Policy and public communication methods among U.S. state prisons during the first year of the COVID-19 pandemic.

BACKGROUND: Throughout the first year of the COVID-19 pandemic, our research team monitored and documented policy changes in United States (U.S.) prison systems. Data sources included prison websites and official prison social media accounts. Over 2500 data sources relevant to the COVID-19 pandemic in U.S. prisons were located and summarized in to five different categories: 1) prevention, 2) case identification and intervention, 3) movement, 4) social communication and connection, and 5) programming, recreation, and privileges. RESULTS: All state prison systems reportedly enacted multiple policies intended to limit the spread of COVID-19 during the pandemic. Document analysis revealed that the most commonly released policies were restrictions on social contacts and privileges, basic preventive measures (e.g., distribution of masks), and basic case identification measures (e.g., verbal screening and temperature checks). Utilization of social media for policy communication varied significantly across states, though relevant data was more often released on Facebook than Twitter. CONCLUSIONS: Together, our work provides foundational knowledge on the wide breadth of policies that were reportedly enacted in the first year of the pandemic that may be used as a base for quantitative work on policy effectiveness and examinations of implementation.

Acute liver failure following minocycline treatment - a case report and review of the literature.

We present the case of a 23-year-old female patient with acute liver failure following intake of minocycline. This patient had severe hypereosinophilia and massively increased IgE levels. Experimental studies in this case revealed elevated IFN-γ-, as well as TNF-α-producing CD4+ and CD8+ T-cells after in vitro stimulation with minocycline, indicating a type I/IgE-mediated as well as type II/cytotoxic reaction in the pathogenesis of minocycline-induced liver failure. Although mild forms of liver involvement are well known side effects of minocycline, only 8 cases with acute liver failure have been reported, and we present a review of all cases.

The epidermal Ca(2+) gradient: Measurement using the phasor representation of fluorescent lifetime imaging.

Ionic gradients are found across a variety of tissues and organs. In this report, we apply the phasor representation of fluorescence lifetime imaging data to the quantitative study of ionic concentrations in tissues, overcoming technical problems of tissue thickness, concentration artifacts of ion-sensitive dyes, and calibration across inhomogeneous tissue. We used epidermis as a model system, as Ca(2+) gradients in this organ have been shown previously to control essential biologic processes of differentiation and formation of the epidermal permeability barrier. The approach described here allowed much better localization of Ca(2+) stores than those used in previous studies, and revealed that the bulk of free Ca(2+) measured in the epidermis comes from intracellular Ca(2+) stores such as the Golgi and the endoplasmic reticulum, with extracellular Ca(2+) making a relatively small contribution to the epidermal Ca(2+) gradient. Due to the high spatial resolution of two-photon microscopy, we were able to measure a marked heterogeneity in average calcium concentrations from cell to cell in the basal keratinocytes. This finding, not reported in previous studies, calls into question the long-held hypothesis that keratinocytes increase intracellular Ca(2+), cease proliferation, and differentiate passively in response to changes in extracellular Ca(2+). The experimental results obtained using this approach illustrate the power of the experimental and analytical techniques outlined in this report. Our approach can be used in mechanistic studies to address the formation, maintenance, and function of the epidermal Ca(2+) gradient, and it should be broadly applicable to the study of other tissues with ionic gradients.

[Acral necrosis in metastatic ovarian carcinoma. A single episode of Moschowitz syndrome during gemcitabine chemotherapy]. / Akrale Nekrosen bei metastasiertem Ovarialkarzinom. Ausdruck eines singulären Moschkowitz-Syndroms unter Gemcitabin-Chemotherapie.

For some time now, there have been reports of acral necrosis as a paraneoplasia that may occur in association with a number of different malignant tumours. There have also been a series of reports about acral necrosis associated with chemotherapy with various cytostatics. The treatment of choice if these lesions occur is plasmapheresis. Ultimately, the occurrence of thrombotic microangiopathy (TMA) can only be prevented by close monitoring through regular laboratory controls before each new cycle of chemotherapy. In the differential diagnosis, Raynaud's syndrome should be considered as a premonitory paraneoplasia, a risk factor for the occurrence of acral necrosis in patients with a malignant tumour undergoing chemotherapy, particularly patients with ovarian carcinoma receiving gemcitabine treatment.

