Ondansetron-Induced Life Threatening Hypokalemia.

Ondansetron is widely used in general practice for nausea and vomiting due to any cause. We report a rare side effect, life-threatening hypokalaemia following intravenous Ondansetron injection. It may be judicious to restrict the use of Odansetron to patients with severe vomiting due to chemotherapy or in post-operative state. Life-threatening hypokalemia can occur without any warning and may be difficult to manage in a primary set up.

Recovery of plants from pea and strawberry meristems cryopreserved for 28 years.

Meristems isolated from in vitro strawberry shoot cultures (Fragaria x ananassa Duch. cv. Redcoat) and in vitro germinated pea seedlings (Pisum sativum L. cv. Century) were treated with cryoprotectants, slowly frozen to -40 degree C (0.6 degree C per min for pea and 0.84 degree C per min for strawberry), and stored in liquid nitrogen in 1979. In 2007, several ampoules containing cryopreserved meristems of each species were thawed, cultured in vitro, and scored for viability. Meristems which differentiated into plants upon thawing and reculture were considered viable. Fifty-nine percent of the 91 strawberry meristems thawed in 2007 were viable after 28 years of cryopreservation, as compared to 56 percent viability after 8 weeks cryopreservation, as reported in the original study. Fourteen percent of the 78 pea meristems thawed in 2007 were viable after 28 years, as compared to 61 percent after 26 weeks of cryopreservation, as reported in the original study. With both strawberry and pea meristems there was variability in viability between ampoules. Viability between thawed ampoules of strawberry meristems ranged from 35 to 80 percent. Four of eight thawed ampoules of pea meristems contained no viable meristems, while the highest viability from a single ampoule was 77 percent. Shoots obtained from surviving meristems were rooted in vitro, transferred to soil, and produced phenotypically normal plants.

Five-year results of viscocanalostomy.

PURPOSE: To prospectively study the success rates and complications of viscocanalostomy. METHODS: Prospective nonrandomized case series of 46 eyes (46 patients) with medically uncontrolled primary and secondary open angle glaucoma. All patients in the study underwent viscocanalostomy. Control of intraocular pressure was used to measure success. Pre and postoperative glaucoma medications, visual acuity, complications, and adjunctive procedures were recorded. RESULTS: At 60 months, qualified success (intraocular pressure below 21 mmHg with glaucoma medication) was achieved in 37 (82%) patients and complete success (intraocular pressure below 21 mmHg without medication) in 25 (54%) patients. Nd:YAG laser goniopuncture was performed in 33 (72%) patients with significant post laser reduction of intraocular pressure. No sight threatening complications were observed in this series. Visual acuity remained unchanged in 33 patients (72%). CONCLUSIONS: Viscocanalostomy appears to be a safe and effective intraocular pressure lowering procedure in eyes with primary open angle glaucoma and certain types of secondary open angle glaucoma.

Immunohistochemical analysis of p53 expression in primary breast carcinomas.

Expression of p53 protein was investigated by immunohistochemical techniques in archival cases of 134 primary breast carcinomas comprising 13 comedo ductal carcinoma in situ (DCIS), 105 invasive ductal carcinomas, 7 contained the comedo DCIS component adjacent to the invasive ductal component, 5 invasive lobular carcinomas, three colloid carcinomas and one medullary carcinoma. Overexpression of p53 gene product was studied to determine the association with clinico-pathological parameters and also its relationship to c-erbB2. Overexpression of p53 protein was observed in 31% (4/13) of comedo DCIS, 37% (39/105) of invasive ductal carcinomas, 57% (4/7) of carcinomas containing both the in situ and invasive lesions and all medullary carcinomas. A significant relationship (p < 0.05) was observed between strong immunoreactivity of p53 protein and absence of estrogen receptor, histological grade and c-erbB2 but not with lymph node metastases or age of patient. These observations suggest that overexpression of p53 protein may play an important role in tumor progression from noninvasive to invasive in some breast carcinomas and may have potential as an indicator for poorer prognosis.

