New-onset seizure activity in a transplant patient on immunosuppressive therapy.

The evaluation of new-onset seizure activity must raise a much broader differential than just epilepsy. This case study highlights that broad differential and identifies an important, but less common, cause of seizure activity in specific patient populations. Information is summarized from recent primary research, case series, literature reviews, and meta-analyses. In the appropriate clinical context, the diagnosis of posterior reversible encephalopathy syndrome (PRES) should be considered as a cause of seizures. Posterior reversible encephalopathy syndrome is a neurotoxic syndrome characterized by posterior cerebral edema on imaging and triggered by a variety of inciting or predisposing factors. This article reviews suggestions for the identification and management of PRES. Because of the myriad factors, nurse practitioners should be familiar with PRES and may encounter it through primary care, emergency or urgent care, hospitalist medicine, or a variety of specialty roles.

Low temperature decreases bone mass in mice: Implications for humans.

OBJECTIVES: Humans exhibit significant ecogeographic variation in bone size and shape. However, it is unclear how significantly environmental temperature influences cortical and trabecular bone, making it difficult to recognize adaptation versus acclimatization in past populations. There is some evidence that cold-induced bone loss results from sympathetic nervous system activation and can be reduced by nonshivering thermogenesis (NST) via uncoupling protein (UCP1) in brown adipose tissue (BAT). Here we test two hypotheses: (1) low temperature induces impaired cortical and trabecular bone acquisition and (2) UCP1, a marker of NST in BAT, increases in proportion to degree of low-temperature exposure. METHODS: We housed wildtype C57BL/6J male mice in pairs at 26 °C (thermoneutrality), 22 °C (standard), and 20 °C (cool) from 3 weeks to 6 or 12 weeks of age with access to food and water ad libitum (N = 8/group). RESULTS: Cool housed mice ate more but had lower body fat at 20 °C versus 26 °C. Mice at 20 °C had markedly lower distal femur trabecular bone volume fraction, thickness, and connectivity density and lower midshaft femur cortical bone area fraction versus mice at 26 °C (p < .05 for all). UCP1 expression in BAT was inversely related to temperature. DISCUSSION: These results support the hypothesis that low temperature was detrimental to bone mass acquisition. Nonshivering thermogenesis in brown adipose tissue increased in proportion to low-temperature exposure but was insufficient to prevent bone loss. These data show that chronic exposure to low temperature impairs bone architecture, suggesting climate may contribute to phenotypic variation in humans and other hominins.

Predictors of Perceived Educational Value in Emergency Medicine Residency Simulation Cases.

OBJECTIVES: This study was designed to identify characteristics associated with the perceived educational value of simulation cases in an emergency medicine residency curriculum. METHODS: Following 17 individual emergency medicine simulation cases, a standard feedback questionnaire was completed by emergency medicine residents. Multiple linear regression was performed to identify significant variables that predict perceived educational value. RESULTS: A total of 374 feedback responses were analyzed from 60 residents over a 2-year period. Complete data for inclusion in a regression analysis were available for 288 responses. The linear regression has an R2 value of 0.979, indicating that the model explains nearly 98% of the variation. The perceived usefulness of the simulation cases, PGY, and the reported the stressfulness of the exercise were all positively associated with perceived benefit. Familiarity with the clinical scenario, role of team leader, and perceived difficulty of the scenario did not influence the residents' perception of benefit. CONCLUSIONS: Multiple variables related to the scenario and the participants contribute to the perceived educational value of simulation cases in an emergency medicine residency curriculum. Specific predictors of educational value were PGY, stressfulness, and perceived utility. Being team leader, the familiarity of the scenario, or the perceived difficulty of the case did not influence the reported educational value. Recognition of these variables should help educators involved in the creation of educationally valuable simulation cases in the future.

Case series of patients with ruptured abdominal aortic aneurysm.

INTRODUCTION: Traditionally, patients with suspected ruptured abdominal aortic aneurysm (rAAA) are taken immediately for operative repair. Computed tomography (CT) has been considered contraindicated. However, with the emergence of endovascular repair, this approach to suspected rAAA could be changing. METHODS: We present retrospective data in a case series of 110 patients with rAAA. Patients were managed at a single tertiary medical center over a five-year period. At this site, there was an established multidisciplinary protocol in which patients with suspected rAAA undergo CT with consideration for endovascular aortic repair (EVAR). RESULTS: Our results demonstrated a mortality of 30% with our institutional protocol for CT in suspected rAAA. Comparing patients who ultimately had EVAR with open repair, those able to have endovascular aneurysm repair (EVAR) had lower mortality, shorter hospital stays for survivors, and a greater likelihood of being discharged to home than those with open repair. While survivors were more likely to have had EVAR, surviving patients were younger, had a significantly lower creatinine at presentation, and required fewer blood transfusions than those who died. CONCLUSION: Based on this case series, an institutional approach endorsing CT for presumed rAAA appears to be reasonable. Our results suggest that EVAR may be beneficial in appropriately-selected patients and that CT may potentially facilitate superior management options for patient care.

