Floppy eyelid syndrome and mental retardation

OBJECTIVE: To report four subjects with a combination of floppy eyelid syndrome, mental retardation, and increased mechanical stimulus to the affected side. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: The authors retrospectively reviewed the charts of four mentally retarded subjects with floppy eyelid syndrome. INTERVENTION: Surgical tightening of three upper lids and one lower lid was performed in three subjects. MAIN OUTCOME MEASURE: Relief of symptoms. RESULTS: The affected eyelids were treated surgically; in case 1 by anterior lamellar repositioning and lateral and medial canthal tightening, in case 2 by horizontal upper lid shortening, and in case 3 by horizontal lid shortening of both upper and lower lids. There was marked relief from symptoms in all three cases. In case 4, surgery was deferred at parental request. CONCLUSIONS: These cases support the role of mechanical factors in the pathogenesis of floppy eyelid syndrome. Subjects with mental retardation may cooperate poorly with examination, and we believe that there should be a careful search for floppy eyelid syndrome in the presence of chronic conjunctivitis or unexplained epitheliopathy.     

Emergency coronary bypass surgery after coronary angioplasty: the national heart, lung, and blood institute''s percutaneous transluminal coronary angioplasty registry experience

The frequency and outcome of emergency CABG for complications of PTCA in the NHLBI PTCA Registry were analyzed. Emergency surgery was performed in 202 patients (6.6%). The most frequent indications for emergency operation were coronary dissection in 46%, coronary occlusion in 20%, prolonged angina in 14% and coronary spasm in 11%. Emergency surgery was most often necessary in patients in whom lesions could not be reached or traversed, but more than 25% of patients who required emergency surgery had initially successful dilatation followed by abrupt reclosure of the vessel. The mortality rate with emergency CABG was 6.4%, and nonfatal Ml occurred in 41% of patients, with Q waves developing in approximately 60% of patients with MI. However, 53% of patients managed with emergency CABG for severe ischemic events with PTCA did not have evidence of MI or die and had an uncomplicated postoperative course. No baseline clinical predictors of emergency surgery were identified. Lesion eccentricity was associated with a significant increase in frequency of emergency operation, and the incidence of emergency surgery declined with increasing experience with PTCA.     

Patient-focused sedation and analgesia in the ICU

Patient-focused sedation and analgesia in the ICU encompasses a strategy of comprehensive structured management that matches initial evaluation, monitoring, medication selection, and the use of protocols with patient characteristics and needs. This is best accomplished through interdisciplinary management by physicians, nurses, and pharmacists. An early consideration is that of the potential predisposing and precipitating factors, as well as prior sedative or analgesic use, factors that may influence pharmacologic and supportive therapy. Frequent monitoring with validated tools improves communication among clinicians and plays an important role in detecting and treating pain and agitation while avoiding excessive or prolonged sedation. Patient-focused management encompasses selecting medications best suited to patient characteristics, including the presence of organ dysfunction that may influence drug metabolism or excessive risk for side effects. The use of protocols to optimize drug therapy has emerged as a key component of management, resulting in reductions in the duration of sedation, mechanical ventilation, and ICU length of stay demonstrated with strategies to titrate medications to specific targets, daily interruption of sedation, intermittent rather than continuous therapy, and analgesia-based therapy. While much attention is paid to the initiation and maintenance of therapy, greater emphasis must be placed on careful de-escalation of therapy in order to avoid analgesic or sedative withdrawal. Finally, more work is needed to explore the relationship of critical illness and sedation management with long-term psychological outcomes.     

Dispersed adult rat pancreatic islet cells in culture: A, B, and D cell function

The availability of suitably characterized dispersed islet cell preparations may assist in studies of islet function. Since freshly dispersed adult rat islet cells failed to respond appropriately to secretagogues (no alteration in insulin, glucagon, or somatostatin release after glucose change; modest response to IBMX), these cells were established in primary monolayer culture. We then tested the hypothesis that islet function is at least partially determined by islet structure. B cells which had attached to Petri dishes during a culture period of four days were well preserved at the ultrastructural level, with mitochondria clustered at the cell face attached to the Petri dish and secretory granules concentrated towards the portion of the cell facing the medium. Since it was not possible to estimate cellular hormone content or hormone release as a function of the number of specific types of cells, fractional rates of release and hormone content ratios were compared with those for intact islets maintained in culture in parallel. Whereas the ratio of somatostatin:insulin content was similar for islets and cells (approximately 0.7:100), the dispersed cell population appeared depleted in glucagon (glucagon:insulin ratios being 17:100 for islets and 4:100 for cells) reflecting either degranulation or relative loss of A cells. In contrast to the lack of responsiveness seen with freshly dispersed islet cells, the cultured cells released insulin in response to glucose and glucose plus IBMX in a fashion comparable to that seen with cultured islets. Proinsulin biosynthesis (incorporation of [3H] leucine) was higher in cultured cells than islets. Somatostatin release was lower from dispersed cells than from islets while the opposite was true for glucagon.(ABSTRACT TRUNCATED AT 250 WORDS)     

An evaluation of patient-specific characteristics on attainment of target sedation in an intensive care unit

Background

Sedation of mechanically ventilated patients should optimize comfort and safety while avoiding over-sedation and adverse outcomes. To our knowledge, characteristics associated with attaining target sedation are unknown.

Postobstructive diuresis. Studies in a dialyzed patient with a solitary kidney

Urinary excretion was studied in a volume-expanded, dialyzed patient who experienced a profound diuresis after passage of a uric acid calculus which had obstructed the ureter of his solitary horseshoe kidney. Natriuresis (23 per cent of the filtered load of sodium at peak flow) was accompanied by massive urinary losses of water, potassium, magnesium, calcium, bicarbonate, phosphate and uric acid. The data suggest that inhibition of proximal tubular reabsorptive processes was the major factor producing diuresis. Persistent free water clearance and initial potassium secretion indicate that the function of the distal tubule was largely intact. This diuretic pattern in association with retained ability to modulate sodium excretion after completion of diuresis suggests that volume expansion was the primary cause of blockade to proximal tubular reabsorption. Recommendations are made for the clinical management of the patient with diuresis after relief of obstruction.     

Hyperinsulinism in endotoxin shock dogs

Extreme hyperinsulinism was observed in endotoxin-shock dogs made hyperglycemic by glucose infusion. Qualitatively (at least in terms of gel filtration characteristics), the insulin secreted under these conditions was normal. Hyperinsulinism was not observed in endotoxin-shock dogs not given glucose. Thus hyperinsulinism does not explain the hypoglycemia so frequently observed in endotoxintreated dogs.Hyperinsulinism could not be explained by impaired degradation of insulin as disappearance of labeled insulin as well as cold insulin was comparable in control and endotoxin-treated animals. An adrenergic mechanism (either beta receptor stimulation or postadrenergic hyperresponsiveness of the beta cells) probably does not explain the hyperinsulinism observed in endotoxin-shock dogs given glucose as beta blockade failed to inhibit the hyperinsulinism.Hyperinsulinism was not observed in endotoxin-shock dogs given tolbutamide. A tenfold rise in plasma IRG was observed in endotoxin-treated dogs wheter glucose was infused or not. The persistently low IRI levels in endotoxin-treated dogs not given glucose suggest that hyperresponsiveness of the beta cell to glucagon was not present in these animals.Extreme hyperinsulinism in response to induced hyperglycemia in endotoxin-shock dogs is unexplained. Hyperresponsiveness of the beta cell to glucose during endotoxin shock seems likely.     

Recall of Awareness During Paralysis Among ED Patients Undergoing Tracheal Intubation

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