Incessant Atrial Tachycardia From the Left Atrial Appendage Treated With Appendage Ligation.

A previously healthy man presented in shock due to incessant tachycardia. He ultimately required extracorporeal membrane oxygenation for support and clipping of his appendage for arrhythmia control. This case highlights the importance of early recognition of cardiogenic shock, aggressive hemodynamic support, and a multidisciplinary approach to managing these challenging arrhythmias.

Pulmonary gangliocytic paraganglioma: An under-recognized mimic of carcinoid tumor.

Gangliocytic paragangliomas are rare neoplasms occurring almost exclusively in the ampullary region of the gastrointestinal tract. Although these tumors are not typically considered in the differential diagnosis of primary pulmonary neoplasia, 5 cases of primary pulmonary gangliocytic paragangliomas have been previously reported. Herein we report our experience with 3 additional examples, all referred to our Anatomic Pathology Consultation service. The patients (a 32-year-old man, a 69-year-old woman and a 55-year-old man) each presented with an endobronchial (2 cases) or upper lobe lung mass, ranging from 1.5 to 2.5 cm in maximum dimension. Biopsy and endobronchial debulking specimens demonstrated the classic triphasic morphology of gangliocytic paraganglioma, with epithelial, spindled and ganglion-like cells. By immunohistochemistry, the tumors were positive for keratin, synaptophysin and chromogranin A in the epithelial component, S100 protein and glial fibrillary acidic protein (GFAP) in the Schwannian spindled cells, and synaptophysin in ganglion cells. TTF1 expression was seen in the epithelial components of 2 cases. The Ki-67 labelling index was low (<2%). Primary pulmonary gangliocytic paragangliomas should be distinguished from carcinoid tumors, given the different natural histories and risk stratification approaches for these morphologically similar tumors. Awareness that gangliocytic paraganglioma may occur in the lung and appropriate immunohistochemical studies are key to correct diagnosis.

In Search of Real Circumcision: Ritual Failure and Circumcision in Paul.

This article applies the theoretical framework of 'ritual failure', a sub-discipline of ritual criticism, to Paul's discussion of circumcision in his letter to the Galatians, Philippians and Romans. It is argued that the application of this theoretical perspective clarifies the dynamics at stake and provides a new way of understanding the development in Paul's position regarding circumcision. There is movement from an attitude of strong propagation, by way of indifference and a subsequent attitude of rejection, to one of modified reintegration into Paul's thinking. At every turn of this development, ritual failure plays a pivotal role and functions as a catalyst for the development of Paul's theology.

Patients' Willingness to Take Multiple-Tablet Antiretroviral Therapy Regimens for Treatment of HIV.

BACKGROUND: The costs of combination antiretroviral therapy (cART) for HIV, consisting of separate, particularly generic, components (multiple-tablet regimens, MTR) are generally much lower than those of single-tablet regimens (STR) comprising the same active ingredients. OBJECTIVES: To assess whether patients would be willing to take MTR, once-daily, instead of STR, with the goal of reducing general healthcare costs. In addition, we aimed to examine whether willingness was associated with particular patient characteristics. METHODS: Data from the ATHENA cohort database in The Netherlands of adult HIV-1-infected patients in care and taking cART ≥6 months were used to select 1000 potential participants for an online patient survey on patient preferences and satisfaction. Participants were asked whether they would be willing to take three pills with the equivalent active ingredients simultaneously instead of STR to reduce costs. Multivariate logistic regression was used to examine associations between patient characteristics and willingness to take MTR instead of STR. RESULTS: Forty-seven percent (n = 152) of the 322 respondents answered 'yes' and 26 % (n = 83) answered 'maybe' when asked whether they would be willing to take three pills with the equivalent active ingredients simultaneously to reduce costs. Non-Dutch patients were significantly more likely to answer 'no' (OR: 2.49; 95 % CI: 1.17-5.30) or 'maybe' (OR: 2.63; 95 % CI: 1.24-5.60). Answering 'no' was less common among patients who had been taking cART ≥15 years (OR: 0.23; 95 % CI: 0.09-0.58). Commonly reported concerns included the dosing frequency, efficacy and tolerability of MTR. CONCLUSIONS: HIV-infected patients do not necessarily oppose the decision to prescribe MTR instead of STR to reduce healthcare costs. However, the potential trade-off in terms of convenience should be carefully weighed against the projected savings.

