Efficacy and safety of fluoroless ureteroscopy and retrograde intrarenal surgery for the treatment of urolithiasis: A comparative study

INTRODUCTION

Ureteroscopy (URS) and retrograde intrarenal surgery (RIRS) are traditionally guided by fluoroscopy, but the risks of exposure to ionizing radiation may present a matter of concern for patients and urologists. The aim of this study was to evaluate the efficacy and safety of fluoroless URS and RIRS compared with conventional fluoroscopy-guided procedures for the treatment of ureteral and renal stones.

MATERIAL AND METHODS

Patients treated with URS or RIRS for urolithiasis between August 2018 and December 2019 were retrospectively evaluated and grouped according to the use of fluoroscopy. Data was collected from individual patient records. The main outcomes were stone-free rate (SFR) and complications, compared between the fluoroscopy and fluoroless groups. A subgroup analysis by type of procedure (URS and RIRS) and a multivariate analysis to identify predictors of residual stones were conducted.

RESULTS

A total of 231 patients met the inclusion criteria: 120 (51.9%) in the conventional fluoroscopy group and 111 (48.1%) in the fluoroless group. No significant differences were found between groups regarding SFR (82.5% vs 90.1%, p=.127) or postoperative complication rate (35.0% vs 31.5%, p=.675). In the subgroup analysis these variables did not present significant differences, regardless of the procedure considered. In the multivariate analysis the fluoroless technique was not an independent predictor of residual lithiasis (OR 0.991; 95% IC 0.407-2.411; p=.983), when adjusted for procedure type, stone size and stone number.

CONCLUSION

URS and RIRS can be done without fluoroscopic guidance in selected cases, without affecting the efficacy or safety of the procedure.

Lumbar intervertebral disc segmentation for computer modeling and simulation

BACKGROUND AND OBJECTIVE

The present work had as its main objective the development of a method for localizing and automatically segmenting lumbar intervertebral discs (IVD) in 3D from magnetic resonance imaging (MRI), with the goal of supporting the generation of finite element (FE) models from actual lumbar spine anatomy, by providing accurate and personalized information on the shape of the patient's IVD. The extension of the method to allow performing separate segmentations of the IVD's two main structures - annulus fibrosus (AF) and nucleus pulposus (NP) - as well as automatically detecting degenerated IVD where this distinction is no longer possible was also an objective of the work.

METHODS

The method presented here evolves from 2D segmentations in the sagittal profile using Gabor filters towards 3D segmentations. It works by detecting the spine curves and intensity regions corresponding to IVD. As so, the 2D method from Zhu et al. (2013) was partially implemented, modified and adapted to 3D use, and then tested with eight spines from two separated online datasets. The 3D adaptation was achieved by using vertebral body segmentation masks to approximate the shape of the vertebrae and to adjust the spine curves accordingly.

RESULTS

The method showed average values of 85%, 83% and 96% for the Dice coefficient, sensitivity and specificity, respectively. The method correctly identified 65 of 68 (96%) IVD as either healthy or degenerated. The method's Dice coefficient is within the range of existing 3D IVD segmentation methods in the literature (81-92%). The method took on average 6-7 s to perform a full 3D segmentation, which is well within the range of the existing methods (2 s - 19 min).

CONCLUSIONS

The developed method can be used to generate accurate 3D models of the IVD based on MRI, with AF/NP distinction and detection of marked degeneration by comparing each IVD with the remaining spine levels. Further work shall improve the method towards distinguishing between specific levels of degeneration for clinically oriented FE modeling.

Prevalence and major causes of ruminal lesions in intensive cattle fattening units

Ruminal acidosis is frequent in cattle fattening systems associated with grain-rich fibre-poor diets. This study aimed to assess the prevalence of ruminal lesions compatible with ruminal acidosis intensive fattening farms and its risk factors on farm. Rumens of 218 out of 1960 bullocks from six farms were classified in slaughterhouses, and the management practices and the type of feed were compared. The prevalence of lesions compatible with ruminal acidosis was high (65%), where 47% and 18% of the animals had ruminal lesions compatible with subacute and acute disease, respectively. Prevalence of lesions differed significantly between the farms, with differences in the management and feeding practices. Ruminal lesions compatible with ruminal acidosis are prevalent in cattle fattening units in Portugal and husbandry and feeding practices are likely to have an impact.

