Pre-operative gastric ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study.

Point-of-care gastric sonography offers an objective approach to assessing individual pulmonary aspiration risk before induction of general anaesthesia. We aimed to evaluate the potential impact of routine pre-operative gastric ultrasound on peri-operative management in a cohort of adult patients undergoing elective or emergency surgery at a single centre. According to pre-operative gastric ultrasound results, patients were classified as low risk (empty, gastric fluid volume ≤ 1.5 ml.kg-1 body weight) or high risk (solid, mixed or gastric fluid volume > 1.5 ml.kg-1 body weight) of aspiration. After sonography, examiners were asked to indicate changes in aspiration risk management (none; more conservative; more liberal) to their pre-defined anaesthetic plan and to adapt it if patient safety was at risk. We included 2003 patients, 1246 (62%) of which underwent elective and 757 (38%) emergency surgery. Among patients who underwent elective surgery, 1046/1246 (84%) had a low-risk and 178/1246 (14%) a high-risk stomach, with this being 587/757 (78%) vs. 158/757 (21%) among patients undergoing emergency surgery, respectively. Routine pre-operative gastric sonography enabled changes in anaesthetic management in 379/2003 (19%) of patients, with these being a more liberal approach in 303/2003 (15%). In patients undergoing elective surgery, pre-operative gastric sonography would have allowed a more liberal approach in 170/1246 (14%) and made a more conservative approach indicated in 52/1246 (4%), whereas in patients undergoing emergency surgery, 133/757 (18%) would have been managed more liberally and 24/757 (3%) more conservatively. We showed that pre-operative gastric ultrasound helps to identify high- and low-risk situations in patients at risk of aspiration and adds useful information to peri-operative management. Our data suggest that routine use of pre-operative gastric ultrasound may improve individualised care and potentially impact patient safety

Causes of mortality in laying hens in different housing systems in 2001 to 2004

<p>Abstract</p> <p>Background</p> <p>The husbandry systems for laying hens were changed in Sweden during the years 2001 – 2004, and an increase in the number of submissions for necropsy from laying hen farms was noted. Hence, this study was initiated to compare causes of mortality in different housing systems for commercial laying hens during this change.</p> <p>Methods</p> <p>Based on results from routine necropsies of 914 laying hens performed at the National Veterinary Institute (SVA) in Uppsala, Sweden between 2001 and 2004, a retrospective study on the occurrence of diseases and cannibalism, i.e., pecking leading to mortality, in different housing systems was carried out. Using the number of disease outbreaks in caged flocks as the baseline, the expected number of flocks with a certain category of disease in the other housing systems was estimated having regard to the total number of birds in the population. Whether the actual number of flocks significantly exceeded the expected number was determined using a Poisson distribution for the variance of the baseline number, a continuity correction and the exact value for the Poisson distribution function in Excel 2000.</p> <p>Results</p> <p>Common causes of mortality in necropsied laying hens included colibacillosis, erysipelas, coccidiosis, red mite infestation, lymphoid leukosis and cannibalism. Less common diagnoses were Newcastle Disease, pasteurellosis and botulism. Considering the size of the populations in the different housing systems, a larger proportion of laying hens than expected was submitted for necropsy from litter-based systems and free range production compared to hens in cages (<it>P </it>< 0.001). The study showed a significantly higher occurrence of bacterial and parasitic diseases and cannibalism in laying hens kept in litter-based housing systems and free-range systems than in hens kept in cages (<it>P </it>< 0.001). The occurrence of viral diseases was significantly higher in indoor litter-based housing systems than in cages (<it>P </it>< 0.001).</p> <p>Conclusion</p> <p>The results of the present study indicated that during 2001–2004 laying hens housed in litter-based housing systems, with or without access to outdoor areas, were at higher risk of infectious diseases and cannibalistic behaviour compared to laying hens in cages. Future research should focus on finding suitable prophylactic measures, including efficient biosecurity routines, to reduce the risk of infectious diseases and cannibalism in litter-based housing systems for laying hens.</p

Crystal Structure of the Minimalist Max-E47 Protein Chimera

Max-E47 is a protein chimera generated from the fusion of the DNA-binding basic region of Max and the dimerization region of E47, both members of the basic region/helix-loop-helix (bHLH) superfamily of transcription factors. Like native Max, Max-E47 binds with high affinity and specificity to the E-box site, 5′-CACGTG, both in vivo and in vitro. We have determined the crystal structure of Max-E47 at 1.7 Å resolution, and found that it associates to form a well-structured dimer even in the absence of its cognate DNA. Analytical ultracentrifugation confirms that Max-E47 is dimeric even at low micromolar concentrations, indicating that the Max-E47 dimer is stable in the absence of DNA. Circular dichroism analysis demonstrates that both non-specific DNA and the E-box site induce similar levels of helical secondary structure in Max-E47. These results suggest that Max-E47 may bind to the E-box following the two-step mechanism proposed for other bHLH proteins. In this mechanism, a rapid step where protein binds to DNA without sequence specificity is followed by a slow step where specific protein:DNA interactions are fine-tuned, leading to sequence-specific recognition. Collectively, these results show that the designed Max-E47 protein chimera behaves both structurally and functionally like its native counterparts

Nurses' perceptions of aids and obstacles to the provision of optimal end of life care in ICU

Contains fulltext : 172380.pdf (publisher's version ) (Open Access

Insulin differentially influences brain glucose and lactate in traumatic brain injured patients

AIM: Hypo- and hyperglycemia must be avoided to prevent additional brain damage following traumatic brain injury (TBI). However, the optimal blood glucose range requiring insulin remains unknown. Cerebral microdialysis is helpful in unmasking signs of metabolic impairment, thereby identifying deleterious blood glucose levels. METHODS: A retrospective analysis of prospectively collected cerebral microdialysis samples obtained from 20 non-diabetic patients with severe TBI treated at the trauma surgical intensive care unit at the University Hospital Zürich, Switzerland. RESULTS: The impact of different arterial blood glucose values and concomitant insulin administration on cerebral interstitial glucose and lactate levels was investigated. In addition, energetic impairment was determined by calculating lactate-to-glucose ratios. Insulin administration was associated with significantly reduced cerebral glucose concentrations and significantly increased lactate-to-glucose ratios with arterial blood glucose levels 7 mM, insulin administration was associated with significantly increased interstitial glucose values, significantly decreased lactate concentrations, and markedly diminished lactate-to-glucose ratios. CONCLUSION: Insulin exerts differential effects that depend strongly on the underlying arterial blood glucose concentrations. To avoid energetic impairment, insulin should not be administered at arterial blood glucose levels 7-8 mM, insulin administration appears to be encouraged to increase extracellular glucose concentrations and decrease energetic impairment reflected by reduced interstitial brain lactate and decreased lactate-to-glucose ratios. Nevertheless, frequent analysis is required to minimize the risk of inducing impaired brain metabolism