[Brain death diagnosis after sedation with propofol or sufentanil. Recommendations for the usage of toxicological analytics]

BACKGROUND

Before the clinical diagnosis of brain death is made, toxicological analyses are often performed for the exclusion of effective serum levels of previously applied sedating drugs. For propofol and sufentanil there are no uniform recommendations for the usage of toxicology test results.

OBJECTIVES

To develop a standard practice in the diagnosis of brain death after therapeutic application of one of these drugs.

MATERIAL AND METHODS

Based on the current literature and the available analytical assays, an ad hoc working group consisting of specialists in toxicology and intensive care medicine compiled recommendations for the usage of toxicological analytics in the diagnosis of brain death at the Rostock University Hospital.

RESULTS

For propofol, current analytical assays allow the quantification of serum concentrations of 0.2 μg/ml and lower; the execution of clinical brain death diagnostics is recommended by the ad hoc group only at propofol serum levels lower than  0.4 μg/ml. For sufentanil, the currently prevalent assays set lower determination limits of about 0.2 ng/ml in serum and 0.1 ng/ml in urine, which is above the cautiously adopted lower therapeutic serum concentration of 0.02 ng/ml. Therefore after negative determination of sufentanil (< 0.2 ng/ml) in blood serum, the following alternative procedures are recommended: (1) the execution of clinical brain death diagnostics under administration of naloxone; or (2) at intact renal function the additional negative determination of sufentanil in urine (< 0.1 ng/ml). If an assay allowing the detection of sufentanil at ≤ 0.01 ng/ml is available, brain death diagnostics should be carried out only at a serum level lower than  0.02 ng/ml.

CONCLUSION

These recommendations may serve as a proposal for similar standards in other hospitals.

Ein neuer Zugang zu ionischen Thionylimiden. Einkristallstruktur von N(CH3)4NSO / A New Access to Ionic Thionylimides. Single Crystal Structure of N(CH3)4NSO

Single crystals of N(CH3)4NSO have been prepared via ion exchange from RbNSO or CsNSO and tetraalkylammonium halides in liquid ammonia and investigated by X-ray single crystal techniques (I4̅, a = 1137.6(1), c = 1134.9(2) pm, Z = 8, T = -100 °C). The crystal structure of N(CH3)4NSO is related to the CsCl-type of structure. Using the same preparative route NMe3BzNSO has been obtained. Its lattice powder data (orthorhombic primitive; a = 896.3(2), b = 1235.4(3), c = 1070.7(4) pm).

Changes in insulin sensitivity in response to different modalities of exercise: a review of the evidence

Type 2 diabetes is an increasingly prevalent condition with complications including blindness and kidney failure. Evidence suggests that type 2 diabetes is associated with a sedentary lifestyle, with physical activity demonstrated to increase glucose uptake and improve glycaemic control. Proposed mechanisms for these effects include the maintenance and improvement of insulin sensitivity via increased glucose transporter type four production. The optimal mode, frequency, intensity and duration of exercise for the improvement of insulin sensitivity are however yet to be identified. We review the evidence from 34 published studies addressing the effects on glycaemic control and insulin sensitivity of aerobic exercise, resistance training and both combined. Effect sizes and confidence intervals are reported for each intervention and meta-analysis presented. The quality of the evidence is tentatively graded, and recommendations for best practice proposed.

Automated detection of proliferative diabetic retinopathy using a modified line operator and dual classification

Proliferative diabetic retinopathy (PDR) is a condition that carries a high risk of severe visual impairment. The hallmark of PDR is neovascularisation, the growth of abnormal new vessels. This paper describes an automated method for the detection of new vessels in retinal images. Two vessel segmentation approaches are applied, using the standard line operator and a novel modified line operator. The latter is designed to reduce false responses to non-vessel edges. Both generated binary vessel maps hold vital information which must be processed separately. This is achieved with a dual classification system. Local morphology features are measured from each binary vessel map to produce two separate feature sets. Independent classification is performed for each feature set using a support vector machine (SVM) classifier. The system then combines these individual classification outcomes to produce a final decision. Sensitivity and specificity results using a dataset of 60 images are 0.862 and 0.944 respectively on a per patch basis and 1.00 and 0.90 respectively on a per image basis.