Seroprevalence and SARS-CoV-2 antibodies distribution in Portugal following mass vaccination campaign

Introduction

Information on post-infection and vaccine-induced SARS-CoV-2 seroprevalence is important for public health policies. A 3rd wave of National Serological Survey (ISN3COVID-19) was conducted to measure SARS-CoV-2 seroprevalence and characterize specific antibodies distribution in Portuguese population in September - November 2021, following a mass vaccination campaign.

Methods

ISN3COVID-19 was a cross-sectional epidemiological study that collected serum samples and questionnaire data on a sample of Portuguese residents aged 1 year or older (n = 4545). SARS-CoV-2 IgG anti-nucleoprotein and anti-spike antibody levels were measured using Abbott Chemiluminescent Microparticle Immunoassays. Seroprevalence was estimated for the overall sample and stratified by age group, sex, region and self-reported chronic conditions. Medians and respective 95% confidence intervals (95%CI) were used to describe the distribution of SARS-CoV-2 antibodies in specific population subgroups.

Results

The overall seroprevalence of SARS-CoV-2 (post-infection or vaccine-induced) was 86.4% (95%CI: 85.2 to 87.6%), post-infection seroprevalence was 7.5% (95%CI: 6.6 to 8.5). Higher seroprevalence was observed among 50-59 years-old (96.5%), women (88.3%), and those with two or more self-reported chronic conditions (90.8%). Higher IgG (anti-Spike) levels were estimated for individuals vaccinated with the booster dose (median=12601.3 AU/ml; 95%CI: 4127.5 to 19089.1) and for those vaccinated with two doses of Spikevax® vaccine (median=7012.7 AU/ml, 95%CI: 5568.8 to 8456.6).

Conclusions

The SARS-CoV-2 seroprevalence was high and consistent with vaccine coverage in Portugal. Seropositivity was associated with sex, age and previous chronic conditions. The anti-SARS-CoV-2 anti-spike IgG levels varied according to vaccine brand and number of doses. These results show that monitoring seroprevalence and SARS-CoV-2 antibody distribution is of paramount importance to guide public health policies.

Key messages

• Significant increase in SARS-CoV-2 seroprevalence following the mass vaccination campaign consistent with the high vaccine coverage achieved in Portugal.

• Continuous monitoring of the population‐level IgG response after vaccination remains important to guide further public health measures.

Novel perfusion ex-vivo culture system enables physiological and pathological studies on porcine arteries

Introduction

Routine cardiovascular interventions such as cardiac bypass, balloon angioplasty and stenting provoke vascular activation and remodelling often leading to rehospitalization and further interventions. Conventional in vitro models fail to account for the complex vascular environment essential for vascular tissue fitness.

Purpose

Our research aims to culture whole porcine arteries in using a novel cost efficient and versatile perfusion system (EasyFlow) and identify the contribution of adventitial progenitors to post-injury remodelling.

Methods

EasyFlow insert was 3D printed to convert a conventional 50 ml centrifuge tube into a mini bioreactor. Porcine arteries were excised and cultured under constant pulsatile flow for up to 7 days. Injury was performed by balloon catheter at day 0. Tissues were evaluated by doppler ultrasound, immunofluorescence and confocal imaging and PCR, at different timepoints.

Results

The EasyFlow adaptor takes advantage of 50 ml centrifuge tubes isolating reaction space from the environment and reducing the culture volume. The adaptability of the design facilitates the incubation of vessels of different size and origin while the self-contained perfusion allows parallel cultures and minimal media consumption. EasyFlow perfusion culture of porcine arteries preserves the endothelial coverage and the smooth muscle cell organisation, as compared to static culture.

Gene expression analysis and immunofluorescence indicated an increased expression of platelet-derived growth factor receptor beta (PDGFRb) and a decrease in smooth muscle actin (SMA) in the static culture, compared to the perfusion. Furthermore, static culture showed an increased cellular activation in adventitia (proliferating cell nuclear antigen expression), as compared to perfused tissues. Balloon injury followed by flow culture recapitulated the early hallmarks of vascular remodelling, including intimal denudation indicated by loss of platelet endothelial cell adhesion molecule signal, smooth muscle cell disarray shown by loss of actin stress fibre organisation and activation in the media, as supported by confocal microscope and gene expression analysis, accompanied by significant morphological changes based on ultrasound imaging.

