Along with issues associated with being older, older persons with

Along with issues associated with being older, older persons with cognitive impairment, who may experience problems with their memory, reasoning, insight, or their ability to learn, have special needs when

presenting to busy ED environments. Another second significant sub-group includes people residing in long term care. Persons living in long term care are in general older, have complex medical histories and are more likely to present to the ED with cognitive impairment [23]. They Inhibitors,research,lifescience,medical experience longer waiting hours, are resource intensive, are more likely to die in hospital [24,25]. A third important sub-group includes older people at the end-of-life. The chaotic ED environment can be particularly burdensome for older patients requiring palliative care. A study by Beyon et al. found that among older people who died in ED, over half of them presented to the ED with a diagnosis that triggered palliative Inhibitors,research,lifescience,medical care [26]. However, in ED palliative care is often not provided [27]. High quality care has been shown to be associated with improved survival and health outcomes of elderly patients [28]. The anticipated “greying” of the population, with its attendant increase in older

ED patient attendances, mandates an evaluation of the capacity Inhibitors,research,lifescience,medical of EDs to deliver quality care to this vulnerable patient group. Accurate assessment of current levels of quality of care in EDs is required to enable Inhibitors,research,lifescience,medical a targeted approach to care that is identified as inadequate, to improve patient outcomes. Quality

indicators allow levels of performance to be determined and, as part of a quality management system, provide opportunity for benchmarking and improved care delivery [29]. Inhibitors,research,lifescience,medical The development of a comprehensive set of quality indicators (QIs) will aid in improving delivery of care in the ED to the geriatric population. This will be timely in the context of the anticipated burgeoning in the numbers of elderly presenting to EDs. In order to be learn more considered valid, QIs should be [29,30]: 1. Specific & defined, with content validity in the QI definition (including a defined Adenylyl cyclase numerator, denominator, clinical exclusions to the denominator & covariates used for risk adjustment) 2. Meaningful with evidence to link them to the desired outcome 3. Structured to facilitate comparison of care delivery between facilities 4. Amenable to improvement by each particular facility, and 5. Efficiently measurable. Review of the literature revealed one previous publication of a group of ED-specific QIs aimed at geriatric patients [31]. These, proposed by the Society for Academic Emergency Medicine (SAEM) indicators, pertain to 3 clinical domains (cognitive assessment, pain, and transitional care) and have a predominant focus on process of care, rather than structure or outcome.

Among the 55 explicit requests for euthanasia reported by the phy

Among the 55 explicit requests for euthanasia reported by the physicians, 6 were granted, whereas in 44 cases the physician chose to intensify the alleviation of symptoms, and in 1 case no decision was reported, except for doing everything possible to prolong the life. For almost half of the physicians, “deep sedation for distress in terminal phase” Inhibitors,research,lifescience,medical was the term that best described the decision to deliberately administer a medication to hasten death; much less frequently “symptom treatment” or “non-treatment decision”. Only 5 physicians reported “euthanasia”. Discussion and conclusions Main findings For the first time, this study provides data on end-of-life medical decisions on a

representative sample of all deaths in France. In 12.2% of cases, the decision was to do everything possible

to prolong life. Non-treatment decisions were Inhibitors,research,lifescience,medical made in 16.8% of cases, treatment was withheld in 14.6% and withdrawn in 4.2%. Alleviation of symptoms with opioids and/or benzodiazepines was intensified in 28.1% of cases, A drug was administered to deliberately hasten death Inhibitors,research,lifescience,medical in 0.8% of cases, at the patient’s request in 11 out of the 38 cases concerned. The study shows that end-of-life medical decisions that may hasten death are relatively frequent in France. Most of such decisions are in compliance with the law, which allows physicians to withhold or withdraw life prolonging treatment and to intensify alleviation of symptoms even if unintended side effects may hasten death (“double effect”), Inhibitors,research,lifescience,medical as long

as the first intention is not to hasten death. In a much smaller number of cases (3.1%), the death followed a decision made with the declared intention of hastening death. The patient’s pathology is the main factor governing this type of decision. Even though most end-of-life medical decisions are made in compliance with the 2005 law, and decisions leading to a strong likelihood of death are more frequently taken after discussion with the patient or trusted third party and the medical staff (other doctors, nursing staff), the study Inhibitors,research,lifescience,medical shows that the legal provisions governing these decisions are not always fully respected. Strengths and limitations For the Thalidomide first time in France, this study provides data on end-of-life decisions on a representative sample of deaths, whatever the cause, wherever the death took place. It gives objective results on this important issue that will inform and assist both public and legislative debate. The Doxorubicin French national end-of-life watchdog Observatoire National de la Fin de Vie (ONFV) has noted the lack of available scientific data on medical practices in this regard in France [13]. This survey also shows that investigating this sensitive topic and even exploring illegal practices is possible in France; this was by no means certain when the study was first launched.

