Research Note: Delay in sampling influences the profile of phytate in gizzard digesta and ileal digestibility of phosphorus in broilers.

The objective of this study was to investigate the effect of different durations of time delay when sampling digesta from the gizzard and ileum of broilers on the degradation of myo-inositol hexakisphosphate (InsP6) and digestibility of phosphorus (P). There was 1 experimental diet with a supplemental phytase activity of 1,212 phytase units/kg feed, which was provided to birds from day 13 to 18 after hatching. The diet was formulated to provide 6.6 g/kg Ca and 1.9 g/kg nonphytate P and fed to 24 cages of 6 birds. The 24 cages of birds were further randomly divided into 6 subgroups of 4 cages from which the digesta samples in the gizzard and ileum were collected at 0, 5, 10, or 20 min postmortem. The results showed that the concentration of InsP6 decreased linearly (P = 0.002), InsP5 decreased quadratically (P = 0.038), and the summation of concentrations of P in InsP6-4 decreased linearly (P = 0.028) in the gizzard digesta with the increasing delay of sampling. In the ileum, the digestibility of phytate P tended to decrease linearly (P = 0.087), and the digestibility of total P decreased linearly (P = 0.026) with prolonged delay. In conclusion, delay in sampling could alter the measured profile of InsP esters in gizzard digesta probably because of a continued effect of supplemental phytase, while the ileal digestibility of total P could diminish. Therefore, standard sampling procedures should be implemented to minimize variance.

Effects of the Serber first step in 3DHZETRN-v2.1.

3DHZETRN-v2 includes a detailed three dimensional (3D) treatment of neutron/light-ion transport based on a quasi-elastic/multiple production assumption allowing improved agreement of the neutron/light-ion fluence compared with results of three Monte Carlo (MC) codes in the sense that the variance with respect to the individual MC results is less than the variance among the MC code results. The current numerical methods are no longer the main limitation to HZETRN code development and further changes in the nuclear model are required. In a prior study, an improved quasi-elastic spectrum based on a solution of the transport approximation to nuclear media effects showed promise, but the remaining multiple-production spectrum was based on a database derived from the Ranft model that used Bertini multiplicities. In the present paper, we will implement a more complete Serber first step into the 3DHZETRN-v2 code, but we retain the Bertini-Ranft branching ratios and evaporation multiplicities. It is shown that the new Serber model in the 3HZETRN-v2 code reduces the variance with individual MC codes, which are largely due to nuclear cross section model differences. The code will be available through the software system, OLTARIS, for shield design and validation and provides a basis for personal computer software capable of space shield analysis and optimization.

Variation of near surface atmosphere microbial communities at an urban and a suburban site in Philadelphia, PA, USA.

Microorganisms are abundant in the near surface atmosphere and make up a significant fraction of organic aerosols with implications on both human health and ecosystem services. Despite their importance, studies investigating biogeographical patterns of the atmospheric microbiome between urban and suburban areas are limited. Urban and suburban locations (including their microbial communities) vary considerably depending on climate, topography, industrial activities, demographics and other socio-economic factors. Hence, we need more location-specific data to make informed decision affecting air quality, human health, and the implication of a changing climate and policy decisions. The objective of this study was to describe how the atmospheric microbiome varies in composition and function between urban and suburban sites. We used high-throughput sequencing to analyze microbial communities collected at different times from PM2.5 samples collected by active sampling method (using a pump and an impactor) and dust settling of TSP collected by passive sampling method (no pump and no impactor) from an urban and suburban site. We found diverse communities unique in composition at both sites with equivalent functional potential. Taxonomic composition varied significantly with Proteobacteria, Firmicutes, Actinobacteria, Bacteroidetes, and Other phyla in greater relative abundance at the urban site. In contrast, Cyanobacteria, Tenericutes, Fusobacteria, and Deinococcus, were enriched at the suburban site. Community diversity also demonstrated a high degree of temporal variation within site. We identified over one-third of the communities as potentially pathogenic taxa (urban: 47.52% ± 14.40%, suburban: 34.53% ± 14.60%) and determined the majority of organisms come from animal-associated host or are environmental non-specific. Potentially pathogenic taxa and source environments were similar between active- and passive- sampling method results. Our research is novel it adds to the underrepresented set of studies on atmospheric microbial structure and function across land types and is the first to compare suburban and urban atmospheric communities.