Conclusion

This work lay the basis for future investigations into the pathological remodelling of blood vessels, by providing a robust and controlled culture system for the maintenance of porcine blood vessels in culture.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): University of Surrey En-Face Staining of Arterial Lumen

Bladder pain induced by prolonged peripheral alpha 1A adrenoceptor stimulation involves the enhancement of transient receptor potential vanilloid 1 activity and an increase of urothelial adenosine triphosphate release

AIM

Pathophysiological mechanisms of chronic visceral pain (CVP) are unknown. This study explores the association between the sympathetic system and bladder nociceptors activity by testing the effect of a prolonged adrenergic stimulation on transient receptor potential vanilloid 1 (TRPV1) activity and on urothelial adenosine triphosphate (ATP) release.

METHODS

Female Wistar rats received saline, phenylephrine (PHE), PHE + silodosin, PHE + naftopidil or PHE + prazosin. TRPV1 knockout and wild-type mice received saline or PHE. Visceral pain behaviour tests were performed before and after treatment. Cystometry was performed, during saline and capsaicin infusion. Fos immunoreactivity was assessed in L6 spinal cord segment. Human urothelial ATP release induced by mechanical and thermal stimulation was evaluated.

RESULTS

Subcutaneous, but not intrathecal, PHE administration induced pain, which was reversed by silodosin, a selective alpha 1A adrenoceptor antagonist, but not by naftopidil, a relatively selective antagonist for alpha 1D adrenoceptor. Silodosin also reversed PHE-induced bladder hyperactivity and L6 spinal cord Fos expression. Thus, in subsequent experiments, only silodosin was used. Wild-type, but not TRPV1 knockout, mice exhibited phenylephrine-induced pain. Capsaicin induced a greater increase in voiding contractions in PHE-treated rats than in control animals, and silodosin reversed this effect. When treated with PHE, ATP release from human urothelial cells was enhanced either by mechanical stimulation or by lowering the thermal threshold of urothelial TRPV1, which becomes abnormally responsive at body temperature.

CONCLUSION

This study suggests that the activation of peripheral alpha 1A adrenoceptors induces CVP, probably through its interaction with TRPV1 and ATP release.

Acyl sugars and whitefly (Bemisia tabaci) resistance in segregating populations of tomato genotypes

The wild tomato, Solanum pennellii, is an important source of resistance genes against tomato pests. This resistance is due to the presence of acyl sugars (AS), which are allelochemicals that have negative effects on arthropod pests. There are no commercially available tomato cultivars that exhibit significant levels of resistance to arthropod pests. Therefore, this study evaluated resistance to whitefly (Bemisia tabaci) in F2 and F2RC1 tomato genotypes with high AS levels from a cross between Solanum lycopersicum 'Redenção' and the S. pennellii accession, LA-716. Plants were exposed to B. tabaci biotype B at the pre-flowering stage. In both generations, there were significant, negative correlations between AS content and oviposition preference and nymph development. Whitefly exhibited a lower preference for oviposition and produced fewer nymphs in genotypes with high AS levels and the wild parent S. pennellii than in the low AS-level genotypes and Redenção cultivar, demonstrating that the breeding program was effective in transferring resistance to the F2 and F2RC1 generations. RVTA-2010-pl#31 and RVTA-2010-pl#94 in the F2 population are promising genotypes that produced materials with high AS levels in the F2RC1 generation (RVTA-2010-31-pl#177 and RVTA-2010-94-pl#381).

Point prevalence of surgical checklist use in Europe: relationship with hospital mortality

BACKGROUND

The prevalence of use of the World Health Organization surgical checklist is unknown. The clinical effectiveness of this intervention in improving postoperative outcomes is debated.

METHODS

We undertook a retrospective analysis of data describing surgical checklist use from a 7 day cohort study of surgical outcomes in 28 European nations (European Surgical Outcomes Study, EuSOS). The analysis included hospitals recruiting >10 patients and excluding outlier hospitals above the 95th centile for mortality. Multivariate logistic regression and three-level hierarchical generalized mixed models were constructed to explore the relationship between surgical checklist use and hospital mortality. Findings are presented as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

A total of 45 591 patients from 426 hospitals were included in the analysis. A surgical checklist was used in 67.5% patients, with marked variation across countries (0-99.6% of patients). Surgical checklist exposure was associated with lower crude hospital mortality (OR 0.84, CI 0.75-0.94; P=0.002). This effect remained after adjustment for baseline risk factors in a multivariate model (adjusted OR 0.81, CI 0.70-0.94; P<0.005) and strengthened after adjusting for variations within countries and hospitals in a three-level generalized mixed model (adjusted OR 0.71, CI 0.58-0.85; P<0.001).