Although the number of graft infections

is generally low

Although the number of graft infections

is generally low (1-6%), they are associated with significant rates of limb loss (30-50%) and mortality (25-75%).15 Debridement, graft preservation, and muscle flap coverage have been used as an alternative to graft removal and extra-anatomic bypass. Meland and Arnold, in their classic paper, describe the role of muscle flaps in the management of 24 periprosthetic graft infections.15 The Inhibitors,research,lifescience,medical infected grafts were treated with extensive debridement followed by muscle flap coverage and postoperative wound irrigation with a povidone-iodine solution delivered through implanted catheters. Systemic intravenous antibiotics were also employed. Frequently used donor sites include the sartorius, rectus femoris, and rectus abdominis. Although not advocated in this study, the gracilis and omentum are additional sources of well-vascularized soft tissue. Utilizing this treatment strategy, a 66% limb salvage rate was achieved over a mean follow-up of 41 months. In our reconstructive surgery institute at The Methodist Hospital, this protocol has been modified, Inhibitors,research,lifescience,medical Inhibitors,research,lifescience,medical yielding even higher rates of graft preservation and limb salvage. The closed-suction irrigation system has been abandoned in favor of antibiotic-impregnated beads. Polymethyl methacrylate bone cement is combined with powdered vancomycin and tobramycin and fashioned into small beads secured on a heavy nonabsorable suture. When implanted within the wound, the beads offload their

antibiotic payload, achieving local concentrations exceeding 100 times the mean inhibitory concentration. These supraphysiologic antibiotic concentrations have proved active against biofilms while being associated with limited Inhibitors,research,lifescience,medical systemic absorption, avoiding potential ototoxicity and nephrotoxicity.16 Serial debridement and antibiotic bead exchange is undertaken until a clean culture-negative wound has been obtained

(Figure 4A). The antibiotic beads are removed and the graft covered Inhibitors,research,lifescience,medical with a local muscle flap (Figure 4B-D). Utilizing this treatment protocol in conjunction with 6 weeks of culture-specific intravenous antibiotics, we have achieved a 96% long-term limb salvage rate.17 Figure 4 (A) Infected prosthetic vascular graft treated with antibiotic impregnated beads. (B) Elevated sartorius muscle flap. Adenosine (C) Vascular graft learn more enshrouded by muscle flap. (D) Long-term follow-up with graft preservation. Conclusion In conclusion, both pedicle and free muscle flaps enjoy intrinsic biologic advantages over local skin and fasciocutaneous flaps, making them a powerful, multipurpose tool in the armamentarium of the limb salvage surgeon. Funding Statement Funding/Support: The authors have no funding disclosures. Footnotes Conflict of Interest Disclosure: All authors have completed and submitted the Methodist DeBakey Cardiovascular Journal Conflict of Interest Statement and none were reported.
Introduction Cardiovascular diseases remain the number one cause of death in industrialized countries.

Current arrays are in the hundreds of electrodes, and keeping tot

Current arrays are in the hundreds of electrodes, and keeping total volume of the multielectrode below 1% of the brain volume is challenging. Alternatively, wireless data transmission or implanted recording are options. Wireless data transmission at Ibrutinib ic50 optical and infrared (IR)

frequencies are needed to obtain adequate single-channel data rates. Radio-frequency (RF) transmission of whole-brain data would draw Inhibitors,research,lifescience,medical excessive power due to bandwidth constraints. Multiplexing RF wavelengths is likely inadequate, but optical/IR or ultrasound allow frequency and spatial multiplexing. Implanted electrical recording would require a 1000-fold increase in the power efficiency of electronics relative to current devices to scale to whole-brain simultaneous recordings. Optical imaging Light scattering Inhibitors,research,lifescience,medical imposes significant limits on optical techniques, but strategies exist which could negate the effects of scattering, such as implantable optics, infrared fluorescence or bioluminescence, and online inversion of the Inhibitors,research,lifescience,medical scattering matrix. In larval zebrafish, a calcium indicator (GCaMP5G) in vivo captured, at 0.8 Hz, 80% of all

