Sinusitis of the maxillary antrum

Twenty-four adults with clinical evidence of sinusitis were studied by 65 needle punctures of the maxillary antrum. Fourteen of 15 sinuses with normal transillumination and 19 of 26 that were dull had normal aspirates, whereas 24 of 24 that were opaque had abnormal aspirates (P less than 0.001). Marked mucosal thickening as determined radiologically (Water's view) was associated with abnormal aspirates whereas lesser mucosal thickening was not (P less than 0.001). In acute sinusitis, there was a strong correlation between high aspirate leukocyte counts (greater than 1000 per cubic millimeter) and infection as manifested by bacterial titers of greater than 10(5) per milliliter or the isolation of virus fungus (P greater than 0.001). Anterior-nasal-swab cultures correlated poorly with direct aspirate culters. Organisms frequently recovered from the sinus included Haemophilus influenzae, Strepto coccus pneumoniae, and anaerobic bacteria. Rhinovirus was recovered twice. Antibiotics were usedful in patients with acute sinusitis if the organism was sensitive in vitro (P less than 0.001).

Measuring children's participation in recreation and leisure activities: construct validation of the CAPE and PAC

There is a need for psychometrically sound measures of children's participation in recreation and leisure activities, for both clinical and research purposes. This paper provides information about the construct validity of the Children's Assessment of Participation and Enjoyment (CAPE) and its companion measure, Preferences for Activities of Children (PAC). These measures are appropriate for children and youth with and without disabilities between the ages of 6 and 21 years. They provide information about six dimensions of participation (i.e. diversity, intensity, where, with whom, enjoyment and preference) and two categories of recreation and leisure activities: (i) formal and informal activities; and (ii) five types of activities (recreational, active physical, social, skill-based and self-improvement). This paper presents information about the performance of the CAPE and PAC activity type scores using data from a study involving 427 children with physical disabilities between the ages of 6 and 15 years. Intensity, enjoyment and preference scores were significantly correlated with environmental, family and child variables, in expected ways. Predictions also were supported with respect to differences in mean scores for boys vs. girls, and children in various age groups. The information substantiates the construct validity of the measures. The clinical and research utility of the measures are discussed.

Principles for Sustainable Governance of the Oceans

Pressures being exerted on the ocean ecosystems through overfishing, pollution, and environmental and climate change are increasing. Six core principles are proposed to guide governance and use of ocean resources and to promote sustainability. Examples of governance structures that embody these principles are given.

Synthesis of proteins by automated flow chemistry

Ribosomes can produce proteins in minutes and are largely constrained to proteinogenic amino acids. Here, we report highly efficient chemistry matched with an automated fast-flow instrument for the direct manufacturing of peptide chains up to 164 amino acids long over 327 consecutive reactions. The machine is rapid: Peptide chain elongation is complete in hours. We demonstrate the utility of this approach by the chemical synthesis of nine different protein chains that represent enzymes, structural units, and regulatory factors. After purification and folding, the synthetic materials display biophysical and enzymatic properties comparable to the biologically expressed proteins. High-fidelity automated flow chemistry is an alternative for producing single-domain proteins without the ribosome.

Factors affecting family-centred service delivery for children with disabilities

BACKGROUND

The provision of family-centred services (FCS) emphasizes a partnership between parents and service providers so that families are involved in every aspect of services for their child. There is evidence that providing FCS is associated with improvements in parents' satisfaction with services, decreased parental stress, and positive child outcomes.

METHODS

The purpose of this study was to examine factors that are most important in determining parent perceptions of the family centredness of care and parent satisfaction with service. A cross-sectional survey was completed by 494 parents, 324 service providers, and 15 CEOs from 16 organizations delivering children's rehabilitation services. Analyses were completed using a structural equation modelling approach.

RESULTS

Survey return rates ranged from 77 to 94%. Findings indicate that the principal determinants of parent satisfaction with services are the family-centred culture at the organization and parent perceptions of FCS. Parent satisfaction with services was also influenced by the number of places where services were received and the number of health and development problems experienced by their child.

CONCLUSION

Parent satisfaction with services is strongly influenced by the perception that services are more family centred, fewer places where services were received and fewer health and development problems for their child. Ways in which organizations can improve satisfaction through carrying out family-centred behaviours are discussed.

