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Adada H, Valley MA, Nour SA, Mehta J, Byrd RP, Anderson JL, Roy T. Epidemiology of extra-pulmonary tuberculosis in the United States: high rates persist in the post-HIV era. Int J Tuberc Lung Dis 2015; 18:1516-21. [PMID: 25517822 DOI: 10.5588/ijtld.14.0319] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The incidence of tuberculosis (TB) in the United States has declined following a logarithmic pattern, with few exceptions. One exception was during the acquired immunodeficiency syndrome (AIDS) epidemic, which was thought to have caused the deviation. However, since then, alternative explanations have been proposed, including the increased burden of chronic diseases, immigration, and the increase in the use of immune suppressant medications. METHODS Epidemiological data of the Center for Disease Control and Prevention (CDC) and the Bureau of the Census were analyzed regarding TB incidence, human immunodeficiency virus (HIV) infection, immigration status, and age for the period 1953-2011. RESULTS Data analysis identified a deviation from the logarithmic decline in TB cases that started in the mid-2000s. This divergence did not appear to be related to HIV status. The overall decline in TB cases since 1953 has been almost exclusively due to a reduction in pulmonary TB (PTB) and not to extra-pulmonary TB (EPTB). CONCLUSIONS The HIV/AIDS epidemic likely played a significant role in the 1979-1985 deviation, but not subsequently. Furthermore, EPTB as a proportion of total TB cases has remained high. Further studies to delineate the etiologies of these findings are needed.
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Affiliation(s)
- H Adada
- Department of Pulmonary and Critical Care Medicine, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - M A Valley
- Department Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - S A Nour
- Department of Pulmonary and Critical Care Medicine, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - J Mehta
- Department of Pulmonary and Critical Care Medicine, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - R P Byrd
- Department of Pulmonary and Critical Care Medicine, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - J L Anderson
- Department Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - T Roy
- Department of Pulmonary and Critical Care Medicine, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
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Valley MA, Rosenstein SW, Lautenschlager EP, O'Gara MM. Early prediction of the need for orthognathic surgery in cleft lip and palate patients. Northwest Dent Res 1998; 6:24-8. [PMID: 9487916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Valley MA, Rogers JN, Gale DW. Relief of recurrent upper extremity sympathetically-maintained pain with contralateral sympathetic blocks: evidence for crossover sympathetic innervation? J Pain Symptom Manage 1995; 10:396-400. [PMID: 7673773 DOI: 10.1016/0885-3924(95)00015-q] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A case of recurrent right upper extremity sympathetically maintained pain was completely relieved with contralateral sympathetic blocks. Yet Ipsilateral blocks produced no change in pain. Surgical sympathectomy of the contralateral thoracic sympathetic chain produced significant and persistent pain relief. This case, to our knowledge the first such reported, raises questions regarding the accepted sympathetic innervation of the upper extremity.
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Affiliation(s)
- M A Valley
- 509th Medical Group/SGH, Whiteman AFB, Missouri 65305, USA
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Valley MA, Sang CN. Use of glycopyrrolate to treat intraoperative penile erection. Case report and review of the literature. Reg Anesth 1994; 19:423-428. [PMID: 7848955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Penile erections following the initiation of either axial regional or general anesthesia is rare; however, when it occurs in patients undergoing urologic procedures it may delay, or even cancel, the planned surgery. The purpose of this case report and review is to enhance anesthesiologists' understanding of this phenomenon so that they may better formulate a logical treatment scheme in such an event. METHODS We present a case of intraoperative erection after the initiation of continuous spinal anesthesia that was treated with intravenous glycopyrrolate. From the literature, 72 references were reviewed. RESULTS Glycopyrrolate successfully treated intraoperative penile erection. The physiology and pharmacology of erection are reviewed, and pharmacologic treatment options and surgical treatments are reviewed. CONCLUSIONS In patients with coronary artery disease, or in situations where cardiovascular stability is desired, glycopyrrolate is an effective means of relieving intraoperative penile erections. Other pharmacologic interventions, based on the physiology of erections, are presented. Nitric oxide, a potent smooth muscle relaxant, has been shown to be involved in the initiation and maintenance of erections; future research involving specific inhibitors of this chemical is indicated for the possible treatment of intraoperative penile erections.
