Growth and Break-Up of Methanogenic Granules Suggests Mechanisms for Biofilm and Community Development

Methanogenic sludge granules are densely packed, small, spherical biofilms found in anaerobic digesters used to treat industrial wastewaters, where they underpin efficient organic waste conversion and biogas production. Each granule theoretically houses representative microorganisms from all of the trophic groups implicated in the successive and interdependent reactions of the anaerobic digestion (AD) process. Information on exactly how methanogenic granules develop, and their eventual fate will be important for precision management of environmental biotechnologies. Granules from a full-scale bioreactor were size-separated into small (0.6-1 mm), medium (1-1.4 mm), and large (1.4-1.8 mm) size fractions. Twelve laboratory-scale bioreactors were operated using either small, medium, or large granules, or unfractionated sludge. After >50 days of operation, the granule size distribution in each of the small, medium, and large bioreactor sets had diversified beyond-to both bigger and smaller than-the size fraction used for inoculation. Interestingly, extra-small (XS; <0.6 mm) granules were observed, and retained in all of the bioreactors, suggesting the continuous nature of granulation, and/or the breakage of larger granules into XS bits. Moreover, evidence suggested that even granules with small diameters could break. "New" granules from each emerging size were analyzed by studying community structure based on high-throughput 16S rRNA gene sequencing. Methanobacterium, Aminobacterium, Propionibacteriaceae, and Desulfovibrio represented the majority of the community in new granules. H2-using, and not acetoclastic, methanogens appeared more important, and were associated with abundant syntrophic bacteria. Multivariate integration (MINT) analyses identified distinct discriminant taxa responsible for shaping the microbial communities in different-sized granules.

Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery

INTRODUCTION Recent studies have advocated the use of perioperative fluid restriction in patients undergoing major abdominal surgery as part of an enhanced recovery protocol. Series reported to date include a heterogenous group of high- and low-risk procedures but few studies have focused on rectal cancer surgery alone. The aim of this study was to assess the effects of perioperative fluid volumes on outcomes in patients undergoing elective rectal cancer resection. METHODS A prospectively maintained database of patients with rectal cancer who underwent elective surgery over a 2-year period was reviewed. Total volume of fluid received intraoperatively was calculated, as well as blood products required in the perioperative period. The primary outcome was postoperative morbidity (Clavien-Dindo grade I-IV) and the secondary outcomes were length of stay and major morbidity (Clavien-Dindo grade III-IV). RESULTS Over a 2-year period (2012-2013), 120 patients underwent elective surgery with curative intent for rectal cancer. Median total intraoperative fluid volume received was 3680ml (range 1200-9670ml); 65/120 (54.1%) had any complications, with 20/120 (16.6%) classified as major (Clavien-Dindo grade III-IV). Intraoperative volume >3500ml was an independent risk factor for the development of postoperative all-cause morbidity (P=0.02) and was associated with major morbidity (P=0.09). Intraoperative fluid volumes also correlated with length of hospital stay (Pearson's correlation coefficient 0.33; P<0.01). CONCLUSIONS Intraoperative fluid infusion volumes in excess of 3500ml are associated with increased morbidity and length of stay in patients undergoing elective surgery for rectal cancer.

Modafinil reduces patient-reported tiredness after sedation/analgesia but does not improve patient psychomotor skills

BACKGROUND

Early recovery of patients following sedation/analgesia and anesthesia is important in ambulatory practice. The aim of this study was to assess whether modafinil, used for the treatment of narcolepsy, improves recovery following sedation/analgesia.

METHODS

Patients scheduled for extracorporeal shock wave lithotripsy were randomly assigned to one of four groups. Two groups received a combination of fentanyl/midazolam with either modafinil or placebo. The remaining groups received remifentanil/propofol with either modafinil or placebo. Modafinil 200 mg was administered to the treatment group patients 1 h before sedation/analgesia. Groups were compared using the digital symbol substitution test (DSST), trail making test (TMT), observer scale of sedation and analgesia (OAA/S) and Aldrete score. Verbal rating scale (VRS) scores for secondary outcome variables e.g. energy, tiredness and dizziness were also recorded before and after treatment.

RESULTS

Sixty-seven patients successfully completed the study. Groups received similar doses of sedation and analgesic drugs. No statistically significant difference was found for DSST between groups. No significant adverse effects occurred in relation to modafinil. No statistically significant difference between groups was identified for TMT, OAA/S and Aldrete scores. The mean VRS score for tiredness was lesser in the modafinil/fentanyl/midazolam group [1.3 (2.0)] compared with the placebo group [3.8 (2.5)], P=0.02. Such a difference was not found between the remifentanil/propofol groups [placebo 2.6 (2.2) vs. modafinil 3.1(2.7)], p>0.05. Dizziness was greater in the modafinil/remifentanil/propofol group 1.7 (2.0) vs. placebo 0.0 (0.5), p<0.05.

CONCLUSION

Modafinil reduces patient-reported tiredness after sedation/analgesia but does not improve recovery in terms of objective measures of patient psychomotor skills.

