Treatment, not delivery, of the late preterm and term fetus with supraventricular arrhythmia

OBJECTIVE

While in-utero treatment of sustained fetal supraventricular arrhythmia (SVA) is standard practice in the previable and preterm fetus, data are limited on best practice for late preterm (34 + 0 to 36 + 6 weeks), early term (37 + 0 to 38 + 6 weeks) and term (> 39 weeks) fetuses with SVA. We reviewed the delivery and postnatal outcomes of fetuses at ≥ 35 weeks of gestation undergoing treatment rather than immediate delivery.

METHODS

This was a retrospective case series of fetuses presenting at ≥ 35 weeks of gestation with sustained SVA and treated transplacentally at six institutions between 2012 and 2022. Data were collected on gestational age at presentation and delivery, SVA diagnosis (short ventriculoatrial (VA) tachycardia, long VA tachycardia or atrial flutter), type of antiarrhythmic medication used, interval between treatment and conversion to sinus rhythm and postnatal SVA recurrence.

RESULTS

Overall, 37 fetuses presented at a median gestational age of 35.7 (range, 35.0-39.7) weeks with short VA tachycardia (n = 20), long VA tachycardia (n = 7) or atrial flutter (n = 10). Four (11%) fetuses were hydropic. In-utero treatment led to restoration of sinus rhythm in 35 (95%) fetuses at a median of 2 (range, 1-17) days; this included three of the four fetuses with hydrops. Antiarrhythmic medications included flecainide (n = 11), digoxin (n = 7), sotalol (n = 11) and dual therapy (n = 8). Neonates were liveborn at 36-41 weeks via spontaneous vaginal delivery (23/37 (62%)) or Cesarean delivery (14/37 (38%)). Cesarean delivery was indicated for fetal SVA in two fetuses, atrial ectopy or sinus bradycardia in three fetuses and obstetric reasons in nine fetuses that were in sinus rhythm at the time of delivery. Twenty-one (57%) cases were treated for recurrent SVA after birth.

CONCLUSION

In-utero treatment of the near term and term (≥ 35-week) SVA fetus is highly successful even in the presence of hydrops, with the majority of cases delivered vaginally closer to term, thereby avoiding unnecessary Cesarean section. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

COVID-19: booster(s) vs. hospitalization and Intensive Care Unit admission

OBJECTIVE

As the pandemic continues, different vaccine protocols have been implemented to maintain the protection of vaccines and to provide protection against new variants. The aim of this study was to assess hospitalized patients' vaccination status and document the efficacy of boosters.

PATIENTS AND METHODS

The patients that were hospitalized due to COVID-19 were enrolled from 28 hospitals in Turkey for five months from September 2021. 5,331 confirmed COVID-19 patients from collaborating centers were randomly enrolled to understand/estimate the distribution of vaccination status in hospitalized patients and to compare the efficacy of vaccination/booster protocols.

RESULTS

2,779 men and 2,552 women of which 2,408 (45.2%) were admitted to Intensive Care Units participated in this study. It was found that the highest risk reduction for all age groups was found in groups that received 4 doses. Four doses of vaccination for every 3.7 people under 50 years of age, for every 5.7 people in the 50-64 age group, and for every 4.3 people over 65 years of age will prevent 1 patient from being admitted to intensive care. Regardless of the type of vaccine, it was found that the risk of ICU hospitalization decreased in those who were vaccinated compared to those who were not vaccinated. Regardless of the type of vaccine, the ICU risk was found to decrease 1.25-fold in those who received 1 or 2 doses of vaccine, 1.18-fold in those who received 3 doses, and 3.26-fold in those who received 4 doses.

CONCLUSIONS

The results suggested that the addition of a fourth dose is more effective in preventing intensive unit care even in disadvantaged groups.

Prognostic significance of the metastatic lymph node ratio compared to the TNM classification in stage III gastric cancer

Background

We aimed to evaluate a comparative analysis of the prognostic value of the metastatic lymph node ratio (LNR) and pN (TNM) in stage III gastric cancer.

Patients and Methods

A total of 159 stage III gastric cancer patients with curative gastrectomy were retrospectively analyzed. Cutoff values for LNR were designated according to 25%, 50% and 75% percentiles, 0.07, 0.20 and 0.44 respectively. The LNR was divided into four groups as 0 > LNR1 ≤ 0.07; 0.07 > LNR2 ≤0.20; 0.20 > LNR3 ≤0.44; 0.44 > LNR4 ≤1.

Results

The mean age of the patients was 61.1 ± 11.3 years. Male predominance was apparent (73.6%). The 1-year overall survival and recurrence rates were 73.6% and 33.6%, respectively. The univariate cox regression analysis demonstrated age and LNR were the main variables that affected overall survival (OS) (p < 0.05). Harvested lymph nodes less than 16 did not affect OS (p = 0.255). The results of the multivariate cox regression analysis revealed that only LNR was an independent prognostic factor (P < 0.001), while pN was not (p > 0.05). Similar results, as with overall survival, could not be revealed clearly for disease free survival (DFS).

Conclusions

LNR was an independent significant prognostic factor and superior to pN staging in predicting OS but not for DFS in stage III gastric cancer patients. The high LNR levels in our research were found to be associated with poor survival rates. The percentile system we used to determine cutoff values may be considered as a reliable method. Similarly, LNR also provides a reliable prognostic parameter in future staging systems to help guide treatment algorithm plans.

