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Total Intravenous Anaesthesia (TIVA) is an innovative alternative to traditional inhalational anaesthesia. Often incorrectly perceived as overly complex, TIVA has numerous advantages over inhalational drugs, such as a lower risk of nausea, less pain and better cognitive recovery. Taking on TIVA is a practical, easy to read and engaging guide to TIVA. It demystifies this important technique and will empower the novice but also support more experienced practitioners. It is a clear step-by-step approach to treating everything from routine elective to paediatric, geriatric, obese and pregnant patients. Pharmacokinetic models, dosage calculations, and the use of TIVA in emergency medicine are also elucidated. Written by international experts in the field with many years of experience both conducting and teaching TIVA, this handbook is an essential resource for experienced and novice anaesthetists alike who want to improve their understanding and confidence with the technique.
Powder X-ray diffraction patterns for three forms of MIL-53(Al), a metal organic framework (MOF) compound with breathing characteristics, were investigated using the Rietveld refinement method. These three samples are referred to as the MIL-53(Al)as-syn (the as synthesized sample), orthorhombic, Pnma, a = 17.064(2) Å, b = 6.6069(9) Å, c = 12.1636(13) Å, V = 1371.3(2) Å3, Z = 4), MIL-53(Al)LT-H (low-temperature hydrated phase, monoclinic P21/c, a = 19.4993(8) Å, b = 15.2347(6) Å, c = 6.5687(3) Å, β = 104.219(4) °, V = 1891.55(10) Å3, Z = 8), and MIL-53(Al)HT-D (high-temperature dehydrated phase, Imma, a = 6.6324(5) Å, b = 16.736(2) Å, c = 12.840(2), V = 1425.2(2) Å3, Z = 4). The crystal structures of the “as-syn” sample and the HT-D sample are confirmed to be the commonly adopted ones. However, the structure of the MIL-53(Al)LT-H phase is confirmed to be monoclinic with a space group of P21/c instead of the commonly accepted space group Cc, resulting in a cell volume double in size. The structure has two slightly different types of channel. The pore volumes and pore surface area were estimated to be 0.11766 (8) cm3/g and 1461.3(10) m2/g for MIL-53(Al)HT-D (high-temperature dehydrated phase), and 0.08628 (5) cm3/g and 1401.6 (10) m2/g for MIL-53(Al)as-syn phases, respectively. The powder patterns for the MIL-53(Al)as-syn and MIL-53(Al)HT-D phases are reported in this paper.
Introduction: Oxygen is commonly administered to prehospital patients presenting with acute myocardial infarction (AMI). We conducted a systematic review to determine if oxygen administration, in AMI, impacts patient outcomes. Methods: We conducted a systematic search using MeSH terms and keywords in Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central, clinicaltrials.gov and ISRCTN for relevant randomized controlled trials and observational studies comparing oxygen administration and no oxygen administration. The outcomes of interest were: mortality (≤30 days, in-hospital, and intermediate 2-11 months), infarct size, and major adverse cardiac events (MACE). Risk of Bias assessments were performed and GRADE methodology was employed to assess quality and overall confidence in the effect estimate. A meta-analysis was performed using RevMan 5 software. Results: Our search yielded 1192 citations of which 48 studies were reviewed as full texts and a total of 8 studies were included in the analysis. All evidence was considered low or very low quality. Five studies reported on mortality finding low quality evidence of no benefit or harm. Low quality evidence demonstrated no benefit or harm from supplemental oxygen administration. Similarly, no benefit or harm was found in MACE or infarct size (very low quality). Normoxia was defined as oxygen saturation measured via pulse oximetry at ≥90% in one recent study and ≥94% in another. Conclusion: We found low and very low quality evidence that the administration of supplemental oxygen to normoxic patients experiencing AMI, provides no clear harm nor benefit for mortality or MACE. The evidence on infarct size was inconsistent and warrants further prospective examination.
