Effervescent agents in acute esophageal food impaction.

Acute esophageal food impaction (AEFI) occurs frequently. Few data are published describing the use of effervescent agents (EAs) for treatment of AEFI. We aimed to evaluate the effectiveness, cost, and safety of EAs in the treatment of AEFI. We retrospectively identified patients aged 18 years and older who were seen in the emergency department of 2 hospitals in 1 metropolitan area from January 1, 2011, through April 4, 2016, who had a clinical diagnosis of AEFI. We collected and analyzed data on outcomes and cost associated with the use of EAs, glucagon, and no pharmacologic therapy. During the study period, 239 patients with AEFI met the inclusion criteria. Of the 45 patients who received EA monotherapy, 25 (55.6%) responded successfully, compared with 11 of 62 (17.7%) who received glucagon monotherapy (P < .001) and 16 of 93 (17.2%) who had no therapy (P < .001). Ten of 39 patients (25.6%) who were given both glucagon and EA responded successfully. The other 177 patients had endoscopy, which was successful in all cases. Median hospitalization charges for patients who responded successfully to EA alone were $1,136, compared with $2,602 for responders to glucagon alone (P < .001) and $1,194 for those who cleared their bolus spontaneously (P < .001). All patients who received EA monotherapy had lower median hospitalization costs ($2,384) than all patients who received glucagon monotherapy ($9,289; P = .03) and all patients who received neither ($8,386; P = .02). Effervescent agents are a safe, effective, and cost-saving initial strategy in the treatment of acute esophageal food impaction.

What goes down must come up: role of the posteromedial cortices in encoding and retrieval.

The hypothesis that the neural network supporting successful episodic memory retrieval overlaps with the regions involved in episodic encoding has garnered much interest; however, the role of the posteromedial regions remains to be fully elucidated. Functional magnetic resonance imaging (fMRI) studies during successful encoding typically demonstrate deactivation of posteromedial cortices, whereas successful retrieval of previously encoded information has been associated with activation of these regions. Here, we performed an event-related fMRI experiment during an associative face-name encoding and retrieval task to investigate the topography and functional relationship of the brain regions involved in successful memory processes. A conjunction analysis of novel encoding and subsequent successful retrieval of names revealed an anatomical overlap in bilateral posteromedial cortices. In this region, a significant negative correlation was found: Greater deactivation during encoding was related to greater activation during successful retrieval. In contrast, the hippocampus and prefrontal cortex demonstrated positive activation during both encoding and retrieval. Our results provide further evidence that posteromedial regions constitute critical nodes in the large-scale cortical network subserving episodic memory. These results are discussed in relation to the default mode hypothesis, the involvement of posteromedial cortices in successful memory formation and retention, as well as potential implications for aging and neurodegenerative disease.

An assessment of opinion of Indian physicians about emergency medicine in India.

BACKGROUND: Emergency medicine (EM) has recently been recognized as a specialty in India and formal training programmes are yet to be developed. METHODS: A survey was devised to elicit the opinion of recently graduated physicians in Chennai, India about EM as well as about the current state of EM in India. A convenience sample of 130 respondents filled out a 21-question survey. RESULTS: Ninety-four per cent of respondents stated that EM was essential for providing quality healthcare; 94% of respondents felt there needs to be a change in emergency departments in India, with only 20% stating they were proud of the emergency departments in India. Seventy-six per cent of respondents were more likely to consider EM if the specialty was recognized by the Medical Council of India and 76% were inclined to pursue the specialty if there were more training programmes. CONCLUSION: Recently graduated physicians found flaws in the current state of emergency care in India; however, overall they remain interested in the field of EM.

Regional Differences following Partial Salivary Gland Resection.

