Markedly increased risk of postoperative bleeding complications during perioperative bridging anticoagulation in general and visceral surgery

BACKGROUND

Increasing numbers of patients receiving oral anticoagulants are undergoing elective surgery. Low molecular weight heparin (LMWH) is frequently applied as bridging therapy during perioperative interruption of anticoagulation. The aim of this study was to explore the postoperative bleeding risk of patients receiving surgery under bridging anticoagulation.

METHODS

We performed a monocentric retrospective two-arm matched cohort study. Patients that received perioperative bridging anticoagulation were compared to a matched control group with identical surgical procedure, age, and sex. Emergency and vascular operations were excluded. The primary endpoint was the incidence of major postoperative bleeding. Secondary endpoints were minor postoperative bleeding, thromboembolic events, length of stay, and in-hospital mortality. Multivariate analysis explored risk factors of major postoperative bleeding.

RESULTS

A total of 263 patients in each study arm were analyzed. The patient cohort included the entire field of general and visceral surgery including a large proportion of major oncological resections. Bridging anticoagulation increased the postoperative incidence of major bleeding events (8% vs. 1%; p < 0.001) as well as minor bleeding events (14% vs. 5%; p < 0.001). Thromboembolic events were equally rare in both groups (1% vs. 2%; p = 0.45). No effect on mortality was observed (1.5% vs. 1.9%). Independent risk factors of major postoperative bleeding were full-therapeutic dose of LMWH, renal insufficiency, and the procedure-specific bleeding risk.

CONCLUSION

Perioperative bridging anticoagulation, especially full-therapeutic dose LMWH, markedly increases the risk of postoperative bleeding complications in general and visceral surgery. Surgeons should carefully consider the practice of routine bridging.

Indication for allogeneic stem cell transplantation in Glanzmann’s thrombasthenia

Glanzmann’s thrombasthenia (GT) is an autosomal recessive disorder characterized by a lack of thrombocyte aggregation due to the absence of thrombocyte glycoproteins IIb and αIIbβ3. The role of haematopoietic stem cell transplantation (HSCT) in GT remains controversial. However, HSCT offers the only curative approach for patients with a severe clinical phenotype.

In this review, we will discuss the limitation of current status evidence and the specific risk of GT, in particular the alloimmunization and refractoriness to thrombocyte infusions. 19 successful HSCT in 18 GT type I patients have been reported. Mean age at transplantation was 5 years. All patients are still alive. The majority received sibling bone marrow transplant with busulfan and cyclophosphamid conditioning. GvHD incidence was within the normal range, but 10 patients showed alloimmunization of thrombocytes. Median follow up is 25 months.

Fine motor skills in a population of children in remote Australia with high levels of prenatal alcohol exposure and Fetal Alcohol Spectrum Disorder

BACKGROUND

Many children in the remote Fitzroy Valley region of Western Australia have prenatal alcohol exposure (PAE). Individuals with PAE can have neurodevelopmental impairments and be diagnosed with one of several types of Fetal Alcohol Spectrum Disorder (FASD). Fine motor skills can be impaired by PAE, but no studies have developed a comprehensive profile of fine motor skills in a population-based cohort of children with FASD. We aimed to develop a comprehensive profile of fine motor skills in a cohort of Western Australian children; determine whether these differed in children with PAE or FASD; and establish the prevalence of impairment.

METHODS

Children (n = 108, 7 to 9 years) were participants in a population-prevalence study of FASD in Western Australia. Fine motor skills were assessed using the Bruininks-Oseretsky Test of Motor Proficiency, which provided a Fine Motor Composite score, and evaluated Fine Manual Control (Fine Motor Precision; Fine Motor Integration) and Manual Coordination (Manual Dexterity; Upper-Limb Coordination). Descriptive statistics were reported for the overall cohort; and comparisons made between children with and without PAE and/or FASD. The prevalence of severe (≤ 2nd percentile) and moderate (≤16th percentile) impairments was determined.

RESULTS

Overall, Fine Motor Composite scores were 'average' (M = 48.6 ± 7.4), as were Manual Coordination (M = 55.7 ± 7.9) and Fine Manual Control scores (M = 42.5 ± 6.2). Children with FASD had significantly lower Fine Motor Composite (M = 45.2 ± 7.7 p = 0.046) and Manual Coordination scores (M = 51.8 ± 7.3, p = 0.027) than children without PAE (Fine Motor Composite M = 49.8 ± 7.2; Manual Coordination M = 57.0 ± 7.7). Few children had severe impairment, but rates of moderate impairment were very high.

CONCLUSIONS

Different types of fine motor skills should be evaluated in children with PAE or FASD. The high prevalence of fine motor impairment in our cohort, even in children without PAE, highlights the need for therapeutic intervention for many children in remote communities.

[Distal Forearm Fractures in Children and Adolescents: Frequency and Health Care Provision in Germany]

BACKGROUND

Despite their frequent occurrence, there are no standardized recommendations for treating distal forearm fractures in growing children. Due to the marked remodelling capacity, conservative therapy is the first choice treatment of fractures in children. However, there are concerns that the possibilities of conservative treatments are often underestimated. Information on the health care situation in Germany on this issue is scarce.

METHODS

The present study is based on routine data of a German Health Insurance fund, the Gmünder ErsatzKasse (GEK). Data on diagnoses and treatment of insured persons aged 0-15 years were analysed for the period from 01/07/2005 to 30/06/2009 regarding the frequency of distal forearm fractures and fracture treatment.

RESULTS

The overall incidence rate was 56.8 per 10 000 person-years (64.5 in boys; 48.7 in girls). Most of the distal forearm fractures occurred during spring and summer months. The majority of the fractures were immobilized in a plaster cast (84.2%; n=2 609). 8.7% (n=270) of the fractures were treated with closed reduction and percutaneous osteosynthesis. 4.5% (n=138) were treated with closed reduction without any form of osteosynthesis. Only 1.4% (n=43) of the fractures were treated with open reduction.

