Low molecular weight versus standard heparin for prevention of venous thromboembolism after major abdominal surgery. The Thromboprophylaxis Collaborative Group

Low-molecular-weight heparin (LMWH) is effective in the prevention of postoperative venous thromboembolism but does it have the safety advantages over standard heparin (SH) that have been claimed? In a multicentre randomised trial in 3809 patients undergoing major abdominal surgery (1894 LMWH, 1915 SH) heparin was given preoperatively and continued for at least 5 postoperative days. Patients were assessed in the postoperative period and were followed up for at least 4 weeks, the emphasis being on safety. Major bleeding events occurred in 69 (3.6%) patients in the LMWH group and 91 (4.8%) patients in the SH group (relative risk 0.77, 95% confidence interval 0.56-1.04; p = 0.10). 93 indices of major bleeding were observed in the 69 LMWH patients and 141 in the SH patients. (p = 0.058). Severe bleeding was less frequent in the LMWH group (1.0% vs 1.9%; p = 0.02), as was wound haematoma (1.4% vs 2.7%; p = 0.007). Bleeding episodes with LMWH were less likely to lead to further surgery to evacuate a haematoma or to control bleeding, and injection site bruising was also less common in the LMWH group. No significant differences were found in the efficacy of the two agents. Perioperative death rates were 3.3% in the LMWH group and 2.5% in the SH group; pulmonary emboli were detected in 0.7% and 0.7%; and deep-vein thrombosis was diagnosed in 0.6% of patients in each group. Follow-up was done on 91% of 3699 evaluable patients. There were 19 further deaths (10 LMWH, 9 SH group) and 25 patients with thromboembolic complications (15 and 10). Of the 3 patients with fatal pulmonary emboli during follow-up 2 had received LMWH and 1 SH. The two drugs were of similar efficacy. The primary end point, the frequency of major bleeding, showed a 23% reduction in the LMWH group, but this difference was not significant. The secondary safety end points revealed that LMWH was significantly better than SH. Fatal pulmonary embolism occurs rarely (0.09%) following discharge from hospital so the cost benefit ratio would not justify prolonged prophylaxis in this setting.

Bicarbonate does not improve hemodynamics in critically ill patients who have lactic acidosis. A prospective, controlled clinical study

STUDY OBJECTIVE

To determine whether correction of acidemia using bicarbonate improves hemodynamics in patients who have lactic acidosis.

DESIGN

Prospective, randomized, blinded, crossover study. Each patient sequentially received sodium bicarbonate and equimolar sodium chloride. The order of the infusions was randomized.

SETTING

Intensive care unit of a tertiary care hospital.

PATIENTS

Fourteen patients who had metabolic acidosis (bicarbonate less than 17 mmol/L and base excess less than -10) and increased arterial lactate (mean, 7.8 mmol/L). All had pulmonary artery catheters and 13 were receiving catecholamines.

MEASUREMENTS AND MAIN RESULTS

Sodium bicarbonate (2 mmol/kg body weight over 15 minutes) increased arterial pH (7.22 to 7.36, P less than 0.001), serum bicarbonate (12 to 18 mmol/L, P less than 0.001), and partial pressure of CO2 in arterial blood (PaCO2) (35 to 40 mm Hg, P less than 0.001) and decreased plasma ionized calcium (0.95 to 0.87 mmol/L, P less than 0.001). Sodium bicarbonate and sodium chloride both transiently increased pulmonary capillary wedge pressure (15 to 17 mm Hg, and 14 to 17 mm Hg, P less than 0.001) and cardiac output (18% and 16%, P less than 0.01). The mean arterial pressure was unchanged. Hemodynamic responses to sodium bicarbonate and sodium chloride were the same. These data have more than 90% power of detecting a 0.5 L/min (7%) change in mean cardiac output after administration of sodium bicarbonate compared with that after sodium chloride. Even the 7 most acidemic patients (mean pH, 7.13; range, 6.90 to 7.20) had no significant hemodynamic changes after either infusion.

CONCLUSIONS

Correction of acidemia using sodium bicarbonate does not improve hemodynamics in critically ill patients who have metabolic acidosis and increased blood lactate or the cardiovascular response to infused catecholamines in these patients. Sodium bicarbonate decreases plasma ionized calcium and increases PaCO2.

Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning: a randomised controlled clinical trial

OBJECTIVE

To assess neurological sequelae in patients with all grades of carbon monoxide (CO) poisoning after treatment with hyperbaric oxygen (HBO) and normobaric oxygen (NBO).

DESIGN

Randomised controlled double-blind trial, including an extended series of neuropsychological tests and sham treatments in a multiplace hyperbaric chamber for patients treated with NBO.

SETTING

The multiplace hyperbaric chamber at the Alfred Hospital, a university-attached quarternary referral centre in Melbourne providing the only hyperbaric service in the State of Victoria.

PATIENTS

All patients referred with CO poisoning between 1 September 1993 and 30 December 1995, irrespective of severity of poisoning. Pregnant women, children, burns victims and those refusing consent were excluded.

INTERVENTION

Daily 100-minute treatments with 100% oxygen in a hyperbaric chamber--60 minutes at 2.8 atmospheres absolute for the HBO group and at 1.0 atmosphere absolute for the NBO group--for three days (or for six days for patients who were clinically abnormal or had poor neuropsychological outcome after three treatments). Both groups received continuous high flow oxygen between treatments.

MAIN OUTCOME MEASURES

Neuropsychological performance at completion of treatment, and at one month where possible.

RESULTS

More patients in the HBO group required additional treatments (28% v. 15%, P = 0.01 for all patients; 35% v. 13%, P = 0.001 for severely poisoned patients). HBO patients had a worse outcome in the learning test at completion of treatment (P = 0.01 for all patients; P = 0.005 for severely poisoned patients) and a greater number of abnormal test results at completion of treatment (P = 0.02 for all patients; P = 0.008 for severely poisoned patients). A greater percentage of severely poisoned patients in the HBO group had a poor outcome at completion of treatment (P = 0.03). Delayed neurological sequelae were restricted to HBO patients (P = 0.03). No outcome measure was worse in the NBO group.

CONCLUSION

In this trial, in which both groups received high doses of oxygen, HBO therapy did not benefit, and may have worsened, the outcome. We cannot recommend its use in CO poisoning.

Treatment of resistant intracranial hypertension with hypertonic saline. Report of two cases

The authors describe two patients with traumatic cerebral edema and intracranial hypertension in whom the continued use of mannitol and furosemide resulted in a progressive lessening of the effect of these agents on the intracranial pressure (ICP) and caused prerenal failure. Intravenous administration of hypertonic saline (50 ml and 20 ml of a 5-mmol/ml saline solution over 10 minutes in Cases 1 and 2, respectively) produced a prolonged reduction in the ICP and improved renal function in both cases. It is suggested that if a reduction in ICP without diuresis is required in patients with traumatic cerebral edema, treatment with intravenous hypertonic saline should be considered.

Data Portal for the Library of Integrated Network-based Cellular Signatures (LINCS) program: integrated access to diverse large-scale cellular perturbation response data

The Library of Integrated Network-based Cellular Signatures (LINCS) program is a national consortium funded by the NIH to generate a diverse and extensive reference library of cell-based perturbation-response signatures, along with novel data analytics tools to improve our understanding of human diseases at the systems level. In contrast to other large-scale data generation efforts, LINCS Data and Signature Generation Centers (DSGCs) employ a wide range of assay technologies cataloging diverse cellular responses. Integration of, and unified access to LINCS data has therefore been particularly challenging. The Big Data to Knowledge (BD2K) LINCS Data Coordination and Integration Center (DCIC) has developed data standards specifications, data processing pipelines, and a suite of end-user software tools to integrate and annotate LINCS-generated data, to make LINCS signatures searchable and usable for different types of users. Here, we describe the LINCS Data Portal (LDP) (http://lincsportal.ccs.miami.edu/), a unified web interface to access datasets generated by the LINCS DSGCs, and its underlying database, LINCS Data Registry (LDR). LINCS data served on the LDP contains extensive metadata and curated annotations. We highlight the features of the LDP user interface that is designed to enable search, browsing, exploration, download and analysis of LINCS data and related curated content.

