Methazolamide-Induced Delirium

A 74-year-old man became delirious 2 days after beginning oral therapy with methazolamide. The delirium was manifested by intermittent psychosis, incontinence of bowel and bladder, lethargy, and disorientation. These symptoms continued for 25 days despite many changes in his drug regimen, and complete laboratory, urologic, and neurologic work-ups. The symptoms resolved completely within 1 week of discontinuing methazolamide. This is the first case reported of delirium associated with methazolamide not accompanied by a metabolic imbalance.     

Effect of chronic ethanol administration on the uptake and degradation of asialoglycoproteins by the perfused rat liver

We have shown previously reduced binding, internalization, degradation and receptor-ligand dissociation during receptor-mediated endocytosis (RME) of 125I-asialoorosomucoid (ASOR) by hepatocytes isolated from rats fed ethanol for 4-6 weeks. In the present study, we investigated the effect of ethanol feeding on RME by using the intact perfused liver as a model. Male, Sprague-Dawley rats were fed a liquid diet containing either ethanol (36% of calories) or isocaloric carbohydrate. Receptor-mediated endocytosis of 125I-ASOR was then examined over a time course of perfusion. In all cases, clearance of the labeled glycoprotein was followed by a slower but steady appearance of acid-soluble products in the medium. Ethanol-fed animals had a significantly (P less than 0.01) slower rate of clearance of the labeled ligand from the circulating perfusate than did control animals. Impairment of ASOR surface binding and degradation in ethanol-fed animals was also demonstrated in this model. When we examined the subcellular distribution of labeled ligand after various times of perfusion, we found that in control livers, a shift of radiolabeled ligand from the subcellular fractions containing endosomes and plasma membranes to fractions containing lysosomes occurred, while significantly less ligand was shifted to the lysosomes of ethanol-treated rats. These results show that ethanol administration inhibits RME of ASOR in the isolated perfused liver model, thus confirming our earlier reported defects in isolated hepatocytes. In addition, transport of ligand along the intracellular RME pathway was also shown to be altered by ethanol treatment as indicated by the impaired movement of ASOR from the endosomal to the lysosomal compartment.     

Hand-assisted laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma.

OBJECTIVE: We report our experience with hand-assisted laparoscopic nephroureterectomy (HALN) for upper urinary tract transitional cell carcinoma and compare our results with a contemporary series of open nephroureterectomy (ON) performed at our institution. METHODS: Between August 1996 and May 2003, 90 patients underwent nephroureterectomy for upper-tract transitional cell carcinoma (TCC). Thirty-eight patients underwent HALN, while 52 had an ON. End-points of comparison included operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of hospital stay, pathologic grade and stage of tumor, and tumor recurrence. RESULTS: The mean patient age was 72.3 and 70.6 years in the ON and HALN groups, respectively. Mean operative duration was 243 minutes (ON) and 244 minutes (HALN), with an EBL of 478mL in the open group versus 191 mL in the hand-assisted group (P<0.001). No intraoperative complications occurred, but postoperative complications occurred in 4% and 11% of the ON and HALN groups, respectively (P=0.21). The mean hospital duration was 7.1 days (ON) versus 4.6 days (HALN) (P<0.01). No difference existed in the pathologic grade or stage distribution of urothelial tumors between the 2 groups. The mean follow-up was 51.0 months in the ON group and 31.7 months in the HALN group. Recurrence of urothelial carcinoma occurred in 50% of patients who underwent ON and 40% treated by HALN (P=0.38) at a median interval of 9.1 and 7.7 months, respectively, after surgery. CONCLUSION: Hand-assisted laparoscopic nephroureterectomy is an effective modality for the treatment of upper urinary tract urothelial carcinoma. Patients benefited from less intraoperative blood loss and a shorter hospitalization with an equivalent intermediate-term oncologic outcome compared with that of the open approach.     

