatest variability among the districts included in the study were case identification number and date of diagnosis. Conclusion: The IDSR and CBS systems are essential for malaria elimination, as shown by the significant gaps in reporting between the two systems. These findings highlight the need for further investigation into these discrepancies. Strengthening the CBS system will help to reach the objective of malaria elimination in Botswana.

Contexte : Un système fiable de reportage des informations assure que tous les cas de paludisme sont testés, traités et suivis pour éviter toute transmission ultérieure. Le Botswana avait visé à éliminer le paludisme pour 2018, et la surveillance est essentielle. Cette étude s'est concentrée sur l'évaluation de la couverture de la nouvelle surveillance basée sur les cas de paludisme (CBS) introduite en 2012, dans laquelle on saisit les informations relatives aux cas de paludisme rapportés au sein du système intégré de surveillance et de réponse aux maladies (IDSR).Méthodes: Une étude rétrospective, descriptive, basée sur des données de routine et concentrée sur les trois districts à risque élevé de Ngami, Chobe et Okavango. Les variables de données agrégées ont été extraites de l'IDSR et comparées aux données de la CBS.Résultats : L'IDSR a rapporté 456 cas de paludisme en 2013 et 1346 en 2014, dont seulement 305 et 884, respectivement, ont été rapportés par la CBS. La CBS a rapporté 34% de cas de moins que l'IDSR, ce qui montre une différence substantielle entre les deux systèmes de déclaration. Les indicateurs clés du paludisme qui ont la plus grande variabilité parmi les districts ont inclus le numéro d'identification des cas et la date du diagnostic.Conclusion : Les systèmes IDSR et CBS sont essentiels pour l'élimination du paludisme, comme le montrent les disparités significatives de la déclaration entre les deux systèmes. Ces résultats sont en faveur d'investigations ultérieures relatives à ces disparités. Le renforcement du système de CBS aidera à assurer la réalisation de l'objectif d'élimination du paludisme au Botswana.

Marco de referencia: Los sistemas fiables de presentación de informes garantizan el examen, el tratamiento y el seguimiento de todos los casos de paludismo con el fin de evitar la transmisión. Botswana busca eliminar el paludismo en el 2018 y la vigilancia representa un aspecto fundamental. En el presente estudio se evaluó la utilización de un nuevo sistema de vigilancia del paludismo basada en los casos (CBS, por Case-Based Surveillance), introducido en el 2012, que capta información sobre los casos de paludismo notificados al sistema Integrado de Vigilancia y Respuesta Sanitaria (IDSR, por Integrated Disease Surveillance and Response).Métodos: Un estudio retrospectivo descriptivo sobre los datos corrientes, con un interés especial en tres distritos de alto riesgo de transmisión, a saber: Ngami, Chobe y Okavango. Los datos agregados de las variables se extrajeron del IDSR y se compararon con los datos del CBS.Resultados: En el 2013, el sistema IDSR notificó 456 casos de paludismo y 1346 en 2014, de los cuales solo 305 y 884, respectivamente, se informaban en el CBS. El sistema CBS notificó 34% menos de casos que el sistema IDSR, lo cual puso de manifiesto diferencias considerables en los mecanismos de presentación de informes. Los indicadores fundamentales del paludismo que exhibieron una mayor variabilidad entre los distritos fueron el número de identificación del caso y la fecha del diagnóstico, en ese orden.Conclusión: Los sistemas IDSR y CBS son primordiales en la eliminación del paludismo, pero presentan deficiencias notables de notificación. Estas observaciones incitan a practicar nuevas investigaciones sobre las discrepancias encontradas. El fortalecimiento del sistema CBS ayudara a garantizar el cumplimiento del objetivo de eliminación del paludismo en Botswana.

Advances in malaria elimination in Botswana: a dramatic shift to parasitological diagnosis, 2008-2014.