Plasmodium knowlesi Malaria in Sabah, Malaysia, 2015-2017: Ongoing Increase in Incidence Despite Near-elimination of the Human-only Plasmodium Species

BACKGROUND

Malaysia aims to eliminate malaria by 2020. However, while cases of Plasmodium falciparum and Plasmodium vivax have decreased substantially, the incidence of zoonotic malaria from Plasmodium knowlesi continues to increase, presenting a major challenge to regional malaria control efforts. Here we report incidence of all Plasmodium species in Sabah, including zoonotic P. knowlesi, during 2015-2017.

METHODS

Microscopy-based malaria notification data and polymerase chain reaction (PCR) results were obtained from the Sabah Department of Health and State Public Health Laboratory, respectively, from January 2015 to December 2017. From January 2016 this was complemented by a statewide prospective hospital surveillance study. Databases were matched, and species was determined by PCR, or microscopy if PCR was not available.

RESULTS

A total of 3867 malaria cases were recorded between 2015 and 2017, with PCR performed in 93%. Using PCR results, and microscopy if PCR was unavailable, P. knowlesi accounted for 817 (80%), 677 (88%), and 2030 (98%) malaria cases in 2015, 2016, and 2017, respectively. P. falciparum accounted for 110 (11%), 45 (6%), and 23 (1%) cases and P. vivax accounted for 61 (6%), 17 (2%), and 8 (0.4%) cases, respectively. Of those with P. knowlesi, the median age was 35 (interquartile range: 24-47) years, and 85% were male.

CONCLUSIONS

Malaysia is approaching elimination of the human-only Plasmodium species. However, the ongoing increase in P. knowlesi incidence presents a major challenge to malaria control and warrants increased focus on knowlesi-specific prevention activities. Wider molecular surveillance in surrounding countries is required.

Optimal assessment of cervical spine trauma in critically ill patients: a prospective evaluation

There is no uniformly accepted protocol for the radiological assessment of the cervical spine in critically ill trauma patients. The Alfred Trauma Centre receives about 40% of Victorian patients with major trauma. A protocol was developed for cervical spine evaluation, comprising three plain X-rays and a swimmer's view added when necessary to visualize C7-T1, CT and/or MRI for abnormal regions, and functional (flexion/extension) X-rays to exclude cervical spine instability due to soft tissue trauma. Functional X-rays were performed "actively" in conscious patients and "passively" in unconscious patients. One hundred consecutive patients were prospectively evaluated and 91 survived to complete data collection. Six (6.6%) had unstable cervical spine injuries--five detected with plain X-rays and one (1.1%) detected only with passive functional X-rays. Static cervical X-rays cost $93.00 per patient. Functional cervical X-rays added $42.00 per patient and were uncomplicated. Collar complications were common when collars remained on for more than 72 hours. This low detection rate is clinically important because of the enormous potential social and economic costs of missed unstable cervical spine fractures.

Decrease in left ventricular contractility after tumor necrosis factor-alpha infusion in dogs

Whether systolic contractility or diastolic compliance changes soon after tumor necrosis factor-alpha (TNF-alpha) exposure is not known. Accordingly, we measured hemodynamics, left ventricular contractility using the slope of the end-systolic pressure-volume relationship, and diastolic pressure-volume relationships in six control dogs and in six dogs receiving 60 micrograms.kg-1.h-1 i.v. of TNF-alpha. Mean aortic pressure decreased by 22% 1 h after TNF-alpha infusion and remained decreased (P < 0.05). Cardiac output increased by 19% 1 h after TNF-alpha infusion and remained significantly greater than control values (P < 0.05). Left ventricular contractility decreased by 23% (P < 0.05) 1 h after TNF-alpha infusion and decreased by 52% (P < 0.01) 5 h after TNF-alpha infusion. The diastolic pressure-volume relationship did not change in the TNF-alpha group or the control group. Ejection fraction did not change after TNF-alpha infusion despite the decrease in contractility because afterload decreased. We conclude that TNF-alpha is important in causing the hypotensive, hyperdynamic circulation of sepsis. The new finding that left ventricular contractility is decreased shortly after TNF-alpha infusion suggests that TNF-alpha, or another mediator released very soon after TNF-alpha, is an important myocardial depressant factor.

