Use of polymerase chain reaction as a diagnostic tool for neonatal sepsis can result in a decrease in use of antibiotics and total neonatal intensive care unit length of stay

OBJECTIVE

To retrospectively determine if a negative 16S ribosomal RNA (rRNA) polymerase chain reaction (PCR) (PCR(-)) could lead to a decrease in the number of antibiotic doses and neonatal intensive care unit (NICU) length of stay (LOS) for infants admitted to the NICU for presumed early-onset sepsis (EOS) with negative blood culture results (BC(-)).

STUDY DESIGN

Analysis included 419 infants, greater than 35 weeks gestational age, with PCR(-), BC(-) and LOS > 48 h. Both the investigators and clinical care team were unaware of the PCR results. The actual number of antibiotic doses (AAD) administered was compared to an estimated number of antibiotics doses (EAD) that would have been given until PCR(-) results were available by 18 h. The number of antibiotic doses saved was calculated as (AAD-EAD). The actual NICU LOS in hours (aLOS) for a subset of infants who remained in the hospital primarily for antibiotic therapy was compared to an estimated LOS (eLOS) if infants with PCR(-) were discharged from the NICU when clinically stable. The number of hours saved was calculated as (aLOS-eLOS).

RESULTS

Approximately eight antibiotic doses and 85 NICU hours per infant could be saved using PCR(-) results available at 18 h.

CONCLUSIONS

Use of 16S rRNA PCR could decrease the number of antibiotics doses and NICU LOS for infants admitted for EOS. This may facilitate: (1) earlier NICU discharge; (2) parental satisfaction; and (3) decreased health care costs.

Non-invasive measurement of reduced ventilation:perfusion ratio and shunt in infants with bronchopulmonary dysplasia: a physiological definition of the disease

BACKGROUND

An objective definition of bronchopulmonary dysplasia (BPD) is required to interpret trial outcomes and provide a baseline for prognostic studies. Current definitions do not quantify disease severity. The cardinal measures of impaired gas exchange are a reduced ventilation:perfusion ratio (V(A):Q) and increased right to left shunt. These can be determined non-invasively by plotting arterial oxygen saturation (Spo(2)) against inspired oxygen pressure (PIo(2)).

AIMS

To describe the reduced V(A):Q and shunt in infants with BPD and evaluate these as graded measures of pulmonary dysfunction.

METHODS

21 preterm infants with BPD were studied. PIo(2) was changed stepwise to vary Spo(2) between 86% and 94%. Pairs of PIo(2) and Spo(2) data points for each infant were plotted and analysed to derive reduced V(A):Q ratio and shunt.

RESULTS

In every infant, the Spo(2) versus PIo(2) curve was shifted to the right of the normal because of a reduced V(A):Q. The mean (SD) shift was 16.5 (4.7) kPa (normal 6 kPa). Varying degrees of shunt were also present, but these were less important in determining Spo(2) within the studied range. The degree of shift was strongly predictive of the PIo(2) required to achieve any Spo(2) within the range 86-94% (R(2)>0.9), permitting shift and V(A):Q to be determined from a single pair of PIo(2) and SpO(2) values in this range.

CONCLUSIONS

The predominant gas exchange impairment in BPD is a reduced V(A):Q, described by the right shift of the Spo(2) versus PIo(2) relationship. This provides a simpler method for defining BPD, which can grade disease severity.

The 'fixed performance' venturi: effect of downstream pressure on outflow and FIO2

Fixed performance venturi devices should provide a predetermined oxygen concentration at an outflow which exceeds an adult's peak resting inspiratory flow rate (approximately 30 l.min(-1)). Campbell's original description mentioned the sensitivity of the venturi device to downstream resistance but gave no further details. This study examined outflow and oxygen concentration from the five standard venturi devices (24-60% O(2)) when downstream pressure increased. Outflow was exquisitely sensitive to small increases in pressure. The outflow at zero downstream pressure for the 24-40% O(2) venturi devices ranged from 40 to 50 l.min(-1) but only 2-3 mmH(2)O was needed to halve this flow and increase oxygen concentration. The 60% O(2) venturi delivered a maximum of only 30 l.min(-1) at zero downstream pressure and flow was reduced further by increasing this pressure. An increase in downstream pressure of only a few mmH(2)O increased oxygen concentration and decreased outflow of all the venturi devices tested, in most to less than normal peak tidal flow in adults.

