Augmenting prehospital care.

INTRODUCTION: The challenging environment of prehospital casualty care demands providers to make prompt decisions and to engage in lifesaving interventions, occasionally without them being adequately experienced. Telementoring based on augmented reality (AR) devices has the potential to decrease the decision time and minimise the distance gap between an experienced consultant and the first responder. The purpose of this study was to determine whether telementoring with AR glasses would affect chest thoracotomy performance and self-confidence of inexperienced trainees. METHODS: Two groups of inexperienced medical students performed a chest thoracotomy in an ex vivo pig model. While one group was mentored remotely using HoloLens AR glasses, the second performed the procedure independently. An observer assessed the trainees' performance. In addition, trainees and mentors evaluated their own performance. RESULTS: Quality of performance was found to be superior with remote guidance, without significant prolongation of the procedure (492 s vs 496 s, p=0.943). Moreover, sense of self-confidence among participant was substantially improved in the telementoring group in which 100% of the participants believed the procedure was successful compared with 40% in the control group (p=0.035). CONCLUSION: AR devices may have a role in future prehospital telementoring systems, to provide accessible consultation for first responders, and could thus positively affect the provider's confidence in decision-making, enhance procedure performance and ultimately improve patient prognosis. That being said, future studies are required to estimate full potential of this technology and additional adjustments are necessary for maximal optimisation and implementation in the field of prehospital care.

Pharmacologic treatment of seasonal allergic rhinitis: Synopsis of Guidance From the 2017 Joint Task Force on Practice Parameters

DESCRIPTION: The Joint Task Force on Practice Parameters, which comprises representatives of the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI), formed a workgroup to review evidence and provide guidance to health care providers on the initial pharmacologic treatment of seasonal allergic rhinitis in patients aged 12 years or older. METHODS: To update a prior systematic review, the workgroup searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 18 July 2012 to 29 July 2016 to identify studies that addressed efficacy and adverse effects of single or combination pharmacotherapy for seasonal allergic rhinitis. In conjunction with the Joint Task Force, the workgroup reviewed the evidence and developed recommendations about initial treatment approaches by using the Grading of Recommendations Assessment, Development and Evaluation approach. Members of the AAAAI, the ACAAI, and the general public provided feedback on the draft document, which the Joint Task Force reviewed before finalizing the guideline. RECOMMENDATION 1: For initial treatment of seasonal allergic rhinitis in persons aged 12 years or older, routinely prescribe monotherapy with an intranasal corticosteroid rather than an intranasal corticosteroid in combination with an oral antihistamine. (Strong recommendation). RECOMMENDATION 2: For initial treatment of seasonal allergic rhinitis in persons aged 15 years or older, recommend an intranasal corticosteroid over a leukotriene receptor antagonist. (Strong recommendation). RECOMMENDATION 3: For treatment of moderate to severe seasonal allergic rhinitis in persons aged 12 years or older, the clinician may recommend the combination of an intranasal corticosteroid and an intranasal antihistamine for initial treatment. (Weak recommendation)

Management of children with chronic wet cough and protracted bacterial bronchitis: CHEST guideline and expert panel report

BACKGROUND: Wet or productive cough is common in children with chronic cough. We formulated recommendations based on systematic reviews related to the management of chronic wet cough in children (aged ≤ 14 years) based on two key questions: (1) how effective are antibiotics in improving the resolution of cough? If so, what antibiotic should be used and for how long? and (2) when should children be referred for further investigations? METHODS: We used the CHEST expert cough panel's protocol for systematic reviews and the American College of Chest Physicians (CHEST) methodologic guidelines and GRADE framework (the Grading of Recommendations Assessment, Development and Evaluation). Data from the systematic reviews in conjunction with patients' values and preferences and the clinical context were used to form recommendations. Delphi methodology was used to obtain consensus for the recommendations/suggestions made. RESULTS: Combining data from the systematic reviews, we found high-quality evidence in children aged ≤ 14 years with chronic (> 4 weeks' duration) wet/productive cough that using appropriate antibiotics improves cough resolution, and further investigations (eg, flexible bronchoscopy, chest CT scans, immunity tests) should be undertaken when specific cough pointers (eg, digital clubbing) are present. When the wet cough does not improve following 4 weeks of antibiotic treatment, there is moderate-quality evidence that further investigations should be considered to look for an underlying disease. New recommendations include the recognition of the clinical diagnostic entity of protracted bacterial bronchitis. CONCLUSIONS: Compared with the 2006 Cough Guidelines, there is now high-quality evidence for some, but not all, aspects of the management of chronic wet cough in specialist settings. However, further studies particularly in primary health) are required.

