EXPLORING MEDICAL STUDENTS' COMPETENCY IN UNDERSTANDING PRIMARY IMMUNODEFICIENCY DISEASES IN INDIA.

Primary Immunodeficiency Disease (PID) represents a class of diverse illnesses marked by compromised immune system performance. For better patient outcomes, PIDs must be diagnosed and treated quickly. Medical graduates are essential to the detection and treatment of these illnesses. The purpose of this study was to evaluate medical students' knowledge about PIDs in different Indian medical colleges. To perform this analytical investigation, college students from Maharashtra-area universities were enlisted between March and April of 2023. The participants received a questionnaire from mediators from every institution. Of the 500 students in the study, 66% were between the ages of 22 and 24 and 52% were female. Their understanding ratings had an average of 16.3±6.2 and varied between 4 and 32. A set of students classified as below average (86%) and a mean/above average (14%), were separated among the students. The largest percentage of above-average knowledge was demonstrated by VI-year participants (p<0.05). This investigation emphasizes how critical it is to provide focused educational activities to improve medical students' comprehension of PIDs in India.

Clinical evaluation of the safety and efficacy of a 1064 nm diode laser, and vacuum assisted pulsed electromagnetic fields and multipolar radio frequency for noninvasive fat reduction of the abdomen and flanks.

BACKGROUND: Noninvasive cosmetic body contouring techniques are growing rapidly, and noninvasive lipolysis has been shown to have low pain, little downtime and produce consistent long-term results. The objective of this study was to evaluate the safety and efficacy of a 1064 nm diode laser combined with vacuum assisted PEMF and RF energies for noninvasive fat reduction of the abdomen and flanks. METHODS: Subjects received a series of three treatments 8 weeks apart, each consisting of a diode laser session, followed by vacuum assisted PEMF and RF. Before and after photographs were graded for overall fat reduction by three blinded evaluators. Ultrasound was used to measure changes in the thickness of adipose tissue. Subject satisfaction was assessed using the 5-Point Likert Subject Satisfaction Scale and a subject questionnaire at 16 and 24-week follow-up visits. Throughout each treatment, the subjects were given the Wong-Baker Faces Pain Rating Scale (WBFS) to assess discomfort and pain of the treatment. RESULTS: Thirty-nine subjects (average age 48.6 years) from four clinical sites were enrolled. Evaluators identified the correct before and after images 73.1% of the time and images were graded an average score of 1.12 (SE 0.1) correlating to more than a "slight change." Adipose tissue was reduced by 31.9% based on ultrasound measurements (p < 0.001). Subject satisfaction was high with an average satisfaction score of 7.8 ("satisfied") out of 10. The overall pain over time on average was rated "hurts little bit." Ninety percent of subjects reported either a mild, moderate, or significant improvement in their fat reduction and skin surface appearance. Almost 77% (76.7%) of subjects reported that they would recommend the treatment to a friend. There were six reports of adverse events related to the device during the study that were all transient and resolved rapidly. CONCLUSION: A significant reduction of subcutaneous adipose tissue was measured after treatment with a combination of diode laser and vacuum assisted PEMF and RF. Treatment pain was low and tolerable, and subjects had high levels of satisfaction with the results.

EFFECTS OF SOCIAL ESTRANGEMENT ON YOUNG PEOPLE'S MATURATION: A REVIEW OF THE RESEARCH.

