ED BP Management for Subarachnoid Hemorrhage.

PURPOSE OF REVIEW: To review most recent literature on management of blood pressure in acute aneurysmal subarachnoid hemorrhage (SAH) and provide practice recommendations for the emergency clinician. RECENT FINDINGS: There is increased risk of aneurysmal rebleeding with systolic blood pressure (SBP) greater than 160 mmHg in the acute setting. Avoiding large degrees of blood pressure variability improves clinical outcomes in aneurysmal SAH. Acute lowering of SBP to a range of 140-160 mmHg decreases risk of rebleeding while also maintaining cerebral perfusion pressure (CPP) after aneurysmal rupture. Treatment with a short acting antihypertensive agent allows for rapid titration of blood pressure (BP) and reduces BP variability. Elevations in intracranial pressure occur commonly after SAH due to increased intracranial blood volume, cerebral edema, or development of hydrocephalus. Clinicians should be familiar with changes in cerebral autoregulation and effects on CPP when treating elevated BP, in order to mitigate the risk of secondary neurological injury.

Behavioral Assessment With the Coma Recovery Scale-Revised Is Safe and Feasible in Critically Ill Patients With Disorders of Consciousness.

OBJECTIVES: Accurate classification of disorders of consciousness (DoC) is key in developing rehabilitation plans after brain injury. The Coma Recovery Scale-Revised (CRS-R) is a sensitive measure of consciousness validated in the rehabilitation phase of care. We tested the feasibility, safety, and impact of CRS-R-guided rehabilitation in the ICU for patients with DoC after acute hemorrhagic stroke. DESIGN: Retrospective cohort study. SETTING: This single-center study was conducted in the neurocritical care unit at the University of Maryland Medical Center. PATIENTS: We analyzed records from consecutive patients with subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH), who underwent serial CRS-R assessments during ICU admission from April 1, 2018, to December 31, 2021, where CRS-R less than 8 is vegetative state/unresponsive wakefulness syndrome (VS/UWS); CRS-R greater than or equal to 8 is a minimally conscious state (MCS). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcomes included adverse events during CRS-R evaluations and associations between CRS-R and discharge disposition, therapy-based function, and mobility. We examined the utility of CRS-R compared with other therapist clinical assessment tools in predicting discharge disposition. Seventy-six patients (22 SAH, 54 ICH, median age = 59, 50% female) underwent 276 CRS-R sessions without adverse events. Discharge to acute rehabilitation occurred in 4.4% versus 41.9% of patients with a final CRS-R less than 8 and CRS-R greater than or equal to 8, respectively (odds ratio [OR] 13.4; 95% CI, 2.7-66.1; p < 0.001). Patients with MCS on final CRS-R completed more therapy sessions during hospitalization and had improved mobility and functional performance. Compared with other therapy assessment tools, the CRS-R had the best performance in predicting discharge disposition (area under the curve: 0.83; 95% CI, 0.72-0.94; p < 0.0001). CONCLUSIONS: Early neurorehabilitation guided by CRS-R appears to be feasible and safe in the ICU following hemorrhagic stroke complicated by DoC and may enhance access to inpatient rehabilitation, with the potential for lasting benefit on recovery. Further research is needed to assess generalizability and understand the impact on long-term outcomes.

Unambiguous identification of the second 2+ state in 12C and the structure of the Hoyle state.

The second J(π)=2+ state of 12C, predicted over 50 years ago as an excitation of the Hoyle state, has been unambiguously identified using the 12C(γ,α0)(8)Be reaction. The alpha particles produced by the photodisintegration of 12C were detected using an optical time projection chamber. Data were collected at beam energies between 9.1 and 10.7 MeV using the intense nearly monoenergetic gamma-ray beams at the HIγS facility. The measured angular distributions determine the cross section and the E1-E2 relative phases as a function of energy leading to an unambiguous identification of the second 2+ state in 12C at 10.03(11) MeV, with a total width of 800(130) keV and a ground state gamma-decay width of 60(10) meV; B(E2:2(2)+→0(1)+)=0.73(13)e(2) fm(4) [or 0.45(8) W.u.]. The Hoyle state and its rotational 2+ state that are more extended than the ground state of 12C presents a challenge and constraints for models attempting to reveal the nature of three alpha-particle states in 12C. Specifically, it challenges the ab initio lattice effective field theory calculations that predict similar rms radii for the ground state and the Hoyle state.