Multidrug-resistant tuberculosis care in the United States.

BACKGROUND: To examine the utilization of the Tuberculosis (TB) Centers of Excellence (COE) medical consultation service and evaluate how these services were being employed for patients in relation to multidrug-resistant TB (MDR-TB).METHODS: Medical consults are documented in a secure database. The database was queried for MDR-TB consultations over the period 1 January 2013-31 December 2017. All were analyzed to assess provider type, center, setting, year of call, and type of patient (pediatric vs. adult). A subgroup was randomly selected for thematic analysis.RESULTS: The centers received 1560 MDR-TB consultation requests over this period. Providers requesting consults were primarily physicians (55%). The majority of requests were from public health departments (64%) and for adult patients (80%). Four major topic areas emerged: 1) initial management of MDR-TB, 2) MDR-TB longitudinal treatment and complications, 3) management of persons exposed to MDR-TB, and 4) MDR-TB treatment completion.CONCLUSIONS: Analysis of these consultations provides insight into the type of expert advice about MDR-TB that was provided. These findings highlight topics where increased medical training and education may help to improve MDR-TB-related practices.

Updated deterministic radiation transport for future deep space missions.

NASA's deterministic transport code HZETRN, and its three-dimensional (3D) counterpart, 3DHZETRN, are being used to characterize the space radiation environment over a wide range of scenarios, including future planned missions to the moon or Mars. Combined with available spaceflight measurements, these tools provide the fundamental input for risk models used to quantify possible astronaut health decrements and satisfy agency limits in support of exploration initiatives. Further research is therefore needed to improve radiation transport and nuclear physics models while at the same time continuing to expand the available measurement database (ground-based and spaceflight) to validate such efforts. In this work, significant updates to the deterministic radiation transport models are presented. Charged muons and pions are fully coupled with the existing solutions developed for neutron and light ion (Z ≤ 2) transport. This update includes the 3D nature of pion production as well as the pion interactions, resulting in further production of energetic nucleons within shielding. Additional updates related to low energy proton recoils in hydrogenous materials and capture/decay processes associated with charged pions at rest are also described. Included in this work is the coupling of single and double-differential cross sections from Geant4 into HZETRN and 3DHZETRN. This enables a direct comparison of deterministic and Monte Carlo transport methodologies using the same nuclear databases for specific interactions. Comparisons between Geant4 and 3DHZETRN are shown and establish that the transport methodologies are in excellent agreement when the same cross sections are used. The deterministic codes are also compared to ISS data, and it is found that the updated 3D procedures are within measurement uncertainty (±5%) at cutoff rigidities below 1 GV, which approaches free space conditions.

The impact of age and feeding length on phytase efficacy during the starter phase of broiler chickens.

Phytase is of importance to the poultry industry because of its ability to hydrolyze phytate and release phosphorus (P) for use by poultry. However, the effect of age on phytase efficacy is not fully understood. A total of 864 day-old broiler chicks were used to investigate the effect of age and feeding length on phytase efficacy using growth performance, mineral utilization, and tibia ash as response criteria of evaluation. The experiment was arranged as a 3 × 2 × 2 factorial in a randomized complete block design with 3 diets including; a positive control (PC; 0.4% non-phytate P (nPP)), a negative control (NC; 0.2% nPP) and a NC diet supplemented with phytase at 2,000 FYT/kg; 2 ages (i.e., days 14 and 22); and 2 feeding lengths (i.e., 2 and 5 D) with 8 replicates each. Birds fed the NC had decreased (P < 0.01) body weight gain and feed efficiency compared with birds fed the PC regardless of age or feeding length. Similarly, birds fed the phytase-supplemented diet had improved (P < 0.01) performance as compared to birds fed the NC regardless of age. There were no significant differences in P utilization between birds fed for 2 to 14 D or 22 D and birds fed for 5 D to both ages. However, phytase was more efficacious at day 14 than day 22 when mineral utilization was considered because the super dose of phytase elicited greater response in birds fed the phytase supplemented diet for 2 D until day 14. In contrast, percentage tibia ash improved (P < 0.01) in birds fed phytase supplemented diet for 5 D at both ages as compared with birds fed for 2 D. In conclusion, testing phytase products, even at high doses, for 2 D during the second week in the life cycle of broiler chicks, can be recommended from the results of this study.