Peritoneal trophoblastic implant.

A case of persistent trophoblastic tissue on the pelvic peritoneum is presented. While most cases are secondary to conservative surgery for tubal ectopic pregnancy, primary implantation can also occur as highlighted by this case. A brief pathophysiology of the condition is presented. The importance of monitoring the serum for beta subunit human chorionic gonadotrophin (HCG) is emphasised.

Endotracheal intubation by paramedics during in-hospital CPR.

STUDY OBJECTIVE: To examine whether well-trained paramedics can perform emergent, successful, uncomplicated, endotracheal intubations during in-hospital cardiopulmonary resuscitation (CPR). DESIGN: Retrospective review of medical records of in-patients undergoing emergent, endotracheal intubations during in-hospital, CPR over 8 months, with comparison of the performance of the paramedics against that of other hospital-based personnel. SETTING: A 437-bed Midwestern community teaching hospital. PATIENTS: Adult in-patients in general medical/surgical wards. MAIN OUTCOME MEASURES: The rapidity of response of paramedics and other medical personnel to a cardiorespiratory arrest (code 4) announcement, and reported difficulties, success rate, rapidity, and complications of endotracheal intubation. RESULTS: In the 47 cardiorespiratory arrests requiring intubation that we analyzed, the median response times (with values in parentheses representing interquartile range [IQR]) for paramedics, nurse anesthetists (CRNAs), anesthesiologists, and other physicians respectively, were 2.00 (4.25), 4.00 (2.0), 4.00 (15.0), and 7.00 (8.0) min, requiring a median of 1.0 attempt for all groups (mean values, 1.4, 1.125, 1.0, and 1.4 respectively) to place an endotracheal tube. The paramedics were successful in 13 of 15 instances. Median times (seconds) required for intubation by various groups (same order as response times, with IQR given in parentheses) were 60 (30), 150 (270), 45 (30), and 60 (30). Difficulties were reported by all groups, including patients' resistance to intubation, airway obstruction by extraneous material, and difficulty in visualizing the glottis. Reported complications (4%) were confined to groups other than the paramedics. CONCLUSIONS: Paramedics can successfully, and without undue difficulty or complications, place endotracheal tubes during in-hospital CPR. Appropriately trained paramedics may be incorporated into hospital-based CPR teams in two contexts: (1) to provide an acceptable, long-term solution to the scarcity of personnel highly skilled in endotracheal tube placement during in-hospital CPR, and (2) to fulfill the need for hospitals to have on-site, qualified professionals to perform emergent endotracheal intubation during CPR. In the latter situation, personnel skilled in airway management could supplement the paramedics on demand. Further investigation in this area could be fruitful in view of the small sample size covered in this study.

Cardiopulmonary resuscitation in elderly patients hospitalized in the 1990s: a favorable outcome.

OBJECTIVE: To compare the clinical characteristics and survival of elderly and younger hospitalized patients who sustain cardiac arrest and receive cardiopulmonary resuscitation (CPR) in the 1990's and to assess predictors of survival. DESIGN: Retrospective survey of cardiac arrest database and hospital charts, plus telephone follow-up. SETTING: 450-bed acute care teaching hospital. STUDY POPULATION: Seventy-eight hospitalized patients 70 years or older and 73 hospitalized patients under 70 years of age. MEASUREMENTS: Survey of cardiac arrest data base, hospital charts, and telephonic follow-up to allow (1) comparison of clinical characteristics, survival, and long-term follow-up between two age groups and (2) univariate and multivariate analysis of predictors of mortality. MAIN RESULTS: Pre-arrest clinical characteristics were not significantly different between the age groups. Prior to arrest the majority of patients were functionally active, and over one-third were hospitalized for acute coronary artery syndromes. In approximately 85% of the patients, the arrest was witnessed, and 70% of the patients had their cardiac rhythm monitored at onset of the arrest. Survival was not significantly different between the age groups; 26% of the total 151 patients were discharged. No significant difference was noted in pre-post arrest functional status of survivors. Survival at 1, 2, and 3 years in elderly and younger survivors was 86% versus 80%, 76% versus 67%, and 71% versus 61%, respectively. Multivariate analysis identified the presence of coronary artery disease, admission systolic blood pressure, and functional level to be independent pre-arrest predictors of mortality. At the time of the arrest, the initial cardiac rhythm and duration of CPR were found to be independent predictors of mortality. CONCLUSIONS: Elderly patients hospitalized in the 1990's who receive CPR have outcomes similar to younger patients who receive CPR. The favorable outcome in the elderly patients may reflect patient selection: the majority of our patients were functionally active prior to hospitalization, without multiple serious illnesses; many were hospitalized for acute coronary artery syndromes; and, in most cases, the arrest was witnessed with the patient's cardiac rhythm monitored at onset of the arrest.

