Antimicrobial Resistance in Papua New Guinea: A Narrative Scoping Review

Antimicrobial-resistant bacterial infections are a known threat to the public health of low-income countries and are undercharacterized in Papua New Guinea. A scoping literature review of scientific peer-reviewed publications on antimicrobial resistance in Papua New Guinea was conducted, and their results were summarized. Many of the available data on resistant bacteria in Papua New Guinea have come from Port Moresby and Goroka and have been focused on Staphylococcus aureus, as well as important pediatric pathogens such as Streptococcus pneumoniae and Haemophilus influenzae. Progressive resistance to the commonly used antibiotics penicillin and chloramphenicol among most clinically important bacterial pathogens has prompted healthcare workers to adopt expensive broad-spectrum antibiotics. There is already evidence of resistance to newly adopted antibiotics among several Gram-negative organisms. Drivers of antimicrobial resistance in Papua New Guinea include a high burden of infectious diseases, inappropriate antibiotic prescription practices, poor regulation of antibiotics, incomplete adherence, substandard drug quality, and overcrowding of healthcare facilities. There is a lack of information on antimicrobial resistance among priority pathogens and from several important regions of Papua New Guinea.

Influence of Intestinal Helminth Burden on Clinical Manifestations, Therapeutic Response, and Leishmania braziliensis Load in Patients with New World Cutaneous Leishmaniasis

Leishmania braziliensis is the most important cause of cutaneous leishmaniasis (CL) in the Americas. A Th1-type immune response is required to control Leishmania infection, but an exaggerated inflammatory response leads to the development of ulcers seen in CL. Infection with intestinal helminths has the potential to inhibit the Th1 response in a manner that depends both on the species of helminth present as well as the burden of helminthiasis. We conducted a prospective cohort study of CL patients from an endemic area between January and December 2017 with either negative or high intestinal helminth burden to characterize relationships between helminth burden, L. braziliensis quantification within CL lesions, clinical aspects of CL, and therapeutic response. Of 234 participants with leishmaniasis who underwent stool examination at the time of diagnosis, 45% had detectable helminth infection. The overall cure rate after 90 days was 66%, with a median time to resolution of disease of 40 days (interquartile range: 30-65 days). There was no significant association between the type of helminth infection or the magnitude of intestinal helminth burden at the time of diagnosis and L. braziliensis genomic DNA (gDNA) detected in biopsies from CL lesions. Likewise, there was no association between helminth burden and response to treatment after 90 days. Considering quantification of parasite DNA in CL lesions, participants who were cured at 90 days had a median of 0.017 ng/mg gDNA, and participants who failed therapy had a median of 0.091 ng/mg gDNA (P = 0.03). The results indicate that cutaneous Leishmania load may influence therapeutic response in CL.

497 Targeting Improvements in The Elective Aneurysm Pathway in The Dorset and Wiltshire Vascular Network (DWVN)

Introduction

Two consecutive NVR reports identified the DWVN as the 7th slowest network to treat patients with AAAs. We aimed to detect if there were any significant delays in our pathway.

Method

We performed a retrospective audit of patients having elective open and endovascular repair. 144 patients who had AAA repair between 30/06/2016-01/08/2018 were included. Data were collected on the following stages: the date the AAA reached ≥55mm, referral date, date clinician reviewed, CT scan date, CPET testing date, MDT date and operation date. The time in days between each stage was recorded and any delays documented.

Results

At RBH the longest delay was between MDT and surgery (median 73 days, IQR 32 days-130 days). At DCH the major delay was between CPET and MDT (median 28.5 days, IQR 10 days-31 days). At SDH the longest stage was between MDT and operation (median of 88 days, IQR 37 days-154 days).

Examples of reasons for delays across the three hospitals included awaiting specialist opinions, patient being unwell and no ITU beds available.

Conclusions

The pathway for elective AAA treatment in the DWVN is slow across all three hospitals. The greatest delay is often between MDT and surgery. Targeting this stage could significantly shorten the pathway.

Assessment of the status and trends in abundance of a coastal pinniped, the Australian sea lion Neophoca cinerea