Radiographic changes induced after cervical facet radiofrequency denervation

BACKGROUND CONTEXT: Paraspinal infections after zygapophyseal (facet) radiofrequency denervation (RFD) are a serious but rare complication of this procedure. We are aware of only one case report of an epidural abscess after facet joint injection. PURPOSE: To report post-procedure inflammatory changes after cervical facet RFD. STUDY DESIGN: Case report. PATIENT SAMPLE: A 35-year-old Caucasian female. METHODS: Retrospective case review. RESULTS: The patient underwent cervical RFD and was admitted to the hospital 7 days after her procedure with severe neck pain. Magnetic resonance imaging (MRI) with contrast revealed what appeared to be evidence of a paraspinal muscle abscess although blood tests were negative. She was treated with antibiotic therapy, yet she never developed systemic signs of infection. A follow-up MRI without contrast revealed no evidence of infection, and she was discharged home on hospital day 6. At her first follow-up visit, she was still experiencing scalp pain and paraspinal muscle spasm. During subsequent follow-up visits, she has continued to improve clinically without experiencing signs of infection. Another follow-up MRI 6 weeks after her discharge home revealed persistent minimal left paraspinal enhancement at C2-3, possibly representing post-procedure granulation tissue with no evidence of abscess. CONCLUSIONS: Post-procedural MRI findings after radiofrequency lesioning can resemble radiographic findings associated with a paraspinal abscess. Patients with radiographic findings consistent with abscess should only be treated if clinical signs or symptoms of systemic infection are present.     

Preventing the airborne spread of Staphylococcus aureus by persons with the common cold: effect of surgical scrubs, gowns, and masks.

OBJECTIVE: Transmission of Staphylococcus aureus via air may play an important role in healthcare settings. This study investigates the impact of barrier precautions on the spread of airborne S. aureus by volunteers with experimentally induced rhinovirus infection (ie, the common cold). DESIGN: Prospective nonrandomized study. SETTING: Wake Forest University School of Medicine (Winston-Salem, NC).Participants. A convenience sample of 10 individuals with nasal S. aureus carriage selected from 593 students screened for carriage. INTERVENTION: Airborne S. aureus dispersal was studied in the 10 participants under the following clothing conditions: street clothes, surgical scrubs, surgical scrubs and a gown, and the latter plus a face mask. After a 4-day baseline period, volunteers were exposed to a rhinovirus, and their clinical course was followed for 12 days. Daily swabs of nasal specimens, pharynx specimens, and skin specimens were obtained for quantitative culture, and cold symptoms were documented. Data were analyzed by random-effects negative binomial models. RESULTS: All participants developed a common cold. Incidence rate ratios (IRRs) indicated that, compared with airborne levels of S. aureus during sessions in which street clothes were worn, airborne levels decreased by 75% when surgical scrubs were worn (P<.001), by 80% when scrubs and a surgical gown were worn (P<.001), and by 82% when scrubs, a gown, and a face mask were worn (P<.001). The addition of a mask to the surgical scrubs and gown did not reduce the airborne dispersal significantly (IRR, 0.92; P>.05). Male volunteers shed twice as much S. aureus as females (incidence rate ratio, 2.04; P=.013). The cold did not alter the efficacy of the barrier precautions. CONCLUSIONS: Scrubs reduced the spread of airborne S. aureus, independent of the presence of a rhinovirus-induced cold. Airborne dispersal of S. aureus during sessions in which participants wore surgical scrubs was not significantly different from that during sessions in which gowns and gowns plus masks were also worn.     