A major issue among adolescents in recent years has been social isolation, or the sensation cut off and alone from peers and society. The effects of social isolation on youngsters and adolescents are investigated with special attention paying to the possible negative effects on their physical and mental health. Multiple studies have shown a link between adversity in life domains and adolescent social isolation. Firstly, it can have a major effect on mental health, raising the probability of experiencing things like anxiety, sadness and even suicidal thoughts. Second, it prevents the development of vital social abilities, making it harder to make and keep close friends. In addition, social isolation is associated with worse academic performance, which in turn reduces the number of courses a student can take and the number of jobs they can have in the future. After looking over 520 papers, 15 were chosen for the systematic review. Four researches reported the implications on general health, while two investigations reported on ramifications affecting the Hypothalamic-pituitary-adrenal (HPA) axis area along with social and mental growth of children. In conclusion, social isolation affects youth development across a wide spectrum, including psychological well-being, interpersonal skills, and academic success. Children and adolescents who experience isolation are more likely to suffer from anxiety and sadness, according to the review's findings. Cortical levels rise and mental growth slows in socially isolated children. Children and adolescents should be monitored by health professionals during and after the COVID-19 pandemic to ensure that their mental and physical health needs are met.

Nosocomial acquisition of influenza is associated with significant morbidity and mortality: Results of a prospective observational study.

BACKGROUND: Nosocomial acquisition of influenza is known to occur but the risk after exposure to a known case and the outcomes after acquisition are poorly defined. METHODS: Prospective observational study of patients exposed to influenza from another patient in a multi-site healthcare organisation, with follow-up of 7 days or until discharge, and PCR-confirmation of symptomatic disease. Multivariable analysis was used to investigate association of influenza acquisition with high dependency unit/intensive care unit (HDU/ITU) admission and in-hospital mortality. RESULTS: 23/298 (7.7%) contacts of 11 cases were subsequently symptomatic and tested influenza-positive during follow-up. HDU/ITU admission was significantly higher in these secondary cases (6/23, 26%) compared to flu-negative contacts (20/275, 7.2%; p = 0.002). In-hospital mortality was significantly higher in secondary cases (5/23, 21.7%) compared to flu-negative contacts (11/275, 4%; p < 0.001). In multivariable analysis, age (OR 1.25 95% CI: 1.01-1.54, p = 0.02) and being a secondary case (OR 4.77, 95% CI: 1.63-13.9, p = 0.008) were significantly associated with HDU/ITU admission in contacts. Age (OR 1.00, 95% CI: 0.93-1.00, p = 0.02), being a secondary case after exposure to influenza (OR 3.81, 95% CI 1.09-13.3, p = 0.049) and co-morbidity (OR 1.29 per unit increment in the Charlson score, 95% CI 1.02-1.61, p = 0.03) were significantly associated with in-hospital mortality in contacts. CONCLUSIONS: Nosocomial acquisition of influenza was significantly associated with increased risk of HDU/ITU admission and in-hospital mortality.

Real-world deployment of lateral flow SARS-CoV-2 antigen detection in the emergency department to provide rapid, accurate and safe diagnosis of COVID-19.

BACKGROUND: Point-of-care (POC) SARS-CoV-2 lateral-flow antigen detection (LFD) testing in the emergency department (ED) could inform rapid infection control decisions but requirements for safe deployment have not been fully defined. METHODS: Review of LFD test results, laboratory and POC-RT-PCR results and ED-performance metrics during a two-week high SARS-CoV-2 prevalence period followed by several months of falling prevalence. AIM: Determine whether LFD testing can be safely deployed in ED to provide an effective universal SARS-CoV-2 testing capability. FINDINGS: 93% (345/371) of COVID-19 patients left ED with a virological diagnosis during the 2-week universal LFD evaluation period compared to 77% with targeted POC-RT-PCR deployment alone, on background of approximately one-third having an NHS Track and Trace RT-PCR test-result at presentation. LFD sensitivity and specificity was 70.7% and 99.1% respectively providing a PPV of 97.7% and NPV of 86.4% with disease prevalence of 34.7%. ED discharge-delays (breaches) attributable to COVID-19 fell to 33/3532 (0.94%) compared with the preceding POC-RT-PCR period (107/4114 (2.6%); p=<0.0001). Importantly, LFD testing identified 1 or 2 clinically-unsuspected COVID-19 patients/day. Three clinically-confirmed LFD false positive patients were appropriately triaged based on LFD action-card flowchart, and only 5 of 95 false-negative LFD results were inappropriately admitted to non-COVID-19 areas where no onward-transmission was identified. LFD testing was restricted to asymptomatic patients when disease prevalence fell below 5% and detected 1-3 cases/week. CONCLUSION: Universal SARS-CoV-2 LFD testing can be safely and effectively deployed in ED alongside POC-RT-PCR testing during periods of high and low disease prevalence.