Serum pseudocholinesterase and very-low-density lipoprotein metabolism.

Serum pseudocholinesterase (PChE) was discovered in 1932. Since this protein mimics many of the catalytic properties of acetylcholinesterase, it has traditionally been referred to as PChE, even though its true biological function is unknown. Serum PChE is synthesized in the liver and secreted into the circulation as a sialated glycoprotein. Although no convincing evidence of biological function exists, a significant number of obese and diabetic patients have elevated levels of PChE. The same phenomenon is found in experimental animal models of obesity, diabetes and hyperlipoproteinemia. Streptozotocin-induced diabetic mice showed increased serum PChE activity concomitant with increased serum triacylglycerol and PChE activity declined with treatment. Iso-OMPA, a nontoxic inhibitor of serum PChE, reduced serum and liver triacylglycerols and serum VLDL in streptozotocin-induced rodent diabetes. These findings suggest that PChE may have a role in VLDL metabolism.

Septic pulmonary embolism due to periodontal disease.

Three weeks following a toothache, a 56-year-old man developed cough, sputum, fever, and pleuritic chest pain. He had mild periodontal disease and his chest radiographs and chest computed tomographic (CT) scans showed multiple pulmonary nodules. The CT scan strongly suggested septic pulmonary embolism. Aspirated pus from one of the nodules yielded pure growth of Streptococcus intermedius. Lesions resolved with antimicrobial therapy. The usual predisposing factors for septic pulmonary embolism were absent, and, the isolation of S intermedius from the pus, the antecedent toothache, and periodontal disease all suggested the gingiva as the source. We hypothesize that periodontal infection led to bacteremia, seeding of the lungs, and multiple anaerobic pulmonary abscesses, akin to reported instances of infective endocarditis from dental foci without any prior dental procedures. To our knowledge, this presentation of septic pulmonary embolism is unprecedented.

Physiologic baroreceptor activity in the fetal lamb.

OBJECTIVE: We investigated the influences of gestational age and behavioral state on fetal baroreceptor activity. STUDY DESIGN: Two protocols were used to analyze low-voltage fast activity and high-voltage slow activity in eight chronically instrumented ovine fetuses at days 127 to 142. In protocol 1 correction of fetal heart rate to mean arterial blood pressure was assessed under physiologic conditions, and the linear regression slope of fetal heart rate on mean arterial pressure was calculated. In protocol 2 an injection of 7.5 micrograms of norepinephrine was given during consecutive behavioral cycles. The ratio of fetal heart rate decrease to mean arterial pressure increase was determined as representing baroreceptor activity. RESULTS: Under protocol 1 the slope was steeper in high-voltage slow activity (2.33 +/- 1.03) than in low-voltage fast activity (0.89 +/- 0.37) (n = 21, p less than 0.001), indicating that fetal heart rate changes are sensitive to blood pressure changes during high-voltage slow activity. Under protocol 2 inverse relationships were found between the ratio of fetal heart rate decrease to mean arterial pressure increase and gestational age in low-voltage fast activity and high-voltage slow activity. CONCLUSION: Fetal baroreceptor activity increased during high-voltage slow activity and decreased with gestational age.

