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Duke University School of Nursing Scholar Dr. Marilyn Oermann to be Honored with
the Elizabeth Russell Belford Award for Excellence in Education
from Sigma Theta Tau International
Durham, NC…Dr. Marilyn Oermann, director of evaluation and education research at Duke University School of Nursing is the recipient of the Elizabeth Russell Belford Award for Excellence in Education by the Sigma Theta Tau International (STTI), the honor society of nursing. The award, named in honor of one of the five founding members of STTI, is awarded every two years and pays tribute to excellence in teaching, significant contributions toward advancing the science of nursing and influencing the professional practice and public image of nursing.
Dr. Oermann's career has been devoted to developing concepts of evaluation, clinical teaching, and teaching in nursing. Through her many books, articles, and speeches, she has guided how nurse educators teach and evaluate student learning.
"Marilyn Oermann is an internationally respected nurse scholar whose personal scholarship and extensive mentoring of others has strengthened the field of nursing. We are proud that she is a member of our school community and congratulate her on this honor," said Dr. Catherine Gilliss, PhD, RN, FAAN, Dean and Vice Chancellor for Nursing Affairs, Helene Fuld Health Trust Professor of Nursing at Duke University School of Nursing.
Dr. Oermann, PhD, RN, ANEF, FAAN, came to Duke in July 2013 from the University of North Carolina at Chapel Hill, where she was the Frances Hill Fox Term Distinguished Professor and Chair of Adult and Geriatric Health in the School of Nursing. Dr. Oermann's scholarship focuses on nursing education, with an emphasis on both teaching and evaluation in nursing. With funding from the National League for Nursing and Laerdal Medical, she recently completed a multisite study on the effects of monthly practice on nursing students' CPR psychomotor skill performance.
She is currently completing a feasibility study on the use of simulation for high stakes testing. Dr. Oermann is the author or co-author of 15 books (several of which won national awards), more than 130 articles in peer-reviewed journals, and a wide variety of other publications. Her current books include Evaluation and Testing in Nursing Education (4th ed., 2013), Writing for Publication in Nursing (2nd ed., 2010), Clinical Teaching Strategies in Nursing (3rd ed., 2010) and Teaching in Nursing and Role of the Educator: The Complete Guide to Best Practice in Teaching, Evaluation, and Curriculum Development (in press).
Dr. Oermann is the editor of the Journal of Nursing Care Quality and Nurse Author & Editor. She is past editor of the Annual Review of Nursing Education, and edited six volumes of that series. She lectures widely on writing for publication and nursing education topics.
She earned her PhD and MSNEd at the University of Pittsburgh, and has received Distinguished Alumni Awards from both the School of Nursing and the School of Education. She also received a Distinguished Alumni Award from Pennsylvania State University School of Nursing, where she earned her BSN. Dr. Oermann was the first Mary Killeen Endowed Visiting Scholar at Arizona State University, and has held a number of other visiting faculty positions.
She is a Fellow of the National League of Nursing Academy of Nursing Education and American Academy of Nursing. Dr. Oermann has extensive administrative experience and has evaluated nursing programs in her administrative roles and also as a consultant to schools of nursing. At the national level Dr. Oermann has served in many leadership roles for the National League for Nursing, including Chair of the Evaluation and Learning Advisory Council and member of the NLN Foundation for Nursing Education Review Panel.
She is currently a member of the NLN Strategic Steering Committee, and has also served as a member of two NLN Think Tanks (Nursing Education Priorities, Simulation for High Stakes Testing), the NLN Research Grants Review Committee, and the NLN Blue Ribbon Panel on Clinical Nursing Education.
Dr. Oermann will receive the award during the 42nd Biennial Convention for STTI on Nov. 16 to 20 in Indianapolis.


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Monday 30 May 2016
I hadn't seen the Bar-Headed Goose on the Serpentine for several days and had assumed that it had gone back to wherever it came from, probably Regent's Park, either on its own wings or because someone had arrived with a van and captured it. But today there was again a Bar-Headed Goose, near Bluebird Boats.
And there was another Bar-Headed Goose a bit along the shore, near the Lido restaurant. I thought it was the same one that had moved along while I wasn't looking, but it wasn't. Note the dark smudge on the side of its chest -- it has one on either side. Comparing pictures from a few days ago shows that this is the one I saw earlier.
The one in the upper picture has no smudges, but it has a dark shadow on its bill, and also the black stripe on its head extends the whole way to its eye. Both these features exist on both sides of its head. It would be interesting if these two birds were of opposite sex and became mates. There is a small population of feral Bar-Headed Geese in Britain already.
Apart from that it was a very ordinary day. The Black Swan was mooching around in the middle of the Serpentine, and didn't come over for his usual biscuit. Maybe moulting is making him feel itchy and irritable.
The White Mallard was with his normal-coloured mate, but he seems to be moulting too, as he is missing the little curly feathers above his tail that show that he is a drake. Unless, of course, this is a different white Mallard, but I don't think so.
Virginia Grey has brought a touch of distinction to today's post by sending me two splendid pictures. The female Mute Swan was carrying her cygnets when she climbed on to the little island in the Long Water, causing them to fall off.
And a Grey Heron had caught a very large perch and was turning it round in an attempt to swallow it head first. It flew away still holding its prey, so we don't know whether it succeeded in eating it. Herons are prone to grabbing things too large to swallow.
The young Coots on the Serpentine are quite large now, and have been capable of feeding themselves for some time, but that doesn't stop them from begging to be fed when their parents are around.
There were a lot of Swifts over the Serpentine.
No sign of the Little owlets, but this wasn't surprising as there was a Magpie in the chestnut tree looking at the nest hole.
When I came back later they were still out of sight, but their father was on a branch.
6 comments:
- Dom G30 May 2016 at 22:02
That is one good-looking goose.ReplyDelete
Love the tumbling cygnets photo - clumsy mum! And that grey heron catch is special too.
Swifts still coming in off the sea down in Dorset today.Replies
Well, two geese really. And thanks to Virginia for two splendid pictures.Delete
The cascade of cygnets is really eye-catching, but all photos are charming.ReplyDeleteReplies
All credit to Virginia for catching the moment.Delete
Agree, the Bar-Headed Geese are handsome birds. Saw some free walking and flying at Kew Gardens a few years ago. Do you know to where they are native? I'm wondering if the markings are camouflage in certain environments (just speculating).ReplyDeleteReplies
They're native to northern India, spending the summer north of the Himalayas and the winter to the south, and migrating over the mountains at enormous altitudes. I'd describe the head pattern as simple disruptive colouring to mask the outline of the bird's head.Delete

subset: commoncrawl


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Victor Yampolsky
Maestro Yampolsky says Leonard Bernstein brought him to the United States, and so he thinks of his career as a "thank you note" to the great American composer.
Showcasing the Northwestern Symphony Orchestra in Asia
Ninety members of the Northwestern University Symphony Orchestra are spending spring break showcasing their talents on a concert tour of Asia. They'll perform in Beijing, Shanghai and Hong Kong.
> Galleries: Follow the students' tour in photos
Conducted by Maestro Victor Yampolsky, the concert repertoire includes Symphony No. 5 by Gustav Mahler and Symphonic Dances from "West Side Story" by Leonard Bernstein.
Co-hosted by the Bienen School of Music, the Roberta Buffett Institute for Global Studies and the Northwestern Alumni Association, the tour not only provides an opportunity for students to perform on the world stage, but also supports the Bienen School's mission to attract the best and brightest students from around the globe.
Follow the Northwestern Symphony Orchestra as it tours Asia from March 23 to April 1. Ninety student musicians from the Bienen School of Music will showcase their talents through performances in Beijing, Shanghai and Hong Kong. Photo galleries will be shared throughout the 10-day tour.
Maestro Yampolsky says Leonard Bernstein brought him to the United States, and so he thinks of his career as a "thank you note" to the great American composer.
She describes the viola's sound as more endearing, intimate and charming than a violin. "It's a comforting sound that reminds me of a loving grandparent."
In 2017, he was one of two Northwestern cellists invited to play in the prestigious Queen Elisabeth International Cello Competition in Brussels.
Published: January 31, 2018. Updated: March 26, 2018.Back to top


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Never dreamed I'd be here, but I'm glad I am! Saw an interesting quote on the web a while back by James Thurber, the American writer best known for Walter Mitty. He wrote: "Let us not look back in anger or forward in fear, but around in awareness." What are you aware of today? What made you aware?
For me, it is the little things in life–sunshine, smooth traffic, good coffee. In this regard I am pretty easy to please. The ordinary every day passage of life is pretty fascinating when you stop to think about it and the merger of thoughtful awareness and imagination is the source of good fiction.
I try not to carry the baggage from the past–it just weighs me down and holds me back. That is hard to do because life can be hard too. I also remember waking up one morning several years ago thinking–I am done being afraid of the "them" that the TV wants us to be afraid of. It was a very liberating feeling! We all are afraid at times. When there is a health scare. When there's too much month left at the end of the money. When our kids are out later than they should be. etc etc etc……. But if we give that full reign to the worst, then we end up making our own world very small indeed.
So I am lifting my mug of hot creamy coffee to say: Hey there–I'm looking for a bigger world, one that keeps me curious and excited enough to haul it out of bed in the morning. Part of the purpose of my writing–both fiction and non-fiction–is trying to stay aware. I invite you to share your experience and I will share mine. This could be the beginning of a great friendship!
Comments? Concerns? Questions? firstname.lastname@example.com


