Tracheal intubation under fluoroscopic control X ray-guided orotracheal intubation in three cases of impossible direct laryngoscopy

Three patients are described in whom it was impossible to visualise the larynx at direct laryngoscopy. Tracheal intubation was successfully and rapidly achieved with the aid of continuous fluoroscopy.     

On the need of a sampling strategy in biological monitoring: The example of hexane exposure

Ambient and biological monitoring of hexane exposure were repeatedly carried out in 14 female shoe makers. Airborne hexane (Ci-H) was measured in 4-h samples collected by a diffusive method. Urinary spot samples were collected before, during (at noon), and at the end of a work shift. 2,5-Hexanedione (2,5HD) in urine collected at noon was poorly related to morning Ci-H. End-of-shift 2,5HD were also poorly related to afternoon air samples. The correlation was still relatively low when end-of-shift 2,5HD was related to 8-h TWA Ci-H (r= 0.44; P<0.01 on=" a=" linear=" scale,=" and=">r-0.58, P< 0.01=" on=" a=" log-log=" scale).=" end-of-shift=" 2,5hd=" levels=" estimated=" on=" the=" basis=" of=" pre-shift=" values=" using=" a=" mathematical=" model=" were=" much=" higher=" (2.3=" times=" on=" average)=" than=" those=" experimentally=" measured=" during=" the=" study=" period.=" owing=" to=" its=" relatively=" long=" half-time,=" 2,5hd=" seems=" to=" be=" influenced=" not=" only=" by=" current=" exposure,=" but=" also=" by=" hexane=" absorbed=" during=" the=" day(s)=" preceding=" sampling.=" the=" lack=" of=" a=" sampling=" strategy=" may=" account=" not=" only=" for=" inconsistencies=" between=" environmental=" and=" biological=" data,=" but=" also=" for=" a=" possible=" misuse=" of=" biological=" monitoring=" when=" utilized=" for=" risk=" assessment.=" despite=" sometimes=" poor=" correlations=" with=" ci-h,=" 2,5hd=" may=" still=" be=" preferred=" to=" other=" indicators=" as=" a=" marker=" of=" effective=" internal=" dose.=" a=" sampling=" strategy=" should=" ensure=" that=" measured=" values=" are=" representative=" of=" the=" individual=" risk=" for=" adverse=">     

Immunological changes among workers occupationally exposed to styrene

The functional status of the immune system was investigated in a group of 71 workers exposed to styrene and in 65 control subjects, recruited according to the same selection criteria and comparable as to sex, age, and confounding variables. Air and biological monitoring were used to characterize styrene exposure (median of the main urinary metabolites in the next-morning spot samples: 106 mg/g creatinine). Phenotypic analysis of peripheral blood lymphocytes (PBL) by automated flow cytometry revealed a reduced proportion of T lymphocyte subsets (CD3⁺, CD4⁺ and CD4⁺45⁺), with no changes in CD8⁺, and a higher proportion of B lymphocytes (CD19⁺) among styrene-exposed workers. The exposed workers showed a higher proportion of activation markers, namely DR and interleukin-2 receptors (CD25). Immunoglobulin subclasses were comparable in the two groups. An increased prevalence of abnormally low values was apparent for CD2⁺, CD3⁺, CD4⁺, CD4⁺45⁺ and CD11b subsets among workers exposed to styrene, whereas CD19⁺, DR⁺ and CD25⁺ showed an increased prevalence of abnormally high values. Natural killer-related phenotypes (CD56⁺, CD56+16⁺, and CD56⁺16^–) were more expressed among styrene workers, with average increase of 30%. However, the frequency distribution of the lytic activity of natural killer cells against K-562 target cells was shifted towards lower values in the exposed workers as compared to control subjects. Dose-response relationships between indices of internal dose and prevalence of abnormal values were detectable for T lymphocyte subsets, NK phenotypes, and activation markers. These findings suggest that moderate exposure to styrene is associated with an altered distribution of lymphocyte subsets. The decreased proportion of T lymphocytes, mainly of T helper-inducer cells, could hamper regulatory functions, thus suggesting a negative modulation by styrene exposure. Since a proper balance between immunocycte subsets is important for immunological responses, such changes should be regarded as adverse effects.     

General anesthesia and undiagnosed cerebral metastasis. Clinical case

A case of late recovery from anesthesia in a patient undergoing bronchoscopy for surgical removal of metastatic bronchial mass is presented. The patient was comatose and a CT scan revealed the presence of bleeding inside a tumor, probably a metastasis, located in the right cerebellum. This report demonstrates that undetected cerebral metastases might lead to late recovery from anesthesia and underlines that accurate neurologic examination is mandatory in patients affected by tumors potentially spreading to the brain.     