CONCLUSION

Our study shows that boys suffer distal forearm fractures more frequently than girls and that incidences tend to be higher in older children. In addition, analyses indicated seasonal differences between the age groups. In childhood, distal forearm fractures were treated more often conservatively than operatively. However, it was remarkable that fractures in the case of closed reduction were more frequently fixed with an osteosynthesis than just by immobilization in a plaster cast.

Visual-motor integration, visual perception, and fine motor coordination in a population of children with high levels of Fetal Alcohol Spectrum Disorder

BACKGROUND

Visual-motor integration (VMI) skills are essential for successful academic performance, but to date no studies have assessed these skills in a population-based cohort of Australian Aboriginal children who, like many children in other remote, disadvantaged communities, consistently underperform academically. Furthermore, many children in remote areas of Australia have prenatal alcohol exposure (PAE) and Fetal Alcohol Spectrum Disorder (FASD), which are often associated with VMI deficits.

METHODS

VMI, visual perception, and fine motor coordination were assessed using The Beery-Buktenica Developmental Test of Visual-Motor Integration, including its associated subtests of Visual Perception and Fine Motor Coordination, in a cohort of predominantly Australian Aboriginal children (7.5-9.6 years, n=108) in remote Western Australia to explore whether PAE adversely affected test performance. Cohort results were reported, and comparisons made between children i) without PAE; ii) with PAE (no FASD); and iii) FASD. The prevalence of moderate (≤16th percentile) and severe (≤2nd percentile) impairment was established.

RESULTS

Mean VMI scores were 'below average' (M=87.8±9.6), and visual perception scores were 'average' (M=97.6±12.5), with no differences between groups. Few children had severe VMI impairment (1.9%), but moderate impairment rates were high (47.2%). Children with FASD had significantly lower fine motor coordination scores and higher moderate impairment rates (M=87.9±12.5; 66.7%) than children without PAE (M=95.1±10.7; 23.3%) and PAE (no FASD) (M=96.1±10.9; 15.4%).

CONCLUSIONS

Aboriginal children living in remote Western Australia have poor VMI skills regardless of PAE or FASD. Children with FASD additionally had fine motor coordination problems. VMI and fine motor coordination should be assessed in children with PAE, and included in FASD diagnostic assessments.

Prevalence and risk factors of sexual dysfunction in postpartum Australian women

INTRODUCTION

Female sexual dysfunction is highly prevalent and reportedly has adverse impacts on quality of life. Although it is prevalent after childbirth, women rarely seek advice or treatment from health care professionals.

AIM

The aim of this study was to assess the sexual functioning of Australian women during the first year after childbirth.

METHODS

Postpartum women who had given birth during the previous 12 months were invited to participate in this cross-sectional study. A multidimensional online questionnaire was designed for this study. This questionnaire included a background section, the Female Sexual Function Index, the Patient Health Questionnaire (PHQ-8), and the Relationship Assessment Scale. Responses from 325 women were analyzed.

RESULTS

Almost two-thirds of women (64.3%) reported that they had experienced sexual dysfunction during the first year after childbirth, and almost three-quarters reported they experienced sexual dissatisfaction (70.5 %). The most prevalent types of sexual dysfunction reported by the affected women were sexual desire disorder (81.2%), orgasmic problems (53.5%), and sexual arousal disorder (52.3%). The following were significant risk factors for sexual dysfunction: fortnightly or less frequent sexual activity, not being the initiator of sexual activity with a partner, late resumption of postnatal sexual activity (at 9 or more weeks), the first 5 months after childbirth, primiparity, depression, and relationship dissatisfaction.

CONCLUSION

Sexual satisfaction is important for maintaining quality of life for postpartum women. Health care providers and postpartum women need to be encouraged to include sexual problems in their discussions.

Determinants of the introduction of prelacteal feeds in the Maldives

BACKGROUND AND OBJECTIVES

This study identified the determinants of the introduction of prelacteal feeds in the Maldives.

SUBJECTS AND METHODS

A cohort of 458 mothers was recruited from antenatal clinics at two major hospitals in Malé, the Maldives. The mothers were followed up after birth at 4 weeks, 3 months, and 6 months. The child's birth, the type of infant delivery, the time breastfeeding was initiated, gender of the infants, types of prelacteal feeds, and feeding method were recorded.

RESULTS

After birth, 4.1% of infants received infant formula from the hospitals, whereas 10.6% and 7.4% of them received honey and dates, respectively, as prelacteal ritual feeds. Factors associated with introduction of ritual feeds as prelacteal feeds included the infant being a boy (p=0.05; adjusted odds ratio [AOR]=1.78; 95% confidence interval [CI], 1.07-2.98), attitude toward prelacteal feeds (p=0.01; AOR=2.87; 95% CI, 1.48-5.58), and maternal employment (p=0.01; AOR=2.3; 95% CI, 1.4-3.9). Higher maternal age was inversely associated with introduction of ritual feeds as a prelacteal feed (p=0.05; AOR=0.5; 95% CI, 0.3-0.9). Introduction of infant formula as the prelacteal feed was positively associated with birth by cesarean section (p=0.01; AOR=4.6; 95% CI, 1.6-13.3) and inversely associated with maternal mother's feeding method being breastfeeding (p=0.05; AOR=0.15; 95% CI, 0.04-0.6). Prelacteal feeding was associated with cessation of breastfeeding before 6 months (p=0.01; AOR 6.0; 95% CI, 1.64-21.80).

CONCLUSIONS

Health professionals need to distinguish between religious and cultural practices in order to develop appropriate health education programs to reduce the unnecessary use of early additional feeds. Understanding the barriers related to the initiation of breastfeeding after cesarean section is also important.