Numerical techniques to find optimal input parameters for achieving mean particles' temperature and axial velocity in atmospheric plasma spray process.

We numerically find values of four process input parameters, namely, the argon flow rate, the hydrogen flow rate, the powder feed rate, and the current, that yield the desired mean particles' temperature and the mean particle velocity (collectively called mean particles' characteristics, or MPCs) in an atmospheric plasma spray process just before the particles arrive at the substrate to be coated. Previous studies have shown that the coating quality depends upon the MPCs. The process is simulated by using the software, LAVA-P-3D, that provides MPCs close to their experimental values. Thus, numerical rather than physical experiments are conducted. We first use the design of experiments to characterize the sensitivity of the MPCs to process parameters. We then identify relationships between the significant input parameters and the MPCs by using two methods, namely, the least squares regression and the response surface methodology (RSM). Finally, we employ an optimization algorithm in conjunction with the weighted sum method to find optimum values of the process input variables to achieve desired values of the MPCs. The effects of weights assigned to the objective functions for the temperature and the velocity, and the difference in using the regression and the RSM model have been studied. It is found that these values of the process parameters provide MPCs within 5% of their desired values. This methodology is applicable to other coating processes and fabrication technologies such as hot forging, machining and casting.

Pituitary metastases: presentation and outcomes from a pituitary center over the last decade.

PURPOSE: Highlight and characterize manifestations, diagnostic/management approaches and outcomes in a contemporary cohort of patients with pituitary metastases (PM) from a large European pituitary center-over 10 years. METHODS: Retrospective review of PM cases between 1/2009 and 12/2018. Clinical, laboratory, imaging data at PM detection and during follow-up were analysed. RESULTS: 18 cases were identified (14 females; median age at diagnosis 61.5 years). Most common primary malignancies were lung (39%) and breast (32%). Most frequent presenting manifestation was visual dysfunction (50%). Gonadotrophin, ACTH, TSH deficiency were diagnosed in 85%, 67%, 46% of cases, respectively; diabetes insipidus (DI) was present in 17%. 33% of cases were detected during investigation for symptoms unrelated to PM. PM management included radiotherapy (44%), transsphenoidal surgery (17%), transsphenoidal surgery and radiotherapy (6%) or monitoring only (33%). One-year survival was 49% with median survival from PM detection 11 months (range 2-47). CONCLUSIONS: In our contemporary series, clinical presentation of PM has evolved; we found increased prevalence of anterior hypopituitarism, decreased rates of DI and longer survival compared with older literature. Increased availability of diagnostic imaging, improvements in screening and recognition of pituitary disease and longer survival of patients with metastatic cancer may be contributing factors.

Physically informed artificial neural networks for atomistic modeling of materials.

Large-scale atomistic computer simulations of materials heavily rely on interatomic potentials predicting the energy and Newtonian forces on atoms. Traditional interatomic potentials are based on physical intuition but contain few adjustable parameters and are usually not accurate. The emerging machine-learning (ML) potentials achieve highly accurate interpolation within a large DFT database but, being purely mathematical constructions, suffer from poor transferability to unknown structures. We propose a new approach that can drastically improve the transferability of ML potentials by informing them of the physical nature of interatomic bonding. This is achieved by combining a rather general physics-based model (analytical bond-order potential) with a neural-network regression. This approach, called the physically informed neural network (PINN) potential, is demonstrated by developing a general-purpose PINN potential for Al. We suggest that the development of physics-based ML potentials is the most effective way forward in the field of atomistic simulations.

Individual- and community-level risk factors for ESBL Enterobacteriaceae colonization identified by universal admission screening in London.