Clinical outcomes and programming strategies of implantable cardioverter defibrillator (ICD) devices during childhood in hypertrophic cardiomyopathy: a UK national cohort study

Background

Sudden cardiac death (SCD) is the most common mode of death in childhood hypertrophic cardiomyopathy (HCM). ICDs have been shown to be effective at terminating malignant ventricular arrhythmias but at the expense of a high incidence of complications. The optimal device and programming strategies to reduce complications in this patient group are unknown.

Purpose

To describe the programming strategies and clinical outcomes of ICD implantation in childhood HCM.

Methods

Anonymised, non-invasive clinical data were collected from a retrospective, longitudinal multi-centre cohort of children (&lt;16 years) with HCM (n=687) and an ICD in-situ from the United Kingdom.

Results

96 patients (61 male (64%), 6 non-sarcomeric (6%)) underwent ICD implantation at a median age 14yr (IQR 11–16, range 3–16) and weight 52.3 kg (IQR 34.8–63.1). Indication for ICD was primary prevention in 72 (75%). 82 (85%) had an endovascular system, 3 (3%) epicardial and 11 (12%) subcutaneous system. 61 patients (74%) were receiving one or more cardioactive medications at implantation [B blockers n=66, 70%, disopyramide n=14, 15%, amiodarone n=7, 7%, calcium channel blocker n=7, 9%, other n=5, 6%]. Programming practices varied: all had VF therapies activated (median 220bpm, IQR 212–230); 70 (73%) had a VT zone programmed (median rate 187 bpm, SD 20.9), of which 26 (27%) had therapies activated. 50 patients (61%) had antitachycardia pacing (ATP) activated. Over a median follow up of 53.6 months (IQR 27.3,108.4), 4 patients (4.2%) died following arrhythmic events despite a functioning device. 25 patients had 53 appropriate therapies (ICD shock n=47, ATP n=8), incidence rate 5.22 (95% CI 3.5–7.8). On univariable analysis, secondary prevention indication for ICD implantation was the only predictor of therapy [16 (64%) vs 8 (11.3%), p value &lt;0.001]. 8 (8.3%) patients had 9 inappropriate therapies (ICD shock n=4, ATP n=5), incidence rate 1.37 (95% CI 0.65–2.8), caused by T wave oversensing (n=2), lead migration (n=1), supraventricular tachycardia (n=1). Device complications were seen in 30 patients (31%), including lead complications (n=16) and infection (n=10). No clinical characteristics predicted time to inappropriate therapy or lead complication.

Conclusions

In a contemporary cohort of children with HCM, the incidence of inappropriate therapies is lower than previously reported, yet complication rates remain higher than reported in adult patients. No clinical, device or programming strategies were associated with inappropriate therapies or lead complications.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): British Heart Foundation

A prospective international Aspergillus terreus survey: an EFISG, ISHAM and ECMM joint study

OBJECTIVES

A prospective international multicentre surveillance study was conducted to investigate the prevalence and amphotericin B susceptibility of Aspergillus terreus species complex infections.

METHODS

A total of 370 cases from 21 countries were evaluated.

RESULTS

The overall prevalence of A. terreus species complex among the investigated patients with mould-positive cultures was 5.2% (370/7116). Amphotericin B MICs ranged from 0.125 to 32 mg/L, (median 8 mg/L).

CONCLUSIONS

Aspergillus terreus species complex infections cause a wide spectrum of aspergillosis and the majority of cryptic species display high amphotericin B MICs.

Influence of physical exercise on baroreceptor sensitivity during pregnancy

BACKGROUND

Baroreceptor sensitivity (BRS) refers to the magnitude of change in the heart rate in response to change in blood pressure (e.g. upon standing). The impact of regular antenatal exercise on maternal BRS is unclear.

AIMS

To determine whether supervised weekly exercise influences BRS, and to determine if posture and calculation method are important in antenatal BRS measurement.

STUDY DESIGN AND SUBJECTS

Eighty-one healthy pregnant women were randomly assigned to an exercise or control group. The exercise group attended weekly classes from the 20th week of pregnancy onwards.

OUTCOME MEASURES

Cardiovascular assessments (beat-to-beat blood pressure, heart rate) were performed at 12-16, 26-28, 34-36 weeks and 12 weeks following birth. BRS was calculated using two methods ("sequence" and "beat-to-beat").

RESULTS

Fifty-one women (63%) completed the study. Mean BRS reduced progressively in all women (p < 0.025) and was lowest in those who exercised (0.046 < p < 0.002). Postnatal increases in BRS were independent of posture. Training-induced BRS (beat-to-beat) reduction occurred earlier than BRS (sequence), and only BRS (sequence) was affected by posture. Heart rate variability reduced with advancing gestation (p < 0.002) and was more pronounced in the exercise group (p < 0.029).

CONCLUSIONS

Weekly exercise exaggerated the reductions in BRS and HRV during pregnancy and is likely linked to diminished parasympathetic activity.

Influence of antenatal physical exercise on heart rate variability and QT variability

OBJECTIVE

We sought to characterise the influence of an antenatal exercise programme on ECG-derived cardiac variables.

