CT scan findings in oesophagogastric perforation after out of hospital cardiopulmonary resuscitation.

Rupture of the oesophagus or stomach at the time of cardiopulmonary resuscitation can occur with accidental oesophageal intubation. The common site of rupture is the lesser curvature of the stomach, but can also occur at the oesophagogastric junction. The patient presented with a massive pneumoperitoneum after an out of hospital ventricular fibrillation arrest. CT scanning was helpful in making the diagnosis. In out of hospital resuscitation, current JRCALC (Joint Royal Colleges Ambulance Liaison Committee) recommendations may not avoid this complication.

Regional brain atrophy in cognitively intact adults with a single APOE epsilon4 allele.

OBJECTIVE: To determine whether cognitively intact adults with the APOE epsilon3/epsilon4 genotype show reduced gray matter density on voxel-based morphometry (VBM) vs those homozygous for the epsilon3 allele. METHODS: Participants were healthy, cognitively intact, right-handed adults, age 19 to 80, who completed genotyping, neuropsychological testing, and MRI. Forty-nine participants had the epsilon3/epsilon3 genotype and 27 had the epsilon3/epsilon4 genotype. Gray matter data were analyzed using the general linear model as implemented in the Statistical Parametric Mapping package, adjusting for age and sex. RESULTS: The epsilon3/epsilon4 participants showed lower gray matter density than the epsilon3/epsilon3 participants in right medial temporal and bilateral frontotemporal regions as well as other areas. There were no regions in which epsilon3/epsilon4 participants showed higher gray matter density than epsilon3/epsilon3 participants. CONCLUSIONS: Regionally reduced gray matter density is detectable in cognitively intact adults with a single copy of the APOE epsilon4 allele.

Integrable wide-free-spectral-range Fabry-Perot optical filters using free-standing LiNbO3 thin films.

We demonstrate the use of free-standing thin films of a complex oxide for chip-scale optical filtering. The films are used as low-order etalons with very large free spectral ranges that exceed 6.78 THz (> 50 nm at 1550 nm) and use a small chip area (< 500 microm2) when they are integrated. The films are produced by crystal ion slicing; this process exfoliates a micrometers-thin layer of single-crystal optical material from a bulk parent by means of high-energy-ion implantation. The etalons, which are 10 microm thick with Ag deposited on both surfaces, are integrated into a silica-on-silicon waveguide block.

Chronic deep brain stimulation for the treatment of tremor in multiple sclerosis: review and case reports.

BACKGROUND: Deep brain stimulation (DBS) offers a non-ablative alternative to thalamotomy for the surgical treatment of medically refractory tremor in multiple sclerosis. However, relatively few outcomes have been reported. OBJECTIVE: To provide a systematic review of the published cases of DBS use in multiple sclerosis and to present four additional patients. METHODS: Quantitative and qualitative review of the published reports and description of a case series from one centre. RESULTS: In the majority of reported cases (n=75), the surgical target for DBS implantation was the ventrointeromedial nucleus of the thalamus. Tremor reduction and improvement in daily functioning were achieved in most patients, with 87.7% experiencing at least some sustained improvement in tremor control postsurgery. Effects on daily functioning were less consistently assessed across studies; in papers reporting relevant data, 76.0% of patients experienced improvement in daily functioning. Adverse effects were similar to those reported for DBS in other patient populations. CONCLUSIONS: Few of the studies reviewed used highly standardised quantitative outcome measures, and follow up periods were generally one year or less. Nonetheless, the data suggest that chronic DBS often produces improved tremor control in multiple sclerosis. Complete cessation of tremor is not necessarily achieved, there are cases in which tremor control decreases over time, and frequent reprogramming appears to be necessary.

Deep brain stimulation in neuropsychiatric disorders.

Deep brain stimulation (DBS) of the ventral intermediate nucleus of the thalamus, subthalamic nucleus, and internal globus pallidus has been put forth as an alternative to surgical ablation for the treatment of movement disorders. In this paper, the authors discuss the history and putative physiologic mechanisms underlying DBS of these target regions. The authors then review empirical findings pertaining to the effects of DBS on neurological symptoms, cognitive functioning, and psychiatric symptoms in Parkinson's disease and essential tremor, the disorders for which the procedure has been most extensively applied. Finally, emerging and potential novel areas of application of DBS for the treatment of neuropsychiatric disorders and symptoms are discussed.

Follow family-focused care principles.

Making the transition from traditional obstetrics care to single-room maternity care involves changes in the physical facility, cross-education, and new roles. The most important success factor is the staff's response to the change.

Performance of subclinical compulsive checkers on putative tests of frontal and temporal lobe memory functions.

