[Lymphogranuloma venereum, an STI that is sometimes recognized late in secondary care]. / Lymphogranuloma venereum.

Lymphogranuloma venereum (LGV) is an invasive sexually transmitted infection caused by Chlamydia trachomatis genotypes L1, L2 and L3. Until recently, LGV was rarely seen in developed countries. However, an outbreak of LGV infections in Europe amongst men who have sex with men (MSM) has been reported in the past decades. Diagnosing LGV can be challenging since there is no pathognomic clinical presentation. Most patients are diagnosed with LGV by Community Healthcare Services and general practitioners. Recent data show that a significant diagnostic delay can occur when patients present in a hospital with symptoms due to LGV infection. This can result in unnecessary additional diagnostic procedures and a subsequent diagnostic delay. In order to create more awareness, we describe 3 cases in our hospital with an initially unrecognized LGV infection. We also discuss the epidemiology, clinical manifestations, diagnostic process and treatment of LGV infection.

The utility of peripheral venous lactate in emergency department patients with normal and higher lactate levels: A prospective observational study.

OBJECTIVE: to assess the utility of peripheral venous lactate (PVL) in Emergency Department patients. METHODS: arteriovenous agreement was assessed in three subgroups: PVL <2 mmol/l, PVL ≥ 2 mmol/l to < 4 mmol/l and PVL ≥ 4 mmol/l. The predictive value of PVL to predict arterial lactate (AL) ≥2 mmol/l was assessed at different cut-off values. RESULTS: 74 samples were analysed. The venous-arterial mean difference and 95% limits of agreement for the subgroups were 0.25 mmol/l (-0.18 to 0.68), 0.37 mmol/l (-0.57 to 1.32) and -0.89 mmol/l (-3.75 to 1.97). PVL ≥2 mmol/l predicts AL ≥2 mmol/l with 100% sensitivity. CONCLUSION: PVL <2 mmol/l rules out arterial hyperlactatemia. As agreement declines in higher levels, arterial sampling should be considered.

Agreement between arterial and peripheral venous lactate levels in the ED: A systematic review.

BACKGROUND: In the Emergency Department, lactate measurement is a useful tool to risk-stratify critically ill patients. However, it is unclear whether arterial or peripheral venous lactate levels can be used interchangeably for this purpose. In this systematic review, we provide an overview of studies investigating the agreement between arterial and peripheral venous lactate levels in the Emergency Department. METHODS: PubMed, Embase, the Cochrane Central Register of Controlled Trials/Wiley, Web of Science/Clarivate Analytics, and references of selected articles were assessed for all studies comparing arterial and peripheral venous lactate levels in adult patients in the emergency department. Two reviewers independently screened all potentially relevant titles and abstracts for eligibility using a standardized data-worksheet. RESULTS: Nine studies were included. Peripheral venous lactate levels tend to be higher than arterial lactate levels with mean differences ranging from 0.18 mmol/l to 1.06 mmol/l. Importantly, poorer agreement occurs in hyperlactatemia. At a cut-of level of 1.6 mmol/l, peripheral venous lactate can rule out arterial hyperlactatemia with a sensitivity between 94% and 100%. At a cut off value of 2 mmol/l, sensitivities of 97% and 100% were found. CONCLUSION: Agreement between arterial and peripheral venous lactate is poor in hyperlactatemia, making peripheral venous lactate an unreliable parameter to use interchangeably in the ED. In clinical practice, peripheral venous lactate can be used as a screening tool to rule out arterial hyperlactatemia at a cut-off value of 2 mmol/l. However, hyperlactatemia should be confirmed using arterial sampling in case of a peripheral venous lactate level > 2 mmol/l.

Pitfalls in SIADH-diagnosed hyponatraemia: Report of two cases.

In the majority of hospitalised patients with hyponatraemia, syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the primary cause. Before considering SIADH, adrenal, thyroid and pituitary insufficiency should be ruled out. However, the evaluation of these contains potential pitfalls which could lead to incorrect diagnosing of SIADH. Here we present two cases in which a suspected SIADH turned out to be caused by hypopituitarism, emphasising the importance of correctly excluding adrenal, thyroid and pituitary insufficiency.

