A 25-Year-Old Chronic Ketamine User with Urinary Symptoms; a Case Report.

Ketamine is mainly used for short-acting general anesthesia, chronic pain, sedation, depression, and bipolar disorder. Long-term ketamine use may cause lower urinary tract symptoms and voiding dysfunction. Small capacity and fibrotic bladder can be associated with chronic ketamine use. Here, we present a 25-year-old male with a history of chronic ketamine use complicated with contracted heart-shape bladder.

An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department.

BACKGROUND: The skin, soft tissue, and most parts of the musculoskeletal system are relatively superficial anatomical structures and ideal targets for ultrasound examination in the emergency departments. Soft tissue and musculoskeletal ultrasound applications are relatively underused compared to traditional emergency applications, such as trauma, abdominal aortic aneurysm, and chest and cardiovascular systems. MAIN TEXT: It is important to have knowledge about sonoanatomy and landmarks within the skin, soft tissue, and musculoskeletal systems. Portable machines equipped with high-resolution transducers are now available to fulfill this field of applications in many emergency departments. After needling practice, emergency physicians can not only diagnose and identify pathological findings but also provide interventional procedures and treatments. In this review, we will introduce point-of-care ultrasound (POCUS) applications regarding the soft tissue and musculoskeletal systems: soft tissue infections, joint effusions, foreign bodies, long bone fractures, muscle and tendon injuries, vascular occlusions, and procedures. CONCLUSIONS: With POCUS, emergency physicians can visualize the structures beneath the skin and provide better and safer cares in the emergency departments.

Periampullary Diverticulum Perforation Following Endoscopic Retrograde Cholangiopancreatography (ERCP); a Case Report.

Endoscopic Retrograde Cholangiopancreatography (ERCP) is widely used for the diagnosis and treatment of biliary and pancreatic tract disease. Perforation is a rare complication of it, but it is associated with high rate of mortality, an overall mortality rate of 1.0-1.5%. Here, a case of massive subcutaneous emphysema following ERCP was reported without an obvious retroperitoneal or peritoneal perforation.

Hookworm infestation as unexpected cause of recurrent pancreatitis.

Parasite infestation is still associated with significant morbidity and mortality. Hookworm infestation is a very rare cause of pancreatitis. This parasitic infestation might be asymptomatic. Acute pancreatitis as a result of the hookworms migrating into the ampulla of Vater with chronic inflammation was a very rare complication. Were port a case of hookworm infestation that was associated with significant complication of recurrent pancreatitis. The patient was treated with mebendazole. He was asymptomatic and had gained weight at the 3-month follow-up. Our case demonstrates that pancreatitis secondary to hookworm infection can occur and may resolve after anthelmintic treatment.

Okadaic Acid, a Bioactive Fatty Acid from Halichondria okadai, Stimulates Lipolysis in Rat Adipocytes: The Pivotal Role of Perilipin Translocation.

Lipid metabolism in visceral fat cells is correlated with metabolic syndrome and cardiovascular diseases. Okadaic-acid, a 38-carbon fatty acid isolated from the black sponge Halichondria okadai, can stimulate lipolysis by promoting the phosphorylation of several proteins in adipocytes. However, the mechanism of okadaic acid-induced lipolysis and the effects of okadaic acid on lipid-droplet-associated proteins (perilipins and beta-actin) remain unclear. We isolated adipocytes from rat epididymal fat pads and treated them with isoproterenol and/or okadaic acid to estimate lipolysis by measuring glycerol release. Incubating adipocytes with okadaic acid stimulated time-dependent lipolysis. Lipid-droplet-associated perilipins and beta-actin were analyzed by immunoblotting and immunofluorescence, and the association of perilipin A and B was found to be decreased in response to isoproterenol or okadaic acid treatment. Moreover, okadaic-acid treatment could enhance isoproterenol-mediated lipolysis, whereas treatment of several inhibitors such as KT-5720 (PKA inhibitor), calphostin C (PKC inhibitor), or KT-5823 (PKG inhibitor) did not attenuate okadaic-acid-induced lipolysis. By contrast, vanadyl acetylacetonate (tyrosine phosphatase inhibitor) blocked okadaic-acid-dependent lipolysis. These results suggest that okadaic acid induces the phosphorylation and detachment of lipid-droplet-associated perilipin A and B from the lipid droplet surface and thereby leads to accelerated lipolysis.

Small bowel intramural hematoma secondary to abdominal massage.

Oral anticoagulant therapy with warfarin is commonly used to prevent thromboembolic event in patients at risk with atrial fibrillation [1]. Spontaneous intramural hematoma of small intestine is rare complication of anticoagulant therapy and occurs in patient who receives excessive warfarin that may result in potentially serious complications. Small bowel intramural hematoma secondary to warfarin therapy is a recognized complication [2]. In the present report, we report an unusual case of small bowel intramural hemorrhage secondary to anticoagulant therapy after abdominal massage. The emergency physicians should be aware that the potential spontaneous small bowel intramural hemorrhage in the patients has a high index of suspicion because most patients are treated nonoperatively with a good outcome.

Comparing different patterns for managing febrile children in the ED between emergency and pediatric physicians: impact on patient outcome.