Inflatable penile prosthesis and salvage protocol for mechanical failure: is it really necessary?

INTRODUCTION: Penile prosthesis patients with mechanical failure who wish continued treatment require device removal and replacement. Infection rates as high as 18% have been reported for procedures involving replacement of malfunctioning penile prosthesis compared with 2% for primary implantation. AIM: The aim of this study is to compare the outcomes of patients who have had a penile prosthesis replacement for mechanical failure to determine if those who had a mini-salvage washout procedure had better outcomes than those who did not. METHODS: A retrospective chart review was performed of all patients undergoing inflatable penile prosthesis replacement for mechanical failure from 1997 to 2010. Demographics, past medical history, reason for device failure, type of device, time from original implantation to failure, operative details, culture results, and follow-up data were analyzed. MAIN OUTCOME MEASURES: Infection rates for penile implant revisions with and without mini-salvage washout. RESULTS: Forty-two patients underwent a mini-salvage procedure for mechanical failure and 87 patients underwent standard sterile replacement. There were no infections in the mini-salvage group and two (2.3%) in the standard sterile group (P=1.00). In patients with culture data available, two patients in each group had coagulase negative staphylococcus on culture, but none of these patients developed an infection. One patient who developed an infection had an intraoperative culture, which revealed no growth. The other patient with an infection did not undergo intraoperative culture testing. Operating room (OR) time was longer with the mini-salvage procedure (156 ± 36 minutes vs. 131 ± 31 minutes, P<0.001). CONCLUSIONS: Performing a mini-salvage procedure for patients undergoing penile prosthesis replacement for mechanical failure adds to operative time but did not significantly change the infection rate and may not be indicated. Furthermore, intraoperative culture results were not predictive of postoperative infection.

Amorphous no longer: the centrosome comes into focus.

Recent genetic and biochemical studies have provided new insights into the molecular basis of centrosome-mediated microtubule nucleation. In addition, molecules and mechanisms involved in microtubule severing and stabilization at the centrosome, assembly of proteins onto centrosomes and regulation of centrosome duplication and separation are being defined. Characterization of centrosome function, together with studies implicating centrosomes in tumorigenesis and demonstrating that centrosomes are highly organized, are beginning to bring into focus an organelle once viewed as an 'amorphous cloud'.

Ileovesicostomy: update.

Currently, we have different technical options for treating clinically complex scenarios such as neurogenic bladder, difficult to manage lower urinary tract obstruction and many disasters sometimes seen after prostate cancer treatment. During the seventies, clean intermittent bladder catheterization was established as the best treatment option for these patients. As a method, suprapubic urinary diversion has undergone a major evolution over the past fifty years trying to solve the most refractory and poor prognosis cases. Continent ileovesicostomy is an easy emptying and low-pressure non-catheterizable urinary conduit that enables safe and durable urine elimination. In this article a detailed and updated knowledge of this technique is provided.

Microbubble intensification of bioprocessing.

Microbubbles have been involved in industrial processing since the 1970s with the introduction of dissolved air flotation into common practice. The turn of the century saw microbubbles become regularly used in medical imaging. But in bioprocessing, only this decade has seen rapid advances in R&D, with some bioprocesses, particularly in wastewater treatment, adopted at full industrial scale, and others at pilot scale, such as anaerobic digestion and fermentation, which is full industrial scale for many biomanufacturing and pharmaceutical processes. This article reviews the methods of microbubble generation only briefly, as it turns out only one generation method, fluidic oscillation through microporous diffusers, has the requisite features for introduction into full scale fermentation processes. Subsequently, six fundamental physicochemical hydrodynamics mechanisms that have been exploited by microbubble innovations in bioprocessing are presented and analyzed, particularly for the roles they play in bioprocessing applications. Some examples are drawn with applications to microalgal and yeast processing, as well as usage in wastewater treatment processes. Because the smallest microbubbles can increase rates in some of these six fundamental processes by several orders of magnitude over conventional processing methods, with the optimal contacting patterns, the promise for wider exploitation in bioprocessing is substantial.