of the 100 000 neurons of the whole brain at single-cell resolution3 but scaling this to thicker, less transparent brains is quite challenging. Whole-brain multi-photon excitation could overheat the brain, except in very short experiments, unless ultrabright Inhibitors,research,lifescience,medical inorganic indicators or similar strategies can be developed.4 For beam

scanning microscopies, optical phase modulators, in principle, could reposition beams at 1-GHz switching rates with fluorescence lifetimes in the 0.1-1.0 ns range constrain and enable design of ultrafast scanning. Ultrasound Ultrasound is attenuated by brain tissue at the 100-MHz frequencies needed for single-cell resolution ultrasound imaging such that it is hard to detect even Inhibitors,research,lifescience,medical in theory. Nevertheless, ultrasound may be a viable medium for spatially multiplexed data transmission from embedded devices5. Molecular recording devices These fall within reasonable physical limits, but their development represents major challenges in synthetic biology. Innovative therapeutic Ketanserin and preventative neurotechnologies A subset of the above imaging methods have variations capable of patterned neuronal stimulation, notably electrical and optical methods. This may enable repair or accommodation of disorders acquired during a lifetime of trauma and environmental and immune factors. Some psychiatric and neurodegenerative diseases can be prevented at even earlier stages, via their inherited, (auto)immune and microbial/viral origins. Genomics is finally overcoming decades of false-positives in such diseases including autism, schizophrenia, obsessive-compulsive disorder, bipolar disorder, etc.

We have shown this in victims of childhood abuse,40 assaults and

We have shown this in victims of childhood abuse,40 assaults and accidents in adulthood,78 and in find more patients who gained awareness during surgical procedures.79 These studies support Janet’s 1 889 observations21 and confirm the notion that what makes memories traumatic is a failure of the central nervous system to synthesize the sensations related to the traumatic memory into an integrated semantic memory. Sensor}’ elements of the experience

are registered separately and are often retrieved without the patient appreciating the context to which this sensation or emotion refers. These observations lead to the notion that Inhibitors,research,lifescience,medical in PTSD the brain’s natural ability to integrate experience breaks down. A variety of CNS structures have been implicated in these integrative processes: (i) the parietal lobes are thought to integrate information between different cortical association areas80; (ii) the hippocampus is thought to create a cognitive map that allows Inhibitors,research,lifescience,medical for the categorization of experience and its connection with other autobiographical information81; (iii) the corpus callosum allows for the transfer of information by both hemispheres,82′ integrating emotional and cognitive aspects of the experience; (iv) the cingulate gyrus is thought to play the role of both an amplifier and a filter that helps integrate the emotional and cognitive Inhibitors,research,lifescience,medical components

Inhibitors,research,lifescience,medical of the mind83; and (v) the dorsolateral frontal cortex, which is where sensations and impulses are “held in mind” and compared with previous information to plan appropriate actions. The frontal lobes, in general, are thought to function as a “supervisory system” for the integration of experience.81 Recent neuroimaging studies of patients with PTSD have suggested a role for most of these structures in the neurobiology of PTSD. Neuroimaging studies in PTSD As of 1999, there have been seven Inhibitors,research,lifescience,medical published studies utilizing neuroimaging of patients with

PTSD.85-91 Four studies have used magnetic resonance imaging (MRI) to measure hippocampal volume in individuals with PTSD, and three studies have Phosphoprotein phosphatase used positron emission tomography (PET)85, 88-91 to measure differential activation of the CNS in response to traumatic and nontraumatic scripts in patients with PTSD. Hippocampal volume Three different studies have shown that people with chronic PTSD have decreased hippocampal volumes, ranging from 8%87-92 to 26% ,86 The fact that the only prospective study of acutely traumatized individuals, Stialev et al (ref 93 and personal communication, 1999) failed to find a correlation between hippocampal volume and PTSD severity suggests that this hippocampal shrinkage is a function of chronicity. Recent research suggests that the hippocampal changes may not be irreversible.

