Suctioning in the management of bronchiolitis: A prospective observational study

BACKGROUND

Bronchiolitis accounts for a considerable number of Emergency Department (ED) visits by infants each year and is the leading cause of respiratory infection in children 2 years of age and younger. Suctioning remains one of the main supportive treatments, but suctioning practices of nasal aspiration and deep suctioning vary among practitioners in bronchiolitis management. Our objective was to explore associations between suction type and respiratory distress, oxygen saturation, and markers of respiratory compromise such as airway escalation, disposition, ED length of stay (LOS), and outpatient outcomes.

METHODS

This was a prospective observational study on infants (aged 2-23 months) in a pediatric ED with bronchiolitis from September 2022 to April 2023. Infants with tracheostomies, muscular weakness, and non-invasive positive pressure ventilation were excluded. Infants were grouped into nasal aspiration, deep suctioning, or combination groups. Mean differences in respiratory scores (primary outcome) and oxygen saturation were measured at three timepoints: pre-suction, 30 and 60 min post-suction. Escalation to airway adjuncts, disposition, and ED LOS were also recorded. Discharged families were contacted for phone call interviews.

RESULTS

Of 121 enrolled infants (nasal aspiration n = 31, deep suctioning n = 68, combination n = 22), 48% (n = 58) were discharged, and 90% (n = 52) completed the study call. There was no interaction between suction type and timepoint (p = 0.63) and no effect between suction type and respiratory score (p = 0.38). However, timepoint did have an effect on respiratory score between 0 and 30 min post-suction (p = 0.01) and between 0 and 60 min post-suction (p < 0.001). Admitted infants received more deep suctioning or a combination of suctioning compared to those discharged (p = 0.005). Suction type had no effect on oxygen saturation, airway adjunct escalation, length of stay, or outpatient outcomes (p > 0.11).

CONCLUSIONS

There was no difference in respiratory scores or outpatient outcomes between suction types. Deep suctioning may not be needed in all infants with bronchiolitis.

Examining trust between supervisors and trainees in the pediatric emergency department

Objective

Lack of trust between supervisors and trainees can have harmful consequences. Trust has been examined between physicians, patients, and staff in multiple settings but has not been examined in a bidirectional manner in the pediatric emergency department (PED). Debra Meyerson in 1996 discussed the theory of swift trust, a type of trust that develops quickly between temporary groups through reliance on categories. Meyerson describes categories as groups unified by social identities such as gender or profession. We explored the applicability of swift trust in the relationship between supervisors and trainees in the PED.

Methods

This multimethods study used qualitative interviews and the validated interpersonal mistrust trust measure (IMTM) to assess baseline trusting style. PED attendings from a single institution and residents from various training levels, specialties, and institutions rotating through the same PED were sampled until thematic saturation was reached. Interviews were analyzed using directed content analysis. IMTM scores were triangulated with interviewee's reported trusting styles.

Results

Seventeen PED attendings and 16 residents participated. Residents and attendings emphasized different factors that influence trust. Common factors across groups included affect, the need for vulnerability, and appropriate communication. Most described reliance on certain categories (level of training, specialty, etc.) when making trusting decisions. Categories such as gender and race were noted to be unimportant when making trusting decisions about others, although some participants believed these attributes played into decisions made by others. Quantitative data from the IMTM supported qualitative conclusions regarding trusting style.

Conclusions

The trusting relationship between supervisors and trainees in the PED dovetails with the swift trust theory. Common factors that influence trust reveal entry points for attendings and residents to improve trust and ultimately prevent negative patient outcomes. Future studies may examine how reliance on categories influences an individual's trust in their colleagues.

Evaluation of continuous ampicillin/sulbactam infusion in critically ill patients

Continuous infusion (CI) of beta-lactam-antibiotics may improve pharmacodynamics in critically ill patients, but resulting concentrations have not been studied. Therapeutic drug monitoring is increasingly used to ensure antibiotic concentration. The aim of this study is to evaluate therapeutic ampicillin/sulbactam concentrations of a continuous infusion regimen.

