P1383Procedural differences during de novo paroxysmal atrial fibrillation ablation with a contact force-sensing ablation catheter between Europe and U.S

Background

Although pulmonary vein isolation (PVI) is considered the standard approach of atrial fibrillation ablation worldwide, procedural practice during the ablation varies by geographical region. Using the same magnetic sensor enabled contact force-sensing ablation catheter for the treatment of de novo paroxysmal atrial fibrillation, a comparison of procedural detail between Europe and U.S operators can provide insights into geographic specific clinical practices. 

Purpose

To characterize and compare procedural differences during paroxysmal atrial fibrillation ablation performed with a magnetic sensor enabled contact force-sensing catheter across European and U.S. centers. 

Methods

Procedural data were prospectively collected in clinical cases performed with a new magnetic sensor enabled, contact force ablation catheter within the first 6 months of use at participating centers in Europe and the U.S. Procedure time, PVI time, PVI confirmation method, fluoroscopy usage and lesion delivery parameters were analyzed based on geographies. 

Results

A total of 131 cases across 35 centers in 11 European countries, and 95 cases across 26 U.S. centers were analyzed. Target geometry was created with the ablation catheter in 94 out of 131 (71.8%) European cases, while only 5 out of 95 U.S. cases (5.3%) reported the use of the ablation catheter for model creation. Although a steerable sheath (64.1% and 67.3%) was commonly used with the ablation catheter in both geographies, difference in the utilization of bidirectional contact force catheter (52.7% and 90.5%) and the automated lesion marking module (76.3% and 81.1%) were observed in European and U.S. cases, respectively. The use of adenosine or isoproterenol to confirm PVI was reported in 25% and 64% of the European and U.S. cases. Average waiting periods were 18.2 minutes and 26.5 minutes from reported European and U.S. cases. Total procedural time, mapping time, and fluoroscopy time were similar between European and U.S. cases. (Table). First pass PVI were 66.4% and 72.6% for European and U.S. cases, respectively.

Conclusion

Total procedural time and RF time were similar between European and U.S. cases during de novo paroxysmal atrial fibrillation ablation using the same ablation catheter. Differences in workflow including the use of a mapping catheter for geometry creation and waiting period were observed between the two geographies.

Summary of procedural details De novo PAF N Procedural time(min) Mapping time (min) PVI time (min) Total RF time (min) Fluoro time( min) Europe 131 144.0 ± 56.9 16.6 ± 17.1 69.8 ± 35.0 33.2 ± 15.6 11.6 ± 10.1 U.S. 95 137.6 ± 64.8 18.1 ± 23.5 58.8 ± 31.5 32.3 ± 22.2 12.0 ± 15.8

P981Comparison of automark utilization and lesion metric target during paroxysmal atrial fibrillation ablation with a contact force-sensing ablation catheter: European and U.S. multicenter Experiences

Background

Accurate delivery of transmural lesion is associated with improved durability of pulmonary vein isolation and reduced reconduction. Lesion quality depends on multiple parameters such as radiofrequency power, tissue-catheter contact, duration of energy application, and catheter tip temperature. Consequently, energy delivery parameters vary based on individual operators’ preferences and procedural needs.

Purpose

To characterize and compare the utilization of automated lesion marking feature and lesion delivery parameters used during paroxysmal atrial fibrillation ablation performed with a magnetic sensor enabled contact force-sensing catheter across European and U.S. centers.

Methods

Procedural data were prospectively collected in clinical cases performed with a new magnetic sensor enabled, contact force ablation catheter within the first 6 months of use at participating centers in Europe and the U.S. Use of bidirectional CF catheters, steerable sheaths, automated lesion marking software and associated lesion delivery parameters during paroxysmal atrial fibrillation ablation were evaluated.

Results

A total of 149 cases across 37 centers in 11 European countries, and 112 cases across 31 U.S. centers were analyzed. A bidirectional contact force catheter (56.4% and 90.2%), a steerable sheath (65.8% and 69.6%), and the automated lesion marking module (77.9% and 90.2%) were used in most European and U.S. cases, respectively. The most commonly reported energy delivery parameters were: lesion index (LSI), Force-Time Integral (FTI), and time from European cases; LSI, average force, and FTI for U.S. cases (Table). Target LSI values were recorded for 126 cases in Europe and 34 in the U.S, ranging from 3 to 6. In anterior/roof segments, most common LSI target values for anterior/roof and posterior/inferior segments were 6 (42.9%) and 5 (51.2%) in Europe, and 5.5 (44.1%) and 5 (54.5%) in the U.S. PVI was confirmed with an average of 20.3 minutes waiting period (69.1%) for European cases and exit block (57.1%) in U.S. cases. First pass PVI were 67.1% and 74.4% for European and U.S. cases, respectively.

Conclusion

Energy delivery parameters and PVI confirmation method varied considerably by geography during paroxysmal atrial fibrillation ablation using the magnetic sensor enabled, contact force ablation catheter. Further study on efficacy implication on these differences in practice should be examined.

Energy delivery parameters used Paroxysmal AF N LSI FTI Time Imp Drop Avg Force Other N/A Europe 149 44.0 % 13.4 % 7.0 % 6.0 % 2.4 % 1.0 % 26.2 % U.S. 112 31.2% 17.9 % 6.2 % 8.0 % 23.2 % 11.7 % 1.8 % Energy delivery parameters used in paroxysmal AF ablation in Europe and U.S.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Adenosine tri-phosphate (ATP)-based cleaning monitoring in health care: how rapidly does environmental ATP deteriorate?

BACKGROUND

Ensuring cleaning compliance of housekeeping staff is critical to ensure adequate application of surface disinfectants. Adenosine triphosphate (ATP) testing has been recommended as a way to monitor cleaning compliance; however, little is known about the stability of ATP on environmental surfaces.