Caffeine improves barrier function in male skin.

The influence of androgens, especially testosterone and its effector dihydrotestosterone, results in a constitutive disadvantage for male skin, e.g. reduced viability of hair at the scalp and reduced epidermal permeability barrier repair capacity. Dihydrotestosterone can act, among others, as an adenyl cyclase inhibitor. Caffeine on the other hand is an inexpensive and (in regular doses) harmless substance used in various cosmetic products, which can act as a phosphodiesterase inhibitor. To prove the hypothesis that caffeine as a phosphodiesterase inhibitor is able to override testosterone-induced effects on barrier function, we performed a double-blind placebo controlled study with healthy volunteers. In this study, 0.5% caffeine in a hydroxyethylcellulose gel preparation (HEC) was applied on one forearm, HEC without caffeine on the other forearm of male and female volunteers for 7 days and transepidermal water loss (TEWL) was measured before and at the end of the treatment period. Basal TEWL did not differ significantly between male and female subjects but the application of caffeine significantly reduced TEWL in male skin compared with female skin. We conclude that caffeine is beneficial for barrier function in male skin.

Extracellular pH Controls NHE1 expression in epidermis and keratinocytes: implications for barrier repair.

We have previously shown that the Na+/H+ antiporter (NHE1) is an essential endogenous pathway responsible for stratum corneum (SC) acidification. Since the epidermis must re-establish its epidermal barrier after acute barrier perturbations, we asked whether the NHE1 was, in turn, regulated by changes in barrier status. We found that in vivo epidermal NHE1 expression was upregulated within hours of barrier disruption. We next asked whether NHE1 was regulated by barrier status per se, or by the SC alkalinization that accompanies barrier perturbation. NHE1 was upregulated by alkalinizing SC pH, whereas this antiporter was downregulated by acidifying SC pH, independent of changes in barrier status. Moreover, acidifying SC pH overrode the effects of barrier break in regulating NHE1 expression, suggesting that SC alkalinization is the major stimulus for increased NHE1 expression. Finally, we confirmed that the keratinocyte NHE1 antiporter is regulated by extracellular pH independent of barrier status, by demonstrating that NHE1 was upregulated in cultured keratinocytes exposed to pH 8.3 medium and downregulated in cultured keratinocytes exposed to pH 6.3 medium. These data suggest that the keratinocyte NHE1 is regulated by extracellular pH. SC barrier break also upregulates NHE1 expression, but this response seems to be mediated by concomitant changes in SC pH.

The ENaC channel is required for normal epidermal differentiation.

Ionic fluxes are important for critical aspects of keratinocyte differentiation, including synthesis of differentiation-specific proteins, enzymatic catalysis of protein cross-linking, post-transcriptional processing of profilaggrin, and lipid secretion. The epithelial sodium channel is expressed in epidermis and the expression of its alpha and beta subunits is enhanced as keratinocytes differentiate. In order to ascertain the role of the epithelial sodium channel in epidermal differentiation, we examined skin of mice in which the epithelial sodium channel alpha subunit had been deleted. Newborn -/- mice, in which the alpha subunit had been completely inactivated, demonstrated epithelial hyperplasia, abnormal nuclei, premature secretion of lipids, and abnormal keratohyaline granules. In addition, immunohistochemistry demonstrated that expression of the differentiation markers K1, K6, and involucrin were abnormal. These data suggest that the epithelial sodium channel modulates ionic signaling for specific aspects of epidermal differentiation, such as synthesis or processing of differentiation- specific proteins, and lipid secretion.

Vitamin C stimulates sphingolipid production and markers of barrier formation in submerged human keratinocyte cultures.

