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How to assess and treat an ostomate presenting with bleeding from their stoma or peristomal skin

BACKGROUND Initiation of parenteral nutrition (PN) after a period of starvation can be complicated by refeeding syndrome (RFS). RFS is associated with electrolyte abnormalities including hypomagnesemia, hyponatremia, and hypophosphatemia. Risk factors include recent weight loss, low body mass index, and electrolyte deficiencies; however, these associations are not strong. We hypothesized that a validated measure of nutrition risk, computed tomography (CT)-measured psoas muscle density, can be used to predict the development of hypophosphatemia associated with RFS. METHODS A retrospective analysis of surgical patients initiated on PN with an abdominal CT scan within the past 3 months was conducted. CT-measured psoas muscle density was assessed as a predictive variable for the development of electrolyte abnormalities. Daily electrolyte and clinical outcome measures were recorded. RESULTS One hundred nine patients were stratified based on Hounsfield unit average calculation (HUAC). The lowest 25th percentile of patients had HUAC

Combining natural capital accounting tools and ecosystem restoration approaches builds on existing frameworks to track changes in ecosystem stocks and flows of services and benefits as a result of restoration. This approach highlights policy-relevant benefits that arise due to restoration efforts and helps to maximize opportunities for return on investment. Aligning the System of Environmental Economic Accounting–Ecosystem Accounting (SEEA EA) framework with risk assessment tools, we developed a risk register for peatlands in two contrasting catchments in Ireland, based on available information relating to peatland stocks (extent and condition) and flows (services and benefits), as well as knowledge of pressures. This approach allowed for identification of areas to target peatland restoration, by highlighting the potential to reduce and reverse negative trends in relation to provisioning, regulating, and cultural services, flows relating to non-use values, as well as abiotic flows. We also highlighted ways to reduce and reverse the effects of historical and ongoing pressures through restoration measures, aligning our approach with that outlined in the SER International Principles and Standards for the Practice of Ecological Restoration. Building on the synergies between the SEEA EA and the SER Standards is highlighted as a means to develop transdisciplinary collaboration, to assist in setting and achieving targets set out under the UN Decade on Ecosystem Restoration as well as integrating regional policy targets set under the EU Biodiversity Strategy for 2030, and the related EU Habitats and EU Water Framework Directives.

There are 415,000 children in foster care in the USA. Many of those children will turn 18 before being adopted, meaning they will “age-out” and essentially be on their own as adults. We wanted to see if formal mentoring programs improved outcomes for those aging out of foster care and the Journey Up Mentorship Program in Salt Lake City offered such a program. Forty-nine youth who had aged out of foster care with the help of mentors were surveyed and found they scored significantly higher in their ability to get jobs and were less at risk for addiction, homelessness, and incarceration compared to data from the National Youth in Transition for Utah. Fifteen additional youth were interviewed in focus groups to explore the results further. Qualitative data showed participants were not less at risk given their stories, and benefited from mentors’ consistency, positive role modeling, and lessons on being an adult. This is consistent with other studies on the topic of mentoring but should be expanded into more specified comparative studies and use larger sample sizes.

Ecosystem accounting is a tool to integrate nature into decision-making in a more structured way. Applying the use of nationally available datasets at catchment scale and following the System of Environmental Economic Accounting-Ecosystem Accounting (SEEA-EA) framework, we present results from a catchment case study in Ireland, highlighting findings specifically in relation to the development of ecosystem extent and condition accounts. In the absence of a national ecosystem map, CORINE landcover mapping formed the basic data for extent and type of ecosystems, distinguishing woodlands and forest, peatland and heathland, grasslands and cropland and urban areas, with limited coverage of linear freshwater rivers, hedgerows and coastal ecosystems. Additional remote sensing data provided higher resolution at catchment scale, while limited site-level survey data were available. Condition data gathered for reporting under the EU Water Framework Directive were available at sub-basin level for surface waterbodies. Data were available at national level for habitats reported for the EU under the Habitats Directive (59 habitats reported), covering ~ 25% of the study area. Data for ecosystem types outside of these reporting frameworks were in the form of ancillary data only, providing information on pressures, threats and intensity of use. Our findings in Ireland reflect work across the European region, highlighting the role of data gathering and stakeholder engagement. We outline some of the data gaps to provide information for future research and alignment of data for the purpose of NCA, both at catchment and national scale. © Farrell C et al.

