Antiparasitic,nematicidal and antifouling constituents from Juniperus berries

A bioassay‐guided fractionation of Juniperus procera berries yielded antiparasitic, nematicidal and antifouling constituents, including a wide range of known abietane, pimarane and labdane diterpenes. Among these, abieta‐7,13‐diene (1) demonstrated in vitro antimalarial activity against Plasmodium falciparum D6 and W2 strains (IC₅₀ = 1.9 and 2.0 µg/mL, respectively), while totarol (6), ferruginol (7) and 7β‐hydroxyabieta‐8,13‐diene‐11,12‐dione (8) inhibited Leishmania donovani promastigotes with IC₅₀ values of 3.5–4.6 µg/mL. In addition, totarol demonstrated nematicidal and antifouling activities against Caenorhabditis elegans and Artemia salina at a concentration of 80 µg/mL and 1 µg/mL, respectively. The resinous exudate of J. virginiana afforded known antibacterial E‐communic acid (4) and 4‐epi‐abietic acid (5), while the volatile oil from its trunk wood revealed large quantities of cedrol (9). Using GC/MS, the two known abietanes totarol (6) and ferruginol (7) were identified from the berries of J. procera, J. excelsa and J. phoenicea. Copyright © 2008 John Wiley & Sons, Ltd.     

The relationship between cerebral T2 hyperintensity and fixation suppression of vestibulo-ocular reflex in elderly patients with dysequilibrium symptoms

OBJECTIVES: To evaluate the relationship between cerebral T2 hyperintensity on MRI and visual suppression of vestibulo-ocular reflex (VOR) in elderly patients with dysequilibrium symptoms. METHODS: Eighty-nine elderly patients with no MRI abnormalities in the infratentorial region aged 60-89 years complaining dysequilibrium symptoms were studied. Cases with whom a definitive diagnosis of peripheral or central disease could be established were not included. T2 hyperintense lesions in the cerebrum: basal ganglia, subcortical white matter and periventricular white matter were evaluated. VOR in darkness and fixation-suppressed VOR using pseudo-sinusoidal rotation stimuli were recorded to calculate visual suppression rate. Correlation between visual suppression rate and semi-quantitative scores for severity of T2 hyperintensity in the cerebrum was investigated. RESULTS: Patients with T2 hyperintensity in the cerebrum exhibited significantly lower visual suppression rate than those without lesions in the cerebrum. Multiple regression analysis showed that visual suppression rate was significantly and negatively correlated with severity of lesions in the basal ganglia, but not with patient age, severity of subcortical white matter lesions, or that of periventricular white matter lesions. CONCLUSIONS: In elderly patients with dizziness with a non-specific history and otoneurological findings, fixation suppression of vestibular nystagmus was associated with T2 hyperintensities in the basal ganglia.     

Accuracy of Sonographically Guided Biopsy Using a Freehand Versus Needle‐Guided Technique

Sonographically guided biopsy is performed by one of two techniques: the freehand and needle‐guided techniques. To our knowledge, the relationship between the location of the local anesthetic tract and the biopsy needle tract as well as direct comparison of the two biopsy techniques has not been previously validated. The aim of this study was to validate the different parameters related to the two biopsy techniques using computed tomography as the reference standard for assessing final tract positions. There were statistically significant differences between the freehand and guided techniques in the following parameters: number of passes required for contrast agent injection (P = .003), number of passes required to insert the needle (P = .005), time required to inject the anesthetic/contrast agent (P = .005), time required to insert the biopsy needle (P = .02), and distance between contrast tract and final needle position (P = .03). No statistical difference was identified for the angle between the contrast tract and needle position. This difference likely reflects the confidence of the radiologist in identifying the needle location during the procedure. Using a commercially available guide that has a fixed angle can result in a faster, more efficient, and reproducible biopsy technique compared to the freehand technique, especially for those who have less experience in performing sonographically guided biopsies.     

