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Prior work suggests that substance-dependent mothers insensitively respond to their child's emotional needs, which can increase children's risk for psychopathology. However, the mechanisms and processes underlying these associations remain unclarified. Mothers' insensitivity to children's distress is an especially unique predictor of child maladjustment, yet no study has examined whether or how different types of insensitivity to child distress uniquely affect the development of internalizing problems in children of alcohol-dependent mothers. To bridge these gaps, this study examined longitudinal mediational pathways between maternal alcohol dependence symptoms, 2 types of maternal insensitivity to child distress (disengagement and intrusiveness), and 2 types of child internalizing symptoms (affective and anxiety problems) in a majority Black and Latinx sample of young children (Mage = 2.14 years) and their mothers. Results revealed that maternal disengagement mediated associations between maternal alcohol dependence symptoms and child internalizing problems such that alcohol dependence predicted increased disengagement to children's distress, which subsequently predicted increases in children's affective problems. Maternal alcohol dependence symptoms were not associated with intrusiveness to child distress; however, increased intrusiveness predicted later increases in child anxiety problems. Findings support a differentiated approach to studying maternal insensitivity to child distress, specifically indicating that mothers with alcohol dependence symptoms may be more or less likely to display certain types of insensitivity to child distress which may differentially influence children's risk for internalizing problems. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background Prophylactic intra-aortic balloon counterpulsation (IABC) is commonly used in selected patients undergoing coronary artery bypass graft (CABG) surgery, but definitive evidence is lacking. The aim of the multicentre PINBALL Pilot randomised controlled trial (RCT) was to assess the feasibility of performing a definitive trial to address this question. Methods Patients listed for CABG surgery with impaired left ventricular function and at least one additional risk factor for postoperative low cardiac output syndrome were eligible for inclusion if the treating surgical team was uncertain as to the benefit of prophylactic IABC. The primary outcome of feasibility was based on exceeding a pre-specified recruitment rate, protocol compliance and follow-up. Results The recruitment rate of 0.5 participants per site per month did not meet the feasibility threshold of two participants per site per month and the study was stopped early after enrolment of 24 out of the planned sample size of 40 participants. For 20/24 (83%) participants, preoperative IABC use occurred according to study assignment. Six (6)-month follow-up was available for all enrolled participants, [IABC 1 death (8%) vs. control 1 death (9%), p = 0.95]. Conclusion The PINBALL Pilot recruitment rate was insufficient to demonstrate feasibility of a multicentre RCT of prophylactic IABC in high risk patients undergoing CABG surgery.

Funding: This work was supported by the EPSRC (grants EP/R004471/1 and EP/S027432/1). Supporting data for this publication is available at https://doi.org/10.17863/CAM.62937. Crowdwork can enable invaluable opportunities for people with disabilities, not least the work fexibility and the ability to work from home, especially during the current Covid-19 pandemic. This paper investigates how engagement in crowdwork tasks is affected by individual disabilities and the resulting implications for HCI. We first surveyed 1,000 Amazon Mechanical Turk (AMT) workers to identify demographics of crowdworkers who identify as having various disabilities within the AMT ecosystem-including vision, hearing, cognition/mental, mobility, reading and motor impairments. Through a second focused survey and follow-up interviews, we provide insights into how respondents cope with crowdwork tasks. We found that standard task factors, such as task completion time and presentation, often do not account for the needs of users with disabilities, resulting in anxiety and a feeling of depression on occasion. We discuss how to alleviate barriers to enable effective interaction for crowdworkers with disabilities. Publisher PDF

Background A positive circumferential resection margin (CRM) has been associated with higher rates of locoregional recurrence and worse survival in oesophageal cancer. The aim of this study was to establish if clinicopathological and radiological variables might predict CRM positivity in patients who received neoadjuvant chemotherapy before surgery for oesophageal adenocarcinoma. Methods Multivariable analysis of clinicopathological and CT imaging characteristics considered potentially predictive of CRM was performed at initial staging and following neoadjuvant chemotherapy. Prediction models were constructed. The area under the curve (AUC) with 95% confidence intervals (c.i.) from 1000 bootstrapping was assessed. Results A total of 223 patients were included in the study. Poor differentiation (odds ratio (OR) 2·84, 95 per cent c.i. 1·39 to 6·01) and advanced clinical tumour status (T3–4) (OR 2·93, 1·03 to 9·48) were independently associated with an increased CRM risk at diagnosis. CT‐assessed lack of response (stable or progressive disease) following chemotherapy independently corresponded with an increased risk of CRM positivity (OR 3·38, 1·43 to 8·50). Additional CT evidence of local invasion and higher CT tumour volume (14 cm3) improved the performance of a prediction model, including all the above parameters, with an AUC (c‐index) of 0·76 (0·67 to 0·83). Variables associated with significantly higher rates of locoregional recurrence were pN status (P = 0·020), lymphovascular invasion (P = 0·007) and poor response to chemotherapy (Mandard score 4–5) (P = 0·006). CRM positivity was associated with a higher locoregional recurrence rate, but this was not statistically significant (P = 0·092). Conclusion The presence of advanced cT status, poor tumour differentiation, and CT‐assessed lack of response to chemotherapy, higher tumour volume and local invasion can be used to identify patients at risk of a positive CRM following neoadjuvant chemotherapy., A positive circumferential resection margin (CRM) has been shown to be an adverse prognostic indicator after oesophagectomy for adenocarcinoma. Clinical tumour status, tumour volume, poor differentiation, lack of response following chemotherapy and radiological assessment of invasion can be used to predict CRM positivity in oesophageal adenocarcinoma. CRM assessment is still important