Learning two things at once: differential constraints on the acquisition and consolidation of perceptual learning.

Learning is often prevented by events that occur after training, an outcome that is usually attributed to the disruption of consolidation-the transfer of learning to long-term memory. Here, we provide evidence from perceptual learning that improvements in performance can also be blocked by intervening events that occur during the acquisition phase of learning-the period of active practice. Listeners improved on each of two conditions of auditory temporal-interval discrimination (100 and 350 ms) when the two were practiced consecutively, even though that is a classic disruption-of-consolidation regimen. However, when practice on these two conditions was interleaved, there was no learning on either condition. The failure to improve in the interleaved case indicates that, at least in some circumstances, learning can be prevented during acquisition by events that do not disrupt consolidation itself. These results thus suggest that acquisition and consolidation are distinct phases in human learning.

Hemorrhagic stroke following elective cesarean delivery.

We present a case of hemorrhagic stroke after cesarean delivery under combined spinal-epidural anesthesia in an 35-year-old Hispanic patient treated with anticoagulants for protein C deficiency. She required vasopressor therapy for intraoperative hypotension and developed severe headache immediately after administration. To our knowledge, this is the first case of stroke occurring in a pregnant woman following vasopressor therapy for spinal anesthesia-induced hypotension. Although the exact cause of her hemorrhagic stroke is uncertain, the hypertensive response that may have led to the hemorrhagic stroke occurred following administration of commonly used doses of vasopressor agents. We discuss the possible causes of stroke.

The ability of the community pharmacist to learn the proper actuation techniques of inhaler devices.

Today, greater responsibility is placed on community pharmacists for the education of patients than ever before. Thus community pharmacists were recruited for this study and asked to demonstrate the proper steps in the actuation sequences of 3 inhaler devices. Baseline measurements were followed by an instructional session on the proper actuation technique, and then a posttest was conducted 4 to 6 weeks later. The mean changes between baseline and postinstruction percentage scores for the metered-dose inhaler device, the Turbuhaler, and the Diskus were (mean +/- SD) 17.1% +/- 15.4%, 22.6% +/- 18.7%, and 38.4% +/- 19.6%, respectively. This study demonstrates that a single instructional session can dramatically improve a community pharmacist's ability to demonstrate the correct method of actuation.

The misconception of using floating patterns as an accurate means of measuring the contents of metered-dose inhaler devices.

BACKGROUND: Patients and physicians have searched for a reproducible method of determining the amount of medication that a metered-dose inhaler (MDI) contains as well as a reliable method of determining when their MDI is empty. Previously, patients have been instructed to float their canister in water, and depending upon the position attained, have been able to estimate the amount of medication within the canister. OBJECTIVE: To investigate whether the floating patterns of MDIs are a reliable method of determining the contents contained within an inhaler canister, including that of the newer devices containing the non-chlorofluorocarbon (CFC) propellant. METHODS: Fifteen albuterol sulfate MDIs (Proventil HFA; Schering, Kenilworth, NJ), 15 triamcinolone acetonide MDIs (Azmacort; Rhjne-Poulenc Rorer, Collegeville, PA), and 15 fluticasone propionate MDIs (Flovent; GlaxoSmith Kline, Research Triangle Park, NC) were obtained from their respective companies. Each device was floated in a clear container full of water before any actuations. The devices were then actuated into the air at 2-minute intervals and each subsequently floated following 25%, 50%, 75%, and 100% of the prescribed number of actuations and its position within the container observed. The canisters were then actuated until no visual spray was produced from the nozzle and again their floating positions within the container observed. RESULTS: Each of the three MDIs tested had unique floating patterns both before any actuation as well as throughout the various actuations. CONCLUSIONS: This study demonstrates that the floating method is not an accurate means by which patients can identify the amount of medication contained within an inhaler device. This includes both conventional MDIs containing CFC propellant, as well as the newer non-CFC MDIs.

Feasibility of the membrane bioreactor process for water reclamation.

