Ten-Fold Elevation of Chromogranin A Level Unrelated to a Neuroendocrine Tumor: A Case Report of the Diagnostic Interference of Proton Pump Inhibitors.

Chromogranin A (CgA) is a well-known biomarker for neuroendocrine tumors (NETs). However, due to its non-specificity, a proper assessment of CgA test results requires a detailed knowledge of the factors, conditions, and medications influencing its serum concentration. We describe a case of a 61-year-old patient presenting with a mass suspicious of a gastrointestinal NET and an exceedingly high level of serum CgA persistent after mass resection. Following a thorough review of patient's medical history and clinical presentation, along with radiographic and pathological findings, no evidence of a NET was detected. A trial of proton-pump inhibitor (PPI) withdrawal led to a dramatic normalization of CgA level, marking it as the culprit causing this tumor marker elevation. This case highlights the significant impact of PPI use on CgA level, and should incentivize clinicians to provide proper education to patients prior to testing.

Motor Cortex Response to Pleasant Odor Perception and Imagery: The Differential Role of Personality Dimensions and Imagery Ability.

Background: Neuroimaging studies have shown a complex pattern of brain activation during perception of a pleasant odor and during its olfactory imagery. To date, little is known regarding changes in motor cortex excitability during these tasks. Bergamot essential oil (BEO) is extensively used in perfumes and cosmetics for its pleasantness. Therefore, to further our understanding of the human sense of smell, this study aimed to investigate the effect of perception and imagery of a pleasant odor (BEO) on motor cortex using Transcranial magnetic stimulation (TMS). Materials and Methods: We examined the primary motor cortex (M1) excitability during perception of a pleasant odor (BEO) or perception of odorless saline (experiment 1). Furthermore, we tested the effect of olfactory imagery (OI) of BEO on corticospinal excitability (experiment 2). The increase in motor evoked potential (MEP) amplitude was correlated with personality dimensions scores, pleasantness, vividness, and general imagery ability. Results: The results indicate that the corticospinal excitability changed after both perception and imagery of a pleasant odor (BEO). The correlation analysis shows an association with neuroticism personality trait (experiment 1) and with general olfactory imagery ability (experiment 2). Conclusion: Both perception of a pleasant odor and its olfactory imagery modulate motor cortex excitability. The enhanced brain activation is affected by specific individual characteristics. Overall, our findings provide physiological evidence for a complex interaction between the olfactory and motor systems.

Acute social and somatic stress alters cortical metaplasticity probed with non-invasive brain stimulation in humans.

Studying the neuronal mechanisms that govern the cortical adaptations to acute stress is critical for understanding the development of neuropsychiatric diseases. Homeostatic plasticity stabilizes the neural activity in which a previous synaptic event drives subsequent synaptic plasticity. In this study, we evaluated the effect of acute stress induced with the socially evaluated cold pressor test (SECPT) on cortical metaplasticity in humans using a non-invasive brain stimulation protocol. After being exposed to the SECPT and control stress conditions, 30 healthy participants were tested for cortical metaplasticity assessed with changes in the amplitude of the motor evoked potential (MEP) induced by a single-pulse transcranial magnetic stimulation (TMS). Cortical metaplasticity was induced by combining priming with cathodal tDCS (cTDCS) followed by a sub-threshold 1-Hz repetitive stimulation (rTMS) test session. Our results showed that SECPT induced cardiovascular adaptations (increase in systolic, diastolic blood pressure, and heart rate), indicating that SECPT effectively induced acute stress. Also, in our experiments stimulation of subjects with 1-Hz rTMS after they had undergone the SECPT condition induced inhibition of MEP whereas 1-Hz rTMS administered after the control condition induced a facilitatory (physiologic) response pattern. Here we observed that acute stress impairs homeostatic metaplasticity. The dysfunctional regulation of cortical plastic changes after stress could play a pivotal role in the pathogenesis of neurological and psychiatric diseases.

The Opioid Crisis: How to Lessen the Burden on Emergency Departments by At-risk Populations.