Introduction: Opioids are routinely administered for analgesia to prehospital patients experiencing chest discomfort from acute myocardial infarction (AMI). We conducted a systematic review to determine if opioid administration impacts patient outcomes. Methods: We conducted a systematic search using MeSH terms and keywords in Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central and Clinicaltrials.gov for relevant randomized controlled trials and observational studies comparing opioid administration in AMI patients from 1990 to 2017. The outcomes of interest were: all-cause short-term mortality (≤30 days), major adverse cardiac events (MACE), platelet activity and aggregation, immediate adverse events, infarct size, and analgesia. Included studies were hand searched for additional citations. Risk of Bias assessments were performed and GRADE methodology was employed to assess quality and overall confidence in the effect estimate. Results: Our search yielded 3001 citations of which 19 studies were reviewed as full texts and a total of 9 studies were included in the analysis. The studies predominantly reported on morphine as the opioid. Five studies reported on mortality (≤30 days), seven on MACE, four on platelet activity and aggregation, two on immediate adverse events, two on infarct size and none on analgesic effect. We found low quality evidence suggesting no benefit or harm in terms of mortality or MACE. However, low quality evidence indicates that opioids increase infarct size. Low-quality evidence also shows reduced serum P2Y12 (eg: clopidogrel and ticagrelor) active metabolite levels and increased platelet reactivity in the first several hours post administration following an increase in vomiting. Conclusion: We find low and very low quality evidence that the administration of opioids in STEMI may be adversely related to vomiting and some surrogate outcomes including increased infarct size, reduced serum P2Y12 levels, and increased platelet activity. We found no clear benefit or harm on patient-oriented clinical outcomes including mortality.
Determining infectious cross-transmission events in healthcare settings involves manual surveillance of case clusters by infection control personnel, followed by strain typing of clinical/environmental isolates suspected in said clusters. Recent advances in genomic sequencing and cloud computing now allow for the rapid molecular typing of infecting isolates.
To facilitate rapid recognition of transmission clusters, we aimed to assess infection control surveillance using whole-genome sequencing (WGS) of microbial pathogens to identify cross-transmission events for epidemiologic review.
Clinical isolates of Staphylococcus aureus, Enterococcus faecium, Pseudomonas aeruginosa, and Klebsiella pneumoniae were obtained prospectively at an academic medical center, from September 1, 2016, to September 30, 2017. Isolate genomes were sequenced, followed by single-nucleotide variant analysis; a cloud-computing platform was used for whole-genome sequence analysis and cluster identification.
Most strains of the 4 studied pathogens were unrelated, and 34 potential transmission clusters were present. The characteristics of the potential clusters were complex and likely not identifiable by traditional surveillance alone. Notably, only 1 cluster had been suspected by routine manual surveillance.
Our work supports the assertion that integration of genomic and clinical epidemiologic data can augment infection control surveillance for both the identification of cross-transmission events and the inclusion of missed and exclusion of misidentified outbreaks (ie, false alarms). The integration of clinical data is essential to prioritize suspect clusters for investigation, and for existing infections, a timely review of both the clinical and WGS results can hold promise to reduce HAIs. A richer understanding of cross-transmission events within healthcare settings will require the expansion of current surveillance approaches.