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Affiliation(s)
- M A Valley
- Pain Management Clinic, Wilford Hall Medical Center, Texas
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Gale DW, Valley MA, Rogers JN, Poterack KA. Effects of neurolytic concentrations of alcohol and phenol on Dacron and Gore-Tex vascular prosthetic grafts. Reg Anesth 1994; 19:395-401. [PMID: 7848949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Neurolytic nerve block, using either alcohol (A) or phenol (P), is frequently used to treat intractable pain. However, these agents may disrupt the integrity of prosthetic vascular grafts. To investigate this possibility, the tensile strength of Dacron (Meadox Medicals, Oakland, NJ) and Gore-Tex (W.L. Gore Associates, Flagstaff, AZ) vascular grafts was determined after in vitro exposure to various clinically used concentrations of A or P. METHODS Segments of Dacron and Gore-Tex graft were placed in the following solutions: saline (S), 6% and 9% P, and 25%, 50%, 75%, and 100% A, and stored at 23 degrees +/- 1 degree C for 72 hours. Axial maximum load (in kilonewtons, KN) and strain (in mm/mm) were determined with an Instron universal testing machine (Instron Corporation, Camden, MA). Samples from the S, 9% P, and the 100% A groups were evaluated using a scanning electron microscope. RESULTS Dacron tensile strength decreased a maximum of 23% after exposure to 50%, 75%, and 100% A. Dacron strain capacity decreased after exposure to A (50%, 75%, 100%) and P (6%, 9%). Scanning electron microscope of both P and A showed significant degradation. No changes were found in the Gore-Tex group after exposure to P or A, however, scanning electron microscope of the 100% A sample showed moderate fiber degradation. CONCLUSIONS The study shows that Dacron woven grafts are degraded by concentrations of A of at least 50%, and to a lesser extent, concentrations of at least 6%, while Gore-Tex had only minimal changes. While neurolytic block offers distinct advantages in patients with terminal cancer pain, the findings suggest that the use of more conservative modalities, such as oral medication regimens, be considered for the treatment of intractable pain in patients with vascular prosthetic grafts that are proximate to the proposed site of neurolysis.
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Affiliation(s)
- D W Gale
- Department of Anesthesiology, Wilford Hall Medical Center, Lackland AFB, Texas
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Valley MA, Sheplock GJ, Rogers JN. Probable cervical midline epidural septum complicating the treatment of a patient with upper extremity sympathetically maintained pain. J Pain Symptom Manage 1994; 9:208-11. [PMID: 7516959 DOI: 10.1016/0885-3924(94)90132-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We present a woman who developed left arm sympathetically maintained pain (SMP, or "shoulder-hand syndrome") as a result of brachial plexus injury. After confirmatory diagnosis with both stellate local anesthetic block and intravenous phentolamine infusion, the patient had a cervical epidural catheter placed and a local anesthetic infusion started. After numerous unilateral blocks were obtained, a cervical epidurogram demonstrated a probable cervical midline epidural septum. Catheter placement was adjusted, and a successful chemical sympathectomy was performed for 6 days. This resulted in significant relief of the patient's shoulder pain as well as almost complete resolution of the patient's left arm SMP symptoms. This case represents, to our knowledge, the first documentation of the use of phentolamine for the diagnosis of SMP secondary to pathology at a site proximal to that of symptomatology, as well as the first documentation of presumptive cervical midline epidural septum.
