Refractory Shock from Amlodipine Overdose Overcomed with Hyperinsulinemia.

Intoxication from calcium channel blockers exhibits almost 50% mortality rates. Amlodipine is a long-acting dihydropyridine and inappropriate dosage poses a great threat for profound vasodilation, hypotension, and refractory vasopressor-resistant shock. A 72-year-old woman with unremarkable medical history presented to the emergency department due to amlodipine overdose after a suicide attempt attributed to COVID-19 pandemic severe anxiety disorder. Vital signs at presentation: heart rate 82 beats/ min, arterial pressure 72/55 mmHg, and oxygen saturation 98%. Resuscitation was initiated with intravenous infusion of normal saline 0,9%, noradrenaline, and calcium chloride, while activated charcoal was orally administrated; however, blood pressure remained at 70/45 mmHg. Abruptly, she experienced acute pulmonary edema and was finally intubated. We commenced high-dose insulin infusion with Dextrose 10% infusion to maintain euglycemic hyperinsulinemia. Hemodynamic improvement occurred after 30 min, systolic blood pressure raised to 95 mmHg, and decongestion was achieved with intravenous furosemide. Insulin effect was dose-dependent and patient's hemodynamic status improved after insulin uptitration. Eight days later, the patient was weaned from the mechanical ventilation and she was successfully discharged after 14 days. High-dose intravenous infusion of insulin up to 10 units/kg per hour appears as an inotropic agent possibly through alterations in myocardial metabolism of fatty acids and augmentation of insulin secretion and uptake. This regimen possibly exhibits additional vasotropic properties. We conclude that euglycemic hyperinsulinemia is a potentially advantageous treatment in CCB toxicity.

CMOS plasmonics in WDM data transmission: 200 Gb/s (8 × 25Gb/s) transmission over aluminum plasmonic waveguides.

We demonstrate wavelength-division-multiplexed (WDM) 200 Gb/s (8 × 25 Gb/s) data transmission over 100 µm long aluminum (Al) surface-plasmon-polariton (SPP) waveguides on a Si3N4 waveguide platform at telecom wavelengths. The Al SPP waveguide was evaluated in terms of signal integrity by performing bit-error-rate (BER) measurements that revealed error-free operation for all eight 25 Gb/s non-return-to-zero (NRZ) modulated data channels with power penalties not exceeding 0.2 dB at 10-9. To the best of our knowledge, this is the first demonstration of WDM enabled data transmission over complementary-metal-oxide-semiconductor (CMOS) SPP waveguides fueling future development of CMOS compatible plasmo-photonic devices for on-chip optical interconnections.

User's acceptability of OvuSense: a novel vaginal temperature sensor for prediction of the fertile period.

Measuring changes in core body temperature provides a valid method to detect ovulation and increase fertility. 'OvuSense' is a novel vaginal sensor that can predict the fertility window by recording and analysing the changes in intravaginal temperature records. This study aimed to determine patients 'acceptability and satisfaction after using OvuSense'. We approached 13 women to complete a patient satisfaction survey after using OvuSense in a prospective, longitudinal, comparative study, to test its validity and accuracy in detecting ovulation over a minimum period of three cycles. All 13 women agreed to participate in this survey. The majority of the participants found the usage of the reader to be very easy; 76.9% of the women said it was extremely comfortable to use the device during the night and 76.9% found the idea of using the intravaginal reader to be very convenient. Overall, 69.2% of women were extremely satisfied using the device. The idea of detecting intravaginal core body temperature changes appears to be highly acceptable by women.

Double Duct to Mucosa Pancreaticojejunostomy for Bifid Pancreatic Duct following Pylorus Preserving Pancreaticoduodenectomy: A Case Report.

