Use, timing and factors associated with tracheal intubation in septic shock: a prospective multicentric observational study.

BACKGROUND: No recommendation exists about the timing and setting for tracheal intubation and mechanical ventilation in septic shock. PATIENTS AND METHODS: This prospective multicenter observational study was conducted in 30 ICUs in France and Spain. All consecutive patients presenting with septic shock were eligible. The use of tracheal intubation was described across the participating ICUs. A multivariate analysis was performed to identify parameters associated with early intubation (before H8 following vasopressor onset). RESULTS: Eight hundred and fifty-nine patients were enrolled. Two hundred and nine patients were intubated early (24%, range 4.5-47%), across the 18 centers with at least 20 patients included. The cumulative intubation rate during the ICU stay was 324/859 (38%, range 14-65%). In the multivariate analysis, seven parameters were significantly associated with early intubation and ranked as follows by decreasing weight: Glasgow score, center effect, use of accessory respiratory muscles, lactate level, vasopressor dose, pH and inability to clear tracheal secretions. Global R-square of the model was only 60% indicating that 40% of the variability of the intubation process was related to other parameters than those entered in this analysis. CONCLUSION: Neurological, respiratory and hemodynamic parameters only partially explained the use of tracheal intubation in septic shock patients. Center effect was important. Finally, a vast part of the variability of intubation remained unexplained by patient characteristics. Trial registration Clinical trials NCT02780466, registered on May 23, 2016. https://clinicaltrials.gov/ct2/show/NCT02780466?term=intubatic&draw=2&rank=1.

Calosphaeria Canker of Sweet Cherry Caused by Calosphaeria pulchella in California and South Australia.

California is the second largest sweet cherry producer in the United States with annual revenues up to $200 million. The South Australian cherry industry generates about 10% of Australia's overall production with approximately 1,500 metric tons of cherries produced yearly. In California, perennial canker diseases and subsequent branch dieback are responsible for extensive damage throughout sweet cherry orchards, reducing annual yields and tree longevity. Surveys of cherry orchards and isolation work were conducted in California to identify the main canker-causing agents. Calosphaeria pulchella was the main fungus isolated from cankers, followed by Eutypa lata and Leucostoma persoonii, respectively. Preliminary surveys in cherry orchards in South Australia documented C. pulchella and L. persoonii in cankers. The pathogenicity of C. pulchella in sweet cherry was confirmed following field inoculations of 2- to 3-year-old branches. C. pulchella was able to infect healthy wood and produce cankers with as much virulence as E. lata or L. persoonii. Spore trapping studies were conducted in two sweet cherry orchards in California to investigate the seasonal abundance of C. pulchella spores. Experiments showed that rain and sprinkler irrigation were important factors for aerial dissemination. Finally, this study illustrates the symptoms and signs of the new disease Calosphaeria canker.

First Report of Calosphaeria pulchella Associated with Branch Dieback of Sweet Cherry Trees in California.

California is the second largest sweet cherry producer in the United States with approximately 10,800 ha and an average annual crop value of approximately $150 million. Perennial canker diseases constitute major threats to the cherry industry productivity by reducing tree health, longevity, and yields. During the course of summer 2006, we observed severe limb and branch dieback of sweet cherry (Prunus avium L.) in San Joaquin, San Benito, Contra Costa, and Stanislaus counties of California. Isolation from diseased branches repeatedly yielded the fungus Calosphaeria pulchella (Pers.: Fr.) J. Schröt. (1,2). Cankers and vascular necroses had developed in tree limbs and branches, generally initiating from the heart wood and later spreading into the sapwood. External symptoms of disease may be unapparent throughout the early stages of infection, particularly in large diameter shoots. Older infections often appeared as wilted leaves. Branches and trunks affected with cankers from which C. pulchella was isolated also generally bore perithecia of C. pulchella beneath the periderm. Perithecia were nonstromatic and arranged in dense, circinate groups, with elongated necks converging radially and fissuring the periderm. Asci were unitunicate, clavate, and 45 to 55 × 5 to 5.5 µm. Ascospores were allantoid to suballantoid, hyaline, and 5 to 6 × 1 µm. Colonies on potato dextrose agar (PDA) were dark pink to red in their center with a white margin. Conidia were hyaline, allantoid to oblong-ellipsoidal, and (3-) 4 to 6 (-9) × 1.5 to 2 (-2.5) µm. Identification of C. pulchella isolates also was confirmed by sequence comparison in GenBank database using the internal transcribed spacer region (ITS1-5.8S-ITS2) of the rDNA. Sequences of California isolates shared 100% similarity with C. pulchella reference isolate CBS 115999 (EU367451) (2). ITS sequences of the California isolates used in this study were deposited into GenBank (Nos. HM237297 to HM237300). Pathogenicity of four isolates recovered from the margin of active cankers was determined by branch inoculations. In December 2006, 2- to 4-year-old twigs of P. avium cv. Bing were inoculated with a 5-mm cork borer to remove bark and by placing an agar plug from the growing margin of 8-day-old colonies directly into the fresh wound, mycelium side down. Ten branches per isolate were inoculated. Ten control shoots were inoculated with noncolonized agar plugs. Inoculations were covered with vaseline and wrapped with Parafilm to retain moisture. Branches were harvested in July 2007 and taken to the laboratory to be examined for canker development, and the extent of vascular discoloration in each branch was assessed. Isolations from the edge of discolored tissue were conducted to fulfill Koch's postulates. After 8 months, C. pulchella was reisolated from 100% of the inoculated branches. Length of vascular discoloration averaged 62.5 mm in branches inoculated with the four C. pulchella isolates and 16.5 mm in the control twigs. No fungi were reisolated from the slightly discolored tissue of the controls. To our knowledge, this study constitutes the first report of C. pulchella as a pathogen of sweet cherry trees in California. References: (1) M. E. Barr. Mycologia 77:549, 1985. (2) U. Damm et al. Persoonia 20:39, 2008.

