Pre-hospital ECPR in an Australian metropolitan setting: a single-arm feasibility assessment-The CPR, pre-hospital ECPR and early reperfusion (CHEER3) study

INTRODUCTION

Survival from refractory out of hospital cardiac arrest (OHCA) without timely return of spontaneous circulation (ROSC) utilising conventional advanced cardiac life support (ACLS) therapies is dismal. CHEER3 was a safety and feasibility study of pre-hospital deployed extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) for refractory OHCA in metropolitan Australia.

METHODS

This was a single jurisdiction, single-arm feasibility study. Physicians, with pre-existing ECMO expertise, responded to witnessed OHCA, age < 65 yrs, within 30 min driving-time, using an ECMO equipped rapid response vehicle. If pre-hospital ECPR was undertaken, patients were transported to hospital for investigations and therapies including emergent coronary catheterisation, and standard intensive care (ICU) therapy until either cardiac and neurological recovery or palliation occurred. Analyses were descriptive.

RESULTS

From February 2020 to May 2023, over 117 days, the team responded to 709 "potential cardiac arrest" emergency calls. 358 were confirmed OHCA. Time from emergency call to scene arrival was 27 min (15-37 min). 10 patients fulfilled the pre-defined inclusion criteria and all were successfully cannulated on scene. Time from emergency call to ECMO initiation was 50 min (35-62 min). Time from decision to ECMO support was 16 min (11-26 min). CPR duration was 46 min (32-62 min). All 10 patients were transferred to hospital for investigations and therapy. 4 patients (40%) survived to hospital discharge neurologically intact (CPC 1/2).

CONCLUSION

Pre-hospital ECPR was feasible, using an experienced ECMO team from a single-centre. Overall survival was promising in this highly selected group. Further prospective studies are now warranted.

Accidental Ingestion of an Implant Screwdriver: A Case Report and Literature Review

Head and neck oncology patients are high risk for ingestion or aspiration of dental instruments during treatment, due to altered anatomy and sensation. This article describes a case report of accidental ingestion of an implant screwdriver during the prosthetic phase of oral rehabilitation of a 79 year old oncology patient. The management protocol is described which included referral to the medical Accident and Emergency department, where the object was safely removed from the stomach via endoscopy. A review of similar cases of ingestion/inhalation in the literature suggests implant screwdrivers should be retrieved as safe passage through the gastrointestinal system is not assured. Awareness of the medical history and risk factors should alert clinicians to be extra cautious, and preventative strategies should be implemented at all times. Preventative measures include ligation of instruments with floss/suture material, treatment in a more vertical position, and use of rubber dam where possible.

A systematic review of ultrasound-guided FNA of lesions in the head and neck--focusing on operator, sample inadequacy and presence of on-spot cytology service

The objective of this review is to perform a systematic review of ultrasound-guided fine-needle aspiration (FNA) services for head and neck lesions with assessment of inadequacy rates and related variables such as the presence of immediate cytological assessment. A computer-based systematic search of articles in English language was performed using MEDLINE (1950 to date) from National Health Service evidence healthcare database and PubMed. Full texts of all relevant articles were obtained and scrutinized independently by two authors according to the stated inclusion and exclusion criteria. The primary search identified 932 articles, but only 78 met all the study criteria. The overall inadequacy rate was 9.3%, 16 studies had on-site evaluation by a cytopathologist/specialist clinician with a rate of 6.0%. In seven studies, a cytotechnician was available to either assess the sample or prepare the slides with an average inadequacy rate of 11.4%. In 1 study, the assessment was unclear, but the inadequacy rate for the remaining 54 studies, without immediate assessment, was 10.3%. The rate for the cytopathologist/specialist clinicians was significantly different to no on-site assessment but this was not found for assessment by cytotechnicians. The review suggests that the best results are obtained with a cytopathologist-led FNA service, where the pathologist reviews the specimen immediately, in relation to the clinical context, thereby deciding on adequacy and need for further biopsies. A systematic review looking at ultrasound-guided FNA of head and neck lesions has not been published previously.

