Refractory vasospasm with a malignant course

We present a patient with two rare disorders, recurrent vasospastic angina leading to cardiac transplant and acute aortic occlusion. The patient had recurrent episodes of coronary vasospasm presenting with unstable angina, acute myocardial infarction, and sudden cardiac death in spite of adequate therapy with nitrates and calcium-channel blockers. He went on to have a cardiac transplant. The patient later presented with acute aortic occlusion with concomitant renal and mesenteric artery spasm. The circumstances of the presentation raise the possibility of a generalized vasospastic predisposition that is responsible for both events. Smoking, the only known major risk factor other than atherosclerosis, was noted to be temporally related to both events in our patient.     

Cardiorespiratory Fitness and Atherosclerotic Cardiovascular Outcomes by Levels of Baseline-Predicted Cardiovascular Risk: The Look AHEAD Study

BackgroundWe evaluated the associations of cardiorespiratory fitness with atherosclerotic cardiovascular disease (ASCVD) by levels of baseline-predicted ASCVD risk among adults with type 2 diabetes.MethodsWe analyzed data from 4203 adults with type 2 diabetes in the Look AHEAD (Action for Health in Diabetes) study. Cardiorespiratory fitness was assessed using maximal exercise testing and categorized into low, moderate, and high; baseline-predicted. ASCVD risk was calculated using the American College of Cardiology/American Heart Association Pooled Cohort Equation. We used Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for ASCVD events (fatal and nonfatal myocardial infarction and stroke).ResultsOver a median of 9.6 years, there were 295 ASCVD events. The effect of fitness on outcomes was different across levels of 10-year predicted ASCVD risk (P for interaction < .001). Among participants with a baseline-predicted risk of 7.5% to 20%, the HR of low (vs high) fitness group was 1.94 (95% CI, 1.12-3.35) for ASCVD events. Fitness was not significantly associated with ASCVD events in the groups with baseline-predicted risk <7.5% (HR 1.53; 95% CI, 0.49-4.76) or ≥20% (HR 1.40; 95% CI, 0.88-2.24). A similar pattern was observed for myocardial infarction and stroke separately.ConclusionsIn a large sample of type 2 diabetes individuals, the association of low fitness with incident ASCVD was modified by the baseline-predicted 10-year ASCVD risk. Our findings suggest the utility of assessing fitness in ASCVD risk stratification in type 2 diabetes, especially among those with intermediate predicted 10-year risk of ASCVD.     

Neuraxial anaesthesia in paediatrics

Neuraxial anaesthesia is a valuable tool in the practice of paediatric anaesthesia. Spinal and epidural blockade are used for a variety of surgical cases as the sole anaesthetic or as an adjunct to general anaesthesia, and confer significant postoperative analgesia. Caudal epidural anaesthesia is used extensively for lower abdominal, urological, and orthopaedic procedures in the setting of outpatient surgery. Lumbar and thoracic epidural infusions via a catheter can provide analgesia for chest and upper abdominal procedures. The potential complications associated with neuraxial anaesthesia can be minimized by prudent technique and careful management. The use of the ultrasound for real-time visualization during paediatric neuraxial blocks may improve safety, success rate, and pain control after surgery.     

Factors associated with injection cessation, relapse and initiation in a community-based cohort of injection drug users in Chennai, India

