Sigmoid Diverticulitis in an Obese Pediatric Patient Without Genetic Predisposition.

Sigmoid diverticulitis has historically been a rare cause of abdominal pain in pediatrics, with minimal cases documented in the literature. The patient studied is one of the first reported cases of acquired pediatric uncomplicated sigmoid diverticulitis in whom lifestyle was the main contributing factor, as all associated known genetic risk factors were absent. Given the rarity of the diagnosis, many pediatricians may not consider the diagnosis; however, with the increasing incidence in younger patients, consideration of diverticulitis on the differential diagnosis with lower abdominal pain, especially in patients predisposed to diverticular disease, is increasingly important to avoid misdiagnosis and potential delays in appropriate treatment.

Dorsal root ganglion stimulator for avascular necrosis of the hip.

Dorsal root ganglion stimulation is a fairly recent treatment that has emerged in chronic pain management, often used in cases involving patients with complex regional pain syndrome. We describe a 24-year-old woman with severe left hip pain secondary to avascular necrosis in whom multiple treatments failed, including oral analgesics and radiofrequency ablation. A dorsal root ganglion stimulator was implanted with significant pain relief.

Management of complex regional pain syndrome.

Complex regional pain syndrome (CRPS) is a relatively rare, chronic, and debilitating condition that significantly impacts the patient's quality of life. There is an overall paucity of literature addressing the management of CRPS in immunocompromised patients. We define features of CRPS, outline its treatment options, and describe a course of CRPS management for a 35-year-old patient who had heart transplantation requiring immunosuppressive medications.

Alcohol neurolysis of digital nerves.

Alcohol neurolysis is a well-established treatment in chronic pain management, often used in cases of intractable cancer-related pain that is refractory to other management therapies. We describe a 76-year-old woman with chronic toe neuritis who failed multiple treatments, including oral and topical analgesics, nerve blocks, and radiofrequency ablations. Alcohol neurolysis was performed via digit block of the toe resulting in 100% pain relief.

Effect of adding tetracaine to bupivacaine on duration of analgesia in supraclavicular brachial plexus nerve blocks for ambulatory shoulder surgery.

The objective of this study was to determine if the addition of 1% tetracaine to 0.25% bupivacaine prolonged the duration of postoperative analgesia of supraclavicular brachial plexus nerve blockade for patients undergoing ambulatory shoulder surgery. We conducted a prospective, double-blinded, randomized controlled clinical study at an ambulatory surgery center utilizing ultrasound- and nerve stimulation-guided supraclavicular nerve blockade for postoperative analgesia. The control group received 30 mL of 0.25% bupivacaine plus 4 mL preservative-free saline. The study group received 30 mL of 0.25% bupivacaine plus 4 mL of 1% tetracaine. Patients documented their visual analog scale scores and intake of pain medications for 3 days. Primary outcomes included time of first postoperative pain, time of first postoperative pain pill, and time of return of motor and sensory function. Secondary outcomes included pain score and pain medication intake trends and adverse events secondary to the nerve block. A total of 84 patients completed the study, 42 patients in each group. The study group was statistically significantly older than the control group (mean age, 54 vs 48 years; P = 0.04). The mean duration of analgesia was 16.6 ± 8.3 h for the control group and 17.1 ± 7.3 h for the study group (P = 0.69). No outcomes were statistically different. In conclusion, there was no significant difference in duration of postoperative analgesia with the addition of 1% tetracaine to 0.25% bupivacaine in supraclavicular brachial plexus nerve blockade. No differences were identified in postoperative pain medications, pain scores, or complications.

Prospective randomized controlled study to determine the effect of topical application of botulinum toxin A for crow's feet after treatment with ablative fractional CO2 laser.

BACKGROUND: Botulinum toxin Type A (BoNT A) for the treatment of facial wrinkles is delivered through local injection. We previously demonstrated that topical surface application of BoNT A has negligible cutaneous bioavailability and is not effective in treating wrinkles. OBJECTIVE: To determine the effect of BoNT A solution applied topically on the skin surface immediately after ablative fractional CO2 laser treatment. METHODS: We conducted a randomized controlled trial for patients with periorbital wrinkles (crow's feet) (n = 10). Treatment was performed on both sides of the face with fractional ablative CO2 laser followed by the application of topical solutions of BoNT A on one side and normal saline as control on the other side. Pretreatment assessment was performed, and at 1 and 4 weeks after treatment. RESULTS: There was a clinically significant greater degree of improvement in wrinkles after treatment with CO2 laser, on the topically applied BoNT A side. Also, the difference between the 2 treatment types (laser followed by topical BoNT A vs laser followed by saline) at 1 week and at 1 month was statistically significant. CONCLUSION: Topically, noninjectable form of BoNT A applied on the surface of the skin after ablative fractional CO2 laser is effective in the treatment of lateral periorbital wrinkles.