Ultrasound-guided fine needle aspiration cytology in the diagnosis and management of thyroid nodules

OBJECTIVE

To examine the accuracy of fine needle aspiration cytology (FNAC) in the diagnosis of thyroid nodules and compare the inadequacy rates for ultrasound-guided and freehand FNAC.

METHODS

A retrospective study of 434 patients with thyroid nodules who underwent diagnostic FNAC over a 2-year period. Cytological diagnoses have been compared with the histological assessment of resection specimens in 69 cases.

RESULTS

The inadequacy rate was significantly lower from ultrasound guided FNAC (24/373 cases, 6.4%) than from freehand FNAC (8/61 cases, 13.1%) (P = 0.043). Seventy-six percentage of patients had a non-neoplastic cytological diagnosis and, after multidisciplinary review, the patients were reassured and assigned to clinical follow-up. Sixty-seven patients had a resection for cytological appearances consistent with non-neoplastic disease (n = 34), suspicious of follicular neoplasia (n = 23), or suspicious of malignancy (n = 10), and two patients had resections following inadequate cytology with ultrasound appearances suspicious of a neoplasm. The overall accuracy of FNAC analysis for malignancy was 97.0%, with sensitivity 83.3%, specificity 98.0%, positive predictive value 71.4% and negative predictive value 98.4%. The overall accuracy of FNAC analysis for the prediction of neoplasia was 97.5%, with sensitivity 80.5%, specificity 97.8%, positive predictive value 89.2% and negative predictive value 95.9%. Difficulties in cytological diagnosis were associated with lymphoid infiltrates and with degenerative changes in follicular adenomas.

CONCLUSION

Ultrasound-guided FNAC has a significantly lower yield of inadequate aspirates than palpable FNAC. The ability of FNAC to predict neoplasia in 89% patients and to exclude neoplasia in 95.9% patients makes an important contribution to the multidisciplinary assessment of patients.

Auxiliary functions in photosynthesis: the role of the FtsH protease

Oxygenic photosynthesis can be described effectively by using two long-standing models: the Z-scheme and the chemiosmotic hypothesis. However, these models do not reveal the dynamic nature of the thylakoid membrane and the four major complexes that it binds. The composition of the photosynthetic apparatus is continually changing in response to a range of environmental stimuli. In addition, many photosynthetic components have some of the highest turnover rates in Nature. Changes in composition and turnover of photosynthetic components require the degradation of existing and damaged polypeptides and the resynthesis and co-ordinated assembly of new polypeptides and their associated cofactors. This is achieved by several auxiliary functions, including proteolysis, protein targeting and the action of molecular chaperones. Some of the components involved in these functions, such as translocons, chaperones and proteases, have been identified but many of the auxiliary functions of photosynthesis remain uncharacterized. Among the proteases known to be associated with the thylakoids is the zinc metalloprotease FtsH, which might also act as a chaperone. Here we provide an overview of the thylakoid FtsH protease and discuss its role in the maintenance and assembly of the photosynthetic apparatus.

Mutation analysis and embryonic expression of the HLXB9 Currarino syndrome gene

The HLXB9 homeobox gene was recently identified as a locus for autosomal dominant Currarino syndrome, also known as hereditary sacral agenesis (HSA). This gene specifies a 403-amino acid protein containing a homeodomain preceded by a very highly conserved 82-amino acid domain of unknown function; the remainder of the protein is not well conserved. Here we report an extensive mutation survey that has identified mutations in the HLXB9 gene in 20 of 21 patients tested with familial Currarino syndrome. Mutations were also detected in two of seven sporadic Currarino syndrome patients; the remainder could be explained by undetected mosaicism for an HLXB9 mutation or by genetic heterogeneity in the sporadic patients. Of the mutations identified in the 22 index patients, 19 were intragenic and included 11 mutations that could lead to the introduction of a premature termination codon. The other eight mutations were missense mutations that were significantly clustered in the homeodomain, resulting, in each patient, in nonconservative substitution of a highly conserved amino acid. All of the intragenic mutations were associated with comparable phenotypes. The only genotype-phenotype correlation appeared to be the occurrence of developmental delay in the case of three patients with microdeletions. HLXB9 expression was analyzed during early human development in a period spanning Carnegie stages 12-21. Signal was detected in the basal plate of the spinal cord and hindbrain and in the pharynx, esophagus, stomach, and pancreas. Significant spatial and temporal expression differences were evident when compared with expression of the mouse Hlxb9 gene, which may partly explain the significant human-mouse differences in mutant phenotype.

