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Clinical diagnostics in sudden onset disasters have historically been limited. We set out to design, implement, and evaluate a mobile diagnostic laboratory accompanying a type 2 emergency medical team (EMT) field hospital.
Methods:
Available diagnostic platforms were reviewed and selected against in field need. Platforms included HemoCue301/WBC DIFF, i-STAT, BIOFIRE FILMARRAY multiplex rt-PCR, Olympus BX53 microscopy, ABO/Rh grouping, and specific rapid diagnostic tests. This equipment was trialed in Katherine, Australia, and Dili, Timor-Leste.
Results:
During the initial deployment, an evaluation of FilmArray tests was successful using blood culture identification, gastrointestinal, and respiratory panels. HemoCue301 (n = 20) hemoglobin values were compared on Sysmex XN 550 (r = 0.94). HemoCue WBC DIFF had some variation, dependent on the cell, when compared with Sysmex XN 550 (r = 0.88-0.16). i-STAT showed nonsignificant differences against Vitros 250. Further evaluation of FilmArray in Dili, Timor-Leste, diagnosed 117 pathogens on 168 FilmArray pouches, including 25 separate organisms on blood culture and 4 separate cerebrospinal fluid pathogens.
Conclusion:
This mobile laboratory represents a major advance in sudden onset disaster. Setup of the service was quick (< 24 hr) and transport to site rapid. Future deployment in fragmented health systems after sudden onset disasters with EMT2 will now allow broader diagnostic capability.
Following stage 1 palliation, delayed sternal closure may be used as a technique to enhance thoracic compliance but may also prolong the length of stay and increase the risk of infection.
Methods
We reviewed all neonates undergoing stage 1 palliation at our institution between 2010 and 2017 to describe the effects of delayed sternal closure.
Results
During the study period, 193 patients underwent stage 1 palliation, of whom 12 died before an attempt at sternal closure. Among the 25 patients who underwent primary sternal closure, 4 (16%) had sternal reopening within 24 hours. Among the 156 infants who underwent delayed sternal closure at 4 [3,6] days post-operatively, 11 (7.1%) had one or more failed attempts at sternal closure. Patients undergoing primary sternal closure had a shorter duration of mechanical ventilation and intensive care unit length of stay. Patients who failed delayed sternal closure had a longer aortic cross-clamp time (123±42 versus 99±35 minutes, p=0.029) and circulatory arrest time (39±28 versus 19±17 minutes, p=0.0009) than those who did not fail. Failure of delayed sternal closure was also closely associated with Technical Performance Score: 1.3% of patients with a score of 1 failed sternal closure compared with 18.9% of patients with a score of 3 (p=0.0028). Among the haemodynamic and ventilatory parameters studied, only superior caval vein saturation following sternal closure was different between patients who did and did not fail sternal closure (30±7 versus 42±10%, p=0.002). All patients who failed sternal closure did so within 24 hours owing to hypoxaemia, hypercarbia, or haemodynamic impairment.
Conclusion
When performed according to our current clinical practice, sternal closure causes transient and mild changes in haemodynamic and ventilatory parameters. Monitoring of SvO2 following sternal closure may permit early identification of patients at risk for failure.
The optimal approach to unifocalisation in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (pulmonary artery/ventricular septal defect/major aortopulmonary collaterals) remains controversial. Moreover, the impact of collateral vessel disease burden on surgical decision-making and late outcomes remains poorly defined. We investigated our centre’s experience in the surgical management of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals.
Materials and methods
Between 1996 and 2015, 84 consecutive patients with pulmonary artery/ventricular septal defect/major aortopulmonary collaterals underwent unifocalisation. In all, 41 patients received single-stage unifocalisation (Group 1) and 43 patients underwent multi-stage repair (Group 2). Preoperative collateral vessel anatomy, branch pulmonary artery reinterventions, ventricular septal defect status, and late right ventricle/left ventricle pressure ratio were evaluated.