Role of antenatal care and iron supplementation during pregnancy in preventing low birth weight in Nepal: comparison of national surveys 2006 and 2011

Background

Low birth weight (LBW) is a major cause of neonatal deaths in developing countries including Nepal. Its social determinants in Nepal have rarely been identified. This study aimed to identify the factors associated with low birth weight among under-five children comparing data from the Nepal Demographic and Health Surveys (NDHS) of 2006 and 2011.

Methods

Pooled data from the Nepal Demographic and Health Surveys (NDHS) of 2006 and 2011 were analysed initially and the two survey data were then compared separately. The association between LBW and socio-demographic and health related factors were analysed using multiple logistic regression analysis with a stepwise backward elimination procedure. Complex Sample Analysis method was used to account for study design and sampling.

Results

A total of 2845 children, 923 children in 2006 and 1922 children in 2011, had their birth weight recorded. The mean birth weight was 3024 (SD = 654.5) grams. A total of 12.1% (95% Confidence interval (CI); 10.6%-13.7%) children had low birth weight (<2500 grams) at the time of birth. Attending antenatal care was found to be consistently associated with low birth weight for the pooled survey data, and both 2006 and 2011 survey data, respectively. Not attending antenatal care increased the odds of having a LBW infant by more than two times [OR 2.301; 95% CI (1.526-3.471)]. Iron supplementation, which is an integral part of antenatal care in Nepal, was also significantly associated with birth weight for combined and individual surveys. Mothers not consuming iron supplementation during their pregnancy were more likely to have LBW infants [OR 1.839; 95% CI (1.282-2.363)]. Residing in the Far-western and Eastern region were also significant risk factors for LBW in the pooled dataset and in 2011 survey.

Conclusions

The current study indicated there was no significant decrease in the LBW prevalence and there is a need of targeted interventions aimed at decreasing the high rate of LBW through increasing antenatal care and consumption of iron supplementation during pregnancy.

Factors associated with small size at birth in Nepal: further analysis of Nepal Demographic and Health Survey 2011

Background

The global Low Birth Weight (LBW) rate is reported to be 15.5% with more than 95% of these LBW infants being from developing countries. LBW is a major factor associated with neonatal deaths in developing countries. The determinants of low birth weight in Nepal have rarely been studied. This study aimed to identify the factors associated with small size at birth among under-five children.

Methods

Data from the 2011 Nepal Demographic and Health Survey (NDHS) were used. The association between small size at birth and explanatory variables were analysed using Chi-square tests (χ²) followed by logistic regression. Complex Sample Analysis was used to adjust for study design and sampling.

Results

A total of 5240 mother- singleton under five child pairs were included in the analysis, of which 936 (16.0%) children were reported as small size at birth. Of 1922 infants whose birth weight was recorded, 235 (11.5%) infants had low birth weight (<2500 grams). The mean birth weight was 3030 grams (standard deviation: 648.249 grams).

The mothers who had no antenatal visits were more likely (odds ratio (OR) 1.315; 95% confidence interval (CI) (1.042-1.661)) to have small size infants than those who had attended four or more antenatal visits. Mothers who lived in the Far-western development region were more likely to have (OR 1.698; 95% CI (1.228-2.349)) small size infants as compared to mothers from the Eastern development region. Female infants were more likely (OR 1.530; 95% CI (1.245-1.880)) to be at risk of being small than males.

Conclusion

One in every six infants was reported to be small at birth. Attendance of antenatal care programs appeared to have a significant impact on birth size. Adequate antenatal care visits combined with counselling and nutritional supplementation should be a focus to reduce adverse birth outcomes such as small size at birth, especially in the geographically and economically disadvantaged areas such as Far-western region of Nepal.

Exclusive breastfeeding practices in relation to social and health determinants: a comparison of the 2006 and 2011 Nepal Demographic and Health Surveys

BACKGROUND

Exclusive breastfeeding (EBF) for the first six months can have a significant impact on reducing child morbidity and mortality rates. The objective of this study was to compare the determinants of and trends in EBF in infants ≤ 5 months from the 2006 and 2011 Nepal Demographic and Health Surveys.

METHODS

Data on mother/infant pairs having infants of ≤ 5 months from 2006 (n = 482) and 2011 (n = 227) were analysed. The EBF rate, determinants of EBF, and changes in EBF rates between the 2006 and 2011 surveys were examined using Chi-square test and multiple logistic regression.

RESULTS

The EBF rate for ≤ 5 months in 2006 was 53.2% (95% CI, 47.1%-59.3%) and 66.3% (95% CI, 56.6%-74.8%) in 2011. In 2006, infants ≤ 4 months were more likely to be EBF [(aOR) 3.086, 95% CI (1.825-5.206)] after controlling for other factors. A geographic effect was also found in this study, with the odds of EBF higher for infants from the Hills [aOR 3.426, 95% CI (1.568-7.474)] compared to those form the mountains. The odds of EBF were also higher for higher order infants [aOR 1.968, 95% CI (1.020-3.799)]. Infants whose fathers belonged to non-agricultural occupation were less likely to be provided with EBF. Infants who were delivered in the home were more likely to experience EBF [aOR 1.886; 95% CI (1.044-3.407)]. In 2011, infants of age ≤ 4 months were more likely [aOR 4.963, 95% CI (2.317-10.629)] to have been breastfed exclusively. While there was an increase in the EBF rate between 2006 and 2011 surveys, the significant increase was noticed only among the infants of four months [32.0%; 95% CI (19.9%-47.0%)] in 2006 to [65.5%; 95% CI (48.1-79.6)] in 2011.

CONCLUSIONS

The proportion of infants who were EBF was higher in Nepal in 2011survey compared to 2006 survey; however, this is still below the recommended WHO target of 90%. Infant's age, ecological region, parity and father's occupation were associated with EBF. Further interventions such as peer counselling, antenatal counselling and involving fathers in the community to promote EBF in Nepal are recommended.