Evaluation of a new apolipoprotein(a) isoform-independent assay for serum Lipoprotein(a)

The risk factor, Lipoprotein(a), [(Lp(a)], has been measured in numerous clinical studies by a variety of immunochemical assay methods. It is becoming apparent that for many of these assays antibody specificity towards the apolipoprotein(a) [apo(a)] repetitive component [the kringle 4-type 2 repeats] and apo(a) size heterogeneity can significantly affect the accuracy of serum Lp(a) measurements. To address this issue, we investigated whether our current in house Lp(a) [Mercodia] assay showed such bias compared to a recently available assay [Apo-Tek], claiming to possess superior capability for isoform-independent measurement of Lp(a). Levels of Lipoprotein(a) by both Apo-Tek and Mercodia assays correlated inversely with apo(a) isoform sizes. No significant differences were observed between assays in ranges of Lp(a) concentration within each isoform group. The Mercodia assay exhibited similar isoform-independent behaviour to that of Apo-Tek for the quantitation of serum Lipoprotein(a). Essentially identical results were obtained by the two methods, suggesting that Mercodia assay's capture monoclonal antibody also (as is the case for Apo-Tek) does not recognize the kringle 4-type 2 repetitive domain of apo(a). Correlation of Lp(a) concentrations in patient specimens between Apo-Tek and Mercodia assays showed good agreement, although an overall higher degree of imprecision and non-linearity was noted for the Apo-Tek procedure. A change-over to the Apo-Tek assay would therefore not improve on our current assessment of risk contribution from Lp(a) for atherosclerotic vascular disease in individuals with measurable levels of circulating Lipoprotein(a).

Hypometria in Parkinson's disease: automatic versus controlled processing

OBJECTIVES

The aim was to investigate whether patients with Parkinson's disease (PD) make movements that are of smaller amplitude when required to attend to a secondary task at the same time as performing a motor task.

METHODS

Thirteen patients with idiopathic Parkinson's disease (mean age, 67.1 yrs) and 14 healthy control subjects (mean age, 66.2 yrs) were tested. The motor task was repeated opposition of the thumb and forefinger and the secondary task was a lexical decision task.

RESULTS

The PD patients made hypometric movements, and the amplitude was further decreased when they performed the secondary task at the same time. There was no significant change for the control subjects.

CONCLUSION

The unpaced motor task was less automatic for the PD patients than for the control subjects, and hence more subject to interference from a secondary task. We relate this to the underactivation of the supplementary motor cortex (SMA).

Micrographia in Parkinson's disease: the effect of providing external cues

OBJECTIVE

To investigate whether micrographia in patients with Parkinson's disease is lessened either by giving visual targets or by continually reminding them that they should write with a normal amplitude.

METHODS

Eleven patients with Parkinson's disease (mean age 65.4 years) were compared with 14 control subjects (mean age 67.1 years). The subjects wrote with a stylus on a graphics tablet. There were three conditions: free writing, writing with dots to indicate the required size, and writing with continuous verbal reminders ("big"). Each condition was performed twice.

RESULTS

The patients wrote with a more normal amplitude when given either the visual cues or the auditory reminders. This improvement persisted when, shortly afterwards, the patients wrote freely without external cues. The increase in amplitude was achieved mainly by an increase in movement time rather than in peak velocity.

CONCLUSION

Whereas the visual cues directly specified the required amplitude the auditory reminders did not. One effect of external cues is that they draw attention to the goal, and thus encourage the patients to write less automatically.

