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OBJECTIVE: To evaluate the influence of neurally adjusted ventilatory assist (NAVA) and positive end-expiratory pressure (PEEP) on the control of breathing in rabbits with acute lung injury. DESIGN: Prospective animal study. SETTING: Experimental laboratory in a university hospital. SUBJECTS: Male White New Zealand rabbits (n = 18). INTERVENTION: Spontaneously breathing rabbits with hydrochloric acid-induced lung injury were ventilated with NAVA and underwent changes in NAVA gain and PEEP (six nonvagotomized and five vagotomized). Seven other nonvagotomized rabbits underwent 4 hrs of ventilation with hourly titration of PEEP, Fio2, and NAVA gain. MEASUREMENTS AND MAIN RESULTS: We studied diaphragm electrical activity, respiratory pressures, and breathing pattern. After lung injury, 0 cm H2O of PEEP resulted in high tonic and no discernible phasic diaphragm electrical activity in the nonvagotomized rabbits; stepwise increases in PEEP (up to 11.7 +/- 2.6 cm H2O) reduced tonic but increased phasic diaphragm electrical activity. Increasing the NAVA gain reduced phasic diaphragm electrical activity to almost half and abolished esophageal pressure swings. Tidal volume remained at 4-5 mL/kg, and respiratory rate did not change. In the vagotomized group, lung injury did not induce tonic activity, and phasic activity and tidal volume were several times higher than in the nonvagotomized rabbits. Four hours of breathing with NAVA restored breathing pattern and neural and mechanical breathing efforts to pre-lung injury levels. CONCLUSIONS: Acute lung injury can cause a vagally mediated atypical diaphragm activation pattern in spontaneously breathing rabbits. Modulation of PEEP facilitates development of phasic diaphragm electrical activity, whereupon implementation of NAVA can efficiently maintain unloading of the respiratory muscles without delivering excessive tidal volume in rabbits with intact vagal function. [ABSTRACT FROM AUTHOR]

Pediatric Philadelphia chromosome positive (Ph+) acute T-cell lymphoblastic leukemia can mimic chronic myelogenous leukemia (CML) in T-lineage blast crisis (BC). Differentiating the 2 is critical in guiding therapy as most children with de novo Ph+ acute T-cell lymphoblastic leukemia are treated with chemotherapy and tyrosine kinase inhibitors, whereas T-lineage BC of CML can include hematopoietic stem cell transplantation. We present a unique case of CML in T-lineage BC. The patient was treated with induction chemotherapy plus imatinib followed by matched unrelated donor hematopoietic stem cell transplantation. She is currently off all medications and in complete disease remission., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Though new local anesthetics (LA), effective test-dosing, and new regional anesthetic techniques may have improved the safety of regional anesthesia, the optimal management plan for LA-induced cardiac toxicity remains uncertain. Accordingly, we evaluated current approaches to LA cardiotoxicity among academic anesthesiology departments in the United States. A 19-question survey regarding regional anesthesia practices and approaches to LA cardiac toxicity was sent to the 135 academic anesthesiology departments listed by the Society of Academic Anesthesiology Chairs-Association of Anesthesiology Program Directors. Ninety-one anonymously completed questionnaires were returned, at a response rate of 67%. The respondents were categorized into groups according to the number of peripheral nerve blocks (PNBs) performed each month: >70 PNBs (38%), 51-70 PNBs (13%), 31-50 PNBs (20%), 11-30 PNBs (23%), and <10 PNBs (6%). Anesthesia practices administering >70 PNBs were 1.7-times more likely to use ropivacaine (NS), 3.9-times more likely to consider lipid emulsion infusions for resuscitation (P = 0.008), and equally as likely to have an established plan for use of invasive mechanical cardiopulmonary support in the event of LA cardiotoxicity (NS) than low-PNB volume centers. We conclude that there are differences in the management and preparedness for treatment of LA toxicity among institutions, but the safety implications of these differences are undetermined.

Recent epidemiological studies illustrate that the link between violence and mental disorder is stronger than most psychiatrists previously believed. The connections between psychosis--particularly schizophrenia--and violence and between alcohol-related disorders and violence are especially clear. However, only a small minority of all people who commit violent acts are psychotic, and they are responsible for relatively little violent crime. This article reviews recent epidemiological and case register studies of mental disorder and violence. Lay and professional beliefs about the relationship between violence and mental disorder are reviewed and related to research findings. The implications of these findings for the psychiatric assessment of potential violence are discussed.

No definite comment can be made, at this time, with respect to the safety of glucocorticoid therapy in the human fetus and newborn. Obstetricians and pediatricians need to be aware of the potential risks. Whether the fetal changes that have been reported thus far are permanent and whether they will have any postnatal functional significance are questions of major importance. Probably the greatest risk associated with antenatal steroid therapy is the potential abuse of this treatment. Longer treatment periods or higher doses of steroids will increase the risk for potentially adverse side effects. The recently stated opinion of Taeusch et al seems appropriate: "We conclude that steroids are effective in reducing risk of RDS, but safer and more efficacious approaches for the prevention of RDS should be sought" (91). Further studies are needed to determine the mechanisms of action of glucocorticoids and their risk/benefit ratios in regard to fetal and neonatal well being.

Because of the involvement of prostaglandins in the labor mechanism, it was hypothesized that elevated prostaglandin levels would presage preterm deliveries. A comparison of plasma 13,14-dihydro-15-ketoprostaglandin F2 alpha (PGFM) levels was made between pregnant patients who eventually delivered at term (N = 22) and those who delivered preterm (N = 17). Maternal blood was collected from each patient at approximately 1-week intervals between 16 and 40 weeks' gestation and during labor. Mixed cord blood was also obtained at delivery. PGFM was measured in plasma by radioimmunoassay. Plasma PGFM concentrations did not vary throughout pregnancy. PGFM concentrations did increase during labor, and the highest levels were found in cord blood at delivery. Mean PGFM levels during labor and in cord blood were not significantly different between the preterm and term groups. In 1 preterm delivery patient the PGFM concentration during labor was higher than that of all other patients, including those who delivered at term. Excluding this patient, preterm labor PGFM concentrations were significantly lower (P less than .05) than those at term. In general, the study provides evidence that most cases of preterm labor are not characterized by elevated prostaglandin levels.

The authors analyzed the USC/DRME Practice Study data to determine if the characteristics of physician patient encounters change with patient age. The only significant change observed was a decline in encounter time for patients 65 years of age and older compared with those 45 through 64 years of age. This decrease was significant for raw data and for data weighted for the number of physicians of various types and standardized for complexity of case mix in various age groups, also for both nonhospital and hospital encounters and for almost all classes of encounters. Three types of generalists and four types of medical subspecialists were studied; encounter times for all types were, for patients 65 and older, either the same as or less than those for patients 45 through 64. The observed phenomenon may reflect a conscious decision on the part of some physicians to allot less time to elderly patients.