OBJECTIVES: We evaluated risk factors for gastrointestinal carriage of Enterobacteriaceae which produce extended-spectrum ß-lactamases (ESBL-E), including individual-level variables such as antibiotic use and foreign travel, and community-level variables such as housing and deprivation. METHODS: In an observational study in 2015, all patients admitted to a London hospital group were approached to be screened for ESBL-E carriage using rectal swabs for 4 months. Patients completed a risk factor questionnaire. Those with a residential postcode in the local catchment area were linked to a database containing community-level risk factor data. Risk factors for ESBL-E carriage were determined by binary logistic regression. RESULTS: Of 4006 patients, 360 (9.0%) carried ESBL-E. Escherichia coli was the most common organism (77.8%), and CTX-M-type ESBLs were the most common genes (57.9% CTX-M-15 and 20.7% CTX-M-9). In multivariable analysis, risk factors for phenotypic ESBL-E among the 1633 patients with a residential postcode within the local catchment area were: travel to Asia (OR 4.4, CI 2.5-7.6) or Africa (OR 2.4, CI 1.2-4.8) in the 12 months prior to admission, two or more courses of antibiotics in the 6 months prior to admission (OR 2.0, CI 1.3-3.0), and residence in a district with a higher-than-average prevalence of overcrowded households (OR 1.5, CI 1.05-2.2). . CONCLUSIONS: Both individual and community variables were associated with ESBL-E carriage at hospital admission. The novel observation that household overcrowding is associated with ESBL-E carriage requires confirmation, but raises the possibility that targeted interventions in the community could help prevent transmission of antibiotic-resistant Gram-negative bacteria.

Is the humoral immunity dispensable for the pathogenesis of psoriasis?

BACKGROUND: Imbalances of T-cell subsets are hallmarks of disease-specific inflammation in psoriasis. However, the relevance of B cells for psoriasis remains poorly investigated. OBJECTIVE: To analyse the role of B cells and immunoglobulins for the disease-specific immunology of psoriasis. METHODS: We characterized B-cell subsets and immunoglobulin levels in untreated psoriasis patients (n = 37) and compared them to healthy controls (n = 20) as well as to psoriasis patients under disease-controlling systemic treatment (n = 28). B-cell subsets were analysed following the flow cytometric gating strategy based on the surface markers CD24, CD38 and CD138. Moreover, immunofluorescence stainings were used to detect IgA in psoriatic skin. RESULTS: We found significantly increased levels of IgA in the serum of treatment-naïve psoriasis patients correlating with disease score. However, IgA was only observed in dermal vessels of skin sections. Concerning B-cell subsets, we only found a moderately positive correlation of CD138+ plasma cells with IgA levels and disease score in treatment-naïve psoriasis patients. Confirming our hypothesis that psoriasis can develop in the absence of functional humoral immunity, we investigated a patient who suffered concomitantly from both psoriasis and a hereditary common variable immune defect (CVID) characterized by a lack of B cells and immunoglobulins. We detected variants in three of the 13 described genes of CVID and a so far undescribed variant in the ligand of the TNFRSF13B receptor leading to disturbed B-cell maturation and antibody production. However, this patient showed typical psoriasis regarding clinical presentation, histology or T-cell infiltrate. Finally, in a group of psoriasis patients under systemic treatment, neither did IgA levels drop nor did plasma cells correlate with IgA levels and disease score. CONCLUSION: B-cell alterations might rather be an epiphenomenal finding in psoriasis with a clear dominance of T cells over shifts in B-cell subsets.

Demonstration of acid and water recovery systems: Applicability and operational challenges in Indian metal finishing SMEs.