Rapid detection of mitochondrial sequence polymorphisms using multiplex solid-phase fluorescent minisequencing

This work describes a novel method, multiplex solid-phase fluorescent minisequencing, for the simultaneous detection of several point mutations and/or small deletions and insertions. The method is applied to the analysis of mitochondrial DNA polymorphisms for the purposes of individual identification. A database of 152 British Caucasians and 103 British Afro-Caribbeans has been constructed, and the probability of a chance match between two unrelated individuals is calculated as 0.054 for Caucasians and 0.026 for Afro-Caribbeans.

Nucleotide sequence of the psbE, psbF and trnM genes from the chloroplast genome of Chlamydomonas reinhardtii

We have determined the nucleotide sequences of the psbE and psbF genes, which encode the alpha and beta subunits, respectively, of cytochrome b-559, from the chloroplast genome of the green alga Chlamydomonas reinhardtii. In contrast to other organisms psbE is not co-transcribed with psbF. The primary structures of the gene products are very similar to the equivalent proteins in cyanobacteria and plants. Each subunit contains a single histidine residue that is thought to ligate haem. Upstream of the psbE gene, a trnM gene is located which encodes an elongator tRNA(Met) molecule.

Roles of insulin resistance and beta-cell dysfunction in the pathogenesis of glucose intolerance in cystic fibrosis

The roles of insulin deficiency and insulin resistance in the pathogenesis of glucose intolerance in cystic fibrosis (CF) were evaluated in eight patients (aged 16.5 +/- 1.9 yr), four with normal glucose tolerance (NGT) and four with impaired glucose tolerance (IGT), and in seven healthy control (CN) subjects. First and second phase insulin secretions were evaluated during a hyperglycemic clamp. Hepatic glucose production (HGP) and insulin-stimulated glucose disposal were measured using [6,6-2H2]glucose and a stepwise hyperinsulinemic-euglycemic clamp. First and second phase insulin levels were significantly lower in both groups of CF patients compared with control values. There was an inverse relationship between glycohemoglobin level and first phase insulin (r = -0.81; P = 0.015) and second phase insulin (r = -0.97; P < 0.001). During the hyperglycemic clamp, the insulin sensitivity index was lower in CF-IGT, but not CF-NGT, compared with control values (6.66 +/- 1.79, 12.82 +/- 1.61, and 13.02 +/- 1.78 mumol/kg.min/pmol.L, respectively; P < 0.05). Basal HGP and fasting plasma glucose were higher in CF vs. CN [24.8 +/- 2.9 vs. 16.9 +/- 1.4 mumol/kg.min (P = 0.036) and 5.8 +/- 0.2 vs. 5.4 +/- 0.1 mmol/L (P = 0.035), respectively]. During the hyperinsulinemic euglycemic clamp, insulin-stimulated glucose disposal was significantly lower in CF-IGT (45.68 +/- 4.87 mumol/kg.min) vs. CF-NGT (78.99 +/- 1.34 mumol/kg.min) and CN (71.74 +/- 6.88 mumol/kg.min). Insulin sensitivity was lower in CF-IGT vs. CF-NGT (7.04 +/- 0.86 and 14.38 +/- 0.84 mumol/kg.min/pmol.L; P < 0.05). We conclude that 1) glycohemoglobin is a strong correlate of insulin deficiency in CF; and 2) glucose intolerance in this group of CF patients occurred as a consequence of concomitant insulin deficiency and insulin resistance.

Associations between viral infections and respiratory disease in artificially reared calves

Market-purchased, week-old, dairy bred calves entering a commercial calf-rearing unit were blood sampled at six-week intervals until three months old. Viral infections were monitored by ELISA for antibodies to bovine herpesvirus 1, bovine respiratory syncytial virus, parainfluenzavirus-3, bovine adenovirus subgroup 1 and bovine viral diarrhoea virus (BVDV). The immunoperoxidase test was used to detect BVDV in serum. The total immunoglobulin concentration in the initial blood sample was measured by the zinc sulphate turbidity test. The relationship between clinical respiratory disease, viral seroconversion and the initial concentration of serum immunoglobulin was investigated by the use of the relative risk statistic, Fisher's exact test, chi 2 techniques and the correlation coefficient. Treatment rates for respiratory disease of 45 per cent were observed during the first period of the study and 19 per cent during the second period. During the first period there was a significant positive association between clinical respiratory disease and seroconversion for all the viruses except parainfluenzavirus-3 and BVDV but in the second period there was no such relationship. Similarly, in the first period, but not in the second, there was a significant negative association between clinical respiratory disease and both antiviral immunoglobulin as measured by ELISA and total immunoglobulin as measured by the zinc sulphate turbidity test. Two of the 536 calves that survived to three months of age were found to be persistently infected with BVDV.

