Diagnosing Staphylococcus aureus endocarditis by detecting antibodies against S. aureus capsular polysaccharide types 5 and 8

Consecutive serum samples from patients with Staphylococcus aureus endocarditis or septicemia or non-S. aureus endocarditis and febrile nonsepticemic controls were tested for antibodies against S. aureus capsular polysaccharide (CP) types 5 and 8 by ELISA. The upper normal antibody levels were defined as the upper 99.5% confidence limits of the values from the febrile controls. All available patient isolates were tested for the presence of CP type 5 or 8 (85% of the isolates expressed either serotype), and all five patients with S. aureus endocarditis had positive antibody levels against the corresponding serotype within the first 10 days of infection. Three other endocarditis patients lacked isolates for CP testing but two of these were positive. Positive antibody levels were found in 0 of 28 septicemia patients, in 1 of 12 non-S. aureus endocarditis patients, and in 3 of 37 febrile controls. Thus, testing for anti-CP 5 or 8 antibodies, especially together with CP serotyping of the patient's isolate, seems to provide important information in the differential diagnosis of endocarditis in patients with S. aureus septicemia.     

Clinical significance of the WHO grades of follicular lymphoma in a population-based cohort of 505 patients with long follow-up times

The prognostic value of grading follicular lymphoma has been debated since the 1980s. There is consensus that World Health Organization (WHO) grades 1 and 2 are indolent, but not whether grades 3A or 3B are aggressive. We retrospectively reviewed the follicular lymphoma diagnoses according to the 2008 WHO classification in all diagnostic specimens from a population-based cohort of 505 patients with a median follow-up time of 10·0years (range, 4·6-16·0). After excluding 43 patients with concomitant diffuse large B-cell lymphoma, 345 remained with grade 1-2, 94 with grade 3A, and 23 with grade 3B follicular lymphoma. Grades 1-2 and 3A seemed equally indolent, with indistinguishable clinical courses, even in patients receiving anthracyclines. Compared with grades 1-3A and independently of clinical factors, grade 3B correlated with higher mortality (P=0·008), but outcome was improved after upfront anthracycline-containing therapy (P=0·015). In contrast to grade 1-3A patients, grade 3B patients experienced no relapses or deaths beyond 5years of follow-up. Furthermore, patients with grade 3B were predominantly male and seldom presented with bone-marrow involvement. We conclude that follicular lymphoma grade 1-3A is indolent and incurable with conventional therapy. Grade 3B appears to be an aggressive but curable disease.     

Hypoxic ventilatory response after rocuronium-induced partial neuromuscular blockade in men with obstructive sleep apnoea

Obstructive sleep apnoea and residual neuromuscular blockade are, independently, known to be risk factors for respiratory complications after major surgery. Residual effects of neuromuscular blocking agents are known to reduce the hypoxic ventilatory response in healthy volunteers. Patients with obstructive sleep apnoea have impaired control of breathing, but it is not known to what extent neuromuscular blocking agents interfere with the regulation of breathing in such patients. In a physiological study in 10 unsedated men with untreated obstructive sleep apnoea, we wished to examine if partial neuromuscular blockade had an effect on hypoxic ventilatory response (isocapnic hypoxia to oxygen saturation of 80%) and hypercapnic ventilatory response (normoxic inspired carbon dioxide 5%). The hypoxic ventilatory response was reduced by 32% (p = 0.016) during residual neuromuscular block (rocuronium to train-of-four ratio 0.7), but the hypercapnic ventilatory response was unaffected. We conclude that neuromuscular blockade specifically depresses peripheral chemosensitivity, and not respiratory muscle function since the hypercapnic ventilatory response was unaffected.     

Syringe exchange for prevention of HIV infection in Sweden: practical experiences and community reactions.

