A case of Kingella kingae endocarditis complicated by native mitral valve rupture

We report a case of Kingella kingae endocarditis in a patient with a history of recent respiratory tract infection and dental extraction. This case is remarkable for embolic and vasculitic phenomena in association with a large valve vegetation and valve perforation. Kingella kingae is an organism known to cause endocarditis, however early major complications are uncommon. Our case of Kingella endocarditis behaved in a virulent fashion necessitating a combined approach of intravenous antibiotic therapy and a valve replacement. It highlights the importance of expedited investigation for endocarditis in patients with Kingella bacteraemia.

Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke

BACKGROUND: The timing of cardiac surgery after stroke in infective endocarditis (IE) remains controversial. We examined the relationship between the timing of surgery after stroke and the incidence of in-hospital and 1-year mortalities. METHODS: Data were obtained from the International Collaboration on Endocarditis-Prospective Cohort Study of 4794 patients with definite IE who were admitted to 64 centers from June 2000 through December 2006. Multivariate logistic regression and Cox regression analyses were performed to estimate the impact of early surgery on hospital and 1-year mortality after adjustments for other significant covariates. RESULTS: Of the 857 patients with IE complicated by ischemic stroke syndromes, 198 who underwent valve replacement surgery poststroke were available for analysis. Overall, 58 (29.3%) patients underwent early surgical treatment vs 140 (70.7%) patients who underwent late surgical treatment. After adjustment for other risk factors, early surgery was not significantly associated with increased in-hospital mortality rates (odds ratio, 2.308; 95% confidence interval [CI], .942-5.652). Overall, probability of death after 1-year follow-up did not differ between 2 treatment groups (27.1% in early surgery and 19.2% in late surgery group, P = .328; adjusted hazard ratio, 1.138; 95% CI, .802-1.650). CONCLUSIONS: There is no apparent survival benefit in delaying surgery when indicated in IE patients after ischemic stroke. Further observational analyses that include detailed pre- and postoperative clinical neurologic findings and advanced imaging data (eg, ischemic stroke size), may allow for more refined recommendations on the optimal timing of valvular surgery in patients with IE and recent stroke syndromes.

Regulation of redox and DNA repair genes by arsenic : low dose protection against oxidative stress?

We have evaluated the molecular responses of human epithelial cells to low dose arsenic to ascertain how target cells may respond to physiologically relevant concentrations of arsenic. Data gathered in numerous experiments in different cell types all point to the same conclusion: low dose arsenic induces what appears to be a protective response against subsequent exposure to oxidative stress or DNA damage, whereas higher doses often provoke synergistic toxicity. In particular, exposure to low, sub-toxic doses of arsenite, As(III), causes coordinate up-regulation of multiple redox and redox-related genes including thioredoxin (Trx) and glutathione reductase (GR). Glutathione peroxidase (GPx) is down-regulated in fibroblasts, but up-regulated in keratinocytes, as is glutathione S-transferase (GST). The maximum effect on these redox genes occurs after 24 h exposure to 5–10 mM As(III). This is 10-fold higher than the maximum As(III) concentrations required for induction of DNA repair genes, but within the dose region where DNA repair genes are co-ordinately down-regulated. These changes in gene regulation are brought about in part by changes in DNA binding activity of the transcription factors activating protein-1 (AP-1), nuclear factor kappa-B, and cAMP response element binding protein (CREB). Although sub-acute exposure to micromolar As(III) up-regulates transcription factor binding, chronic exposure to submicromolar As(III) causes persistent down-regulation of this response. Similar long-term exposure to micromolar concentrations of arsenate in drinking water results in a decrease in skin tumour formation in dimethylbenzanthracene (DMBA)/phorbol 12-tetradecanoate 13-acetate (TPA) treated mice. Altered response patterns after long exposure to As(III) may play a significant role in As(III) toxicology in ways that may not be predicted by experimental protocols using short-term exposures.

