A randomised cross-over comparison of the transverse and longitudinal techniques for ultrasound-guided identification of the cricothyroid membrane in morbidly obese subjects.

We compared the transverse and longitudinal approaches to ultrasound-guided identification of the cricothyroid membrane, to determine which was faster and more successful. Forty-two anaesthetists received a one-hour structured training programme consisting of e-learning, a lecture and hands-on training, and then applied both techniques in a randomised, cross-over sequence to obese females with body mass index 39.0 - 43.9 kg.m(-2) . The mean (SD) time to identify the cricothyroid membrane was 24.0 (12.4) s using the transverse technique compared with 37.6 (17.9) s for the longitudinal technique (p = 0.0003). Successful identification of the cricothyroid membrane was achieved by 38 (90%) anaesthetists using either technique. All anaesthetists were successful in identifying the cricothyroid membrane with at least one of the techniques. We advocate the learning and application of these two techniques for identification of the cricothyroid membrane before starting anaesthesia in difficult patients, especially when anatomical landmarks are impalpable. Further use in emergency situations is feasible, if clinicians have experience and the ultrasound machine is readily available.

Tracheal intubation in patients with anticipated difficult airway using Boedeker intubation forceps and McGrath videolaryngoscope.

BACKGROUND: Videolaryngoscopes with sharp angulated blades improve the view of the vocal cords but this does not necessarily result in higher success rates of intubation The aim of this study was to evaluate the efficacy of using Boedeker intubation forceps in conjunction with McGrath Series 5 Videolaryngoscope (MVL) in patients with predictors for difficult intubation. METHODS: The study was conducted at the Department of Anaesthesia, Copenhagen University Hospital from September to December 2013. Patients with one or more predictors of difficult intubation scheduled for general anaesthesia were assessed for eligibility. Patients were intubated using Boedeker intubation forceps and MVL. The primary endpoint was time to intubation. The secondary endpoints were intubation success rate, number of intubation attempts, intubation conditions and post-operative hoarseness. RESULTS: Thirty-three patients were assessed for eligibility, and 25 patients were included in the study with a median SARI score of 3 (IQR 3-4). Twenty-two (88%, 95% confidence interval [74-100%]) of the patients were successfully intubated by the method with a median time to intubation of 115 s (IQR 78-247). Steering and advancement of the tube were reported as acceptable in 21 (84%) and 22 cases (88%), respectively, and excellent in 10 cases (45%) for both measures. Ten cases (40%) were intubated on the first attempt. There were three cases (12%) of failed intubation; in these cases, successful intubation was obtained by using a styletted tube. CONCLUSION(S): Most patients with anticipated difficult intubation can be successfully intubated with Boedeker intubation forceps and MVL. However, endotracheal tube placement failed in 3/25 patients despite a good laryngeal view.

A cost analysis of reusable and disposable flexible optical scopes for intubation.

BACKGROUND: Intubation using a flexible optical scope (FOS) is a cornerstone technique for managing the predicted and unpredicted difficult airway. The term FOS covers both fibre-optic scopes and videoscopes. The total costs of using flexible scopes for intubation are unknown. The recent introduction of a disposable flexible scope for intubation merits closer scrutiny of the total costs associated with both modalities. METHODS: The costs incurred during intubations using FOSs at a large anaesthesia department were identified, and a series of intubations using a disposable scope were analyzed for comparison. Recognized health-economic methodology was applied. RESULTS: During a 1-year period, 360 FOS intubations were performed. In this clinical setting, the average cost of an intubation using a reusable FOS was €177.7. When using the disposable Ambu(®) aScope (Ambu A/S, Ballerup, Denmark), the cost was €204.4. The break-even point, i.e. the number of intubations per month where the cost of using disposable and non-disposable equipment is identical, was 22.5/month. A subgroup analysis looking solely at intubations performed with flexible videoscopes revealed that the cost per intubation was equal for disposable and reusable videoscopes. CONCLUSION: At our institution, the total cost of an intubation is greater when using disposable compared with reusable equipment (€204.4 vs. €177.7). If video equipment with an external monitor is considered mandatory, the expenses are of equal magnitude. The cost analysis is particularly sensitive to the actual number of flexible optic intubations performed; with fewer intubations, the total cost will begin to favour disposable equipment.

It is possible to perform a double-blind hyperbaric session: a double-blinded randomized trial performed on healthy volunteers.