AimAlthough manual adjustment of automatic cone beam computed tomography (CBCT) matching may improve the target coverage in certain points of interest, concerns exist that this may lead to dosimetric uncertainties which would negate the theoretical benefit of this approach. The objective of this study is to evaluate the dosimetric impact of manual adjustments made after automatic bony registration on CBCT in prostate patients.MethodsA total of 50 CBCT datasets of ten high-risk prostate cancer patients were randomly chosen. Each CBCT dataset was registered three times. Method (A): Automatic registration, Method (M1): Manual adjustment carried out by two experienced radiation therapists, Method (M2): Manual adjustment carried out by different radiation therapists with varying levels of experience. The clinical target volume (CTV), planning target volume (PTV), the bladder and the rectum were subsequently contoured on each CBCT dataset by a radiation oncologist blinded to the registration methods. The absolute difference of various dosimetric parameters were then analysed and compared with the original planning doses. A comparison of the three matching methods employed was also carried out.ResultsThere was a statistically significant difference in the magnitude of move taken in the inferior superior direction between M1 and M2 method. There were no significant differences observed in any of the dosimetric parameters examined in relation to the rectum, bladder or CTV. The only significant difference observed was the volume of PTV covered by the prescription isodose (95%) which was statistically significant lower in method A compared with both M1 and M2. There was no difference observed between M1 and M2 methods. The mean duration of the automated registration and subsequent analysis was 64 seconds compared with 91 seconds for automated registrations which included the additional manual adjustment.FindingsCBCT-based manual adjustments of automated bony-based registrations during the image-guided radiotherapy verification of prostate cancer patients can improve PTV coverage without impacting negatively on the doses received by the organs at risk. This strategy is associated with a small increase in overall treatment time.

Background: The risk of acquiring Lyme disease has been evaluated by xenodiagnostic procedures with laboratory strains of Borrelia burgdorferi and laboratory-reared Ixodes ticks, or by clinical trials in which diagnosis was based on clinical findings, culture, or serologic tests. Objective: Our purpose was to determine the risk of infection from tick bites in a natural setting in which wild strains of B. burgdorferi were involved, by a biopsy culture technique. Methods: Skin biopsy specimens were obtained from Ixodes scapularis tick bite sites, processed, and examined for the presence of B. burgdorferi . Results: B. burgdorferi was cultivated from only 2 of 48 skin biopsy specimens. In both instances duration of tick attachment was approximately 24 hours. Conclusion: In a hyperendemic region for Lyme disease the risk of infection after a deer tick bite appears to be low, particularly if the tick has been attached for less than 24 hours.

This paper gives crude estimates of the environmental consequences associated with the birth of one baby in the United States. We calculate the magnitude of one hundred environmental impacts which one American born today will cause over a lifetime. The impacts are grouped under five headings: waste generation, mineral consumption, energy consumption, ecosystem alteration, and food consumption. We also consider, but do not quantify, impacts on extinctions of species and indigenous cultures. Our purpose is to emphasize the role of population growth in the creation of environmental problems, and to make potential parents aware of their ability to impact the global environment. We conclude that one especially effective way for individuals to protect the national and global environment, and hence protect the wellbeing of all existing people, is to stop creating more humans.

Background: We recently demonstrated that cultivation of Borrelia burgdorferi from skin biopsy specimens obtained from erythema migrans lesions was an efficacious procedure to confirm the diagnosis of Lyme disease. Objective: Our purpose was to investigate the efficacy of our microbiologic technique on blood samples obtained from patients with Lyme disease and erythema migrans. Methods: Whole blood samples were obtained from 52 patients with erythema migrans and early localized or early disseminated Lyme disease and placed into polystyrene tubes containing 6 ml of modified Barbour-Stoenner-Kelly medium, processed, and examined for B. burgdorferi by dark-field microscopy. Results: B. burgdorferi was cultured from the blood of two of our 52 patients (4%). Clinically, both of these patients were considered to have early localized Lyme disease. Conclusion: The culture of B. burgdorferi from the blood of patients with early Lyme disease does not appear to be an efficacious procedure to confirm the diagnosis of Lyme disease. However, the demonstration of spirochetemia in patients with erythema migrans without any extracutaneous evidence of disseminated illness does have therapeutic significance.

