Factors associated with definitive peritoneal drainage for spontaneous intestinal perforation in extremely low birth weight neonates

PURPOSE

Peritoneal drainage (PD) constitutes a definitive therapy for a subset of extremely low birth weight (ELBW) infants with spontaneous intestinal perforation (SIP). We investigated the factors which may differentiate these patients from those who require a laparotomy (LAP) after initial PD.

METHODS

A retrospective chart review of all ELBW infants (<1000 grams) who underwent PD at two tertiary neonatal intensive care units over a 42-month period was performed. Demographic, clinical, laboratory, and radiological data of the entire patient cohort were collected. Patients who underwent definitive PD were compared to those who required LAP following PD. Statistical comparisons were performed using independent samples T-tests for continuous variables, and Fisher's exact test for categorical variables.

RESULTS

Sixteen ELBW infants with SIP underwent PD. Five patients (31%) had definitive PD and 11 (69%) subsequently required LAP. Patients who had definitive PD had a lower percent band count at diagnosis (3.2+/-1.5 vs. 18.0+/-4.8; p=0.01), and were less likely to require vasopressor therapy at diagnosis and drain placement (40% vs. 91%, p=0.06), 24 hours later (40% vs. 100%, p=0.02), and 48 hours later (20% vs. 91%, p=0.01). There were no other statistically significant differences in any of the measured variables. Survival to discharge was 80% for PD and 82% for LAP (p=1.0).

CONCLUSION

Peritoneal drainage for spontaneous intestinal perforation in ELBW neonates is more likely to be definitive in the absence of bandemia and vasopressor requirement. These may be important factors in deciding whether to proceed to laparotomy.

Diagnosed diabetic retinopathy in France, Italy, Spain, and the United Kingdom

AIM

The objective of this study was to describe the proportion and characteristics of patients diagnosed with diabetic retinopathy (DR) in France, Italy, Spain, and the United Kingdom (UK).

METHODS

To estimate the proportion of patients with type 1 and type 2 diabetes diagnosed with DR, we conducted a cross-sectional survey of general practitioners in each country using physician records. In addition, diabetes specialists were recruited in Italy and Spain. We extracted data from the medical notes of a sample of DR patients to characterize DR severity and clinical characteristics.

RESULTS

The average number of physicians per country was 41 (range: 34-49). The proportion of diagnosed DR ranged from 10.3% (95% CI, 6.7-14.0%) in Spain to 19.6% (95% CI, 16.0-23.1%) in the UK. Of 752 DR patients studied, 53.9% were male; mean age (+/-SD) was 64.2+/-12.8 years. Consistently across countries, mild non-proliferative DR was the most common severity level of diagnosed DR. Proliferative DR (PDR) ranged from 19.7% (France) to 31.5% (UK). Diabetic macular oedema was reported in approximately 10% of patients. Hypertension (73.1%), dyslipidemia (63.2%), and neuropathy (52.1%) were the most common co-morbidities.

CONCLUSIONS

Country-specific prevalence of diagnosed DR may reflect clinical management of diabetes, healthcare systems, or record-keeping accuracy. Across countries, up to 30% of DR patients had a diagnosis of PDR, which could suggest that patients are diagnosed only when their disease is advanced.

Assessment of intakes and doses to workers followed for 15 years after accidental inhalation of 60CO

Intakes and doses are assessed for seven workers who accidentally inhaled particles containing Co in the same incident. Comprehensive whole body data to 15 y, and some early urine and fecal data, are available for each individual. The biokinetic and dosimetric models currently recommended by ICRP have been used to assess these cases. It was not possible to obtain good fits to the data using the ICRP models with their default parameter values. However, good fits to all the measurement data were obtained by varying parameter values following a procedure similar to that recommended in recently developed guidelines for assessment of internal doses from monitoring data. It was found that retention in the lungs was much longer than predicted by the ICRP Human Respiratory Tract Model, and so for each case it was necessary to reduce the particle transport clearance of material from the deep lungs. This reduction in lung clearance rates, and the use of specific AMAD values, were the dominating factors in changing assessed doses from those calculated using ICRP default values.

