Emergency department management of adults with infectious meningitis and encephalitis.

Infectious meningitis and encephalitis are often life-threatening illnesses, though prompt workup and targeted treatment can greatly reduce morbidity and mortality. Although presentation of central nervous system infection can sometimes be subtle, this issue focuses on evidence-based strategies for identifying combinations of signs and symptoms to narrow the diagnosis. Identifying meningitis versus encephalitis; bacterial versus viral, fungal, or iatrogenic causes; and providing prompt empiric antimicrobials and appropriate diagnostic testing are key to management. Cerebrospinal fluid testing findings are outlined to help determine a potential cause for symptoms, along with blood and serum testing options. International society guidelines and evidence regarding the need for computed tomography prior to lumbar puncture are presented, which can help reduce unnecessary imaging. Disposition criteria are expanded to help determine whether a patient can go home, or the level of hospital care that will be required for those admitted.

Obstructive Sleep Apnea High-Risk Prevalence, Symptoms and Sleepiness among Patients with Uncontrolled Type 2 Diabetes Mellitus Seen at the Out-Patient Department of Philippine General Hospital

@#Objectives. We determined the prevalence of patients at risk for obstructive sleep apnea (OSA) with uncontrolled type 2 diabetes mellitus (T2DM) at the out-patient department (OPD) of the University of the Philippines-Philippine General Hospital (UP-PGH) from December 1, 2018 - February 28, 2019. We described the demographic characteristics of patients with uncontrolled T2DM and compared them with high and low OSA risk, its association, and correlation with the quality of sleep. Methods. This is a prospective cross-sectional study among uncontrolled T2DM. The questionnaires were Berlin Questionnaire (screen OSA-HR) and Epworth Sleepiness Score (level of sleepiness). Clinicodemographic profile and significant laboratory data were obtained. Descriptive statistics utilized. Chi-square test was used to compare categorical variables between patients with high vs low OSA risk and to determine if an association exists between OSA-HR and sleep quality. Results. A total of 240 participants, 88 males and 151 females, were included in the study. The overall prevalence of OSA-HR among patients with uncontrolled type 2DM is 58.33%. The majority of the OSA–HR patients (105 /140) was 46 years old and above. There is a significant association of tonsillar grade, Mallampati score, BMI, HbA1c, hypercholesterolonemia, and Epworth sleepiness on OSA High risk. There is also a substantial association with age, BMI, Mallampati score, tonsillar grade, hypertension, asthma, HbA1c, and hypercholesterelonemia on the level of sleepiness of OSA-HR. Conclusion. There is a high prevalence of high OSA-risk among patients with uncontrolled DM. Factors associated with high OSA-risk among uncontrolled diabetes mellitus include HbA1c, dyslipidemia, BMI, Mallampati score, tonsillar grade, and Epworth score.

Obstructive Sleep Apnea High-Risk Prevalence, Symptoms and Sleepiness among Patients with Uncontrolled Type 2 Diabetes Mellitus Seen at the Out-Patient Department of Philippine General Hospital

@#Objectives. We determined the prevalence of patients at risk for obstructive sleep apnea (OSA) with uncontrolled type 2 diabetes mellitus (T2DM) at the out-patient department (OPD) of the University of the Philippines-Philippine General Hospital (UP-PGH) from December 1, 2018 - February 28, 2019. We described the demographic characteristics of patients with uncontrolled T2DM and compared them with high and low OSA risk, its association, and correlation with the quality of sleep. Methods. This is a prospective cross-sectional study among uncontrolled T2DM. The questionnaires were Berlin Questionnaire (screen OSA-HR) and Epworth Sleepiness Score (level of sleepiness). Clinicodemographic profile and significant laboratory data were obtained. Descriptive statistics utilized. Chi-square test was used to compare categorical variables between patients with high vs low OSA risk and to determine if an association exists between OSA-HR and sleep quality. Results. A total of 240 participants, 88 males and 151 females, were included in the study. The overall prevalence of OSA-HR among patients with uncontrolled type 2DM is 58.33%. The majority of the OSA–HR patients (105/140) was 46 years old and above. There is a significant association of tonsillar grade, Mallampati score, BMI, HbA1c, hypercholesterolonemia, and Epworth sleepiness on OSA High risk. There is also a substantial association with age, BMI, Mallampati score, tonsillar grade, hypertension, asthma, HbA1c, and hypercholesterelonemia on the level of sleepiness of OSA-HR. Conclusion. There is a high prevalence of high OSA-risk among patients with uncontrolled DM. Factors associated with high OSA-risk among uncontrolled diabetes mellitus include HbA1c, dyslipidemia, BMI, Mallampati score, tonsillar grade, and Epworth score.

Redox-influenced seismic properties of upper-mantle olivine.