In hyperbaric medicine, blinded trials are remarkably few, making results susceptible to criticism. The scopes of the present study are to present a method for a double-blinded randomized clinical study and evaluate the validity of the method in a hyperbaric setting. Twenty-two healthy volunteers with no diving experience were included. The volunteers were randomized either to a "therapeutic pressure" group (15 msw, 253 kPa) or to a "placebo" group (2 msw, 120 kPa). The two profiles were made equal regarding noise, temperature and ventilation. The volunteers were asked whether they had been exposed to placebo or therapeutic pressure. They were asked to present their certainness of the answer on a visual analogue scale (VAS). Fisher's exact test calculates a probability of P = 0,328, which indicates that the volunteers have no valid opinion as to whether they were exposed to 15 msw or to 2 msw. It is found that it is possible to perform a blinded treatment on healthy volunteers with no prior diving experience.

Patient education--a strategy for prevention of infections caused by permanent central venous catheters in patients with haematological malignancies: a randomized clinical trial.

A functioning tunnelled central venous catheter (CVC) is a crucial device for patients with haematological malignancies receiving high-dose intravenous chemotherapy. Despite the advantages, CVC infections are a major cause of sepsis and prolonged hospital stay. This study investigated the impact of patient education regarding provision of their own catheter care on the frequency of CVC-related infections (CRIs) and was conducted at a specialized haematological unit at the University Hospital of Copenhagen Rigshospitalet. From May to September 2002, 82 patients fitted with tunnelled double-lumen Hickman catheters were randomized consecutively. The intervention group (42 participants) received individualized training and supervision by a clinical nurse specialist, with the aim of becoming independently responsible for their own catheter care. The control group (40 participants) followed the standard CVC procedures carried out by nurses inside and outside the central hospital. A significant reduction in CRIs was found in the intervention group, with a >50% reduction in the incidence rate of CRIs. We conclude that systematic individualized, supervised patient education is able to reduce catheter-related infections.

Rectal bacteriotherapy for recurrent Clostridium difficile-associated diarrhoea: results from a case series of 55 patients in Denmark 2000-2012.

Clostridium difficile infection is one of the most common nosocomial infections. Among other alternatives to standard treatment with vancomycin for recurrent infection are faecal microbiota transplantation and rectal bacteriotherapy with a fixed mixture of intestinal bacterial strains isolated from faeces of healthy persons to mimic a theoretical normal microflora. Developed by Dr. Tvede and Dr. Rask-Madsen, the latter method has been in use for selected patients during the last 25 years in Denmark. In this study we reviewed the medical records of patients treated with rectal bacteriotherapy for relapsing C. difficile in Denmark, 2000-2012. The primary end point was recurrent diarrhoea within 30 days after treatment. A total of 55 patients were included in this case series. Thirty-five patients (64%) had no recurrence within 30 days of bacteriotherapy. Patients with recurrence tended to be older (75.8 years vs. 61.3 years; p 0.26), and more often have preexisting gastrointestinal illness and longer duration of time from the first CDI to bacteriotherapy (221.6 days vs. 175.3 days; p 0.18). Treatment success was 80% in the subgroup of patients with no known gastrointestinal illness and first C. difficile episode less than 6 months before bacteriotherapy. The most common adverse events were abdominal pain (10.9%) and worsening diarrhoea (4.3%). One patient was hospitalized 10 days after treatment with appendicitis, fever, and Escherichia coli bacteremia. The results from this study indicate that rectal bacteriotherapy is a viable alternative to faecal microbiota transplantation in patients with relapsing C. difficile-associated diarrhoea.

Experimental studies of survival of anaerobic bacteria at 4 degrees C and 22 degrees C in two different transport systems.

The survival of anaerobic bacteria on swabs in two different transport systems at 4 degrees C and 22 degrees C was evaluated. The transport systems were a charcoal-impregnated cotton swab in modified Stuart transport medium (MST), and a viscose swab in modified SIFF transport medium (BTM) (Bionor). The following eight clinical strains of anaerobic bacteria were tested for quantitative recovery at 24 h, 48 h, 72 h, and 96 h; Fusobacterium necrophorum, Bacteroides melaninogenicus, Bacteroides intermedius, Peptostreptococcus anaerobius, Peptococcus magnus, Clostridium perfringens, Clostridium tetani, and Actinomyces israelii. Additionally, a mixture of Staphylococcus aureus and Escherichia coli was tested together with Bacteroides fragilis, Fusobacterium necrophorum and Clostridium perfringens. Both transport systems preserved the bacteria, but the BTM medium gave a better quantitative recovery of the bacteria than the MST in 29/64 (45%) of the experiments, whereas the opposite was the case in 15/64 (23%) of the experiments (p < 0.05). There was no significant strain-related difference between the recovery of 10 different B. fragilis strains. There was no major difference in the recovery of the anaerobes in the two systems at 4 degrees C compared to 22 degrees C, except for Fusobacterium necrophorum, which survived best at 4 degrees C in the Bionor transport system.

