Short communication: Influence of an aqueous myrrh suspension on yogurt culture bacteria over yogurt shelf life.

Myrrh is an essential oil and natural flavoring approved by the US Food and Drug Administration, and it has antibacterial and antifungal activity against pathogens. Our objective was to determine the effect of an aqueous myrrh suspension on Streptococcus thermophilus and Lactobacillus delbrueckii ssp. bulgaricus counts in peptone solution and yogurt, as well as pH and titratable acidity of yogurt during 5 wk of storage at 1 to 4°C. The myrrh suspension (10% wt/vol) was prepared and incorporated into a pure culture dilution in peptone and into yogurt mix at a 1% (vol/vol) level. A control with no myrrh was also prepared, and 3 replications were conducted. Streptococcus thermophilus were enumerated using Streptococcus thermophilus agar with aerobic incubation at 37°C for 24 h, and Lactobacillus delbrueckii ssp. bulgaricus were enumerated using de Man, Rogosa, and Sharpe agar adjusted to pH 5.2, with anaerobic incubation at 43°C for 72 h. During the 8-h period after inoculation, S. thermophilus and L. delbrueckii ssp. bulgaricus counts in peptone solution at 37°C and 43°C, respectively, were not significantly different in the presence or absence of the aqueous myrrh suspension. Counts of S. thermophilus in yogurt containing myrrh (mean ± SD; 4.96 ± 0.58 log cfu/mL) were not significantly different from those in the control yogurt (4.87 ± 0.39 log cfu/mL). The log counts for L. delbrueckii ssp. bulgaricus in yogurt containing myrrh (5.04 ± 1.44 log cfu/mL) and those of the control (5.52 ± 1.81 log cfu/mL) did not differ, and the counts remained within 1 log of each other throughout 5 wk of storage. The pH of the yogurts containing the aqueous myrrh suspension was not significantly different from that of the control yogurts, and their pH values were within 0.1 pH unit of each other in any given week. Titratable acidity values remained steady around 1.1 to 1.2% lactic acid for both yogurt types throughout the storage period, with no significant differences between them. Yogurt culture bacteria can survive in the presence of a myrrh suspension in yogurt with no significant change in pH or titratable acidity. Therefore, it may be beneficial to add an aqueous myrrh suspension to yogurt.

Mexican Queso Chihuahua: functional properties of aging cheese.

Queso Chihuahua, a semi-hard cheese manufactured from raw milk (RM) in northern Mexico, is being replaced by pasteurized milk (PM) versions because of food safety concerns and the desire for longer shelf life. In this study, the functional traits of authentic Mexican Queso Chihuahua made from RM or PM were characterized to identify sources of variation and to determine if pasteurization of the cheese milk resulted in changes to the functional properties. Two brands of RM cheese and 2 brands of PM cheese obtained in 3 seasons of the year from 4 manufacturers in Chihuahua, Mexico, were analyzed after 0, 4, 8, 12, and 16 wk of storage at 4°C. A color measurement spectrophotometer was used to collect color data before and after heating at 232°C for 5 min or 130°C for 75 min. Meltability was measured using the Schreiber Melt Test on samples heated to 232°C for 5 min. Sliceability (the force required to cut through a sample) was measured using a texture analyzer fitted with a wire cutter attachment. Proteolysis was tracked using sodium dodecyl sulfate-PAGE. Compared with PM cheeses, RM cheeses showed less browning upon heating, melted more at 232°C, and initially required a greater cutting force. With aging, cheeses increased in meltability, decreased in whiteness when measured before heating, and required less cutting force to slice. Seasonal variations in the cheesemilk had minimal or no effect on the functional properties. The differences in the functional properties can be attributed, in part, to the mixed microflora present in the RM cheeses compared with the more homogeneous microflora added during the manufacture of PM cheeses. The degree of proteolysis and subsequent integrity of the cheese matrix contribute to melt, slice, and color properties of the RM and PM cheeses. Understanding the functional properties of the authentic RM cheeses will help researchers and cheesemakers develop pasteurized versions that maintain the traditional traits desired in the cheeses.

Etiologic factors for recurrent carotid artery stenosis.

