Serologic test for syphilis as a surrogate marker for human immunodeficiency virus infection among United States blood donors

BACKGROUND: This study evaluated the usefulness of the serologic test for syphilis (STS) in preventing the transmission of human immunodeficiency virus (HIV), hepatitis B and C viruses, and human T- lymphotropic virus via the transfusion of seronegative, infectious window-period blood. STUDY DESIGN AND METHODS: Demographic and laboratory information on blood donations made between January 1992 and June 1994 in 18 American Red Cross regions was analyzed. It was assumed that the same proportion of HIV-positive and HIV-infectious window- period donations reacted on STS and were negative on other screening tests (hepatitis B and C viruses and human T-lymphotropic virus). This proportion multiplied by the estimated number of HIV-infectious window- period donations is the number of post-screening HIV-infectious donations removed by STS. RESULTS: Of 4,468,570 donations, 12,145 (0.27%) were STS positive and 377 (0.008%) were HIV positive. Among donations that were negative on other screening tests, STS-reactive donations were 12 times more likely to be HIV positive (odds ratio = 11.9; 95% CI = 5,26). However, of an estimated 13 infectious window- period donations, 0.2 would have been removed because of a reactive STS, at a cost of over $16 million. CONCLUSION: STS is a poor marker and a costly strategy for preventing post-screening HIV infections and other blood-borne diseases.     

Evidence that opioids may have toll-like receptor 4 and MD-2 effects

Opioid-induced proinflammatory glial activation modulates wide-ranging aspects of opioid pharmacology including: opposition of acute and chronic opioid analgesia, opioid analgesic tolerance, opioid-induced hyperalgesia, development of opioid dependence, opioid reward, and opioid respiratory depression. However, the mechanism(s) contributing to opioid-induced proinflammatory actions remains unresolved. The potential involvement of toll-like receptor 4 (TLR4) was examined using in vitro, in vivo, and in silico techniques. Morphine non-stereoselectively induced TLR4 signaling in vitro, blocked by a classical TLR4 antagonist and non-stereoselectively by naloxone. Pharmacological blockade of TLR4 signaling in vivo potentiated acute intrathecal morphine analgesia, attenuated development of analgesic tolerance, hyperalgesia, and opioid withdrawal behaviors. TLR4 opposition to opioid actions was supported by morphine treatment of TLR4 knockout mice, which revealed a significant threefold leftward shift in the analgesia dose response function, versus wildtype mice. A range of structurally diverse clinically-employed opioid analgesics was found to be capable of activating TLR4 signaling in vitro. Selectivity in the response was identified since morphine-3-glucuronide, a morphine metabolite with no opioid receptor activity, displayed significant TLR4 activity, whilst the opioid receptor active metabolite, morphine-6-glucuronide, was devoid of such properties. In silico docking simulations revealed ligands bound preferentially to the LPS binding pocket of MD-2 rather than TLR4. An in silico to in vitro prediction model was built and tested with substantial accuracy. These data provide evidence that select opioids may non-stereoselectively influence TLR4 signaling and have behavioral consequences resulting, in part, via TLR4 signaling.     

Conventional versus endoscopic powered adenoidectomy: A comparative study

Background: Adenoidectomy is a commonly performed ENT surgery. It is conventionally performed using the curettage method. This present article aims to evaluate endoscopic powered adenoidectomy as an alternative.     

Conventional Versus Endoscopic Powered Adenoidectomy: A Comparative Study

Background

Adenoidectomy is a commonly performed ENT surgery. It is conventionally performed using the curettage method. This present article aims to evaluate endoscopic powered adenoidectomy as an alternative.

Methods

Sixty consecutive cases requiring adenoidectomy were randomized into two groups of thirty each. Group A underwent conventional adenoidectomy using the curettage method and Group B underwent endoscopic assisted micro-debrider adenoidectomy. The parameters studied were intra-operative time, intra-operative bleeding and completeness of resection, collateral damage, post operative pain and recovery time.

