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Acute angle-closure glaucoma is a rare complication of general anesthesia. If not treated in time, acute angle-closure glaucoma can potentially cause permanent loss of vision. Physicians should therefore be vigilant for the possibility of acute angle-closure glaucoma in patients who experience postoperative change or loss of vision. Recently, some reported a case of bilateral acute angle-closure glaucoma after general anesthesia, in which the use of ephedrine was a possible trigger. This report begins by examining a case of unilateral acute angle-closure glaucoma. The potential triggers of this complication are discussed. This article concludes with a flowchart to aid anesthesiologists to accurately diagnose postoperative ophthalmic pathology.

Background. About 15% of liver transplantations (LTs) in Eurotransplant are currently performed in patients with a high-urgency (HU) status. Patients who have acute liver failure (ALF) or require an acute retransplantation can apply for this status. This study aims to evaluate the efficacy of this prioritization. Methods. Patients who were listed for LT with HU status from January 1, 2007, up to December 31, 2015, were included. Waiting list and posttransplantation outcomes were evaluated and compared with a reference group of patients with laboratory Model for End-Stage Liver Disease (MELD) score (labMELD) scores >= 40 (MELD 40+). Results. In the study period, 2299 HU patients were listed for LT. Ten days after listing, 72% of all HU patients were transplanted and 14% of patients deceased. Patients with HU status for primary ALF showed better patient survival at 3 years (69%) when compared with patients in the MELD 40+ group (57%). HU patients with labMELD >= 45 and patients with HU status for acute retransplantation and labMELD >= 35 have significantly inferior survival at 3-year follow-up of 46% and 42%, respectively. Conclusions. Current prioritization for patients with ALF is highly effective in preventing mortality on the waiting list. Although patients with HU status for ALF have good outcomes, survival is significantly inferior for patients with a high MELD score or for retransplantations. With the current scarcity of livers in mind, we should discuss whether potential recipients for a second or even third retransplantation should still receive absolute priority, with HU status, over other recipients with an expected, substantially better prognosis after transplantation.

Supplemental Digital Content is available in the text., Background. Several risk models to predict outcome after liver transplantation (LT) have been developed in the last decade. This study compares the predictive performance of 7 risk models. Methods. Data on 62 294 deceased donor LTs performed in recipients ≥18 years old between January 2005 and December 2015 in the United Network for Organ Sharing region were used for this study. The balance of risk, donor risk index (DRI), Eurotransplant-DRI, donor-to-recipient model (DRM), simplified recipient risk index, Survival Outcomes Following Liver Transplantation (SOFT), and donor Model for End-stage Liver Disease scores were calculated, and calibration and discrimination were evaluated for patient, overall graft, and death-censored graft survival. Calibration was evaluated by outcome of high-risk transplantations (>80th percentile of the respective risk score) and discrimination by concordance index (c-index). Results. Patient survival at 3 months was best predicted by the SOFT (c-index: 0.68) and Balance of Risk score (c-index: 0.64), while the DRM and SOFT score had the highest predictive capacity at 60 months (c-index: 0.59). Overall, graft survival was best predicted by the SOFT score at 3-month follow-up (c-index: 0.65) and by the SOFT and DRM at 60-month follow-up (c-index: 0.58). Death-censored graft survival at 60-month follow-up is best predicted by the DRI (c-index: 0.59) and Eurotransplant-DRI (c-index: 0.58). For patient and overall graft survival, high-risk transplantations were best defined by the DRM. For death-censored graft survival, this was best defined by the DRI. Conclusions. This study shows that models dominated by recipient factors have the best performance for short-term patient survival. Models that also include sufficient donor factors have better performance for long-term graft survival. Death-censored graft survival is best predicted by models that predominantly included donor factors.

We investigate whether the boundaries of an ionospheric region of different density than its surroundings will drift relative to the background E×B drift and, if so, how the drift depends on the degree of density enhancement and the altitude. We find analytic solutions for discrete circular features in a 2-D magnetised plasma. The relative drift is proportional to the density difference, which suggests that where density gradients occur they should tend to steepen on one side of a patch while they are weakened on the other. This may have relevance to the morphology of polar ionospheric patches and auroral arcs, since the result is scale-invariant. There is also an altitude dependence which enters through the ion-neutral collision frequency. We discuss how the 2-D analytic result can be applied to the real ionosphere.

Background: This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.Methods: A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to GRADE Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.Results: All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials, meta-analyses of good quality trials or large cohort studies. The level of evidence for the use of each item is presented accordingly.Conclusions: The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Acceptance criteria for liver allografts are ever more expanding because of a persisting wait-list mortality. Older livers are therefore offered and used more frequently for transplantation. This study aims to analyze the use and longterm outcome of these transplantations. Data were included on 17,811 first liver transplantations (LTs) and information on livers that were reported for allocation but not transplanted from 2000 to 2015 in the Eurotransplant (ET) region. Graft survival was defined as the period between transplantation and date of retransplantation or date of recipient death. In the study period, 2394 (13%) transplantations were performed with livers ≥70 years old. Graft survival was 74%, 57%, and 41% at 1-, 5-, and 10-year follow-up, respectively. A history of diabetes mellitus in the donor (hazard ratio [HR], 1.3; P = 0.01) and positive hepatitis C virus antibody in the recipient (HR, 1.5; P < 0.001) are specific risk factors for transplantations with livers ≥70 years old. Although donor age is associated with a linearly increasing risk of graft loss between 25 and 80 years old, no difference in graft survival could be observed when "preferred" recipients were transplanted with a liver