AIM

To assess the stability of ATP from various sources to determine if it is stable for sufficient time to be an effective means of assessing environmental cleaning and disinfection in health care.

METHODS

Purified ATP, ATP derived from ATS-T (blood-based test soil) and ATP derived from 10(7) colony-forming units/site of micro-organisms (Pseudomonas aeruginosa, Enterococcus faecalis, Candida albicans) were evaluated in liquid suspension and dried on to surfaces to assess stability over 29 days. Cleaners and disinfectants were sprayed on to surface-dried material with no wiping to determine their effect on microbial viability and ATP stability.

FINDINGS

Surface-dried P. aeruginosa, E. faecalis and C. albicans retained 65-96% of their original ATP level on Day 29, despite reduced or no viability. Surface-dried ATS-T had 100% and 3% of its original ATP on Days 4 and 29, respectively. Deterioration of the ATP signal was most pronounced for suspensions. Purified ATP was stable over 29 days in suspension or dried on to a surface.

CONCLUSIONS

ATP residuals from organic material and micro-organisms (dead or alive) are stable when dried on to surfaces. In the absence of cleaning and disinfection, the relative light unit signal will not deteriorate rapidly, making ATP a good marker to monitor cleaning.

Intermediate-level disinfection with accelerated hydrogen peroxide prevents accumulation of bacteria in Versajet™ tubing during repeated daily debridement using simulated-use testing with an inoculated pork hock

OBJECTIVE

This study assesses the feasibility of using the Versajet™ system (VJS) on an inoculated pork hock (PH) skin surface sequentially for 8 days with daily cleaning and intermediate-level disinfection (ILD).

METHODS

Daily, PHs were inoculated with bacteria suspended in artificial test soil (ATS). An ILD protocol with accelerated hydrogen peroxide (AHP, OxivirTB(®)) was employed to clean and disinfect the VJS between debridements.

RESULTS

PH skin contains 6.1-6.8×10(6)cfu/cm(2) bacteria. Bacterial counts in the handpiece and discharge hoses immediately after debridement of the PHs, and before cleaning, increased throughout the study period (5.19-6.43log10cfu/mL). Cleaning with the ILD protocol was reduced bacterial counts on the VJS by 6-log. Protein, a surrogate marker of organic contamination, was also reduced post-cleaning and ILD. Compared to a maximum post-debridement level of protein (57.9 μg/mL) obtained before ILD, VJS protein levels dropped to 9.8 (handpiece) and 13.8 μg/mL (discharge hose).

CONCLUSIONS

Disinfection of the handpiece and discharge hose after debridement with AHP resulted in a 6-log reduction in bacterial count and 4.2 fold reduction in protein. An ILD protocol with an AHP may be a feasible method for serial skin surface debridements with the VJS for up to eight days.

Manual Methods Are Suboptimal Compared With Automated Methods for Cleaning of Single‐Use Biopsy Forceps •

OBJECTIVE

Most reusable biopsy forceps and all of the currently available single-use biopsy forceps do not have a port that allows fluid flow down the inner tubular shaft of the device. Reusable biopsy forceps are widely used and reprocessed in healthcare facilities, and single-use biopsy forceps are reprocessed either in-house (eg, in Canada and Japan) or by third-party reprocessors (eg, in the United States). The objective of this study was to determine the cleaning efficacy of automated narrow-lumen sonic irrigation cleaning, sonication-only cleaning, and manual cleaning for biopsy forceps.

DESIGN

A simulated-use study was performed by inoculating the inner channel of single-use biopsy forceps with artificial test soil containing both Enterococcus faecalis and Geobacillus stearothermophilus at concentrations of 10(6) colony-forming units per milliliter. The cleaning methods evaluated were manual cleaning, sonication-only cleaning, and "retroflush" cleaning by an automated narrow-lumen irrigator. Bioburden and organic soil reduction after washing was evaluated. Forceps used in biopsies of patients were also tested to determine the worst-case soiling levels.

RESULTS

Only retroflush irrigation cleaning could effectively remove material from within the shaft portion of the biopsy forceps: it achieved an average reduction of more than 95% in levels of protein, hemoglobin, carbohydrate, and endotoxin. However, even this method of cleaning was not totally effective, as only a 2 log10 reduction in bioburden could be achieved, and there were low residual levels of hemoglobin and carbohydrate.

CONCLUSION

The data from this evaluation indicate that manual and sonication-only cleaning methods for biopsy forceps were totally ineffective in removing material from within the biopsy forceps. Even the use of retroflush cleaning was not totally effective. These findings suggest that in-hospital reprocessing of biopsy forceps with currently available equipment and cleaning methods is suboptimal.

Effects of the cowpea chlorotic mottle bromovirus beta-hexamer structure on virion assembly

The X-ray crystal structure of Cowpea chlorotic mottle bromovirus (CCMV) revealed a unique tubular structure formed by the interaction of the N-termini from six coat protein subunits at each three-fold axis of the assembled virion. This structure, termed the beta-hexamer, consists of six short beta-strands. The beta-hexamer was postulated to play a critical role in the assembly and stability of the virion by stabilizing hexameric capsomers. Mutational analyses of the beta-hexamer structure, utilizing both in vitro and in vivo assembly assays, demonstrate that this structure is not required for virion formation devoid of nucleic acids in vitro or for RNA-containing virions in vivo. However, the beta-hexamer structure does contribute to virion stability in vitro and modulates disease expression in vivo. These results support a model for CCMV assembly through pentamer intermediates.