Anti-inflammatory properties of molecular hydrogen: investigation on parasite-induced liver inflammation

Molecular hydrogen reacts with the hydroxyl radical, a highly cytotoxic species produced in inflamed tissues. It has been suggested therefore to use gaseous hydrogen in a new anti-inflammatory strategy. We tested this idea, with the aid of the equipment and skills of COMEX SA in Marseille, a group who experiments with oxygen-hydrogen breathing mixtures for professional deep-sea diving. The model used was schistosomiasis-associated chronic liver inflammation. Infected animals stayed 2 weeks in an hyperbaric chamber in a normal atmosphere supplemented with 0.7 MPa hydrogen. The treatment had significant protective effects towards liver injury, namely decreased fibrosis, improvement of hemodynamics, increased NOSII activity, increased antioxidant enzyme activity, decreased lipid peroxide levels and decreased circulating TNF-alpha levels. Under the same conditions, helium exerted also some protective effects, indicating that hydroxyl radical scavenging is not the only protective mechanism. These findings indicate that the proposed anti-inflammatory strategy deserves further attention.

Incidence of hyponatraemia and hyponatraemic seizures in severe respiratory syncytial virus bronchiolitis

AIM

To document the incidence and early evolution of hyponatraemia (serum sodium < 136 mmol l(-1)) associated with respiratory syncytial virus (RSV) bronchiolitis in infants requiring intensive care.

METHODS

In a retrospective review over two winter seasons, 130 infants were admitted with confirmed RSV infection, of whom 39 were excluded because of either pre-existing risk factors for hyponatraemia: diuretic therapy (n = 14), cardiac disease (n = 10), renal disease (n = 2) or lack of admission sodium data (n = 13).

RESULTS

The incidence of admission hyponatraemia in the remaining infants (median age 6 wk) was 33% (30/91), with 11% (10/91) exhibiting a serum sodium less than 130 mmol l(-1) . Hyponatraemic and normonatraemic infants were of a similar age (median 6 vs 7 wk, p = 0.82). With fluid restriction and diuretic therapy, the incidence of hyponatraemia at 48 h had decreased to 3.3%, odds ratio 0.07 (95% confidence interval 0.02-0.24, p < 0.001). Four infants (4%) suffered hyponatraemic seizures at admission (sodium 114-123 mmol l(-1)); three had received hypotonic intravenous fluids at 100-150 ml kg(-1) d(-1) before referral to intensive care. All four were managed successfully with hypertonic (3%) saline, followed by fluid restriction, resulting in immediate termination of seizure activity and normalization of serum sodium values over 48 h.

CONCLUSION

Hyponatraemia is common among infants with RSV bronchiolitis presenting to intensive care. Neurological complications may occur and fluid therapy in vulnerable infants should be tailored to reduce this risk.

Hypoalbuminaemia in critically ill children: incidence, prognosis, and influence on the anion gap

AIMS

Hypoalbuminaemia has significance in adult critical illness as an independent predictor of mortality. In addition, the anion gap is predominantly due to the negative charge of albumin, thus hypoalbuminaemia may lead to its underestimation. We examine this phenomenon in critically ill children, documenting the incidence, early evolution, and prognosis of hypoalbuminaemia (<33 g/l), and quantify its influence on the anion gap.

METHODS

Prospective descriptive study of 134 critically ill children in the paediatric intensive care unit (ICU). Paired arterial blood samples were taken at ICU admission and 24 hours later, from which blood gases, electrolytes, and albumin were measured. The anion gap (including potassium) was calculated and then corrected for albumin using Figge's formula.

RESULTS

The incidence of admission hypoalbuminaemia was 57%, increasing to 76% at 24 hours. Neither admission hypoalbuminaemia, nor extreme hypoalbuminaemia (<20 g/l) predicted mortality; however, there was an association with increased median ICU stay (4.9 v 3.6 days). After correction for albumin the incidence of a raised anion gap (>18 mEq/l) increased from 28% to 44% in all samples (n = 263); this discrepancy was more pronounced in the 103 samples with metabolic acidosis (38% v 73%). Correction produced an average increase in the anion gap of 2.7 mEq/l (mean bias), with limits of agreement of +/-3.7 mEq/l.

CONCLUSION

Admission hypoalbuminaemia is common in critical illness, but is not an independent predictor of mortality. However, failure to correct the anion gap for albumin may underestimate the true anion gap, producing error in the interpretation of acid-base abnormalities. This may have treatment implications.

