Diffuse bronchiectasis as the primary manifestation of endobronchial sarcoidosis.

Sarcoidosis is an idiopathic disease that most commonly involves the lungs and is characterized by granulomatous inflammation. Bronchiectasis is one pulmonary manifestation of sarcoidosis, although it is almost always observed as traction bronchiectasis in the setting of fibrotic lung disease. A 50-year-old woman was evaluated for chronic cough and bronchiectasis with a small amount of peripheral upper lobe honeycombing and no significant pulmonary fibrosis or lymphadenopathy. After an extensive laboratory and imaging evaluation did not identify a cause of her bronchiectasis, bronchoscopy was performed to assess for primary ciliary dyskinesia and revealed a diffuse cobblestone appearance of the airway mucosa. Endobronchial biopsies and lymphocyte subset analysis of bronchoalveolar lavage fluid were consistent with a diagnosis of sarcoidosis. We believe endobronchial sarcoidosis should be included in the differential diagnosis of patients presenting with bronchiectasis.

A Systematic Evaluation of Burst Spinal Cord Stimulation for Chronic Back and Limb Pain.

BACKGROUND: Traditional tonic spinal cord stimulation (SCS) has been approved by FDA for chronic pain of intractable back and limb pain. However, it induces paresthesia and relieves pain poorly to some extent. Recently, burst SCS has been developed for pain reduction without the mandatory paresthesia. STUDY DESIGN: A systematic review of burst SCS for chronic back and limb pain. OBJECTIVE: The objective of this systematic review is to determine the effects of burst SCS on pain relief without paresthesia for various conditions including failed back surgery syndrome, painful diabetic neuropathy, and radiculopathy. METHODS: The available literature on burst SCS in managing chronic pain without paresthesia was reviewed. The 2011 American Academy of Neurology (AAN) Classification of Evidence Guidelines Process Manual was used to grade the evidence and risk of bias. Data sources included relevant literature identified through searches of PubMed, MEDLINE/OVID, SCOPUS, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES: The primary outcome measure was pain relief and paresthesia status. Secondary outcome measures were improvement in pain quality, functional status, and complications. RESULTS: For this review, five studies including a total of 117 patients met the eligibility criteria. All studies were graded a Class IV study. LIMITATIONS: The limitations of this systematic review include an overall paucity of high quality studies. CONCLUSION: Burst SCS is a new approach that possibly causes more pain reduction for short-term duration than tonic SCS without eliciting paresthesia. The evidence based on this systematic review for burst SCS in treating chronic intractable pain is considered fair and limited. This is an AAN recommendation level U. Further research is needed with a larger sample size and a standardized study design.

Interactions of light intensity, insecticide concentration, and time on the efficacy of systemic insecticides in suppressing populations of the sweetpotato whitefly (Hemiptera: Aleyrodidae) and the citrus mealybug (Hemiptera: Pseudococcidae).

The impact of light intensity on the uptake and persistence of the systemic neonicotinoid insecticides, imidacloprid and dinotefuran, were evaluated in poinsettia (Euphorbia pulcherrima Willd.) and yellow sage (Lantana camara L.). Insecticide residues were measured in leaves sampled from the treated plants at four time intervals after treatment to determine the relationship between insecticide concentration and efficacy against two insect pests: sweetpotato whitefly, Bemisia tabaci Gennadius, and the citrus mealybug, Planococcus citri Risso. The insecticides were evaluated at their respective label rate and at the comparable label rate of the other insecticide under two different light environments: ambient and shade. The uptake of dinotefuran into yellow sage was more rapid at both treatment rates than both rates of imidacloprid, resulting in higher percent mortality of whitefly nymphs (89.8-100) compared with imidacloprid (14.1-89.2) across all 4 wk. Additionally, plants that received both rates of dinotefuran had fewer whitefly pupae (< 1.0) at week 4 compared with imidacloprid-treated plants (23.7-25.3). The uptake of dinotefuran into poinsettia plants was also more rapid and resulted in quicker and higher percent mortality of whitefly nymphs (89.5-99.6) compared with imidacloprid (14.1-89.2) across all 4 wk. However, despite efficient uptake, the efficacy of both systemic insecticides was less for citrus mealybug where percent mortality values were <50% among all the treatments across the 4 wk. The use of the two systemic insecticides evaluated in regards to pest management in horticultural cropping systems is discussed.

Effect of pesticides on adult rove beetle Atheta coriaria (Coleoptera: Staphylinidae) survival in growing medium.

