Radiologist
3 years of experience

San Francisco Va Medical Center
4150 Clement St
San Francisco, CA 94121
415-221-4810
Locations and availability (2)

Education ?

Medical School Score
Florida State University (2007)
  • Currently 2 of 4 apples

Affiliations ?

Dr. Wallace is affiliated with 2 hospitals.

Hospital Affilations

Score

Rankings

  • Mt Auburn Hospital
    330 Mount Auburn St, Cambridge, MA 02138
    • Currently 2 of 4 crosses
  • San Francisco Veterans Affairs Medical Center
    4150 Clement St, San Francisco, CA 94121
  • Publications & Research

    Dr. Wallace has contributed to 46 publications.
    Title Leukocyte Compartments in the Mouse Lung: Distinguishing Between Marginated, Interstitial, and Alveolar Cells in Response to Injury.
    Date May 2012
    Journal Journal of Immunological Methods
    Excerpt

    We developed a flow cytometry-based assay to simultaneously quantify multiple leukocyte populations in the marginated vascular, interstitial, and alveolar compartments of the mouse lung. An intravenous injection of a fluorescently labeled anti-CD45 antibody was used to label circulating and marginated vascular leukocytes. Following vascular flushing to remove non-adherent cells and collection of broncho-alveolar lavage (BAL) fluid, lungs were digested and a second fluorescent anti-CD45 antibody was added ex vivo to identify cells not located in the vascular space. In the naïve mouse lung, we found about 11 million CD45+ leukocytes, of which 87% (9.5 million) were in the vascular marginated compartment, consisting of 17% NK cells, 17% neutrophils, 57% mononuclear myeloid cells (monocytes, macrophage precursors and dendritic cells), and 10% T cells (CD4+, CD8+, and invariant NKT cells). Non-vascular compartments including the interstitial compartment contained 7.7×10(5)cells, consisting of 49% NK cells, 25% dendritic cells, and 16% other mononuclear myeloid cells. The alveolar compartment was overwhelmingly populated by macrophages (5.63×10(5)cells, or 93%). We next studied leukocyte margination and extravasation into the lung following acid injury, a model of gastric aspiration. At 1 h after injury, neutrophils were markedly elevated in the blood while all other circulating leukocytes declined by an average of 79%. At 4 h after injury, there was a peak in the numbers of marginated neutrophils, NK cells, CD4+ and CD8+ T cells and a peak in the number of alveolar NK cells. Most interstitial cells consisted of DCs, neutrophils, and CD4+ T cells, and most alveolar compartment cells consisted of macrophages, neutrophils, and NK cells. At 24 h after injury, there was a decline in the number of all marginated and interstitial leukocytes and a peak in alveolar neutrophils. In sum, we have developed a novel assay to study leukocyte margination and trafficking following pulmonary inflammation and show that marginated cells comprise a large fraction of lung leukocytes that increases shortly after lung injury. This assay may be of interest in future studies to determine if leukocytes become activated upon adherence to the endothelium, and have properties that distinguish them from interstitial and circulating cells.

    Title Adenosine A2a Receptors Induced on Inkt and Nk Cells Reduce Pulmonary Inflammation and Injury in Mice with Sickle Cell Disease.
    Date January 2011
    Journal Blood
    Excerpt

    We showed previously that pulmonary function and arterial oxygen saturation in NY1DD mice with sickle cell disease (SCD) are improved by depletion of invariant natural killer T (iNKT) cells or blockade of their activation. Here we demonstrate that SCD causes a 9- and 6-fold induction of adenosine A(2A) receptor (A(2A)R) mRNA in mouse pulmonary iNKT and natural killer (NK) cells, respectively. Treating SCD mice with the A(2A)R agonist ATL146e produced a dose-dependent reversal of pulmonary dysfunction with maximal efficacy at 10 ng/kg/minute that peaked within 3 days and persisted throughout 7 days of continuous infusion. Crossing NY1DD mice with Rag1(-/-) mice reduced pulmonary injury that was restored by adoptive transfer of 10(6) purified iNKT cells. Reconstituted injury was reversed by ATL146e unless the adoptively transferred iNKT cells were pretreated with the A(2A)R alkylating antagonist, FSPTP (5-amino-7-[2-(4-fluorosulfonyl)phenylethyl]-2-(2-furyl)-pryazolo[4,3-ε]-1,2,4-triazolo[1,5-c]pyrimidine), which completely prevented pro-tection. In NY1DD mice exposed to hypoxia-reoxygenation, treatment with ATL146e at the start of reoxygenation prevented further lung injury. Together, these data indicate that activation of induced A(2A)Rs on iNKT and NK cells in SCD mice is sufficient to improve baseline pulmonary function and prevent hypoxia-reoxygenation-induced exacerbation of pulmonary injury. A(2A) agonists have promise for treating diseases associated with iNKT or NK cell activation.

    Title Interleukin-10/ceftriaxone Prevents E. Coli-induced Delays in Sensorimotor Task Learning and Spatial Memory in Neonatal and Adult Sprague-dawley Rats.
    Date February 2010
    Journal Brain Research Bulletin
    Excerpt

    Intrauterine infection during pregnancy is associated with early activation of the fetal immune system and poor neurodevelopmental outcomes. Immune activation can lead to alterations in sensorimotor skills, changes in learning and memory and neural plasticity. Both interleukin-10 (IL-10) and Ceftriaxone have been shown to decrease immune system activation and increase memory capacity, respectively. Using a rodent model of intrauterine infection, we examined sensorimotor development in pups, learning and memory, via the Morris water maze, and long-term potentiation in adult rats. Pregnant rats at gestational day 17 were inoculated with 1 x 10(5) colony forming units of Escherichia coli (E. coli) or saline. Animals in the treatment group received IL-10/Ceftriaxone for 3 days following E. coli administration. Intrauterine infection delayed surface righting, negative geotaxis, startle response and eye opening. Treatment with IL-10/Ceftriaxone reduced the delay in these tests. Intrauterine infection impaired performance in the probe trial in the Morris water maze (saline 25.13+/-1.01; E. coli 20.75+/-1.01; E. coli+IL-10/Ceftriaxone 20.2+/-1.62) and reduced the induction of long-term potentiation (saline 141.5+/-4.3; E. coli 128.7+/-3.9; E. coli+IL-10/Ceftriaxone 140.0+/-10). In summary, the results of this study indicate that E. coli induced intrauterine infection delays sensorimotor and learning and memory, while IL-10/Ceftriaxone rescues some of these behaviors. These delays were also accompanied by an increase in interleukin-1beta levels, which indicates immune activation. IL-10/Ceftriaxone prevents these delays as well as decreases E. coli-induced interleukin-1beta activation and may offer a window of time in which suitable treatment could be administered.