What impact have women physicians had on women's health?

The proportion of women in medicine in the United States is approaching that of men, but women physicians are still the minority in positions of power. Research has shown that women physicians order more preventive tests for women patients, are more attuned to patients' psychosocial needs, and have developed more patient-oriented communication styles than men physicians. Recent organized efforts of women physicians have brought attention to many gender gaps in medical research and practice. If more women move into policy-making positions, especially in education and research, their gender-sensitive perspective could permanently influence the profession as a whole.

Reciprocal neurological developments of twins discordant for hydrocephalus.

Studies of 10 sets of twins discordant for hydrocephalus in early life revealed striking differences in degree and nature of development of verbal vs. non-verbal cognitive functions, birth order, and hand and eye preference. Despite similar (four dizygotic pairs) or identical (six monozygotic pairs) genetic endowment and grossly similar intra- and extra-uterine environmental and socio-economic influences, the consistency of the differences between the hydrocephalic children and their seemingly normal twins indicate systematic differences in pre-, peri- and/or early postnatal organization and development of hemispheric function. Follow-up studies also documented development of above-average intelligence, despite drastically reduced cerebral mantle size in hydrocephalus of early onset. The atypical patterns of development of the non-hydrocephalic twins also confirm previously described qualifications reported in studies of the significance of genetic vs. environmental factors in twins.

Pulmonary meningioma. Immunohistochemical and ultrastructural features.

Two cases of solitary primary pulmonary tumors showing the immunohistochemical and ultrastructural features of meningothelial meningiomas are presented. The benign clinical and radiologic course, the negative computed tomography scan of the brain (case 1), and negative neuropathologic investigation (case 2) support the diagnosis of a primary pulmonary meningioma rather than a metastazing malignant intracranial meningioma. Negative neuroendocrine markers (neuron-specific enolase, chromogranin, bombesin) and the lack of neurosecretory granules by electron microscopy confirm the diagnosis of this rare pulmonary tumor.

In vitro fertilization and gender politics.

From the point of view of the couple rather than the individual, infertility is in many ways a social rather than a physiological problem. Originally developed to bypass the blocked or missing Fallopian tubes of infertile women, IVF treatment has expanded to cases of male infertility due to poor sperm motility or low sperm count. In these cases, the woman may be physiologically normal reproductively, but nonetheless must undergo hormonal stimulation, sonargrams, and laparoscopy. Health care professionals so take it for granted that the most sophisticated techniques will be sought for correction of patients' problems that they rarely question patients on their motivations to undergo discomforting, expensive, and possibly dangerous treatments. Despite our culture's emphasis on motherhood, men are often the dominant partner in reproductive decisions. The increasing popularity of the use of IVF treatment in cases of male infertility is understandable in the light of men's investment in biological parenting and women's willingness to take on the physiological responsibility for treatment.

[Course and blood coagulation findings following systemic short-term fibrinolysis in acute myocardial infarct]. / Verlauf der Gerinnungsbefunde nach systemischer Kurzfibrinolyse beim akuten Myokardinfarkt.

