The Physical Compatibility of Glycopyrrolate and Rocuronium.

OBJECTIVE: Scientific evidence has rarely, if at all, been reported in the literature demonstrating analytical confirmation of the physical compatibility and stability of glycopyrrolate and rocuronium combined. The purpose of this experiment was to determine if glycopyrrolate and rocuronium are physically compatible. METHODS: Glycopyrrolate and rocuronium were combined in various containers, observed over a 60-minute period, and compared against positive and negative controls. Measured metrics included color change, precipitate formation, Tyndall beam test, turbidity, and pH. Statistical analyses were used to assess significance of data trends. RESULTS: The combination of glycopyrrolate and rocuronium did not result in any color change, precipitate formation, a positive Tyndall beam test, or a significantly positive turbidity and did not result in any significant change in pH, regardless of container. CONCLUSION: Per the protocol used in this study, glycopyrrolate and rocuronium were determined to be physically compatible.

"What an Affliction": Mary Todd Lincoln's Fatal Pernicious Anemia.

To date, no single diagnosis has unified the psychiatric illness and the numerous poorly defined physical complaints that Mary Lincoln (née Todd, 1818-1882) suffered in adulthood. Here, I show that her physical ailments spanned 30 years and included sore mouth, pallor, paresthesias, the Lhermitte symptom, fever, headaches, fatigue, resting tachycardia, edema, episodic weight loss, progressive weakness, ataxia, and visual impairment. Long thought hypochondriacal, these findings, plus their time course and her psychopathology (irritability, delusions, hallucinations, with preserved clarity), are all consistent with vitamin B12 deficiency. Pernicious anemia most probably caused this deficiency: she lacked risk factors for other causes, and her consanguineous parents both derived from a region of Scotland having a high incidence of pernicious anemia. A diagnosis of chronic multisystem pernicious anemia would clarify the conduct of Mary Lincoln as First Lady and widow, and illuminate challenges faced by her husband, President Abraham Lincoln. Her case highlights many forgotten features of the natural history of untreated pernicious anemia and is unique in the medical literature in demonstrating such a course extending over a lifetime.

Systemic disease after hip replacement: aeromedical implications of arthroprosthetic cobaltism.

BACKGROUND: A multisystem illness recently reported in recipients of the newest generation of metal-on-metal hip prostheses has been ascribed to toxic effects of cobalt and possibly chromium. CASE REPORT: We present a case of insidiously developing neurologic illness that occurred in a physically active professional. DISCUSSION: This case illustrates the potential for a hip prosthesis to occultly impair safe functioning of aviators. Based on this case and others, we suggest modifications to aeromedical policy relating to waiver requests after hip replacement, including routine monitoring of serum cobalt and chromium levels in recipients of metal-on-metal hip prostheses. The evaluation of aviators having an elevated cobalt level is also discussed.

Abraham Lincoln's marfanoid mother: the earliest known case of multiple endocrine neoplasia type 2B?

The nature and cause of President Abraham Lincoln's unusual physical features have long been debated, with the greatest attention directed at two monogenic disorders of the transforming growth factor ß system: Marfan syndrome and multiple endocrine neoplasia type 2B. The present report examines newly discovered phenotypic information about Lincoln's biological mother, Nancy Hanks Lincoln, and concludes that (a) Lincoln's mother was skeletally marfanoid, (b) the President and his mother were highly concordant for the presence of numerous facial features found in various transforming growth factor ß disorders, and (c) Lincoln's mother, like her son, had hypotonic skeletal muscles, resulting in myopathic facies and 'pseudodepression'. These conclusions establish that mother and son had the same monogenic autosomal dominant marfanoid disorder. A description of Nancy Hanks Lincoln as coarse-featured, and a little-known statement that a wasting disease contributed to her death at age 34, lends support to the multiple endocrine neoplasia type 2B hypothesis.

Dentistry-based approaches to sleep-disordered breathing, algorithms, and multidisciplinary perspectives.

Sleep disorders affect more than 20 percent of the U.S. population, but less than 7 percent have been medically diagnosed. Dentists are ideally positioned to identify many patients who fall under the grouping of sleep-disordered breathing. This paper presents perspectives on sleep-related issues from various medical specialties with a goal to broaden the dentist's appreciation of this topic and open avenues of communication. Algorithms are proposed to guide dentists following positive screenings for sleep-disordered breathing.

Risk of adverse clinical outcomes with concomitant use of clopidogrel and proton pump inhibitors following percutaneous coronary intervention.

BACKGROUND: Recent studies have suggested that proton pump inhibitors (PPIs) attenuate the benefits of clopidogrel. The clinical relevance of this interaction in patients who have undergone percutaneous coronary intervention (PCI) is unknown. We hypothesized that post-PCI patients discharged on clopidogrel will have higher cardiovascular events if concomitant PPI therapy is used. AIMS: To determine whether post-PCI patients discharged on clopidogrel will have higher cardiovascular events if concomitant PPI therapy is used. METHODS: We reviewed the medical records of all the patients discharged on clopidogrel who underwent PCI from January 2003 to August 2004. The primary outcome studied was a major adverse cardiovascular event (MACE), which was defined as a composite of death, myocardial infarction, and target vessel failure. RESULTS: Of the 315 post-PCI patients who were discharged on clopidogrel, 72 were discharged on PPI. During a mean follow-up period of 50 months, patients discharged on concomitant clopidogrel-PPI therapy had a MACE rate of 56% (vs. 38% in the clopidogrel alone group) (P = 0.025) and had 95% excess risk of MACE. CONCLUSION: Concomitant use of clopidogrel and PPI in post-PCI patients is associated with a higher risk of MACE. This suggests that PPIs may attenuate clopidogrel's beneficial antiplatelet effect, which is crucial after PCI. Prospective randomized studies are warranted to provide definitive evidence for this interaction.

Abraham Lincoln did not have type 5 spinocerebellar ataxia.

An autosomal dominant genetic disorder, type 5 spinocerebellar ataxia (SCA5), occurs in multiple descendants of one paternal uncle and one paternal aunt of President Abraham Lincoln. It has been suggested that Lincoln himself had the disease and that his DNA should be tested for an SCA5-conferring gene. Herein, I review the pertinent phenotypes of Lincoln, his father, and his paternal grandmother, and conclude that 1) Lincoln's father did not have SCA5, and, therefore, that Lincoln was not at special risk of the disease; 2) Lincoln had neither subclinical nor visible manifestations of SCA5; 3) little evidence suggests SCA5 is a "Lincolnian" disorder; and 4) without additional evidence, Lincoln's DNA should not be tested for SCA5.