Defining the Role of Dexmedetomidine in the Prevention of Delirium in the Intensive Care Unit.

Dexmedetomidine is a highly selective α 2 agonist used as a sedative agent. It also provides anxiolysis and sympatholysis without significant respiratory compromise or delirium. We conducted a systematic review to examine whether sedation of patients in the intensive care unit (ICU) with dexmedetomidine was associated with a lower incidence of delirium as compared to other nondexmedetomidine sedation strategies. A search of PUBMED, EMBASE, and the Cochrane Database of Systematic Reviews yielded only three trials from 1966 through April 2015 that met our predefined inclusion criteria and assessed dexmedetomidine and outcomes of delirium as their primary endpoint. The studies varied in regard to population, comparator sedation regimen, delirium outcome measure, and dexmedetomidine dosing. All trials are limited by design issues that limit our ability definitively to conclude that dexmedetomidine prevents delirium. Evidence does suggest that dexmedetomidine may allow for avoidance of deep sedation and use of benzodiazepines, factors both observed to increase the risk for developing delirium. Our assessment of currently published literature highlights the need for ongoing research to better delineate the role of dexmedetomidine for delirium prevention.

A comparison of fluorescent and nonfluorescent light sources for phototherapy.

We have compared fluorescent and nonfluorescent light sources for phototherapy for newborn infants with hyperbilirubinemia. Phototherapy was provided by a tungsten halogen lamp and conventional fluorescent light with identical radiant flux of 6 microW/sq cm. For 22 infants treated with the nonfluorescent lamp the mean duration of phototherapy was 33.77 hours and the mean reduction of bilirubin was 3.84 mg/100 ml/day. This did not differ significantly from infants treated with conventional fluorescent lights. The nonfluorescent light can be utilized for infants in incubators or on radiant warmers. These results provide additional support for the relationship between radiant flux as a practical measure of phototherapy dose and the clinical response of a reduction in serum bilirubin.

The pigeon's recognition of drawings of depth-rotated stimuli.

Four experiments used a four-choice discrimination learning paradigm to explore the pigeon's recognition of line drawings of four objects (an airplane, a chair, a desk lamp, and a flashlight) that were rotated in depth. The pigeons reliably generalized discriminative responding to pictorial stimuli over all untrained depth rotations, despite the bird's having been trained at only a single depth orientation. These generalization gradients closely resembled those found in prior research that used other stimulus dimensions. Increasing the number of different vantage points in the training set from one to three broadened the range of generalized testing performance, with wider spacing of the training orientations more effectively broadening generalized responding. Template and geon theories of visual recognition are applied to these empirical results.

Seeing and knowing: knowledge attribution versus stimulus control in adult humans (Homo sapiens).

Interest in cognition in nonhuman animals has inspired new approaches to discovering animals' ability to attribute knowledge to others (e.g., D. J. Povinelli, K. E. Nelson, & S. T. Boysen, 1990). The assumptions of such experiments were tested in this study by training a group of humans (Homo sapiens) to use accurate information provided by a confederate who was watching as 1 container among 4 was baited; a 2nd group was similarly trained to use accurate information provided by a confederate whose back was turned during baiting. On a single reversal trial, the roles of the 2 confederates were switched. Subjects were able to learn their respective tasks but attended to different aspects of the confederates, as revealed by the reversal trial. Although attributional interpretations can be applied to such data, many of the choices in this experiment can be explained more readily with the basic principles of contingency-based learning.

Clinical signs and symptoms are not enough for the correct diagnosis of allergic conjunctivitis.

