State University Health Sciences Center Research Articles

The Evaluation, Management, and Prevention of Stingray Injuries in Travelers

Although sharks may attack man without warning, stingrays are docile, usually nonaggressive, and do not attack man unless disturbed, by coastal waders or divers or caught or netted by fishermen. Because stingrays are ubiquitous in all temperate and tropical oceans worldwide, and even occur in many tropical freshwater river systems, human stingray injuries are common but rarely fatal. In the United States alone, 750 to 2,000 stingray injuries are reported each year compared with more than 300 scorpionfish envenomings annually, many in home aquarists, and thousands of catfish‐inflicted spine injuries, most of which are not reported.1–6 On very rare occasions, stingrays have launched off surface waters and into anchored or speeding motorboats, inflicting fatal human injuries. Several fatalities from penetrating thoracic stingray injuries and septic stingray wounds have now been reported.1–4,7 Although not as common as injuries caused by other venomous fish, stingray injuries are an important group of, mostly preventable, marine envenomings.1–4 Since the 1950s, stingray injuries treated in emergency departments and/or reported to poison control centers have only been described retrospectively and, often, incompletely. To date, no prospective multicenter collaborative investigations by coastal medical centers have been conducted to verify the frequencies and fatal and nonfatal outcomes of stingray injuries. Nevertheless, as more vacationing travelers spend more leisure time exploring seacoasts and tropical reefs, often in isolated island areas without immediate access to advanced health care services, there will be greater potential for stingray injuries with poor outcomes. A retrospective meta‐analysis of the descriptive epidemiology of stingray injuries, the mechanisms of stingray envenoming, the multiple clinical presentations of stingray injuries, and the management strategies for stingray injuries is now indicated and may improve the clinician’s ability to better manage and to prevent stingray injuries in travelers. To describe the epidemiology, pathophysiology, presenting manifestations, and any … Corresponding Author: James H. Diaz, MD, MPH&TM, DrPH, Program in Environmental and Occupational Health Sciences, Schools of Public Health and Medicine, Louisiana State University Health Sciences Center in New Orleans, 2021 Lakeshore Drive, Suite 200, New Orleans, LA 70122, USA. E‐mail: jdiaz{at}lsuhsc.edu

First Responder Culture: Implications for Mental Health Professionals Providing Services Following a Natural Disaster

<P>Hurricane Katrina made landfall on August 29, 2005. The storm surge caused multiple levee breaches and left 80% of New Orleans and most of St. Bernard Parish underwater. Metropolitan New Orleans was in a state of chaos. First responders worked in the streets and at shelters of last resort to provide care for the remaining citizens. They engaged in crowd control, dealt with looting and gunfire incidents, and focused on rescue and recovery. During this time, all communication systems failed. First responders had no radio or telephone contact and were left isolated without backup. Multiple first responders described New Orleans and St. Bernard as “war zone(s).” Several first responders, who were also military veterans, reflected that the experience was worse than that which they had endured in Vietnam or Iraq. </P> <H4>ABOUT THE AUTHORS</H4> <P>Mindy Kronenberg, PhD; Howard J. Osofsky, MD, PhD; Michele Many, LCSW; and Melissa Hardy, GSW, are with the Department of Psychiatry, Louisiana State University Health Sciences Center. Joy D. Osofsky, PhD, is with the Departments of Pediatrics and Psychiatry, Louisiana State University Health Sciences Center. James Arey, PhD, LPC, is Commander, New Orleans Police Department SWAT Negotiation Team.</P> <P>Address correspondence to: Mindy Kronenberg, PhD; e-mail <A HREF="mailto:mkrone@lsuhsc.edu">mkrone@lsuhsc.edu</A>.</P> <P>Dr. Kronenberg, Dr. Howard Osofsky, Ms. Many, Ms. Hardy, Dr. Joy Osofsky, and Dr. Arey have disclosed no relevant financial relationships. </P> <H4>EDUCATIONAL OBJECTIVES</H4> <OL> <LI>Assess why a culturally sensitive approach is important in providing mental health treatment to first responders.</LI> <LI>Identify key elements of post-disaster mental health treatment for first responders.</LI> <LI>Discuss specific interventions utilized for first responders following Hurricane Katrina.</LI> </OL>