    Title Nkt Cells Mediate Pulmonary Inflammation and Dysfunction in Murine Sickle Cell Disease Through Production of Ifn-gamma and Cxcr3 Chemokines.
    Date September 2009
    Journal Blood
    Excerpt

    Ischemia-reperfusion injury (IRI) triggers an inflammatory cascade that is initiated by the activation of CD1d-restricted iNKT cells. In sickle cell disease (SCD), misshapen erythrocytes evoke repeated transient bouts of microvascular IRI. Compared with C57BL/6 controls, NY1DD mice have more numerous and activated (CD69(+), interferon-gamma(+) [IFN-gamma(+)]) lung, liver, and spleen iNKT cells that are hyperresponsive to hypoxia/reoxygenation. NY1DD mice have increased pulmonary levels of IFN-gamma, IFN-gamma-inducible chemokines (CXCL9, CXCL10), and elevated numbers of lymphocytes expressing the chemokine receptor CXCR3. Treating NY1DD mice with anti-CD1d antibody to inhibit iNKT cell activation reverses baseline pulmonary dysfunction manifested as elevated vascular permeability, decreased arterial oxygen saturation, and increased numbers of activated leukocytes. Anti-CD1d antibodies decrease pulmonary levels of IFN-gamma and CXCR3 chemokines. Neutralization of CXCR3 receptors ameliorates pulmonary dysfunction. Crossing NY1DD to lymphocyte-deficient Rag1(-/-) mice decreases pulmonary dysfunction. This is counteracted by the adoptive transfer of 1 million NKT cells. Like mice, people with SCD have increased numbers of activated circulating iNKT cells expressing CXCR3. Together, these data indicate that iNKT cells play a pivotal role in sustaining inflammation in SCD mice by a pathway involving IFN-gamma and production of chemotactic CXCR3 chemokines and that this mechanism may translate to human disease.

    Title Prepartum and Intrapartum Caesarean Section Rates at Mater Mothers' Hospital Brisbane 1997-2005.
    Date April 2009
    Journal The Australian & New Zealand Journal of Obstetrics & Gynaecology
    Excerpt

    To document the rise in prepartum and intrapartum caesarean section and the demographic and medical factors contributing to the rise.

    Title A Comparison Between Back Squat Exercise and Vertical Jump Kinematics: Implications for Determining Anterior Cruciate Ligament Injury Risk.
    Date September 2008
    Journal Journal of Strength and Conditioning Research / National Strength & Conditioning Association
    Excerpt

    Women are up to eight times more likely than men to suffer an anterior cruciate ligament (ACL) injury, and knee valgus is perhaps the most at-risk motion. Women have been shown to have more knee valgus than men in squatting movements and while landing. The purposes were to investigate whether a relationship exists between lower-extremity frontal plane motions in squatting and landing, whether gender differences exist, and whether squat or hip abduction strength relates to knee valgus while landing. Eleven collegiate Division III soccer players and 11 recreationally trained men were tested for maximal vertical jump height and for squat and hip abduction strength. On the second day of testing, subjects performed light (50% one repetition maximum) and heavy (85%) squat protocols and three landings from their maximal vertical jump height. Pearson's product-moment correlation coefficients and a 2 x 10 factorial analysis of variance with t-test post hoc comparisons (p </= 0.05) were conducted. No strong correlations were shown between any of the squat conditions (eccentric and concentric light, eccentric and concentric heavy) and landing for hip abduction or knee valgus angles. Squat strength did not correlate well with knee valgus angle during landing in men or women. However, hip abduction strength did in women (R = 0.51) but not men (R = 0.10). In hip abduction angle, the eccentric portion of the light squat, eccentric and concentric portions of the heavy squat, and vertical jump landing conditions were different between genders. In knee valgus angle, only the heavy squat conditions were significantly different. Squat strength and observing squat kinematics do not seem to be a method of identifying those at risk while landing; however, hip abduction strength may be in women.

    Title Watchful Waiting and Health Related Quality of Life for Patients with Localized Prostate Cancer: Data from Capsure.
    Date May 2008
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Watchful waiting is an alternative to active treatment for men with low risk prostate cancer but it is unclear how health related quality of life (HRQoL) may change over time for men who select this option. We report on HRQoL in men with localized prostate cancer who selected watchful waiting. MATERIALS AND METHODS: HRQoL outcomes were reviewed for 310 men diagnosed with prostate cancer from 1990 to 2001 within Cancer of the Prostate Strategic Urological Research Endeavor who chose watchful waiting. The UCLA Prostate Cancer Index and RAND 36-Item Health Survey were completed at enrollment and approximately every 6 months. A random slopes model was developed to assess time trends in HRQoL for up to 5 years after diagnosis, adjusting for age at diagnosis and specific comorbidities. RESULTS: Significant decreases with time were observed in 7 domains of the RAND 36-Item Health Survey and 4 of the UCLA Prostate Cancer Index scales. CONCLUSIONS: Men with prostate cancer who chose watchful waiting in the current study had better or similar HRQoL outcomes compared to men without prostate cancer at the start of the study. Many of these scores were significantly affected by increasing age and decreased with time. The physical domain scores as well as sexual function scores decreased more than expected from the aging process alone.

    Title Bee Swarmings in Children.
    Date October 2007
    Journal The American Journal of Emergency Medicine
    Excerpt

    Africanized honeybees (Apis mellifera scutellata) are now found in the southern and southwestern United States. Swarmings can result in hundreds to thousands of stings delivering a venom load capable of producing multisystem organ failure and death. The literature on mass envenomations is scarce, being limited to case reports and case series. There are no prospective studies on mass envenomations in children. METHODS: All patients were admitted to our toxicology service, and all stingers were counted. Laboratory data and clinical assessments were obtained at baseline, 8, and 16 hours after presentation. RESULTS: Nineteen patients with a median age of 3.6 years and a median of 2.64 stings per kilogram (range, 1-4.5) were enrolled. Fifteen children had vomiting. Only a mild increase in creatine kinase was seen. None developed coagulopathy or renal insufficiency. CONCLUSION: Envenomations of up to 4.5 stings per kilogram resulted in only mild systemic illness. Vomiting does not portend involvement of other organ systems.

    Title Clinical and Psychosocial Characteristics of Men with Erectile Dysfunction: Baseline Data from Exceed.
    Date March 2007
    Journal The Journal of Sexual Medicine
    Excerpt

    INTRODUCTION: Erectile dysfunction (ED) is associated with psychological impairment, and further research is required to understand their relationship. AIM: We present descriptive baseline results from a longitudinal observational study of North American men seeking treatment for ED. METHODS: Patients completed clinical and health-related quality-of-life information at baseline and three follow-up points over 12 months; 162 patients had usable baseline data, including clinical history and current status, sociodemographic information, and standard paper-and-pencil scales of psychosocial characteristics. Scores on the International Index of Erectile Functioning erectile functioning subscale were collapsed into mild (N = 27), moderate (N = 41), or severe (N = 94) categories. Using chi-square, anova, and logistic regression, we identified baseline characteristics associated with ED severity. MAIN OUTCOME MEASURE: The main outcome measure was the degree of psychosocial impairment associated with mild, moderate, and severe ED. RESULTS: Severe ED was significantly associated with not having a regular sex partner; a history of prostate cancer; and worse scores on measures of positive affect, belonging/loneliness, sexual self-efficacy-strength, psychological adjustment, marital happiness, anxiety at last intercourse, and depression. In a multivariate logistic regression model, poorer sexual self-efficacy was most closely associated with severe ED. The model rescaled R(2) was 0.63 (area-under-the-curve, 0.91). CONCLUSIONS: Severe ED is related to impairment across a broad range of psychosocial domains, and clinicians should consider offering patients assistance in dealing with its psychosocial impact.

