A survey of emergency department use in patients with cyclic vomiting syndrome

Background

The Bonfils intubating fiberscope has a limited upward tip angle of 40° and requires retromolar entry into the hypopharynx. These factors may make its use less desirable when managing the difficult airway because most anesthesia providers are well versed in midline oral intubation rather than the lateral retromolar approach. The Center for Advanced Technology and Telemedicine at the University of Nebraska Medical Center has developed a novel fiberscope with a more anterior 60° curve to allow for easier midline insertion and intubation. The objective of this work was to evaluate the novel fiberscope, in comparison to the Bonfils intubating fiberscope, in terms of use and function in difficult airway intubation.

Methods

Twenty-two anesthesia providers participated in simulated intubations of a difficult airway mannequin to compare the Bonfils intubating fiberscope with the novel curved Boedeker intubating fiberscope. The intubations were assessed based upon the following variables: recorded Cormack Lehane airway scores, requests for cricoid pressure, time to intubation, number of intubation attempts and success or failure of the procedure.

Results

Participants using the Bonfils fiberscope recorded an average Cormack Lehane (CL) airway score of 1.67 ± 1.02 (median = 1); with the novel fiberscope, the recorded average airway grade improved to 1.18 ± 0.50 (median = 1). The difference in airway scores was not statistically significant (p = 0.34; Fishers Exact Test comparing CL grades 1&2 vs. 3&4). There was, however, a statistically significant difference in intubation success rates between the two devices. With the Bonfils fiberscope, 68% (15/22) of participants were successful in intubation compared to a 100% success rate in intubation with the novel fiberscope (22/22) (p = 0.008). After the intubation trial, the majority of participants (95%) indicated a preference for the novel fiberscope (n = 20).

Conclusions

With this data, we can infer that the novel fiberscope curvature appears to improve or maintain the quality of an intubation attempt (airway score, cricoid pressure requirement, intubation time, number of attempts, placement success). The data indicate that the novel fiberscope offers a superior intubation experience to currently available best practices. The instrument was well received and would be welcomed by most study participants should the device become clinically available in the future.     

CD117 (c-KIT) overexpression in patients with extensive-stage small-cell lung carcinoma.

BACKGROUND: The aim of this study was to determine the incidence and role of CD117 (c-KIT) overexpression as a predictive/prognostic marker in extensive-stage small-cell lung carcinoma (ESSCLC). We performed a retrospective study on subjects with a biopsy-proven diagnosis of ESSCLC. PATIENTS AND METHODS: A chart review for demographic and clinical data was performed on patients with ESSCLC diagnosed between 1991 and 2001. CD117 overexpression was evaluated using immunohistochemistry (A4052 polyclonal antibody) performed on archival paraffin-embedded specimens. RESULTS: Two hundred and twenty-three patients with ESSCLC were identified, of whom 193 (84 females, 109 males) with a mean age of 68.5 years (range 42-90) had adequate tissue specimens available for CD117 testing. The most commonly presenting symptom was weight loss, seen in 61 patients (31.6%). Of the 193 specimens, 54 (27.9%) showed CD117 overexpression. The median length of survival for CD117-positive patients was 9 months as compared with the CD117-negative population, in whom the survival was 6 months (P = 0.025, Cox proportional hazard method). CONCLUSIONS: CD117 overexpression detected using immunohistochemistry is observed in about a third of patients with ESSCLC and does not have statistically significant prognostic value. However, CD117 may be a potential target for site-specific immunotherapy in ESSCLC. Our findings suggest a role for clinical trials assessing the role of selective tyrosine kinase inhibitor STI-571 (alone or in combination with conventional therapy) in patients with ESSCLC.     

A comparative study of saliva and serum paracetamol levels using a simple spectrophotometric method.

The relationship between saliva and serum paracetamol levels was investigated in ten healthy male volunteers. The salivary and serum paracetamol levels showed significant correlation with each other. The salivary and serum paracetamol concentration ratio was highly dependent on sampling time. The salivary and serum paracetamol half-lives showed significant correlation with each other while the area under curve of paracetamol concentration in saliva and serum failed to show significant correlation.     

Detection of natural and induced phenoloxidase activities in human serum

Natural and induced phenoloxidase activities were detected in human serum using nine different phenolic substrates, namely, tyrosine, tyramine, L-DOPA, DL-DOPA, dopamine, catechol, hydroquinone, protocatechuic acid and pyrogallol. Phenoloxidase activity was induced anew in serum using exogenous elicitors, such as proteases or detergents. Among the proteases and detergents tested, pronase, SDS and Tween 20 were the best elicitors of phenoloxidase activities in serum, wherein, hydroquinone was the best phenolic substrate for both untreated as well as pronase treated serum and SDS or Tween 20 treated serum resulted in highest oxidation of dopamine or tyrosine, respectively. In the present study, all these oxidative reactions were inhibited by phenoloxidase inhibitors, namely, PTU and tropolone, thereby, confirming the role of phenoloxidase in human serum.     