Background: Combined transorbital and transnasal endoscopic surgery for access to the skull base has contributed to the gradual expansion of the remit of the endoscopic skull base surgeon. Method: We present our technique of Silastic® sheet aided combined transorbital and transnasal endoscopic resection of anterior skull base malignancies, with a description of surgical technique and our method of safeguarding the orbital contents with appropriate suggested indications. Results: Patient underwent resection of non-intestinal type adenocarcinoma. There were no immediate or delayed postoperative complications related to transorbital access. Conclusion: In cases where tumour infiltrates medial orbital wall and there is an indication to remove the lamina papyracea and/or periorbita, we find the initial transorbital approach advantageous to find a dissection plane in healthy tissue and to achieve partial devascularisation of tumour by cauterisation of anterior and posterior ethmoidal artery. Moreover, this approach can be combined with intraorbital placement of Silastick sheet to prevent a prolapse of orbital contents into the nasal cavity during transnasal resection which may lead to its damage.

Background Tumour recurrence following oesophagectomy for oesophageal cancer is common despite neoadjuvant treatment. Understanding patterns of recurrence and risk factors associated with locoregional and systemic recurrence might influence future treatment strategies. Methods This was a cohort study involving patients undergoing resection for adenocarcinoma or squamous cell carcinoma of the oesophagus between 2000 and 2014. Clinicopathological factors associated with locoregional and systemic recurrence were analysed using multivariable logistic regression to determine odds ratios (ORs) and 95 per cent confidence intervals. Results Some 698 patients were identified. Lymphovascular invasion (OR 2·09, 95 per cent c.i. 1·18 to 3·71) and preoperative stenting (OR 3·70, 1·34 to 10·23) were independent risk factors for isolated locoregional recurrence. Pathological nodal disease in patients with pT1-2 (pN1: OR 2·72, 1·35 to 5·48; pN2-3: OR 5·00, 2·35 to 10·66) or pT3-4 (pN1: OR 3·03, 1·51 to 6·07; pN2-3: OR 5·75, 3·15 to 10·49) disease predisposed to systemic recurrence. Poor or no response to chemotherapy was also an independent risk factor for isolated systemic recurrence (OR 1·85, 1·05 to 3·26). A positive resection margin (R1 resection) was not associated with a significantly increased risk of isolated locoregional recurrence (OR 1·37, 0·81 to 2·33). Conclusion These findings confirm that oesophageal adenocarcinoma is frequently a systemic disease. Understanding the key predictors of local and systemic recurrence may facilitate the tailoring of oncological therapies to the individual patient.

Background: Selected adult patients with obstructive sleep apnoea-hypopnea syndrome (OSAHS) may benefit from surgical intervention. At present, the dominant technique for the diagnosis of the anatomical locus of upper airway obstruction during sleep is drug-induced sedation endoscopy (DISE). This technique is widespread, but has generated controversy related to its artificiality. Methodology: We present a technique for the acquisition of high-quality and consistent recordings of snoring sounds, suitable for advanced acoustic analysis and correlation with the findings of DISE. Results: Analysis of the generated recordings demonstrates distinct frequency-domain characteristics of snoring sounds generated by distinct anatomical subsites, for example the soft palate, or tongue base. Conclusions: Supplemental information may potentially be obtained from the waveform of snoring sounds produced by the patient; however, no robust quantitative “assay” has been developed or been clinically validated. This may in part be related to inconsistencies or insufficient quality of the sound data acquired. This novel technique may circumvent these difficulties and permit more advanced analysis techniques with potential clinical applicability.

Summary Purpose The goal of this data challenge was to create a structured dynamic with the following objectives: (1) teach radiologists the new rules of General Data Protection Regulation (GDPR), while building a large multicentric prospective database of ultrasound, computed tomography (CT) and MRI patient images; (2) build a network including radiologists, researchers, start-ups, large companies, and students from engineering schools, and; (3) provide all French stakeholders working together during 5 data challenges with a secured framework, offering a realistic picture of the benefits and concerns in October 2018. Materials and methods Relevant clinical questions were chosen by the Societe Francaise de Radiologie. The challenge was designed to respect all French ethical and data protection constraints. Multidisciplinary teams with at least one radiologist, one engineering student, and a company and/or research lab were gathered using different networks, and clinical databases were created accordingly. Results Five challenges were launched: detection of meniscal tears on MRI, segmentation of renal cortex on CT, detection and characterization of liver lesions on ultrasound, detection of breast lesions on MRI, and characterization of thyroid cartilage lesions on CT. A total of 5,170 images within 4 months were provided for the challenge by 46 radiology services. Twenty-six multidisciplinary teams with 181 contestants worked for one month on the challenges. Three challenges, meniscal tears, renal cortex, and liver lesions, resulted in an accuracy > 90%. The fourth challenge (breast) reached 82% and the lastone (thyroid) 70%. Conclusion Theses five challenges were able to gather a large community of radiologists, engineers, researchers, and companies in a very short period of time. The accurate results of three of the five modalities suggest that artificial intelligence is a promising tool in these radiology modalities.

Background:Nasal obstruction is a common ENT complaint; however, decisions on its management are challenging, with high rates of dissatisfaction following surgery. This study investigated the practice of UK clinicians in the evaluation of nasal patency.Method:Seventy-eight UK-based rhinologists were surveyed at the 2015 British Academic Conference in Otolaryngology.Results:Clinical history and examination are almost universally used to evaluate nasal blockage. The most commonly used test was the nasal misting pattern (73 per cent), followed by peak nasal inspiratory flow (19 per cent). The Sino-Nasal Outcome Test 22 or 23 was utilised by 29 per cent of respondents. Sixty-three per cent of respondents reported that a lack of equipment was the principle reason for not using objective measures, followed by time constraints and a lack of correlation with symptom scores.Conclusion:British clinicians rely on clinical skills to evaluate nasal blockage. There is a desire for a simple, non-invasive device that objectively measures airflow for nasal breathing during physiological resting and correlates with subjective symptom scores.