METHODS

Fifity-one healthy pregnant women were recruited and randomly assigned (2 × 2×2 design) to an exercise group or a control group. Exercising groups attended weekly classes from the 20th week of pregnancy onwards. Cardiovascular assessments (heart rate variabiliy (HRV), QT, and the QT variability index (QTVI)) were performed at 12-16, 26-28, 34-36 weeks and 12 weeks following birth, during supine rest and exercise conditions.

RESULTS

Advancing gestation was associated with an increased maternal heart rate (p = 0.001), shorter QT interval (p = 0.003), diminished HRV (p = 0.002) and increased QTVI (p = 0.002). Each of these changes was reversed within 12 weeks postpartum (p < 0.004). The Exercise group displayed exaggerated changes for all variables (except QT) but only during supine rest in the third trimester (p < 0.029).

CONCLUSION

Advancing gestation is associated with a shift in HRV/QTVI towards values that have been associated with an elevated risk of arrhythmia. A 20-week exercise programme undertaken between mid and late pregnancy exaggerated these changes during rest in the third trimester of pregnancy.

Recruitment of pregnant women to an exercise-intervention study

We share here our experience of recruiting pregnant women into an exercise intervention study. Recruitment challenges were anticipated owing to the study design, which required four hospital visits for cardiovascular assessment, a long-term (nine-month) commitment, and adherence to a 20-week exercise programme. Fifty-three women were assigned to one of three groups (no-exercise, land exercise or water exercise) using a 2 × 2 × 2 flexible randomisation design. Seven hundred forty-four women were screened at an antenatal clinic, of whom 501 were eligible to participate in the study. One hundred forty-five women were subsequently approached: 46 (32%) of whom agreed to participate, 42 (29%) were interested but then declined and 57 (39%) declined outright. Our study design helped recruit pregnant women as it allowed them some choice of group membership. We also noted that the participant-researcher relationship is important in reducing attrition. Our experience provides indications of likely recruitment and attrition rates for future randomised controlled trials of this type.

Changes in heart rate variability and QT variability during the first trimester of pregnancy

The risk of new-onset arrhythmia during pregnancy is high, presumably relating to changes in both haemodynamic and cardiac autonomic function. The ability to non-invasively assess an individual's risk of developing arrhythmia during pregnancy would therefore be clinically significant. We aimed to quantify electrocardiographic temporal characteristics during the first trimester of pregnancy and to compare these with non-pregnant controls. Ninety-nine pregnant women and sixty-three non-pregnant women underwent non-invasive cardiovascular and haemodynamic assessment during a protocol consisting of various physiological states (postural manoeurvres, light exercise and metronomic breathing). Variables measured included stroke volume, cardiac output, heart rate, heart rate variability, QT and QT variability and QTVI (a measure of the variability of QT relative to that of RR). Heart rate (p < 0.0005, p < 0.0005, p < 0.0005) and cardiac output (p = 0.043, p < 0.0005, p < 0.0005) were greater in pregnant women in all physiological states (respectively for the supine position, light exercise and metronomic breathing state), whilst stroke volume was lower in pregnancy only during the supine position (p < 0.0005). QTe (Q wave onset to T wave end) and QTa (T wave apex) were significantly shortened (p < 0.05) and QTeVI and QTaVI were increased in pregnancy in all physiological states (p < 0.0005). QT variability (p < 0.002) was greater in pregnant women during the supine position, whilst heart rate variability was reduced in pregnancy in all states (p < 0.0005). Early pregnancy is associated with substantial changes in heart rate variability, reflecting a reduction in parasympathetic tone and an increase in sympathetic activity. QTVI shifted to a less favourable value, reflecting a greater than normal amount of QT variability. QTVI appears to be a useful method for quantifying changes in QT variability relative to RR (or heart rate) variability, being sensitive not only to physiological state but also to gestational age. We support the use of non-invasive markers of cardiac electrical variability to evaluate the risk of arrhythmic events in pregnancy, and we recommend the use of multiple physiological states during the assessment protocol.

Effect of solvents on the accuracy of the Mini Root ZX apex locator

AIM

To evaluate ex vivo, the effects of three solvents on the accuracy of a contemporary electronic root canal length measurement device (ERCLMD), the Mini Root ZX.

METHODOLOGY

The actual working length (AWL) of 56 extracted maxillary incisor teeth were measured with an ERCLMD. All root canals were prepared with the ProTaper system to AWL. Of them, 20 were filled with gutta-percha and a resin-based sealer (Group A), 20 with gutta-percha and a zinc oxide/eugenol-based sealer (Group B), and 16 roots were used as the control group (Group C). Removal of the root filling and repreparation processes were performed using the ProTaper system. Guttasolv and Resosolv were used as the solvents in Group A and Guttasolv and Endosolv E in Group B. After the removal of the root fillings had been achieved, the same ERCLMD was used to measure the working length (WL). Differences between AWL and WL measurements were analysed by paired t-test, and the accuracy of ERCLMD was assessed using chi-squared tests.

RESULTS

There were significant differences between AWL and WL measurements in subgroups A2 (Resosolv group) and B2 (Endosolv E group). In these subgroups, WL was shorter than AWL (P < 0.05). Also, the accuracy of the Resosolv group was significantly lower than the others (P < 0.05) at a ±0.5 mm margin of error.

CONCLUSIONS

Removing root fillings may require use of a solvent. In these cases, ERCLMDs may exhibit a lower accuracy, thus operators must exercise additional care when measuring the working length using ERCLMDs.