CONCLUSIONS

The use of surgical checklists varies across European nations. Reported use of a checklist was associated with lower mortality. This observation may represent a protective effect of the surgical checklist itself, or alternatively, may be an indirect indicator of the quality of perioperative care.

CLINICAL TRIAL REGISTRATION

The European Surgical Outcomes Study is registered with ClinicalTrials.gov, number NCT01203605.

Boosting innovation in the water sector--the role and lessons learned from collaborative projects

A key worldwide challenge in most sectors is to boost the effective adoption of innovation, as underpinned by the new European Union research programme Horizon 2020, which focuses on increasing innovation in Europe from 2014 to 2020. This is particularly relevant in the water sector, often perceived as conservative and averse to change. This paper discusses the role that collaborative knowledge-transfer projects can play in effectively rolling out R&D in the water industry. LNEC (Laboratório Nacional de Engenharia Civil) has designed a structured model based on a phased programme and a network of utilities and researchers. The paper presents the core principles, the rationale, the model and methods used, and the theoretical background, as well as the project's impact, outcomes and products. The discussion highlights the lessons learnt and provides a formal analysis of the advantages of focusing on middle management as an effective entry point, even if innovation is needed across the organization. Making training materials, guidelines, use cases, data and software publicly available after the project's end has proven to have a decisive multiplying effect. The paper also argues in favour of the collaborative model as a basis for R&D sustainability, and details on-going and planned developments.

How different do visuo-tactile criteria assess caries lesions activity status on occlusal surfaces?

OBJECTIVES

We tested the association between active caries lesions assessed by two different criteria and clinical features of these caries lesions.

MATERIALS AND METHODS

Three examiners examined forty-nine 3- to 12-year-old children: one examiner used the Nyvad criteria, another examiner used the International Caries Detection and Assessment System with an additional criteria--Lesion Activity Assessment (ICDAS + LAA), and a reference examiner classified lesions regarding plaque stagnation, colour, lustre, cavities, depth and texture. Logistic regressions were used to test associations. For analyses, we grouped sound sites and inactive lesions vs active caries lesions, but also considering only inactive vs active lesions.

RESULTS

Active lesions scored by both criteria were similarly associated with different clinical parameters tested, except when the sound sites were excluded from the analysis. In these cases, active lesions according to ICDAS + LAA were associated only with cavitation and texture. Texture was associated with divergences between criteria when differentiating sound or inactive lesions from active ones. Fewer divergences in differentiating active from inactive lesions were observed when lesions present lustre.

CONCLUSION

Most clinical signs associated with active caries lesions were similar, but texture and severity tend to have a greater importance when using ICDAS + LAA for distinguishing caries activity status. Attention should be given to differences due to texture and lustre when using different indices.

Symptomatic giant Schmorl's node treated by a decompression procedure

Schmorl's nodes (SN) are common lesions that represent disc material prolapse through the vertebral endplate, into the vertebral body with generally limited clinical significance. Rarely they have been related to the onset of back pain, usually self-limited. Recently giant variants of SN have been described, with very discrete clinical and imaging expression. Knowledge of the typical imaging appearance in both CT-scan and MRI may preclude the use of unnecessary diagnostic and treatment procedures. The authors present a case of symptomatic giant SN resembling these rare variants by its size and persistent pain, but also featuring distinct classic SN characteristics. Although not usually needed when the image is typical, a percutaneous biopsy was performed which allowed both the definitive diagnosis and, surprisingly, the almost immediate and complete resolution of the symptoms. Five years later the patient is pain free and a new MRI showed a significant decrease of the lesion size and no edema of the vertebral body.

Influence of examiner experience on clinical performance of visual inspection in detecting and assessing the activity status of caries lesions

Our hypothesis was that a method of caries activity evaluation based on the clinical features of the lesions would be less time consuming but more influenced by the examiner's experience than the scoring system used in association with the International Caries Detection and Assessment System (ICDAS). Thus, the aim of this study was to evaluate the performance of three groups of examiners with different levels of experience using two different methods to assess the activity status of caries lesions by visual inspection. A cross-sectional study in a dental office setting was performed selecting 18 children, aged three to eight years, who had sought dental treatment at a dental school. Examinations to detect caries lesions were performed using visual inspection by six examiners with different levels of experience: two undergraduate dental students, two specialists in pediatric dentistry, and two graduate students. The examiners used ICDAS and two different methods to assess caries activity: using an additional score system or considering the examination of clinical features. Two benchmark examiners examined the children in a joint session, and their consensus was considered to be the reference standard. The sensitivity, specificity, and reproducibility were calculated for different thresholds: all, cavitated, and active caries lesions. Multilevel analyses were performed to compare the different methods and examiners. No differences were observed among the examiners, either in detecting all lesions and cavitated lesions or regarding the activity assessment. The methods of assessing activity status performed similarly, but the time spent on examinations was shorter for the method evaluating clinical features. In conclusion, the experience of examiners does not significantly influence the performance of visual inspection, and both methods of assessing activity status result in similar diagnostic accuracy.