Background: Malaria elimination requires infection detection using quality assured diagnostics and appropriate treatment regimens. Although Botswana is moving towards malaria elimination, reports of unconfirmed cases may jeopardise this effort. This study aimed to determine the proportion of cases treated for malaria that were confirmed by rapid diagnostic testing (RDT) and/or microscopy. Methods: This was a retrospective descriptive study using routine national data from the integrated disease surveillance and case-based surveillance systems from 2008 to 2014. The data were categorised into clinical and confirmed cases each year. An analysis of the data on cases registered in three districts that reported approximately 70% of all malaria cases was performed, stratified by year, type of reporting health facilities and diagnostic method. Results: During 2008-2014, 50 487 cases of malaria were reported in Botswana, and the proportion of RDT and/or blood microscopy confirmed cases improved from 6% in 2008 to 89% in 2013. The total number of malaria cases decreased by 97% in the same period, then increased by 41% in 2013. Conclusion: This study shows that malaria diagnostic tests dramatically improved malaria diagnosis and consequently reduced the malaria burden in Botswana. The study identified a need to build capacity on microscopy for species identification, parasite quantification and guiding treatment choices.

Contexte : L'élimination du paludisme requiert la détection des infections grâce à des diagnostics de qualité garantie et à des traitements appropriés. Le Botswana évolue vers l'élimination du paludisme, mais des déclarations de cas non confirmés pourraient compromettre cet effort. Cette étude a visé à déterminer la proportion de cas traités pour paludisme et confirmés par des tests de diagnostic rapide (RDT) et/ou microscopie.Méthodes : Etude rétrospective descriptive qui a utilisé les données nationales de routine des systèmes de surveillance intégrée des maladies et de surveillance basée sur les cas de 2008 à 2014. Les données ont été classées en cas cliniques et confirmés chaque année. Une analyse des données des cas enregistrés dans trois districts déclarant environ 70% des cas de paludisme a été réalisée et stratifiée par année, par type de structure de santé et par méthode de diagnostic.Résultats : En 2008­2014, il y a eu 50 487 cas de paludisme déclarés au Botswana et les cas confirmés par RDT et/ou la microscopie se sont améliorés de 6% en 2008 à 89% en 2013. De plus, le nombre total de cas a chuté de 97% dans la même période, puis est remonté de 41% en 2013.Conclusion : Cette étude a montré que l'utilisation des tests de diagnostic du paludisme avaient considérablement amélioré le diagnostic et avaient par conséquent réduit le fardeau du paludisme au Botswana. L'étude a identifié un besoin de renforcement des capacités en matière de microscopie pour l'identification des espèces et la quantification des parasites et pour guider le choix des traitements.

Marco de referencia: La eliminación del paludismo exige detectar el parasitismo con medios diagnósticos de calidad garantizada y administrar esquemas terapéuticos apropiados. Botswana avanza hacia la eliminación del paludismo, pero los informes de casos no confirmados pueden poner en peligro este esfuerzo. En el presente estudio se determinó la proporción de casos tratados por paludismo, con confirmación diagnóstica mediante pruebas de diagnóstico rápido, examen microscópico o ambos.Métodos: Un estudio retrospectivo descriptivo a partir de los datos corrientes de ámbito nacional de los Sistemas de Vigilancia Integrada de Enfermedades y de Vigilancia Basada en los Casos, del 2008 al 2014. Los datos se categorizaron en casos clínicos y casos confirmados cada año. Se realizó un análisis de datos de los casos registrados en tres distritos que notifican alrededor del 70% de los casos de paludismo, estratificados por año, tipo de establecimiento de salud que notificaba y método diagnóstico.Resultados: Del 2008 al 2014 se notificaron 50 487 casos de paludismo en Botswana y la proporción de casos confirmados mediante pruebas rápidas o examen microscópico de muestras sanguíneas aumentó del 6% en el 2008 al 89% en el 2013. Además, el número total de casos disminuyó un 97% durante el mismo período y luego aumentó de nuevo un 41% en el 2013.Conclusión: El presente estudio puso de manifiesto que las pruebas diagnósticas del paludismo mejoraron de manera notable el diagnóstico y con ello disminuyeron la carga de morbilidad por paludismo en Botswana. El estudio reveló la necesidad de fortalecer la capacidad en materia de microscopia con el fin identificar la especie, cuantificar los parásitos y orientar las opciones terapéuticas.