Co-delivery of lymphopoietic cytokines in live Salmonella vaccines enhances the T cell response (47.17)

Live bacteria vaccine S. Typhi elicits strong mucosal and systemic immune responses. It is useful as a live vector to deliver heterologous antigens. Additionally, delivery of a eukaryotic expression vector by attenuated Salmonella leads to temporary expression of the coded gene in host cells after invasion. Because Salmonella invades preferentially macrophages and dendritic cells, the live bacteria could also be used to deliver immunomodulatory molecules to antigen-presenting cells. We hypothesize that co-delivery of lymphopoietic cytokine such as IL-2, IL-7 and IL-15, which has potential in promoting immune memory, enhances the efficacy of vaccination.

Murine IL-2, IL-7 and IL-15 were cloned into eukaryotic expression vector pCMS-EGFP, and introduced into S. Typhi(F1), which carries Y. pestis protective antigen F1. Mice were immunized intranasally with above derivative strains, and boosted with purified antigen F1 in alum adjuvant Alhydrogel.

This prime-boost strategy elicited strong mucosal and systemic antibody responses, as well as cell-mediated responses, e.g. antigen-specific proliferation and IFN-γ production of splenocytes. Inclusion of cytokine, however, further enhanced the cell-mediated responses. Antibody responses were not affected.

Our data strongly support our hypothesis that production of lymphopoietic cytokine during priming vaccination promotes memory T cell responses.

LEE-encoded regulator (Ler) mutants elicit serotype-specific protection, but not cross protection, against attaching and effacing E. coli strains

We previously showed that single dose orogastric immunization with an attenuated regulatory Lee-encoded regulator (ler) mutant of the rabbit enteropathogenic Escherichia coli (REPEC) strain E22 (O103:H2) protected rabbits from fatal infection with the highly virulent parent strain. In the current study we assessed the degree of homologous (serotype-specific) and heterologous (cross-serotype) protection induced by immunization with REPEC ler mutant strains of differing serotypes, or with a prototype strain RDEC-1 (O15:H-) which expresses a full array of ler up-regulated proteins. We constructed an additional ler mutant using RDEC-1 thus, permitting immunization with a ler mutant of either serotype, O15 or O103, followed by challenge with a virulent REPEC strain of the same or different serotypes. Consistent with our previous data, the current study demonstrated that rabbits immunized with a RDEC-1 ler mutant were protected from challenge with virulent RDEC-H19A (RDEC-1 transduced with Shiga toxin-producing phage H19A) of the same serotype. Rabbits immunized with RDEC-1 or E22 derivative ler mutants demonstrated significant increase in serum antibody titers to the respective whole bacterial cells expressing O antigen but not to the LEE-encoded proteins. However, immunization with the ler mutants of either E22 or RDEC-1 failed to protect rabbits from infections with virulent organisms belonging to different serotypes. In contrast, rabbits immunized with the prototype RDEC-1 were cross protected against challenge with the heterologous E22 strain as shown by normal weight gain, and the absence of clinical signs of disease or characteristic attaching and effacing (A/E) lesions. Immunization with RDEC-1 induced significantly elevated serum IgG titers to LEE-encoded proteins. We thus, demonstrated homologous protection induced by the REPEC ler mutants and heterologous protection by RDEC-1. The observed correlation between elevated immune responses to the LEE-encoded proteins and the protection against challenge with heterologous virulent REPEC strain suggests that serotype-non-specific cross protection requires the expression of, and induction of antibody to, LEE-encoded virulence factors.

Application of IDEAS guidelines: the IDEAS/IAEA intercomparison exercise on internal dose assessment

As part of the EU Fifth Framework Programme IDEAS project 'General Guidelines for the Evaluation of Incorporation Monitoring Data', and in collaboration with the International Atomic Energy Agency, a new intercomparison exercise for the assessment of doses from intakes of radionuclides was organised. Several cases were selected, to cover a wide range of practices in the nuclear fuel cycle and medical applications. The cases were: (1) acute intake of HTO, (2) acute inhalation of the fission products 137Cs and 90Sr, (3) acute inhalation of 60Co, (4) repeated intakes of 131I, (5) intake of enriched uranium and (6) single intake of Pu isotopes and 241Am. This intercomparison exercise especially focused on the effect of the Guidelines proposed by the IDEAS project for harmonisation of internal dosimetry.

