Radial artery catheterization by surgical exposure in infants

56 radial arteries were cannulated by cutdown technique in 54 critically ill infants (age (mean±SD) 12.2±25.9 days, weight 2710±910 g) for continuous pressure monitoring and repeated blood sampling. 30 patients survived their illness, 24 died. The mean catheterization time in the survivors was 8.1±4.1 in the non-survivors 6.9±5.6 days. Most cannulae were removed electively. 27 of the surviving infants were followed up after 10.5±5.1 months. 25 (86%) vessels were patent, 4 (14%) occluded. No trophic changes of hands or fingers were noted. We conclude that radial artery cannulation by cutdown in infants is a quick and safe technique and is suitable in patients with severe peripheral vasoconstriction.     

Severity of foraminal lumbar stenosis and the relation to clinical symptoms and response to periradicular infiltration—introduction of the “melting sign”

Background Context

Nerve root compression causing symptomatic radiculopathy can occur within the intervertebral foramen. Sagittal magnetic resonance imaging (MRI) sequences are reliable in detection of nerve root contact to intraforaminal disc material, but a clinically relevant classification of degree of contact is lacking.

Ergonomic assessment of robotic general surgeons: a pilot study

Journal of Robotic Surgery - Inadequacies exist in the ergonomics of upper body positioning of robotic surgeons; these deficits in biomechanical efficacy predispose surgeons to musculoskeletal...     

Comparing the Course of Mental Health Over the First Year After Stroke With Healthy Controls in Colombia,South America

Background

Stroke is a primary cause of death and disability in upper-middle–income countries such as Colombia. Given the lack of comprehensive rehabilitation for stroke patients in Colombia, there is a need to assess longitudinal mental health problems poststroke in this region.

Intravenous metronidazole for treatment of infections involving anaerobic bacteria.

Intravenous metronidazole was administered, either by continuous or intermittent infusion, to 20 patients with infections involving anaerobic bacteria; 14 of the 20 patients were changed to oral administration of metronidazole for completion of therapy. Six of eight patients with infections derived from oropharyngeal bacterial flora were cured; the addition of ampicillin was required in one patient, however, because of an incomplete response to metronidazole. Eight of eleven evaluable patients with infections derived from bowel flora were also cured by metronidazole or metronidazole plus an aminoglycoside. Of 93 anaerobic bacteria isolated before therapy, 89 were susceptible to 16 micrograms or less of metronidazole per ml. Mean plasma levels of metronidazole were 27.6 +/- 11.4 micrograms/ml in patients receiving continuous infusions of drug and 19.9 +/- 10.7 micrograms/ml (trough) in patients receiving intermittent infusions. Two patients developed peripheral neuropathy during therapy. Metronidazole is an effective agent for the treatment of anaerobic infections. Because metronidazole is not active against facultative and aerobic bacteria, the addition of a second antimicrobial agent may be required for the treatment of mixed anaerobic-aerobic infections.     

Induced bronchus-associated lymphoid tissue serves as a general priming site for T cells and is maintained by dendritic cells