Background The opioid crisis in the United States of America has been worsening due to previous sharp increases in opioid prescriptions and a lack of resources available to those affected. Emergency departments (ED) across the nation have been exhausted with a constant influx of patients related to opioid-related issues. Because of limited resources, it is crucial to efficiently distribute rehabilitation and mental wellness efforts amongst those most susceptible to opioid abuse. By identifying common environments and characteristics of the population presenting to ED's for opioid-related issues, we can (1) lessen the economic burden on the healthcare system while (2) increasing the rate of successful treatment for those affected by opioid addiction. Methods Data was obtained regarding ED visits for opioid-related issues at the level of all 50 states from the Healthcare Cost and Utilization Project's (HCUP) State Emergency Department Databases (SEDD) and nationally from the Nationwide Emergency Department Sample (NEDS). Rates of ED admissions for opioid-related issues were statistically analyzed to identify characteristics of the population that are most at risk for presenting to the ED for opioid-related issues. Results Statistical analysis showed residents of Large Metropolitan areas (M=351.94, p=0.022, CI±42.89), those earning incomes below the 25th percentile (M=359.14, p=0.008, CI ±61.39), and 25-44-year-old population (M=456.71, p=0.001, CI±27.01) to be the most likely subset of the population to report to the ED for opioid-use issues. Conversely, those earning incomes above the 75th percentile were significantly less likely to utilize ED's for opioid-related issues (M=143.10, p=0.026, CI±0.026). Conclusion Results demonstrated that patients between the ages of 25 and 44 were more likely to develop opioid use disorders. This provides an opportunity to educate this population via opioid education centers. Additionally, residents of Large Metropolitan areas would benefit from naloxone distribution centers. Lastly, higher income levels appear to be related to a decrease in ED presentation for opioid abuse. This provides evidence for medication-assisted therapy (MAT) to be provided by low-income insurance plans.

Treating Bell's Palsy With Osteopathic Manipulative Medicine: A Case Report.

Bell's palsy (BP) occurs when the facial nerve (CN VII) is swollen, inflamed, or compressed, resulting in facial weakness or paralysis; etiology is unknown. BP patients often succumb to a decreased quality of life due to the inability to make facial expressions, increased sensitivity to auditory stimuli, and dysregulation in tear and saliva production. Despite conventional examination and therapy options, the syndrome is majorly regarded as idiopathic and left unresolved for many patients. In this case of a patient with BP, treatment with osteopathic manipulative treatment (OMT) which focused on restoring a normal structure-function relationship resolved the patient's symptoms. The osteopathic manipulative procedures utilized findings from an osteopathic structural exam and addressed those somatic dysfunctions with OMT. The authors report that the patient's symptoms improved after the application of OMT and without the use of pharmaceuticals. The results of the case study suggest that treating BP with OMT can rapidly improve symptoms and can be used without or concurrently with other treatment modalities, if applicable. Patient's consent for this case report was obtained in written and verbal form.

Effects of taurine acute intake on cortical excitability and post-exercise facilitation: A TMS study.

Taurine (TAU) is one of the most abundant amino acids in the brain. It has many important physiological functions. The effects of TAU supplementation on brain function need to be further characterized in humans. The purpose of this study was to investigate whether a single dose of Taurine (TAU) intake would modulate corticospinal excitability and post-exercise facilitation (PEF) of the motor evoked potentials (MEP).

Circulating Cell-Free DNA to Determine the Fetal RHD Status in All Three Trimesters of Pregnancy.

OBJECTIVE: To estimate the accuracy of a new assay to determine the fetal RHD status using circulating cell-free DNA. METHODS: This was a prospective, observational study. Maternal blood samples were collected in each trimester of pregnancy in 520 nonalloimmunized RhD-negative patients. Plasma samples were analyzed for circulating cell-free DNA using the SensiGENE RHD test, which used primers for exons 4 and 7 as previously described and incorporated a new primer design for exon 5 of the RHD gene. Neonatal serology for RhD typing using cord blood at birth was undertaken and results were stored in a separate clinical database. After unblinding the data, results of the DNA analysis were compared with the neonatal serology. RESULTS: Inconclusive results secondary to the presence of the RHD pseudogene or an RHD variant were noted in 5.6%, 5.7%, and 6.1% of the first-, second-, and third-trimester samples, respectively. The incidence of false-positive rates for RhD (an RhD-negative fetus with an RHD-positive result) was 1.54% (95% confidence interval [CI] 0.42-5.44%), 1.53% (CI 0.42-5.40%), and 0.82% (CI 0.04-4.50%), respectively. There was only one false-negative diagnosis (an RhD-positive fetus with an RHD-negative result), which occurred in the first trimester (0.32%; 95% CI 0.08-1.78%). Genotyping for mismatches across repeated samples revealed that this error was related to mislabeling of samples from two patients collected on the same day at one of the collection sites. Overall test results were in agreement across all three trimesters (P>.99). CONCLUSION: Circulating cell-free DNA can accurately predict the fetal RhD status in all three trimesters of pregnancy.