Influence of age and duration of feeding low-phosphorus diet on phytase efficacy in broiler chickens during the starter phase.

A total of 1,408 male broiler chickens were used to evaluate the impact of age and duration of feeding low-phosphorus (P) diet on the efficacy of phytase using growth performance, nutrient utilization, tibia ash, and plasma indices. Diets were formulated with 2 non-phytate P (nPP) concentrations (i.e., 0.20 and 0.40%) and 2 phytase concentrations (i.e., 1,000 and 2,000 FTU/kg) added to the 0.20% nPP diet. Four dietary treatments with 8 replicate cages each were fed to broiler chicks at different ages and for different duration. Specifically, these were days 6 to 8 (12 birds per replicate), 12 to 14, 9 to 14, 20 to 22, or 6 to 22 (8 birds per replicate). Parameters were measured on the last day of each period. Duration of feeding effect was examined by comparing responses of birds fed for 2 or 5 D at day 14 and for 2 or 16 D at day 22; age effect was determined by comparing responses of birds fed for 2 D at age 8, 14 and 22 D post-hatching. Body weight gain and gain-to-feed ratio were increased (P < 0.01) in birds fed diets supplemented with phytase; however, an increase in duration of feeding improved (P < 0.01) feed efficiency with birds fed for 16 D performing better than birds fed for 2 D at day 22. In addition, phytase supplementation improved (P < 0.01) apparent P and calcium digestibility and retention, but the age effect on phytase efficacy was more apparent at day 14 and the duration of feeding effect was evident in birds fed for 2 D due to the increased levels of mineral utilization at that age/duration of feeding as compared with the other groups. The results of this study show that phytase efficacy was at optimum in birds fed low-P diet for 2 D at day 14. This period can be recommended for further bioefficacy studies of phytase.

Prevalence, impact and specialised treatment of urinary incontinence in women with chronic lung disease.

OBJECTIVES: To determine in women with clinically stable chronic lung disease (CLD) and healthy women; (1) prevalence of urinary incontinence; (2) risk factors for urinary incontinence; (3) effects of a standard course of specialised physiotherapy treatment (PT) in women with CLD. DESIGN: Prospective prevalence study; PT study in CLD subgroup. SETTING: Tertiary metropolitan public hospital. PARTICIPANTS: Women with cystic fibrosis (CF, n=38), chronic obstructive pulmonary disease (COPD, n=27) and 69 healthy women without CLD. PT study - 10 women with CLD. INTERVENTIONS: Five continence PT sessions over 3 months. MAIN OUTCOME MEASURES: Prevalence and impact of incontinence (questionnaire), number of leakage episodes (7-day accident diary), pelvic floor muscle function (ultrasound imaging) and quality of life (King's Health Questionnaire). RESULTS: The majority of women in all three groups reported episodes of incontinence (CF 71%; COPD 70%; healthy women 55%). Compared to age-matched healthy controls, women with CF reported more episodes of incontinence (P=0.006) and more commonly reported stress incontinence (P=0.001). A logistic regression model revealed that women with CLD were twice as likely to develop incontinence than healthy women (P=0.05). Women with COPD reported significantly more 'bother' with incontinence than age-matched women with incontinence. There was a significant reduction in incontinence episodes following treatment, which was maintained after three months. CONCLUSIONS: The presence of CLD is an independent predictor of incontinence in women. In older women this is associated with more distress than in age-matched peers without CLD. Larger treatment studies are indicated for women with CLD and incontinence.

Current patient and healthcare worker attitudes to eHealth and the personally controlled electronic health record in major hospitals.