    Title Longitudinal Differences in Psychological Outcomes for Men with Erectile Dysfunction: Results from Exceed.
    Date March 2007
    Journal The Journal of Sexual Medicine
    Excerpt

    INTRODUCTION: The direction of the relationship between psychological adjustment and erectile dysfunction (ED) is unclear and may differ for different men, and few studies have examined psychological outcomes for men receiving ED treatment. AIM: This study assessed the impact of ED therapy at baseline and 12-month follow-up, using standard psychological measures. METHODS: Using an observational ED registry, we collected clinical and psychosocial data at baseline and 3, 6, and 12 months. Participants had (i) a patient-reported outcomes questionnaire at baseline and at least one follow-up; and (ii) data about ED treatments received during the study. Treated men were classified as responders based on improvements in International Index of Erectile Function scores from baseline to 12 months. MAIN OUTCOME MEASURES: The main outcome measures were changes in psychological outcomes in relation to treatment status and baseline ED severity. RESULTS: Of 153 patients, 40 responded to treatment, 49 did not respond to treatment, and 64 did not receive treatment. Treatment responders reported significant improvements in 12-month sexual self-efficacy but only small improvements or no change across five other psychological domains, whereas nonresponders reported small decrements. There was a trend for differences in sexual self-efficacy to vary by baseline ED severity, as well as by treatment response. CONCLUSIONS: Diagnosing and successfully treating ED significantly affects patient psychological adjustment, so providers should actively diagnose and treat ED.

    Title Myokymia After Snake Envenomation in Arizona.
    Date August 2005
    Journal Wilderness & Environmental Medicine
    Title Watchful Waiting and Health Related Quality of Life for Patients with Localized Prostate Cancer: Data from Capsure.
    Date January 2005
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Watchful waiting is an alternative to active treatment for men with low risk prostate cancer but it is unclear how health related quality of life (HRQoL) may change over time for men who select this option. We report on HRQoL in men with localized prostate cancer who selected watchful waiting. MATERIALS AND METHODS: HRQoL outcomes were reviewed for 310 men diagnosed with prostate cancer from 1990 to 2001 within Cancer of the Prostate Strategic Urological Research Endeavor who chose watchful waiting. The UCLA Prostate Cancer Index and RAND 36-Item Health Survey were completed at enrollment and approximately every 6 months. A random slopes model was developed to assess time trends in HRQoL for up to 5 years after diagnosis, adjusting for age at diagnosis and specific comorbidities. RESULTS: Significant decreases with time were observed in 7 domains of the RAND 36-Item Health Survey and 4 of the UCLA Prostate Cancer Index scales. CONCLUSIONS: Men with prostate cancer who chose watchful waiting in the current study had better or similar HRQoL outcomes compared to men without prostate cancer at the start of the study. Many of these scores were significantly affected by increasing age and decreased with time. The physical domain scores as well as sexual function scores decreased more than expected from the aging process alone.

    Title Increasing Prevalence of Gout and Hyperuricemia over 10 Years Among Older Adults in a Managed Care Population.
    Date November 2004
    Journal The Journal of Rheumatology
    Excerpt

    OBJECTIVE: To determine whether the prevalence of gout and/or clinically significant hyperuricemia increased in a managed care population over 10 years. METHODS: The study was a descriptive analysis utilizing an administrative claims database to ascertain 10-year trends in prevalence of gout and/or hyperuricemia. Prevalence rates were calculated cross-sectionally for each year (1990-99) and expressed/compared as rates per 1000 enrollees. RESULTS: The prevalence of gout and/or hyperuricemia in the overall population increased by about 2 cases per 1000 enrollees over 10 years. In the > 75 year age group, rates increased from 21 per 1000 persons in 1990 to 41 per 1000 in 1999. In the 65-74 year age group, prevalence increased from between 21 and 24 per 1000 persons in the years 1990-92 to over 31 per 1000 during the years 1997-99. Prevalence rates in younger age groups (< 65 years) stayed consistently low during the years under study. There were sex differences in most age groups, with men having the greater burden of disease at every time point. CONCLUSION: Prevalence of gout and/or hyperuricemia in the overall study population increased during the 10-year period. When stratified by age, there were increases in prevalence among groups over age 65 in both sexes. Although gout prevalence increased in both sexes over the 10-year period, men still had most of the burden of disease. In ages younger than 65, men had 4 times higher prevalence than women (4:1 ratio), but in the older age groups (> 65), the gender gap narrowed to 1 woman to every 3 men with gout and/or hyperuricemia (3:1 ratio).

    Title Patterns of Practice in the United States: Insights from Capsure on Prostate Cancer Management.
    Date September 2004
    Journal Current Urology Reports
    Excerpt

    The Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) is a national disease registry of more than 10,000 patients with prostate cancer treated at 31 primarily community-based sites across the country. The database tracks oncologic and health-related quality-of-life outcomes. Because the urologists participating in the project treat according to their usual practices, CaPSURE facilitates the study of trends in disease-management strategies, offering a reflection of "real world" practice patterns. This review highlights key studies during the past several years that document downward risk migration, validates widely used prognostic nomograms, establishes prostate-specific antigen doubling time as a surrogate endpoint for disease-specific mortality, assesses the impact of treatment on patient-reported quality of life, and presents national trends in imaging test use and primary treatment strategies for localized disease.

    Title Reduced Placental Perfusion Causes an Increase in Maternal Serum Leptin.
    Date May 2004
    Journal Placenta
    Excerpt

    OBJECTIVE: We tested the hypothesis that the inadequately perfused placenta increases production of leptin, which can be detected in maternal serum. STUDY DESIGN: Sprague-Dawley rats (n=13), on day 14 of gestation, had placement of clips on the aorta and the ovarian arteries providing 35 per cent occlusion of the vessels. Eight rats had sham surgery and 14 rats served as non-surgical controls. All animals were sacrificed on day 19 of gestation. Maternal serum was obtained, and pups and placentae were weighed. RESULTS: Both placental weights and pup weights were reduced due to reduced uterine perfusion and were negatively correlated with maternal serum leptin (P=0.018 and 0.028, respectively). Maternal serum leptin was increased in the treatment group (2.21 ng/ml+/-64 ng/ml) compared to controls (1.66 ng/ml+/-38 ng/ml) (P=0.031). CONCLUSIONS: Our findings suggest that reduced placental perfusion results in an increase in maternal serum leptin. Further investigation is needed to determine if maternal serum leptin may be useful in identifying pregnancies with uteroplacental insufficiency.

    Title Oropharyngeal Scintigraphy: a Reliable Technique for the Quantitative Evaluation of Oral-pharyngeal Swallowing.
    Date April 2004
    Journal Dysphagia
    Excerpt

    A valid and reliable technique to quantify the efficiency of the oral-pharyngeal phase of swallowing is needed to measure objectively the severity of dysphagia and longitudinal changes in swallowing in response to intervention. The objective of this study was to develop and validate a scintigraphic technique to quantify the efficiency of bolus clearance during the oral-pharyngeal swallow and assess its diagnostic accuracy. To accomplish this, postswallow oral and pharyngeal counts of residual for technetium-labeled 5- and 10-ml water boluses and regional transit times were measured in 3 separate healthy control groups and in a group of patients with proven oral-pharyngeal dysphagia. Repeat measures were obtained in one group of aged (> 55yr) controls to establish test-retest reliability. Scintigraphic transit measures were validated by comparison with radiographic temporal measures. Scintigraphic measures in those with proven dysphagia were compared with radiographic classification of oral vs. pharyngeal dysfunction to establish their diagnostic accuracy. We found that oral ( p = 0.04), but not pharyngeal, isotope clearance is swallowed bolus-dependently. Scintigraphic transit times do not differ from times derived radiographically. All scintigraphic measures have extremely good test-retest reliability. The mean difference between test and retest for oral residual was -1% (95% CI -3%-1%) and for pharyngeal residual it was -2% (95% CI -5%-1%). Scintigraphic transit times have very poor diagnostic accuracy for regional dysfunction. Abnormal oral and pharyngeal residuals have positive predictive values of 100% and 92%, respectively, for regional dysfunction. We conclude that oral-pharyngeal scintigraphic clearance is highly reliable, bolus volume-dependent, and has a high predictive value for regional dysfunction. It may prove useful in assessment of dysphagia severity and longitudinal change.