Diffusion dialysis, acid retardation and nanofiltration plants were acquired from Europe and demonstrated in several Indian metal finishing companies over a three year period. These companies are primarily small and medium enterprises (SMEs). Free acid recovery rate from spent pickling baths using diffusion dialysis and retardation was in the range of 78-86% and 30-70% respectively. With nanofiltration, 80% recovery rate of rinse water was obtained. The demonstrations created awareness among the metal finishing companies to reuse resources (acid/water) from the effluent streams. However, lack of efficient oil separators, reliable chemical analysis and trained personnel as well as high investment cost limit the application of these technologies. Local manufacturing, plant customization and centralized treatment are likely to encourage the uptake of such technologies in the Indian metal finishing sector.

Development and validation of a clinical prediction model for patient-reported pain and function after primary total knee replacement surgery.

To develop and validate a clinical prediction model of patient-reported pain and function after undergoing total knee replacement (TKR). We used data of 1,649 patients from the Knee Arthroplasty Trial who received primary TKR across 34 centres in the UK. The external validation included 595 patients from Southampton University Hospital, and Nuffield Orthopaedic Centre (Oxford). The outcome was the Oxford Knee Score (OKS) 12-month after TKR. Pre-operative predictors including patient characteristics and clinical factors were considered. Bootstrap backward linear regression analysis was used. Low pre-operative OKS, living in poor areas, high body mass index, and patient-reported anxiety or depression were associated with worse outcome. The clinical factors associated with worse outcome were worse pre-operative physical status, presence of other conditions affecting mobility and previous knee arthroscopy. Presence of fixed flexion deformity and an absent or damaged pre-operative anterior cruciate ligament (compared with intact) were associated with better outcome. Discrimination and calibration statistics were satisfactory. External validation predicted 21.1% of the variance of outcome. This is the first clinical prediction model for predicting self-reported pain and function 12 months after TKR to be externally validated. It will help to inform to patients regarding expectations of the outcome after knee replacement surgery.

Intensive care unit (ICU)-acquired bacteraemia and ICU mortality and discharge: addressing time-varying confounding using appropriate methodology.

BACKGROUND: Studies often ignore time-varying confounding or may use inappropriate methodology to adjust for time-varying confounding. AIM: To estimate the effect of intensive care unit (ICU)-acquired bacteraemia on ICU mortality and discharge using appropriate methodology. METHODS: Marginal structural models with inverse probability weighting were used to estimate the ICU mortality and discharge associated with ICU-acquired bacteraemia among patients who stayed more than two days at the general ICU of a London teaching hospital and remained bacteraemia-free during those first two days. For comparison, the same associations were evaluated with (i) a conventional Cox model, adjusting only for baseline confounders and (ii) a Cox model adjusting for baseline and time-varying confounders. FINDINGS: Using the marginal structural model with inverse probability weighting, bacteraemia was associated with an increase in ICU mortality (cause-specific hazard ratio (CSHR): 1.29; 95% confidence interval (CI): 1.02-1.63) and a decrease in discharge (CSHR: 0.52; 95% CI: 0.45-0.60). By 60 days, among patients still in the ICU after two days and without prior bacteraemia, 8.0% of ICU deaths could be prevented by preventing all ICU-acquired bacteraemia cases. The conventional Cox model adjusting for time-varying confounders gave substantially different results [for ICU mortality, CSHR: 1.08 (95% CI: 0.88-1.32); for discharge, CSHR: 0.68 (95% CI: 0.60-0.77)]. CONCLUSION: In this study, even after adjusting for the timing of acquiring bacteraemia and time-varying confounding using inverse probability weighting for marginal structural models, ICU-acquired bacteraemia was associated with a decreased daily ICU discharge risk and an increased risk of ICU mortality.

Tuberculosis treatment outcomes among disadvantaged patients in India.

