COVID-19 vulnerabilities are intensified by declining human serum albumin levels.

What is the topic of this review? Human serum albumin (HSA) a common factor in COVID-19 vulnerabilities. What advances does it highlight? Understanding of HSA capacity, and systemic vulnerabilities to COVID-19. Raising HSA in COVID-19 patients may alleviate systemic injury caused by diminished native HSA binding. A change in fluid therapy administration into the portal system of the liver is proposed to safely raise HSA levels. ABSTRACT: The specific nature of the vulnerabilities to COVID-19 are an intrinsic part of COVID-19 infection in many patients. This paper proposes that vulnerabilities to COVID-19 may be intensified by a decrease in human serum albumin (HSA) as a ligand carrier for nutrients. A mechanism for COVID-19 vulnerabilities is evident from consideration of ligand carriers such as HSA as intermediaries. We hypothesise that low levels of pool HSA binding, caused for whatever reason, affect the performance of albumin as a carrier protein reducing the availability of nutrients. Hypoalbuminaemia (low HSA) has been implicated as an indicator of COVID-19 and long-COVID-19. The levels of HSA directly affect the immune system and vulnerabilities to age, diabetes and obesity in COVID-19. Any slight reduction in available HSA has profound effects on ligand concentrations in the small capillaries where damage occurs in COVID-19. The clinical implication is that attempts should be made to return HSA to clinical levels to compensate for the additional ligands caused by infection (SARS-CoV-2 virions, antibodies and cellular breakdown products). Therapeutic albumin is usually given peripherally, and usual preparations are unbound to ligands, but we suggest that a clinical trial of HSA therapy via the hepatic portal vein should be considered.

Postoperative fever in the time of COVID-19.

Summary: Postoperative fever is common following orthopedic trauma surgery. As the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection increases in the community, migration into the acute care hospital setting intensifies, creating confusion when fever develops postoperatively. The transmission dynamics of SARS-CoV-2 make it difficult to adequately gauge and pinpoint risk groups with questionnaires at the time of hospital admission. This is particularly problematic when asymptomatic or presymptomatic patients infected with SARS-CoV-2 require urgent surgery and cannot be screened effectively. One approach is to treat every patient as though they were SARS-CoV-2-positive in preparation for surgery, but doing so could exacerbate shortages of personal protective equipment and staffing limitations. Uncertainty regarding the etiology of postoperative fever could be significantly reduced by universal SARS-CoV-2 testing of all surgical patients at the time of hospital admission in addition to routine screening, but testing capacity and a rapid turnaround time would be required.

Fatal Infection with Murray Valley Encephalitis Virus Imported from Australia to Canada, 2011.

Murray Valley encephalitis virus (MVEV), a flavivirus belonging to the Japanese encephalitis serogroup, can cause severe clinical manifestations in humans. We report a fatal case of MVEV infection in a young woman who returned from Australia to Canada. The differential diagnosis for travel-associated encephalitis should include MVEV, particularly during outbreak years.

Beyond Columnar Organization: Cell Type- and Target Layer-Specific Principles of Horizontal Axon Projection Patterns in Rat Vibrissal Cortex.

Vertical thalamocortical afferents give rise to the elementary functional units of sensory cortex, cortical columns. Principles that underlie communication between columns remain however unknown. Here we unravel these by reconstructing in vivo-labeled neurons from all excitatory cell types in the vibrissal part of rat primary somatosensory cortex (vS1). Integrating the morphologies into an exact 3D model of vS1 revealed that the majority of intracortical (IC) axons project far beyond the borders of the principal column. We defined the corresponding innervation volume as the IC-unit. Deconstructing this structural cortical unit into its cell type-specific components, we found asymmetric projections that innervate columns of either the same whisker row or arc, and which subdivide vS1 into 2 orthogonal [supra-]granular and infragranular strata. We show that such organization could be most effective for encoding multi whisker inputs. Communication between columns is thus organized by multiple highly specific horizontal projection patterns, rendering IC-units as the primary structural entities for processing complex sensory stimuli.

Neurocomputational mechanisms underlying perception and sentience in the neocortex.

