Portable recording in the assessment of obstructive sleep apnea. ASDA standards of practice

The objective assessment of patients with a presumptive diagnosis of obstructive sleep apnea (OSA) has primarily used attended polysomnographic study. Recent technologic advances and issues of availability, convenience and cost have led to a rapid increase in the use of portable recording devices. However, limited scientific information has been published regarding the evaluation of the efficacy, accuracy, validity, utility, cost effectiveness and limitations of this portable equipment. Attaining a clear assessment of the role of portable devices is complicated by the multiplicity of recording systems and the variability of clinical settings in which they have been analyzed. This paper reviews the current knowledge base regarding portable recording in the assessment of OSA, including technical considerations, validation studies, potential advantages and disadvantages, issues of safety, current clinical usage and areas most in need of further study.

Randomized, placebo-controlled evaluation of prochlorperazine versus metoclopramide for emergency department treatment of migraine headache

STUDY OBJECTIVE

To determine the comparative efficacy of i.v. metoclopramide and prochlorperazine for the initial emergency department treatment of migraine headache.

DESIGN

Prospective, randomized, double-blind, placebo-controlled trial.

SETTING

Military community hospital ED with an annual census of 75,000.

PARTICIPANTS

Seventy consenting adults from a convenience sample of patients presenting with migraine headache similar to that experienced in at least one prior episode. Exclusion criteria were pregnancy, fever, signs of meningismus, altered sensorium, drug or alcohol use, oxygen saturation less than 90%, recent trauma or seizure, "worst headache," abnormal blood pressure, recent (within 48 hours) use of metoclopramide or prochlorperazine, and allergy to metoclopramide or prochlorperazine.

INTERVENTIONS

In a random manner, each subject received a 2-mL i.v. injection of identical-appearing fluid containing metoclopramide (10 mg), prochlorperazine (10 mg), or saline solution (placebo). No other analgesics or medications were administered during the initial study period; rescue agents were administered by the choice of the treating physician after all data were collected.

MEASUREMENTS

Patients scored their nausea, pain, and sedation before receiving the 2-mL injections and at 30 minutes after injection. Ten-centimeter nonhatched visual analog scales were used for these measurements, with distance from the left end (zero) calculated for each use. Clinically important successful treatment was defined a priori as achievement of the following criteria: patient satisfaction and either a decrease of 50% or more in the 30-minute pain score (compared with the initial score) or an absolute pain score of 2.5 cm or less. Failure to achieve these criteria constituted treatment failure. Differences between groups were analyzed with the Kruskal-Wallis ANOVA and chi 2 tests. Data are reported as frequency percentages and median values, with a two-tailed P value of .05 or less considered significant.

RESULTS

Nausea, pain, and sedation scores were similar in all three groups before therapy. Thirty minutes after treatment, pain scores differed among those treated with prochlorperazine (1.1 cm), with metoclopramide (3.9 cm), and with placebo (6.1 cm, P = .003). Clinical success occurred more commonly after treatment with prochlorperazine (82%) than after metoclopramide (46%) or placebo (29%, P = .03). However, metoclopramide and placebo scores did not differ (P = .14). Nausea tended to be improved after prochlorperazine, compared with metoclopramide or placebo, at 30 minutes (P = .64). Four patients (6%) returned to the ED for relapse of migraine headache within 24 hours (three in the placebo group and one in the metoclopramide group).

CONCLUSION

i.v. prochlorperazine relieves the headache and tends to improve nausea better than metoclopramide in ED patients with acute migraine headache.

Synthetic cathinones: chemistry, pharmacology and toxicology of a new class of designer drugs of abuse marketed as "bath salts" or "plant food"

In 2000s, many synthetic cathinones have received a renewed popularity as designer drugs of abuse, particularly among young people. Despite being marketed as "bath salts" or "plant food" and labeled "not for human consumption", people utilize these substances for their amphetamine or cocaine like effects. Since the time of their appearance in the recreational drug market, in several countries have been signaled numerous confirmed cases of abuse, dependence, severe intoxication and deaths related to the consumption of synthetic cathinones. The aim of this paper is to summarize the clinical, pharmacological and toxicological information about this new class of designer drugs of abuse.