Lateral variations of seismic wave speeds and attenuation (dissipation of strain energy) in the Earth's upper mantle have the potential to map key characteristics such as temperature, major-element composition, melt fraction and water content. The inversion of these data into meaningful representations of physical properties requires a robust understanding of the micromechanical processes that affect the propagation of seismic waves. Structurally bound water (hydroxyl) is believed to affect seismic properties but this has yet to be experimentally quantified. Here we present a comprehensive low-frequency forced-oscillation assessment of the seismic properties of olivine as a function of water content within the under-saturated regime that is relevant to the Earth's interior. Our results demonstrate that wave speeds and attenuation are in fact strikingly insensitive to water content. Rather, the redox conditions imposed by the choice of metal sleeving, and the associated defect chemistry, appear to have a substantial influence on the seismic properties. These findings suggest that elevated water contents are not responsible for low-velocity or high-attenuation structures in the upper mantle. Instead, the high attenuation observed in hydrous and oxidized regions of the upper mantle (such as above subduction zones) may reflect the prevailing oxygen fugacity. In addition, these data provide no support for the hypothesis whereby a sharp lithosphere-asthenosphere boundary is explained by enhanced grain boundary sliding in the presence of water.

Effect of rifampin on the pharmacokinetics and pharmacodynamics of prasugrel in healthy male subjects.

OBJECTIVE: Prasugrel is a thienopyridine antiplatelet agent for the prevention of atherothrombotic events in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Since cytochrome P450 enzymes CYP3A4 and CYP2B6 play a major role in prasugrel's active metabolite formation, the effect of potent CYP induction by rifampin on the pharmacokinetics of prasugrel and on the pharmacodynamic response to prasugrel was evaluated in healthy male subjects. RESEARCH DESIGN AND METHODS: This was an open-label, two-period, fixed-sequence study conducted at a single clinical research center. In the first treatment period, subjects received prasugrel as an oral 60-mg loading dose (LD) on the first day followed by ten oral, 10-mg daily maintenance doses. After a 2-week washout period, subjects received oral rifampin alone (600 mg once daily) for 8 days, followed by coadministration of oral rifampin with prasugrel, given as a 60-mg LD on the first day followed by five daily 10-mg MDs. Blood collection for pharmacokinetic and pharmacodynamic analyses occurred after the LD and fifth MD of prasugrel in both periods. CLINICAL TRIAL SYNOPSIS: clinicalstudyresults.org ID #8976 RESULTS: Rifampin coadministration (600 mg daily) did not affect exposure to prasugrel's active metabolite (R-138727). However, at 2 and 4 h after the prasugrel loading dose (60 mg), rifampicin coadministration was associated with a 6-9 percentage point decrease (p < 0.01) in the magnitude of platelet inhibition; similarly, a 5-17 percentage point decrease (p < 0.05) was observed with rifampin coadministration during the prasugrel maintenance dose (10 mg) period. Post hoc in vitro experiments demonstrated a dose-dependent R-138727-rifampin interaction at the P2Y(12) level unrelated to enzyme induction. A limitation of this study is that while results of the in vitro post hoc study indicate a pharmacodynamic interaction with rifampin, the mechanism underlying this interaction has not been elucidated. CONCLUSIONS: Dose adjustment should not be necessary when prasugrel is administered with CYP inducers since formation of prasugrel's active metabolite is not affected by potent enzyme induction with rifampin.

[Surgical and anesthetic managements of patients with porphyria].

Although the morbidity of porphyria is rare, the surgical and anesthetic managements of patients with porphyria should be prudent, for various stresses including surgery and anesthesia may cause occurrence or exacerbation of this disease, occasionally resulting in the mortal course. Several drugs such as barbiturate, diazepam, pentazocine, and pancuronium, which can be used during anesthesia or after operation, reportedly exacerbate the disease. Furthermore, the acute exacerbation of porphyria may be misdiagnosed as acute abdomen, ileus, acute appendicitis, cholelithiasis, urolithiasis, or ectopic pregnancy. The managements of patients with acute porphyria during anesthesia and after surgery are discussed along with the introduction of our case report. Since there is no definitive treatment of porphyria, the most important thing is to understand the disease and to prevent the acute exacerbation of the disease. When patients are suspected of porphyria or possible porphyria, careful management is required during anesthesia and after operation with selecting secure drugs against the disease.

[Anesthetic management of a patient with acute intermittent porphyria].