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Affiliation(s)
- M A Valley
- Wilford Hall Medical Center/SGHSA, Department of Anesthesiology, Lackland Air Force Base, TX 78236-5300
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Valley MA, McKenzie AM, Bourke DL, Raja SN. Effects of epidural test dose volume on skin perfusion, temperature, and reflex vasoconstriction. Reg Anesth 1994; 19:52-8. [PMID: 8148295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVES The authors sought to define the effects of differing volumes of epidural test dose on skin perfusion, skin temperature, and reflex vasoconstriction to a maximal inspiration (inspiratory gasp vasoconstrictive response, IGVR). METHODS With informed consent and Institutional Review Board approval, the authors studied 40 patients undergoing epidural anesthesia. Skin perfusion was monitored in glabrous skin on the foot using laser Doppler. Inspiratory gasp vasoconstrictive response and temperature measurements were obtained at 1-minute intervals. After a baseline period, 5 patients received 60 mg intravenous lidocaine HCl; 5 received 5 mL normal saline, via epidural catheter; and 30 patients received 50 mg lidocaine HCl and 20 mcg epinephrine in 2.5, 5.0, or 7.5 mL normal saline (10 patients each). Inspiratory gasp vasoconstrictive response was defined as the percent change in perfusion from baseline produced by an inspiratory gasp. Perfusion was normalized by expressing each patient's value as a percentage of the respective baseline value. RESULTS Significant increases in perfusion, of up to 169% of baseline, were seen 12 minutes after the test dose. Inspiratory gasp vasoconstrictive response showed significant changes from baseline in all test groups. The temperature change was insignificant. Control groups did not show perfusion or IGVR changes. CONCLUSIONS Skin perfusion and IGVR changed significantly after epidural test dose; the minimal effect of volume appears to be 5 mL of lidocaine-epinephrine solution; the presence of IGVR or perfusion changes, or both, are positive predictors of successful placement of the catheter into the epidural space; and temperature changes as observed here were not reliable predictors of proper placement of epidural catheters.
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Affiliation(s)
- M A Valley
- United States Air Force Medical Corps, Wilford Hall USAF Medical Center, Department of Anesthesiology, Lackland AFB, TX 78236
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Rogers JN, Valley MA. Reflex sympathetic dystrophy. Clin Podiatr Med Surg 1994; 11:73-83. [PMID: 8124658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
In summary, RSD is pain of neuropathic origin. The diagnosis is often obscure and requires a complete history, physical, and psychological evaluations. The diagnosis depends on symptoms (burning pain, allodynia and hyperpathia); signs (edema, sudomotor changes, temperature changes); and objective measurements, such as skin temperature, QSART, radiographs, and triple-phase bone scans; as well as the clinical response to a sympathetic block. Management of RSD should be designed to promote restoration of function utilizing physical therapy made possible by sympathetic, central, or peripheral nerve blockade. Medications may include nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, and vasoactive drugs. Psychologic support is an important part of the patient's rehabilitation. Dorsal column or peripheral nerve stimulators, sympathectomies, and narcotics should be considered only when other more conservative measures have failed.
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Affiliation(s)
- J N Rogers
- Department of Anesthesiology, University of Texas Health Science Center at San Antonio
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Abstract
OBJECTIVE The objective of this study was to develop an indirect technique for evaluating dynamic changes in sympathetic function in humans. METHODS We used laser Doppler to monitor sympathetic mediated vasoconstrictive responses (VRs) produced by 3 different provocative stimuli: 4-second inspiratory gasp (IG), ice-water immersion (Ice), and a spring-loaded pin prick (Pin). Skin perfusion on the thenar eminence was continuously monitored in 10 normal subjects (aged 25 to 36 years) using laser Doppler. Ten trials of the 3 stimuli were presented to each subject at 1-minute intervals. We determined the VR, the percent decrease in perfusion produced by each stimulus, and the 2 standard deviation variation in perfusion. RESULTS No subject found the IG maneuver uncomfortable. In contrast, the Pin and Ice stimuli were reported to be uncomfortable by 8 and 10 subjects, respectively. Five subjects found Pin and Ice stimuli overtly painful. Vasoconstrictive response was 54.1 +/- 2.3% (mean +/- SEM) with IG, 49.2 +/- 2.0% with Ice, and 24.0 +/- 1.8% with Pin. Baseline variation was approximately 15% in all trials. CONCLUSION Inspiratory gasp vasoconstrictive response (IGVR) is a sensitive indirect technique for evaluating sympathetic efferent function. We observed that the magnitude of the VR elicited by the IG stimuli was similar to that induced by cold water. Unlike the VR induced by Pin or Ice, IGVR is not dependent on noxious input via somatic afferents; therefore, it can be used in patients with diseases that produce a peripheral neuropathy, such as diabetes mellitus. Present uses of this technique and speculation on future uses are presented.