The basis for computation in the brain is the quantum threshold of "soliton," which accompanies the ion changes of the action potential, and the refractory membrane at convergences. Here, we provide a logical explanation from the action potential to a neuronal model of the coding and computation of the retina. We also explain how the visual cortex operates through quantum-phase processing. In the small-world network, parallel frequencies collide into definable patterns of distinct objects. Elsewhere, we have shown how many sensory cells are meanly sampled from a single neuron and that convergences of neurons are common. We also demonstrate, using the threshold and refractory period of a quantum-phase pulse, that action potentials diffract across a neural network due to the annulment of parallel collisions in the phase ternary computation (PTC). Thus, PTC applied to neuron convergences results in a collective mean sampled frequency and is the only mathematical solution within the constraints of the brain neural networks (BNN). In the retina and other sensory areas, we discuss how this information is initially coded and then understood in terms of network abstracts within the lateral geniculate nucleus (LGN) and visual cortex. First, by defining neural patterning within a neural network, and then in terms of contextual networks, we demonstrate that the output of frequencies from the visual cortex contains information amounting to abstract representations of objects in increasing detail. We show that nerve tracts from the LGN provide time synchronization to the neocortex (defined as the location of the combination of connections of the visual cortex, motor cortex, auditory cortex, etc.). The full image is therefore combined in the neocortex with other sensory modalities so that it receives information about the object from the eye and all the abstracts that make up the object. Spatial patterns in the visual cortex are formed from individual patterns illuminating the retina, and memory is encoded by reverberatory loops of computational action potentials (CAPs). We demonstrate that a similar process of PTC may take place in the cochlea and associated ganglia, as well as ascending information from the spinal cord, and that this function should be considered universal where convergences of neurons occur.

Incidence and Risk Factors for Bone Stress Injuries in United States Air Force Special Warfare Trainees.

OBJECTIVES: To determine (1) the incidence rate of lower extremity (LE) bone stress injuries (BSIs) in United States Air Force Special Warfare (AFSPECWAR) trainees during the first 120 days of training, and (2) factors associated with sustaining a LE BSI. DESIGN: Retrospective cohort study. METHODS: AFSPECWAR Airmen (n = 2,290, mean age = 23.7 ± 3.6 years) entering an intensive 8-week preparatory course "SW-Prep" between October 2017 and May 2021. We compared anthropometric measurements, previous musculoskeletal injury (MSKI), fitness measures, and prior high-impact sports participation in those that did and did not suffer a BSI during the 120-day observation period using independent t-tests and chi-square tests. A multivariable binary logistic regression was used to determine factors associated with suffering a BSI. RESULTS: A total of 124 AFSPECWAR trainees suffered a BSI during the surveillance period, yielding an incidence proportion of 5.41% and an incidence rate of 1.4 BSIs per 100 person-months. The multivariate logistic regression revealed that lower 2-minute sit-up scores, no prior history of participation in a high-impact high-school sport, and a history of prior LE MSKI were associated with suffering a BSI. A receiver operator characteristic curve analysis yielded an area under the curve (AUC) of 0.727. CONCLUSION: BSI incidence proportion for our sample was similar to those seen in other military settings. Military trainees without a history of high-impact sports participation who achieve lower scores on sit-ups tests and have a history of LE MSKI have a higher risk for developing a LE BSI during the first 120 days of AFSPECWAR training.

Impact of an Integrated Human Performance Support Group: Evaluation of Air Force Special Warfare Candidate Training and Musculoskeletal Injury Outcomes Over Eight Fiscal Years.