Crossed immunoelectrophoresis used for bacteriological diagnosis in patients with endocarditis.

Sera from 151 patients suspected of having endocarditis were obtained during a period of 3 1/2 years at Rigshospitalet, Copenhagen. The sera were examined by crossed immunoelectrophoresis for antibodies to bacteria causing endocarditis. The patients were divided into four groups: 1. Patients with definite endocarditis, 2. Patients with culture-negative endocarditis, 3. Patients with uncertain endocarditis, and 4. Patients without endocarditis. In sera from patients suffering from endocarditis caused by viridans streptococci, precipitating antibodies were demonstrated by crossed immunoelectrophoresis (diagnostic specificity = 86%; diagnostic sensitivity = 100%) while other bacterial etiologies of endocarditis were less reliably demonstrated by this method.

Demonstration of toxin A and B by polymerase chain reaction and McCoy cell assay in clinical isolates of Clostridium difficile from Denmark.

A polymerase chain reaction (PCR) for demonstration of gene fragments of Clostridium difficile was established. One hundred and sixty-eight clinical isolates of C. difficile from three population groups were tested for production of cytotoxins by McCoy cell line assay (MCA) and for fragments of toxin A and B genes by PCR. The fragments for PCR amplification were at the 5' end of the toxin genes, which was found to be specific for C. difficile. Full agreement between the PCR and MCA results was found with respect to toxicity. Fifty-eight of the 168 strains were cytotoxin positive. Isolates from 41 normal healthy children did not differ regarding cytotoxicity compared to isolates from hospitalized children. In adult hospitalized patients a much higher frequency of toxin-producing isolates was found. In two strains from two children, not of the same family, only the toxin A gene fragment was demonstrated, indicating that some strains of C. difficile only harbour the gene for enterotoxin. When two isolates from different periods of time were tested from 36 of the healthy children, a variation in cytotoxicity was found: in seven children strains changed from non-toxic to toxic and in four vice versa. This may be explained by a fluctuating colonization of toxic and non-toxic C. difficile strains, or it may indicate the need for examination of more than one strain from a positive faecal sample to demonstrate cytotoxicity.

IgG antibody response in bacterial endocarditis using ELISA with multiple antigens.

By means of enzyme-linked immunosorbent assays (ELISAs) the antibody responses were detected in sera from normal persons (n = 275), patients with various types of bacteremia (n = 137), and patients with endocarditis (n = 28). Four ELISAs were evaluated. As antigens ultrasonic extracts of Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus faecalis, and nonhemolytic streptococci were used. The antibody levels against S. aureus increased with age, while antibodies against the other bacteria showed no age variation. The different ELISA systems showed many serological cross-reactions. The ELISA in this limited material was 72% successful in identifying cases of bacterial endocarditis caused by S. aureus (diagnostic sensitivity 84%; diagnostic specificity 89%), while in other cases of bacterial endocarditis it was less successful.

Immunological properties of meningococcal lipopolysaccharide from serogroups A, B & C.

The aim of the study was to measure and compare the oxidative burst, chemotaxis and cytokine production of human white blood cells, stimulated with meningococcal lipopolysaccharides (LPS) extracted from three different serogroups (A, B and C) of Neisseria meningitidis, and to evaluate whether convalescent sera from patients with meningococcal disease could modify cell stimulation of LPS. All three preparations of LPS from groups A, B and C were tested using the Limulus amoebocyte lysate assay (LAL), and the KDO concentrations of the LPS extracts were measured. Equivalent amounts of biologically active LPS, judged by LAL, and LPS with the same KDO concentration were assayed. IL-1alpha, IL-1beta, IL-6 and TNF-alpha production was stimulated by all three LPS preparations. All three preparations stimulated oxidative burst in monocytes (MNC). Only group A LPS stimulated neutrophil chemotaxis, while none of the three LPS stimulated superoxide production. Pooled convalescent sera from five patients with meningococcal disease suppressed the activity of neutrophils stimulated with LPS from groups B and C (p<0.05, Mann-Whitney U-test).