Severity assessment tools in ICU patients with 2009 influenza A (H1N1) pneumonia

The aim of this study was to determine if severity assessment tools (general severity of illness and community-acquired pneumonia specific scores) can be used to guide decisions for patients admitted to the intensive care unit (ICU) due to pandemic influenza A pneumonia. A prospective, observational, multicentre study included 265 patients with a mean age of 42 (±16.1) years and an ICU mortality of 31.7%. On admission to the ICU, the mean pneumonia severity index (PSI) score was 103.2 ± 43.2 points, the CURB-65 score was 1.7 ± 1.1 points and the PIRO-CAP score was 3.2 ± 1.5 points. None of the scores had a good predictive ability: area under the ROC for PSI, 0.72 (95% CI, 0.65-0.78); CURB-65, 0.67 (95% CI, 0.59-0.74); and PIRO-CAP, 0.64 (95% CI, 0.56-0.71). The PSI score (OR, 1.022 (1.009-1.034), p 0.001) was independently associated with ICU mortality; however, none of the three scores, when used at ICU admission, were able to reliably detect a low-risk group of patients. Low risk for mortality was identified in 27.5% of patients using PIRO-CAP, but above 40% when using PSI (I-III) or CURB65 (<2). Observed mortality was 13.7%, 13.5% and 19.4%, respectively. Pneumonia-specific scores undervalued severity and should not be used as instruments to guide decisions in the ICU.

Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection

INTRODUCTION

Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection, although relatively common, remains controversial.

METHODS

Prospective, observational, multicenter study from 23 June 2009 through 11 February 2010, reported in the European Society of Intensive Care Medicine (ESICM) H1N1 registry.

RESULTS

Two hundred twenty patients admitted to an intensive care unit (ICU) with completed outcome data were analyzed. Invasive mechanical ventilation was used in 155 (70.5%). Sixty-seven (30.5%) of the patients died in ICU and 75 (34.1%) whilst in hospital. One hundred twenty-six (57.3%) patients received corticosteroid therapy on admission to ICU. Patients who received corticosteroids were significantly older and were more likely to have coexisting asthma, chronic obstructive pulmonary disease (COPD), and chronic steroid use. These patients receiving corticosteroids had increased likelihood of developing hospital-acquired pneumonia (HAP) [26.2% versus 13.8%, p < 0.05; odds ratio (OR) 2.2, confidence interval (CI) 1.1-4.5]. Patients who received corticosteroids had significantly higher ICU mortality than patients who did not (46.0% versus 18.1%, p < 0.01; OR 3.8, CI 2.1-7.2). Cox regression analysis adjusted for severity and potential confounding factors identified that early use of corticosteroids was not significantly associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0-4.8, p < 0.05). When only patients developing acute respiratory distress syndrome (ARDS) were analyzed, similar results were observed.

CONCLUSIONS

Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection did not result in better outcomes and was associated with increased risk of superinfections.

Influence of the discomfort reported by children on the performance of approximal caries detection methods

This in vivo study aimed to evaluate the performance of methods of approximal caries detection in primary molars and to assess the influence of the discomfort caused by these methods on their performance. Two examiners evaluated 76 children (4-12 years old) using visual inspection (ICDAS), radiography and a laser fluorescence device (DIAGNOdent pen, LFpen). The reference standard was visual inspection after temporary separation with orthodontic rubbers. Surfaces were classified as sound, noncavitated (NC) or cavitated (Cav), and performance was assessed at both NC and Cav thresholds. Wong-Baker faces scale was employed to assess the discomfort. Multilevel analysis was performed to verify the influence of discomfort on performance, considering the number of false-positives and false-negatives as outcome. At NC threshold, visual inspection achieved better performance (sensitivities and accuracies around 0.67) than other methods (sensitivities around 0.25 and accuracies around 0.35). At Cav threshold, visual inspection presented lower sensitivity (0.23 and 0.19), and LFpen (0.52 and 0.42) and radiography (0.52) presented similar sensitivities. Concerning the influence of the discomfort, at NC threshold, when discomfort was present, the number of false-negative results was lower with LFpen and the number of false-positive results was higher with visual inspection. At Cav threshold, the number of false-positive results was higher with LFpen. In conclusion, radiography and LFpen achieved similar performance in detecting approximal caries lesions in primary teeth and the discomfort caused by visual inspection and LFpen can influence the performance of these methods, since a higher number of false-positive or false-negative results occurred in children who reported discomfort.