Peripheral intravenous cannulation is the most common invasive hospital procedure but is associated with a high failure rate. This study aimed to improve the A-DIVA scale (Adult Difficult Intra Venous Access Scale) by external validation, to predict the likelihood of difficult intravenous access in adults. This multicenter study was carried out throughout five hospitals in the Netherlands. Adult participants were included, regardless of their indication for intravenous access, demographics, and medical history. The main outcome variable was defined as failed peripheral intravenous cannulation on the first attempt. A total of 3587 participants was included in this study. The first attempt success rate was 81%. Finally, five variables were included in the prediction model: a history of difficult intravenous cannulation, a difficult intravenous access as expected by the practitioner, the inability to detect a dilated vein by palpating and/or visualizing the extremity, and a diameter of the selected vein less than 3 millimeters. Based on a participant&rsquo, s individual score on the A-DIVA scale, they were classified into either a low, moderate, or high-risk group. A higher score on the A-DIVA scale indicates a higher risk of difficult intravenous access. The five-variable additive A-DIVA scale is a reliable and generalizable predictive scale to identify patients at risk of difficult intravenous access.

Background Both University of Wisconsin (UW) and histidine-tryptophan-ketoglutarate (HTK) solutions are currently used in the Eurotransplant region for preservation of liver allografts. Previous studies on their effect have led to a lot of discussion. This study aims to compare the effect of HTK and UW on graft survival. Methods First liver transplantations in recipients 18 years or older from January 1, 2007, until December 31, 2016, were included. Graft survival was compared for livers preserved with HTK and UW at 30 days, 1, 3, and 5 years. Multivariable analysis of risk factors was performed and outcome was adjusted for important confounders. Results Of all 10 628 first liver transplantations, 8176 (77%) and 2452 (23%) were performed with livers preserved with HTK and UW, respectively. Kaplan-Meier curves showed significant differences in graft survival between HTK and UW at 30 days (89% vs 93%, P=

This is the fourth updated Enhanced Recovery After Surgery (ERASA wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.All recommendations on ERASThe evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS

Background Outcome after liver transplantation (LT) is determined by donor, transplant and recipient risk factors. These factors may have different impact on either patient or graft survival (outcome type). In the literature, there is wide variation in the use of outcome types and points in time (short term or long term). Objective of this study is to analyze the predictive capacity of risk factors and risk models in LT and how they vary over time and per outcome type.Methods All LTs performed in the Netherlands from January 1, 2002, to December 31, 2011, were analyzed with multivariate analyses at 3-month, 1-year, and 5-year for patient and (non-)death-censored graft survival. The predictive capacity of the investigated risk models was compared with concordance indices.Results Recipient age, model for end-stage liver disease sodium, ventilatory support, diabetes mellitus, hepatocellular carcinoma, previous malignancy, hepatitis C virus antibody, hepatitis B virus antibody, perfusion fluid, and Eurotransplant donor risk index (ET-DRI) had significant impact on outcome (graft or patient survival) at 1 or multiple points in time. Significant factors at 3-month patient survival (recipient age, model for end-stage liver disease sodium, ventilatory support) were used to compose a concept model. This model, had a higher c-index than the balance-of-risk score, DRI, ET-DRI, donor-recipient model and simplified recipient risk index for long-term patient and non-death-censored graft survival.Conclusions In this study, the effects of recipient risk factors and models on different outcome types and time points were shown. Short-term patient survival mainly depends on recipient risk factors, long-term graft survival on donor risk factors and is more difficult to predict. Next to the concept model, the donor-recipient model has a higher predictive capacity to other risk models for (long-term) patient and non-death-censored graft survival. The DRI and ET-DRI best predicted death-censored graft survival. Knowledge about risk factors and models is critical when using these for waitlist management and/or help in organ allocation and decision-making.

Apart from donor and recipient risk factors, the effect of center-related factors has significant impact on graft survival after liver transplantation (LT). To investigate this effect in Eurotransplant, a retrospective database analysis was performed, including all LT's in adult recipients (≥18 years) in the Eurotransplant region from 1.1.2007 until 31.12.2013. Additionally, a survey was sent out to all transplant centers requesting information on surgeons' experience and exposure. In total, 10 265 LT's were included (median follow-up 3.3 years), performed in 39 transplant centers. Funnel plots showed significant differences in graft survival between the transplant centers. After correction for donor and recipient risk, with the Eurotransplant donor risk index (ET-DRI) and the simplified recipient risk index (sRRI) and random effects, these differences diminished. Mean historical volume (in the preceding 5 years) was a significant (P