INTRODUCTION: The Special Warfare Training Wing and Special Warfare Human Performance Support Group (HPSG; all-co-authors) were established in fiscal year (FY) 2019 to consolidate and oversee all Air Force Special Warfare (AFSPECWAR) training and provide embedded medical and human performance support to candidates with the goal of improving graduation rates and the longevity of the AFSPECWAR operator. The purpose of this manuscript is to assess the impact of the HPSG on AFSPECWAR graduation rates, musculoskeletal injury (MSKI) incidence, and cost. MATERIALS AND METHODS: Graduation rates, MSKI incidence (including incidence density and cumulative incidence probability), and MSKI-related health care costs were assessed across all AFSPECWAR training pipelines spanning 8 FYs 2015-22, including Indoctrination, Assessment, and Selection Courses (Selection); Tactical Air Control Party (TACP); Special Tactics (ST), and Guardian Angel (GA). RESULTS: A total of 5,728 distinct candidates were assessed over the time frame. There were significant decreases in attrition when comparing the HPSG era (FY 19-22) with the prior 4-year period for the ST (47% vs. 82% graduates) and TACP (34% vs. 41% graduates) training pipelines. The corresponding Selection (36% graduates) and GA (80% graduates) pipeline attrition rates remained stable. MSKI incidence rates (both incidence density and cumulative incidence probability) overall were not significantly different when comparing the pre-HPSG and HPSG time frames; however, they varied between the two time frames by course. GA candidates had a decrease in MSKI during the apprentice course in the HPSG era compared with the pre-HPSG era (2.4-1.0 cases per 100 trainee weeks; P < .001), which corresponds to a nearly 20% reduction in the cumulative incidence probability (i.e., proportion of trainees injured) after 10 weeks of course. For ST and TACP courses, however, significantly increased incidence of MSKI was observed when comparing the two time frames (P < .001), while for Selection courses, the rates remained stable. A significant reduction in the cost of MSKI-related management (62% total relative value units, 83% total costs) was observed. CONCLUSION: The impact of the HPSG on attrition, MSKI incidence, and cost-of-care was not consistent across all training pipelines; however, taken together, there were no increases in attrition, and the cost of MSKI management was significantly lower.

Terlipressin with limited fluid resuscitation in a swine model of hemorrhage.

BACKGROUND: Principles of damage control resuscitation include minimizing intravenous fluid (IVF) administration while correcting perfusion pressure as quickly as possible. Recent studies have identified a potential advantage of vasopressin over catecholamines in traumatic shock. Terlipressin (TP) is a vasopressin analogue used to reverse certain shock etiologies in some European countries. STUDY OBJECTIVE: We evaluated three dosages of TP when combined with a limited colloid resuscitation strategy on mean arterial pressure (MAP) and lactatemia in a swine model of isolated hemorrhage. METHODS: Sixty anesthetized swine underwent intubation and severe hemorrhage. Subjects were randomized to one of four resuscitation groups: 4 mL/kg Hextend(®) (Hospira Inc, Lake Forest, IL) only, 3.75 µg/kg TP + Hextend, 7.5 µg/kg TP + Hextend, or 15 µg/kg TP + Hextend. MAP and heart rate were recorded every 5 min. Baseline and serial lactate values at 30-min intervals were recorded and compared. RESULTS: Subjects receiving 7.5 µg/kg TP had significantly higher MAPs at times t15 (p = 0.012), t20 (p = 0.004), t25 (p = 0.018), t30 (p = 0.032), t35 (p = 0.030), and t40 (p = 0.021). No statistically significant differences in lactate values between TP groups and controls were observed. CONCLUSION: Subjects receiving 7.5 µg/kg of TP demonstrated improved MAP within 10 min of administration. When combined with minimal IVF resuscitation, TP doses between 3.75 and 15 µg/kg do not elevate lactate levels in hemorrhaged swine.

Comparison of ChitoFlex®, CELOX™, and QuikClot® in control of hemorrhage.

BACKGROUND: Exsanguinating extremity wounds remain the primary source of battlefield mortality. Operating forces employ three agents in Iraq: HemCon® (HemCon Medical Technologies, Inc., Portland, OR), QuikClot® (Z-Medica Corporation, Wallingford, CT), and CELOX™ (SAM Medical, Tualatin, OR). Anecdotal reports suggest that these agents are less useful on small entrance, linear-tract injuries. ChitoFlex® (HemCon Medical Technologies, Inc., Portland, OR) has been introduced but is untested. STUDY OBJECTIVES: To compare the equivalency of the ChitoFlex® dressing, QuikClot® ACS+™ dressing, CELOX™, and standard gauze in their effectiveness to control bleeding from non-cavitary groin wounds. METHODS: Forty-eight swine were randomly assigned to one of four treatment groups: standard gauze dressing (SD), ChitoFlex® dressing (CF), QuikClot® ACS+™ dressing (QC), and CELOX™ dressing (CX). A groin injury with limited vessel access was created in each animal. Subjects were resuscitated with 500 mL of hetastarch. The primary endpoint was 180-min survival. Secondary endpoints included total blood loss in mL/kg, incidence of re-bleeding, survival times among the animals that did not survive for 180 min, failure to achieve initial hemostasis, incidence of recurrent bleeding, time to initial re-bleeding, amount of re-bleeding, and mass of residual hematoma. RESULTS: Survival occurred in 10 of 12 SD animals, 10 of 12 CF animals, 10 of 12 QC animals, and 9 of 12 CX animals. No statistically significant difference was found. CONCLUSION: In our study of limited-access extremity bleeding, ChitoFlex® performed equally well in mitigating blood loss and promoting survival. The ChitoFlex® dressing is an equally effective alternative to currently available hemostatic agents. However, no agents were superior to standard gauze in our model of limited access.