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In separate half-hour segments for the last three hours, George Noory played and commented on six different interviews from former guests in the C2C family that are no longer with us, yet whose legacies and ideas live on. First was Jim Marrs, who passed away in 2017. Marrs mentioned his belief that a secret space fleet existed and that a contact from the Navy told him he was trained and physically modified to breathe and work on other planets in the solar system. He also discussed the ancient astronaut theory, stating that there have been "reports of gods flying through the air throughout history." The next tribute interview segment was with R. Gary Patterson, recorded on April 21, 2016 – the day that rockstar Prince died. Patterson described him as one of a handful of artists who "affect an entire generation" and lamented that drug use and abuse is common among music stars, often as an aid to deal with their grueling schedules. Patterson traced the major events of Prince's life.
2012 researcher John Major Jenkins was interviewed on December 21, 2010, exactly two years before the infamous date when the world was supposed to end. Jenkins emphasized that the Mayan calendar was conceived as a system of cycles and not based on linear time like our modern calendar. The 2012 date should be looked at as the start of a new cycle, not as the end of all time. In the third hour, George replayed part of an interview from May 21, 2009, with Patrick Heron, who researched Biblical references to the Antichrist. Heron decried the hysteria of other researchers who he said had "all been wrong," and described his interpretation of the Book of Revelation, which he said refers to "the beast from the abyss." Heron went on to list all the signs of this person and offered his opinion that this figure would appear soon.
Next was a show with the late Brad Steiger from August 18, 2011. Steiger described his newest research into the UFO phenomenon and revelations about some sort of object which orbited the moon 13,000 years ago and may have been put there by an alien civilization. He said that if you look into the UFO subject, "you really have to know yourself" in order to remain balanced. A segment featuring UFO researcher Bob Mitchell and his work with supposed time traveler "John Titor II" ended the program. Mitchell said that "the only way you can time travel is with a spaceship," and then introduced "John Titor" himself, who described his life and training in an elite Air Force time travel unit.
Movies Vs. Television
First-hour guest "Mr. Lobo" discussed recent film releases and the emergence of new media such as Netflix, which earlier in the day briefly surpassed Disney as the most valuable media company. Lobo expressed his opinion that the Star Wars franchise may be oversaturated at this time, and said they've presently "got too much product." Television, on the other hand "is a much more forgiving atmosphere" he said, and can afford to take some risks to establish shows and characters.
News segment guests: Charles R. Smith / Peter Davenport


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Hello Frnds,
Plz suggest me where i can watch free online movie.......provide me some good website.........
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Partners of Open Food Facts
A big thank you to Open Food Facts partners!
Open Food Facts is an associative project and citizen of general interest to improve the food and the health of all. Tens of thousands of volunteers are involved in the project, and the infrastructure needed to support and facilitate their work is funded by one-on-one donations and committed partners.
Contact us if you also want to support our action!
Note: to stay independent, we do not accept financial support from companies and foundations related to the food industry, but we are happy to collaborate with producers to automatically integrate data and photos of their products into the database.
The development of the Open Food Facts database and mobile application is carried out with the financial support of the French public health agency Santé publique France .
6-12-2018: Public Health France and Open Food Facts join forces to strengthen the openness of food data and promote the use of Nutri-Score
The internationalization and extension of the Eco-Score and the development of the new Open Food Facts mobile app is supported by Google.org through its Google Impact Challenge for Climate and Google Fellowship programs.
28-5-2021: Open Food Facts laureate of the Google Fellowship and the Google Impact Challenge for Climate
The development of the new Open Food Facts cross-platform mobile application is sponsored thanks to the generous award of the Ford Foundation and Mozilla Open Source Support Program (MOSS), with the support of Open Collective.
4-22-2020: Open Food Facts gets an award by the Mozilla and Ford foundations for a new mobile app for even greater impact.
The development of privacy-first and personalized healthier product recommendations in the new Open Food Facts cross-platform mobile application is possible thanks to the support of NLNet Foundation and the European Union.
The development of the Folksonomy Engine project to make Open Food Facts more useful to many more people is possible thanks to the support of the NLNet Foundation and the European Union.
The backend of the Open Food Facts database, web site and API is written in the Perl programming language, and part of the development is supported by The Perl Foundation .
Summer 2020: The Perl Foundation is funding one intern through the Outreachy program to work on improving the code quality of Open Food Facts.
Summer 2021: The Perl Foundation is funding one intern through the Outreachy program to work on improving the code quality of Open Food Facts.
Web hosting and technical infrastructure
The site and the Open Food Facts database are hosted on servers generously provided by the Free Foundation .
10-9-2018: 2 new servers to host Open Food Facts thanks to the Free Foundation
Artificial intelligence algorithms and many Open Food Facts projects are running on servers generously provided by the OVHcloud .
Scientific collaborations
The Nutri-Score was developed by the EREN Nutritional Epidemiology Research Team which uses the Open Food Facts database to check the validity of Nutri-Score in different countries.
07-08-2015: Application to the products available on the French market of the nutritional profile associated with the 5-color system (5-C): consistency with the consumption benchmarks of the PNNS
NutriNet-Santé is a cohort study that tracks the nutrition and health of volunteers for several years. EREN uses NutriNet data cross-referenced with Open Food Facts data to study the long-term effects of food additives.
→ Participate in Nutri-Net to help research (For French residents).
The AFNIC foundation for Digital Solidarity supports the development of a united internet, training and awareness of its uses, by supporting local and structuring digital solidarity initiatives and research projects on the theme of digital solidarity.
The foundation is supporting Open Food Facts's environmental and educational efforts to make food not only good for you, but also good for the planet.
Other supports
XWiki regularly hosts Open Food Facts events such as the Open Food Facts association general assembly in its office in Paris.


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The Control of Nitrogen Oxides Emissions
Journal Archive
The Control of Nitrogen Oxides Emissions
Progress Reviewed at International Symposium
Nitrogen oxides (NOx) emissions were first identified as major contributors to air pollution after studies made during the 1950s into the formation of photochemical smog in Los Angeles. These observations led directly to legislation in the United States of America regulating emission of NOx to the atmosphere from both stationary and mobile sources. Since that time it has been recognised that such emissions constitute a global problem. A recent symposium sponsored by The Netherlands Ministry of Health and Environmental Protection and the U.S. Environmental Protection Agency, held in Maastricht during May, reviewed the state of the art in research and development relating to national and international policies on NOx control. More than 300 delegates attended, demonstrating the current interest in the subject, and over 75 papers were presented.
The control of nitrogen oxides resulting from nitric acid production was the subject of papers presented by W. Toering of UKF, Rotterdam and A. Kayaert of Nederlandse Stikstof Maatschappij, based on their operational experience. Both pollution control and energy recovery result from the use of suitable platinum metal catalyst systems for the treatment of tail gases.
Emissions from mobile sources were considered in papers presented by H. D. Pletka of degussa, Hanau and A. E. R. Budd of Johnson Matthey Chemicals Limited. The latter traced the history of ceramic honeycomb supported platinum group metal catalysts from their first recorded industrial application in controlling NOx emissions from the tail gases of nitric acid manufacturing plants, to the development of three-way catalysts for the simultaneous control of NOx, carbon monoxide and hydrocarbon emissions in petrol engined vehicle exhaust gases. In addition, reference was made to the successful application of platinum group metals catalysts in catalytic combustion systems for both gas turbine and catalytic engines. Catalytic combustion, that is flameless combustion promoted by a catalyst, promises a number of advantages, including low NOx emissions without the use of tail gas clean-up devices.
Catalytic clean-up devices are the best developed and most practical method of mobile NOx emission control currently available, and it is probable that platinum group metal catalyst technology will continue to play an important role in the control of stationary sources of NOx emissions for some time to come.
The full proceedings of the symposium, and the discussion, are to be published in October by Elsevier Scientific Publishing Company.


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The outgoing Nigerian government is entertaining bids in a last-minute auction on Friday of 45 oil exploration licenses. For VOA, Gilbert da Costa in Abuja reports that the plan is going ahead despite a court order not to sell two of them and widespread criticism over timing and transparency.
The Nigerian government says the sale of new oil drilling rights will grow reserves and production capacity, as well as generate income and attract new investment.
Nigeria expects to generate $500 million in signature bonuses alone from the auction.
The West African country, the world's eighth biggest exporter of crude oil, sits atop a colossal reserve of oil and gas.
The auction has attracted great interest from oil companies around the world despite ongoing violence in the oil-rich Niger Delta.
Energy Minister Edmund Daukoro has promised the auction will be fair and transparent. But analysts say the exercise is mostly for show and that the real decisions have been made in advance, with Asian companies most favored.
The timing of the bid is also causing controversy in Nigeria because it comes in the last days of the government of President Olusegun Obasanjo, who is scheduled to hand the office to president-elect Umaru Yar'Adua on May 29.
Lai Mohammed of the opposition Action Congress party says the process lacks legitimacy and credibility.
"We believe that in the twilight of an administration, it is questionable and quite improper for you to be auctioning oil blocks," he said. "What are you going to achieve by auctioning these oil blocks in less than three weeks to your departure?"
"You are only making sure that your cronies and friends are rewarded for loyalty. We believe it is indecent to hawk off billions of dollars worth of oil blocks in their twilight of their departure," he continued.
Ironically, Mr.Obasanjo revoked exploration rights that his predecessor granted days before Mr. Obasanjo took over in 1999.
In the current case, the authorities have ignored a court order suspending the sale of two of the 45 blocks until the court rules on a dispute between the oil ministry and Shell Oil Company.
Bidding was introduced in 2005 to encourage transparency and openness in the country's oil sector. Before, oil blocks were allocated on a discretionary basis, a process fraught with widespread abuse.
Eleven of the blocks are located in deep water offshore. Ten are in shallow waters. Thirteen are onshore in the troubled Niger Delta, and 11 are in the little-fancied inland basins.