Tumor necrosis factor alpha decreases in vivo diaphragm contractility in dogs

In this study, we hypothesized that tumor necrosis factor alpha (TNF alpha) is an important mediator of sepsis-related impairment in diaphragm contractility (1-2). In 12 anesthetized, ventilated dogs, bipolar stimulating electrodes were placed on the phrenic nerves and diaphragm electromyographic activity (EMG) and shortening were recorded with needle electrodes and piezoelectric crystals, respectively. Transdiaphragmatic pressure (Pdi) was also recorded using esophageal (Pes) and abdominal balloon catheters (Pdi = Pab-Pes). Dogs were randomized to receive saline injection (n = 6), or TNF alpha 60 micrograms/kg (n = 6). All parameters were recorded hourly for 6 h. Mean arterial blood pressure decreased 1 h after infusion in TNF alpha animals (p < 0.05) with no significant change thereafter. Cardiac output increased early after TNF alpha infusion (p < 0.05) and remained at greater than baseline values at study termination. Diaphragm pressure generation and costal shortening decreased progressively from 3 to 6 h post TNF alpha infusion (p < 0.05) with no significant change in control animals. Compound diaphragm action potential in response to supramaximal phrenic stimulation decreased in TNF alpha animals (p < 0.01) with no significant change in control animals 3 and 6 h postinfusion. We conclude that TNF alpha infusion was associated with significant declines in isotonic and quasi-isometric diaphragm contraction and that this could be explained, at least in part, by impaired neuromuscular transmission.

Pulse wave analysis: a preliminary study of a novel technique for the prediction of pre-eclampsia

OBJECTIVE

To investigate whether first-trimester arterial pulse wave analysis (PWA) can predict pre-eclampsia.

DESIGN

This was a prospective screening study.

SETTING

The Homerton University Hospital, a London teaching hospital.

POPULATION

Two hundred and ten low-risk women with a singleton pregnancy were analysed.

METHODS

Radial artery pulse waveforms were measured between the 11(+0) and 13(+6) weeks of gestation and the aortic waveform derived by applying a generalised transfer function. Augmentation pressure (AP) and augmentation index at heart rate of 75 beats per minute (AIx-75), measures of arterial stiffness, were calculated. The multiple of the gestation-specific median in controls for AP and AIx-75 were calculated. Logistic regression models were developed and their predictive ability assessed using the area under the receiver operator curve.

MAIN OUTCOME MEASURES

Prediction of pre-eclampsia by AIx-75.

RESULTS

Fourteen (6.7%) women developed pre-eclampsia, and 196 remained normotensive. Eight of the 14 women developed pre-eclampsia before 34 weeks of gestation (early-onset pre-eclampsia). For a false-positive rate of 11%, AIx-75 had a detection rate of 79% for all cases of pre-eclampsia and 88% for early-onset pre-eclampsia.

CONCLUSION

First-trimester arterial PWA can play a significant role in understanding the pathophysiology of pre-eclampsia and may play a role in early screening.

Internal urinary sphincter in maintenance of female continence

The integrity of the bladder neck was assessed in 98 continent women. Radiological and physiological evidence showed that half of these women had an incompetent bladder neck, but they were still continent. These data devalue the urodynamic finding of an incompetent bladder neck as an indication for surgery for incontinence and question the physiological importance of the internal sphincter.

Percutaneous tracheostomy in critically ill patients: a prospective, randomized comparison of two techniques

OBJECTIVE

To prospectively compare two commonly used methods for percutaneous dilational tracheostomy (PDT) in critically ill patients.

DESIGN

Prospective, randomized, clinical trial.

SETTING

Trauma and general intensive care units of a university tertiary teaching hospital, which is also a level 1 trauma center.

PATIENTS

One hundred critically ill patients with an indication for PDT.

INTERVENTIONS

PDT with the Ciaglia technique using the Ciaglia PDT introducer set and the Griggs technique using a Griggs PDT kit and guidewire dilating forceps.