The purpose of this study was to describe the range of appearances of adrenal phaeochromocytomas on T2-weighted MRI, correlate appearances with histopathology, and quantify the incidence of the previously described hyperintense appearance. The appearance and MR characteristics of 44 phaeochromocytomas were reviewed retrospectively. T2-weighted appearances were grouped: (1) 'classical', homogeneous, high signal intensity, isointense to CSF; (2) homogeneous, isointense or minimally hyperintense to spleen, hypointense to CSF; (3) heterogeneous, marbled appearance; (4) heterogeneous, multiple high signal intensity pockets. All 44 adrenal phaeochromocytomas were well circumscribed, 1.2-15 cm in maximum diameter, with no visual or quantitative signal loss on chemical shift imaging. On T2-weighted MRI 5/44 (11%) had group 1 appearance; 15/44 (34%) group 2, 7/44 (16%) group 3; and 17/44 (39%) group 4. Homogeneous group 1 and 2 lesions were smaller (mean 4.5 cm) than heterogeneous group 3 and 4 lesions (mean 6.3 cm). Increasing MRI heterogeneity correlated pathologically with increasing amounts of haemorrhage, necrosis and fibrosis. No MRI features were predictive of malignancy. Non-functioning phaeochromocytomas were larger than functioning lesions. No size difference was seen between syndrome and sporadic lesions. In this large series we report a wide range of appearances of adrenal phaeochromocytomas on T2-weighted MRI. The previously described classical hyperintense phaeochromocytoma is relatively uncommon.

Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) for peritoneal surface malignancy is associated with a morbidity rate of 30-50% and a mortality rate of 1-10%. Recently, the St George Hospital in Sydney has been commissioned as the Nationally Funded Center for treatment of peritoneal surface malignancy in Australia.The clinical and treatment-related data regarding 140 consecutive patients were prospectively collected. A comparison between the initial 70 patients (Group I) and the subsequent 70 patients (Group II) was performed. Univariate and multivariate analyses were conducted to identify the significant risk factors for moderate to severe morbidity.The hospital mortality was 4%. Sixty-one patients (44%) had moderate morbidity. Twenty-eight patients (20%) experienced severe morbidity. The mean hospital stay was 30 days. Twenty-seven patients (19%) were readmitted after initial discharge for management of delayed complications. The severe morbidity rate reduced from 30% to 10%, and the delayed morbidity rate reduced from 29% to 10%, when comparing Groups I and II. There were also reduced transfusion requirement, duration of operation, and intensive care unit stay. In the multivariate analysis, Group I (vs Group II; P = .005), performing small bowel resection (P = .005), and4 peritonectomy procedures (vsor= 4; P = .013) were the three independent risk factors for severe complications.The study suggests that there is a learning curve associated with this procedure. With accumulated experience in this procedure, an acceptable morbidity rate can be achieved.

In patients with locally advanced rectal cancer, neoadjuvant long course (45-54 Gy in 25-30 fractions) chemoradiotherapy (CRT) may reduce tumour size and result in downstaging. In patients with primary resectable tumour short course (25 Gy in 5 fractions) radiotherapy (SCRT) reduces local recurrence but downstaging the disease or altering tumour size has not been described. We aimed to assess change in tumour size on MRI after SCRT or CRT.Nineteen patients with rectal carcinoma underwent MRI before and after SCRT or CRT. In each case, tumour length and width were documented and number of locoregional lymph nodes recorded. Total mesorectal excision was performed in 15 patients and MR findings correlated with histopathology.Ten patients received SCRT and nine CRT. Tumour length reduced by 19% overall (15% following SCRT, 23% following CRT). Greater than 30% reduction (partial response) in maximum tumour thickness was seen in 4/10 (40%) following SCRT and 5/9 (56%) following CRT.Significant reduction in tumour size can be achieved with preoperative long course CRT and SCRT. This unexpected finding following SCRT has not been previously described.

Objective:To determine the prevalence of thyroid malignancy in the first UK case series of patients with incidentally detected thyroid lesions on 18F-fluorodeoxyglucose positron emission tomography imaging.Methods:A total of 235 patients were evaluated with 18F-fluorodeoxyglucose positron emission tomography imaging. Incidental focal uptake in the thyroid gland was identified in nine patients (3.8 per cent). A retrospective review of their case notes was conducted.Results:The rate of malignancy was 55 per cent. The mean and standard deviation of the maximum standardised uptake value was 13.1 ± 7.3 in those patients with malignancy and a nodule identified as positive on positron emission tomography. This value was 2.8 ± 1.2 in those patients without malignancy but with a nodule identified as positive on positron emission tomography (p = 0.01). A palpable thyroid nodule was more likely in those with malignant lesions (p = 0.14).Conclusion:The prevalence of incidental thyroid lesions found on 18F-fluorodeoxyglucose positron emission tomography in patients with other primary malignancies is low, but the incidence of malignancy in these patients is high. Patients with a palpable thyroid nodule, focal uptake on 18F-fluorodeoxyglucose positron emission tomography and an increased maximum standardised uptake value require further investigation.