Did microbial larviciding contribute to a reduction in malaria cases in eastern Botswana in 2012-2013?

Setting: Larviciding has potential as a component of integrated vector management for the reduction of malaria transmission in Botswana by complementing long-lasting insecticide nets and indoor residual sprays. Objective: To evaluate the susceptibility of local Anopheles to commonly used larvicides. Design: This field test of the efficacy of Bacillus thuringiensis subsp. israliensis vs. Anopheles was performed by measuring larval density before treatment and 24 h and 48 h after treatment in seven sites of Bobirwa district, eastern Botswana, in 2012 and 2013. Vector density and malaria cases were compared between Bobirwa and Ngami (northwestern Botswana), with no larviciding in the control arm. Results: Larviciding reduced larval density by 95% in Bobirwa in 2012, with two cases of malaria, while in 2013 larval density reduction was 81%, with 11 cases. Adult mosquito density was zero for both years in Robelela village (Bobirwa), compared to respectively four and 26 adult mosquitoes per room in Shorobe village (Ngami) in 2012 and 2013. There were no cases of malaria in Robelela in either year, but in Shorobe there were 20 and 70 cases, respectively, in 2012 and 2013. Conclusion: Larviciding can reduce the larval density of mosquitoes and reduce malaria transmission in Botswana. Large-scale, targeted implementation of larviciding in districts at high risk for malaria is recommended.

Contexte : Les opérations larvicides ont, en tant qu'élément de la gestion intégrée des vecteurs, le potentiel de réduire la transmission du paludisme au Botswana en complétant les moustiquaires imprégnées d'insecticide rémanent et la pulvérisation d'insecticide a effet rémanent. Objectif : Evaluer la sensibilité des Anophèles locaux aux larvicides généralement utilisés.Schéma : Le test de terrain de l'efficacité du Bacillus thuringiensis sous-espèce israeliensis a été réalisé vis-à-vis d'Anopheles en mesurant la densité larvaire avant traitement et 24 h et 48 h après traitement dans sept sites du district de Bobirwa (est du Botswana) en 2012 et 2013. La densité vectorielle et les cas de paludisme ont été comparés à Bobirwa et à Ngami (nord-ouest du Botswana), le district témoin sans opérations larvicides.Résultats : Les opérations larvicides ont réduit la densité larvaire de 95%, avec deux cas en 2012, tandis qu'en 2013 la réduction de la densité larvaire a été de 81%, avec 11 cas à Bobirwa. La densité de moustiques adultes a été de zéro pour les deux années dans le village de Robelela (Bobirwa), comparé à quatre et à 26 adultes par pièce dans le village de Shorobe (Ngami) en 2012 et 2013, respectivement. Il n'y a pas eu de cas de paludisme à Robelela au cours des deux années, mais respectivement 20 et 70 cas sont survenus à Shorobe en 2012 et 2013.Conclusion: Les opérations larvicides peuvent réduire la densité larvaire des moustiques et réduire la transmission du paludisme au Botswana. La mise en œuvre à grande échelle et ciblée d'opérations larvicides dans les districts à haut risque de paludisme est recommandée.

