Methods of management of flail chest

We have treated 30 patients with flail chest, with priority given to associated factors (pain, secretions retention, hemo-/pneumothorax and underlying pulmonary contusion). When this treatment was insufficient IMV+PEEP was instituted; in this group there was a 58.8% incidence of pneumonia, 47.5% of sepsis and 11.7 days average stay in the ICU. These were significantly different when compared to the patients controlled without mechanical ventilatory support (7.7% pneumonia, 0% sepsis, 3.2 days).Surgical fixation was limited to 4 patients who presented with multiple and greatly displaced rib fractures, which made fixation by mechanical ventilation unpredictable.     

Evoked electromyographic technique for quantitative assessment of the innervation status of laryngeal muscles

OBJECTIVES: The purpose of this study was to develop a minimally invasive, noninjurious evoked electromyographic technique that could accurately quantitate the level of innervation of laryngeal muscles with recurrent laryngeal nerve stimulation. METHODS: A four-phase study was conducted in 24 canines, including 1) identification of the best stimulation-recording configuration, 2) statistical analysis of sensitivity and accuracy, 3) evaluation of safety, and 4) identification of the laryngeal muscle(s) that contribute to the evoked response. RESULTS: The results demonstrated that an entirely noninvasive technique is not feasible. The stimulating cathode must be invasive to ensure discrete activation of the recurrent laryngeal nerve, whereas both recording electrodes should remain on the surface with one overlying the thyroid ala. This configuration proved to be highly accurate, with an error rate of only 6% to 7%, and with sensitivity sufficient to detect a signal in a nerve with fewer than 1% of the axons intact. There was no evidence of nerve injury in any animal over the course of 350 stimulus needle penetrations. By use of neuromuscular blockade to identify those muscles generating the surface response, the thyroarytenoid muscle was found to be the primary contributor, whereas the posterior cricoarytenoid muscle was uninvolved. CONCLUSIONS: This evoked electromyographic technique could provide quantitative information regarding the extent of muscle innervation during denervation and regeneration in case of laryngeal paralysis.     

Asymptomatic near-total airway obstruction by a cylindrical tracheal foreign body

OBJECTIVES/ HYPOTHESIS: The objective was to present the unique case of previously unreported asymptomatic cylindrical tracheal foreign body causing near-total airway obstruction. The asymptomatic nature of the case made diagnosis and management challenging. STUDY DESIGN: A retrospective case review at an urban health maintenance organization medical center. METHODS: A 3.5-year-old asymptomatic boy was incidentally discovered to have a metallic foreign body in his mid trachea on a screening scoliosis roentgenogram. He underwent rigid bronchoscopic retrieval the following day. RESULTS: The foreign body was found to be a corroded, 9 x 6-mm metallic cylinder with a narrowed luminal diameter of 2.0 mm. Intubation was maintained in the pediatric intensive care unit for 48 hours, and extubation was performed in the operating room under direct bronchoscopy. Mitomycin C was applied to a circumferential area of denuded tracheal mucosa. CONCLUSION: Tracheal foreign bodies are distinctly different clinical entities from bronchial foreign bodies. Asymptomatic bronchial foreign bodies are relatively common, but to the authors' knowledge, an asymptomatic tracheal foreign body had not been reported previously. Discussion focused on pathophysiology with reference to Poiseuille's law, diagnosis, and management of asymptomatic tracheal foreign bodies, including the possibility of elective bronchoscopic retrieval.     

Asystole and severe bradycardia in preterm infants

Transient episodes of apnea and bradycardia are common in preterm infants. Pronounced asystole or sinus arrest, however, is relatively rare and the clinical significance of such events is unknown. OBJECTIVE: The purpose of our study was to: (1) evaluate the prevalence of severe bradycardic and asystolic events in infants studied with polygraphic cardiorespiratory monitoring, (2) characterize these events, and (3) correlate the events with other clinical findings. METHODS: A total of 583 studies were performed in 454 preterm infants at a post-conceptional age 37.4 +/- 2.5 (range 34-42 weeks). Asystolic pauses were defined as no QRS complex for >or=3 s consistent with a heart rate <20 beats per minute (bpm). Severe bradycardia was defined as no QRS for >or=2 s consistent with a heart rate of 21-30 bpm. RESULTS: Eight infants (29.5 +/- 3.9 weeks' gestational age, birth weight 1,283 +/- 445 g) met the criteria of having had at least 1 asystolic event (heart rate 相似文献   