OBJECTIVES/SPECIFIC AIMS: Hepatitis C virus (HCV) has a high prevalence among individuals in jail and prisons. Access to HCV treatment has been restricted in jails and prisons. We hypothesized that HCV infection in inmates would be associated with increased mortality in people who were hospitalized while incarcerated. METHODS/STUDY POPULATION: We created and then linked a database of people who were incarcerated and admitted at Lemuel Shattuck Hospital (2004, 2008, 2011) to the Massachusetts Vital Statistic Registry (updated through end of 2015). Death was classified using the Automatic Classification of Medical Entry Death Code. The primary outcome of interest was mortality within 1 year of hospitalization, and the secondary outcome was mortality at any time. The primary indicator of interest was HCV, defined as the presence of the ICD-9 code for HCV on discharge. Covariates included in univariate and multivariate modeling included age, year of admission, and race/ethnicity classified as: White, Black, Hispanic or Other (i.e., Asian, Native American, Multi-Racial, or No answer). RESULTS/ANTICIPATED RESULTS: Of the 1,541 hospital admissions, 21% had HCV, and 57% were white, 22% black, 8% Hispanic and 12% other. Of the 273 total deaths (18% of cohort), 82 deaths occurred within 1 year of hospitalization (5.3% of the entire cohort, 30% of all deaths). The primary cause of death was vascular (21%), followed by chronic liver disease (18%), cancer (17%), overdose/suicide/trauma (19%), pulmonary (7%) and infection (6%). People with HCV were more likely to die of chronic liver disease (40% vs 7%, p<0.001). In the multivariable adjusted model, people with HCV were more likely to die within 1 year of hospitalization (HR 1.59, 95% CI 1.02, 2.49) and more likely to die at any time (HR 1.38, 95% CI 1.06, 1.79). Age, race and gender were not associated with risk of death. Compared to 2004, people admitted in 2008 (HR 2.05, 95% CI, 1.50-2.80) and 2011 (HR 4.02, 95% CI 2.77, 5.83) were more likely to die within 1 year. DISCUSSION/SIGNIFICANCE OF IMPACT: Despite advances in HCV treatment in the community, HCV in inmates is associated with increased mortality.
We present observations of 50 deg2 of the Mopra carbon monoxide (CO) survey of the Southern Galactic Plane, covering Galactic longitudes l = 300–350° and latitudes |b| ⩽ 0.5°. These data have been taken at 0.6 arcmin spatial resolution and 0.1 km s−1spectral resolution, providing an unprecedented view of the molecular clouds and gas of the Southern Galactic Plane in the 109–115 GHz J = 1–0 transitions of 12CO, 13CO, C18O, and C17O.
We present a series of velocity-integrated maps, spectra, and position-velocity plots that illustrate Galactic arm structures and trace masses on the order of ~106 M⊙ deg−2, and include a preliminary catalogue of C18O clumps located between l = 330–340°. Together with the information about the noise statistics of the survey, these data can be retrieved from the Mopra CO website and the PASA data store.
BACKGROUND: IGTS is a rare phenomenon of paradoxical germ cell tumor (GCT) growth during or following treatment despite normalization of tumor markers. We sought to evaluate the frequency, clinical characteristics and outcome of IGTS in patients in 21 North-American and Australian institutions. METHODS: Patients with IGTS diagnosed from 2000-2017 were retrospectively evaluated. RESULTS: Out of 739 GCT diagnoses, IGTS was identified in 33 patients (4.5%). IGTS occurred in 9/191 (4.7%) mixed-malignant GCTs, 4/22 (18.2%) immature teratomas (ITs), 3/472 (0.6%) germinomas/germinomas with mature teratoma, and in 17 secreting non-biopsied tumours. Median age at GCT diagnosis was 10.9 years (range 1.8-19.4). Male gender (84%) and pineal location (88%) predominated. Of 27 patients with elevated markers, median serum AFP and Beta-HCG were 70 ng/mL (range 9.2-932) and 44 IU/L (range 4.2-493), respectively. IGTS occurred at a median time of 2 months (range 0.5-32) from diagnosis, during chemotherapy in 85%, radiation in 3%, and after treatment completion in 12%. Surgical resection was attempted in all, leading to gross total resection in 76%. Most patients (79%) resumed GCT chemotherapy/radiation after surgery. At a median follow-up of 5.3 years (range 0.3-12), all but 2 patients are alive (1 succumbed to progressive disease, 1 to malignant transformation of GCT). CONCLUSION: IGTS occurred in less than 5% of patients with GCT and most commonly after initiation of chemotherapy. IGTS was more common in patients with IT-only on biopsy than with mixed-malignant GCT. Surgical resection is a principal treatment modality. Survival outcomes for patients who developed IGTS are favourable.