Chronic post-traumatic lateral dislocation of the radial head

Chronic dislocation of the radial head in children due to undiagnosed Monteggia's lesion is uncommon. Although it can initially be asymptomatic pain, restriction of movement and secondary arthritic changes may develop as the child grows. The treatment of chronic radial head dislocation remains controversial varying from benign neglect to surgical reduction. Only five chronic lateral Monteggia's lesions have been described with variable surgical results associated with redislocation. A case of chronic post-traumatic lateral dislocation of the radial head in a child treated with ulna osteotomy rigidly fixed and reattachment of the annular ligament is presented. At 2 years follow-up, the clinical result was very satisfying and concentric reduction was maintained. The authors conclude this may be an effective procedure for chronic post-traumatic lateral dislocation of the radial head in children.

Diversity of Campylobacter jejuni and Campylobacter coli genotypes from human and animal sources from Rio de Janeiro, Brazil

To compare the genotypes of Campylobacter jejuni and Campylobacter coli isolates of human and animal origin collected in Rio de Janeiro City, 30 C. jejuni and 35 C. coli isolates from animal sources (n=45) and human patients with gastroenteritis (n=20) were genotyped by PCR-based techniques, namely random amplified polymorphic DNA (RAPD-PCR) and enterobacterial repetitive intergenic consensus sequence (ERIC-PCR). RAPD-PCR identified 50 types and ERIC-PCR identified 22 genotypes, among the 65 Campylobacter isolates. Both PCR methods discriminated the C. jejuni and C. coli groups of isolates. Combining the results of both methods, no single genotype was shared between isolates from human and animal sources. Two groups of two C. coli isolates each with identical genotypes were found among poultry and pig isolates. A high level of genetic diversity observed among the Campylobacter isolates suggests lack of overlap between isolates from different sources.

Differential effects of midazolam and pentylenetetrazole on behavioral repetition and variation

The present study investigated the effects of midazolam and pentylenetetrazole upon repeating and varying sequences of responses. Rats were exposed to a multiple schedule with two components. Under the VARY component, water was provided if the current sequence of four responses differed from each of the five previous ones; under the REPEAT component, water delivery was contingent upon a particular four-response sequence. Each component was signaled by specific exteroceptive stimuli. Overall, sequence variability was affected by midazolam, and to a lesser degree, by pentylenetetrazole. With the REPEAT contingency, drug administration increased behavior variation, thus reducing accuracy; with the VARY contingency, behavior variation and accuracy were not altered. These results were explained on the basis of the disruptive effects of both drugs upon the discriminative control exerted by previous responses within a sequence and by exteroceptive stimuli.

New issues in severity scoring: interfacing the ICU and evaluating it

Since the development of the first general outcome prediction models, these instruments have been widely used in the intensive care unit (ICU), both for patient evaluation and for ICU evaluation. Since some of these uses have been serious questioned, we assisted in the last years to the exploration of alternative paths for increasing the predictive power of the models and to enhance their applicability and utility in the real world. Part of these efforts focused on the exploration of more meaningful outcomes (clinical and non-clinical) with a strong tonic into the relation between outcomes and resources use. Also, since it is now widely recognized that the ICU is not an island, but it is integrated in a continuum of care, more and more efforts are being made to optimize and evaluate the interface between the ICU and the hospital, both at ICU admission and at ICU discharge. The objective of this review is to present and discuss, to the clinician working in the ICU, these emerging issues.