Imaging has a wide role and numerous applications in the management of urological cancers. These include detection, characterization, staging, delivery of treatment and surveillance of cancer. The main modalities in clinical use include ultrasound, CT, and MRI. The application and the role of the modalities vary with each tumour type. Ultrasound plays an important role in the detection of renal and testicular cancer. Most staging investigations, assessment of treatment response and surveillance is performed using CT for renal, testicular and advanced bladder and prostate cancer. For local staging of prostate and bladder cancer, MRI has better performance than CT or US. Both US and CT are extensively used of biopsies and increasingly for the delivery of therapy particularly for renal cancer.

Background: Recent studies have suggested there are a large number of potentially preventable deaths in Australian hospitals. Aim: This study aimed to document antecedent factors in hospital deaths in an attempt to identify potentially preventative factors. Methods: The study was conducted at three separate acute hospitals. Demographics of all deaths were recorded over a 6-month period as well as antecedent factors present within 0‐8 and 8‐48 h of all deaths including vital sign abnormalities, cardiorespiratory arrests and admission to intensive care. Separate analysis was performed on ‘not for resuscitation’ deaths. Results: There were a total of 778 deaths, of which 549 (71%) were ‘not for resuscitation’. There were 171 (22%) deaths preceded by arrest and 160 (21%) preceded by admission to intensive care. Of the remaining deaths, 30% had severely abnormal physiological abnormalities documented. This incidence was 50% in the non-do not resuscitate (DNR) subgroup. Concern about the patient’s condition was expressed in the patient’s notes by attending nursing staff and junior medical staff in approximately onethird of non-DNR deaths. Hypotension (30%) and tachypnoea (17%) were the most common antecedents in the non-DNR deaths. Conclusion: There is a high incidence of serious vital sign abnormalities in the period before potentially preventable hospital deaths. These antecedents may identify patients who would benefit from earlier intervention. (Intern Med J 2001; 31: 343‐348)

We describe Brucella sp. infection and associated lesions in a harbor porpoise (Phocoena phocoena) found on the coast of Belgium. The infection was diagnosed by immunohistochemistry, transmission electron microscopy, and bacteriology, and the organism was identified as B. ceti. The infection’s location in the porpoise raises questions of abortion and zoonotic risks.

Objectives To evaluate the effectiveness of a medical emergency team (MET) in reducing the rates of selected adverse events. Design Cohort comparison study after casemix adjustment. Patients and setting All adult (> or = 14 years) patients admitted to three Australian public hospitals from 8 July to 31 December 1996. INTERVENTION STUDIED: At Hospital 1, a medical emergency team (MET) could be called for abnormal physiological parameters or staff concern. Hospitals 2 and 3 had conventional cardiac arrest teams. Main outcome measures Casemix-adjusted rates of cardiac arrest, unanticipated admission to intensive care unit (ICU), death, and the subgroup of deaths where there was no pre-existing "do not resuscitate" (DNR) order documented. Results There were 1510 adverse events identified among 50 942 admissions. The rate of unanticipated ICU admissions was less at the intervention hospital in total (casemix-adjusted odds ratios: Hospital 1, 1.00; Hospital 2, 1.59 [95% CI, 1.24-2.04]; Hospital 3, 1.73 [95% CI, 1.37-2.16]). There was no significant difference in the rates of cardiac arrest or total deaths between the three hospitals. However, one of the hospitals with a conventional cardiac arrest team had a higher death rate among patients without a DNR order. Conclusions The MET hospital had fewer unanticipated ICU/HDU admissions, with no increase in in-hospital arrest rate or total death rate. The non-DNR deaths were lower compared with one of the other hospitals; however, we did not adjust for DNR practices. We suggest that the MET concept is worthy of further study.

In critically ill patients, serial measurements of blood lactate may indicate adequacy of therapy and predict development of multi-organ failure. We studied the accuracy, precision, and repeatability of the newly developed 800 Series Lactate Sensor (Ciba Corning Diagnostic Corp., Medfield, U.S.A.). Lactate levels determined with the sensor were compared with the standard laboratory method (Abbott TDX) in 75 paired arterial blood samples from 20 patients. Agreement between methods was determined and the mean coefficient of variation calculated for repeated measurements. The bias of the sensor was -0.38 mmol/l (CI -0.23 to -0.53), and the precision ±0.67. The coefficient of variation for repeated measurements was 1.95% with the sensor, and 11.5% with the TDX (P=0.007). The new sensor offers a more reproducible, rapid method of measuring lactate, vital for serial measurements. The relatively wide limits of agreement between the methods reflect the greater variability of the TDX assay.

BACKGROUND: Malignant pediatric brain tumors constitute a heterogeneic group of central nervous system tumors, and general markers of diagnosis and prognosis are not available. Recently, a panel of CD markers (CD15, CD24, CD29) was used to define increasing neural differentiation of embryonic stem cells. Although these CD markers have been associated with worse prognosis due to presence of tumor propagating cells, alterations in adhesion and migration in various cancer types, no studies of multiple CD markers in pediatric brain tumors have been performed. METHODS: We have collected tumors, including medulloblastomas (MB), ependymomas (EP) and juvenile astrocytomas, from >20 pediatric brain tumor patients. Frozen tumor sections and cultured tumor cells were stained for CD15, CD24 and CD29 and analyzed using fluorescence microscopy or flowcytometry. RESULTS: MB contained a mixture of cells with strong CD15 labeling inside vessels and cells with diffuse CD15 staining in the parenchyma of the tumor tissue. Cells strongly labeled with CD15 were also positive for the leukocyte marker CD45. The previously proposed association between CD15 expression and prognosis in MB could instead of reflecting abundance of tumor propagating cells depend on infiltrating immune cells. In low-grade pediatric tumors and EP, larger areas stained weakly for CD15 while few cells displayed strong staining. CD24 was expressed on the vast majority of cells in pediatric brain tumors, despite grade of malignancy. MB, however, displayed an intense and aberrant staining for CD24. Computerized image analysis of frozen tumor sections showed that proliferation of cells and the expression of CD29 correlated in a sub-group of MB. CONCLUSIONS: Our preliminary data show that CD15, CD24 and CD29 are differentially expressed in high- and low-malignant pediatric brain tumors in vivo. By defining the patterns of CD antigen expression in different pediatric tumors their relationship to biological behavior and thus prognosis can be established. (Less)