The rove beetle Atheta coriaria (Kraatz) (Coleoptera: Staphylinidae) is a natural enemy (biological control agent) commercially available for control of certain greenhouse insect pests, including fungus gnats, shore flies, and thrips. This study assessed the compatibility of pesticides (insecticides and fungicides) used in greenhouses with A. coriaria adults. Treatments were applied to 473-ml deli squat containers half-filled with a growing medium. We evaluated the effects of the pesticides when releases of A. coriaria adults were performed both before and after application of the designated pesticide solutions. All three of the neonicotinoid-based insecticides (clothianidin, dinotefuran, and thiamethoxam) were directly harmful to A. coriaria adults with < or = 3.2 adults recovered (out of 20) among all three treatments across all experiments. In addition, the organophosphate insecticide chlorpyrifos at the low (0.25 fl oz/100 gal) and high (0.50 fl oz/100 gal) label rates; the plant-derived essential oil product (Indoor Pharm) containing soybean and rosemary oil; and the insecticide/miticide chlorfenpyr were directly harmful to A. coriaria adults with recovery rates -8.6 (out of 20) among all the treatments. The fungicides (azoxystrobin, fosetyl-aluminum, and mefenoxam) were not directly toxic to A. coriaria adults, with < or = 17.7 adults recovered (out of 20) across all experiments. The insecticides (Bacillus thuringiensis subsp. israelensis, flonicamid, Metarhizium anisopliae strain52, and spinosad) and insect growth regulator azadirachtin were also not directly toxic to A. coriaria adults. Furthermore, many of these same treatments did not inhibit the ability of adult A. coriaria to consume fungus gnat (Bradysia sp. nr. coprophila) larvae in a feeding behavior experiment. Although the neonicotinoid-based insecticides were directly harmful to adult A. coriaria, when adults were released 48, 72, or 96 h after application, survival increased dramatically over time. This study has quantitatively demonstrated that certain pesticides (both insecticides and fungicides) are compatible with and can be used along with A. coriaria in systems that use this natural enemy to manage fungus gnat larvae.

Effect of commercially available plant-derived essential oil products on arthropod pests.

Plant-derived essential oil products, in general, are considered minimum-risk pesticides and are exempt from Environmental Protection Agency registration under section 25(b) of the Federal Insecticide Fungicide and Rodenticide Act. However, many of the plant-derived essential products available to consumers (homeowners) have not been judiciously evaluated for both efficacy and plant safety. In fact, numerous plant-derived essential oil products labeled for control of arthropod pests have not been subject to rigorous evaluation, and there is minimal scientific information or supporting data associated with efficacy against arthropod pests. We conducted a series of greenhouse experiments to determine the efficacy and phytotoxicity of an array of plant-derived essential oil products available to consumers on arthropod pests including the citrus mealybug, Planococcus citri (Risso); western flower thrips, Frankliniella occidentalis (Pergande); twospotted spider mite, Tetranychus urticae Koch; sweetpotato whitefly B-biotype, Bemisia tabaci (Gennadius); and green peach aphid, Myzus persicae (Sulzer). Although the products Flower Pharm (cottonseed, cinnamon, and rosemary oil) and Indoor Pharm (soybean, rosemary, and lavender oil) provided > 90% mortality of citrus mealybug, they were also the most phytotoxic to the coleus, Solenostemon scutellarioides (L.) Codd, plants. Both GC-Mite (cottonseed, clove, and garlic oil) and Bugzyme (citric acid) were most effective against the twospotted spider mite (> or = 90% mortality). However, SMC (canola, coriander oil, and triethanolamine), neem (clarified hydrophobic extract of neem oil), and Bug Assassin (eugenol, sodium lauryl sulfate, peppermint, and citronella oil) provided > 80% mortality. Monterey Garden Insect Spray, which contained 0.5% spinosad, was most effective against western flower thrips with 100% mortality. All the other products evaluated failed to provide sufficient control of western flower thrips with < 30% mortality. In addition, the products Pest Out (cottonseed, clove, and garlic oil), Bang (Pipereaceae), and Fruit & Vegetable Insect Spray (rosemary, cinnamon, clove oil, and garlic extract) had the highest flower (transvaal daisy, Gerberajamesonii [H. Bolus ex Hook.f]) phytotoxicity ratings (> or = 4.5 of 5) among all the products. None of the plant-derived essential oil products provided sufficient control of sweetpotato whitefly B-biotype or green peach aphid 7, 14, and 21 d after application. Furthermore, the products Bug Assassin (eugenol, sodium lauryl sulfate, peppermint, and citronella oil) and Sharpshooter (sodium lauryl sulfate and clove oil) were phytotoxic to the poinsettia, Euphorbia pulcherrima Willd. ex Klotzsch, plants. This study is one of the first to quantitatively demonstrate that commercially available plant-derived essential oil products vary in their effectiveness against certain arthropod pests stated on the label and are phytotoxic.