BACKGROUND: The current health system in Australia is comprised of both electronic- and paper-based medical records. The Federal Government has approved funding for the development of an individual health identifier and a universally adopted online health repository. AIMS: To determine attitudes and beliefs of patients and healthcare workers regarding the use of stored medical information and the personally controlled electronic health record (PCEHR) in selected major hospitals in Victoria. METHODS: Qualitative survey of patients and healthcare workers (n = 600 each group) conducted during 2014 across five major hospitals in Melbourne to measure the awareness, attitudes and barriers to electronic health and the PCEHR. RESULTS: Of the patients, 93.3% support the concept of a shared electronic healthcare record, 33.7% were aware of the PCEHR and only 11% had registered. The majority of healthcare workers believed that the presence of a shared health record would result in an increased appropriateness of care and patient safety by reducing adverse drug events and improving the timeliness of care provided. However, only 46% of healthcare workers were aware of the PCEHR. CONCLUSIONS: This study provides a baseline evaluation of perceptions surrounding eHealth and PCHER in acute health services in five metropolitan centres. While there appears to be a readiness for adoption of these strategies for healthcare documentation, patients require motivation to register for the PCEHR, and healthcare workers require more information on the potential benefits to them to achieve more timely and efficient care.

Voriconazole exposure and the risk of cutaneous squamous cell carcinoma in allogeneic hematopoietic stem cell transplant patients.

BACKGROUND: Voriconazole is a commonly used antifungal medication in allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients. In solid organ transplantation, voriconazole use has been associated with the development of cutaneous squamous cell carcinoma (SCC). We sought to determine if voriconazole use was associated with SCC in patients undergoing allo-HSCT. METHODS: We retrospectively reviewed consecutive adult patients who underwent allo-HSCT at Mayo Clinic from January 2007 through July 2012. Multivariable Cox models were created to assess the relationship of SCC with two time-dependent voriconazole exposure variables: (i) history of voriconazole exposure (yes/no), and (ii) cumulative days of voriconazole use. RESULTS: In our cohort of 381 allo-HSCT patients, SCC developed in 26 of 312 patients exposed to voriconazole (25 post-voriconazole) and in 1 of 69 patients who received alternative antifungal agent(s). Cumulative incidence of SCC was estimated to be 19% at 5 years post allo-transplant. Cumulative days of voriconazole use was found to be a risk factor for SCC, and this relationship persisted in a multivariable model using previously identified risk factors as covariates (hazard ratio 1.859 for each 180 days of use, P < 0.001). CONCLUSION: This is the first study, to our knowledge, to identify cumulative days of voriconazole use as a risk factor for SCC development following allo-HSCT, and may help guide appropriate antifungal use in this patient population.

Evidence-based guidelines for laboratory screening for infectious diseases before initiation of systemic immunosuppressive agents in patients with autoimmune bullous dermatoses.

Autoimmune bullous dermatoses (ABD) compromise the skin's innate barrier function for preventing infection. Treating patients with ABD frequently requires systemic immunosuppressive therapy, often with multiple agents. Currently, no pretreatment infection testing guidelines are available for clinicians caring for patients with ABD. We performed a systematic literature review in other medical disciplines that use similar iatrogenic immunosuppressive medications to treat various diseases and conditions and developed infection-testing recommendations for patients with ABD before initiating immunosuppressive therapy. Assessing individual patient risk factors for latent infection and preventable communicable diseases can direct testing for select infections before starting immunosuppressive therapy. Testing patients for hepatitis B virus, hepatitis C virus, and Mycobacterium tuberculosis infection is recommended before initiating rituximab treatment.

Oral ribavirin therapy for respiratory syncytial virus infections in moderately to severely immunocompromised patients.

