Non invasive transcutaneous blood carboxyhemoglobine level: reliability in victims of carbon monoxide poisoning

Introduction: Carbon monoxide (CO) poisoning is one of the mostcommon causes of fatal poisoning. Symptoms of CO poisoning arenonspecific and the documentation of elevated carboxyhemoglobin(HbCO) levels in arterial blood sample is the only standard ofconfirming suspected exposure. The treatment of CO poisoning requiresnormobaric or hyperbaric oxygen therapy, according to the symptomsand HbCO levels. A new device, the Rad-57 pulse CO-oximeter allowsnoninvasive transcutaneous measurement of blood carboxyhemoglobinlevel (SpCO) by measurement of light wavelength absorptions.Methods: Prospective cohort study with a sample of patients, admittedbetween October 2008 - March 2009 and October 2009 - March 2010,in the emergency services (ES) of a Swiss regional hospital and aSwiss university hospital (Burn Center). In case of suspected COpoisoning, three successive noninvasive measurements wereperformed, simultaneously with one arterial blood HbCO test. A controlgroup includes patients admitted in the ES for other complaints (cardiacinsufficiency, respiratory distress, acute renal failure), but necessitatingarterial blood testing. Informed consent was obtained from all patients.The primary endpoint was to assess the agreement of themeasurements made by the Rad-57 (SpCO) and the blood levels(HbCO).Results: 50 patients were enrolled, among whom 32 were admittedfor suspected CO poisoning. Baseline demographic and clinicalcharacteristics of patients are presented in table 1. The median age was37.7 ans ± 11.8, 56% being male. Median laboratory carboxyhemoglobinlevels (HbCO) were 4.25% (95% IC 0.6-28.5) for intoxicated patientsand 1.8% (95% IC 1.0-5.3) for control patients. Only five patientspresented with HbCO levels >= 15%. The results disclose relatively faircorrelations between the SpCO levels obtained by the Rad-57 and thestandard HbCO, without any false negative results. However, theRad-57 tend to under-estimate the value of SpCO for patientsintoxicated HbCO levels >10% (fig. 1).Conclusion: Noninvasive transcutaneous measurement of bloodcarboxyhemoglobin level is easy to use. The correlation seems to becorrect for low to moderate levels (<15%). For higher values, weobserve a trend of the Rad-57 to under-estimate the HbCO levels. Apartfrom this potential limitation and a few cases of false-negative resultsdescribed in the literature, the Rad-57 may be useful for initial triageand diagnosis of CO.

Thalamic connectivity in patients with essential tremor treated with MR imaging-guided focused ultrasound: in vivo fiber tracking by using diffusion-tensor MR imaging.

PURPOSE: To use diffusion-tensor (DT) magnetic resonance (MR) imaging in patients with essential tremor who were treated with transcranial MR imaging-guided focused ultrasound lesion inducement to identify the structural connectivity of the ventralis intermedius nucleus of the thalamus and determine how DT imaging changes correlated with tremor changes after lesion inducement. MATERIALS AND METHODS: With institutional review board approval, and with prospective informed consent, 15 patients with medication-refractory essential tremor were enrolled in a HIPAA-compliant pilot study and were treated with transcranial MR imaging-guided focused ultrasound surgery targeting the ventralis intermedius nucleus of the thalamus contralateral to their dominant hand. Fourteen patients were ultimately included. DT MR imaging studies at 3.0 T were performed preoperatively and 24 hours, 1 week, 1 month, and 3 months after the procedure. Fractional anisotropy (FA) maps were calculated from the DT imaging data sets for all time points in all patients. Voxels where FA consistently decreased over time were identified, and FA change in these voxels was correlated with clinical changes in tremor over the same period by using Pearson correlation. RESULTS: Ipsilateral brain structures that showed prespecified negative correlation values of FA over time of -0.5 or less included the pre- and postcentral subcortical white matter in the hand knob area; the region of the corticospinal tract in the centrum semiovale, in the posterior limb of the internal capsule, and in the cerebral peduncle; the thalamus; the region of the red nucleus; the location of the central tegmental tract; and the region of the inferior olive. The contralateral middle cerebellar peduncle and bilateral portions of the superior vermis also showed persistent decrease in FA over time. There was strong correlation between decrease in FA and clinical improvement in hand tremor 3 months after lesion inducement (P < .001). CONCLUSION: DT MR imaging after MR imaging-guided focused ultrasound thalamotomy depicts changes in specific brain structures. The magnitude of the DT imaging changes after thalamic lesion inducement correlates with the degree of clinical improvement in essential tremor.