A mutant of virulent Borrelia burgdorferi 297 was apparently selected for by long-term storage at 5 degrees C. This mutant was found to lack the plasmid which encodes outer surface protein A (OspA) and OspB. In addition to the loss of the OspA and OspB proteins, the mutant lacked two lipoproteins, of 20 and 7.5 kDa, that were observed in the wild type. Since the mutant was not recovered from the tissues or blood of hamsters injected with the mutant, the mutant was determined to be noninfectious. Hamsters vaccinated with noninfectious mutant 297 were protected completely from challenge with virulent wild-type 297 spirochetes. Prechallenge sera from hamsters vaccinated with mutant 297 lacked antibodies to OspA and OspB, while those from hamsters vaccinated with virulent wild-type 297 or avirulent 297 exhibited antibodies to these proteins. Hamsters vaccinated with virulent wild-type 297 or mutant 297 elicited antibodies to OspC and a 39-kDa protein (P39), whereas hamsters vaccinated with avirulent 297 lacked these antibodies. These results suggest that OspC and/or P39 are important for the development of a protective immune response. Study of this mutant may elucidate factors important to the development of a Lyme disease vaccine.

Many formulations of Thimerosal (49.55% mercury by weight)-containing Rho(D) immune globulins (TCRs) were routinely administered to Rh-negative mothers in the US prior to 2002.It was hypothesized: (1) if prenatal Rho(D)-immune globulin preparation exposure was a risk factor for neurodevelopmental disorders (NDs) then more children with NDs would have Rh-negative mothers compared to controls; and (2) if Thimerosal in the Rho(D)-immune globulin preparations was the ingredient associated with NDs, following the removal of Thimerosal from all manufactured Rho(D)-immune globulin preparations from 2002 in the US the frequency of maternal Rh-negativity among children with NDs should be similar to control populations.Maternal Rh-negativity was assessed at two sites (Clinic A-Lynchburg, VA; Clinic B-Rockville and Baltimore, MD) among 298 Caucasian children with NDs and known Rh-status. As controls, maternal Rh-negativity frequency was determined from 124 Caucasian children (born 1987-2001) without NDs at Clinic A, and the Rh-negativity frequency was determined from 1,021 Caucasian pregnant mothers that presented for prenatal genetic care at Clinic B (1980-1989). Additionally, 22 Caucasian patients with NDs born from 2002 onwards (Clinics A and B) were assessed for maternal Rh-negativity.There were significant and comparable increases in maternal Rh-negativity among children with NDs (Clinic: A=24.2%), autism spectrum disorders (Clinic: A=28.3%, B=25.3%), and attention-deficit-disorder/attention-deficit-hyperactivity-disorder (Clinic: A=26.3%) observed at both clinics in comparison to both control groups (Clinic: A=12.1%, B=13.9%) employed. Children with NDs born post-2001 had a maternal Rh-negativity frequency (13.6%) similar to controls.This study associates TCR exposure with some NDs in children.