Bifid pancreatic duct represents a relatively rare anatomical variation of the pancreatic ductal system, in which the main pancreatic duct is bifurcated along its length. This paper describes the challenging surgical management of a 68-year-old male patient, with presumptive diagnosis of periampullary malignancy who underwent a successful double duct to mucosa pancreaticojejunostomy for bifid pancreatic duct. Following pylorus preserving pancreaticoduodenectomy, careful intraoperative inspection of the cut surface of the residual dorsal pancreas identified the main in addition to the secondary pancreatic duct orifice. Bifid duct anatomy was confirmed via intraoperative probing and direct visualization of the ductal orifices. A decision was made for the performance of an end-to-site double duct to mucosa pancreaticojejunostomy. Postoperative outcome was favorable without any complications. Although bifid pancreatic duct is relatively rare, pancreatic surgeons should be aware of this anatomical variation and be familiar with the surgical techniques for its successful management. Lack of knowledge and surgical expertise for dealing with this anatomical variant may lead to serious, life threatening postoperative complications following pancreatic resections.

0.48Tb/s (12x40Gb/s) WDM transmission and high-quality thermo-optic switching in dielectric loaded plasmonics.

We demonstrate Wavelength Division Multiplexed (WDM)-enabled transmission of 480Gb/s aggregate data traffic (12x40Gb/s) as well as high-quality 1x2 thermo-optic tuning in Dielectric-Loaded Surface Plasmon Polariton Waveguides (DLSPPWs). The WDM transmission characteristics have been verified through BER measurements by exploiting the heterointegration of a 60 µm-long straight DLSPPW on a Silicon-on-Insulator waveguide platform, showing error-free performance for six out of the twelve channels. High-quality thermo-optic tuning has been achieved by utilizing Cycloaliphatic-Acrylate-Polymer as an efficient thermo-optic polymer loading employed in a dual-resonator DLSPPW switching structure, yielding a 9 nm wavelength shift and extinction ratio values higher than 10 dB at both output ports when heated to 90°C.

Endometrial thickness for invasive investigations in women with postmenopausal bleeding.

OBJECTIVE: To determine the prevalence of endometrial hyperplasia and endometrial cancer in postmenopausal women with endometrial thickness of 4.1-8 mm on transvaginal ultrasound scan. DESIGN: Prospective observational study carried out in the Heart of England NHS Trust Teaching Hospital in the West Midlands, UK, in a population of 58 women with postmenopausal bleeding. METHOD: Prospective analysis of all women referred to the Rapid Access Clinic in the Heart of England Hospital with a history of postmenopausal bleeding over a 12-month period (April 2007-April 2008). Endometrial histology was taken as the final diagnosis. The main outcome measure was endometrial histology in women with postmenopausal bleeding with endometrial thickness of 4.1-8 mm. RESULTS: All women (n = 58) diagnosed with endometrial thickness of 4.1-8 mm on transvaginal sonography were included in the analysis. Pipelle endometrial biopsy could only be performed in 22 women (37.9%). Hysteroscopy was performed in 45 women (77.5%). Out of these, a histological diagnosis was available in 28 women (62.2%). In the remaining 17 women, the endometrium was observed as atrophic on hysteroscopy. In these 17 cases, either no or insufficient endometrial sample was obtained. In total, two (3.4%) women were diagnosed with complex endometrial hyperplasia and two (3.4%) women were diagnosed with endometrial carcinoma. CONCLUSION: There was a significant prevalence of endometrial hyperplasia and endometrial cancer in postmenopausal women with a history of postmenopausal bleeding and who had endometrial thickness of 4.1-8 mm. Therefore, the current recommendation of histological assessment on all women with endometrial thickness >4 mm should remain unchanged.

Traumatic occipital meningoencephalocele presenting with homonymous hemianopia in a professional driver.

BACKGROUND: This study presents the case of a 32-year-old male who is a chronic headache sufferer. He is a professional driver who presented with homonymous hemianopia secondary to a traumatic occipital meningoencephalocele. This is the first time such an association has been reported. CONCLUSIONS: The complete lack of previous visual symptoms supports the belief of late development of the hemianopia. However, the chronicity and the nature of the patients' headaches could have justified further investigations in the past.

Evaluation of popliteal arteries with CT angiography in popliteal artery entrapment syndrome.