Determinants of complementary feeding practices among Nepalese children aged 6-23 months: findings from Demographic and Health Survey 2011

Background

The adoption of inappropriate feeding practices is one of the reasons for under nutrition in Nepal and elsewhere. The objective of this study was to describe the rate of and identify the factors associated with providing the World Health Organization (WHO) recommended infant feeding practices of minimum dietary diversity, minimum meal frequency and minimum acceptable diet in Nepal amongst young children between 6–23 months in 2011.

Methods

Data from Nepal Demographic and Health Survey (NDHS) 2011 was used. Prevalence of minimum dietary diversity, minimum meal frequency and minimum acceptable diet was obtained by using descriptive statistics. A Chi-square test (χ²) followed by multiple logistic regression analyses were used to determine the adjusted effect of potential factors on the outcome variables.

Results

Of the 698 children aged 6–23 months; while 535 (76.6%) received the minimum meal frequency, only 212 (30.4%) children received the minimum dietary diversity, and 185 (26.5%) received an acceptable diet. Children of older mothers (>35 years); educated mothers and fathers; and mothers from all the development regions except the Mid-western region were more likely to have been provided with the recommended dietary diversity. Children of mothers who had attended ≥4 antenatal visits and who lived in the Eastern region were more likely to provide their child with the recommended meal frequency. Children of mothers, who attended ≥ 4 antenatal visits, were educated and whose fathers had at least a secondary education were more likely to meet the recommended acceptable diet standards.

Conclusion

Young children aged less than two years in Nepal are at risk for not meeting the WHO recommended infant feeding standards given that only about one in three children were provided with the recommended dietary diversity and acceptable diet. This finding suggests that the majority of children are at risk of under nutrition. An appropriate mix of health education and food supplements could be a feasible option for Nepal to improve the number of children who meet the recommended infant feeding guidelines, reduce under nutrition and improve the survival rates of young children.

Factors associated with the introduction of prelacteal feeds in Nepal: findings from the Nepal Demographic and Health Survey 2011

Background

A prelacteal feed is any food except mother’s milk provided to a newborn before initiating breastfeeding. Prelacteal feeding is a major barrier to exclusive breastfeeding. It is a prevalent practice in Nepal. Little is known about the factors associated with providing prelacteal feeds to the Nepalese newborn. This study explored the factors associated with providing prelacteal feeds to children under three years in Nepal using the Nepal Demographic and Health Survey (NDHS) 2011.

Methods

This study utilised the NDHS 2011 child dataset which is a nationally representative study. The rates of providing prelacteal feeds were reported as a proportion. Complex Sample Analysis method was used to account for the cluster design and sample weight of the study. Chi-square tests and multiple logistic regression were used to analyse the factors associated with providing prelacteal feeds.

Results

A sample of 3948 mothers were included in the study. A total of 841 [26.5% (95% CI: 23.1%–30.3%)] weighted proportion) of mothers reported of providing prelacteal feeds to their newborn infants. Plain water (n = 75), sugar/glucose (n = 35), gripe water (n = 3), sugar/salt solution (n = 3), fruit juice (n = 3), infant formula (n = 96), tea (n = 3) and other milk other than breast milk (n = 556) were some of the types of prelacteal feeds reported. The multiple regression analysis showed that the mothers who had no education, were not working, were from the middle wealth quintile, who had not attended four antenatal care visits, were first time mothers and who were from the Terai/Plain region were more likely to provide prelacteal feeds.

Conclusions

Given that one in four infants were provided with prelacteal feeds, there is a need to implement breastfeeding promotion programs to increase the practice of exclusive breastfeeding and reduce prelacteal feeding practices. Breastfeeding counseling at antenatal clinics and peer support for exclusive breastfeeding should be included as part of breastfeeding promotion programs. Mobilisation of female community health volunteers for peer counseling is also a feasible option for Nepal.

A magnetohydrodynamic model of solar wind interaction with asteroid gaspra

The solar wind response to a small-sized magnetized body is modeled on the basis of a two-dimensional magnetohydrodynamic (MHD) plasma description including Hall current corrections (Hall-MHD model). Basic features of the magnetic signatures observed near Galileo's closest approach to asteroid Gaspra are reproduced, assuming Gaspra's magnetic dipole momentto be of the order of 10(14) ampere.meters squared and tilted to the solar wind flow direction at an angle of about 45 degrees .

Procedure for rapid isolation of photosynthetic reaction centers using cytochrome c affinity chromatography

Horse heart cytochrome c linked to Sepharose 4B is used to purify reaction centers from Rhodopseudomonas sphaeroides R-26. This procedure allows for an initial recovery of 80-90% of the bacterial reaction centers present in chromatophore membranes. High purity reaction centers (A(280)/A(802) < 1.30) can be obtained with a 30% recovery. Reaction centers from wild-type Rps. sphaeroides and Rps. capsulata also bind to a cytochrome c column. Cytochrome c affinity chromatography can also be used to isolate photosystem I complexes from spinach chloroplasts.

Labeling quinone-binding sites in photosynthetic reaction centers: A 38-kilodalton protein associated with the acceptor side of photosystem II

2-Acetoxymethyl-1,4-naphthoquinone (2-AcOMeNQ) binds with rapid kinetics and high affinity to the primary quinone Q(A) site of reaction centers from Rhodopseudomonas capsulata. Binding of 2-AcOMeNQ fully restores electron-transfer activity with kinetics that is similar, but not identical, to that seen with ubiquinone-50. When bound at the Q(A) site, 2-AcOMeNQ preferentially labels the L subunit. This preference suggests that 2-AcOMeNQ labels primarily the region of a quinone-binding site that is close to the first isoprenoid unit of the side chain, which is expected from the location and structure of the reaction region of the molecule. In photosystem II particles from Synechococcus sp., 2-AcOMeNQ primarily labels two polypeptides with apparent molecular masses of 38 and 19 kDa. Labeling of only the 38-kDa polypeptide is sufficiently sensitive to 3-(3,4-dichlorophenyl)-1,1-dimethylurea (DCMU) to conclude that it is involved in binding quinones on the acceptor side of photosystem II. Although we have not yet identified the 38-kDa protein, its properties suggest that it is the D2 protein. From the DCMU-sensitive labeling and from homologies to functionally important regions of the bacterial reaction-center subunits, we propose that the 38-kDa protein is intimately involved in binding the cofactors that mediate primary photochemistry.