METHODS

Medical records of all patients admitted to ICU between January 2019 and December 2020 were retrospectively reviewed. Each patient received a 2/1 g ampicillin/sulbactam loading dose, followed by a continuous infusion of 8/4 g per 24 h. Ampicillin serum concentrations were measured. Main outcomes were reaching of plasma concentrations breakpoint defined by minimum inhibitory concentration (MIC at 8 mg/l) and 4-fold MIC (MIC at 32 mg/l) during steady state of CI.

RESULTS

In 50 patients a total of 60 concentration measurements were performed. The first concentration was measured after a median of 29 h (IQR 21-61 h). Mean ampicillin concentration was 62.6 ± 39.1 mg/l. Furthermore, serum concentrations exceeded the defined MIC breakpoint in all measurements (100 %) and were above the 4-fold MIC in 43 analyses (71.1 %). However, patients suffering from acute kidney injury exhibited significant higher serum concentrations (81.1 ± 37.7 mg/l vs. 38.2 ± 24.8 mg/l; p < 0.001). Also, there was a negative correlation between ampicillin serum concentrations and GFR (r = -0.659; p < 0.001).

CONCLUSION

The described dosing regimen for ampicillin/sulbactam is safe with respect to the defined MIC breakpoints for ampicillin, and continuous subtherapeutic concentration is unlikely. However, with impaired renal function drug accumulation occurs, and with increased renal clearance, drug levels can be below the 4-fold MIC breakpoint.

A Mixed Methods Needs Assessment for a Debriefing Intervention Following Critical Cases

OBJECTIVE

The emergency department (ED) is a demanding environment, and critical events have been identified as contributors to stress. Debriefing is a possible intervention for staff, but there is little information regarding formulation and implementation. A needs assessment was conducted to describe the emotions of pediatric ED (PED) staff following critical events and assess opinions regarding debriefing.

METHOD

This mixed methods study used convergent design for triangulation. After critical cases, PED staff members were given the Peritraumatic Distress Inventory (PDI). Additionally, a questionnaire with 2 open-ended questions on debriefing was administered. Themes were extracted from the questionnaire using directed content analysis.

RESULTS

A total of 719 responses were collected for 142 critical cases. Physical reactions were often endorsed in the PDI, and these reactions were mirrored in the qualitative data, which included physiological responses such as stress, adrenaline high, anxiety, fatigue, and overwhelm. Helplessness and grief were 2 of the emotional PDI items frequently endorsed, which were reflected in the qualitative strand by themes such as helplessness, sadness, disheartenment, and regret. There was considerable variability between critical cases such that not every critical case elicited a desire for a debrief.

CONCLUSIONS

PED staff report measurable levels of stress after critical patient cases that warrant follow-up. Formal debriefing immediately after critical patient cases with specific caveats may be valuable for the reduction of stress. Any formal debriefing program will need to balance various goals with attention to the session length, setting, and timing.

Parental attitudes in the pediatric emergency department about the COVID-19 vaccine

BACKGROUND

COVID-19 vaccinations are now recommended in the United States (U.S.) for children ≥ 6 months old. However, pediatric vaccination rates remain low, particularly in the Hispanic/Latinx population.

OBJECTIVE

Using the 4C vaccine hesitancy framework (calculation, complacency, confidence, convenience), we examined parental attitudes in the emergency department (ED) towards COVID-19 vaccination, identified dimensions of parental vaccine hesitancy, and assessed parental willingness to have their child receive the COVID-19 vaccine.

METHODS

As part of a larger multi-methods study examining influenza vaccine hesitancy, we conducted interviews that included questions about COVID-19 vaccine authorization for children. We used directed content analysis to extract qualitative themes from 3 groups of parents in the ED: Hispanic/Latinx Spanish speaking (HS), Hispanic/Latinx English speaking (HE), non-Hispanic/non-Latinx White English speaking (WE). Themes were triangulated with the Parent Attitudes about Childhood Vaccines (PACV) survey, where higher scores indicate increased vaccine hesitancy.