Marco de referencia: La aplicación de larvicidas podría convertirse en un componente del plan integrado de control de los vectores destinado a disminuir la transmisión del paludismo en Botswana, que complemente la utilización de mosquiteros impregnados de insecticidas de larga duración y la fumigación de interiores con insecticidas de acción residual.Objetivo: Evaluar la susceptibilidad de los anófeles locales a los larvicidas más utilizados.Método: Se llevó a cabo un ensayo sobre el terreno de la eficacia de Bacillus thuringiensis subespecie israliensis contra el género Anopheles, mediante la medición de la densidad larvaria antes del tratamiento y 24 h y 48 h después del mismo, en siete lugares del distrito de Bobirwa (Botswana oriental) en el 2012 y el 2013. Se compararon la densidad del vector y los casos de paludismo en Bobirwa y en Ngami (Botswana nororiental), que constituyó la rama testigo del estudio sin tratamiento larvicida.Resultados: La aplicación del larvicida en Bobirwa disminuyó un 95% la densidad larvaria y se presentaron dos casos de paludismo en el 2012, pero en el 2013 esta disminución fue del 81% y se presentaron 11 casos. La densidad de mosquitos adultos fue cero en ambos años en la localidad de Robelela (Bobirwa), en comparación con cuatro a 26 adultos por pieza en Shorobe (Ngami) en el 2012 y el 2013, respectivamente. No se presentaron casos de paludismo en Robelela en estos dos años, pero en Shorobe ocurrieron 20 casos en el 2012 y 70 en el 2013.Conclusión: La aplicación de larvicidas puede disminuir la densidad de mosquitos y la transmisión del paludismo en Botswana. Se recomienda una aplicación de larvicida dirigida en gran escala en los distritos con alto riesgo de transmisión de paludismo.

Impact of thrombelastography in paediatric intensive care.

We assessed the clinical impact of thrombelastography (TEG®) results (TEG® 5000, Haemonetics Corporation, Braintree, MA, USA) by measuring their ability to cause changes in a theoretical treatment plan and contribute to the understanding of haemostasis. We prospectively included paediatric intensive care unit (PICU) patients who had standard tests of haemostasis and TEG ordered and had an arterial catheter or extracorporeal access port in situ. Blood for standard tests and TEG was taken simultaneously. Independent of patient care, general patient information and results of standard laboratory tests were presented to five clinicians who were asked to document their theoretical treatment plan. Clinicians were then shown TEG results and asked if they caused a change in their plan, if they confirmed initial standard laboratory test results, if they enabled a better understanding of haemostasis and if they provided additional information. Inter-rater agreement between the clinicians was determined. Forty-two TEG results were obtained from 34 patients. Overall, the inclusion of TEG results led to a change in treatment plan in 97 of 207 occasions (47%), confirmed standard laboratory test results in 177 of 204 occasions (87%), enabled a better understanding of haemostasis in 140 of 204 occasions (69%) and provided additional information in 131 of 204 occasions (64%). Variation existed between clinicians, seemingly due to individual differences, with poor inter-rater agreement. We conclude that TEG results led to changes in treatment plans almost half the time, confirmed findings of standard tests and provided a better understanding of haemostasis, but randomised controlled trials are required to determine the role and influence of TEG results on patient outcome.

Intensive care management of children intubated for croup: a retrospective analysis.

Croup remains the commonest reason for acute upper airway obstruction in children, yet there are scarce contemporary data of airway management in those requiring intubation. We performed a retrospective analysis of the intensive care management of children intubated for croup in two quaternary Paediatric Intensive Care Units: Royal Children's Hospital Melbourne, Australia and Alberta Children's Hospital Calgary, Canada. Patients intubated for less than three days were compared with those intubated for greater than three days. Patients less than 10 kg body weight were compared to those greater than 10 kg. Demographic, clinical and microbiological data were recorded. Seventy-seven cases of croup requiring intubation were identified. The median duration of intubation was 60 hours. Parainfluenza was the most common viral aetiology, detected in 30% of cases. Antibiotics were prescribed in 51% of patients. Corticosteroids were prescribed pre intubation in two-thirds of patients and all post intubation, with the median dose being prednisolone 3 mg/kg/day. Primary extubation failure occurred in 6.5% of patients. Neither the duration of intubation nor patient size were associated with extubation failure. An air leak test was performed in 69% of patients and poorly predicted extubation success. One non-urgent tracheostomy was performed and there was one death from hypoxic ischaemic encephalopathy. Endotracheal tube leak is poorly recorded and may not predict successful extubation.