Background Sugammadex, a γ-cyclodextrin derivative, belongs to a new class of selective relaxant binding agents. Sugammadex was approved 10-years ago by the European medicines agency and today is used in clinical anesthesia and emergency medicine globally. In this review, indications for neuromuscular block, the challenge of neuromuscular monitoring and the practice of under-dosing of sugammadex as a potential cost-saving strategy are discussed. Main body Reversal of neuromuscular block is important to accelerate the spontaneous recovery of neuromuscular function. Sugammadex is able to reverse a rocuronium- or vecuronium-induced neuromuscular block rapidly and efficiently from every depth of neuromuscular block. However, since sugammadex was introduced in clinical anesthesia, several studies have reported administration of a lower-than-recommended dose of sugammadex. The decision to under-dose sugammadex is often motivated by cost reduction concerns, as the price of sugammadex is much higher than that of neostigmine outside the United States. However, under-dosing of sugammadex leads to an increased risk of recurrence of neuromuscular block after an initial successful (but transient) reversal. Similarly, when not using objective neuromuscular monitoring, under-dosing of sugammadex may result in residual neuromuscular block in the postoperative care unit, with its attendant negative pulmonary outcomes. Therefore, an appropriate dose of sugammadex, based on objective determination of the depth of neuromuscular block, should be administered to avoid residual or recurrent neuromuscular block and attendant postoperative complications. Whether the reduction in perioperative recovery time of the patient can be translated into additional procedural cases performed, faster operative turnover times, or improved organizational resource utilization, has yet to be determined in actual clinical practice that includes verification of neuromuscular recovery prior to tracheal extubation. Conclusions The current review addresses the indications for neuromuscular block, the challenge of neuromuscular monitoring, the practice of under-dosing of sugammadex as a potential cost-saving strategy in reversal of deep neuromuscular block, the economics of sugammadex administration and the potential healthcare cost-saving strategies.

Background Although patient-centred care could help increase the value of healthcare, practice variations in hip and knee surgery suggest that physicians guide clinical decisions more than patients do. This raises the question whether treatment outcomes still meet patients’ expectations. This study investigated whether treatment outcomes measured by patient-reported outcome measures fulfil patients’ main expectations (i.e. decreased pain or improved functioning). Methods Patients who underwent hip or knee surgery in 20 Dutch hospitals in 2014 were invited to a survey consisting of the KOOS Physical Function Short Form or the HOOS Physical Function Short Form, the NRS pain and the EQ-5D. Patients were asked their main reason for surgery and whether the expectations regarding this reason were fulfilled. Results A total of 2776 patients completed the survey. The most common reason for surgery was improved functioning (43.7%). Patients who were unable to choose between pain relief and improved functioning and patients who aimed for pain relief experienced more problems before surgery. However, patients who were unable to choose improved more than patients who wanted to improve their functioning on the NRS pain during use and the EQ-5D. More patients who aimed for pain relief felt that their expectations were fulfilled compared to other patients. Conclusions Although an expectation for an outcome was not related to a greater improvement on that outcome, patient expectations were an indication of patients’ improvement due to surgery. Differences in expectation fulfilment may be due to unrealistic expectations. To achieve optimal value, tailoring treatment using patient preferences and managing patient expectations is vital.

ObjectivesTo analyse a potential association between surgical quality and time of day.DesignA retrospective analysis of complete sets of quality forms filled out by the procuring and accepting surgeon on organs from deceased donors.SettingProcurement procedures in the Netherlands are organised per region. All procedures are performed by an independent, dedicated procurement team that is associated with an academic medical centre in the region.ParticipantsIn 18 months’ time, 771 organs were accepted and procured in The Netherlands. Of these, 17 organs were declined before transport and therefore excluded. For the remaining 754 organs, 591 (78%) sets of forms were completed (procurement and transplantation). Baseline characteristics were comparable in both daytime and evening/night-time with the exception of height (p=0.003).Primary outcome measureAll complete sets of quality forms were retrospectively analysed for the primary outcome, procurement-related surgical injury. Organs were categorised based on the starting time of the procurement in either daytime (8:00–17:00) or evening/night-time (17:00–8:00).ResultsOut of 591 procured organs, 129 organs (22%) were procured during daytime and 462 organs (78%) during evening/night-time. The incidence of surgical injury was significantly lower during daytime; 22 organs (17%) compared with 126 organs (27%) procured during evening/night-time (p=0.016). This association persists when adjusted for confounders.ConclusionsThis study shows an increased incidence of procurement-related surgical injury in evening/night-time procedures as compared with daytime. Time of day might (in)directly influence surgical performance and should be considered a potential risk factor for injury in organ procurement procedures.

Topic list that was used during the semi-structured interviews. (DOCX 14Â kb)

Background House dust contains mite allergens as well as bacterial products such as lipopolysaccharide (LPS). Asthma exacerbations are associated with the level of exposure to allergens and LPS. LPS can potentiate allergen effects in steroid-naive patients. Long-acting β2-agonists (LABA) were shown to inhibit LPS-induced bronchial inflammation in healthy volunteers. The aim of this study was to assess the effect of LPS on the allergen-induced eosinophilic inflammation [primary endpoints: eosinophil counts and eosinophil cationic protein (ECP)] induced by bronchial instillation of house dust mite (HDM) in patients with asthma on maintenance treatment with inhaled corticosteroids (ICS). Methods Thirty-two nonsmoking asthmatics with HDM allergy were treated with run-in medication (fluticasone propionate 100 μg bid) during 2 weeks before the study day. All patients underwent bronchial challenge with HDM, and half of them were randomized to receive additional LPS. Both groups were randomized to receive pretreatment with a single inhalation of 100 μg salmeterol 30 min before bronchial segmental challenge. Six hours later, bronchoalveolar lavage (BAL) was collected for leukocyte cell count, differentials, and cellular activation markers. Results Challenge with HDM/LPS induced a significant increase in eosinophil cationic protein (P = 0.036) and a trend toward an increase in BALF eosinophils as compared to HDM challenge. Conclusion Lipopolysaccharide promotes eosinophilic airway inflammation in patients with asthma despite being on maintenance treatment with ICS.