The CbrA-CbrB two-component regulatory system controls the utilization of multiple carbon and nitrogen sources in Pseudomonas aeruginosa.

A novel two-component system, CbrA-CbrB, was discovered in Pseudomonas aeruginosa; cbrA and cbrB mutants of strain PAO were found to be unable to use several amino acids (such as arginine, histidine and proline), polyamines and agmatine as sole carbon and nitrogen sources. These mutants were also unable to use, or used poorly, many other carbon sources, including mannitol, glucose, pyruvate and citrate. A 7 kb EcoRI fragment carrying the cbrA and cbrB genes was cloned and sequenced. The cbrA and cbrB genes encode a sensor/histidine kinase (Mr 108 379, 983 residues) and a cognate response regulator (Mr 52 254, 478 residues) respectively. The amino-terminal half (490 residues) of CbrA appears to be a sensor membrane domain, as predicted by 12 possible transmembrane helices, whereas the carboxy-terminal part shares homology with the histidine kinases of the NtrB family. The CbrB response regulator shows similarity to the NtrC family members. Complementation and primer extension experiments indicated that cbrA and cbrB are transcribed from separate promoters. In cbrA or cbrB mutants, as well as in the allelic argR9901 and argR9902 mutants, the aot-argR operon was not induced by arginine, indicating an essential role for this two-component system in the expression of the ArgR-dependent catabolic pathways, including the aruCFGDB operon specifying the major aerobic arginine catabolic pathway. The histidine catabolic enzyme histidase was not expressed in cbrAB mutants, even in the presence of histidine. In contrast, proline dehydrogenase, responsible for proline utilization (Pru), was expressed in a cbrB mutant at a level comparable with that of the wild-type strain. When succinate or other C4-dicarboxylates were added to proline medium at 1 mM, the cbrB mutant was restored to a Pru+ phenotype. Such a succinate-dependent Pru+ property was almost abolished by 20 mM ammonia. In conclusion, the CbrA-CbrB system controls the expression of several catabolic pathways and, perhaps together with the NtrB-NtrC system, appears to ensure the intracellular carbon: nitrogen balance in P. aeruginosa.

Frequencies of circulating MDSC correlate with clinical outcome of melanoma patients treated with ipilimumab.

Metastatic melanoma has a poor prognosis with high resistance to chemotherapy and radiation. Recently, the anti-CTLA-4 antibody ipilimumab has demonstrated clinical efficacy, being the first agent to significantly prolong the overall survival of inoperable stage III/IV melanoma patients. A major aim of patient immune monitoring is the identification of biomarkers that predict clinical outcome. We studied circulating myeloid-derived suppressor cells (MDSC) in ipilimumab-treated patients to detect alterations in the myeloid cell compartment and possible correlations with clinical outcome. Lin(-) CD14(+) HLA-DR(-) monocytic MDSC were enriched in peripheral blood of melanoma patients compared to healthy donors (HD). Tumor resection did not significantly alter MDSC frequencies. During ipilimumab treatment, MDSC frequencies did not change significantly compared to baseline levels. We observed high inter-patient differences. MDSC frequencies in ipilimumab-treated patients were independent of baseline serum lactate dehydrogenase levels but tended to increase in patients with severe metastatic disease (M1c) compared to patients with metastases in skin or lymph nodes only (M1a), who had frequencies comparable to HD. Interestingly, clinical responders to ipilimumab therapy showed significantly less lin(-) CD14(+) HLA-DR(-) cells as compared to non-responders. The data suggest that the frequency of monocytic MDSC may be used as predictive marker of response, as low frequencies identify patients more likely benefitting from ipilimumab treatment. Prospective clinical trials assessing MDSC frequencies as potential biomarkers are warranted to validate these observations.

