Severe adenovirus pneumonia requiring extracorporeal membrane oxygenation support--Serotype 7 revisited.

INTRODUCTION: Adenovirus causing severe fatal pneumonia has been well described in infants, children, and patients with immunocompromised function, but reports in previously healthy adults are rare. We report 3 cases of severe adenovirus pneumonia in whom conventional mechanical ventilation failed and required extracorporeal membrane oxygenation support. METHODS: Retrospective case records review of 3 patients admitted to the medical intensive care unit, Singapore General Hospital, a tertiary care university-affiliated hospital, with severe adenovirus pneumonia requiring extracorporeal membrane oxygenation support from February to March 2013. RESULTS: All 3 patients were previously healthy immunocompetent adults from the community with negative HIV serology. Duration prior to development of respiratory failure requiring intubation and invasive mechanical ventilation was 2, 8 and 3 days. Veno-venous extracorporeal membrane oxygenation (ECMO) support as rescue ventilation was instituted in all 3 patients after 2, 16, and 5 days of conventional mechanical ventilator support. Duration on ECMO support was 16, 22, and 9 days and mechanical ventilation was 18, 62, and 19 days respectively. Length of stay in intensive care unit was 18, 68, and 21 days, and length of stay in hospital was 20, 70, and 31 days respectively. Two of the 3 patients died. CONCLUSION: The mainstay of treatment for patients with severe adenovirus pneumonia is still supportive, with the use of antivirals not apparently effective. Whilst ECMO support for rescue ventilation may be considered, the outcomes do not appear as promising as other viral pneumonias, mirroring that previously described in the paediatric population.

Malignant pleural mesothelioma in Singapore.

AIM: To examine the clinical characteristics and outcomes of malignant pleural mesothelioma (MPM) in Singapore. METHODS AND MATERIALS: A retrospective case note review of patients diagnosed with MPM between 1997 and 2007. Overall survival (OS), locoregional recurrence-free survival (LRS) and metastasis-free survival (MFS) were estimated using Kaplan Meier method and comparison were done using log rank test. Multivariate analysis was not done due to the small number of patients. RESULTS: There were 39 patients diagnosed with MPM. Fifty-nine percent of patients presented with Stage III and IV disease. Eight (21%) patients had surgery with 2 patients receiving trimodality treatment and adjuvant chemotherapy respectively. Three patients received adjuvant RT and one patient had no adjuvant therapy. Twelve patients received palliative RT or chemotherapy. Median follow-up was 27.0 weeks. Median overall survival (OS) for all patients was 8.0 months (95% CI 6.3-9.7). One-year and 2-year OS were 25.6% and 6.4% respectively. Thirty-eight patients died of progressive disease and one patient died of other cause. Locoregional recurrences and distant metastases occurred in 3/8 and 5/8 surgically treated patients respectively. Overall, distant metastases occurred in 44% of patients. Surgery did not affect survival outcomes although patients with dual modality treatment showed a trend towards improved survival. Epithelioid tumours had better prognosis (median OS 10.2 months) compared to biphasic (median OS 8.0 months) and sarcomatoid tumours (median OS 1.4 months). CONCLUSION: Future management of MPM will need to emphasize on both locoregional and systemic control and hence, inclusion of patients in clinical trials for multimodality treatment should be encouraged.

Measuring exposure to racism: development and validation of a Race-Related Stressor Scale (RRSS) for Asian American Vietnam veterans.

This article describes the development and validation of the Race-Related Stressor Scale (RRSS), a questionnaire that assesses exposure to race-related stressors in the military and war zone. Validated on a sample of 300 Asian American Vietnam veterans, the RRSS has high internal consistency and adequate temporal stability. Hierarchical regression analyses revealed that exposure to race-related stressors accounted for a significant proportion of the variance in posttraumatic stress disorder (PTSD) symptoms and general psychiatric symptoms, over and above (by 20% and 19%, respectively) that accounted for by combat exposure and military rank. The RRSS appears to be a psychometrically sound measure of exposure to race-related stressors for this population. Race-related stressors as measured by the RRSS appear to contribute uniquely and substantially to PTSD symptoms and generalized psychiatric distress.

Differential effects of neurotoxic destruction of descending noradrenergic pathways on acute and persistent nociceptive processing.

Although many pharmacological studies indicate that bulbospinal noradrenergic projections contribute to antinociception, lesions of the major brainstem noradrenergic cell groups have provided conflicting evidence. Here we used a new immunotoxin, anti-dopamine beta-hydroxylase-saporin, to re-examine the contribution of noradrenergic pathways to nociception and to morphine analgesia. We treated rats intrathecally by lumbar puncture with the immunotoxin and examined dopamine beta-hydroxylase (DbetaH) immunoreactivity seven and 14 days after treatment. There was no change in DbetaH staining at 7 days; however, 14 days after treatment we demonstrated significant destruction of noradrenergic neurons in the locus coeruleus and in the A5 and A7 cell groups. There was a concomitant loss of noradrenergic axons in the dorsal and ventral horns of the lumbosacral and cervical cord. Consistent with the lack of anatomical changes, we found no difference in nociceptive responses in the hot-plate, tail-flick or formalin tests one week post-toxin. On day 14 we examined the behavioral response to injection of formalin into the hindpaw and found that responses during the second phase of pain behavior were significantly reduced. There was no change during the first phase. Formalin-evoked fos expression in the spinal cord was also reduced. We also evaluated morphine analgesia in the formalin test and found that toxin-treated animals exhibited enhanced morphine analgesia. These results establish the utility of using this immunotoxin to selectively destroy subpopulations of noradrenergic cell groups and provide evidence that acute and persistent nociception are differentially regulated by descending noradrenergic pathways.