Prognostic value of low and high ankle-brachial index in hospitalized medical patients

BackgroundPeripheral arterial disease (PAD) is frequently underdiagnosed in the clinical practice, leading to a lack of opportunity to detect subjects at a high risk for cardiovascular (CV) death. The ankle-brachial pressure index (ABI) represents a noninvasive, objective tool to diagnose PAD and to predict adverse outcome.MethodsABI was determined by means of Doppler velocimetry, in 707 patients, aged 50 years or older, consecutively hospitalized in an internal medicine ward, who were followed-up for at least 12 months in order to assess all-cause and CV mortality.ResultsSymptomatic PAD affected 8% of the population while the prevalence of PAD, defined as ABI < 0.90, was 29%; high ABI (> 1.40) was found in 8% of the patients. After a mean follow-up period of 1.6 years, both low and high ABI were independently associated with CV mortality with a hazard ratio of 1.99 (p = 0.016) for low and 2.13 (p = 0.04) for high ABI, compared with normal ABI (0.90–1.40). High ABI also independently predicted all-cause mortality with a hazard ratio of 1.77 (p = 0.04).DiscussionABI measurement reveals a large number of individuals with asymptomatic PAD among those hospitalized in an internal medicine department. An increased mortality was observed in patients with both low and high ABI. Hospital admission for any reason may serve as an opportunity to detect PAD and start appropriate preventive actions.     

Behavioral activation, inhibition and mood symptoms in early-onset bipolar disorder

BACKGROUND: Hypomania/mania and depression are hypothesized to correspond to high and low expressions of behavioral activation system (BAS) activity, respectively, in bipolar individuals. In contrast, behavioral inhibition system (BIS) activity is hypothesized to regulate anxiety. The aim of the present study was to examine whether self-reported levels of BAS functioning in bipolar adolescents corresponded with levels of concurrent manic and depressive symptomatology. The secondary aim was to investigate whether self-reported BIS levels were associated with self-reported anxiety symptoms. METHODS: Twenty-five adolescents diagnosed with bipolar I, II or not otherwise specified were recruited from a treatment-development study. Adolescents were interviewed using the Depression and Mania Rating Scales of the Kiddie Schedule for Affective Disorders and Schizophrenia and given the Self-Report for Childhood Anxiety Related Disorders. Next, they completed the Behavioral Inhibition/Activation Scales. RESULTS: Contrary to hypotheses, adolescents with higher BAS levels exhibited less severe concurrent mania symptoms. Furthermore, levels of BAS sensitivity were not associated with concurrent levels of depression. As predicted, BIS scores correlated positively with self-reported anxiety scores. Adolescents reporting higher levels of the motor activity symptoms of mania also reported higher levels of anxiety symptoms. LIMITATIONS: The conclusions are based upon cross-sectional analyses in a small sample. CONCLUSIONS: In bipolar adolescents, mania and depression appear to be independent of self-reported behavioral activation levels. However, mood symptoms in adolescent patients are closely tied to components of anxiety, which may lead to diminished approach behaviors.     

Multiple biomarker use for detection of adverse events in patients presenting with symptoms suggestive of acute coronary syndrome

BACKGROUND: We investigated multiple biomarkers of various pathophysiologic pathways to determine their relationships with adverse outcomes in patients presenting with symptoms of acute coronary syndrome. METHODS: We obtained plasma specimens from 457 patients on admission and measured 7 biomarkers: myeloperoxidase (MPO), soluble CD40 ligand (CD40L), placental growth factor (PlGF), metalloproteinase-9 (MMP-9), high-sensitivity C-reactive protein (hsCRP), cardiac troponin I (cTnI), and N-terminal pro-B-type natriuretic peptide (NT-proBNP). We used the Modification of Diet in Renal Disease formula to calculate the estimated glomerular filtration rate (eGFR). Endpoints were cardiac events (myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, cardiac death) and all-cause mortality. We estimated cumulative event rates over a 4-month period with the Kaplan-Meier method and relative risk (RR) with the Cox proportional hazards model. RESULTS: Patients with increased PlGF, NT-proBNP, hsCRP, or cTnI or decreased eGFR had 11% to 20% higher all-cause mortality rates than patients with concentrations within reference intervals: 20.4% (eGFR), 16.0% (PlGF), 15.8% (hsCRP), 12.7% (NT-proBNP), and 11.3% (cTnI; all P < or = 0.03). No differences in mortality rates were observed between those with increased vs normal concentrations of MPO, CD40L, or MMP-9. Decreased eGFR (RR 3.4, P = 0.004) and increased NT-proBNP (RR 7.9, P = 0.04) were independently predictive of mortality, and PlGF (RR 2.0, P = 0.08) approached significance. Patients with increased NT-proBNP (12.3%) or cTnI (33.8%) had higher cardiac event rates (each P <0.02), with increased MPO (11.1%) showing a trend (P = 0.09). Patients in whom both cTnI and MPO were increased had a cardiac event rate of 43%. CONCLUSION: Multiple biomarkers that are likely indicative of different underlying pathophysiologic mechanisms are independently predictive of increased risk for adverse events in patients with acute coronary syndrome.     