Australian sea lions Neophoca cinerea are endemic to Australia, with their contemporary distribution restricted to South Australia (SA) and Western Australia (WA). Monitoring of the species has proved challenging due to prolonged breeding events that occur non-annually and asynchronously across their range. The most recent available data from 80 extant breeding sites (48 in SA, 32 in WA) enabled us to estimate the species-wide pup abundance to be 2739, with 82% (2246) in SA and 18% (493) in WA, mostly based on surveys conducted between 2014 and 2019. We evaluated 1776 individual site-surveys undertaken between 1970 and 2019 and identified admissible time-series data from 30 breeding sites, which revealed that pup abundance declined on average by 2.0% yr-1 (range 9.9% decline to 1.7% growth yr-1). The overall reduction in pup abundance over 3 generations (42.3 yr) was estimated to be 64%, with over 98% of Monte Carlo simulations producing a decline >50% over a 3-generation period, providing strong evidence that the species meets IUCN ‘Endangered’ criteria (decline ≥50% and ≤80%). The population is much smaller than previously estimated and is declining. There is a strong cline in regional abundances (increasing from west to east), with marked within-region heterogeneity in breeding site pup abundances and trends. Results from this study should improve consistency in the assessment of the species and create greater certainty among stakeholders about its conservation status. To facilitate species management and recovery, we prioritise key data gaps and identify factors to improve population monitoring.

Surveillance for Healthcare-Associated Infections: Hospital-Onset Adult Sepsis Events versus Current Reportable Conditions

BACKGROUND

U.S. hospitals are required by CMS to publicly report CLABSI, CAUTI, C.diffficile, MRSA bacteremia, and selected SSIs for benchmarking and pay-for-performance programs. It is unclear, however, to what extent these conditions capture the full breadth of serious healthcare-associated infections (HAIs). CDC's hospital-onset Adult Sepsis Event (HO-ASE) definition could facilitate more comprehensive and efficient surveillance for serious HAIs, but the overlap between HO-ASE and currently reportable HAIs is unknown.

METHODS

We retrospectively assessed the overlap between HO-ASEs and reportable HAIs among adults hospitalized between June 2015-June 2018 in 3 hospitals. Medical record reviews were conducted for 110 randomly selected HO-ASE cases to determine clinical correlates.

RESULTS

Amongst 282,441 hospitalized patients, 2,301 (0.8%) met HO-ASE criteria and 1,260 (0.4%) had reportable HAIs. In-hospital mortality rates were higher with HO-ASEs than reportable HAIs (28.6% vs 12.9%). Mortality rates for HO-ASE missed by reportable HAIs were substantially higher than mortality rates for reportable HAIs missed by HO-ASE (28.1% vs 6.3%). Reportable HAIs were only present in 334/2,301 (14.5%) HO-ASEs, most commonly CLABSIs (6.0% of HO-ASEs), C.difficile (5.0%), and CAUTI (3.0%). On medical record review, most HO-ASEs were caused by pneumonia (39.1%, of which only 34.9% were ventilator-associated), bloodstream infections (17.4%, of which only 10.5% were central line-associated), non-C.difficile intra-abdominal infections (14.5%), urinary infections (7.3%, of which 87.5% were catheter-associated), and skin/soft tissue infections (6.4%).

CONCLUSIONS

CDC's HO-ASE definition detects many serious nosocomial infections missed by currently reportable HAIs. HO-ASE surveillance could increase the efficiency and clinical significance of surveillance while identifying new targets for prevention.

Phenotypic Characterization of CD4+ T Lymphocytes in Periportal Fibrosis Secondary to Schistosomiasis

Schistosomiasis is a parasitic disease that affects about 166 million people around the world. It is estimated that 5%-10% of individuals with schistosomiasis develop severe forms of the disease, which are characterized by pulmonary hypertension, ascites, periportal fibrosis, and other significant complications. The chronic phase of the disease is associated with a Th2 type immune response, but evidence also suggests there are roles for Th1 and Th17 in the development of severe disease. The aim of this study was to evaluate the CD4+ T lymphocyte profile of patients with different degrees of periportal fibrosis secondary to schistosomiasis. These individuals had been treated for schistosomiasis, but since they live in a S. mansoni endemic area, they are at risk of reinfection. They were evaluated in relation to the degree of periportal fibrosis and classified into three groups: without fibrosis or with incipient fibrosis (WF/IFNE), n=12, possible periportal fibrosis/periportal fibrosis, n=13, and advanced periportal fibrosis/advanced periportal fibrosis with portal hypertension, n=4. We observed in the group without fibrosis a balance between the low expression of Th2 cytokines and high expression of T reg cells. As has already been described in the literature, we found an increase of the Th2 cytokines IL-4, IL-5, and IL-13 in the group with periportal fibrosis. In addition, this group showed higher expression of IL-17 and IL-10 but lower IL-10/IL-13 ratio than patients in the WF/IFNE group. Cells from individuals who present any level of fibrosis expressed more TGF-β compared to the WF/IFNE group and a positive correlation with left lobe enlargement and portal vein wall thickness. There was a negative correlation between IL-17 and the thickness of the portal vein wall, but more studies are necessary in order to explore the possible protective role of this cytokine. Despite the fibrosis group having presented a higher expression of pro-fibrotic molecules compared to WF/IFNE patients, it seems there is a regulation through IL-10 and T reg cells that is able to maintain the low morbidity of this group.

