Survival of polymeric microstructures subjected to interrogatory touch.

Polymeric arrays of microrelief structures have a range of potential applications. For example, to influence wettability, to act as biologically inspired adhesives, to resist biofouling, and to play a role in the "feel" of an object during tactile interaction. Here, we investigate the damage to micropillar arrays comprising pillars of different modulus, spacing, diameter, and aspect ratio due to the sliding of a silicone cast of a human finger. The goal is to determine the effect of these parameters on the types of damage observed, including adhesive failure and ploughing of material from the finger onto the array. Our experiments point to four principal conclusions [1]. Aspect ratio is the dominant parameter in determining survivability through its effect on the bending stiffness of micropillars [2]. All else equal, micropillars with larger diameter are less susceptible to breakage and collapse [3]. The spacing of pillars in the array largely determines which type of adhesive failure occurs in non-surviving arrays [4]. Elastic modulus plays an important role in survivability. Clear evidence of elastic recovery was seen in the more flexible polymer and this recovery led to more instances of pristine survivability where the stiffer polymer tended to ablate PDMS. We developed a simple model to describe the observed bending of micropillars, based on the quasi-static mechanics of beam-columns, that indicated they experience forces ranging from 10-4-10-7 N to deflect into adhesive contact. Taken together, results obtained using our framework should inform design considerations for microstructures intended to be handled by human users.

Acupuncture for Pain and Nausea in the Intensive Care Unit: A Feasibility Study in a Public Safety Net Hospital.

OBJECTIVES: To explore the feasibility and acceptability of providing acupuncture treatment to relieve pain and nausea symptoms in intensive care unit (ICU) patients. DESIGN: Prospective feasibility study. SETTINGS/LOCATION: Public safety net hospital with a 20-bed mixed medical/surgical ICU. SUBJECTS: Patients from all services admitted to the ICU from November 14, 2014 to April 2015. INTERVENTIONS: Three 20 min acupuncture treatments given for consented patients who were experiencing pain and/or nausea, in addition to usual care. OUTCOME MEASURES: Primary outcomes assessed were the proportion of patients offered acupuncture who accepted it, their perceptions of the effects of acupuncture treatment on pain and nausea, and the incidence of adverse effects related to acupuncture. Secondary outcomes included medication use, ICU and hospital length of stay, and frequency and pattern of Traditional Chinese Medicine (TCM) diagnoses. RESULTS: Of the 576 patients admitted to the ICU, 32.2% were deemed eligible for acupuncture and 42% of these (8% of total) received it. Self-reported pain level immediately after treatment decreased from the pain score reported immediately before treatment by 2.36 points. The majority of patients reported a benefit from acupuncture on symptoms of pain and also an anxiolytic effect. No major adverse effects were reported. There was a significant decrease in morphine usage after each treatment. The most common single TCM diagnosis was Qi and blood stagnation. CONCLUSIONS: Acupuncture is feasible, safe, and acceptable in an ICU setting by patients from diverse backgrounds.

A Simplified Protocol for the Treatment of Alcohol Withdrawal.

OBJECTIVES: The aim of the study was to evaluate a novel simplified tool for symptom-triggered treatment of alcohol withdrawal. METHODS: This retrospective cohort study involved inpatients in a county hospital with an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis of alcohol withdrawal syndrome (AWS) or delirium tremens between January 1, 2007 and December 31, 2008. The study used the Highland Alcohol Withdrawal Protocol (HAWP)-a simplified derivative of the Revised Clinical Institute Withdrawal Assessment for Alcohol. Multivariable regression analysis was performed to compare severity of withdrawal to hospital length of stay, total dose of sedative given, and risk of complications. RESULTS: The study identified 442 patients with a primary diagnosis of AWS or delirium tremens, and those with another primary medical diagnosis complicated by alcohol withdrawal. After adjusting for demographic variables, each one-point increase in the initial and maximum HAWP scores correlated with an increase in the hospital length of stay of 0.3 days [95% confidence interval (95% CI), 0.17 to 0.43 days] and 0.45 days (95% CI, 0.32-0.57 days), and a 15.8 mg (95% CI, 6.6-25.1 mg) and 19.8 mg (95% CI, 11.1-28.5 mg) increase in the total dose of lorazepam given, respectively. The complication rate of seizures, intubations, pneumonia, and death was 13.1%, 12.9%, 6.1% and 0.9%, respectively; a composite endpoint of these outcomes also correlated with initial and maximum HAWP scores (odds ratio 1.09, 95% CI, 1.03%-1.14%). CONCLUSIONS: The HAWP correlates with medication received and complications, and as such appears to give an indication of AWS severity. It is feasible and shorter than prior scales, and merits further study to confirm its effectiveness as part of symptom-triggered protocols to manage alcohol withdrawal in the hospital.