[Splenic abscess]. / Het miltabces.

Splenic abscess is a rare and potentially lethal clinical condition. The most common symptoms of a splenic abscess - abdominal pain, nausea and fever - are non-specific. As a result, a splenic abscess is often not considered in the initial work-up. This might lead to a delay in diagnosis and treatment. In this case series we successively describe a 41-year-old female with a splenic abscess after Streptococcus milleri bacteraemia, a 78-year-old male with a splenic abscess caused by a colon carcinoma and a 52-year-old male with a splenic abscess resulting from a colosplenic fistula after bariatric surgery. By emphasizing the different aetiologies, the different clinical presentations and the different therapeutic options of a splenic abscess, we aim to create greater awareness of this rare clinical phenomenon.

The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review.

BACKGROUND: Acute deterioration in critical ill patients is often preceded by changes in physiological parameters, such as pulse, blood pressure, temperature and respiratory rate. If these changes in the patient's vital parameters are recognized early, excess mortality and serious adverse events (SAEs) such as cardiac arrest may be prevented. The Early Warning Score (EWS) is a scoring system which assists with the detection of physiological changes and may help identify patients at risk of further deterioration. OBJECTIVES: The aim of this systematic review is to evaluate the impact of the use of the Early Warning Score (EWS) on particular patient outcomes, such as in-hospital mortality, patterns of intensive care unit admission and usage, length of hospital stay, cardiac arrests and other serious adverse events of adult patients on general wards and in medical admission units. DESIGN AND SETTING: Systematic review of studies identified from the bibliographic databases of PubMed, EMBASE.com and The Cochrane Library. SELECTION CRITERIA: All controlled studies which measured in-hospital mortality, ICU mortality, serious adverse events (SAEs), cardiopulmonary arrest, length of stay and documentation of physiological parameters which used a EWS on the ward or the emergency department to identify patients at risk were included in the review. DATA COLLECTION AND ANALYSIS: Three reviewers (NA, AT and EH) independently screened all potentially relevant titles and abstracts for eligibility, by using a standardized data-worksheet. Meta-analysis was not possible due to heterogeneity. MAIN RESULTS: Seven studies met the inclusion criteria. The results of our included studies were mixed, with a positive trend towards better clinical outcomes following the introduction of the EWS chart, sometimes coupled with an outreach service. Six of the seven included studies used mortality as an endpoint: two of these studies reported no significant difference in in-hospital mortality rate; two found a significant reduction of in-hospital mortality; two other studies described a trend towards improved survival. Although, both ICU mortality and serious adverse events were not significantly improved, there was a trend towards reduction of these endpoints after introduction of the EWS. However only two studies looked respectively at each endpoint. There were conflicting results concerning cardiopulmonary arrests. One study found a reduction in the incidence of cardiac arrest calls as well as in the mortality of patients who underwent CPR, while another one found an increased incidence of cardio-pulmonary arrests. Neither study met all methodological quality criteria. CONCLUSION: The EWS itself is a simple and easy to use tool at the bedside, which may be of help in recognizing patients with potential for acute deterioration. Coupled with an outreach service, it may be used to timely initiate adequate treatment upon recognition, which may influence the clinical outcomes positively. However, the use of adapted forms of the EWS together with different thresholds, poor or inadequate methodology makes it difficult in drawing comparisons. A general conclusion can thus not be generated from the lack of use of a single standardized score and the use of different populations. In future large multi-centre trials using one standardized score are needed also in order to facilitate comparison.

Population size, cage area, and dominance rank effects on productivity and well-being of laying hens.