RESULTS

Factors influencing vaccine hesitancy were mapped to the 4C framework from 58 sets of interviews and PACVs. HE and HS parents, compared to WE parents, had less knowledge about COVID-19 and its vaccine, and more beliefs in COVID-19 vaccine myths. However, both HS and HE parent groups were more inclined to endorse COVID-19 vaccine effectiveness as a reason to have their children vaccinated. HS parents felt that COVID-19 increased their fear of illnesses in general and were worried about confusing COVID-19 with other infections. Median PACV scores of HS (Mdn = 20) and HE (Mdn = 20) parent groups were higher than of WE parents (Mdn = 10), but parental willingness to have their child receive COVID-19 vaccination was similar across groups.

CONCLUSIONS

Higher COVID-19 vaccine hesitancy among HS and HE parents compared to WE parents may be attributed to insufficient knowledge about COVID-19, its vaccine, along with COVID-19 vaccine myths. Efforts to provide targeted vaccine education to different populations is warranted.

Teaching Infant Cardiopulmonary Resuscitation to Caregivers in the Emergency Department

OBJECTIVES

Infant cardiopulmonary resuscitation (CPR) has been taught to caregivers of infants in inpatient settings. There are no studies to date that look at teaching infant CPR in the emergency department (ED). Using a framework of cognitive load theory, we compared teaching infant CPR to caregivers in a pediatric ED versus an inpatient setting.

METHODS

Knowledge tests, 1-minute infant CPR performances on a Resusci Baby QCPR (Laerdal) manikin, and self-reported questionnaires were completed before and after caregivers were self-taught infant CPR using Infant CPR Anytime kits. The proportions of chest compression depth and rate that met quality standards from the American Heart Association's Basic Life Support program were measured.

RESULTS

Seventy-four caregivers participated. Mean knowledge scores (out of a total score of 15) increased in both settings (ED preintervention: Mean (M) = 4.53 [SD = 1.97]; ED postintervention: M = 10.47 [SD = 2.90], P < 0.001; inpatient preintervention: M = 4.83 (SD = 2.08); inpatient postintervention: M = 10.61 [SD = 2.79], P < 0.001). Improvement in the proportion of chest compression that met high quality standards for depth increased in the inpatient group only. Neither groups had improvements in compression rates. There were no statistically significant differences in the difficulty of learning CPR, frequency of interruptions/distractions, or difficulty staying concentrated in learning CPR between the 2 settings.

CONCLUSIONS

Caregivers in the ED and inpatient settings after a self-instructional infant CPR kit did not demonstrate adequate infant CPR performance. However, both groups gained infant CPR knowledge. Differences in cognitive loads between the 2 settings were not significant.

Pediatric emergency department shift experiences and moods: An exploratory sequential mixed-methods study

OBJECTIVE

The objective was to investigate the impact of affective, social, behavioral, and cognitive factors on pediatric emergency department (PED) provider mood changes during clinical shifts, with the introduction of a novel on-shift measure.

METHODS

The nominal group technique was used to generate the ED experience survey (EDES), encompassing factors that may influence PED provider mood. Providers were alerted via experience sampling method to complete the EDES and positive and negative affect schedule at randomly generated times. Analyses were conducted using multilevel modeling of moods within shifts within persons.

RESULTS

Measures were completed 221 times during 137 shifts by 52 PED providers. Positive mood tended to increase with higher self-rated capacity to deal with challenging patient situations (p < 0.001). Having to repeat patient assessments was negatively associated with positive mood during the beginning, but not rest of shift (p = 0.01). Changes in positive mood varied across provider groups (p < 0.001). Negative mood tended to decrease with higher self-rated quality of interactions with patients/families (p < 0.001). Needing a restroom break during any time on duty was associated with negative mood (p < 0.001). Furthermore, negative mood was associated with the need to process emotions during the shift beginning (p = 0.01). Finally, not knowing about patients' outcomes was associated with negative mood during the shift end (p < 0.001).