Laser assisted drug delivery: a review of an evolving technology.

BACKGROUND: Topically applied drugs have a relatively low cutaneous bioavailability. OBJECTIVE: This article reviews the existing applications of laser assisted drug delivery, a means by which the permeation of topically applied agents can be enhanced into the skin. RESULTS: The existing literature suggests that lasers are a safe and effective means of enhancing the delivery of topically applied agents through the skin. The types of lasers most commonly studied in regards to drug delivery are the carbon dioxide (CO2 ) and erbium:yttrium-aluminum-garnet (Er:YAG) lasers. Both conventional ablative and fractional ablative modalities have been utilized and are summarized herein. LIMITATIONS: The majority of the existing studies on laser assisted drug delivery have been performed on animal models and additional human studies are needed. CONCLUSIONS: Laser assisted drug delivery is an evolving technology with potentially broad clinical applications. Multiple studies demonstrate that laser pretreatment of the skin can increase the permeability and depth of penetration of topically applied drug molecules for both local cutaneous and systemic applications.

Inexact trajectory planning and inverse problems in the Hamilton-Pontryagin framework.

We study a trajectory-planning problem whose solution path evolves by means of a Lie group action and passes near a designated set of target positions at particular times. This is a higher-order variational problem in optimal control, motivated by potential applications in computational anatomy and quantum control. Reduction by symmetry in such problems naturally summons methods from Lie group theory and Riemannian geometry. A geometrically illuminating form of the Euler-Lagrange equations is obtained from a higher-order Hamilton-Pontryagin variational formulation. In this context, the previously known node equations are recovered with a new interpretation as Legendre-Ostrogradsky momenta possessing certain conservation properties. Three example applications are discussed as well as a numerical integration scheme that follows naturally from the Hamilton-Pontryagin principle and preserves the geometric properties of the continuous-time solution.

Extremely preterm infant mortality rates and cesarean deliveries in the United States.

OBJECTIVES: To estimate trends in infant mortality rates and cesarean delivery rates for extremely preterm infants born in the United States. METHODS: This national population-based study used public data from the Centers for Disease Control and Prevention to investigate extremely preterm infants born alive between 22 0/7 and 27 6/7 weeks of gestational age from 1999 to 2005. RESULTS: There were 177,552 extremely preterm infant births (fewer than 1% of all births) from 1999 to 2005. The number of annual extremely preterm births increased by 7% compared with a 4.5% increase for births at all gestations. During the study years, the extremely preterm infant mortality rate (percentage of infants who died in the first year) remained steady (range 33-34%; P=.22), whereas the cesarean delivery rate increased from 43% to 54% (P<.001). The infant mortality rate after cesarean delivery increased from 24% to 26% (P=.012). At each gestational age, the annual cesarean delivery rate increased over time (P<.001 for each), whereas gestational age-specific infant mortality rates were unchanged except for a 2% decline from 2004 to 2005 for infants born at 24 weeks of gestation (P=.01). CONCLUSION: A significant rise in the cesarean delivery rate in the United States from 1999 to 2005 for infants born at less than 28 weeks of gestation was not associated with an improvement in the infant mortality rate.

Validation and feasibility of intraoperative three-dimensional transesophageal echocardiographic cardiac output.

BACKGROUND: In this pilot study, we attempted to validate three-dimensional transesophageal echocardiography (3DTEE) cardiac output and assess its feasibility intraoperatively. METHODS: Twenty patients undergoing cardiac surgery underwent simultaneous cardiac output determinations during the clinically stable prebypass period by 3DTEE and thermodilution. RESULTS: The correlation coefficient between cardiac output measured by the two methods was 0.86. The 3DTEE mean bias was 0.27 L/min, limits of agreement -1.64 to 2.17 L/min (approximately +/-35%). Three-dimensional data acquisition averaged 43 s; postprocessing took 7 min. CONCLUSIONS: Three-dimensional TEE can measure cardiac output and is feasible perioperatively. Measurements have good correlation with thermodilution, though with a significant bias and wide limits of agreement.