    Title Do Impotent Men with Diabetes Have More Severe Erectile Dysfunction and Worse Quality of Life Than the General Population of Impotent Patients? Results from the Exploratory Comprehensive Evaluation of Erectile Dysfunction (exceed) Database.
    Date October 2003
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: Little is known regarding how diabetic men with erectile dysfunction (ED) differ from the general population of impotent men. The primary objective of this study was to compare disease-specific health-related quality of life (HRQOL) and severity of ED in impotent men with and without diabetes. RESEARCH DESIGN AND METHODS: Validated functional and HRQOL questionnaires (including the International Index of Erectile Function, the Sexual Self-Efficacy Scale, and the Psychological Impact of Erectile Dysfunction scales) were administered to patients in an ED disease registry. Men with ED and a history of diabetes (n = 20) were compared with men with ED and no history of diabetes (n = 90) at baseline and at the 12-month follow-up. RESULTS: Diabetic impotent men reported worse erectile function and intercourse satisfaction at baseline, and ED had a greater impact on their emotional life. Diabetic men with ED had significantly different trends over time in the Erectile Function (P < 0.001), Intercourse Satisfaction (P < 0.013), Sexual Desire (P < 0.016), Overall Satisfaction (P < 0.023), and the Sexual Experience-Psychological Impact domains (P < 0.002). In addition, there was a trend toward a difference over time in the Emotional Life-Psychological Impact domain (P < 0.067). CONCLUSIONS: Impotent men with diabetes present with worse ED than nondiabetic men with ED, resulting in worse disease-specific HRQOL in the diabetic men. Although diabetic patients initially respond well to ED treatment, responses do not appear to be durable over time. Therefore, clinicians must provide longer-term follow-up when treating ED in diabetic patients.

    Title Longitudinal Differences in Disease Specific Quality of Life in Men with Erectile Dysfunction: Results from the Exploratory Comprehensive Evaluation of Erectile Dysfunction Study.
    Date April 2003
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We assessed the impact of erectile dysfunction therapy on 1-year health related quality of life using a validated erectile dysfunction specific instrument. MATERIALS AND METHODS: Using an observational erectile dysfunction registry clinical, sociodemographic and health related quality of life information was collected at baseline, and 3, 6 and 12 months later. Only men who reported undergoing erectile dysfunction treatment were included in this analysis sub-sample. Patients were classified as treatment responders based on improvements in International Index of Erectile Function scores. Changes in health related quality of life scores from baseline were compared between responders and nonresponders. RESULTS: The cohort consisted of 89 patients, of whom 40 (45%) responded to therapy by International Index of Erectile Function criteria. Responders and nonresponders had comparable baseline disease severity and health related quality of life. At 1 year responders reported significantly better health related quality of life and greater improvement from baseline in sexual experience (mean change -1.64 versus 3.19) and emotional life (mean -3.01 for responders versus 1.75) domains of the Psychological Impact of Erectile Dysfunction scales (p <0.01). This 4.5 to 5 point difference in mean change score (1/2 SD) was considered moderately clinically significant. CONCLUSIONS: Men who respond to erectile dysfunction treatment report significantly better health related quality of life 1 year after initial presentation for erectile dysfunction than nonresponders. This finding should motivate providers to be more proactive in diagnosing and treating men with erectile dysfunction since successful therapy appears to improve health related quality of life. These data suggest that men in whom primary therapy for erectile dysfunction fails should be offered secondary treatment because many men in this study in whom previous therapies failed reported improved health related quality of life when they began effective secondary treatment.

    Title Acute Propylene Glycol Ingestion.
    Date September 2002
    Journal Journal of Toxicology. Clinical Toxicology
    Excerpt

    BACKGROUND: We describe a case of acute propylene glycol toxicity following ingestion of ethanol and propylene glycol-containing antifreeze in which blood lactate, serum propylene glycol, ethanol, and CO2 concentrations were serially measured. CASE REPORT: A 61-year-old man was hospitalized after acute ingestion of ethanol and automotive antifreeze. His clinical presentation and course were essentially unremarkable. Initial lab tests revealed serum ethanol concentration, 167 mg/dL, normal serum electrolytes and osmol gap, 120 mOsm/kg. Intravenous 10% ethanol infusion was begun for suspected ethylene glycol toxicity and discontinued at approximately 17 hours post-ingestion. Toxicological analysis of urine was positive for ethanol and propylene glycol, and negative for ethylene glycol, methanol, and isopropanol. Blood lactate was mildly elevated and serum CO2 concentration was normal. Gas chromatographic analysis of serial serum specimens for propylene glycol concentration revealed a maximum value of 470 mg/dL at 7 hours and a nonlinear decline to below detection limit (3 mg/dL) at 57 hours after antifreeze ingestion. The patient was discharged on hospital day 2. CONCLUSION: The propylene glycol elimination pattern, absence of significant acid-base disturbance, and minimal lactate elevation in this case are consistent with ethanol-related inhibition of propylene glycol metabolism. The effect of ethanol on clinical outcome after acute propylene glycol intoxication remains uncertain.

    Title Biomechanics of Failed Deglutitive Upper Esophageal Sphincter Relaxation in Neurogenic Dysphagia.
    Date July 2002
    Journal American Journal of Physiology. Gastrointestinal and Liver Physiology
    Excerpt

    Our aims were to examine the etiology and biomechanical properties of the nonrelaxing upper esophageal sphincter (UES) and the relationship between UES opening and failed relaxation. We examined the relationships among swallowed bolus volume, intrabolus pressure, sagittal UES diameter, the pharyngeal swallow response, and geniohyoid shortening in 18 patients with failed UES relaxation, 23 healthy aged controls, and 15 with Zenker's diverticulum. Etiology of failed UES relaxation was 56% medullary disease, 33% Parkinson's or extrapyramidal disease; and 11% idiopathic. Extent of UES opening ranged from absent to normal and correlated with preservation of the pharyngeal swallow response (P = 0.012) and geniohyoid shortening (P = 0.046). Intrabolus pressure was significantly greater compared with aged controls (P < 0.001) or Zenker's diverticulum (P < 0.001). The bolus volume-dependent increase in intrabolus pressure evident in controls was not observed in failed UES relaxation. The nonrelaxing UES therefore displays a constant loss of sphincter compliance throughout the full, and potentially normal, range of expansion during opening. Adequacy of UES opening is influenced by the degree of preservation of the pharyngeal swallow response and hyolaryngeal traction. In contrast, the stenotic UES displays a static loss of compliance, only apparent once the limit of sphincter expansion is reached.