Comparison of techniques for extracting viral RNA from isolation-negative serum for dengue diagnosis by the polymerase chain reaction

Aiming at the improvement of the molecular diagnosis of dengue, three well-established methods of RNA extraction from serum of patients with clinical symptoms of dengue were compared. The methods were based on the QIAamp Viral RNA kit, the Chomczynski-Sacchi technique and TRIzol. One hundred samples were examined using the same protocol for reverse transcription-polymerase chain reaction (RT-PCR). Out of the 100 samples tested, none was positive by either the Chomczynski-Sacchi technique or TRIzol, and six were positive using the QIAamp viral RNA kit. Of the six positive samples, only one was collected before 5 days of the beginning of the disease, and it was also positive for viral isolation. These results were confirmed later by serology (MAC-ELISA) that showed that 19 samples were positive for IgM antibodies against dengue. These data indicate that PCR is a useful method for detection of dengue virus infections in IgM-positive samples, and the best method of RNA extraction from clinical samples, to be used for dengue diagnosis by PCR is the QIAamp Viral RNA kit.

[Aggressive angiomyxoma of the vulva]

An unusual myxoid and vascular appearing neoplasm of the vulva, termed an Aggressive Angiomyxoma, is described in two cases report. The clinical presentation and recurrence pattern were typical for previously described neoplasms of the same cellular pattern. The histopathology, difficulties in determining the surgical margins, and the treatment of this tumor are discussed.

Mortality after discharge from intensive care: the impact of organ system failure and nursing workload use at discharge

OBJECTIVES

Mortality after ICU discharge accounts for approx. 20-30% of deaths. We examined whether post-ICU discharge mortality is associated with the presence and severity of organ dysfunction/failure just before ICU discharge.

PATIENTS AND METHODS

The study used the database of the EURICUS-II study, with a total of 4,621 patients, including 2,958 discharged alive to the general wards (post-ICU mortality 8.6%). Over a 4-month period we collected clinical and demographic characteristics, including the Simplified Acute Physiology Score (SAPS II), Nine Equivalents of Nursing Manpower Use Score, and Sequential Organ Failure Assessment (SOFA) score.

RESULTS

Those who died in the hospital after ICU discharge had a higher SAPS II score, were more frequently nonoperative, admitted from the ward, and had stayed longer in the ICU. Their degree of organ dysfunction/failure was higher (admission, maximum, and delta SOFA scores). They required more nursing workload resources while in the ICU. Both the amount of organ dysfunction/failure (especially cardiovascular, neurological, renal, and respiratory) and the amount of nursing workload that they required on the day before discharge were higher. The presence of residual CNS and renal dysfunction/failure were especially prognostic factors at ICU discharge. Multivariate analysis showed only predischarge organ dysfunction/failure to be important; thus the increased use of nursing workload resources before discharge probably reflects only the underlying organ dysfunction/failure.

CONCLUSIONS

It is better to delay the discharge of a patient with organ dysfunction/failure from the ICU, unless adequate monitoring and therapeutic resources are available in the ward.

[Adolescent mothers caring for their child]

This is a qualitative research that had the objective of understanding the perception of adolescent mothers about their child[symbol: see text]s care. The phenomenological approach was used to analyze data gathered from 7 mothers. To the adolescent mothers caring for their child means feeding the child, do his/her hygiene, care for his/her illness, promote rest, give attention, give love, give educational support and promote leisure. These themes converge to 3 main categories: attend to the biological, psychological and social necessities of the child.

Features and trends in Helicobacter pylori antibiotic resistance in Lisbon area, Portugal (1990-1999)

The features of Helicobacter pylori antibiotic resistance in Lisbon from 1990 to 1999 were studied. Overall resistance rates to amoxycillin, tetracycline, metronidazole, clarithromycin and ciprofloxacin were 0, 0, 30.6, 19.0 and 9.6%, respectively. The incidence of resistance to clarithromycin was much higher in isolates from children (44.8%) than adults (14.6%). For metronidazole, the contrary was observed (children: 19.0%, adults: 32.3%). Ciprofloxacin-resistant isolates were all from adult patients. Concerning the adult population, the resistance rate to metronidazole showed a slight increase during the decade, while for clarithromycin and ciprofloxacin a significant increase was observed (4.6 to 22.0% and 0 to 20.9%, respectively).

The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Results of a prospective, multicentre study. Working Group on Sepsis related Problems of the ESICM

OBJECTIVE

To evaluate the performance of total maximum sequential organ failure assessment (SOFA) score and a derived measure, delta SOFA (total maximum SOFA score minus admission total SOFA) as a descriptor of multiple organ dysfunction/failure in intensive care.

DESIGN

Prospective, multicentre and multinational study.

SETTING

Forty intensive care units (ICUs) from Australia, Europe, North and South America.