CONCLUSIONS

PED providers' mood during shifts are impacted by ED-specific factors spanning physical, social, behavioral, affective, and cognitive features. Future research may explore potential entry points for mitigation of clinician stress to support provider well-being and ultimately improve patient care.

Capillary blood gas in infants with bronchiolitis: Can end-tidal capnography replace it?

OBJECTIVES

To explore the predictive ability of capillary blood gas (CBG) pCO₂ for respiratory decompensation in infants aged ≤6 months with bronchiolitis admitted from the emergency department; to determine whether end-tidal CO₂ (etCO₂) capnography can serve as a less invasive substitute for CBG pCO₂.

STUDY DESIGN

This was a prospective cohort study of previously healthy infants aged ≤6 months admitted for bronchiolitis from the emergency department (ED). Initial CBG pCO₂ and etCO₂ capnography were obtained in the ED prior to inpatient admission. Simple logistic regression modeling was used to examine the associations of CBG pCO₂ and etCO₂ capnography with respiratory decompensation. Pearson's correlation measured the relationship between CBG pCO₂ and etCO₂ capnography.

RESULTS

Of 134 patients, 61 had respiratory decompensation. There was a significant association between CBG pCO₂ and respiratory decompensation (OR = 1.07, p = 0.003), even after outlying values were excluded (OR = 1.06, p = 0.005). End tidal CO₂ capnography was not significantly associated with decompensation (OR = 1.02, p = 0.17), even after outlying values were excluded (OR = 1.02, p = 0.24). There was a moderate correlation between etCO₂ capnography and CBG pCO₂ (r = 0.39, p < 0.001).

CONCLUSION

In infants with bronchiolitis, CBG pCO₂ provides an objective measure for predicting respiratory decompensation, and a single etCO₂ measurement should not replace its use.

Surge activation by the emergency department for COVID-19

In March 2020, the American College of Emergency Physicians (ACEP) published a national strategic plan for COVID-19, which provides general guidelines yet leaves logistical details for institutions to determine. Key capabilities from this plan provided a crucial foundation for a 16-day Emergency Department (ED) surge planning process at one pediatric institution. This paper describes critical milestones and lessons learned during this brief period, including derivation of criteria for ED surge activation, a full-scale surge drill, and the resultant ED surge protocol. The framework of real-time evaluation was used throughout the planning process and involved constant and iterative synthesis of real-time feedback from multidisciplinary stakeholders for responsive decision-making. Ultimately, the objective of this paper is to provide timely and readily actionable information to other institutions seeking guidance to apply the ACEP strategic plan for COVID-19.

Factors influencing termination of resuscitation in children: a qualitative analysis

BACKGROUND

Pediatric Advanced Life Support provides guidelines for resuscitating children in cardiopulmonary arrest. However, the role physicians' attitudes and beliefs play in decision-making when terminating resuscitation has not been fully investigated. This study aims to identify and explore the vital "non-medical" considerations surrounding the decision to terminate efforts by U.S.-based Pediatric Emergency Medicine (PEM) physicians.

METHODS

A phenomenological qualitative study was conducted using PEM physician experiences in terminating resuscitation within a large freestanding children's hospital. Semi-structured interviews were conducted with 17 physicians, sampled purposively for their relevant content experience, and continued until the point of content saturation. Resulting data were coded using conventional content analysis by 2 coders; intercoder reliability was calculated as κ of 0.91. Coding disagreements were resolved through consultation with other authors.

RESULTS

Coding yielded 5 broad categories of "non-medical" factors that influenced physicians' decision to terminate resuscitation: legal and financial, parent-related, patient-related, physician-related, and resuscitation. When relevant, each factor was assigned a directionality tag indicating whether the factor influenced physicians to terminate a resuscitation, prolong a resuscitation, or not consider resuscitation. Seventy-eight unique factors were identified, 49 of which were defined by the research team as notable due to the frequency of their mention or novelty of concept.

CONCLUSION

Physicians consider numerous "non-medical" factors when terminating pediatric resuscitative efforts. Factors are tied largely to individual beliefs, attitudes, and values, and likely contribute to variability in practice. An increased understanding of the uncertainty that exists around termination of resuscitation may help physicians in objective clinical decision-making in similar situations.