BACKGROUND: Popliteal artery entrapment is an uncommon clinical entity that occurs due to compression of the popliteal artery by adjacent muscle and tendinous structures. Early diagnosis should be established through a combined approach of careful physical examination and history-taking, duplex ultrasonography, and CT angiography. PATIENTS AND METHODS: We have studied retrospectively 16 patients of popliteal artery entrapment syndrome, 9 men and 7 women. All patients were scanned with a scanner Picker PQ 5000 after bolus injection of nonionic contrast medium and they all underwent a two-part examination first, with the knee in a neutral position, and, second, with the knee hyperextended. RESULTS: At the second phase of the examination 3 patients showed normal findings, 10 patients have shown mild stenosis of the popliteal artery or more severe stenosis due to compression, 2 patients have exhibited bilateral stenosis and 1 patient has also showed popliteal venous compression. CONCLUSION: CT angiography images and three-dimensional images are useful not only for depiction of the arterial changes but also identification of the abnormal anatomic structures responsible for the entrapment.

Enhancement of virchow-robin spaces. An MRI evaluation.

Virchow-Robin spaces are enclosed spaces filled with interstitial fluid and covered with pia that accompany arteries, arterioles, veins and venules as they perforate the brain. They are round, linear or punctuate areas depending on the image that parallel cerebrospinal fluid attenuation or signal intensity. They are classically described as isointense to cerebrospinal fluid on images obtained with all pulse sequences. They appear hypointense relative to brain on T1-weighted MR scans and present a high signal intensity on T2-weighted MR scans. They also show complete signal suppression on fluid-attenuated inversion recovery (FLAIR) scans and no enhancement after intravenous contrast administration. However, many pathologic states result in abnormal dilation with an increased number of Virchow-Robin spaces visible on MRI imaging and many pathological conditions cause the spaces to enhance. The purpose of this study is to present the major causes of Virchow-Robin enhancement.

Enhancement of robin-virchow spaces MRI evaluation.

The perivascular spaces are normally microscopic. Even in normal brain some Robin-Virchow spaces are usually seen in the area of substantia innominata at the level of anterior commissure. Many pathologic states result in abnormal dilatation with an increased number of spaces visible on MRI imaging. Dilatation is most commonly associated with anterior abnormalities that arise due to aging, diabetes, hypercholesterolemia, smoking, hypertension and other vascular risk factors. The precise etiology of dilatation is currently unknown.

Role of rescue IVF-ET treatment in the management of high response in stimulated IUI cycles.

Rescue in-vitro fertilisation and embryo transfer (IVF-ET) has been used in high response gonadotrophin intrauterine insemination (IUI) cycles to minimise the risks of ovarian hyperstimulation and multiple gestation. Such unplanned IVF treatment increases the cost of treatment. But can this added cost and the risks associated with IVF be justified? We present our experience with this treatment using clinical pregnancy and live birth rates as the primary outcomes. Between 1998 to 2001, 40 women undergoing IUI cycles who over responded (>3 follicles measuring >15 mm in diameter on the planned day of hCG administration) to gonadotrophin were offered the choice of conversion to IVF-ET or cancel the cycle. 17/40 declined rescue IVF/ET and had their cycles cancelled. 23/40 converted to IVF/ET and underwent transvaginal oocyte retrieval. 21/23 had embryo transferred. The clinical pregnancy and live birth rates were 52% and 48%, respectively. Rescue IVF-ET offers excellent clinical pregnancy and live birth rates in high responders. However, affordability can be an obstacle in the utilization of this treatment option.

Biocompatibility of two commercial forms of mineral trioxide aggregate.

AIM: To examine the biocompatibility of two commercial forms of mineral trioxide aggregate (MTA), by evaluating the morphology of an established cell line. METHODOLOGY: The two cements were cast on glass cover slips and cured for 1 or 28 days. Saos-2 osteosarcoma cells were trypsinized and seeded at a density of 1 x 10(5) cells and were then placed in medium over the material-coated coverslips for 1, 5 and 7 days. After these time intervals the media were discarded and the cells fixed. Cell morphological investigation was performed by scanning electron microscopy at various magnifications ranging from x 250 to x 500. The biocompatibility of cement constituents, alusilicate flux and bismuth oxide was also investigated. RESULTS: All cement samples cured for 1 day showed a confluent cell monolayer after 5 and 7 days. The response to both materials was similar. Materials cured for 28 days showed incomplete cell confluence after 1 and 5 days. Alusilicate flux and bismuth oxide did not demonstrate biocompatibility. CONCLUSIONS: The 1-day cured samples of two commercial forms of MTA showed good biocompatibility. However, the 28-day cured samples were less biocompatible after 1 and 5 days.