Result

Sixty cases of adenoidectomy were done using conventional surgery and powered endoscopic adenoidectomy in the study period from Aug 04 to Dec 05. The time taken in Group A (conventional surgery) varied from 22–39 minutes (95% Confidence Interval (CI) −27.7 – 30.9)and in Group B (powered endoscopic surgery) from 27–55 minutes(95% CI 36.6 – 41.9) (p<0.05). The average blood loss in Group A was 21 ml (range 10–50) as compared to 31.67 ml (range 10-60) in Group B (p<0.05). The resection was invariably complete in Group B whereas seven(23%) cases had more than 50% residual adenoid tissue in Group A. Three cases in group A had collateral damage whereas in Group B, there were no added injuries. Post operative pain was studied only in cases undergoing adenoidectomy alone. Group A (n=8) demonstrated a pain score of 1.64–2.63–3.63 (95% CI) whereas Group B (n=11) demonstrated a pain score of 1.19–2.13–3.06 (95% CI). This difference was not statistically significant. In group A, the mean recovery period was 3.5 days and 2.93 days in Group B(p<0.05).

Conclusion

Endoscopic powered adenoidectomy was found to be a safe and effective tool for adenoidectomy. The study parameters where endoscopic powered adenoidectomy fared better were completeness of resection, accurate resection under vision, lesser collateral damage and faster recovery time. On the other hand, conventional adenoidectomy scored in matter of lesser operative time and intra-operative bleeding.Key Words: Adenoidectomy, Powered adenoidectomy, Endoscopic adenoidectomy     

Optimal protocol selection for cardiopulmonary exercise testing in severe COPD

BACKGROUND: The current recommendations of 8 to 12 min for the optimal targeted duration of symptom-limited maximal cardiopulmonary exercise testing (CPET) to attain maximal oxygen consumption are based on results from healthy individuals and may not be applicable to patients with severe COPD. We aimed to determine the optimal duration for a CPET to attain the peak oxygen consumption (VO2peak) in a group of patients with severe COPD using different carefully conducted workload protocols. METHODS: We studied 11 subjects with severe COPD (mean FEV1, 32% predicted; 95% confidence interval [CI], 27 to 38% predicted). They completed four incremental, symptom-limited exercise tests on a cycle ergometer using four protocols (4, 8, and 16 W/min continuous ramp protocols, and 8 W/min step protocol) using a randomized double-blind design. RESULTS: The mean duration of these 44 tests was 6.3 min (95% CI, 5.0 to 9.0 min). The duration of the exercise tests differed significantly for the protocols used, as follows: 16-W ramp protocol, 4.0 min (95% CI, 3.0 to 5.1 min); 8-W ramp protocol, 6.6 min (95% CI, 5.0 to 9.0 min); 8-W step protocol, 6.0 min (95% CI, 4.0 to 8.0 min); and 4-W ramp protocol, 8.7 min (95% CI, 4.4 to 13.0 min; p<0.001). The maximal workload significantly increased as the ramp slope increased from 4 to 8 to 16 W/min (maximal workload, 35.6 vs 50.7 vs 64.3 W, respectively; p<0.001). Maximal minute ventilation, heart rate, Borg ratings, and VO2 peak, were not different among the four protocols. No differences were found between the ramp and step protocols. CONCLUSIONS: In patients with severe COPD (Global Initiative for Chronic Obstructive Lung Disease stages III-IV), a targeted duration of 5 to 9 min for a CPET appears to be more appropriate than the 8 to 12 min proposed in the current guidelines. Maximal workload, in contrast to VO2peak, is highly dependent on the ramp incrementation rate.     

Activity monitoring and energy expenditure in COPD patients: a validation study

There is increasing interest in the objective measurement of physical activity in chronic obstructive pulmonary disease (COPD) patients due to the close relationship between physical activity level, health, disability and mortality. We aimed to (a) determine the validity and reproducibility of an activity monitor that integrates accelerometry with multiple physiologic sensors in the determination of energy expenditure in COPD subjects and (b) to document the independent contribution of the additional physiologic sensors to accelerometry measures in improving true energy expenditure determination. Eight subjects (4 male, FEV(1) 56.4 +/- 14.1%, RV 145.0 +/- 75.7%) performed 2 separate 6-minute walk and 2 incremental shuttle walk exercise tests. Energy expenditure was calculated during each exercise test using the physiologic activity monitor and compared to a validated exhaled breath metabolic system. Test-retest reproducibility of physiologic activity monitor during the walking tests was comparable to an exhaled breath metabolic system. Physiologic sensor data significantly improved the explained variance in energy expenditure determination (r(2)=0.88) compared to accelerometry data alone (r(2)=0.68). This physiologic activity monitor provides a valid and reproducible estimate of energy expenditure during slow to moderate paced walking in a laboratory setting and represents an objective method to assess activity in COPD subjects.     