An HIV prevention project, including syringe exchange, among intravenous drug users was started in Lund, Sweden, in November 1986. The program has been effective in reaching local addicts. Practical problems have been few. The educational and epidemiological effects on HIV infection are promising, and local drug treatment programs have benefited from the project in that previously untreated users have been attracted to treatment. The syringe exchange has been much debated. In general, the medical society, local authorities, and mass media have been supportive, while many politicians and social workers, especially in other parts of the country, have been strongly opposed. At present, the existence of the project is threatened.     

Caring for women undergoing second-trimester medical termination of pregnancy

Objective

The objective was to explore the experiences and perceptions of nurses/midwives caring for women undergoing second-trimester medical termination of pregnancy (MTOP).

Study design

The study had a qualitative design using semistructured interviews. It took place in three wards at one gynecological clinic in a general hospital in Stockholm. Twenty-one nurses/midwives with experience in second-trimester abortion care were interviewed following a semistructured interview guide. The interviews were recorded, transcribed verbatim and then analyzed using qualitative content analysis to identify common themes.

Results

The analysis revealed two themes: “The professional self,” with six subthemes describing the experiences and perceptions described in terms of professional behavior, and “The personal self,” with four subthemes containing the experiences and perceptions described in terms of personal values.

Conclusions

Taking care of women undergoing second-trimester MTOP is a task that requires professional knowledge, empathy and the ability to reflect on ethical attitudes and considerations. Difficult situations that arise during the process are easier to handle with increased knowledge and experience. The feeling of supporting women's rights bridges the difficulties nurses/midwives face in caring for women undergoing second-trimester MTOP. The findings of this study support the need for training, mentoring and support by experienced colleagues to help nurses/midwives feel secure in their professional role in difficult situations and feel confident in their personal life situation.

Implications statement

Taking care of women undergoing second-trimester MTOP is a task that requires professional knowledge and empathy. Difficult situations that arise during the process are easier to handle with increased knowledge and experience. Mentorship from experienced colleagues and structured opportunities for reflection on ethical issues enable the nurses/midwives to develop security in their professional roles and also feel confident in their personal life situation. The feeling of doing something good for women's rights bridges the difficulties nurses/midwives face in caring for women undergoing second-trimester MTOP.     

Social Issues Among Children With High or Intermediate Imperforate Anus: A Proxy Perspective

PROBLEM:  Children with imperforate anus (IA) may be psychosocially affected.
METHODS:  Parents of children with IA and parents in two comparison groups rated their children using a study-specific questionnaire and the Competence Scales in the Child Behavior Checklist (CBCL). Teachers rated Academic and Adaptive Functioning Scales in the Teacher's Report Form (TRF).
FINDINGS:  School items were rated favorably by the fathers of children with IA, and mothers reported less expression of their children's will. Children with IA were socially competent according to CBCL, although they received lower ratings on the TRF.
CONCLUSIONS:  Psychosocial issues seem to be challenging for children with IA, and this needs attention in care management.     

A unifying model for timing of walking onset in humans and other mammals

The onset of walking is a fundamental milestone in motor development of humans and other mammals, yet little is known about what factors determine its timing. Hoofed animals start walking within hours after birth, rodents and small carnivores require days or weeks, and nonhuman primates take months and humans approximately a year to achieve this locomotor skill. Here we show that a key to the explanation for these differences is that time to the onset of walking counts from conception and not from birth, indicating that mechanisms underlying motor development constitute a functional continuum from pre- to postnatal life. In a multiple-regression model encompassing 24 species representative of 11 extant orders of placental mammals that habitually walk on the ground, including humans, adult brain mass accounted for 94% of variance in time to walking onset postconception. A dichotomous variable reflecting species differences in functional limb anatomy accounted for another 3.8% of variance. The model predicted the timing of walking onset in humans with high accuracy, showing that this milestone in human motor development occurs no later than expected given the mass of the adult human brain, which in turn reflects the duration of its ontogenetic development. The timing of motor development appears to be highly conserved in mammalian evolution as the ancestors of some of the species in the sample presented here diverged in phylogenesis as long as 100 million years ago. Fundamental patterns of early human life history may therefore have evolved before the evolution of primates.     