BACKGROUND: Glutathione S-transferase (GST) enzymes are involved in detoxifying chemotherapy agents and clearing reactive oxygen species formed by radiation. In this study, we explored the relationship between the host GSTP1-105 polymorphism (rs1695), tumor GSTpi protein expression, and clinical outcomes in pediatric medulloblastoma. We hypothesized that the GSTP1-105 G-allele and increased tumor GSTpi expression would be associated with lower progression-free survival and fewer adverse events. METHODS: The study included 106 medulloblastoma/primitive neuroectodermal tumor (PNET) patients seen at Texas Children’s Cancer Center. Genotyping was performed using an Illumina HumanOmni1-Quad BeadChip and tumor GSTpi expression was assessed using immunohistochemistry. We used the Kaplan-Meier method for survival analyses and multivariable logistic regression for toxicity comparisons. RESULTS: Patients with a GSTP1-105 AG/GG genotype or who had received a higher dose of craniospinal radiation (median 36 Gy) had a greater risk of requiring hearing aids than their respective counterparts (OR 4.0, 95%CI 1.2 - 13.6, and OR 3.1, 95%CI 1.1 - 8.8, respectively). Additionally, there was a statistically significant interaction between the two variables. Compared with the lowest risk group (GSTP1-105 AA-lower dose radiation) patients with a GSTP1-105 AG/GG genotype who received a higher dose radiation were 8.4 times more likely to require hearing aids (95%CI 1.4 - 49.9, p-trend ¼ 0.005). When adjusted for age, gender, and amifostine use, the association remained. CONCLUSIONS: The GSTP1-105 G-allele is associated with permanent ototoxicity in pediatric medulloblastoma/PNET and strongly interacts with radiation dose. A possible mechanism for this finding is that the GSTP1-105 G-allele leads to reduced GSTpi free radical detoxification in the setting of multimodality therapy including cisplatin and radiation. Patients with this allele should be considered for clinical trials employing radiation dose modifications and more targeted cytoprotectant strategies than are currently being used with amifostine.

Fibroids are common in women of reproductive age and non-surgical management with uterine artery embolisation for symptomatic patients is increasingly performed. In this chapter, the role of diagnostic radiology, in particular MRI, in the diagnosis, mapping and assessment of fibroid disease prior to embolisation is discussed. While ultrasound is readily available, MRI has been shown to be more accurate at characterising fibroids and defining their number and location. In particular fibroid vascularity prior to embolisation is well demonstrated with Gadolinium-enhanced MRI. Contraindications to embolisation such as pedunculated fibroids on a narrow stalk or non-vascular, degenerated fibroids are also readily identified with MRI. Following embolisation, early change in fibroid vascularity can be demonstrated which has a prognostic implication to long-term response. Post-embolisation appearances such as intra-fibroid gas, infection and fibroid passage are also discussed and demonstrated. Given that uterine artery embolisation is increasingly being performed, diagnostic radiologists therefore need to be familiar with pre-treatment diagnosis and assessment and typical post-embolisation appearances.

To describe thin-section pulmonary computed tomographic (CT) features in asymptomatic elderly individuals.Institutional review board approval was given, and informed consent was obtained. Two study groups (older group, over 75 years of age; younger group, under 55 years) were prospectively identified from outpatient requests for CT of the abdomen or brain. Fifty-six consecutive volunteers (older group: n = 40, 18 men, 22 women; younger group: n = 16, eight men, eight women) with no known respiratory disease were included. Prone thin-section CT imaging was performed, and two observers independently scored images for the presence and extent of CT features (including reticular pattern, ground glass opacity, and thin-walled cystic air spaces). Group comparisons were made, and logistic regression analysis was used to assess relationships between CT findings and age and smoking history.A limited predominantly subpleural basal reticular pattern was identified in the majority (24 of 40, 60%) of individuals in the older group and was absent (zero of 16) in the younger group (P.001). Cysts were seen in 10 (25%) of the 40 subjects in the older group but were seen in none of the subjects in the younger group (P = .02). Bronchial dilation and wall thickening were also seen significantly more frequently (P.001) in the older group (24 [60%] and 22 [55%] of 40, respectively) than in the younger group (both one [6%] of 16). All findings were independent of pack-year smoking history with multiple logistic regression analysis.Thin-section CT findings usually associated with interstitial lung disease are frequently seen in asymptomatic elderly individuals and are absent in younger subjects. Therefore, these findings may not necessarily represent clinically relevant disease.

Summary The authors report the case of an acute chloroform poisoning and the related therapeutic implications. Massive chloroform ingestion is rapidly followed by coma, respiratory failure and circulatory shock which are life threatening. An acute hepatitis may occur later in association with renal involvement. Even though major liver failure may occur, a complete recovery of liver function will occur naturally. Hence, hepatic transplantation should be avoided. Therapy with N-acetylcystein may be of interest as suggested by our present report.