Use of Audiobooks as an Environmental Distractor to Decrease State Anxiety in Children Waiting in the Pediatric Emergency Department: A Pilot and Feasibility Study

Objectives: Anxiety and anticipatory stressors are commonly experienced by children visiting the Pediatric Emergency Department (PED), but little research exists that addresses the efficacy of interventions to decrease this stress. This one-sample pretest-postest pilot study gathered preliminary data on the feasibility and effectiveness of utilizing audiobooks to reduce fear and state anxiety in children in the PED. Methods: Participants were 131 children in kindergarten through 8th grade (M = 9.4 years, 54% female), triaged urgent or emergent, presenting to the PED. Participants self-reported fear (Children's Fear Scale) and state anxiety (modified State-Trait Anxiety Inventory for Children; mSTAIC) before and after listening to an age-appropriate audiobook (two options). Data regarding patient experience were also collected. Paired samples t-test was used to examine pre-post intervention changes in fear and state anxiety. Results: Significant, albeit small, improvements in fear and the mSTAIC states of nervous, calm, happy, and relaxed were found after use of the audiobook (Cohen's d _z = 0.22-0.35). Small, yet significant correlations were found between child age/grade level and improvements in fear and in the mSTAIC states of scared and relaxed, suggesting that the audiobook was more beneficial for older participants. Over 60% of participants liked the audiobook content "a lot" as well as enjoyed listening to the audiobook "a lot." Without prompting, 15% of participants requested to listen to an additional audiobook. Conclusions: Listening to an audiobook is feasible and could be effective in decreasing fear and state anxiety for children during a waiting period in the PED. The technology is low-cost, simple, and portable. The results of this study should be interpreted with prudence due to the lack of a control group and results that, although significant, were modest based on effect size conventions; future studies should explore the impact of audiobooks on patient stress with an expanded sample size and control group.

Defining "Swarming" as a New Model to Optimize Efficiency and Education in an Academic Emergency Department

BACKGROUND

Academic emergency medicine is a constant balance between efficiency and education. We developed a new model called swarming, where the bedside nurse, resident, and attending/fellow simultaneously evaluate the patient, including initial vital signs, bedside triage, focused history and physical examination, and discussion of the treatment plan, thus creating a shared mental model.

OBJECTIVES

To combine perceptions from trainee physicians, supervising physicians, nurses, and families with in vivo measurements of emergency department swarms to better conceptualize the swarming model.

METHODS

This mixed methods study was conducted using a convergent design. Qualitative data from focus groups with nurses, residents, and attendings/fellows were analyzed using directed content analysis. Swarming encounters were observed in real time; durations of key aspects and family satisfaction scores were analyzed using descriptive statistics. The qualitative and quantitative findings were integrated a posteriori.

RESULTS

From the focus group data, 54 unique codes were identified, which were grouped together into five larger themes. From 39 swarms, mean (±SD) time (minutes) spent in patient rooms: nurses = 6.8 (±3.0), residents = 10.4 (±4.1), and attendings/fellows = 9.4 (±4.3). Electronic documentation was included in 67% of swarms, and 39% included orders initiated at the bedside. Mean (±SD) family satisfaction was 4.8 (±0.7; Likert scale 1-5).

CONCLUSIONS

Swarming is currently implemented with significant variability but results in high provider and family satisfaction. There is also consensus among physicians that swarming improves trainee education in the emergency setting. The benefits and barriers to swarming are underscored by the unpredictable nature of the ED and the observed variability in implementation. Our findings provide a critical foundation for our efforts to refine, standardize, and appraise our swarming model.