Since 1966, 29 patients with recurrent carotid artery stenosis have been encountered. The mean (+/- SEM) internal between initial carotid endarterectomy and secondary presentation was 67.5 +/- 9.2 months (range 6 to 180 months). There was a disproportionate number of women with recurrent stenosis. The mean age at initial endarterectomy in patients with recurrent stenosis, 54.6 +/- 1.4 years, was significantly less (P less than 0.001) than that of all patients who had endarterectomy. To define the etiologic factors for recurrence, 21 of these patients were matched with case-control patients of the same age and sex who had undergone endarterectomy the same year but did not develop recognized recurrent stenosis. There was no significant difference in the incidence of hypertension, diabetes mellitus, coronary artery disease, bilateral carotid disease, other vascular operations, or family history for atherosclerosis in patients with recurrent stenosis compared to control patients. The indications for primary endarterectomy, angiographic distribution of disease, and operative details were similar in both groups. There was no difference in the incidence of regular, therapeutic aspirin ingestion following initial endarterectomy (52.5% in both groups). There was a striking difference in smoking habits. Ninety-five percent of patients with recurrent stenosis continued to smoke following initial endarterectomy, compared to 23.8% of control patients (P less than 0.001). Lipid fractionation studies were performed in both groups, and there were no significant differences in levels of cholesterol, triglycerides, high-density lipoprotein (HDL)-cholesterol, and total cholesterol/HDL-cholesterol ratio. Dose-response platelet aggregometry detected no differences between groups in the sensitivity of platelets to adenosine diphosphate (ADP), collagen, and epinephrine. Reoperation in patients with recurrent stenosis was associated with minimal morbidity, no deaths, and generally excellent results.

Dilation of knitted Dacron aortic prostheses and anastomotic false aneurysms: etiologic considerations.

Five patients with knitted Dacron aortic bifurcation prostheses developed prosthetic dilation and anastomotic false aneurysms. The interval between placement of prostheses and secondary presentation ranged from 4 to 10 years. Three patients presented with femoral false aneurysms (one ruptured) and two presented with aortic false aneurysms (one ruptured). In all cases, anastomotic sutures remained intact on the prosthesis and there was no evidence of infection. The mean (+/- SEM) increase in diameter of prostheses was 85.7 +/- 19.1% (range 76% to 137%). Dilated prostheses were removed in four cases and were tested for tensile strength and studied with scanning electron microscopy. These were compared to normal, nondilated knitted Dacron prosthetic fabric from the same manufacturer. There was no loss of breaking strength in dilated prostheses. Furthermore, on examination with scanning electron microscopy, there was no evidence of degeneration or fracturing of individual Dacron filaments. However, dilated prostheses were found to have a greatly expanded knit. The distance between loops was significantly increased and the number of fibers per 1000 microns was significantly less in comparison to normal knitted Dacron fabric. These studies confirm an association between prosthetic dilation and false aneurysm formation. Further, they suggest that the cause of prosthetic dilation is loss of compactness of the knit not associated with intrinsic Dacron fiber deterioration. A fabrication defect is most likely responsible.

Percutaneous transluminal balloon angioplasty of the iliac artery for contralateral ischemia.

The cases of three patients with lower extremity ischemia from ipsilateral iliac artery occlusion and contralateral iliac artery stenosis are presented. Planned treatment was percutaneous transluminal angioplasty (PTA) of the contralateral iliac artery, rendering it an adequate donor vessel for subsequent femorofemoral bypass. Because of adequate collateral vessels across the pelvis, cross-femoral bypass was unnecessary following PTA. Current technology allows simultaneous intraoperative PTA and femorofemoral bypass. We do not recommend this on the basis of our experience.

Ultrasonographic examination by emergency physicians of patients at risk for ectopic pregnancy.