MEASUREMENTS AND MAIN RESULTS

Surgical time, difficulties, and surgical and anesthesia complications were measured at 0-2 hrs, 24 hrs, and 7 days postprocedure. Groups were well matched, and there were no differences between the two methods in surgical time or in anesthesia complications. Major bleeding complications were 4.4 times more frequent with the Griggs PDT kit. With the Ciaglia PDT kit, both intraoperative and at 2 and 24 hrs, surgical complications were less common (p = .023) and the procedure was more often completed without expert assistance (p = .013). Tracheostomy bleeding was not associated with either anticoagulant therapy or an abnormal clotting profile. Multivariate analysis identified the predictors of PDT complications as the Griggs PDT kit (p = .027) and the Acute Physiology and Chronic Health Evaluation (APACHE) II score (p = .041). The significant predictors of time required to complete PDT were the APACHE II score (p = .041), a less experienced operator (p = .0001), and a female patient (p = .013).

CONCLUSIONS

Patients experiencing PDT with the Ciaglia PDT kit had a lower surgical complication rate (2% vs. 25%), less operative and postoperative bleeding, and less overall technical difficulties than did patients undergoing PDT with the Griggs PDT kit. Ciaglia PDT is, therefore, the preferred technique for percutaneous tracheostomy in critically ill patients.

Novel octaketide macrolides related to 6-deoxyerythronolide B provide evidence for iterative operation of the erythromycin polyketide synthase

BACKGROUND

The macrolide antibiotic erythromycin A, like other complex aliphatic polyketides, is synthesised by a bacterial modular polyketide synthase (PKS). Such PKSs, in contrast to other fatty acid and polyketide synthases which work iteratively, contain a separate set or module of enzyme activities for each successive cycle of polyketide chain extension, and the number and type of modules together determine the structure of the polyketide product. Thus, the six extension modules of the erythromycin PKS (DEBS) together catalyse the production of the specific heptaketide 6-deoxyerythronolide B.

RESULTS

A mutant strain of the erythromycin producer Saccharopolyspora erythraea, which accumulates the aglycone intermediate erythronolide B, was found unexpectedly to produce two novel octaketides, both 16-membered macrolides. These compounds were detectable in fermentation broths of wild-type S. erythraea, but not in a strain from which the DEBS genes had been specifically deleted. From their structures, both of these octaketides appear to be aberrant products of DEBS in which module 4 has 'stuttered', that is, has catalysed two successive cycles of chain extension.

CONCLUSIONS

The isolation of novel DEBS-derived octaketides provides the first evidence that an extension module in a modular PKS has the potential to catalyse iterative rounds of chain elongation like other type I FAS and PKS systems. The factors governing the extent of such 'stuttering' remain to be determined.

A smoking cessation programme conducted through dental practices in the UK

OBJECTIVES

To assess the feasibility of using primary care dentists and the dental team providing smoking cessation advice in practice.

DESIGN

A prospective study to examine the success of a smoking cessation programme.

SETTING

54 primary care dental practices in the UK.

METHOD

Training and educational materials were supplied to members of the dental team and to potential recruits smoking 10 or more cigarettes a day. Recruitment was over 6 months and subjects were followed up for 9 months. In addition to dentists' counselling, nicotine patches were made available, on request, at cost price. Salivary cotinine assay was used for validation of smoking levels at initial counselling and 9 months after recruitment.

RESULTS

54 practices were enrolled but only 22 recruited patients. Records of 154 eligible patients were evaluated. Compliance to attend follow up clinics was poor--only 74 reported at 9 months. Among them 17 (11%) were successful in giving-up tobacco for 9 months as validated by patient histories and salivary cotinine assay. A large variation performance of the dental practices was noted.

CONCLUSIONS

Motivated dentists with staff support and access to information on smoking counselling are able to contribute to tobacco control measures in the community. The success of this programme closely parallels those reported in general medical practice settings. In view of the very considerable attrition rates found at all levels of the programme in the present study and the uneven performance of the participating practices the quit rate reported here may not accurately reflect what could be achieved in an individual primary care setting.

Quality assessment of the management of road traffic fatalities at a level I trauma center compared with other hospitals in Victoria, Australia. Consultative Committee on Road Traffic Fatalities in Victoria

OBJECTIVES

Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria, Australia, has identified problems including those contributing to death and the potential preventability of deaths in road fatalities who survived until at least the arrival of ambulance services. The present analysis examines the outcomes at a Level I trauma center compared with other hospital groups in Victoria.