The humoral immune response to Helicobacter pylori infection in children with recurrent abdominal pain.

The systemic humoral immune response to Helicobacter pylori antigens was investigated in 36 children with recurrent abdominal pain (RAP). H. pylori was cultured and Helicobacter-like organisms (HLO) were seen in six children, three of whom had active and two inactive chronic gastritis. None of these children had endoscopic abnormalities. All sex children had increased IgG antibodies to heat-stable H. pylori antigens which were of the IgG1 and IgG3 subclasses. Using six other IgG tests, four of which were commercially available, two to five H. pylori-positive children were found seropositive. Five of six H. pylori-negative children with inactive chronic gastritis and no endoscopic abnormalities had increased IgM antibody levels in addition to increased or borderline increased IgG antibody levels to H. pylori, indicating activity in a chronic H. pylori infection. Five children without H. pylori and with no morphological changes, but with gastritis or duodenitis by endoscopy, had significantly lower IgG and IgA antibody levels compared to other groups. Six of nineteen children without H. pylori, and with no morphological or endoscopic changes had increased IgG and IgM antibody levels to H. pylori. All H. pylori-negative children were seronegative by the four commercial kits. Overall, 12 (33%) of 36 children with RAP were either H. pylori positive by culture and microscopy or had increased IgG antibody levels to H. pylori, which is significantly different from the 10-14% seropositive rate of asymptomatic children. H. pylori may therefore be a cause of RAP in one quarter to one third of the children with RAP in whom other etiologies of RAP are excluded. Further studies on a large number of children are needed for an extended evaluation of the humoral immune response to H. pylori and for further examination of commercial kits which seem to give a high number of false-negative results.

A rapid method for purification of homogeneous Legionella pneumophila cytotoxic protease using fast protein liquid chromatography.

A purification method was developed to isolate Legionella pneumophila cytotoxic protease in a form suitable for biological assays. Culture supernatant of a clinical isolate of L. pneumophila, Knoxville 1 strain, was used as the starting material. The protease was purified by FPLC on a Mono Q column followed by ultrafiltration. The isolated proteolytic enzyme has a specific activity of 90 azocasein units/mg protein and is a 42 kDa monomeric protein as determined by SDS-PAGE and gel filtration chromatography. It is heat-labile and toxic to a variety of cells e.g. McCoy, SIRC, HeLa, and rhabdomyosarcoma cells, baby hamster and green monkey kidney cells, and human embryonic lung fibroblasts.

A European survey of diagnostic methods and testing protocols for Clostridium difficile.

OBJECTIVE: To conduct a survey of the methods used in clinical microbiology laboratories in Europe to diagnose infection with Clostridium difficile. METHODS: A questionnaire was devised and sent to a co-ordinating member of the Study Group in each of eight European countries. This co-ordinator was in charge of forwarding the questionnaire to hospital laboratories arbitrarily selected. The number of laboratories in each country was determined on the basis of one laboratory for 10,000 beds of hospitalization. This questionnaire covered different aspects pertaining to Clostridium difficile associated to diarrhea (CDAD) diagnosis such as circumstances of request, criteria used for undertaking C. difficile investigations, methods used for the diagnosis, etc. RESULTS: A total of 212 questionnaires were completed and submitted for analysis: 87.7% of laboratories reported routinely performing C. difficile diagnostic tests. Methods used included toxin detection (93%), culture (55%), and glutamate dehydrogenase (GDH) detection (5.9%). Among the laboratories detecting toxins, different enzyme immunoassays (EIA) and cytotoxicity assays were used in 79% and 17.3% of cases, respectively. Among the different strategies reported, 4.8% were considered suboptimal for the diagnosis of C. difficile infections, but marked discrepancies could be observed between countries. The overall incidence (median) of CDAD was estimated at 1.1 for 1,000 patient admissions. CONCLUSION: The results of this study suggest marked discrepancies between laboratories and also between countries regarding the criteria by which C. difficile is investigated for, and the methods and the strategies that are used for the diagnosis of C. difficile. These discrepancies could be explained by the lack of clear guidelines for C. difficile diagnosis in each country, and by the importance that physicians attach to C. difficile. Precise guidelines for C. difficile diagnosis would be the first step to make possible accurate comparison of the incidence and the epidemiology of CDAD from one hospital to another or from one country to another.