Dietary advanced glycation end-products, its pulmonary receptor, and high mobility group box 1 in aspiration lung injury.

BACKGROUND: Gastric aspiration is a significant cause of acute lung injury and acute respiratory distress syndrome. Environmental risk factors, such as a diet high in proinflammatory advanced glycation end-products (AGEs), may render some patients more susceptible to lung injury after aspiration. We hypothesized that high dietary AGEs increase its pulmonary receptor, RAGE, producing an amplified pulmonary inflammatory response in the presence of high mobility group box 1 (HMGB1), a RAGE ligand and an endogenous signal of epithelial cell injury after aspiration. MATERIALS AND METHODS: CD-1 mice were fed either a low AGE or high AGE diet for 4 wk. After aspiration injury with acidified small gastric particles, bronchoalveolar lavage and whole-lung tissue samples were collected at 5 min, 1 h, 5 h, and 24 h after injury. RAGE, soluble RAGE (sRAGE), HMGB1, cytokine and chemokine concentrations, albumin levels, neutrophil influx, and lung myeloperoxidase activity were measured. RESULTS: We observed that high AGE-fed mice exhibited greater pulmonary RAGE levels before aspiration and increased bronchoalveolar lavage sRAGE levels after aspiration compared with low AGE-fed mice. Lavage HMGB1 levels rose immediately after aspiration, peaking at 1 h, and strongly correlated with sRAGE levels in both dietary groups. High AGE-fed mice demonstrated higher cytokine and chemokine levels with increased pulmonary myeloperoxidase activity over 24 h versus low AGE-fed mice. CONCLUSIONS: This study indicates that high dietary AGEs can increase pulmonary RAGE, augmenting the inflammatory response to aspiration in the presence of endogenous damage signals such as HMGB1.

Liver transplantation in glycogen storage disease type I.

Glycogen storage disease type I (GSDI), an inborn error of carbohydrate metabolism, is caused by defects in the glucose-6-transporter/glucose-6-phosphatase complex, which is essential in glucose homeostasis. Two types exist, GSDIa and GSDIb, each caused by different defects in the complex. GSDIa is characterized by fasting intolerance and subsequent metabolic derangements. In addition to these clinical manifestations, patients with GSDIb suffer from neutropenia with neutrophil dysfunction and inflammatory bowel disease.With the feasibility of novel cell-based therapies, including hepatocyte transplantations and liver stem cell transplantations, it is essential to consider long term outcomes of liver replacement therapy. We reviewed all GSDI patients with liver transplantation identified in literature and through personal communication with treating physicians. Our review shows that all 80 GSDI patients showed improved metabolic control and normal fasting tolerance after liver transplantation. Although some complications might be caused by disease progression, most complications seemed related to the liver transplantation procedure and subsequent immune suppression. These results highlight the potential of other therapeutic strategies, like cell-based therapies for liver replacement, which are expected to normalize liver function with a lower risk of complications of the procedure and immune suppression.

HIV-related stigma within communities of gay men: a literature review.

While stigma associated with HIV infection is well recognised, there is limited information on the impact of HIV-related stigma between men who have sex with men and within communities of gay men. The consequences of HIV-related stigma can be personal and community-wide, including impacts on mood and emotional well-being, prevention, testing behaviour, and mental and general health. This review of the literature reports a growing division between HIV-positive and HIV-negative gay men, and a fragmentation of gay communities based along lines of perceived or actual HIV status. The literature includes multiple references to HIV stigma and discrimination between gay men, men who have sex with men, and among and between many gay communities. This HIV stigma takes diverse forms and can incorporate aspects of social exclusion, ageism, discrimination based on physical appearance and health status, rejection and violence. By compiling the available information on this understudied form of HIV-related discrimination, we hope to better understand and target research and countermeasures aimed at reducing its impact at multiple levels.