A 40-y-o female was scheduled for modified radical hysterectomy and pelvic lymphadenotomy for malignant ovarian tumor. Her past history revealed frequent episodes of reddish discoloration of her urine after physical strain. Her blood and urine samples were submitted for chemical analysis of metabolites of hemoglobin and porphyrin on suspicion of acute intermittent porphyria (AIP). Since these examinations took some days, the patient had to undergo the operation before the results arrived. To prevent an acute exacerbation of possible AIP, some anesthetic drugs had to be avoided. After premedication with atropine 0.5 mg IM, the patient had an epidural catheter placed for later use. General anesthesia was induced with intravenous fentanyl 0.3 mg IV, and inhalation of sevoflurane (0.5-4%) in nitrous oxide and oxygen by mask to eliminate psychological stress during the operation. Then, 0.5% bupivacaine was used through the epidural catheter to block the afferent physical stimulation from the lower half the body. Special attention was paid to stabilize the cardiovascular system. Color of the urine was carefully monitored with a densitometer to find out any early sign of a relapse of AIP during the operation. After the operation, reddish urine and rapid respiration suggested a possible exacerbation of AIP. Fluid therapy with glucose, sedation with chlorpromazine IV and an epidural infusion of buprenorphine (0.5 mg) were performed. The urine became clear several days after the operation and the postoperative course was uneventful. Anesthetic management of patients with AIP is discussed along with the introduction of pertinent literatures.

[The effect of drug therapy and stellate ganglion block with or without oxygen inhalation on sudden hearing loss].

Forty-one patients suffering from sudden hearing loss were studied by the following method. Twenty patients (group A) were treated with oral administration of prednisolone, intravenous administration of vitamin B and C, furosemide and stellate ganglion block. Another 21 patients (group B) were treated with oral administration of these drugs, stellate ganglion block and oxygen inhalation. Forty six percent of all these patients, 35 percent of group A and 57 percent of group B, regained less than 20 dB of their normal hearing level. The patients who are younger, having shorter duration from first finding of symptoms to starting of therapy and smaller average deficiency of hearing, without dizziness are easy to recover. Oxygen inhalation with drug therapy and stellate ganglion block is a useful treatment for sudden hearing loss.

[Assessment of the autonomic nervous activities under nitrous oxide-enflurane anesthesia by heart rate fluctuation analysis].

For numerical expression of the autonomic nervous activities during 60% nitrous oxide (N2O), enflurane (Enf) and oxygen anesthesia, heart rate fluctuations were studied in 13 female patients undergoing a laparoscopic examination. Atropine (0.5 mg im) and hydroxidine (50 mg im) were given one hour prior to induction of anesthesia with thiamylal (5 mg.kg-1 iv). Following the induction, succinylcholine (1 mg.kg-1 iv) was administered, and the trachea was intubated. Enf concentration was monitored throughout the study and expressed by the end-tidal values. An electrocardiogram in lead 2 was recorded on a magnetic tape for 3 minutes each time, before the induction of anesthesia (baseline value), during anesthesia with both 1.9% Enf and 1.0% Enf, then 5 and 20 min after tracheal extubation. These data were subjected later to computer analysis for heart rate fluctuations. At 1.9% Enf and after the skin incision, the R-R intervals and the coefficient variation of R-R interval (CV-RR) were significantly reduced to 90% (P less than 0.05) and 32% (P less than 0.01) of the baseline values respectively. A significant reduction (P less than 0.01) was also observed in both the high frequency component (HFC: 0.15-0.4 Hz) and the low frequency component (LFC: 0.05-0.15 Hz) of the power spectrum of heart rate fluctuations. The peak amplitude and the band area of the HFC were reduced to 20 and 35% of the baseline values, while those of the LFC was reduced to around 14%.(ABSTRACT TRUNCATED AT 250 WORDS)

[The autonomic nervous activities in man under thoracic epidural anesthesia assessed by heart rate fluctuation analysis].

The R-R intervals of an electrocardiogram, the coefficient variation of R-R intervals (CV-RR), and the power spectrum of heart rate fluctuation were studied just before surgical operations in a group of 10 patients who underwent high thoracic epidural anesthesia (TEA), and before anesthesia in a control group of 10 patients who were scheduled for general anesthesia without TEA. When TEA was performed, the CV-RR increased significantly (P less than 0.05). An increasing tendency (P less than 0.1) was also observed in the R-R intervals and the spectral analysis of the peak amplitude of the low frequency component (LFC) of 0.05 to 0.15 Hz. This tendency was found, too, in the band areas of the LFC and the high frequency component (HFC) of 0.15 to 0.4 Hz. These data indicate that the sympathetic innervation of the heart might have been interrupted by TEA and the vagal tone might have become dominant. Subsequent intravenous administration of atropine 0.5 mg reduced the R-R intervals, the CV-RR, the peak amplitude and the band areas of the LFC and HFC (P less than 0.01), as were seen in the control group. These evidences will show that the heart rate regulation of man in a supine position is dominantly influenced by the vagal tone, and it will become more prominent under TEA by blocking the cardiac sympathetic innervation at spinal level. Present study also suggests that a contribution of the cardiac sympathetic nerve on heart rate fluctuation, even on LFC, is only slight.(ABSTRACT TRUNCATED AT 250 WORDS)