BACKGROUND: Allergic Conjunctivitis (AC) has a high incidence in the general population and sometimes it is difficult to make a correct diagnosis, distinguish among the different subtypes of AC, and therefore, to indicate the suitable therapy. OBJECTIVE: To determine the best way to carry out an appropriate diagnosis of AC. METHODS: Thirty-one patients with clinical manifestations of AC and eleven controls were studied by measuring allergic and immunologic parameters. Only those patients confirmed as having AC were treated with ketotifen fumarate and further evaluated. RESULTS: According to allergic and immunological parameters, patients were divided into two groups. Group I patients had positive prick test toward at least one allergen, 60% exhibited high levels of tear-IgE, and only 36% conjunctival eosinophils. By contrast, patients from Group II had negative prick tests and laboratory findings similar to the control group. In group I there was a good correlation between levels of tear-IgE and eosinophils (r = 0.55; p = 0.009); key symptoms and signs and prick test (r = 0.52; p = 0.015), and prick test and eosinophils (r = 0.50 p = 0.022). The cardinal signs and symptoms scores dropped significantly in Group I as a consequence of the treatment (p < 0.0001). CONCLUSION: In order to have a reliable AC diagnosis, allergen-skin prick test, IgE in tears, and conjunctival eosinophils must be studied. Serum IgE is less important.

Plexiform schwannoma.

A 33-year-old man had a multinodular tumor on his left index finger. Microscopy revealed a plexiform nerve sheath tumor resembling schwannoma. Including this case, 11 patients from 9 to 39 years old, have been reported with plexiform schwannoma. One patient had von Recklinghausen's neurofibromatosis, and all but one were free of recurrence from 1.5 to 6 years later. Plexiform schwannoma should be distinguished from plexiform neurofibroma because it appears to have neither a significant association with neurofibromatosis nor a propensity for malignant transformation.

On-farm and postharvest processing sources of bacterial contamination to melon rinds.

Multistate and international foodborne illness outbreaks, particularly involving cantaloupe and often involving rare Salmonella spp., have increased dramatically over the past 13 years. This study assessed the sources and extent of melon rind contamination in production fields and at processing and packing facilities. In the spring of 1999, cantaloupe (Cucumis melo L. [reticulatus group] cv. Cruiser) sampled from two sites in the Rio Grande River Valley showed that postharvest-processed melon rinds often had greater plate counts of bacterial contaminants than field-fresh melons. Cantaloupe in the field had 2.5 to 3.5 log CFU g(-1) rind total coliforms by aerobic plate counts, whereas washed melons had 4.0 to 5.0 log CFU g(-1). In the fall of 1999, coliforms on honeydew melons (C. melo [inodorous group] cv. Honey Brew) ranged from 2.6 to 3.7 log CFU g(-1) after processing, and total and fecal coliforms and enterococci never fell below 2.5 log CFU g(-1). A hydrocooler at another site contaminated cantaloupe rinds with up to 3.4 log CFU g(-1) total and fecal enterococci; a secondary rinse with chlorinated water incompletely removed these bacteria. Sources of coliforms and enterococci were at high levels in melon production soils, especially in furrows that were flood irrigated, in standing water at one field, and in irrigation water at both sites. At one processing facility, wash water pumped from the Rio Grande River may not have been sufficiently disinfected prior to use. Because soil, irrigation water, and process water were potential sources of bacterial contamination, monitoring and management on-farm and at processing and packing facilities should focus on water quality as an important control point for growers and packers to reduce bacterial contamination on melon rinds.

Prognostic value of clinical variables for recurrent ischemic events after acute myocardial infarction.

Recurrent ischemia after acute myocardial infarction (AMI) has been largely associated with a poor prognosis. This study was carried out to analyze the relationship among different clinical variables and both postinfarction angina and reinfarction after AMI. A total of 452 consecutive patients (mean age 58.2 +/- 12 years) were admitted to the coronary care unit and were studied prospectively. More than half of the patients received some type of thrombolytic therapy. Death occurred in 45 patients (9.9%) during hospital stay. Postinfarction angina was diagnosed in 81 patients (17.9%) and reinfarction in 22 (4.9%). Patients who developed reinfarction had a high mortality rate (45.5%) compared with those who did not develop such an event (8.1%) (p < 0.0001; odds ratio: 9.4; 95% confidence interval 3.5-25.4). On the other hand, postinfarction angina had no significant association with mortality. Multivariate analysis revealed that a history of angina (> 1 week) was predictive of the occurrence of postinfarction angina and that the use of fibrinolytic treatment, prodromal symptoms, and postinfarction angina were significantly related to reinfarction. We conclude that several simple clinical variables are clear independent predictors of postinfarction angina and reinfarction following AMI and should be taken into account in routine clinical practice or when planning intervention trials.