94. Clinical Correlates of Cdc’s Hospital-onset Adult Sepsis Event Surveillance Definition and Association with Reportable Healthcare-associated Infections

Background

Hospital-onset (HO) sepsis is associated with substantial mortality but is not tracked or reported by most hospitals. CDC’s Adult Sepsis Event (ASE) definition may facilitate standardized surveillance but little is known about the clinical correlates of HO-ASEs and their association with currently reportable healthcare-associated infections (HAIs).

Methods

In this retrospective study of all adult patients admitted to an academic medical center between June 2015–2018, we assessed the overlap between HO-ASEs and HAIs reported to the National Healthcare Safety Network (NHSN) and reviewed a random subset of 110 HO-ASE cases to determine their clinical correlates.

Results

The cohort included 168,249 hospitalized patients, including 2,139 (1.3%) with HO-ASE and 2,133 (1.3%) with NHSN HAIs. Amongst the 2,139 HO-ASE patients, 480 (22.4%) had ≥1 HAI: 8.1% VAE, 6.2% CLABSI, 6.1% C.difficile, 3.1% CAUTI, 1.3% MRSA bacteremia, and 0.8% SSI. HO-ASE was associated with higher in-hospital mortality rates than HAIs (28.6% vs 14.6%, p< 0.001). HO-ASE associated mortality was high even when NHSN-reportable HAIs were absent (26.5%) whereas NHSN-reportable HAI mortality was relatively low when HO-ASE was absent (8.4%). Amongst the 110 reviewed HO-ASE cases, 102 (93%) were possible or confirmed infections, most commonly pneumonia (39%, of which 35% were ventilator-associated), non-C.difficile intra-abdominal infections (15%), febrile neutropenia (14%), urinary tract infection (7%, of which 88% were catheter-associated), and skin/soft tissue infection (7%). Most (86%) infections flagged by HO-ASEs were acquired in the hospital rather than the community. The most common non-infectious events flagged by HO-ASE were pulmonary edema and periprocedural blood loss associated with blood cultures and empiric antibiotics.

Conclusion

CDC’s hospital-onset ASE definition accurately identifies patients with nosocomial sepsis who have very high mortality rates and are generally not captured by currently reportable HAI metrics. Routine hospital-onset ASE surveillance could provide a broader window into serious nosocomial infections, identify new targets for prevention, and further improve outcomes for hospitalized patients.

Disclosures

All Authors: No reported disclosures

Heterogeneous mass distribution of the rubble-pile asteroid (101955) Bennu

The gravity field of a small body provides insight into its internal mass distribution. We used two approaches to measure the gravity field of the rubble-pile asteroid (101955) Bennu: (i) tracking and modeling the spacecraft in orbit about the asteroid and (ii) tracking and modeling pebble-sized particles naturally ejected from Bennu's surface into sustained orbits. These approaches yield statistically consistent results up to degree and order 3, with the particle-based field being statistically significant up to degree and order 9. Comparisons with a constant-density shape model show that Bennu has a heterogeneous mass distribution. These deviations can be modeled with lower densities at Bennu's equatorial bulge and center. The lower-density equator is consistent with recent migration and redistribution of material. The lower-density center is consistent with a past period of rapid rotation, either from a previous Yarkovsky-O'Keefe-Radzievskii-Paddack cycle or arising during Bennu's accretion following the disruption of its parent body.

Two-Loop Four-Graviton Scattering Amplitudes

We present the analytic form of the two-loop four-graviton scattering amplitudes in Einstein gravity. To remove ultraviolet divergences we include counterterms quadratic and cubic in the Riemann curvature tensor. The two-loop numerical unitarity approach is used to deal with the challenging momentum dependence of the interactions. We exploit the algebraic properties of the integrand of the amplitude in order to reduce it to a minimal basis of Feynman integrals. Analytic expressions are obtained from numerical evaluations of the amplitude. Finally, we show that four-graviton scattering observables depend on fewer couplings than naïvely expected.

Characterization of memory T cells in individuals resistant to Schistosoma mansoni infection

Schistosomiasis affects about 240 million people worldwide and is estimated that about 700 million people live in areas at risk of infection. In the context of immune response associated with infection by Schistosoma mansoni, the role of memory T cells is not well understood.

AIM

To evaluate the frequency of memory CD4⁺ and CD8⁺ T cells from individuals resistant and susceptible to Schistosoma mansoni infection.