Safety of inhaled budesonide: clinical manifestations of systemic corticosteroid-related adverse effects

Inhaled corticosteroid (ICS) therapy is central to the long-term management of asthma and is extensively used in the management of chronic obstructive pulmonary disease (COPD). While administration via inhalation limits systemic exposure compared with oral or injected corticosteroids and, therefore, the risk of systemic corticosteroid-related adverse effects, concerns over the long-term safety of ICS persist. The assessment of the long-term effects of ICS therapy requires considerable research effort over years or even decades. Surrogate markers/predictors for clinical endpoints such as adrenal crisis, reduced final height and fractures have been identified for use in relatively short-term studies. However, the predictive value of such markers remains questionable.Inhaled budesonide has been available since the early 1980s and there is a considerable evidence base investigating the safety of this agent. To assess the long-term safety of inhaled budesonide therapy in terms of the actual incidence of the clinical endpoints adrenal crisis/insufficiency, reduced final height, fractures and pregnancy complications, we undertook a review of the scientific literature. The external databases BIOSIS, Cochrane Central Register of Controlled Trials, Current Contents, EMBASE, International Pharmaceutical Abstracts and MEDLINE were searched, in addition to AstraZeneca's internal product literature database Planet, up to 29 February 2008. Only original articles of epidemiological studies, national surveys, clinical trials and case reports concerning inhaled budesonide were included.Eight surveys of adrenal crisis were found. The only survey with specified criteria for diagnosis involved 2912 paediatricians and endocrinologists and revealed 33 patients with adrenal crisis associated with ICS therapy; only one patient used budesonide (in co-treatment with fluticasone propionate). In addition, 14 case reports of adrenal crisis in budesonide-treated patients were found. In only two of these, budesonide was used at recommended doses and in the absence of interacting medication.Three retrospective studies and one prospective study assessing final height were found. None of them showed any reduced final height in patients receiving inhaled budesonide during childhood or adolescence.Seventeen epidemiological studies investigating the risk of fractures were found. When adjusting for confounding factors, they did not provide any unequivocal data for an increased fracture risk with budesonide. Four prospective placebo-controlled clinical trials of 2-6 years duration with inhaled budesonide in patients with asthma or COPD were found. None of the studies identified any association between inhaled budesonide and increased risk for fractures.Four studies using data from the Swedish birth and health registries showed there was no increased risk for congenital malformations, cardiovascular defects, decreased gestational age, birth weight or birth length among infants born to women using inhaled budesonide during pregnancy compared with the general population. This was confirmed by five observational studies in Australia, Canada, Hungary, Japan and the US. Similarly, one randomized clinical trial comparing pregnancy outcomes among asthma patients receiving inhaled budesonide or placebo did not demonstrate any difference in outcome of pregnancy.In summary, based on 25 years of experience with different doses and in different populations, inhaled budesonide therapy only in very rare cases appears to be associated with an increased risk of adrenal crisis, reduction in final height, increases in the number of fractures or complications during pregnancy.     

Lower body temperatures in infants delivered by caesarean section than in vaginally delivered infants

Clinical experience suggests that infants delivered by caesarean section have difficulties maintaining normal body temperature during the first hours after birth. To test this hypothesis, body and skin temperatures were measured and compared in healthy full-term caesarean section and vaginally delivered newborn infants. The babies were studied during the first 90 min after birth. Axillary and skin temperatures were significantly higher in the vaginally delivered group than in infants delivered by caesarean section. Infants born by non-elective caesarean section were slightly warmer during the first 90 min after birth compared to infants born by elective caesarean section. There were no significant differences in temperatures between infants cared for in a cot as compared to those cared for in an incubator. An incubator creates a physical barrier between babies and parents and incubator care might cause parental anxiety. Thus the routine of putting healthy, full-term caesarean section infants in incubators can be abandoned from a thermoregulatory point of view.