De Novo Discovery of High-Affinity Peptide Binders for the SARS-CoV-2 Spike Protein

The β-coronavirus SARS-CoV-2 has caused a global pandemic. Affinity reagents targeting the SARS-CoV-2 spike protein are of interest for the development of therapeutics and diagnostics. We used affinity selection-mass spectrometry for the rapid discovery of synthetic high-affinity peptide binders for the receptor binding domain (RBD) of the SARS-CoV-2 spike protein. From library screening with 800 million synthetic peptides, we identified three sequences with nanomolar affinities (dissociation constants K d = 80-970 nM) for RBD and selectivity over human serum proteins. Nanomolar RBD concentrations in a biological matrix could be detected using the biotinylated lead peptide in ELISA format. These peptides do not compete for ACE2 binding, and their site of interaction on the SARS-CoV-2-spike-RBD might be unrelated to the ACE2 binding site, making them potential orthogonal reagents for sandwich immunoassays. These findings serve as a starting point for the development of SARS-CoV-2 diagnostics or conjugates for virus-directed delivery of therapeutics.

Guidelines for the diagnosis and management of carcinoid tumours. Part 1: the gastrointestinal tract. A statement from a Canadian National Carcinoid Expert Group

Carcinoid tumours are relatively rare and, in general, slow growing. They can be "non-functioning" tumours, presenting as a tumour mass, or "functioning" tumours secondary to the production of several biopeptides leading to the carcinoid syndrome. Though these tumours represent 0.25% of an oncology practice, a proper understanding of the clinical course of the disease and of the importance of appropriate diagnostic and therapeutic measures is very important. Proper patient management can lead to cure, particularly if the tumour can be fully resected, or to long-term palliation with medical treatment or cytoreductive surgery, or both, with significant prolongation of survival. A good understanding of the use of somatostatin analogues to achieve effective symptomatic control and of the importance of adequate follow-up and cardiac monitoring to prevent or effectively treat cardiac complications can contribute significantly to optimal control of this complex disease, ultimately improving the quality of life of affected patients. This article, developed by a group of Canadian experts, provides a framework that will assist clinicians in taking an optimal approach to managing their patients with carcinoid tumour.

Neither baseline tests of molecular hypercoagulability nor D-dimer levels predict deep venous thrombosis in critically ill medical-surgical patients

OBJECTIVE

Predicting patients who are harboring asymptomatic deep venous thrombosis (DVT), or who are at particular risk of developing DVT, is a desirable clinical goal since prevention or early treatment of DVT might reduce the risk of fatal pulmonary embolism. Thus validation of simple laboratory tests that reliably predict venous thromboembolism (VTE) would be clinically very important. Tests that might be useful for these applications include markers of hypercoagulability (predicting patients at risk of DVT) and D-dimer (predicting which patients may have acute DVT).

METHODS

In a prospective cohort study we measured a panel of hypercoagulability markers at the time of ICU admission, and six commercial D-dimer assays were performed serially during the ICU stay in medical-surgical ICU patients who were screened for DVT with biweekly lower limb compression ultrasonography. Ultrasonography was also performed at the time of any clinically suspected DVT events. We matched cases with DVT with controls without DVT for length of stay in the ICU to generate receiver operating characteristics (ROC) curves.

RESULTS

One hundred ninety-seven patients were enrolled. Blood was collected on a total of 763 occasions (median number of occasions per patient: 3, range 1-21). None of the assays predicted DVT, as indicated by the areas under the ROC curves, that did not differ significantly from 50%.

CONCLUSION

In critically ill patients, neither tests of hypercoagulability nor D-dimer levels predict patients at risk of DVT and thus they should not be used to guide diagnostic testing for DVT.

A comparison of three scoring systems for mortality risk among retrieved intensive care patients

AIMS

To assess the impact of two paediatric intensive care unit retrieval teams on the performance of three mortality risk scoring systems: pre-ICU PRISM, PIM, and PRISM II.

METHODS

A total of 928 critically ill children retrieved for intensive care from district general hospitals in the south east of England (crude mortality 7.8%) were studied.

RESULTS

Risk stratification was similar between the two retrieval teams for scores utilising data primarily prior to ICU admission (pre-ICU PRISM, PIM), despite differences in case mix. The fewer variables required for calculation of PIM resulted in complete data collection in 88% of patients, compared to pre-ICU PRISM (24%) and PRISM II (60%). Overall, all scoring systems discriminated well between survival and non-survival (area under receiver operating characteristic curve 0.83-0.87), with no differences between the two hospitals. There was a tendency towards better discrimination in all scores for children compared to infants and neonates, and a poor discrimination for respiratory disease using pre-ICU PRISM and PRISM II but not PIM. All showed suboptimal calibration, primarily as a consequence of mortality over prediction among the medium (10-30%) mortality risk bands.