Photooxidation of antenna bacteriochlorophyll in chromatophores from carotenoidless mutant Rhodopseudomonas sphaeroides and the attendant loss of dimeric exciton interaction

Intense continuous illumination of purified chromatophores from carotenoidless mutant Rhodopseudomonas sphaeroides results in progressive photooxidative loss of the near infrared absorption band near 860 nm assigned to antenna bacteriochlorophyll. The quantum yield of this reaction is low, approximately 1.7 x 10(-5). The loss in near infrared absorption is accompanied by a proportional shift in the absorption maximum to shorter wavelengths. The double circular dichroism feature in the near infrared decreases at a faster rate than does the absorbance. These results are explained by a model in which the antenna bacteriochlorophyll, initially associated as dimers (lambda(max) = 860.2 nm), is progressively converted to the monomeric state (lambda(max) = 851.9 nm). The wavelength shift is attributed to disruption of exciton coupling in the dimer. Acetone/methanol extraction indicates that the maximum molar extinction coefficients of the dimer and monomer do not differ by more than 4%. The occurrence of an absorption maximum at 852 nm for monomeric bacteriochlorophyll in a protein complex demonstrates that it is not necessary to invoke aggregation of the chromophores as the origin of the shift from 770 nm in typical organic solvents.

Montelukast does not prevent reactive airway disease in young children hospitalized for RSV bronchiolitis

AIM

To evaluate the long-term effect of montelukast on symptoms of cough and wheeze following RSV bronchiolitis.

METHODS

Fifty eight patients (aged < or = 24 months) hospitalized with a first episode of RSV bronchiolitis were enrolled in this double blind prospective randomized trial comparing montelukast (n = 31) vs placebo (n = 27).

RESULTS

During the 3-month treatment period, there were no statistical significant differences between the two groups for symptom-free days and nights (48.5 [interquartile range 33.0.0-66.0] for montelukast vs 57.0 [29.0-71.0] for placebo p = 0.415) nor disease-free days and nights (44.5 days [26.0-54.0] vs 53.0 [22.3-71.0]; p = 0.266). During the 1 year follow-up, there were 41 exacerbations in the montelukast group vs 54 exacerbations in the placebo group (p = 0.57). Time to first exacerbation was not different. Number of unscheduled visits and need to start inhaled steroids were comparable in the two groups.

CONCLUSION

Treatment with montelukast after hospital admission for RSV bronchiolitis in children younger than 2 years of age did not reduce symptoms of cough and wheeze. We cannot exclude that a subgroup of children may, however, benefit from this treatment.

Molecular Orientation in Quantasomes: III. A Flow Dichroism Apparatus and Its Application to the Study of the Structure of Spinach Quantasomes

A new apparatus is described for measuring dichroism spectra with very high sensitivity for macromolecular structures oriented in a hydrodynamic gradient. The method has been used to explore the dichroism spectrum of quantasome aggregates isolated from spinach chloroplasts. The quantasome flow dichroism resembles qualitatively that observed previously using electric field orientation, in that a pigment absorbing at wavelengths longer than 680 mmu exhibits appreciably greater dichroism than those absorbing at shorter wavelengths. It is shown that the absorption oscillator for this long wavelength absorption lies parallel to the streamlines of the sheer gradient, which is assumed to be the direction in which the planes of the chloroplast lamellae are oriented.

Palliative Sedierung

Terminal illnesses can cause distressing symptoms such as severe pain, mental confusions, feelings of suffocation, and agitation. Despite skilled palliative care in some cases these symptoms may not respond to standard interventions. After all other means to provide comfort and relief to a dying patient have been tried and are unsuccessful, clinical caregivers and patients can consider palliative sedation. Sedation in the context of palliative medicine is the monitored use of medications to induce varying degrees of unconsciousness to bring about a state of decreased or absent awareness in order to relieve the burden of otherwise refractory suffering. Palliative sedation is not intended to cause death or shorten life. The patient and family should agree with plans for palliative sedation. Because cases involving palliative sedation are emotionally stressful, the patient, family, and health care workers can all benefit from talking about the complex medical, ethical, and emotional issues they raise.

Calcium influences cellular and extracellular product formation during biofilm-associated growth of a marine Pseudoalteromonas sp

Bacteria undergo a variety of physiological changes following a switch from planktonic growth to surface-associated biofilm growth. Here, it is shown that biofilm development of a marine isolate, Pseudoalteromonas sp. 1398, results in global changes in its cytosolic and extracellular proteomes. Calcium influences these proteome responses, and affects the amount of surface-associated biomass and extracellular matrix material produced by Pseudoalteromonas sp. 1398. Four extracellular proteins, characterized by N-terminal sequencing, showed increased abundances, while one protein, flagellin, showed reduced abundance at higher [Ca2+]. Immunoblotting and transmission-electron-microscopy analysis confirmed that higher [Ca2+] and surface-associated growth results in the repression of flagella production. Two-dimensional gel electrophoresis (2DGE) studies combined with cluster analysis of global proteome responses demonstrated that Ca2+ had a greater regulatory influence on Pseudoalteromonas sp. growing in biofilms than on planktonic cultures. Approximately 22 % of the total cytosolic proteins resolved by 2DGE had differing abundances in response to a switch from planktonic growth to surface-associated growth when the cells were cultivated in 1 mM Ca2+. At higher [Ca2+] this number increased to 38 %. Fifteen cellular proteins that were differentially expressed in response to biofilm growth and/or Ca2+ were analysed by N-terminal sequencing and/or MS/MS. These proteins were identified as factors involved in cellular metabolic functions, putative proteases and transport proteins, although there were several proteins that had not been previously characterized. These results indicate that Ca2+ causes global changes in matrix material, as well as in cellular and extracellular protein profiles of Pseudoalteromonas sp. 1398. These changes are more pronounced when the bacterium grows in biofilms than when it grows in planktonic culture.