The red arrows describe couplings between areas that were more

The red arrows describe couplings between areas that were more strongly connected in MS participants than controls during the working memory … In the detailed analysis of pair-wise correlations it was revealed that MS participants had stronger couplings between the right substantia nigra and the left thalamus (−10 −12 14, P = 0.003). In Figure ​Figure7A,7A, it is shown that both Inhibitors,research,lifescience,medical anterior medial and lateral aspects of the thalamus were more strongly coupled

to the right substantia nigra in MS participants than in controls. The results also showed that the left PPC was more strongly coupled to anterior parts of the left DLPFC (−20 56 36, P = 0.012, Fig. ​Fig.7B),7B), whereas it was more weakly coupled to the right caudate head (14 22 6, P = 0.037, Fig. ​Fig.7C)7C) in MS Inhibitors,research,lifescience,medical participants compared to controls. The couplings with different functional connectivity in MS participants and controls are visualized in the schematic diagram of the thalamo-striato-cortical network in Figure ​Figure6.6. The red arrows show that MS participants had stronger couplings within the cerebral

cortex (PPC DLPFC) and within subcortical regions (Substantia nigra Thalamus) compared to controls. The blue arrow in Figure ​Figure77 shows Inhibitors,research,lifescience,medical that MS participants had weaker couplings between the cerebral cortex and striatum (PPC Caudate). Figure 7 Images of regions of interest (ROIs) with different functional connectivity Inhibitors,research,lifescience,medical to the seed regions in MS participants. (A) The image shows stronger functional connectivity between the right substantia nigra and the left thalamus in MS participants compared … Discussion During performance of the complex working memory task, the MS participants showed increased activation in the bilateral PPC. This finding is in line with previous

studies that also found increased bilateral cortical activation in MS patients, especially in regions that are normally activated by the administered task (Chiaravalloti et al. 2005; Sweet et al. 2006; Morgen et al. 2007). Frequent findings of hyperactivation Inhibitors,research,lifescience,medical in MS patients have been interpreted as a compensatory reorganization in order to maintain normal performance (Lenzi et al. 2008; Genova et al. 2009). However, the hypothesis of compensatory brain Rolziracetam networks in MS patients is challenged by an alternative hypothesis proposed by Hillary et al. (2006) and Hillary (2008). They argue that increased brain activation in MS patients is a response to increased cognitive demand, which in turn is associated with poorer performance. This argument is well in line with the neural efficiency hypothesis, discussed by Neubauer and Fink (2009). The results in this study support the latter theory, because the MS participants performed worse than the controls during the complex working memory task, and still showed higher activation in cortical areas when solving the administered task.

The INcreasing Stroke Treatment through INterventional


The INcreasing Stroke Treatment through INterventional

behavioral Change Tactics (INSTINCT) trial is a cluster randomized, controlled trial aimed at increasing appropriate tPA use in ischemic stroke by first determining hospital-specific barriers and then providing targeted, professional educational interventions. Barriers were determined using a partial grounded theory method, whereby qualitative data obtained through focus group discussions is coded into themes using a previously-described taxonomy[9]. Qualitative methods are uniquely Inhibitors,research,lifescience,medical suited to develop understanding of complex situations that are difficult to measure quantitatively[10]. The milieu of clinician attitudes, institutional practices, and hospital resources involved in emergency stroke care in the community is a prime example of such a setting for which qualitative methods may provide important insights. Our primary objective was to describe the qualitatively-derived Inhibitors,research,lifescience,medical barriers to clinician compliance with guidelines recommending the use of tPA in appropriate patients as discovered in the barrier assessment phase of INSTINCT. Methods Inhibitors,research,lifescience,medical Ethics Statement The protocol was approved by the University of Michigan Institutional Review Board (IRBMED) and all relevant site IRBs. Written informed consent was obtained Inhibitors,research,lifescience,medical from

all participants in focus groups and interviews. INSTINCT Trial Overview The INSTINCT trial is evaluating the hypothesis that initial barrier assessment focused on tPA use in stroke followed by targeted, interactive educational interventions will increase appropriate tPA use[11]. These educational initiatives were planned to be specifically

tailored to the needs of each site. A schematic of the INSTINCT trial is depicted in Figure ​Figure1.1. After site selection and randomization, an initial period of barrier assessment was conducted which involved focus groups, interviews, and surveys. The results of the barrier assessments were Florfenicol then used Inhibitors,research,lifescience,medical to tailor site-specific continuing medical education (CME) lectures to the most important barriers that participants reported. Additional interventions to improve stroke care occurred concurrently and included assistance with clinical protocol development, 24-7 telephone access to the University of Michigan acute stroke team, mock stroke codes, and targeted messaging. Examples of targeted messaging include informing participants of their site’s progress and the overall performance of other sites within INSTINCT and IPI-145 ic50 critical incident debriefing, where a physician from the clinical coordinating center contacted local physicians to discuss specific instances of deviations from American Stroke Association guidelines or treatment complications.