Clostridium and Bacillus Binary Enterotoxins: Bad for the Bowels,and Eukaryotic Being

Some pathogenic spore-forming bacilli employ a binary protein mechanism for intoxicating the intestinal tracts of insects, animals, and humans. These Gram-positive bacteria and their toxins include Clostridium botulinum (C2 toxin), Clostridium difficile (C. difficile toxin or CDT), Clostridium perfringens (ι-toxin and binary enterotoxin, or BEC), Clostridium spiroforme (C. spiroforme toxin or CST), as well as Bacillus cereus (vegetative insecticidal protein or VIP). These gut-acting proteins form an AB complex composed of ADP-ribosyl transferase (A) and cell-binding (B) components that intoxicate cells via receptor-mediated endocytosis and endosomal trafficking. Once inside the cytosol, the A components inhibit normal cell functions by mono-ADP-ribosylation of globular actin, which induces cytoskeletal disarray and death. Important aspects of each bacterium and binary enterotoxin will be highlighted in this review, with particular focus upon the disease process involving the biochemistry and modes of action for each toxin.     

Excessive neutrophils and neutrophil extracellular traps contribute to acute lung injury of influenza pneumonitis

Complications of acute respiratory distress syndrome (ARDS) are common among critically ill patients infected with highly pathogenic influenza viruses. Macrophages and neutrophils constitute the majority of cells recruited into infected lungs, and are associated with immunopathology in influenza pneumonia. We examined pathological manifestations in models of macrophage- or neutrophil-depleted mice challenged with sublethal doses of influenza A virus H1N1 strain PR8. Infected mice depleted of macrophages displayed excessive neutrophilic infiltration, alveolar damage, and increased viral load, later progressing into ARDS-like pathological signs with diffuse alveolar damage, pulmonary edema, hemorrhage, and hypoxemia. In contrast, neutrophil-depleted animals showed mild pathology in lungs. The brochoalveolar lavage fluid of infected macrophage-depleted mice exhibited elevated protein content, T1-α, thrombomodulin, matrix metalloproteinase-9, and myeloperoxidase activities indicating augmented alveolar-capillary damage, compared to neutrophil-depleted animals. We provide evidence for the formation of neutrophil extracellular traps (NETs), entangled with alveoli in areas of tissue injury, suggesting their potential link with lung damage. When co-incubated with infected alveolar epithelial cells in vitro, neutrophils from infected lungs strongly induced NETs generation, and augmented endothelial damage. NETs induction was abrogated by anti-myeloperoxidase antibody and an inhibitor of superoxide dismutase, thus implying that NETs generation is induced by redox enzymes in influenza pneumonia. These findings support the pathogenic effects of excessive neutrophils in acute lung injury of influenza pneumonia by instigating alveolar-capillary damage.     

Mechanisms of anticancer activity of sulforaphane from Brassica oleracea in HEp-2 human epithelial carcinoma cell line

Sulforaphane (SFN) an isothiocyanate formed by hydrolysis of glucosinolates found in Brassica oleraceae is reported to possess anticancer and antioxidant activities. In this study, we isolated SFN from red cabbage (Brassica oleraceae var rubra) and evaluated the comparative antiproliferative activity of various fractions (standard SFN, extract and purified SFN) by MTT assay in human epithelial carcinoma HEp -2 and and Vero cells. Probable apoptotic mechanisms mediated through p53, bax and bcl-2 were also examined. The SFN fraction was collected by HPLC, enriched for its SFN content and confirmed. Expression of apoptosis-related proteins was detected by western blotting and RT PCR. Results showed that Std SFN and purified SFN concentration found to have closer IC50 which is equal to 58.96 microgram/ml (HEp-2 cells), 61.2 microgram/ml (Vero cells) and less than the extract which is found to be 113 microgram/ml (HEp-2 cells) and 125 microgram/ml (Vero cells). Further studies on apoptotic mechanisms showed that purified SFN down-regulated the expression of bcl-2 (antiapoptotic), while up-regulating p53 and Bax (proapoptotic) proteins, as well as caspase-3. This study indicates that purified SFN possesses antiproliferative effects the same as Std SFN and its apoptotic mechanism in HEp-2 cells could be mediated through p53 induction, bax and bcl-2 signaling pathways.     

Primary Cardiac Sarcoidosis with Syncope and Refractory Atrial Arrhythmia: A Case Report and Review of the Literature

We discuss the case of a 38-year-old black man who presented at our hospital with his first episode of syncope, recently developed atrial arrhythmias refractory to pharmacologic therapy, and a left atrial thrombus. He was diagnosed with primary cardiac sarcoidosis characterized by predominant involvement of the epicardium that caused atrial fibrillation and atrial flutter. Histologic analysis of his epicardial lesions yielded a diagnosis of sarcoidosis. This patient''s atrial arrhythmia was successfully treated with a hybrid operation that involved resection of his atrial appendage, an Epicor maze procedure, and radiofrequency ablation during a catheter-based electrophysiologic study. The cardiac sarcoidosis was successfully managed with corticosteroid therapy.Our case report shows that sarcoidosis can initially manifest itself as syncope with new-onset atrial arrhythmia. Sarcoidosis is important in the differential diagnosis because of its progressive nature and its potential for treatment with pharmacologic, surgical, and catheter-based interventions.     

Antrochoanal Polyp Presenting as Obstructive Sleep Apnea

Antrochoanal polyps (ACPS) are uncommon in children presenting to the pediatric clinic. They commonly present with unilateral nasal obstruction. ACPS presenting as obstructive sleep apnea (OSA) in a young child is an uncommon initial presentation. A high level of suspicion is needed to diagnose OSA in young children as the presenting symptoms may be nonspecific and sometimes misleading.