Setting: Urban slums and poor rural areas in India, 2012-2014. Objective: To describe the characteristics of tuberculosis (TB) patients enrolled in treatment through Operation ASHA, a non-governmental organisation serving disadvantaged populations in India, and to identify risk factors for unfavourable treatment outcomes. Design: This was a retrospective cohort study. Patient characteristics were assessed for their relationship with treatment outcomes using mixed effects logistic regression, adjusting for clustering by treatment centre and Indian state. Outcomes were considered favourable (cured/treatment completed) or unfavourable (treatment failure, loss to follow-up, death, switch to multidrug-resistant TB treatment, transfer out). Results: Of 8415 patients, 7148 (84.9%) had a favourable outcome. On multivariable analysis, unfavourable outcomes were more common among men (OR 1.31, 95%CI 1.15-1.51), older patients (OR 1.12, 95%CI 1.04-1.21) and previously treated patients (OR 2.05, 95%CI 1.79-2.36). Compared to pulmonary smear-negative patients, those with extra-pulmonary disease were less likely to have unfavourable outcomes (OR 0.72, 95%CI 0.60-0.87), while smear-positive pulmonary patients were more likely to have unfavourable outcomes (OR 1.38, 95%CI 1.15-1.66 for low [scanty/1+] and OR 1.71, 95%CI 1.44-2.04 for high [2+/3+] positive smears). Conclusion: The treatment success rate within Operation ASHA is comparable to that reported nationally for India. Men, older patients, retreatment cases and smear-positive pulmonary TB patients may need additional interventions to ensure a favourable outcome.

Contexte: Bidonvilles urbains et zones rurales pauvres, Inde, 2012­2014.Objectif: Décrire les caractéristiques des patients atteints de tuberculose (TB) enrôlés dans un traitement à travers l'Opération ASHA, une organisation non-gouvernementale au service des populations désavantagées en Inde, et identifier les facteurs de risque de résultat défavorable du traitement.Schéma: Etude rétrospective de cohorte. Les caractéristiques des patients ont été évaluées en fonction de leur relation avec les résultats du traitement grâce à une régression logistique à effets mixtes ajustée sur le regroupement par centre de traitement et par l'état d'Inde. Le résultat a été considéré comme favorable (guéri/traitement achevé) ou défavorable (échec du traitement, perte de vue, décès, évolution vers un traitement de TB multirésistante, transfert).Résultats: De 8415 patients, 7148 (84,9%) ont eu un résultat favorable. En analyse multi-variable, les résultats défavorables ont été plus fréquents parmi les hommes (OR 1,31 ; IC 95% 1,15­1,51), les patients plus âgés (OR 1,12 ; IC95% 1,04­1,21) et les patients déjà traités (OR 2,05 ; IC95% 1,79­2,36). Comparés aux patients atteints de TB pulmonaire à frottis négatif, les patients atteints de TB extra-pulmonaire ont été moins susceptibles d'avoir un résultat défavorable (OR 0,72 ; IC95% 0,60­0,87), tandis que les patients atteints de TB pulmonaire à frottis positif ont été plus susceptibles d'avoir un résultat défavorable (OR 1,38 ; IC95% 1,15­1,66 pour les frottis positifs faibles [rares/1+] et OR 1,71 ; IC95% 1,44­2,04 pour les frottis élevés [2+/3+]).Conclusion: Le taux de succès du traitement dans le cadre de l'Opération ASHA est comparable à celui rapporté au niveau national en Inde. Les hommes, les patients plus âgés, les cas en retraitement et les patients atteints de TB pulmonaire à frottis positif pourraient avoir besoin d'interventions supplémentaires afin d'assurer un résultat favorable.

