Oral medication-induced esophageal injury in elderly patients

SUMMARY: ABSTRACT Although oral medication induced esophageal injury (OMIEI), is a well-known and preventable condition, many cases are still missed, particularly in the elderly patients.OBJECTIVE To determine the frequency and outcome of oral medication-induced esophageal injury in elderly patients.METHODS Records of 390 patients aged over 65 years, with diagnoses of dysphagia, odynophagia, and noncardiac chest pain, over the period of 11 years, were selected for a retrospective review. Patients who had barium studies only, in whom endoscopy was not done or was unsuccessful, and those with incomplete data were excluded, leaving 250 patients for further review.RESULTS Diagnosis of OMIEI was made in 27% (68 of 250) patients. Fifty-one of 68 (75%) patients with OMIEI responded to conservative management, including H2 blockers, proton pump inhibitors, antacids, or sucralfate. The remaining 17 patients (25%) developed esophageal strictures requiring dilation.CONCLUSIONS A high index of clinical suspicion and low threshold for empiric treatment and diagnostic measures (endoscopy, barium swallow study), may be helpful, if indicated, for early diagnosis and prompt therapy of OMIEI.     

Left ventricular intracavitary mass and pericarditis secondary to metastatic renal cell carcinoma--a case report

Cardiac metastases from renal cell carcinoma are a well-recognized entity. However, this phenomenon is extremely rare in the absence of vena caval extension. The authors report a patient who after successful resection of renal cell carcinoma presented with left ventricular mass causing left ventricular outflow tract obstruction. There was also metastatic pericardial and intramyocardial involvement. Such a unique combination of cardiac metastasis, in the same patient, has not been reported previously.     

Dentistry as a possible route of hepatitis C transmission in Pakistan

AIMS AND OBJECTIVES: To identify the role of dental surgical procedures in contributing to the transmission of hepatitis C. DESIGN: Prospective observational pilot study. SETTING: Shaikh Zayed Federal Postgraduate Medical Institute Lahore, Pakistan. METHODS: Exposure to dental procedures, injections, tattooing, surgical intervention, blood transfusions, family history of hepatitis, diabetes mellitus and contact with jaundiced patients was evaluated in 78 consecutive adult patients of both sexes suffering from chronic hepatitis C. MAIN OUTCOME MEASURES: Distribution of risk factors for acquiring hepatitis C with emphasis on role of dentistry as a possible route of transmission. RESULTS: Dental procedures were the major source of exposure (39.7%) followed by injections (16.6%), surgical procedures (16.6%), diabetes (12.8%), family history of hepatitis (9%), blood transfusions (7%), tattooing (5.1%) and history of contact with a jaundiced patient (2.6%). There was a statistically significant difference in distribution of risk factors, with dental procedures being the commonest factor (p < 0.001). CONCLUSIONS: The high prevalence of dental procedures in patients with chronic hepatitis C stresses the importance of ineffective infection control methods practiced by dental surgeons as a risk factor for acquiring hepatitis C and which were probably the source of infection. Large epidemiological studies are needed to elucidate the role of dentistry in transmitting hepatitis C.     

High-resolution voxelation mapping of human and rodent brain gene expression

Voxelation allows high-throughput acquisition of multiple volumetric images of brain gene expression, similar to those obtained from biomedical imaging systems. To obtain these images, the method employs analysis of spatially registered voxels (cubes). For creation of high-resolution maps using voxelation, relatively small voxel sizes are necessary and instruments will be required for semiautomated harvesting of such voxels. Here, we describe two devices that allow spatially registered harvesting of voxels from the human and rodent brain, giving linear resolutions of 3.3 and 1 mm, respectively. Gene expression patterns obtained using these devices showed good agreement with known expression patterns. The voxelation instruments and their future iterations represent a valuable approach to the genome scale acquisition of gene expression patterns in the human and rodent brain.     