Coordination of research on internal dosimetry in Europe: the CONRAD project

The EUropean RAdiation DOSimetry Group (EURADOS) initiated in 2005 the CONRAD Project, a Coordinated Network for Radiation Dosimetry funded by the European Commission (EC), within the 6th Framework Programme (FP). The main purpose of CONRAD is to generate a European Network in the field of Radiation Dosimetry and to promote both research activities and dissemination of knowledge. The objective of CONRAD Work Package 5 (WP5) is the coordination of research on assessment and evaluation of internal exposures. Nineteen institutes from 14 countries participate in this action. Some of the activities to be developed are continuations of former European projects supported by the EC in the 5th FP (OMINEX and IDEAS). Other tasks are linked with ICRP activities, and there are new actions never considered before. A collaboration is established with CONRAD Work Package 4, dealing with Computational Dosimetry, to organise an intercomparison on Monte Carlo modelling for in vivo measurements of (241)Am deposited in a knee phantom. Preliminary results associated with CONRAD WP5 tasks are presented here.

IMBA Professional Plus: a flexible approach to internal dosimetry

IMBA (Integrated Modules for Bioassay Analysis) is a suite of software modules that implement the current ICRP biokinetic and dosimetric models for estimation of intakes and doses. The IMBA modules have gone through extensive quality assurance, and are now used for routine formal dose assessment by Approved Dosimetry Services throughout the UK. HPA has continued to develop the IMBA modules. In addition, several projects, sponsored by organisations both in the USA and in Canada, have resulted in the development of customised user-friendly interfaces (IMBA Expert 'editions'). These enable users not only to use the standard ICRP models, but also to change many of the parameter values from ICRP defaults, and to apply sophisticated data handling techniques to internal dose calculations. These include: fitting measurement data with the maximum likelihood method; using multiple chronic and acute intakes; and dealing with different data types, such as urine, faces and whole body simultaneously. These interfaces were improved further as a result of user-feedback, and a general 'off-the-shelf' product, IMBA Professional, was developed and made available in January 2004. A new version, IMBA Professional Plus, was released in April 2005, which is both faster and more powerful than previous software. The aim of this paper is to describe the capabilities of IMBA Professional Plus, and the mathematical methods used.

The work of the CONRAD task group 5.2: research studies on biokinetic models

The objective of this Task Group is the coordination of research studies on biokinetic models and the evaluation of the implications of new biokinetic models on dose assessment and safety standards. For this the new ICRP models, which will be used for a revision of ICRP Publications 30, 54, 68 and 78, are implemented into six different computer codes in five European countries and quality assured by intercomparison procedures. The work has started with the implementation of the new ICRP Alimentary Tract Model. New systemic models and the new NCRP wound model will follow. The work also includes the evaluation of experimental results in terms of formulation by the new model structures and a quality assurance of model formulation.

Simian varicella virus gene 61 encodes a viral transactivator but is non-essential for in vitro replication

Simian varicella virus (SVV) is closely related to varicella-zoster virus (VZV), the causative agent of chickenpox and shingles. The SVV and VZV gene 61 polypeptides are homologs of the HSV-1 ICP0, a viral transactivator which appears to play a role in viral latency and reactivation. In this study, the molecular properties of the SVV 61 were characterized. The SVV open reading frame (ORF) 61 encodes a 54.1-kDa polypeptide with 37% amino acid identity to the VZV 61. Homology to the HSV-1 ICP-0 is limited to a conserved RING finger motif at the amino terminus of the protein. A nuclear localization sequence (nls) at the carboxy-terminus directs the SVV 61 to the cell nucleus, while a SVV 61nls(-) mutant is confined to the cell cytoplasm. The SVV 61 transactivates its own promoter as well as SVV immediate early (IE, ORF 62), early (ORFs 28 and 29), and late (ORF 68) gene promoters in transfected Vero cells. The RING finger and nls motifs are required for efficient SVV 61 transactivation. The SVV 61 has no effect on the ability of the major SVV transactivator (IE62) to induce SVV promoters. Generation and propagation of a SVV gene 61 deletion mutant demonstrated that the SVV 61 is non-essential for in vitro replication. SVV gene 61 is expressed in liver, lung, and neural ganglia of infected monkeys during acute simian varicella.