ResumoRelato do caso de uma criança recém‐nascida de três dias de idade com um cisto ovariano gigante programada para a cirurgia. A paciente recebeu uma dose de sugamadex para reverter o bloqueio neuromuscular induzido por rocurônio. Uma recuperação rápida e eficiente do bloqueio neuromuscular foi obtida dentro de 90 segundos. Não foram observados efeitos adversos ou outros problemas de segurança. Além disso, uma revisão da literatura sobre o uso de sugamadex em recém‐nascidos foi feita.AbstractA case is reported in which a 3‐days old neonate with a giant ovarian cyst was scheduled for surgery. The patient received a dose of sugammadex to reverse a rocuronium‐induced neuromuscular block. A fast and efficient recovery from neuromuscular block was achieved within 90s. No adverse events or other safety concerns were observed. Furthermore, a review of the literature on the use of sugammadex in neonates was performed.

Background Shifting care from the secondary to the primary system may present an opportunity to ensure that the increasing number of patients with chronic heart failure (CHF) receive high-quality care while containing costs. However, shifting from secondary to primary care might seem radical to patients. A qualitative insight into patients’ issues, preferences, expectations and needs may help arrange a smooth transition from secondary to primary care for CHF patients. The aim of this exploratory study is therefore to gain insights into the way CHF patients in secondary care perceive the possibility of substitution of CHF care from secondary to primary care. Methods In total, fifteen semi-structured interviews were conducted with CHF patients. Topics discussed during the interviews were the advantages and disadvantages, attitudes of patients, preferences regarding the substitution and trust in the GP and cardiologist. A thematic analysis was performed. Results The minority of the patients welcomed the idea of substitution. Against that, the majority of the patients had various concerns. This attitude was mainly influenced by two main themes, confidence and security and accessibility. Most patients had more confidence in secondary than in primary care because of the greater level of knowledge and more possibilities for examination in secondary care and because of good relationships and positive previous experiences in secondary care. Patients also indicated that the general practice is geographically more easily accessible than the hospital. Conclusion Patients had various concerns regarding the substitution of care for chronic heart failure. Addressing these concerns by informing them appropriately may contribute to a smooth and patient-friendly substitution from secondary to primary care. The fears and needs of patients could also be taken into account by policymakers when optimising the way substitution is organised, or when substitution is introduced. Electronic supplementary material The online version of this article (10.1186/s12875-017-0688-z) contains supplementary material, which is available to authorized users.

Item does not contain fulltext Between March 2012 and August 2013, 591 quality forms were filled out for abdominal organs in the Netherlands. In 133 cases (23%), there was a discrepancy between the evaluation from the procuring and transplanting surgeons. Injuries were seen in 148 (25%) organs of which 12 (2%) led to discarding of the organ: one of 133 (0.8%) livers, five of 38 (13%) pancreata and six of 420 (1.4%) kidneys (P < 0.001). Higher donor BMI was a risk factor for procurement-related injury in all organs (OR: 1.06, P = 0.011) and donor after cardiac death (DCD) donation in liver procurement (OR: 2.31, P = 0.034). DCD donation is also associated with more pancreata being discarded due to injury (OR: 10.333, P = 0.046). A higher procurement volume in a centre was associated with less injury in pancreata (OR = -0.95, P = 0.013) and kidneys (OR = -0.91, P = 0.012). The quality form system efficiently monitors the quality of organ procurement. Although there is a relatively high rate of organ injury, the discard rate is low and it does not significantly affect 1-year graft survival for any organ. We identified higher BMI as a risk factor for injury in abdominal organs and DCD as a risk factor in livers. A higher procurement volume is associated with fewer injuries.

SummaryPneumococcal pneumonia is a frequent cause of gram-positive sepsis and has a high mortality. The endothelial protein C receptor (EPCR) has been implicated in both the activation of protein C (PC) and the anti-inflammatory actions of activated (A)PC. The aim of this study was to determine the role of the EPCR in murine pneumococcal pneumonia and sepsis. Wild-type (WT), EPCR knockout (KO) and Tie2-EPCR mice, which overexpress EPCR on the endothelium, were infected intranasally (pneumonia) or intravenously (sepsis) with viable Streptococcus pneumoniae and euthanised at 24 or 48 hours after initiation of the infection for analyses. Pneumonia did not alter constitutive EPCR expression on pulmonary endothelium but was associated with an influx of EPCR positive neutrophils into lung tissue. In pneumococcal pneumonia EPCR KO mice demonstrated diminished bacterial growth in the lungs and dissemination to spleen and liver, reduced neutrophil recruitment to the lungs and a mitigated inflammatory response. Moreover, EPCR KO mice displayed enhanced activation of coagulation in the early phase of disease. Correspondingly, in pneumococcal sepsis EPCR KO mice showed reduced bacterial growth in lung and liver and attenuated cytokine release. Conversely, EPCR-overexpressing mice displayed higher bacterial outgrowth in lung, blood, spleen and liver in pneumococcal sepsis. In conclusion, EPCR impairs antibacterial defense in both pneumococcal pneumonia and sepsis, which is associated with an enhanced pro-inflammatory response.