The stability of thiamine and thiamine tetrahydrofurfuryl disulfide added to table wines

Both thiamine hydrochloride and thiamine tetrahydrofurfuryl disulfide were added separately to table wines at concentrations equivalent to 0.3 and 1.5 microgram of free thiamine per kJ of caloric energy. The resultant mean increments in thiamine activity, measured by Lactobacillus fermenti microbiological assay after 21 months of storage, were in the range 55 to 103% of the added vitamin, indicative of high bioavailability of thiamine from this source.

A study of the predominant genotypes of bovid herpesvirus 1 found in the U.K

The genotypic classification of 84 U.K. isolates of bovid herpesvirus 1 was determined by the restriction endonuclease technique. Preliminary studies with six enzymes (EcoRI, HindIII, HpaI, BamHI, PstI and BstEII) showed that the principal genotypic variants, including the live vaccine strains used in the U.K., could be identified from the digestion patterns with just two endonucleases: HindIII and HpaI. Isolates from the 1960s were all categorised as genotype 2b. From 1977 onwards, genotype 1 has predominated in mainland Britain, with occasional type 2b isolates. Type 2b viruses were isolated from both respiratory and genital disease cases. There was no evidence of genotypes 2a or 3 in the U.K.

Effect of station examination item sampling on generalizability of student performance

This article may be of interest to physical therapy educators who are responsible for structuring station or practical examinations used to evaluate physical therapy students. The global intent of the article is to provide information that may be useful in selecting test items. Specifically, the purposes of this study were 1) to examine how two item-sampling strategies (one based on different diagnostic concepts, or diagnostic probes, and the other based on different anatomical sites) influenced the generalizability of a station examination, 2) to determine the interrater reliability during the station examination, and 3) to determine whether the status of the rater (that of observer or simulated patient) influenced the rating. Using a nested study design, 24 physical therapy students were assessed by eight raters. The raters were randomly and equally assigned to four teams. Each team assessed six students. One rater acted as the simulated patient for the first three students in each group, and the other rater acted as observer. This order was reversed for the last three students. Each student performed nine mini-diagnostic patient cases consisting of three diagnostic probes reproduced at three different anatomical sites. The results demonstrate that 1) similar diagnostic concepts can be generalized across anatomical sites, although different concepts or skills cannot be generalized at a given anatomical site or across sites; 2) interrater reliability was excellent; and 3) the status of the raters (ie, simulated patient or observer) did not bias the ratings.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolation and reactivation of bovid herpesvirus 1 in goats

A virus isolate, recovered from the brain of a goat which died following signs of nervous disease, was identified as BHV-1. Differentiation with the antigenically related caprine herpesvirus (BHV-6) was achieved by restriction endonuclease fingerprinting. Eighteen months after the last clinical episode, BHV-1 infection was reactivated in a seropositive goat from the same herd following dexamethasone treatment.

Behavioural consequences of hypertension: effects of age and type of antihypertensive agent

In order to investigate the effects on behaviour of hypertension, age, and the types of antihypertensive agents, we have conducted a retrospective analysis in 100 hypertensive patients receiving chronic treatment in our Hypertension Clinic. A group of 80 normotensive subjects, matched for age, were included in the study. Half of the hypertensive patients were under the age of 50 (young group) and half were over the age of 50 yrs (old group). The antihypertensive agents had not been administered according to any specific protocol, but represented the choice of the individual clinicians treating the patients in the clinic. All patients had received treatment for at least one year, and usually for two years. The behavioural tests performed were designed to measure sensory-perceptive ability, cognitive ability and psychomotor function and were those employed and described in our previous studies. The results achieved were varied, but indicated that older age was associated with an impairment in performance as was blood pressure. Test performances in the young hypertensives were similar to those achieved by older normotensives. These results were more prominent in cognitive and psychomotor functions than in the sensory-perceptive tests. The antihypertensive drugs used also affected these results; the worst behavioural performances tended to be in patients receiving the central nervous system agonists (methyl-dopa and clonidine) and better performances in patients receiving beta-blockers alone when compared with the other groups. Surprisingly, patients receiving diuretics showed poorer performance levels, but these were better in patients who received a beta-blocker in combination with their diuretic.(ABSTRACT TRUNCATED AT 250 WORDS)