Abnormal Involuntary Movement Scale (AIMS) and Extrapyramidal Symptom Rating Scale (ESRS): cross-scale comparison in assessing tardive dyskinesia

Assessing tardive dyskinesia (TD) has been complicated by the use of different research criteria and rating scales. We studied concordance between two commonly used scales, the Abnormal Involuntary Movement Scale (AIMS) and Extrapyramidal Symptom Rating Scale (ESRS), to study interscale concordance and criteria to define TD. Patients with schizophrenia or schizoaffective disorder (N = 374) were rated at baseline with both scales. Linear and logistic regression models explored relationships between scale ratings and mapped scores for corresponding items. TD was defined as at least mild in > or = 2 anatomical areas, or moderate or greater symptoms in > or = 1 area at baseline. Logistic regression was used to find simplified criteria for predicting AIMS-defined TD by ESRS scores. There was a strong association on corresponding item ratings. "Mild" was defined as AIMS score of 2 and ESRS 2 or 3, and "moderate or greater" as AIMS score > or = 3 and ESRS > or = 4. Using these criteria, there was 96.0% (359/374) agreement between AIMS- and ESRS-defined TD cases. The ESRS Clinical Global Impressions of severity of dyskinesia (CGI-SD) best predicted AIMS-defined TD. An ESRS CGI-SD > or = 4 (95% CI: 3.61, 4.76) was associated with > or = 95% probability of AIMS-defined TD. High concordance between the scales for dyskinesia scores was found. Findings suggest that the ESRS CGI-SD score can serve as a simplified criterion for identifying AIMS-defined TD, and may be a useful tool for future research-based TD analyses, when occurring in the context of a full movement disorder assessment.     

Behavioral alterations in lewis rats following two-day continuous 3-nitropropionic acid administration

The mitochondrial toxin, 3-nitropropionic acid (3-NP), produces motor dysfunction and striatal atrophy in rats. However, rat strain and method of administration may contribute to variability in the deficits caused by 3-NP toxicity. To evaluate this, changes in nocturnal spontaneous locomotor activity from chronic administration of 3-NP using an osmotic mini pump, were examined in the Lewis rats. Lewis rats were treated with 3-NP or saline for 2 days and behavior was tested daily for a 15 day period. Animals receiving 3-NP displayed significantly less spontaneous activity than animals in the saline group. 3-NP treated animals also weighed significantly less when compared to saline treated animals. These results demonstrate that even though there were no significant alterations in overt anatomical pathology, even short-term exposure to 3-NP produced significant effects. This short-term administration may present a potential paradigm for examination of sub-threshold neurotoxicity.     

Doublecortin interacts with the ubiquitin protease DFFRX, which associates with microtubules in neuronal processes

Doublecortin (DCX) is a microtubule-associated protein involved in neuronal migration, which causes X-linked lissencephaly and subcortical laminar heterotopia (SCLH) when mutated. Here we show that DCX interacts with the ubiquitin-specific protease Drosophila fat facets related on X chromosome (DFFRX). This interaction was confirmed by targeted mutagenesis, colocalization, and immunoprecipitation studies. DFFRX is thought to deubiquitinate specific substrates including beta-catenin, preventing their degradation by the proteasome. Interestingly, unlike beta-catenin, no ubiquitinated forms of DCX could be detected, and indeed we show that DCX interacts with a novel recognition domain in DFFRX, located outside of its catalytic site. We also show that DFFRX associates with microtubules at specific subcellular compartments, including those enriched in DCX. These results thus suggest that in addition to vesicular trafficking, DCX may play a role in the regulation of cell adhesion via its interaction with DFFRX in migrating and differentiating neurons.     