METHODS

Between 1992 and 1994, 257 consecutive eligible fatalities were evaluated. Problems in management and preventable deaths were identified at the trauma center (TC) and in pooled data from other hospital groups, i.e., specialist teaching (Level II), other metropolitan (Level III), large regional (Level III), and small regional hospitals.

RESULTS

Mean problems identified and those contributing to death (controlled for the number of areas of care), were less frequent at TC (1.7 and 0.6) than at other hospital groups (specialist teaching, 1.9 and 1.1*; metropolitan, 3.1* and 1.6*; large regional, 3.8* and 1.8*; small regional, 5.1* and 2.6*) (*p < 0.05 compared with TC). Preventable and potentially preventable deaths were also less common at TC (20%) than at the other hospital groups (specialist teaching, 40%*; metropolitan, 41%*; large regional, 53%*; small regional, 62%*) (*p < 0.05 compared with TC). When a Trauma and Injury Severity Score of 75% or more was used to define preventable death, a similar trend was identified.

CONCLUSION

Management of patients with major trauma at a Level I trauma center was associated with fewer problems contributing to death and fewer preventable and potentially preventable deaths than at the different hospital groups. A trauma system in Victoria, including bypass of major trauma patients to designated hospitals with 24-hour trauma services, is likely to decrease the frequency of problems, including the preventable death rates.

Predictive value of cervimetric labour patterns in primigravidae

From a study of 2000 consecutive labours the outcome of the 684 primigravid patients admitted in spontaneous labour has been examined according to their cervimetric progress during the first stage of labour. A partogram and labour stencil were used to identify dysfunctional labour which was treated with a standard protocol of augmentation by oxytocin. This policy achieved labours with a mean 'observed first stage' of 6.3 h and a caesarean section rate of 8.7%. There was one stillbirth due to multiple congenital abnormalities and no increase in perinatal morbidity. Our data show that the type of first stage cervimetric pattern is helpful in predicting the outcome of labour. A normal cervimetric pattern resulted in a vaginal delivery rate of 98.4%; primary dysfunctional labour, which could be improved by oxytocin, had a 93.8% incidence of vaginal delivery, but if there was no improvement in the rate of cervical dilatation when this was administered the vaginal delivery rate was only 22.7% . A prolonged latent phase was associated with a caesarean section rate of 16.7% and the incidence of neonatal intubation was nearly as high as that found in uncorrected primary dysfunctional labour. The neonatal asphyxia in secondary arrest was minimal with an overall caesarean section rate of 28.4%; there was no increased incidence of neonatal morbidity with this cervimetric type.

Toombak use and cigarette smoking in the Sudan: estimates of prevalence in the Nile state

BACKGROUND

Survey data on the prevalence of use of oral snuff (toombak) and cigarette consumption according to various demographic factors are needed in the Sudan.

METHODS

A house to house cross-sectional survey of a random population sample of 4,535 households was performed. Of the 23,367 household members identified, 21,648 (92.6%) eligible individuals were questioned about tobacco use.

RESULTS

Among children and adolescents (4-17 years) prevalence of tobacco use was quite low (2%, range 1-2%), but there was an abrupt increase up to 25% in late adolescence. Among the adult population aged 18 years and older the prevalences of toombak use (34%) and cigarette smoking (12%) among males were significantly higher than among females (2.5 and 0.9%, respectively). The prevalence of toombak use among the male population aged 18 years and older was significantly higher in the rural than in the urban areas (35% vs 24%), while cigarette smoking had a higher prevalence in urban areas (18% vs 12%). The highest rates of toombak use were found in rural areas among the male population ages 30 years and older (mean 46.6%, range 45-47%).

CONCLUSIONS

In view of the high prevalence of tobacco use, especially of toombak, among the population surveyed, there is an urgent need to educate the public on the health consequences of these habits.