Accuracy of near-patient vs. inbuilt spirometry for monitoring tidal volumes in an in-vitro paediatric lung model

Spirometric monitoring provides precise measurement and delivery of tidal volumes within a narrow range, which is essential for lung-protective strategies that aim to reduce morbidity and mortality in mechanically-ventilated patients. Conventional anaesthesia ventilators include inbuilt spirometry to monitor inspiratory and expiratory tidal volumes. The GE Aisys CS² anaesthesia ventilator allows additional near-patient spirometry via a sensor interposed between the proximal end of the tracheal tube and the respiratory tubing. Near-patient and inbuilt spirometry of two different GE Aisys CS² anaesthesia ventilators were compared in an in-vitro study. Assessments were made of accuracy and variability in inspiratory and expiratory tidal volume measurements during ventilation of six simulated paediatric lung models using the ASL 5000 test lung. A total of 9240 breaths were recorded and analysed. Differences between inspiratory tidal volumes measured with near-patient and inbuilt spirometry were most significant in the newborn setting (p < 0.001), and became less significant with increasing age and weight. During expiration, tidal volume measurements with near-patient spirometry were consistently more accurate than with inbuilt spirometry for all lung models (p < 0.001). Overall, the variability in measured tidal volumes decreased with increasing tidal volumes, and was smaller with near-patient than with inbuilt spirometry. The variability in measured tidal volumes was higher during expiration, especially with inbuilt spirometry. In conclusion, the present in-vitro study shows that measurements with near-patient spirometry are more accurate and less variable than with inbuilt spirometry. Differences between measurement methods were most significant in the smallest patients. We therefore recommend near-patient spirometry, especially for neonatal and paediatric patients.

Microbe-like inclusions in tree resins and implications for the fossil record of protists in amber

During the past two decades, a plethora of fossil micro-organisms have been described from various Triassic to Miocene ambers. However, in addition to entrapped microbes, ambers commonly contain microscopic inclusions that sometimes resemble amoebae, ciliates, microfungi, and unicellular algae in size and shape, but do not provide further diagnostic features thereof. For a better assessment of the actual fossil record of unicellular eukaryotes in amber, we studied equivalent inclusions in modern resin of the Araucariaceae; this conifer family comprises important amber-producers in Earth history. Using time-of-flight secondary ion mass spectrometry (ToF-SIMS), we investigated the chemical nature of the inclusion matter and the resin matrix. Whereas the matrix, as expected, showed a more hydrocarbon/aromatic-dominated composition, the inclusions contain abundant salt ions and polar organics. However, the absence of signals characteristic for cellular biomass, namely distinctive proteinaceous amino acids and lipid moieties, indicates that the inclusions do not contain microbial cellular matter but salts and hydrophilic organic substances that probably derived from the plant itself. Rather than representing protists or their remains, these microbe-like inclusions, for which we propose the term 'pseudoinclusions', consist of compounds that are immiscible with the terpenoid resin matrix and were probably secreted in small amounts together with the actual resin by the plant tissue. Consequently, reports of protists from amber that are only based on the similarity of the overall shape and size to extant taxa, but do not provide relevant features at light-microscopical and ultrastructural level, cannot be accepted as unambiguous fossil evidence for these particular groups.

Intra-unit-cell electronic nematicity of the high-T(c) copper-oxide pseudogap states

In the high-transition-temperature (high-T(c)) superconductors the pseudogap phase becomes predominant when the density of doped holes is reduced. Within this phase it has been unclear which electronic symmetries (if any) are broken, what the identity of any associated order parameter might be, and which microscopic electronic degrees of freedom are active. Here we report the determination of a quantitative order parameter representing intra-unit-cell nematicity: the breaking of rotational symmetry by the electronic structure within each CuO(2) unit cell. We analyse spectroscopic-imaging scanning tunnelling microscope images of the intra-unit-cell states in underdoped Bi(2)Sr(2)CaCu(2)O(8 +) (delta) and, using two independent evaluation techniques, find evidence for electronic nematicity of the states close to the pseudogap energy. Moreover, we demonstrate directly that these phenomena arise from electronic differences at the two oxygen sites within each unit cell. If the characteristics of the pseudogap seen here and by other techniques all have the same microscopic origin, this phase involves weak magnetic states at the O sites that break 90 degrees -rotational symmetry within every CuO(2) unit cell.

