Expression of Human Immunodeficiency Virus Transactivator of Transcription (HIV-Tat1-86) Protein Alters Nociceptive Processing that is Sensitive to Anti-Oxidant and Anti-Inflammatory Interventions.

Despite the success of combined antiretroviral therapy (cART) in reducing viral load, a substantial portion of Human Immunodeficiency Virus (HIV)+ patients report chronic pain. The exact mechanism underlying this co-morbidity even with undetectable viral load remains unknown, but the transactivator of transcription (HIV-Tat) protein is of particular interest. Functional HIV-Tat protein is observed even in cerebrospinal fluid of patients who have an undetectable viral load. It is hypothesized that Tat protein exposure is sufficient to induce neuropathic pain-like manifestations via both activation of microglia and generation of oxidative stress. iTat mice conditionally expressed Tat(1-86) protein in the central nervous system upon daily administration of doxycycline (100 mg/kg/d, i.p., up to 14 days). The effect of HIV-Tat protein exposure on the well-being of the animal was assessed using sucrose-evoked grooming and acute nesting behavior for pain-depressed behaviors, and the development of hyperalgesia assessed with warm-water tail-withdrawal and von Frey assays for thermal hyperalgesia and mechanical allodynia, respectively. Tissue harvested at select time points was used to assess ex vivo alterations in oxidative stress, astrocytosis and microgliosis, and blood-brain barrier integrity with assays utilizing fluorescence-based indicators. Tat protein induced mild thermal hyperalgesia but robust mechanical allodynia starting after 4 days of exposure, reaching a nadir after 7 days. Changes in nociceptive processing were associated with reduced sucrose-evoked grooming behavior without altering acute nesting behavior, and in spinal cord dysregulated free radical generation as measured by DCF fluorescence intensity, altered immunohistochemical expression of the gliotic markers, Iba-1 and GFAP, and increased permeability of the blood-brain barrier to the small molecule fluorescent tracer, sodium fluorescein, in a time-dependent manner. Pretreatment with the anti-inflammatory, indomethacin (1 mg/kg/d, i.p.), the antioxidant, methylsulfonylmethane (100 mg/kg/d i.p.), or the immunomodulatory agent, dimethylfumarate (100 mg/kg/d p.o.) thirty minutes prior to daily injections of doxycycline (100 mg/kg/d i.p.) over 7 days significantly attenuated the development of Tat-induced mechanical allodynia. Collectively, the data suggests that even acute exposure to HIV-1 Tat protein at pathologically relevant levels is sufficient to produce select neurophysiological and behavioral manifestations of chronic pain consistent with that reported by HIV-positive patients.

Diagnostic Accuracy of Neutrophil/Lymphocyte Ratio, Red Cell Distribution Width and Platelet Distribution Width in Ovarian Torsion.

The main aim of this diagnostic case-control study of 136 patients with ovarian cysts (44 patients with ovarian torsion and 92 controls) was to determine the diagnostic value of haematologic inflammatory markers (neutrophil/lymphocyte ratio [NLR], red cell distribution width [RDW] and platelet distribution width [PDW]) for torsioned ovarian cysts. The presence of a torsioned ovarian cyst was identified by a 1.18-fold increase in the NLR (95%CI: 1.04-1.34, P = 0.009), a 1.22-fold increase in the RDW (95%CI: 1.04-1.43, P = 0.023) and a 1.93-fold increase in the PDW (95%CI: 1.19-3.14, P = 0.007). The NLR was the best predictor of a torsioned ovarian cyst (AUC: 0.74; 95% CI: 0.68-0.83). When an NLR cut-off value of 2.44 was used to determine ovarian torsion, the sensitivity, specificity, + LR and -LR were 70.5%, 70.7%, 2.40 and 0.42, respectively. In conclusion, the NLR may have diagnostic and prognostic value in determining torsioned ovarian cysts.

How valuable is P-wave dispersion in the determination of carboxyhemoglobin levels?