OBJECTIVE: To evaluate a diagnostic protocol that includes the early use of endovaginal sonography (EVS) by emergency physicians of patients at risk for ectopic pregnancy. METHODS: During this prospective study, pregnant patients > or = 18 years old and at risk for ectopic pregnancy were assessed. Emergency physicians who had completed a training program performed EVS on a convenience sample of eligible women. Clinical disposition was based on predetermined clinical, laboratory, and ultrasonographic criteria. The EVS examinations were reviewed on video by a gynecologist whose interpretation was correlated with the emergency physician EVS readings and with the final clinical diagnoses. Quantitative serum beta-human chorionic gonadotropin (beta hCG) levels were determined for patients who had no definite intrauterine pregnancy (IUP) on EVS. RESULTS: Of 152 patients studied during a 12-month period, four were lost to follow-up. Emergency physician ultrasonographic diagnoses included: definite IUP, 87/148 (59%); probable abnormal IUP, 17/148 (11%); definite ectopic pregnancy, 3/148 (2%); and no definite IUP, 41/148 (28%). The gynecologist agreed with 93% of the initial interpretations. Twelve of 16 patients who had the final diagnosis of ectopic pregnancy were admitted from the ED with this diagnosis. The ultrasonographic diagnosis of the other four was no definite IUP, and no mass or free fluid. For the latter four patients, the presenting serum beta hCG level was < 2,000 mIU/mL (First International Reference Preparation). They were diagnosed as having ectopic pregnancy after serial outpatient EVS and beta hCG measurements. CONCLUSIONS: The application of EVS to emergency practice appears promising. Emergency physicians trained in its use and who apply this diagnostic tool in conjunction with a defined protocol can stratify the risk of patients who have the potential for ectopic pregnancy.

Abdominal vascular trauma: a review of 106 injuries.

A retrospective analysis of acute abdominal vascular injuries was performed to review outcome variables and treatment principles. The authors review their most recent 5-year experience with 106 major abdominal vascular injuries in 64 patients treated at a combined Army and Air Force urban medical center. The majority of the patients were young men who sustained penetrating injuries. There were 41 (64%) gunshot wounds, 17 (27%) stab wounds, and 6 (9%) sustained blunt trauma. Forty-five patients (71%) came to the hospital in shock. The inferior vena cava in 26 patients (41%) and the aorta in 11 patients (17%) were injured most frequently. Suture repair was possible in 53 (50%) injuries. Ligation was performed in 41 (39%). Overall mortality for the series was 39 per cent. Hemorrhagic shock was the cause of death in 23 patients (92%) with only two late deaths. Transfusion requirement, presence of shock, and number of vessels injured all affected outcome. Immediate stabilization in the emergency department includes appropriate crystalloid and blood product resuscitation with minimal delay for diagnostic studies. Prompt abdominal exploration to control hemorrhage and particular attention to factors associated with coagulopathy remain the key elements in saving the lives of these severely injured patients.

Performance of dwarf and normal laying hens as influenced by protein level and cage density.

The performance of dwarf and normal White Leghorn laying hens with similar genotypes other than for the dwarf gene (dw) was observed over thirteen 28-day periods in a factorial arrangement involving four protein levels (20.0, 18.1, 16.4 or 14.3% protein plus supplemental methionine) and two densities (two or three birds per standard 10 X 16 in cage). The normal birds had significantly higher overall hen-day egg production, egg weight, and body weight, but the dwarf birds excelled for feed efficiency and adult viability. Significant genotype X ration interactions were observed for egg lay, egg weight, body weight, and feed efficiency, primarily due to the relatively poor performance of the dwarf birds on the 14% protein. A significant genotype X density interaction resulted for feed efficiency, due to a higher efficiency in 3-bird than in 2-bird cages for dwarf birds, while the reverse was true for normal birds. These results suggest that the potential of the dwarf gene for increasing the efficiency of commercial egg layers can be enhanced by further study as to optimal nutrition and management regimens.

Properties of frozen dairy desserts processed by microfluidization of their mixes.

Sensory properties and rate of meltdown of nonfat (0% fat) and low-fat (2% fat) vanilla ice creams processed either by conventional valve homogenization or microfluidization of their mixes were compared with each other and to ice cream (10% fat) processed by conventional valve homogenization. Mixes for frozen dairy desserts containing 0, 2, and 10% fat were manufactured. Some of the nonfat and low-fat ice cream mixes were processed by microfluidization at 50, 100, 150, and 200 MPa, and the remaining nonfat and low-fat ice cream mixes and all of the ice cream mix were processed by conventional valve homogenization at 13.8 MPa, first stage, and 3.4 MPa, second stage. The finished frozen and hardened products were evaluated at d 1 and 45 for meltdown rate and for flavor and body and texture by preference testing. Nonfat and low-fat ice creams that usually had a slower meltdown were produced when processing their mixes by microfluidization instead of by conventional valve homogenization. Sensory scores for the ice cream were significantly higher than sensory scores for the nonfat and low-fat ice creams, but the sensory scores for the conventional valve homogenized controls for the nonfat ice cream and low-fat ice cream were not significantly different from the sensory scores for the nonfat ice cream and low-fat ice cream processed by microfluidization of the mixes, respectively. Microfluidization produced nonfat and low-fat ice creams that usually had a slower meltdown without affecting sensory properties.

