Improving the diagnostic yield of echocardiography in acute ischemic stroke: A quality improvement project in a community hospital in Maryland, USA.

Background: Echocardiography is routinely ordered in acute ischemic stroke workup. No standardized or structured criteria is used to select or exclude echocardiography in such settings. Moreover, the diagnostic yield of echocardiography in stroke is low in our medical center. This article presents newly proposed selection criteria for echocardiography in ischemic stroke workup. Methods: A quality improvement project was implemented in a 385-bed community hospital in Maryland, USA. A computerized decision support tool consisting of new criteria for selecting echocardiography in ischemic stroke workup was created. 639 patients hospitalized with ischemic stroke were followed-up over 12 months after intervention, and 686 matched-controls with ischemic stroke were retrospectively analyzed from the 12 months prior to intervention. Cost-effectiveness and diagnostic yield of echocardiography in ischemic stroke were measured before and after intervention. Results: Following intervention, the diagnostic yield of echocardiography in ischemic stroke workup significantly increased by 51% (from 3.8% to 7.8%, odds ratio (OR) 2.1, P= 0.01). The number of echocardiography studies needed to detect and treat one patient with a cardiac source of embolism was reduced from 50 to 25 studies. The overall use of echocardiography in stroke workup significantly decreased (OR 0.4, p < 0.001). Patients with lacunar infarcts or atrial fibrillation had significant reduction in echocardiography (OR 0.2, p < 0.001 and OR 0.4, p < 0.001, respectively). Conclusion: The new criteria for echocardiography selection in hospitalized patients with ischemic stroke significantly improved the cost-effectiveness and the diagnostic yield of echocardiography and reduced unnecessary echocardiography in lacunar infarcts or atrial fibrillation.

Successful use of montelukast in eosinophilic gastroenteritis: a case report and a literature review.

BACKGROUND: Eosinophilic gastrointestinal disorders, also known as eosinophilic gastroenteritis, are rare inflammatory conditions characterized by eosinophilic infiltration of different parts of the gastrointestinal tract, along with peripheral eosinophilia in most cases. Other known causes for gut eosinophilic infiltration must be excluded to confirm the diagnosis of eosinophilic gastroenteritis. Symptoms of the disorder depend on the affected gastrointestinal tract segment and depth of involvement. Treatment includes systemic glucocorticoids and/or dietary therapy with an empiric elimination diet. Second line therapies include the leukotriene receptor antagonist montelukast, and other anti-allergy drugs such as mast cell stabilizers (including cromolyn and the H1-antihistamine ketotifen), suplatast tosilate which is a selective Th-2 cytokines (IL-4 and IL-5) inhibitor, and the monoclonal anti-IgE antibody omalizumab. We report a case of eosinophilic gastroenteritis who was successfully treated and achieved remission with montelukast as an initial monotherapy. Upon extensive literature review, this represents the second reported adult case of eosinophilic gastroenteritis who responds to montelukast alone as a first line therapy. CASE PRESENTATION: A 49-year-old female presented with recurrent abdominal pain, vomiting, diarrhea and unexplained eosinophilia. She was diagnosed with eosinophilic gastroenteritis and was successfully treated with montelukast monotherapy. After 7 days of therapy, the patient responded well and had complete resolution of her gastrointestinal symptoms and peripheral eosinophilia. Patient remained in remission on follow-up after 12 months. We reviewed the literature for leukotriene antagonist use in the treatment of eosinophilic gastroenteritis and included the cases treated with the leukotriene antagonist montelukast as an initial therapy or as a second line therapy for refractory disease. CONCLUSION: Montelukast may be an effective treatment for eosinophilic gastroenteritis, either alone or in combination with systemic steroids or ketotifen. Our patient is the second reported adult case of eosinophilic gastroenteritis who responded to montelukast alone as a first line therapy. Further studies and clinical trials are required to confirm efficacy compared to standard therapy.

Serotyping of dengue virus in 2016-17 outbreak in Kudat, Sabah, Malaysia.