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Amoss celebrates Kentucky Oaks victory by Serengeti Empress
May 04, 2019 Churchill Downs Communications
LOUISVILLE, KY (Saturday, May 4, 2019) – Serengeti Empress proved in winning the 145th Kentucky Oaks at Churchill Downs on Friday that when she's on the lead, she's tough to overtake.
"She just ran them off their feet," said a tired Tom Amoss, trainer of the winner of the 1 1/8-mile Grade I race for 3-year-old fillies. "She took it to them at the starting gate, she just ran them into submission."
The party celebrating the 1 ¾-length victory by Joel Politi's filly, with Jose Ortiz riding, over Liora and rider Channing Hill, continued well into the night. "I haven't been up like that since I was in college, and I'm 57 years old," said Amoss, on his way to getting some early Derby Day rest before the day's racing began.
The Kentucky-bred daughter of Alternation, out of the Bernardini mare Havisham, also was resting in her stall after finishing the Oaks in 1:50.17, on a track upgraded to fast following a muddy morning from overnight rain.
Her Oaks run proved to Amoss just what she's capable of accomplishing.
"Even when Wayne's filly (runner-up Liora, trained by Wayne Catalano) was getting to her at the eighth pole," Amoss said, "and it looked like it was going to be a horse race, 'Serengeti' caught her out of the corner of her eye. She took off again, no one was going to get by us."
The 13-1 shot, sent off from the No. 13 post position, paid $28 to win.
Her fifth victory from eight lifetime starts was worth $705,250, making her a millionaire with earnings of $1,037,120. Amoss said there has been no decision on her next test.
"No plans have been made beyond this race," Amoss said. "She's going to get a well-deserved rest between races. What's that mean? Probably nothing in May."
Among the top races in early June is the Grade I Acorn Stakes at Belmont Park on June 8, which was won in 2018 by last year's Oaks winner, Monomoy Girl.
When Serengeti Empress bled in the March 23 Fair Grounds Oaks, Amoss wasn't sure what to expect from her going forward. But a bullet workout at Churchill Downs showed that it was an isolated incident.
"There were some sleepless nights," he said. "I didn't want to do anything to harm the filly, so I thought we did everything we possibly could to make that happen. I'm glad we were as transparent as we were, on social media, with what we were doing."
LIORA – Less than 24 hours after nearly upsetting the Oaks at odds of 38-1, graded stakes winner Liora was reported to be doing "great" by trainer Wayne Catalano, who was still singing the praises of his charge's effort.
"She ran beautiful, she just got outrun," Catalano said. "The horse that won beat us a couple of times now, but I thought I was going to win at one point in the race. We're proud of her."
Catalano added they would take a look at possibly wheeling Liora back in the Black-Eyed Susan Stakes (GII) at Pimlico Race Course on May 17.
"We're going to see, we're going to take a look at everything," Catalano said
LADY APPLE – Longines Kentucky Oaks third-place finisher Lady Apple is doing well Saturday morning, according Steve Asmussen's assistant Scott Blasi.
"Man, she ran so well," Blasi said. "We're thrilled with her effort. She's a very classy filly and will keep improving down the road."
CHAMPAGNE ANYONE – Trainer Ian Wilkes said that Six Column Stables and Randy Bloch's Champagne Anyone was fine the morning after finishing fourth in Friday's Oaks and would be given a little break.
With speed holding most of the day and no one challenging Serengeti Empress, Wilkes knew his chances for victory were in peril early.
"Before the race, everybody was talking about speed, speed, speed and then they left her alone," Wilkes said. "That's just the way it was. I knew we were in trouble in the first turn and got shuffled back and lost position twice."
BELLAFINA – Kaleem Shah's Bellafina, the fifth-place finisher as the 9-5 favorite in Friday's Kentucky Oaks, was doing fine at her barn on the Churchill Downs backstretch Saturday morning.
Her groom, Garcia Ericson, said his filly had cleaned her feed tub the night before and was bright-eyed following her run in the nine-furlong Oaks.
Neither her rider, Flavien Prat, or her trainer, Simon Callaghan, made any real excuses for the daughter of Quality Road. The English ex-pat Callaghan speculated that his filly may prefer to run shorter distances – one-turn races, he said – and indicated that she would likely next be pointed toward Saratoga's Test Stakes for 3-year-old fillies on Aug. 3, a race run at seven furlongs.
Bellafina will return to her Southern California base to continue her training. Ericson indicated she was likely to fly west Monday
STREET BAND – The chestnut filly Street Band, sixth-place finisher in Friday's $1.25 million Longines Kentucky Oaks, was doing fine back at Barn 28 Saturday morning, reported assistant trainer Corey York.
"She ate it all up last night and she's doing well this morning," York reported. "She'll stay with us here at Churchill and we'll see what's next. She's got lots of options; she can do lots of things. Grass maybe; sprinting maybe. She can do lots of things."
Street Band had won the Fair Grounds Oaks in her previous outing and now sports a bankroll that is approaching $325,000. The daughter of Istan was bred by her trainer, Larry Jones, along with his wife, Cindy, and their friend Ray Francis. Those three now own her, along with Phillip Shelton's Medllion Stable and Michael Behrens' MyRacehorse.com
CHOCOLATE KISSES – Trainer Mark Casse reported all was well with the daughter of Candy Ride (ARG) the morning after her seventh-place finish in the Oaks.
The late-running filly got the trip Casse was hoping for in the 1 1/8-mile test but didn't get the pace set up needed for her best run as Serengeti Empress threw down fractions of :23.25 and :46.65 on the front end.
"We needed an extremely fast pace and we didn't really get that," Casse said. "We really didn't have any excuse."
One silver lining Casse took for the Oaks result was that it may flatter his Kentucky Derby contender, War of Will, by association.
"When (War of Will) won the Risen Star, Serengeti Empress won the Rachel Alexandra and…he didn't get good Ragozin numbers," Casse said. "They said 'well he only ran a fifth of a second faster than that filly' and I said 'She's a hell of a filly, she's going to win the Oaks'. Then of course both of them came back and ran clunkers so that (her win) makes me feel good."
MOTION EMOTION – Trainer Tom Van Berg's experiment to rate Motion Emotion led to an eighth-place effort in Friday's Longines Kentucky Oaks.
"She's fine, it didn't really work trying to rate her," Van Berg said.
The speedy daughter of Take Charge Indy will remain based with Van Berg's string at Churchill Downs.
JELTRIN – Trainer Alexis Delgado said ADR Racing Stable's Jeltrin was fine after her Kentucky Oaks run Friday and would be headed back to Florida on Sunday.
OUT FOR A SPIN – Trainer Dallas Stewart reported Saturday morning that Out for a Spin exited the Oaks in "good shape" after finishing 10th.
Out for a Spin broke from the rail but never responded and was beaten 27 ¾ lengths.
FLOR DE LA MAR – Assistant trainer Jimmy Barnes said Godolphin Racing's filly emerged in good order after finishing 12th in the Kentucky Oaks.
RESTLESS RIDER – Restless Rider, who was the last to cross the Oaks finish line, was fine at Kenny McPeek's barn both after the race and also Derby morning, said assistant trainer Greg Geier.
No decision has been made on what's next for her, he said of Fern Circle Stables and Three Chimneys Farm's filly, who at 4-1 was the second betting choice in Friday's race. She quickly dropped back with jockey Brian Hernandez Jr. and never mounted any serious challenge.
"She had a bad post position (outside No. 14) and she was experiencing something that had never happened to her before," Geier said.
JAYWALK – Trainer John Servis reported that Jaywalk came out of the Oaks with a couple of nicks on her back legs but nothing major. She is scheduled to ship Monday to Servis' home base at Parx.
POSITIVE SPIRIT – The Rodolphe Brisset-trained Positive Spirit has recovered from her spill at the beginning of Friday's Kentucky Oaks (GI) in good order. The Michael J. Ryan and Gerry Dilger-owned half-sister to Kentucky Derby (GI) winner Always Dreaming and Spinaway (GI) winner Hot Dixie Chick clipped heels with champion Jaywalk less than a sixteenth of a mile into the nine-furlong affair, tumbling and unseating jockey Manny Franco in the process. The Demoiselle (GII) winner was caught by outriders before the first turn.
"She's OK," Brisset said. "She is sound and that's what's important. She will more than likely jog tomorrow if all goes well."
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Moment that mattered: a rape conviction for a guru leads to riots in India
The Indian author and politician Shashi Tharoor explains how the completion of a 15-year-long rape case against Gurmeet Ram Rahim Singh – a musician, filmmaker and self-styled spiritual leader – caused a wave of rioting in northern India
25th August 2017 (Taken from: #28)
The conviction of Gurmeet Ram Rahim Singh on 25th August 2017 sparked violence as the spiritual guru's followers took to the streets. At least 38 people died and hundreds were injured in clashes with police in cities throughout northern India.
Most of the fighting was in the city of Panchkula, where an estimated 100,000 followers had gathered in anticipation of the verdict in the local courthouse. It took a total of 15 years to convict Singh, the flamboyant 'godman' (a colloquial Indian term for a charismatic guru) leader of controversial spiritual organisation Dera Sacha Sauda, for the sexual assault of two female followers at the sect's headquarters in Haryana state in 1999.
"I was surprised by the conviction," says Shashi Tharoor, the MP for Thiruvananthapuram in Kerala and author of several books on Indian history. "Although the evidence against Singh seemed overwhelming, in many cases featuring prominent defendants the witnesses either give up or 'turn hostile' – an expression meaning they recant their original accusation. Although we've had charges against wealthy and powerful figures in the past we haven't had a lot of convictions, so it was a surprise. It was perhaps more of a surprise than it should have been to the authorities, who had done nothing to prevent the violence that followed, even though it was known that many of Singh's supporters were assembling in public places."
Followers of the guru hurled rocks at cars, set fire to buses and attacked police officers in Panchkula. According to officials at the local hospital, the majority of deaths were caused by police bullets.
Three days after his conviction, Singh was sentenced to 20 years in prison. Lawyers for the victims said they believed that many more women were sexually abused by Singh. The guru is also due to face separate charges relating to the murder of a local journalist who was shot while investigating sexual exploitation at Dera Sacha Sauda in 2002.
The Gurmeet Singh case has been a huge story in India, not least because he was notorious for his shameless self-promotion. He directed and starred in several blockbuster films (in which he was also credited as cinematographer, editor, soundtrack composer and stuntman) including MSG: The Messenger of God and several sequels, all of which featured a superhuman protagonist tirelessly fighting drug abuse and sexual exploitation, and all of which were panned by critics.
Singh holds 19 Guinness World Records, including one for the world's largest vegetable mosaic (1,858 square metres) and has released several albums on the Universal label. "His biggest hit is called Love Charger," says Tharoor with a laugh. "He was a gaudy showman who lived ostentatiously, grew his hair long, charged around on motorcycles and in expensive cars, wore clothes glittering with sequins and had young women draping themselves over him."
While the 'rockstar baba' might appear a ludicrous figure from afar, he was taken seriously in India. He had at least ten million devotees (he claimed over 60 million), vast wealth and significant political clout – he urged his followers to vote for particular candidates and parties, meaning politicians courted his support.
"The political parties claimed that Singh was helping maintain peace," says Tharoor. "He was keeping people away from drugs and violence. Members got free education for their children. They were provided with food and employment. Ultimately the value of the dera [a Punjabi term used to describe any socio-religious organisation] is that it gives a sense of meaning and purpose to the lives of its members, and that ultimately brings them a sense of dignity and belonging. When a person joins a dera it becomes part of his own identity and sense of self-worth, and that's why many followers become fanatically devoted to their leaders."
When you participate in a cult you essentially mortgage your mind" — Dr Shashi Tharoor
Tharoor suggests that class divisions may have played a role in the sect's success. "Singh had many followers from the so-called 'lower caste' and there is still class prejudice in Sikhism," says Tharoor. "It is said that many of the official Sikh religious bodies are dominated by the upper class. When a dera comes along and offers its members a more exalted position they develop a vested interest in its success."
At Dera Sacha Sauda, which claims to sit at the "confluence of all religions", it appears that such benefits came at a high price. It has been alleged that in addition to women facing sexual assault, hundreds of male followers were bullied into being castrated. "When you participate in a cult you essentially mortgage your mind," says Tharoor. "Millions of people in deras across India have suspended their judgement and surrendered their entire worldly goods in totally handing themselves over to spiritual leaders. Castration seems an extreme step but when you hand over everything you possess, you surrender your body too."
Tharoor lists several recent examples of dera leaders being accused of inappropriate behaviour. Is India particularly susceptible to dubious gurus? "Religious traditions make it more possible," argues Tharoor. "Hindu philosophy is abstruse and since not everyone is able to master these complex texts it's acceptable to seek guidance from 'realised souls'. Simple people have been conditioned over millennia to look up to those who might be considered intermediaries between them and the realisation of God, which creates a space for charlatans to come in."
Millions of people across India have suspended their judgement and surrendered their worldly goods" — Dr Shashi Tharoor
Might Dera Sacha Sauda survive this scandal? Followers of gurus don't tend to abandon their allegiances lightly – on 5th July followers of Punjabi sect leader Ashutosh Maharaj, who died of a suspected heart attack in January 2014, won the right to continue to preserve the body of their godman in a freezer. They insist he is merely meditating. "It's too early to tell," answers Tharoor when asked about Singh's sect.
"Perhaps the whole enterprise will unravel or maybe a reformist figure will take over the dera and give it a different colouring. Singh is apparently planning an appeal and as long as there is the prospect of acquittal his followers will keep it going. But a dera without a spiritual head is difficult to sustain in the long term."
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Our first London Thelwall Lecture will be given on Saturday 5 November by Professor Judith Thompson, who will offer a lecture focusing on Thelwall's elocutionary institution at #57 Lincoln's Inn Fields (where the event is being held). The lecture is entitled "The Ghosts of Garden Court: John Thelwall and the Haunted Summer of 1816."
Programme for afternoon:
3:30pm Tour round 57 Lincolns Inn Fields with David Watkinson
4:30pm Tea & cake
5:00pm Lecture by Judith Thompson (with Q&A)
6:30pm Meal at nearby Ship Tavern
Please email Gordon Bottomley if you are thinking about attending the lecture and/or meal. This will be helpful in terms of estimating number of attendees (particularly for booking a table for the meal). You can, however, just turn up on the day.