Total anomalous pulmonary venous connection: impact of prenatal diagnosis

OBJECTIVES

To investigate whether prenatal screening is effective in the detection of total anomalous pulmonary venous connection (TAPVC) and to identify common prenatal features.

METHODS

This was a retrospective collaborative study involving 19 pediatric cardiac centers in the UK, Ireland and Sweden. Cases with TAPVC born between January 1, 1998 and December 31, 2004, and prenatally diagnosed cases whose estimated dates of delivery were within this time frame, were identified. Cases with functionally univentricular circulation or atrial isomerism were excluded. All available data and stored images were reviewed.

RESULTS

Four-hundred and twenty-four cases with TAPVC were identified prenatally or postnatally, of whom eight (1.9%) had a prenatal diagnosis of TAPVC. Median gestational age at fetal diagnosis was 26 + 6 (range, 22 + 4 to 32 + 0) weeks. Six further fetuses with TAPVC had an abnormality diagnosed on prenatal ultrasound, but not the TAPVC. This included other congenital heart defects (four cases) and isolated pleural effusion (two cases). Seventeen (4.0%) of the 422 liveborn infants had a first-degree relative with congenital heart disease; and six of 17 had a sibling with TAPVC. Two died in utero. Of the liveborn infants diagnosed prenatally with TAPVC, none required urgent intervention for pulmonary venous obstruction and all were alive and well at a median of 2.3 (range, 1.0-7.0) years after surgical repair.

CONCLUSION

Prenatal diagnosis of TAPVC is infrequent using current screening methods. Where there is a family history of TAPVC, specialized fetal echocardiography at 20 and 28 weeks' gestation may be indicated.

Relationship between trait anxiety, dental anxiety and DMFT indexes of Turkish patients attending a dental school clinic

The aims of this study were to evaluate possible relationships between trait anxiety, dental anxiety and the total number of decayed, missing and filled teeth (DMFT) index of patients attending a dental school clinic. A sample of 558 patients was surveyed with the Turkish version of the Spielberger Trait Anxiety Inventory and Dental Anxiety Scale. DMFT index was calculated by clinical and radiographic examination. A significant linear correlation was observed between trait and dental anxiety, but there was no correlation between DMFT index, trait anxiety and dental anxiety. Trait anxiety has an impact on dental anxiety, but does not affect the DMFT index.

Lamotrigine as an augmentation agent in treatment-resistant obsessive-compulsive disorder: a case report

Obsessive-compulsive disorder (OCD) is a relatively common, often chronic and disabling disorder with high rates of partial and/or absent response to standard, recommended treatments. We report a case of treatment-resistant OCD that was successfully treated with a pharmacological augmentation of lamotrigine plus clomipramine. The patient, a 59-year-old woman, was on a stable dose of clomipramine (225 mg/day) when she was started on lamotrigine (up to 150 mg/day). After 10 weeks of this treatment, her clinical condition remarkably improved, as indicated by a significant decrease of the Yale-Brown Obsessive-Compulsive Scale. This case suggests some preliminary evidence that the addition of glutamatergic agent lamotrigine may be useful in treatment-resistant OCD. However, further controlled studies are needed to support this finding.

Computed tomographic pulmonary angiography in the assessment of severity of acute pulmonary embolism and right ventricular dysfunction

BACKGROUND

The distinction between severe pulmonary embolism (PE) and right heart dysfunction is important for predicting patient mortality.

PURPOSE

To identify the role of computed tomographic pulmonary angiography (CTPA) in the assessment of the severity of acute PE and right ventricular dysfunction.

MATERIAL AND METHODS

Eighty-five patients suspected of having PE, as diagnosed by CTPA and scintigraphy, were divided into three groups: hemodynamically unstable PE (HUPE) (n = 20), hemodynamically stable PE (HSPE) (n = 33), and no PE (n = 32). For each patient, obstruction scores, including short-axis diameters of the right ventricle (RV) and left ventricle (LV), main pulmonary artery, and superior vena cava (SVC), were measured. The RV/LV short-axis ratios were calculated. The shapes of the interventricular septum and the reflux of the contrast medium into the inferior vena cava (IVC) were evaluated. The mortality due to PE within a 1-month follow-up period was recorded.

RESULTS

The median CTPA obstruction score (HUPE 64%, HSPE 28%, P < 0.001), median RV/LV short-axis ratio (HUPE 1.4, HSPE 1.0, P < 0.01), median RV diameter (HUPE 55 mm, HSPE 42 mm, P < 0.001), median SVC diameter (HUPE 23 mm, HSPE 19 mm, P < 0.01), interventricular septum convex toward the LV (HUPE 70%, HSPE 18%, P < 0.001), and reflux of the contrast medium into the IVC (HUPE 65%, HSPE 33%, p < 0.05) were significantly different between the HUPE and HSPE groups. With ROC analysis, the CTPA obstruction score and RV/LV short-axis ratio threshold values for the HUPE patients were calculated to be 48% (95% sensitivity, 76% specificity) and 1.1 (85% sensitivity, 76% specificity), respectively. Three patients in the HUPE group died within the first 24 hours. Logistic regression methods revealed only the RV diameter as a significant predictor of death (odds ratio 1.24; 95% CI 1.04-1.48; P = 0.01).