METHODS AND RESULTS

We selected individuals with low (resistant) and high (susceptible) parasite burden using databases generated during previous studies carried out in the same endemic area. The cell surface markers were performed using flow cytometry. In this study, the resistant individuals showed an increase in the CD4⁺ memory T-cell pool associated with an increase in the central memory cell (TCM) and a decrease in the effector memory cell (T_EM ). Individuals susceptible to infection had higher frequencies of effector memory cells compared to resistant individuals.

CONCLUSIONS

These data suggest that resistance to S mansoni infection may be associated with an increase in the number of CD4⁺ memory T cells and susceptibility to infection is associated with a decrease in the central memory cell as well as high proportions of effector memory cells.

The dynamic geophysical environment of (101955) Bennu based on OSIRIS-REx measurements

The top-shape morphology of asteroid (101955) Bennu is commonly found among fast-spinning asteroids and binary asteroid primaries, and might have contributed significantly to binary asteroid formation. Yet a detailed geophysical analysis of this morphology for a fast-spinning asteroid has not been possible prior to the Origins, Spectral Interpretation, Resource Identification, and Security-Regolith Explorer (OSIRIS-REx) mission. Combining the measured Bennu mass and shape obtained during the Preliminary Survey phase of OSIRIS-REx, we find a significant transition in Bennu's surface slopes within its rotational Roche lobe, defined as the region where material is energetically trapped to the surface. As the intersection of the rotational Roche lobe with Bennu's surface has been most recently migrating towards its equator (given Bennu's increasing spin rate), we infer that Bennu's surface slopes have been changing across its surface within the last million years. We also find evidence for substantial density heterogeneity within this body, suggesting that its interior has a distribution of voids and boulders. The presence of such heterogeneity and Bennu's top-shape is consistent with spin-induced failure at some point in its past, although the manner of its failure cannot be determined yet. Future measurements by the OSIRIS-REx spacecraft will give additional insights and may resolve questions regarding the formation and evolution of Bennu's top-shape morphology and its link to the formation of binary asteroids.

Analytic Form of Planar Two-Loop Five-Gluon Scattering Amplitudes in QCD

We present the analytic form of the planar two-loop five-gluon scattering amplitudes in QCD for a complete set of independent helicity configurations of external gluons. These include the first analytic results for five-point two-loop amplitudes relevant for the computation of next-to-next-to-leading-order QCD corrections at hadron colliders. The results were obtained by reconstructing analytic expressions from numerical evaluations. The complexity of the computation is reduced by exploiting physical and analytical properties of the amplitudes, employing a minimal basis of so-called pentagon functions that have recently been classified.

Schistosoma mansoni rSm29 Antigen Induces a Regulatory Phenotype on Dendritic Cells and Lymphocytes From Patients With Cutaneous Leishmaniasis

The immune response induced by Schistosma mansoni antigens is able to prevent immune-mediated diseases. Conversely, the inflammatory response in cutaneous leishmaniasis (CL), although responsible for controlling the infection, is also associated with the pathogenesis of disease. The aim of this study was to evaluate the potential of the S. mansoni Sm29 antigen to change certain aspects of the profiles of monocyte derived dendritic cells (MoDCs) and lymphocytes from subjects with CL in vitro. Expression of surface molecules and intracellular cytokines in the MoDCs and lymphocytes as well as the proliferation of Leishmania braziliensis were evaluated by flow cytometry. Levels of cytokines were evaluated in culture supernatants by ELISA. It was observed that stimulation by rSm29 increased the frequency of expression of CD83, CD80, CD86, and IL-10R in MoDCs compared to non-stimulated cultures. Additionally rSm29 decreased the frequency CD4⁺ and CD8⁺ T cells expressing CD28 and increased the frequency of CD4⁺CD25^hi and CD4⁺CTLA-4⁺ T lymphocytes. Addition of rSm29 to cultures increased IL-10 levels and decreased levels of IL-12p40 and IFN-γ, while not altering TNF levels compared to non-stimulated cultures. This study showed that rSm29 induced a regulatory profile in MoDCs and lymphocytes and thereby regulated the exaggerated inflammation observed in CL. Considering that there are few therapeutic options for leishmaniasis, the use of rSm29 may be an alternative to current treatment and may be an important strategy to reduce the healing time of lesions in patients with CL.

Alternative Inventory and Distribution Policies for a Regional Blood Banking System

This paper deals with the application of mathematical methods to the inventory of blood units in a regional supply system.

A complex simulation model was designed and implemented in the discrete simulation language SIMSCRIPT to investigate alternative inventory and distribution policies for blood units by means of defined objective criteria. These procedures include a method for inventory forecasting and blood donor call-up and a heuristic allocation model for blood units.

Empirical data was collected from the Berlin Blood Donor Service for model construction and validation.

The simulation results suggest that the inventory procedures presented may lead to a considerable cost reduction in a regional blood banking system.