The feasibility of the membrane bioreactor (MBR) process for water reclamation was studied. Process evaluation was based on the following: literature review of MBRs, worldwide survey of MBRs, and preliminary costs estimates. The literature review and the survey have shown that the MBR process offers several benefits over the conventional activated sludge process, including: smaller space and reactor requirements, better effluent water quality, disinfection, increased volumetric loading, and less sludge production. The MBR process can exist in two different configurations, one with the low-pressure membrane modules replacing the clarifier downstream the bioreactor (in series), and the second with the membranes submerged within the bioreactor. Four major companies are currently marketing MBRs while many other companies are also in the process of developing new MBRs. The MBR process operates in a considerably different range of parameters than the conventional activated sludge process. The preliminary cost evaluation has shown that the MBR process is cost competitive with other conventional wastewater treatment processes.

Quantitative assessment of pituitary resistance to thyroid hormone from plots of the logarithm of thyrotropin versus serum free thyroxine index.

Previous studies have shown that, in patients with primary alterations in thyroid hormone secretion, the level of the natural logarithm of serum TSH (lnTSH) is negatively related to the level of free T4. Because such patients can generally be assumed to exhibit normal tissue responsivity to thyroid hormone, we were interested in determining whether the lnTSH/free T4 index (FTI) relationship in patients with established thyroid hormone resistance (THR) exhibit a lower slope than patients with normal tissue sensitivity to thyroid hormone. We have therefore analyzed the relationship between the lnTSH and the FTI in members of three families with documented THR. In these patients, a given dose of T4 was maintained for a 1- to 2-month period, to achieve hormonal equilibration. Two of the families, though not related, exhibited the same mutation, E460K. The third was identified as A317T. As anticipated, the slope of the lnTSH/FTI ratio was significantly lower in the patients with THR than in T4-treated patients who were presumed to have normal sensitivity to thyroid hormone. The slope of the lnTSH/FTI relationship seemed to be characteristic of the specific mutation involved in the three genotypes (wild-type and two mutations) examined. Further, the in vivo slope of the lnTSH/FTI relationship seemed to be linearly related to the T3 association constant of the in vitro translated receptor. These findings support the potential usefulness of measuring the slope of lnTSH, as a function of the FTI, in quantitating pituitary THR.

Vancomycin anaphylaxis and successful desensitization in a patient with end stage renal disease on hemodialysis by maintaining steady antibiotic levels.

BACKGROUND: Vancomycin anaphylaxis is a major management problem in patients with methicillin-resistant Staphylococcus aureus (MRSA) sepsis. Lerner et al in 1984 have described a protocol for desensitization to vancomycin; however, antibiotic blood levels have never been used as a guide in this process. CASE REPORT: A 46-year-old female with ESRD on hemodialysis who developed a dialysis-catheter related MRSA sepsis was found to have anaphylaxis to vancomycin. She underwent successful desensitization to vancomycin using Lerner's protocol. Periodic antibiotic blood levels were used to guide the amount and frequency of vancomycin infusion to successfully maintain desensitization thereafter. DISCUSSION: Lerner described loss of desensitization to vancomycin when antibiotic infusion was stopped after 18 hours followed by successful desensitization to the same drug via the same protocol. This observation points out that desensitization to vancomycin appears to be dependent on some minimal drug level. In our case report, we have for the first time used the concept of blood levels to maintain successful desensitization to an antibiotic. CONCLUSION: We hypothesize that desensitization to vancomycin can be induced and maintained by keeping a minimum antibiotic blood level. Further studies are needed to quantify this.

Comparison of emergency room asthma care to National Guidelines.

BACKGROUND: National Asthma Education and Prevention Program (NAEPP) guidelines were first released in 1991. To date there have been no studies published comparing them with actual care given. OBJECTIVE: The aim of this study was to compare the documented care given in the emergency room (ER) of an urban tertiary care hospital with 1991 NAEPP guidelines. METHODS: A total of 1858 urban emergency room records with a diagnosis of asthma or reactive airway disease were recovered in 1 year (9/95 to 8/96) from pediatric and adult patients seen in the ER. Ten percent (n = 181) of the charts were reviewed for documentation of history, assessment of severity of attack, treatment given, and disposition. RESULTS: History of present attack was documented consistently in all age groups. Nocturnal symptoms were noted in 11%, and frequency of beta agonist use in 38% of the charts. Previous ER visits, hospitalization, ICU admissions, and intubations (HCUM) were documented in 70%. Accessory muscle use was recorded in 76% of the infants and 21% of the adults. Peak flows were obtained in 31% of children and 64% of adults. Steroids were given in the ER in 59% of infants, 83% of children, and 49% of adults. Pediatric patients were referred to their primary care provider 90%, and to pulmonary or allergy clinic 4% of the time. Adults were referred to allergists or pulmonologists 32% of the time. CONCLUSION: There are significant differences in ER evaluation and treatment when compared with the 1991 NAEPP guidelines. Differences also exist between various age groups within the same institution.