Effort thrombosis (Paget-Schroetter syndrome) in a 16-year-old male.

PATIENT: Male, 16. FINAL DIAGNOSIS: Effort thrombosis (Paget-Schroetter Sydnrome). SYMPTOMS: Swollen arms. MEDICATION: -. CLINICAL PROCEDURE: -. SPECIALTY: Metabolic Disorders and Diabetics. OBJECTIVE: Rare disease. BACKGROUND: Thrombotic events in otherwise healthy pediatric patients are rare. In patients presenting with limb swelling, thrombosis must be considered in the differential diagnosis. In pediatric patients with thrombosis, there has been wide variability in the rates of associated thrombophilia. Many pediatric patients may instead have other contributors such as venous catheters or physical activity. CASE REPORT: We present a case of bilateral upper extremity deep venous thrombi in a previously healthy 16-year-old male. The patient presented with swelling and pain in both arms after several days of weight-bearing exercise. Following emergency department evaluation with ultrasound and laboratory testing, the patient was diagnosed with effort thrombosis - also known as Paget-Schroetter syndrome - and rhabdomyolysis. CONCLUSIONS: This case of Paget-Schroetter syndrome is distinguished by elevation in creatine kinase and transaminases. While these findings can be due to physical exertion and effort, effort thrombosis is not classically associated with laboratory abnormalities except an elevated D-dimer. The significance of these laboratory test result abnormalities remains unclear. Given the rarity of effort thrombosis, further epidemiological study is warranted to determine if these laboratory findings are seen in other cases, and, if so, what implications they may have for management and prognosis.

Intraosseous administration of thrombolytics for pulmonary embolism.

BACKGROUND: Massive pulmonary embolism is associated with cardiac dysfunction and ischemia, hemodynamic collapse, and significant potential for death. The American College of Chest Physicians and American College of Emergency Physicians each supports thrombolytic administration to hemodynamically unstable patients with acute pulmonary embolism. OBJECTIVES: In the resuscitation of patients with massive pulmonary embolism and obstructive shock, difficulty with vascular access can hinder care. Alternative options may facilitate delivery of thrombolytics and enhance patient management. CASE REPORT: The case presented is a 36-year-old woman with massive pulmonary embolism associated with hemodynamic instability. She was treated with thrombolytics through a tibial intraosseous line. CONCLUSIONS: To the best of our knowledge, this is the first identified case of a patient not in cardiac arrest in whom thrombolytics were administered via an intraosseous line. Similarly, we believe this is also the first reported case of thrombolytics delivered via an intraosseous line for massive pulmonary embolism in the United States.

The challenge of multiple chemical sensitivity.

Environmental health professionals frequently come across a health-related problem with no clear cause-and-effect relationship. A typical case occurs when a person complains of experiencing symptoms, often in an indoor setting, that may vary from vague to severe. Multiple Chemical Sensitivity (MCS) may be a factor at play in some of these situations. The condition is characterized by persistent symptoms that follow exposure to chemically unrelated compounds at doses well below those that have been established individually to cause harmful effects. An understanding of MCS among environmental health and medical professionals is encouraged. The following article provides a review of the current literature about MCS and discusses the difficulties, from various sources, in resolving health complaints that may be caused by. exposure to low doses of multiple chemicals

Enhanced fitness conferred by naturally occurring variation in the circadian clock.

Natural variation in clock parameters is necessary for the circadian clock to contribute to organismal fitness over a broad geographic range. Considerable variation is evident in the period, phase, and amplitude of 150 Arabidopsis accessions, and the period length is correlated with the day length at the latitude of origin, implying the adaptive significance of correctly regulated circadian timing. Quantitative trait loci analysis of recombinant inbred lines indicates that multiple loci interact to determine period, phase, and amplitude. The loss-of-function analysis of each member of the ARABIDOPSIS PSEUDO-RESPONSE REGULATOR family suggests that they are candidates for clock quantitative trait loci.