New Orleans Medical Students post-Katrina — an Assessment of Psychopathology and Anticipatory Transference of Resilience

<p>Wars, conquest, famines, plagues, earthquakes, tsunamis, forest fires, cyclones, and hurricanes have the potential to cause mass migrations. Hurricane Katrina caused one of the most significant non-war-related migrations in modern history. Not since the Dust Bowl of the 1930s, where residents of the Central Plains states of the United States and Canada were forced to permanently migrate, have more than 1 million people been forced to temporarily or permanently relocate. Even more unique is the fact that the evacuation from eastern and western Louisiana, because of Hurricanes Katrina and Rita, respectively, occurred so quickly, compared with the slower sustained relocation in the 1930s.</p> <H4>ABOUT THE AUTHORS</H4> <p>Harold M. Ginzburg, MD, JD, MPH, is with the Department of Psychiatry and Neurology, Tulane University Health Sciences Center; Department of Psychiatry, Louisiana State University Health Sciences Center; and Department of Psychiatry, Uniformed Services University of the Health Sciences School of Medicine. David J. Bateman is a 3rd-year medical student at Tulane University Medical School.</p> <p>Address correspondence to Harold M. Ginzburg, MD, Clinical Professor of Psychiatry Suite 200, 3340 Severn Avenue, Metairie, LA 70002; fax 504-613-4913; e-mail <a href="mailto:haroldginzburg@hotmail.com">haroldginzburg@hotmail.com</a>.</p> <p>Dr. Ginzburg and Mr. Bateman have disclosed no relevant financial relationships.</p> <p>An acknowledgment to Jan Johnson, MD, for obtaining permission for me to conduct the study, and to Jeff Rouse, MD, for assisting in the development of the mental health questionnaire.</p>

Physician-Psychiatrists’ Role in Disaster Response Efforts

<p>Psychiatrists are the only members of the mental health team with medical training and, in most states, with prescriptive authority for U.S. Drug Enforcement Agency (DEA) scheduled (controlled) substances that include many sedative-hypnotics, anxiolytics, stimulants, and narcotics. During a disaster, the community will look to physicians to provide a critical leadership role in the medical management of the disaster causalities. The community will look toward psychiatrists to work with their physician colleagues in treating the mental health complications of serious medical and surgical conditions and replacing the dislocation of medical services for the chronically medically and mentally ill. Psychiatrists must be prepared to accept this role and have the skills and knowledge to do it well.</p><H4>ABOUT THE AUTHORS</H4> <p>Nicholas G. Pejic, MD, and Harold M. Ginzburg, MD, JD, MPH, are from the Department of Psychiatry, Louisiana State University Health Sciences Center. Dr. Ginzburg is also with the Department of Psychiatry and Neurology, Tulane University Health Sciences Center, and the Department of Psychiatry, Uniformed Services University of the Health Sciences School of Medicine.</p> <p>Address correspondence to: Harold M. Ginzburg, MD, Clinical Professor of Psychiatry, Suite 200, 3340 Severn Avenue, Metairie, LA 70002; fax 504-613-4913; or e-mail <a href="mailto:haroldginzburg@hotmail.com">haroldginzburg@hotmail.com</a>.</p> <p>Dr. Pejic and Dr. Ginzburg have disclosed no relevant financial relationships.</p>

Agency's Goal: Help Children Restore Normalcy in Post-Katrina Louisiana

Agency's Goal: Help Children Restore Normalcy in Post-Katrina Louisiana

In for the Long Haul

In 2005, Hurricane Katrina and the subsequent levee breaks left 80% of New Orleans under water for weeks. Within 4 short weeks, the Louisiana State University Health Sciences Center at New Orleans had relocated its campus temporarily to Baton Rouge and resumed operations. Many lessons were learned in the first year of recovery and disseminated to the field regarding emergency and disaster preparedness and response. As we approach the second anniversary of the nation's most devastating natural disaster, we reflect on the long haul of rebuilding and offer new insights and lessons for sustaining operations and enhancing long-term rebuilding efforts.