Dose-related effect of sevoflurane sedation on higher control of eye movements and decision making

BACKGROUND

Saccadic latency may provide an objective method to assess sedative doses of anaesthetic on cortical oculomotor mechanisms and decision making.

METHODS

We tested the effects of random doses of 0, 0.1, 0.2 and 0.3 MAC sevoflurane in six subjects, in a double-blind study using two measures of behavioural impairment: saccadic latency and stop signal reaction time (SSRT) in a countermanding task.

RESULTS

Saccadic latency and SSRT both increased with increasing doses of sevoflurane. In both measures, reciprocal reaction time was linearly related to dose in each subject: all but two of the twelve regression coefficients were statistically significant (P<0.05). In one subject, SSRT was significantly more sensitive than simple latency (P<0.05); for the others there was no significant difference.

CONCLUSION

Measurements of this kind could potentially provide estimates of cortical effects of sevoflurane sedation, and give a clinically useful measure of cognitive fitness.

Cigarette smoking and the risk of invasive epithelial ovarian cancer in a prospective cohort study

Few cohort studies have examined the association between cigarette smoking and ovarian cancer risk, either overall, or by histological subtype. In relation to the latter, it has been suggested that mucinous ovarian tumours may be aetiologically unrelated to the other types of epithelial tumours and that their respective associations with cigarette smoking may differ. We examined the association between smoking and ovarian cancer risk using data from participants in a randomised controlled trial of screening for breast cancer involving 89,835 women aged 40-59 years at recruitment. Cox proportional hazards models were used to estimate rate ratios (RR) and 95% confidence intervals (CI). During an average of 16.5 years of follow-up, we observed 454 incident cases of ovarian cancer (184 serous, 67 endometrioid, 32 mucinous, 171 other or unknown). We found that women who had smoked for several decades had an approximately two-fold increased risk of epithelial ovarian cancer. Relative to never-smokers, women who had smoked for 40 years or more were at the highest risk (RR=2.50, 95% CI=1.37-4.56). The association with non-mucinous tumours was similar to that observed overall. For mucinous tumours, a two-fold increased risk was observed with smoking of shorter duration, although the number of mucinous tumours in our data-set was small. Long-term cigarette smoking may be associated with an increased risk of epithelial ovarian tumours.

Discriminating between the effect of shunt and reduced VA/Q on arterial oxygen saturation is particularly useful in clinical practice

There is an extensive literature on methods for discriminating between an increased shunt and a reduced ratio of ventilation to perfusion. In this review we prefer the terms "VA/Q" and "reduced or low VA/Q" rather than "V/Q inequality" to refer to the effects on arterial oxygenation of reducing V/Q below 0.8 to about 0.1. Almost without exception the conventional methods for measuring shunt and reduced VA/Q are invasive as well as technically complex. For most clinicians who are dealing with a hypoxemic patient the relevance of these entities is not so obvious as to justify the time and difficulty in either understanding or measuring them. However this review shows that, while an increased shunt and a decreased VA/Q both reduce arterial oxygen saturation (SaO2) at a particular inspired oxygen concentration (PIO2), the effect of shunt and reduced VA/Q have important clinical differences on the relationship between PIO2 and SaO2. The review also outlines a simple non-invasive method for measuring shunt and reduced VA/Q which illustrates the value of discriminating between them in clinical practice.

The effect of low dose sevoflurane on saccadic eye movement latency

We investigated the effects of a low concentration of sevoflurane on a saccadic eye movement task that reflects the performance of higher neural decision and control mechanisms. The experiments were performed double-blind in five subjects, using either 0.15% end-tidal sevoflurane in oxygen, or pure oxygen as a placebo. Saccades were recorded and analysed using a computer-based recording system that also controlled the presentation of visual targets. Administration of oxygen produced no significant change in median latency compared with breathing air; but in four of the five subjects, administration of sevoflurane in oxygen caused a significant increase in latency. These results suggest that measurement of median saccadic latency may be a useful functional measurement of impairment of performance during recovery from anaesthesia.

