Variability in the prescribing of intravenous fluids: A cross sectional multicentre analysis of clinical practice

AIMS

Intravenous (IV) fluid administration continues to be a mainstay of care in General Surgery. Yet if they are prescribed incorrectly significant morbidity including electrolyte abnormalities, renal impairment and cardiac failure can develop. Despite this, it is frequently the responsibility of the most junior staff to prescribe IV fluids. We aim to analyse the understanding of IV fluid prescribing amongst junior doctors and to describe variability in clinical practice.

METHODS

We undertook a multicentre questionnaire study. Foundation doctors and specialty trainees were invited to undertake a two part paper-based questionnaire. Part one analysed baseline knowledge of the concentration of commonly prescribed fluids. Part two consisted of four clinical vignettes requiring a IV fluid prescribing decision by the surveyed doctor.

RESULTS

A total of 143 Doctors working in 8 hospitals were recruited. 65 (45.5%) doctors correctly stated the daily maintenance fluid requirements of water for an adult (25-30 mls/kg/day), while only 54 (37.8%) knew the sodium concentration of 0.9% NaCl. Lack of postgraduate experience (p = 0.011), qualifying from a medical school outside the United Kingdom (p < 0.0001) and working in one of the eight hospitals in this study (p < 0.0001) were associated with a lower knowledge level. There was limited consensus in prescribing in the responses to the 4 clinical scenarios, with 69 unique combinations of fluid choice, rate and volume prescribed.

CONCLUSIONS

Knowledge of the constituents of common IV fluids and routine requirement for fluid and common electrolytes is poor across junior doctors of all grades, driving large variation in clinical practice.

Troponin-T as a biomarker in neonates with perinatal asphyxia

BACKGROUND

Troponin-T is a commonly used cardiac biomarker, which could be useful in perinatal asphyxia. We aimed to analyze troponin-T concentrations in asphyxiated neonates and to correlate the concentrations with clinical outcomes.

METHODS

Data were collected from electronic medical records of neonates diagnosed with perinatal asphyxia over a period of four years.

RESULTS

There were 63 neonates with moderate to severe encephalopathy, in whom serial troponin-T concentrations had been done on days 1, 3, and 7. 53 (84%) asphyxiated infants had troponin-T concentration >100 pg/ml at 2-4 h of life.The difference in troponin-T concentrations between moderate and severe encephalopathy was not statistically significant (173 vs. 263 pg/ml, p value 0.40). The difference in the concentrations at 72 hours between cooled and non-cooled neonates was not significant (48.5 vs. 62.5 pg/ml, p value 0.22). Troponin-T concentration was significantly higher in babies with hypotensive shock and hepatic injury, but not acute kidney injury. There was no significant correlation between troponin-T and the extent of resuscitation needed.Troponin-T concentration on day 1 of life was significantly higher in babies who died than who survived (407 vs. 168 pg/ml, p value 0.03). ROC curve for troponin-T to predict mortality had an area under the curve (AUC) of 0.803; the best cut-off value (190 pg/ml) had 82% sensitivity and 80% specificity.

CONCLUSION

There was no significant difference in troponin-T concentrations between cooled and non-cooled neonates. Troponin-T concentration had a good predictive accuracy for mortality before discharge.

Ordering kinetics in the random-bond XY model

We present a comprehensive Monte Carlo study of domain growth in the random-bond XY model with nonconserved kinetics. The presence of quenched disorder slows down domain growth in d=2,3. In d=2, we observe power-law growth with a disorder-dependent exponent on the time scales of our simulation. In d=3, we see the signature of an asymptotically logarithmic growth regime. The scaling functions for the real-space correlation function are seen to be independent of the disorder. However, the same does not apply for the two-time autocorrelation function, demonstrating the breakdown of superuniversality.

A Prospective Study to Evaluate the Management of Sub-trochanteric Femur Fractures with Long Proximal Femoral Nail

Introduction: Sub-trochanteric fractures of the femur remains one of the most challenging fractures faced by orthopaedic surgeons. This study was done to analyse the management and complications of sub-trochanteric fractures using long proximal femoral nail (PFN). Materials and Methods: This was a prospective study of 50 patients with sub-trochanteric fractures of femur who were treated with long PFN at a tertiary care center from July 2012 to June 2016. The fractures were classified according to Seinsheimer classification. All patients were assessed functionally by Harris Hip Score. Results: Average duration of union was 17.08 weeks (range 13 to 32 weeks), union was achieved in 92% cases. Closed reduction was achieved in 68% cases and open reduction was required in 32% cases. Various intraoperative complications were seen in 12% and delayed complications in 26% of cases. Good anatomical results were achieved in 86% of cases and 14% were fair. As per Harris Hip score, excellent results were noted in 28% cases, good in 56% cases and fair in 16% cases. Conclusion: The long PFN is a reliable implant for subtrochanteric femur fractures, with high rate of bone union and minimal soft tissue damage. Intramedullary fixation has biological and biomechanical advantages, but the surgery is technically demanding.