Targeted Therapies Otitis Media and Otitis Externa

Southern E.N.T. Associates, Department of Otolaryngology Head and Neck Surgery Gratis Faculty, Louisiana State University Health Sciences Center, New Orleans, Louisiana, U.S.A.

Alcohol-Induced Alterations on Host Defense After Traumatic Injury

From the Department of Physiology (P.G., P.E.M.) and National Institute on Alcohol Abuse and Alcoholism - Sponsored Alcohol Research Center (P.G., P.E.M.), Louisiana State University Health Sciences Center, New Orleans, Louisiana. Submitted for publication May 8, 2007. Accepted for publication August 16, 2007. Supported, partially, by grants DOD PR-054196, NIDA DA020419-01A1, NIAAA-07577, NIAAA-09803, and AA11290 (to P.G., P.E.M.). Address for reprints: Patricia E. Molina, MD, PhD, Department of Physiology, LSU Health Sciences Center, 1901 Perdido Street, New Orleans, LA 70112; email: [email protected].

Combination Therapy With Interferon Beta-1a and Doxycycline in Multiple Sclerosis

To evaluate the efficacy, safety, and tolerability of combination therapy with intramuscular interferon beta-1a and oral doxycycline, a potent inhibitor of matrix metalloproteinases, in patients with relapsing-remitting multiple sclerosis (RRMS) having breakthrough disease activity. Open-label, 7-month trial. Louisiana State University Health Sciences Center, Shreveport. Fifteen patients with RRMS taking interferon beta-1a with breakthrough disease activity took doxycycline for 4 months. Patients underwent monthly neurologic examination, magnetic resonance imaging of the brain using triple-dose gadolinium, and safety blood work. Ongoing treatment with intramuscular interferon beta-1a plus oral doxycycline, 100 mg daily, for 4 months. The primary end point was gadolinium-enhancing lesion number change, and the secondary end points were relapse rates, safety and tolerability of the combination of interferon beta-1a and doxycycline in patients with MS, Expanded Disability Status Scale score, serum matrix metalloproteinase-9 levels, and transendothelial migration of monocytes exposed to serum from patients with RRMS. Combination of doxycycline and interferon beta-1a treatment resulted in reductions in contrast-enhancing lesion numbers and posttreatment Expanded Disability Status Scale values (P < .001 for both). Only 1 patient relapsed. Multivariate analyses indicated correlations between decreased serum matrix metalloproteinase-9 levels and enhancing lesion activity reduction. Transendothelial migration of monocytes incubated with serum from patients with RRMS undergoing combination therapy was suppressed. Adverse effects were mild; no adverse synergistic effects of combination therapy or unexpected adverse events were reported. Combination of intramuscular interferon beta-1a and oral doxycycline treatment was effective, safe, and well tolerated. Controlled clinical trials in larger cohorts of patients with MS are needed to evaluate the efficacy and tolerability of this combination. Trial Registration clinicaltrials.gov Identifier: NCT00246324

727: A comparison of magnesium tocolysis versus no tocolysis in patients who deliver preterm