An outbreak of dengue in Kudat, northern Sabah in 2016-2017 provided an opportunity to investigate the circulating serotypes of dengue viruses of cases at Hospital Kudat. Between September 2016 and December 2017, a total of 156 dengue positive sera (tested positive by either NS1 antigen, or IgM and IgG antibody rapid test) were collected from dengue patients who had acute fever and showed signs and symptoms suggestive of dengue. RNA was extracted from the sera using QIAamp RNA Blood Mini Kit, and molecular amplification was performed using one-step RT-PCR kit, followed by nested PCR using HotStart Taq master mix kit with the primers of the dengue C-prM gene. There were 81 (52%) male and 75 (48%) female cases. The age group with the highest number of cases was the 10-19 years old, while the youngest infected was 8 months old and the oldest was 83 years old. RT-PCR results showed 88 sera dengue positive, 48 infected with a single serotype while another 40 with multiple serotypes. All four DENV serotypes were co-circulating during the outbreak period and DENV-1 was predominant. Molecular analysis also indicated 69.2%, 50.0%, 51.9% and 48.9% respectively of the NS1, IgM, IgG and IgM and IgG positive sera were RT-PCR positive for dengue. High number of cases were seen in December 2016, February and May 2017. The dengue outbreak might be related to switching of predominant serotype from DENV 4 to DENV 1.

Serotyping of dengue virus in 2016-17 outbreak in Kudat, Sabah, Malaysia

@# An outbreak of dengue in Kudat, northern Sabah in 2016-2017 provided an opportunity to investigate the circulating serotypes of dengue viruses of cases at Hospital Kudat. Between September 2016 and December 2017, a total of 156 dengue positive sera (tested positive by either NS1 antigen, or IgM & IgG antibody rapid test) were collected from dengue patients who had acute fever and showed signs and symptoms suggestive of dengue. RNA was extracted from the sera using QIAamp RNA Blood Mini Kit, and molecular amplification was performed using one-step RT-PCR kit, followed by nested PCR using HotStart Taq master mix kit with the primers of the dengue C-prM gene. There were 81 (52%) male and 75 (48%) female cases. The age group with the highest number of cases was the 10-19 years old, while the youngest infected was 8 months old and the oldest was 83 years old. RT-PCR results showed 88 sera dengue positive, 48 infected with a single serotype while another 40 with multiple serotypes. All four DENV serotypes were co-circulating during the outbreak period and DENV-1 was predominant. Molecular analysis also indicated 69.2%, 50.0%, 51.9% and 48.9% respectively of the NS1, IgM, IgG and IgM & IgG positive sera were RT-PCR positive for dengue. High number of cases were seen in December 2016, February and May 2017. The dengue outbreak might be related to switching of predominant serotype from DENV 4 to DENV 1.

Single-layer Closure with Tongue Flap for Palatal Fistula in Cleft Palate Patients.

BACKGROUND: Tongue flap is a good option to close a complicated palatal fistula in cleft patients. Most surgeons advocate a double-layer closure to decrease the recurrence rates. In this study, we have reported our experience with a modified single-layer closure with tongue flap in cleft patients. METHOD: All cases done by a single surgeon using this modified technique in a period of 10 years were retrospectively reviewed. A thorough description of this technique is also provided in the study. RESULTS: Only 5 cases were operated on using this technique. The success rate of all these cases was 100%, with no recurrence of fistula and few complications. CONCLUSIONS: This technique provides a way to avoid nasal layer closure in cases where nasal layer is difficult or impossible to close. It also limits the need for a second flap for nasal layer closure.

No-touch, Single-move Technique to Reverse the Needle While Suturing.

The aim of the study is to promote the "no-touch" surgical technique while suturing and to describe an easy way to reverse the needle while suturing. We have provided a step-by-step description of how to handle a needle while suturing using the no-touch technique. We have also provided figures for each step. The described technique is an easy, single-move, no-touch technique to reverse the needle.

Epidemiology of infant burn in Eastern Saudi Arabia.

OBJECTIVES: To identify the epidemiology, pattern, outcome, and impact of infant burns in Eastern Saudi Arabia. METHODS: We conducted a retrospective review of admitted infants charts over 4 years (2008-2013) at the Burn Unit of King Fahad Hospital, Hofuf, Al-Ahsa, Saudi Arabia. The charts were reviewed for age, gender, etiology, site of injury, total body surface area (TBSA), depth of burn, hospital stay, and discharge status. RESULTS: The total number of admissions to the Burn Unit was 510 cases. Out of these cases, 84 were infants, constituting 16.5% of total admissions. Scald burn was the most common etiology affecting 73 infants (86.9%). The highest percentage of total body surface area was between 5-10%, which occurred in 41 infants (48.8%). The average hospital stay was 10 days. No infant mortality was reported during this period. CONCLUSION: The prevalence of burns among infants in our hospital is high, and preventive measures must be implemented to decrease the occurrence of burns in this age group.

Fluctuation of pain by weather change in musculoskeletal disorders.