LH subsequently stimulates secretion of T, predominantly by the t

LH subsequently stimulates secretion of T, predominantly by the testes (Figure 1).11,12 Sustained pituitary overstimulation eventually downregulates and desensitizes GnRH receptors, causing a decrease in hormone levels.13 The overall effect of ADT on hormone levels in prostate cancer differs between treatments. Orchiectomy reduces T and dihydrotestosterone (DHT) but is accompanied by significant rises in both LH and follicle-stimulating hormone (FSH).14,15 GnRH agonists cause an initial surge in LH, FSH, T, and DHT; over time these hormones are suppressed. 16 However, FSH gradually rises during GnRH agonist treatment

and results in a FSH “escape.”17 Figure 1 Gonadotropin-releasing hormone (GnRH), Inhibitors,research,lifescience,medical secreted in pulses from the hypothalamus, stimulates release of luteinizing hormone (LH) from the pituitary gland, along with adrenocorticotropic hormone (ACTH) and prolactin. LH subsequently stimulates secretion … Hence, these distinct modes of action of GnRH agonists produce Inhibitors,research,lifescience,medical different clinical effects. The initial agonist-induced T surge can exacerbate clinical symptoms (clinical flare) in advanced prostate cancer.18 An appreciable proportion of patients (~ 12%) receiving GnRH agonists

fail to achieve castrate T levels ≤ 50 ng/dL.19 T microsurges associated with buy Adriamycin repeat injections also occur with agonists.19 In a Inhibitors,research,lifescience,medical study with goserelin, microsurges (T surges above a castration threshold of 18.5 ng/dL after ≥ 1 repeat injection) occurred in 17.7% to 27% of patients.20 The clinical implications of microsurges are currently unclear. Loss of GnRH receptor sensitivity during long-term agonist therapy can allow renewed T production manifesting as a late breakthrough T escape.19,21 Inhibitors,research,lifescience,medical GnRH agonists usually cause partial FSH suppression.22,23 FSH stimulates prostate cancer cell growth in vitro.24 FSH receptors are present on prostate tumors25 and the

surface of tumor blood vessels 26; they are expressed at higher levels on prostate versus Inhibitors,research,lifescience,medical normal tissue.27 FSH signaling may also contribute to progression of CRPC.28 FSH promotes RANK (receptor activator of nuclear factor κB) expression on CD141+ cells, indicating the acquisition of osteoclast precursor cell characteristics.29 The exact significance of the role of FSH is still being defined. Long-term T control has been suggested to reduce mortality risk among patients with and metastatic disease.10 In 129 patients with metastatic prostate cancer receiving a GnRH agonist, those with high T levels at 6 months had a 1.33-fold increase in mortality risk.10 How May Changing Prostate Cancer Screening Guidelines Impact Use of AdT? PSA is the most utilized biomarker for diagnosing prostate cancer. It is a serine protease inhibitor that was discovered and purified in 1979.30 Thirteen years later, two large studies reported the utility of using PSA screening for prostate cancer.

The procedure is performed in the cardiac catheterization laborat

The procedure is performed in the cardiac catheterization laboratory with echocardiographic and fluoroscopic guidance while the patient is under general anesthesia. To access the left heart, standard transseptal catheterization is performed, and the guide catheter is then percutaneously inserted into the femoral vein. The HDAC inhibitor delivery catheter is inserted into the guide, and the clip is positioned above the mitral valve. Manipulation of the steering mechanism on the handles of the guide and delivery catheter positions the clip on the mitral valve. The clip is actuated (i.e. opened and closed, locked, deployed) through manipulation of levers on the Inhibitors,research,lifescience,medical handle of the delivery catheter. More

than one clip can be delivered, and each one remains repositionable until detachment. Figure 1 MitraClip® System. The first MitraClip procedure was performed about 10 years ago.16 Inhibitors,research,lifescience,medical Subsequently, one randomized trial has proved MitraClip safety17 and short- to mid-term efficacy in selected patients.18 In the so-called “real world” the MitraClip therapy is usually reserved