Impact of Genitourinary Injuries on Patients Requiring an Emergency Laparotomy for Trauma.

Introduction In patients having emergency abdominal surgery for trauma, the presence of urologic injury tends to increase mortality and morbidity. Methods This retrospective study evaluated patients requiring emergency surgery for abdominal trauma at a Level 1 Trauma Center over 30 years (1980-2010). Special attention was given to patients with concomitant genitourinary (GU) injuries. Results Of 1105 patients requiring an emergency laparotomy for trauma, 242 (22%) had urologic injuries including kidney 178 (16%), ureter 47 (4%), and bladder 46 (4%). Of the 242 patients, 50 (20%) died early (<48 hours) and 13 (5%) died later, primarily due to infection. A concept of "seven deadly signs" of hypoperfusion was developed. In patients with GU injuries, the presence of any deadly sign of hypoperfusion increased the mortality rate from 4% (6/152) to 63% (56/90), p<0.001. Of the 53 patients having a nephrectomy, 36 (68%) had one or more deadly signs and 27 (75%) died. Of 17 without deadly signs, only 2 (12%) died (p=0.001). Of 167 GU patients receiving blood, 59 (35%) developed infection vs 3/75(4%) in those receiving no blood (p<0.001). Conclusions The presence of deadly signs of severe injury and hypoperfusion on admission was the major factor determining mortality. With a severely injured kidney plus any deadly signs of hypoperfusion, special efforts should be made to avoid a nephrectomy.

Pericentrin and gamma-tubulin form a protein complex and are organized into a novel lattice at the centrosome.

Pericentrin and gamma-tubulin are integral centrosome proteins that play a role in microtubule nucleation and organization. In this study, we examined the relationship between these proteins in the cytoplasm and at the centrosome. In extracts prepared from Xenopus eggs, the proteins were part of a large complex as demonstrated by sucrose gradient sedimentation, gel filtration and coimmunoprecipitation analysis. The pericentrin-gamma-tubulin complex was distinct from the previously described gamma-tubulin ring complex (gamma-TuRC) as purified gamma-TuRC fractions did not contain detectable pericentrin. When assembled at the centrosome, the two proteins remained in close proximity as shown by fluorescence resonance energy transfer. The three- dimensional organization of the centrosome-associated fraction of these proteins was determined using an improved immunofluorescence method. This analysis revealed a novel reticular lattice that was conserved from mammals to amphibians, and was organized independent of centrioles. The lattice changed dramatically during the cell cycle, enlarging from G1 until mitosis, then rapidly disassembling as cells exited mitosis. In cells colabeled to detect centrosomes and nucleated microtubules, lattice elements appeared to contact the minus ends of nucleated microtubules. Our results indicate that pericentrin and gamma-tubulin assemble into a unique centrosome lattice that represents the higher-order organization of microtubule nucleating sites at the centrosome.

Action spectra for phase shifts of a circadian rhythm in Drosophila.

Action spectra were determined for lightinduced phase shifts of the circadian rhythm of adult emergence in Drosophila pseudoobscura. The action spectra for advance and delay phase shifts are similar; the most effective wavelengths are in the blue region, with a sharp cutoff above 500 nanometers. This similarity suggests that the same photoreceptive pigment mediates both advance and delay phase shifts.

Photosensitivity of the circadian rhythm and of visual receptors in carotenoid-depleted Drosophila.

Drosophila melanogaster was raised on aseptic diets, with and without beta-carotene. The sensitivity of visual receptors in the carotenoid-depleted flies was lowered 3 log units, but the photosensitivity of the circadian rhythm was not affected. This result suggests that the chromophore of the photopigment which mediates light effects on the circadian rhythm is not a carotenoid derivative.

Glomus tumour of the male urethra: an unusual diagnostic.