CONCLUSION

This study found that the parameters useful for distinguishing HUPE and HSPE included CTPA obstruction score, RV and SVC diameters, RV/LV short-axis ratio, interventricular septum shape, and reflux into the IVC. RV dilatation may be a significant predictor for mortality.

An unusual presentation of sirolimus associated cough in a renal transplant recipient

Sirolimus-associated pulmonary problems are rare but life threatening. Pulmonary problems due to sirolimus treatment are interstitial pneumonitis, bronchiolitis obliterans organizing pneumonia (BOOP), and alveolar hemorrhage. We present a case of sirolimus-related cough in the absence of any pulmonary radiological findings. A 55-year-old man with a history of 4 years of hemodialysis therapy because of end-stage renal disease of unknown etiology underwent cadaveric renal transplantation in June 2006. Three days following the initiation of sirolimus therapy he complained of dry cough and fever. There were no clinical or laboratory findings compatible with specific pulmonary disease. After switching sirolimus to tacrolimus, the cough improved within 1-2 days and resolved in 5 days. Sirolimus should be considered in the differential diagnosis of pulmonary problems in the early posttransplantation period even in the absence of radiological findings.

Cardiac risk factors for dental procedures: knowledge among dental practitioners in Wales

OBJECTIVES

To determine knowledge and educational needs of dental practitioners in Wales regarding congenital or acquired cardiac disease and the provision of antibiotic prophylaxis.

DESIGN

Self-administered postal questionnaire.

SETTINGS

Cardiff University Dental Hospital, district general hospitals (HDS), all general dental practices (GDP) and community dental service (CDS) clinics throughout Wales. Methods A questionnaire sent to 1,182 dentists in Wales in 2004-5.

RESULTS

528 questionnaires were returned (a response rate of 45%). These were analysed using one-way analysis of variance to compare summary scores between the occupation groups. Significant differences in knowledge of cardiac risk factors for infective endocarditis and for dental procedures requiring cover were observed between the occupation groups. The majority of dentists (92% GDPs, 94% CDS and 77% HDS) requested postgraduate education in cardiac risk factors and laminated flow diagrams for their surgeries as the preferred educational format.

CONCLUSION

The knowledge of Welsh dentists regarding cardiac conditions or procedures which are risk factors for paediatric and adult patients varied according to place of work. The study identified potential for under- and over-prescription of antibiotic prophylaxis within the current guidance. There was confusion as to which patient groups and cardiac conditions required prophylaxis and for which particular dental procedures. Postgraduate education detailing advances in cardiology practice is necessary for dentists.

Acute pulmonary edema secondary to long-term use of oral ritodrine in a woman with a triplet pregnancy

A 28-year-old primigravida who had taken oral ritodrine for 5 months to stop premature uterine contractions and was admitted in labor in the 33rd week of pregnancy developed acute pulmonary edema after cesarean section. Although parenteral ritodrine is the beta-adrenergic agent used most extensively to treat premature labor, only 1 case of pulmonary edema associated with long-term use of oral ritodrine had been reported so far. The present report presents for the first time computed tomographic findings of acute pulmonary edema secondary to tocolytic therapy.

Diarrhea in neutropenic patients: a prospective cohort study with emphasis on neutropenic enterocolitis

BACKGROUND

Although diarrhea is a frequent complication in neutropenic patients, its true incidence, risk factors and clinical course have not been investigated prospectively.

PATIENTS AND METHODS

The study was carried out at Hacettepe University Hospital for Adults and involved patients over 16 years of age. Patients with malignant diseases who were neutropenic on admission or who became neutropenic during their stay in the wards between January 2001 and February 2003 were included. They were monitored daily until discharge, exitus, or recovery from neutropenia-whichever occurred earlier-to monitor the presence of diarrhea and other infections.

RESULTS

A total of 317 neutropenic episodes in 215 patients were followed. Diarrhea was observed in 18.6% episodes, and the incidence of NEC was 3.5%. The etiology in 27% episodes of diarrhea could not be identified. The use of anthracyclines and mitoxantrone increased the incidence of diarrhea. Prior use of penicillin derivatives plus beta-lactam inhibitors and N-imidazoline derivatives was associated with decreased incidence of diarrhea.

CONCLUSIONS

Diarrhea is a common complication in neutropenic patients. Not only specific conditions like NEC, but also nonspecific diseases like parasitosis may be the cause of diarrhea in this patient population.

Epidemiology and outcome of sepsis in a tertiary-care hospital in a developing country

Sepsis continues to have a substantial mortality and morbidity despite advances in the diagnosis and management of this condition. We retrospectively analysed hospital charts of patients diagnosed to have sepsis between January 2002 and June 2003. Demographic characteristics of patients, microbiological findings and predictors of survival were evaluated. Sixty-nine sepsis episodes that occurred in 63 patients were analysed. The most common underlying diseases were hypertension, malignancies and diabetes mellitus. Renal insufficiency, respiratory distress and disseminated intravascular coagulation developed in 52.2, 30.4 and 30.4% of the episodes respectively; 47.7% of the blood cultures yielded an organism. Gram-negative bacteria were the predominant microorganisms (65.9%). Fifty-five patients (87.3%) died. Mechanical ventilation and underlying renal disease were significant determinants of mortality. In conclusion, Gram-negative bacteria remain the major pathogens in sepsis. The mortality remains very high, and a change in the clinical approach to the septic patient should be employed to improve the outcome.