    Title Postcollection Rise in Methemoglobin Level in Frozen Blood Specimens.
    Date May 2002
    Journal Journal of Toxicology. Clinical Toxicology
    Excerpt

    A patient with nonspecific complaints had four previous venous blood samples showing elevated methemoglobin fractions of 15.6-20.1%. Cooximetry on a fresh specimen revealed a methemoglobin fraction of 0.8%, while that reported by the original laboratory on the simultaneously collected specimen was 14.9%. The laboratory assayed the specimen after holding it in frozen storage. Venous blood from a healthy volunteer was assayed by cooximetry after storage under conditions of room temperature (22-24 degrees C), refrigeration (1-4 degrees C), and freezing (-14 to -12 degrees C). Methemoglobin level in frozen-thawed specimens rose over time from 1.8% (0.29 g/dL) at 6 hour to 10.9% (1.71 g/dL) after 6 days. With the exception of a single specimen stored in an EDTA-containing tube at room temperature for 6 days, methemoglobin in nonfrozen specimens never exceeded 0.8% (0.12 g/dL).

    Title Diagnostic Use of Physicians' Detection of Urine Fluorescence in a Simulated Ingestion of Sodium Fluorescein-containing Antifreeze.
    Date July 2001
    Journal Annals of Emergency Medicine
    Excerpt

    STUDY OBJECTIVE: We sought to assess physicians' ability to accurately determine the presence or absence of sodium fluorescein (SF) in urine at a concentration corresponding to that present after ingestion of a toxic amount of commercial automotive antifreeze. METHODS: We studied 2 different urine specimen evaluation formats--one presenting isolated specimens, and the other presenting specimens grouped for comparison--to determine whether the visual clues afforded by grouped comparison aided the accuracy of the evaluation. On each study day, 3 urine specimens (1 control specimen obtained before SF administration and 2 specimens obtained after SF administration) were obtained from each of 9 or 10 volunteers. Each of these 27 or 30 urine specimens were presented sequentially and in random order to 2 emergency physicians during separate evaluation time periods. Each physician was asked to classify each specimen as fluorescent or nonfluorescent (sequential format). After a rest period, each physician, again separately, was asked to look at the same 27 or 30 urine specimens, this time all together in a test tube rack so that grouped comparisons were possible. The physicians again classified each sample as either fluorescent or nonfluorescent (grouped format). We assessed sensitivity, specificity, and accuracy of the evaluation by each presentation format (sequential or grouped). RESULTS: Mean examiner sensitivity, specificity, and accuracy for detecting the presence of SF in urine using the sequential presentation format were 35%, 75%, and 48%, respectively, whereas the same test performance indices were 42%, 66%, and 50%, respectively, when the grouped format was used. CONCLUSION: Wood's lamp determination of urine fluorescence is of limited diagnostic utility in the detection of SF ingestion in an amount equivalent to toxic ingestion of some ethylene glycol--containing automotive antifreeze products.

    Title Intravenous Pyridoxine-induced Metabolic Acidosis.
    Date July 2001
    Journal Annals of Emergency Medicine
    Excerpt

    STUDY OBJECTIVE: Pyridoxine hydrochloride, the antidote for isonicotinic acid hydrazide (INH)--induced seizures, is available in solution at a concentration of 100 mg/mL at a pH of less than 3. Pyridoxine is often infused rapidly in large doses for INH-induced seizures. Effects of pyridoxine infusion on base deficit in amounts given for INH poisoning have not been studied in human subjects. We hypothesized that this infusion would result in transient worsening of acidosis. METHODS: We conducted a randomized, controlled crossover trial in human volunteers. Five healthy volunteers (mean age, 35 years; range, 29 to 43 years) were randomized to receive intravenous placebo (50 mL of normal saline solution) or 5 g of pyridoxine (50 mL) over 5 minutes. A peripheral intravenous catheter was established in each arm, and a heparinized venous blood sample was obtained for base deficit at baseline and 3, 6, 10, 20, and 30 minutes after infusion. After at least a 1-week washout period, the volunteers were assigned to the alternate arms of the experiments, thus acting as their own control subjects. Data were analyzed by using the 2-tailed paired t test, controlling for multiple comparisons. RESULTS: No difference was noted between groups at baseline. A statistically significant increased base deficit was noted after the pyridoxine infusion versus control at 3 to 20 minutes but not at 30 minutes (P =.1). Maximal mean increase in base deficit (2.74 mEq/L) was noted at 3 minutes. CONCLUSION: A transient increase in base deficit occurs after the infusion of 5 g of pyridoxine in normal volunteers.

    Title Development and Validation of a Self-report Symptom Inventory to Assess the Severity of Oral-pharyngeal Dysphagia.
    Date April 2000
    Journal Gastroenterology
    Excerpt

    BACKGROUND & AIMS: The aim of this study was to develop and evaluate the validity and reliability of a self-report inventory to measure symptomatic severity of oral-pharyngeal dysphagia. METHODS: Test-retest reliability and face, content, and construct validity of a prototype visual analogue scale inventory were assessed in 45 patients who had stable, neuromyogenic dysphagia. RESULTS: Normalized scores varied over time by -0.5% +/- 17.6% (95% confidence interval, -9.2% to 8.2%). Factor analysis identified a single factor (dysphagia), to which 18 of 19 questions contributed significantly, that accounted for 56% of total variance (P < 0.0001). After deletion of 2 questions with poor face validity and patient compliance, this proportion increased to 59%; mean test-retest change was -2% (95% confidence interval, -11% to 7%); and total score correlated highly with an independent global assessment severity score (r = 0.7; P < 0.0001). A mean 70% reduction in score (P < 0.0001) was observed after surgery in patients with Zenker's diverticulum (discriminant validity). CONCLUSIONS: Applied to patients with neuromyogenic dysphagia, the 17-question inventory shows strong test-retest reliability over 2 weeks as well as face, content, and construct validity. Discriminant validity (responsiveness) has been demonstrated in a population with a correctable, structural cricopharyngeal disorder. Responsiveness of the instrument to treatment in neuromyogenic dysphagia remains to be quantified.

    Title Food Pollution.
    Date March 2000
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Title Legal Hemp Products and Urine Cannabinoid Testing.
    Date January 2000
    Journal Journal of Toxicology. Clinical Toxicology
    Title Cricopharyngeal Myotomy Does Not Increase the Risk of Esophagopharyngeal Acid Regurgitation.
    Date December 1999
    Journal The American Journal of Gastroenterology
    Excerpt

    OBJECTIVE: It is not known whether cricopharyngeal myotomy predisposes to esophagopharyngeal regurgitation. Using ambulatory, dual pharyngeal, and esophageal pH monitoring before and after cricopharyngeal myotomy, our aim was to determine the effect, if any, of myotomy on the frequency of esophagopharyngeal acid regurgitation. METHODS: We studied prospectively 18 patients who underwent cricopharyngeal myotomy for pharyngeal dysphagia (10 Zenker's, eight neurogenic dysphagia), of whom 17 agreed to undergo dual pH monitoring preoperatively, and 10 who agreed to both pre- and postoperative monitoring. RESULTS: Symptoms of gastroesophageal reflux disease were present in 30%. Cricopharyngeal myotomy significantly reduced basal upper esophageal sphincter pressure by 49%, from 37+/-5 mm Hg to 19+/-3 mm Hg (p = 0.007). Esophagopharyngeal regurgitation was a rare event and the frequency of it did not differ between patients and healthy controls. Preoperatively, three regurgitation events in two patients did not differ from the postoperative frequency of a total of two events in the same two patients. CONCLUSIONS: Increased esophageal acid exposure is common and esophagopharyngeal regurgitation is rare in unselected patients undergoing cricopharyngeal myotomy for pharyngeal dysphagia. Myotomy does not increase the frequency of esophagopharyngeal acid regurgitation in such patients.