Children creating language: how Nicaraguan sign language acquired a spatial grammar

It has long been postulated that language is not purely learned, but arises from an interaction between environmental exposure and innate abilities. The innate component becomes more evident in rare situations in which the environment is markedly impoverished. The present study investigated the language production of a generation of deaf Nicaraguans who had not been exposed to a developed language. We examined the changing use of early linguistic structures (specifically, spatial modulations) in a sign language that has emerged since the Nicaraguan group first came together: In tinder two decades, sequential cohorts of learners systematized the grammar of this new sign language. We examined whether the systematicity being added to the language stems from children or adults: our results indicate that such changes originate in children aged 10 and younger Thus, sequential cohorts of interacting young children collectively: possess the capacity not only to learn, but also to create, language.

3,4-methylenedioxypyrovalerone (MDPV): chemistry, pharmacology and toxicology of a new designer drug of abuse marketed online

The illicit marketplace of substances of abuse continually offers for sale legal alternatives to controlled drugs to a large public. In recent years, a new group of designer drugs, the synthetic cathinones, has emerged as a new trend, particularly among young people. The 3,4-methylenedioxypyrovalerone (MDPV), one of this synthetic compounds, caused an international alert for its cardiovascular and neurological toxicity. This substance, sold as bath salts, has caused many serious intoxications and some deaths in several countries. The aim of this paper is summarise the clinical, pharmacological and toxicological information about this new designer drug.

Oa1 knock-out: new insights on the pathogenesis of ocular albinism type 1

Ocular albinism type I (OA1) is an X-linked disorder characterized by severe reduction of visual acuity, strabismus, photophobia and nystagmus. Ophthalmologic examination reveals hypopigmentation of the retina, foveal hypoplasia and iris translucency. Microscopic examination of both retinal pigment epithelium (RPE) and skin melanocytes shows the presence of large pigment granules called giant melanosomes or macromelanosomes. In this study, we have generated and characterized Oa1-deficient mice by gene targeting (KO). The KO males are viable, fertile and phenotypically indistinguishable from the wild-type littermates. Ophthalmologic examination shows hypopigmentation of the ocular fundus in mutant animals compared with wild-type. Analysis of the retinofugal pathway reveals a reduction in the size of the uncrossed pathway, demonstrating a misrouting of the optic fibres at the chiasm, as observed in OA1 patients. Microscopic examination of the RPE shows the presence of giant melanosomes comparable with those described in OA1 patients. Ultrastructural analysis of the RPE cells, suggests that the giant melanosomes may form by abnormal growth of single melanosomes, rather than the fusion of several, shedding light on the pathogenesis of ocular albinism.

Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED

OBJECTIVE

To determine differences in infection rates among uncomplicated, repaired wounds managed with: topical bacitracin zinc (BAC); neomycin sulfate, bacitracin zinc, and polymyxin B sulfate combination (NEO); silver sulfadiazine (SIL); and petrolatum (PTR).

METHODS

This was a prospective, randomized, double-blind, placebo-controlled study conducted at a military community hospital with an emergency medicine residency program. Patients were enrolled if they: presented to the ED within 12 hours of injury and did not have puncture wounds, allergies to the agents used, or a history of immunocompromise; were not receiving antibiotics, chemotherapy, or steroids at the time of presentation; had not taken antibiotics within the preceding seven days; did not have an underlying fracture; and were not pregnant as determined by history. Local anesthetics without epinephrine and high-pressure irrigation with normal saline were used for all patients. Wound scrubbing, débridement, and polyglactin subcutaneous (SQ) suture placement were carried out when necessary. Interrupted simple sutures using a monofilament, nonabsorbable material were used for skin closure. Numbered, randomized vials were given to all patients, with standardized instructions to inspect, clean, and redress their wounds three times a day. The wounds were evaluated for clinical infection at the time of follow-up.