Effect of pressure and fat content on particle sizes in microfluidized milk.

Average diameters and particle size distributions in fluid milks with different fat contents and subjected to various homogenization pressures with a "microfluidizer" were evaluated. Skim, 2%, and whole milks were microfluidized at 50, 100, 150, and 200 MPa. Cream containing 41% milk fat was microfluidized at 50, 100, and 150 MPa. Particle sizes were determined by laser light scattering. As microfluidization pressure was increased from 50 to 100 MPa, particle sizes in skim, 2%, and whole milks decreased. Microfluidization at pressures greater than 100 MPa had little additional effect on reducing the particle sizes in skim and 2% milks compared with microfluidization at 100 MPa, but the particle sizes in whole milk increased as the microfluidization pressure was increased from 100 to 200 MPa due to formation of homogenization clusters. The particle sizes in cream increased as the microfluidization pressure was increased from 50 to 150 MPa. When the microfluidization pressure was held constant, the particle sizes increased as the milk fat concentration was increased. The coefficients of variations of the volume-weighted particle size distributions for cream were higher than for skim, 2%, and whole milks. Larger "big" particles and smaller "small" particles were formed in whole milk after microfluidization at 200 MPa than at 100 MPa. Although microfluidization can be used to produce small particles in skim, 2%, and whole milks, a higher than optimum pressure (above 100 MPa) applied to whole milk will not lead to the minimum d(43) (volume-weighted average diameter) due to formation of clusters.

Continuous pulse oximetry during emergency endotracheal intubation.

STUDY OBJECTIVE: To determine whether continuous pulse oximetry improves the recognition and management of hypoxemia during emergency endotracheal intubation. DESIGN: A prospective, serial 14-month study. SETTING: Emergency department, Level I trauma center. TYPE OF PARTICIPANTS: All adult patients requiring emergency intubation for whom data collection would not compromise patient care. INTERVENTIONS: All samples were obtained from a finger site at a five-second sampling interval and stored in computer memory. Patients were intubated by the nasotracheal or orotracheal route. MEASUREMENTS AND MAIN RESULTS: One hundred ninety-one consecutive adult patients qualified for the study and 211 intubation attempts were analyzed. Hypoxemia (O2 saturation, less than 90%) occurred during an intubation attempt in 30 of 111 nonmonitored versus 15 of 100 monitored attempts (P < .05), and the duration of severe hypoxemia (O2 saturation, less than 85%) was significantly greater for nonmonitored attempts (P < .05). CONCLUSION: Continuous pulse oximetry monitoring reduces the frequency and duration of hypoxemia associated with emergency intubation attempts.

50% dextrose: antidote or toxin?

The empiric administration of 50% dextrose to all patients presenting to the ED with altered mental status is a standard of care predicated on the assumption that glucose administration is harmless to non-hypoglycemic patients. Considerable evidence now disputes this assumption. Glucose administration before complete cerebral ischemia in experimental animals worsens neurologic and histologic outcome. Administration of glucose during severe incomplete ischemia has a similar detrimental effect. The translation of these experimental findings into clinical practice has been slow, perhaps hindered by the frequent use of rodent models and large bolus doses of glucose. However, evidence is now provided by primate and human studies and by experimental designs using clinically relevant doses of glucose. These clinical and experimental findings in conjunction with the wide availability of a rapid bedside screen for hypoglycemia provide the rationale for an alteration in the standard of care. The empiric administration of glucose should be avoided in patients at risk for cerebral ischemia, such as those with acute stroke, impending cardiac arrest, or severe hypotension or receiving CPR. A bedside fingerstick blood glucose estimation should be performed immediately on all patients presenting with altered mental status. The administration of 50% dextrose should be reserved for those patients in whom hypoglycemia is demonstrated; this practice will uphold Hippocrates' most basic principle of clinical medicine, "The physician must ... do no harm."