    Title Esophagopharyngeal Acid Regurgitation: Dual Ph Monitoring Criteria for Its Detection and Insights into Mechanisms.
    Date December 1999
    Journal Gastroenterology
    Excerpt

    BACKGROUND & AIMS: A valid technique for the detection of esophagopharyngeal acid regurgitation would be valuable to evaluate suspected reflux-related otolaryngologic and respiratory disorders. The aim of this study was to derive pH criteria that optimally define esophagopharyngeal acid regurgitation and to examine patterns of regurgitation. METHODS: In 19 healthy controls and 15 patients with suspected regurgitation, dual or quadruple pH sensors were used to monitor pharyngeal and esophageal pH. For each combination of the 2 variables, DeltapH and nadir pH, proportions of pH decreases that occurred during or independent of esophageal acidification were calculated to determine the likelihood that an individual pharyngeal pH decrease was a candidate regurgitation event or a definite artifact. RESULTS: Overall, 92% of pharyngeal pH decreases of 1-2 pH units and 66% of pH decreases of this magnitude reaching a nadir pH of <4 were artifactual. Optimal criteria defining a pharyngeal acid regurgitation event were a pH decrease that occurred during esophageal acidification, had a DeltapH of >2 units, and reached a nadir of <4 units in less than 30 seconds. Regurgitation occurred more frequently in subjects in an upright (32 of 35) than in a supine (3 of 35 events; P </= 0.0001) position and was more frequently abrupt (synchronous with esophageal acidification) than delayed (P </= 0.05). CONCLUSIONS: Accepted criteria for gastroesophageal reflux are not applicable to the detection of esophagopharyngeal acid regurgitation, and most regurgitation occurs abruptly and in upright position.

    Title Effect of Magnesium Hydroxide on Iron Absorption After Ferrous Sulfate.
    Date November 1999
    Journal Annals of Emergency Medicine
    Title Self-inflicted Burn Injuries: an 11-year Retrospective Study.
    Date June 1999
    Journal The Journal of Burn Care & Rehabilitation
    Excerpt

    The burns unit at the Royal Brisbane Hospital accepted a total of 2275 admissions from 1986 to 1996. During this 11-year period, 65 cases of self-inflicted burn injury were treated, which made up 2.9% of the total number of admissions. A mortality rate of 21.5% (14 patients) is noted, with all patients dying after admission to the hospital. A common feature of people that self-inflict burn injuries is a psychiatric history, with many patients having histories of self-harm or suicide attempts. Two distinct groups were identified--those with suicidal intent and those with intent of self-harm. Those patients with self-inflicted injuries have an increased mean of 31.4% total body surface area burned as compared with those patients whose injuries are accounted for as accidental, which have a mean total body surface area burned of 10%. Additionally, the mean length of stay in the hospital for patients with self-inflicted injuries was 40 days for acute injuries, which is prolonged; the mean length of stay for acute injuries that were not self-inflicted was 14 days. This investigation discovered 3 cases of repeated self-inflicted burn injury.

    Title Acute Cyanide Toxicity Caused by Apricot Kernel Ingestion.
    Date December 1998
    Journal Annals of Emergency Medicine
    Excerpt

    A 41-year-old woman ingested apricot kernels purchased at a health food store and became weak and dyspneic within 20 minutes. The patient was comatose and hypothermic on presentation but responded promptly to antidotal therapy for cyanide poisoning. She was later treated with a continuous thiosulfate infusion for persistent metabolic acidosis. This is the first reported case of cyanide toxicity from apricot kernel ingestion in the United States since 1979.

    Title Effect of Magnesium Hydroxide on Iron Absorption Following Simulated Mild Iron Overdose in Human Subjects.
    Date December 1998
    Journal Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine
    Excerpt

    OBJECTIVE: To determine the effect of oral magnesium hydroxide [Mg(OH)2] on iron absorption after simulated iron overdose in human subjects. METHODS: A randomized, controlled crossover study was conducted in healthy adult male human volunteers taking no medications. Subjects received an average of 5.0 mg/kg elemental iron orally followed 1 hour later by either oral administration of 4.5 g of Mg(OH)2 per g ingested elemental iron or no treatment. Serial serum specimens were obtained over the 12 hours following iron ingestion and stored at -60 degrees C until standard serum iron assay was performed. After a 2-week washout period, the subjects were enrolled in the alternative trial arm. Individual baseline diurnal variation in serum iron levels was determined over a 12-hour period on the day prior to each trial. Area under time-concentration curves (AUCs) were calculated, and the AUC due to experimental iron ingestion (deltaAUC) was determined by subtracting the baseline diurnal AUC from the experimental AUC for each subject. RESULTS: Thirteen healthy adult male subjects were enrolled. Mean +/- SEM for deltaAUC due to experimental iron ingestion followed by treatment with Mg(OH)2, 78 +/- 23 micromol(hr)/L, was significantly less than that followed by no treatment, 144 +/- 33 micromol(hr)/L (p = 0.03 by signed rank test). CONCLUSIONS: Magnesium hydroxide, administered 1 hour post-iron ingestion at an oral dose of 4.5 g per g elemental iron ingested, significantly reduced iron absorption during a 12-hour period following simulated mild iron overdose in healthy adult human volunteers.

    Title Zolpidem Binds to Omega, Not Mu, Receptors.
    Date April 1998
    Journal Journal of Toxicology. Clinical Toxicology
    Title Antibiotic-induced Convulsions.
    Date January 1998
    Journal Critical Care Clinics
    Excerpt

    Convulsive episodes are associated with the use of a number of antimicrobial agents. Although seizures may be a feature of the disease being treated, antibiotics should be considered possible causes of seizures, particularly if suggested by temporal relationships between seizure activity and drug administration. The astute clinician should be aware of the clinical settings in which antibiotic-induced seizures occur, be familiar with likely agents and their mechanisms of toxicity, and be prepared to institute appropriate management directed at this adverse effect of antimicrobial therapy.

    Title Influence of Altered Tongue Contour and Position on Deglutitive Pharyngeal and Ues Function.
    Date December 1997
    Journal The American Journal of Physiology
    Excerpt

    The potential influence of altered lingual position and contour during the bolus loading phase of the swallow in mediating the swallowed bolus volume-dependent regulation of upper esophageal sphincter (UES) relaxation and opening was studied in 15 healthy volunteers using simultaneous videoradiography and manometry. A maxillary dental splint modulated tongue deformity during the early oral phase of deglutition. We examined the effect of the splint and swallowed bolus density on bolus volume-dependent changes in the timing of events in the swallow sequence and on hypopharyngeal intrabolus and midpharyngeal pressures. Peak mid-pharyngeal pressure (P = 0.001) and hypopharyngeal intrabolus pressure (P = 0.04) were significantly reduced by the splint. The normal volume-dependent earlier onset of sphincter relaxation and opening was preserved with the splint in situ. The splint significantly delayed the onset of hyoid motion and UES relaxation and opening without influencing transit times or total swallow duration. Alterations in tongue contour and position reduce intrabolus pressure and pharyngeal contraction without influencing normal bolus volume-dependent regulation of timing of UES relaxation and opening.