BACKGROUND: Respiratory syncytial virus (RSV) infections may be fatal in immunocompromised patients. Aerosolized ribavirin is used for treatment, but it is very costly, teratogenic, and inconvenient. We aimed to assess the outcome of oral ribavirin treatment, with or without intravenous immunoglobulin (IVIG), for RSV infections in moderately to severely immunocompromised patients. METHODS: Medical records of RSV polymerase chain reaction (PCR)-positive patients during 2011-2013 were reviewed retrospectively. Eligible patients were moderately to severely immunocompromised and received oral ribavirin (600-800 mg twice daily) with or without IVIG (500 mg/kg q 48 h) as per protocol. RESULTS: Of 96 adults with PCR-proven RSV infection, 34 were moderately to severely immunocompromised and received oral ribavirin treatment. The mean age was 56.2 years (range: 18-90); 21 were male. Underlying conditions were hematologic malignancy with or without hematopoietic stem cell transplant (n = 25), lung transplant (n = 3), or receipt of cytotoxic chemotherapy (n = 11). The presenting symptoms were cough (94%), fever (62%), and dyspnea (59%). The most common radiographic findings were patchy and nodular infiltrates and opacities. Of 34 patients, 31 were hospitalized, with 13 admitted to the intensive care unit and 6 required mechanical ventilation. The median absolute lymphocyte count on presentation was 480 cells/mm(3) . RSV pneumonia developed in 24 patients. The median initial duration of oral ribavirin treatment was 10 days (range: 4-11); 4 patients were re-treated. Of 34 patients, 19 received a mean of 2.7 doses of IVIG. Two patients had adverse reactions to ribavirin (hemolytic anemia and lactic acidosis in 1 patient, and altered mental status in another). No patient died from RSV infection. Three patients died from complications of their underlying illness; all others recovered clinically. CONCLUSIONS: Oral ribavirin with or without IVIG is a well-tolerated treatment for RSV infection in moderately to severely immunocompromised hosts. Comparative prospective studies should ideally be performed to determine if oral ribavirin is the optimal therapy for RSV infection in this patient population.

The effects of forage particle length and exogenous phytase inclusion on phosphorus digestion and absorption in lactating cows.

Accurate estimates of phosphorus (P) availability from feed are needed to allow P requirements to be met with reduced P intake, thus reducing P excretion by livestock. Exogenous phytase supplementation in poultry and swine diets improves bioavailability of P, and limited research suggests that this strategy may have some application in dairy cattle rations. The effects of exogenous phytase and forage particle length on site and extent of P digestion were evaluated with 5 ruminally and ileally cannulated lactating cows (188 ± 35 d in milk). Cows were assigned in a 2 × 2 factorial arrangement of treatments in 2 incomplete Latin squares with four 21-d periods. Diets contained P slightly in excess of National Research Council requirements with all P from feed sources. During the last 4d of each period, total mixed ration, refusals, omasal, ileal, and fecal samples were collected and analyzed for total P, inorganic P (Pi), and phytate (Pp). Total P intake was not influenced by dietary treatments but Pp intake decreased and Pi intake increased with supplemental phytase, suggesting rapid action of the enzyme in the total mixed ration after mixing. Omasal flow of Pi decreased with phytase supplementation, but we observed no effect of diet in ileal flow or small intestinal digestibility of any P fraction. Fecal excretion of total P was slightly higher and Pp excretion was lower for cows receiving diets supplemented with phytase. Milk yield and composition were unaffected by diets. When phytase was added to the mixed ration, dietary Pp was rapidly degraded before intake and total-tract Pp digestion was increased. The lack of effect of phytase supplementation on dietary P utilization was probably because these late-lactation cows had a low P requirement and were fed P-adequate diets.

Infectious complications among individuals with clinical monoclonal B-cell lymphocytosis (MBL): a cohort study of newly diagnosed cases compared to controls.

Although the risk of progression from monoclonal B-cell lymphocytosis (MBL) to chronic lymphocytic leukemia (CLL) has been well characterized, it is unknown whether other common complications associated with CLL, such as increased risk of infection, occurs in individuals with MBL. We used the Mayo CLL database to identify cohorts of individuals with newly diagnosed MBL (n=154) or newly diagnosed CLL (n=174) who resided within 50 miles of Mayo Clinic. A cohort of 689 adult patients seen for a general medical examination who resided within 50 miles of Mayo clinic and who enrolled in a case-control study of non-Hodgkin lymphoma (NHL) was used as a comparison cohort. Hospitalization with infection was more common among individuals with MBL (25/154; 16.2%), and CLL (32/174; 18.4%) than controls (18/689; 2.6%). On pooled multivariable Cox proportional hazards analysis of all 1017 patients (controls, MBL and CLL), male sex (hazards ratio (HR)=2.3; P=0.002), major co-morbid health problems (HR=1.7, P=0.04), the presence of CLL (HR=3.2, P<0.001), treatment for progressive CLL (HR=2.4, P=0.001) and the presence of MBL (HR=3.0, P=0.001) were independently associated with risk of hospitalization for infection. These results suggest the risk of serious infection in clinical MBL is substantially greater than the risk of progression requiring treatment.