Pilot study of a web-based antibiotic decision management guide.

BACKGROUND: Use of electronic medical information resources by health-care professionals is increasing. Portable handheld computers have facilitated access to medical knowledge at the point of patient care. Little is known about the impact of mobile medical information tools on physician learning or improvement in decision-making. STUDY DESIGN: A 6-month prospective, randomized pilot study of 12 first-year trauma and critical care Fellows at the R Adams Cowley Shock Trauma Center was conducted from November 1, 2001 to May 31, 2002 at the University of Maryland. Six Fellows were randomized to use the Johns Hopkins Antibiotic Guide (JHABX) on the RIM Blackberry personal digital assistant (PDA) for 6 months of their clinical rotation. Six Fellows were randomized to the non-PDA-use arm. Three-month and 6-month examination raw scores on knowledge of infectious diseases management among Blackberry PDA users versus non-PDA users were obtained. Measurement of antibiotic decision accuracy by diagnosis at 3 and 6 months among Fellows randomized to use the JHABX on the RIM Blackberry PDA was also evaluated. RESULTS: PDA group demonstrated a considerable improvement in test scores over the 3-month time interval, compared with their baseline score (40.8 +/- 2.3 versus 34.3 +/- 4.6, p < 0.05) and compared with the non-PDA group (40.8 +/- 2.3 versus 36.8 +/- 3.3, p < 0.01). Improvement became even more notable at the 6-month interval again, compared with themselves (43.8 +/- 4.5 versus 34.3, p < 0.001) and the non-PDA group (43.8 +/- 4.5 versus 38.1 +/- 5.1, p < 0.001). There was no notable improvement in test scores at 3 months or 6 months in the control group. Overall antibiotic decision accuracy substantially improved from 66% during the initial 3-month period to 86.6% during the second 3-month period (p = 0.005) among users of the JHABX. This was most evident in respiratory, blood, and skin and soft tissue infections. CONCLUSIONS: Web-based handheld technology is highly effective for supplying information to support infectious disease clinical practice. In a hospital intensive care setting, results of this study demonstrate that resident physician knowledge and antibiotic decision selection accuracy improved among Fellows using the JHABX. Reasons for this difference can be multifold and not thoroughly evaluated from this small pilot study. Future studies on the impact of point-of-care technology on patient outcomes are warranted.

A different approach to breast-feeding of the infant with phenylketonuria.

UNLABELLED: We studied the possibility and safety of a new approach to breast-feeding infants with phenylketonuria (PKU). We compared a group of PKU infants being breast-fed according to our new protocol with a group of PKU infants receiving formula only. The breast-fed group consisted of nine infants born between 1994 and 1999 being breast-fed at the time of diagnosis. The formula-fed group consisted of nine PKU infants, born between 1988 and 1997. In the breast-fed group, feedings alternated between breast-feeding and phenylalanine (Phe)-free bottle-feeding. The numbers of breast-feedings were adapted to the plasma Phe concentrations. At each feeding, either bottle- or breast-feeding, the child was allowed to drink until satiety. Data on metabolic control and growth during the first 6 months showed no statistically different results. The mean Phe concentration in the breast- fed group was 170 micro mol/l (range 137-243 micro mol/l) and in the formula- fed group 181 micro mol/l (range 114-257 micro mol/l). Compared to a routine where both bottle and breast are offered at each feeding, this new approach is more convenient for the parents and the child will be able to empty the breast, therefore drinking not only foremilk but also hindmilk. CONCLUSION: the results suggest that this feeding protocol is safe in the strict treatment of otherwise healthy infants with phenylketonuria.