Regenerative medicine aims to repair, replace, or restore function to tissues damaged by aging, disease, or injury. Partial organ resection is not only a common clinical approach in cancer therapy but also an experimental injury model used to examine mechanisms of regeneration and repair in organs. We performed a partial resection, or partial sialoadenectomy, in the female murine submandibular salivary gland (SMG) to establish a model for investigation of repair mechanisms in salivary glands (SGs). After partial sialoadenectomy, we performed whole-gland measurements over a period of 56 d and found that the gland increased slightly in size. We used microarray analysis and immunohistochemistry (IHC) to examine messenger RNA and protein changes in glands over time. Microarray analysis identified dynamic changes in the transcriptome 3 d after injury that were largely resolved by day 14. At the 3-d time point, we detected gene signatures for cell cycle regulation, inflammatory/repair response, and extracellular matrix (ECM) remodeling in the partially resected glands. Using quantitative IHC, we identified a transient proliferative response throughout the gland. Both secretory epithelial and stromal cells expressed Ki67 that was detectable at day 3 and largely resolved by day 14. IHC also revealed that while most of the gland underwent a wound-healing response that resolved by day 14, a small region of the gland showed an aberrant sustained fibrotic response characterized by increased levels of ECM deposition, sustained Ki67 levels in stromal cells, and a persistent M2 macrophage response through day 56. The partial submandibular salivary gland resection model provides an opportunity to examine a normal healing response and an aberrant fibrotic response within the same gland to uncover mechanisms that prevent wound healing and regeneration in mammals. Understanding regional differences in the wound-healing responses may ultimately affect regenerative therapies for patients.

White paper on academic emergency medicine in India: INDO-US Joint Working Group (JWG).

Emergency Medicine (EM) is a new discipline for India. As Medical Council of India (MCI) makes progress in recognizing the need to develop EM residency training programs in India it is important that there exist an established training model for future faculty, residents and medical students. This INDO-US white paper makes a serious attempt to recognize the opportunities and challenges in developing academic emergency medicine in India. The contents of this white paper address the overall scenario and are not targeted towards a person, physician, body, hospital or any other associated entity. This paper emphasizes the importance of MCI recognized training in Emergency Medicine for physicians in India.

Systemic lupus erythematosus in a pediatric patient with congenital acquired immunodeficiency syndrome.

The coexistence of congenital HIV infection with primary rheumatologic disease is rare. We have described a child with congenital AIDS and concurrent systemic lupus erythematosus who presented with small vessel vasculitis with no renal involvement. Oral corticosteroid therapy resulted in significant improvement in her clinical state. The child also responded strongly to potent antiretroviral therapy both virologically and immunologically.

Histochemistry of mouse extraocular muscle.

The organization, histochemical and endplate characteristics, and percentage fiber composition are described for mouse extraocular muscle (EOM). Both recti and obliques, but not the retractor bulbi, have two concentric layers, an inner global and superficial orbital. Three histochemical fiber types, coarse, fine and granular, are present in the EOM. The intermediate diameter coarse fibers are focally innervated and occur in both layers in all muscles. The large diameter granular fibers are focally innervated and occur in all EOM in the global layer. The small diameter fine fibers have multiterminal endplates and occur in both layers of the recti. Fine fibers are not seen in the obliques or retractor bulbi. Focal endplates are confined to a broad diagonal band across the middle one third of the muscle, whereas multiterminal endplates are scattered throughout the length of the muscle.

Bond strength of composite to porcelain treated with new porcelain repair agents.

In vitro tensile bond strengths of composite to porcelain were evaluated using three pretreatments (HF etching, sandblasting, diamond abrasion) of the porcelain, four bonding agents (Clearfil Porcelain Bond, Porcelain Liner M, Porcelain Liner M with Super-Bond C&B, and Scotchprime) and two storage conditions (24 h and thermocycling). The overall coefficient of variation was 27%. Significant differences among bond strengths were observed, with storage condition being the most important factor, followed by bonding agent and then pretreatment. Thermocycling decreased the bond strength of all samples, but samples treated with Scotchprime were affected least. For 24 h storage, Clearfil Porcelain Bond and Scotchprime had bond strengths above 23 MN/m2 to sandblasted porcelain.

Complications of percutaneous feeding tubes.