A specific statistical testing procedure was employed to justify the simulation results statistically. In the final section it is suggested that the inventory methods described in this paper can be implemented within a computer information system providing the blood bank management with decision aids.

A Review of Computer Systems in Blood Banks and Discussion of the Applicability of Mathematical Decision Methods

The fast progress of transfusion medicine is leading to higher requirements in blood donor and transfusion services which can only be met by EDP in the long run.

This article gives an overview on the state of EDP system development in blood banks. The emphasis is on EDP systems in blood donor services. However, some transfusion medical EDP applications are also mentioned. The functional application areas of EDP are shown. The cost-benefit ratio of computer systems in this field is discussed and systems in operation or under development are compared in tabulated, form. Of particular interest in this comparison is the aspect of the applicability of mathematical decision methods for providing decision aids in blood banks by the computer.

The cost-efficiency of systems providing improved medical services at the same time leads to the conclusion that a fast growth of EDP applications in blood donor and transfusion services can be expected.

Evidence of an abnormal epithelial barrier in active, untreated and corticosteroid-treated eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated disease characterized by symptoms related to esophageal dysfunction and an eosinophil-predominant inflammation. This study has aimed to investigate whether the recently observed sensitization to Candida albicans in patients with EoE is owing to pre-existing disease and its underlying abnormal epithelial barrier or, alternatively, is linked to corticosteroid (CS) therapy.

METHODS

Medical histories, as well as serum and tissue samples of 60 patients with EoE (15 CS naive, 45 with current or previous CS therapy) and 20 controls, stored in the Swiss Eosinophilic Esophagitis Database (SEED) and Biobank, were analyzed. We applied ImmunoCAP to measure IgE levels and immunofluorescence techniques to examine epithelial barrier components.

RESULTS

Patients with EoE had higher total IgE levels and were more frequently sensitized to C. albicans than controls. In EoE tissue specimens, increased numbers of eosinophils and mast cells, a higher expression levels of thymic stromal lymphopoietin (TSLP), cathelicidin, proteases, that is, the kallikreins (KLK)-5 and KLK-7, were observed as compared with controls, while reduced expression of lympho-epithelial Kazal-type-related inhibitor (LEKTI), filaggrin, E-cadherin, claudin, occludin, desmoglein-1 was found, independent of CS therapy. In CS-treated EoE, significantly lower numbers of CD1a+ cells and cathelicidin expression were noted as compared to CS-naive EoE.

CONCLUSION

This study provides further evidence that EoE is associated with an abnormal epithelial barrier and postulates that CS therapy, by reducing innate immune mechanisms, may promote C. albicans colonization and likely subsequent sensitization.

Susceptibility of dendritic cells from individuals with schistosomiasis to infection by Leishmania braziliensis

Coinfection with leishmaniasis and schistosomiasis has been associated with increased time to healing of cutaneous lesions of leishmaniasis. The objective of this study was to evaluate the effect of Leishmania braziliensis infection on co-cultures of monocyte-derived dendritic cells (MoDCs) with autologous lymphocytes from patients with schistosomiasis and patients with cutaneous leishmaniasis. MoDCs were differentiated from peripheral blood monocytes, isolated by magnetic beads, infected with L. braziliensis, and co-cultured with autologous lymphocytes. Expression of HLA-DR, CD1a, CD83, CD80, CD86, CD40, and the IL-10 receptor (IL-10R) on MoDCs as well as CD28, CD40L, CD25, and CTLA-4 on lymphocytes were evaluated by flow cytometry. The production of the cytokines IL-10, TNF, IL-12p40, and IFN-γ were evaluated by sandwich ELISA of the culture supernatant. The infectivity evaluation was performed by light microscopy after concentration of cells by cytospin and Giemsa staining. It was observed that the frequency of MoDCs expressing CD83, CD80, and CD86 as well as the MFI of HLA-DR were smaller in the group of patients with schistosomiasis compared to the group of patients with leishmaniasis. On the other hand, the frequency of IL-10R on MoDCs was higher in patients with schistosomiasis than in patients with leishmaniasis. CD4⁺ and CD8⁺ T lymphocytes from patients with schistosomiasis presented a lower frequency of CD28 and a higher frequency of CTLA-4 compared to lymphocytes from patients with leishmaniasis. Levels of IL-10 were higher in the supernatants of co-cultures from individuals with schistosomiasis compared to those with leishmaniasis. However, levels of TNF, IL-12p40, and IFN-γ were lower in the group of individuals with schistosomiasis. Regarding the frequency of MoDCs infected by L. braziliensis after 72h in culture, it was observed that higher frequencies of cells from patients with schistosomiasis were infected compared to cells from patients with leishmaniasis. It was concluded that MoDCs from patients with schistosomiasis are more likely to be infected by L. braziliensis, possibly due to a lower degree of activation and a regulatory profile.