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Ask the experts: European weekend breaks
Our panel comes up with ideas for cheap and easy European weekend breaks
Q: I want a cheap weekend away for two, flying from Birmingham or Bristol. We have just two nights so it has to be somewhere that's easy to get to. Our budget is £400-500. Where do you suggest?
National Geographic Traveller's associate editor, Sarah Barrell: Conveniently accessed by EasyJet's Friday and Sunday evening flights from Bristol, from £64.99 one-way, is a great classic weekend break destination — Barcelona. This arty Spanish city delivers, whether it's your first or fifth visit, with great cheap eats (for lunch, choose the menú del dia at most mid-range restaurants, this offers three courses and a glass of house wine for around a tenner), free entry to city-run museums on Sundays and, of course, the cost-free sights of the buzzing beachfront.
The city's business hotels often slash their rates at weekends and many have upped their game with boutique design quirks and perks, such as the Sky Bar, rooftop plunge pool and free wi-fi at H10 Casanova. Set right on the Grand Via, rooms start at €69 (£53) a night.
National Geographic Traveller's hotel expert, Julia Buckley: With great food, grand sights and a fast pace, Milan is a perfect weekend destination. Flybe goes direct from Birmingham, from £71, though I'd recommend the BMI Regional service from Bristol, from £118, which, with its 1-2 seating configuration, has the feel of a luxury private jet. Milan's stepping into the spotlight this year, with Expo 2015 bringing the largest Leonardo Da Vinci exhibition ever shown in Italy (15 April-19 July at the Palazzo Reale). This is Leonardo's city, of course — his Last Supper mural is at Santa Maria delle Grazie.
Hotels in the city centre are obscenely overpriced, but an easy 20-minute metro ride from the Duomo is the Nu Hotel — a stunning design-led hotel in the pleasant Udine neighbourhood. Rooms start from €103 (£80).
National Geographic Traveller's regular contributor, Suzanne King: Toulouse, in south west France, definitely fits the bill. EasyJet flies from Bristol six days a week (May-September), with returns from just under £50 per person. The flight time is less than two hours and it's only 20-30 minutes to the city centre on the airport shuttle bus, for €5.50 (£4) one way. For a good budget hotel, try Le Père Léon, where double rooms cost €90 (£66) a night and the location is ideal — it's right in the centre, within easy walking distance of the Old Town's attractions, shops and nightlife, and there's a metro station on the doorstep if you fancy going further afield.
Get in touch: If you're in need of travel advice, email our team – email@example.com
Published in the April 2015 issue of National Geographic Traveller (UK)


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This section contains 177 words
(approx. 1 page at 400 words per page)
Chapter 45 and Epilogue Summary
Chapter 45. Bliss approaches Schuyler and Dylan standing over the dead body of Lawrence. Bliss tells them her whole family is missing or dead. Bliss acts distraught when she sees that Dylan is dead too. As Oliver bandages Schuyler's wounds from the fight, she has a realization and tells Oliver that she loves him.
Epilogue. Two weeks later, Mimi lets herself into Jack and Schuyler's love nest. When Jack arrives, they have a brutal vampire battle.
Chapter 45 and Epilogue Analysis
Schuyler realizes that Oliver has always been there for her when she truly needs him. In addition, he is her best friend. Schuyler realizes that these things are what make you love someone rather than the lust she feels for Jack, which she had mistaken for true love. During the struggle with Jack, Mimi realizes there is a very fine...
(read more from the Chapter 45 and Epilogue Summary)
This section contains 177 words
(approx. 1 page at 400 words per page)


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The Deep Throat Cup's hourglass shape provides a sublime tightness. Special valves create a virtual vacuum inside the cup to deliver an amazing sucking sensation. Several unique features combine to create a vivid stimulation, using advanced technology and unprecedented internal design for the epitome of sensations!
How many times TENGA Onacup can be used?
All TENGA Onacup series and Onacap have been designed to be disposed. We would like you to have the best experience with TENGA in a perfect hygiene.
However, some users can utilize TENGA Onacup more than one time if they...
1) Don't ejaculate inside
2) Using condom to play
3) Washing it after used (Difficult to wash & dry)
However, this is not recommended. We highly suggest you to use TENGA 3D, FLIP-AIR LITE and FLIP HOLE, as it can be used more than 50+ times in perfect condition. We will not be responsible for any wrong use on the products and for other purposes. Besides, TENGA is a personal product and should not be shared or used by other people.
Japan Products
Note: Recommended to used with lubricant and condom.


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The Body
A Brief Tour Of Western Dualism From Plato To Plastic Surgery, The Mind Embodied, Culturally Variable Bodies
What is "the body"? If the question seems ridiculous to you, you are undoubtedly not alone. At any given time, in any given culture, most people have an intuitive, if not always easy to articulate, notion of what the body is, and probably regard that notion as shared by all human beings. The fact is, however, that human cultures have not only done an amazing variety of things to human bodies, but have imagined and experienced the nature, limits, and capacities of the human body—and its relation to the self—in extremely diverse ways.
For example, most people living in the early-twenty-first century West believe the body to be a border between the self and the external world, and one that houses only one individual self. Those whose experience departs from this are treated as suffering from a personality disorder. Many non-Western cultures, in contrast, do not regard the skin as an impermeable border between the individual and the natural world, and believe that the physical body may host multiple selves. Another example is the relationship of mind and body. Many cultural systems—Zen Buddhism is one—do not mark a radical distinction between mind and body. In contrast, mind/body dualism has been so thoroughly integrated into the fabric of Western culture that some may have difficulty imagining an experience of the self that does not partake of it.
From the significance of body parts to contemporary theory of the body, different conceptions abound. Neither "race," nor gender, nor sexuality is a universally uniform category. Different cultures imagine different organs as the center of bodily functioning, and privilege different senses; among the Suya of Brazil, for example, hearing is equated with understanding, as seeing is for Europeans and North Americans. And while contemporary biologists attempt to map a basic genetic blueprint, poststructuralists argue that the very notion of a biological body is a human invention.
From a philosophical and anthropological perspective—and to establish limits to an exceedingly broad topic—this article focuses on the intellectual, cultural, and political developments that various disciplines have regarded as landmarks in the history of the idea of the body.
Additional topics
- The Body - A Brief Tour Of Western Dualism From Plato To Plastic Surgery
- The Body - The Mind Embodied
- The Body - Culturally Variable Bodies
- The Body - The Social Skin
- The Body - Politics Re-conceives The Body
- The Body - The Body In The Early Twenty-first Century
- The Body - Bibliography
- Other Free Encyclopedias
Science EncyclopediaScience & Philosophy: Bilateral symmetry to Boolean algebra


