Determinants of survival in sudden cardiac arrest manifesting with pulseless electrical activity.

OBJECTIVE: The proportion of sudden cardiac arrests (SCA) manifesting with pulseless electrical activity (PEA) has increased significantly, and the survival rate remains lower than ventricular fibrillation (VF). However, a subgroup of PEA-SCA cases does survive and may yield key predictors of improved outcomes when compared to non-survivors. We aimed to identify key predictors of survival from PEA-SCA. METHODS: Our study sample is drawn from two ongoing community-based, prospective studies of out-of-hospital SCA: Oregon SUDS from the Portland, OR metro area (Pop. approx. 1 million; 2002-2017) and Ventura PRESTO from Ventura County, CA (Pop. approx. 850,000, 2015-2021). For the present sub-study, we included SCA cases with PEA as the presenting rhythm where emergency medical services (EMS) personnel attempted resuscitation. RESULTS: We identified 1,704 PEA-SCA cases, of which 173 (10.2%) were survivors and 1,531 (89.8%) non-survivors. Patients whose PEA-SCA occurred in a healthcare unit (16.9%) or public location (18.1%) had higher survival than those whose PEA-SCA occurred at home (9.3%) or in a care facility (5.7%). Young age, witness status, PEA-SCA location and pre-existing COPD/asthma were independent predictors of survival. Among witnessed cases the survival rate was 10% even if EMS response time was >10 minutes. CONCLUSIONS: Key determinants for survival from PEA-SCA were young age, witnessed status, public location and pre-existing COPD/asthma. Survival outcomes in witnessed PEA cases were better than expected, even with delayed EMS response.

PHEOCHROMOCYTOMA, THE GREAT MASQUERADER, PRESENTING AS REVERSIBLE CARDIOMYOPATHY: PRIMUM NON NOCERE.

Background: Pheochromocytoma, the great masquerader, can have a varied spectrum of clinical manifestations. It can often cause a diagnostic challenge despite the availability of modern investigation modalities. Case: We present the case of a 38-year-old male who presented with uncontrolled hypertension for the past 10 years and heart failure for one year. The diagnosis of pheochromocytoma was missed in the initial setting, leading to a biopsy of the retroperitoneal mass. Fortunately, the patient survived the procedure. Subsequently, with the involvement of a multi-disciplinary team, he was optimized for surgery under strict cardiac monitoring. After the complete excision of the tumour, he showed significant improvement not only in his clinical symptoms but also in his cardiac status. Conclusions: This case emphasizes the age-old medical phrase of 'Primum non nocere or first, do no harm'. Any invasive procedure in a pheochromocytoma can lead to a massive release of catecholamines causing a hypertensive crisis, pulmonary oedema, and even cardiac arrest. Any young patient presenting with hypertension or heart failure should be investigated for secondary causes. Cardiomyopathy due to pheochromocytoma is because of catecholamine overload and usually reverses or improves after curative surgery.

Dissociable dopaminergic and pavlovian influences in goal-trackers and sign-trackers on a model of compulsive checking in OCD.

RATIONALE: Checking is a functional behaviour that provides information to guide behaviour. However, in obsessive-compulsive disorder (OCD), checking may escalate to dysfunctional levels. The processes underpinning the transition from functional to dysfunctional checking are unclear but may be associated with individual differences that support the development of maladaptive behaviour. We examined one such predisposition, sign-tracking to a pavlovian conditioned stimulus, which we previously found associated with dysfunctional checking. How sign-tracking interacts with another treatment with emerging translational validity for OCD-like checking, chronic administration of the dopamine D2 receptor agonist quinpirole, is unknown. OBJECTIVES: We tested how functional and dysfunctional checking in the rat observing response task (ORT) was affected by chronic quinpirole administration in non-autoshaped controls and autoshaped animals classified as sign-trackers or goal-trackers. METHODS: Sign-trackers or goal-trackers were trained on the ORT before the effects of chronic quinpirole administration on checking were assessed. Subsequently, the effects on checking of different behavioural challenges, including reward omission and the use of unpredictable reinforcement schedules, were tested. RESULTS: Prior autoshaping increased checking. Sign-trackers and goal-trackers responded differently to quinpirole sensitization, reward omission and reinforcement uncertainty. Sign-trackers showed greater elevations in dysfunctional checking, particularly during uncertainty. By contrast, goal-trackers predominantly increased functional checking responses, possibly in response to reduced discrimination accuracy in the absence of cues signalling which lever was currently active. CONCLUSIONS: The results are discussed in terms of how pavlovian associations influence behaviour that becomes compulsive in OCD and how this may be dependent on striatal dopamine D2 receptors.