Marco de referencia: Barriadas urbanas y zonas rurales pobres en la India del 2012 al 2014.Objetivo: Describir las características de los pacientes con tuberculosis (TB) inscritos en tratamiento en el marco de la Operación ASHA, que es una organización no gubernamental que atiende a las poblaciones desfavorecidas en la India, y determinar los factores de riesgo de obtener desenlaces terapéuticos desfavorables.Método: Un estudio retrospectivo de cohortes. Las características de los pacientes se evaluaron con respecto a los desenlaces terapéuticos, mediante un análisis de regresión logística de efectos mixtos y ajuste con relación a los conglomerados, según el centro de tratamiento y el estado de la India. Los desenlaces se consideraron favorables (curación o tratamiento completo) o desfavorables (fracaso terapéutico, pérdida durante el seguimiento, muerte, cambio de tratamiento por TB multirresistente o transferencia a otro centro).Resultados: De los 8415 pacientes, en 7148 el desenlace fue favorable (84,9%). El análisis multivariante reveló que los desenlaces desfavorables eran más frecuentes en los hombres (OR 1,31; IC95% 1,15­1,51), los ancianos (OR 1,12; IC95% 1,04­1,21) y en los pacientes con antecedente de tratamiento antituberculoso (OR 2,05; IC95% 1,79­2,36). Tomando como referencia a los pacientes con baciloscopia negativa, los desenlaces desfavorables fueron menos probables en los pacientes con TB extrapulmonar (OR 0,72; IC95% 0,60­0,87) y más probables en los pacientes con TB pulmonar y baciloscopia positiva (OR 1,38; IC95% 1,15­1,66 para las baciloscopias bajas, de escasos bacilos a 1+ y OR 1,71; IC95% 1,44­2,04 para las baciloscopia altas, de 2+ o 3+).Conclusión: La tasa de éxito del tratamiento antituberculoso en el marco de la Operación ASHA es equivalente a la notificada a escala nacional en la India. Los pacientes de sexo masculino, los ancianos, los casos en retratamiento y los que presentan una TB pulmonar con baciloscopia positiva pueden necesitar intervenciones complementarias a fin de fomentar los desenlaces favorables.

Does appropriate empiric antibiotic therapy modify intensive care unit-acquired Enterobacteriaceae bacteraemia mortality and discharge?

BACKGROUND: Conflicting results have been found regarding outcomes of intensive care unit (ICU)-acquired Enterobacteriaceae bacteraemia and the potentially modifying effect of appropriate empiric antibiotic therapy. AIM: To evaluate these associations while adjusting for potential time-varying confounding using methods from the causal inference literature. METHODS: Patients who stayed more than two days in two general ICUs in England between 2002 and 2006 were included in this cohort study. Marginal structural models with inverse probability weighting were used to estimate the mortality and discharge associated with Enterobacteriaceae bacteraemia and the impact of appropriate empiric antibiotic therapy on these outcomes. FINDINGS: Among 3411 ICU admissions, 195 (5.7%) ICU-acquired Enterobacteriaceae bacteraemia cases occurred. Enterobacteriaceae bacteraemia was associated with an increased daily risk of ICU death [cause-specific hazard ratio (HR): 1.48; 95% confidence interval (CI): 1.10-1.99] and a reduced daily risk of ICU discharge (HR: 0.66; 95% CI: 0.54-0.80). Appropriate empiric antibiotic therapy did not significantly modify ICU mortality (HR: 1.08; 95% CI: 0.59-1.97) or discharge (HR: 0.91; 95% CI: 0.63-1.32). CONCLUSION: ICU-acquired Enterobacteriaceae bacteraemia was associated with an increased daily risk of ICU mortality. Furthermore, the daily discharge rate was also lower after acquiring infection, even when adjusting for time-varying confounding using appropriate methodology. No evidence was found for a beneficial modifying effect of appropriate empiric antibiotic therapy on ICU mortality and discharge.

Addition of Fentanyl to Ropivacaine Infusion in Continuous Thoracic Paravertebral Infusion Does Not Improve Its Analgesic Effect Following Modified Radical Mastectomy: A Randomized Controlled Trial.

