Changes in plasma and milk choline metabolite concentrations in response to the provision of various rumen-protected choline prototypes in lactating dairy cows.

Choline feeding in the form of rumen-protected choline (RPC) has been shown to increase milk production and improve measures of metabolic health (e.g., liver triglyceride) in dairy cows. The objective was to characterize changes in plasma and milk choline and choline metabolite concentrations, including microbial-derived trimethylamine N-oxide (TMAO), in response to increasing ruminal spot-doses, different types of RPC, and ruminal stability of RPC in lactating cows. For experiment 1, 12 mid-lactation (121 ± 16.3 d in milk) Holstein cows were balanced by total plasma choline concentrations and milk yields. Cows were assigned to 1 of 3 lipid-encapsulated RPC products (main plots): prototypes P1, P2, and P3 (containing 59, 56, and 30% choline chloride, respectively). Within each main plot, cows were assigned to a sequence of doses in a 4 × 4 Latin square design: 0, 18, 36, or 54 g of choline chloride. Treatments were preconditioned with ground corn and administered as a single ruminal bolus once per experimental period 1 h postfeeding of a total mixed ration. For experiment 2, we compared a control (0 g of choline chloride) versus P2, and P4 and P5 (60 and 62% choline chloride, respectively) in a repeated 4 × 4 Latin square design. Experiment 2 followed a similar design as experiment 1 with modifications: 12 late-lactation (228 ± 7.10 d in milk) Holstein cows were used; treatments were administered as part of a premeal; and cows received a daily allowance of a total mixed ration as equal provisions every 4 h within 24 h before and after treatment. For both experiments, plasma and milk samples were collected for choline and choline metabolite quantification. Data were analyzed using a mixed model including fixed effects of treatment, period, and time. Contrast statements were used to test for linearity of dose and differences between prototypes for experiment 1 and 2, respectively. Plasma and milk TMAO concentrations increased with RPC dose (peak by h). Milk choline and betaine yields increased with RPC dose in a quadratic manner; albeit, dependent upon RPC type. Milk phosphocholine (PCho) and glycerophosphorylcholine (GPC) yields changed by select RPC dose (experiment 1), however Met, PCho, GPC, phosphatidylcholine, and total choline concentrations in milk, and plasma Met and sphingomyelin concentrations were not responsive. We conclude that plasma or milk choline, betaine, and TMAO concentrations are responsive to RPC type, dose, and stage of lactation evaluated.

Recognition and management of sepsis by junior doctors.

There is growing evidence that outcomes in sepsis are improved by early recognition and treatment. In this study, we assessed junior doctors' ability to recognise and manage sepsis. We also explored junior doctors' perceptions regarding barriers to delivering timely sepsis care. From 46 respondents, only 4% were able to list the systemic inflammatory response syndrome (SIRS) criteria, 50% could define sepsis and 46% could list the Sepsis Six. Following further teaching on sepsis, 35% could list the SIRS criteria, 87% correctly defined sepsis, and 91% could state the Sepsis Six. Junior doctors perceived time pressure when on call to be the greatest barrier in treating sepsis, and their own knowledge to be the least important barrier. Our data suggest that knowledge of sepsis among junior doctors is poor and that there is a lack of insight into this competency gap.

The burden of sepsis in the Emergency Department: an observational snapshot.

The primary aim of our study was to establish what proportion of patients in the Emergency Department (ED) fulfill the criteria for sepsis. All adult patients presenting to ED in two 1-week periods, 6 months apart, were included. Notes were reviewed retrospectively to identify which patients fulfilled the criteria for sepsis and severe sepsis. The proportion of patients with sepsis was 4.3% (95% confidence interval 3.3-5.2%) and the proportion with severe sepsis was 2.2% (95% confidence interval 1.5-2.8%). In conclusion our results suggest that sepsis is more common than previously reported and this represents a significant burden on ED.

Management of persistent wide QRS in flecainide overdose with magnesium sulphate.

Magnesium sulphate was added to conventional medical therapy in the treatment of persistent severe hypotension and wide QRS complex tachyarrhythmia in an 18-year-old woman presenting with a 1200 mg flecainide overdose. Blood pressure was restored with associated resolution of the electrocardiogram abnormalities.

Outpatient laparoscopic adrenalectomy: a Canadian experience.

BACKGROUND: We report our experience at The Ottawa Hospital with outpatient laparoscopic adrenalectomy. METHODS: We report a single surgeon experience. Seventeen consecutive outpatient laparoscopic adrenalectomy were performed between 1994 and 2006. Specific selection criteria were applied. Postoperatively patients were monitored and assessed before discharge. Full discharge instructions were provided. A prescription for analgesic was given. A call back system was put in place. The first postoperative office visit was scheduled within 7 days of surgery. RESULTS: Twelve of 17 patients were females. The mean age was 52.4 years. Our average operating room time was 130 minutes with no conversions. The average stay was about 5.5 hours. Three patients had a 23-hour stay. One admitted with atelectasis. Tumor size ranged from 1 to 5.8 cm. There were no reoperations, late admissions up to 30 days, and no deaths. One patient required admission. Thirteen of 17 patients were contacted by phone after discharge. At our hospital we found a cost saving of C$1478 is made per case. CONCLUSIONS: Laparoscopic adrenalectomy can be safely performed as an outpatient procedure. Strict selection criteria should be applied. Call back systems should be instituted. There is a cost benefit associated with this outpatient procedure.

A rapidly advancing mediastinal mass--overcoming tracheobronchial obstruction.

We report the case of a 7-year-old boy who presented with rapidly advancing airway obstruction secondary to mediastinal T-cell non-Hodgkins lymphoma. His brisk deterioration required transfer to the pediatric intensive care unit and intubation of the trachea. Unforeseen unilateral bronchial involvement led to gas trapping and critical pulmonary hyperinflation. Endobronchial advancement of the tracheal tube beyond the bronchial obstruction relieved pulmonary hyperinflation but subsequent one lung ventilation was poorly tolerated. We report the manufacture of a proximal 'Murphy's eye' which allowed ventilation of the contralateral lung to proceed. To the best of our knowledge this is the first time that this technique has been described in a pediatric patient.

Preventing the forgotten ureteral stent: implementation of a web-based stent registry with automatic recall application.

OBJECTIVES: To describe and analyze a unique computerized system that tracks ureteral stents and automatically sends a notice by e-mail to clinical staff if a stent becomes overdue for removal. METHODS: We have developed an electronic stent register (ESR) and stent extraction reminder facility (SERF) located within our hospital computer network. After stent insertion, a stent "episode" is created in the ESR with a mandatory maximal stent life (MSL). The SERF interrogates the ESR on a daily basis and identifies stents that have breached its MSL, generating daily e-mail notices to personnel until the stent is removed and the ESR updated. The episode data capture initially employing manual entry was changed to barcode technology acquisition. We analyzed the success of patient recall and conducted a prospective, blinded review to determine the success of the data acquisition. RESULTS: A total of 293 episodes were created within 2.4 years. Of the 241 (86%) episodes that were closed, 123 (51%) went beyond the MSL. The mean delay from designated MSL to stent removal was 20.89 days (SD 19.71). In the 7 months before barcode data acquisition, 43 of 71 stents were entered into the ESR (data capture rate 61%). In the 7 months after barcode data acquisition, 52 of 60 stents were entered (data capture rate 87%; P = 0.0009). CONCLUSIONS: The results of our study have shown the ESR and SERF to be robust and valuable tools for the treatment of patients with ureteral stents. Barcode acquisition significantly improved the stent insertion capture rate. This system ensures improved patient safety with an element of protection from potential litigation.