Anaesthetists stress is induced by patient ASA grade and may impair non-technical skills during intubation.

BACKGROUND: The aims of this study were to determine if patient ASA grade was associated with increased stress in anaesthetists with a subsequent effect on non-technical skills. METHODS: Stress was measured using a validated objective (heart rate variability or heart rate) and subjective tool. We studied eight consultant anaesthetists at baseline (rest) and during 16 episodes of intubation with an ASA 1 or 2 patient vs. an ASA 3 or 4 patient. The primary outcome for the study was objective and subjective stress between both patient groups. Secondary outcomes were non-technical skill ratings and the association between stress measurements. RESULTS: ASA 3 or 4 patients were associated with increases in objective stress when compared to baseline (mean 4.6 vs. 6.7; P = 0.004). However, ASA 1 or 2 patients were not associated with increases in stress when compared to baseline (mean 4.6 vs. 4.7; P = 1). There was no significant difference in subjective stress between the groups (P = 0.18). Objective stress negatively affected situational awareness (P = 0.03) and decision-making (P = 0.03); however, these did not decline to a clinically significant threshold. Heart rate variability (r = 0.60; P = 0.002) better correlated with subjective stress when compared to heart rate (r = 0.30; P = 0.15). Agreement between raters for Anaesthetic Non-Technical Skills (ANTS) scores was acceptable (ICC = 0.51; P = 0.003). CONCLUSION: This study suggests that higher patient ASA grade can increase stress in anaesthetists, which may impair non-technical skills.

The meaning of a high plasma free haemoglobin: retrospective review of the prevalence of haemolysis and circuit thrombosis in an adult ECMO centre over 5 years.

AIMS: In adults requiring extracorporeal membrane oxygenation (ECMO), we wanted to determine; i) the frequency of elevated plasma free haemoglobin (PFHb), ii) the reasons for circuit changes and iii) whether elevated PFHb was associated with higher in-hospital mortality. MATERIALS AND METHODS: Patients requiring ECMO between January 2010 and August 2014 were identified from a prospectively collected ECMO database. Their scanned medical records and pathology results were reviewed. Relevant patient, biochemical and circuit data were collected on an Excel spreadsheet and analysed using Stata 13 (StataCorp, College Station, TX). The patients were analysed in three groups, depending on their peak PFHb during ECMO: 'Normal PFHb' (<0.1 g/L), 'Low level PFHb' (0.1 - 0.5 g/L), 'High level PFHb' (>0.5 g/L). MAIN RESULTS: There were 184 ECMO runs (56 VV, 128 VA) - 61 'Normal PFHb', 99 'Low level PFHb', 24 'High level PFHb'. Circuit thrombosis (pump, oxygenator) or haemolysis requiring exchanges were significantly more common in VV ECMO compared to VA ECMO - 23.21% (13/56) vs. 0.78% (1/128), p<0.001. Elevated PFHb was associated with a longer duration of haemofiltration (p<0.001) and ECMO support (p<0.001). In-hospital mortality rates for the 'Normal PFHb', 'Low level PFHb' and 'High level PFHb' groups were 16.39% (10/61), 30.30% (30/99) and 37.50% (9/24), respectively, p=0.067. CONCLUSION: Elevated PFHb values during adult ECMO were common. Severe haemolysis or thrombosis requiring circuit changes were uncommon and occurred almost exclusively on VV ECMO. There was a non-statistically significant increase in in-hospital mortality with elevated PFHb and studies of larger registry data may clarify the prognostic value of PFHb in adult patients.

Extracorporeal membrane modality conversions.