The effect of two cage population sizes (four vs. six/cage) and two cage area treatments (316 cm2 vs. 406 cm2/bird) were compared in a nonconfounded design while maintaining feeder space constant (8.9 cm/bird) for egg production performances and behavioral and physiological indicators of well-being of laying hens. Egg production rates were determined for all members of each cage group (palpations at 48 to 50 wk) and on a cage group basis (20 to 60 wk). Heart weights, plasma corticosterone levels, durations of tonic immobility (TI), and plumage conditions were compared for top and bottom birds in the dominance ranks. Significant reductions in egg production were observed for low ranking hens in the high density (4 and 6/316-cm2) treatments. In addition, high ranking hens of the 6/316-cm2 treatment produced fewer eggs than high ranking hens in the 4/316-cm2 treatment. When high and low ranking individuals were housed in single-hen cages, egg production was improved relative to performances in the social environments. Heart weights of hens, as a percentage of body weight, were increased in the low ranking hens and for hens in the smaller cage size. Plasma corticosterone did not prove to be a useful indicator of well-being. Low ranking individuals had greater durations of TI but differences in feather condition were not detected. The results support the contention that appropriate population sizes and cage space allocations can be determined that will optimize the performance and welfare of layers in cage environments.

Effects of cage and floor pen management on behavior, production, and physiological stress responses of laying hens.

Behavior, physiology, health, egg production, and egg quality characteristics of laying hens housed either 1/1394-cm2 cage (S), 2/1394-cm2 cage (HD), 2/2788-cm2 cage (LD), or in floor pens (P), each containing 25 hens, were monitored in order to assess hen welfare in different management systems. Egg production was highest in P and S hens. There were no differences among treatment groups in feed efficiency, egg weight, or egg taste, although egg shell breaking strengths were lower in HD hens despite their relatively low egg production. Blood spots were most common in eggs from caged hens. With respect to behavior, penned hens locomoted more, spent less time in stationary exploration than caged birds, and utilized nest boxes for activities in addition to egg laying. The HD hens fed less frequently than did the LD, and HD cage pairs engaged less frequently in simultaneous feeding, drinking, and resting behavior than LD pairs. Plasma corticosterone levels were initially found to be higher in pens than cages; this difference disappeared when the use of trap-nesting to capture P birds for sampling was discontinued. Nighttime corticosterone levels were higher in HD hens. In contrast, primary and secondary hemagglutination titers to sheep erythrocyte (SRBC) antigen, heterophil to lymphocyte ratios, hepatic zinc metallothionein, serum zinc, and body weights did not differ among treatments. Mortality, however, was lower in pens. It was concluded that, although there were striking dissimilarities in behavior between the pen and cage environments, physiological and production data did not provide evidence of stress associated with cage housing per se. High density caging, however, may be a stressor; this is discussed with reference to other research.

Behavioral effects of intraventricular dibutyryl cyclic AMP in domestic fowl.

Intraventricular administration of dibutyryl cyclic AMP (dbcAMP) to domestic fowl induced behaviors within 60 seconds which persisted for 7-120 minutes. Stereotyped head movements and increases in preening were observed at the lowest dose (50 nmol), while at higher doses (150 and 225 nmol) head movements were interspersed with escape behavior, increases in locomotor activity, salivation and a loss of coordination. Administration also elicited vocalizations, mainly laying and type 1 warning calls. These calls contained many abnormal elements, possibly caused by relaxation of the syringeal musculature. The rate of calling was influenced by testosterone, being greater in hens and capons than in roosters or capons implanted with testosterone propionate. Caponization also intensified escape behavior. No behaviors were induced by administration of the hydrolysis product of dbcAMP, butyric acid. These behavioral effects of dbcAMP are similar to those reported to occur during electrical stimulation of loci in the avian brain.

Evidence for a positive feedback interaction between progesterone and luteinizing hormone in the induction of ovulation in the hen, Gallus domesticus.