Results
Median follow-up was 4.8 compared with 5.7 years for Groups 1 and 2, respectively, p = 0.65. Median number of major aortopulmonary collaterals/patient was 3, ranging from 1 to 8, in Group 1 compared with 4, ranging from 1 to 8, in Group 2, p = 0.09. Group 2 had a higher number of lobar/segmental stenoses within collateral vessels (p = 0.02). Group 1 had fewer catheter-based branch pulmonary artery reinterventions, with 5 (inter-quartile range from 1 to 7) per patient, compared with 9 (inter-quartile range from 4 to 14) in Group 2, p = 0.009. Among patients who achieved ventricular septal defect closure, median right ventricle/left ventricle pressure was 0.48 in Group 1 compared with 0.78 in Group 2, p = 0.03. Overall mortality was 6 (17%) in Group 1 compared with 9 (21%) in Group 2.
Discussion
Single-stage unifocalisation is a promising repair strategy in select patients, achieving low rates of reintervention for branch pulmonary artery restenosis and excellent mid-term haemodynamic outcomes. However, specific anatomic substrates of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals may be better suited to multi-stage repair. Preoperative evaluation of collateral vessel calibre and function may help inform more patient-specific surgical management.
Preemergence applications of atrazine [2-chloro-4-(ethylamino)-6-(isopropylamino)-s-triazine], chloramben (3-amino-2,5-dichlorobenzoic acid), fluometuron [1,1-dimethyl-3-(α,α,α-trifluro-m-tolyl)urea], propachlor (3-chloro-N-isopropylacetanilide), and trifluralin (α,α,α-trifluro-2,6-dinitro-N,N-dipropyl-p-toluidine) were compared in 10 North Carolina soils and the relationship of activity to soil physical and chemical properties appraised. Oats (Avena sativa L. ‘Carolee’) were used as the indicator plant in bioassays under greenhouse conditions. Fifteen soil properties were measured and correlated with herbicide I50 (50% fresh weight inhibition) values. Organic matter was the soil variable most highly correlated with herbicide phytotoxicity. There was an inverse relationship between herbicide water solubility and inactivation by organic matter. Volume weight determinations and water holding capacity values (0.1 bar) provided relatively good estimates of soil organic matter contents, but were not as highly related to herbicide activity as organic matter content.
Recently, large-scale trials of behavioural interventions have failed to show improvements in pregnancy outcomes. They have, however, shown that lifestyle support improves maternal diet and physical activity during pregnancy, and can reduce weight gain. This suggests that pregnancy, and possibly the whole periconceptional period, represents a ‘teachable moment’ for changes in diet and lifestyle, an idea that was made much of in the recent report of the Chief Medical Officer for England. The greatest challenge with all trials of diet and lifestyle interventions is to engage people and to sustain this engagement. With this in mind, we propose a design of intervention that aims simultaneously to engage women through motivational conversations and to offer access to a digital platform that provides structured support for diet and lifestyle change. This intervention design therefore makes best use of learning from the trials described above and from recent advances in digital intervention design.
Lipid production across the liver was measured in catheterized dairy cows in vivo in the fed state and during 6 days of fasting. Production rates were calculated from the lipid concentrations in arterial, portal and hepatic-venous plasma and from the rates of plasma flow in the portal vein and the hepatic veins.
There was a consistent net hepatic output of triacylglycerol and a net hepatic uptake of free fatty acids in the fed state.
In the fasted state there was a significant change to a net hepatic uptake of triacylglycerol and an increased hepatic uptake of free fatty acids. Both factors are likely to result in an accumulation of triacylglycerol in the liver.