Analysis and occurrence of polybrominated diphenyl ethers in Washington state freshwater fish

A method is described for analyzing polybrominated diphenyl ethers (PBDEs) in fish tissue using gas chromatography with atomic emission detection (GC/AED) and quantitation by compound independent calibration (CIC). The method has the advantage of an element-selective response, including selectivity between bromine and chlorine. An analysis of fish tissue samples from selected locations in Washington State showed total PBDE concentrations ranged from 1.4 microg/kg (wet weight) in rainbow trout from a remote spring-fed stream to 1,250 microg/kg in mountain whitefish from the urbanized Spokane River. Tetra and penta isomers were the major compounds present. There appear to be substantial between-species differences in the ability of fish to metabolize PBDEs.

Surface chemical characterization of 2.5-microm particulates (PM2.5) from air pollution in Salt Lake City using TOF-SIMS, XPS, and FTIR

Particulate matter with a diameter of 2.5 microm collected in Salt Lake City (SLC PM2.5) was studied using TOF-SIMS (time-of-flight secondary-ion mass spectrometry), XPS (X-ray photoelectron spectroscopy), and FTIR (Fourier transform infrared spectroscopy). The high spatial resolution and high surface sensitivity of TOF-SIMS allow the surfaces of individual particulates to be analyzed. The high mass-resolution of TOF-SIMS provides good separation of signals from different chemical species at the same nominal mass, and the extremely high detection sensitivity of TOF-SIMS makes the detection of trace elements possible. Metallic elements such as Li, Na, Mg, Al, K, Ca, Cr, Mn, Fe, Cu, Zn, Cs, and Bi were detected by TOF-SIMS on the surface of SLC PM25. The uranium ion U+ together with its oxide ions UO+ and UO2+ were also found. Inorganic compounds detected include oxides, hydroxides, nitrates, sulfates, silicates, borates, chlorides, etc. Organic compounds detected include hydrocarbons, alcohols, aldehydes, ethers, carboxylic acids, amines, amides, nitriles, etc. A number of polycyclic aromatic hydrocarbons (PAH) and nitrated polycyclic aromatic hydrocarbons were detected by TOF-SIMS. High-resolution XPS Cls spectrum shows functional groups such as C-O, CO2, C-CO2, C-C, and C-H and aromatic pi-pi* shake-up transitions. High-resolution XPS O 1s spectrum indicates the coexistence of different oxygen compounds on the surface of PM2.5. FTIR results confirm the presence of various organic compounds in SLC PM2.5 detected by TOF-SIMS and XPS.

Pictures into words. Visual models and data in psychoanalysis

The psychoanalytic method is considered as an instrument or medium of observation, with attention to certain peculiarities of data collection and recording. Freud's visual models and metaphors are then reviewed. Subsequent approaches to visual data in analysis are examined in the work of Charles Fisher, Mark Kanzer, Bertram Lewin, and M. Robert Gardner. A corresponding theory of therapeutic action is suggested.

Worst-case soiling levels for patient-used flexible endoscopes before and after cleaning

BACKGROUND

The soiling levels of patient-used narrow-lumened flexible endoscopes were assessed for bronchoscopes, duodenoscopes, and colonoscopes. The effect of cleaning on the soil composition and concentration was evaluated.

DESIGN

Suction channels from 10 each of bronchoscopes, duodenoscopes used for endoscopic retrograde cholangiopancreatography, and colonoscopes were assessed immediately after patient use for the levels of bilirubin, hemoglobin, protein, sodium ion, carbohydrate, endotoxin, and viable bacteria. Another 10 suction channels of each type of endoscope were evaluated for the same components after routine cleaning but before processing by high-level disinfection or sterilization for subsequent clinical use.

RESULTS

Recognizing that only soluble components could be quantified, the worst-case soil levels in the suction channels (the average surface area of these channels was 45.6 cm(2), 149.8 cm,(2) and 192.0 cm(2) for bronchoscopes, duodenoscopes, and colonoscopes, respectively) were protein 115 microg/cm(2), sodium ion 7.4 micromol/cm(2), hemoglobin 85 microg/cm(2), bilirubin 299 nmol/cm(2), carbohydrate 29.1 microg/cm(2), endotoxin 9852 endotoxin units/cm(2), and bacteria 7.1 (log(10)) colony-forming units (CFU)/cm(2). Colonoscopes had 4 to 5 times greater soiling on average compared with the other endoscope types. Routine cleaning reduced the levels of bilirubin to below the limits of detection for all endoscopes evaluated (limits of detection were <1 nmol/mL). After cleaning, residual hemoglobin was detectable in bronchoscopes only. After cleaning, the levels of protein, endotoxin, and sodium ion all were reduced fivefold to tenfold for all types of endoscopes. Carbohydrate was reduced to lower than the limit of detection for all endoscopes after cleaning, except the duodenoscopes. The average load of viable bacteria was reduced from 3 log(10) to 5 log(10) CFU/cm(2) (which represents 5.9-9.5 log(10) CFU/endoscope channel) after patient use to approximately 2 log(10) CFU/cm(2) (which represents 3.2-5.3 log(10) CFU/endoscope channel) after cleaning.

CONCLUSIONS

These data demonstrated that cleaning effectively reduced or eliminated many components of soil, but a substantial amount of viable bacteria and protein remained. Hemoglobin levels in before samples indicated that blood was not present in high concentrations in the suction channels of the majority of flexible endoscope samples. Soil that mimics the worst-case composition from patient-used endoscopes would be ideal for simulated-use studies for such medical devices.