Two-Loop Four-Gluon Amplitudes from Numerical Unitarity

We present the first numerical computation of two-loop amplitudes based on the unitarity method. As a proof of principle, we compute the four-gluon process in the leading-color approximation. We discuss the new method, analyze its numerical properties, and apply it to reconstruct the analytic form of the amplitudes. The numerical method is universal, and can be automated to provide multiscale two-loop computations for phenomenologically relevant signatures at hadron colliders.

First measurement of neutrino and antineutrino coherent charged pion production on argon

We report on the first cross section measurements for charged current coherent pion production by neutrinos and antineutrinos on argon. These measurements are performed using the ArgoNeuT detector exposed to the NuMI beam at Fermilab. The cross sections are measured to be 2.6(-1.0)(+1.2)(stat)(-0.4)(+0.3)(syst)×10(-38)  cm(2)/Ar for neutrinos at a mean energy of 9.6 GeV and 5.5(-2.1)(+2.6)(stat)(-0.7)(+0.6)(syst)×10(-39)  cm(2)/Ar for antineutrinos at a mean energy of 3.6 GeV.

Divergent astrovirus associated with neurologic disease in cattle

Using viral metagenomics of brain tissue from a young adult crossbreed steer with acute onset of neurologic disease, we sequenced the complete genome of a novel astrovirus (BoAstV-NeuroS1) that was phylogenetically related to an ovine astrovirus. In a retrospective analysis of 32 cases of bovine encephalitides of unknown etiology, 3 other infected animals were detected by using PCR and in situ hybridization for viral RNA. Viral RNA was restricted to the nervous system and detected in the cytoplasm of affected neurons within the spinal cord, brainstem, and cerebellum. Microscopically, the lesions were of widespread neuronal necrosis, microgliosis, and perivascular cuffing preferentially distributed in gray matter and most severe in the cerebellum and brainstem, with increasing intensity caudally down the spinal cord. These results suggest that infection with BoAstV-NeuroS1 is a potential cause of neurologic disease in cattle.

Can a tibial tunnel in ACL surgery be placed anatomically without impinging on the femoral notch? A risk factor analysis

PURPOSE

To analyze anatomical risk factors and surgical technique dependent variables, which determine the risk for femoral notch impingement in anatomically correct placed tibial tunnels for anterior cruciate ligament (ACL) surgery.

METHODS

Twenty fresh frozen adult human knee specimens under the age of 65 years were used. Digital templates mimicking a tibial tunnel aperture at the tibia plateau were designed for different tibial tunnel diameters and different drill-guide angles. The centres of these templates were placed over the geometric centre of the native tibial ACL footprint. The distances between the anterior borders of the templates and the anterior borders of the footprints (graft free zone) were measured and compared. Furthermore, anatomic risk factors for femoral notch impingement were determined.

RESULTS

The graft free zone was statistically significantly longer for larger drill-guide angles compared to smaller drill-guide angles (p < 0.00001). Furthermore, 8 mm diameter tibial tunnels had a statistically significant larger graft free zone compared to 10-mm-diameter tibial tunnels (p < 0.00001). For the 10 mm diameter tibial tunnels with drill-guide angle of 45°, 9 out of 20 knees (45 %) were "at risk" for notching and 4 out of 20 knees (20 %) had "definite" notching. For 10-mm tunnels with drill-guide angle of 45°, a risk for notching was associated with smaller tibial ACL footprint (p < 0.05).

CONCLUSION

If a perfect centrally positioned tibial tunnel is drilled, a real risk for femoral notch impingement exists depending on the size of the tibial ACL footprint and surgery-related factors. Therefore, in anatomical tibial tunnel placement in single bundle ACL reconstruction surgery, particular attention should be paid to size of the tunnel and drill-guide angle to minimize the risk of femoral notch impingement.

Target feeding for improved smallholder beef production in the Mekong region: lessons from Cambodia and Lao PDR