Direct reconstruction of kinetic parameter images from dynamic PET data

Our goal in this paper is the estimation of kinetic model parameters for each voxel corresponding to a dense three-dimensional (3-D) positron emission tomography (PET) image. Typically, the activity images are first reconstructed from PET sinogram frames at each measurement time, and then the kinetic parameters are estimated by fitting a model to the reconstructed time-activity response of each voxel. However, this "indirect" approach to kinetic parameter estimation tends to reduce signal-to-noise ratio (SNR) because of the requirement that the sinogram data be divided into individual time frames. In 1985, Carson and Lange proposed, but did not implement, a method based on the expectation-maximization (EM) algorithm for direct parametric reconstruction. The approach is "direct" because it estimates the optimal kinetic parameters directly from the sinogram data, without an intermediate reconstruction step. However, direct voxel-wise parametric reconstruction remained a challenge due to the unsolved complexities of inversion and spatial regularization. In this paper, we demonstrate and evaluate a new and efficient method for direct voxel-wise reconstruction of kinetic parameter images using all frames of the PET data. The direct parametric image reconstruction is formulated in a Bayesian framework, and uses the parametric iterative coordinate descent (PICD) algorithm to solve the resulting optimization problem. The PICD algorithm is computationally efficient and is implemented with spatial regularization in the domain of the physiologically relevant parameters. Our experimental simulations of a rat head imaged in a working small animal scanner indicate that direct parametric reconstruction can substantially reduce root-mean-squared error (RMSE) in the estimation of kinetic parameters, as compared to indirect methods, without appreciably increasing computation.

Characterization of nutrient-induced dispersion in Pseudomonas aeruginosa PAO1 biofilm

The processes associated with early events in biofilm formation have become a major research focus over the past several years. Events associated with dispersion of cells from late stage biofilms have, however, received little attention. We demonstrate here that dispersal of Pseudomonas aeruginosa PAO1 from biofilms is inducible by a sudden increase in carbon substrate availability. Most efficient at inducing dispersal were sudden increases in availability of succinate > glutamate > glucose that led to approximately 80% reductions in surface-associated biofilm biomass. Nutrient-induced biofilm dispersion was associated with increased expression of flagella (fliC) and correspondingly decreased expression of pilus (pilA) genes in dispersed cells. Changes in gene expression associated with dispersion of P. aeruginosa biofilms were studied by using DNA microarray technology. Results corroborated proteomic data that showed gene expression to be markedly different between biofilms and newly dispersed cells. Gene families that were upregulated in dispersed cells included those for flagellar and ribosomal proteins, kinases, and phage PF1. Within the biofilm, genes encoding a number of denitrification pathways and pilus biosynthesis were also upregulated. Interestingly, nutrient-induced dispersion was associated with an increase in the number of Ser/Thr-phosphorylated proteins within the newly dispersed cells, and inhibition of dephosphorylation reduced the extent of nutrient-induced dispersion. This study is the first to demonstrate that dispersal of P. aeruginosa from biofilms can be induced by the addition of simple carbon sources. This study is also the first to demonstrate that dispersal of P. aeruginosa correlates with a specific dispersal phenotype.

Biofilms as complex differentiated communities

Prokaryotic biofilms that predominate in a diverse range of ecosystems are often composed of highly structured multispecies communities. Within these communities metabolic activities are integrated, and developmental sequences, not unlike those of multicellular organisms, can be detected. These structural adaptations and interrelationships are made possible by the expression of sets of genes that result in phenotypes that differ profoundly from those of planktonically grown cells of the same species. Molecular and microscopic evidence suggest the existence of a succession of de facto biofilm phenotypes. We submit that complex cell-cell interactions within prokaryotic communities are an ancient characteristic, the development of which was facilitated by the localization of cells at surfaces. In addition to spatial localization, surfaces may have provided the protective niche in which attached cells could create a localized homeostatic environment. In a holistic sense both biofilm and planktonic phenotypes may be viewed as integrated components of prokaryote life.

A comparison of two different doses of ketamine with midazolam and midazolam alone as oral preanaesthetic medication on recovery after sevoflurane anaesthesia in children

BACKGROUND

This investigation prospectively evaluated the effect of oral premedication of two different doses of ketamine with midazolam and midazolam alone on the recovery of children after sevoflurane anaesthesia.

METHODS

In a randomized, double-blind study, 79 children (aged 1-8 years, ASA physical status I or II) were assigned to receive one of three premedications in a volume of 0.5 ml x kg(-1): group 1 received midazolam 0.5 mg x kg(-1) (MD); group 2 received midazolam 0.5 mg x kg(-1) with ketamine 1.8 mg x kg(-1) (MK-1); and group 3 received midazolam 0.5 mg x kg(-1) with ketamine 3 mg x kg(-1) (MK-2). The reactions of the children during administration were noted. Anaesthesia was induced by facemask with incremental sevoflurane administration. All children received alfentanil (15 micro g x kg(-1)). Tracheal intubation was facilitated by mivacurium (0.2 mg x kg(-1)). Anaesthesia was maintained with sevoflurane and an additional dose of alfentanil, if necessary. During recovery, the time interval between discontinuation of anaesthesia and arousal (spontaneous ventilation, extubation) were recorded.