Arterial Spin Labeling—Can Neurointerventionists Rely on This Novel Technique? A Case Series on Successful Use of Arterial Spin Labeling in Acute Stroke Imaging

Presence of ischemic penumbra is the principal factor that decides the need for mechanical thrombectomy in acute stroke patients with large vessel occlusion. Our objective was to evaluate the usefulness of arterial spin labeling (ASL) in detecting diffusion perfusion mismatch and directing patients into mechanical thrombectomy. We retrospectively studied all patients with acute nonhemorrhagic stroke in the anterior circulation, who had undergone stroke imaging with ASL followed by mechanical thrombectomy from July 2016 to November 2016. Area of diffusion perfusion mismatch was graded semiquantitatively into three grades: small, medium, and large. Mismatch was compared with 30-day modified Rankin scale (mRS) score. Interpretable PASL-perfusion images were obtained in all patients. Diffusion perfusion mismatches were present in all patients. Out of six patients with good mRS score, five patients had large diffusion perfusion mismatch. Two out of three patients with poor mRS were secondary to failed recanalization, in spite of large mismatch. One out of nine patients had poor outcome as well as a small area of mismatch. ASL is a rapid noninvasive imaging technique in acute stroke that has got the potential to detect ischemic penumbra.

Short communication: Growth of dairy isolates of Geobacillus thermoglucosidans in skim milk depends on lactose degradation products supplied by Anoxybacillus flavithermus as secondary species

Thermophilic bacilli such as Anoxybacillus and Geobacillus are important contaminants in dairy powder products. Remarkably, one of the common contaminants, Geobacillus thermoglucosidans, showed poor growth in skim milk, whereas significant growth of G. thermoglucosidans was observed in the presence of an Anoxybacillus flavithermus dairy isolate. In the present study, we investigated the underlying reason for this growth dependence of G. thermoglucosidans. Whole-genome sequences of 4 A. flavithermus strains and 4 G. thermoglucosidans strains were acquired, with special attention given to carbohydrate utilization clusters and proteolytic enzymes. Focusing on traits relevant for dairy environments, comparative genomic analysis revealed that all G. thermoglucosidans strains lacked the genes necessary for lactose transport and metabolism, showed poor growth in skim milk, and produced white colonies on X-gal plates, indicating the lack of β-galactosidase activity. The A. flavithermus isolates scored positive in these tests, consistent with the presence of a putative lactose utilization gene cluster. All tested isolates from both species showed proteolytic activity on milk plate count agar plates. Adding glucose or galactose to liquid skim milk supported growth of G. thermoglucosidans isolates, in line with the presence of the respective monosaccharide utilization gene clusters in the genomes. Analysis by HPLC of A. flavithermus TNO-09.006 culture filtrate indicated that the previously described growth dependence of G. thermoglucosidans in skim milk was based on the supply of glucose and galactose by A. flavithermus TNO-09.006.

Survivability of low pathogenic (H9N2) avian influenza virus in water in the presence of Atyopsis moluccensis (Bamboo shrimp)

Low pathogenic avian influenza virus (LPAIV) exhibits an ecological climax with the aquatic ecosystem. The most widely prevalent subtype of LPAIV is H9N2. Wild aquatic birds being the natural reservoirs and ducks, the "Trojan horses" for Avian Influenza Virus (AIV), can contaminate the natural water bodies inhabited by them. The virus can persist in the contaminated water from days to years depending upon the environmental conditions. Various aquatic species other than ducks can promote the persistence and transmission of AIV; however, studies on the role of aquatic fauna in persistence and transmission of avian influenza virus are scarce. This experiment was designed to evaluate the survivability of H9N2 LPAIV in water with and without Atyopsis moluccensis (bamboo shrimp) for a period of 12 days. The infectivity and amount of virus in water were calculated and were found to be significantly higher in water with A. moluccensis than in water without A. moluccensis. The study also showed that A. moluccensis can accumulate the virus mechanically which can infect chicken eggs up to 11 days. The virus transmission potential of A. moluccensis requires further studies.