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Companies are more demanding with the services they offer. Chatbots that answer the most frequent questions are no longer enough. It's necessary to make them more complex. And that's when an API integration comes in.
Get ready to learn how a chatbot with API integration can improve your service delivery.
What is a Chatbot?
Before we get to the integration, it's necessary to know what a chatbot is.
In short, a chatbot is a chatting agent that helps optimize your company's service level.
These agents can use Artificial Intelligence or not.
What does AI do in a Chatbot?
Artificial Intelligence is a more recurring theme these days. It can be considered the most used word when talking about process automation.
It's with it that chatbots and email bots become "intelligent" and understand what is asked of them.
Don't know what email bots are? Find out everything here!
Chatbots that do not have AI are more basic systems. Generally, they're ruled by decision trees, where the user clicks on the option he wants until he gets the answer.
On the other hand, chatbots with AI are more complicated systems. That is, they have more associated technologies that allow them to learn and understand the human language.
These technologies are Machine Learning and NLP (Natural Language Processing), and they allow the system to have a "natural" conversation with a person.
Machine Learning is the area responsible for the system's learning. The NLP is responsible for processing the information, in this case, the language.
What is API Integration?
API stands for "application programming interface".
An API is a computing interface that allows information sharing between different software components.
These interfaces define what kind of requests can be made, how they can be made, which data formats can be used, etc.
In this case, when integrated with chatbots, they allow the expansion of the system functionalities.
Imagine you are talking to the bot and need access to your Client Area. With an integrated API, you can access it directly in the bot without opening another web page.
REST vs. SOAP
Most probably you've heard of REST and SOAP, when the subject is APIs.
Well, that's because they're the most common ways to integrate web-based services.
SOAP is the message transfer protocol, in XML format, for distributed environments use. This protocol works as a framework that allows interoperability between different platforms.
One of the advantages of this protocol is that several programming languages and tools can read and generate messages.
However, it has a negative aspect.
Because it's in XML format and has many meta-information tags, it becomes more "heavy," also taking more time to translate the message data.
REST, on the other hand, is an HTTP-based protocol. It does not impose restrictions on the message format but only on the behavior of the components involved.
Its greatest advantage is the flexibility regarding the message format that the developer uses.
Although it is "lighter" and consequently faster, it brings more interoperability problems.
The REST format is almost always the one used for web services.
What are the Benefits of API Integration in Chatbots?
A smart system without integration is certainly good. But a chatbot AI with integration is much better.
More Complex Bots
Some consider that complex chatbots are those with artificial intelligence. And they are not wrong, admitting that there are much more basic bots.
However, the really complex ones are the ones that have their features expanded.
That is, taking the example previously spoken, it's the difference between a chatbot that directs you to the Client Area and another, with integration, that takes you directly, without leaving the bot, to your account.
More Efficiency
By automating processes, which would otherwise take longer, the efficiency of your chatbot increases exponentially.
Besides answering your users' questions, it also makes certain procedures easier for them.
Improves User Experience
The user experience is becoming a more relevant factor for companies.
They know that if the client cannot solve what they want, they will be frustrated and displeased.
Therefore, the available solutions must be as complete as possible to have only satisfied customers.
Boosts employee productivity
In addition to making procedures easier for customers, these integrations also promote the productivity of your employees.
The bot answers the most frequent and repetitive questions and, with the integration, speeds up other processes.
Therefore, your team is more available to handle more complex requests, which require more attention.
Chatbot API Integration Use Cases
Now that we know a little bit about integration with APIs let's move on to the examples.
What are the practical cases of integration in your chatbot?
Client Authentication
A great advantage of integrations is to authenticate your customers.
To do this, just integrate the chatbot with the software your company uses.
Thus, if the user enters the ID number and is already registered in your company's database, the chatbot returns a response framed with that user's specific case.
If the user isn't already registered, the chatbot can direct him/her to a different stream, where, let's imagine, it requests the data to generate a new commercial lead.
We can say that a large part of the requests made are related to payments.
Requests for Payment References
Companies have begun to find that many users use chatbots to request new payment references. And, before integration, it was necessary to talk to a human assistant to fulfill the request.
However, companies realized that they could easily automate this process.
With the introduction of a specific number (ID number, policy number, etc.), the system crosses the information and returns its payment reference.
Documents Duplicate Requests
Another question much requested by customers is the copy of documents. For example, many customers ask for a second copy of the car insurance document at insurance companies.
To receive the duplicate, the chatbot asks for the policy number and then the code that the user will receive in their phone contact or email.
Once this verification is done, the chatbot returns the asked document by email or post.
Sending Documents
This case is widely used, for example, in marketing campaigns.
In a campaign carried out by a Visor.ai client, users had to send a photo of a receipt proving the purchase of a certain product.
After reading the document sent through OCR technology (Optical Character Recognition) and checking the requirements, the chatbot assigned the user's awards.
Insurance Sales
Another door that the integrations open is the possibility of selling products through the chatbot.
Imagine you want to buy insurance for your new smartphone. You would normally subscribe to this insurance in person or with a human agent.
With API integration in your chatbot, the customer can buy the insurance without any human intervention.
Giving some essential data to fill out the contract, the chatbot crossing and sharing information with other platforms ensures a fast and secure customer subscription.
Location Sharing
Another example of integration happens, for example, in retail stores.
Each store has its own promotions and discounts, and the consumers don't always know what is available.
In these cases, the client shares his/her location with the chatbot, and the chatbot will answer with a map of the nearest stores and their promotional brochures.
The Integration Hub You Need to Know
At Visor.ai, Integration Hub is the tool where you can integrate the APIs you want.
With the REST and SOAP options, you can choose the solution that best suits your needs.
We can also integrate the Visor.ai platform into CRM platforms, such as Salesforce, or communication channels, such as WhatsApp or Facebook Messenger.
Make your chatbot more complex with the different integration options. Increase your customer and team satisfaction even more. Contact us now!
If you are interested in this topic, we also suggest you download these ebooks:


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Several Charles County Public Schools (CCPS) students were part of an inaugural event on Tuesday, Sept. 30, that mixed video conferencing technology and chat rooms with politics and history. The event was a Google Hangout with Congressman Steny Hoyer, who represents Charles County as part of Maryland's Fifth Congressional District in the United States House of Representatives. Students in Advanced Placement (AP) Government classes at La Plata, North Point and Westlake high schools, along with students at two Prince George's County high schools, participated in a question and answer session with Hoyer on issues such as minimum wage and internet fair usage using computers and video conferencing features available through a Google chat setting.
The Google Hangout was hosted by the Close Up Foundation and moderated by the organization's director, Joe Geraghty. The Close Up Foundation partners with educators, schools, and youth organizations throughout the country to help young people become informed about the democratic process and become engaged citizens. According to Jack Tuttle, content specialist in social studies for CCPS, Maryland State Department of Education staff selected CCPS to participate in the event.
Students from Westlake joined their peers at North Point in the Telepresence classroom to participate in the Hangout, and students at La Plata also participated through use of the Telepresence technology at their school. During the Google Hangout, selected students chosen to represent their schools took turns asking Hoyer questions. To prepare for the event and help their students come up with questions, Close Up provided teachers the curriculum and supporting materials on the topics up for discussion.
Students chosen to represent their schools during the event were Carleigh Zimmerman, senior at La Plata, Kristen Kriegh, senior at North Point, and Georgia Benson, senior at Westlake. La Plata's question to Hoyer focused on net neutrality and its impact on cable company incentives, and both North Point and Westlake's questions discussed the possibility and effects of an increase in minimum wage. The idea behind the Google chat is to better connect students on a nationwide level to government leaders.
During his closing remarks to students, Hoyer thanked Close Up and Google for their efforts in organizing the event and remarked how advancements in technology will continue to help students learn and succeed. "Here I am sitting in Washington D.C., and students are at their schools. What a wonderful way technology has found to bring us together in real time, seeing one another, talking to one another and learning from one another," Hoyer added.
Other schools selected to participate were Frederick Douglas and Parkdale high schools from Prince George's County Public Schools. To watch the Google Hangout, visit https://plus.google.com/events/cppdoo8ug8q3bkrihcmvntgngno.
Charles County Public Schools provides 26,500 students in grades prekindergarten through 12 with an academically challenging education. Located in Southern Maryland, Charles County Public Schools has 35 schools that offer a technologically advanced, progressive and high quality education that builds character, equips for leadership and prepares students for life, careers and higher education.