PATIENTS

Data on 1,449 patients, evaluated at admission and then consecutively every 24 h until ICU discharge (11,417 records) during May 1995. Excluded from data collection were all patients with a length of stay in the ICU less than 2 days following uncomplicated scheduled surgery.

MAIN OUTCOME MEASURE

Survival status at ICU discharge.

INTERVENTIONS

The collection of raw data necessary for the computation of a SOFA score on admission and then every 24 h, and basic demographic and clinical statistics.

MEASUREMENTS AND MAIN RESULTS

Mean total maximum SOFA score presented a very good correlation to ICU outcome, with mortality rates ranging from 3.2% in patients without organ failure to 91.3% in patients with failure of all the six organs analysed. A maximum score was reached 1.1 +/- 0.2 days after admission for all the organ systems analysed. The total maximum SOFA score presented an area under the ROC curve of 0.847 (SE 0.012), which was significantly higher than any of its individual components. The cardiovascular score (odds ratio 1.68) was associated with the highest relative contribution to outcome. No independent contribution could be demonstrated for the hepatic score. No significant interactions were found. Principal components analysis demonstrated the existence of a two-factor structure that became clearer when analysis was limited to the presence or absence of organ failure (SOFA score > or = 3 points) during the ICU stay. The first factor comprises respiratory, cardiovascular and neurological systems and the second coagulation, hepatic and renal systems. Delta SOFA also presented a good correlation to outcome. The area under the receiver operating characteristic (ROC) curve was 0.742 (SE 0.017) for delta SOFA, lower than the total maximum SOFA score or admission total SOFA score. The impact of delta SOFA on prognosis remained significant after correction for admission total SOFA.

CONCLUSIONS

The results show that total maximum SOFA score and delta SOFA can be used to quantify the degree of dysfunction/failure already present on ICU admission, the degree of dysfunction/failure that appears during the ICU stay and the cumulative insult suffered by the patient. These properties make it a good instrument to be used in the evaluation of organ dysfunction/failure.

[Endobronchial biopsy and cytology. Comparative study]

A retrospective study was performed in order to evaluate the diagnostic accuracy for lung cancer in histological biopsy specimens and in cytological examination taken at fibre optic bronchoscopy. Of 530 patients suspected of having a malignant lesion, 150 had pathological confirmation (group A) and 380 did not (group B). In group A biopsy was diagnosed in 78.7% and cytology in 58% of the cases, of which brushing was positive in 94.1% and washing in only 38.6% of the cases. In group B brushing disclosed the condition of lung epithelium in 91.8% and washing in only 48% of the cases. It is concluded that brushing had a higher diagnostic accuracy than washing in both groups, although inferior to biopsy.

Eosinophilic leukaemia with trisomy 8 and double gammopathy

Prolonged eosinophilia of unknown cause has generally been described as the hypereosinophilic syndrome, and is characterised by peripheral blood and bone marrow infiltration and frequent multisystem disease. The nature of this disorder has been questioned, and the clinical features are quite variable, suggesting its heterogeneity and probable neoplastic aetiology. A patient with severe eosinophilia, karyotype abnormalities, serum gammopathy and massive organ disease is reported. The clinical course was aggressive despite cytoreduction of eosinophils and terminated in multisystem failure. These findings are consistent with a diagnosis of eosinophilic leukaemia, and it is suggested that chromosome and cell culture studies might be useful in the early diagnosis of this controversial entity.

[Hepatic markers in a population of tavern customers]

We undertook this study to determine the prevalence of hepatic enzymes alterations in ambulant and healthy daily consumers of alcoholic beverages. In order to achieve this aim, a population of 107 regular customers from Coimbra's taverns was utilised. The percentage of results above the reference values was: Alk. Ph.-0%, AST/ALT--10.3%, T. Bil.--18.7%, ALT--37.4%, AST--44.9%, D. Bil.--52.3%, GGT--54.2%, GIDH--55.8%; seven individuals had normal levels of all hepatic markers, seventeen had 1 altered parameter, twenty two had 2, fourteen had 3, fifteen had 4, twenty had 5, eleven had 6, and one had 7. However, most of the alterations occur to levels close to normality. The correlation with the doses of alcohol is positive but low for all studied parameters, being statistically significant for some of them. The main conclusion of the present work is the demonstration that almost all tavern customers may already have disturbances of their hepatic biochemistry, though they look healthy, what represents an important and serious Public Health problem.