Randomised double-blind placebo-controlled trial of aloe vera for irritable bowel syndrome

Aloe vera (AV) is suggested to be beneficial in treating irritable bowel syndrome (IBS) symptoms, but no scientific trials exist to confirm this. We aim to assess the efficacy of AV on IBS in refractory secondary care patients. Patients with IBS were randomised to receive AV or matching placebo for a month. Symptoms were assessed at baseline, 1 and 3 months. Fifty-eight patients randomised, 49 completed the protocol to 1 month and 41 to 3 months. Eleven of thirty-one (35%) AV patients, and 6 of 27 (22%) placebo patients responded at 1 month (p = 0.763). Diarrhoea predominant patients showed a trend towards a response to treatment at 1 month (10/23 V 2/14, p = 0.07). There was no evidence that AV benefits patients with IBS. However, we could not rule out the possibility that improvement occurred in patients with diarrhoea or alternating IBS whilst taking AV. Further investigations are warranted in patients with diarrhoea predominant IBS, in a less complex group of patients.

Delivery of heterologous protein antigens via hemolysin or autotransporter systems by an attenuated ler mutant of rabbit enteropathogenic Escherichia coli

In this report, we describe the use of an attenuated regulatory mutant of a rabbit enteropathogenic Escherichia coli (rEPEC) as a live vaccine vector to deliver heterologous protein antigens using two dedicated transport systems, a Salmonella autotransporter and the E. coli hemolysin apparatus. We previously reported that an isogeneic ler (LEE encoded regulator) mutant of rEPEC O103:H2 is attenuated and immunogenic in rabbits. We first evaluated the Salmonella autotransporter MisL containing the immunodominant B-cell epitope of the circumsporozoite protein from Plasmodium falciparum, (NANP)8, fused to the C-terminal translocator domain under the control of the constitutive Tac17 promoter. The rEPEC ler mutant was able to express and to translocate the (NANP)8 passenger peptide to the bacterial surface. We next investigated the delivery of Shiga toxin B subunit (Stx1B) from human enterohemorrhagic E. coli by the rEPEC ler mutant via the MisL autotransporter or the E. coli hemolysin secretion apparatus. The autotransporter and hemolysin plasmids expressed similar levels of Stx1B (30-40 ng/ml/OD600). Only 6% of Stx1B was found in the autotransporter supernatants; the rest was cell-associated, with a small fraction of the Stx1B surface-exposed as determined by immunofluorescence. In contrast, 88% of Stx1B was secreted into culture supernatants by the hemolysin secretion system. In an in vivo study, no significant protection was observed in rabbits inoculated with the ler mutant harboring the Stx1B-autotransporter plasmid following experimental challenge with RDEC-H19A, the prototype rEPEC containing an Stx-converting phage. In contrast, rabbits inoculated with the rEPEC ler mutant containing the Stx1B-hemolysin fusion were partially protected from RDEC-H19A infection as demonstrated by decreased weight loss (p<0.008) when compared to rabbits inoculated with the parent ler mutant. Our results suggest that attenuated rEPEC are capable of serving as vaccine vectors to express heterologous protein antigens from different cellular locations and deliver these antigens to the intestinal mucosa. With this system, secreted proteins may be more effective than cell-associated antigens in generating protection.

Neo-epitopes are required for immunogenicity of the La/SS-B nuclear antigen in the context of late apoptotic cells

Mechanisms responsible for the induction of anti-nuclear autoantibodies (ANA) following exposure of the immune system to an excess of apoptotic cells are incompletely understood. In this study, the immunogenicity of late apoptotic cells expressing heterologous or syngeneic forms of La/SS-B was investigated following subcutaneous administration to A/J mice, a non-autoimmune strain in which the La antigenic system is well understood. Immunization of A/J mice with late apoptotic thymocytes taken from mice transgenic (Tg) for the human La (hLa) nuclear antigen resulted in the production of IgG ANA specific for human and mouse forms of La in the absence of foreign adjuvants. Preparations of phenotypically healthy cells expressing heterologous hLa were also immunogenic. However, hLa Tg late apoptotic cells accelerated and enhanced the apparent heterologous healthy cell-induced anti-La humoral response, while non-Tg late apoptotic cells did not. Subcutaneous administration of late apoptotic cells was insufficient to break existing tolerance to the hLa antigen in hLa Tg mice or to the endogenous mouse La (mLa) antigen in A/J mice immunized with syngeneic thymocytes, indicating a requirement for the presence of heterologous epitopes for anti-La ANA production. Lymph node dendritic cells (DC) but not B cells isolated from non-Tg mice injected with hLa Tg late apoptotic cells presented immunodominant T helper cell epitopes of hLa. These studies support a model in which the generation of neo-T cell epitopes is required for loss of tolerance to nuclear proteins after exposure of the healthy immune system to an excess of cells in late stages of apoptosis.