Effect of fat replacement by insulin or lupin-kernal fibre on sausage patty acceptability, post-meal perceptions of satiety and food intake in men

The present study examined whether replacing fat with inulin or lupin-kernel fibre influenced palatability, perceptions of satiety, and food intake in thirty-three healthy men (mean age 52 years, BMI 27·4 kg/m²), using a within-subject design. On separate occasions, after fasting overnight, the participants consumed a breakfast consisting primarily of either a full-fat sausage patty (FFP) or a reduced-fat patty containing inulin (INP) or lupin-kernel fibre (LKP). Breakfast variants were alike in mass, protein and carbohydrate content; however the INP and LKP breakfasts were 36 and 37 % lower in fat and 15 and 17 % lower in energy density respectively compared with the FFP breakfast. The participants rated their satiety before breakfast then evaluated patty acceptability. Satiety was rated immediately after consuming the breakfast, then over the subsequent 4·5 h whilst fasting. Food consumed until the end of the following day was recorded. All patties were rated above ‘neither acceptable or unacceptable’, however the INP rated lower for general acceptability (P=0·039) and the LKP lower for flavour (P=0·023) than the FFP. The LKP breakfast rated more satiating than the INP (P=0·010) and FFP (P=0·016) breakfasts. Total fat intake was 18 g lower on the day of the INP (P=0·035) and 26 g lower on the day of the LKP breakfast (P=0·013) than the FFP breakfast day. Energy intake was lower (1521 kJ) only on the day of the INP breakfast (P=0·039). Both inulin and lupin-kernel fibre appear to have potential as fat replacers in meat products and for reducing fat and energy intake in men.

File replacement algorithm for storage resource managers in data grids

The main problem in data grids is how to provide good and timely access to huge data given the limited number and size of storage devices and high latency of the interconnection network. One approach to address this problem is to cache the files locally such that remote access overheads are avoided. Caching requires a cache-replacement algorithm, which is the focus of this paper. Specifically, we propose a new replacement policy and compare it with an existing policy using simulations. The results of the simulation show that the proposed policy performs better than the baseline policy.

Testosterone replacement therapy-perceptions of recipients and partners

Background. The androgenic hormones are important determinants of sexual behaviour in men. Testosterone replacement is important treatment for pituitary disease to maintain normal functioning. Although the physical effects of testosterone replacement have been well documented, little is known about the effects on relationships, particularly from the point of view of the sexual partners of men receiving testosterone replacement.

Aims. This paper reports a study exploring the perceptions of testosterone replacement on well-being and sexual functioning.

Methods. Semi-structured interviews were conducted with five men receiving testosterone implants (recipients), their permanent partners, and five recipients without partners. Recipient serum testosterone concentration was measured at 0, 1 and 4 months after testosterone implantation.

Results. The three groups reported similar effects of testosterone on well-being and sexual functioning. Recipient and partner ratings were also similar. Strength was less affected by decreasing testosterone concentration than energy in men with partners, but both strength and energy declined in men without partners. Decreased testosterone levels had a statistically significantly different effect on libido at time zero between men with and without partners (P < 0·015) and on ability to sustain an erection, but the ability to achieve an erection persisted over the 6 months in both male groups. Intercourse frequency increased from once per week at time 0 to ≥3 per week between 1 and 4 months after implant in men with partners. There were important effects of testosterone deficiency on general and sexual relationships, and these differed between men with partners and those without.

Conclusions. Testosterone has important physical and psychological benefits that may be related to the age at which testosterone replacement commences and the indications for its use. The small sample size may limit the ability to generalize the findings outside the study.

Effect of crude oil extracts from trout offal as a replacement for fish oil in the diets of the Australian native fish Murray cod Maccullochella peelii peelii

The efficacy of trout oil (TO), extracted from trout offal from the aquaculture industry, was evaluated in juvenile Murray cod Maccullochella peelii peelii (25.4-0.81 g) diets in an experiment conducted over 60 days at 23.7-0.8 °C. Five isonitrogenous (48% protein), isolipidic (16%) and isoenergetic (21.8 kJ gm1) diets, in which the fish oil fraction was replaced in increments of 25% (0-100%), were used. The best growth and feed efficiency was observed in fish fed diets containing 50-75% TO. The relationship of specific growth rate (SGR), food conversion ratio (FCR) and protein efficiency ratio (PER) to the amount of TO in the diets was described in each case by second-order polynomial equations (P<0.05), which were: SGR=-0.44TO2+0.52TO+1.23 (r2=0.90, P<0.05); FCR=0.53TO2-0.64TO+1.21 (r2=0.95, P<0.05); and PER=-0.73TO2+0.90TO+1.54 (r2=0.90, P<0.05). Significant differences in carcass and muscle proximate compositions were noted among the different dietary treatments. Less lipid was found in muscle than in carcass. The fatty acids found in highest amounts in Murray cod, irrespective of the dietary treatment, were palmitic acid (16:0), oleic acid (18:1n-9), linoleic acid (18:2n-6) and eicosapentaenoic acid (20:5n-3). The fatty acid composition of the muscle reflected that of the diets. Both the n-6 fatty acid content and the n-3 to n-6 ratio were significantly (P<0.05) related to growth parameters, the relationships being as follows. Percentage of n-6 in diet (X) to SGR and FCR: SGR=-0.12X2+3.96X-32.51 (r2=0.96) and FCR=0.13X2-4.47X+39.39 (r2=0.98); and n-3:n-6 ratio (Z) to SGR, FCR, PER: SGR=-2.02Z2+5.01Z-1.74 (r2=0.88), FCR=2.31Z2-5.70Z+4.54 (r2=0.93) and PER=-3.12Z2-7.56Z+2.80 (r2=0.88) respectively. It is evident from this study that TO could be used effectively in Murray cod diets, and that an n-3:n-6 ratio of 1.2 results in the best growth performance in Murray cod.