A pathogenic role for IgE in autoimmunity: bullous pemphigoid IgE reproduces the early phase of lesion development in human skin grafted to nu/nu mice.

Bullous pemphigoid (BP) is an autoimmune disease characterized by subepidermal blistering. Based on previous work, IgG autoantibodies directed against BP180 are thought to be the primary pathogenic agent in BP. In addition to these IgG autoantibodies, however, most BP patients produce IgE class autoantibodies that also react with BP180, and total IgE levels are often elevated in this disease. To directly test whether BP IgE is pathogenic, 6 ng of total IgE isolated from two BP and two normal sera were injected into human skin grafted onto athymic, nude mice. Twenty-four hours after injection, erythematous, elevated plaques were observed in all human skin grafts receiving BP IgE (n=11), but not control IgE (n=9). Histologic and ultrastructural examination of the lesions showed engorgement of blood vessels and a dermal infiltrate composed of neutrophils, eosinophils, and mast cells, many of which were degranulated. At a higher dose of BP IgE (47 ng), histological separation of the epidermis from the dermis was observed in two of the three grafts. The BP IgE-induced erythematous plaques were reminiscent of those clinically seen in BP. This provides early evidence of a direct demonstration of a pathogenic role for IgE class autoantibodies in a human autoimmune disease.

Identification of aberrant 2'-5' RNA linkage isomers by pellicular anion exchange chromatography.

During chemical RNA synthesis, many undesired products may be formed. In addition to the "n-x" sequences, depurination products, and incompletely deprotected oligonucleotides, linkage isomers may form during condensation and/or deprotection of the synthetic products. Under acidic conditions, bond migration may alter normal 3'-5' diesters to aberrant 2'-5' diesters. This results in isomers that are difficult to identify by MS and LC-MS techniques because the isomers have identical masses. HPLC methods for identification of these isomers have not advanced because the isomers are not expected to exhibit differences in hydrophobicity that allow resolution by reversed-phase columns. Neither are changes in ionic interactions anticipated for these isomers that would allow resolution by ion exchange methods. We observed that chromatography on pellicular anion exchange phases, but not on porous anion exchange phases, completely resolves oligonucleotides with very slight conformation differences (e.g., DNA vs. RNA of identical sequence). Because incorporation of 2'-5' linkages in RNA will alter solution conformation slightly, we considered that this pellicular ion exchanger might also allow resolution of identical RNA sequences harboring aberrant 2'-5' linkages from those lacking aberrant 2'-5' linkages. Using the nonporous DNAPac PA200 column, we demonstrated a chromatographic procedure for resolving synthetic RNA with aberrant linkages from their normally linked counterparts. Under certain conditions, aberrant isomers are not completely resolved from those containing only normal linkages. Therefore, we also developed an independent linkage-confirming method using a 5'-3' exonuclease. This enzyme produces incomplete digestion products during digestion of synthetic RNA containing aberrant 2'-5' linkages, and these are readily resolved by DNAPac PA200 chromatography.

Iron(VI) and iron(V) oxidation of copper(I) cyanide.

Copper(Il) cyanide (Cu(CN)4(3-)) in the gold mine industry presentsthe biggest concern in cyanide management because it is much more stable than free cyanide. Cu(CN)4(3-) is highlytoxic to aquatic life; therefore, environmentally friendly techniques are required for the removal of Cu(CN)4(3-) from gold mine effluent. The oxidation of Cu(CN)4(3-) by iron-(VI) (FeVIO4(2-), Fe(VI)) and iron(V) (FeVO4(3-), Fe(V)) was studied using stopped-flow and premix pulse radiolysis techniques. The stoichiometry with Fe(VI) was determined to be 5HFeO(4-) + Cu(CN)4(3-) + 8H2O - > 5Fe(OH)3 + Cu2+ + 4CNO- +3/202 + 6OH-. The rate law for the oxidation of Cu(CN)4(3-) by Fe(VI) was found to be first-order with each reactant. The rates decreased with increasing pH and were mostly related to a decrease in concentration of reactive protonated Fe(VI) species, HFeO4-. A mechanism is proposed that agrees with the observed reaction stoichiometry and rate law. The rate constant for the oxidation of Cu(CN)4(3-) by Fe(V) was determined at pH 12.0 as 1.35 +/- 0.02 x 10(7) M(-1) s(-1), which is approximately 3 orders of magnitude larger than Fe(VI). Results indicate that Fe(VI) is highly efficient for removal of cyanides in gold mill effluent.