Not well known, used little and needed: Canadian chaplains' experiences of published spiritual assessment tools

What are Canadian chaplains' experiences of published assessment tools? Utilizing a quantitative and qualitative methodology with multiple investigators and theoretical triangulation, this article reports the results of a survey of chaplains in the Canadian Association for Pastoral Practice and Education (CAPPE) and interview results of 15 chaplains in three focus groups. Findings indicated that published spiritual assessment tools are not well know, used little, criticized for being reductionistic and not fitting the clinical situation. Participants noted, however, that spiritual assessment is needed for spiritual care. Thirty percent reported the development of their own tools (not published) and three published tools were mentioned by 50% and more. Discussion, limitations of the research, and suggestions for education, practice, and future research are offered.

Tobacco and alcohol use in lung transplant candidates and recipients

Tobacco and alcohol use among lung transplant candidates and recipients is unknown. Our first goal was to describe tobacco and alcohol use before and after lung transplant in patients with cystic fibrosis (CF) and other pulmonary diseases (non-CF). Our second goal was to determine whether demographic variables, depression, anxiety and social support predicted tobacco and alcohol use. Self-report data from transplant candidates and recipients, and transplant nurse coordinator ratings of post-transplant smoking and drinking were utilized. Data from two samples were analyzed. Sample 1 comprised 219 patients being evaluated for lung transplant, and sample 2 comprised 45 transplant recipients who were 1-7 yrs post-transplant. The results from analyzing sample 1 indicated that 72% of non-CF patients and 16% of CF patients had a history of smoking cigarettes, and the majority of patients in both groups had consumed alcohol in the past. For CF patients, past smoking was related to higher depression scores, and past drinking was related to higher education and lower social support. For non-CF patients, a history of smoking was associated with being Caucasian and older. For CF patients, a history of drinking was associated with being older and less depressed, and for non-CF patients a history of drinking was associated with higher education and lower social support. Post-transplant 100% of recipients reported abstinence from tobacco, and over 60% reported abstinence from alcohol. Transplant coordinator ratings corroborated that no transplant recipients were using tobacco products or consuming alcohol in an excessive or problematic manner. For both groups, consuming alcohol after transplant was related to lower levels of social support. In conclusion, lung recipients remain abstinent from tobacco, and although over 30% of patients consume alcohol after transplant, it is not at problematic levels. Smoking and drinking behaviors were related to demographic variables, depression, and low social support.

Ictal neocortical slowing in temporal lobe epilepsy

BACKGROUND

Temporal lobe epilepsy (TLE) may affect brain regions outside the temporal lobe, causing impaired neocortical function during seizures.

METHODS

The authors selected 11 consecutive patients with mesial TLE and hippocampal sclerosis who underwent intracranial EEG monitoring and had no seizures during a follow-up period of at least 1 year after temporal lobe resection. Secondarily generalized seizures were excluded, and up to three seizures were analyzed per patient (31 seizures total). Electrode contacts were assigned to one of nine cortical regions based on MRI surface reconstructions. EEG during seizures was analyzed for specific patterns including low-voltage fast (LVF), rhythmic polyspike, spike-wave, irregular slowing, and postictal suppression.

RESULTS

Mesial and lateral temporal contacts on the side of seizure onset showed significant increases in ictal patterns such as LVF and polyspike activity, followed by postictal suppression. Bilateral frontal and ipsilateral parietal cortex exhibited large amplitude irregular slow waves during seizures. This frontoparietal slowing persisted into the postictal period. Perirolandic and occipital cortex were relatively spared. These EEG patterns were accompanied by bland staring, minor automatisms, and unresponsiveness or amnesia in the majority of patients studied.