An observational study of the efficacy of azithromycin in erythema annulare centrifugum.

Erythema annulare centrifugum (EAC) is a form of figurate erythema consequent to a cutaneous hypersensitivity reaction to an underlying agent. In the present study, we aimed to assess the role of oral azithromycin in cases of idiopathic EAC. We performed an open trial of azithromycin in 10 patients with idiopathic EAC. Histopathological examination of biopsies was performed to exclude any alternative diagnosis and to assess the depth of the infiltrate. Patients were administered oral azithromycin 250 mg once daily until clinical resolution of the disease, and followed up regularly to monitor for possible relapse. Histopathological examination of the 10 biopsies revealed superficial pattern in 3, deep pattern in 2 and mixed pattern in the remaining 5. Of the 10 patients, 8 responded to azithromycin 250 mg, with no relapse during follow-up. Oral azithromycin might be a promising therapy in cases of idiopathic EAC. Cases with a superficial pattern respond earlier than cases with a deep pattern.

Transfer-free multi-layer graphene as a diffusion barrier.

Graphene is a promising ultra-thin barrier against undesired mass transport, however, the high deposition temperatures or the defect inducing post-deposition transfer processes limit its widespread applicability. Herein we report on the successful blocking of copper (Cu) ion diffusion by large area multi-layer graphene (MLG) membranes deposited directly on silicon oxide (SiO2) via low temperature plasma-enhanced chemical vapor deposition. The barrier strength of MLG is compared to evaporated tantalum (Ta) by applying positive bias-temperature stress (BTS) to Cu/barrier/SiO2/Si test structures. After constant BTS of 4 × 106 V cm-1 at 400 K for 50 min, the MLG barrier device exhibits a negligible flat band voltage shift in capacitance-voltage measurements and no discernible current peak in triangular voltage scans, whereas the Ta barrier allows significant Cu ion transport. Highly limited Cu ion diffusion through MLG suggests that lower energy diffusion paths, like grain boundaries and defects of individual graphene layers, do not align in the direction of an applied stress field. In general, the presented low-temperature direct growth MLG membranes can block undesirable diffusion in many applications, and are especially suitable as Cu diffusion barriers in integrated circuit chips, photovoltaic cells and flexible electronic devices.

Outcomes of combined tibial tuberosity transfer and medial patellofemoral ligament reconstruction for recurrent patellar instability.

Patellofemoral instability is multifactorial and is associated with pathomechanics secondary to anatomical variance. Surgical management of this problem must be tailored to each patient and a thorough clinical and radiological assessment of the anatomical alignment should be carried out pre-operatively. The aim of this study is to assess the role of medial patellofemoral ligament reconstruction combined with tibial tuberosity transfer in patients with increased tibial tuberosity to trochlear groove (TT-TG) distance. Twenty-four patients (27 knees) over 2-years were operated on by a single surgeon, with standardised post-operative rehabilitation and follow up. Mean follow up was 31-months. Two patients had problems with recurrent instability, 1 had a -traumatic re-dislocation at 2 years and a total of 4 required further operation for complications. Mean post--operative Kujala scores were 87.4 (SD 9.8). Combined medial patellofemoral ligament reconstruction and tibial tuberosity transfer is an appropriate treatment for patients with increased TT-TG distance.

Variola virus F1L is a Bcl-2-like protein that unlike its vaccinia virus counterpart inhibits apoptosis independent of Bim.