Two experiments were conducted to test the hypothesis that progesterone (P4) acts to induce a preovulatory rise of luteinizing hormone (LH) by initiating a true positive feedback interaction between P4 and LH. In each experiment, ten hens were stereotaxically implanted with a third ventricle cannula. Aminoglutethimide phosphate (AGP), an inhibitor of steroidogenesis, was administered (200 mg iv) to hens at 10 and 6 hr (Experiment 1) and 10 and 7 hr (Experiment 2) before an expected C1 ovulation. A 20-micrograms injection of P4 (n = 5) or the vehicle (n = 5) was made intraventricularly at 6 hr (Experiment 1) or 7 hr (Experiment 2) before the expected ovulation. Blood samples were taken via branchial vein cannula at regular intervals after the injection. In Experiment 1, four of five P4-treated hens ovulated, and no atretic follicles were found in any of the five P4-treated hens, including the one which did not ovulate. Ovulations were always accompanied by preovulatory LH peaks. By comparison, none of the vehicle-injected animals ovulated and in four of five hens the largest follicle was determined to be atretic. No ovulations occurred in Experiment 2 for either the P4- or vehicle-injected hens. Atresia of the largest follicle occurred in all five hens in the P4-treated group and four of five hens of the vehicle-treated group. The difference in results between Experiment 1 and Experiment 2 can be explained assuming that the steroidogenesis-inhibiting action of the initial AGP injection in Experiment 1 (at 10 hr before ovulation) had diminished prior to the second AGP treatment (at 6 h before ovulation).(ABSTRACT TRUNCATED AT 250 WORDS)

Response of different commercial strains of laying hens to short total photoperiods in interrupted night experiments during days of 24 and 28 hours.

Experiments were conducted: as pilot experiments in which each experimental unit, replicated two or three times, consisted of 15 hens, as practical experiments in which each of four strains was replicated twice in two rooms containing 200 to 265 hens, and as commercial experiments in which each experimental unit consisted of 4 strains of 1000 hens but in which no replication occurred. Short total photoperiods were used in interrupted night experiments with 24-hr and 28-hr days. A light regimen of 2L:6D:2L:18D yielded similar results as 12L:16D for percent egg production, egg mass, egg shell breaking strength, and feed efficiency. Exposure to 28-hr days, in comparison with 24-hr days, resulted in a reduction of number of eggs produced but did not reduce egg mass produced. In one of four strains, the increase in egg size and reduction in number of eggs produced was significantly (P less than .05) less than in the other three strains, Under the 28-hr day regimens shell breaking strength was consistently greater (P less than .01) than under 24-hr light regimens. In an additional experiment, no relationship was found in egg breakage during transport between two populations of eggs that differed in eggshell breaking strength as a result of differences in light regimens received by the hens. Short (2L:10D:2L:10D or 2L:12D:2L:8D) and very short (2L:12D:1/4L:9 3/4D) interrupted night regimens generally yielded lower egg production than 16L:8D or 8L:10D:2L:4D light regimens. There was an indication that there might be strain differences in the response to the interrupted night regimen. Exposure to 2L:6D:2L:8D for 6 weeks at the start and 8 weeks at the end of an 11-month experimental period, with 16L:8D given during the remainder of the period, resulted in lower egg production during the last 8 weeks and no compensatory improvement in egg shell breaking strength or egg weight in comparison with continuous exposure to 16L:8D.

Ovulatory response, and plasma concentrations of luteinizing hormone and progesterone following administration of synthetic mammalian or chicken luteinizing hormone-releasing hormone relative to the first or second ovulation in the sequence of the domestic hen.

Experiments were conducted to investigate hypophyseal and follicular competency at two distinct stages of the hen's egg laying sequence: 1) 14 h prior to the first (C1) ovulation of a sequence (27 h following the previous ovulation); and 2) 14 h prior to the second (C2) ovulation of a sequence (13 h following the previous ovulation). When a single dose of mammalian luteinizing hormone-releasing hormone (mLHRH) or chicken luteinizing hormone-releasing hormone (cLHRH) was injected 14 h prior to a C1 ovulation, premature ovulation was induced in 19 of 20 hens. In contrast, ovulation was premature in only 1 of 20 hens when mLHRH or cLHRH was injected 14 h prior to a C2 ovulation. There was no difference between the two stages of the sequence in the amount of luteinizing hormone (LH) released for up to 60 min following a single i.v. injection of 20 micrograms mLHRH. However, only prior to a C1 ovulation did LH levels further increase to reach preovulatory concentrations. By contrast, progesterone (P4) concentrations were increased within the first 60 min to a lesser extent in hens injected prior to a C2 ovulation compared to a C1 ovulation. In C2-injected birds, P4 fell to levels that were not different from vehicle-injected controls by 45 to 60 min following injection, whereas P4 secretion was maintained in hens injected prior to a C1 ovulation. We suggest that the lack of sustained LH secretion following treatment with either species of LHRH 14 h prior to a C2 ovulation is related to follicular immaturity with respect to ability to produce and secrete P4. At the dosage administered, there was no difference in the ability of mLHRH compared to cLHRH to release LH at either stage of the sequence. Finally, two successive injections of mLHRH at 14 and 13 h prior to a C2 ovulation induced premature ovulation in 6 of 11 hens. It is suggested that LH, and possibly P4, exerts a priming effect on the largest preovulatory follicle to initiate fully potentiated P4 production and secretion.