We report the case of a patient with cardiovascular and respiratory failure due to severe anaphylaxis requiring multiple extracorporeal membrane oxygenation (ECMO) cannulation strategies to provide adequate oxygen delivery and ventilatory support during a period of rapid physiological change. ECMO provides partial or complete support of oxygenation-ventilation and circulation. The choice of which ECMO modality to use is governed by anatomical (vessel size, cardiovascular anatomy and previous surgeries) and physiological (respiratory and/or cardiac failure) factors. The urgency with which ECMO needs to be implemented (emergency cardiopulmonary resuscitation (eCPR), urgent, elective) and the institutional experience will also influence the type of ECMO provided. Here we describe a 12-year-old schoolgirl who, having been resuscitated with peripheral veno-venous (VV) ECMO for severe hypoxemia due to status asthmaticus in the setting of acute anaphylaxis, required escalation to peripheral veno-arterial (VA) ECMO for precipitous cardiovascular deterioration. Insufficient oxygen delivery for adequate cellular metabolic function and possible cerebral hypoxia due to significant differential hypoxia necessitated ECMO modification. After six days of central (transthoracic) VA ECMO support and 21 days of intensive care unit (ICU) care, she made a complete recovery with no neurological sequelae. The use of ECMO support warrants careful consideration of the interplay of a patient's pathophysiology and extracorporeal circuit dynamics. Particular emphasis should be placed on the potential for mismatch between cardiovascular and respiratory support as well as the need to meet metabolic demands through adequate cerebral, coronary and systemic oxygenation. Cannulation strategies occasionally require alteration to meet and anticipate the patient's evolving needs.

High definition versus standard definition white light endoscopy for detecting dysplasia in patients with Barrett's esophagus.

High-definition endoscopy systems provide superior image resolution. The aim of this study was to assess the utility of high definition compared with standard definition endoscopy system for detecting dysplastic lesions in patients with Barrett's esophagus. A retrospective cohort study of patients with non-dysplastic Barrett's esophagus undergoing routine surveillance was performed. Data were retrieved from the central hospital electronic database. Procedures performed for non-surveillance indications, Barrett's esophagus Prague C0M1 classification with no specialized intestinal metaplasia on histology, patients diagnosed with any dysplasia or cancer on index endoscopy, and procedures using advanced imaging techniques were excluded. Logistic regression models were constructed to estimate adjusted odds ratios and 95% confidence intervals comparing outcomes with standard definition and high-definition systems. The high definition was superior to standard definition system in targeted detection of all dysplastic lesions (odds ratio 3.27, 95% confidence interval 1.27-8.40) as well as overall dysplasia detected on both random and target biopsies (odds ratio 2.36, 95% confidence interval 1.50-3.72). More non-dysplastic lesions were detected with the high-definition system (odds ratio 1.16, 95% confidence interval 1.01-1.33). There was no difference between high definition and standard definition endoscopy in the overall (random and target) high-grade dysplasia or cancers detected (odds ratio 0.93, 95% confidence interval 0.83-1.04). Trainee endoscopists, number of biopsies taken, and male sex were all significantly associated with a higher yield for dysplastic lesions. The use of the high-definition endoscopy system is associated with better targeted detection of any dysplasia during routine Barrett's esophagus surveillance. However, high-definition endoscopy cannot replace random biopsies at present time.

Relationship of ECMO duration with outcomes after pediatric cardiac surgery: a multi-institutional analysis.

BACKGROUND: There are very sparse data on the outcomes of children receiving prolonged extracorporeal membrane oxygenation (ECMO) after cardiac surgery. This study was aimed to evaluate the association of ECMO duration with outcomes in children undergoing surgery for congenital heart disease using the Pediatric Health Information System (PHIS) database. METHODS: Patients aged ≤18 years receiving ECMO after pediatric cardiac surgery (with or without cardiopulmonary bypass) at a PHIS-participating hospital (2004-2013) were included. De-identified data obtained from retrospective, observational dataset included demographic information, baseline characteristics, pre-ECMO risk factors, operation details, patient diagnoses, and center data. Outcomes evaluated included in-hospital mortality, length of mechanical ventilation, length of ICU stay, length of hospital stay, and hospital charges. Cox proportional hazards models were fitted to study the probability of study outcomes as a function of ECMO duration. RESULTS: Nine hundred ninety-eight patients from 37 hospitals qualified for inclusion. The median duration of ECMO run was 4 days (IQR: 1.7). After adjusting for patient and center characteristics, there was 12% increase in the odds of mortality for every 24 hours increase in ECMO duration (OR: 1.12, 95% CI: 1.07-1.18, P<0.001). Patients receiving longer duration of ECMO were associated with longer length of mechanical ventilation, longer length of ICU stay, longer length of hospital stay, and higher hospital charges. CONCLUSION: Data from this large multicenter database suggest that longer duration of ECMO support after pediatric cardiac surgery is associated with worsening outcomes.