WHO DELIVER PRETERM CLINT CORMIER, DAVID F. LEWIS, GINA GOMEZ, MICHAEL LUCAS, LISA HOLLIER, University of Texas Health Science Center at Houston, Houston, Texas, Louisiana State University Health Sciences Center at Shreveport, Obstetrics and Gynecology, Shreveport, Louisiana OBJECTIVE: To evaluate whether magnesium sulfate tocolysis improves latency and/or neonatal outcomes in patients who deliver preterm. STUDY DESIGN: This is a retrospective study of patients who presented and delivered between 23 and 34 weeks gestation. The control group consists of patients from 2000 to 2002, when magnesium tocolysis was not used at our institution. The treatment group is made up of patients from 2003 to 2006 when aggressive magnesium tocolysis was used. All included patients presented and delivered on the same admission, thus giving all patients in the study the diagnosis of preterm labor and delivery. Exclusion criteria included premature rupture of membranes, multiple gestation, delivery for maternal indications, and all cases of fetal anomalies. RESULTS: 128 patients were identified that met the study criteria. 68 received aggressive magnesium tocolysis and 60 received no tocolysis. Survival analysis of the duration of time from admission to delivery (pregnancy latency) showed no significant difference between the 2 groups. The mean time from admit to delivery for the magnesium group was 37.3 hours vs. 32.5 hours for those not receiving magnesium. However, this did not reach the level of statistical significance. Neonatal complications were compared between the two groups and no difference was observed for incidence of respiratory distress syndrome, sepsis, pneumonia, intraventricular hemorrhage, and necrotizing enterocolitis. CONCLUSION: Magnesium tocolysis does not appear to significantly lengthen pregnancy in patients who present in preterm labor and ultimately deliver prematurely. There was also no difference in major neonatal complications. Larger, prospective studies may be necessary to determine the true efficacy of magnesium tocolysis.

Lack of Association Between Genital Tract HIV-1 RNA Shedding and Hormonal Contraceptive Use in a Cohort of Louisiana Women

THE QUESTION OF WHETHER systemic hormonal therapies can effect genital tract HIV-1 RNA shedding is plausible since selected cytokine production in the genital tract, which can be influenced by the hormonal milieu, may modulate the replication of HIV-1.1 The observation that genital tract HIV-1 RNA s

Selective Impairment of Nuclear Factor-κB-Dependent Gene Transcription in Adult Cardiomyocytes

The ability of neonatal and adult cardiomyocytes to activate the nuclear factor (NF)-kappaB pathway in response to lipopolysaccharide and interleukin-1beta challenge has been investigated and compared with that of peritoneal macrophages. The activation of the IkappaB kinase and the phosphorylation and degradation of IkappaBalpha and IkappaBbeta was much lower in adult cardiomyocytes than in the neonatal counterparts and macrophages. This restricted activation of the NF-kappaB pathway resulted in a significant reduction in the time of nuclear activation of NF-kappaB, as deduced by electrophoretic mobility shift assays and in the transcription of target genes, such as IkappaBalpha, cyclooxygenase-2 (COX-2) and nitric-oxide synthase-2 (NOS-2). Studies on chromatin immunoprecipitation showed binding of NF-kappaB proteins to the regulatory kappaB sites identified in the promoters of the IkappaBalpha, COX-2, and NOS-2 genes in macrophages and, to a lower extent, in neonatal cardiomyocytes. The binding to these kappaB sites in adult cardiomyocytes was observed only in the IkappaBalpha promoter and was minimal or absent in the COX-2 and NOS-2 promoters, respectively, suggesting a restricted activation of NF-kappaB-regulated genes in these cells. These data indicate that the function of the NF-kappaB pathway in adult cardiomyocytes is limited in time, which results in the expression of a reduced number of genes and provides a functional explanation for the absence of NOS-2 inducibility in these cells under proinflammatory conditions.

Little Rebuilding Evident in New Orleans MH System

Little Rebuilding Evident in New Orleans MH System

Post Katrina: the story of the LSUHSC School of Nursing.