RESULTS

Emergence (spontaneous ventilation, extubation) and recovery times (discharge, Aldrete score=9) did not differ significantly between groups (P=0.24, P=0.59 and P=0.145, respectively).

CONCLUSIONS

The combination of midazolam and ketamine as oral preanaesthetic medication did not significantly affect the recovery time of children after sevoflurane anaesthesia.

Regulation of the embryonic cell proliferation by Drosophila cyclin D and cyclin E complexes

Cell proliferation during Drosophila development occurs in a well known spatial and temporal pattern which can readily be studied in vivo. The cells which form the larval epidermis exit from the cell division cycle during embryogenesis after the 16th round of mitosis when they enter for the first time into a G1/0 phase. We are interested in the mechanistic basis of this cell proliferation arrest. We have shown that the arrest requires the down-regulation of cyclin E/Cdk2 activity by inhibition of cyclin E expression and parallel activation of Dacapo/p27 expression. In addition, up-regulation of Fizzy-related is observed and is required for inhibition of Cdk1 activity. Do these processes result from the down-regulation of D-type cyclin/Cdk complexes? Extensive evidence from mammalian cells, and in particular from tumour cells has suggested that these complexes act as master regulators of cell proliferation upstream of cyclin E. Our genetic analyses indicate that Drosophila cyclin D/Cdk4, which interacts with the Drosophila Rb family member as expected, does not play an essential role in the regulation of cell proliferation.

Does bungee jumping release S-100B protein?

The S-100B protein is a recognised indicator of traumatic brain damage, but the impact threshold at which S-100B is released into serum still remains unknown. The aim of the study was to investigate whether moderate shear forces are able to release S-100B into serum in people who did a bungee jump. Eleven healthy probands jumped from a height of 50 microm and were exposed to an acceleration of about 2.8 g. Blood samples were drawn before the jump, immediately after and 71 min (mean) after the jump. The initial serum values of S-100B of all probands were normal (mean 0.22 microg/l). Also the serum values directly after and 71-min (mean) after the jump showed no increase of S-100B (0.22 microg/l and 0.23 microg/l, mean). This finding indicates that a moderate acceleration and deceleration force to the brain does not activate the release of the protein S-100B into the serum.

Hematopoietic progenitor kinase 1 associates physically and functionally with the adaptor proteins B cell linker protein and SLP-76 in lymphocytes

B cell linker protein (BLNK) is a SLP-76-related adaptor protein essential for signal transduction from the BCR. To identify components of BLNK-associated signaling pathways, we performed a phosphorylation-dependent yeast two-hybrid analysis using BLNK probes. Here we report that the serine/threonine kinase hematopoietic progenitor kinase 1 (HPK1), which is activated upon antigen-receptor stimulation and which has been implicated in the regulation of MAP kinase pathways, interacts physically and functionally with BLNK in B cells and with SLP-76 in T cells. This interaction requires Tyr(379) of HPK1 and the Src homology 2 (SH2) domain of BLNK/SLP-76. Via homology modeling, we defined a consensus binding site within ligands for SLP family SH2 domains. We further demonstrate that the SH2 domain of SLP-76 participates in the regulation of AP-1 and NFAT activation in response to T cell receptor (TCR) stimulation and that HPK1 inhibits AP-1 activation in a manner partially dependent on its interaction with SLP-76. Our data are consistent with a model in which full activation of HPK1 requires its own phosphorylation on tyrosine and subsequent interaction with adaptors of the SLP family, providing a mechanistic basis for the integration of this kinase into antigen receptor signaling cascades.

Characterization of phenotypic changes in Pseudomonas putida in response to surface-associated growth

The formation of complex bacterial communities known as biofilms begins with the interaction of planktonic cells with a surface. A switch between planktonic and sessile growth is believed to result in a phenotypic change in bacteria. In this study, a global analysis of physiological changes of the plant saprophyte Pseudomonas putida following 6 h of attachment to a silicone surface was carried out by analysis of protein profiles and by mRNA expression patterns. Two-dimensional (2-D) gel electrophoresis revealed 15 proteins that were up-regulated following bacterial adhesion and 30 proteins that were down-regulated. N-terminal sequence analyses of 11 of the down-regulated proteins identified a protein with homology to the ABC transporter, PotF; an outer membrane lipoprotein, NlpD; and five proteins that were homologous to proteins involved in amino acid metabolism. cDNA subtractive hybridization revealed 40 genes that were differentially expressed following initial attachment of P. putida. Twenty-eight of these genes had known homologs. As with the 2-D gel analysis, NlpD and genes involved in amino acid metabolism were identified by subtractive hybridization and found to be down-regulated following surface-associated growth. The gene for PotB was up-regulated, suggesting differential expression of ABC transporters following attachment to this surface. Other genes that showed differential regulation were structural components of flagella and type IV pili, as well as genes involved in polysaccharide biosynthesis. Immunoblot analysis of PilA and FliC confirmed the presence of flagella in planktonic cultures but not in 12- or 24-h biofilms. In contrast, PilA was observed in 12-h biofilms but not in planktonic culture. Recent evidence suggests that quorum sensing by bacterial homoserine lactones (HSLs) may play a regulatory role in biofilm development. To determine if similar protein profiles occurred during quorum sensing and during early biofilm formation, HSLs extracted from P. putida and pure C(12)-HSL were added to 6-h planktonic cultures of P. putida, and cell extracts were analyzed by 2-D gel profiles. Differential expression of 16 proteins was observed following addition of HSLs. One protein, PotF, was found to be down-regulated by both surface-associated growth and by HSL addition. The other 15 proteins did not correspond to proteins differentially expressed by surface-associated growth. The results presented here demonstrate that P. putida undergoes a global change in gene expression following initial attachment to a surface. Quorum sensing may play a role in the initial attachment process, but other sensory processes must also be involved in these phenotypic changes.