Evolving concepts of thyroid hormone action.

The past 25 years have witnessed dramatic changes in our concepts of thyroid hormone action. Progress in this area was made possible by the recognition of the central role of triiodothyronine in mediating thyroid hormone action and the recognition of specific nuclear receptors in target tissues as demonstrated by displacement studies. The cloning of the receptors and receptor variants has enabled investigators to undertake detailed analyses of the biochemical events which underlie the physiological and pathological action of thyroid hormone.

Exacerbation of premenstrual asthma caused by an oral contraceptive.

BACKGROUND: The relationship between sex hormones and asthma has not been clarified. Studies have suggested a potential beneficial effect of exogenous sex hormones and/or contraceptive pills on asthma in premenopausal females whereas the data for postmenopausal females are inconsistent. CASE REPORT: A 33-year-old woman suffering from asthma with premenstrual exacerbations had a stable course until she began taking oral contraceptives. At that time she experienced clinical deterioration of her asthma associated with decline of pulmonary function tests. No other precipitating factors were identified. After discontinuing the contraceptives, her condition returned to baseline. CONCLUSION: We found only two reports of worsening of asthma related to hormonal therapy (estrogen in one case, contraceptive pills in the other) in premenopausal women. Our report, together with these observations, suggests that in some premenopausal women exogenous sex hormones and/or contraceptive pills may, contrary to expected, produce exacerbation of asthma.

PIP: Although the mechanism of premenstrual asthma has not been established, hormonal variations during the menstrual cycle are believed to play an important role. About 30-40% of female asthmatics report worsening of asthma symptoms during the premenstrual and/or menstrual period. This article presents a case in which oral contraceptives (OCs) appeared to precipitate an asthma attack. The patient, a 33-year-old White US woman, first developed asthma at age 27 years. The strongest trigger to her asthma attacks was her menstrual period. All periods were associated with a worsening of asthma, typically extending from 1 week before to 2-3 days after the onset of menstrual bleeding. Subsequently, the patient's asthma was stabilized by continuous inhaled steroids. However, clinical deterioration of asthma and a decline of pulmonary function occurred immediately after the woman initiated OC use. There was a rapid stabilization in clinical status once OC use was discontinued. Although the weight of scientific evidence points to a possible beneficial effect of OCs or exogenous sex hormones on premenstrual asthma, this case suggests there may be a subset of women in whom sex hormones exacerbate asthma.

Chicken ovalbumin upstream promoter-transcription factor (COUP-TF) modulates expression of the Purkinje cell protein-2 gene. A potential role for COUP-TF in repressing premature thyroid hormone action in the developing brain.

The cerebellar Purkinje cell-specific PCP-2 gene is transcriptionally activated by thyroid hormone during the 2nd and 3rd weeks of postnatal life in the rat. In contrast, thyroid hormone has no detectable effects on PCP-2 expression in the fetal rat. We now present data that suggest that the orphan nuclear receptor chicken ovalbumin upstream promoter-transcription factor (COUP-TF) represses triiodothyronine (T3)-dependent transcriptional activation of PCP-2 in the immature Purkinje cell. Gel shift assays show that the PCP-2 A1TRE and adjoining sequences (-295/-199 region) bind to rat and mouse brain nucleoproteins in a developmentally regulated fashion and that one of these nucleoproteins could be the orphan nucleoprotein COUP-TF. In support of this hypothesis, in vitro translated COUP-TF binds to the -295/-199 region and COUP-TF represses T3-dependent activation of the PCP-2 promoter in transient transfection analyses. Finally, immunohistochemical studies reveal that COUP-TF is specifically expressed in the immature fetal and early neonatal Purkinje cell and that this expression diminishes coincident with thyroid hormone induction of PCP-2 expression. Our findings are consistent with the hypothesis that the presence or absence of inhibitory proteins bound to the thyroid hormone response element of T3-responsive genes governs the responsivity of these genes to thyroid hormone during brain development.