Comparison of liquid chemical sterilization with peracetic acid and ethylene oxide sterilization for long narrow lumens

The aim of this study was to determine how well peracetic acid liquid chemical sterilization (LCPAS) killed test organisms in the presence of 10% fetal bovine serum and 0.65% salt challenge (RPMI-S) compared with a 100% ethylene oxide (ETO) sterilizer and an ETO hydrochlorofluorocarbon (ETO-HCFC) sterilization method with long (125 cm), narrow (3-mm internal diameter) flexible lumens as the test carrier. The inoculated lumens were dried overnight before processing. The test organisms included Mycobacterium chelonei, Enterococcus faecalis, and Bacillus subtilis. For all 3 organisms tested, the LCPAS process resulted in a 6 log10 reduction in bacterial load compared with a 2.5 log10 to 6 log10 reduction for the 100% ETO and ETO-HCFC sterilizers. Sterilization was achieved for 100%, 61%, and 67% of the lumen test carriers for the LCPAS, 100% ETO, and ETO-HCFC sterilizers, respectively. The data indicate that of the sterilization methods evaluated, LCPAS was the most effective for sterilizing narrow flexible lumens in the presence of residual inorganic and organic soil. This effectiveness was achieved through a combination of organism wash-off and peracetic acid sterilant killing of organisms. Salt was the major compounding factor for effective ETO gas sterilization, because carriers inoculated with organisms in 10% fetal bovine serum alone all were sterilized by both 100% ETO and ETO-HCFC sterilization methods. Our data support the critical need to ensure adequate precleaning of narrow flexible lumen endoscopes before any sterilization method.

Cubism, Freud, and the image of wit

This essay contributes to the psychoanalytic understanding of creativity by applying Freud's theories of jokes and dreams to the interpretation of Cubist-paintings and collages of 1907-14. The selection of Cubism is justified on the basis of various questions which Freud and the Cubists asked in common, questions concerning reality, both external and psychic; the processes of representation and interpretation; the correspondences between the arts and other mental products, such as language and dreams; and the nature of the child and of the so-called primitive mind. Moreover, certain innovative features of Cubism--the incorporation of words, texts, and jokes into painting, and the use of collage--lend themselves to, perhaps even require, exegesis in Freudian terms.

Bacterial killing ability of 10% ethylene oxide plus 90% hydrochlorofluorocarbon sterilizing gas

OBJECTIVES

To use a serum and salt challenge in narrow-lumen carriers to evaluate a 10% ethylene oxide plus 90% hydrochlorofluorocarbon (EO-HCFC) sterilant mixture in a retrofitted 12/88 sterilizer as an alternative to the banned chlorofluorocarbon-ethylene oxide (EO) sterilant mixture.

DESIGN

An EO-HCFC sterilizing gas mixture in a retrofitted 12/88 sterilizer was compared to 100% ethylene oxide (100% EO) sterilizing gas to determine its relative ability to kill seven different bacteria (Escherichia coli, Pseudomonas aeruginosa, Enterococcus faecalis, Bacillus subtilis spores, Bacillus stearothermophilus spores, Bacillus circulans spores, and Mycobacterium chelonei) in the presence or absence of a combined 10% serum and 0.65% salt challenge using both penicylinders (PC) and long narrow-lumen (LU) carriers.

RESULTS

The EO-HCFC sterilant mixture (96% sterile carriers) was equivalent to the 100% EO sterilant (98% sterile carriers) for killing vegetative organisms, as well as spore suspensions, on the 27 PC and 27 LU carriers in the absence of serum and salt. In the presence of serum and salt, the EO-HCFC sterilant mixture was markedly better than the 100% EO sterilant at reducing the bacterial load on the 63 PC carriers (95% vs 62% sterile PC carriers, respectively), whereas both sterilizers were equivalent for the 63 LU carriers (49% vs 40% sterile LU carriers, respectively). Of the seven test organisms, E faecalis, B subtilis, B stearothermophilus, and B circulans were the most difficult to kill for both PC and LU carriers when serum and salt were present.

CONCLUSIONS

The data presented in this report indicate that the EO-HCFC sterilant mixture is an effective alternative for gas sterilization. Indeed, the efficiency of bacterial killing for the EO-HCFC sterilant mixture was similar to that achieved by the 12/88 EO-CFC sterilant mixture.

Improved detection of bacterial growth in continuous ambulatory peritoneal dialysis effluent by use of BacT/Alert FAN bottles

Culture-negative peritonitis is a major complication for patients on continuous ambulatory peritoneal dialysis (CAPD) and precludes organism-specific therapy. The aim of the present study was to compare inoculation of 10 ml of CAPD effluent into BacT/Alert blood culture bottles (FAN [fastidious antimicrobic neutralizing], BacTAlert aerobic [BTA], and BacT/Alert anaerobic [BTAn] bottles) to our conventional method of using 50 ml of concentrated CAPD effluent to inoculate peptone broth bottles (BD bottles) and MacConkey agar and blood agar medium (BA-MAC). The FAN, BTA, and BTAn bottles were monitored automatically in the BacT/Alert blood culture instrument. A total of 207 CAPD effluents were studied, and in 97 bacteria were detected by at least one method. Compared to BTA bottles (79 of 97; 81.4%), BTAn bottles (78 of 97; 80.4%), and BD bottles (88 of 97; 90.7%), the single best broth medium for detecting bacterial growth in CAPD effluents was the FAN bottle (90 of 97 effluents; 92.8%). A total of 125 bacterial species were detected by any method, and the majority (91.8%) of CAPD effluents were infected with a single species. A combination of FAN and BTAn bottles detected 111 of 125 (88.8%) of all organisms, whereas a combination of BD bottles and BA-MAC detected 107 of 125 (85.6%) of all organisms. One or more organisms that would have been completely missed by the conventional method with BD bottles and BA-MAC were detected in 18 CAPD effluents. Of these 18 CAPD effluents, 6 showed no growth by the conventional method with BD bottles and BA-MAC. On the basis of our data, the most sensitive and least labor intensive method was direct inoculation of 10 ml of CAPD effluent into a FAN bottle and a BTAn bottle, which could be automatically monitored by the BacT/Alert blood culture instrument. On the basis of case definitions for peritonitis, the sensitivities and specificities of the methods with FAN and BTAn bottles and with BD bottles and BA-MAC were 81.1 and 98.8% and 74.5 and 96.5%, respectively.