Autonomic nervous system regulation of baseline heart rate in the fetal lamb.

OBJECTIVE: We examined 29 chronically instrumented fetal lambs from 125 to 143 days' gestation to investigate the effects of fetal behavioral states and autonomic nervous system maturation on baseline fetal heart rate. STUDY DESIGN: Behavioral states were defined from electrocorticographic analysis as low-voltage fast activity or high-voltage slow activity. Decrease and increase in baseline fetal heart rate subsequent to administration of propranolol and methylatropine represented beta-sympathetic and parasympathetic activity. RESULTS: Baseline fetal heart rate decreased with gestation in both states, with steeper regression in low-voltage fast activity (p less than 0.001). Positive correlation was noted between gestational age and percent decrease baseline fetal heart rate in both states with steeper regression in high-voltage slow activity (p less than 0.001), and between gestational age and percent increase baseline fetal heart rate with steeper regression in low-voltage fast activity (p less than 0.001). Fetal heart rate beta-sympathetic and parasympathetic tones increased with age in both states, with elevation of beta-sympathetic tone in high-voltage slow activity and parasympathetic tone in low-voltage fast activity. CONCLUSION: Sympathetic and parasympathetic systems influence baseline fetal heart rate in these behavioral states and with age.

Relationship between serum pseudocholinesterase and triglycerides in experimentally induced diabetes mellitus in rats.

This study was designed to understand the reasons for the increase in serum pseudocholinesterase activity in diabetes mellitus. Streptozotocin-induced diabetic rats were used for the study. Serum pseudocholinesterase activity increased with the induction of diabetes (381.5 units/l +/- 11.8) compared to the non-diabetic rats (243.1 units/l +/- 7.2). Serum triglycerides, total low density lipoprotein and glycerol also increased concurrently with the development of diabetes. Insulin treatment of the diabetic rats normalized serum glucose concomitant with the reduction of pseudocholinesterase activity, triglycerides, total low density lipoprotein and glycerol. Heparin injection appeared to activate lipoprotein lipase in the diabetic rats by showing a marked fall in serum triglyceride and total low density lipoprotein levels but not in pseudocholinesterase activity. Administration of tetraisopropylpyrophosphoramide a specific pseudocholinesterase inhibitor, inhibited serum and adipose tissue pseudocholinesterase activity by greater than 80% and liver greater than 50%. Concurrent with the inhibition of pseudocholinesterase activity serum triglyceride, low density lipoprotein and glycerol decreased significantly. In normal rats treatment with tetraisopropylpyrophosphoramide also reduced serum lipoproteins markedly, while glycerol only showed a marginal decrease. Glycerol was used as a marker of adipose tissue lipolysis and total low density lipoprotein which is defined as lipoproteins of density less than 1.063 (LDL + VLDL).(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary embolism. How to 'nail down' the diagnosis.

Pulmonary embolism is a common problem in hospitalized patients. Because its initial symptoms may be nonspecific, pulmonary embolism may be difficult to diagnose. A high index of suspicion, together with careful selection of diagnostic tests, is essential. An algorithm for clinical assessment of suspected pulmonary embolism is presented here.

Chronic obstructive pulmonary disease. Reversing airflow obstruction from chronic bronchitis and emphysema.

Chronic obstructive pulmonary disease (COPD) describes a group of disorders that cause obstruction to expiratory airflow. COPD should be suspected in a patient who has cough, sputum production, wheezing, and/or inappropriate dyspnea on exertion in the setting of prolonged exposure to cigarette smoke. With smoking cessation, avoidance of occupational and other bronchial irritants, and use of bronchodilators, antibiotics, and long-term oxygen when appropriate, the patient can minimize limitations on activity and complications.