Human keratinocytes differentiate in vitro in response to a variety of stimuli, but neither the levels nor the spectrum of ceramides approach those seen in vivo. Ceramide production increases when human keratinocytes are grown at an air-liquid interface, and alterations in ceramide content occur when vitamin C is added to air-exposed, organotypic culture systems (Ponec et al. J Invest Dermatol 109:348, 1997). Here, we assessed whether vitamin C stimulates sphingolipid production in human keratinocytes independent of differentiation and air exposure. When submerged, human keratinocytes were grown in 1.2 mM calcium and serum-containing medium with vitamin C (50 microg per ml) for 9 d, total lipid content remained unchanged, but both glucosylceramide and ceramide content increased. Moreover, selected ceramide and glucosylceramide species: i.e., nonhydroxy ceramide 2 and both alpha- and omega-hydroxylated sphingolipids, increased preferentially [ceramide 4 (6-hydroxy-acylceramide), ceramide 5 (alpha-hydroxyceramide), ceramide 6 (4-hydroxy-alpha-hydroxyceramide), and ceramide 7 (6-hydroxy-alpha-hydroxyceramide); and acylglucosylceramide, glucosylceramide-B, and glucosylceramide-D], whereas ceramide 1, ceramide 3, glucosylceramide-C, and sphingomyelin remained unchanged. Synthesis of the corresponding ceramide and glucosylceramide fractions was enhanced by vitamin C, attributable, in part, to increased ceramide synthase activity (over 2-fold, p = 0.01); both serine palmitoyltransferase and glucosylceramide synthase activities remained unaltered. Finally, increased vitamin C-stimulated sphingolipid production correlated with the presence of lamellar bodies with mature internal contents, an increase in covalently bound omega-hydroxyceramide, and the appearance of prominent, corneocyte-bound lipid envelopes, whereas cornified envelope formation was unchanged. Thus, in submerged human keratinocytes, vitamin C induces both increased sphingolipid production and enhancement of permeability barrier structural markers.

[Postoperative pain therapy in pediatrics. Results of a representative survey in Germany]. / Postoperative Schmerztherapie im Kindesalter. Ergebnisse einer repräsentativen Umfrage in Deutschland.

The last survey addressing postoperative pain management in Germany was published in 1987, special data concerning postoperative pain management in pediatric patients had not been presented previously. The goal of this survey is to present the standard of postoperative pain management in pediatric patients in Germany. A detailed questionnaire was mailed to all German anaesthesia departments and interdisciplinary intensive care units (n = 1,500) to determine the current management of postoperative pain management in pediatric patients. After eight weeks, 42.6% of the survey had been returned. Rectally administered acetaminophen is the standard drug regimen for postoperative analgesia in children. Compared to previous surveys, the use of opioids has increased in popularity. The routine use of non-steroid antiinflammatory drugs (NSAIDs) and spasmolytics as well as the application of regional anaesthesia techniques is uncommon in pediatric postoperative pain management. Compared to other European countries, patient- or parent-controlled analgesia is more popular in Germany. Despite modern concepts of organization and a great variety of drugs available today, 71.1% of the responding anesthesiologists in this survey still believe that pediatric postoperative pain management needs to be improved.

Prophylactically-administered rectal acetaminophen does not reduce postoperative opioid requirements in infants and small children undergoing elective cleft palate repair.

UNLABELLED: Rectal acetaminophen (Ac) is often administered prophylactically at anesthesia induction for postoperative pain management in small children and is thought to have an opioid-sparing effect. We assessed in this double-blinded, prospective, randomized study early opioid requirements after three doses of Ac (10, 20, and 40 mg/kg versus placebo) in 80 children (ASA physical status I, age 11.4 +/- 9.9 mo) undergoing cleft palate repair. Single Ac plasma concentrations were measured. Pain scores assessed in the postanesthesia care unit of > or = 4 of 10 resulted in the IV administration of 25 microg/kg piritramide, a popular European mu receptor agonist (lockout time, 10 min; maximum 0.125 mg/kg). There were no significant differences between groups with regard to the early postoperative pain scores and the overall cumulative IV opioid requirements. Maximal plasma concentrations achieved were only subtherapeutic (Ac 10 mg/kg: 8 microg/mL; Ac 20 mg/kg: 13 microg/mL; Ac 40 mg/kg: 21 microg/mL after 122, 122, and 121 min, respectively). We conclude that rectal Ac up to 40 mg/kg has no opioid-sparing effect, does not result in analgesic Ac plasma concentrations, and lacks proof of its efficacy in infants and small children undergoing cleft palate repair, whereas titrated IV opioid boluses produced rapid and reliable pain relief. IMPLICATIONS: Acetaminophen is widely used prophylactically for postoperative analgesia in children and is thought to have an opioid-sparing effect. We showed that rectal acetaminophen up to 40 mg/kg administered at anesthesia induction lacked proof of efficacy, whereas IV opioid boluses resulted in reliable pain relief in children undergoing cleft palate repair.