Buffalo heifers selected for lower residual feed intake have lower feed intake, better dietary nitrogen utilisation and reduced enteric methane production

This study was conducted to evaluate the utilisation of the residual feed intake (RFI) as a feed efficiency selection tool and its relationship with methane emissions. Eighteen Murrah buffalo (Bubalus bubalis) heifers were fed ad libitum with total mixed ration (TMR) for 120 days. Based on linear regression models involving dry matter intake (DMI), average daily gain (ADG) and mid-test metabolic body size (MBW^0.75 ), heifers were assigned into low and high RFI groups. The RFI varied from -0.09 to +0.12 kg DM/day with average RFI of -0.05 and 0.05 kg DM/day in low and high RFI heifers respectively. Low RFI heifers ate 11.6% less DM each day, yet average daily gain (ADG) and feed utilisation were comparable among low and high RFI groups. Low RFI heifers required significantly (p < .05) less metabolizable energy for maintenance (MEm) compared to high RFI heifers. Apparent nutrient digestibility showed non-significant difference (p > .05) among low and high RFI groups. Although the nitrogen balance was similar among heifers of low and high RFI groups, nitrogen metabolism was significantly higher (p > .05) in high RFI heifers. Comparison of data from heifers exhibiting the low (n = 9) and high (n = 9) RFI showed that the low RFI heifers have lower enteric methane production and methane losses than high RFI heifers. In conclusion, results of this study revealed that selection of more efficient buffalo heifers has multiple benefits, such as decreased feed intake and less emission of methane.

Intussusception of Small Intestine as a Result of Inflammatory Fibroid Polyp Causing Small Bowel Obstruction in an Adult Patient

Intussusception is the telescoping of one segment of bowel into the adjacent segment. It is more commonly seen in children,however rarely encountered in adult patients. Proximal segment of bowel is called intussusceptum which is intussuscepted into the lumen of the adjacent distal segment known as intussuscipiens. There is always a lead point causing this disorder especially in adults. We presented a case of a 45 year old man who presented in emergency department of our institute with history and clinical features of acute intestinal obstruction since 10 days. Patient was resuscitated, investigated and taken for exploratory laparotomy under General anaesthesia. Segment of involved small gut was resected and well circumscribed polypoidal mass was found in intussuscepted bowel. Histopathological examination of the specimen revealed the features of inflammatory fibroid polyp.

Relaxation lifetimes of plasmonically enhanced hybrid gold-carbon nanotubes systems

Recently, we introduced a novel hybridization route for carbon nanotubes using gold nanoparticles, whose close proximity neatly enhances their radiative emission. Here we investigate the mechanisms behind the enhancement by monitoring the de-excitation dynamics of our π-hybrids through two-color pump-probe time-resolved spectroscopy. The de-excitation process reveals a fast component and a slow component. We find that the presence of gold prominently affects the fast processes, indicating a stronger influence of the gold nanoparticle on the intra-band non-radiative relaxation than on the inter-band recombination of the single-walled carbon nanotube. By evaluating the de-excitation times, we estimate the balance between near-field pumping and the faster metal-induced de-excitation contributions, proving the enhanced pumping to be the leading mechanism.

Intra-abdominal pressure and intra-abdominal hypertension in critically ill obstetric patients: a prospective cohort study

BACKGROUND

Critically ill obstetric patients may have risk factors for intra-abdominal hypertension. This study evaluated the intra-abdominal pressure and its effect on organ function and the epidemiology of intra-abdominal hypertension.

METHODS

Obstetric patients admitted to an Intensive Care Unit, with an anticipated stay greater than 24hours, were included. Intra-abdominal pressure was measured daily via a Foley catheter, based on intravesical pressure.

RESULTS

One-hundred-and-one patients were enrolled. The intra-abdominal pressure was 5-7mmHg in 34%; 7-12mmHg in 60%; and ≥12mmHg (intra-abdominal hypertension) in 6%. All six patients with intra-abdominal hypertension were pregnant at the time of admission. The intra-abdominal pressure in four patients normalized to <12mmHg following delivery, but in the remaining two it persisted ≥12mmHg and both these patients died. Correlation between intra-abdominal pressure and organ dysfunction was weak (r=0.211). Statistical comparison between patients with and without intra-abdominal hypertension for risk factors, daily intra-abdominal pressures, and Sequential Organ Failure Assessment score could not be done due to the disproportionately small number of patients with intra-abdominal hypertension as opposed to those without (6 versus 95). Intra-abdominal pressure did not significantly differ between survivors and non-survivors (8.5±1.1 vs 7.9±1.7mmHg, P=0.079).

CONCLUSIONS

The incidence of intra-abdominal hypertension in critically ill obstetric patients was lower than previously defined for mixed Intensive Care Unit populations, with an association with the pregnant state. Normalization of intra-abdominal pressure after delivery was associated with better survival. There was no correlation between intra-abdominal pressure and organ function or mortality.