Vertebrobasilar artery occlusion.

The presentation of vertebrobasilar artery occlusion varies with the cause of occlusion and location of ischemia. This often results in delay in diagnosis. Areas of the brain supplied by the posterior circulation are difficult to visualize and usually require angiography or magnetic resonance imaging. Intravenous thrombolysis and local-intra arterial thrombolysis are the most common treatment approaches used. Recanalization of the occluded vessel significantly improves morbidity and mortality. Here we present a review of the literature and a case of a patient with altered mental status caused by vertebrobasilar artery occlusion.

Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma.

OBJECTIVES: Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children. The objectives were to determine test characteristics for clinically important intraperitoneal free fluid (FF) in pediatric blunt abdominal trauma (BAT) using computed tomography (CT) or surgery as criterion reference and, second, to determine the test characteristics of FAST to detect any amount of intraperitoneal FF as detected by CT. METHODS: This was a prospective observational study of consecutive children (0-17 years) who required trauma team activation for BAT and received either CT or laparotomy between 2004 and 2007. Experienced physicians performed and interpreted FAST. Clinically important FF was defined as moderate or greater amount of intraperitoneal FF per the radiologist CT report or surgery. RESULTS: The study enrolled 431 patients, excluded 74, and analyzed data on 357. For the first objective, 23 patients had significant hemoperitoneum (22 on CT and one at surgery). Twelve of the 23 had true-positive FAST (sensitivity = 52%; 95% confidence interval [CI] = 31% to 73%). FAST was true negative in 321 of 334 (specificity = 96%; 95% CI = 93% to 98%). Twelve of 25 patients with positive FAST had significant FF on CT (positive predictive value [PPV] = 48%; 95% CI = 28% to 69%). Of 332 patients with negative FAST, 321 had no significant fluid on CT (negative predictive value [NPV] = 97%; 95% CI = 94% to 98%). Positive likelihood ratio (LR) for FF was 13.4 (95% CI = 6.9 to 26.0) while the negative LR was 0.50 (95% CI = 0.32 to 0.76). Accuracy was 93% (333 of 357, 95% CI = 90% to 96%). For the second objective, test characteristics were as follows: sensitivity = 20% (95% CI = 13% to 30%), specificity = 98% (95% CI = 95% to 99%), PPV = 76% (95% CI = 54% to 90%), NPV = 78% (95% CI = 73% to 82%), positive LR = 9.0 (95% CI = 3.7 to 21.8), negative LR = 0.81 (95% CI = 0.7 to 0.9), and accuracy = 78% (277 of 357, 95% CI = 73% to 82%). CONCLUSION: In this population of children with BAT, FAST has a low sensitivity for clinically important FF but has high specificity. A positive FAST suggests hemoperitoneum and abdominal injury, while a negative FAST aids little in decision-making.

Small bowel obstruction from capsule endoscopy.

Over the past decade, capsule endoscopy has become the accepted modality for small bowel imaging in the United States. It is very helpful in making the diagnosis of Crohn's disease; however, this patient population is also at an increased risk of small bowel obstruction secondary to capsule impaction. We present the case of a 60-year-old female with undiagnosed Crohn's disease who presented to the emergency department with small bowel obstruction after capsule ingestion. She was successfully disimpacted with diatrizoate upper gastrointestinal (GI) series with small bowel follow-through and intravenous steroids. Review of the endoscopic video images revealed findings consistent with Crohn's disease.

Positive cerebrospinal fluid cultures after normal cell counts are contaminants.

Previous literature on meningitis reports that cerebrospinal fluid (CSF) culture contaminants are threefold more common than true pathogens. Clinical follow-up of patients with CSF contaminants is costly, time-consuming, and potentially unnecessary. In this study, we hypothesized that, in immunocompetent Emergency Department (ED) patients with normal CSF cell counts and negative Gram stains, all positive bacterial cultures are contaminants and patient follow-up is unnecessary. We retrospectively reviewed 191 ED charts of patients with positive CSF cultures over 5 years. We abstracted lumbar puncture results, disposition, and follow-up activities, and determined monetary charges. There were 137 patients (72%) who met inclusion criteria with CSF white blood cells < or = 7 microL, negative Gram stain, and immunocompetence. Ninety-eight were discharged from the ED and 39 were admitted to the hospital for reasons other than meningitis. All 137 positive cultures were found to be contaminants, with coagulase-negative staphylococci found most commonly. Follow-up activities included telephone calls (49%), repeat ED visits (13%), repeat lumbar punctures (9%), unnecessary antibiotic treatment (6%), and hospitalizations (6%), generating $55,000 in charges. Follow-up may be unnecessary in ED patients with positive bacterial CSF cultures who were discharged from the ED, if their initial lumbar punctures were normal.