Increased demand for red meat throughout the Greater Mekong Subregion (GMS) presents smallholder cattle and buffalo farmers with an opportunity to supply better quality animals to expanding regional markets. Cattle were target-fed in Cambodia with introduced forages to achieve gains of 0.19 kg/day over a 104-day period and this practice was compared with traditional cut-and-carry feeding practices where animals lost on average 0.04 kg/day. Target-fed animals were predicted to gain, on average, 25.9 kg more weight than animals fed in a traditional manner (P = 0.057), and to improve their estimated value by more than US$60. These outcomes were similar to outcomes in Lao PDR, where cattle and buffalo in fattening stalls gained 0.32 and 0.22 kg/day, respectively, over a 4-month period, and 0.04 and 0.09 kg/day when free-grazing. Greater weight gains are possible if farmers feed forages at the recommended 15% of bodyweight on a fresh-weight basis per day. Lack of knowledge of animal weights by farmers and traders was addressed by the creation of an accurate weight tape to provide a cheap and easy tool to monitor animal production and health, and to assist in negotiating a fair sale value. However, increased knowledge of appropriate forage plot size and feeding requirements of animals to be target-fed is required for farmers to change from being livestock keepers to livestock producers. To increase supply for the growing demand for red meat, an ongoing, multi-disciplinary extension program should be a priority for livestock improvement programs in the GMS.

First measurements of inclusive muon neutrino charged current differential cross sections on argon

The ArgoNeuT Collaboration presents the first measurements of inclusive muon neutrino charged current differential cross sections on argon. Obtained in the NuMI neutrino beam line at Fermilab, the flux-integrated results are reported in terms of outgoing muon angle and momentum. The data are consistent with the Monte Carlo expectation across the full range of kinematics sampled, 0°<θ(μ)<36° and 0<P(μ)<25 GeV/c. Along with confirming the viability of liquid argon time projection chamber technology for neutrino detection, the measurements allow tests of low-energy neutrino scattering models important for interpreting results from long baseline neutrino oscillation experiments designed to investigate CP violation and the orientation of the neutrino mass hierarchy.

Self expanding wall stents in malignant colorectal cancer: is complete obstruction a contraindication to stent placement?

OBJECTIVE

Technical failures have previously been associated with complete clinical obstruction and complete block to the retrograde flow of gastrograffin is considered by some to be a contraindication to the procedure. We report on the technical and clinical success rates of self-expanding metallic stents (SEMS) in both complete and incomplete obstruction in a prospective series of malignant colorectal obstructions.

METHOD

A prospective study of all patients undergoing attempted palliative and bridge to surgery SEMS placement for malignant colorectal obstruction over a 7-year period (April 1999-October 2006) was undertaken.

RESULTS

Seventy-two patients (49 males) with a mean age of 71 years (range 49-98) were included. Technical success was achieved in 27 of 32 patients (84%) with complete obstruction and 33 of 36 patients (92%) with incomplete obstruction, P < 0.46, Fishers exact test. Clinical success was achieved in 17 of 26 patients (65%) with complete obstruction and 24 of 33 patients (73%) with incomplete obstruction, P < 0.58, Fishers exact test. Although placed correctly in 89% cases, relief of symptoms occurred in only 71%, P = 0.002, matched pairs test. There were two colonic perforations in the series with one procedure related death.

CONCLUSION

Placement of SEMS for obstructing colorectal cancer is technically successful in a high proportion of cases. Complete radiological obstruction is not a contraindication to stent placement. The relief of obstructive symptoms following successful placement of a wall stent is less predictable.

Reversal of refractory septic shock with drotrecogin alpha (activated)

OBJECTIVE

We previously reported that early continuous veno-venous hemodiafiltration (CVVHDF) enables rapid identification of a subgroup of patients with "refractory" septic shock and a 100% risk of death. The objective of this study was to investigate whether early administration of drotrecogin alpha (activated) (DrotAA) to this selected subgroup of septic patients at extremely high risk of death would significantly improve prognosis.

METHOD

Prospective observational study in a medical intensive-care unit of a University Hospital. Twenty-three patients with refractory septic shock were included. "Refractory" shock was defined as persistent circulatory failure despite adequate circulatory support, associated with persisting lactic acidosis despite early CVVHDF. Response to CVVDHF was assessed after 6 h of this continuous procedure. Patients selected by this strategy received DrotAA infusion for four days.

RESULTS

The 28-day mortality rate of the 23 patients was 39%. No difference was observed at inclusion between survivors and nonsurvivors. In patients who finally survived, 12 h of DrotAA infusion was associated with a significant decrease in lactic acidosis and in norepinephrine dose.

CONCLUSION

DrotAA therapy was associated with unexpectedly high 28-day survival in patients with "refractory" septic shock.