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER (LSUHSC) SCHOOL OF NURSING HAS A REMARKABLE STORY TO TELL. Hurricane Katrina blew through New Orleans in August zoo j, followed by a breach in the levees that effectively destroyed 80 percent of our beloved, cany city. As the world watched in horror, people abandoned their homes, their work, and all that constituted normal life. * Post Katrina, it has taken extraordinary effort by many people to regain some elements of normalcy for a city that is by no means repaired and restored. This article tells how, in those early days after the hurricane, nursing education kept on course within the LSUHSC system and how, surprisingly, the catastrophe provided a unique opportunity to plan a refashioned school of nursing. Making Do in Baton Rouge Although all LSUHSC buildings in New Orleans were forced to close for repairs, the six schools of the health sciences centers reopened on September 26, 2005, at our Baton Rouge flagship campus. Ninety-six percent of our students showed up. In efforts to educate our students in Baton Rouge and on other campuses across the state, logistics were daunting. LSU set up a telephone call-in service and established a website that had 2.5 millions hits within days. The Pete Maravich basketball stadium on the Baton Rouge campus was converted into a MASH unit. Staffed almost entirely by volunteers, it briefly became the largest acute care hospital in the country, processing 6,000 patients and triaging 15,000 others with special needs. Faculty slowly trickled into Baton Rouge, and it became possible to begin the process of organizing temporary structures for classrooms and housing. Housing was the most critical issue. Funds from FEMA allowed LSUHSC to hire a recently refurbished Finnish ferry, that normally crossed the Baltic Sea, as home for faculty, staff, and students. Buses were arranged to take students to class, and two meals each day, dinner and breakfast, were provided from the moored, stationary ship, where one could watch the Mississippi River roll inexorably downstream. Finding classroom space and clinical sites presented a major challenge. For an entire academic year, undergraduates had all their lectures before 11 am in a movie theatre where the aroma of popcorn was pervasive, the air was stuffy and stale, and the LCD player perched precariously on a seat in the back row. It was an odd experience to teach in a movie theater. We felt dwarfed by our PowerPoints, which loomed overhead on a huge screen, while with no place to put material we did an odd sort of juggling dance to follow our own notes, manage the PowerPoint, and ensure that our students remained engaged. Fortunately, Southeastern Louisiana University (SLU) lent us space for monthly Friday evening and Saturday classes for our graduate students. SLU also provided lab space, allowed us to place a librarian in their library, and made space available for a few faculty meetings. We were made to feel welcome, but it wasn't our home. Clinical sites were a different story. With scrambling, and the willingness to drive considerable distances and use both evening and night shifts, we were able to patch together sufficient sites. Nurse practitioners in various agencies helped us out, offering to become temporary part-time faculty for clinical supervision. The senior administration determined that all our health disciplines would continue to provide education to our student body. We had been undergoing undergraduate curriculum revision for some time and had just initiated a second-degree, accelerated baccalaureate program. Plus, we had begun development of a doctor of nursing practice program. The disruption provided the impetus to look at things in new ways. We had to be creative and willing to do things differently. We brought all changes to the Louisiana State Board of Nursing. The board, which also had to relocate to Baton Rouge and understood our difficulties and our needs, was willing to work with us, provided we kept them informed. …

Facilitating Behavior Change With Low-literacy Patient Education Materials

Hilary K. Seligman, Assistant Professor of Medicine, Division of General Internal Medicine; DeanSchillinger, Associate Professor of Clinical Medicine and Director, UCSF Center for Vulnerable Popula-tions; Adriana Delgadillo, Research Assistant, Division of General Internal Medicine; Nikki Bengal,Research Assistant, Division of General Internal Medicine, San Francisco General Hospital, University ofCalifornia San Francisco, San Francisco, CA. Andrea S. Wallace, Postdoctoral Fellow, University of NorthCarolina School of Nursing; Darren A. DeWalt, Assistant Professor of Medicine, Division of GeneralInternal Medicine, University of North Carolina School of Medicine; Betsy Bryant Shilliday, AssistantProfessor of Medicine and Pharmacy, Clinical Pharmacist Practitioner, Division of General InternalMedicine, University of North Carolina School of Medicine, Chapel Hill, NC. Connie L. Arnold, AssociateProfessor, Feist-Weiller Cancer Center Section of Cancer Prevention and Control; Terry C. Davis,Professor, Department of Medicine-Pediatrics, Louisiana State University Health Sciences Center—Shreveport, Shreveport, LA.Address correspondence to Dr Seligman, Division of General Internal Medicine, San Francisco GeneralHospital, University of California San Francisco, Box 1364, UCSF, San Francisco, CA 94143. E-mail:hseligman@medsfgh.ucsf.edu