The effects of serine proteinase inhibitors on bone resorption in vitro.

The aims of this study were to identify the role and sites of action of serine proteinases (SPs) in bone resorption, a process which involves a cascade of events, the central step of which is the removal of bone matrix by osteoclasts (OCs). This resorbing activity, however, is also determined by recruitment of new OCs to future resorption sites and removal of the osteoid layer by osteoblasts (OBs), which enables OCs to gain access to the underlying mineralized bone. The resorption systems we have studied consisted of (i) neonatal calvarial explants, (ii) isolated OCs cultured on ivory slices, (iii) mouse OBs cultured on either radiolabelled type I collagen films or bone-like matrix, (iv) bone marrow cultures to assess OC formation and (v) 17-day-old fetal mouse metatarsal bone rudiments to assess OC migration and fusion. Two separate SP inhibitors, aprotinin and alpha(2)-antiplasmin dose-dependently inhibited (45)Ca release from neonatal calvarial explants: aprotinin (10(-6) M) was the most effective SP inhibitor, producing a maximum inhibitory effect of 55.9%. Neither of the SP inhibitors influenced either OC formation or OC resorptive activity. In contrast, each SP inhibitor dose-dependently inhibited OB-mediated degradation of both type I collagen fibrils and non-mineralized bone matrix. In 17-day-old metatarsal explants aprotinin produced a 55% reduction in the migration of OCs from the periosteum to the mineralized matrix after 3 days in culture but after 6 days in culture aprotinin was without effect on OC migration. Primary mouse osteoblasts expressed mRNA for urokinase type plasminogen activator (uPA), tIssue type plasminogen activator (tPA), the type I receptor for uPA, plasminogen activator inhibitor types I and II and the broad spectrum serine proteinase inhibitor, protease nexin I. In situ hybridization demonstrated expression of tPA and uPA in osteoclasts disaggregated from 6-day-old mouse long bones. We propose that the regulation of these various enzyme systems within bone tIssue determines the sites where bone resorption will be initiated.

Interleukin-6 (IL-6), IL-1, receptor activator of nuclear factor kappaB ligand (RANKL) and osteoprotegerin production by human osteoblastic cells: comparison of the effects of 17-beta oestradiol and raloxifene.