Continuity of care and general wellbeing of patients with comorbidities requiring joint replacement

Aim. The aim of this paper is to examine the continuity of care and general wellbeing of patients with comorbidities undergoing elective total hip or knee joint replacement.
Background. Advances in medical science and improved lifestyles have reduced mortality rates in most Western countries. As a result, there is an ageing population with a concomitant growth in the number of people who are living with multiple chronic illnesses, commonly referred to as comorbidities. These patients often require acute care services, creating a blend of acute and chronic illness needs. For example, joint replacement surgery is frequently performed to improve impaired mobility associated with osteoarthritis.
Method. A purposive sample of twenty participants with multiple comorbidities who required joint replacement surgery was recruited to obtain survey, interview and medical record audit data. Data were collected during 2004 and 2005.
Findings. Comorbidity care was poorly co-ordinated prior to having surgery, during the acute care stay and following surgery and primarily entailed prescribed medicines. The main focus in acute care was patient throughput following joint replacement surgery according to a prescribed clinical pathway. General wellbeing was less than optimal: participants reported pain, fatigue, insomnia and alterations in urinary elimination as the chief sources of discomfort during the course of the study.
Conclusion. Continuity of care of comorbidities was lacking. Comorbidities affected patient general wellbeing and delayed recovery from surgery. Acute care, clinical pathways and the specialisation of medicine and nursing subordinated the general problem of patients with comorbidities. Systems designed to integrate and co-ordinate chronic illness care had limited application in the acute care setting. A multidisciplinary, holistic approach is required. Recommendations for further research conclude this paper.

Routine replacement of short peripheral intravenous cannulae in children: evidence of an unnecessary practice

Short peripheral intravenous cannulae (pIVC) are prone to specific problems such as thrombophlebitis, infiltration and bacterial colonisation. This paper presents data from a study of 80 polyurethane pIVC in 59 children within a general paediatric population. There was no significant colonisation of any cannula by bacterial or fungal organisms. This study provides evidence that it is safe not to routinely replace pIVC in this population. It supports the Centers for Disease Control and Prevention (CDC) guidelines for intravenous cannula (IVC) management in children.

Safety and efficacy of routine postoperative ibuprofen for pain and disability related to ectopic bone formation after hip replacement surgery (HIPAID): a randomised control trial

Objectives To determine the benefits and risks of a non-steroidal anti-inflammatory drug (NSAID) as prophylaxis for ectopic bone formation in patients undergoing total hip replacement (or revision) surgery.
Design Double blind randomised placebo controlled clinical trial, stratified by treatment site and surgery (primary or revision).
Setting 20 orthopaedic surgery centres in Australia and New Zealand.
Participants 902 patients undergoing elective primary or revision total hip replacement surgery.
Intervention 14 days' treatment with ibuprofen (1200 mg daily) or matching placebo started within 24 hours of surgery.
Main outcome measures Changes in self reported hip pain and physical function 6 to 12 months after surgery (Western Ontario and McMaster University Arthritis index).
Results There were no significant differences between the groups for improvements in hip pain (mean difference -0.1, 95% confidence interval -0.4 to 0.2, P = 0.6) or physical function (-0.1, -0.4 to 0.2, P = 0.5), despite a decreased risk of ectopic bone formation (relative risk 0.69, 0.56 to 0.83) associated with ibuprofen. There was a significantly increased risk of major bleeding complications in the ibuprofen group during the admission period (2.09, 1.00 to 4.39).
Conclusions These data do not support the use of routine prophylaxis with NSAIDs in patients undergoing total hip replacement surgery.
Trial registration NCT00145730.