A randomized controlled trial was conducted to evaluate pain scores in patients given continuous thoracic paravertebral (TPV) block with ropivacaine alone or with fentanyl in modified radical mastectomy (MRM). Forty female patients ASA classes 1 and 2, aged 18 to 60 years, undergoing MRM were recruited. Preanesthesia with 0.5% ropivacaine, 20 mL, was injected at the T4 TPV space. After 2 hours, patients were randomly assigned to receive a 0.1 mL/kg/h infusion of either 0.2% ropivacaine (group R) or 0.19% ropivacaine plus fentanyl, 2 µg/mL (group RF). Postoperatively, patient-controlled analgesia (PCA) with fentanyl was provided. Visual analog scale (VAS) pain scores at rest and movement were significantly less in group RF at 8 AM on postoperative day 1 (R vs RF: rest: 2 [interquar-tile range, 0-7] vs 1 [0-6]; P = .016; movement: 2.5 [1-8] vs 2 [1-8], P= .042) and on movement 60 minutes postoperatively (R vs RF: 2 [0-9] vs 2 [1-2]; P = .01). Mean total fentanyl consumed via PCA in group R was significantly more (206 ± 31.68 µg vs RF 82.5 ± 35.07 µg, P < .001). Mean total fentanyl consumed via PCA plus TPV infusion was comparable (R: 206 ± 31.68 µg vs RF: 211 ± 25.52 µg, P < .2). Because the mean VAS score was below 3 in all timeframes, addition of fentanyl to ropivacaine in continuous TPV infusion in MRM had no clinical advantage.

Rifle bullet penetration into ballistic gelatin.

The penetration of a rifle bullet into a block of ballistic gelatin is experimentally and computationally studied for enhancing our understanding of the damage caused to human soft tissues. The gelatin is modeled as an isotropic and homogeneous elastic-plastic linearly strain-hardening material that obeys a polynomial equation of state. Effects of numerical uncertainties on penetration characteristics are found by repeating simulations with minute variations in the impact speed and the angle of attack. The temporary cavity formed in the gelatin and seen in pictures taken by two high speed cameras is found to compare well with the computed one. The computed time histories of the hydrostatic pressure at points situated 60 mm above the line of impact are found to have "two peaks", one due to the bullet impact and the other due to the bullet tumbling. Contours of the von Mises stress and of the effective plastic strain in the gelatin block imply that a very small region adjacent to the cavity surface is plastically deformed. The angle of attack is found to noticeably affect the penetration depth at the instant of the bullet tumbling through 90°.

Molecular detection of common intestinal parasites: a performance evaluation of the BD Max™ Enteric Parasite Panel.

The purpose of this study was to evaluate the level of agreement of the BD Max™ Enteric Parasite Panel (EPP) with microscopy for the detection of Giardia duodenalis, Cryptosporidium spp. and Entamoeba histolytica in stool samples. A total of 372 stool samples (partly collected on the basis of positive microscopy and partly unselected, consecutive sample submitted for parasite investigation) were tested with EPP according to manufacturer's instructions and also using microscopy according to standard techniques. Discrepant samples were further tested using PCR by the National Parasitology reference laboratory. Levels of agreement and laboratory turnaround times were measured and compared. Overall, positive and negative percent agreement was high between the two methods. However, microscopy resulted in four false positives and one false negative for G. duodenalis and two false positives for Cryptosporidium. Additionally, microscopy could not differentiate between E. histolytica and Entamoeba dispar. Median laboratory turnaround time was 65 hours for microscopy; results from EPP could be available after four hours. Blastocycstis hominis was detected by microscopy in one sample and would have been missed if only EPP was performed. The EPP was a good alternative to microscopy, detecting a small number of additional positives that were missed by microscopy. The assay is significantly faster than microscopy and allows laboratory workflows to be streamlined. The risk of missing parasites that are not included in the EPP appears to be minimal in the studied population; however, there may be certain patient groups who would benefit from microscopic examination of stools.

Central bronchial carcinoid: Management of a case and anesthetic perspectives.

Obstructing lesions of the central airways present with a variety of symptoms and are often associated with pneumonia or asthma-like states. Anesthesia to these patients often presents challenges right from the preoperative stabilization of underlying lung condition, mask ventilation in the supine position to maintaining oxygenation and ventilation in the intraoperative and postoperative period. We present here a case of a young woman with a central bronchial tumor with significant airway obstruction with potential for major bleeding and subsequent anesthetic management without lung sacrificing measures and cardiopulmonary bypass assistance.