Axillary Artery Injury with Intact Radial Pulse following Fracture-Dislocation of Shoulder: A Case Report.

The occurrence of axillary artery injury following proximal humerus fracture dislocation in elderly patient with low velocity fall is uncommon. The patient could have diverse clinical presentations in spite of intact peripheral pulses. We report the case of an 85-year-old lady who presented to our emergency department with greater tuberosity fracture of the humerus with dislocation of the right shoulder. After closed manipulative reduction of the dislocation, it was observed that the patient had brachial plexus palsy with intact radial pulse. An expanding swelling and bruise around the shoulder was noted and a steady drop in haemoglobin level. CT angiogram revealed avulsion of the posterior circumflex artery which was then treated successfully with stenting.

Axillary Artery Injury with Intact Radial Pulse following Fracture-Dislocation of Shoulder: A Case Report

@#The occurrence of axillary artery injury following proximal humerus fracture dislocation in elderly patient with low velocity fall is uncommon. The patient could have diverse clinical presentations in spite of intact peripheral pulses. We report the case of an 85-year-old lady who presented to our emergency department with greater tuberosity fracture of the humerus with dislocation of the right shoulder. After closed manipulative reduction of the dislocation, it was observed that the patient had brachial plexus palsy with intact radial pulse. An expanding swelling and bruise around the shoulder was noted and a steady drop in haemoglobin level. CT angiogram revealed avulsion of the posterior circumflex artery which was then treated successfully with stenting.

Inflammatory microglia are glycolytic and iron retentive and typify the microglia in APP/PS1 mice.

Microglia, like macrophages, can adopt inflammatory and anti-inflammatory phenotypes depending on the stimulus. In macrophages, the evidence indicates that these phenotypes have different metabolic profiles with lipopolysaccharide (LPS)- or interferon-γ (IFNγ)-stimulated inflammatory cells switching to glycolysis as their main source of ATP and interleukin-4 (IL-4)-stimulated cells utilizing oxidative phosphorylation. There is a paucity of information regarding the metabolic signatures of inflammatory and anti-inflammatory microglia. Here, we polarized primary microglia with IFNγ and show that the characteristic increases in tumor necrosis factor-α (TNFα) and nitric oxide synthase 2 (NOS2) were accompanied by increased glycolysis and an increase in the expression of 6-phosphofructo-2-kinase/fructose-2,6-biphosphatase (PFKFB)3, an enzyme that plays a significant role in driving glycolysis. These changes were associated with increased expression of ferritin and retention of iron in microglia. Significantly, retention of iron in microglia increased TNFα expression and also increased glycolysis suggesting that increased intracellular iron concentration may drive the metabolic and/or inflammatory changes. Analysis of microglia prepared from wildtype mice and from transgenic mice that overexpress amyloid precursor protein (APP) and presenilin 1 (PS1; APP/PS1) revealed genotype-related increases in glycolysis, accompanied by increased PFKFB3, and an increase in the expression of ferritin. The data indicate a distinct metabolic signature of inflammatory microglia from APP/PS1 mice that are also distinguishable by their iron handling profiles.

Retrograde vs. antegrade puncture for infra-inguinal angioplasty.

This study was done to compare antegrade punctures with a retrograde puncture technique for infrainguinal angioplasty. A group of 100 consecutive patients (71 men, 29 women) were randomized for antegrade puncture or retrograde puncture of the common femoral artery. Following retrograde puncture the guidewire was 'turned' and placed into the superficial femoral artery. The time for gaining access, screening time, radiation dose, patient height, weight and complications were recorded. All patients were reviewed the day after the procedure and within 3 months. Data from 46 patients (34 males and 12 females) in the retrograde group and 44 (28 males and 16 females) in the antegrade group were available for analysis. Mean procedure time, screening time, radiation dose, height and weight were 8.3 minutes (range 3-22), 2.1 minutes (0.3-6.5), 7950 mGy cm(-2) (820-71250), 169 cm (149-204) and 79 kg (32-108) for retrograde puncture and 8 min (2-60), 0.7 min (0.0-3.2), 1069 mGy cm(-2) (0-15400), 169 cm (152-186) and 75 kg (39-125) for antegrade punctures, respectively. An average of 1.2 (1-2) punctures was required for retrograde and 1.75 (1-8) for antegrade. Seven small hematomas occurred with antegrade and three for retrograde puncture. Retrograde puncture is technically easier with a tendency to fewer complications but results in a higher radiation dose. This technique should be used in difficult patients at high risk of haematoma formation.

Outcome of "kissing stents" for aortoiliac atherosclerotic disease, including the effect on the non-diseased contralateral iliac limb.

PURPOSE: To assess outcomes following "kissing stents" for aortoiliac atherosclerotic disease, particularly in the non-diseased/non-symptomatic limb. METHODS: Twenty-four patients underwent kissing stenting over 36 months. There were 36 symptomatic and 12 non-symptomatic/non-diseased limbs. Patients were prospectively followed with 3-monthly clinical assessment as well as duplex ultrasound. RESULTS: At 23.5 months follow-up (range 3-36 months), 75% of patients had improvement in symptoms, 20% no change and 5% had deterioration. Sixty-one percent of limbs maintained an increase in ankle-brachial pressure index of >0.1. There were 15 reinterventions in nine patients, including three in non-symptomatic/non-diseased limbs. Primary patency at 6, 12 and 24 months was 94%, 81% and 58%, respectively. Primary assisted and secondary patency rates were 96%, 84% and 84% respectively for diseased limbs, and 92% and 100% for non-symptomatic/non-diseased limbs. Although reinterventions were required, there were no long-term occlusions in the non-diseased/non-symptomatic limb. CONCLUSION: Kissing stents offer an invaluable alternative to surgery. There were no long-term occlusions following kissing stents in a previously non-symptomatic/non-diseased limb.