Aims To characterize factors associated with injection cessation, relapse and initiation. Design The Madras Injection Drug User and AIDS Cohort Study (MIDACS) is a prospective cohort of injection drug users (IDUs) recruited in 2005–06 with semi‐annual follow‐up to 2009. Discrete‐time survival models were used to characterize predictors of time to first injection cessation and relapse. Setting Chennai, India. Participants A total of 855 IDUs who reported injecting in the 6 months prior to baseline and had >1 follow‐up visit. Measurements Cessation was defined as the first visit where no injection drug use was reported (prior 6 months) and relapse as the first visit where drug injection (prior 6 months) was reported after first cessation. Findings All participants were male; median age was 35 years. Over 3 years, 92.7% reported cessation [incidence rate (IR): 117 per 100 person‐years]. Factors associated positively with cessation included daily injection and incarceration and factors associated negatively with cessation included marriage, alcohol and homelessness. Of those who reported cessation, 23.6% relapsed (IR: 19.7 per 100 person‐years). Factors associated positively with relapse included any education, injection in the month prior to baseline, sex with a casual partner, non‐injection drug use, incarceration and homelessness. Alcohol was associated negatively with relapse. The primary reasons for cessation were medical conditions (37%) and family pressure (22%). The majority initiated with non‐injection drugs, transitioning to injection after a median 4 years. Conclusions Injection drug users in southern India demonstrate a high rate of injection cessation over 3 years, but relapse is not uncommon. Compensatory increases in alcohol use indicate that cessation of injection does not mean cessation of all substance use. Family pressure, concerns about general health, fear of human immunodeficiency virus infection and a history of non‐injection drug use are important correlates of cessation.     

Correlation Between Chemical Composition and Antifungal Activity of the Essential Oils of Eight Cinnamomum. Species

Abstract

Fourteen essential oils hydrodistilled from eight Cinnamomum. (Lauraceae) species (C. pubescens. Kochummen, C. impressicostatum. Kosterm, C. microphyllum. Ridl., C. scortechinii. Gamb., C. rhyncophyllum. Miq., C. cordatum. Kosterm, C. zeylanicum. Blume, and C. mollissimum. Hook f.) were examined for their antifungal activity against six dermatophytes (Trichophyton rubrum, T. mentagrophytes, T. tonsurans, Microsporum canis, M. gypseum., and M. audouini)., one filamentous fungi (Aspergillus fumigatus.), and five strains of yeasts (Candida albicans, C. glabrata, C. tropicalis, C. parapsilosis., and Crytococcus neoformans.) by using the broth microdilution method. The antifungal activities of 13 standard compounds that are prevalent constituents in Cinnamomum. oils were also investigated in an effort to correlate the effectiveness of the oils with those of the components of the oils. The chemical composition of the oils was analyzed by GC and GC-MS. Most of the oils showed moderate to strong activity against the fungi. Among the oils, the leaf and bark oils of C. zeylanicum. showed the highest activity against all the fungi with MIC values of 0.04 to 0.63 μ g μ L^{? 1}. Other oils that gave a strong inhibition on fungal growth were the leaf oil of C. cordatum. and bark and twig oils of C. pubescens. and C. impressicostatum.. Cinnamaldehyde, which was the most abundant component of the bark oil of C. zeylanicum., showed the strongest activity against all the fungi studied. Based on the results of the assay on standard samples, it may be that the high levels of cinnamaldehyde, eugenol, geraniol, benzyl benzoate, and methyl cinnamate in the oils and in combination with the minor components is responsible for the high antifungal activity of the oils.     

Anatomical location of the bifurcation of the sciatic nerve in the posterior thigh in infants and children: a formula derived from MRI imaging for nerve localization

BACKGROUND AND OBJECTIVES: Sciatic nerve block is performed at the popliteal fossa for various surgical procedures in infants and children. The aim of this study is to review magnetic resonance imaging scans in children of various ages to assess the location of the division of the nerve in the posterior thigh. METHODS: After Institutional Review Board approval was obtained, measurements of the bifurcation of the sciatic nerve in the posterior thigh were recorded from magnetic resonance images that were previously obtained in children of various ages. Data were recorded in a database and parametric and nonparametric statistical analysis was performed. RESULTS: Measurements were recorded from 59 patient images. Using a linear regression model, we were able to arrive at a formula for determining the point of bifurcation of the sciatic nerve at the posterior thigh. The mathematical formula derived from the linear regression equation was: CONCLUSIONS: We speculate that this knowledge will assist practitioners who use nerve stimulation techniques for sciatic nerve blocks in children of all ages.