Subversion of host cell apoptosis is an important survival strategy for viruses to ensure their own proliferation and survival. Certain viruses express proteins homologous in sequence, structure and function to mammalian pro-survival B-cell lymphoma 2 (Bcl-2) proteins, which prevent rapid clearance of infected host cells. In vaccinia virus (VV), the virulence factor F1L was shown to be a potent inhibitor of apoptosis that functions primarily be engaging pro-apoptotic Bim. Variola virus (VAR), the causative agent of smallpox, harbors a homolog of F1L of unknown function. We show that VAR F1L is a potent inhibitor of apoptosis, and unlike all other characterized anti-apoptotic Bcl-2 family members lacks affinity for the Bim Bcl-2 homology 3 (BH3) domain. Instead, VAR F1L engages Bid BH3 as well as Bak and Bax BH3 domains. Unlike its VV homolog, variola F1L only protects against Bax-mediated apoptosis in cellular assays. Crystal structures of variola F1L bound to Bid and Bak BH3 domains reveal that variola F1L forms a domain-swapped Bcl-2 fold, which accommodates Bid and Bak BH3 in the canonical Bcl-2-binding groove, in a manner similar to VV F1L. Despite the observed conservation of structure and sequence, variola F1L inhibits apoptosis using a startlingly different mechanism compared with its VV counterpart. Our results suggest that unlike during VV infection, Bim neutralization may not be required during VAR infection. As molecular determinants for the human-specific tropism of VAR remain essentially unknown, identification of a different mechanism of action and utilization of host factors used by a VAR virulence factor compared with its VV homolog suggest that studying VAR directly may be essential to understand its unique tropism.

'Congenital follicular melanocytic naevi': a more appropriate term for spotted grouped pigmented naevi.

We report two patients with an uncommon form of pigmented naevus consisting of grouped follicular papules. A biopsy taken from the lesions showed multiple naevus cells, predominantly around the hair follicles, with sparing of the eccrine glands. The clinicohistopathological term given for this condition is 'spotted grouped pigmented naevi type I', and has rarely been reported. We discuss the unusual morphology and differential diagnosis of this condition, and suggest that the term 'congenital follicular melanocytic naevi' is more appropriate for this presentation.

Reversible atrioventricular blocks in thyroid storm.

Atrioventricular blocks or sinoatrial blocks are rarely described in patients with thyrotoxicosis or thyroid storm. The mechanism of these blocks remains obscure. Thyroid storm, being an emergency situation requires early diagnosis and management because if left untreated, it may prove fatal. Usually patients with AV blocks require pacing (temporary or permanent). Here we describe a case who developed AV blocks, did not undergo pacing, but recovered only on antithyroid treatment.

Evaluation of endothelial function and effect of glycemic control (excellent vs. poor / fair control) on endothelial function in uncontrolled type 2 diabetes mellitus.

OBJECTIVE: To evaluate the endothelial functions before and after glycemic control in type II diabetes mellitus. MATERIAL AND METHODS: It was an open, randomized and comparative study on 30 patients of type 2 diabetes mellitus. The study was of 12 weeks spread over 5 visits. The initial visit (visit 1) is for screening of patients. Other visits (visits 2 to 5) constituted the follow up of patients. The primary efficacy parameters included blood sugar (fasting and postprandial) done on each visit and glycosylated hemoglobin (HbA1c) done at visits 1 and 5. Based on glycosylated hemoglobin (HbA1c) only poorly controlled and fairly controlled patients were included in the study. Brachial artery flow mediated vasodilatation (FMD) was studied in all these patient at visits 1 and 5 to see the effect of glycemic control on endothelial functions. Results obtained were statistically analyzed with appropriate method. RESULTS: There was a significant improvement in endothelial functions in patients with fair, good and excellent control of diabetes. During uncontrolled state (HbA1c 10.08 +/- 0.48%) FMD was lowest, i.e., 2.88 +/- 0.53 at 1st week which improved to 11.94 +/- 3.33 at 12th week with control of diabetes (HbA1c 6.74 +/- 0.16%). The FMD in patients who had fair control (HbAlc 8.45 +/- 0.30%) in the beginning was 6.74 +/- 2.43% and after excellent control in these patients FMD rises to 12.81 +/- 3.16%. CONCLUSION: Our data showed that the endothelial functions improved sequentially with control of diabetes from fair to good to excellent glycemic control.

Medial dislocation of the medial meniscus.

We present the first reported case of symptomatic medial dislocation of the medial meniscus in a patient who had no previous history of trauma and who had an otherwise normal knee. The treatment of instability of the medial meniscus is controversial and studies have indicated that certain individuals without a firm meniscal bony insertion may be predisposed to meniscal dislocation. In our patient, the meniscal instability interfered with daily activities. Operative stabilisation by reconstruction of the meniscotibial ligaments cured the symptoms.

Analysis of results of surgical treatment of posttraumatic stiff elbow.

