Inadvertent subclavian artery cannulation with a central venous catheter; successful retrieval using a minimally invasive technique.

A 48-year-old lady was referred to our department as an emergency following an unsuccessful attempt at central venous catheter insertion, resulting in cannulation of the subclavian artery. She underwent angiography with removal of the catheter and closure of the arteriotomy using an Angio-Seal device. While the optimal management of this scenario has yet to be defined, the use of this minimally invasive technique warrants consideration.

Vertebral body and spinal cord infarction in a pile-driver operator with fibrocartilaginous disc embolism.

We describe the case of a male heavy machinery operator who presented from work with a rapidly evolving spinal cord syndrome. Spinal MRI revealed thoracic vertebral body and cord infarction and evolving mild disc prolapse attributed to fibrocartilaginous disc embolism (FCDE). FCDE should be considered as one of the aetiological mechanisms of acute spinal cord infarction in pile-driver/heavy machinery operators, especially in association with adjacent vertebral body infarction and intervertebral disc prolapse. Magnetic resonance imaging (MRI) changes may evolve, warranting early follow-up MRI in appropriate cases.

Supplementation with DHA and the psychological functioning of young adults.

The grey matter of the brain contains high levels of the essential nutrient DHA. Although the role of DHA in the developing brain and in dementia has attracted attention, its influence on the brain of the healthy adult has been little considered. A total of 285 young adult females took 400 mg of DHA, in a double-blind, placebo-controlled trial, for 50 d. After 50 d, recently acquired information was more likely to be forgotten by those who had consumed DHA. No significant differences in mood, reaction times, vigilance or visual acuity were found.

Enteroscopic Management of Ectopic Varices in a Patient with Liver Cirrhosis and Portal Hypertension.

Portal hypertension and liver cirrhosis may predispose patients to varices, which have a propensity to bleed and cause significant morbidity and mortality. These varices are most commonly located in the gastroesophageal area; however, rarely ectopic varices may develop in unusual locations outside of this region. Haemorrhage from these sites can be massive and difficult to control; thus early detection and management may be lifesaving. We present a case of occult gastrointestinal bleeding in a patient with underlying alcoholic liver disease where an ectopic varix was ultimately detected with push enteroscopy.

Tertiary structural changes and iron release from human serum transferrin.

Iron release from human serum transferrin was investigated by comparison of the extent of bound iron, measured by charge transfer absorption band intensity (465 nm), with changes observed by small-angle solution X-ray scattering (SAXS) for a series of equilibrated samples between pH 5.69 and 7.77. The phosphate buffers used in this study promote iron release at relatively high pH values, with an empirical pK of 6.9 for the convolved release from the two sites. The spectral data reveal that the N-lobe release is nearly complete by pH 7.0, while the C-lobe remains primarily metal-laden. Conversely, the radius of gyration, Rg, determined from the SAXS data remains constant between pH 7.77 and 7.05, and the evolution of Rg between its value observed for the diferric protein at pH 7.77 (31.2+/-0.2 A) and that of the apo protein at pH 5.69 (33.9+/-0.4 A) exhibits an empirical pK of 6.6. While Rg is effectively constant in the pH range associated with iron release from the N-lobe, the radius of gyration of cross-section, Rc, increases from 16.9+/-0.2 A to 17.6+/-0.2 A. Model simulations suggest that two different rotations of the NII domain relative to the NI domain about a hinge deep in the iron-binding cleft of the N-lobe, one parallel with and one perpendicular to the plane of the iron-binding site, can be significantly advanced relative to their holo protein positions while yielding constant Rg and increased Rc values consistent with the scattering data. Rotation of the CII domain parallel with the C-lobe iron-binding site plane can partially account for the increased Rg values measured at low pH; however, no reasonable combined repositioning of the NII and CII domains yields the experimentally observed increase in Rg.

Pericardial effusions in sarcoidosis.

A case of sarcoid pericarditis is presented. The associated pericardial effusion was a transudate with a low complement level. Investigating the prevalence of pericardial effusions in sarcoid by echocardiography, we found small effusions in 19 percent of 48 consecutive patients with sarcoid. Additionally, ten previously reported cases of symptomatic parietal pericardial sarcoid are reviewed.