Human granulocytic ehrlichiosis (HGE) is an emerging infection caused by an Ehrlichia species closely related to Ehrlichia equi and Ehrlichia phagocytophila . Recent advances in the isolation and cultivation of this organism have allowed us to develop an immunofluorescence assay (IFA), enzyme immunoassay (EIA), and Western immunoblotting (WB) using HL-60 cell culture-derived human isolates. Antibody was detected in sera from culture-confirmed HGE patients by IFA and EIA, and these samples were reactive when analyzed by immunoblot analysis. HGE patient sera had high antibody titers and did not react with uninfected HL-60 cells. When IFA, EIA, and WB were used to analyze sera from healthy donors or those with a range of other disorders, including infections caused by Ehrlichia chaffeensis , Rickettsia rickettsii , and Coxiella burnetti , no significant cross-reactivity could be detected by EIA or immunoblot analysis with the exception of two of four serum samples from R. rickettsii -infected patients that were reactive by IFA only. Sera from HGE patients did not significantly cross-react in serologic tests for Borrelia burgdorferi . Using sera from patients previously enrolled in two clinical trials of treatment for early Lyme disease, we evaluated a two-step approach for estimation of the seroprevalence of antibodies reactive with the etiologic agent of HGE. On the basis of the immunoblot assay results for sera from culture-confirmed HGE patients, WB was used to confirm the specificity of the antibody detected by EIA and IFA. EIA was found to be superior to IFA in the ability to detect WB-confirmed antibodies to the HGE agent. When EIA and WB were used, 56 (19.9%) patients with early Lyme disease ( n = 281) had either specific immunoglobulin M (IgM) or IgG antibodies; 38 patients (13.5%) had IgM only, 6 (2.1%) had IgG only, and 12 (4.3%) had both IgM and IgG. Therefore, Lyme disease patients are at high potential risk for exposure to Ehrlichia . Analysis by immunoblotting of serial samples from persons with culture-confirmed HGE or patients with Lyme disease and antibodies to the agent of HGE revealed a reproducible pattern of the immune response to specific antigens. These samples confirmed the importance of the 42- to 45-kDa antigens as early, persistent, and specific markers of HGE infection. Other significant immunogenic proteins appear at 20, 21, 28, 30, and 60 kDa. Use of the two-test method of screening by EIA and confirming the specificity by WB appears to offer a sound approach to the clinical immunodiagnosis of HGE.

The correlation of plasmid profiles with infectivity was investigated by using five clones of Borrelia burgdorferi sensu stricto strain B31 (ATCC 35210). Plasmid profiles were determined by pulsed-field and two-dimensional gel electrophoresis. The 50% infectious dose (ID50) in hamsters was determined. The ID50 of the clone that possessed a full complement of eight linear and three circular plasmids was 10(3) cells. The loss of the 27.5- and 40-kb linear plasmids did not decrease the infectivity of these cells. Rather, the loss of the 27.5-kb linear plasmid was associated with a more disseminated infection. A moderate decrease of the ID50 from 10(3) to 10(5) cells correlated with the loss of the 9.0-kb circular plasmid and the 27.5-kb linear plasmid. A major loss of infectivity (ID50 > 10(3) cells) occurred with cells that lost the 24.7- and 27.5-kb linear plasmids and the 9.0-kb circular plasmid. A 3.0-kb HindIII fragment of the 24.7-kb linear plasmid was used as a probe to determine the presence of the homologous sequences in the three genospecies of Lyme disease spirochetes. An analysis of 21 infectious strains of B. burgdorferi sensu stricto, B. garinii, and B. afzelii revealed a consistent association of infectivity with strains possessing a linear plasmid (size range, 24 to 36 kb) that hybridized with the HindIII fragment. Western immunoblotting with hamster antisera against infectious B31 clone C-3 revealed two proteins with molecular masses of 28 and 43 kDa that were absent in the noninfectious B31 clone C-1. Additionally, a 14-kDa protein was absent in C-1 but present in infectious clone C-9 as shown by two-dimensional polyacrylamide gel electrophoresis.

Background: Borrelia burgdorferi has been cultivated from clinically normal skin (previous erythema migrans sites) after antibiotic therapy for Lyme disease. Objective: We investigated the possibility of similar findings in 13 of our patients with antibiotic-treated Lyme disease from whom B. burgdorferi was cultivated from their erythema migrans lesions before antibiotic therapy. Methods: After treatment with doxycycline or a combination of amoxicillin and probenecid, skin biopsy specimens were obtained from clinically normal skin adjacent to the previous biopsy sites and cultured. Results: B. burgdorferi was not cultivated from these post treatment biopsy sites. Conclusion: The failure of B. burgdorferi to survive in the former erythema migrans sites of our antibiotic-treated patients, as well as their favorable clinical response, supports the use of doxycycline or combined amoxicillin and probenecid in the treatment of early Lyme disease but does not preclude the survival of the organism in other tissues.

This article examines the housing circumstances of 70 women over sixty living independently in Sydney, Canberra and Queanbeyan. The four major housing alternatives for older women — home ownership, public rental, private rental and retirement villages —were explored from the women's point of view. Although in line with other studies private rental was revealed as the worst housing option for the aged, important issues were raised concerning problems in the other three sectors. Particular emphasis in the article is placed on the impact of women's social and economic status on their housing experiences in old age.