RESULTS

Among the groups, there was no difference in patient ages; gender; wound location, type, length, or depth; time elapsed from injury to ED treatment; number of wounds scrubbed or necessitating débridement; number of SQ and cutaneous sutures used; and rate of compliance with returning the used vial of dispensed topical agent. The wound infection rates for the treatment groups were: BAC, six of 109 (5.5%); NEO, five of 110 (4.5%); SIL, 12 of 99 (12.1%); and PTR, 19 of 108 (17.6%) (p = 0.0034).

CONCLUSION

The use of topical antibiotics resulted in significantly lower infection rates than did the use of a petrolatum control. BAC and NEO had the lowest wound infection rates.

Post-dural-puncture headache: characteristics, management, and prevention

Post-dural-puncture headache is a common complication after both diagnostic and therapeutic procedures. Prompt recognition of the clinical syndrome, followed by supportive and corrective actions, can decrease the morbidity in those afflicted. The most useful preventive measure during dural puncture in adult patients is the use of smaller cannulae with the bevel aimed parallel to the long axis of the spine.

Heads-up 3D vision system for retinal detachment surgery

Here we present procedural and safety results from our initial experience using 3D heads-up vitrectomy for retinal detachment surgery. The comparison with our outcomes from previous standard surgery shows how the new 3D system seems safe and effective.

Watching language grow in the manual modality: nominals, predicates, and handshapes

All languages, both spoken and signed, make a formal distinction between two types of terms in a proposition--terms that identify what is to be talked about (nominals) and terms that say something about this topic (predicates). Here we explore conditions that could lead to this property by charting its development in a newly emerging language--Nicaraguan Sign Language (NSL). We examine how handshape is used in nominals vs. predicates in three Nicaraguan groups: (1) homesigners who are not part of the Deaf community and use their own gestures, called homesigns, to communicate; (2) NSL cohort 1 signers who fashioned the first stage of NSL; (3) NSL cohort 2 signers who learned NSL from cohort 1. We compare these three groups to a fourth: (4) native signers of American Sign Language (ASL), an established sign language. We focus on handshape in predicates that are part of a productive classifier system in ASL; handshape in these predicates varies systematically across agent vs. no-agent contexts, unlike handshape in the nominals we study, which does not vary across these contexts. We found that all four groups, including homesigners, used handshape differently in nominals vs. predicates--they displayed variability in handshape form across agent vs. no-agent contexts in predicates, but not in nominals. Variability thus differed in predicates and nominals: (1) In predicates, the variability across grammatical contexts (agent vs. no-agent) was systematic in all four groups, suggesting that handshape functioned as a productive morphological marker on predicate signs, even in homesign. This grammatical use of handshape can thus appear in the earliest stages of an emerging language. (2) In nominals, there was no variability across grammatical contexts (agent vs. no-agent), but there was variability within- and across-individuals in the handshape used in the nominal for a particular object. This variability was striking in homesigners (an individual homesigner did not necessarily use the same handshape in every nominal he produced for a particular object), but decreased in the first cohort of NSL and remained relatively constant in the second cohort. Stability in the lexical use of handshape in nominals thus does not seem to emerge unless there is pressure from a peer linguistic community. Taken together, our findings argue that a community of users is essential to arrive at a stable nominal lexicon, but not to establish a productive morphological marker in predicates. Examining the steps a manual communication system takes as it moves toward becoming a fully-fledged language offers a unique window onto factors that have made human language what it is.