Attenuated total reflection design for in situ FT-IR spectroelectrochemical studies

A versatile spectroelectrochemical apparatus is introduced to study the changes in IR spectra of organic and inorganic compounds upon oxidation or reduction. The design is based on an attenuated total reflection device, which permits the study of a wide spectral range of 16,700 (600 nm)-250 cm(-1), with a small opaque region of 2250-1900 cm(-1). In addition, an IR data collection protocol is introduced to deal with electrochemically nonreversible background signals. This method is tested with ferrocene in acetonitrile; concentrations as low as 1 mM produce results that agree with those in the literature.

Absence of Mn-centered oxidation in the S(2) --> S(3) transition: implications for the mechanism of photosynthetic water oxidation

A key question for the understanding of photosynthetic water oxidation is whether the four oxidizing equivalents necessary to oxidize water to dioxygen are accumulated on the four Mn ions of the oxygen-evolving complex (OEC), or whether some ligand-centered oxidations take place before the formation and release of dioxygen during the S(3) --> [S(4)] --> S(0) transition. Progress in instrumentation and flash sample preparation allowed us to apply Mn Kbeta X-ray emission spectroscopy (Kbeta XES) to this problem for the first time. The Kbeta XES results, in combination with Mn X-ray absorption near-edge structure (XANES) and electron paramagnetic resonance (EPR) data obtained from the same set of samples, show that the S(2) --> S(3) transition, in contrast to the S(0) --> S(1) and S(1) --> S(2) transitions, does not involve a Mn-centered oxidation. On the basis of new structural data from the S(3)-state, manganese mu-oxo bridge radical formation is proposed for the S(2) --> S(3) transition, and three possible mechanisms for the O-O bond formation are presented.

Spectroscopic study of the light-harvesting protein C-phycocyanin associated with colorless linker peptides

C-Phycocyanin (PC) trimers associated with linker polypeptides were isolated from the phycobilisome (PBS) rods of Synechococcus sp. PCC 7002. LXY refers to a linker polypeptide (L) having an apparent mass of Y kDa, located at position X in the phycobilisome where X can be R (rod), C (core) or RC (rod-core junction). Measurements of the absorption, fluorescence and excitation anisotropy of PC trimer, PC.LR32.3 and PC.LRC28.5 complexes document the spectroscopic modulation of each linker polypeptide on the PC chromophores. The difference spectra between the PC trimer and the PC-linker complexes show that although the effect induced by the linker polypeptides is qualitatively similar in behavior, the extent of the modulation is greater in PC.LRC28.5. Measurements taken at 77 K show that a red-wavelength component of the PC trimer absorption-fluorescence spectra is the target of the linker's influence and that this component is altered to a greater extent by LRC28.5. In addition the 77 K absorbance of the PC trimer resolves band features that are consistent with an excitonic coupling interaction between neighboring alpha 84 and beta 84 chromophores. These band features are also evident in the absorbance of PC.LR32.3 but are absent in PC.LRC28.5 indicating that LRC28.5 may be perturbing the coupling interaction established in the PC trimer alpha 84-beta 84 chromophore pairs. Structurally, the linker polypeptide should disrupt the C3 symmetry in the central cavity of the associated phycobiliprotein and this asymmetric interaction should serve to guide the transfer of excitation energy along PBS rods toward the core elements.

High-resolution X-ray spectroscopy of rare events: a different look at local structure and chemistry

The combination of large-acceptance high-resolution X-ray optics with bright synchrotron sources permits quantitative analysis of rare events such as X-ray fluorescence from very dilute systems, weak fluorescence transitions or X-ray Raman scattering. Transition-metal Kbeta fluorescence contains information about spin and oxidation state; examples of the characterization of the Mn oxidation states in the oxygen-evolving complex of photosystem II and Mn-consuming spores from the marine bacillus SG- are presented. Weaker features of the Kbeta spectrum resulting from valence-level and 'interatomic' ligand to metal transitions contain detailed information on the ligand- atom type, distance and orientation. Applications of this spectral region to characterize the local structure of model compounds are presented. X-ray Raman scattering (XRS) is an extremely rare event, but also represents a unique technique to obtain bulk-sensitive low-energy (<600 eV) X-ray absorption fine structure (XAFS) spectra using hard (approximately 10 keV) X-rays. A photon is inelastically scattered, losing part of its energy to promote an electron into an unoccupied level. In many cases, the cross section is proportional to that of the corresponding absorption process yielding the same X-ray absorption near-edge structure (XANES) and extended X-ray absorption fine structure (EXAFS) features. XRS finds application for systems that defy XAFS analysis at low energies, e.g. liquids or highly concentrated complex systems, reactive compounds and samples under extreme conditions (pressure, temperature). Recent results are discussed.

[Brachial plexus. Long lasting neurological deficit following interscalene blockade of the brachial plexus]

An interscalene block of the brachial plexus was combined with general anaesthesia for repair of a complex chronic lesion of the shoulder. The localisation of the plexus with electro-stimulation and the injection of Bupivacain 0.5% were accomplished easily and without painful sensations. 48 hours later the block was still partially present. Paraesthesia and a sensory and motor innervation deficit affected mainly the dorsal fascicle, but also areas innervated by the median and lateral fascicles. The deficit did not completely disappear for 18 month. The cause could have been due to direct traumatisation during blockade or operation, toxic action of the injected substance (Bupivacain 0.5%, 30 ml), distension of the plexus, a cervical syndrome or an aseptic plexitis, although a definite determination is not possible. However, the pattern of the lesion and the lack of pain during localisation of the plexus and injection favour traumatisation during the acromioplasty.