A role for fibroblasts in mediating the effects of tobacco-induced epithelial cell growth and invasion.

Cigarette smoke and smokeless tobacco extracts contain multiple carcinogenic compounds, but little is known about the mechanisms by which tumors develop and progress upon chronic exposure to carcinogens such as those present in tobacco products. Here, we examine the effects of smokeless tobacco extracts on human oral fibroblasts. We show that smokeless tobacco extracts elevated the levels of intracellular reactive oxygen, oxidative DNA damage, and DNA double-strand breaks in a dose-dependent manner. Extended exposure to extracts induced fibroblasts to undergo a senescence-like growth arrest, with striking accompanying changes in the secretory phenotype. Using cocultures of smokeless tobacco extracts-exposed fibroblasts and immortalized but nontumorigenic keratinocytes, we further show that factors secreted by extracts-modified fibroblasts increase the proliferation and invasiveness of partially transformed epithelial cells, but not their normal counterparts. In addition, smokeless tobacco extracts-exposed fibroblasts caused partially transformed keratinocytes to lose the expression of E-cadherin and ZO-1, as well as involucrin, changes that are indicative of compromised epithelial function and commonly associated with malignant progression. Together, our results suggest that fibroblasts may contribute to tumorigenesis indirectly by increasing epithelial cell aggressiveness. Thus, tobacco may not only initiate mutagenic changes in epithelial cells but also promote the growth and invasion of mutant cells by creating a procarcinogenic stromal environment.

In vitro dendritic cell infection by pseudotyped adenoviral vectors does not correlate with their in vivo immunogenicity.

Expression of antigens in dendritic cells (DC) can stimulate protective immunity against both viral infection and tumor growth, making them important targets for gene therapy. In-vitro-generated DC are commonly used in gene delivery studies with the assumption that the results will correlate with in vivo activity. Adenovirus Type 5 (Ad5) vectors have been widely used with DC, but these cells lack the primary receptor (CAR) used by Ad5 and are poorly infected. We investigated the use of Ad5 vector particles pseudotyped with fibers from other Ad serotypes in DC targeting. Several fiber proteins, including those from Ad16 (Subgroup B) and Ad37 (Subgroup D), conferred dramatically increased in vitro infection. Surprisingly, neither dendritic cell infection nor the immune response to an Ad-delivered antigen was improved when the modified viruses were tested in vivo. These results underscore the importance of using appropriate animal models in gene delivery studies.

Temporal and regional expression of NMDA receptor subunit NR3A in the mammalian brain.

NR3A is a developmentally regulated N-methyl-D-aspartate receptor (NMDAR) subunit that was previously known as NMDAR-L or chi-1. Unlike other NMDAR subunits, NR3A inhibits the NMDAR-associated ion channel in a novel manner, and a role in synaptogenesis has been suggested for this subunit. Here, we report a comprehensive study to delineate the temporal and anatomic expression of NR3A protein in the mammalian brain by using a monoclonal anti-NR3A antibody. NR3A protein was found to peak at postnatal day (P) 8, and to decrease gradually from P12 to adulthood in the rat central nervous system. Moreover, NR3A protein was heavily expressed in all areas of the isocortex, portions of the amygdaloid nuclei, and selective cell layers and nuclei of the hippocampus, thalamus, hypothalamus, brainstem, and spinal cord. NR3A protein was also expressed in the cerebellar cortex, whereas only weak signal was detected in the previous in situ studies by using riboprobes. At an ultrastructural level, NR3A was associated specifically with asymmetrical synapses and localized to postsynaptic membranes. This information will facilitate future research on NMDARs by providing clues to possible inclusion of the NR3A subunit in NMDARs in many brain regions.