Sensitivity of children's inflection to grammatical structure

What is the input to the mental system that computes inflected forms like walked, came, dogs, and men? Recent connectionist models feed a word's phonological features into a single network, allowing it to generalize both regular and irregular phonological patterns, like stop-stopped, step-stepped and fling-flung, cling-clung. But for adults, phonological input is insufficient: verbs derived from nouns like ring the city always have regular past tense forms (ringed), even if they are phonologically identical to irregular verbs (ring the bell). Similarly, nouns based on names, like two Mickey Mouses, and compounds based on possessing rather than being their root morpheme, such as two sabertooths, take regular plurals, even when they are homophonous with irregular nouns like mice and teeth. In four experiments, testing 70 three- to ten-year-old children, we found that children are sensitive to such nonphonological information: they were more likely to produce regular inflected forms for forms like to ring ('to put a ring on') and snaggletooth (a kind of animal doll with big teeth) than for their homophonous irregular counterparts, even when these counterparts were also extended in meaning. Children's inflectional systems thus seem to be like adults': irregular forms are tied to the lexicon but regular forms are computed by a default rule, and words are represented as morphological tree structures reflecting their derivation from basic word roots. Such structures, which determine how novel complex words are derived and interpreted, also govern whether words with irregular sound patterns will be regularized: a word can be irregular only if its structure contains an irregular root in 'head' position, allowing the lexically stored irregular information to percolate up to apply to the word as a whole. In all other cases, the inflected form is compouted by a default regular rule. This proposal fits the facts better than alternatives appealing to ambiguity reduction or semantic similarity to a word's central sense. The results, together with an analysis of adult speech to children, suggest that morphological structure and a distinction between mechanisms for regular and irregular inflection may be inherent to the design of children's language systems.

Biliopancreatic diversion preserving the stomach and pylorus in the treatment of hypercholesterolemia and diabetes type II: results in the first 10 cases

BACKGROUND

Besides weight loss Scopinaro's operation produces correction of hypercholesterolemia and noninsulin dependent diabetes mellitus in all patients who suffer from these conditions. These results encouraged us to perform biliopancreatic diversion (BPD) without gastric resection, thus preserving the functions of the stomach and pylorus in moderately overweight patients with hypercholesterolemia associated with diabetes type II and hypertriglyceridemia.

METHODS

Between March 1996 and July 1997 we performed BPD without gastric resection on 10 moderately overweight patients [mean body mass index (BMI) = 33.2 kg/m2]. All patients had suffered from hypercholesterolemia and hypertriglyceridemia for more than 5 years. Ten patients suffered from diabetes type 11; four of them had had insulin treatment or oral anti-diabetic agents; the other patients all had hyperglycaemia in the fasted state and diabetes confirmed by preoperative oral glucose tolerance test (OGTT). Five patients suffered from hypertension.

RESULTS

In all patients, cholesterol and triglyceride levels returned to normal within the first postoperative month. Glycemia also stabilized at normal values in nine patients within the early weeks after surgery. One patient who took 70 U of insulin reduced his daily intake to 35 U 2 months postoperatively. In all patients blood pressure returned to normal. Weight loss was predictably slight (10-15 kg).

CONCLUSIONS

Our experience with the procedure found that this new method seems to be as effective in controlling lipidic metabolism and diabetes II as the original version of BPD. As expected, weight loss is only moderate, so that the modified BPD is not suitable for very obese patients.

Identification and characterization of YME1L1, a novel paraplegin-related gene

A gene responsible for an autosomal recessive form of hereditary spastic paraplegia (SPG7) was recently identified. This gene encodes paraplegin, a mitochondrial protein highly homologous to the yeast mitochondrial AAA proteases Afg3p, Rca1p, and Yme1p, which have both proteolytic and chaperone-like activities at the inner mitochondrial membrane. By screening the expressed sequence tag database, we identified and characterized a novel human gene, YME1L1 (YME1L1-like1, HGMW-approved symbol). This gene encodes a predicted protein of 716 amino acids highly similar to all mitochondrial AAA proteases and in particular to yeast Yme1p. Expression and immunofluorescence studies revealed that YME1L1 and paraplegin share a similar expression pattern and the same subcellular localization in the mitochondrial compartment. YME1L1 may represent a candidate gene for other forms of hereditary spastic paraplegia and possibly for other neurodegenerative disorders.