In order to find out the fluctuation of pain by weather change, a descriptive cross-sectional study was conducted among 138 individuals having musculoskeletal disorders (MSDs) attending the out patient department (OPD) of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University (BSMMU) Hospital, Dhaka, during March 2004 to June 2004. Data were collected by face to face interview employing a pre-tested interview schedule containing structured questions. Among 138 respondents, male were predominant (52.2%). Mean age of the respondents was 39.42±10.79 years, while the most common age group was found as '31 to 40 years'. By occupation, majority were housewives (40.58%), followed by businessmen (29.71%), service holder (15.22%), laborer (7.97%), and students (6.52%). The primary sites of pain were back and low back (38.4%), knee (24.6%), leg (8.7%), ankle and heel (8.0%), hand and wrist (6.5%), neck (5.8%), shoulder (5.8%), and elbow (2.2%). Highest number (47.8%) patients reported aching pain, while one fifth (20.3%) of them experienced burning pain. About 36.2 percent respondents mentioned 'prolonged standing' as the main cause of pain aggravation, while almost half (48.6%) of the patients perceived that 'application of heat' was the key relieving factor of their pain. About two third (63%) of the respondents were sensitive to weather change; among them 56.3 percent reported that their pain increased during cold weather. Moreover, more than two third (67.4%) study-patients experienced deterioration of pain due to seasonal variation; of them 59.1 percent reported that their pain was exacerbated in winter season. Of all respondents, less than one third (30.4%) experienced aggravation of pain due to lunar change; of them majority (85.7%) experienced increased pain during dark fortnights. Our study concluded that weather change might have an important role in fluctuation of pain among individuals having musculoskeletal disorders.

Quantitation of the critically ischemic zone at risk during acute coronary occlusion using PET.

Critical myocardial ischemia has been defined experimentally during acute coronary occlusion as flow reduction of 50% or more since cellular ATP depletion begins to occur beyond this flow reduction threshold, placing tissue at risk of cellular injury. To test the hypothesis that critically ischemic fractional left ventricular mass can be measured noninvasively with PET, nine dogs were imaged in a multi-slice positron camera using the perfusion tracer 13N-ammonia, while radiolabeled microspheres were injected into the left atrium during acute coronary occlusion. Images were processed using a 50% threshold and the size of the resulting perfusion defect was expressed as a fraction of total left ventricular image volume. The critically ischemic left ventricular fraction determined in vitro from the microsphere perfusion data, ranged from 5% to 30% of the total left ventricular weight and correlated closely with that determined noninvasively by PET with r = 0.94 (y = 1.05X - 2.0%). We conclude that the fraction of left ventricular myocardium rendered critically ischemic during acute coronary occlusion can be measured accurately and noninvasively in vivo using perfusion imaging with positron emission tomography.

Synthesis and in vitro receptor binding studies of fluorotamoxifen analogues.

We describe the synthesis of new fluorotamoxifen analogues with the fluorine atom positioned on the end of the aliphatic chain of tamoxifen. The binding of fluorotamoxifens to cytosol estrogen receptors of rat uteri was determined with [3H]estradiol (5 nM). The fluorotamoxifens had similar or superior binding affinities compared with tamoxifen. The IC50 value was as follows: tamoxifen, 5 x 10(-7) M; fluorotamoxifen (VII), 5 x 10(-7) M; N,N-diethylfluorotamoxifen (IV)-cis, 1 x 10(-6) M, and trans, 2 x 10(-7) M; and (cis) fluoromethyl-N,N-diethyltamoxifen (VI) 1 x 10(-7) M. Therefore, the fluorinated tamoxifens have potential use in imaging estrogen receptors by PET.

Induction of nitrate transport in maize roots, and kinetics of influx, measured with nitrogen-13.

Unlike phosphate or potassium transport, uptake of nitrate by roots is induced, in part, by contact with the substrate ion. Plasmalemma influx of (13)N-labeled nitrate in maize roots was studied in relation to induction of the uptake system, and the influence of short-term N starvation. Maize (Zea mays) roots not previously exposed to nitrate had a constitutive transport system (state 1), but influx increased 250% during six hours of contact with 100 micromolar nitrate, by which time the transport mechanism appeared to be fully synthesized (state 2). A three-day period of N starvation prior to induction and measurement of nitrate influx resulted in a greater capacity to transport nitrate than in unstarved controls, but this was fully expressed only if roots were kept in contact with nitrate for the six hours needed for full induction (state 2E). A kinetic analysis indicated a 160% increase in maximum influx in N-starved, induced roots with a small decrease in K(m). The inducible component to nitrate influx was induced only by contact with nitrate. Full expression of the nitrate inducible transport system was dependent upon mRNA synthesis. An inhibitor of cytoplasmic protein synthesis (cycloheximide) eliminated the formation of the transport system while inhibition by chloramphenicol of mitochondrial- or plastid-coded protein synthesis had no effect. Poisoning of membrane-bound proteins effectively disabled both the constitutive and induced transport systems.