Characterization of restricted diffusion in uni- and multi-lamellar vesicles using short distance iMQCs.

Improved understanding of the entrapment, transport, and release of drugs and small molecules within vesicles is important for drug delivery. Most methods rely on contrast agents or probe molecules; here, we propose a new MRI method to detect signal from water spins with restricted diffusion. This method is based on intermolecular double quantum coherences (iDQCs), which can probe the restricted diffusion characteristics at well-defined and tunable microscopic distance scales. By using an exceedingly short (and previously inaccessible) distance, the iDQC signal arises only from restricted diffusion spins and thereby provides a mechanism to directly image vesicle entrapment, transport, and release. Using uni- and multi-lamellar liposomes and polymersomes, we show how the composition, lamellar structure, vesicle size, and concentration affects the iDQC signal between coupled water spins at very short separation distances. The iDQC signal correlates well with conventional diffusion MRI and a proposed biexponential (multicompartmental) diffusion model. Finally, the iDQC signal was used to monitor dynamic changes in the lamellar structure as temperature-sensitive liposomes released their contents. These short distance iDQCs can probe the amount and diffusion of water entrapped in vesicles, which may be useful to further understand vesicle properties in materials science and drug delivery applications.

Effects of dietary supplementation with a protease on the apparent ileal digestibility of the weaned piglet.

The effects of an acid-stable protease (RONOZYME ProAct) supplemented to a corn (Zea mays)-soybean (Glycine max) meal-based diet on apparent ileal digestibility (AID) of nutrients were evaluated in 120 weaned piglets (28 d old; 8.17 ± 0.90 kg). Pigs were divided into 2 equal groups and had free access to mash diet containing 0.4% Cr(2)O(3) as indigestible marker [basal diet (Std)] or this diet supplemented with RONOZYME ProAct at 15,000 PROT [the amount of enzyme that releases 1 µmol of pnitroaniline from 1 µM of substrate (Suc-Ala-Ala-Pro-Phe-p-nitroaniline) per min at pH 9.0 and 37°C)/kg (ProA). The ileal content was collected for the digestibility determination after euthanasia of 35 piglets of each group after 14 d of study and 25 piglets of each group after 29 d. Compared to group Std, AID of CP was increased (P < 0.05) after 29 d of treatment in group ProA. The AID of the indispensable AA, Met + Cys, and branched-chain AA was increased (P < 0.05) at the end of the study. In the protease supplemented pigs, the AID of the individual AA was not improved after 14 d of treatment whereas it was increased (P < 0.05) at the end of the experiment for Arg, Asp + Asn, Glu + Gln, His, Ile, Lys, Phe, Thr, Tyr ,and Val. In conclusion, dietary protease supplementation increased AID of AA in piglets.

Submental intubation: a literature review.

A literature review was performed to analyse the evidence supporting submental intubation and to aid in the development of a new airway algorithm in craniofacial surgery patients. A systematic search of Pub Med, OVID, the Cochrane Database and Google Scholar between January 1984 and April 2011 was performed. Measured variables included the outcome, complications, publishing specialty journal and method of intubation including technique modifications, indications for the procedure, devices utilized and the total procedure time to complete the submental intubation. Of the 842 patient cases from 41 articles represented in the review, the success rate was 100%. Minor complications were reported in 60 patients and included superficial skin infections (N=23), damage to the tube apparatus (N=10), fistula formation (N=10), right mainstem bronchus tube dislodgement/obstruction (N=5), hypertrophic scarring (N=3), accidental extubation in paediatric patients (N=2), excessive bronchial flexion (N=2), lingual nerve paresthesia (N=1), venous bleeding (N=2), mucocele (N=1), and dislodgement of the throat pack sticker in the submental wound (N=1). The average reported time to complete a submental intubation was 9.9 min. Submental intubation is a safe, effective and time efficient method for securing an airway when increased surgical exposure or restoration of occlusion is a priority.

Flash pulmonary oedema during anidulafungin administration.