Standardized problem list generation, utilizing the Mayo canonical vocabulary embedded within the Unified Medical Language System

VOCABULARY: The Mayo problem list vocabulary is a clinically derived lexicon created from the entries made to the Mayo Clinic's Master Sheet Index and the problem list entries made to the Impression/ Report/Plan section of the Clinical Notes System over the last three years. The vocabulary was reduced by eliminating repetition including lexical variants, spelling errors, and qualifiers (Administrative or Operational terms). Qualifiers are re-coordinated with other terms, at run-time, which greatly increased the number of input strings which our system is capable of recognizing.

IMPLEMENTATION

The Problem Manager is implemented using standard windows tools in a Windows NT environment. The interface is designed using Object Pascal. HTTP calls are passed over the World Wide Web to a UNIX based vocabulary server. The server returns a document, which is read into Object Pascal structures, parsed, filtered and displayed.

STUDY

This paper reports the results of a recent Usability Trial focused on assessing the viability of this mechanism for standardized problem entry. Eight clinicians engaged in eleven scenarios and responded as to their satisfaction with the systems performance. These responses were observed, videotaped and tabulated. Clinicians in this study were able to find acceptable diagnoses in 91.1% of the scenarios. The response time was acceptable in 92.5% of the scenarios. The presentation of related terms was stated to be useful in at least one scenario by seven of the eight participants. All clinicians wanted to make use of shortcuts which would minimize the amount of typing necessary to encode the concept they were searching for (e.g. Abbreviations, Word Completion).

CONCLUSIONS

Clinicians are willing to choose a canonical term from a suggested list (as opposed to their own wording). Clinicians want an "intelligent" system, which would suggest terms within a category (e.g. Types of "Migraine"). They are able to make functional use of our system, in its current state of development. Finally, all clinicians appreciate the value of encoding their problems in a standardized vocabulary, toward improved research, education and practice.

Comparison of ion plasma, vaporized hydrogen peroxide, and 100% ethylene oxide sterilizers to the 12/88 ethylene oxide gas sterilizer

OBJECTIVE

The performance of a standard gas sterilizer, which uses a mixture of 12% ethylene oxide (EtO) and 88% chlorofluorocarbon as the sterilizing gas (12/88), was compared to selected gas, ion plasma, and vaporized hydrogen peroxide (H2O2) sterilizers that do not use chlorofluorocarbons. The effect of serum and salt on sterilizer performance was evaluated.

DESIGN

Test carriers (porcelain and stainless steel penicylinders, or 125-cm lengths of plastic tubing [internal diameter of 3.2 mm]) were inoculated with Escherichia coli, Enterococcus faecalis, Pseudomonas aeruginosa, Mycobacterium chelonei, Bacillus stearothermophilus spores, Bacillus subtilis spores, and Bacillus circulans spores and then subjected to sterilization using 12/88, 100% EtO, ion plasma, or vaporized H2O2. The bacterial inoculum was prepared with and without 10% serum and 0.65% salt, and the residual bacterial load after sterilization as determined using viable counts.

RESULTS

All of the sterilizers tested effected a six-log10 reduction of the bacterial inoculum on penicylinders, unless 10% serum and 0.65% salt were present, in which case the 100% EtO, vaporized H2O2, and ion plasma sterilizers were not as effective as the 12/88 sterilizer. None of the sterilizers could eradicate 10(6) CFU of all of the bacteria in 10% serum and 0.65% salt when inoculated inside a narrow lumen.

CONCLUSIONS

The margin of safety for the 100% EtO, vaporized H2O2, and ion plasma sterilizers is less than that of the 12/88 sterilizer. The inability of all sterilizers, including the 12/88, to kill organisms in narrow lumens reliably when serum and salt were present raises concern about the current practice of gas sterilization of flexible endoscopes.

Transmission of Ureaplasma urealyticum from mothers to full and preterm infants

This study assessed maternal genital colonization and subsequent neonatal transmission rate of Ureaplasma urealyticum in pregnant women in an average socioeconomic population. In addition very low birth weight infants were assessed to determine whether the presence of U. urealyticum correlated with increased risk of developing respiratory problems. The study group consisted of 108 sequential full term mothers and 104 preterm mothers delivering in a tertiary care hospital in central Canada. The genital carriage rates (assessed using placental sampling) of ureaplasmas in term and preterm mothers were 25.9 and 19.2%, respectively (P = 0.3185). Acquisition of ureaplasmas in the neonatal respiratory tract of neonates occurred significantly (P = 0.0182) more often in preterm neonates (11 of 130; 8.5%) than in term neonates (2 of 110; 0.9%). Very low birth weight (VLBW) infants (< or = 1500 g) were at greater risk (P = 0.042) of acquiring ureaplasmas in their respiratory tracts (5 of 26; 19%) than larger preterm neonates (6 of 104; 5.8%). All VLBW infants with respiratory colonization by ureaplasmas (5 of 5) developed bronchopulmonary dysplasia compared with 33% (7 of 21) of VLBW neonates without ureaplasmas (P = 0.028). This difference in bronchopulmonary dysplasia development among VLBW infants was independent of further stratification by birth weight. These VLBW neonates with ureaplasmas also stayed significantly (P = 0.037) longer in the neonatal intensive care unit (43.6 +/- 10.4 days) than did other preterm neonates (22.1 +/- 20.8 days). Our results demonstrate that VLBW preterm neonates have increased risk of acquiring U. urealyticum.(ABSTRACT TRUNCATED AT 250 WORDS)