A 56-year-old man was referred to a reconstructive urologist for evaluation of a tender nodule in the penoscrotal area. Penile Doppler ultrasound showed a non-compressible mass with internal vascularity within the corpora spongiosum, and MRI identified an enhancing, solid mass arising from the ventral aspect of the urethra. Surgical resection warranted partial excision and reconstruction of the urethra, which was achieved by a dorsal onlay buccal mucosal graft urethroplasty through a perineal incision with penile invagination. The histopathology report concluded to an invasive, high-grade urothelial carcinoma, for which an aggressive oncological approach was considered. However, discussion with the pathology team led to the identification of a glomus tumour for which the patient did not need additional procedures. Urethral glomus tumours are extremely rare and should be included in the differential diagnosis of urethral masses. This case exemplifies the importance of teamwork in the management of uncommon cases.

Numerical analysis of solutocapillary Marangoni-induced interfacial waves.

Spreading problems and solutocapillary waves are now routinely treated by semi-analytic lubrication theory leading to a 1D spatiotemporal system to be integrated numerically. In this review, such theories have been shown to be robust predictors of the pseudo-steady propagation at long times with only an initial transient period when the lubrication assumptions breakdown and the wave front is retarded due to bottom friction. Linear stability theory for bottom friction effects leads to 1D evolution equations that predict the scale of Marangoni stresses needed to excite waves and the solitary wave structure of their propagation. In general, applications which are sensitive to Marangoni effects naturally have high values of the Marangoni number (at least hundreds and potentially much higher in evaporation problems). Even when the Marangoni-induced effects are small amplitude, the gradients in stresses are such that numerical resolution requirements are steep. The idealization of interfacial dynamics to a domain with zero thickness (molecular effects) is computationally more demanding than the boundary layers induced in say high Reynolds number laminar flows. Therefore, specialized computational methods for treating open deformable interfaces with high transverse gradients are both required and are being successfully developed as reported here.

Mutation analysis of the THRA1 gene in breast cancer: deletion/fusion of the gene to a novel sequence on 17q in the BT474 cell line.

We have previously described a common region of deletion and allele loss on chromosome 17q in sporadic breast cancers that is likely to contain a tumor suppressor gene. The region, mapped to 17q12-q21, was bordered by D17S250 and D17S579 on the centromeric and telomeric sides, respectively. This deletion region overlaps the BRCA1 locus, which predisposes to familial breast and ovarian cancer. The most frequent loss of heterozygosity was observed at the thyroid hormone receptor alpha (THRA1) locus. Southern analysis revealed a rearrangement of THRA1 in the BT474 breast cancer cell line. This rearrangement represented a deletion of exons 8-10 of one THRA1 allele that was also coamplified with ERBB2. Northern blots showed two mutant transcripts in BT474 cells. Analysis of the mutant transcripts revealed fusion of the THRA1 exon 7 by splicing to a novel sequence designated BTR for "BT474 transcribed rearrangement." BTR was found to be highly conserved and mapped to 17q. The deletion in BT474 cells spans the entire BRCA1 region. To search for additional mutations in the THRA1 gene, all nine protein-encoding exons of THRA1 were examined for point mutations via single strand conformation analysis in a series of primary breast tumors, breast cancer cell lines, and lymphoblastoid cell lines derived from the youngest affected members of several German breast cancer families. No point mutations were detected, including the unrearranged THRA1 allele in BT474. We have thus excluded THRA1 as a commonly mutated sporadic breast cancer tumor suppressor gene and as the BRCA1 gene.

Transmural myocardial infarction with normal coronary angiograms and with single vessel coronary obstruction. Clinical-angiographic features and five-year follow-up.

Angiographic, clinical, and five-year follow-up study of 20 cases of myocardial infarction with normal coronary angiograms (MI-NCA) and 20 cases of myocardial infarction with single vessel obstruction (MI-SVO) are presented. MI-SVO patients differed from MI-NCA in being older (53.7 vs 44.5 years, p = 0.025), predominantly male (90 percent vs 40 percent, p = 0.001), frequently having large left ventricular akinetic segments (50 percent vs 15 percent, p = 0.01), and frequently having antecedent typical angina (55 percent). MI-NCA was more frequently associated with definite mitral valve prolapse (25 percent vs 10 percent, NS); migraine, or Raynaud's phenomenon (45 percent vs 5 percent, p = 0.001); birth control pill ingestion in women (33 percent vs 0 percent, p = 0.05); paroxysmal atrial flutter (25 percent vs 0 percent, p = 0.01); and antecedent atypical angina (25 percent). Frequency of cigarette smoking and hypertension and the mean serum cholesterol levels were similar in both groups. On follow-up, MI-NCA patients more commonly had neurologic events (25 percent vs 5 percent, p = 0.05) and second myocardial infarction (15 percent vs 0 percent, p = 0.02), but deaths occurred infrequently in both groups. These data suggest a variety of pathophysiologic causes for MI-NCA.