to high-risk and extreme patients (mainly due to age, co-morbidities, and Inhibitors,research,lifescience,medical left ventricle dysfunction). Despite this, it has confirmed an excellent safety profile (30-day mortality 2%–5%) and acceptable mid-term outcomes (1-year survival 75%–85%, 1-year freedom from MR >2+ 80%) especially in terms of improvements in symptoms and quality of life.19–22 Major advantages of the MitraClip are its excellent safety even in end-stage patients and the possibility to operate on the beating heart, monitoring the efficacy of Inhibitors,research,lifescience,medical the implant during the procedure. On the other hand, MR recurrence (higher than in the surgical experience) is the most debated issue. Longer follow-up is needed to verify MitraClip outcomes in terms of MR recurrence and clinical benefit (survival and quality of life). European guidelines assigned an indication class IIb, level of evidence C, signifying that MitraClip may be considered Inhibitors,research,lifescience,medical in patients with symptomatic severe MR despite optimal medical therapy, who are judged inoperable or at crotamiton high

surgical risk by a heart-team, and with life expectancy greater than 1 year.23 The randomized RESHAPE and COAPT trials, respectively in Europe and the US, are currently evaluating the benefit of MitraClip compared to optimal medical therapy to support a higher recommendation class in the forthcoming guidelines. A different approach to obtain transcatheter leaflet repair is off-pump adjustable chordal implantation, for which several devices are currently under development. The Babic device (from the name of the inventor, Uros Babic, MD)24 creates two continuous guiding tracks from the left ventricular puncture site through the target leaflet. The device is then exteriorized via the transseptal catheter and femoral vein.

He labeled the stabilized compound Ro 5-0690, and placed it, on t

He labeled the stabilized compound Ro 5-0690, and placed it, on the shelf. In 1957, Ro 5- 0690 was found, literally during a, laboratory cleanup, and submitted for pharmacological evaluation, which showed that it had similar activities to meprobamate. This was sheer luck! Prompted by these findings, the structure of Ro 5-0690 was correctly identified as 1,4-benzodiazepine. Ro 5-0690, the first anxiolytic benzodiazepine, was introduced into clinical use in 1960 with the generic name of methaminodiazepoxide Inhibitors,research,lifescience,medical (chlordiazepoxide), and the brand name of Librium. It was followed

by the introduction of diazepam (Valium), another anxiolytic benzodiazepine, in 1963. From the late 1960s through the 1970s, sales of diazepam topped those of all other drugs in the United States. The introduction of benzodiazepines vastly extended Inhibitors,research,lifescience,medical the use of psychotropic drugs, ranging from the treatment of schizophrenia, see more depression, and bipolar disorder to the alleviation of anxiety and other neurotic conditions, making psychotropic

drugs one of the most, prosperous businesses of the pharmaceutical industry. Psychotropic drugs The term “psychotropic” was coined by Ralph Gerard, an American neurophysiologist, Inhibitors,research,lifescience,medical in the mid-1950s,17 for drugs with an effect on mental activity and behavior. During the 1950s, a scries of Inhibitors,research,lifescience,medical new psychotropic drugs, such as chlorpromazine, imipramine, and iproniazid, were introduced. Their effectiveness in the treatment of schizophrenia, depression, and bipolar disorder was instrumental in shifting the site of psychiatric practice

from psychiatric hospitals to the community. Chlorpromazine Chlorpromazine (CPZ), has a phemothiazine nucleus with a dimethylaminopropyl side chain. Synthesized by Paul Charpentier on December 11, 1950, in the Laboratories of Rhône Poulenc, at the time a major French pharmaceutical company, CPZ was released Inhibitors,research,lifescience,medical in May 1951 for clinical investigation as a, potentiator of general, anesthesia.55 The basic phenothiazine nucleus was synthesized by Bernthsen in 1883, and later introduced out as an anthelminthic agent for the treatment, of enterobiasis. Expectations that it might be effective in the treatment of protozoal infections were not fulfilled. Instead, Henri Laborit, a surgeon in the French Navy, at the Bizerte Naval Hospital in Sidi-Abdallah, Tunisia, found promethazine, one of the antihistaminic phenothiazines synthesized in the early 1940s, to be eminently suited for the prevention of surgical shock.56,57 It produced “euphoric quietude“ with a ”state of indifference“ and when given prior to surgery patients remained ”calm, somewhat somnolent, and relaxed.“58 In 1950 Laborit.