Radiation Exposure by Three-Dimensional Rotational Angiography (3DRA) During Trans-catheter Melody Pulmonary Valve Procedures (TMPV) in a Pediatric Cardiac Catheterization Laboratory

This retrospective study aims to evaluate radiation exposure by three-dimensional rotational angiography (3DRA) during trans-catheter Melody pulmonary valve (TMPV) procedures. 3DRA has been reported to have added value in the management of complex congenital heart disease aiding in the performance of interventional procedures albeit with concerns of higher radiation exposure. We test the hypothesis that 3DRA does not cause additional radiation exposure during TMPV procedures. We analyzed all 81 TMPV procedures performed at St. Louis Children’s Hospital, MO, USA, from January 1, 2011 to December 31, 2014. Dose-area product (DAP), DAP indexed to body weight (DAP/BW), fluoroscopy time (FT), and weight–fluoroscopy time product of each procedure were recorded. We reviewed each procedure’s images to determine whether additional interventions were performed (e.g., pulmonary artery angioplasty or treatment of conduit pseudo-aneurysm). 3DRA was used in 36 % of the procedures. 3DRA group had a higher number of additional procedures performed. The 3DRA group did not differ from the non-3DRA group in DAP, DAP/BW, and weight–fluoroscopy time product. 3DRA does not cause greater radiation exposure during TMPV procedures.     

Comparison of Management Strategies for Neonates With Symptomatic Tetralogy of Fallot

BackgroundNeonates with tetralogy of Fallot and symptomatic cyanosis (sTOF) require early intervention.ObjectivesThis study sought to perform a balanced multicenter comparison of staged repair (SR) (initial palliation [IP] and subsequent complete repair [CR]) versus primary repair (PR) treatment strategies.MethodsConsecutive neonates with sTOF who underwent IP or PR at ≤30 days of age from 2005 to 2017 were retrospectively reviewed from the Congenital Cardiac Research Collaborative. The primary outcome was death. Secondary outcomes included component (IP, CR, PR) and cumulative (SR): hospital and intensive care unit lengths of stay; durations of cardiopulmonary bypass, anesthesia, ventilation, and inotrope use; and complication and reintervention rates. Outcomes were compared using propensity score adjustment.ResultsThe cohort consisted of 342 patients who underwent SR (IP: surgical, n = 256; transcatheter, n = 86) and 230 patients who underwent PR. Pre-procedural ventilation, prematurity, DiGeorge syndrome, and pulmonary atresia were more common in the SR group (p ≤0.01). The observed risk of death was not different between the groups (10.2% vs 7.4%; p = 0.25) at median 4.3 years. After adjustment, the hazard of death remained similar between groups (hazard ratio: 0.82; 95% confidence interval: 0.49 to 1.38; p = 0.456), but it favored SR during early follow-up (<4 months; p = 0.041). Secondary outcomes favored the SR group in component analysis, whereas they largely favored PR in cumulative analysis. Reintervention risk was higher in the SR group (p = 0.002).ConclusionsIn this multicenter comparison of SR or PR for management of neonates with sTOF, adjusted for patient-related factors, early mortality and neonatal morbidity were lower in the SR group, but cumulative morbidity and reinterventions favored the PR group, findings suggesting potential benefits to each strategy.     

Bradycardia Associated with Hiatal Hernia and Gastroesophageal Reflux Relieved by Surgery

A man known to have familial dysautonomia presented with a cardiac arrhythmia due to development of hiatal hernia and gastroesophageal reflux. Preoperative symptoms and assessment are described including use of power spectrum analysis of heart rate fluctuations which was consistent with enhanced parasympathetic stimulation. After surgical repair of hiatal hernia and fundoplication, bradycardia resolved, gastroesophageal reflux symptoms subsided, and the power spectrum analysis of heart rate confirmed decreased parasympathetic influence. Power spectrum analysis proved to be a useful adjunct in confirming preoperative autonomic imbalance and assessing the postoperative result. It is concluded that in individuals with disorders such as familial dysautonomia that are associated with autonomic dysfunction, cardiac arrhythmias may be a sign of esophageal pathology. Thus, cardiac evaluations should be accompanied by investigation of gastroesophageal structure and function and appropriate treatment may prevent a catastrophic arrhythmia.     