Does the Brain Function as a Quantum Phase Computer Using Phase Ternary Computation?

Here we provide evidence that the fundamental basis of nervous communication is derived from a pressure pulse/soliton capable of computation with sufficient temporal precision to overcome any processing errors. Signalling and computing within the nervous system are complex and different phenomena. Action potentials are plastic and this makes the action potential peak an inappropriate fixed point for neural computation, but the action potential threshold is suitable for this purpose. Furthermore, neural models timed by spiking neurons operate below the rate necessary to overcome processing error. Using retinal processing as our example, we demonstrate that the contemporary theory of nerve conduction based on cable theory is inappropriate to account for the short computational time necessary for the full functioning of the retina and by implication the rest of the brain. Moreover, cable theory cannot be instrumental in the propagation of the action potential because at the activation-threshold there is insufficient charge at the activation site for successive ion channels to be electrostatically opened. Deconstruction of the brain neural network suggests that it is a member of a group of Quantum phase computers of which the Turing machine is the simplest: the brain is another based upon phase ternary computation. However, attempts to use Turing based mechanisms cannot resolve the coding of the retina or the computation of intelligence, as the technology of Turing based computers is fundamentally different. We demonstrate that that coding in the brain neural network is quantum based, where the quanta have a temporal variable and a phase-base variable enabling phase ternary computation as previously demonstrated in the retina.

Ovarian torsion in a three-year-old girl.

BACKGROUND: Ovarian torsion is the fifth most encountered gynecological emergency requiring surgery. Representing only 2.7% of surgical emergencies, it is an entity that is worth being familiar with in the emergency department (ED). OBJECTIVES: Untreated ovarian torsion may result in loss of ovarian function, tissue necrosis, and death from thromboembolism or sepsis. Presenting with vague symptoms and abdominal pain, diagnosing ovarian torsion can be difficult, especially in children. The objective of this article is to present a case of pediatric ovarian torsion and to review its epidemiology, diagnosis, and treatment. CASE REPORT: A 3-year-old girl presented to the ED with vomiting, fever, anorexia, and abdominal pain. Initially diagnosed with appendicitis by physical examination and computed tomography scan, this patient was taken to the operating room for surgical exploration. The patient was subsequently found to have ovarian torsion, which was treated appropriately. CONCLUSION: Although a rare phenomenon, this case serves to increase awareness of the clinical presentation of ovarian torsion in the pediatric patient. Abdominal pain in the female child represents a challenging differential diagnosis, for which a physician must consider ovarian torsion.

SARS-CoV-2 Bound Human Serum Albumin and Systemic Septic Shock.

The emergence of the COVID-19 virus and the subsequent pandemic have driven a great deal of research activity. The effects of COVID-19 are caused by the severe respiratory syndrome coronavirus 2 (SARS-CoV-2) and it is the underlying actions of SARs-CoV-2 virions on the endothelial glycocalyx that we consider here. One of the key factors in COVID-19 infection is its almost unique age-related profile, with a doubling in mortality every 10 years after the age of 50. The endothelial glycocalyx layer is essential in maintaining normal fluid homeostasis, but is fragile and prone to pathophysiological damage. It is physiologically significant in capillary microcirculation and in fluid distribution to the tissues. Human serum albumin (HSA), the most abundant protein in plasma, is created in the liver which also maintains its concentration, but this reduces by 10-15% after 50 years of age. HSA transports hormones, free fatty acids and maintains oncotic pressure, but SARS-CoV-2 virions bind competitively to HSA diminishing its normal transport function. Furthermore, hypoalbuminemia is frequently observed in patients with such conditions as diabetes, hypertension, and chronic heart failure, i.e., those most vulnerable to SARS-CoV-2 infection. Hypoalbuminemia, coagulopathy, and vascular disease have been linked in COVID-19 and have been shown to predict outcome independent of age and morbidity. Hypoalbuminemia is also known factor in sepsis and Acute respiratory distress syndrome (ARDS) occurs when fluids build-up in the alveoli and it is associated with sepsis, whose mechanism is systemic, being associated with the fluid and logistic mechanisms of the circulation. Glycocalyx damage is associated with changes plasma protein concentration, particularly HSA and blockage of albumin transport can produce the systemic symptoms seen in SARS-CoV-2 infection and sepsis. We therefore conclude that albumin binding to SARS-CoV-2 virions may inhibit the formation of the endothelial glycocalyx by inhibition of albumin transport binding sites. We postulate that albumin therapy to replace bound albumin might alleviate some of the symptoms leading to sepsis and that clinical trials to test this postulation should be initiated as a matter of urgency.