CONCLUSIONS

Prominent irregular slowing occurs in bilateral frontal and ipsilateral parietal association cortex during and after temporal lobe seizures. EEG slowing in the frontoparietal association cortex may signify physiologic impairment that contributes to widespread altered cerebral function during partial seizures.

Clinical audit of the use of fresh-frozen plasma and platelets in a tertiary teaching hospital and the impact of a new transfusion request form

AIM

To carry out an audit of the appropriateness of fresh-frozen plasma (FFP) and platelets (Plt) transfusion with reference to the Australian National Health and Medical Research Council/Australian Society of Blood Transfusion Clinical Practice Guidelines, and to assess the impact of a self-educating transfusion request form.

METHODS

A prospective review of the clinical indications and laboratory data in all transfusion episodes of FFP and Plt occurring in a tertiary teaching hospital in South Australia in two 2-month periods of the years 2002 and 2003.

RESULTS

Reversal of warfarin has emerged as the major indication to transfuse FFP (34%). More than 72% FFP and 88% Plt were prescribed in an appropriate manner, and the majority were monitored adequately. The transfusion request form further improved the appropriate uses and was met with a satisfactory compliance. Further grounds for improvement are in FFP usage by the haematology unit and in cardiac bypass surgery, and Plt by surgical units.

CONCLUSION

Clinical transfusion audit helps to identify current pattern of usage and areas of improvement. A self-educating transfusion specific request form is also beneficial.

Localization and physical property experiments conducted by Opportunity at Meridiani Planum

The location of the Opportunity landing site was determined to better than 10-m absolute accuracy from analyses of radio tracking data. We determined Rover locations during traverses with an error as small as several centimeters using engineering telemetry and overlapping images. Topographic profiles generated from rover data show that the plains are very smooth from meter- to centimeter-length scales, consistent with analyses of orbital observations. Solar cell output decreased because of the deposition of airborne dust on the panels. The lack of dust-covered surfaces on Meridiani Planum indicates that high velocity winds must remove this material on a continuing basis. The low mechanical strength of the evaporitic rocks as determined from grinding experiments, and the abundance of coarse-grained surface particles argue for differential erosion of Meridiani Planum.

Localization and physical properties experiments conducted by Spirit at Gusev Crater

The precise location and relative elevation of Spirit during its traverses from the Columbia Memorial station to Bonneville crater were determined with bundle-adjusted retrievals from rover wheel turns, suspension and tilt angles, and overlapping images. Physical properties experiments show a decrease of 0.2% per Mars solar day in solar cell output resulting from deposition of airborne dust, cohesive soil-like deposits in plains and hollows, bright and dark rock coatings, and relatively weak volcanic rocks of basaltic composition. Volcanic, impact, aeolian, and water-related processes produced the encountered landforms and materials.

Therapeutic efficacy of pooled buffy-coat platelet components prepared and stored with a platelet additive solution

Despite the introduction of platelet additive solutions for the preparation of pooled platelet components, only a few studies of limited scope have evaluated the clinical efficacy of platelets stored in these solutions. The current report presents an analysis of data to evaluate the response to the transfusion of pooled buffy-coat components suspended in storage solution with reduced (35%) plasma content in comparison with 100% plasma products. During the euroSPRITE clinical trial of platelet components treated with a pathogen inactivation process, control treatment group platelet components were prepared in 100% allogeneic donor plasma (plasma control) or in platelet additive solution (T-Sol) mixed with plasma (T-Sol control). Control group thrombocytopenic patients received either plasma control or T-Sol control platelet components. One-hour and 24-h platelet count increments (CIs) and corrected count increments (CCIs) were analysed for these two types of preparation. In addition, haemostatic assessments were conducted for each transfusion. One-hour and 24-h mean platelet CIs and post-transfusion haemostatic scores were not significantly different for patients receiving platelet components suspended in 100% plasma and T-Sol plasma mixtures. Pooled buffy-coat platelet components prepared in reduced plasma content mixtures provided therapeutic platelet CIs with effective haemostasis.