Management of metastatic tumors invading the peripheral nervous system

The authors present the results of a retrospective review of 37 surgically treated metastases to nerve (malignant peripheral non-neural sheath nerve tumors). Tumor frequencies, presentations, management, and prognosis are discussed. Thirty-seven patients who were treated for metastases to nerve between 1969 and 2006 at the Louisiana State University Health Sciences Center were identified in a review of patient records. Notes regarding patient history and physical examination findings were reviewed to provide information on presenting symptoms and signs. Imaging and histopathological examination results were also reviewed. Cases were analyzed depending on the primary tumor and the location of metastasis. There included 37 surgically treated lesions, 16 of which originated in the breast and 10 of which originated in the lung. In two cases melanomas had metastasized to nerve, and one tumor each had metastasized from the bladder, rectum, skin, head and neck, and thyroid, and from a primary Ewing sarcoma. There was a single lymphoma that had metastasized to the radial nerve and one chordoma and one osteosarcoma, each of which had metastasized to the brachial plexus. The nervous system is involved in numerous ways by oncological process. Direct involvement of the peripheral nervous system occurs mostly from direct extension, although it occasionally occurs because of distant spread from the primary tumor to nerve. Surgical excision of the metastatic lesion with margins has been useful mostly in the control of pain. Nevertheless, patients eventually succumb to their primary malignancy.

Pelvic plexus tumors

Pelvic plexus tumors are unusual entities. These lesions often reach significant size prior to clinical presentation due to vague lower extremity or other symptoms refractory to exhaustive workup and the potential space of the retroperitoneum. The authors retrospectively reviewed the charts of 44 patients who presented to Louisiana State University Health Sciences Center with pelvic plexus tumors. All such patients were included in the present study if there was at least 12 months of follow-up. Clinical evaluations were examined, including typical clinical presentation, imaging studies, and other preoperative evaluations. These tumors include 38 peripheral neural sheath tumors (86%), two malignant neural sheath tumors (5%), and four nonneural sheath tumors (9%). The authors also examined the relation of pelvic neural sheath tumors to neurofibromatosis Type 1 (NF1). Histopathological examination confirmed 18 solitary neurofibromas (41%), 12 NF1-associated neurofibromas (27%), eight schwannomas (18%), two malignant nerve sheath tumors (5%), and four other nonneural sheath tumors (9%). The other nonneural sheath tumors consisted of one each of desmoid, ganglioma, lipoma, and an unspecified calcified mass. The optimal treatment for retroperitoneal lesions remains operative excision with adjunctive therapy specific to the lesion encountered.

Tumors of the brachial plexus

Tumors of the brachial plexus are relatively rare and present a clinical challenge for the neurosurgeon. The management of these tumors therefore requires not only an understanding of the complex anatomy of the brachial plexus but also an appreciation of the appropriate surgical approach to the various tumors that may be encountered. Over a 30-year period (1969-1999), 226 patients with brachial plexus tumors were evaluated and surgically treated by the senior authors (R.L.T., D.G.K.). In the present paper they review the most common benign and malignant brachial plexus tumors and discuss management and surgical principles established through their experience at the Louisiana State University Health Sciences Center.

Neurobiological Effects of Childhood Abuse

Child abuse and violence are significant public health problems. Research indicates a strong correlation between early childhood abuse and enduring neurobiological changes in specific regions of the brain. These neurobiological changes are often reflected in psychopathology and lifelong maladaptive behaviors. However, emerging research suggests that these neurobiological changes may be modified through specific evidence-based interventions. Nurses must be able to evaluate the current research and translate the findings into their practice, remembering that prevention is the most effective remedy for abuse and violence.

Thoracic Outlet Syndrome: Part II. Management and Outcomes of 133 Operative Neurogenic Thoracic Outlet Syndrome Cases

Neurogenic thoracic outlet syndrome (NTOS) is the most common variant of thoracic outlet syndrome. This article presents a 25-year experience of management of 133 operative NTOS patients, at the Louisiana State University Health Sciences Center, which have been divided into 2 subcategories of “disputed NTOS” or “true NTOS.” The clinical presentations, results of neurologic examinations, radiologic evaluations, operative procedures, intraoperative findings, and nerve action potential results and outcomes of the management are evaluated.