The Soliton and the Action Potential - Primary Elements Underlying Sentience.

At present the neurological basis of sentience is poorly understood and this problem is exacerbated by only a partial knowledge of how one of the primary elements of sentience, the action potential, actually works. This has consequences for our understanding of how communication within the brain and in artificial brain neural networks (BNNs). Reverse engineering models of brain activity assume processing works like a conventional binary computer and neglects speed of cognition, latencies, error in nerve conduction and the true dynamic structure of neural networks in the brain. Any model of nerve conduction that claims inspiration from nature must include these prerequisite parameters, but current western computer modeling of artificial BNNs assumes that the action potential is binary and binary mathematics has been assumed by force of popular acceptance to mediate computation in the brain. Here we present evidence that the action potential is a temporal compound ternary structure, described as the computational action potential (CAP). The CAP contains the refractory period, an analog third phase capable of phase-ternary computation via colliding action potentials. This would best fit a realistic BNN and provides a plausible mechanism to explain transmission, in preference to Cable Theory. The action potential pulse (APPulse), is made up of the action potential combined with a coupled synchronized soliton pressure pulse in the cell membrane. We describe a model of an ion channel in a membrane where a soliton deforms the channel sufficiently to destroy the electrostatic insulation thereby instigating a mechanical contraction across the membrane by electrostatic forces. Such a contraction has the effect of redistributing the force lengthways thereby increasing the volume of the ion channel in the membrane. Na ions, once attracted to the interior, balance the forces and the channel reforms to its original shape. A refractory period then occurs until the Na ions diffuse from the adjacent interior space. Finally, a computational model of the action potential (the CAP) is proposed with single action potentials significantly including the refractory period as a computational element capable of computation between colliding action potentials.

Expression of cutaneous lymphocyte-associated antigen by CD8(+) T cells specific for a skin-tropic virus.

Virus-specific CD8(+) T cells traffic to infected tissues to promote clearance of infection. We used herpes simplex virus type 2 (HSV-2) as a model system to investigate CD8(+) T cell trafficking to the skin in humans. Using human leukocyte antigen (HLA) class I tetramers, we observed that HSV-specific CD8(+) T cells in the peripheral blood expressed high levels of cutaneous lymphocyte-associated antigen (CLA). In contrast, CD8(+) T cells specific for non-skin-tropic herpesviruses lacked CLA expression. CLA-positive HSV-2-specific CD8(+) T cells had the characteristics of central memory cells, expressing CCR7, CD62L, and CD28, and they proliferated briskly in response to antigen. CLA is related to a functional E-selectin ligand, and both E-selectin and CLA-positive cells were detected in HSV-2-infected skin. HSV-2-specific T cells adhered to cells transfected with E-selectin. A higher proportion of HSV-specific CD8(+) T cells recovered from herpes lesions express CLA compared with blood, consistent with a role for CLA in skin homing. To our knowledge, this is the first report of expression of tissue-specific adhesion-associated molecules by virus-specific CD8(+) T cells. The evaluation of vaccines for skin and mucosal pathogens should include study of the induction of appropriate tissue-specific homing molecules.

Pneumococcal bacteremia in febrile infants presenting to the emergency department before and after the introduction of the heptavalent pneumococcal vaccine.