Experimental rabies in skunks and foxes. Pathogenesis of the spongiform lesions

The pathogenesis of rabies spongiform lesions in striped skunks (Mephitis mephitis) and red foxes (Vulpes vulpes) was studied by light and electron microscopy and peroxidase-antiperoxidase immunocytochemistry. Studies in skunks included use of several street virus variants (different antigenic profiles as tested by monoclonal antibodies) different routes of inoculation (intranasal, intracerebral and intramuscular), immunosuppression of infected skunks, different preparations of virus (brain and salivary gland suspensions and infective tissue culture fluids), and sequential development of the lesions. Foxes (Vulpes vulpes) were infected intramuscularly with a street virus isolate. Except for the group of immunosuppressed skunks, all animals that developed clinical signs of rabies had encephalitis characterized by varying degrees of mononuclear perivascular cuffing, focal gliosis, and Negri bodies. Spongiform change occurred in the neuropil of the grey matter (especially thalamus and cerebral cortex) in rabid animals from all groups, but not in controls or exposed animals that did not develop rabies. Rabies antigen (detected by peroxidase-antiperoxidase immunocytochemistry) occurred only in small amounts in many thalami; some vacuolated areas were devoid of antigen. Ultrastructurally, there was a gradation in lesions from small to large membrane-bound vacuoles in cellular processes (mainly dendrites, less frequently axons) and to large tissue spaces containing granular and/or membranous material. These studies indicate that rabies spongiform change occurs in skunks given street virus of several different antigenic profiles and challenge virus standard rabies virus and that the distribution of the lesions has remarkable similarities to those of the traditional spongiform encephalopathies. The occurrence of the lesion is not affected by the immune response, the route of inoculation of virus, the preparation (suspension of salivary gland or brain, or tissue culture fluid), or the incubation period. The paucity of antigen in many thalami suggests that incorporation of viral components into vacuolar membranes is not necessary for development of the spongiform change. The development of the lesions includes formation of small membrane-bound vacuoles in cellular processes, rapid enlargement (less than 3 days) with compression of adjacent neural tissue, and rupture resulting in the large tissue spaces readily visible by light microscopy.     

Long-term precision of 18F-fluoride PET skeletal kinetic studies in the assessment of bone metabolism.

(18)F-Fluoride PET allows noninvasive evaluation of regional bone metabolism and has the potential to become a useful tool for assessing patients with metabolic bone disease and evaluating novel drugs being developed for these diseases. The main PET parameter of interest, termed K(i), reflects regional bone metabolism. The aim of this study was to compare the long-term precision of (18)F-fluoride PET with that of biochemical markers of bone turnover assessed over 6 mo. METHODS: Sixteen postmenopausal women with osteoporosis or significant osteopenia and a mean age of 64 y underwent (18)F-fluoride PET of the lumbar spine and measurements of biochemical markers of bone formation (bone-specific alkaline phosphatase and osteocalcin) and bone resorption (urinary deoxypyridinoline) at baseline and 6 mo later. Four different methods for analyzing the (18)F-fluoride PET data were compared: a 4k 3-compartmental model using nonlinear regression analysis (K(i-4k)), a 3k 3-compartmental model using nonlinear regression analysis (K(i-3k)), Patlak analysis (K(i-PAT)), and standardized uptake values. RESULTS: With the exception of a small but significant decrease in K(i-3k) at 6 mo, there were no significant differences between the baseline and 6-mo values for the PET parameters or biochemical markers. The long-term precision, expressed as the coefficient of variation (with 95% confidence interval in parentheses), was 12.2% (9%-19%), 13.8% (10%-22%), 14.4% (11%-22%), and 26.6% (19%-40%) for K(i-3k), K(i-PAT), mean standardized uptake value, and K(i-4k), respectively. For comparison, the precision of the biochemical markers was 10% (7%-15%), 18% (13%-27%), and 14% (10%-21%) for bone-specific alkaline phosphatase, osteocalcin, and urinary deoxypyridinoline, respectively. Intraclass correlation between the baseline and 6-mo values ranged from 0.44 for K(i-4k) to 0.85 for K(i-3k). No significant correlation was found between the repeated mean standardized uptake value measurements. CONCLUSION: The precision and intraclass correlation observed for K(i-3k) and K(i-PAT) was equivalent to that observed for biochemical markers. This study provided initial data on the long-term precision of (18)F-fluoride PET measured at the lumbar spine, which will aid in the accurate interpretation of changes in regional bone metabolism in response to treatment.