To determine whether probiotic prophylaxes reduce the odds of Clostridium difficile infection (CDI) in adults and children.
Individual participant data (IPD) meta-analysis of randomized controlled trials (RCTs), adjusting for risk factors.
We searched 6 databases and 11 grey literature sources from inception to April 2016. We identified 32 RCTs (n=8,713); among them, 18 RCTs provided IPD (n=6,851 participants) comparing probiotic prophylaxis to placebo or no treatment (standard care). One reviewer prepared the IPD, and 2 reviewers extracted data, rated study quality, and graded evidence quality.
Probiotics reduced CDI odds in the unadjusted model (n=6,645; odds ratio [OR] 0.37; 95% confidence interval [CI], 0.25–0.55) and the adjusted model (n=5,074; OR, 0.35; 95% CI, 0.23–0.55). Using 2 or more antibiotics increased the odds of CDI (OR, 2.20; 95% CI, 1.11–4.37), whereas age, sex, hospitalization status, and high-risk antibiotic exposure did not. Adjusted subgroup analyses suggested that, compared to no probiotics, multispecies probiotics were more beneficial than single-species probiotics, as was using probiotics in clinical settings where the CDI risk is ≥5%. Of 18 studies, 14 reported adverse events. In 11 of these 14 studies, the adverse events were retained in the adjusted model. Odds for serious adverse events were similar for both groups in the unadjusted analyses (n=4,990; OR, 1.06; 95% CI, 0.89–1.26) and adjusted analyses (n=4,718; OR, 1.06; 95% CI, 0.89–1.28). Missing outcome data for CDI ranged from 0% to 25.8%. Our analyses were robust to a sensitivity analysis for missingness.
Moderate quality (ie, certainty) evidence suggests that probiotic prophylaxis may be a useful and safe CDI prevention strategy, particularly among participants taking 2 or more antibiotics and in hospital settings where the risk of CDI is ≥5%.
While previous work showed that the Centers for Disease Control and Prevention toolkit for carbapenem-resistant Enterobacteriaceae (CRE) can reduce spread regionally, these interventions are costly, and decisions makers want to know whether and when economic benefits occur.
Orange County, California
Using our Regional Healthcare Ecosystem Analyst (RHEA)-generated agent-based model of all inpatient healthcare facilities, we simulated the implementation of the CRE toolkit (active screening of interfacility transfers) in different ways and estimated their economic impacts under various circumstances.
Compared to routine control measures, screening generated cost savings by year 1 when hospitals implemented screening after identifying ≤20 CRE cases (saving $2,000–$9,000) and by year 7 if all hospitals implemented in a regional coordinated manner after 1 hospital identified a CRE case (hospital perspective). Cost savings was achieved only if hospitals independently screened after identifying 10 cases (year 1, third-party payer perspective). Cost savings was achieved by year 1 if hospitals independently screened after identifying 1 CRE case and by year 3 if all hospitals coordinated and screened after 1 hospital identified 1 case (societal perspective). After a few years, all strategies cost less and have positive health effects compared to routine control measures; most strategies generate a positive cost-benefit each year.
Active screening of interfacility transfers garnered cost savings in year 1 of implementation when hospitals acted independently and by year 3 if all hospitals collectively implemented the toolkit in a coordinated manner. Despite taking longer to manifest, coordinated regional control resulted in greater savings over time.
Antineuronal antibodies are associated with psychosis, although their clinical significance in first episode of psychosis (FEP) is undetermined.
To examine all patients admitted for treatment of FEP for antineuronal antibodies and describe clinical presentations and treatment outcomes in those who were antibody positive.
Individuals admitted for FEP to six mental health units in Queensland, Australia, were prospectively tested for serum antineuronal antibodies. Antibody-positive patients were referred for neurological and immunological assessment and therapy.