Nerve conduction studies of the lateral femoral cutaneous nerve. Implications in the diagnosis of meralgia paresthetica

The diagnosis of meralgia paresthetica, while based on clinical suspicion, can be confirmed via electrophysiological testing. Previous testing of the sensory conduction of the lateral femoral cutaneous nerve placed the stimulating electrode one centimeter medial to the anterior superior iliac spine (ASIS). This position is both uncomfortable for the patient and difficult for the operator to perform. The following article suggests an alternate position for the stimulating electrode, four centimeters distal to the ASIS. Twenty subjects served as their own controls and both the old technique and the new technique were performed. Using the old technique, the response rate was 35% (7 out of 20 subjects). Using the new technique, the response rate was 90% (18 out of 20 subjects). These results indicate a significantly higher response rate when the only variable altered is the electrode placement. This simple change in technique requires no more effort, cost, or training on the part of the operator yet produces a much higher percentage of responses.     

Differences in the magnitude of long-term potentiation produced by theta burst and high frequency stimulation protocols matched in stimulus number

Theta-burst stimulation (TBS: four pulses at 100 Hz repeated with 200 ms inter-burst-intervals) and another commonly used high-frequency stimulation protocol (HFS: 1 s burst of equally spaced pulses at 100 Hz) were compared for the magnitude of LTP produced in rat hippocampal slices. The total number of pulses applied during tetanus (TET) was either 40, 100, 200, or 300. In a conventional analysis of the last 10 min of the post-TET period, a two-way ANOVA revealed no difference either in LTP of the field excitatory post-synaptic potential (fEPSP) between TBS and HFS or differences across pulse number at 40, 100, or 200 pulses. At 300 pulses, there was a significant main effect by pulse number but not by protocol. A linear regression analysis showed that stimulation protocol accounted for only about 10% of the change in magnitude while pulse number contributed to 30% of the change. However, when an extended analysis of the same data was performed across the entire post-TET period with a repeated-measure ANOVA, a small but persistent increase in TBS over HFS at 200 pulses was significant. A difference between TBS and HFS at 300 pulses that occurred only during the early phase of LTP was also significant. These results suggest that, over a range of stimuli, the number of pulses in an induction protocol, rather than the pattern of stimulation, determines the magnitude of late phase LTP, while TBS produces greater potentiation than HFS in the early phase of LTP with higher TET number.     

Contribution of impaired glucose tolerance in subjects with the metabolic syndrome: Baltimore Longitudinal Study of Aging

BACKGROUND: In addition to fasting plasma glucose (FPG), we examined the contribution of the oral glucose tolerance test (OGTT) in the prevalence of subjects with the metabolic syndrome (MS). METHODS AND RESULTS: Study participants were white adults in the Baltimore Longitudinal Study of Aging who underwent a fasting 2-hour OGTT. In men between the ages of 20 to 39, 40 to 59, 60 to 79, and 80 to 95 years, the prevalence of the MS by Adult Treatment Panel (ATP) III criteria (which excludes OGTT) was 11%, 28%, 32%, and 15%, respectively; whereas in women the prevalence was 5%, 12%, 24%, and 16%, respectively. If the current ATPIII dysglycemia criteria also included a 2-hour postchallenge glucose (2hPG) of 7.8 mmol/L or higher, the prevalence of the MS increased from 25% to 33% in men and from 15% to 21% in women (P<.0001). In study participants with FPG less than 5.6 mmol/L, the prevalence of the MS increased from 16% to 23% in men and from 9% to 13% in women. In men between the ages of 20 to 39, 40 to 59, 60 to 79, and 80 to 95 years and FPG less than 5.6 mmol/L, the prevalence of the MS increased to 15%, 32%, 40%, and 29%, respectively (P<.005 for men between 40 and 95 years of age), with inclusion of an abnormal 2hPG. In women between the ages of 20 to 39, 40 to 59, 60 to 79, and 80 to 95 years and FPG less than 5.6 mmol/L, the prevalence of the MS increased to 7%, 14%, 33%, and 31%, respectively, with inclusion of an abnormal 2hPG (P<.001 for women between 60 and 95 years of age). CONCLUSION: The prevalence of the MS is significantly underestimated when the current ATPIII criteria of FPG 6.1 mmol/L or higher is the only determinant of dysglycemia.