Self-incompatibility in ryegrass 12. Genotyping and mapping the S and Z loci of Lolium perenne L

Perennial ryegrass (Lolium perenne L.) is an outcrossing, wind-pollinated species exhibiting a gametophytic two-locus system of self-incompatibility (S and Z). The two incompatibility loci were genotyped in a cross between a doubled-haploid plant crossed as the female parent with a normal heterozygous plant. The S and Z loci were found to segregate in the expected 1:1 ratio and also segregated independently. The two loci were mapped to linkage groups one and two respectively, in accordance with the Triticeae consensus map. In addition, there were notable associations between the segregation of particular alleles mapping to the S locus region of linkage group 1 and those mapping to the WG889/CDO920 loci region of linkage group 3 which resulted in significant segregation distortions. No such associations were found between the Z locus and this region or any other region of the genome. The L. perenne S and Z loci showed conserved synteny with the equivalent loci in rye (Secale cereale L.).

Effect of videotape feedback on anaesthetists' performance while managing simulated anaesthetic crises: a multicentre study

The aim of this study was to examine the performance of anaesthetists while managing simulated anaesthetic crises and to see whether their performance was improved by reviewing their own performances recorded on videotape. Thirty-two subjects from four hospitals were allocated randomly to one of two groups, with each subject completing five simulations in a single session. Individuals in the first group completed five simulations with only a short discussion between each simulation. Those in the second group were allowed to review their own performance on videotape between each of the simulations. Performance was measured by both 'time to solve the problem' and mental workload, using anaesthetic chart error as a secondary task. Those trainees exposed to videotape feedback had a shorter median 'time to solve' and a smaller decrease in chart error when compared to those not exposed to video feedback. However, the differences were not statistically significant, confirming the difficulties encountered by other groups in designing valid tests of the performance of anaesthetists.

An integrated (2)H and (13)C NMR study of gluconeogenesis and TCA cycle flux in humans

Hepatic glucose synthesis from glycogen, glycerol, and the tricarboxylic acid (TCA) cycle was measured in five overnight-fasted subjects by (1)H, (2)H, and (13)C NMR analysis of blood glucose, urinary acetaminophen glucuronide, and urinary phenylacetylglutamine after administration of [1,6-(13)C(2)]glucose, (2)H(2)O, and [U-(13)C(3)]propionate. This combination of tracers allows three separate elements of hepatic glucose production (GP) to be probed simultaneously in a single study: 1) endogenous GP, 2) the contribution of glycogen, phosphoenolpyruvate (PEP), and glycerol to GP, and 3) flux through PEP carboxykinase, pyruvate recycling, and the TCA cycle. Isotope-dilution measurements of [1,6-(13)C(2)] glucose by (1)H and (13)C NMR indicated that GP in 16-h-fasted humans was 10.7 +/- 0.9 micromol.kg(-1).min(-1). (2)H NMR spectra of monoacetone glucose (derived from plasma glucose) provided the relative (2)H enrichment at glucose H-2, H-5, and H-6S, which, in turn, reflects the contribution of glycogen, PEP, and glycerol to total GP (5.5 +/- 0.7, 4.8 +/- 1.0, and 0.4 +/- 0.3 micromol.kg(-1).min(-1), respectively). Interestingly, (13)C NMR isotopomer analysis of phenylacetylglutamine and acetaminophen glucuronide reported different values for PEP carboxykinase flux (68.8 +/- 9.8 vs. 37.5 +/- 7.9 micromol.kg(-1).min(-1)), PEP recycling flux (59.1 +/- 9.8 vs. 27.8 +/- 6.8 micromol.kg(-1).min(-1)), and TCA cycle flux (10.9 +/- 1.4 vs. 5.4 +/- 1.4 micromol.kg(-1).min(-1)). These differences may reflect zonation of propionate metabolism in the liver.