Multiple sclerosis and pregnancy: therapeutic considerations

For women with multiple sclerosis (MS) who become pregnant, the risks and benefits of ongoing therapy for the health of both the mother and the fetus must be carefully considered. Based on a literature review and our MS center’s standard practices, we provide guidance to aid clinical decision making in the absence of clear evidence-based clinical practice guidelines. Women seeking to achieve pregnancy should generally discontinue disease-modifying therapy use prior to attempting conception. For example, the immunosuppressant mitoxantrone is teratogenic and should be prescribed only with the assurance of effective contraception. Conception should be discouraged for patients on fingolimod, because of the limited information available on human pregnancy outcomes. Current evidence, including data from pregnancy registries for glatiramer acetate (GA), interferon beta-1a (IFNβ-1a), and natalizumab, has not shown specific patterns of malformations suggesting teratogenicity. Pregnancy registry data have not been published for IFNβ-1b. During breastfeeding, intravenous immunoglobulin and corticosteroids are generally safe and may be associated with a reduction in postpartum relapses; however, a washout period is recommended between corticosteroid administration and the resumption of breastfeeding. Clinical data on the use of IFNβ, GA, and natalizumab during lactation are limited. Mitoxantrone is contraindicated during breastfeeding, and fingolimod should be avoided in nursing mothers, because of a lack of data.     

Disparities in Access to Surgical Care within a Lower Income Country: An Alarming Inequity

Background

Surgical care is not uniformly available worldwide. Inequities in surgical care and access may also vary within countries, and the present study aimed to explore these disparities in Pakistan.

Methods

The National Health Survey of Pakistan was analyzed. The proportion of people with a history of abdominal surgery (AS) was calculated and associated factors were determined by weighted multivariate logistic regression. Factors tested were age, gender, urban/rural residence, province, literacy, community development index (CDI), and economic status (ES). The CDI was developed for each sampling unit from select household and individual data. The ES was constructed from ownership of assets.

Results

A total of 59 million adults were represented. Abdominal surgery had been performed in 3.2 % adults (95 % confidence interval [CI] = 2.67, 3.84), which corresponded to an annual rate of 85.9 abdominal surgeries per 100,000 population. Wide disparities were noted, with annual rates of AS varying from 37.8 to 215.6 per 100,000 population. Urban residents were independently twice as likely as rural populations to have had AS (95 % CI = 1.3, 2.8). Higher age (OR = 2.6; 95 % CI = 1.7, 4.0), female gender (OR = 1.5; 95 % CI = 1.1, 2.1), and higher ES (OR = 1.9; 95 % CI = 1.2, 2.9) were also independently associated with AS. In rural populations ES was the only factor associated with surgery, whereas in urban populations gender and CDI had important roles to play.

Conclusions

Access to surgical care is disparate and grossly inadequate in Pakistan. This likely contributes to significant preventable morbidity and death. Physical access to surgical facilities, especially in rural areas and for those with a low CDI, is an important concern and should be prioritized in any forthcoming national policies.     

Prevention of propofol injection pain,using lidocaine in a large volume does it make a difference? A prospective randomized controlled double blinded study

PurposePropofol has become one of the most common anesthetic agents used for anesthesia because of its unique pharmacologic properties. Pain during bolus injection is a major drawback of propofol. The target of this study was to study the effect of lidocaine used in a large volume on prevention of propofol injection pain. Our hypothesis is that IV administration of diluted lidocaine in a large volume before propofol injection could be more effective in prevention of both immediate and delayed types of pain associated with propofol injection than the most commonly used method of mixing lidocaine with propofol (30 mg lidocaine/added to the 20 ml propofol syringe).Methods100 Patients with age range (20–60) years and classified ASA1 and ASA2 undergoing general anesthesia for elective surgery were included in this study. Patients were classified into two groups, the first (study) group, in which 30 mg lidocaine diluted into a total volume of 20 ml using normal saline was given IV after venous occlusion with rubber tourniquet followed by propofol injection. In the second (control) group, 30 mg lidocaine was mixed with propofol and given to the patient as commonly used.ResultsThis study showed a highly significant reduction in the propofol injection pain in the study group compared to the control group.Conclusionlidocaine when given diluted in a large volume after venous occlusion has dramatically reduced propofol injection pain in adults.