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Customize your JAMA Network experience by selecting one or more topics from the list below.
Tyburski JG, Wilson RF, Warsow KM, McCreadie S. A Trial of Ciprofloxacin and Metronidazole vs Gentamicin and Metronidazole for Penetrating Abdominal Trauma. Arch Surg. 1998;133(12):1289–1296. doi:10.1001/archsurg.133.12.1289
© 2023
To determine whether a combination of ciprofloxacin hydrochloride and metronidazole hydrochloride would be as effective or more effective than a combination of gentamicin sulfate and metronidazole hydrochloride for preventing infection in patients with penetrating abdominal trauma, to evaluate the factors associated with increased risk of infection, and to determine the serum peak and trough levels of gentamicin with the dosage regimen of 2.5 mg/kg every 12 hours.
Randomized double-blind study.
Level I trauma center.
Eighty-four patients with penetrating intra-abdominal injuries (gunshot wound, 69; stab wound, 15) thought to require laparotomy.
The patients were randomized during treatment in the emergency department to be given a combination of ciprofloxacin hydrochloride, 400 mg every 12 hours, and metronidazole hydrochloride, 500 mg every 6 hours, or a combination of gentamicin sulfate, 2.5 mg/kg every 12 hours, and metronidazole hydrochloride, 500 mg every 6 hours.
Of 68 patients with intra-abdominal injuries who could be observed for at least 48 hours after laparotomy, posttraumatic infections developed in 12 (18%), and nosocomial infections developed in 6 (9%). The incidence of posttraumatic infections in patients who were given gentamicin and metronidazole (5/33 [15%]) was not significantly lower than the incidence in patients who were given ciprofloxacin and metronidazole (7 of 35 [20%]; P=.75). The presence of any infection increased the mean±SD length of hospital stay from 8.7±3.5 days to 23.3±10.9 days and increased the mean±SD hospital charges from $24,507±$9860 to $104,920±$49,083 (P<.001). Univariate analysis showed the factors most significantly associated with infection were as follows: (1) the use of blood transfusions (P<.001), (2) the penetrating abdominal trauma index of 35 or more (P<.002), (3) injury to the colon requiring a colostomy (P=.004), and (4) a trauma score of less than 12 (P<.02). Multivariate analysis showed the only significant factor was the receipt of blood transfusions (F=10.165; P<.005).
Ciprofloxacin and gentamicin, each in combination with metronidazole, were equivalent in their ability to prevent infections after penetrating abdominal trauma; other factors, especially the receipt of blood transfusions, had much more effect on the incidence of infection. Infection greatly increases the length of hospital stay and hospital charges. The use of an increased dosing regimen of 2.5 mg/kg every 12 hours of gentamicin sulfate was effective at obtaining a therapeutic peak serum concentration.
INFECTION IS the leading cause of morbidity and mortality in patients who survive at least 48 hours after a penetrating wound of the abdomen.1-12 Current therapeutic approaches to reduce the incidence of infection in patients with penetrating abdominal injuries include prompt surgical intervention and empirical antibiotic therapy to prevent or minimize the growth of enteric gram-negative aerobes and anaerobes. However, the optimal antibiotics to be used and the optimal duration of therapy continue to be controversial. Although gentamicin is inexpensive and frequently is used to prevent infection by gram-negative aerobes in patients with abdominal injuries or who are undergoing surgery, it can have many adverse effects, especially with prolonged use of high doses, and obtaining optimal peak and trough levels at the usual dose of 1.5 mg/kg every 8 hours can be difficult. Ciprofloxacin, on the other hand, seems to be safer and has a spectrum of activity that adequately overlaps that of the aminoglycosides. Metronidazole is effective against enteric anaerobes, safe, and inexpensive.
The present study was designed to determine whether a combination of ciprofloxacin and metronidazole would be as effective or more effective than a combination of gentamicin and metronidazole for preventing infection in patients with penetrating abdominal trauma, to evaluate the factors associated with increased risk of infection, and to determine the serum peak and trough levels of gentamicin with the dosage regimen of 2.5 mg/kg every 12 hours.
Patients were eligible for inclusion in the study if they could give informed consent and had a penetrating abdominal injury that required surgical intervention. Patients were excluded from the study if they could not provide informed consent, were younger than 18 years, were pregnant, had a history of hypersensitivity reactions to any of the medications, or had a history of renal failure that required dialysis. The study format was approved by the Wayne State University (Detroit, Mich) Human and Animal Investigation Committee.
During their initial treatment in the emergency department, 84 patients with penetrating abdominal trauma initially thought to require an emergency laparotomy were enrolled in the study. The penetrating injuries were due to gunshot wounds in 69 patients (82%) and stab wounds in 15 patients (18%). For the 84 patients, the mean±SD age was 30±12 years, and the mean±SD initial findings included a systolic blood pressure of 121±26 mm Hg, a trauma score of 11.7±0.8, a revised trauma score of 7.6±0.7, and a penetrating abdominal trauma index (PATI), which quantifies the number and severity of the various abdominal organs injured, of 20±14.
The patients were randomized, by the dispensing pharmacist who used a previously prepared randomization schedule, to be given a combination of ciprofloxacin hydrochloride, 400 mg every 12 hours, and metronidazole hydrochloride, 500 mg every 6 hours, or a combination of gentamicin sulfate, 2.5 mg/kg every 12 hours, and metronidazole hydrochloride, 500 mg every 6 hours. (The gentamicin-metronidazole and ciprofloxacin-metronidazole combinations are referred to as gentamicin and ciprofloxacin, respectively, in the remainder of the article.) All treatment regimens were prepared in 100 mL of isotonic sodium chloride and administered over a 60-minute period. The pharmacists dispensing the antibiotics were the only individuals who know which drug was being given. Surgery was performed within 4 hours of the initial antibiotic administration. Patients with colon injuries were treated for 96 hours, and patients with stomach or small bowel injuries were treated for 24 hours. Patients with other injuries were given only 1 dose of antibiotics. This dosing schedule was established based on the relative concentration of bacterial contamination predicated by the organ injured.
Owing to the double-blinding, all patients receiving antibiotics for more than 24 hours (colon injuries) underwent pharmacokinetic studies. Thirty minutes before the fourth dose of the antibiotic and 30 minutes after the infusion of the fourth dose was completed, blood specimens were drawn for determination of trough and peak levels, respectively. The dosages were then adjusted as needed to obtain peak levels of 10 to 15 µmol/L (5-7 µg/mL) and trough levels of less than 4 µmol/L (2 µg/mL).
Data were obtained prospectively, and differences were evaluated by analysis of variance, the Fisher exact test, and χ2 analysis. A multivariate analysis of variance also was performed on all factors thought to be factors in the development of infection. Data are reported as mean±SD unless otherwise noted.
The diagnosis of pneumonia was made when a new infiltrate was evident on a chest radiograph and a Gram stain of sputum showed numerous polymorphonuclear lymphocytes with a predominance of 1 type of bacteria and the core body temperature was 38.6°C or more or the white blood cell count was abnormal or showed a shift to the left. That is, the radiological and sputum findings needed to be associated with some sign of systemic infection for the diagnosis of pneumonia to be made.
Wound infections were diagnosed by the presence of cellulitis and purulent drainage. Intra-abdominal infections were defined as intra-abdominal abscesses that were drained surgically or with radiological guidance. Patients were observed throughout the hospital stay and in the outpatient clinic. All patients were evaluated at least once after discharge.
Of the 84 patients enrolled in the study, 3 did not undergo surgery because additional studies indicated that abdominal penetration had not occurred; this was confirmed on later follow-up. Eleven patients had "negative" laparotomies in which no organ injuries were found, and 2 died of their injuries within 24 hours of the operation. Therefore, 68 patients were available for complete evaluation.
Of the 68 remaining patients who underwent a laparotomy for intra-abdominal injuries and survived at least 48 hours, infections developed in 18 (26%) while they were in the hospital; 12 patients (18%) had infections directly related to trauma (abdominal infection, 7; wound infection, 5), and 10 (15%) had nosocomial infections (pneumonia, 7; urinary tract infection, 5); 1 patient had an infection at the intravenous catheter site. Four patients had more than 1 type of infection. No infections developed during the 30 days after discharge.
Of the 18 patients in whom infections developed, multiple organ failure developed in 3 (17%), and they died. One 21-year-old man died on day 12 of pneumonia and multiple organ failure after a gunshot wound to the bladder and iliac arteries causing severe prolonged hypotension that required transfusion of 28 units of blood in the operating room. A 47-year-old man died on day 32 of multiple organ failure due to intra-abdominal infection, pneumonia, and a urinary tract infection after a gunshot wound involving the liver, diaphragm, spleen, and pancreas that required intraoperative transfusion of 19 units of blood. The third death (due to intra-abdominal infection and multiple organ failure), on day 36, was a 50-year-old man with a gunshot wound of the chest causing a hemopneumothorax and injuries to the colon, small bowel, spleen, and mesentery. Thus, the mortality rate for nosocomial pneumonia was 28% (2 of 7 patients), and for intra-abdominal infection, it was 14% (1 of 7).
The cultures from the infections produced 16 aerobic gram-positive cocci (Staphylococcus epidermidis, 7; Enterococcus species, 5; and Streptococcus species, 4). The 10 aerobic gram-negative bacilli cultured included the following: Acinetobacter species, 4; Escherichia coli, 2; Klebsiella species and Proteus species, 2; Enterobacter species, 1; and Pseudomonas species, 1. Candida organisms were recovered from 6 infections, but only 1 anaerobic genus (Bacteroides) was found.
Because the organisms obtained from the various infections were so variable, no patterns were discernible except for 4 Candida species found in 6 abdominal infections. The sputum specimens for patients with pneumonia produced 6 additional gram-negative aerobes, 2 organisms considered normal flora, and 1 Candida species.
Of the 68 patients with abdominal injuries who survived at least 48 hours, 33 were given gentamicin, and 35 were given ciprofloxacin. The demographics for these 2 groups were similar (Table 1).
The incidence of infection (posttraumatic and nosocomial) was almost the same for the patients who were given gentamicin as for the patients who were given ciprofloxacin. There was no difference in the incidence of trauma or nosocomial infections between the gentamicin- and ciprofloxacin-treated patients, but there was a tendency for a higher incidence of pneumonia in the gentamicin-treated patients (Table 2).
The types of organisms recovered from the patients with infections were extremely variable. More organisms overall were obtained from patients treated with ciprofloxacin than from patients treated with gentamicin (Table 3). The incidence of gram-positive cocci was similar in both groups; however, the incidence of gram-negative aerobes and Candida species, tended to be higher for ciprofloxacin-treated patients than for gentamicin-treated patients. The only organisms seen more frequently in gentamicin-treated patients were Streptococcus species and Klebsiella and Proteus species. Many of the organisms found in the ciprofloxacin-treated patients tended to be antibiotic-resistant species (Candida species, 6; Acinetobacter species, 4;Enterococcus species, 3; and Pseudomonas species, 1).