Objective Decision-making requires weighing potential gains and losses. Adolescents who have experienced maltreatment may be more sensitive to potential gains or losses than other adolescents. The aim of these analyses was to examine trajectories of decision-making over time in adolescents based on maltreatment history and severity. Method The study included 69 adolescents 13 to 17 years old (M = 14.9). Maltreatment history and severity were assessed using the Childhood Trauma Questionnaire. Adolescents also completed a modified Iowa Gambling Task (mIGT). Outcomes of interest were the percentage of advantageous responses and net score (measure of overall performance integrating advantageous and disadvantageous plays) for each of three blocks. Results The trajectory of performance across blocks was defined using a conditional linear growth curve model with factor loadings fixed at block 1, block 2, and block 3. Greater maltreatment severity was associated with less increase in net score over time (M = -4.453, p < .001). In contrast, abuse severity (M = 6.675, p = .002) and the presence of neglect (M = 13.058, p = .002) were associated with sharper increases in net score. A regression revealed maltreatment severity, presence of abuse, presence of neglect, and abuse severity significantly predicted the percentage of advantageous plays only during the second block of the mIGT (R2 = .180, p = .030). Conclusions This study provides evidence that maltreatment history and severity are associated with the trajectory of decision-making over time. It also provides support for the importance of examining performance trajectory and heterogeneity in maltreatment regarding cognitive processing.

ispartof: Anesthesia And Analgesia vol:128 issue:6 pages:E130-E130 ispartof: location:United States status: published

The effects of increasing aflatoxin B1 concentration (0, 0.75, 1.5 mg/kg) on broilers with or without necrotic enteritis or virginiamycin were determined. In the 23-d study, 22 male Cobb 500 chicks per pen were allotted to 12 treatments (3 × 2 × 2 factorial arrangement) with 8 replications. Intestines of 5 birds per pen were examined for lesions on d 21. Birds were allowed to consume feed and water ad libitum. Aflatoxin was included in the diets from d 0. All birds received a 10× dose of coccidiosis vaccine on d 10. Pens of birds where necrotic enteritis was being induced were on Clostridium perfringens pathogen (CPP) contaminated litter from d 0. Aflatoxin decreased gain and feed intake and resulted in poorer feed:gain, increased mortality, and higher lesion scores. Inducing necrotic enteritis increased lesion scores and decreased feed intake and gain. Adding virginiamycin to the diets improved gain, feed intake, feed conversion, and decreased mortality. There was a 3-way interaction (aflatoxin × virginiamycin × CPP) on gain; increasing aflatoxin decreased gain and the effects of CPP and virginiamycin were dependent on aflatoxin concentration. In the absence of aflatoxin virginiamycin increased gain but was unable to prevent the growth suppression caused by CPP. At 0.75 mg/kg of aflatoxin virginiamycin no longer increased growth in non-CPP challenged birds but was able to increase growth in CPP-challenged birds. At the 1.5 mg/kg of aflatoxin concentration, virginiamycin increased gain in non-CPP-challenged birds but challenging birds with CPP had no effect on gain. Virginiamycin improved overall feed conversion with the greatest improvement at 1.5 mg/kg (aflatoxin × virginiamycin, P < 0.05). Aflatoxin increased lesion scores in unchallenged birds but not in challenged birds (aflatoxin × CPP, P < 0.001). Aflatoxin and necrotic enteritis decrease broiler performance and interact to decrease weight gain, virginiamycin helps improve gain in challenged birds at 0.75 mg/kg of aflatoxin, but not at 1.5 mg/kg of aflatoxin.

Understanding the pathogenesis of an infectious disease is critical for developing new methods to prevent infection and diagnose or cure disease. Adherence of microorganisms to host tissue is a prerequisite for tissue invasion and infection. Fungal cell wall adhesins involved in adherence to host tissue or abiotic medical devices are critical for colonization leading to invasion and damage of host tissue. Here, with a main focus on pathogenic Candida species, we summarize recent progress made in the field of adhesins in human fungal pathogens and underscore the importance of these proteins in establishment of fungal diseases.

BACKGROUND In clinical research, neuromuscular monitoring must present a stable response for a period of 2 to 5 min before administration of a neuromuscular blocking agent. The time required to reach this stable response may be shortened by applying a 5-s tetanic stimulus. OBJECTIVES The aim of this study was to test whether tetanic stimulation interferes with onset and recovery times after a single dose of rocuronium 0.6 mg kg followed by spontaneous recovery. DESIGN A randomised, open-label, controlled trial. SETTING A single-centre trial, study period from January 2014 to July 2015. PATIENTS Fifty children aged 2 to 11 years scheduled for elective paediatric surgery. INTERVENTION Patients were randomly allocated to receive either tetanic stimulation (group T) or not (group C) before calibration of the neuromuscular monitor. MAIN OUTCOME MEASURES Onset and recovery times. Initial and final T1 height, time to obtain initial T1 height stability and monitor settings were also analysed. RESULTS There was no significant difference in mean onset time [(C: 57.5 (± 16.9) vs. T: 58.3 (± 31.2) s; P = 0.917]. Mean times to normalised train-of-four (TOF) ratios of 0.7, 0.8 and 0.9 were significantly shorter in the tetanic stimulation group [C: 40.1 (±7.9) vs. T: 34.8 (±10) min; P = 0.047, C: 43.8 (±9.4) vs. T: 37.4 (±11) min; P = 0.045 and C: 49.9 (±12.2) vs. T: 41.7 (±13.1) min; P = 0.026, respectively]. The mean time required for T1 height stabilisation was similar in the two groups [C: 195.0 (± 203.0) vs. T: 116.0 (± 81.6) s; P = 0.093], but the initial and final T1 height values were significantly lower in the tetanic stimulation group (C: 98.0 vs. T: 82.7%; P