Oestrogen inhibits bone resorption, at least in part, by regulating the production of several cytokines, including interleukin-6 (IL-6), IL-1, receptor activator of nuclear factor kappaB ligand (RANKL) and osteoprotegerin (OPG) by cells of the osteoblastic lineage. The selective oestrogen receptor modulator raloxifene (RAL) acts on bone in a similar manner to oestrogen, although the mechanisms of action of RAL on osteoblasts still remain unclear. We investigated and compared the effects of 17-beta oestradiol (E(2)) and RAL on the regulation of IL-6, IL-1, RANKL and OPG in vitro in primary human osteoblastic (HOB) cells and in an immortalised clonal human bone marrow stromal cell line (HCC1) with osteoblastic characteristics. We tested E(2) and RAL at concentrations ranging from 10(-12) to 10(-6) M. IL-6, IL-1alpha and IL-1beta, OPG and RANKL were measured by ELISA. RANKL and OPG mRNA steady state level was assessed by quantitative PCR analysis. Both E(2) and RAL led to a significant reduction in IL-6 production in the HOB cells, although the effect was more marked with E(2) (P<0.05). IL-1alpha and IL-1beta also decreased significantly following treatment with E(2) and RAL in the HCC1 cells (E(2) (10(-8), 10(-7) and 10(-6) M), % reduction (means+/-S.E.M.) compared with vehicle-treated cells - IL-1alpha: 84+/-7.4, 70.8+/-2.9*, 78.2+/-4.8*; IL-1beta: 79+/-10, 72.8+/-8.2*, 66.6+/-2.8*; RAL (10(-8), 10(-7) and 10(-6) M) - IL-1alpha: 72.4+/-5*, 79+/- 5.2*, 102+/-7.7; IL-1beta: 67.9+/-3.2*, 69+/-2.5*, 73.8+/- 6.2*; *P<0.05). OPG protein concentration decreased significantly in a dose-dependent manner following treatment with E(2) and RAL (% reduction E(2) (10(-8), 10(-7) and 10(-6) M) - HOB: 72.5+/-8.4*, 80+/-6.7*, 62.8+/-8.9*; HCC1: 109+/-4, 98.8+/-6, 54.5+/-3.4*; RAL (10(-8), 10(-7) and 10(-6) M) - HOB: 81.5+/-5.5*, 62.7+/-7.4*, 55.2+/-10.9*; HCC1: 92.7+/-7.4, 67+/-12.2*, 39+/-4.5*; *P<0.05). In the HCC1 cells, RANKL protein did not change significantly following E(2). In contrast, a significant reduction in RANKL was seen with RAL at 10(-7) and 10(-6) M (66+/-6.4% and 74+/-3% respectively). There was no change in OPG mRNA expression following E(2) or RAL in the HCC1 cells, although in the HOB cells we observed a significant reduction in OPG mRNA. RANKL mRNA decreased significantly in the HCC1 cells following RAL (10(-8), 10(-7)and 10(-6) M) treatment (% change from controls: 52+/-2*, 62+/-1*, 53+/-5.8*; *P<0.05). Similar results were seen in the HOB cells with RAL at 10(-6) M (RANKL mRNA: 72+/-5.5, P<0.05). In addition, there was a significant decrease in the RANKL/OPG ratio after RAL at 10(-6) M (HOB: 65.6+/-5*, HCC1: 56.9+/-20*; *P<0.05). RANKL/OPG ratio did not change significantly in the HCC1 cells following E(2). However, in contrast to RAL, we observed an increase in the RANKL/OPG ratio in the HOB cells following treatment with E(2). In conclusion, the study shows that RAL and E(2) have divergent cell-specific effects on the regulation of cytokines. The data also suggest that, in contrast to E(2), RAL may exert its anti-resorptive actions, at least in part, via the RANKL/OPG pathway. Further in vivo studies are required to confirm this.

Spontaneous disappearance of a normal adnexa associated with a contralateral polycystic-appearing ovary.

BACKGROUND: Absence of the adnexa may be congenital or acquired. However, the etiology is often uncertain. CASE: A 27-year-old woman presented with a 3-year history of subfertility. Her irregular menstruation was associated with acne vulgaris, alopecia, and elevated body mass index. Transvaginal ultrasonography of the pelvis showed a normal uterus, a normal right ovary, but a polycystic-appearing left ovary. A hysterosalpingogram demonstrated a normal uterine cavity, prompt filling and spilling of contrast material from the left fallopian tube, but no filling on the right. Subsequent laparoscopy showed an unexpected absence of right adnexa and presence of a solitary rounded free-floating mass enshrouded in the omentum. She did not have a history of abdominal pain or surgery. CONCLUSION: The evidence suggests that the patient might have had an asymptomatic infarction of the right adnexa.

An evaluation of accelerated Portland cement as a restorative material.

Biocompatibility of two variants of accelerated Portland cement (APC) were investigated in vitro by observing the cytomorphology of SaOS-2 osteosarcoma cells in the presence of test materials and the effect of these materials on the expression of markers of bone remodelling. Glass ionomer cement (GIC), mineral trioxide aggregate (MTA) and unmodified Portland cement (RC) were used for comparison. A direct contact assay was undertaken in four samples of each test material, collected at 12, 24, 48 and 72 h. Cell morphology was observed using scanning electron microscopy (SEM) and scored. Culture media were collected for cytokine quantification using enzyme-linked immunosorbent assay (ELISA). On SEM evaluation, healthy SaOS-2 cells were found adhering onto the surfaces of APC variant, RC and MTA. In contrast, rounded and dying cells were observed on GIC. Using ELISA, levels of interleukin (IL)-1beta, IL-6, IL-18 and OC were significantly higher in APC variants compared with controls and GIC (p<0.01), but these levels of cytokines were not statistically significant compared with MTA. The results of this study provide evidence that both APC variants are non-toxic and may have potential to promote bone healing. Further development of APC is indicated to produce a viable dental restorative material and possibly a material for orthopaedic