Long-term Outcome and Late Side Effects in Endometrial Cancer Patients Treated with Surgery and Postoperative Radiation Therapy.

BACKGROUND: We retrospectively reviewed the long-term outcome and late side effects of endometrial cancer (EC) patients treated with different techniques of postoperative radiotherapy (PORT). METHODS: Between 1999 and 2012, 237 patients with EC were treated with PORT. Two-dimensional external beam radiotherapy (2D-EBRT) was used in 69 patients (30 %), three-dimensional EBRT (3D-EBRT) in 51 (21 %), and intensity-modulated RT (IMRT) with helical Tomotherapy in 47 (20 %). All patients received a vaginal brachytherapy (VB) boost. Seventy patients (29 %) received VB alone. RESULTS: After a median of 68 months (range, 6-154) of follow-up, overall survival was 75 % [95 % confidence interval (CI), 69-81], disease-free survival was 72 % (95% CI, 66-78), cancer-specific survival was 85 % (95 % CI, 80-89), and locoregional control was 86 % (95 % CI, 81-91). The 5-year estimates of grade 3 or more toxicity and second cancer rates were 0 and 7 % (95 % CI, 1-13) for VB alone, 6 % (95 % CI, 1-11) and 0 % for IMRT + VB, 9 % (95 % CI, 1-17) and 5 % (95 % CI, 1-9) for 3D-EBRT + VB, and 22 % (95 % CI, 12-32) and 12 % (95 % CI, 4-20) for 2D-EBRT + VB (P = 0.002 and P = 0.01), respectively. CONCLUSIONS: Pelvic EBRT should be tailored to patients with high-risk EC because the severe late toxicity observed might outweigh the benefits. When EBRT is prescribed for EC, IMRT should be considered, because it was associated with a significant reduction of severe late side effects.

Carbon dioxide efflux in a rhodic hapludox as affected by tillage systems in southern Brazil

Agricultural soils can act as a source or sink of atmospheric C, according to the soil management. This long-term experiment (22 years) was evaluated during 30 days in autumn, to quantify the effect of tillage systems (conventional tillage-CT and no-till-NT) on the soil CO2-C flux in a Rhodic Hapludox in Rio Grande do Sul State, Southern Brazil. A closed-dynamic system (Flux Chamber 6400-09, Licor) and a static system (alkali absorption) were used to measure soil CO2-C flux immediately after soybean harvest. Soil temperature and soil moisture were measured simultaneously with CO2-C flux, by Licor-6400 soil temperature probe and manual TDR, respectively. During the entire month, a CO2-C emission of less than 30 % of the C input through soybean crop residues was estimated. In the mean of a 30 day period, the CO2-C flux in NT soil was similar to CT, independent of the chamber type used for measurements. Differences in tillage systems with dynamic chamber were verified only in short term (daily evaluation), where NT had higher CO2-C flux than CT at the beginning of the evaluation period and lower flux at the end. The dynamic chamber was more efficient than the static chamber in capturing variations in CO2-C flux as a function of abiotic factors. In this chamber, the soil temperature and the water-filled pore space (WFPS), in the NT soil, explained 83 and 62 % of CO2-C flux, respectively. The Q10 factor, which evaluates CO2-C flux dependence on soil temperature, was estimated as 3.93, suggesting a high sensitivity of the biological activity to changes in soil temperature during fall season. The CO2-C flux measured in a closed dynamic chamber was correlated with the static alkali adsorption chamber only in the NT system, although the values were underestimated in comparison to the other, particularly in the case of high flux values. At low soil temperature and WFPS conditions, soil tillage caused a limited increase in soil CO2-C flux.