17-hydroxyprogesterone caproate for preterm rupture of the membranes: a multicenter, randomized, double-blind, placebo-controlled trial.

OBJECTIVE: Preterm rupture of membranes (PROM) is associated with an increased risk of preterm birth and neonatal morbidity. Prophylactic 17-hydroxyprogesterone caproate (17OHP-C) reduces the risk of preterm birth in some women who are at risk for preterm birth. We sought to test whether 17OHP-C would prolong pregnancy or improve perinatal outcome when given to mothers with preterm rupture of the membranes. STUDY DESIGN: This is a multicenter, double-blind, placebo-controlled, randomized clinical trial. The study included singleton pregnancies with gestational ages from 23(0/7) to 30(6/7) weeks at enrollment, documented PROM, and no contraindication to expectant management. Consenting women were assigned randomly to receive weekly intramuscular injections of 17OHP-C (250 mg) or placebo. The primary outcome was continuation of pregnancy until a favorable gestational age, which was defined as either 34(0/7) weeks of gestation or documentation of fetal lung maturity at 32(0/7) to 33(6/7) weeks of gestation. The 2 prespecified secondary outcomes were interval from randomization to delivery and composite adverse perinatal outcome. The planned sample size was 222 total women. RESULTS: From October 2011 to April 2014, 152 women were enrolled; 74 women were allocated randomly to 17OHP-C, and 78 were allocated randomly to placebo. The trial was stopped when results of a planned interim analysis suggested that continuation was futile. The primary outcome was achieved in 3% of the 17OHP-C group and 8% of the placebo group (P = .18). There was no significant between-group difference in the prespecified secondary outcomes, randomization-to-delivery interval (17.1 ± 16.1 vs 17.0 ± 15.8 days, respectively; P = .76) or composite adverse perinatal outcome (63% vs 61%, respectively; P = .93). No significant differences were found in other outcomes, which included rates of chorioamnionitis, postpartum endometritis, cesarean delivery, individual components of the composite outcome, or prolonged neonatal length of stay. CONCLUSION: Compared with placebo, weekly 17OHP-C injections did not prolong pregnancy or reduce perinatal morbidity in patients with PROM in this trial.

Vertical and horizontal transmission of Candida albicans in very low birth weight infants using DNA fingerprinting techniques.

BACKGROUND: Very low birth weight infants (VLBW, < or = 1500 g) are at increased risk for invasive disease caused by fungi, and colonization is an important risk factor. This study was designed to examine the effect of maternal flora on Candida colonization of VLBW infants. METHODS: Body site samples were collected within 24 hours of delivery from mothers who gave birth to VLBW infants, from their infants at birth, and then weekly for 12 weeks or until death or discharge. Yeast isolates were identified as Candida albicans by standard methods and typed by DNA fingerprinting using a C. albicans strain-specific DNA probe (CARE-2). RESULTS: Sixty-six percent (50/76) of mothers were colonized with yeast and 51% (39/76) of their infants had a Candida species isolated at least once. Of 46 infants born to C. albicans-colonized mothers, 18 (39%) became colonized with C. albicans. Twenty-two percent (17/76) of the infants in the study were colonized with C. albicans by 1 week of age; 76% of these infants (13/17) were born to C. albicans-colonized mothers suggesting vertical transmission. DNA fingerprinting was performed on these 13 mother-infant pairs and 11 pairs demonstrated identical band patterns, confirming vertical transmission. However, of all infants colonized with C. albicans by the first week of age, just 65% (11/17) had a maternal source, and among all infants colonized at any time point, only 41% (11/27) became colonized by vertical transmission. CONCLUSIONS: Both vertical and horizontal transmission contribute to Candida colonization of VLBW infants in the neonatal intensive care unit.