50% dextrose: antidote or toxin?

The empiric administration of 50% dextrose to all patients presenting to the ED with altered mental status is a standard of care predicated on the assumption that glucose administration is harmless to nonhypoglycemic patients. Considerable evidence now disputes this assumption. Glucose administration before complete cerebral ischemia in experimental animals worsens neurologic and histologic outcome. Administration of glucose during severe incomplete ischemia has a similar detrimental effect. The translation of these experimental findings into clinical practice has been slow, perhaps hindered by the frequent use of rodent models and large bolus doses of glucose. However, evidence is now provided by primate and human studies and by experimental designs using clinically relevant doses of glucose. These clinical and experimental findings in conjunction with the wide availability of a rapid bedside screen for hypoglycemia provide the rationale for an alteration in the standard of care. The empiric administration of glucose should be avoided in patients at risk of cerebral ischemia, such as those with acute stroke, impending cardiac arrest, or severe hypotension or receiving CPR. A bedside fingerstick blood glucose estimation should be performed immediately on all patients presenting with altered mental status. The administration of 50% dextrose should be reserved for those patients in whom hypoglycemia is demonstrated; this practice will uphold Hippocrates' most basic principle of clinical medicine, "The physician must...do no harm."

MAST-associated compartment syndrome (MACS): a review.

Compartment syndromes occur following lower extremity injuries and have been associated with the use of pneumatic or "medical" antishock trousers (MAST). Review of 12 previously reported cases and 15 new cases suggests that lower extremity trauma and systemic hypotension are cofactors responsible for the development of compartment syndrome but MAST use also contributes to the process by prolonging muscle ischemia. Complications of lower limb compartment hypertension may be averted by early recognition and fasciotomy. Associated amputations and mortality are directly related to the severity of injury, or indirectly to delay in diagnosis and treatment of the compartment syndrome and its complications.

A randomized comparison study of bretylium tosylate and lidocaine in resuscitation of patients from out-of-hospital ventricular fibrillation in a paramedic system.

A prospective, randomized study using either bretylium tosylate (BT) or lidocaine (L) as the first-line antiarrhythmic for patients in refractory ventricular fibrillation was conducted using the Milwaukee County Paramedic System. If the patient did not respond to the initial American Heart Association protocol, BT (10 to 30 mg/kg total) or L (2 to 3 mg/kg total) was given randomly as the first antiarrhythmic. If the patient failed to convert, the alternate antiarrhythmic was given. In the L group, 81% (39/48) of the patients obtained an organized electrical rhythm and 56% (27/48) converted to a rhythm with a pulse. The resuscitation rate (admission to an emergency department with pulse) was 23% (11/48), and the save rate was 10.4% (5/48). In the BT group, 74% (32/43) obtained an organized electrical rhythm, 35% (15/43) were converted, 23% (10/43) were resuscitated, and 5% (2/43) were saved. The only significant difference in outcome was that L converted patients better than did BT (P less than .05). Of the 24 patients known to be on digitalis preparations prior to arrest, 41% (5/12) in the L group were resuscitated and 16% (2/12) were resuscitated in the BT group. Data were analyzed for witnessed arrest outcome and for patients given multiple antiarrhythmics.

Limitations of prehospital predictors of acute myocardial infarction and unstable angina.

Studies have attempted to define predictive indicators of diagnosis and/or prognosis for acute myocardial infarction (AMI) in the emergency department and to identify the need for hospital admission in patients with chest pain. Because prehospital predictors have not been defined, dispatchers, paramedics, and base station physicians continue to triage based on patient history. We reviewed 401 patients presenting in one year to an urban paramedic system with chest pain, normal vital signs, and stable rhythms to identify predictors of AMI and unstable angina. Thirty-one percent (123) had a diagnosis of AMI, 26% (105) unstable angina, and 43% (173) "other" diagnoses. Two-hundred seventy-eight patients required nitroglycerin administration, 182 required IV morphine, 14 developed arrhythmias requiring lidocaine, and two suffered cardiac arrest in the field. Nine other patients had a cardiac arrest after arrival in the ED. When comparing AMI and unstable angina patients to the "others," 64% (132) versus 36% (74) had radiation of pain (P less than .003), 72% (95) versus 28% (37) had diaphoresis (P less than .0001). Neither difficulty breathing, nausea/vomiting, vital signs, initial rhythm, nor past history of myocardial infarction were helpful in discriminating AMI and unstable angina from others. Comparing AMI alone versus others, the presence of ST segment elevation on lead II was present in 15% (18) AMIs, 3% (3) unstable angina, and 8% (14) others (P = .005). Diaphoresis also was a predictor of diagnosis with 51% (63) of the AMIs and 25% (69) of others exhibiting this sign (P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Vascular injury related to lumbar disk surgery.