Detection of Candida dubliniensis in oropharyngeal samples of Turkish HIV-positive patients

The incidence of Candida dubliniensis in immunocomprimised patients in Turkey has not yet been determined. In this study the presence of C. dubliniensis in oral rinse samples of human immunodeficiency virus (HIV)-positive patients and healthy controls were investigated. Phenotypic tests like inability of growth at 45 degrees C, colony formation on Staib agar, intracellular beta-D-glucosidase activity, carbohydrate assimilation profiles and polymerase chain reaction with species-specific primers (DUBF and DUBR) were carried out for differentiation of C. dubliniensis. Of the 35 patients, four (11.4%) had C.dubliniensis in their oral cavity. Antifungal susceptibility testing of these C. dubliniensis isolates showed fluconazole MICs ranging from <0.06 to 32 microg ml(-1) and amphotericin B from <0.06 to 0.25 microg ml(-1). One isolate was dose-dependently susceptible to fluconazole (32 microg ml(-1)). This study demonstrates C. dubliniensis in HIV-positive patients from Turkey.

Principles of good use of antibiotics in hospitals

Rational use of antimicrobials is a key element for a successful strategy against development of resistance to antimicrobials. The physician should establish the need and the reason for therapy, select the appropriate antimicrobial agent, and then decide on the optimum dose and dosing interval, duration, as well as route of administration. In a particular hospital, the present status of antimicrobial use should be determined, and a strategy should be developed to improve it. This usually encompasses a combination of educative, facilitative and restrictive measures. Good infection control practice is a critical component for success of such a programme.

Comparison of cefepime and ceftazidime in combination with amikacin in the empirical treatment of high-risk patients with febrile neutropenia: a prospective, randomized, multicenter study

A total of 208 adult patients with cancer and febrile neutropenia from 5 medical institutions were randomized to receive either cefepime (2 g b.i.d.) or ceftazidime (2 g t.i.d.) in combination with amikacin (15 mg/kg/o.d.). Ninety-seven patients in the ceftazidime (CEZ) group and 98 in the cefepime group (CEF) were evaluable for efficacy. In 68 patients (35%), infection could be documented. The average duration of antibiotic therapy was 11 and 12 d and response rates to the empirical regimen were 36 and 30% for the CEZ and CEF groups, respectively (p > 0.05). The average time of defervescence in responders was 3 d for both groups. Modification of the initial regimen with antivirals and/or azole antifungals raised the number of responders to 44% and 35%, respectively (p > 0.05). Vancomycin was additionally given to 29 patients in the CEZ group and to 27 patients in the CEF group. Twenty-six patients in each group received empirical amphotericin B. Mild, reversible study drug-related side-effects were observed in 12 patients (12%) in the CEZ group and 13 patients (13%) in the CEF group (p > 0.05). Cefepime in combination with amikacin seems to be as effective, safe and tolerable as ceftazidime + amikacin in patients with high-risk neutropenia and fever.

Polypurine tract formation by Ty1 RNase H

To better understand the mechanism by which Ty1 RNase H creates the polypurine tract (PPT) primer, we have demonstrated the polymerase-dependent hydrolytic activity of Ty1 reverse transcriptase (RT) during minus-strand synthesis. Using RNase H and polymerase mutants of the recombinant Ty1 RT protein, we show that the two domains of Ty1 RT can act independently of one another. Our results indicate that RNA/DNA substrates containing a short RNA PPT, which serve as primers for plus-strand DNA synthesis, are relatively resistant to RNase H cleavage. RNA substrates with a correct 5' end but with 3' end extending beyond the plus-strand initiation site were cleaved specifically to generate the correct 3' end of the PPT. Using long RNA/DNA duplexes containing the PPT, we show that Ty1 RT is able to make specific internal cleavages that could generate the plus-strand primer with correct 5' and 3' ends. Long RNA/DNA duplexes with mutations in the PPT or in a U-rich region upstream of the PPT, which abolish plus-strand initiation in vivo, were not cleaved specifically at the 5' end of the PPT. Our work demonstrates that the in vitro enzyme can recapitulate key processes that control proper replication in vivo.

A case of relapsed tardive dyskinesia due to clozapine dose reduction

There is no proven effective treatment for tardive dyskinesia (TD). However, clozapine has been reported to be effective in suppressing TD symptoms. In this article, we report a TD case who received clozapine. The patient recovered from TD symptoms with a dose of 450 mg/day clozapine. At the end of the first year, clozapine was decreased to a dose of 250 mg/day and TD symptoms re-emerged.

Patient satisfaction with nursing care at a university hospital in Turkey

Patient satisfaction is an important measure of service quality (SQ) in health care organizations. Patients' satisfaction and their expectations of care are valid indicators of quality nursing care. This article reports the results of a survey patient satisfaction with nursing care, administered by interview to 422 adults discharged from a university hospital in Turkey. The direct measurement of patient satisfaction with nursing care is a new phenomenon for this university hospital, and this was the first time that such an evaluation had been done in this particular hospital. In this study, SERVQUAL scale was used for determining patient satisfaction with nursing care. Weighted scores in dimensions of SERVQUAL were generally low, and there were statistically significant differences in means paired t-tests (p < .01). Sociodemographic characteristics of the patients (age, gender, education level) with regard to patient satisfaction were determined. Several statistically significant differences were found between the sociodemographic characteristics and weighted scores for dimensions of SERVQUAL (p < 0.5). According to results, the SQ gap scores for five dimensions were negative to meet expectations. The negative scores for tangibles, reliability, responsiveness, assurance, and empathy indicate areas needing improvement. In this hospital, results of this study support the need for nurses to take steps to improve patient satisfaction with nursing care.