Barriers to recruiting ethnic minorities to mental health research: a systematic review

Disparities in the prevalence of mental illness are widely reported for people from ethnic minorities. Unlike the United States, there is no legislation for clinical research in the UK to mandate the inclusion of ethnic minorities and they are underrepresented in European trials compared with those conducted in the United States. This restricts generalization of research findings. This systematic review of the barriers to the recruitment of ethnic minority participants into psychiatric research is based on a comprehensive literature search. Nine included papers explore such barriers based on the authors’ and participants’ experiences of research. These barriers are mainly categorized as: participant related, practical issues, family/community related, health service related and research process issues. This review provides a compilation of important barriers to recruitment which can facilitate future research. The barriers that were identified are not all unique to participants from ethnic minorities, although the way in which they manifest themselves is often distinct in minority groups. It is important that these barriers are considered when designing research design so that solutions to overcome such obstacles can be incorporated in research protocols from the start and appropriate resources allocated. Copyright © 2014 John Wiley & Sons, Ltd.     

Cardiotoxicity from Capecitabine Chemotherapy: Prospective Study of Incidence at Rest and During Physical Exercise

BackgroundPhysical activity may increase the risk of cardiotoxicity (myocardial ischemia, major arrhythmias) of 5-Fluorouracil, but this risk has never been investigated for its prodrug capecitabine.Patients and MethodsOne hundred and ninety-two consecutive patients undergoing capecitabine chemotherapy from December 1, 2010 through July 31, 2016 were prospectively evaluated. The baseline evaluation included electrocardiography (ECG) and echocardiography (2DE); a follow-up evaluation, including ECG and exercise stress testing (2DE in case of ECG abnormalities), was done after ≥10 days of treatment. Cardiotoxicity was suspected from ischemic ECG changes, new kinetic abnormalities at 2DE, Lown classification ≥2 ventricular arrhythmia, symptomatic arrhythmias, or positive stress test, and confirmed by a negative stress test after capecitabine washout.ResultsCardiotoxicity was diagnosed in 32 patients (16.7%): six at rest and 26 during exercise. All 32 patients had ECG abnormalities: ST-segment changes (24 patients), negative T-waves (2) and/or arrhythmias: ventricular arrhythmias (14 cases), supraventricular tachycardia (2), complete heart block (1). Eight patients had typical symptoms, 6 had atypical symptoms, 1 had syncope, 17 (53%) were asymptomatic. Cardiotoxicity was more common in patients with atypical symptoms during daily life (OR = 15.7) and in those on a therapeutic schedule of 5 days/week (OR = 9.44).ConclusionCapecitabine cardiotoxicity is frequent, and often elicited by physical effort. Oncologists, cardiologists, and general practitioners should be aware of this risk. Active cardiotoxicity surveillance with ECG (and echocardiogram and/or stress testing in suspected cases) during therapy is recommended.Clinical Trials registration numberCRO-2010-17.     

Lifestyle intervention improves microvascular reactivity and increases serum adiponectin in overweight hypertensive patients

Background and aimsObesity and hypoadiponectinemia are often associated with high blood pressure. Moreover, microvascular dysfunction is reported to be an early event in patients with hypertension and may be involved in the pathogenesis of organ damage.Methods and resultsWe investigated the impact of 8-week moderate-intensity aerobic training on adiponectin plasma levels and skin microvascular reactivity in 24 overweight sedentary patients (18 men, age 44 ± 6 years, body mass index 28 ± 3 kg/m²) with never-treated grade 1 essential hypertension. Twenty-four age- and sex-matched hypertensive patients, who were examined twice at 8-week intervals in the absence of exercise training, served as controls. Exercise training was followed by a significant reduction in waist circumference (from 97 ± 9 to 95 ± 9 cm, p < 0.05) and an increase in adiponectin plasma levels (from 11.9 ± 3 to 12.5 ± 4 mg/L, p < 0.05). An inverse correlation was found between adiponectin change and waist circumference change (r = ?0.43, p < 0.05). The area under the curve after post-occlusive reactive hyperemia at skin laser-Doppler examination increased significantly after aerobic training (from 876 ± 539 to 1468 ± 925 PU/s, p < 0.001). A positive correlation was found between exercise-induced variations of post-occlusive reactive hyperemia and adiponectin plasma levels (r = 0.41, p < 0.05). Office or 24-h blood pressure values did not change significantly.ConclusionIn sedentary overweight patients with mild hypertension, moderate aerobic training improves cutaneous microvascular reactivity and adiponectin plasma levels. These changes precede blood pressure reduction and may serve as biomarkers of the efficacy of non-drug treatment in hypertensive patients.