Comparing maternal and neonatal outcomes after conventional cesarean section (CS) versus a "natural" or "skin-to-skin" cesarean section (SSCS).Retrospective cohort of women who underwent a SSCS (01-2013 until 12-2013) compared to conventional CS (08-2011 to 08-2012). CS before 37 weeks, under general anesthesia and in case of fetal distress were excluded. Main outcome measures were maternal blood loss, post-operative infection and admission; neonatal infection and admission; procedural outcomes.We analyzed 285 (44%) women in the SSCS-group and 365 (56%) in the conventional CS-group. There were no significant differences in surgical site infection (2.1% versus 1.6%; RR 1.1; 95%CI 0.64-2.0), or other maternal outcomes. Fewer neonates born after SSCS were admitted to the pediatric ward (9.5% versus 18%; RR 0.58; 95%CI 0.41-0.80) and fewer neonates had a suspected neonatal infection (2.0% versus 7.3%; RR 0.40; 95%CI 0.19-0.83). No differences were observed for other outcomes. Mean operation time was 4m42s longer in the SSCS-group compared to the conventional CS-group (58m versus 53m; 95%CI 2m44s-6m40s). Mean recovery time was 14m46s shorter (114m versus 129m; 95%CI 3m20s-26m).Adverse maternal and neonatal outcomes were not increased after skin-to-skin cesarean compared to conventional cesarean delivery.

The Boolardy Engineering Test Array is a 6 x 12 m dish interferometer and the prototype of the Australian Square Kilometre Array Pathfinder (ASKAP), equipped with the first generation of ASKAP's phased array feed (PAF) receivers. These facilitate rapid wide-area imaging via the deployment of simultaneous multiple beams within a 30 square degree field of view. By cycling the array through 12 interleaved pointing positions and using 9 digitally formed beams we effectively mimic a traditional 1 hour x 108 pointing survey, covering 150 square degrees over 711 - 1015 MHz in 12 hours of observing time. Three such observations were executed over the course of a week. We verify the full bandwidth continuum imaging performance and stability of the system via self-consistency checks and comparisons to existing radio data. The combined three epoch image has arcminute resolution and a 1-sigma thermal noise level of 375 micro-Jy per beam, although the effective noise is a factor 3 higher due to residual sidelobe confusion. From this we derive a catalogue of 3,722 discrete radio components, using the 35 percent fractional bandwidth to measure in-band spectral indices for 1,037 of them. A search for transient events reveals one significantly variable source within the survey area. The survey covers approximately two-thirds of the Spitzer South Pole Telescope Deep Field. This pilot project demonstrates the viability and potential of using PAFs to rapidly and accurately survey the sky at radio wavelengths., 20 pages, 13 figures, 4 tables. Accepted for publication in MNRAS

Cell walls are essential organelles for fungi; they define cell shape during growth and provide osmotic integrity and protection against harmful influences in the growth environment. Fungal walls also play an important role in developing fungal infections as they form the first contact between the pathogen and the host immune system. In many ascomycetes, the cell wall consists of a polysaccharide matrix surrounded by a layer of covalently bound glycoproteins. With the complete genome sequences being available for many species, cell wall research in recent years has largely focused on identifying and elucidating the functions of cell wall proteins. In this chapter, we discuss, with a main focus on proteomics, new insights and advances in fungal cell wall research.

In light of the donor organ shortage and the high number of liver transplantation (LT) candidates on the waiting list, the number of extended criteria donors (ECD) increased over time. Among the criteria defining an ECD, donor age is stretched most, so that the use of septuagenarian, octogenarian and even nonagenarian donors increasingly became common practice (1,2). This article is protected by copyright. All rights reserved.

The glycosylphosphatidylinositol-modified protein Rhd3/Pga29 of the human pathogen Candida albicans belongs to a family of cell wall proteins that are widespread among Candida species but are not found in other fungi. Pga29 is covalently linked to the beta-1,3-glucan framework of the cell wall via beta-1,6-glucan. It is a small and abundant O-glycosylated protein and requires the protein-O-mannosyl transferase Pmt1 for glycosylation. Furthermore, Pga29 is strongly expressed in yeast cells but is downregulated in hyphae. Removal of the PGA29 gene in C. albicans leads to a significant reduction of cell wall mannan; however, Pga29 does not seem to have a major role in maintaining cell wall integrity. In addition, adhesion capacity and hyphae formation appear normal in pga29 deletion mutants. Importantly, the pga29 deletion mutant is less virulent, and infection of reconstituted human epithelium with the pga29 mutant results in a diminished induction of proinflammatory cytokines, such as GM-CSF, TNF, IL-6 and IL-8. We propose that the reduced virulence of the pga29 mutant is a consequence of altered surface properties, resulting in altered fungal recognition.