OBJECTIVE: The management of children with fever of indefinite source still remains controversial. This study aimed to compare different practice patterns between pediatric physicians (PPs) and emergency physicians (EPs) in the management of pediatric fever in the emergency department (ED) and correlate them to existing practice guidelines. Their impact on patient outcomes was also discussed. METHODS: Medical records of patients 3 to 36 months of age who presented to the ED with fever of indefinite source from June 1 to December 31, 2006, were retrospectively reviewed on day 5 after the patient's first visit. At the same time, telephone follow-up was carried out to determine whether the patient had been visiting or being admitted to another clinic or hospital after discharge. Variation in practice patterns were compared for the number of laboratory tests, ED length of stay (LOS), and the rate of immediate admission. Patient outcomes were measured as the rate of unscheduled revisit within 72 hours and the rate of subsequent admission. Compliance with existing practice guidelines between PPs and EPs were evaluated by dividing all eligible patients into 3 groups: (1) toxic appearing patients (group A), (2) nontoxic patients with body temperature (BT) > or = 39 degrees C (group B), and (3) nontoxic patients with BT below 39 degrees C (group C). RESULTS: A total of 345 patients who met the inclusion and exclusion criteria were enrolled into this study. Pediatric physicians and EPs treated 163 and 182 febrile children, respectively. In group A, PPs admitted more patients than EPs (41% vs 12 %), whereas more unscheduled revisits were seen in EP-treated patients (44% vs 10%). In group B, PPs ordered more laboratory tests than EPs (2.3 vs 0.7 tests per patient), and their patients also had a longer ED LOS (3.4 +/- 3.2 vs 1.5 +/- 1.1 hours). However, no difference was found in their rates of immediate admission and unscheduled revisit. In group C, PPs admitted more patients (15% vs 0%) and ordered more laboratory tests (2.0 vs 0.5 tests/patient) than EPs. Longer ED LOS (3.3 +/- 3.9 vs 1.0 +/- 1.4 hours) was also noted among PP-treated patients. However, no difference was noted in their rates of unscheduled revisit. In all groups, the rates of subsequent admission were similar. CONCLUSION: Compliance with existing practice guidelines (admit the toxic cases and work up those with BT > or = 39 degrees C) was higher among PPs, which resulted in a lower rate of unscheduled revisit, but no significant difference was found in the rate of subsequent admission.

Terminal ileum perforation from a misplaced percutaneous suprapubic cystostomy.

Iatrogenic bowel injury is a recognized complication of percutaneous suprapubic cystostomy. In the present report, we report an unusual case of small bowel perforation caused by a misplacement of suprapubic catheter into terminal ileum. For safe placement of a suprapubic catheter, the patients must have an adequately distended bladder and be placed in Trendelenburg position that allows safe extraperitoneal puncture of the bladder.

Low plasma vasopressin/norepinephrine ratio predicts septic shock.

To evaluate if low plasma vasopressin and high norepinephrine concentrations predict grave prognosis of sepsis, a prospective sample of consecutive patients visiting the emergency department of a university teaching hospital who met the American College of Chest Physicians criteria of sepsis or severe sepsis was enrolled. Besides septic workup, we measured serum vasopressin and norepinephrine concentrations to correlate the impending outcome. One hundred eighty-two patients aged 27 to 99 years met the inclusive criteria and were classified as those with septic shock (n = 72), severe sepsis (n = 56), and those with sepsis only (n = 54) according to the outcome within 6 hours. Thirty healthy subjects were included as control. The plasma vasopressin level at baseline was significantly lower for those who finally developed septic shock (septic shock group, 3.6 +/- 2.5 pg/mL; 95% confidence interval [CI], 3.0-4.2 pg/mL; severe sepsis group, 21.8 +/- 4.1 pg/mL, 95% CI, 20.7-22.9 pg/mL; sepsis group, 10.6 +/- 6.5 pg/mL, 95% CI, 8.8-12.4 pg/mL, P < .001), whereas the norepinephrine level was highest for the same group (septic shock group, 3650 +/- 980 pg/mL, 95% CI, 3420-3880 pg/mL; severe sepsis group, 3600 +/- 1000 pg/mL, 95% CI, 3330-3870 pg/mL; sepsis group, 1720 +/- 320 pg/mL, 95% CI, 1630-1810 pg/mL). The vasopressin/norepinephrine ratio was significantly lower for the patients with final diagnosis of septic shock (P < .001). The mean interval between the time of samples drawn and the time of the most severe occurring sequelae was 2.4 +/- 0.8 hours. Receiver operating characteristic analysis revealed that the vasopressin/norepinephrine ratio 1 x 10(-3) had a sensitivity of 97% (95% CI, 90%-99%) and a specificity of 85% (95% CI, 78%-91%) for detecting impending septic shock. Low serum vasopressin/norepinephrine ratio can predict impending septic shock.

Decline in titin content in rat skeletal muscle after denervation.

Titin, an elastic and giant myofibrillar protein, is responsible for generating passive tension and maintaining sarcomere structure in striated muscles. Several studies have reported attenuation of passive tension and disorganization of sarcomere in atrophic muscles, but the changes of titin have not been investigated after denervation. For this purpose, we used sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and immunofluorescent staining to examine titin in innervated and denervated tibialis anterior (TA) muscles of the rat. With increasing denervation time, we found a greater loss of titin than myosin heavy chain (MHC) and actin contents in atrophic TA muscle. The ratios of titin/MHC and titin/actin gradually decreased following denervation. In contrast, ratios of MHC/actin in the denervated groups showed no significant differences with the controls even at 56 days postdenervation. The ultrastructure of myofibrils also showed disturbed arrangements of myofilaments and a disorganized contractile apparatus in denervated muscle. Immunofluorescent staining displayed translocation of the titin epitope from the Z-line to the I-band, suggesting that the apparent cleavage of titin occurred near the Z-line region during the atrophying process. Our study provides evidence that titin is more sensitive to degradation than MHC and actin after denervation. Moreover, the titin decline results in the loss of titin-based sarcomeric integrity in atrophic muscle.