BACKGROUND: Surgical management of posttraumatic elbow stiffness has been reported with poor outcome following treatment. Sequential release in earlier stages of stiffness yielded much better results. The goal of our study was to assess the outcome in improvement of the range of motion of the elbow after surgical release and to analyze a tailor-made approach according to individual needs to yield good result. MATERIALS AND METHODS: A prospective study was conducted in 47 cases of elbow stiffness due to various types of injuries. All the cases were treated with sequential release if there was no progress after adequate supervised conservative management except in unreduced dislocations. All the cases were followed up for a minimum period of 24 months. Overall outcome was rated with the functional scoring system by Mayo Clinic Performance Index. RESULTS: Twenty-five (44.68%) out of 47 patients had excellent results with a mean preoperative range of motion of 33.9 degrees and postoperative range of motion of 105 degrees with net gain in range of motion of 71.1 degrees ('t' test value is 19.27, P < 0.01). None of the patients had elbow instability. Patients not having heterotopic ossification, who underwent surgery from three to six months post injury had a mean gain of 73.5 degrees. In patients who waited for more than six months had mean gain of 66.8 degrees. However, the results in cases having heterotopic ossification followed a slightly different pattern. In cases where release was performed from three months to six months had mean gain of 77.5 degrees. Cases in which release was performed after six months had gain of 57.1 degrees. CONCLUSIONS: In cases of posttraumatic elbow stiffness after a failed initial conservative treatment, early arthrolysis with sequential surgical soft tissue release yields good result than delayed surgery.

Early changes in gene expression that influence the course of primary glomerular disease.

Serial changes in glomerular capillary loop gene expression were used to uncover mechanisms contributing to primary glomerular disease in rat models of passive Heymann nephritis and puromycin nephrosis. Before the onset of proteinuria, podocyte protein-tyrosine phosphatase (GLEPP1) expression was transiently decreased in the nephrosis model, whereas the immune costimulatory molecule B7.1 was stimulated in both models. To relate these changes to the development of proteinuria, the time of onset and intensity of proteinuria were altered. When the models were induced simultaneously, proteinuria and anasarca occurred earlier with the collapse of glomerular capillary loops. Upregulation of B7.1 with the downregulation of GLEPP1, Wilms' tumor gene (WT1), megalin, and vascular endothelial growth factor started early and persisted through the course of disease. In the puromycin and the combined models, changes in GLEPP1 expression were corticosteroid-sensitive, whereas B7.1, WT1, vascular endothelial growth factor, and most slit diaphragm genes involved later in the combined model, except podocin, were corticosteroid-resistant. There was a very early increase in the nuclear expression of podocyte transcription factors ZHX2 and ZHX1 that may be linked to the changes in gene expression in the combined proteinuric model. Our studies suggest that an early and persistent change in mostly steroid-resistant glomerular gene expression is the hallmark of severe and progressive glomerular disease.

Evaluation of methods for AmpC beta-lactamase in gram negative clinical isolates from tertiary care hospitals.

The purpose of this study was to simultaneously screen for Extended-spectrum beta-lactamases (ESBL) and AmpC beta-lactamases in gram negative clinical isolates from four tertiary care hospitals and further to compare two detection methods three-dimensional extraction method and AmpC disk test for AmpC beta-lactamases. A total of 272 isolates were screened for ESBL and AmpC beta-lactamase by modified double disk approximation method (MDDM). Synergy observed between disks of ceftazidime/cefotaxime and clavulanate were considered as ESBL producer. Isolates showing reduced susceptibility to either of the test drugs (ceftazidime or cefotaxime) and cefoxitin were considered as presumptive AmpC producers and further confirmed by three-dimensional extraction method and AmpC disk test. A total of 173 (64%) of the isolates were found to be ESBL positive and 61 (23%) showed resistant to cefoxitin. ESBL was detected in 80 (62%) isolates of E. coli and 71 (73%) of Klebsiella spp. The occurrence of AmpC beta-lactamases was found to be 8% (22) of the total isolates and the two detection methods for AmpC beta-lactamase showed concordant results. Screening for ESBL and AmpC can be simultaneously done by MDDM method and confirmation for AmpC beta-lactamase should be carried out routinely in tertiary care hospitals by AmpC disk test, as it is a simple and rapid procedure.