Spectroscopic fingerprint of phase-incoherent superconductivity in the cuprate pseudogap state [corrected]

A possible explanation for the existence of the cuprate "pseudogap" state is that it is a d-wave superconductor without quantum phase rigidity. Transport and thermodynamic studies provide compelling evidence that supports this proposal, but few spectroscopic explorations of it have been made. One spectroscopic signature of d-wave superconductivity is the particle-hole symmetric "octet" of dispersive Bogoliubov quasiparticle interference modulations. Here we report on this octet's evolution from low temperatures to well into the underdoped pseudogap regime. No pronounced changes occur in the octet phenomenology at the superconductor's critical temperature Tc, and it survives up to at least temperature T approximately 1.5 Tc. In this pseudogap regime, we observe the detailed phenomenology that was theoretically predicted for quasiparticle interference in a phase-incoherent d-wave superconductor. Thus, our results not only provide spectroscopic evidence to confirm and extend the transport and thermodynamics studies, but they also open the way for spectroscopic explorations of phase fluctuation rates, their effects on the Fermi arc, and the fundamental source of the phase fluctuations that suppress superconductivity in underdoped cuprates.

Development of microalgae communities in the Phytotelmata of allochthonous populations of Sarracenia purpurea (Sarraceniaceae)

The phytotelmata of the North American pitcher plant Sarracenia purpurea are colonised by a great variety of aquatic organisms and, thus, provide an ideal model to study trophic interactions in small freshwater ecosystems. Although algae are discussed as a potential food source for predators, little is known about the structure of algae coenoses in pitchers of S. purpurea. This study aims to elucidate temporal shifts in the algae community structure in pitchers of an allochthonous population of S. purpurea in Saxony, Germany. A total of 78 algae taxa was found in the pitchers. Mean algae abundances in new and old pitchers were similar (2.6 x 10(5) and 2.3 x 10(5) algae ml(-1), respectively). Taxa from the orders Chlamydomonadales, Chlorococcales, and Ochromonadales were the primary colonisers. With increasing age of the pitchers the filamentous green algae from the order Klebsormidiales became more abundant. In contrast, pennate diatoms dominated the algae coenoses in the fen. Algae community structure in vase-shaped 50 ml Greiner tubes was similar to those of natural pitchers. Differences in the temporal patterns of algae coenoses in individual pitchers suggested a colonisation of the pitchers by algae via trapped insects, air and rain water rather than via the surrounding fen. Biomass of algae approximated 0.3 mg C ml(-1), which corresponds to 82.8 % of the living biomass (bacteria, heterotrophic nanoflagellates, algae, protozoans and rotifers). Rotifers were abundant in new pitchers; nematodes and mites were seldom found in all pitchers. A similar qualitative and quantitative composition of the aquatic biocoenoses was observed in pitchers of another allochthonous S. purpurea population growing in Blekinge, Sweden. Biomass of algae represented nearly one quarter of the total organic matter content in the pitchers. Thus, nitrogen and phosphorus compounds present in the algae biomass might be used by the carnivorous S. purpurea plant as additional food source in allochthonous populations in Europe lacking top predators.

Morphology and nrITS phylogeny of the genus Pinguicula L. (Lentibulariaceae), with special attention to embryo evolution

The genus Pinguicula (Lentibulariaceae) is unusual within the dicot order Lamiales because of the occurrence of both embryos with two cotyledons and those with just one cotyledon. In order to elucidate the infrageneric relationships and the evolutionary history of the embryo, we analysed (1) the internal transcribed spacers ITS1 and ITS2 of the nuclear ribosomal DNA (nrITS) of 29 Old and New World taxa of Pinguicula, and (2) the morphological and anatomical characters of the seeds. We suggest that the cotyledon number and spermoderm structure were quite unstable in the evolution of Pinguicula. Although basal nodes of the nrITS tree are sensitive to taxon sampling, all tree topologies found in this study imply homoplasy in the cotyledon number.