Synchronous reconstruction for combined aortoiliac and femoropopliteal occlusive lesions. The role of proximal bypass.

Between January 1984 and December 1986, 31 patients underwent synchronous revascularization (SR) because of the serious clinical condition of a lower limb and presence of arteriographically visible lesions. Average follow-up was 30 months. Operative mortality was 10%. Two patient populations were identified: Group I (N = 13): patients who underwent ilio-femoral or aorto-femoral proximal revascularization (PR); Group II (N = 18): patients who had axillo-femoral PR. Group I patients were younger than those in Group II (64 yr versus 72 yr; p less than 0.01). An association of pre-operative risk factors (arterial hypertension; coronary, renal or respiratory insufficiency) was twice as frequent in Group II as in Group I (p less than 0.02). The rate of SR compared to PR alone was 15%. However, there was no statistically significant difference between Groups I and II. Comparison of the actuarial survival curves for patients ahd the patency rates of SR in Groups I and II failed to reveal any statistically significant differences. Axillo-femoral bypass can be used for PR when SR is necessary in high risk patients.

Hydronephrosis after aortofemoral bypass graft. A prospective study.

This prospective study was designed to determine the frequency and natural history of hydroureteronephrosis (HUN) after placement of an aortobifemoral vascular graft. A total of 30 patients were evaluated by the study protocol, which included: pre and postoperative biological kidney function tests, preoperative and early postoperative (14th day) intravenous pyelograms and a late (mean 18th month) urologic examination by renal ultrasonic tomography. Four asymptomatic, early cases of HUN were observed in the 57 ureters examined (7%); all four complications regressed in less than 30 days. No cases of symptomatic early or late HUN were observed in this series. Asymptomatic early HUN was a frequent complication in our series (7%) but its benign course does not justify systematic screening. These asymptomatic complications contrast with the symptomatic cases of early or late HUN reported in the literature which necessitated urologic and vascular investigations.

A review of the radiographic manifestations of gout.

Hyperuricemia and gout are found in high percentages of the Pacific Island population. As local clinicians and radiologists are more likely to have patients with either the diagnosis or suspicion of gout, a pictorial review of the common radiographic manifestations is presented especially for their information.

Diffuse venous malformation with intraosseous involvement.

A young boy with a large venous malformation of his left arm and hand was evaluated for Maffucci's syndrome. Initial hand films were remarkable for cystic bony lesions suggestive of enchondromas. Additional roentgenograms and magnetic resonance imaging studies showed the bony abnormalities were the result of a venous malformation infiltrating bone. Magnetic resonance imaging is a useful diagnostic tool in differentiating enchondromas from vascular anomalies. Venous malformations infiltrating bone should be included in the differential diagnosis of Maffucci's syndrome.

Testicular microlithiasis: ultra sound appearance.

Testicular microlithiasis is a diffuse, benign condition involving both testicles without architectural distortion. Multiple, bright echoes are present on ultrasound examination which rarely cause shadowing. Many associated conditions have been reported in patients with this entity. As this is a benign entity, knowledge of its appearance and associated conditions to prevent unnecessary surgery is important.

Colonic sphincters revisited: simulators of organic disease.

Barium enema examinations establish the presence of neoplastic or inflammatory disease in the colon. Areas of narrowing commonly encountered appear to represent organic disease. These areas are in expected locations throughout the colon and have been described. Not much attention had been given to these areas in recent literature, however, which has led to unnecessary colonoscopies and even surgeries. The sphincters of Rossi, Balli, and Payr-Strauss are involved in nerve reflexes; the sphincters of Hirsch, Moultier, and Busi are a thickening of longitudinal and circular muscle fibers. Cannon's sphincter is an overlap of the superior and inferior mesenteric nerve plexuses. When an area of narrowing is encountered where a known sphincter is located, insufflation of more air, changing patient position, administering 2 mg of glucagon intramuscularly or 0.5 mg to 1 mg intravenously will aid in the distinction between a sphincter and organic disease.