Emergency physicians frequently manage patients with percutaneous feeding catheters. These devices are associated with a variety of complications, and often subtle presentations. It is imperative that the emergency physician become knowledgeable in the evaluation of these patients. The physician must be adept at managing current complications and proactive in avoiding future problems, always cognizant of the potential for fatal outcomes.

Evaluation of abdominal pain in the elderly.

Evaluation of the older patient presents a unique challenge to the emergency physician. The increased age of the population, a high incidence of comorbidity, general poverty of history and clinical signs in acute abdominal conditions, poor reliability of diagnostic procedures, and the variable presentations of diseases with significant morbidity and mortality summarize the problems to be encountered with the complaint of abdominal pain in the elderly. The correct diagnosis is often difficult to establish and coexisting complicating diseases influence the patient's condition and the ED management. The emergency physician must maintain a wide differential and have a low threshold for admission and more extensive evaluation in this patient population.

Elderly patients with altered mental status.

Mental status changes in the elderly are a source of concern and a challenge for the emergency physician. A variety of medical conditions and psychiatric disturbances are potential causes of those symptoms. Acute changes must be differentiated from mental status alterations occurring as a result of chronic conditions. This article focuses on the emergency evaluation, treatment, and differential diagnosis of this symptom complex.

Non-organic failure to thrive: decision for placement and videotaped evaluations.

Infants hospitalized for non-organic failure to thrive in the first six months of life are in a life-threatening situation and are already at risk for poor bonding with mother. In light of this, the meaning and use of foster care and how this separation affects the developing mother-child relationship are the issues addressed through examination of 16 cases in which 8 of the infants were placed in foster care and 8 discharged home after the failure to thrive hospitalization. This paper examines (1) maternal histories of pregnancy, labor and delivery and the neonatal status of placed and non-placed infants; (2) the developmental and weight status of placed children; (3) the nature of the decision criteria for after-hospital care; and (4) the mother-infant relationship at initial intake in terms of mother's report of events and observations of feeding and play interactions during a videotaped assessment process. The study found that the interactions between mother and infant in those situations which required foster care were clearly more dysfunctional when compared to those in which the baby was discharged home to mother. Babies in the two groups were comparable in weight status at the time of hospitalization although babies in foster placement had slightly lower scores on the Bayley Scales. Maternal histories of pregnancy, labor, and delivery were similar for the two groups as were the birth and neonatal histories of the infants.

Non-organic failure to thrive: implications of placement through analysis of videotaped interactions.

This paper presents 6-month follow-up on a group of 16 infants hospitalized during the first months of life for non-organic failure to thrive (N-O FTT) and their mothers. Eight of these infants were placed in foster care and eight were returned home with their parents following hospitalization. The effects of placement on infant outcomes were examined through comparison of developmental scores and weight percentile changes, and the implications of foster care placements for mother-infant interactions were examined through analysis of patterns of interaction in videotaped sessions of feeding and play six months after hospital discharge. This analysis showed that (1) mothers in both groups failed to make significant progress in resolving their own emotional or psychological conflicts through treatment available; (2) weight and developmental status of the infants did not improve as expected in either group, and finally that (3) the patterns of interaction between mother and infant showed little change over time, and, regardless of placement at home or in foster care, remained concerning.

The benefit of a special elective gynecologic oncology program for obstetrics and gynecology residents.

OBJECTIVE: To assess the benefit of a special elective gynecologic oncology program for Obstetrics and Gynecology (Ob/Gyn) residents. METHODS: We reviewed our housestaff records from July 1992 to June 1998 and the National Residency Matching Program (NRMP) subspeciality match results for gynecologic oncology from its inception in 1994 to 1999. RESULTS: From July 1992 to June 1998, a total of 146 residents participated in our elective program. Of the 104 candidates who went through our program and subsequently participated in the NRMP, 55 (53%) obtained match positions. After completion of the elective, 42 of the 146 residents (29%) did not participate in the NRMP for gynecologic oncology and therefore were not eligible to obtain match appointments. During the study period, there were 255 other residents in the United States who applied for gynecologic oncology fellowship positions through the NRMP and did not participate in our program. Of these 255 candidates, 137 (54%) matched. CONCLUSION: The percentage of residents who went through our program, participated in the NRMP, and obtained fellowships did not differ significantly from the percentage of residents who matched without participating in the program. However, almost one-third of the residents who went through our program did not participate in the NRMP. The reasons for their lack of participation were not formally evaluated, but are likely related to a personal decision to pursue another carrer pathway, a decision facilitiated by their experience in our program. Therefore, it appears that the main benefits of the program are to help potential candidates decide whether or not to pursue a career in gyencologic oncology and to aid fellowship programs in identifying exceptional candidates for subspecialty training.