Serologic testing for reactive arthritis

The objective of the study was to determine the sensitivity and specificity of quantitative serum antibody response to Salmonella enteritidis lipopolysaccharide (LPS) as a diagnostic test for post-Salmonella reactive arthritis (ReA). In a single food-source outbreak of Salmonella enteritidis, serum was collected from dysenteric individuals with and without ReA at 6, 12, and 24 months post infection. Serum was also collected from control patients with no prior exposure to Salmonella infection. Quantitative measurements of isotypic antibodies to Salmonella enteritidis LPS were performed by an ELISA. Sensitivity and specificity of quantitative isotypic antibody levels over time were plotted on receiver operator characteristic (ROC) curves. Serum IgG and IgA anti-LPS were found to be present in higher levels in the ReA patients than in controls. Using the optimal cutoff of 0.10 selected from an ROC curve, IgG anti-LPS is 88% sensitive and 94% specific, and IgA anti-LPS is 75% sensitive and 100% specific. We conclude that IgA anti-LPS is both sensitive and specific in distinguishing prior exposure to Salmonella LPS in ReA patients compared to unexposed controls.

Secretory immune response and clinical sequelae of Salmonella infection in a point source cohort

OBJECTIVE

To determine the kinetic isotypic serum and secretory immune response to Salmonella enteritidis in a cohort of individuals exposed to the organism in a single food source outbreak of dysentery. To determine the clinical outcome and immunogenetics of the exposed cohort and to correlate these features with the immune response.

METHODS

Following a single point source outbreak of Salmonella enteritidis, a cohort of dysenteric individuals were ascertained using a reactive arthritis screening questionnaire (QUEST). Serum and stimulated saliva samples were obtained at 6, 12, and 24 months following the outbreak of dysentery; examinations were conducted at the same time. Two unexposed control groups were ascertained: (1) general rheumatology clinic patients and (2) well nonarthritic family practice patients. An ELISA to determine quantitative IgA responses to Salmonella enteritidis lipopolysaccharide (LPS) was performed.

RESULTS

Eleven of the 84 exposed individuals with dysentery developed reactive arthritis (ReA) of reactive enthesitis (ReE). There was a prolonged salivary IgA anti-LPS response in both the ReA/ReE and DYS (dysentery alone) patients compared with unexposed controls. A ratio of salivary IgA anti-LPS/serum IgA anti-LPS > 1 was associated with a good outcome (remission) of ReA, whereas a ratio < 1 was associated with chronic disease.

CONCLUSIONS

There is a more prolonged humoral immune response to Salmonella LPS in exposed individuals than hitherto described. A risk factor in the prolongation of ReA is the inability to mount an appropriate specific salivary (secretory) immune response.

Analysis of risk factors associated with prostate cancer extension to the surgical margin and pelvic node metastasis at radical prostatectomy

We analyzed data from 107 consecutive patients with clinical stage B prostate cancer in an attempt to identify those at high risk for having involved margins or nodal metastasis. Each patient underwent transrectal ultrasound-guided sextant biopsies of the prostate. Patient age, surgical approach to prostatectomy, pre-biopsy prostate specific antigen (PSA) level, and number, location and maximum Gleason score of positive biopsies were statistically evaluated for all patients groups. Prostate volume and PSA density (PSAD) were calculated for all patients undergoing prostatectomy. Of the 101 patients who underwent radical prostatectomy 64 had negative margins, 37 had at least 1 positive margin and 11 of the 37 had more than 1 positive margin. Involved margins were most common at the apex (62%) and mid portion (59%) of the gland. Prostatectomy was not performed on 6 patients with nodal metastases evident on frozen section examination. Therefore, 43 patients are considered to be at high risk for having residual disease after surgery. The mean PSAD, PSA level and number of positive biopsies were significant (p < 0.05) predictors of tumor extension to the surgical margin. The mean number of positive biopsies, biopsy Gleason score and PSA level were significantly greater (p < 0.05) in patients with nodal metastases. Only 15% of the patients with a single positive biopsy had positive margins versus 47% of those with multiple positive biopsies (p < 0.05). Of the patients with tumor positive nodes on frozen section 67% had 5 or more positive biopsies, whereas only 9% of all others had that many positive biopsies (p < 0.05). The number of positive biopsy sites, PSAD and PSA level were significantly associated with tumor at the surgical margin or metastatic to the pelvic nodes.

Humoral immune response of humans to lipooligosaccharide and outer membrane proteins of Haemophilus ducreyi

The humoral immune response to purified lipooligosaccharide (LOS) and outer membrane proteins (OMP) of Haemophilus ducreyi was evaluated. Sera from chancroid-endemic (Uganda, Kenya) and -nonendemic (Canada) countries were tested by an ELISA. The response to OMPs was cross-reactive with other Haemophilus species, and elevated levels of antibody were detected in patients that did not have chancroid. The LOS component stimulated an H. ducreyi-specific immune response that was detected only in patients with chancroid. The sensitivity of the LOS ELISA was 96% (95% confidence interval, 89.9%-100%) and the specificity was 97% (95% confidence interval, 95.8%-98.2%). Thus, the anti-H. ducreyi LOS immune response is a significant diagnostic and epidemiologic indicator.