Associations between viral infection and respiratory disease in young beef bulls

Blood samples were taken from bull calves at two Meat and Livestock Commission performance testing centres, just after weaning at six months of age and at six weekly intervals until the end of the performance test seven months later. Sera were assayed by specific ELISAS for antibodies to bovine herpes virus 1 (BHV1), respiratory syncytial virus, parainfluenza 3 (Pi3) and adenoviruses A and B. Seroconversions between each sampling were related to the occurrence of clinical respiratory disease using chi-squared (chi 2) and relative risk (RR) analyses. In 294 bulls there were 123 cases of respiratory disease. Seroconversion to bovine respiratory syncytial virus (RR = 4.7, chi 2 = 96.3, P less than 0.001) and adenovirus A (RR = 1.8, chi 2 = 8.9, P less than 0.001) and adenovirus B (RR = 1.9, chi 2 = 5.6, P less than 0.05) were significantly associated with clinical respiratory disease. There was evidence that prior exposure to respiratory syncytial virus (RR = 0.4, chi 2 = 9.8, P less than 0.01) Pi3 (RR = 0.4, chi 2 = 12.8, P less than 0.01) and adenovirus A (RR = 0.7, chi 2 = 7.5, P less than 0.01) conferred some protection against respiratory disease after arrival at the centre. It is concluded that vaccination before weaning, at least against bovine respiratory syncytial virus, would be beneficial.

Serological comparisons of antigenically related herpesviruses in cattle, red deer and goats

Serological comparisons were made using related herpesviruses from cattle (bovid herpesvirus 1), red deer (herpesvirus of cervidae 1) and goats (bovid herpesvirus 6) by virus neutralization and enzyme-linked immunosorbent assays. The test samples comprised field sera from British cattle, red deer and goats and sera from experimentally infected or immunized animals. Both the cervine and caprine viruses appeared to be more closely related to bovid herpesvirus 1 than they were to each other. Cattle sera reacted most strongly with the bovine virus and deer sera with the cervine virus. Antibodies to the caprine virus were not detected in the samples from British goats.

Contact dermatitis in hairdressers

18 cases of hand dermatitis in hairdressers seen over a 5-year period are reviewed. The diagnoses in these patients are discussed with reference to other studies of hand dermatitis in hairdressers. Contact allergy due to paraphenylenediamine and related hair dyes was the presenting complaint in younger hairdressers, while formaldehyde allergy occurred in those who were older. The prognosis in the former group of workers with respect to continued employment in the trade tended to be poorer than the latter. Follow-up revealed that hand dermatitis often resulted in the worker not continuing to work in the hairdressing trade.

British pilot study of exercise therapy. I. Middle-aged men

The physiological and biochemical effects of a carefully graduated course of vigorous gymnasium training with two or three weekly exercise sessions lasting only 15 minutes have been studied in middle-aged London business men. Activity diaries and psychological questionnaires indicated that these men had a positive attitude to exercise which was probably greater than average. The gymnasium exercises caused a large oxygen debt and considerable rises in plasma catecholamines and lactate levels. A close correlation was found between the pulse rate during exercise and the Borg scale of perceived exertion, so that both could be used to ensure that short periods of exercise were sufficiently vigorous to produce a training effect, and protect against over-exertion. The acceptability of this particular exercise regime was shown by the low fall-out and injury rate. It is suggested that this exercise training programme possesses many features which are advantageous if increased physical activity is to be more widely used as a method of reducing some of the risk factors in coronary heart disease.