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In 2011, new tools to evaluate life expectancy are available. Controversy about PSA-based screening for prostate cancer is still going on, with new data from the US Preventive services task force. A brief behavioral treatment for insomnia can be efficient and durable. Gliptines are be useful to avoid treatment-induced hypoglycemia in diabetic patients. New Alzheimer diagnostic criteria, including biomarkers, have been published.

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Driving requires integrating multiple motor, sensory, and cognitive skills. As people age, cognition becomes increasingly vulnerable due to impairment and dementia. Older drivers suffering from dementia, even at an early stage, have been shown to be significantly more likely to develop unsafe driving. Primary care physicians have the difficult task to assess these persons' driving capacity. This paper briefly describes the consequences of altered cognition on driving capacity and proposes an algorithm to address this challenge.

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In 2010, a study emphasizes the difficulty to predict disability trajectories in the last year of life. A meta analysis shows the effectiveness of post-acute geriatric rehabilitation in reducing functional decline after hospitalisation. Several studies evaluated pneumococcal and herpes zoster vaccines' efficacy. A short and simple intervention is effective in reducing benzodiazepine use. The effect of vitamine D on falls and fractures has been further evaluated in several studies. Diagnostic criteria for dementias, including Alzheimer's disease, are moving to better acknowledge their preclinical stages.

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BACKGROUND: Documented snowmobile-related fatalities and injuries have increased; however, reports of peripheral nerve injuries are rare. METHODS: This case series describes a cluster of severe disabling brachial plexus injuries incurred during snowmobiling. Medical record abstraction was used to identify relevant patient and event characteristics. RESULTS: All study patients were younger male snowmobile drivers. All incidents occurred at speeds in excess of 40 mph. Blood alcohol concentrations exceeded legal intoxication limits in most cases. Complete damage of the brachial plexus occurred in four of the six patients; severe disability occurred in all cases. Five of the six patients sustained associated orthopedic shoulder complex injuries. CONCLUSION: This first report of severe peripheral nerve damage may signal the advent of more severe nonfatal snowmobile-related injuries that mimic motorcycle-related injuries, because the maximum attainable speeds of snowmobiles have increased. Surveillance of snowmobile-related injuries is warranted to identify the full spectrum of snowmobile injuries and recommend public safety measures.

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OBJECTIVE: To longitudinally evaluate unbound and total serum phenytoin concentrations during intravenous phenytoin maintenance dosage and to determine the relationship among phenytoin protein binding, serum albumin, and unbound fatty acid concentrations in patients with head injuries during intensive care unit (ICU) and convalescent care. DESIGN: Serum albumin and phenytoin unbound fraction were determined twice weekly during ICU and convalescent care in 10 patients receiving phenytoin following acute brain injury. Phenytoin protein binding was also determined in 10 healthy control subjects. MAIN OUTCOME MEASURES: Longitudinal serum phenytoin concentrations associated with dosage adjustments targeted to achieve unbound phenytoin serum concentrations between 1.0 and 2.0 mg/L were documented during ICU and convalescent care. Longitudinal phenytoin binding was correlated with serum albumin and unbound fatty acid concentrations in neurotrauma patients. RESULTS: ICU patients received intravenous therapy for a mean of 15.0 days. The mean +/- SD initial phenytoin intravenous dosage regimen of 6.0 +/- 0.7 mg/kg/d resulted in mean +/- SD total and unbound phenytoin concentrations of 3.2 +/- 2.3 and 0.3 +/- 0.2 mg/L. Two patients had seizures associated with low phenytoin concentrations. Four patients continued to receive oral phenytoin therapy during convalescent care; phenytoin dosage requirements decreased over time in these patients. During acute and convalescent care, the phenytoin unbound fraction ranged from 6.0% to 18.3% and correlated with albumin (r2 = 0.61, p < 0.0001) but did not correlate with unbound fatty acid concentrations. The mean phenytoin unbound fraction was 10.1% and 8.9% for the ICU and convalescent patients with brain injuries, respectively, and was 7.0% for the healthy volunteers. CONCLUSIONS: Phenytoin protein binding was significantly correlated with albumin and was more variable in ICU and convalescent patients with brain injuries than in healthy volunteers. The high dosage requirements and subtherapeutic unbound phenytoin concentrations observed during acute care are best explained by increased metabolism. Phenytoin dosage requirements decreased during convalescence.