WHAT IS KNOWN AND OBJECTIVE: Anidulafungin is an echinocandin antifungal used to treat invasive fungal infections caused by Candida or Aspergillus species. While the echinocandins are generally well tolerated, novel adverse reactions may occur. Specifically, echinocandins have been associated with histamine-mediated infusion reactions. We describe a novel case of flash pulmonary oedema associated with anidulafungin administration, which may be related to histamine release. CASE SUMMARY: A 52-year-old male developed flash pulmonary oedema after the first dose of anidulafungin, which was characterized by acute onset of spasmodic cough with shortness of breath and chest tightness with subsequent new bilateral perihilar and interstitial oedema visualized on chest X-ray. The patient was treated appropriately with diphenhydramine, hydrocortisone and albuterol with complete recovery and a normal follow-up chest X-ray the following day. WHAT IS NEW AND CONCLUSION: This is the first report of pulmonary oedema attributable to an echinocandin antifungal agent. While such infusion-related adverse events including pulmonary oedema appear uncommon, it is important for clinicians to be aware of this possibility and maintain the drug's infusion rate to <1·1 mg/min and monitor for signs and symptoms of pulmonary oedema.

Bronchoscopy in suspected pulmonary TB with negative induced-sputum smear and MTD(®) Gen-probe testing.

INTRODUCTION: In our institution, patients with suspected pulmonary TB undergo multiple induced-sputum sampling for microscopy, culture and nucleic acid amplification (NAA) with the MTD(®) Gen-probe assay. Those with negative induced-sputum results still suspected with TB are then referred for bronchoscopy. We sought to determine the diagnostic yield of bronchoscopy in these patients with negative initial induced-sputum results both via smear and NAA testing. METHODS: We identified 30 consecutive cases of suspected pulmonary TB between 2001 and 2007, who had undergone a diagnostic bronchoscopy after negative results on induced-sputum smears and the MTD(®) Gen-probe on at least 2 samples. RESULTS: The cohort (M = 20 & F = 10) had a median age of 37 (range 16-85 yrs); were predominantly foreign born (27/30); HIV-negative (29/30) individuals with strongly positive TST's (mean 18 + 5 mm). Induced-sputum cultures were negative for M-TB in all patients after a full 60-day incubation period. BAL was culture positive for M-TB in 3/30 cases (10%) with 2 strains being pan-sensitive and the third being INH resistant. BAL microscopy with acid-fast smear (n = 30) and BAL Gen-probe (n = 23) were negative in all cases. A third of the patients (9/27, 33%) with negative bronchoscopy results were treated for culture negative TB. Treatment for latent TB was initiated in 5/27 (18%) individuals whereas 13/27 (48%) received no further treatment. CONCLUSION: Bronchoscopy provided diagnostic confirmation of pulmonary TB in 10% of subjects at least 2 negative induced-sputum samples by smear microscopy and NAA testing.

Tachycardia in adults with cystic fibrosis is associated with normal autonomic function.

BACKGROUND: Whether autonomic dysfunction contributes to tachycardia in cystic fibrosis (CF) is unknown. METHODS: Heart rate variability (HRV) was assessed to determine high frequency power and the low/high frequency power ratio (HF, LF/HF) as markers of vagal and sympathovagal balance, respectively, under spontaneous and controlled breathing (15 breaths per minute (bpm)) conditions in 17 CF and 17 healthy control subjects. RESULTS: Under spontaneously breathing conditions, the CF group was tachycardic (75.4 ± 11.2 vs 60.2 ± 9.0 br/min P < 0.001) and tachypnoeic (22.6 ± 5.8 vs 13.6 ± 4.1 br/min, P= 0.001) compared with controls. No significant difference in HRV was observed between groups during spontaneous or controlled breathing. Coexistent diabetes mellitus and ß(2) agonist use were not associated with altered autonomic control. During controlled breathing, the CF group showed a negative correlation between forced expiratory volume in 1 s (FEV(1)) % predicted and HF power (P= 0.013, r=-0.59) and a positive correlation between FEV(1) % predicted and LF/HF ratio (P= 0.002, r= 0.69) suggesting an exaggerated normal vagal response. CONCLUSION: CF patients have normal autonomic function.