STUDY OBJECTIVE: Fever is among the most common presenting complaints of infants and children younger than 3 years who present to the emergency department (ED). The evaluation and management of the febrile child is evolving rapidly. We compare the proportion of pneumococcal bacteremia between febrile infants and children younger than 3 years who had and had not received the heptavalent pneumococcal vaccine and who had received blood culture tests in our ED. METHODS: We performed a non-concurrent prospective observational cohort study, with a standardized medical record review to collect data of patients treated in the ED of a tertiary care military hospital during 24 months. Patients were eligible if they were younger than 36 months and had a temperature greater than or equal to 100.4 degrees F (38 degrees C). A data collection sheet was used to abstract age, temperature, and whether CBC count and blood cultures were obtained. Heptavalent pneumococcal vaccine status and blood culture results were obtained through review of the computerized medical record. Descriptive analysis was used for comparing the 2 groups. Group size analysis was based on the prevalence of occult bacteremia caused by Pneumococcus before the introduction of heptavalent pneumococcal vaccine. Interobserver variation was assessed by independent review of 10% of abstracted records. The main outcome measure was the proportion of positive pneumococcal blood cultures in infants and children younger than 3 years who had received at least 1 vaccination of heptavalent pneumococcal vaccine versus those who had not. RESULTS: Three thousand five hundred seventy-one patients met entry criteria; 1,428 had blood cultures obtained, and 833 of them received at least 1 immunization of heptavalent pneumococcal vaccine. All groups were similar in age, sex, and temperature. Positive blood culture results, including probable contaminants, were obtained for 4.2% (58/1,383) of the patients. In the heptavalent pneumococcal vaccine group, there were 0 of 833 (0%) positive pneumococcal blood cultures compared with 13 of 550 (2.4%) in the unimmunized group (P<.001; 95% confidence interval 1.4% to 3.3%). CONCLUSION: Pneumococcal bacteremia was found to be lower in our patients who had received the heptavalent pneumococcal vaccine than in the patients who had not.

Relationships between structure, in vivo function and long-range axonal target of cortical pyramidal tract neurons.

Pyramidal tract neurons (PTs) represent the major output cell type of the neocortex. To investigate principles of how the results of cortical processing are broadcasted to different downstream targets thus requires experimental approaches, which provide access to the in vivo electrophysiology of PTs, whose subcortical target regions are identified. On the example of rat barrel cortex (vS1), we illustrate that retrograde tracer injections into multiple subcortical structures allow identifying the long-range axonal targets of individual in vivo recorded PTs. Here we report that soma depth and dendritic path lengths within each cortical layer of vS1, as well as spiking patterns during both periods of ongoing activity and during sensory stimulation, reflect the respective subcortical target regions of PTs. We show that these cellular properties result in a structure-function parameter space that allows predicting a PT's subcortical target region, without the need to inject multiple retrograde tracers.The major output cell type of the neocortex - pyramidal tract neurons (PTs) - send axonal projections to various subcortical areas. Here the authors combined in vivo recordings, retrograde tracings, and reconstructions of PTs in rat somatosensory cortex to show that PT structure and activity can predict specific subcortical targets.

Treatment of suspected symptomatic cholelithiasis with glycopyrrolate: a prospective, randomized clinical trial.

STUDY OBJECTIVE: Glycopyrrolate is advocated for the treatment of acute pain from suspected symptomatic cholelithiasis. However, there is no clinical evidence to substantiate its use. This study is designed to evaluate the efficacy of glycopyrrolate in relieving acute abdominal pain of suspected biliary tract origin. METHODS: Between July 2002 and April 2003, a convenience sample of patients presenting to the emergency department with upper abdominal pain of suspected biliary tract origin was randomized to receive either intravenous glycopyrrolate or placebo (normal saline solution). Pain level was assessed at baseline using a visual analog scale, with a repeat assessment 20 minutes after intervention. Patients and clinicians were blinded to the study drug. RESULTS: Because of difficulty with patient enrollment, the trial was terminated before achievement of the initial goal of 54 patients. On analysis of the 38 patients completing the study protocol, glycopyrrolate and placebo groups had similar demographic and baseline characteristics. There was no significant difference in pain relief between patients receiving glycopyrrolate and those receiving placebo (median decrease in visual analog pain scale pain 3 mm [95% confidence interval -2 to 17 mm] versus 8 mm [95% confidence interval -2 to 20 mm], respectively). CONCLUSION: Although limited by small size and convenience sampling, these results fail to demonstrate any improvement in pain of suspected biliary tract origin with the administration of glycopyrrolate. Further study is needed to determine whether intravenous glycopyrrolate has any significant analgesic effect for patients with this condition.