Cognitive functioning is susceptible to the level of blood glucose.

RATIONALE: It is traditionally assumed that under normal conditions the brain is well supplied with glucose, its basic fuel. However, given the limited stores of glucose in the brain and its dependence on a continual peripheral supply of glucose, it was considered whether the availability of glucose, and the ability to efficiently utilise glucose, affects cognitive functioning. OBJECTIVE: There is increasing evidence that the provision of blood glucose influences memory. To date, the impact of blood glucose on non-memory task performance has received little attention. The present study investigated whether the performance of non-memory tasks was susceptible to the level of blood glucose. Two studies are reported in which the influence of a glucose containing drink on six cognitive tests was considered. RESULTS: The consumption of a glucose containing drink resulted in faster performance on the Porteus Maze and greater Verbal Fluency. Higher levels of blood glucose on arrival at the laboratory were associated with better performance on the Water Jars test. With both the Porteus Maze and Block Design tests, after taking a glucose drink, poor performance was associated with blood glucose that remained at higher levels. CONCLUSION: It was suggested that we should consider two physiological mechanisms, firstly, that an equilibrium develops between plasma and brain glucose, such that those with higher levels of blood glucose could be expected to have higher levels of brain glucose and secondly, whether there are individual differences in the efficiency with which glucose is taken from the blood; those with poor glucose control perform some cognitive tasks more poorly.

Glucose tolerance predicts performance on tests of memory and cognition.

The hypothesis that the ability to control blood glucose levels influence memory and other aspects of cognition was considered. Individual differences in the ability to control blood glucose were measured by giving a glucose tolerance test (GTT) to 46 young adult females. A factor analysis of a series of measures of glucose tolerance produced four dimensions. A week later, having eaten their normal breakfast, they took tests of memory, reaction times and vigilance. The speed with which blood glucose increased, having its lowest point in the GTT, was associated with memory measured a week later. While performing the tests those with higher levels of blood glucose on arrival in the laboratory had quicker reaction times when monitoring eight but not four, two or one lamps. The finding was interpreted as demonstrating that higher levels of blood glucose specially influence tasks placing higher demands on the brain.

The influence of breakfast and a snack on psychological functioning.

Although there are reports that breakfast influences both mood and memory, there has been no attempt to consider whether a subsequent snack is beneficial. One hundred and fifty young female adults either fasted or consumed breakfasts of either 10 or 50 g of carbohydrate (corn flakes). Half received a further 25 g of carbohydrate in the form of corn flakes after 1 1/2 h (snack). Predictably, those who ate breakfast, and/or a snack, reported feeling less hungry. The larger the caloric intake, the less subjects reported hunger. Those who consumed a snack reported a better mood. Eating a larger breakfast was associated with poorer mood later in the morning, an effect reversed by eating a snack. Memory for the word lists was not influenced by eating breakfast, however, 20 but not 60 min after a midmorning snack, more words were recalled. Those who had eaten breakfast, as opposed to fasting, did, however, spend longer trying to recall the words. This finding was interpreted as evidence that eating breakfast was associated with better motivation. On a number of occasions, better memory was associated with lower blood glucose levels. These findings support previous observations that better glucose tolerance was associated with better memory.

Modulation of 7,12-dimethylbenz[a]anthracene disposition and hepatocarcinogenesis by dieldrin and chlordecone in rainbow trout.