The effect of manual lung hyperinflation and postural drainage on pulmonary complications in mechanically ventilated trauma patients

This study questioned whether manual lung hyperinflation (MHI) and postural drainage reduced the incidence of nosocomial pneumonia or improved other outcome variables in mechanically ventilated trauma patients. Patients were withdrawn from the study if they developed nosocomial pneumonia according to a predetermined definition or on the clinical suspicion of nosocomial pneumonia by the attending intensivist. Of the 46 patients who fulfilled all the inclusion criteria and were enrolled into the study, 22 patients were randomized to group A (physiotherapy) and 24 patients to group B (control group). Twice as many patients were withdrawn in group B (8/24) compared with group A (4/22), although the differences were not statistically significant, [X2(1, 1) = 1.36, P = 0.24]. The length of time receiving mechanical ventilation and in the ICU was similar between the two groups and there were no differences in pulmonary dysfunction ("worst" daily PaO2/FiO2 ratio) between the two groups. There were no ICU deaths in either group. Physiotherapy as used in this study was not associated with a reduced incidence of nosocomial pneumonia based on standard clinical criteria. Nevertheless the trend to more frequent nosocomial pneumonia in the control patients suggests that a larger study in more severely injured patients with stricter clinical criteria for the definition of nosocomial pneumonia is indicated.

The effects of subcutaneous hormone implants during climacteric

Climacteric symptoms in 120 women were treated with a total of 469 hormone implants (oestradiol 50 mg and testosterone 100 mg) over a period of four years. All patients with a uterus were given an oral progestogen to prevent endometrial hyperplasia. There was a marked response to treatment, hot flushes being improved in all patients, depression in 99% and loss of libido in 92%. Patient acceptability of this type of treatment was good and there were few side effects or complications. After therapy, the serum oestradiol exceeded the serum oestrone but remained within normal limits. When climacteric symptoms returned and re-implantation occurred the serum levels of oestrone, oestradiol, luteinising hormone (LH), follicle stimulating hormone (FSH) and testosterone were within the normal range for the reproductive age. This indicates that the return of symptoms is due to a change in the hormone levels rather than absolute hypo- oestrogenism .

Oral manifestations of an HIV positive cohort in the era of highly active anti-retroviral therapy (HAART) in South London

BACKGROUND

Human Immunodeficiency Virus (HIV) infection is associated with oral manifestations of diagnostic and prognostic importance. With the advent of Highly Active Anti-retroviral Therapy (HAART) there is anecdotal evidence to suggest that the prevalence of oral lesions has declined. The number of prevalence studies, carried out in the era of HAART is, however, meagre. Our aim was to study the prevalence of the oral manifestations of HIV in a population, predominantly on HAART, attending a Genito-Urinary Medicine Centre in South London.

METHODS

This cross sectional study included 203 adult volunteers, comprising 76% males and 24% females. One third of the subjects were from the predominantly African or Afro- Caribbean ethnic minority groups resident in London. The relationship between the prevalence of oral lesions and demographic variables, therapeutic regimes, viral load and CD4 counts were evaluated.

RESULTS

One hundred (49%) of the patients had no detectable oral lesions. Oral lesions detected most frequently included oral hairy leukoplakia (9.9%), HIV associated periodontal diseases (9.9%) and oral candidiasis (4.9%). Three subjects had multiple papillomatous growths. Most cases (n = 17/20) of oral hairy leukoplakia were in individuals with a detectable (> 400 copies/ml) plasma RNA viral load. The majority (n = 8/10) of our patients with oral candidiasis had a plasma RNA viral load > 10,000 copies/ml and half (n = 5/10) had a CD4 count < 200 cells/mm3. Logistic regression analysis suggested that the presence of an oral lesion was not associated with any demographic features except for periodontal diseases which were associated with tobacco smoking (P = 0.023).

CONCLUSIONS

The prevalence of so called 'strongly associated' oral lesions of HIV is low in this South London HIV-infected population on HAART, and the relative frequency is different from that cited in the literature from the pre-HAART era. The oral lesions detected were found mostly in people with low CD4 counts and high HIV-1 RNA viral loads, suggesting they were very immunocompromised, not on, or declining therapy, or that their therapy was failing.

Deaths From Plasmodium knowlesi Malaria: Case Series and Systematic Review

BACKGROUND

Plasmodium knowlesi causes severe and fatal malaria, and incidence in Southeast Asia is increasing. Factors associated with death are not clearly defined.

METHODS

All malaria deaths in Sabah, Malaysia, from 2015 to 2017 were identified from mandatory reporting to the Sabah Department of Health. Case notes were reviewed, and a systematic review of these and all previously reported fatal P. knowlesi cases was conducted. Case fatality rates (CFRs) during 2010-2017 were calculated using incidence data from the Sabah Department of Health.