Use of an adsorption enzyme immunoassay to evaluate the Haemophilus ducreyi specific and cross-reactive humoral immune response of humans

Serodiagnosis of chancroid is limited by the cross-reactivity of Haemophilus ducreyi with Haemophilus influenzae and Haemophilus parainfluenzae. This research describes an adsorption enzyme immunoassay (EIA) that assesses the humoral immune response of North Americans and Africans to H. ducreyi. Adsorption effectively removed anti-H. influenzae and anti-H. parainfluenzae antibodies, revealing that North American control sera had no residual anti-H. ducreyi reactivity. However, African control sera still had a residual anti-H. ducreyi response. Assessment of the duration of the humoral immune response in sera from African patients with chancroid showed that the humoral antibodies persisted for up to 8 months after the diagnosis. This may explain the lack of specificity of the adsorption EIA in areas where chancroid is endemic. The detection of the humoral immune response was affected by the strain of H. ducreyi used, with indigent strains being most useful. Using H. ducreyi 35000 for Canadian sera, the sensitivity of the adsorption EIA was 100% and the specificity was 88%. For African sera, H. ducreyi strain R018 was used, and the adsorption EIA had a sensitivity of 81% and a specificity of only 23%. These data reveal that the existing humoral response in a country where chancroid is endemic differs from that in a country where it is not, and that care must be used interpreting unadsorbed humoral immune responses. The adsorption EIA approach may prove useful as an epidemiologic tool for definition of existing (past and present) levels of exposure to H. ducreyi.

Endoscopic and videofluoroscopic evaluations of swallowing and aspiration

A new procedure for evaluating oropharyngeal dysphagia utilizing fiberoptic laryngoscopy was compared to the videofluoroscopy procedure. Twenty-one subjects were given both examinations within a 48-hour period. Results of the fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopy examinations were compared for presence or absence of abnormal events. Good agreement was found, especially for the finding of aspiration (90% agreement). The FEES was then measured against the videofluoroscopy study for sensitivity, specificity, positive predictive value, and negative predictive value. Sensitivity was 0.88 or greater for three of the four parameters measured. Specificity was lower overall, but was still 0.92 for detection of aspiration. It was concluded that the FEES is a valid and valuable tool for evaluating oropharyngeal dysphagia. Some specific patients and conditions that lend themselves to this procedure are discussed.

Regulation of the phage phi 29 prohead shape and size by the portal vertex

Bacteriophage phi 29 of Bacillus subtilis packages its double-stranded DNA into a preformed prohead during morphogenesis. The prohead is composed of the scaffold protein gp7, the capsid protein pg8, the portal protein gp10, and the dispensable head fiber protein gp8.5. Our objective was to elucidate the phi 29 prohead assembly pathway and to define the factors that determine prohead shape and size. The structural genes of the phi 29 prohead were cloned and expressed in Escherichia coli individually or in combination to study form determination. The scaffold protein was purified from E. coli as a soluble monomer. In vivo and in vitro studies showed that the scaffolding protein interacted with both the portal vertex and capsid proteins. When the scaffold protein interacted only with the capsid protein in vivo, particles were formed with variable size and shape. However, in the presence of the portal vertex protein, particles with uniform size and shape were produced in vivo. SDS-PAGE analysis showed that the latter particles contained the proteins of the scaffold, capsid, head fiber, and portal vertex. These results suggest that the scaffolding protein serves as the linkage between the portal vertex and the capsid proteins, and that the portal vertex plays a crucial role in regulating the size and shape of the prohead.

Microencapsulated enzyme systems for the acceleration of cheese ripening

Enzymes and substrates encapsulated in either milkfat-coated microcapsules or liposomes have been investigated for potential use as agents to accelerate cheese ripening. Milkfat-coated microcapsules have been used to efficiently encapsulate cell-free extracts, viable cells, purified enzymes, and spores. Encapsulation efficiency was dependent on the conditions used during capsule production. Addition of these microcapsules to cheese has resulted in increased levels of flavour compounds such as diacetyl, acetoin, methanethiol, and methyl ketones, compared to levels in control cheeses. Limitations due to cofactors have been overcome by co-encapsulating enzymes which recycle needed cofactors. Liposomes have been used to carry cell-free extracts and enzymes into cheese. Trials with different types of liposomes revealed that enzymes could be entrapped more efficiently and liposomes retained in the cheese curd better when multilammelar vesicles rather than small unilamellar vesicles or reverse phase evaporation vesicles were used. The stability of liposome preparations was found to be adversely affected by increased pH, temperature, and sodium chloride concentrations, as well as by negative surface charge. Encapsulation efficiency was found to increase by using a dehydration-rehydration procedure for liposome preparation. Temperature sensitive liposomes were investigates as a means of obtaining controlled release of the enzymes into the cheese.

Analgesic efficacy of two ibuprofen-codeine combinations for the treatment of postepisiotomy and postoperative pain

Our purpose was to compare the analgesic efficacy and safety of single oral doses of the combination of ibuprofen 400 mg plus codeine 60 mg and the combination of ibuprofen 200 mg plus codeine 30 mg with ibuprofen 400 mg alone, codeine sulfate 60 mg alone, and placebo. One hundred ninety-five patients with severe pain resulting from episiotomy, cesarean section, or gynecologic surgery completed a randomized, double-blind, stratified, parallel-group study. Patients were observed during a 4-hour period after medication. Based on the sum of the pain intensity differences (SPID), total pain relief (TOTPAR), and most of the hourly direct measures of pain and relief, both doses of the combination and ibuprofen 400 mg alone were statistically superior to placebo. Codeine 60 mg was statistically superior to placebo based on TOTPAR, the global ratings, and a few hourly measures. The mean effect of the combination of ibuprofen 400 mg plus codeine 60 mg was significantly superior to the mean effect of ibuprofen 400 mg alone 1/2, 1, and 2 hours after medication and to the mean effect of ibuprofen 400 mg alone and codeine 60 mg alone for SPID, TOTPAR, and other measures as well. The low-dose combination was significantly more effective than codeine 60 mg for a few hourly measures but was not significantly superior to ibuprofen 400 mg. Based on these findings it appears that the combination of ibuprofen 400 mg plus codeine 60 mg, particularly in the first few hours after medication, is more efficacious than its constituents.