Previous research suggests that compulsive checking is associated with a deficit in memory for actions. In addition, evidence indicates frontal lobe involvement in both obsessive-compulsive disorder and in the monitoring of self-ordered actions. We examined the relationship between compulsive checking and performance on tests putatively related to frontal and temporal lobe memory functions. Subjects consisted of two groups of 14 university students identified as checkers or noncheckers according to the checking subscale of the Maudsley Obsessional-Compulsive Inventory. Checkers demonstrated significantly poorer ability to monitor their responses on the frontal task and a trend toward better long-term visuospatial memory. When the effect of trait anxiety was controlled for, the frontal effect was reduced to a trend, but the visuospatial memory advantage was enhanced. Although both a frontal deficit and enhanced long-term visuospatial memory may contribute to compulsive checking, trait anxiety seems to play a moderating role.

Thiopyronine- and 8-methoxypsoralen-sensitized photodynamic effect on cell growth, colony forming ability and RNA synthesis in Saccharomyces mutants deficient in DNA repair.

We compared the photodynamic effects of thiopyronine (TP) and visible light, and 8-methoxypsoralen (8-MOP) and ultraviolet A (UV-A) light, on growth, colony forming ability and RNA synthesis in a repair-proficient Saccharomyces strain and three mutants deficient in DNA repair mechanisms (DNA repair assays). With 8-MOP and UV-A repair-deficient mutants were significantly more sensitive than the repair-proficient strain indicating that the system is sensitive for the detection of DNA damage. With TP and visible light, the photodynamic effects were comparable in the mutants and the control, indicating no DNA damage. These results support previous work showing that the main target of TP photosensitization in eukaryotes is not nuclear DNA.

Isolation of V79 fibroblast cell lines containing elevated metallothionein levels that have increased resistance to the cytotoxic effects of ultraviolet-A radiation.

Isolated clones of V79 Chinese hamster lung fibroblasts, selected for resistance against cadmium toxicity, were exposed to monochromatic 365 nm ultraviolet-A (UVA; 320 nm to visible light) radiation and examined for cell survival. All three of the Cd-resistant V79 clones (V79Cd) tested exhibited significant increases in survival after irradiation compared with control cultures similar to the increased survival observed in Zn acetate-induced V79 cells. Dose-modifying factors calculated for these survival experiments were all approximately 1.5. When characterized for steady-state levels of metallothionein (MT) mRNA and associated Cd-binding activity, all of the Cd-resistant V79Cd clones demonstrated elevated constitutive levels of both, implicating MT as the mechanism responsible for the observed cellular resistance to Cd and also to 365 nm UVA radiation. However, whereas levels of intracellular MT protein correlated with differences in survival against Cd, MT intracellular levels did not correlate well with protection against 365 nm UVA. Increased cell survival after exposure to 365 nm UVA radiation mediated by MT appeared to reach a threshold level and MT only provided a limited degree of protection. Since UVA radiation is known to cause cell death mediated through the intracellular generation of reactive oxygen species (ROS), these results suggest that the role of MT in ameliorating cellular photooxidative damage produced by UVA is by reducing intracellular ROS.

Underdiagnosis and undertreatment of chronic sinusitis in children.

A review of outpatients diagnosed with sinusitis during the previous year by the allergy services of Childrens Hospital of Los Angeles and Kaiser Permanente, Orange County, revealed 34 patients who had protracted discomforting and debilitating symptoms. The mean duration of symptoms was approximately six months (range 1-14 months). None had been previously diagnosed as having sinusitis or received appropriate treatment. Although all were referred for evaluation of allergic rhinitis and/or asthma, approximately 1/3 were found to have neither of these conditions. Among patients who had asthma, their asthmatic symptoms were aggravated by the sinusitis. All patients eventually responded favorably to appropriate antibiotic therapy. Earlier diagnosis and appropriate therapy would have foreshortened the course of this very discomforting condition. In recent years, we have observed a marked increase in the number of patients referred with the chief complaint of "worsening allergy" and who were subsequently found to have sinusitis. Most of the patients experienced significant incapacitation for protracted periods before a correct diagnosis was made and treatment instituted. In all but a few cases, prompt and sustained improvement followed appropriate therapy. The purpose of this report is to present a retrospective review of 34 illustrative cases.

[Ambulatory surgery in the United States. Reasons of its existence and future]. / La chirurgie ambulatoire aux USA. Ses raisons d'être et son avenir.

Ambulatory surgery has been gaining momentum in the United States over the past decade. This does not result from an initiative taken by the medical profession, but from a government plan aimed at checking the soaring costs of medical care. Since this rise was chiefly caused by hospital costs, the attempted savings have primarily affected our privilege of admitting the patients to hospital as we wanted. It has become impossible to admit a patient to hospital for diagnostic testing. Even for major surgery (such as resection of the esophagus, duodenopancreatotomy, etc.), the patient comes to hospital on the very morning of the operation. In addition, the medical mutual benefit insurance companies, in particular, the HMOs, have decided that some operations must be performed without any stay in hospital. This has resulted in the creation of ambulatory surgery units, which were either integrated in hospital surgery departments, or independent, and of which we discuss the pros and cons. In addition, an infrastructure aimed at facilitating postoperative care at home or in smaller private units has been set up. Laparoscopic surgery has further increased the percentage of ambulatory operations. There certainly will be no retreat now.