Effects of aminoglutethimide on luteinizing hormone and steroid secretion, and ovulation in the hen, Gallus domesticus.

Two experiments were conducted: 1) to assess the ovulation-blocking ability and steroidogenesis-inhibiting activity of aminoglutethimide in the laying hen; and 2) to determine whether LHRH or progesterone (P4) administration can overcome the ovulation-blocking effect of aminoglutethimide. Aminoglutethimide inhibited ovulation and suppressed the secretion of P4 and testosterone (T) in a dose-related fashion. In the absence of any increase in plasma P4 and T, there was no preovulatory increase in plasma LH. These results indicate that the preovulatory surge of LH is initiated by an increase in steroid. The effectiveness of P4 and LHRH to stimulate LH release and overcome the ovulation-blocking effect of aminoglutethimide was tested in the second experiment. Administration of 500 micrograms P4 (im) to aminoglutethimide-treated hens resulted in a significant and sustained release of LH [peak, 3.08 +/- 0.62 (+/- SEM) ng/ml; 120 min after injection] and induced ovulation in the absence of any increase in plasma T or estrogen. In contrast, injection of 20 micrograms LHRH (iv) failed to overcome the blocking effect of aminoglutethimide and caused an attenuated (peak, 2.17 +/- 0.37 ng/ml; 60 min after injection) and short-lived increase in plasma LH. These results are consistent with the model for a true positive feedback mechanism in which P4 initiates and sustains the preovulatory LH surge of the hen.

Plasma luteinizing hormone levels throughout development and relative to ovulation in pinealectomized hens (Gallus domesticus).

The role of the pineal gland in the reproductive endocrinology of the hen was examined. Chicks were pinealectomized or sham-operated at 2-3 days of age and the developmental LH profile, body weights, and age of lay of the first egg were compared to those of unoperated controls. There were no differences in any of the parameters measured throughout development. When the birds were mature, LH levels during the evening prior to a first ovulation of the sequence were also compared among the three groups of hens. No differences were found between the pinealectomized and unoperated-control hens. The sham-operated animals showed significant differences from the control hens at three time periods but differed from the pinealectomized group at only one time period. It is possible that the somewhat unusual LH profile exhibited by the sham-operated group is a result of the surgery.

Investigations of the significance of the crepuscular LH peak in the ovulatory cycle of the hen (Gallus domesticus).

The crepuscular (occurring at dusk) peak of LH was characterized and its functional significance in the ovulatory cycle of the hen, Gallus domesticus, examined. Serial blood sampling on the night before the first ovulation (C1) of the sequence was followed by normal ovulations in six out of eight hens whereas blood sampling before a second or third ovulation (C2 or C3) of the sequence resulted in blocked ovulations in six out of seven hens. The difference in incidence of blocked ovulations was significant (P less than 0.02). Associated with normal ovulations was a significant (P less than 0.05) crepuscular peak in plasma LH whereas in those hens in which ovulation was blocked, no rise in LH at onset of darkness was detected. Serial blood sampling of hens on a night when 'lights-off' was delayed revealed a significant (P less than 0.05) crepuscular peak of LH at the time when the lights usually went off, indicating that the rise in LH had the property of a daily rhythm. When a 'lights-off' signal was given 4 h early before a C1 ovulation, a crepuscular peak of LH was induced (P less than 0.05) and preovulatory rises of LH and progesterone were significantly advanced (P less than 0.005 and P less than 0.02 respectively) compared with control hens, although not by the entire 4-h interval. This indicated that the crepuscular LH peak could be induced by the lights-off signal.(ABSTRACT TRUNCATED AT 250 WORDS)