Soil fertility, organic carbon and fractions of the organic matter at different distances from eucalyptus stumps

Knowledge on variations in vertical, horizontal and temporal characteristics of the soil chemical properties under eucalyptus stumps left in the soil is of fundamental importance for the management of subsequent crops. The objective of this work was to evaluate the effect of eucalyptus stumps (ES) left after cutting on the spatial variability of chemical characteristics in a dystrophic Yellow Argisol in the eastern coastal plain region of Brazil. For this purpose, ES left for 31 and 54 months were selected in two experimental areas with similar characteristics, to assess the decomposition effects of the stumps on soil chemical attributes. Soil samples were collected directly around these ES, and at distances of 30, 60, 90, 120 and 150 cm away from them, in the layers 0-10, 10-20 and 20-40 cm along the row of ES, which is in-between the rows of eucalyptus trees of a new plantation, grown at a spacing of 3 x 3 m. The soil was sampled in five replications in plots of 900 m² each and the samples analyzed for pH, available P and K (Mehlich-1), exchangeable Al, Ca and Mg, total organic carbon (TOC) and C content in humic substances (HS) and in the free light fraction. The pH values and P, K, Ca2+, Mg2+ and Al3+ contents varied between the soil layers with increasing distance from the 31 and 54-monthold stumps. The highest pH, P, K, Ca2+ and Mg2+ values and the lowest Al3+ content were found in the surface soil layer. The TOC of the various fractions of soil organic matter decreased with increasing distance from the 31 and 54-month-old ES in the 0-10 and 10-20 cm layers, indicating that the root (and stump) cycling and rhizodeposition contribute to maintain soil organic matter. The C contents of the free light fraction, of the HS and TOC fractions were higher in the topsoil layer under the ES left for 31 months due to the higher clay levels of this layer, than in those found under the 54-month-old stumps. However, highest C levels of the different fractions of soil organic matter in the topsoil layer reflect the deposition and maintenance of forest residues on the soil surface, mainly after forest harvest.

Yield of intermittent versus continuous EEG in comatose survivors of cardiac arrest treated with hypothermia.

INTRODUCTION: Electroencephalography (EEG) has a central role in the outcome prognostication in subjects with anoxic/hypoxic encephalopathy following a cardiac arrest (CA). Continuous EEG monitoring (cEEG) has been consistently developed and studied; however, its yield as compared to repeated standard EEG (sEEG) is unknown. METHODS: We studied a prospective cohort of comatose adults treated with therapeutic hypothermia (TH) after a CA. cEEG data regarding background activity and epileptiform components were compared to two 20 minute sEEG extracted from the cEEG recording (one during TH, and one in early normothermia). RESULTS: In this cohort, 34 recordings were studied. During TH, the agreement between cEEG and sEEG was 97.1% (95% CI: 84.6 - 99.9%) for background discontinuity and reactivity evaluation, while it was 94.1% (95% CI 80.3 - 99.2%) regarding epileptiform activity. In early normothermia, we did not find any discrepancies. Thus, concordance was very good during TH (kappa 0.83), and optimal during normothermia (kappa=1). The median delay between CA and the first EEG reactivity testing was 18 hours (range: 4.75 - 25) for patients with perfect agreement and 10 hours (range: 5.75 - 10.5) for the three patients in whom there were discordant findings (P=0.02, Wilcoxon). CONCLUSION: Standard intermittent EEG has comparable performance than continuous EEG both for variables important for outcome prognostication (EEG reactivity) and identification of epileptiform transients in this relatively small sample of comatose survivors of CA. This finding has an important practical implication, especially for centers where EEG resources are limited.