Use of a high-flow oxygen delivery system in a critically ill patient with dementia.

We used a high-flow nasal cannula with a patient who required a high fraction of inspired oxygen but could not tolerate a nasal or facial mask. We saw a 92-year-old woman with delirium and dementia in the intensive care unit for multi-lobar pneumonia with severe hypoxemia. Attempts to oxygenate the patient failed because she was unable to tolerate various facial and nasal masks. We then tried a high-flow nasal cannula (Vapotherm 2000i), which she tolerated well, and she had marked improvement in gas exchange and quality of life. The patient had severe health-care-associated pneumonia, accompanied by delirium and hypoxemia. It became apparent that the patient's death was imminent, and the goal of therapy was palliative. She had previously clearly expressed a desire not to undergo intubation and mechanical ventilation. In a situation where the patient was agitated and unable to tolerate a mask, the high-flow cannula reduced her agitation and improved her dyspnea, oxygenation, tolerance of oxygen therapy, and comfort at the end of life. Oxygen via high-flow cannula may enhance quality of life by reducing hypoxemia in patients who are unable to tolerate a mask but need a high oxygen concentration.

Ethics training for military medical trainees: the Brooke Army Medical Center experience.

Biomedical ethics training during graduate medical education programs is required by the Accreditation Council for Graduate Medical Education. Apart from this requirement, medical ethics education is an integral component of military medical practice. Although ethics education and training are required, tools to assess the effectiveness of ethics education are not well developed. Furthermore, although biomedical ethics education is mandated for new Army physician trainees, there has not been a systematic objective assessment of the effectiveness of that training. We report the concept underlying the design and implementation of a military biomedical ethics seminar for new Army physician trainees. Combining a didactic component and case analysis through small-group discussions, we emphasized providing tools to analyze ethical dilemmas both in the medical center environment and in the operational medicine environment. A total of 47 Army interns participated in the seminar. Eighty-nine percent of participants agreed or strongly agreed that the ethics orientation met expectations. Seventy-two percent agreed or strongly agreed that the information presented would affect their practice. Ninety-six percent thought that the small-group discussions were effective, and 80% thought that the presentations enhanced knowledge from medical school.

Effect of diatomaceous earth and Trichoderma harzianum T-22 (Rifai strain KRL-AG2) on the fungus gnat Bradysia sp. nr. coprophila (Diptera: Sciaridae).

This study, consisting of three experiments, was designed to assess whether diatomaceous earth, when applied to the surface of growing media, reduces adult fungus gnat Bradysia sp. nr. coprophila (Diptera: Sciaridae) emergence or inhibits the females from laying eggs; and whether fungus gnat adults are attracted to the fungus Trichoderma harzianum T-22 (Rifai strain KRL-AG2) under laboratory conditions. In the first two experiments, diatomaceous earth was applied at two different thicknesses (3.1 and 6.3 mm) and conditions (dry and moist) to the surface of a growing medium (Universal SB 300 Mix) after the growing medium had been artificially inoculated with second or third instars of fungus gnats, or before female fungus gnat adults were released into each deli squat container. In the third experiment, preparations of the fungus T. harzianum at the highest recommended label rate (0.889 kg/m3) were amended into the growing medium and processed 24, 48, or 72 h before use in a series of three two-choice trials with a two-armed experimental arena. In the first two experiments, the dry or moist layers of diatomaceous earth, in general, did not affect fungus gnats in terms of preventing adult emergence or egg laying by the females. During the course of these experiments, we observed that the diatomaceous earth dry treatments expanded as a result of absorbing moisture from the growing medium, creating fissures that allowed the fungus gnat larvae to pupate and females to lay eggs. In the third experiment, fungus gnat adults were not attracted to the T. harzianum treatments in any of the trials.

Advance directives and do-not-resuscitate orders on general medical wards versus the intensive care unit.

The records of 335 patients admitted to the general medicine wards and to the medical intensive and coronary care unit (MICCU) at Brooke Army Medical Center were retrospectively reviewed to assess the frequency of advance directives and "do not resuscitate" (DNR) designations. Two hundred sixty-seven (79.7%) were admitted to the ward and 68 (20.3%) were admitted to the MICCU. Advance directives were executed in 14.9% of patients. DNR designations were made for 21 (7.9%) patients on the ward and 11 (16.2%) patients in the MICCU (p = 0.064). There were no statistical differences in mean length of stay, presence of advance directives, or documentation of advance directives in ward versus MICCU patients. However, there was a statistical difference in the number of deaths in the MICCU as compared with that on the ward (9.7 vs. 2.7%, p < 0.05). The frequency of advance directives and DNR designations did not differ between ward and MICCU patients in this population, although there was a trend for greater DNR designations in the MICCU environment.