Intra-Arterial Thrombolysis Within Three Hours of Stroke Onset in Middle Cerebral Artery Strokes

Background and Purpose

The Prolyse in Acute Cerebral Thromboembolism II (PROACT II) trial showed improved outcomes in patients with proximal middle cerebral artery (MCA) occlusions treated with intra-arterial (IA) thrombolysis within 6 h of stroke onset. We analyzed outcomes of patients with proximal MCA occlusions treated within 3 h of stroke onset in order to determine the influence of time-to-treatment on clinical and angiographic outcomes in patients receiving IA thrombolysis.

Methods

Thirty-five patients from three academic institutions with angiographically demonstrated proximal MCA occlusions were treated with IA thrombolytics within 3 h of stroke onset. Outcome measures included outcomes at 30–90 day follow-up, recanalization rates, incidence of symptomatic intracranial hemorrhage, and mortality in the first 90 days. The endpoints were compared to the IA treated and control groups of the PROACT II trial.

Results

The median admission National Institutes of Health Stroke Scale (NIHSS) score was 16 (range 4–24). The mean time to initiation of treatment was 106 min (range 10–180 min). Sixty-six percent of patients treated, had a modified Rankin Scale (mRS) score of 2 or less at 1–3 month follow-up compared to 40% in the PROACT II trial. The recanalization rate was 77% (versus 66% in PROACT II). The symptomatic intracranial hemorrhage rate was 11% (versus 10% in PROACT II) and the mortality rate was 23% (versus 25% in PROACT II).

Conclusion

Time-to-treatment is just as important in IA thrombolysis as it is in IV thrombolysis, both for improving clinical outcomes and recanalization rates as well.     

Inhibition of sphincter of Oddi function by the nitric oxide carrier S-nitroso-N-acetylcysteine in rabbits and humans.

Nitric oxide (NO) is an inhibitor of gastrointestinal smooth muscle. Model systems of the gut predict the NO will complex with biological thiol (SH) groups, yielding S-nitrosothiols (RS-NO), which may limit the propensity to form mutagenic nitrosamines. The inhibitory effects of NO and its biologically relevant adducts on sphincter of Oddi (SO) motility have been inferred from animal studies; however, their importance in regulating human SO is not known. The objectives of this study were to (a) provide histologic confirmation of nitric oxide synthase (NOS) in human SO; (b) characterize the pharmacology of S-nitroso-N-acetylcysteine (SNAC), an exemplary S-nitrosothiol, on SO motility in a rabbit model; and (c) study the effects of topical SNAC on SO motility in humans. Immunocytochemical and histochemical identification of NOS was performed in human SO. The pharmacologic response of SNAC was defined in isolated rabbit SO using a standard bioassay. Topical SNAC was then applied to the duodenal papilla in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and biliary manometry. NOS was localized to nerve fibers and bundles of the SO in rabbits and humans. SNAC inhibited spontaneous motility (frequency and amplitude) as well as acetylcholine-induced elevations in SO basal pressure in the rabbit model. In patients undergoing ERCP and biliary manometry, topical SNAC inhibited SO contraction freqency, basal pressure, and duodenal motility. NOS is localized to neural elements in human SO, implicating a role for NO in regulating SO function. Supporting this concept, SNAC is an inhibitor of SO and duodenal motility when applied topically to humans during ERCP. Our data suggest a novel clinical approach using local NO donors to control gastrointestinal motility and regulate sphincteric function.     

Foot Protective System : A Boon to Demining Soldiers

Background

A significant number of soldiers suffer serious injuries or die in the process of demining and a protective device is necessary in such operations.

Methods

All the patients involved in demining operations using the foot protection devices in last one year were analysed.

Results

We received 35 patients, of which only five had limb injuries and 30 had eye injuries. Of the five, three had closed calcaneal fractures and two contusion of foot. No fatality, amputation or compound fracture occured.

Conclusion

Early results after the use of this device during demining operations are encouraging.Key Words: Mine blast injury, Demining, Spider boot