Immunoglobulins of patients recovering from Yersinia enterocolitica infections exhibit Graves' disease-like activity in human thyroid membranes.

Substantial evidence suggests a link between infections with Yersinia enterocolitica (YE) and Graves' disease. We have now examined the sera of 72 patients recovering from YE infection for immunoglobulins that interacted with the TSH receptor in human thyroid membranes. Compared with controls, in concentrations between 1 and 4 mg/mL, patient IgG produced a significant, concentration-dependent inhibition of TSH binding (p less than 0.001) and stimulation of adenylate cyclase activity (p less than 0.005-0.05). Whereas IgG from normal individuals caused no stimulation of adenylate cyclase, IgG from controls caused some concentration-dependent displacement of TSH, as previously reported. However, IgG from convalescents of YE infections was significantly more potent than normal IgG in reducing the binding of TSH to the membrane. Thus, at each examined concentration, YE patients' IgG displaced more TSH than IgG from normal controls. For each milligram per milliliter increment of IgG in the assay, patients' IgG caused a 10.2% inhibition of TSH binding (r -0.90, p less than 0.001), significantly greater than that seen with normal IgG (p less than 0.02). The present studies provide the first demonstration that IgG of patients recovering from YE infections react with the human TSH receptor. The antibodies presumably are produced against the TSH-binding protein present in YE. However, in view of lack of evidence for thyroid dysfunction in the sera of patients recovering from yersiniosis and the presence of TSH-binding proteins in other bacteria, we postulate that infection with YE is neither necessary nor sufficient to cause thyroid autoimmune disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Haemophilus segnis endocarditis.

Haemophilus segnis is a rarely recognised commensal in the oropharynx. We wish to report the first published case of endocarditis caused by H. segnis. The patient, a 76-year-old female did not recover until after 2 courses of ampicillin given for a total of 57 days. In the second course of treatment, ampicillin was combined with 10 days of netilmicin therapy.

[Generalized toxic symptoms caused by Clostridium difficile infection in a patient with Wilms' tumor]. / Universel toksisk påvirkning forårsaget af infektion med Clostridium difficile hos en patient med Wilms' tumor.

This case report describes a 15 months-old patient with Wilms' tumor, who was treated with radical operation and chemotherapy. During hospitalization the patient suffered from recurrent lung infections, which were treated with appropriate antibiotics. Subsequently, the patient developed severe abdominal affection with daily melena, liver and kidney involvement, and generalized edema and hypertension. Cl. difficile and its cytotoxin was demonstrated in feces, and the patient was successfully treated with vancomycin. Although rare, Cl. difficile may cause severe generalised illness in children under two years of age, and it is important to examine any infant with abdominal symptoms for the occurrence of Cl. difficile, even though no diarrhoea is present.

[Antibiotic resistance of E coli isolated from healthy persons]. / Antibiotikaresistens hos E. coli isoleret fra raske normalpersoner.

INTRODUCTION: The aim of the study was to determine the antibiotic susceptibility of E. coli isolates in stools from healthy Danes. METHODS: Sixty-nine persons from Copenhagen participated in the study. Three faecal samples from each participant were examined by culture for each of three periods. E. coli was isolated selectively and tested for sensitivity against sulfamethizole, trimethoprim, the combination of sulfamethizole and trimethoprim, ampicillin, mecillinam, cefuroxime, nitrofurantoin, and ciprofloxacin. RESULTS: Altogether, 184 strains of E. coli were isolated from 66 of the 69 persons. Fifty-eight (31.5%) of the strains isolated from 30 persons (43.5%) were resistant to sulfamethizole, 32 (17.4%) strains isolated from 18 persons (26.1%) were resistant to trimethoprim, 31 (16.8%) strains isolated from 17 persons (24.6%) were resistant to trimethoprim + sulfamethizole, 57 (31%) strains from 31 persons (44.9%) were resistant to ampicillin, 29 (15.8%) of the strains from 24 persons (34.8%) were resistant to nitrofurantoin, two (1.1%) strains from two persons (2.9%) were resistant to cefuroxime, whereas none of the strains was resistant to mecillinam and ciprofloxacin. DISCUSSION: The high prevalence of resistance to sulfamethizole, ampicillin, trimethoprim, and nitrofurantoin is surprising, as none of the persons had been treated with antibiotics, but it may reflect the widespread use of antibiotics in animals for food production. The consequences of the results for empiric antibiotic treatment of, for instance, urinary tract infection are discussed.