Effect of seasonal changes in upwelling activity on the foraging locations of a wide-ranging central-place forager, the New Zealand fur seal

Lactating New Zealand fur seals ( Arctocephalus forsteri (Lesson, 1828)) that breed at Cape Gantheaume, South Australia, experience broad-scale seasonal changes in ocean productivity. To assess how seasonal changes in ocean productivity influenced foraging behaviour, 18 lactating New Zealand fur seals were fitted with satellite transmitters and time–depth recorders (TDRs). Using temperature and depth data from TDRs, we used the presence of thermoclines as a surrogate measure of upwelling activity in continental-shelf waters. During the austral autumn 80% of lactating fur seals foraged on the continental shelf (114 ± 44 km from the colony), in a region associated with the Bonney upwelling. In contrast, during winter months seals predominantly foraged in oceanic waters (62%), in a region associated with the Subtropical Front (460 ± 138 km from the colony). Our results indicate that lactating New Zealand fur seals shift their foraging location from continental-shelf to oceanic waters in response to a seasonal decline in productivity over the continental shelf, attributed to the cessation of the Bonney upwelling. This study identified two regions used by lactating New Zealand fur seals: (1) a nearby and seasonally productive upwelling system and (2) a distant and permanent oceanic front.

[Evaluation of amoxicillin-clavulanic acid prescriptions in a teaching hospital of Parisian suburb]

OBJECTIVE

Prospective study of amoxicillin-clavulanic acid (amox-clav) prescriptions in the medical departments of a teaching hospital that prescribes this antibiotic very often.

DESIGN

From April to May 2004, each patient treated by amox-clav was included. Data were collected (age, sex, past diseases, associated-diseases, reason for hospitalization, prior antibiotic therapy, date of amox-clav prescription, indication for amox-clav prescription, other associated antibiotics, nosocomial or community-acquired infection, site of infection, bacteriologic samples and bacterial identification, treatment duration and status of the physician). Data were analysed by a muldisciplinary group and compared with a referential used for antibiotic prescriptions in our hospital.

RESULTS

One hundred and two medical files were analysed. Seventy-one percent of amox-clav prescriptions were in adequation with the referential. Combination of three criteria (indication of antibiotic therapy, choice of amox-clav and of an antibiotic combination) showed that 58 (57%) was acceptable, 29 (28%) was debatable and 15 (15%) was unacceptable. Unacceptable prescriptions were often made by a junior. The majority of inadequate antibiotic prescriptions referred to acute pulmonary infections. Antibiotic combinations were often inadequate and treatment duration was too long. The quality of the prescription was more accurate when made by a senior.

CONCLUSION

An effort should be made in our teaching hospital to optimize antibiotic prescriptions.

Prospective study on the presentation and outcome of patients with an acute hernia

Recent advances in hernia surgery should help to make operation more acceptable to patients and their doctors. The aim of this study was to prospectively assess the presentation and management of patients with an acute hernia in light of these changes. Data on all patients admitted with an acute hernia between March 2001 and February 2004 was entered on a prospective database. During the 3 year study period, of the 91 patients admitted with an acute hernia, 41 were ventral, 24 femoral, 24 inguinal and 2 parastomal. Forty-six had a previous medical assessment, 18 of these had been declared unfit for operation at that assessment; ten were ASA4 (ASA, American Society of Anaesthesiology), five ASA3 and three ASA2. Eleven patients were on the waiting list for operation, three of whom had a previous acute hospital admission. For 30 patients this hospital admission was the first indication that they had a hernia while the remaining were aware that they had a hernia but did not seek medical advice. Of the five patients who died, two while being assessed for operation and three postoperatively, three were ASA4 and had a ventral hernia while two were ASA3 with a femoral hernia. Despite advances in hernia surgery there is still room for improvement in preoperative assessment of patients presenting with an acute hernia.

The ontogeny of diving behaviour in New Zealand fur seal pups (Arctocephalus forsteri)

This study investigated the development of diving in 21 New Zealand fur seal pups, Arctocephalus forsteri (Lesson, 1828), prior to weaning at Cape Gantheaume, Kangaroo Island. Diving behaviour was examined using time–depth recorders, which were deployed during two time periods, 5 months prior to weaning (n = 6) and 2 months prior to weaning (n = 15). Scats were also examined to assess whether fur seal pups foraged prior to weaning. The maximum dive depth attained was 44 m, while the maximum dive duration was 3.3 min. Immediately prior to weaning, fur seal pups spent a greater proportion of their time diving at night, and concomitantly several measures of diving performance also increased. In general, pups dived successively deeper (6–44 m between June and September), and the average number of dives per day, dive frequency, and vertical distance travelled increased. Prey remains were present in approximately 30% of scats and indicated that some pups were foraging as early as June (5–6 months of age, approximately 4–5 months prior to weaning). Of the scats that contained prey remains, fish (South American pilchard, Sardinops sagax (Jenyns, 1842); Australian anchovy, Engraulis australis (White, 1790); and redbait, Emmelichthys nitidus Richardson, 1845) accounted for 43% of the prey items found, crustaceans accounted for 36%, and cephalopods (Gould's squid, Nototodarus gouldi (McCoy, 1888)) accounted for 20%.