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Affiliation(s)
- M A Valley
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD
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Valley MA, Bourke DL, Hamill MP, Raja SN. Time course of sympathetic blockade during epidural anesthesia: laser Doppler flowmetry studies of regional skin perfusion. Anesth Analg 1993; 76:289-94. [PMID: 8424505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We studied the time course of sensory and sympathetic blockade in response to epidural local anesthetic test and bolus doses in 11 patients. Sympathetic activity was measured by monitoring cutaneous perfusion in the foot and the reflex vasoconstrictive response to deep inspiration (IGVR) using laser Doppler flowmetry. Sensory tests included the detection of touch, cold and painful stimuli. Following the 3-mL test dose perfusion increased to 192 +/- 38% (mean +/- SEM) of baseline (P < 0.05) in the patients with successful epidural anesthesia (9 of 11). In 8 of these patients, IGVR decreased to 73 +/- 10% of baseline (P < 0.05) within 6 min of the test dose, and preceded changes in sensation to cold, pin-prick, and light touch by 3.8 +/- 3.5 min (P < 0.2), 9.6 +/- 3.1 min (P < 0.01), and 11.6 +/- 2.7 min (P < 0.01), respectively. Five control patients who received only 60 mg of lidocaine intravenously and the two patients with failed epidurals did not show any perfusion or IGVR changes. This study confirms that sympathetic block precedes sensory block in sacral dermatomes after epidural anesthesia. Perfusion and IGVR changes are sensitive measures of sympathetic blockade and may predict successful epidural catheter placement.
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Affiliation(s)
- M A Valley
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD 21205
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Affiliation(s)
- M A Valley
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland 21205
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Affiliation(s)
- M A Valley
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Valley MA, Kalloo AN, Curry CS. Peroral pharyngeal block for placement of esophageal endoprostheses. Reg Anesth 1992; 17:102-6. [PMID: 1374637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The placement of plastic peroral endoprostheses frequently is done in the United States as a palliation for esophageal cancer. However, the combination of topical local anesthetics and sedatives, the most commonly used means to achieve anesthesia, can cause complications and often does not adequately suppress the gag reflex. The purpose of this study was to compare sedation requirements in patients receiving the standard topical local anesthetic versus patients receiving peroral pharyngeal plexus block. METHODS From December 1987 through April 1991, 11 patients underwent endoscopic esophageal stent placement. The first six patients received topical 10% lidocaine spray, the other five patients received pharyngeal plexus blocks. Supplemental sedation was given until the patient closed their eyes but were responsive to verbal stimuli. Completeness of block was evaluated by stimulating the posterior oropharynx. Total sedative requirements were recorded for each patient. RESULTS Patients receiving pharyngeal plexus block had profound anesthesia and suppression of the gag reflex, as determined by examination and the patient's tolerance of the procedure. Patients receiving only topical anesthesia and intravenous sedation tolerated the procedure poorly and required a greater amount of intravenous sedation than those in the blocked group (p less than 0.01). There were no anesthetic complications in patients receiving pharyngeal blocks. CONCLUSIONS Our experience indicates that the endoscopic placement of esophageal endoprostheses is optimally performed with the aid of pharyngeal plexus block. This block provides profound anesthesia with minimal risk in debilitated, high-risk patients. The neuroanatomy of the oropharynx is also reviewed.
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Affiliation(s)
- M A Valley
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD 21205
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Mirenda JV, Valley MA, Gutlove DP. The use of pressure support ventilation in the operating room. Anesthesiol Rev 1990; 17:41-4. [PMID: 10149045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Pressure support ventilation is used in intensive care units to improve patient-ventilator synchrony and facilitate weaning. An anesthesia machine that employs this mode of ventilation can now be used to allow smooth inductions, emergence, and maintenance of anesthesia while the patient is mechanically ventilated.
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Affiliation(s)
- J V Mirenda
- Department of Anesthesiology, Wilford Hall USAF Medical Center, Lackland, Texas
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