    Title Predictors of Outcome Following Cricopharyngeal Disruption for Pharyngeal Dysphagia.
    Date July 1997
    Journal Dysphagia
    Excerpt

    The indications for, and predictors of outcome following cricopharyngeal disruption in pharyngeal dysphagia are not clearly defined. Our purpose was to examine the symptomatic response to cricopharyngeal disruption, by either myotomy or dilatation, in patients with oral-pharyngeal dysphagia and to determine pre-treatment manometric or radiographic predictors of outcome. Using simultaneous pharyngeal videoradiography and manometry, we studied 20 patients with pharyngeal dysphagia prior to cricopharyngeal dilatation (n = 11) or myotomy (n = 8), and 23 healthy controls. We measured peak pharyngeal pressure, hypopharyngeal intrabolus pressure, upper esophageal sphincter diameter, and coordination. Response rate to sphincter disruption was 65%. The extent of sphincter opening was significantly reduced in patients compared with controls (p = 0.004), but impaired sphincter opening was not a predictor of outcome. Increased hypopharyngeal intrabolus pressures (> 19 mmHg for 10 ml bolus; > 31 mmHg for 20 ml bolus) was a significant predictor of outcome (p = 0.01). Neither peak pharyngeal pressure nor incoordination were predictors of outcome. In pharyngeal dysphagia, hypopharyngeal intrabolus pressure, and not peak pharyngeal pressure, is a predictor of response to cricopharyngeal disruption. The relationship between intrabolus pressure and impaired sphincter opening is an indirect measure of sphincter compliance which helps predict therapeutic response.

    Title Mechanisms of Oral-pharyngeal Dysphagia in Patients with Parkinson's Disease.
    Date March 1996
    Journal Gastroenterology
    Excerpt

    BACKGROUND & AIMS: Oral-pharyngeal dysphagia in Parkinson's disease is well recognized. The aim of this study was to establish the mechanisms of oral-pharyngeal dysphagia in these patients. METHODS: Using simultaneous videoradiography and pharyngeal manometry, we studied 19 patients with Parkinson's disease (12 with oral-pharyngeal dysphagia and 7 without oral-pharyngeal dysphagia) and compared them with 23 healthy controls. RESULTS: the clinical severity of Parkinson's disease predicted neither the presence nor the severity of dysphagia. Minor alterations in oral function were common in controls and patients, but pharyngeal dysfunction was significantly more prevalent in patients. Incomplete upper esophageal sphincter (UES) relaxation was present in 4 patients (21%), all of whom showed increased hypopharyngeal intrabolus pressure, but not all of whom had a diminished UES opening. The patients had a reduced UES diameter (P = 0.004) and a higher intrabolus pressure compared with the controls (P = 0.007). Pharyngeal contraction pressures were lower in patients, but 6 patients with dysphagia and an abnormal pharyngeal wall motion had normal peak pressures. CONCLUSIONS: An incomplete UES relaxation and a reduced UES opening, both associated with high intrabolus pressure, are prevalent in Parkinson's disease. Oral-pharyngeal dysphagia in Parkinson's disease is multifactorial, with the majority of patients showing oral and pharyngeal dysfunction, even before the clinical expression of dysphagia. Impaired pharyngeal bolus transport is the major determinant of dysphagia.

    Title Influence of Cold Stimulation on the Normal Pharyngeal Swallow Response.
    Date February 1996
    Journal Dysphagia
    Excerpt

    We examined the potential influence of cold stimulation of the anterior tonsillar pillars, before and after topical anesthesia, on the temporal linkage between the oral and pharyngeal components of the swallow. We hypothesized that if elicitation of the pharyngeal swallow were dependent upon stimulation of faucial mucosal receptors this response would be facilitated by cold tactile stimulation and inhibited by topical anesthesia. In 14 healthy volunteers undergoing simultaneous videoradiography and manometry we measured and compared regional transit and clearance times, and the timing of hyoid motion, upper esophageal sphincter relaxation, and opening within the swallow sequence. There was a significant, volume-dependent forward shift in timings of hyoid motion, upper esophageal sphincter (UES) relaxation profile, and opening which were influenced neither by cold stimulation nor topical anesthesia. Regional transit and clearance times and UES coordination were not influenced by cold stimulation. Pharyngeal clearance time was prolonged by tonsillar pillar anesthesia due to earlier arrival of the bolus head at this region (p = 0.002). We conclude that the normal pharyngeal swallow response is neither facilitated nor inhibited by prior cold tactile stimulation or topical anesthesia to the tonsillar pillars, respectively. These observations do not support the hypothesis that elicitation of the pharyngeal swallow response is dependent upon stimulation of mucosal receptors in the tonsillar arches.

    Title Influence of Mucosal Receptors on Deglutitive Regulation of Pharyngeal and Upper Esophageal Sphincter Function.
    Date November 1994
    Journal The American Journal of Physiology
    Excerpt

    The potential influence of mucosal sensory receptors on the regulation of oral-pharyngeal swallow events was studied in 15 healthy volunteers using simultaneous videoradiography and manometry. We determined the effects of selective pharyngeal and oral plus pharyngeal anesthesia on the following temporal and manometric measures in response to liquid and viscous swallows: regional transit and clearance times; motion of hyoid and larynx; upper esophageal sphincter relaxation, opening, and closure; and pharyngeal contraction wave characteristics. Under the influence of mucosal anesthesia no subjects demonstrated aspiration during deglutition. Neither regional transit and clearance times nor pharyngosphincteric coordination was influenced significantly by pharyngeal mucosal anesthesia or oral plus pharyngeal anesthesia. Although midpharyngeal and distal pharyngeal contraction amplitudes were not influenced by mucosal anesthesia, midpharyngeal contraction wave duration was reduced significantly by both pharyngeal (P = 0.02) and oral plus pharyngeal anesthesia (P = 0.0005). We conclude that 1) neither elicitation of the pharyngeal swallow response nor temporal regulation among swallow events is dependent on mucosal sensory receptors and 2) duration of the pharyngeal contraction is influenced by sensory input from the oral-pharyngeal mucosa.

    Title Expediting the Early Hospital Care of the Adult Patient with Nontraumatic Chest Pain: Impact of a Modified Ed Triage Protocol.
    Date December 1993
    Journal The American Journal of Emergency Medicine
    Excerpt

    A prospective study that compared a traditional emergency department (ED) triage protocol with an expedited protocol was conducted to determine if minimizing the subjectivity of nursing triage would result in more efficient management of adult patients presenting with nontraumatic chest pain. The traditional protocol triaged 382 patients into 1 of 5 categories of acuity. The expedited study group (418 patients) were triaged as usual but subsequently were treated as if they were triage category 1 or 2 (medical evaluation within 15 minutes of arrival). Traditional triage led to 40% of acute myocardial infarction (AMI) patients being triaged into inappropriately low-acuity categories. The expedited protocol resulted in significant improvement in the following intervals: ED arrival to triage, triage to cubicle, ED arrival to cubicle, ED arrival to electrocardiogram (ECG) ordered, ED arrival to ECG available, ED arrival to physician evaluation, and ED arrival to decision to thrombolyse. Study patients with non-AMI cardiac chest pain and AMI cardiac chest pain were evaluated by a physician an average of 12 minutes and 8 minutes after ED arrival, respectively. Delays in interdepartmental processes, such as ECG-technician responsiveness, thrombolysis protocol fulfillment and thrombolytic agent delivery, negated benefits derived from improvements in internal processes. Effective coordination of the numerous processes involved in the initial ED management of adult patients with nontraumatic chest pain is required to make thrombolytic therapy for AMI within 30 minutes of patient arrival a routinely achievable goal.