OBJECTIVE: To determine whether or not wave/interval dispersions in electrocardiography (ECG) are increased, and to define whether wave and interval dispersions are correlated with carboxyhemoglobin (COHb) levels. METHODS: ECG, complete blood count, and biochemical parameters were taken from 87 patients with carbon monoxide (CO) poisoning as well as 90 control patients with similar age, gender, and body mass index distribution. COHb levels were recorded in CO-poisoning patients. The COHb levels and the relationships with ECG parameters were studied. RESULTS: Pmax, Pmin, Pd, PRmax, PRmin, PRd, QTmax, QTmin, QTd, cQTmax, cQTmin, cQTd, Tmax, Tmin, and Td in ECG were higher in intoxicated patients than the control group (p < 0.05 for all). Pearson's correlation analyses showed moderately significant positive correlations between COHb level and Pmax (r = 0.224; p = 0.037) and Pd (r = 0.222; p = 0.039). The receiver-operator characteristic (ROC) curve showed that a Pd value of 38 ms determined by ECG separates patients with a COHb ≥ 20% with area under the ROC curve of 0.78 (95%CI = 0.71-0.83), a sensitivity of 67.9% (95%CI = 59.4-75.6), a specificity of 95% (95%CI = 83.0-99.2], a positive predictive value of 97.9% (95%CI = 92.5-99.7), and a negative predictive value of 46.3% (95%CI = 35.3-57.7.) CONCLUSION: A significant increase in wave/interval dispersions in the ECG of CO-poisoning patients compared with controls may show that not only a part is affected but both atrium and the ventricles as a whole are affected by hypoxic ischemia. When COHb levels of the patients are unavailable, P dispersion on ECG may show CO poisoning level of the patient.

Diagnosing isolated nasal fractures in the emergency department: are they missed or overdiagnosed? Ten years experience of 535 forensic cases.

AIM: Nasal bone is the most common broken bone of the face. Incorrect assessments of nasal trauma are frequently encountered in forensic evaluations. Here, we aimed to determine the reasons and frequency of erroneous assessments of nasal trauma in emergency department (ED). METHODS: This is a cross-sectional multicentric study analyzing the Forensic Medical Department archive retrospectively. Epidemiologic features, type of fracture (depressed or non-depressed), and specialty of the doctor examining the cases in ED were studied. Forensic evaluation was reported by analyzing all radiologic examinations (CT and X-ray), medical records, and after repeated physical examination of nasal trauma by the forensic council, consisting of a forensic expert, a radiologist and an otolaryngologist. Nasal fracture was diagnosed when at least two of three physicians agreed. RESULTS: A total of 535 cases (mean age 31.7 ± 14.4, 87.1 % males) were analyzed. The most common causes of injuries were assault (81.8 %), followed by traffic accident (15.3 %) and falls from a height (2.1 %). There were misdiagnoses in ten patients (1.9 %) and overdiagnosis in 135 (24.5 %). The possibility of fracture overdiagnosis was 13.5 times higher than missing it. General practitioners and emergency physicians have 19.7 times (95 % CI 5.5-22. 3) and 3.4 times (95 % CI 1.5-7.8) the tendency to report soft tissue nasal injuries as non-depressed fractures, respectively. CONCLUSION: We found that nasal fractures are rarely missed while the overdiagnosis was very common. Examination of patients by a general practitioner or an emergency physician without consultation with a specialist and using only plain radiographs were found to be independent parameters affecting overdiagnosis.

Wildflower (Hyoscyamus reticulatus) causes QT prolongation.

INTRODUCTION: In the environment, there are hundreds of poisonous and injurious plants with a wide variety of toxicity. Among all plants with anticholinergic effect, Hyoscyamus reticulatus is a species whose clinicopathological effects have been poorly described in literature. The paper is especially aimed at drawing attention to the possibly fatal syndrome of prolonged QT, as well as to clinical and laboratory changes in six members of a single family poisoned with this plant. CASES: Six female patients aged from 19 to 49 presented to our emergency room with a suspicion of being poisoned after having ingested a plant known as 'the mad axe plant' (Hyoscyamus reticulatus). At least one of anticholinergic symptoms including flushing, mydriasis, dry mouth and tachycardia was present in all of the patients. In addition, different levels of agitation were observed in four of the patients. A euphoric emotional state was present in two patients. The corrected QT distances were found to be prolonged in three of the patients. DISCUSSION AND CONCLUSION: Based on economical, social and cultural reasons, it is a very common habit in our country, especially in our region in spring and summer months, to consume some plants growing spontaneously in rural areas as food. Intoxication with Hyoscyamus reticulatus is a plant poisoning that is poorly described in literature. Its classical symptoms are predominantly anticholinergic. Although it is commonly self-limited and can be corrected with close observation and supportive treatments, it should be kept in mind that the prolongation of QT interval can accompany the symptoms of poisoning with this plant (Tab. 1, Fig. 3, Ref. 19).

What are the predictors of scapula fractures in high-impact blunt trauma patients and why do we miss them in the emergency department?