Wound infection due to fresh water contamination by Aeromonas hydrophila.

We report the case of a 24-year-old man who sustained a scalp laceration in a diving accident. His wound became infected, and he was treated with an oral cephalosporin, with subsequent progression of the infection. Cultures subsequently grew Aeromonas hydrophila. Many strains of Aeromonas are not sensitive to the antibiotics commonly used for wound infections. Aeromonas must be suspected as a pathogen in all wounds occurring in fresh water if proper treatment is to be initiated.

Bond strength of composite to etched and sandblasted porcelain.

In vitro tensile bond strengths of composite to porcelain treated by acid etching or sandblasting were measured. A 9.5% HF gel was applied for 30, 60, 150, or 300 seconds at 23 degrees C. Al2O3 particles were applied as wet-10.2, dry-33.5, dry-48.0, or dry-78.0 microns. Average roughness (Ra) was measured by profilometry before and after each treatment. Both longer etching time and sandblasting using Al2O3 with larger particle sizes produced increased surface roughness of porcelain. Etching with 9.5% hydrofluoric acid gel produced higher bond strengths than sandblasting with a series of Al2O3 particles. Etching longer than 60 seconds produced increased cohesive failures in porcelain, whereas most failures observed with sandblasted surfaces were adhesive.

Resolving conflict in a multicultural nursing department.

As a result of the turn toward recruitment from overseas in the 1980s, various challenges must be met and obstacles overcome to achieve harmony among multicultural staffs. A program was implemented to address volatile multicultural issues as part of the Nursing Incentive Reimbursement Award project in New Jersey. Nurses who participated in this sensitive program gave positive feedback, generally reporting that awareness was raised and collegial relationships improved. Specific interventions for dealing with a multicultural staff are offered.

Longitudinal fMRI in elderly reveals loss of hippocampal activation with clinical decline.

BACKGROUND: Previous cross-sectional fMRI studies in subjects with prodromal Alzheimer disease (AD) have reported variable results, ranging from hypoactivation, similar to patients with AD, to paradoxically increased activation or hyperactivation compared to cognitively normal older individuals. We have hypothesized that subjects in early phases of prodromal AD may experience a period of hippocampal hyperactivation, followed by loss of hippocampal activation as the disease progresses. METHODS: We studied 51 older individuals without dementia (Clinical Dementia Rating [CDR] at baseline of 0, n = 21, and 0.5, n = 30) with longitudinal clinical and neuropsychological assessments, as well as fMRI during a face-name associative memory paradigm. Whole brain and region-of-interest analyses were applied to the longitudinal fMRI data. RESULTS: Subjects classified as CDR 0 at baseline showed no difference in fMRI activity over 2 years, whereas those who were CDR 0.5 at baseline demonstrated a decrease in fMRI activity in the right hippocampus (p < 0.001). Dividing the subjects on the basis of their clinical and neuropsychological change over the 2 years, we found that subjects with more rapid decline demonstrated both the highest hippocampal activation at baseline, and the greatest loss of hippocampal activation. These findings remained significant after accounting for age, hippocampal volume, and APOE epsilon4 carrier status. CONCLUSIONS: Clinical decline is associated with loss of hippocampal activation in older subjects. Longitudinal fMRI provides a reliable indicator of brain activation over time, and may prove useful in identifying functional brain changes associated with cognitive decline on the trajectory toward clinical Alzheimer disease.