The present study examined whether modified xenobiotic transport, resulting from chlordecone (CD) or dieldrin pretreatment, would alter polycyclic aromatic hydrocarbon (PAH) or organochlorine (OC) target organ doses and subsequent tumor organospecificity or incidence rates in rainbow trout. Additionally, the potential for exposure to dieldrin or CD, following PAH exposure, to enhance tumor incidence was assessed. Evaluation of CD pretreatment effects on [14C]CD disposition in trout was conducted following two i.p. (0-15 mg/kg) and two dietary (0-0.4 mg/kg/d) pretreatment regimes. To assess the influence of OC pretreatment on cancer induced by the PAH 7,12-dimethylbenz[a]anthracene (DMBA), juvenile trout were fed control, CD (0.1, 0.4 mg/kg/d), or dieldrin (0.1, 0.3 mg/kg/d) diets for 9 wk, received a waterborne [3H]DMBA exposure (1 mg/L, 20 h), and resumed control, CD, or dieldrin diets for 33 wk. [3H]DMBA disposition and hepatic [3H]DMBA binding were examined immediately and 24 h after exposure. Hepatic and stomach tumor incidences were determined 33 wk after DMBA exposure. CD pretreatment did not influence [14C]CD or [3H]DMBA hepatic concentrations, hepatic [3H]DMBA DNA binding, or hepatic/stomach tumor incidence. It did, however, elevate bile [14C]CD and [3H]DMBA concentrations. Postinitiation exposure to CD weakly enhanced DMBA-induced hepatic tumor incidence at the low but not the high CD dose. Dieldrin pretreatment did not influence stomach [3H]DMBA equivalents or stomach tumor incidence but did cause an elevation in biliary and hepatic concentrations of [3H]DMBA equivalents. [3H]DMBA binding to liver DNA was significantly increased and hepatic tumor incidence was elevated by dieldrin pretreatment. Dieldrin treatment following DMBA initiation did not enhance hepatic or stomach tumor incidence. Ecoepidemiology studies, to date, have reported correlations between the co-occurrence of PAHs and OCs and elevated tumor incidence in feral fish, but cause-and-effect relationships have been difficult to establish. The results of the present study confirm that OCs, such as dieldrin and CD, play a role in modifying PAH-induced carcinogenesis in fish.

Retrospective study into the delivery of telephone cardiopulmonary resuscitation to "999" callers.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is an essential part of the chain of survival, with early administration directly affecting the patient's chance of survival. Pre-arrival telephone CPR instructions provide callers who have no CPR training on how to undertake this intervention. With the emergency medical dispatcher unable to see the caller or the patient, it is possible that problems will arise, presenting barriers, that stop the caller undertaking effective CPR. OBJECTIVE: To examine how commonly barriers to telephone CPR occur and whether this affects the time it takes to perform the intervention. METHOD: A retrospective quantitative analysis was undertaken using a convenience sample of 100 emergency calls. Calls were identified in the emergency control room as cardiac arrests and confirmed by the responding paramedics as cardiac arrests. The calls were listened to, established if CPR instructions were given, if the instructions were followed, if anything hindered the instructions undertaken, and the time taken to reach key points. FINDINGS: 18 cases had bystander CPR administered. An additional 56 of cases had CPR instructions provided but "barriers" in 49% (n = 27) hindered the effectiveness of these. The median time to recognition of cardiac arrest was 40 seconds, with time to first ventilation being 4 min 10 s and time to first compression 5 min 30 s. These times were notably higher in those cases where a barrier to effective telephone CPR existed. CONCLUSIONS: Barriers to undertaking telephone CPR occurred with a high degree of frequency. These barriers affect the ability of the caller to perform rapid and effective telephone CPR.

Predicting non-cardiac aetiology: a strategy to allocate rescue breathing during bystander CPR.

AIMS: Optimal care for out-of hospital cardiac arrest (OHCA) patients may depend on the underlying aetiology of OHCA. Specifically chest compression only bystander CPR may provide greater benefit among those with cardiac aetiology and chest compressions plus rescue breathing may provide greater benefit among those with non-cardiac aetiology. The aim of this study was to generate a simple predictor model to identify OHCA patients with non-cardiac aetiology in order to accurately allocate rescue breathing. METHODS: We used two independent cohorts of OHCA patients from a randomized pre-hospital trial and a prospective hospital registry (total n=3086) to assess whether the characteristics of age, gender and arrest location (private versus public) could sufficiently discriminate non-cardiac aetiology. We used logistic regression models to generate a receiver operator curve and likelihood ratios. RESULTS: Overall, 965/3086 (31%) had a final diagnosis of a non-cardiac cause. Using 8 exclusive groups according to age, gender, and location, the frequency of non-cardiac aetiology varied from a low of 16% (55/351) among men >age 50 in a public location up to 58% (199/346) among women <60 in a private location. Although each characteristic was predictive in the logistic regression model, the area under the curve in the receiver operating curve was only 0.66. The associated positive likelihood ratios ranged from 1 to 3 and the negative likelihood ratios ranged from 1 to 0.4. CONCLUSION: The results highlight the challenge of accurately identifying non-cardiac aetiology by characteristics that could be consistently used to allocate bystander rescue breathing.