The correlation between blood levels of ibuprofen and clinical analgesic response

A clinical trial comparing ibuprofen, 400, 600, and 800 mg, with aluminum ibuprofen, 400 mg, and placebo was conducted in patients with moderate or severe pain subsequent to third molar extraction. Pain intensity ratings and ibuprofen serum levels were obtained at baseline, 30 minutes, 1 hour, and hourly thereafter for 3 hours. Pain intensity ratings were also obtained at hours 4, 5, and 6. Serum levels at 1, 2, and 3 hours correlated significantly with the log dose of ibuprofen (r = 0.35, 0.49, and 0.48, respectively) and with global analgesic response as measured by the percentage of the sum of the pain intensity scores (r = 0.28, 0.34, and 0.26, respectively). However, possibly because of differences in drug formulation, the percentage of the sum of the pain intensity scores did not correlate significantly with log dose. The highest correlations were found between contemporaneous serum levels and pain intensity difference values, particularly at hour 1 (r = 0.54). Our results support the proposition that increased ibuprofen serum levels lead to increased analgesia.

Comparative study of flurbiprofen, zomepirac sodium, acetaminophen plus codeine, and acetaminophen for the relief of postsurgical dental pain

The relative analgesic efficacy and safety of single oral doses of 50 and 100 mg of flurbiprofen (Ansaid, Upjohn) were compared with 100 mg of zomepirac sodium, 650 mg of acetaminophen plus 60 mg of codeine, 650 mg of acetaminophen alone, and placebo in a randomized, double-blind, parallel-group study. A total of 182 patients entered the study with moderate pain from a third molar extraction and were evaluated for six hours. For many efficacy variables, all active treatments were significantly (p less than or equal to 0.05) more effective than placebo. The two doses of flurbiprofen gave approximately similar results, suggesting a plateau effect above 50 mg. With the exception of relief at one hour, there were no significant differences between zomepirac and either dose of flurbiprofen. However, the mean response with zomepirac was greater than with either 50 or 100 mg of flurbiprofen during the first four hours and lower during the last two hours. The analgesic effects of acetaminophen alone were not significantly different from acetaminophen in combination with codeine. At the first hour, acetaminophen plus codeine led to significantly better pain relief than did 100 mg of flurbiprofen. After the first hour, flurbiprofen resulted in greater mean scores than acetaminophen alone or acetaminophen plus codeine, and these differences were significant at the fifth and sixth hours. Five patients had adverse reactions while receiving acetaminophen, acetaminophen plus codeine, or placebo. There were no adverse effects with flurbiprofen or zomepirac.

Endoscopic "salvage" cytology in neoplasms metastatic to the upper gastrointestional tract

Endoscopic "salvage" cytology was the only successful nonoperative diagnostic method in two patients with malignancy metastatic to the upper gastrointestinal tract. Smears and cell blocks of centrifuged material aspirated from the endoscope channel provided diagnoses of malignancies when other diagnostic techniques had been nonproductive. The results in these cases support the general utility of this technique and indicate its successful application in this specific clinical setting.

Effect of caffeine on acetaminophen analgesia

Our objective was to determine the value of caffeine in combination with acetaminophen in the relief of pain from uterine cramping, episiotomy, and third molar extraction. In the dental study, 173 patients received two or four tablets of 500 mg acetaminophen or the combination of 500 mg acetaminophen and 65 mg caffeine. In the three postpartum studies, 1345 patients received one, two, or three tablets of acetaminophen, the combination, or a placebo. The mean scores for the summary variable percent sum of the pain intensity differences (% SPID) were higher in all for the combination than for acetaminophen alone, and in two studies the null hypothesis of no differences was rejected. The relative potency estimates for % SPID were 1.9, 1.8, and 1.3 for the three studies in which bioassays could be performed and the pooled relative potency was 1.7 with a 95% confidence interval of 1.1 to 3.1. The results were essentially the same among pain models and among patient groups with similar habitual caffeine consumption. Onset of analgesia was also faster with the combination. We conclude that caffeine enhances the analgesic efficacy of acetaminophen.

The stereoscanning electron microscopy and ultrastructural histochemistry of the avian and reptilian surfactant systems: Indian dove, desert spiny and Taiwan golden skink lizards

Lung tissues from the Indian dove, Scardafella inca, desert spiny lizard, Sceloporus magister, and the Taiwan golden skink lizard, Mabuya aurates, were studied by transmission electron microscopy utilizing ruthenium red as a carbohydrate stain and with the so-called lipid-carbohydrate retention procedures to elucidate the morphology of the surfactant systems. Stereoscopic scanning electron microscopic procedures were utilized for a comparative anatomical study of these three species, and the results were compared with the rat and frog in the companion article. The avian lung tissues demonstrated several perculiarities. The ciliated epithelial cells of the bronchus had cytoplasmic ciliated projections between the boundaries of mucus secreting cells. The discrete morphology of the main bronchus, secondary bronchi, parabronchi, and the air capillaries, and their three-dimensional morphologic perspective were elucidated. The skink illustrated an arrangement of primary, secondary, and tertiary septa, with elaborate tertiary septal pits, similar to the amphibian. All septa contained a solid connective tissue core. The desert lizard was similar to the skink except the tertiary septal pits were rudimentary. All three species had a modified great alveolar pneumocyte and a laminated surfactant which included a carbohydrate matrix material between layered phospholipid-based membranes. The ruthenium red additionally stained the homogeneous surface-lining material. A comparative analysis of the surfactant systems of these three species with each other, and with the rodent and amphibian in the companion article, were discussed in terms of phylogenetic origin.