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Enteral feeding very early after trauma has been hypothesized to attenuate the stress response and to improve patient outcome. We tested this hypothesis in a prospective, randomized clinical trial in patients with blunt trauma. Following resuscitation and control of bleeding, 52 patients were randomized to receive early feedings (target, < 24 hours) or late feedings (target, 72 hours). Feeding was given via nasoduodenal feeding tubes. A rapid advance technique was used to achieve full volume and strength within 24 hours (goal, 1.5 g protein/kg.day). Patients who underwent at least 5 days of therapy were considered to have completed the study: 38 in all, 19 in each feeding group. Patients were similar in age, gender, Injury Severity Score, and mean PaO2/FiO2 ratio. The early group, however, had more patients with a PaO2/FiO2 < 150. After feeding began, the amount fed per day was the same in both groups. We found no significant differences in metabolic responses as measured by plasma lactate and urinary total nitrogen, catecholamines, and cortisol. Both groups achieved nitrogen retention. In addition, we found no significant differences in intensive care unit (ICU) days, ventilator days, organ system failure, specific types of infections, or mortality, although the early group had a greater number of total infections. In this study, early enteral feeding after blunt trauma neither attenuated the stress response nor altered patient outcome.

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We studied the infectious risk of different methods of managing vascular catheters during long-term use. Consecutive surgical ICU patients requiring triple lumen catheters, pulmonary artery catheters, or arterial catheters for greater than 7 days were prospectively randomized to one of three management groups: a) percutaneous (PERC) puncture with every 7-day catheter change at a new site, b) no weekly change (NWC) with a new site when changed, or c) guidewire exchange (GWX) with every 7-day catheter change at the same site. In all groups, a catheter change was mandatory for a positive blood culture, skin site infection, or sepsis without a likely source. Cultures were obtained when clinically indicated and at the time of every catheter change. Catheter-related sepsis (CRS) was defined as a positive blood culture and catheter culture with the same organism. A total of 112 patients met evaluation criteria. There were no intergroup differences in age, primary diagnosis, severity of injury or illness, number of study days, number of protocol violations, route of catheterization, number of catheters present/patient day, catheter sepsis rate, or bacteremia rate. The NWC group demonstrated an increased number of days/catheter, fewer catheter/subcutaneous tract segment cultures/patient, and a reduced incidence of catheter tip colonization. These results occurred in a setting where the number of CRS episodes/patient was 0.17 for GWX, 0.22 for PERC, and 0.16 for NWC. We conclude that there is no difference in infectious risk between these three methods of long-term catheter management. The method with the least complications and expense should be used.(ABSTRACT TRUNCATED AT 250 WORDS)

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A review of the world literature revealed only five reported cases of azygos vein disruption from blunt chest trauma. Four of these were isolated injuries. We report a case of isolated complete azygos vein transection as a result of blunt motor vehicular trauma. Emergency thoracotomy and venous ligation resulted in successful resuscitation. Shearing forces as a result of deceleration were felt to be a possible etiology.

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A 73-year-old male underwent uneventful three-vessel coronary artery bypass grafting after which he received iv protamine sulfate for reversal of systemic heparinization. Shortly thereafter, the patient developed and succumbed to an anaphylactoid reaction attributed to protamine. The patient had none of the previously reported risk factors for hypersensitivity to the drug and was therefore not considered at high risk for such a severe adverse reaction. Although uncommon, the fatal outcome of this low-risk patient seriously addresses the need for alternative measures for heparin reversal.

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Diffuse ganglioneuromatosis of the entire alimentary tract is a characteristic finding in the multiple endocrine neoplasia type II B syndrome. Symptoms and complications of colonic involvement are common. We report a 37-yr-old woman with multiple endocrine neoplasia type II B syndrome and a colovesical fistula complicating sigmoid diverticulitis.

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A major function of the liver is to maintain normal levels of plasma amino acids. This function may depend in part on tissue levels of high-energy phosphate. Experiments were performed in adult mongrel dogs to assess the relationship between plasma amino acid clearance (PAAC) and tissue high-energy phosphate after 90 minutes of warm hepatic ischemia. In addition, when PAAC was assessed in the anhepatic dog, PAAC fell to low levels after hepatectomy. After 90 minutes of warm ischemia, both tissue adenosine triphosphate (ATP) and PAAC fell to low levels, with PAAC similar to those levels observed in anhepatic dogs. Recovery of ATP and PAAC progressed over a 48-hour period but did not reach control values. Mortality rate was 33% in a group of 12 animals at 48 hours after ischemia. At 24 hours after ischemia, total free plasma amino acid levels were significantly higher in those animals that were dying as compared with those that were surviving (4352 mumol/L versus 2850 mumol/L; p less than 0.05). There was a strong correlation between PAAC and ATP (r = 0.81). PAAC appears to be an indicator of hepatic functional recovery and tissue ATP levels after ischemia.

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Laser Doppler flowmetry (LDF) accurately measures cutaneous microcirculatory blood flow. We compared change in LDF flow to change in thermodilution cardiac output in ten critically ill surgical patients. A subset analysis of three patients with low cardiac output (cardiac index less than 2 L/min X m2) showed no correlation. We conclude that, under these study conditions, LDF microcirculatory flow did not reflect macrocirculatory flow. We conjecture that overcoming cutaneous vasoregulation with thermal vasodilation may obviate these results.

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This report describes a patient with simultaneous Crohn's disease of the terminal ileum and ulcerative colitis of the left colon and rectum. Well documented cases of "mixed" ileocolitis are quite rare.

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