Torsion einer Leberzyste bei einem Kalb

Ein 7 Tage altes männliches Fleckviehkalb wurde wegen Inappetenz und Auftreibung des Abdomens vorgestellt. Im Rahmen der sonographischen Untersuchung wurde im ventralen Abdomen eine zweigeteilte, durch zahlreiche hyperechogene Septen gekammerte Struktur mit anechogenem Inhalt festgestellt. Bei der diagnostischen Laparotomie des Tieres zeigte sich eine gestielte, durch eine Drehung um 720° zweigeteilte, mit der Facies diaphragmatica der Leber stegartig verbundene Leberzyste. Die Zyste konnte chirurgisch vollständig entfernt werden. Der Heilungsverlauf des Kalbes war komplikationslos und die Entwicklung der Körpermasse entsprach der seiner Altersgenossen. Die histopathologische Untersuchung der Zystenwand bestätigte das Vorliegen einer serösen Leberzyste.

[Torsion of a liver cyst in a calf]

A 7-day-old male calf was presented because of an abdominal distension and a reduced feed intake. Sonographic examination showed a multi-chambered mass with anechoic content, separated by numerous hyperechoic septa in the ventral aspect of the abdomen. During diagnostic laparotomy, the cystic mass adhering to the diaphragmatic surface of the liver was determined to be a liver cyst with a 720°-torsion separating the cyst into two parts. A complete resection of the pedunculated cyst was achieved. The calf recovered completely and body-weight gain following surgery was typical for its age and breed. Histopathological examination of the cystic wall confirmed the diagnosis of a serosal liver cyst.

Non-attendance at diabetic eye screening and risk of sight-threatening diabetic retinopathy: a population-based cohort study

AIMS/HYPOTHESIS

This study evaluated whether repeated non-attendance for diabetic eye screening is associated with the risk of sight-threatening diabetic retinopathy (STDR).

METHODS

This was a cohort study of 6,556 residents with diabetes who were invited for screening between 2008 and 2011 in a population-based eye screening programme in inner London and who attended for their first-ever screen in 2008. The proportion of participants with STDR was evaluated in relation to the number of years in which screening was missed.

RESULTS

The proportion of participants who did not attend screening decreased between 2009 and 2011 (annual reduction 1.6% [95% CI 0.9%, 2.3%]). The adjusted relative odds of STDR for 210 participants who did not attend two consecutive years of screening were 3.76 (95% CI 2.14, 6.61; p < 0.001), compared with participants who were screened annually. In 605 participants with mild non-proliferative retinopathy at the first screen, the adjusted relative odds of developing proliferative or moderate to severe non-proliferative retinopathy were 5.72 (95% CI 7.43, 22.83; p = 0.013) for 53 participants who missed two screens.

CONCLUSIONS/INTERPRETATION

Patients who do not attend diabetic eye screening are at increased risk of developing STDR. Tracing of non-attenders with evidence of established retinopathy should be an important fail-safe procedure.

Changes in detection of retinopathy in type 2 diabetes in the first 4 years of a population-based diabetic eye screening program: retrospective cohort study

OBJECTIVE

Annual diabetic eye screening has been implemented in England since 2008. This study aimed to estimate changes in the detection of retinopathy in the first 4 years of the program.

RESEARCH DESIGN AND METHODS

Participants included 32,340 patients with type 2 diabetes resident in three London boroughs with one or more screening records between 2008 and 2011. Data for 87,570 digital images from 2008 to 2011 were analyzed. Frequency of sight-threatening diabetic retinopathy (STDR) was estimated by year of screen for first screens and for subsequent screens according to retinopathy status at first screen.