[Evaluation of the metabolic state and functional activity of immunocompetent cells in children with relapsing herpetic viral infection]

Specific features of the immune response were studied (during the clinical remission period) in 40 children (aged 3 to 6) with a relapsing herpes viral infection (RHVI). The following was established: an increased relative and absolute quantity of lymphocytes, a reduced percentage content of CD+ and an increased absolute count of CD+ in the peripheral blood. Changes in the immunity humoral chain manifested themselves by an increased content of class G immunoglobulins and of circulating immune complexes (CIC) in the blood serum. A reduced quantity of phagocyting blood neutrophils was registered with the absorbing ability being preserved. Changes in the metabolic status of immune-competent cells were established; they were described by a high activity of the plastic exchange reaction, a tensed energetic potential and a reduced glutathione-recovery reaction modulating the proliferative activity of lymphocytes. A reduced reserve potential of oxygen-dependent biocenosis of neutrophyl granulocytes was detected in the peripheral blood. Obviously, the structural and metabolic changes in the blood lymphocytes as well as the abnormalities in the functional activity of neutrophyl granulocytes, observed during the clinical remission period in the RHVI period, are a cause predetermining the relapses of the disease and can be regarded as a criterion for applying the immune rehabilitation.

Rosaria succina spec. nov.--a fossil cyanobacterium from tertiary amber

A fossil cyanobacterium found in a piece of Tertiary amber is assigned to the recent genus Rosaria N. Carter (Stigonemataceae) and described as R. succina. The fossil allows a new systematic evaluation of the genus Rosaria.

Evaluation of transabdominal ultrasound-guided amniocentesis in the late gestational mare

Serial transabdominal amniocentesis was performed on eight mares in late gestation. Ultrasonography was used to identify the two placental fluid sacs and the foetus. A biopsy guide attached to the transducer allowed visualisation of the needle path during insertion. Amniotic fluid was obtained in 85 per cent of the attempts, although as mares approached parturition substantial pools of amniotic fluid were more difficult to locate. Two mares aborted during the study probably because of complications of the procedures, whereas six mares produced normal foals at term. The abortions preclude clinical use of this technique currently. However, there was sufficient success in retrieval of amniotic fluid and outcome of pregnancies to continue the study of amniocentesis in larger groups of mares to determine the clinical and research value of this technique.

Double cervices in two llamas

Double cervices were diagnosed in 2 female llamas that were infertile. The condition is uncommon in other species. The condition results from the failure of fusion of the müllerian ducts during embryonic development. Diagnosis was facilitated by vaginoscopy. One case was verified as didelphia, with 2 uterine bodies and 2 cervices.

Tinnitus and otoacoustic emissions: is there a link?

Attempts to identify the mechanisms underlying tinnitus and to develop effective treatments have been frustrating, in part because there are no objective measures of tinnitus. Following Kemp's initial reports of evoked and spontaneous otoacoustic emissions (OAEs), many people hoped that OAEs were an objective correlate of tinnitus. The results of several studies suggest that in about 6 to 12% of normal-hearing persons with tinnitus and spontaneous otoacoustic emissions (SOAEs), the SOAEs are at least partly responsible for the tinnitus. In addition, recent work indicates that some subjects with tinnitus display oscillating or ringing evoked otoacoustic emissions (EOAEs). In these cases, it is hypothesized that the oscillating EOAEs and tinnitus are related to a common underlying pathology rather than the emissions being the source of the tinnitus.

Transrectal ultrasonography of the caudal portion of abdominal and pelvic cavities in horses

A 5-MHz transducer was used transrectally to image palpable structures in the caudal portion of abdominal and pelvic cavities of 12 horses. In 8 healthy horses, structures scanned transrectally included the left kidney, spleen, urinary bladder, urethra, accessory sex organs in the male, portions of the intestinal tract, caudal portion of the aorta, and iliac arteries, and, in small horses, the cranial mesenteric artery. The transrectal technique was used to evaluate these structures in 4 horses with clinical signs indicating intrapelvic or intra-abdominal disease. Seemingly, transrectal ultrasonography provided diagnostic information about structures accessible to transrectal palpation.