Central venous catheter tip in the right atrium: a risk factor for neonatal cardiac tamponade

Fatal cardiac tamponade is a well recognised complication of the use of central venous catheters in neonatal patients. There is controversy over optimum catheter tip position to balance catheter performance against risk of adverse events. We report a series of five cases of tamponade occurring in one neonatal unit over a 4-year period, related to catheter tip placement in the right atrium. Right atrial catheter angulation, curvature or looping (CA) was present in all five cases on plain radiograph. It was frequently seen in other patients over the same period. Review of the literature indicates that CA was present in 6 of the 11 previous cases where the presence or absence of CA can be determined. Where right atrial catheter tip placement is accepted, clinicians should be aware of this characteristic catheter configuration, which is a major risk factor for cardiac tamponade. We recommend that catheter tips should not be placed in the right atrium to avoid risk of tamponade.

A Ty1 reverse transcriptase active-site aspartate mutation blocks transposition but not polymerization

Reverse transcriptases (RTs) are found in a wide variety of mobile genetic elements including viruses, retrotransposons, and infectious organellar introns. An invariant triad of aspartates is thought to be required for the catalytic function of RTs. We generated RT mutants in the yeast retrotransposon Ty1, changing each of these active-site aspartates to asparagine or glutamate. All but one of the mutants lacked detectable polymerase activity. The novel exception, D(211)N, retained near wild-type in vitro polymerase activity within virus-like particles but failed to carry out in vivo transposition. For this mutant, minus-strand synthesis is impaired and formation of the plus-strand strong-stop intermediate is eliminated. Intragenic second-site suppressor mutations of the transposition defect map to the RNase H domain of the enzyme. Our results demonstrate that one of the three active-site aspartates in a retrotransposon RT is not catalytically critical. This implies a basic difference in the polymerase active-site geometry of Ty1 and human immunodeficiency virus RT and shows that subtle mutations in one domain can cause dramatic functional effects on a distant domain of the same enzyme.

Risk Factors and Predictors of Outcome in Patients with Cancer and Breakthrough Candidemia

Hematogenous candidiasis adds substantially to the morbidity and mortality rates of patients with cancer. Little is known about the risk factors and outcome in patients with breakthrough (BT) candidemia while on systemic antifungal therapy. All 479 episodes of candidemia in 474 consecutive patients with candidemia that was diagnosed at M. D. Anderson Cancer Center from 1988 through 1992 were studied retrospectively. A total of 49 patients had BT candidemia, defined as candidemia that developed after at least 5 days of systemic antifungal therapy. Risk factors for BT candidemia and predictors of mortality were investigated. Multivariate analysis revealed that intensive care unit stay, neutropenia, use of corticosteroids, and duration of neutropenia as significant risk factors for BT candidemia. Seventy-six percent of patients with BT candidemia died, compared with 50% of patients with non-BT infection. In multivariate analysis, intensive care unit stay, being and remaining neutropenic, APACHE III score, and disseminated disease were independent prognostic factors. In conclusion, identification of risk factors and predictors of a poor outcome in patients with cancer with BT candidemia may have important implications in early diagnosis and appropriate therapy of these patients.

Predictors of outcome in cancer patients with candidemia

BACKGROUND

Hematogenous candidiasis is associated with a substantial mortality and morbidity in critically ill patients. Candidemia is the best marker for hematogenous infection; therefore, most studies have examined the outcome of candidemia. However, few have focused on the predictors of outcome in cancer patients with candidemia.

MATERIALS AND METHODS

We conducted a MEDLINE search for all study reports published from 1974 to 1999 on candidemia and prognostic factors including predictors of mortality. Ten articles that provided sufficient data were evaluated in detail.

RESULTS

The overall mortality rate was reported to be 33%-75%. Univariate analyses identified severity of underlying disease, performance status, neutropenia, Candida species, source of candidemia and the extent of visceral involvement as important prognostic variables. In multivariate analyses, however, only host factors and extent of infection (rather than infecting Candida species) were predictive of mortality.

CONCLUSIONS

Older age, poor performance status, presence and persistence of neutropenia, and extensive organ involvement with candidiasis are the most important prognostic factors for candidemia in cancer patients.

Susceptibility testing of voriconazole, fluconazole, itraconazole and amphotericin B against yeast isolates in a Turkish University Hospital and effect of time of reading

Voriconazole is a promising azole effective against a variety of fungi, including yeasts. In this study, we tested in vitro activities of voriconazole, fluconazole, itraconazole and amphotericin B against some ATCC and reference strains and 250 clinical yeast isolates. We also evaluated the effect of time of reading on MIC results. Voriconazole was the most active agent against Candida and Trichosporon isolates, including the putatively fluconazole-resistant C. krusei (MIC(90) 0.25 microg/ml) and C. glabrata (MIC(90) 0.5 microg/ml). Amphotericin B MICs were scattered in a considerably narrow range in both RPMI 1640 and Antibiotic Medium 3. MICs at 24 hours and 48 hours were similar in general for all antifungals tested. The highest percentage of strains that showed 24-hour and 48-hour MICs within +/-1-log(2) dilution was observed for amphotericin B tested in RPMI (99%), and the lowest for amphotericin B tested in Antibiotic Medium 3 (80%). In conclusion, voriconazole is very effective against a wide spectrum of Candida species and 24-hour readings could substitute 48-hour MIC evaluation.