AIM: To find out the predictors of scapula fractures in high-impact blunt trauma patients and the predictors of missing them in the emergency department (ED). METHODS: This is a retrospective descriptive review of patients treated at a single hospital over a 3.5-year period. The study included 1,039 high-impact blunt trauma patients of any age. The patients were divided into two groups: patients with scapula fractures (the patient group) and others (the control group). The patient group was re-assessed into two subgroups: patients with and without missed scapula fractures. Logistic regression analysis was used to assess the predictors of a scapular fracture in the ED. RESULTS: The incidence of scapula fractures was 4%. The Injury Severity Scores (ISS) of the scapula fracture group were significantly higher than those of the control group (P < 0.0001). Patients with scapula fractures were significantly older (P < 0.001). Patients with scapular body fractures stayed for significantly longer in the intensive care unit (ICU) (P = 0.039) and their mean Abbreviated Injury Scale (AIS)face score was higher (P = 0.04) compared to scapular fractures without body parts. Scapula fractures were missed in 35.7% of patients. All bilateral scapula fractures were missed. Computerized tomography showing shoulder region or scapula was obtained in 26.7% of missed injuries. CONCLUSION: After matching for ISS, the mortality of patients with scapula fracture was significantly higher than the control group. We observed that fractures in the glenoid and scapular neck occurred higher than in the body region. We found that the seniority of the ED doctor, consultation ratio for orthopedics in ED, and the existence of brain contusion were important parameters for missing scapula fractures in ED.

The main differences in oral exposures in children and adults.

OBJECTIVES: This study aimed to determine the epidemiological differences between children and adult oral exposures in patients admitted to the busiest emergency department (ED) in the Eastern Anatolia region of Turkey. METHODS: The characteristics of 1950 patients were investigated retrospectively and in a cross-sectional manner in a two-year period. RESULTS: The ratio of poisoning exposures among all emergency admissions was 0.6%. Of these, 44.5% were children, and 54.4% were unintentional. The mortality rate was 0.1% and the rate of hospitalization was 14.9%. Among the children and adults, 50.3% and 29.5% were male, respectively. While the first two causes of exposures in both children and adults were licit drugs and foods, there were differences in other causes. Among causes, licit drugs and corrosive materials constituted the forefront in the 0-1 and 1-5-year age groups. In parasuicidal causes, the most common exposure was found to be licit drugs, followed by organophosphates. The most common cause of hospitalization was plants (60.5%). The hospitalization rate was found to be significantly high in males and unintentional exposures. The rate of admissions to the psychiatry polyclinic following exposure was 15%. CONCLUSION: This study hereby presents the original findings as to predict the problems in exposures. The distribution of etiological agents and suicidal intent rate may differ among pediatric and adult population (Tab. 4, Fig. 1, Ref. 50).

Predictors of missed injuries in hospitalized trauma patients in the emergency department.

AIM: To determine the extent of missed injuries in patients hospitalized with major trauma in a Turkish Level 1 emergency department. We also tried to identify the primary factors contributing to each missed injury and to determine their subsequent adverse short-term clinical outcomes. METHODS: This is a retrospective analysis of prospectively collected data on a cohort of trauma patients. Trauma patients were divided into two groups: patients with missed injury and others. Logistic regression was used to define factors affecting "missed injury". RESULTS: A total of 670 hospitalized trauma patients were included. The incidence of missed injuries in the patients and the rate of missed injury per patient were 13.3% (95% CI 6-20) and 1.64, respectively. The most frequently missed diagnosis was injuries of the musculoskeletal system (38%; 95% CI 30-46). It was "clavicle fracture and/or dislocation" (35%; 95% CI 16-53) when the rate of missed diagnosis according to the frequency of the specific injury was calculated. A multiple logistic regression analysis showed that the predictors of missed injuries were patient's age (OR 0.74, 95% CI 0.63-0.87), total number of injuries (OR 1.74, 95% CI 1.38-2.20), and ISS (OR 1.10, 95% CI 1.03-1.18). Radiological errors were prominent in almost 90% (95% CI 85-95). Missed injury caused additional hospital stay (30%; 95% CI 21-40) and additional surgery was required (15%; 95% CI 8-23). CONCLUSION: The study highlights the need for a trauma team approach and the need for support of radiological report in the ED.

The neural generation of a unified illusion in human vision.

The neural mechanisms of visual binding in humans were investigated by measuring the brain's high-frequency electric responses (36-44 Hz) to the subjective visual perception of a unified three-dimensional illusion. 40 Hz synchronization was found over occipital and right parieto-temporal areas 500-300 ms before visual awareness of the three-dimensional Gestalt was reported, but not during the viewing of the illusion. At lower frequency bands (8-13 Hz and 13-20 Hz) no corresponding synchronization was found. 40 Hz synchronization thus directly correlates with the construction and emergence of a unified visual percept and may reflect the rapid formation of transient functional connections between spatially separated cortical areas.