It is generally believed that to be most effective and safe, the peak serum level for gentamicin should be at least 10 µmol/L (5 µg/mL), and the trough level should be less than 4 µmol/L (<2 µg/mL). The pharmacokinetic studies performed after the fourth dose of gentamicin (which was given at 2.5 mg/kg every 12 hours) revealed a peak level of 16.8±5.5 µmol/L (8.0±2.6 µg/mL) and a trough level of 1.3±1.0 µmol/L (0.6±0.5 µg/mL). The volume of distribution was 0.35±0.11 L/kg (normal, 0.24±0.08 L/kg). The dose of gentamicin had to be adjusted for only 2 of the patients to obtain a peak level of at least 10 µmol/L (5 µg/mL).
The biggest differences between the 18 patients with infections and the 50 patients without infections were the average number of units of blood transfused (Table 4) and the incidence of blood transfusions (83% [15 of 18 patients] vs 20% [10 of 50 patients]) (P<.001). Other major differences between the patients with infections and the patients without infections included the PATI, the trauma score, operating room (OR) time, and the injury severity score (ISS).
The receipt of any blood transfusion during the first 24 hours after admission to the hospital was associated with a significant increase in the infection rate (15 of 25 patients [60%] vs 3 of 43 [7%], P<.001). Even with only 1 to 4 units of blood, the infection rate was 45% (5 of 11 patients). The infection rate was particularly high in the patients who received massive transfusions (10 or more units of blood during the first 24 hours after admission to the hospital; Table 5). Multivariate analysis of variance showed that this was the only factor that significantly correlated with an increased incidence of infection (F=10.165, P<.001).
An elevated PATI of 19 or less was associated with an infection rate of only 4% (1 of 28 patients). However, a PATI of 35 or more was associated with an infection rate of 54% (6 of 11, P=.001) (Table 5).
The 56 patients with a normal trauma score and a normal revised trauma score had an infection rate of 20% (11 of 56 patients). In contrast, any physiological abnormality causing the trauma score or revised trauma score to be abnormal increased the infection rate to 58% (7 of 12 patients, P=.011).
As the OR time increased from less than 2 hours, to 2 to 4 hours, and to 4 hours or more, the infection rate rose from 8% (1 of 13 patients) to 22% (9 of 41) to 57% (8 of 14), respectively. A longer OR time, especially if more than 4 hours, also was associated with increases of the ISS, PATI, number of blood transfusions, infection rate, and length of hospital stay (LOS). As might be expected, the PATI was particularly apt to be higher in the patients with an OR time exceeding 4 hours (vs an OR time <2 hours; 33±11 vs 11±9, P<.001).
The incidence of infection tended to rise with the number and type of organs injured (Table 6). The infection rate in patients with only 1 injured organ (2 of 16 patients [12%]) tended to be lower than in those with 2 injured organs (6 of 28 [21%]) and than in those with 3 or more injured organs (10 of 24 [42%], P=.09).
Of the organ injuries associated with infection, the most prominent were colon injuries requiring a colostomy, and of 12 patients with such injuries, infections developed in 9 (75%). In contrast, of 18 patients with colon injuries not requiring a colostomy, an infection developed in only 1 (6%), and of 4 patients with rectal injuries (all underwent colostomy), no infections developed. We could discern no relevant pattern to the combinations of organs injured, other than the greater the number injured, the higher the risk of infection.
The LOS for the 68 patients who had intra-abdominal injuries was 12.4±8.3 days. The major cause of a prolonged LOS was the presence of an infection. The 18 patients with infections (vs the 50 without infections) had an LOS of 23.3±10.9 days (vs 8.7±3.5 days, P<.001). When correlation coefficients were calculated for the LOS vs all the other factors studied, the most significant correlations were the presence of an infection (r=0.76), the use of blood transfusions (r=0.67), the trauma score (r=0.50), and the PATI (r=0.47). Even the receipt of only 1 to 4 units of blood increased the LOS to 13.6±9.3 (vs 9.2±2.9 in those not receiving blood, P=.01). Multivariate analysis showed that the only significant factors correlating with the LOS were the presence of infection (F=25.67; P<.001) and use of blood (F=9.01; P=.0039).
The hospital charges for the 68 patients with abdominal injuries surviving at least 48 hours were $45,793±$6507. For the 18 patients in whom infections developed, the charges were $104,920±$49,083, and for the 50 without infections, the charges were $24,507±$9860 (P<.001). The charge per day also was higher in the patients with infections ($4503±$1728 vs $2817±$591) (P<.001). A wound infection increased hospital charges to $71,673±$10,138, while an intra-abdominal infection increased hospital charges to $120,519± $34,990.
A number of randomized double-blind studies have been performed to determine whether selected antibiotics are more effective for reducing the incidence of infection in patients with penetrating wounds of the abdomen.1-12 In these studies, the incidence of posttraumatic infections involving the abdominal cavity or abdominal wall has ranged from 7.0%9 to 20.6%.2,7
In 3 articles describing patients having only colon or small bowel injuries,8,10,12 the cumulative posttraumatic infection rate was 16.8% (56 of 334 patients). In 9 articles that included all intra-abdominal injuries (colon, small bowel, and other), the cumulative posttraumatic infection rate was 13.8% (224 of 1618).1-7,9,11 In the present study, the posttraumatic infection rate was 18% (12 of 68), and for injuries involving the colon or small bowel, the infection rate was 22% (11 of 51). For other injuries, the posttraumatic infection rate was 6% (1 of 17). In the present study, the higher posttraumatic infection rate associated with colon and small bowel injuries may be related to the relatively large number of colostomies performed (12 of 30 patients [40%]) owing to the colon injuries.
Although many reports have not included nosocomial infections in their statistics, such infections can have profound effects on outcome. Indeed, in 2 of the 3 deaths after 48 hours of hospitalization in the present study, nosocomial pneumonia was an important factor. Of the 6 patients who had only nosocomial infections, 1 patient died, and the mean LOS in the 5 survivors was 22±10 days. The hospital charges for these 5 patients averaged $105,000 each, which is almost $80,000 more per hospitalization than the charges for the patients without infections.
Overall, 5 (7%) of 70 patients with proved intra-abdominal injuries in the present study died. Two died of massive injuries with prolonged shock within 24 hours of admission to the hospital and were excluded from the study, and 3 died later (on days 12, 32, and 36) of sepsis with multiple organ failure related to severe intra-abdominal infections, pneumonia, or both. The injuries in the 3 patients who died later were considered severe (mean ISS, 21; mean PATI, 33), and the number of units of blood given during the first 24 hours to the 5 patients who died was 25±16; no errors in management were found on review of the medical records.
Relatively few studies included the mortality rates in published reports. The overall mortality rate in the present study for patients with proved abdominal injuries (5 of 70 patients [7%]) is comparable to that in other series, such as the series of Sims et al4 (6.1%); however, 41% of the patients in that series had stab wounds, and the mortality rate with stab wounds usually is low; in the present study, none of the 12 patients with stab wounds died.
The combined incidence of posttraumatic infections and nosocomial infections in the patients treated with gentamicin (30%) was not significantly higher than the incidence in patients treated with ciprofloxacin (23%). In addition, the demographics and organ injuries for the 2 groups were almost identical.
The microorganisms found in the present study were so extremely varied that it was difficult to draw any conclusions about them. There were, however, 4 peritoneal cultures of Candida species from patients with abdominal infections. In addition, for 6 of 8 cases of pneumonia, the cultures showed gram-negative bacilli, and no specific gram-positive organisms, except normal flora, were found in sputum. Interestingly, there were more organisms per infection in ciprofloxacin-treated patients than in gentamicin-treated patients (2.08±0.64 vs 1.00±0.47, P<.001).
In almost all previous studies of gentamicin sulfate, the dosage used has been 1.5 mg/kg every 8 hours (sometimes associated with an initial dose of 2 mg/kg), and in such studies, it has been difficult to obtain the peak levels of 13 to 17 µmol/L that generally are considered to be effective. Fabian et al1 noted that gentamicin sulfate in dosages of 2 mg/kg initially and then 1.5 mg/kg every 8 hours resulted in 48% of the patients having peak levels less than 13 µmol/L. Indeed, 6 of the 7 therapeutic failures (intra-abdominal infection, wound infection, or necrotizing fasciitis) in their study occurred in patients treated with a combination of gentamicin and clindamycin, and subtherapeutic levels of gentamicin were found in 3 of the 6 patients who experienced therapeutic failure. Reed et al13 noted similar problems, especially a decrease in therapeutic half-lives with amikacin in the patients they studied. In light of this, we dosed the gentamicin sulfate for the present study at 2.5 mg/kg every 12 hours.
Based on the pharmacokinetic studies performed in the present study, the peak levels that would have been obtained if the gentamicin sulfate had been given at 1.5 mg/kg every 8 hours would have been only 9 µmol/L. The peak levels obtained in the present study were therapeutic (16.8±5.5 µmol/L) with the regimen of 2.5 mg/kg every 12 hours.
Since severely injured patients tend to have higher volumes of distribution for most drugs, they also would tend to have the lowest blood levels, further reducing the likelihood that gentamicin sulfate in doses of 1.5 mg/kg every 8 hours would be effective. It also would seem prudent to readminister the antibiotics to patients who have experienced major blood loss, once the bleeding has been controlled. Indeed, virtually all of the studies in which gentamicin sulfate or tobramycin sulfate have been used in doses of 1.5 mg/kg every 8 hours should probably be viewed with some skepticism.
Few studies have reviewed all of the factors thought to increase the risk of infection in abdominal trauma. In the study by Nichols et al,14 the use of blood or blood products was not as important as a critical condition on admission to the hospital, an operation lasting more than 4 hours, 3 or more injured organs, colon injury, or an age of 45 years or older. When correlation coefficients were determined for all of the factors that might be associated with infection in patients in the present study, the highest correlations were seen with the use of blood transfusions (r=0.58) and the PATI (r=0.43).
It is generally assumed that there is an increased risk of infection after allogeneic blood transfusions,15,16 particularly massive transfusions.17,18 It has been shown that allogeneic blood transfusions cause immunosuppression by increasing numbers of suppressor T cells and by altering cytokine production and the function of monocytes and natural killer cells.19 There also is an obvious association between the need for blood transfusions and shock. However, the incidence of infection in patients with an initial systolic blood pressure of 90 mm Hg or more was 7% (3 of 42 patients) if no blood was transfused and 62% (10 of 16) if blood was transfused. For an initial systolic blood pressure of less than 90 mm Hg, no infection occurred in the 1 patient who received no transfusions, but the infection rate was 56% (5 of 9) in the patients who received blood transfusions. Multivariate analysis showed the need for blood transfusion was the only significant factor predicting infections in the present study.
In an attempt to better quantify injuries and the risk of complications after abdominal trauma, Moore et al20 described the PATI in 1981. In calculating the PATI, each abdominal organ is given a risk factor of 1 to 5, and the severity of each organ injury also is graded on a scale of 1 to 5. Thus, the PATI for each abdominal organ injury may range from 1 to 25, but if multiple organs are injured, the PATI may be much higher.