Cuff leak test and laryngeal survey for predicting post-extubation stridor.

BACKGROUND AND AIMS: Evidence for the predictive value of the cuff leak test (CLT) for post-extubation stridor (PES) is conflicting. We evaluated the association and accuracy of CLT alone or combined with other laryngeal parameters with PES. METHODS: Fifty-one mechanically ventilated adult patients in a medical-surgical intensive care unit were tested prior to extubation using; CLT, laryngeal ultrasound and indirect laryngoscopy. Biometric, laryngeal and endotracheal tube (ETT) parameters were recorded. RESULTS: PES incidence was 4%. CLT demonstrated 'no leak' in 20% of patients. Laryngeal oedema was present in 10% of the patients on indirect laryngoscopy, and 71% of the patients had a Grades 1-3 indirect laryngoscopic view. Mean air column width on laryngeal ultrasound was 0.66 ± 0.15 cm (cuff deflated), mean ratio of ETT to laryngeal diameter was 0.48 ± 0.07, and the calculated CLT and laryngeal survey composite was 0.86 ± 1.25 (range 0-5). CLT and the CLT and Laryngeal survey composite measure were not associated with or predict PES. Age, sex, peri-extubation steroid use, intubation duration and body mass index were not associated with PES. CONCLUSION: Even including ultrasonographic and indirect laryngoscopic examination of the airway, no single aspect of the CLT or combination with laryngeal parameters accurately predicts PES.

Seronegative catastrophic antiphospholipid syndrome in a young female presenting with a headache.

BACKGROUND: Catastrophic antiphospholipid syndrome (CAPS) is a rare disease that causes rapid vascular occlusion in multiple organ systems. Initial presentation varies depending on the organs affected. Although headache is a common complaint in the emergency department (ED), it is a very rare presentation of CAPS. CASE REPORT: A 43-year-old previously healthy woman presented to the ED with severe headache. Subarachnoid hemorrhage was excluded and she was discharged home. She returned 36 h later with diabetic ketoacidosis, hyperthyroidism, and thrombosis in her cerebral venous sinus, aorta and splenic artery. She was treated with heparin, steroids, plasmapharesis, and i.v. immunoglobulin, after which she improved. This constellation of symptoms is highly suggestive of CAPS initiated by a polyglandular autoimmune syndrome, despite negative serology. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although a rare cause of headache, CAPS is a potentially fatal disease that requires early identification and initiation of appropriate treatment.

Management of subcutaneous emphysema with "gills": case report and review of the literature.

BACKGROUND: Subcutaneous emphysema is often a symptom of a serious pathologic condition but rarely requires direct treatment. Subcutaneous emphysema itself occasionally may interfere with effective cardiopulmonary resuscitation and require direct intervention. OBJECTIVE: The aim of this article is to present a case of subcutaneous emphysema during cardiac arrest and to describe a therapeutic technique that we call the "gills" procedure, as well as the background and rationale for this and other similar techniques. CASE REPORT: A 56-year-old man sustained cardiac arrest in the setting of a perforated duodenal ulcer with massive subcutaneous emphysema and pneumomediastinum that interfered with effective cardiopulmonary resuscitation. A "gills" procedure consisting of bilateral skin incisions over the clavicles was performed, with the return of spontaneous circulation. CONCLUSION: Subcutaneous emphysema and pneumomediastinum can cause tension physiology, impairing normal cardiovascular and pulmonary function. Only with release of this tension can normal cardiopulmonary function return. The gills procedure is one of several possible therapeutic options.

A cluster of fulminant, fatal necrotizing community-associated methicillin-resistant Staphylococcus aureus pneumonias.

Community-associated methicillin-resistant Staphylococcus aureus is a frequent cause of skin and soft-tissue infections and is increasingly identified as a cause of pneumonia in immunocompetent patients. Panton-Valentine leukocidin, one of several leukocytotoxic peptides secreted by these cocci, is associated with increased virulence. A cluster of 3 unrelated patients with fatal pneumonia presumably caused by community-associated methicillin-resistant S aureus positive for Panton-Valentine leukocidin were treated in a 3-week period. Despite aggressive care and appropriate, timely administration of antibiotics, all 3 patients died. This article reviews the clinical and laboratory features suggestive of this lethal isolate, including unique findings on Gram stains of sputum.