Analysis of a mini-outbreak of methicillin-resistant Staphylococcus aureus in a surgical ward by using arbitrarily primed-polymerase chain reaction

In November 1995, an increase was noticed in the number of methicillin-resistant Staphylococcus aureus (MRSA) isolates from a surgical ward at Hacettepe University Hospital. All MRSA isolates obtained from clinical specimens in this ward (14 MRSA isolates from wound cultures of 10 patients) were collected prospectively for 10 weeks. Surveillance cultures were taken from ward personnel (nose cultures from 4 physicians, 7 nurses, 1 secretary, 1 waiter), 2 surgical dressing containers and 1 nebulizer. MRSA was isolated from one of the surgical dressing containers, the nebulizer and nose cultures of 3 physicians, 3 nurses and the ward secretary. Arbitrarily primed polymerase chain reaction (AP-PCR) analysis showed that most MRSA isolates belonged to 2 major clones (pattern A, pattern B). Pattern A was the most frequent one and was present in 4 clinical isolates, surgical dressing container-1. Pattern B was identified in 3 clinical isolates and nose culture of physician-3. AP-PCR analysis revealed that this mini-MRSA outbreak was caused by contamination of surgical dressing container with MRSA and nasal MRSA carriage in ward staff. AP-PCR seems to be a valuable typing method for analysis of nosocomial MRSA outbreaks because of its simplicity and rapidity.

Fate of the stented arterial duct

BACKGROUND

The technical aspects of ductal stenting have been reported, but little is known of the fate of the duct after stent implantation.

METHODS AND RESULTS

Nineteen patients underwent stent implantation to maintain ductal patency. Eight had hypoplastic left heart (HLH) syndrome, 10 had pulmonary atresia, and 1 had tricuspid atresia. Median survival with HLH was 57 (12 to 907) days. Stent implantation was successful in all cases of HLH, but there were no long-term survivors. Two well-palliated infants died at transplantation. Median survival with duct-dependent pulmonary flow was 183 (0 to 1687) days, with 3 patients well at latest follow-up (56, 55, and 9 months, respectively). There were 2 operative deaths due to ductal spasm and 4 late deaths, 1 due to duct thrombosis, 1 due to chronic lung disease, and 2 of unknown cause. Stent implantation failed in 4 of the 11 cases. Assessment of endothelialization was possible in 13 cases; the stent was partially covered in 3 and fully endothelialized in all 10 cases assessed >8 weeks after implantation. In patients stented for inadequate pulmonary flow, ductal intimal hyperplasia occurred by 9 months in all 3 survivors but responded to repeated dilation.

CONCLUSIONS

Ductal stenting cannot be recommended. In patients with HLH, it provides only short-term palliation even when combined with pulmonary artery banding. With duct-dependent pulmonary blood flow, the procedure carries high risk, and duration of palliation is poor. In patients with bilateral ducts and absent central pulmonary arteries, good palliation may be achieved, but repeated angioplasty is necessary to counteract intimal hyperplasia.

Progressive disease of the atrioventricular conduction axis in an infant of an anti-Ro positive mother

A child of a mother with maternal anti-Ro and anti-La antibodies presented antenatally with abnormal myocardial function, and was found to have a first degree heart block at birth. The extent of the abnormality in the conduction system progressed, with appearance of left bundle branch block in addition to further prolongation of PR interval. A pacemaker was implanted prophylactically, but patient has remained well, with no further deterioration in her atrioventricular conduction.

Haemolysis following implantation of duct occlusion coils

OBJECTIVES

To describe the incidence and management of haemolysis after transcatheter coil occlusion of the arterial duct.

DESIGN

Prospective clinical and echocardiographic follow up of patients who have undergone implantation of the Cook detachable duct occlusion coil.

SETTING

Tertiary paediatric cardiac centre.

PATIENTS

Five cases of haemolysis (two girls aged 6 and 11 months; three boys aged 6, 17, and 14 months) from a series of 137 duct coil implantations.

MAIN OUTCOME MEASURES

The occurrence of clinically significant haemolysis after implantation of duct occlusion coils and resolution of haematuria after completion of duct occlusion.

RESULTS

Haemolysis was detected in five of 137 procedures following implantation of Cook detachable duct coils. Four patients became symptomatic 12 hours after the procedure but in one haemolysis was detected three months later. Resolution of ongoing haemolysis was achieved within 48 hours of detection with further coil implantations, but haematuria persisted for up to 10 days. In one patient the extensive destruction of erythrocytes resulted in acute renal failure requiring peritoneal dialysis.

CONCLUSIONS

Haemolysis is an important complication after duct coil implantation. It occurred in 3.6% of 137 procedures in this series and is most likely to occur in young patients with relatively large ducts. Further coil implantation to occlude the duct completely is not only successful but technically relatively straightforward and should be undertaken early if major complications such as severe anaemia and renal failure are to be avoided.