Sixty twin-bearing ewes were allocated to one of four dietary treatments investigating the effects of supplementary iodine or cobalt during late pregnancy on lamb serum immunoglobulin G (IgG), triiodothyronine (T3), thyroxine (T4) and vitamin E concentrations, and lamb IgG absorption efficiency. Ewes were offered grass silage ad libitum supplemented with 800 g per ewe per day of a 190 g/kg crude protein (CP) concentrate from day 126 of gestation until parturition plus one of the following supplements (n = 15 per treatment); no supplement (C); 26.6 mg iodine per day for final 3 weeks pre partum (I-3); 26.6 mg iodine/day for final week pre partum (I-1); 20 mg cobalt/day for final 3 weeks pre partum (Co-3). Lambs were blood sampled at 24 and 72 h post partum for serum IgG and vitamin E concentrations. Ten lambs from C and I-3 were blood sampled at 1 h post partum for serum IgG, vitamin E, T3 and T4 concentrations. There were no differences in serum IgG, vitamin E or T4 values (P > 0.05) at 1 h post partum between lambs born to the C and I-3 ewes. T3 levels were lower in I-3 compared with C progeny (P < 0.05). Supplemental iodine reduced colostral IgG absorption efficiency (P < 0.001) and lamb serum IgG concentrations at 24 and 72 h post partum (P < 0.001). Serum vitamin E concentration in I-3 and I-1 lambs was lower than in Co-3 lambs at 24 h post partum, while at 72 h post partum I-3, I-1 and Co-3 lambs had significantly lower concentrations than C lambs (P < 0.001). Supplementing the ewe’s diet with 26.6 mg/day of iodine for the final week of pregnancy reduced lamb serum IgG concentration at 24 and 72 h post partum. The lower total and free T3 values in the progeny of I-3-treated ewes suggest interference in the synthesis and metabolism of thyroid hormones when ewes receive excessive dietary iodine for 3 weeks immediately pre partum. Based on these findings, the indications are that the toxicity level for iodine in the diet of the pregnant ewe should be lowered to 20 mg per ewe per day, equivalent to 40% of its current level. The finding that high-level cobalt supplementation during the final 3 weeks of pregnancy will have a negative effect on serum vitamin E concentration at 72 h post partum is a new and significant finding and previously has not been reported in the literature.
In order to extend the dynamic range of a hydrogen sensor with a metal-insulator-semiconductor (MIS) type structure, Pd-Cr and Pd-Ni alloy gated samples were studied. The PdCr gated sample shows quite stable and reproducible response, and could measure hydrogen concentrations from 100 to 50, 000 ppm. While the Pd-Ni gated sample shows turn-on/off response drift, this drift is probably due to the presence of oxygen on the surface of the insulator and the formation of metal hydride. Furthermore, the effect of oxygen on the sensors response was investigated; oxygen may deplete protons from the metal/insulator interface and could reduce the sensor's response.
An MIS Hydrogen sensor with a Pd0.96Cr0.04/AlN/Si structure was fabricated, exhibiting the dynamic range considerably wider than that of analogous devices with pure Pd gates. A useful response could be obtained for Hydrogen concentrations as large as 50, 000 ppm. Although the response amplitude was much reduced at the lower concentrations, satisfactory signal to noise down to 50 ppm could be obtained. The saturating magnitude of the electrical response is in the range of 0.1 to 0.5 V, which is the same as that for the pure Pd gated devices, inspite of the 3 orders of magnitude difference in the saturation hydrogen concentration. This result will be discussed in terms of the response mechanism of these devices.
A brief history of research into the unusual laminated and spherulitic East Kirkton Limestone (Brigantian, Viséan) is given. It documents the paucity of fossil finds until 1984, when S. P. Wood discovered a previously unsuspected terrestrial biota. Some early finds, such as stromatolites, have since been overlooked, while others were misinterpreted, e.g. a ‘fish-bone’ collected before 1870 proves to be amphibian. A formal lithostratigraphic description is given of the three beds that comprise the c. 15 m sequence in East Kirkton Quarry: the East Kirkton Limestone, overlain by Little Cliff Shale and Geikie Tuff, the latter two being here formally named. Lithological descriptions and a unit-by-unit distribution of major elements of the biota are provided for a measured section comprising 88 units. This is based on bed-by-bed excavations carried out 1985-92, supplemented by nine boreholes. Two 3 m-thick massive limestones lenses are recorded from the quarry and a probable third was proved in a borehole. Brief reports are given on the ‘stromatolites’ (by M. R. Walter), bivalve molluscs (R. M. C. Eagar and R. B. Wilson), ostracods (J. Pollard) and gypsum pseudomorphs.
We present an engineering analysis of the rate of evaporation of solvent in the hanging drop method of protein crystal growth. Our results are applied to 18 different drop and well arrangements commonly encountered in the laboratory. We take into account the chemical nature of the salt, the drop size and shape, the drop concentration, the well size, the well concentration, and the temperature. We find that the rate of evaporation increases with temperature, drop size, and with the salt concentration difference between the drop and the well. The evaporation possesses no unique half-life. Once the salt in the drop achieves about 80% of its final concentration, further evaporation suffers from the law of diminishing returns.