A survey was conducted to explore the perception of intensive care registrars on the impact of activities outside the intensive care unit (ICU), particularly in medical emergency teams, on their training and the care of patients. An anonymous mail-out survey was sent to 356 trainees registered with the Joint Faculty of Intensive Care Medicine, half of whom were determined to be involved in ICU duties. No patients were involved and respondents participated voluntarily. The main outcome measures were barriers and predictors of satisfaction with ICU training. One-hundred-and-thirty-six (38%) trainees responded. Seventy-eight percent had participated in a medical emergency team, of whom 99% of respondents stated the medical emergency team included an ICU registrar but rarely (3%) an ICU consultant. Sixty-six percent of respondents reported that medical emergency team involvement had a positive effect on training but 77% reported little or no supervision of team duties. While trainees did not believe they spent too much time performing medical emergency team duties, the time spent on medical emergency teams at night, when ICU staffing levels are at their lowest, was the same as during the day. Serious concern was expressed about the negative impact of medical emergency team activities on their ability to care for ICU patients and the additional stress on ICU medical and nursing staff. Overall, ICU trainees regarded participation in a medical emergency team as positive on training and on patient care in wards, but other results have resource implications for the provision of clinical emergency response systems, care of patients in ICUs and the training of the future intensive care workforce.

The intravenous urogram (IVU) forms part of the initial workup for patients with unexplained hematuria. With recent advances in computed tomography (CT) and magnetic resonance imaging (MRI) technology, the future of the IVU is a subject of ongoing debate (1), although at present it still remains integral to the diagnosis and surveillance of urothelial malignancy. It consists of a series of plain x-rays of the renal tract followed by intravenous administration of water-soluble, iodinated, contrast medium. The contrast medium is excreted by the kidneys, enabling visualization of high-density contrast-filled calyces, renal pelvis, ureters, and bladder. Tumors are demonstrated as filling defects (Fig. 3.1).

The Intensive Care Clinical Information System (ICCIS) Program commenced in 2011 and is the largest program of its type globally. ICCIS, initiated by intensive care clinicians, is being delivered collaboratively by the Agency for Clinical Innovation (ACI) Intensive Care Services Network, eHealth ICCIS Program Team and iMDsoft. Underpinning this high performance team is strong collaboration, clinical engagement, communication and leadership for the design, build and delivery of the ICCIS solution. The Clinical Engagement Model was embedded in the development of ICU business requirements to inform the selection, design and build of the ICCIS solution for NSW. A proactive communications and engagement plan was implemented, the Agile Project Management model adopted, and organisational change management framework developed. TheACI ICCISWorkingGroupwas established in 2013 toprovide clinical leadership for the project and production phases. Formation of ACI ICCIS WG Subject Matter Expert Reference Groups for reporting, pharmacy, technical, research, paediatric and neonatal requirements followed. Clinician engagement has increased throughout the ICCIS Program with a 400% increase in active voluntary clinician participation from the initial clinical evaluation group (n=18) to the establishment of the ACI ICCIS Working Group and specialty subgroups (n=70) in the design and build phase. Effective engagementwith the broader ICU community through proactive communications was demonstrated by an increase in viewer hits from 400 in 12 months (2013 first video release) to 480 in two weeks with the second video release in 2014. The success of the ICCIS Program’s clinical leadership and engagement demonstrates the impact of a high performance collaborative team. The success of the ICCIS Program is contingent on active engagement of intensive care clinicians to deliver ICCIS on behalf of clinicians for the benefit of patient care and clinician satisfaction.

Leptospirosis is usually a mild illness, although the severity of clinical manifestations may vary between the serovars of leptospires. In May 1993, a 48-year-old man from Ghana presented with severe icteric leptospirosis, initially managed as viral haemorrhagic fever. The causative serovar, bataviae, had not been previously diagnosed in human infection in Australia.

Summary Background Medical emergency team (MET) call criteria are late signs of a deteriorating clinical condition. Some early signs predict in-hospital death but have a high prevalence so their use as single sign call criteria could be wasteful of resources. This study searched a large database to explore the association of combinations of recordings of early signs (ES), or early with late signs (LS) with in-hospital death. Methods A cross-sectional survey was undertaken of 3046 non-do not attempt resuscitation adult admissions in 5 hospitals without MET over 14 days. The medical records were reviewed for recordings of 26 ES and 21 LS and in-hospital death. Combinations of ES with or without LS were examined as predictors of death. Global modified early warning scores (GMEWS) were calculated. Findings ES with LS, plus LS only, had higher odd ratios than ES alone. Four combinations of ES were strongly associated with death: cardiovascular plus respiratory with decrease in urinary output, cardiovascular plus respiratory with a decrease in consciousness, respiratory with decrease in urinary output, and cardiovascular plus respiratory. In other combinations, recordings of SpO 2 90–95%, systolic blood pressure 80–100mmHg or decrease in urinary output in turn occurring with one or more disturbed blood gas variable were associated with death. Compared with admissions whose GMEWS were 0–2, admissions with GMEWS 5–15 were 27.1 times more likely to die while those with GMEWS 3–4 were 6.5 times more likely. Conclusions The results support the inclusion of early signs of a deteriorating clinical condition in sets of call criteria.