Of 113 consenting participants, six had antineuronal antibodies (anti-N-methyl-D-aspartate receptor antibodies [n = 4], voltage-gated potassium channel antibodies [n = 1] and antibodies against uncharacterised antigen [n = 1]). Five received immunotherapy, which prompted resolution of psychosis in four.
A small subgroup of patients admitted to hospital with FEP have antineuronal antibodies detectable in serum and are responsive to immunotherapy. Early diagnosis and treatment is critical to optimise recovery.
Contaminated hands of healthcare workers (HCWs) are an important source of transmission of healthcare-associated infections. Alcohol-based hand sanitizers, while effective, do not provide sustained antimicrobial activity. The objective of this study was to compare the immediate and persistent activity of 2 hand hygiene products (ethanol [61% w/v] plus chlorhexidine gluconate [CHG; 1.0% solution] and ethanol only [70% v/v]) when used in an intensive care unit (ICU).
Prospective, randomized, double-blinded, crossover study
Three ICUs at a large teaching hospital
In total, 51 HCWs involved in direct patient care were enrolled in and completed the study.
All HCWs were randomized 1:1 to either product. Hand prints were obtained immediately after the product was applied and again after spending 4–7 minutes in the ICU common areas prior to entering a patient room or leaving the area. The numbers of aerobic colony-forming units (CFU) were compared for the 2 groups after log transformation. Each participant tested the alternative product after a 3-day washout period.
On bare hands, use of ethanol plus CHG was associated with significantly lower recovery of aerobic CFU, both immediately after use (0.27 ± 0.05 and 0.88 ± 0.08 log10 CFU; P = .035) and after spending time in ICU common areas (1.81 ± 0.07 and 2.17 ± 0.05 log10 CFU; P<.0001). Both the antiseptics were well tolerated by HCWs.
In comparison to the ethanol-only product, the ethanol plus CHG sanitizer was associated with significantly lower aerobic bacterial counts on hands of HCWs, both immediately after use and after spending time in ICU common areas.
The putative Thoka gene, with large effects on fecundity, originated in Icelandic sheep. The gene was introduced to the UK in 1985 through a programme of crossbreeding and established in Cheviot sheep (Russel et al., 1997). Ewes have been retained in the flock as putative Thoka gene carriers if they have lambed in each of the first three years and had at least two sets of twins. Progeny tests on a separate population of ewes have been used on two occasions to identify rams believed to carry the gene. Despite this complex breeding programme, the actual segregation of a gene for fecundity has yet to be unambiguously demonstrated in this flock. The purpose of this study is to use complex segregation analysis to demonstrate the existence of this gene, estimate the size of its effect and frequency of the favourable allele within the population.
This paper reports on a non-conventional method for the management of facial carbuncles, highlighting its superiority over conventional surgical treatment in terms of cosmetic outcome and shorter duration of wound healing.
The mainstay of treatment for carbuncles involves the early administration of antibiotics in combination with surgical intervention. The conventional saucerisation, or incision and drainage, under normal circumstances results in moderate to large wounds, which may need secondary surgery such as skin grafting, resulting in a longer duration of wound healing and jeopardising cosmetic outcome.
The reported three cases presented with extensive carbuncles over the chin, face and lips region. In addition to early commencement of intravenous antibiotics, the pus was drained, with minimal incision and conservative wound debridement, with the aim of maximal skin conservation. This was followed by thrice-daily irrigation with antibiotic-containing solution for a minimum of 2 consecutive days. The wounds healed within two to four weeks, without major cosmetic compromise.
The new method showed superior cosmetic outcomes, with a shorter duration of wound healing. Conservative surgical management can be performed under regional anaesthesia, which may reduce morbidity and mortality; patients with facial carbuncles often have higher risks with general anaesthesia.