RESULTS

Among 16,621 first-ever screens, the frequency of STDR was 7.1% in 2008, declining to 6.4% in 2011 (P = 0.087). The proportion with a duration of diabetes of <1 year at first screen increased from 18.7% in 2008 to 48.6% in 2011. Second or later screens were received by 26,308 participants. In participants with mild nonproliferative retinopathy at first screen, the proportion with STDR at second or later screen declined from 21.6% in 2008 to 8.4% in 2011 (annual change -2.2% [95% CI -3.3 to -1.0], P < 0.001). In participants with no retinopathy at first screen, STDR declined from 9.2% in 2008 to 3.2% in 2011 (annual change -1.8% [-2.0 to -1.7], P < 0.001). Declining trends were similar in sociodemographic subgroups.

CONCLUSIONS

After the inception of population-based diabetic eye screening, patients at lower risk of STDR contribute an increasing proportion to the eligible population, and the proportion detected with STDR at second or subsequent screening rounds declines rapidly.

Region and task-specific activation of Arc in primary motor cortex of rats following motor skill learning

Motor learning requires protein synthesis within the primary motor cortex (M1). Here, we show that the immediate early gene Arc/Arg3.1 is specifically induced in M1 by learning a motor skill. Arc mRNA was quantified using a fluorescent in situ hybridization assay in adult Long-Evans rats learning a skilled reaching task (SRT), in rats performing reaching-like forelimb movement without learning (ACT) and in rats that were trained in the operant but not the motor elements of the task (controls). Apart from M1, Arc expression was assessed within the rostral motor area (RMA), primary somatosensory cortex (S1), striatum (ST) and cerebellum. In SRT animals, Arc mRNA levels in M1 contralateral to the trained limb were 31% higher than ipsilateral (p<0.001), 31% higher than in the contralateral M1 of ACT animals (p<0.001) and 48% higher than in controls (p<0.001). Arc mRNA expression in SRT was positively correlated with learning success between two sessions (r=0.52; p=0.026). For RMA, S1, ST or cerebellum no significant differences in Arc mRNA expression were found between hemispheres or across behaviors. As Arc expression has been related to different forms of cellular plasticity, these findings suggest a link between M1 Arc expression and motor skill learning in rats.

Crohn's disease unmasked following etanercept treatment for ankylosing spondylitis

We describe the case of a 45-year-old man with ankylosing spondylitis being treated with etanercept who presented with a 1 month history of abdominal pain. CT abdomen revealed an ileocaecal mass associated with an abscess, resulting in a laparotomy and right hemi-colectomy. Histology of the resected specimen showed the classical features of Crohn's disease. Etanercept was stopped and he was started on adalimumab. He is currently in clinical remission from both ankylosing spondylitis and Crohn's disease.

Balling gun-induced trauma in cattle: clinical presentation, diagnosis and prevention

Pharyngeal trauma in cattle can occur during the administration of oral medication using a balling gun. The number of cases of severe complications due to bolus application that have been referred to our hospital has increased from nil between 1996 and 2008 to three or four per year. In our experience, reports by bovine veterinarians of patients with severe and often fatal pharyngeal trauma, which were not referred to the clinic, have become more common in recent years as well. The incidence of this complication is likely to be higher than this number of referrals suggests. Diagnosis without the help of imaging techniques, such as radiography and endoscopy, may be difficult, especially in cases where exploration of the pharynx cannot be carried out, or is unable to confirm the absence or presence of a lesion. Prognosis is often poor in cases where perforation has been confirmed. Boluses are increasingly administered by the owners or farm personnel without the supervision of a veterinarian. In order to prevent losses due to balling gun-induced injuries, the veterinarian plays a crucial role in giving advice to his clients. Five cases of cattle suffering from varying degrees of balling gun-induced trauma are presented, and consideration is given to incorrect application techniques.