Emergency response systems (ERS) are based on a set of triggers used to identify patients "at risk". This study aimed to establish the association between recordings of disturbed physiological variables and adverse events.A cross-sectional survey of 3,046 non Do Not Attempt Resuscitation (non DNAR) adult admissions in five hospitals over 14 days. Medical records were reviewed for 26 early signs (ES) and 21 late signs (LS) of critical conditions and serious adverse events (SAE): death, cardiac arrest, severe respiratory problems, or transfer to a critical care area. The LS included published medical emergency team (MET) call criteria.There were 12,384 ES and 1,410 LS. The 'top five' ES and the odds (OR) for death were: base deficit -5 to -8 mmol/L=40.2 (95% C.I. 7.7-208.8), partial airway obstruction OR=38.7 (3.9-64.4), poor peripheral circulation OR=34.4 (6.8-174.0),expected drain fluid loss OR=30.1 (6.1-148.9), pH7.37.2 OR=29.0 (3.1-268.3). For LS: urine output200 mL in 24 h OR=188.6 (95% C.I. 30.1-1179.8), pH7.2 OR=116.1 (7.1-1906.1), unresponsive to voice OR=34.8 (10.7-113.0), anuric OR=29.0 (3.1-268.3), base deficit-8.0 mmol/L OR=29.0 (3.1-268.3). OR for the other SAE were similar. Pulse oximetry abnormalities were associated with all SAE. The risk for death for ES: SpO2 90-95% OR=8.1 (3.0-21.3) and LS: SpO290% OR=9.0 (4.2-19.4).Both ES and LS were associated with adverse events. This study confirms the validity of current MET call criteria but points to the need to expand them. It provides a possible explanation for the failure to demonstrate efficacy of a MET in some trials because current call criteria maybe too late in the progress of the patient's critical condition. It allows the modelling of ERS and education programmes focused on signs of critical conditions. It potentially brings together ICU outreach and ward based responses. Broader use of clinical signs, monitoring such as pulse oximetry and objective data such as blood gas results may assist early intervention and help prevent loss of life.

Background: The value of the sigmoid tonometer in predicting sigmoid ischaemia and postoperative enteric organism infection has been reported but the value of tonometric measurements has been challenged. The purpose of this study was to examine the use of tonometric measurements in a series of patients undergoing infrarenal aortic aneurysm repair. Methods: We assessed the results obtained when sigmoid (n= 11) and gastric (n = 8) tonometry were performed in patients undergoing infrarenal aortic aneurysm repair (n= 11). We measured blood flow ultrasonically (n = 6) in the inferior mesenteric artery (IMA) and IMA stump pressures. Sigmoid and gastric tonometry were measured prior to clamping of the infrarenal aorta, during cross clamping and after clamp release at 1, 4, 16 and 20 h. Ultrasonic flow was measured before clamping. Stump pressures in the IMA were measured before, during and after clamping. Results: The IMA was chronically occluded in five patients. The IMA flow was 37.5 ± 8.7 mL/min (mean ± s.e.). The mean IMA stump pressures before, during and after clamping were 64 ± 13, 48 ± 8 and 69 ± 10 mmHg, respectively, and did not differ significantly. Mean systematic arterial pressures at these times were 89 ± 7, 95 ± 5 and 86 ± 8 mmHg. These did not differ significantly or when compared with IMA stump pressure. The gradient between systemic arterial pressure and IMA stump pressure did not vary significantly at any of these times. Sigmoid and gastric intramucosal pH (pHi) did not differ significantly at any of the above times. Both sigmoid and gastric pHi dropped on clamp application but 4 h afterwards had returned to baseline levels. Systemic arterial pH reflected significant ischaemia during clamping and shortly after release of the clamp (P= 0.008). Conclusions: Tonometry may reflect systemic events as much as regional ischaemia. Useful tonometry results may depend on the development of a trend rather than individual measurements. The routine use of tonometry to detect intestinal ischaemia may not be cost-effective in aortic surgery.

To estimate the prevalence of recordings in case notes of disturbed physiological variables in adult admissions in general hospital wards.Retrospective cross-sectional survey of 3160 admissions in general wards in five hospitals in a 14-day period.Recordings of 26 potential early signs (ES) and 21 potential late signs (LS) of critical conditions. Eight late signs were classified as Liverpool Hospital Equivalent Calling Signs (LES).54.7% admissions had at least one recording of early signs, 16.0% late signs and 6.4% LES. When ranked in order of recordings per 100 admissions, the top five ES were SpO(2) 90-95% (193.7), systolic blood pressure (SBP) 80-100 mmHg (85.2), pulse rate 40-49 or 121-140 b/min (32.0), SBP 181-240 mmHg (23.0) and "Other" (22.1) (mainly breathlessness or temperature38 degrees C). The top five LS were SpO290% (31.5), pulse rate40 or140 /min (6.6), SBP80 mmHg (4.2), GCSor = 8 (3.8) and unresponsiveness to verbal commands (2.4). There were average signs per admission of ES 4.4, LS 0.6 and LES 0.19. Although there were differences in rates of recordings of signs across the five hospitals, the patterns of top 10 most frequent were similar.There was a high incidence of recordings of disturbed physiological variables in general ward patients. Changes to hospital emergency response systems to include rapidly responding teams to patients with the signs of developing critical conditions should be supported by training programmes for ward staff on the early recognition and management of patients with the warning signs.

To analyse agreement between two methods for blood glucose measurement in intensive care patients: capillary blood using a reagent strip and glucometer with arterial blood using a blood gas analyser.Prospective, single-centre, observational study in a 12-bed tertiary referral intensive care unit.Blood glucose levels were measured in consecutive patients using simultaneous measurements of capillary blood samples using glucometry and from a multi-electrode arterial blood gas analyser. An a priori subgroup of patients with tissue hypoperfusion was identified (defined as systolic blood pressure90 mmHg or vasopressor dependency). A total of 493 paired measurements were obtained; 75 of these were from patients with systemic hypoperfusion.Overall, the mean difference (bias) was 0.12 mmol/l (2.15 mg/dl) and precision 0.77 mmol/l (13.8 mg/dl); 95% limits of agreement were -0.14 and 1.66 mmol/l (-2.5 and 29.8 mg/dl). In patients with systemic hypoperfusion the bias was 0.24 mmol/l (4.0 mg/dl) and precision 0.9 mmol/l (16.2 mg/dl); 95% limits of agreement -2.05 and 1.58 mmol/l (36.8 and 28.4 mg/dl).In a general population of intensive care patients, there is statistical agreement between blood glucose measured from capillary blood glucometry and arterial blood gas analysis. However, in patients with systemic hypoperfusion, the accuracy of agreement between these two measurement techniques may be such that that biochemical hypoglycaemia (2.5 mmol/l, 44.9 mg/dl) may go undetected if used interchangeably.