CONCLUSIONS

PIM appears to offer advantages over the other two scores in terms of being less affected by the retrieval process and easier to collect. Recalibration of all scoring systems is needed.

Visualization of oxygen radical production in mouse liver in response to infection with Schistosoma mansoni

BACKGROUND/AIMS

The tropical parasite S. mansoni induces granulomatous inflammation in the liver, following the lodging of eggs in this organ. In vitro studies suggested that the host's response might involve the production of oxygen radicals.

METHODS

In an attempt to investigate the situation at the site of inflammation, under disease conditions, livers of infected mice were treated with dichlorodihydrofluorescein diacetate which fluoresces after oxidation.

RESULTS

Fluorescence of the oxidized tracer revealed that oxygen radicals were produced by granulomatous inflammatory cells. The phenomenon reached its highest intensity close to the eggs. The membranes of the cells were strongly labelled, probably reflecting membrane-associated NADPH oxidase activity. The cytoplasm of hepatocytes was also fluorescent but with lower intensity; hepatocyte membranes or nuclei were not labelled. Fluorescence was reduced drastically by treatment with catalase and antioxidants, indicating the occurrence of H2O2. Treatment with superoxide dismutase had no effect. Neither the livers of uninfected animals nor those of infected animals before parasite egg deposition were labelled. Eosinophil peroxidase activity was released in the areas of inflammatory cells, but was not found in hepatocytes.

CONCLUSIONS

The H2O2/peroxidase system, which is the cornerstone of the antimicrobial defense associated with inflammation, is activated in close contact with parasite eggs. The process does contribute to egg killing in vivo. Moreover, hepatocytes undergo oxidative stress in the entire organ. This finding is in agreement with the parasite-induced decrease of liver antioxidant defenses demonstrated previously.

Enzymatic activity of dystrophic chicken sarcoplasmic reticulum

We have isolated sarcoplasmic reticulum from normal and dystrophic chicken muscle, using an improved isolation procedure. Dystrophic sarcoplasmic reticulum has a reduced level of calcium-sensitive ATPase activity, phosphoenzyme formation, and steady-state calcium transport. Anion-stimulated calcium transport by dystrophic sarcoplasmic reticulum is also reduced when measured under the proper conditions, and dystrophic sarcoplasmic reticulum shows no alteration in calcium efflux rate. Active calcium phosphate loading of the normal and dystrophic sarcoplasmic reticulum preparations indicates that a reduced percentage jof the dystrophic vesicles are capable of active calcium transport. The loaded dystrophic sarcoplasmic reticulum vesicles exhibit the same relative reductions in enzymatic activity as the starting sarcoplasmic reticulum preparations. However, the enzyme activities of normal and dystrophic sarcoplasmic reticulum are similar in the presence of detergent and exogenous phospholipid. On the basis of these results, we suggest that the lipid microenvironment of the dystrophic enzyme is altered.

Gd-DOTA-enhanced MR imaging and color Doppler US of renal allograft necrosis

In 21 recipients of renal transplants suspected of allograft necrosis, the authors correlated the results of imaging to pathologic and histologic data in order to describe the magnetic resonance (MR) imaging and color Doppler ultrasonographic (US) characteristics of infarction. All patients underwent MR imaging performed with and without gadolinium tetraazacyclododecanetetraacetic acid (DOTA) and color Doppler US. Nonenhanced T1-weighted images showed no obvious changes, whereas nonenhanced T2-weighted images demonstrated a slight increase in signal intensity in areas of ischemic necrosis and low or heterogeneous signal intensity in areas of hemorrhagic necrosis. Gd-DOTA-enhanced MR images showed no contrast material uptake in infarcted areas. Color Doppler US characteristics of infarction included absence of Doppler signal and alteration of the cortical echogenic structure, particularly in cases of ischemic necrosis. Color Doppler US allows measurement of vascular resistance and assessment of intrarenal vasculature and the renal pedicle. Gd-DOTA-enhanced MR imaging is useful in confirming the diagnosis of infarction and provides an accurate evaluation of the extent of the infarct.