Mucosal vaccination via the respiratory tract can elicit protective immunity in animal infection models, but the underlying mechanisms are still poorly understood. We show that a single intranasal application of the replication-deficient modified vaccinia virus Ankara, which is widely used as a recombinant vaccination vector, results in prominent induction of bronchus-associated lymphoid tissue (BALT). Although initial peribronchiolar infiltrations, characterized by the presence of dendritic cells (DCs) and few lymphocytes, can be found 4 d after virus application, organized lymphoid structures with segregated B and T cell zones are first observed at day 8. After intratracheal application, in vitro–differentiated, antigen-loaded DCs rapidly migrate into preformed BALT and efficiently activate antigen-specific T cells, as revealed by two-photon microscopy. Furthermore, the lung-specific depletion of DCs in mice that express the diphtheria toxin receptor under the control of the CD11c promoter interferes with BALT maintenance. Collectively, these data identify BALT as tertiary lymphoid structures supporting the efficient priming of T cell responses directed against unrelated airborne antigens while crucially requiring DCs for its sustained presence.Bronchus-associated lymphoid tissue (BALT) is part of the mucosal immune system of the lung and is characterized by the aggregation of lymphoid cells at the bifurcations of the upper bronchioles (Bienenstock and Befus, 1984). Like other lymphoid follicles, BALT is composed of B cells surrounded by a parafollicular region of T cells (Sminia et al., 1989). Recirculating lymphocytes are believed to enter BALT via high endothelial venules and leave these structures by efferent lymphatics (Lührmann et al., 2002/2003; Xu et al., 2003). Although BALT is largely absent in normal mice, it spontaneously forms in mice deficient for the chemokine receptor CCR7 (Kocks et al., 2007). In humans, it is neither found at birth nor in healthy adults but transiently arises during childhood and adolescence (Tschernig and Pabst, 2000). In both humans and mice, pulmonary infection and inflammation can induce BALT (Moyron-Quiroz et al., 2004). Data derived from splenectomized lymphotoxin-α–deficient mice, which lack all secondary lymphoid organs but do develop BALT, suggest that BALT can serve as induction sites for adaptive immune responses to pathogens with lung tropism (Moyron-Quiroz et al., 2004). However, mechanisms that control the development and maintenance of BALT are largely unknown.Modified vaccinia virus Ankara (MVA) is a highly attenuated orthopoxvirus that lost its capacity to replicate in mammalian cells (Meyer et al., 1991). Recently, MVA was proposed to represent a useful agent for mucosal vaccination via the respiratory route in a nonhuman primate model (Corbett et al., 2008). In mice, MVA delivered via the intranasal (i.n.) route has been shown to induce long-lasting and protective antibody and T cell immune responses (Gherardi and Esteban, 2005; Kastenmuller et al., 2009). However, little is known about the immunological events after respiratory MVA infection.The present report demonstrates that a single i.n. application of the replication-deficient MVA is sufficient to induce the long-lasting presence of BALT and that the lung-specific depletion of DCs interferes with BALT maintenance. Ex vivo imaging of antigen-specific T cell–DC interactions within BALT by two-photon microscopy indicates that, independent of the specific antigenic challenge inducing its formation, BALT can function as a general priming site for T cell responses directed against antigens that reach the lower respiratory tract.     

Poliomyelitis eradication: progress, challenges for the end game, and preparation for the post-eradication era

In 1988, the World Health Assembly resolved to eradicate poliomyelitis globally by the year 2000. Dramatic progress toward this goal has occurred: three of the six WHO regions (Region of the Americas, European Region, and Western Pacific Region) are now polio free; and the number of polio-endemic countries decreased from over 125 in 1988 to 30 in 1999. Intensified efforts currently are underway to reach the target as soon as possible after 2000 in the three remaining polio-endemic WHO regions (African Region, Eastern Mediterranean Region, and South-East Asia Region). Even in polio-endemic regions, many countries are already polio free as the geographic extent of poliovirus shrinks while others. especially those experiencing conflict and war, pose substantial challenges to implementing the proven polio eradication strategies. Increasing attention and research now are devoted to the certification of polio eradication in the polio-free regions (that will include the first phase of implementing the Global Plan of Action for the laboratory containment of wild poliovirus) and formulating a policy for stopping all polio vaccination once eradication, containment, and global certification have been achieved. This report outlines the progress toward polio eradication and highlights some of the remaining issues and challenges that must be addressed before polio becomes a disease that future generations know only by history.     

Altered Mental Status and End Organ Damage Associated with the use of Gacyclidine: A Case Series

Introduction

Over the past decade, there has been a sharp increase in the number of newly identified synthetic drugs. These new drugs are often derivatives of previously abused substances but have unpredictable toxicity. One of these drugs is gacyclidine, a derivative of phencyclidine (PCP). Gacyclidine has been studied as a neuroprotective agent in trauma and as a therapy of soman toxicity. There are no previous reports of its use as a drug of abuse.

Case Reports

During a two-month period in the summer of 2013, a series of patients with severe agitation and end-organ injury were identified in an urban academic Emergency Department (ED). A urine drug of abuse screen was performed on all patients, and serum samples were sent for comprehensive toxicology analysis. A total of five patients were identified as having agitation, rhabdomyolysis, and elevated troponin (Table 1). Three of the five patients reported use of methamphetamine, and all five patients had urine drug screens positive for amphetamine. Comprehensive serum analysis identified methamphetamine in three cases, cocaine metabolites in one case, and a potential untargeted match for gacyclidine in all five cases. No other drugs of abuse were identified.

Discussion

This is the first series of cases describing possible gacyclidine intoxication. The possible source of the gacyclidine is unknown but it may have been an adulterant in methamphetamine as all patients who were questioned reported methamphetamine use. These cases highlight the importance of screening for new drugs of abuse when patients present with atypical or severe symptoms. Gacyclidine has the potential to become a drug of abuse both by itself and in conjunction with other agents and toxicity from gacyclidine can be severe. It is the role of the medical toxicology field to identify new agents such as gacyclidine early and to attempt to educate the community on the dangers of these new drugs of abuse.