Croce et al,21 in a review of 592 patients with penetrating trauma, found that as the PATI rose from 1 to 10, to 11 to 15, to 16 to 25, and 26 or more, the incidence of abdominal septic complications rose from 2% to 4% to 7% to 27%, respectively. Thus, a PATI of 26 or more was a strong predictor of infection. In the present study, a PATI of 20 or more was associated with a total infection rate of 42% (17 of 40 patients) vs 4% (1 of 28) in patients with a lower PATI, and the abdominal infection rate was 18% (7 of 40). All 7 of the patients in the present study with intra-abdominal infections had a PATI of 26 or more.
Nichols et al14 noted that as the OR time increased from less than 2 hours, to 2 to 4 hours, to 4 or more hours, the total infection rate rose from 12% to 33% to 38%, respectively. In the present study, the total infection rate for the same OR durations was 8% (1 of 13 patients), 22% (9 of 41) and 57% (8 of 14). However, many factors affect the OR time, particularly the number of organs injured and the severity of the injuries, and this would be reflected in the PATI and ISS.
Nichols et al14 noted that as the number of organs injured increased from 1 to 3 or more, the infection rate also increased from 20% to 46%. In the present study, the total infection rate also rose as the number of organs injured increased: 12% (2 of 16 patients), 21% (6 of 28), and 42% (10 of 24), respectively for 1, 2, and 3 or more organs injured.
Fabian et al1 found that posttraumatic infection rates with bowel injuries were 24% (4 of 17 patients) for colon injuries, 18% (2 of 11) for stomach injuries, and 6% (2 of 35) for small bowel injuries. In the present study, the incidence of abdominal infections was 33% (2 of 6 patients) for pancreatic injuries, 21% (3 of 14) for stomach injuries, 15% (4 of 26) for small bowel injuries, and 13% (4 of 30) for colon injuries. If the colon injuries were divided according to their severity, the abdominal infection rate was 33% (4 of 12) in those having a colostomy and 0% (0 of 18) in those who underwent primary repair of colon injuries.
The LOS is not mentioned in many reports of penetrating abdominal trauma. Nichols et al,14 however, reported a mean LOS of 13.9 days compared with the overall LOS of 12.4 days in the present study; the LOS was 8.7±3.5 days for the 50 patients without infections and 23.3±10.9 days for the 18 patients with infections.
There is virtually no information in the literature about the cost of infections after trauma. It is clear, however, that any factor, especially infection, that increases LOS greatly increases the cost of medical care. Not only did infection increase the LOS, but it also increased the cost per day by about 60%. In the present study, the development of an infection, on the average, increased hospital charges more than 4-fold. It also should be emphasized that the hospital charges given in the present article do not include charges for professional care.
The incidence of infection (18% posttraumatic and 9% nosocomial) after penetrating abdominal trauma was almost identical in the patients receiving gentamicin or ciprofloxacin. Gentamicin in dosages of 2.5 mg/kg every 12 hours produced much better peak levels than would have been expected with previously reported doses of 1.5 mg/kg every 8 hours. The most significant factor associated with an increased risk of infection was the use of blood transfusions. The presence of infection increased the LOS almost 3-fold (23.3 vs 8.7 days) and increased hospital charges more than 4-fold ($104,920 for patients with an infection vs $24,507 for patients with no infection).
John M. Davis, MD, Neptune, NJ: I would like to compliment the authors on a thoughtful and thought-provoking study. I appreciate their submitting the manuscript to me in advance of the meeting. The study shows a number of risk factors contributing to posttraumatic infection as part of a double-blinded prospective randomized trial. These factors include number of transfusions, OR time, shock, the number of organs injured, and a number of different injury severity scores. I would like to ask the authors a number of questions. First of all, I consider cefoxitin, or single-agent therapy, as the standard, and I think a lot of trauma surgeons around the country do, so I wonder if you could comment on the cost of combination therapy vs single-agent therapy in management of trauma patients.
The second issue is that there are a number of recent studies, Patch probably publishing the first, and Fabian and Kudsk, a more recent study, advocating a single-day, 24-hour antibiotic coverage vs prolonged therapy, even for colon injuries, and showing no significant difference with a shorter course of therapy. And so I would like to ask the authors to justify their prolonged use, and as a tail to that question, to perhaps comment on infections that they saw in the colon-injured patients, what kind of organisms they saw, resistance patterns, and so on, with prolonged antibiotic use.
The study compared ciprofloxacin with gentamicin, and I know there are a number of reasons why I don't like using gentamicin. The pharmacodynamics and pharmacokinetic studies are costly. There is the risk of toxicity; recently I saw in the JAMA a description of vestibular toxic effects. So could you comment on the risk of aminoglycoside use in these patients?
Finally, I for a long time viewed with interest the studies documenting the risk of infection associated with large blood transfusions, but I have never known how to use that information. In mortally injured trauma patients, you have got to give them blood. I wonder if you could comment on how you recommend us to interpret it. Is this a marker, do you watch these patients more closely, or how do you use that information?
Finally, I would like to thank the Society for the opportunity of reviewing this paper.
Dr Tyburski: I would agree with you that a lot of us use single-agent therapy. This study was designed, I think, and again, to quote President Dellinger, there were 2 aspects of the study. The people who produced the drug were trying to get an indication for ciprofloxacin, I think, and we were trying to look at gentamicin dosing and see what other factors would associate with infection.
I would agree a lot of us do use single-agent therapy. I am going to skip down to your third question, the use of gentamicin. If you remember the data presented just a day ago gave a nephrotoxicity rate with gentamicin of 12% to 14%. The average age in that study, if I recall, was around 60 or 62 years of age. The average age here was 30 years. I think in this trauma population the use of gentamicin is exceedingly safe. We know of very little nephrotoxicity in this population. There were 3 mortalities that were over 24 hours; 2 of them did get gentamicin. One who died at 12 days had some renal [problems] throughout that you could maybe extrapolate to the use of gentamicin. The other 2 died long after their gentamicin dosings were over; they died of late sepsis 30 days out. So we didn't see this nephrotoxicity in this population. This is very high GFR, high volume of distribution, basically street-warrior type of a population we are seeing.
I am glad you brought up the length of coverage. Within our own group there is a large debate over how long people should keep people on antibiotics. It seems to be age-specific, not to the patient, actually the prescriber is what I was just referring to. And it seems the people who have been on the service longer like to put patients on longer doses of antibiotics. This is how this protocol was set up. However, it is routine now in our group not to try to allow antibiotics to go longer than 24 to 48 hours at the most in these trauma patients. We did try to stratify that a little bit. If there was no hollow organ injury, we tried to give them only 1 dose.
A comment on the use of transfusion, we agree, there is not a lot you can do. Stop the bleeding, I guess, is my best advice. We do watch them more closely. We have looked at end-tidal CO2 use in these patients, we have looked at the transfusions, we have looked at their pulmonary vascular resistance, and we do alert ourselves to a higher incidence of infections and mortalities with those patients.
Dietmar H. Wittmann, MD, PhD, Milwaukee, Wis: I have 2 points to make. You did pharmacokinetics on aminoglycosides. My question is why didn't you do it on ciprofloxacin and metronidazole also? If you would have done it on metronidazole, for example, you would have found that metronidazole has an elimination half-life of about 8 hours, which would enable you to give the drug every 24 hours, just like ceftriaxone, for example.
The second point is, you were using antimicrobials in trauma patients. Trauma implies tissue injury, tissue injury implies acidotics as an environment, and aminoglycosides don't work well in an acid environment. Maybe in that group for the aminoglycosides you didn't need any of the aminoglycosides at all.
Dr Tyburski: It is true, Dr Wittmann, we did not look at the levels of either ciprofloxacin or metronidazole. The previous work that had been done that we were part of did look at some of the levels of metronidazole. We didn't find that a significant contribution. Some people have even suggested that the dosage of ciprofloxacin we used was a little bit high. Those are data that are not presented here. We were looking specifically at gentamicin. And as we well know, it is expensive to get levels on these drugs. I think those data would have been valuable additions to the paper, and I think it would have reinforced the increased volume of distribution and increased renal clearance of these drugs in these young trauma populations.
We didn't show the acid-base data here, but hopefully the patients, at least systemically, weren't underresuscitated. Again, we tried to use many markers of that and tried to get them out of an acid environment. But I do think, and I will state again that I do think that the gentamicin in this population, it is a cheap drug, and it seems to be relatively safe, at least in this young, rather healthy, hyperdynamic population.
Charles H. Cook, MD, Columbus, Ohio: I was intrigued by the incidence of Candida infection in the ciprofloxacin treatment group. I wondered if you did a Fisher exact or χ2 to determine whether it was statistically different from the gentamicin treatment group, and if so, or not, how you might explain that finding.
Dr Tyburski: We did look at the statistical significance of that, and it was just barely missed. It was a P value of .09 or something like that. I am not sure what to make of that. In other words, it is a little bit unusual. Most of those patients had perforation of the abdominal viscera, and perhaps with these high-dose antibiotics we did select out, fungus; maybe ciprofloxacin was better at selecting out fungus, but it is pure speculation. The numbers were too small to make any real conclusions on any of the data. We were looking to see if because ciprofloxacin has better gram-positive coverage than gentamicin that we would have had more gram-positive infections with the gentamicin. That wasn't true. Except for that 1 point that was not statistically significant, there was very little I could make out of the microbiological data.
E. Patchen Dellinger, MD, Seattle, Wash: Could I just comment that if you could get your superannuated surgeons to feel confident, a single dose of gentamicin, 7 mg/kg or maybe just 500 mg across the board and a single dose of 1 g of metronidazole would take care of all of your patients very cheaply, very effectively, and very safely.
Dr Tyburski: Our common clinical practice now is to give a single 7 mg/kg dose of gentamicin. We had a hard time getting this through the IRB because it was quite a change at the time in the dosing, but we do routinely use single-dosing antibiotics now.
This study was sponsored in part by an educational grant from Bayer Corporation, West Haven, Conn, manufacturer of ciprofloxacin.
Presented at the 18th Annual Meeting of Surgical Infection Society, New York, NY, May 1, 1998.
Reprints: James G. Tyburski, MD, Department of Surgery, Detroit Receiving Hospital, 4201 St Antoine, Detroit, MI 48201.


text:
ARJ Holding-@ IDEX 19th – 23rd 2017
- 22/02/2017
- Posted by: ARJ IT Desk
- Categories: Exhibition, Funding, Innovation, International, New Business, New product, News
ARJ Holding at IDEX 2017
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Well done ARJ ????
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