Impact of diagnosis-related groups on the quality of postoperative care of patients with neck dissections.

Two hundred eighty patients underwent neck dissection over a 10-year period: 138 during the 5-year period before the institution of Diagnosis-Related Group (DRG) reimbursement and 142 during the 5 years after DRG regulations. A comparison of these two groups by site of tumor, stage of disease, histopathology, previous treatment, type of neck dissection, whether neck dissection was carried out alone or in combination with another procedure, presence of preexisting disease, postoperative complications, and mortality revealed no significant differences. A 35% reduction in the length of hospital stay from 16 to 10 days was identified in the post-DRG group with no detrimental effects on patient care. The variables found to have the greatest impact on length of hospital stay were the extent of operation and postoperative complications.

Peripheral hearing loss following head trauma in children.

The purpose of this prospective study was to determine the incidence and type of hearing loss occurring in children who suffered head injuries. Fifty children admitted to the neurosurgical service after sustaining head trauma were studied. Neurologic, otologic, and audiologic evaluations were performed. Diagnostic studies included skull roentgenograms and computerized tomography scans. A 32% incidence of conductive hearing loss and a 16% incidence of high-frequency sensorineural hearing loss was found in this group. All patients with temporal bone fractures had conductive hearing losses, but the presence of a skull vault fracture did not correlate with the presence, type, or degree of hearing loss. In addition, there was no correlation between either cause of injury, loss of consciousness, or Glasgow Coma Scale scores and the presence, type, or degree of hearing loss. There was a significant incidence of both sensorineural and conductive hearing loss in this series of patients, which indicates that close audiologic and otologic follow-up is necessary for all head injury patients.

Acute bladder entrapment without perforation after trauma.

Acute bladder entrapment within a pubic bone fracture is a rare entity. Computed tomography revealed bladder entrapment without perforation in a man who had been struck by an automobile and had presented with mild hematuria. At the pelvic stabilization surgery, the bladder was manually reduced into its normal anatomic position without complications.

Buccal mucosa urethroplasty for adult urethral strictures.

Urethral strictures are difficult to manage. Some treatment modalities for urethral strictures are fraught with high patient morbidity and stricture recurrence rates; however, an extremely useful tool in the armamentarium of the Reconstructive Urologist is buccal mucosal urethroplasty. We like buccal mucosa grafts because of its excellent short and long-term results, low post-operative complication rate, and relative ease of use. We utilize it for most our bulbar urethral stricture repairs and some pendulous urethral stricture repairs, usually in conjunction with a first-stage Johanson repair. In this report, we discuss multiple surgical techniques for repair of urethral stricture disease. Diagnosis, evaluation of candidacy, surgical techniques, post-operative care, and complications are included. The goal is to raise awareness of buccal mucosa grafting for the management urethral stricture disease.

A simplified and unified approach to anterior urethroplasty.

The management of patients with urethral stricture can be a complex process. However, with the appropriate tools, the urologist experienced in urethral surgery can manage most cases without too much difficulty. Here, we describe three surgical techniques--anastomotic urethroplasty, buccal mucosal graft-onlay urethroplasty and the two-staged Johanson urethroplasty--that, in our experience, can accommodate the majority of patients with urethral stricture and provide excellent long-term results. Diagnosis and evaluation of candidacy for each of the surgical techniques are important aspects of treatment planning, and are also described. The aim of the article is to increase the awareness of the technique and application of these three urethroplasty procedures, which can be implemented by all urologists who actively care for and surgically treat patients with urethral stricture disease.