Point of Care Echocardiography in an Acute Thoracic Dissection with Tamponade in a Young Man with Chest Pain, Tachycardia, and Fever.

BACKGROUND: Although thoracic aortic dissections are uncommon in young patients, they must be considered in the differential diagnosis in the presence of chest pain and abnormal vital signs. Although computed tomography angiography is the test of choice for thoracic dissection in the emergency department, point of care (POC) transthoracic echocardiography has a high specificity in the diagnosis of this disease. It is especially helpful in patients with proximal ascending dissections in the presence of a pericardial effusion. CASE REPORT: This case report illustrates a young patient presenting with chest pain, persistent tachycardia, and fever with a presumed upper respiratory infection who had an ascending thoracic dissection with tamponade discovered on POC echocardiography. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POC echocardiography should be an important part of the algorithm in young patients presenting with chest pain and abnormal vital signs that do not improve with supportive measures. Definitive care in patients who present with a thoracic aortic dissection in the presence of cardiac tamponade diagnosed on POC echocardiography should not be delayed in order to wait for other imaging methods to be performed. POC echocardiography may expedite care and treatment in young patients presenting with this deadly disease.

Backboard time for patients receiving spinal immobilization by emergency medical services.

BACKGROUND: Use of backboards as part of routine trauma care has recently come into question because of the lack of data to support their effectiveness. Multiple authors have noted the potential harm associated with backboard use, including iatrogenic pain, skin ulceration, increased use of radiographic studies, aspiration and respiratory compromise. An observational study was performed at a level 1 academic trauma center to determine the total and interval backboard times for patients arriving via emergency medical services (EMS). FINDINGS: Patients were directly observed. Transport time was recorded as an estimate of initiation of backboard use; arrival time, nurse report time and time of removal from the backboard were all recorded. National Emergency Department Overcrowding Study (NEDOCS) score, Emergency Severity Index (ESI) and demographic information were recorded for each patient encounter. Forty-six patients were followed. The mean total backboard time was 54 min (SD ±65). The mean EMS interval was 33 min (SD ±64), and the mean ED interval was 21 min (SD ±15). The ED backboard interval trended inversely to ESI (1 = 5 min, 2 = 10 min, 3 = 25 min, 4 = 26 min, 5 = 32 min). CONCLUSION: Patients had a mean total backboard time of around an hour. The mean EMS interval was greater than the mean ED interval. Further study with a larger sample directed to establishing associated factors and to target possible reduction strategies is warranted.

Nausea, vomiting, and diarrhea in a 9-year-old girl.

Cryptosporidiosis is reported in an otherwise healthy child. Her history was significant for playing in natural waters during a camping trip 1 week prior. Several days later, she began improving despite an incorrect diagnosis and inappropriate antibiotic therapy. Nitazoxanide was given once the diagnosis was established. Obtaining a thorough patient history, administering appropriate antibiotics, and counseling patients on preventive measures are critical steps in treating and managing the transmission of this parasite. The case emphasizes the value of stool ova and parasite examination for proper diagnosis of pediatric diarrheal illness in the emergency setting. In addition, the often overlooked diagnosis of cryptosporidiosis is reviewed as an important cause of diarrheal illness in the immunocompetent pediatric population.

Retinoic acid induces nuclear accumulation of Raf1 during differentiation of HL-60 cells.

All trans-retinoic acid (RA) is a standard therapeutic agent used in differentiation induction therapy treatment of acute promyelocytic leukemia (APL). RA and its metabolites use a diverse set of signal transduction pathways during the differentiation program. In addition to the direct transcriptional targets of the nuclear RAR and RXR receptors, signals derived from membrane receptors and the Raf-MEK-ERK pathway are required. Raf1 phosphorylation and the prolonged activation of Raf1 persisting during the entire differentiation process are required for RA-dependent differentiation of HL-60 cells. Here we identify a nuclear redistribution of Raf1 during the RA-induced differentiation of HL-60 cells. In addition, the nuclear accumulation of Raf1 correlates with an increase in Raf1 phosphorylated at serine 621. The serine 621 phosphorylated Raf1 is predominantly localized in the nucleus. The RA-dependent nuclear accumulation of Raf1 suggests a novel nuclear role for Raf1 during the differentiation process.