[Importance of the benzylpenicillin nucleus and the side chain of the beta-lactams. Demonstration by skin tests and RAST in penicillin allergic patients]. / Importancia del núcleo bencilpenicilina y las cadenas laterales de los beta-lactámicos. Demostración por pruebas cutáneas y RAST en pacientes alérgicos a Penicilina.

We studied 30 patients with beta-Lactams allergy demonstrated by clinical findings. The aim of this work was to determine the capacity of the beta-Lactams nucleus and the side chain in the induction of specific IgE to BPO, Ax, Amp, performed by intradermal skin test and RAST. The patients were divided by clinical manifestations in: 1-Accelerated reactions (n:19); and 2-Immediate reactions (n:11). The Prick tests were performed with BPO-PL, Ax-PL, Amp-PL, MDM-BP, MDM-Ax, MDM-Amp. The accelerated group presented BPO-PL (+) in 2 cases, Ax-PL & Amp-PL (+) in 4 cases, and all of the reactives were (+) in 13 out of 19 cases. The immediate group presented MDM-BP (+) in 10 out of 11 cases and MDM-Amp was (+) in 1 out of 11 cases. The RAST's were performed in all patients(n:30). In accelerated group were (+) to BPO-PL in 13 out of 19 cases, to Ax-PL in 3 out of 19 cases, to Amp-PL in 1 out 19 cases, to BPO-PL and Ax-PL on overlap in 1 out of 19 cases, and 1 case was negative to all reactives. The immediate group presented RAST's negatives in 11 out of 11 cases. The control group(n:20) presented Prick (+) to Ax-PL in 1 out of 20 cases, and the others reactives were negatives in all cases. The RAST's to all reactives were (-) in 20 out of 20 subjects. These results indicate that BPO was the most important determinant, and the side chain of the Ax or Amp were others determinants of the beta-Lactams drugs. These determinants induced specific IgE, and in rare occasions appears specific IgE for two different determinants on overlap in the same patient. The intradermal skin testing is the method of choice to study the penicillin allergies, because non satisfactory RAST's have yet been developed for minor determinant-specific IgE antibodies.

[Gastric ruptures caused by diving accidents. Apropos of 2 cases. Review of the literature]. / Les ruptures gastriques par accident de plongée. A propos de 2 cas, revue de la littérature.

Underwater diving was responsible for gastric rupture in two cases seen personally and five cases of total gastric rupture reported in the literature. The various possible mechanisms for onset of this rupture are envisaged, the diagnosis of this rare accident being established from the existence of a large pneumoperitoneum. Emergency laparotomy allows suture of wound and ensures recovery.

[Popliteal aneurysms. Our experience apropos of 119 cases]. / Les anévrysmes poplités. Notre expérience à propos de 119 cas.

The authors report their experience of 119 popliteal aneurysms diagnosed in 76 patients. They feel that the prevalence of such aneurysms is underestimated. In 56% of cases there were bilateral aneurysms and in 24% of cases there was an associated aortic aneurysm. In 68% of cases, the popliteal aneurysm presented with complications. Clinical examination of the popliteal fossa gave a diagnosis in 66% of cases. In 1/3 of cases, arteriography failed to provide direct visual evidence of the aneurysm. The arteriographic diagnosis was then that of a femoro-popliteal thrombosis, of stenosis or isolated popliteal thrombosis. In all these difficult cases, echotomography is essential to diagnosis. The authors feel that indications for surgery should be as wide as possible. They consider that there are three types of contraindications: an excessively precarious physical condition, absence of a distal vascular network, an asymptomatic thrombosed popliteal aneurysm.