Geochronological constraints on post-extinction recovery of the ammonoids and carbon cycle perturbations during the Early Jurassic

This paper presents the first quantitative study of the Early Jurassic recovery of ammonoids after the end-Triassic mass extinction based on detailed U-Pb ID-TIMS (isotope dilution thermal ionization mass spectrometry) geochronology from ash bed zircons placed within a clear phylogenetical and biochronological framework at the subzonal and species level. This study was triggered by the discovery of a rich Peruvian succession of ammonites, deposited concomitantly with an unusually large number of ash beds. Two major phases of rediversification are observed during the Psiloceras spelae and Angulaticeras zones that correspond to positive peaks in the delta C-13(org) curve, providing a possible link between biodiversity and the global carbon cycle. In the case of the post-extinction recovery, the development of the earliest Hettangian ammonites occurs within the genus Psiloceras, which begins with the occurrence of P. spelae and then explodes into worldwide development of smooth psiloceratids of the Psiloceras planorbis group s.l. This rapid biodiversification likely occurred less than 100 ka after the end-Triassic crisis; the genus Psiloceras occupied all the possible ecological niches worldwide, from the Pacific deep waters to the NW European shallow deposits and also in some rare Tethyan occurrences like at Germig in Tibet. This global dispersion allowed the differentiation of the group in several major phyla, the Schlotheimiidae, Discamphiceratinae, Arietitidae and Lytocerataceae, which were the roots of all other Jurassic and Cretaceous ammonites. (C) 2012 Elsevier B.V. All rights reserved.

Carbon content in Amazonian Oxisols after forest conversion to pasture

Soil plays an important role in the C cycle, and substitution of tropical forest by cultivated land affects C dynamic and stock. This study was developed in an area of expansion of human settlement in the Eastern Amazon, in Itupiranga, State of Pará, to evaluate the effects of native forest conversion to Brachiaria brizantha pasture on C contents of a dystrophic Oxisol. Soil samples were collected in areas of native forest (NF), of 8 to 10 year old secondary forest (SF), 1 to 2 year old SF (P1-2), 5 to 7 year old SF (P5-7), and of 10 to 12 year old SF (P10-12), and from under pastures, in the layers 0-2, 2-5 and 5-10 cm, to evaluate C levels and stocks and carry out separation of OM based on particle size. After deforestation, soil density increased to a depth of 5 cm, with greater increase in older pastures. Variation in C levels was greatest in the top soil layer; C contents increased with increasing pasture age. In the layers 2-5 and 5-10 cm, C content proved to be stable for the types of plant cover evaluated. Highest C concentrations were found in the silt fraction; however, C contents were highest in the clay fraction, independent of the plant cover. An increase in C associated with the sand fraction in the form of little decomposed organic residues was observed in pastures, confirming greater sensitivity of this fraction to change in soil use.

Closed and open grade I and II tibial shaft fractures treated by reamed intramedullary nailing.

OBJECTIVE: To evaluate the results of closed and open grade I and II tibial shaft fractures treated by reamed nail and unreamed nailing. SUBJECTS AND METHODS: Between 1997 and 2000, 119 patients with tibial shaft fractures were treated with reamed tibial nails. Postoperatively 96 patients (70 closed and 26 grade I and II open fractures) were followed clinically and radiologically for up to 18 months. The nail was inserted either by patellar tendon splitting or by nonsplitting technique. The nail was inserted after overreaming by 1.5 mm. Postoperatively, patients with isolated tibial fracture were mobilized by permitting partial weight bearing on the injured leg for 6 weeks. Patients with associated ankle fractures were allowed to walk with a Sarmiento cast. RESULTS: Postoperatively, 6 (6.3%) patients developed a compartment syndrome after surgery. In 48 (50%) cases, dynamization of the nail was carried out after a mean period of 12 weeks for delayed union. Overall, a 90.6% union was obtained at a mean of 24 weeks without difference between closed or open fractures. Two (2.1%) patients with an open grade II fracture developed a deep infection requiring treatment. A 9.4% rate of malunion was observed. Eight (8.3%) patients developed screw failure without clinical consequences. At the last follow-up, 52% of patients with patellar tendon splitting had anterior knee pain, compared to those (14%) who did not have tendon splitting. CONCLUSION: Reamed intramedullary nail is a suitable implant in treating closed as well as grade I and II open tibial shaft fractures.