Preventing unrecognized deterioration & improving outcomes of critically ill patients using the National Early Warning Score 2 in a high dependency unit in Bangladesh: A quality improvement project

This Quality Improvement Project (QIP) aimed to assess the acceptability and utility of the National Early Warning Score 2 (NEWS2) in a Bangladeshi level-2 care setting. All nurses and physicians were trained on NEWS2 scores and a proper response before starting the QIP. Utilization of NEWS2 and patient outcome were documented and analyzed. Acceptability was acknowledged by increase in utilization, and utility by reduction in unrecognized deterioration of patients. The modified NEWS2 was well adopted and utilized by the nursing staff. There was a statistically significant reduction in unrecognized deterioration leading to cardiac arrest and the need for transfer to the Intensive Care Unit after implementation of NEWS2. With adequate training, motivation and appropriate modification, NEWS2 can become a well-accepted, widely adopted and realistic bedside monitoring tool in resource-limited settings like Bangladesh.

Field dissipation of 4-nonylphenol, 4-t-octylphenol, triclosan and bisphenol A following land application of biosolids

The persistence of contaminants entering the environment through land application of biosolids needs to be understood to assess the potential risks associated. This study used two biosolids treatments to examine the dissipation of four organic compounds: 4-nonylphenol, 4-t-octylphenol, bisphenol A and triclosan, under field conditions in South Australia. The pattern of dissipation was assessed to determine if a first-order or a biphasic model better described the data. The field dissipation data was compared to previously obtained laboratory degradation data. The concentrations of 4-nonylphenol, 4-t-octylphenol and bisphenol A decreased during the field study, whereas the concentration of triclosan showed no marked decrease. The time taken for 50% of the initial concentration of the compounds in the two biosolids to dissipate (DT50), based on a first-order model, was 257 and 248 d for 4-nonylphenol, 231 and 75 d for 4-t-octylphenol and 289 and 43 d for bisphenol A. These field DT50 values were 10- to 20-times longer for 4-nonylphenol and 4-t-octylphenol and 2.5-times longer for bisphenol A than DT50 values determined in the laboratory. A DT50 value could not be determined for triclosan as this compound showed no marked decrease in concentration. The biphasic model provided a significantly improved fit to the 4-t-octylphenol data in both biosolids treatments, however, for 4-nonylphenol and bisphenol A it only improved the fit for one treatment. This study shows that the use of laboratory experiments to predict field persistence of compounds in biosolids amended soils may greatly overestimate degradation rates and inaccurately predict patterns of dissipation.

Degradation of 4-nonylphenol, 4-t-octylphenol, bisphenol A and triclosan following biosolids addition to soil under laboratory conditions

Land application of biosolids is common practice in many countries, however, there are some potential risks associated with the presence of contaminants within the biosolids. This laboratory study examined the degradation of four commonly found organic compounds, 4-nonylphenol, 4-t-octylphenol, bisphenol A, and triclosan, in soil following the addition of two biosolids over 32 weeks. The pattern of degradation was assessed to determine if it followed a standard first-order decay model or if a biphasic model with a degrading and a recalcitrant fraction better described the data. The time taken for the initial concentrations to decrease by 50% (DT50), based on a first-order model, was 12-25 d for 4-nonylphenol, 10-14 d for 4-t-octylphenol, 18-102 d for bisphenol A, and 73-301 d for triclosan. For 4-nonylphenol, bisphenol A and triclosan, the biphasic model fitted the degradation data better than the first-order model, indicating the presence of a degrading fraction and a non-degrading recalcitrant fraction. The recalcitrant fraction for these three compounds at the completion of the 32 week experiment was 17-21%, 24-42%, and 30-51% of the initial concentrations, respectively. For 4-t-octylphenol, the first-order model was sufficient in explaining the degradation data, indicating that no recalcitrant fraction was present. This study showed that biphasic degradation occurred for some organic compounds in biosolids amended soil and that the use of standard first-order degradation models may underestimate the persistence of some organic compounds following land application of biosolids.

The ischemic preconditioning paradox in deceased donor liver transplantation-evidence from a prospective randomized single blind clinical trial

While animal studies show that ischemic preconditioning (IPC) is beneficial in liver transplantation (LT), evidence from few smaller clinical trials is conflicting. From October 2003 to July 2006, 101 deceased donors (DD) were randomized to 10 min IPC (n = 50) or No IPC (n = 51). Primary objective was efficacy of IPC to decrease reperfusion (RP) injury. Both groups had similar donor risk index (DRI) (1.54 vs. 1.57). Aminotransferases on days 1 and 2 were significantly greater (p < 0.05) in IPC recipients. In multivariate analyses, IPC had an independent effect only on day 2 aspartate transferase. Prothrombin time, bilirubin and histological injury were similar in both groups. IPC had no significant effect on plasma TNF-alpha, IL-6 and IL-10 in the donor and TNF-alpha and IL-6 in the recipient. In contrast, IPC recipients had a significant rise in systemic IL-10 levels after RP (p < 0.05) and had fewer moderate/severe rejections within 30 days (p = 0.09). Hospital stay was similar in both groups. One-year patient and graft survival in IPC versus No IPC were 88% versus 78% (p = 0.1) and 86 versus 76% (p = 0.25), respectively. IPC increases RP injury after DDLT, an 'IPC paradox'. Other potential benefits of IPC are limited. IPC may be more effective in combination with other preconditioning regimens.

Targeted retentive device for oro-dental infections: formulation and development

Fibers loaded with amoxycillin trihydrate were prepared for oro-dental infections using melt spinning technique. Ethylene vinyl acetate, a biocompatible polymer was used for providing controlled release effect over a period of several days. The fibers were evaluated for in vitro release in alkaline borate buffer pH 8.1 in a biological shaker which was rotated at 50 rpm at 37 degrees C. In situ studies were carried out in continuous flow through apparatus which simulated the conditions of periodontal pocket. Microbiological evaluation was carried out on strains commonly implicated in oro-dental infections namely S. aureus, S. mutans, and Bacteroides cereus. Results of in vitro release studies revealed that the effect was sustained over a period of 6 days and followed Fickian diffusion mechanism. In situ release study samples were well above the minimum inhibitory concentration of the drug. These samples were effective in inhibiting the growth of the above-mentioned strains. The optimized formulation was characterized for general appearance, content uniformity, and SEM. Stability studies carried out on the formulation showed the degradation rate constant value of 2.79 x 10(-4) per day. Retentive fibers were found to be very effective in controlled delivery of amoxycillin, and hence can be feasible alternative to systemic administration.