Caecal diverticulitis: a rare cause of right iliac fossa pain.

We present a case of a young boy with an unusual cause of right iliac fossa pain. His history, examination and laboratory investigations suggested a diagnosis of acute appendicitis. However preoperative abdominal CT revealed an inflamed solitary caecal diverticulum and a normal appendix. He was subsequently treated conservatively and recovered well, saving him from undergoing a general anaesthetic and abdominal surgery.

ECMO in acute and chronic adult respiratory failure: recent trends and future directions.

Extracorporeal membrane oxygenation (ECMO) can be used to preserve or enhance systemic oxygen delivery in patients with refractory cardiac or respiratory failure. Although widely accepted as a standard of care for many indications in children and for adult cardiogenic shock, ECMO for adult respiratory failure is more controversial. This controversy arose over thirty years ago after the disappointing results of the first flawed, randomized study and is fueled by a group of non-ECMO clinicians who repeatedly criticize the methodology of more recent studies which show probable benefit. In spite of this, there is probably now more evidence to support the use of ECMO in refractory acute respiratory distress syndrome than for any other form of rescue therapy. The purpose of this review is to update clinicians regarding trends in ECMO research over the last 12 months and speculate on how the clinical use of ECMO and associated technology will evolve.

Correlation of thromboelastography with standard tests of anticoagulation in paediatric patients receiving extracorporeal life support.

UNLABELLED: Children requiring extracorporeal life support (ECLS) are at significant risk for thrombotic and haemorrhagic complications. Thromboelastography (TEG) is increasingly being used to assist in monitoring the coagulation status of critically ill patients. Its role in heparinised children receiving ECLS is unknown. METHODS: A retrospective review of TEG in 27 children (mean age 2 years and 8 months) receiving ECLS in a tertiary paediatric intensive care unit between December 2006 and April 2008. Paired TEG (kaolin and heparinase) analysis was performed on 171 occasions. On all occasions activated partial thromboplastin time (APTT) and platelet count were performed within 4 hours of the TEG (mean 6.5 minutes after TEG). On 158 occasions, the activated clotting time (ACT) was measured simultaneously with TEG. RESULTS: The TEG (kaolin) sample was not interpretable due to the heparin effect in 89 (52%) samples. There was a weak correlation between TEG (heparinase) variables and APTT, and between TEG and ACT with a stronger correlation between TEG (Maximum amplitude) and platelet count. CONCLUSION: TEG monitoring should always include paired samples in heparinised children on ECLS. In this heterogeneous population, weak, and moderate correlations exist between TEG and standard haematological tests. Prospective studies, with simultaneous sampling for TEG and conventional laboratory tests, must be performed in order to establish its absolute utility as a clinical tool in this population.

Extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a technique that involves oxygenation of blood outside the body, and provides support to selected patients with severe respiratory or cardiac failure. The two major ECMO modalities are venoarterial and venovenous. Data from several randomised trials support the use of ECMO in neonatal respiratory failure, and a recent randomised controlled trial of ECMO in adults has produced encouraging results. The evidence base for ECMO use in cardiac disease is developing, but progress has been slowed by considerations of clinical equipoise and evolving indications for ECMO. Advancing ECMO technology and increasing experience with ECMO techniques have improved patient outcomes, reduced complications and expanded the potential applications of ECMO. Awareness of the indications and implications of ECMO among doctors managing patients with severe but potentially reversible respiratory or cardiac failure may help facilitate better communication between health care teams and improve patient recovery.