Severity of illness on admission to the intensive care unit (ICU), as measured by commonly used scoring systems, e.g., the Acute Physiological and Chronic Health Evaluation scoring system (APACHE 2) and the Simple Acute Physiological Score (SAPS 2), has been shown to correlate with short-term mortality in groups of patients [1–5].

Objective: To document the characteristics and incidence of serious abnormalities in patients pri- or to admission to intensive care units. Design and setting: Prospec- tive follow-up study of all patients admitted to intensive care in three acute-care hospitals. Patients: The study population totalled 551 pa- tients admitted to intensive care: 90 from the general ward, 239 from op- erating rooms (OR) and 222 from the Emergency Department (ED). Measurements and results: Patients from the general wards had greater severity of illness (APACHE II me- dian 21) than those from the OR (15) or ED (19). A greater percentage of patients from the general wards (47.6%) died than from OR (19.3%) and ED (31.5%). Patients from the general wards had a greater number of serious antecedents before admis- sion to intensive care 43 (72%) than those from OR 150 (64.4%) or ED 126 (61.8%). Of the 551 patients 62 had antecedents during the period 8-48 h before admission to intensive care, and 53 had antecedents both within 8 and 48 h before their admis- sion. The most common antecedents during the 8 h before admission were hypotension (n=199), tachycardia (n=73), tachypnoea (n=64), and sud- den change in level of consciousness (n=42). Concern was expressed in the clinical notes by attending staff in 70% of patients admitted from the general wards. Conclusions: In over 60% of patients admitted to intensive care potentially life-threatening ab- normalities were documented during the 8 h before their admission. This may represent a patient population who could benefit from improved re- suscitation and care at an earlier stage.

Two immature female fin whales stranded on the Belgian and French coastlines, were examined post mortem. The main gross findings were massive parasitic infestation, associated with a large thrombus in one whale, and severe emaciation. Microscopical investigations revealed multinucleated syncytia with large intranuclear inclusion bodies in various tissues, and positive immunolabelling for morbillivirus antigens. Other evidence of morbillivirus infection was provided by the demonstration of specific viral structures in syncytia and in cell cultures, and the detection of neutralizing antibodies to canine distemper virus. To the authors' knowledge, this is the first firm report of morbillivirus infection in baleen whales. (C) 2000 Harcourt Publishers Ltd.

One hundred and fifteen final year medical students of the University of New South Wales (UNSW) who were gathered together for mid-year lectures were asked to respond to a questionnaire which sought their perceptions of their knowledge of and competence in those skills required to prevent loss of life of patients with acute reversible life-threatening illnesses. There were 101 responders (88% response rate). A high proportion of students lacked practical experience of many of the skills or had not witnessed some procedures. They lacked confidence in their ability to manage acute emergencies. The results were similar to those in a separate study of the perceptions of New South Wales interns and resident medical officers of their competencies at the beginning of their intern year. The authors concluded that undergraduate education in critical care had not kept pace with the rapid evolution of critical care practice and describe the development and implementation of an explicit vertical and horizontal curriculum of critical care in the undergraduate curriculum of the UNSW.

We aimed to evaluate the tonometer in the assessment of gastrointestinal ischaemia induced by an infrarenal aortic cross-clamp. Nine anaesthetized pigs were cannulated for haemodynamic monitoring and radionuclide labelled microsphere (RLM) injection. Gastric and sigmoid tonometers were positioned. After haemodynamic stabilization an infrarenal aortic cross-clamp was applied. Animals were sacrificed at the completion of the study and tissue sampled from the stomach and sigmoid colon for regional blood flow measurements. Measurements were made pre-clamp, post-clamp, pre-release and post-release. Haemodynamic parameters, gastric intramucosal pH (pHi) and blood flow did not change throughout the experiment. Arterial pH increased during cross-clamp and returned to baseline post-release. Arterial bicarbonate fell post release. Sigmoid blood flow fell during cross-clamp. The sigmoid pHi fall, delayed until pre-release, remained low post-release. Although there was a consistent fall in sigmoid pHi, 63% of post-clamp values remained within the baseline range. We conclude that maintaining haemodynamic parameters around baseline values resulted in maintenance of gastric mucosal perfusion as indicated by a steady gastric pHi. However, below the aortic cross-clamp, delay between change in sigmoid colon blood flow and change in pHi and wide variation in sigmoid pHi limits the value of an individual pHi measurement in detecting ischaemia.

Objective: To describe the use of inhaled nitric oxide (NO) in four patients with severe pulmonary embolism. Setting: The intensive care unit (ICU) of a university teaching hospital. Patients: Four patients with severe pulmonary embolism on the basis of clinical, haemodynamic or blood-gas parameters received NO by inhalation either during spontaneous respiration (two cases) or while mechanically ventilated (two cases). Interventions: Conventional management of pulmonary embolism in addition to the use of inhaled NO. Measurements and results: Description of clinical course, haemodynamic and gas-exchange data. Dose-response data are also described for three patients. Conclusions: We reported four cases of pulmonary embolism where the administration of inhaled NO resulted in an improvement in pulmonary haemodynamic and gas-exchange parameters. Two patients were weaned from NO and survived until discharged from the ICU. Inhaled NO might be a useful adjunct in pulmonary embolism to improve stability of the patient prior to thrombolysis or surgery.