Pharmacodynamics and tolerability of acetyl starch as a new plasma volume expander in patients undergoing elective surgery.

OBJECTIVE: Acetyl starch (ACS) is a new synthetic colloid solution for plasma volume expansion and is now undergoing phase II clinical trials. We compared the pharmacodynamics and tolerability of ACS with those ofhydroxyethyl starch (HES) in 32 patients (American Society of Anesthesiologists physical status I and II) undergoing elective surgery. SUBJECTS, MATERIAL AND METHODS: In this prospective, randomized, double-blind trial patients received either 15 ml/kg ACS 6% (average molecular weight (Mw) 200,000/molar substitution (MS) 0.5) or HES 6% (Mw 200,000/MS 0.5) i.v. up to a maximum dose of 1000 ml. Hemodynamic parameters, rheologic parameters, volume effect, acid-base status as well as effects on hemostasis were studied. RESULTS: After infusion of ACS and HES there was a similar increase in central venous pressure and mean arterial pressure in both groups. Acid-base status was not significantly altered after the end of the colloid infusions. After ACS infusion, plasma acetate concentration increased from 0.13+/-0.16 mg/dl to 2.87+/-1.13 mg/dl, however, after 24 h there was no significant difference in plasma acetate concentration compared to HES. The volume effect ranged from 104-116%(ACS) and from 88-118% (HES) of the colloid dose administered. These differences were not statistically significant. Partial thromboplastin time (aPTT) was only slightly increased after ACS infusion (from 38.6+/-5.7 sec to 41.4+/-5.1 sec), but was significantly increased after HES infusion (from 38.7+/-5.7 sec to 46.1+/-7.0 sec). CONCLUSION: ACS and HES are equally effective plasma volume expanders; ACS might be a new, alternative colloid solution with fewer coagulation side-effects than HES.

[The use of lithium hydroxide for carbon dioxide absorption prevents formation of compound A during sevoflurane anesthesia]. / Die Anwendung von Lithiumhydroxid als Kohlendioxidabsorbens verhindert das Entstehen von Compound A während Sevoflurananästhesie.

UNLABELLED: Aim of the study was the clinical investigation of sevoflurane degradation when using water-free lithiumhydroxide versus moist Drägersorb 800 for carbon dioxide absorption. METHODS: Concentrations of Compound A in the inspiratory gas mix and serum fluoride levels were measured in two groups of 8 patients each. RESULTS: When water-free lithiumhydroxide was used for carbon dioxide absorption, concentration of Compound A in the inspiratory gas mix was ca. 1 ppm (near minimal level of detection) as compared to ca. 20 ppm for moist Drägersorb 800. The concentration of fluoride increased during sevoflurane anesthesia (15.0 +/- 4.8 mumol/l with lithiumhydroxide versus 21.9 +/- 4.0 mumol/l with Drägersorb 800 after 60 mins). CONCLUSIONS: When lithiumhydroxide is used, there is only minimal formation of compound A from sevoflurane degradation. Since serum fluoride levels increased in both patient groups, we conclude that this is caused mainly by metabolism of sevoflurane. Capacity of lithiumhydroxide for carbon dioxide absorption is similar to that of Drägersorb 800. Therefore, the use of lithiumhydroxide increases patient safety.

Omega-hydroxyceramides are required for corneocyte lipid envelope (CLE) formation and normal epidermal permeability barrier function.