Methoxetamine: from drug of abuse to rapid-acting antidepressant

Methoxetamine is a dissociative anaesthetic showing pharmacodynamic similarities with its analogue ketamine, a medication with demonstrated rapid-acting antidepressant effects. Like ketamine and other arylcyclohexylamine compounds, methoxetamine is thought to be both a noncompetitive NMDA receptor antagonist and a dopamine reuptake inhibitor. Furthermore, it acts as an agonist at dopamine D2, serotonin 5HT2, muscarinic cholinergic, sigma-1, opioid mu and k receptors. The hypothesis is that methoxetamine can produce rapid antidepressant effects in patients with resistant and non-resistant unipolar and bipolar depression.

Emergency department evaluation and treatment of pelvic fractures

Pelvic fractures are associated with a high morbidity and mortality rate. This article reviews the anatomy of the pelvis, discusses fracture patterns commonly seen in patients with an injured pelvis, and proposes a new method of classifying pelvic fractures based on potential associated injuries. Finally, algorithms for the management of hemodynamically stable and unstable patients with pelvic fractures are presented.

Tuberculosis in Southern Brazilian wild boars (Sus scrofa): First epidemiological findings

Bovine tuberculosis (bTB) is a zoonosis caused mainly by Mycobacterium bovis that affects domestic and wild animals. In Brazil, there are no epidemiological studies on tuberculosis in wild animal populations and their possible role in the disease maintenance in cattle herds; thus, the aim of this study was to evaluate the occurrence of tuberculosis in wild boars in Rio Grande do Sul, southern Brazil. Tissue samples of animals hunted under government consent were submitted to histopathology and M. bovis polymerase chain reaction (PCR) as screening tests; the positive samples were subsequently submitted to bacterial isolation, the gold standard diagnosis. Eighty animals were evaluated, of which 27.9% and 31.3% showed histopathological changes and M. bovis genome presence, respectively. Moreover, 23.8% of the animals had at least one organ with isolates classified as Mycobacterium tuberculosis complex (MTC). Three hunting points were risk factors for positive results on screening tests. This study shows the occurrence of tuberculosis in a wild boars' population, and raise the possibility of these animals to play a role as disease reservoirs in southern Brazil. These results may help to improve the Brazilian tuberculosis control programme, as well as elucidate the circulation of mycobacteria in this country.

Suboptimal response to GnRHa long protocol is associated with a common LH polymorphism

The aim of this observational preliminary trial was to estimate the association between the most common polymorphism of LH (LH-β variant: v-βLH), with different profiles of ovarian response to recombinant human FSH (rhFSH). A total of 60 normogonadotrophic patients undergoing a gonadotrophin-releasing hormone analogue long down-regulation protocol followed by stimulation with recombinant human FSH (rhFSH) for IVF/intracytoplasmic sperm injection, and in whom at least five oocytes were retrieved were retrospectively included. On the basis of the total rhFSH consumption, patients were divided into three groups: Group A: 22 women requiring a cumulative dose of rhFSH >3500 IU; Group B: 15 patients requiring 2000-3500 IU; Group C (control): 23 women requiring <2000 IU. The presence of v-βLH was evaluated using specific immunoassays. Peak oestradiol concentrations were significantly lower in Group A when compared with both groups B (P < 0.05) and C (P < 0.001). Group A had a significantly lower (P < 0.05) number of oocytes retrieved (7.3 ± 1.5, 11.7 ± 2.4 and 14.7 ± 4.1 in the three groups, respectively). Seven carriers (31.8%) of v-βLH were found in Group A, whereas only one variant (6.7%) was observed in Group B; no variant was detected in Group C. These preliminary results suggest that v-βLH is more frequent in women with ovarian resistance to rhFSH.

Benign intracranial hypertension: a non-thrombotic complication of the primary antiphospholipid syndrome?