Abdominal compartment syndrome successfully treated with neuromuscular blockade.

A 48 year old male admitted to the intensive care unit after a cardiac arrest complicated by a stroke intra-operatively during automatic implantable cardioverter defibrillator placement. He post-operatively developed a rigid abdomen, elevated peak and plateau pressures, hypoxia and renal insufficiency. He was diagnosed with abdominal compartment syndrome with an intra-abdominal compartment pressure of 40mmHg. The patient was administered 10 mg of intravenous cisatracuriumbesylate in preparation for bedside surgical abdominal decompression. Cisatracurium eliminated the patients need for surgical intervention by reducing his abdominal compartment pressures to normal and improving his hypoxia and renal function. This case illustrates that neuromuscular blockade should be attempted in patients with abdominal compartment syndrome prior to surgical intervention.

Morphine-induced cardiogenic shock.

OBJECTIVE: Although animal and human models suggest that direct suppression of myocardial contractility may occur with morphine administration, to our knowledge, clinical observation of this potentially important effect has not been reported. This case report presents a unique case of morphine-induced transient reversible cardiogenic shock. CASE SUMMARY: A 44-year-old woman with a history of hypertension, diabetes, and asthma presented with a 3-day history of epigastric pain. Initial investigation results revealed elevated serum lipase level and computed tomography imaging that was consistent with a diagnosis of mild acute pancreatitis. Intravenous fluids and morphine, via patient-controlled analgesia, were started and the patient was admitted. The next day, she developed cardiogenic shock with a globally reduced left ventricular ejection fraction (LVEF) of 26% and was admitted to the intensive care unit. Morphine was discontinued and norepinephrine and naloxone were concurrently administered. Over the next 24 hours her clinical status improved, and an echocardiogram 29 hours after the initial echocardiogram showed normal LV function (LVEF 62%). DISCUSSION: To our knowledge, this represents the first reported case of clinically significant morphine-induced cardiogenic shock. An objective causality assessment using the Naranjo probability scale suggests that the cardiogenic shock was probably related to morphine. Other causes of shock were ruled out. Additionally, the fact that the transient nature of the observed LV dysfunction reversed with discontinuation of morphine and administration of naloxone provides further support, particularly with the evidence that opiates may depress cardiac myocytes and cardiac output in animal and human models. CONCLUSIONS: Opiates can cause severe LV dysfunction. Physicians should consider emergent evaluation for myocardial depression in patients who are receiving opioids and present with persistent hypotension or pulmonary edema without other known etiology.

Acute agitated delirious state associated with Taser exposure.

BACKGROUND: The use of the Taser (Taser International, Scottsdale, Arizona) as a form of nonlethal force is increasingly common because of its safety profile. Tasers have been associated with in-custody mortality particularly in agitated individuals, though potential explanatory mechanisms are poorly understood. While Tasers are often used to subdue acutely agitated individuals, no study has reported Taser exposure precipitating agitation or delirium, even though high-voltage electrical exposure is well documented independently to precipitate acute delirium. OBJECTIVES: We present a case of an acute agitated or delirious state occurring post-Taser exposure in a resting, otherwise nonagitated individual. CASE REPORT: The patient was a 37-year-old African American male with no prior psychiatric history, tasered multiple times during an arrest episode. He became delirious and agitated while in the emergency department, requiring sedation and intubation, followed by 3 days of continued refractory delirium. Toxicology screening demonstrated therapeutic doses of methadone and trace amounts of marijuana, not thought to be associated with the acute onset of the patient's agitated or delirious state. Imaging, neurological, and psychiatric assessments were similarly not contributory. CONCLUSION: The occurrence of acute agitation and delirium in this patient without any prior psychiatric history or significant substance use suggests an association with Taser exposure. This case report is thought to be the first report demonstrating a temporal association between Taser exposure and an acute or delirious state. Further studies to explore the association between Taser exposure and acute agitation are needed.

Successful use of a polymerized hemoglobin blood substitute in a critically anemic Jehovah's Witness.

A stable, polymerized hemoglobin product has been formulated that overcomes the three traditional hurdles of hemoglobin-based blood substitutes: nephrotoxicity, osmotic diuresis, and blood-borne pathogens. We present a case of a patient with persistent colonic bleeding and a hemoglobin of 2.9 g/100 mL. Since her religious faith prevented her from accepting blood products, we offered a hemoglobin-based substitute and describe the use of this product.