UNLABELLED: A series of 16 consecutive patients with acute myocardial infarction was investigated with respect to changes in coagulatory parameters after intravenous short-term treatment with 1,500 000 IU streptokinase (SK) over a period of 90 minutes. Samples for coagulation assays (fibrinogen, thrombin, time activated partial thromboplastin time (aPTT), normotest, thrombin-coagulase time, platelets, antithrombin III, plasminogen and antiplasmin activity, alpha 2-macroglobulin, alpha 1-antitrypsin, factor X a were collected before and immediately after iv SK, and after 4, 8, 12, 24, 36, 48 and 72 hours. Platelets, antithrombin III, factor X a, alpha 1-antitrypsin and alpha 2-macroglobulin showed no changes over the observed period. The concentrations of fibrinogen and the activities of plasminogen and antiplasmin decreased clearly during the first 24 hours, reaching a minimum immediately after SK administration. Thrombin time and aPTT were prolonged for 36 hours, with a maximum in the first hours after lysis. CONCLUSIONS: Invasive diagnostic and/or therapeutic procedures during the first 24 hours after SK lysis should be carried out only for a definite, strict indication and under repeated control of the coagulatory status. After 24-36 hours there is a trend to normalisation of haemostasis. After 36 hours, surgery may be performed without fear of complications due to abnormal coagulability.

Spina bifida--a vanishing nightmare?

Detailed analysis is presented on the dramatic decline in spina bifida births and other congenital central nervous system defects in the past 12 years, in both Sheffield and the rest of Great Britain. In Sheffield, there was an average of 20 spina bifida births per year up to 1972, but since then there has been a progressive fall to only one in 1984. This decrease may be partly attributable to antenatal diagnosis and terminations of affected pregnancies, but there is no known explanation for the rest of the fall, which has also been experienced throughout Great Britain. The virtual elimination of spina bifida is now possible, as long as the existing methods of prevention and antenatal diagnostic facilities are used even more fully. Relaxation of our effort and a reverse in the 'natural' trend could bring the incidence of spina bifida back to where it was 15 years ago.

The family history of "simple" congenital hydrocephalus. An epidemiological study based on 270 probands.

A longitudinal study was carried out on the family history of 270 babies with uncomplicated congenital hydrocephalus. They had 453 siblings of whom 5 (11.1 per 1,000) had congenital hydrocephalus and 9 (19.9 per 1,000) had neural tube defects. These data, together with those obtained from the literature, indicate that the aetiology of the two conditions is probably the same in many cases, although there are unusual exceptions in special families, even apart from families with the sex-linked recessively inherited hydrocephalus. These findings suggest that the parents of children with uncomplicated hydrocephalus should have adequate antenatal tests for the detection of neural tube defects as well as for hydrocephalus and may need similar prophylactic treatment as do the parents of children with spina bifida and anencephaly.

Brain and ventricular volume in hydrocephalus.

A study is presented based on CT scans, using advanced computer techniques, to determine brain volume in a representative sample of sixteen subjects, with treated and untreated hydrocephalus, whose ventricle size varied from normal to extreme and from symmetrical to grossly asymmetrical dilatation. The calculations take into account the maximal head circumference at the time of the CT scans and the results are correlated with the patients' intellectual and neurological conditions.

The family history of uncomplicated congenital hydrocephalus: an epidemiological study based on 270 probands.

A longitudinal study was carried out on the family history of 270 babies with uncomplicated congenital hydrocephalus. They had 453 siblings of whom five (11.1/1000) had congenital hydrocephalus and nine (19.9/1000) neural tube defects. These data, together with those obtained from previously published reports indicate that the aetiology of the two conditions is probably the same in many cases, although there are unusual exceptions in special families even apart from those with the sex linked, recessively inherited hydrocephalus.

Isosorbide in the management of infantile hydrocephalus.

Experience with 101 hydrocephalic infants treated primarily with isosorbide is reported. For those with moderate hydrocephalus the aim was to avoid shunt surgery, and this was achieved in 31 of the 43 infants. In cases with severe hydrocephalus or when the cerebrospinal fluid was abnormal the aim was to delay shunt surgery until the optimum time, with a lower risk of complications. Five of 48 such infants avoided shunts and 30 achieved a worthwhile delay. Nine other children were treated with isosorbide following shunt complications. Toxic effects were infrequent, not severe, and reversible on stopping treatment or reducing dosage. 63 infants eventually had shunts inserted.