We have developed a new high resolution two-dimensional model of the high latitude ionosphere in which nonlinear advection terms are closely coupled with the electrodynamics. The model provides a self-consistent description of the ionospheric feedback on the electrodynamical perturbations produced by auroral arc-related particle precipitation in regions with strong ambient electric fields. We find in particular that a heretofore neglected ion Pedersen advection term can introduce considerable changes in the electron density profile, the current density distribution, the conductivities and the electron temperatures. We find that the convective effects can carry the ionisation more than 150 km outside the precipitation region in a few minutes, with attendant large changes in the current distribution and E-region densities that become enhanced outside the region of particle precipitation. The production of a tongue of ionisation that slowly decays outside the auroral boundaries contrasts with the sharp geometric cut-off and associated stronger current densities found in previous studies.

Contains fulltext : 81109.pdf (Publisher’s version ) (Closed access) Sugammadex is the first selective relaxant binding agent which was originally designed to reverse the steroidal NMB drug rocuronium. The results of recent studies demonstrate that sugammadex is effective for reversal of rocuronium and vecuronium-induced neuromuscular block without apparent side-effects. This is in contrast to the currently available cholinesterase inhibitors used to reverse neuromuscular block and which are even ineffective against profound neuromuscular block and have a number of undesirable side-effects. Sugammadex-rocuronium complexes are highly hydrophilic and it has been demonstrated that sugammadex is excreted in a rapid and dose-dependent manner in urine, resulting in a complete elimination from the body. The ability of sugammadex to reverse rocuronium and vecuronium-induced neuromuscular block may have major implications for routine anesthetic practice. Once sugammadex becomes commercially available, anesthesiologists will be capable of maintaining the desired depth of neuromuscular block at any time, thereby assuring optimal surgical conditions. The mechanism by which sugammadex encapsulates rocuronium and vecuronium appears to be superior to currently used neuromuscular block reversal strategies in terms of speed, efficacy and side effects. In this article, clinical studies of sugammadex are discussed.

Background: In African settings the treatment results of Burkitt\'s lymphoma (BL) seem to be less favourable compared with Western settings. The aim of this retrospective study was to analyse some factors that affect the treatment of BL. Patients and Methods: Over a 16 year period, data were extracted of 80 patients. Results: Complete remission 5%, very good partial response 35%, partial response 16%, no response 10%, data missing 34%. Of all patients, 56% did have a positive response to treatment. However, 51% of this subgroup of patients did not finish treatment. There was no difference in completion of treatment between patients living in Katete district fi nishing treatment vs. living outside Katete district (respectively 25% vs. 32%, P = 0.7148). Conclusion: There is potential for higher cure rates for BL in tropical settings if full effort is put into compliance since a majority of patients, even while having a good prognosis, abandon treatment. Large distance to hospital makes no difference in completing the chemotherapy course. Keywords: Burkitt's lymphoma, chemotherapy, complianceAfrican Journal of Paediatric Surgery Vol. 6 (1) 2009: pp. 3-6

Aim: To investigate the influence of tendinous and synaptic changes induced by unilateral lower limb suspension (ULLS) on the tendon tap reflex. Methods: Eight young men underwent a 23-day period of ULLS. Muscle cross-sectional area (CSA), torque and electromyographic (EMG) activity of the plantar flexor muscles (normalized to the M wave), Achilles tendon–aponeurosis mechanical properties, soleus (SOL) H and T reflexes and associated peak twitch torques were measured at baseline, after 14 and 23 days of ULLS, and 1 week after resuming ambulatory activity. Results: Significant decreases in muscle CSA (−9%), in maximal voluntary torque (−10%) and in the associated SOL EMG activity (−16%) were found after ULLS (P < 0.05). In addition to a 36% (P < 0.01) decrease in tendon–aponeurosis stiffness, normalized H reflex increased by 35% (P < 0.05). An increase in the slope (28%, P < 0.05) and intercept (85%, P < 0.05) of the T reflex recruitment curve pointed to an increase in the gain and to a decrease in the sensitivity of this reflex, possibly resulting from the decrease in the tendon–aponeurosis stiffness at low forces. Following ULLS, changes in tendinous stiffness correlated with changes in neuromuscular efficiency (peak twitch torque to reflex ratio) at higher tendon tap forces. Conclusion: These findings point out the dual and antagonistic influences of spinal and tendinous adaptations upon the tendon tap reflex in humans under conditions of chronic unloading. These observations have potential implications for the sensitivity of the short-latency Ia stretch response involved in rapid compensatory contractions to unexpected postural perturbations.

Inleiding: In dit artikel wordt uiteengezet welke dataverzamelingsmethoden er tot nu toe gebruikt zijn bij CQ-index (CQI) onderzoek en wat de respons en representativiteit van respondenten waren. Methode: Uit verschenen CQI publicaties werd de volgende informatie gehaald: gebruikte dataverzamelingsmethode(n), aantal verstuurde herinneringen, het aantal vragen van de gebruikte CQ-index, respons, representativiteit van respondenten voor leeftijd en geslacht. Met correlaties is bekeken waar de respons mee samenhing. Resultaten: Bijna driekwart (22) van de CQI metingen vond schriftelijk plaats. Bij uitzondering werd mondeling (2), via internet (1) of via een combinatie van internet en schriftelijke vragenlijsten (3) gegevens verzameld. De respons was het hoogst bij een mondelinge dataverzameling en het laagst bij dataverzameling via internet. De respons was niet gerelateerd aan de leeftijd van respondenten of het aantal vragen in de vragenlijst. Mannen vulden over het algemeen eerder een internetvragenlijst in dan vrouwen en mannen waren doorgaans ondervertegenwoordigd bij schriftelijke dataverzamelingen. Conclusie: Tot nu toe worden bij CQI onderzoek de gegevens voornamelijk schriftelijk verzameld. De respons varieert zowel binnen als tussen dataverzamelingsmethoden en een combinatie van methoden kan de respons verhogen. De keuze van een dataverzamelingsmethode heeft invloed op de demografische samenstelling van de groep respondenten.