Freshwater ecosystems--structure and response

Before it is possible to predict the impact of human activities on the natural environment it is necessary to understand the forces that drive and, therefore, control that environment. This paper is concerned with the freshwater component of the aquatic environment. The driving forces involved (some of which are under man's control) can be divided into the physical and the chemical, but the response is, almost entirely, biological. Although most impacts of the food processing industry might be perceived to be on running waters, this is not always the case, but we can apply the same basic rules to both static and running waters. The physical forces that determine how a lake functions are as follows. In early spring, in the temperate zone, the temperature of the surface water in lakes rises and the sunlight input increases. This results in stratification of the water body. The cooler, deeper water is separated, physically, by gravity. This isolated water plays a very different role in the function of the lake and is analogous to how a river works. Man's activities drive these systems by our input of inorganic and organic substances. The inorganic inputs, particularly of phosphorous, stimulate undesirable algal growths, some of which may produce particularly dangerous toxins. We must now accept that climate change, driven by man, will exacerbate these problems. Organic inputs from the food industry, i.e., carbohydrates, lipids, and proteins, will all impact lakes and rivers by increasing the biological oxygen demand. The worst case scenario is total loss of oxygen from the water as a result of microbial activity. Lipids create the greatest oxygen demand but carbohydrates (more easily biodegradable) also result in unsightly "sewage fungus." Protein waste can be degraded to produce ammonia and sulfide, both of which produce toxicity problems. Bioremediation processes, particularly phytoremediation, can alleviate these problems in a cost-effective manner and this paper will address these options.

Expression of calretinin in human ovary, testis, and ovarian sex cord-stromal tumors

Calretinin, a calcium-binding protein, is primarily expressed in certain subtypes of neurons. It has also been found to be present in mesothelial cells and mesotheliomas but not in many types of carcinomas. Using a polyclonal anti-calretinin antibody, we investigated the expression of calretinin immunohistochemically in nonneoplastic human ovaries and testes and ovarian sex cord-stromal tumors (SCSTs). In ovaries, calretinin was expressed in theca interna cells, hilus cells, and scattered individual stromal cells. Oocytes, granulosa cells, theca externa cells, rete ovarii, and most stromal cells were negative. Expression of calretinin was also seen in the ovarian surface epithelium and in collapsed and flat epithelial inclusion glands (EIGs), but not in round, columnar, and ciliated EIGs. In some glands, a transition from calretinin-positive to calretinin-negative epithelium was observed. In postpubertal testes, calretinin was expressed in Leydig cells, but not in germ cells or most rete testes and Sertoli cells. In ovarian SCSTs, strong calretinin staining was seen in all hilus cell tumors (4/4) and the Leydig cell component of Sertoli-Leydig cell tumors (10/10). The Sertoli cell component showed focal weak positivity in 5/10. Fibrothecomas were completely negative (0/8). In granulosa cell tumors, the tumor cells were either completely negative (8/14) or weakly positive at the periphery of the tumor (6/14) while scattered stromal cell staining was seen in 9/14 cases. The expression of calretinin in normal Leydig cells, theca interna cells, the Leydig cell component of Sertoli-Leydig cell tumors, and hilus cell tumors suggests its functional relationship with androgen production. Its pattern of expression in ovarian SCSTs is useful in the differential diagnosis of these tumors. The presence of a transition from calretinin-positive, flat, nonciliated epithelium to calretinin-negative, columnar, ciliated epithelium in the same glands provides strong evidence for mullerian metaplasia.

Non-invasive assessment of shunt and ventilation/perfusion ratio in neonates with pulmonary failure

AIMS

To make non-invasive measurements of right to left (R-L) shunt and reduced ventilation/perfusion ratio (V(A)/Q) in neonates with pulmonary failure and to examine sequential changes in these variables after treatment.

METHODS

Twelve neonates with pulmonary failure were studied. They ranged in gestational age from 24 to 37 (median 27) weeks and were 1-39 (median 4) days old. Shunt and reduced V(A)/Q were derived from their effects on the relation between inspired oxygen pressure (PIO(2)) and arterial oxygen saturation measured with a pulse oximeter (SpO(2)). Pairs of PIO(2) v. SpO(2) data points were obtained by varying PIO(2) in a stepwise fashion. A computer algorithm based on a model of pulmonary gas exchange fitted a curve to these data. With PIO(2) on the abscissa, an increase in shunt produced a downward movement of the curve, whereas reducing V(A)/Q to < 0.8 shifted the curve to the right. The right shift gives a variable that is inversely related to V(A)/Q, the PIO(2) - PO(2) difference, where PO(2) is mixed capillary oxygen pressure.

RESULTS

Ten of the 12 infants on the first study day had large shunts (range 5.9-31.0%, median 19.9%, normal < 8%) and large PIO(2) - PO(2) differences (range 9.7-64.4 kPa, median 19.8 kPa, normal < 7 kPa) equivalent to a median V(A)/Q of 0.2 (normal median V(A)/Q = 0.8). Sequential improvement in shunt and V(A)/Q were shown in most infants after treatment. Sudden large changes in these variables were shown in two infants.