Omega-hydroxyceramides (omega-OHCer) are the predominant lipid species of the corneocyte lipid envelope in the epidermis. Moreover, their omega-esterified-derivatives (acylCer) are major components of the stratum corneum extracellular lamellae, which regulate cutaneous permeability barrier function. Because epidermal omega-OHCer appear to be generated by a cytochrome P450-dependent process, we determined the effects of a mechanism-based inhibitor of omega-hydroxylation, aminobenzotriazole (ABT), on epidermal omega-OH Cer formation and barrier function. We first ascertained that ABT, but not hydroxybenzotriazole (OHBT), a chemical relative with no P450 inhibitory activity, inhibited the incorporation of [14C]-acetate into the omega-OH-containing Cer species in cultured human keratinocytes (68.1% +/- 6.9% inhibition versus vehicle-treated controls; p < 0.001), without altering the synthesis of other Cer and fatty acid species. In addition, ABT significantly inhibited the omega-hydroxylation of very long-chain fatty acids in cultured human keratinocytes. Topical application of ABT, but not OHBT, when applied to the skin of hairless mice following acute barrier disruption by tape-stripping, resulted in a significant delay in barrier recovery (e.g., 38.3% delay at 6 h versus vehicle-treated animals), assessed as increased transepidermal water loss. The ABT-induced barrier abnormality was associated with: (i) a significant decrease in the quantities of omega-OHCer in both the unbound and the covalently bound Cer pools; (ii) marked alterations of lamellar body structure and contents; and (iii) abnormal stratum corneum extracellular lamellar membrane structures, with no signs of cellular toxicity. Furthermore, pyridine-extraction of ABT- versus vehicle-treated skin, which removes all of the extracellular lamellae, leaving the covalently attached lipids, showed numerous foci with absent corneocyte lipid envelope in ABT- versus vehicle-treated stratum corneum. These results provide the first direct evidence for the importance of omega-OHCer for epidermal permeability function, and suggest further that acylCer and/or corneocyte lipid envelope are required elements in permeability barrier homeostasis.

Recovery and pharmacokinetic parameters of desflurane, sevoflurane, and isoflurane in patients undergoing urologic procedures.

STUDY OBJECTIVE: To compare the pharmacokinetics and the speed of recovery after inhalation anesthesia with desflurane, sevoflurane, and isoflurane in elective surgery. DESIGN: Prospective, randomized study. SETTING: University medical center. PATIENTS: 30 ASA physical status I and II adults presenting for elective surgery. INTERVENTIONS: Anesthesia was induced with etomidate and maintained with desflurane (n = 10), sevoflurane (n = 10), or isoflurane (n = 10) and nitrous oxide. The inhalation drugs were titrated until an adequate clinical depth of anesthesia was reached. At the end of anesthesia, the patients breathed oxygen via the endotracheal tube and after extubation via a face mask. MEASUREMENTS AND MAIN RESULTS: The groups were similar with respect to age, weight, duration of anesthesia, and mean arterial pressure. Mean end-tidal concentration (FA = FA0) at the end of anesthesia was 6.34 +/- 1.15% after desflurane, 1.85 +/- 0.42% after sevoflurane, and 1.10 +/- 0.24% after isoflurane. FA/FA0 decreased significantly faster with desflurane than with isoflurane, while there was little difference between desflurane and sevoflurane. As for the terminal half-life (t1/2), there were no differences among the groups (8.16 +/- 3.15 min after desflurane, 9.47 +/- 4.46 min after sevoflurane, and 10.0 +/- 5.57 min after isoflurane). The time until a command was followed for the first time was the same in all three groups (13.0 +/- 4.7 min after desflurane, 13.4 +/- 4.4 min after sevoflurane, and 13.6 +/- 3.4 min after isoflurane). There was no significant correlation between duration of anesthesia and the time until recovery. CONCLUSIONS: There are only minor differences with regard to the recovery phase in premedicated patients who receive clinically titrated inhalation anesthesia with desflurane, sevoflurane, or isoflurane.

[Infection or SIRS--the problem of definition]. / Sepsis oder SIRS--das Problem der Definition.

Despite the knowledge about sepsis for many years, the definition of sepsis is contested more than ever since the early 90th. Therefore, the comparability of many clinical investigations and scientific work in the past is still impaired. To define the entrance criteria for further clinical studies, in 1991 a consensus conference was held in the USA, but its recommendations have not found unequivocal acceptance. Therefore, these recommendations are presented and their meaning will be discussed.

Clinical pharmacokinetics of sevoflurane.