    Title Relevant Factors in the Identification of Hearing Loss.
    Date March 1992
    Journal Ear and Hearing
    Excerpt

    This study examined factors which may affect early identification of hearing loss. The medical records of 123 children with educationally significant hearing impairment were examined. Information about each child's degree and type of hearing loss, etiology, referral source, birth and medical history, additional handicaps, age of suspicion of loss, mode of identification, age of identification, and age at which aided was entered into a database for further analysis. The age range for identification was 7 weeks to 10 yr, with a median age of 2.1 yr. Children with a greater degree of hearing loss, an additional handicap, additional medical conditions, or an etiology strongly associated with hearing loss were identified earlier than those without these factors. Unexpectedly, children with a history of middle ear dysfunction were identified no later than those without, and children with a positive family history of hearing loss were identified later than those with a negative family history. These results agree with other studies which show that, in general, children are identified and habilitated at a later age than that recommended by both the American Speech-Language-Hearing Association Committee and the Joint Committee on Infant Hearing.

    Title Blunt Aortic Trauma: Signs of High Risk.
    Date July 1990
    Journal The Journal of Trauma
    Excerpt

    In the last 10 years, our center has managed 60 cases of aortic rupture from blunt chest trauma. Nineteen patients died (32%), 11 of whom were moribund on admission. Two patients out of ten who had undergone aortography at other institutions arrived at our hospital with massive bleeding in the left chest and died despite immediate operation. Six patients exsanguinated 1 to 2 1/2 hours after admission while aortography was being arranged or performed, and review of these cases to identify clinical signs of high risk revealed that left hemothorax, pseudocoarctation, and/or supraclavicular hematoma were present in five of the six. It appeared that the survival rate of patients suspected of blunt aortic trauma who had any of these clinical signs might be improved if they were taken directly to the operating room. To investigate this possibility we reviewed all cases from the past 10 years (excluding patients moribund on arrival or who had aortography elsewhere) in whom suspicion of aortic trauma led to aortography or surgery. Thirteen of the 17 patients (76%) with one or more signs of high risk had torn the aortic isthmus, compared to 26 of 154 patients (17%) without these signs. Five of the high-risk group (29%) exsanguinated, compared to one (less than 1%) of the others. No patient in this series died from unsuspected aortic trauma, which we attribute to the liberal use of aortography. Except for the patients with exsanguinating hemorrhage preoperatively, there were no operative or postoperative deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Hepatic Vein Bullet Embolus As a Complication of Left Thoracic Gunshot Injury.
    Date February 1987
    Journal Annals of Emergency Medicine
    Excerpt

    The case of a patient with a hepatic vein bullet embolus complicating a left ventricular gunshot injury is described. The patient presented hypotensive with a left midaxillary entrance wound. Initial radiographs showed a bullet fragment below the right hemidiaphragm. Emergency open thoracotomy was performed with release of a tense pericardial effusion and repair of a left ventricular penetrating wound. Surgical exploration failed to reveal direct penetrating injury to the diaphragm or abdominal viscera. After a hepatic venogram localized the bullet fragment in a branch of the right lobe hepatic vein, a periscopically directed catheter extraction of the fragment was successfully performed. A discussion of missile embolization, its pathology, clinical presentation, diagnosis, and management is presented.

    Title Adenosine A2a Receptor Activation Reduces Infarct Size in the Isolated, Perfused Mouse Heart by Inhibiting Resident Cardiac Mast Cell Degranulation.
    Date
    Journal American Journal of Physiology. Heart and Circulatory Physiology
    Excerpt

    Mast cells are found in the heart and contribute to reperfusion injury following myocardial ischemia. Since activation of A2A adenosine receptors (A2AARs) inhibits reperfusion injury, we hypothesized that ATL146e (a selective A2AAR agonist) might protect hearts in part by reducing cardiac mast cell degranulation. Hearts were isolated from 5 groups of congenic mice: A2AAR(+/+); A2AAR(-/-); mast cell deficient (KitW-sh/W-sh); and chimeric mice prepared by transplanting bone marrow from A2AAR(-/-) or A2AAR(+/+) mice to radiation-ablated A2AAR(+/+) mice. Six weeks after bone marrow transplantation, cardiac mast cells were repopulated with >90% donor cells. In isolated-perfused hearts subjected to ischemia-reperfusion injury, ATL146e or CGS21680 (100 nmol/L) decreased infarct size (IS, % area at risk) from 38 +/- 2% to 24 +/- 2% and 22 +/- 2% in ATL146e- and CGS21680-treated hearts, respectively (P<0.05) and significantly reduced mast cell degranulation, measured as tryptase release into reperfusion buffer. These changes were absent in A2AAR(-/-) hearts and in hearts from chimeric mice with A2AAR-/- bone marrow. Vehicle-treated KitW-sh/W-sh mice had lower IS (11 +/- 3%) than WT mice, and ATL146e had no significant protective effect (16 +/- 3%). These data suggest that in ex vivo, buffer-perfused hearts, mast cell degranulation contributes to ischemia-reperfusion injury. In addition, our data suggest that A2AAR activation is cardioprotective in the isolated heart at least in part by attenuating resident mast cell degranulation. Key words: Langendorff, tryptase, ATL146e, bone marrow chimera.

    Title Falsely Elevated Salicylate Levels.
    Date
    Journal Journal of Medical Toxicology : Official Journal of the American College of Medical Toxicology
    Excerpt

    We report a case of falsely elevated salicylate levels resulting from hyperlipidemia in which improper sample processing led to reproducible errors in analysis. While hyperlipidemia has been shown to alter spectrophotometric laboratory results, spuriously elevated salicylate levels resulting from hyperlipidemia have not been previously reported in the literature.

    Title Congenital Portosystemic Shunts: Imaging Findings and Clinical Presentations in 11 Patients.
    Date
    Journal European Journal of Radiology
    Excerpt

    OBJECTIVE: To evaluate the clinical anatomy and presentations of congenital portosystemic shunts, and determine features that promote recognition on imaging. MATERIALS AND METHODS: Institutional review board approval was obtained for this HIPAA-compliant study. The requirement for written informed consent was waived. Radiology reports were retrospectively reviewed from non-cirrhotic patients who underwent imaging studies from January 1999 through February 2009. Clinical sources reviewed included electronic medical records, archived images and histopathological material. RESULTS: Eleven patients with congenital portosystemic shunts were identified (six male and five female; age range 20 days to 84 years). Seven patients had extrahepatic and four patients had intrahepatic shunts. All 11 patients had absent or hypoplastic intrahepatic portal veins, a feature detected by CT and MRI, but not by US. Seven patients presented with shunt complications and four with presentations unrelated to shunt pathophysiology. Three adult patients had four splenic artery aneurysms. Prospective radiological evaluation of five adult patients with cross-sectional imaging had failed prospectively to recognize the presence of congenital portosystemic shunts on one or more imaging examinations. CONCLUSIONS: Congenital portosystemic shunts are associated with splenic artery aneurysms, a previously unrecognized association. Portosystemic shunts were undetected during prospective radiologic evaluation in the majority of adult patients, highlighting the need to alert radiologists to this congenital anomaly.

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