Benign intracranial hypertension is a rare complication of systemic lupus erythematosus often attributed to cerebral sinus thrombosis which impairs venous drainage and cerebrospinal fluid outflow. We report the case of a woman with a primary antiphospholipid syndrome who developed benign intracranial hypertension with no actual evidence of venous cerebral thrombosis and with no other possible cause for this clinical manifestation than high titres of anticardiolipin antibodies and a lupus anticoagulant.

Multi-functional flow cytometry analysis of CD4+ T cells as an immune biomarker for latent tuberculosis status in patients treated with tumour necrosis factor (TNF) antagonists

Although monitoring tuberculosis (TB) infection during long-term treatment with tumour necrosis factor (TNF) antagonists is of great importance, no monitoring strategy has yet proved successful. Indeed, even the newly proposed interferon-gamma release assays (IGRAs) are known to produce dynamic changes in IFN-γ plasma levels, making them unreliable indicators of patients' pathological/clinical status. We used intracellular cytokine flow cytometry (ICCFC) to investigate the performance of multi-functional CD4(+) T cells producing IFN-γ, interleukin (IL)-2 and/or TNF in response to Mycobacterium tuberculosis-specific antigens in subjects treated with TNF antagonists. Patients were classified into three groups based on their TB status before commencement of treatment and on IFN-γ level fluctuations evaluated by IGRA during a 36-month follow-up period. The cytokine profile of M. tuberculosis-specific CD4(+) T cells showed that latent tuberculosis infection (LTBI) subjects had a higher frequency of double-positive IFN-γ(+) IL-2(+) CD4(+) T cells and triple-positive IFN-γ(+) IL-2(+) TNF(+) CD4(+) T cells compared to those without LTBI, who showed IFN-γ-level fluctuations over time. In contrast, this latter group of patients showed similar proportions of cells producing IFN-γ alone, IL-2 alone and IL-2 in combination with TNF in response to M. tuberculosis-specific antigens. It therefore appears that patients with and without LTBI infection are characterized by different intracellular cytokine profiles. This is the first study evaluating ICCFC in patients treated with TNF antagonists, and suggests that multi-functional analysis of CD4(+) T cells could be useful for ruling out TB infection in patients classified at screening as LTBI-negative but who show IGRA fluctuations under long-term TNF antagonist treatment.

Biliopancreatic diversion for treatment of morbid obesity: experience in 50 cases

BACKGROUND

Biliopancreatic diversion (BPD) by Scopinaro's method is an operation advocated by some surgeons as an effective treatment for morbid obesity.

METHODS

Between February 1995 and April 1997 we performed BPD by Scopinaro's method on 50 patients with morbid obesity (23 males), average age 41.4 years (range 20-63 years), average body weight 135.08 kg (range 89-256 kg), mean body mass index (BMI) 50.65 kg/m2 (range 37.01-81.56 kg/m2).

RESULTS

In all cases a gradual decrease in weight was obtained [mean BMI at 1 month: 44.8 kg/m2, at 6 months (31 patients): 35.09 kg/m2, at 1 year (23 patients): 31.36 kg/m2, at 18 months (14 patients): 29.89 kg/m2 and at 2 years (5 patients): 29.27 kg/m2]. At the same time a significant improvement in the pathological conditions associated with morbid obesity was observed. The patients were able to suspend oral antihypertensive and antidiabetic therapy as these parameters spontaneously returned to normal values by the sixth postoperative month; all cases showed a marked reduction in hypercholesterolemia and hypertriglyceridemia. Postoperative complications were: one death (2%) on the third day due to heart failure; two late intestinal occlusions (4%); one acute dilatation of the stomach (2%); one peritonitis caused by early dehiscence of the anastomosis (2%); five anastomotic ulcers (10%); two cases of protein malnutrition (4%).

CONCLUSIONS

BPD by Scopinaro's method is a bariatric procedure which is technically complex. However is it safe and reproducible and it induces a substantial weight loss.