Cerebral metabolic effects of a verbal fluency test: a PET scan study.

Sixteen normal volunteers were studied with [F-18] fluorodeoxyglucose and positron emission tomography scans during behavioral activation with a verbal fluency test, and 35 age-matched controls were studied with resting-state scans. There was an overall increase of the cerebral glucose metabolic rate of 23.3% during verbal fluency activation, compared to the resting state, with the greatest activation in bilateral temporal and frontal lobes. A negative correlation between test performance scores and indices of metabolism was found in frontal, temporal, and parietal regions. Damage to the left frontal lobe maximally affects scores on verbal fluency tests, but performing the test activates a network of regions, of which the left frontal lobe is only one. Proficient performance in verbal fluency seems to require less metabolic activation than poor performance, perhaps because of the efficiency of cognitive strategies employed.

Preparation of [11C]carbon dioxide from [11C]cyanide.

[11C]Carbon dioxide was prepared from [11C]cyanide. First, [11C]CH4 was produced by the (p, alpha) reaction on a N2/H2 mixture and was converted to [11C]CN- by reaction with ammonia over platinum at 1273 K. The [11C]CN- was adsorbed on a cobalt(II, III) oxide/ceramic furnace material at room temperature and was subsequently converted to [11C]CO2 by heating the cobalt(II, III) oxide to 948 K over a 10 min period and collecting the [11C]CO2 in a trap at 77 K. Specific activities as high as 600 mCi/mumol at end of bombardment (EOB) were obtained in a 15 microA irradiation for 10 min.

Synthesis of nitrogen-13 labeled alkylamines via amination of organoboranes.

Organoboranes react with nitrogen-13 labeled ammonia to produce alkylamines in moderate yield. When 13N labeled ammonia was bubbled into a tetrahydrofuran solution containing 0.5M tridecylborane, 1-[13N]aminodecane was formed in 25-30 min from the end of bombardment (EOB) in 40-60% overall yield. 1-[13N]aminooctane and 1-[13N]aminohexane were also synthesized from appropriate organoboranes in similar yield.

Carbon-11 labeled dialkylketones: synthesis of 9-[11C]heptadecan-9-one.

9-[11C]heptadecan-9-one was synthesized from di-n-octylthexylborane via cyanidation with K11CN. The rearrangement of the organoborane intermediate followed by alkaline oxidation produced the title compound in 55-60 min from the end of bombardment (EOB) in 50-70% overall yield. The reaction sequence is applicable for the synthesis of various dialkyl ketones.

Synthesis and identification of [76As]arsenic trichloride.

Radiosynthesis of arsenic trichloride (AsCl3) was achieved using 76As as the radionuclide of choice for preliminary investigations. The synthesis required neutron activation of arsenic trioxide (As2O3) followed by reaction with sulfur monochloride (S2Cl2) under a dry inert atmosphere. The synthesized 76AsCl3 was purified by distillation or partially purified by treatment with dry acetonitrile followed by filtration. Identification was accomplished by thin layer chromatography (TLC) and reversed phase high performance liquid chromatography (HPLC). 76AsCl3 was used for synthesis of a dihydrophenarsazine derivative.

Use of 11C as a tracer for studying the synthesis of [11C]urea from [11C]cyanide.

The use of reversed-phase liquid chromatography and radiochemical detection with carbon-11 (t1/2 = 20.4 min) as a tracer allowed the study of the preparation of [11C]urea from [11C]cyanide at no-carrier-added concentrations. [11C]cyanate was readily prepared by permanganate oxidation of [11C]cyanide at 75 degrees C. The conversion of NH4O11CN (approximately 0.03 mM) to [11C]urea in the presence of excess ammonium ions (0.28 M) was found to best fit pseudo first order reaction kinetics with a rate constant of 0.065 +/- 0.008 min-1 at 75 degrees C. Heating at higher temperatures (180-200 degrees C) revealed that the conversion of NH4O11CN to [11C]urea occurred in high yield in less than 3 min. The hydrolysis of [11C]cyanate to [11C]carbonate, a possible side reaction, was found to proceed at a rate of 0.010 +/- 0.001 min-1 at 113 degrees C.