Race-related stress among Asian American veterans: a model to enhance diagnosis and treatment.

This article addresses theoretical principles and clinical descriptions of the phenomenon of race-related stress and trauma experienced by Asian American Vietnam veterans. A conceptual model of race-based stress is presented, comprised of five principles, by which to understand mental health difficulties that can arise in regard to race-based stressors. The model describes (a) the relationship between life threat and physical similarity to the "enemy," (b) the relationship between fear and prejudice, (c) dehumanization as it impacts race hate and combat indoctrination, (d) additive life threat related to exploitation of one's physical similarity to the "enemy," and (e) race-based remorse. The article delineates factors affecting treatment seeking and disclosure of race-based stresses, guidelines for interviewing veterans about race-related events and ethnic self-worth, and the harmful effects of race hate.

Case series of bronchoscopic removal of tracheobronchial foreign body in six adults.

Tracheobronchial foreign body is rare in adults. Diagnosis is difficult and requires a high index of suspicion. We report 6 cases of tracheobronchial foreign bodies in adults and their removal, as well as a literature review of this topic. Case records, chest radiographs and computed tomographies (CT) of the thorax were reviewed. There were 5 males and 1 female with a median age of 63.5 years. One patient could not protect his airway (tracheostomy). Foreign bodies were sutures (2), vegetable matter like peanuts, vegetables and popcorn (3), and a voice prosthesis. Main symptoms were cough, haemoptysis and breathlessness. There were few signs on physical examination and chest X-rays were not helpful in diagnosis. All patients had fibreoptic bronchoscopy although 3 subsequently required rigid bronchoscopy for foreign body removal. All foreign bodies were successfully removed without any complications.

Sumatriptan and lost productivity time: a time series analysis of diary data.

Two previously conducted clinical studies assessed lost nonworkplace activity time and lost workplace productivity time due to migraine symptoms in subjects using sumatriptan for 6 months to treat their migraines after a 12- to 18-week period of using their usual therapy without sumatriptan. Although statistically significant differences in lost nonworkplace activity time and lost workplace productivity time between the usual therapy and sumatriptan treatment periods were detected using the Wilcoxon signed-rank test, this test could not determine whether differences were attributable to inherent trends in the data. This current study employed time series analysis, which detects and controls for preexisting trends in data, to further explore the possibility that the observed reductions in lost time in the two clinical studies were related to management of the subjects with sumatriptan. The intercepts and slopes of the computed linear models suggest that the initiation of sumatriptan therapy produced savings of 0.8 hours of nonworkplace activity time and 0.5 hours of workplace productivity time per patient per week. These savings were sustained throughout the sumatriptan treatment period. Preexisting trends in the data were not detected in the models. Thus the productivity gains are not associated with either time effects or the statistical phenomenon of regression to the mean, but variables that are extreme in initial measurements will tend to be closer to the center of the distribution in subsequent measurements. This strengthens the hypothesis that management of migraine with sumatriptan is associated with reductions in lost productivity time.

Race-related PTSD: the Asian American Vietnam veteran.

This article presents a conceptual framework by which to understand race-related post-traumatic stress disorder (PTSD) for the Asian American Vietnam veteran. The framework draws from cognitive schema theory, social behaviorism, the notion of cumulative racism as trauma, and the assumption that bifurcation and negation of one's bicultural identity is injurious. Classifications of race-related stress or trauma that may be experienced by Asian American Vietnam veterans, with exemplifying clinical case material, are presented. These types of stressors include being mistaken for Vietnamese, verbal and physical assaults that are race-related, death and near-death experiences that are race-related, racial stigmatization, dissociation from one's Asian identity, and marginalization. As studies of combat trauma and sexual assault forced the psychological stresses attendant to war and sexist oppression into public consciousness, so this article addresses psychological stress and trauma attendant to racism.

The 'biliterate' ballot controversy: language acquisition and cultural shift among immigrants.

PIP: This US study tested the validity of assumptions made regarding multilingual electoral ballot provisions. Rationale for language assistance was found to exist on the basis of number and proportion of recent immigrants, proportion of foreign born, lag of biliterate skill behind bilingual ability, linguistic differences between the Chinese language and English, and the discriminatory structure of the labor market. In California, where close to 1/2 the population is an ethnic minority, the issue is particularly relevant. Bilingual advocates view English-only advocates as "un-American" on legal and ideological grounds, while English-only advocates consider it "un-American" to be non-English speaking. In addition to census data and the existing literature, this study relies on the structured interview survey data of a representative sample of the Chinese adult population of San Francisco's Chinatown. 2/3 of the immigrants believed an immigrant should make some cultural changes, and 1/2 of the immigrants had done so. Data failed to support the claim that immigrants are uninformed that English is necessary for sociopolitical participation. Their more recent pattern of immigration, the linguistic differences between Asian languages and the English language, and structural constraints of US society make successive language acquisition difficult for Chinese migrant adults. Policy recommendations include: 1) changing language assistance criteria in the electoral process, 2) adding Vietnamese as a single language minority, 3) not considering Asian language minorities as 1 generic category, 4) justifying electoral assistance on several grounds, 5) disseminating data bearing directly on misguided assumptions related to language and cultural shift factors, and 6) renaming the "bilingual ballots" to "biliterate ballots."^ieng