This report summarizes the Walter Reed Army Medical Center experience with six patients operated on from 1949 through 1982 for vascular injury related to lumbar disk surgery. All had common iliac artery injuries generated by L4-5 disk operations. Four patients had isolated arterial injuries and two had combined arteriovenous injuries. Three underwent vascular repair acutely, two with shock and one with a false aneurysm. Delay in diagnosis occurred in two patients who presented 6 weeks and 3 years postinjury with minimally symptomatic arteriovenous fistulae. A sixth patient had a known arterial injury and was operated on after a 1-month delay. All patients survived. Two patients had had repeated back operations, suggesting that this may be a risk factor for perforation of the anterior spinal ligament by an operative rongeur.

Circadian variation in sudden cardiac death: effects of age, sex, and initial cardiac rhythm.

STUDY OBJECTIVE: Previous studies based on data obtained from vital statistics records have demonstrated circadian variation in the occurrence of sudden cardiac death. The purpose of this study was to examine the effects of age, sex, and initial cardiac rhythm on circadian variability in sudden cardiac death. METHODS: This study employed a retrospective analysis of the records of adult patients with witnessed cardiac arrest who underwent resuscitation in an urban paramedic system during a 5-year period. RESULTS: The records of 2,250 consecutive patients with witnessed cardiac arrest were reviewed. Spectral analysis was used to decompose the data into frequency components. A circadian variation in the occurrence of sudden cardiac death was demonstrated, with a low occurrence rate between midnight and 6 AM and a 2.4-fold increase between the rate at 6 AM and the rate at noon. The same circadian pattern was noted among both men and women, among both patients aged 18 to 70 and those older than 70 years, and among patients with various initial cardiac arrest rhythms (ventricular tachycardia or fibrillation, asystole, and electromechanical dissociation). However, the outcome of resuscitation in these patients (ie, the rate of successful resuscitation and the rate of survival) did not demonstrate circadian variation. CONCLUSION: Witnessed out-of-hospital sudden cardiac death demonstrated circadian variation, and this variability was observed regardless of the patient's age, sex, or initial cardiac arrest rhythm. The outcome of resuscitation did not show circadian variability. These results suggest a common pathophysiologic mechanism leading to sudden cardiac death.

Emergency airway management in hanging victims.

STUDY OBJECTIVE: To determine the incidence, demographics, clinical indicators of survival, and frequency of cervical-spine fractures to define appropriate emergency airway management in hanging victims. DESIGN: Medical examiner records, paramedic reports, and emergency department and hospital medical records were reviewed retrospectively for the period January 1, 1978, to January 1, 1990. SETTING: Urban paramedic system with nine receiving hospitals. PARTICIPANTS: A total of 160,724 medical examiner and paramedic records were reviewed to identify a total study population of 306 hanging victims. One hundred eighty-two victims (59%) were found dead at the scene, and the emergency medical system was not notified. An additional 57 (19%) were seen by paramedics and declared dead at the scene. Sixty-seven (22%) were treated and transported to nine receiving EDs; 39 of these 67 received oral or nasal endotracheal intubation. RESULTS: The incidence of hanging was 0.19% of all medical examiner cases and paramedic runs during the 12-year study. Those hanging victims who survived to receive paramedic transport and treatment by physicians were typically male and attempted suicidal hanging in a public place (most frequently jail) with available bedding or clothes. No hanging victim treated and transported by paramedics had documentation of cervical-spine or spinal cord injury. CONCLUSION: In nonjudicial hanging victims seen by paramedics and transported to an ED, cervical-spine injury is rare. Cerebral hypoxia rather than spinal cord injury is the probable cause of death and should be the primary concern in treatment of this patient population. Following external stabilization of the neck, nasal or oral endotracheal intubation is appropriate emergency airway management in hanging victims.