Sudden onset fatigue (SOF) in patients with breast cancer: Characteristics and symptomatology

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Background: Cancer-related fatigue is underrecognized and poorly managed. Unpredictability and rapid onset in fatigue is stressed by cancer patients but seldom addressed by health care professionals. Although sudden onset of cancer-related fatigue is anecdotally documented across qualitative studies, the symptom has never been systematically investigated. Our purpose is to describe the symptom and clinical characteristics of SOF in breast cancer patients receiving chemotherapy. Methods: This is a cross-sectional descriptive study enrolling female breast cancer outpatients undergoing chemotherapy in an urban cancer center. A brief questionnaire assessing the symptom characteristics of SOF was completed by subjects. Comprehensive metabolic panel and complete blood counts, were obtained. Descriptive statistics described the symptom characteristics of SOF. Mann-Whitney tests examined the differences between those who did and did not experience SOF. Results: Thirty patients have been enrolled. Median age 53 years (31 to 65; SD=7.7), 60% were Black. 80% (n=24) experienced SOF in the past 7 days with a median of 4 days a week and 2.5 episodes per day. SOF was most likely (75%) to occur in the afternoon while patients were engaging in activities. Levels of fatigue before, during, and after a specific episode of SOF were 5, 9, and 5, respectively, on 0–10 (highest) rating scale. Weakness, sweating, or pain sometimes accompanied SOF. When SOF occurred, individuals immediately needed to stop activities to rest until it went away. Those who experienced SOF had significantly lower levels of calcium (Median=8.9 vs. 9.4), albumin (Median=3.7 vs. 7.1), and hematocrit (Median=32.1 vs. 36) (p<0.05). Those who experienced SOF also had higher levels of GPT (Median=25.5 vs. 17), lower levels of total protein (Median=6.7 vs. 7.1), WBC (Median=4.9 vs. 8.9), RBC (Median=3.4 vs. 3.9), and hemoglobin (Median=10.7 vs. 11.4). Conclusions: Our ongoing study is one of the first to identify the characteristics of patients at high risk of SOF. SOF needs to be recognized and managed when patients undergo chemotherapy. Associated conditions should be identified and addressed. The ultimate goal is to minimize the distress and improve the quality of life of patients receiving chemotherapy.

No significant financial relationships to disclose.

A combination of lidocaine and nitrous oxide in oxygen is more effective in preventing pain on propofol injection than either treatment alone

BACKGROUND AND OBJECTIVE

Propofol is an intravenous (i.v.) anaesthetic agent that possesses many of the qualities of an ideal anaesthetic agent. The most significant side-effect associated with propofol is pain on injection. Despite optimal therapy, the incidence of pain on propofol injection remains a problem. This prospective, randomized, double blinded study evaluated the effect of three different treatment strategies in decreasing pain on propofol injection.

METHODS

We studied 102 adult, ASA I-II patients, scheduled for elective surgical procedures. Combination of i.v. lidocaine and nitrous oxide (N2O) in oxygen (O2) inhalation pre-treatment was compared with either treatment alone in the prevention of pain on propofol injection. A standard propofol injection technique and scoring system, to measure the pain on injection was used.

RESULTS

Demographic variables were similar between the groups. The incidence of no pain on propofol injection was similar in the lidocaine and N2O groups (63.6% vs. 57.5%) (95% confidence interval (CI): 0.17-0.29, P = 0.61). Combination therapy was associated with a greater incidence of no pain on injection (84% vs. 63.6%) (95% CI: 0.06-0.48, P = 0.04).

CONCLUSION

Combination of i.v. lidocaine and N2O in O2 inhalation pre-treatment is more effective than either treatment alone in decreasing pain on propofol injection.

Challenging the precepts of family-centered care: testing a philosophy

Family-centered care (FCC) is a model of patient care delivery that encourages the inclusion of the family in the planning and provision of care. Although this model has been discussed extensively in the literature and adopted by some institutions, it is one that many have difficulty implementing. The purpose of this study was to test the elements of a FCC philosophy developed for maternal/child units at a major medical center. Questionnaires developed for this study and translated into four languages were completed by 193 parent/patient participants. The questionnaire asked participants to rate the importance of FCC interventions and report which interventions had been provided. Most of the participants were Caucasian, married, female, had an annual income of $20,000 or less, had 12 or fewer years of education, and were younger than 40 years of age. Overall, "feeling welcome when I come to the hospital" was the highest rated item by parents of hospitalized neonates and children and perinatal patients. Findings from this study will be used to implement a FCC care philosophy.

Alterations in vertebral growth following prolonged plaster immobilisation

Long-term immobilisation in serial plasters for scoliosis, including the period of the adolescent growth spurt, leads to an increase in height of the vertebral bodies and a decrease of their height to width ratio. These changes are at the expense of the disc which is reduced in thickness. This stimulating effect on the vertebral body growth is probably due to the changes in mechanical factors.