RESULTS

Six malaria deaths occurred in Sabah during 2015-2017, all from P. knowlesi. Median age was 40 (range, 23-58) years; 4 cases (67%) were male. Three (50%) had significant cardiovascular comorbidities and 1 was pregnant. Delays in administering appropriate therapy contributed to 3 (50%) deaths. An additional 26 fatal cases were included in the systematic review. Among all 32 cases, 18 (56%) were male; median age was 56 (range, 23-84) years. Cardiovascular-metabolic disease, microscopic misdiagnosis, and delay in commencing intravenous treatment were identified in 11 of 32 (34%), 26 of 29 (90%), and 11 of 31 (36%) cases, respectively. The overall CFR during 2010-2017 was 2.5/1000: 6.0/1000 for women and 1.7/1000 for men (P = .01). Independent risk factors for death included female sex (odds ratio, 2.6; P = .04), and age ≥45 years (odds ratio, 4.7; P < .01).

CONCLUSIONS

Earlier presentation, more rapid diagnosis, and administration of intravenous artesunate may avoid fatal outcomes, particularly in females, older adults, and patients with cardiovascular comorbidities.

Prolonged pregnancy: is induction of labour indicated? A prospective study

A prospective controlled study of 2000 patients to determine the incidence of postmaturity and the effect of a policy of non-induction of labour in prolonged pregnancy is reported. 'Certain postmaturity' was identified in 4% of the patients and was associated with an increased incidence of babies with Apgar scores of less than 5 at 1 min; induction of labour at 42 weeks gestation did not affect the neonatal outcome compared with that in patients allowed to go into spontaneous labour. Induction of labour in patients designated as 'certain postmature' and 'uncertain postmature' reduced the number of vaginal deliveries and increased the caesarean section rate from 9.6 to 26.7 and from 2.2 to 31.2% respectively. The failure to improve the perinatal outcome does not support or justify induction of labour for uncomplicated postmaturity.

Fetal activity in 100 normal third trimester pregnancies

The incidence of fetal breathing movements (FBM), fetal trunk movements (FTM), and total fetal activity (TFA) was assessed in 100 normal pregnancies between 28 weeks and term. One 30-minute recording was made from each patient between 0900 and 1700 hours. The mean incidences of FBM, FTM and TFA were respectively 37 +/- 26 (SD) per cent, 18 +/- 10 per cent, and 53 +/- 24 per cent. The mean breathing rate was 48 +/- 12 per minute, and the mean nunber of movements per 30-minute study period was 29 +/- 15. There was a slightly higher incidence of FBM postprandially, but this failed to reach statistical significance. The mean incidence of FBM was lower before 31 weeks and after 40 weeks, compared to that between 31 and 40 weeks, when the values of FBM and FTM were constant. The breathing rate was directly related to gestational age. The mean number of movements per 30-minute study period was inversely related to gestational age, but the duration of movements increased progressively towards term, so that the incidence of FTM was constant throughout the third trimester. There was only one recording of TFA below 10 per cent.

Mass spectrometry of the humanized monoclonal antibody CAMPATH 1H

Two mass spectrometric techniques, electrospray ionization (ESI) and matrix-assisted laser desorption ionization (MALDI) have been used to study the intact humanized monoclonal antibody CAMPATH 1H, its fully and partially deglycosylated species, and 13 fragments prepared from it. The transformed ESI mass spectra of the glycosylated species gave complex patterns of molecular masses (M(r's). These have been substantially assigned to the presence of a mixture of glycoforms, each resulting from the combination of a single protein species with specific glycans of four distinct masses. The MALDI mass spectra of the glycosylated species, with the exception of that of the smallest fragment Fc/2, which indicated the presence of three of the glycans, gave single M(r) values comparable to the mean M(r) calculated from the ESI results. The M(r) values for the 10 prepared nonglycosylated species support the validity of the published amino acid sequence for the antibody and define the cleavage sites for the enzymic fragmentations. It is concluded that mass measurement of the Fc/2 fragment using ESI techniques provides a convenient means of preliminary assessment of the major glycosylated entities.