CONCLUSION

This simple non-invasive method distinguishes between shunt and reduced V(A)/Q in neonates with pulmonary failure.

Blink duration as a measure of low-level anaesthetic sedation

BACKGROUND AND OBJECTIVE

Variability in blink duration was examined to see whether it was sensitive to sevoflurane sedation at 0.05 and 0.1 minimum alveolar concentration (MAC).

METHODS

Blinks were measured with an infrared transducer in eight subjects. Sedation was scored using a visual analogue scale (VAS).

RESULTS

At baseline, 0.05 and 0.1 MAC sevoflurane, respectively, the overall median value of blink duration and its interquartile range were 95 (80-110) ms, 198 (163-245) ms and 210 (130-980) ms. The median percentage of blinks exceeding 500 ms was 0% (0-0.7%), 33.3% (25.5-34.7%) and 25% (15.7-63.3%) respectively. Values during 0.05 and 0.1 MAC sevoflurane were significantly different from baseline (P < 0.035) but not from each other. Baseline visual analogue scales showed large intersubject variability. Compared with baseline, VAS scores were higher at 0.05 MAC (P < 0.035) but not at 0.1 MAC. After discontinuing sevoflurane, median blink duration returned to baseline with a recovery half-life of 2.6 min (R2 = 0.95). Conclusion Blink duration is a sensitive measure of sevoflurane sedation even at 0.05 MAC.

CT appearance of some colonic villous tumors

OBJECTIVE

A review was made of the CT studies and pathology reports of four patients with surgically resected colonic villous adenomatous tumors, two of whom had focal carcinomatous invasion.

CONCLUSION

Two patients had villous tumors with IV contrast-enhancing convolutional gyral patterns. The other two patients had tumor masses that showed oral contrast medium collecting in surface interstices, analogous to findings with barium enemas. One of the latter also had an unusual cluster of mesenteric vessels adjacent to the lesion.

Origin and environmental setting of ancient agriculture in the lowlands of Mesoamerica

Archaeological research in the Gulf Coast of Tabasco reveals the earliest record of maize cultivation in Mexico. The first farmers settled along beach ridges and lagoons of the Grijalva River delta. Pollen from cultivated Zea appears with evidence of forest clearing about 5100 calendar years B.C. (yr B.C.) [6200 (14)C years before the present (yr B.P.)]. Large Zea sp. pollen, typical of domesticated maize (Zea mays), appears about 5000 calendar yr B.C. (6000 yr B.P.). A Manihot sp. pollen grain dated to 4600 calendar yr B.C. (5800 yr B.P.) may be from domesticated manioc. About 2500 calendar yr B.C. (4000 yr B.P.), domesticated sunflower seeds and cotton pollen appear as farming expanded.

13C isotopomer analysis of glutamate by J-resolved heteronuclear single quantum coherence spectroscopy

13C NMR isotopomer analysis is a powerful method for measuring metabolic fluxes through pathways intersecting in the tricarboxylic acid cycle. However, the inherent insensitivity of 13C NMR spectroscopy makes application of isotopomer analysis to small tissue samples (mouse tissue, human biopsies, or cells grown in tissue culture) problematic. (1)H NMR is intrinsically more sensitive than 13C NMR and can potentially supply the same information via indirect detection of 13C providing that isotopomer information can be preserved. We report here the use of J-resolved HSQC (J-HSQC) for 13C isotopomer analysis of tissue samples. We show that J-HSQC reports isotopomer multiplet patterns identical to those reported by direct 13C detection but with improved sensitivity.

Quantifying tracer levels of (2)H(2)O enrichment from microliter amounts of plasma and urine by (2)H NMR

A simple and sensitive (2)H NMR measurement of (2)H(2)O enrichment from a 10 microl volume of body fluid is presented. The method allows (2)H-enrichment levels of 0.1% or above to be rapidly determined from 10 microl of plasma or urine. The measurement is insensitive to the presence of plasma protein, allowing direct analysis of (2)H(2)O enrichment from native plasma samples. Magn Reson Med 45:156-158, 2001.