Cerebral spinal fluid.

The advent of very sensitive and rapid agglutination tests has been a major advance in facilitating the rapid diagnosis of bacterial meningitis (Table 3). Future investigations will focus on the use of monoclonal antibodies that have been found to be more sensitive and specific than polyclonal antiserums. Modifications of enzyme immunoassays of bacterial antigens to improve speed and technical reliability are in progress. The day may come with the present advances in technology that within 1 hour of receiving a CSF specimen, both the identity and antimicrobial sensitivity of the invading pathogen will be known to the physician. In addition, through quantitation of bacterial antigen, a reliable prognosis as to the outcome of the treated meningitis will also be possible. Finally, the continued refinement of reliable antiserums to group B Neisseria meningitidis, as well as other bacteria responsible for meningitis, particularly in the immunocompromised host will occur.

Fever in the wake of a stroke.

We performed a prospective study of the frequency and cause of fever, defined as a rectal temperature of greater than or equal to 101 degrees F detected within the first 5 days, in 104 consecutive adults admitted to a community/teaching hospital because of a nontraumatic stroke. Fever was documented in 23 patients. A source for the fever was identified in 19 patients and was attributed to a pulmonary insult, either aspiration chemical pneumonitis or an infectious pneumonia, in 13 of these patients. Patients who experienced lacunar infarcts did not develop fever. Fever occurring in the wake of a stroke should not be attributed to the vascular process, but should direct attention to inflammatory disorders of the lungs.

Fever following abdominal surgery. Unusual infectious causes.

Identification of the cause and subsequent specific therapy are indicated for those prolonged or relapsing fevers that follow abdominal surgery. On rare occasions, these fevers can be attributed to potentially life-threatening occult infections, including maxillary sinusitis, acute cholecystitis, antibiotic-related pseudomembranous colitis, toxic shock syndrome, systemic candidiasis, and transfusion-related cytomegalovirus disease, malaria, and babesiosis. Early recognition and appropriate treatment of these infections relieve anxiety, reduce hospital costs, and increase patient survival rates.

Antibiotic irrigations. A plea for controlled clinical trials.

Although the medical literature describes the perioperative use of antibiotic irrigations in abdominal, pelvic, orthopedic and vascular surgery, the lack of well-designed and executed, controlled clinical studies often precludes a definitive assessment of the value of this technique. Future randomized, double-blind, controlled clinical trials are required to establish its merit. In this age of cost consciousness, lavages with antibiotic solutions cannot at present be regarded as conventional medical therapy.

Recurrent bacterial pneumonia: a contemporary perspective.

Numerous clinical disorders predispose to "recurrent bacterial pneumonia." Identification and treatment of some of these predisposing conditions will reduce associated morbidity, mortality, and health care expenditures. In young adults these disorders include cystic fibrosis, the immotile-cilia syndrome, Young's syndrome, pulmonary sequestration, and bronchiectasis. Disorders enhancing recurrent bacterial pneumonia in older adults include chronic obstructive lung disease, bronchial obstruction, specific malignancies, hypogammaglobulinemia, alcoholism, neurologic diseases, and esophageal abnormalities.

Human infections derived from dogs.

Infected dogs, including those that appear healthy, have been implicated in the genesis of certain infectious disorders in humans. Failure to appreciate the epidemiologic features of these infections can result in delayed diagnosis and therapy, with occasional fatal results. Efforts directed toward patient education, frequent veterinarian examinations of household pets, and thorough hand washing after animal contact will reduce the incidence of dog-related infections in humans.

Bacteremic urosepsis: a phenomenon unique to elderly women.

Bacteremia constitutes a major challenge to the aged patient because the pathophysiological derangements that ensue pose an immediate threat to life. Compared to younger adults the elderly suffer bacteremia more frequently in association with pneumococcal pneumonia and salmonella enteritis/colitis. A prospective study to detect bacteremia was performed on 68 consecutive women with pyelonephritis requiring hospitalization. The data indicate that bacteremia occurs more frequently in elderly than in young women with nonobstructive pyelonephritis.

Pneumonia in the elderly: a nursing home perspective.

The development of pneumonia is a life-threatening event in a nursing home resident. Staphylococcus aureus and Klebsiella pneumoniae are major identifiable bacterial pathogens. Some elderly patients with pneumonia can be effectively treated in the nursing home. The clinical impression of pneumonia merits radiologic confirmation. Cefuroxime, trimethoprim-sulfamethoxazole and cefaclor offer theoretic advantages in the treatment of bacterial pneumonia in elderly nursing home residents.