Revolutionary changes in medicine and ophthalmology--the St. Louis, MO, effect: Homer G. Phillips Hospital and Dr. Howard Phillip venable.

PURPOSE: To provide information on the revolutionary changes in medicine, particularly on the development of African-Americans in ophthalmology, created by Homer G. Phillips Hospital in St. Louis and the late Dr. Howard Phillip Venable. METHODS: Very little has been written about Homer G. Phillips Hospital and Dr. H. Phillip Venable. Through personal interviews with physicians trained by Dr. Venable and literature review, I was able to obtain information on Homer G. Phillips Hospital and Dr. Venable's influence in breaking the color line in medicine and ophthalmology. RESULTS: Homer G. Phillips Hospital in St. Louis was a major teaching hospital for African-American doctors. Dr. Venable was one of a few African-American ophthalmologists in the 1940s. Dr. Venable then trained approximately 40 African-American ophthalmologists at Homer G. Phillips Hospital between 1943 to 1979, when the hospital closed. CONCLUSION: The ophthalmologists trained by Dr. Venable have gone forward to treat thousands of patients with blinding eye diseases such as glaucoma and diabetes, and to influence others to become ophthalmologists. Although the hospital has closed and Dr. Venable has passed away, their existence has reformed the medical treatment received by African-Americans and other people.

Invasive fungal disease in systemic lupus erythematosus: a systematic review of disease characteristics, risk factors, and prognosis.

OBJECTIVES: Invasive fungal disease (IFD) is a life-threatening complication of systemic lupus erythematosus (SLE) and/or its treatment. We conducted a systematic review to characterize IFD in SLE and identify risk factors and outcomes. METHODS: MEDLINE, Embase, and Web of Science were searched up to June 2013 using MeSH terms and keywords pertaining to SLE and IFD. Two independent reviewers selected adult cohort studies and case series/reports on IFD in SLE based on the established classification criteria for both diseases. RESULTS: In total, 393 cases from 182 studies met the criteria for inclusion. Cryptococcus spp., Aspergillus spp., and Candida spp. were the most common fungal pathogens. Cohorts described IFD in 0.6-3.2% of SLE inpatients and 0.28% of SLE outpatients. IFD occurred at a median of 2 years of disease duration (IQR: 0.5-7.1), and 39% of cases occurred within the first year of SLE. Disease activity and corticosteroid dose >60mg/day emerged as risk factors for IFD. IFD was associated with a mortality rate of 53% (161/316 cases), and worse in the absence of antifungal therapy (n = 43). Overall, 44 cases of IFD were only diagnosed on autopsy. CONCLUSIONS: Our systematic review confirms the severe sequelae of IFD in SLE. Cases occurred in patients with active SLE, who were on high daily corticosteroids doses and at early stages of disease. This highlights the role of poor disease control and a high "net state of immunosuppression" in risk. IFD in SLE should be prospectively examined in the modern era.

Development of a ballistic model of combat groin injury.

BACKGROUND: The current leading cause of death to troops in Operations Enduring Freedom results from improvised explosive devices. The need for accurate models of combat trauma in research is an ever present challenge and crucial to our efforts to save the lives of our injured troops. Current swine models of groin injury use a scalpel to create the wound, which provides for a controlled environment but limits the resemblance to real combat injuries. We sought to develop a reliable ballistic model of fragmentation injury that will allow for new research and training opportunities in the field of combat casualty care. METHODS: A jet remote opening device was developed to inflict a fragmentation injury to the groin of 20 anesthetized swine. Laser positioning ensured alignment. After hemorrhage, subjects were treated with standard resuscitative measures and monitored for 180 minutes to determine survival. RESULTS: Subject survival was 95% at 3 minutes postinjury and 75% at 180 minutes. Survival rates were similar to actual survival data collected from Operations Enduring Freedom (p = 0.993). Blood loss during initial hemorrhage averaged 15.4 (±6.0) mL/kg. No instances of peritoneal violation by the shrapnel fragments were revealed on necropsy. CONCLUSIONS: We developed a ballistic mechanism of injury in a model that replicates improvised explosive device-created wounds. The injury was reliably reproduced in each subject, with survival rates equating those of real casualties. We think that this model represents a true effectiveness model of injury that opens the doors for advanced research endeavors in combat casualty care.