Out-of-hospital cardiac arrest in South Asian and white populations in London: database evaluation of characteristics and outcome.

OBJECTIVE: To compare out-of-hospital cardiac arrest (OOHCA) characteristics in white and South Asian populations within Greater London. METHODS: Data for OOHCAs were extracted from 1 April 2003 to 31 March 2007. Primary study variables included age, gender, ethnicity, response times from 999 call to ambulance arrival, initial cardiac rhythm, whether bystander cardiopulmonary resuscitation was provided before arrival of the London Ambulance Service (LAS) NHS Trust crew, whether the arrest was witnessed (bystander or LAS crew) and hospital outcome, including survival to hospital admission and discharge. RESULTS: Of 13 013 OOHCAs of presumed cardiac cause, 3161 (24.3%) had ethnicity codes assigned. These comprised 63.1% (n = 1995) white and 5.8% (n = 183) South Asian people, with the remainder from other backgrounds. White patients were on average 5 years older than South Asians (69.5 vs 64.6, p<0.005). Response time (7.48 min vs 7.46 min), bystander cardiopulmonary resuscitation (34.4% vs 29.7%), initial cardiac rhythm (29.5% vs 30.4%) and survival to admission (22.2% vs 22.5%) and discharge (8.7% vs 8.9%) were comparable between the two ethnic groups. South Asians were slightly more likely to have a witnessed an OOHCA than their white counterparts (OR = 1.1, 95% CI 1.0 to 1.2). DISCUSSION: The quality of care provided was comparable between white and South Asian populations. The data support the emerging view that South Asians' high mortality from coronary heart disease reflects higher incidence rather than higher case fatality. South Asians had an OOHCA at a significantly younger age. The study demonstrates the importance of ethnic coding within the emergency services.

Alteration of infrared spectrum of serum transferrin by iron binding and lowered pH.

Difference infrared spectra are reported for human serum transferrin in D2O as a function of iron binding or increased acidity. Spectral features detected as iron is bound at high pH include difference bands that are indicative of reduced solvent exposure and binding site ligation. More extensive spectral alterations, some of which indicate titration of carboxylic acid groups, are induced in the apo protein by lowering the pH in a manner consistent with that entailed in endocytosis.

The effects of nutrients on mood.

A recent major theory was that a meal high in carbohydrate increased the rate that tryptophan enters the brain, leading to an increase in the level of the neurotransmitter serotonin that modulates mood. Although such a mechanism may be important under laboratory conditions it is unlikely to be of significance following the eating of any typical meal. As little as 2-4% of the calories of a meal as protein will prevent an increased availability of tryptophan. Arguably the food with the greatest impact on mood is chocolate. Those who crave chocolate tend to do so when they feel emotionally low. There have been a series of suggestions that chocolate's mood elevating properties reflect 'drug-like' constituents including anandamines, caffeine, phenylethylamine and magnesium. However, the levels of these substances are so low as to preclude such influences. As all palatable foods stimulate endorphin release in the brain this is the most likely mechanism to account for the elevation of mood. A deficiency of many vitamins is associated with psychological symptoms. In some elderly patients folate deficiency is associated with depression. In four double-blind studies an improvement in thiamine status was associated with improved mood. Iron deficiency anaemia is common, particularly in women, and is associated with apathy, depression and rapid fatigue when exercising.

Declining Blood Glucose Levels after a Cognitively Demanding Task Predict Subsequent Memory.

There is a series of reports that failing levels of blood glucose are associated with enhanced cognitive functioning. The hypothesis was examined that declining blood glucose levels are associated with enhanced memory only when individuals are subjected to cognitive demand. Subjects consumed either a placebo or a glucose containing drink, and then either sat quietly for 20 min, or performed a vigilance task. All subjects then attempted to recall a list of words. In those who performed the vigilance task, and consumed a glucose drink, memory was better when blood glucose levels fell more markedly. Those whose blood glucose levels fell more markedly also produced fewer errors while performing the vigilance task. In no instance did a fall in blood glucose predict the memory of those who had not performed the demanding vigilance test.