X-ray reference powder patterns and structures have been determined for a series of cobalt-, nickel- and zinc-containing niobates, Co(NixZn1−x)Nb4O12 (x = 0.2, 0.4, 0.6, 0.8). The Co(NixZn1−x)Nb4O12 series crystallize in the space group of Pbcn, which is of the disordered columbite-type structure (α-PbO2). The lattice parameters range from a = 14.11190(13) to 14.1569(3) Å, b = 5.69965(6) to 5.71209(13) Å, c = 5.03332(5) to 5.03673(11) Å, and V = 404.844(8) to 407.296(17) Å3 from x = 0.8 to 0.2, respectively. Co(NixZn1−x)Nb4O12 contains double zig-zag chains of NbO6 octahedra and single chain of (Ni,Zn,Co)O6 octahedra run parallel to the bc-plane. Within the same chain the NbO6 octahedra share edges, while the adjacent NbO6 chains are joined to each other through common oxygen corners. These double NbO6 chains are further linked together along the -direction through another (Co,Ni,Zn)O6 units, via common oxygen corners. The edge-sharing (Co,Ni,Zn)O6 also forms zig-zag chains along the c-axis. Powder X-ray diffraction patterns of this series of compounds have been submitted to be included in the Powder Diffraction File.
The structure of a series of lanthanide iron cobalt perovskite oxides, R(Fe0.5Co0.5)O3 (R = Pr, Nd, Sm, Eu, and Gd), have been investigated. The space group of these compounds was confirmed to be orthorhombic Pnma (No. 62), Z = 4. From Pr to Gd, the lattice parameter a varies from 5.466 35(13) Å to 5.507 10(13) Å, b from 7.7018(2) to 7.561 75(13) Å, c from 5.443 38(10) to 5.292 00(8) Å, and unit-cell volume V from 229.170(9) Å3 to 220.376(9) Å3, respectively. While the trend of V follows the trend of the lanthanide contraction, the lattice parameter “a” increases as the ionic radius r(R3+) decreases. X-ray diffraction (XRD) and transmission electron microscopy confirm that Fe and Co are disordered over the octahedral sites. The structure distortion of these compounds is evidenced in the tilt angles θ, ϕ, and ω, which represent rotations of an octahedron about the pseudocubic perovskite p, p, and p axes. All three tilt angles increase across the lanthanide series (for R = Pr to R = Gd: θ increases from 12.3° to 15.2°, ϕ from 7.5° to 15.8°, and ω from 14.4° to 21.7°), indicating a greater octahedral distortion as r(R3+) decreases. The bond valence sum for the sixfold (Fe/Co) site and the eightfold R site of R(Fe0.5Co0.5)O3 reveal no significant bond strain. Density Functional Theory calculations for Pr(Fe0.5Co0.5)O3 support the disorder of Fe and Co and suggest that this compound to be a narrow band gap semiconductor. XRD patterns of the R(Fe0.5Co0.5)O3 samples were submitted to the Powder Diffraction File.
During the past three years radiocarbon assay has emerged as a primary tool in the quantitative assignment of sources of urban and rural particulate pollution. Its use in several major field studies has come about because of its excellent (fossil/biogenic) discriminating power, because of advances in 14C measurements of small samples, and because of the increased significance of carbonaceous particles in the atmosphere. The problem is especially important in the cities, where increased concentrations of fine particles lead to pollution episodes characterized by poor visibility and changes in the radiation balance (absorption, scattering), and immediate and possibly long-term health effects. Efforts in source apportionment in such affected areas have been based on emissions inventories, dispersion modeling, and receptor modeling – ie, chemical and physical (and statistical) characterization of particles collected at designated receptor sites. It is in the last category that 14C has become quite effective in helping to resolve particle sources. Results are presented for studies carried out in Los Angeles, Denver, and Houston which incorporated 14C measurements, inorganic and organic chemical characterization, and receptor modeling. The 14C data indicated wide ranging contributions of biogenic and fossil carbon sources – eg, <10% to 60% contemporary (biogenic) in Houston – depending on meteorological, biological, and anthropological activity. The combined (chemical, isotopic, statistical) data point to sources such as vehicles, wood combustion, power plants, and vegetation.