BACKGROUND: Esophagectomy is frequently accompanied by substantial complications with secondary disturbance of the immune system. After esophagectomy for adenocarcinoma of the distal esophagus and/or gastroesophageal junction, the majority of patients develops an early recurrence and dies within 2 years. The aim of this study was to determine the relevance of perioperative complications on the timing of death due to recurrence. METHODS: A consecutive series of 351 patients who underwent esophagectomy for adenocarcinoma of the esophagus and gastroesophageal junction was reviewed. RESULTS: Of the 351 included patients, 191 patients (54%) died due to recurrence of esophageal adenocarcinoma. Of these 191 patients, 77 (40%), 138 (72%), and 186 patients (97%) died before 12, 24, and 60 months, respectively. Multivariate Cox regression analysis demonstrated that T-stage, lymph node ratio >0.20, the presence of extracapsular lymph node involvement, but not complications were significant factors for the prediction of death due to cancer recurrence. However, in the patients who died, multivariate Cox regression analysis demonstrated that not only the presence of extracapsular lymph node involvement but also the occurrence of complications were significantly related with a shorter time interval until death due to recurrence. CONCLUSION: The relation between perioperative complications and cancer recurrence per se is not causal. However, postoperative complications are independently associated with the early timing of death due to cancer recurrence. A possible explanation for this phenomenon is that immunologic host factors enhance microscopic residual disease to develop more rapidly into clinically manifest recurrence

4-Methylthioamphetamine (4-MTA) belongs to a group of new amphetamine derivatives that is usually sold as "ecstasy" or "flatliners" on the illicit drug market. Large interindividual differences in 4-MTA mediated toxicity have been reported in humans. Therefore, we tested whether CYP2D6 or its variant alleles as well as CYP3A4 influence the susceptibility to 4-MTA. For this purpose, we used the colony formation assay with Chinese hamster lung fibroblast V79 cells expressing human wild-type CYP2D6 (CYP2D6*1), the low activity alleles CYP2D6*2, CYP2D6*9, as well as human CYP3A4. The obtained results showed that the expression of wild type CYP2D6*1 clearly enhanced the susceptibility to the cytotoxic effects of 4-MTA compared with the parental cells devoid of CYP-dependent enzymatic activity. Toxicity in V79 CYP2D6*1 was also higher compared to the V79 cell lines expressing the low activity alleles CYP2D6*2 and CYP2D6*9. In contrast to CYP2D6, the CYP3A4 isoenzyme did not enhance 4-MTA toxicity. In conclusion, our results suggest that CYP2D6 rapid metabolizers may be more susceptible to 4-MTA toxicity than CYP2D6 poor metabolizers.

Analysis of fungal secretomes using mass spectrometry is a useful technique in cell biology. Knowledge of the secretome of a human fungal pathogen may yield important information of host-pathogen interactions and may be useful for identifying vaccines candidates or diagnostic markers for antifungal strategies. In this chapter, with a main focus on sample preparation aspects, we describe the methodology that we apply for gel-independent batch identification and quantification of proteins that are secreted during growth in liquid cultures. Using these techniques with Candida and other yeast species, the majority of the identified proteins are classical secretory proteins and cell wall proteins containing N-terminal signal peptides for secretion, although dependent on sample preparation quality and the mass spectrometric analysis also usually, a number of nonsecretory proteins are identified.

Background Patient-reported outcome measures (PROMs) measure patients’ perspectives on health outcomes and are increasingly used in health care. To really capture the patient’s perspective, patient involvement in PROM development is essential. As earlier research showed varying degrees of patient involvement in PROM development, this study aimed to investigate why PROM developers do or do not involve patients and what the costs and benefits of patient involvement are. Methods PROM developers who, according to an earlier scoping review, involved patients in several phases of PROM development or did not involve patients at all, were contacted for a telephone interview. The interviews were recorded and transcribed. The transcripts were sent to the developers for approval. Preliminary results 41 PROM developers who involved patients were contacted. Currently 12 interviews have taken place and 6 additional developers have agreed to an interview. PROM developers perceive patient involvement as necessary to create a valid questionnaire. Most developers do not actively consider which methods should be used to involve patients, but rely on personal experiences or guidelines set by PROMIS or the Food and Drug Administration. Negative aspects of patient involvement were time investment, logistical problems and patients taking over interviews or focus groups. Despite these negative aspects, developers highly recommend patient involvement. To give more insight into the reasons for not involving patients, 16 PROM developers who did not involve patients will be contacted shortly. Discussion Although PROM developers agree that patient involvement is necessary, most do not actively consider pros and cons of different methods that can be used to involve patients. Although guidelines for PROM development may be a good start, to optimize patient involvement developers should not simply follow guidelines but should explicitly think about which methods would suit their study. Key messages Even though patient involvement may have some negative consequences, PROM developers highly recommend involving patients in PROM development. To optimize patient involvement in PROM development, PROM developers should actively consider which methods should be used and further build and improve upon the guidelines for patient involvement.