Science and science education in schools after the Great Exhibition.

The development of science education in England and Wales was slow in the 19th century. Here, I examine the causes of this slow development, and also the factors that affected the direction that science education took in elementary schools, secondary schools and universities.

Radiocontrast interference in screening tests for genetic-metabolic diseases.

Screening tests for genetic metabolic diseases remain extremely useful due to their rapidity, ease of interpretation and substantial reduction of cost. However, interferences in these tests are still a source of concern in laboratory medicine. Cost considerations have so compressed the duration of the medical work-up that the administration of radiologic contrast may often antedate the collection of body fluids for genetic-metabolic testing. It has been found that under these circumstances, certain contrast media may interfere with the urinary studies of amino acids, organic acids, and tests involving ultraviolet absorption such as those concerned with purines, pyrimidines, and related compounds. The consequences of interference may be misdiagnosis, repeated testing, extensive and expensive work-ups, and unnecessary delay and anxiety for the family. As in all testing, it is prudent to avoid medications and atypical diets, if possible. In the case of contrast media, it is a simple matter to collect samples for analysis prior to the administration of radiocontrast so as to avoid the pitfalls and yet not delay the diagnostic work-up.

Medicolegal pitfalls in the involuntary confinement of psychiatric patients in Louisiana.

Involuntary confinement of psychiatric patients is an area fraught with medicolegal risks. This is especially important in states such as Louisiana with large rural areas where involuntary confinement or treatment is often initiated by non-psychiatrists. This paper discusses errors that are frequently made in the process in Louisiana and attempts to help the physician avoid them.

Legal approaches to the restraint of trade of nurse practitioners: disparate reimbursement patterns.

Nurse practitioners (NPs) can face, and have faced, several challenges in the health care environment. As with the denial of hospital admitting or staff privileges, the granting of inequitable reimbursement levels by state administrative bodies, physicians, insurers, and other members of the health care community may limit NP practice. Several strategies are discussed that will demonstrate how nurse practitioners can use legal and administrative mechanisms (e.g., antitrust laws) to eliminate restraints of trade and assure the availability of more equitable direct reimbursement patterns.

Restraint of trade implications for nurse practitioners: denial of hospital admitting or staff privileges.

Denial of hospital admitting or staff privileges can limit the practice of a nurse practitioner. The Sherman Antitrust Act (1982) with restraint of trade stipulations has been used successfully by nonphysician health care providers to gain hospital admitting and staff privileges. Cases are discussed to offer examples to nurse practitioners for a potential legal recourse for gaining desired privileges.

Objectively measured hyperactivity--II. Caffeine and amphetamine effects.

Errors of commission and omission, chair movements, and reaction times were assessed in fifteen previously diagnosed hyperactive children on a Continuous Performance Test after four drug regimens: amphetamine at doses of 1.6 and 5.0 mg twice a day, as well as 300 mg caffeine administered alone and with 1.6 mg amphetamine twice a day, produced significant reductions in errors of commission and increased reaction times in those children scoring 24 or more on the Conner's Abbreviated Parent Questionnaire. In addition, subjective symptoms on this questionnaire were significantly reduced by all drug treatments. The high (600 mg) daily dose of caffeine was observed to significantly control hyperactive symptoms, however, it also produced a number of side effects as well.

Objectively measured hyperactivity--I. Comparison with normal controls.

Seventy-five normal (control) children were compared to 15 hyperactive children on a Continuous Performance Test over an eight-week period. The control children were observed to have a relatively constant number of correct responses, chair movements, and reaction times throughout the testing period. However, when the hyperactive children were differentiated according to their scores on the Conner's Abbreviated Parent Questionnaire, those children scoring one standard deviation above the normative mean were later revealed to have more errors of commission and omission, chair movements, and a longer reaction time than did the normal control children.

Binocular pattern stabilization by afterimage technique: reliability of children's time-dependent judgments of chromatic features.

To investigate visual afterimage technique as a means of producing retinally stabilized pattern, children's judgments of time-dependent shifts in chromatic appearance of random-dot configurations were twice examined within a 3-wk. interval. 13 subjects, aged 7 to 12 yr., were very consistent (r = .93) in their test-retest response times. This supports the belief that after image procedures can be developed as a reliable means of studying developmental aspects of stabilized pattern perception.

Cerebro-hepato-renal syndrome. Report of a case with histochemical and ultrastructural observations.

A new case of the cerebro-hepato-renal syndrome is being reported. The neuropathologic changes consisted of developmental abnormalities of cerebral and cerebellar cortex and of the inferior olives. In addition, there were metabolic changes in the central nervous system, indicated by an accumulation of lipid within histiocytes of free in gray and white matter, deficiency in myelination and gliosis of the white matter, and marked proliferation of protoplasmic astrocytes in the gray matter. A unique feature of this case was the presence of numerous clusters of lipid-filled macrophages and occasional cholesterol crystals in the molecular layer of the cerebellum. The histochemical reactions and ultrastructural appearances of the lipid deposits are suggestive of accumulation of several different types of lipids.