Sevoflurane is a comparatively recent addition to the range of inhalational anaesthetics which has been recently released for clinical use. In comparison to older inhalational agents such as isoflurane or halothane, the most important property of sevoflurane is its low solubility in the blood. This results in a more rapid uptake and induction than the 'older' inhalational agents, improved control of depth of anaesthesia and faster elimination and recovery. The more rapid pharmacokinetics are a result of the low blood/gas partition coefficient of 0.69. With an oil/gas partition coefficient of 47.2, the minimum alveolar concentration (MAC) of sevoflurane is 2.05%. Two to 5% of the drug taken up is metabolised by the liver. The pharmacokinetics of sevoflurane do not change in children, obese patients or patients with renal insufficiency. The pharmacokinetics and pleasant odour of sevoflurane make mask induction feasible, which is an obvious advantage in paediatric anaesthesia. The hepatic metabolism of sevoflurane results in the formation of inorganic fluoride. Upon contact with alkaline CO2 absorbent, a small amount of sevoflurane is degraded and a metabolite (compound A) is formed and inhaled in trace amounts. Whether inorganic fluoride or compound A are nephrotoxic is presently a matter of controversy.

[Ketoacidosis in a 14 month old child caused by fasting]. / Fasteninduzierte Ketoazidose bei einem 14 Monate alten Kleinkind.

Preoperative starvation in order to prevent pulmonary aspiration is mandatory in elective pediatric surgery. Hypoglycemia, thirst and unwellness have been reported as undesired side effects. The metabolic response towards decreasing blood-glucose concentrations in fasting children includes gluconeogenesis and production of ketone bodies to meet the energetic demand. Accumulation of beta-hydroxybutyrate und acetoacetate in blood can lead to ketoacidosis. We report a case of a severe intraoperative ketoacidosis in a fourteen months old child complicating 36 hours of starvation.

Carbon dioxide absorption: toxicity from sevoflurane and desflurane.

The degradation of volatile anaesthetics by desiccated carbon dioxide absorbents can result in adverse outcomes. Desiccated carbon dioxide absorbent reacting with desflurane can cause potentially life-threatening intraoperative carbon monoxide exposure; the reaction with sevoflurane can cause the formation of several toxic breakdown products, e.g. compound A. Compound A-related renal toxicity in humans is still a matter of controversy.

Thoracoscopic microsurgical technique for vertebral surgery--anesthetic considerations.

BACKGROUND: The thoracoscopic microsurgical technique (TMT) for vertebral and spinal cord surgery is associated with the benefits of reduced postoperative pain, accelerated return to physical activity and reduced complication rates. However, because of the surgeon's requirement of a non-ventilated lung, it confronts the anesthesiologist with the need for extremely long duration of single-lung ventilation (SLV). METHODS: We describe our experiences with 82 patients, whom we anesthetised from 1993 until 1996 for TMT. Because of the potential risk of depression of hypoxic pulmonary vasoconstriction during SLV by volatile anesthetics, we primarily used a total intravenous technique (55 patients). With more experience, we also used a combination of volatile and intravenous anesthetics (16 patients) and, finally, volatile anesthetics only (11 patients). Data from patients anesthetised for TMT were compared with data from 22 patients operated with open thoracotomy from 1984 until 1992. RESULTS: While the operating time (290.1 +/- 133.2 min for TMT vs. 312.3 +/- 113.6 for thoracotomy) and the anesthesia time (431.2 +/- 140.3 for TMT vs. 416.4 +/- 102.1 for thoracotomy) showed no significant differences, the TMT required an extremely long time of SLV (270.2 +/- 133.2 min) to gain access to the spine using left-sided double-lumen tubes. While the oxygenation index (PaO2/FiO2), as a marker for pulmonary oxygenation capacity, decreased significantly after initiation of SLV for TMT, it was markedly enhanced with increasing duration (270.2 +/- 133.2 min) of SLV. Oxygenation index showed no significant difference when comparing the different anesthetic techniques for TMT. CONCLUSION: We conclude that despite the long duration of SLV, TMT is a reasonable alternative to open thoracotomy for thoracic neurosurgical spine procedures because of the substantial clinical benefits of accelerated return to physical activity, reduced complication rates and reduced intensive care unit and hospital stay.