Beta receptor isoforms are not essential for thyroid hormone-dependent acceleration of PCP-2 and myelin basic protein gene expression in the developing brains of neonatal mice.

In rat pups, thyroid hormone dependent brain development coincides with the appearance of the thyroid hormone receptor (TR)beta1 isoform. This finding led to the suggestion that TRbeta1 plays an essential role in brain development. The recent availability of a mouse TRbeta knockout strain allowed us to test this possibility by determining whether TRbeta is essential for the normal developmental pattern of expression of two thyroid hormone regulated brain genes, myelin basic protein (MBP), and Purkinje cell protein 2 (Pcp-2). Northern analysis of total mRNA from the brains of wild-type mice established that, as in the rat pup, the initial rate of rise of the MBP and Pcp-2 mRNA is slowed in the hypothyroid state. Supporting the effectiveness of TRbeta gene deletion was the finding that the thiiodothyronine (T3) nuclear binding capacity in the livers and brains of knockout animals was consistent with the fractional contribution of TRbeta1 to total binding capacity in the wild-type tissues. Further, no TRbeta1 could be detected by isoform-specific immunoprecipitation of nuclear receptor extracts. However, deletion of the functional TRbeta in the TRbeta knockout mice did not affect the normal ontogeny of expression of the Pcp-2 and MBP genes in the postnatal pup. We conclude that TRbeta is not essential for the normal developmental expression of these T3 dependent brain genes.

Partial atrophy in prostate needle cores: another diagnostic pitfall for the surgical pathologist.

We have seen in consultation a variant of atrophy, which is frequently confused with well-differentiated adenocarcinoma of the prostate. We have designated this entity as partial atrophy to distinguish it from its more common counterpart of fully developed atrophy. Partial atrophy is defined as benign prostate glands with relatively scant cytoplasm, yet the glands are not fully atrophic in that they do not appear basophilic at low magnification. Fifty-one cases of partial atrophy were identified (4 from Johns Hopkins Hospital, 47 from consultation). Within the partial atrophy focus, irregular (crinkled) nuclei were frequent in 23.5% and occasionally present in 33.3% of cases. Visible nucleoli were frequent in 25.4% of cases. Basal cells were not identifiable in 27.4% of cases or were hard to identify in 35.3% of cases. No intraluminal crystalloids or blue-tinged mucinous secretion was identified in partial atrophy. Adenocarcinoma or glands suspicious for cancer were present in other cores in 15.6% of cases. More fully developed atrophy was present in simultaneously obtained needle cores in 35.3% of cases. In the cases in which regular atrophy was the only coexisting condition, it was present within one 10x field from the partial atrophy in 22.2%, farther than one 10x field from the partial atrophy in 11.1%, and present in the same gland as the partial atrophy in 66.7%. Partial atrophy may be confused with low-grade adenocarcinoma because of the focus of crowded glands, irregular nuclei, and visible nucleoli. Clues for recognizing partial atrophy include relatively scant cytoplasm, distinct crinkled nuclei, pale cytoplasm similar to adjacent, more recognizably benign glands, and association with more fully developed benign atrophy.

Lack of effect of thyroid hormone on late fetal rat brain development.

Studies were undertaken to test whether alterations in fetal brain thyroid hormone levels during the final week of gestation can prematurely induce gene expression in brain or affect cerebellar morphogenesis. Pregnant dams were treated either by administration of 0.025% methimazole (MMI) in the drinking water from day 14 post conception (PC14) or administration of 2.5 mg T4/100 g BW on PC15. On PC21, treatment with MMI resulted in a 53% fall in fetal brain T3 levels and excess T4 resulted in a 2- to 3-fold increase to concentrations observed in adult brains. Neither excess nor reduced levels of T3 caused alterations in the expression of the myelin basic protein, Pcp-2 or calmodulin kinase IV genes. Cerebella of control brains showed early evidence of foliation and the presence of a several cell thick Purkinje cell layer and an external granule layer. No treatment induced effects were evident. Thus, at the late fetal stage in the rat, the developing brain appears to be unresponsive to thyroid hormone despite the presence of thyroid hormone receptors. We infer the presence of as yet unidentified factors that suppress precocious response to thyroid hormone or the absence of cofactors essential for such a response.