Role of cysteinyl leukotrienes in adenosine 5'-monophosphate induced bronchoconstriction in asthma

BACKGROUND: Adenosine induced bronchoconstriction in patients with asthma is thought to be mediated by the synthesis and release of autacoids from airway mast cells. In vitro, adenosine induced constriction of asthmatic bronchi is blocked by a combination of specific histamine and cysteinyl leukotriene receptor antagonists, but the relative contribution of these mediators in vivo is unclear. We hypothesised that adenosine induced bronchoconstriction in asthmatic patients may be blocked by pretreatment with the orally active selective cysteinyl leukotriene-1 (CysLT(1)) receptor antagonist, montelukast. METHODS: In a randomised, double blind, crossover study, oral montelukast (10 mg) or placebo was administered once daily on two consecutive days to 18 patients with mild to moderate persistent atopic asthma. Incremental doses of adenosine 5'-monophosphate (AMP) from 0.39 to 400 mg/ml were inhaled by dosimeter and the dose producing a 20% fall in FEV(1) (PC(20)AMP) after AMP inhalation was recorded. Leukotriene E(4) (LTE(4)) urinary concentrations were measured by enzyme immunoassay 4 hours after AMP challenge. RESULTS: Montelukast pretreatment provided highly significant protection against adenosine induced bronchoconstriction, with geometric mean PC(20)AMP values of 52.6 mg/ml (95% CI 35.2 to 78.7) after placebo and 123.9 mg/ml (95% CI 83.0 to 185.0) after montelukast (p=0.006). The geometric mean of the montelukast/placebo PC(20)AMP ratio was 2.4 (95% CI 1.3 to 4.2). Montelukast had no significant effect on 4 hour urinary excretion of LTE(4) compared with placebo. CONCLUSIONS: Selective CysLT(1) receptor antagonism with montelukast provides highly significant protection against AMP induced bronchoconstriction in patients with atopic asthma, implying that cysteinyl leukotrienes are generated from airway mast cells through preferential activation of their A(2B) receptors.     

Sexual activity as a trigger for ventricular tachycardia in a patient with implantable cardioverter defibrillator

Occurrence of life threatening arrhythmias and sudden death during or following sexual activity is infrequent. We describe a patient with an implantable cardioverter defibrillator who developed increased ventricular ectopic activity followed by sustained ventricular tachycardia during extramarital coitus. A review of literature and management is discussed.     

An algorithm for the treatment of schizophrenia in the correctional setting: the Forensic Algorithm Project

The Forensic Algorithm Project (FAP) was born of the need for a holistic approach in the treatment of the inmate with schizophrenia. Schizophrenia was chosen as the first entity to be addressed by the algorithm because of its refractory nature and high rate of recidivism in the correctional setting. Schizophrenia is regarded as a spectrum disorder, with symptom clusters and behaviors ranging from positive to negative symptoms to neurocognitive dysfunction and affective instability. Furthermore, the clinical picture is clouded by Axis II symptomatology (particularly prominent in the inmate population), comorbid Axis I disorders, and organicity. Four subgroups of schizophrenia were created to coincide with common clinical presentations in the forensic inpatient facility and also to parallel 4 tracks of intervention, consisting of pharmacologic management and programming recommendations. The algorithm begins with any antipsychotic medication and proceeds to atypical neuroleptic usage, augmentation with other psychotropic agents, and, finally, the use of clozapine as the common pathway for refractory schizophrenia. Outcome measurement of pharmacologic intervention is assessed every 6 weeks through the use of a 4-item subscale, specific for each forensic subgroup. A "floating threshold" of 40% symptom severity reduction on Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale items over a 6-week period is considered an indication for neuroleptic continuation. The forensic algorithm differs from other clinical practice guidelines in that specific programming in certain prison environments is stipulated. Finally, a social commentary on the importance of state-of-the-art psychiatric treatment for all members of society is woven into the clinical tapestry of this article.