Painless Scrotal Ulcers Become Something Unexpected: A Rare Case of Scrotal Calciphylaxis.

Calciphylaxis is an uncommon vascular disorder that presents with painful skin necrosis due to calcium accumulation in the skin and adipose tissue. It often presents in patients with multiple comorbidities like end-stage renal disease (ESRD) and in patients who are on long-term dialysis. This case highlights the atypical presentation of painless ulceration as seen in our patient. A 68-year-old Caucasian male with a past medical history of ESRD on hemodialysis (HD), diabetes mellitus II, and peripheral vascular disease presented to the hospital with altered mental status and severe left foot necrosis. During the hospital course, the patient developed a painless scrotal wound and eschar with sloughing. The ulcer was non-tender to palpation. Ultrasound identified calcifications in the scrotal tissue and CT of the pelvis without contrast showed extensive calcification of the arterial system. A clinical diagnosis of calciphylaxis was made. Treatment was initiated with sodium thiosulfate. The patient stabilized over the next few days; however, a few days later, the patient was readmitted and unfortunately passed away due to cardiac arrest. This case delineates the atypical presentation of calciphylaxis. Although painful skin necrosis is a well-reported and classic presentation of this disease, the lack of pain perception despite such a severe condition in our patient is of particular interest. This case calls for a closer look into the diagnosis of calciphylaxis, especially in the presence of nontender skin ulcers. This diagnosis should be part of the differential in a patient with ESRD on HD even when the presentation is atypical as early diagnosis and intervention can prevent fatal outcomes.

Identifying Risk Factors Associated with Inappropriate Use of Acid Suppressive Therapy at a Community Hospital.

Purpose. By examining the prescribing patterns and inappropriate use of acid suppressive therapy (AST) during hospitalization and at discharge we sought to identify the risk factors associated with such practices. Methods. In this retrospective observational study, inpatient records were reviewed from January 2011 to December 2013. Treatment with AST was considered appropriate if the patient had a known specific indication or met criteria for stress ulcer prophylaxis. Results. In 2011, out of 58 patients who were on AST on admission, 32 were newly started on it and 23 (72%) were inappropriate cases. In 2012, out of 97 patients on AST, 61 were newly started on it and 51 (84%) were inappropriate cases. In 2013, 99 patients were on AST, of which 48 were newly started on it and 36 (75%) were inappropriate cases. 19% of the patients inappropriately started on AST were discharged on it in three years. Younger age, female sex, and 1 or more handoffs between services were significantly associated with increased risk of inappropriate AST. Conclusion. Our findings reflect inappropriate prescription of AST which leads to increase in costs of care and unnecessarily puts the patient at risk for potential adverse events. The results of this study emphasize the importance of examining the patient's need for AST at each level of care especially when the identified risk factors are present.

Osteopathic Manipulative Treatment for Older Patients: A National Survey of Osteopathic Physicians.

CONTEXT: The mission of the American Academy of Osteopathy (AAO) emphasizes "the integration of osteopathic principles, practices and manipulative treatment in patient care." Osteopathic manipulative treatment (OMT) can be used to address serious conditions affecting older persons (≥65 years). However, the percentage of osteopathic physicians who use OMT in older patients, the differences in conditions for which OMT is used, and the OMT techniques used in older patients compared with younger patients are unknown. OBJECTIVE: To determine the use of OMT by osteopathic physicians in older patients compared with younger patients. METHODS: Members of the AAO were invited, via 3 e-mail messages sent over the course of a 4-month period, to participate in an anonymous online survey. The survey asked physicians to report the percentage of patients by age group (<65 years, 65-79 years, and ≥80 years) to whom they provided OMT, the types of musculoskeletal and system-based conditions for which OMT was used, and the specific OMT techniques used. RESULTS: A total of 197 of 629 AAO members (31.3%) responded to the survey. Respondents indicated that OMT was used at approximately the same rate in all patients in the 3 age groups. Osteopathic manipulative treatment was frequently used to manage a variety of musculoskeletal conditions, with the exception of osteoporosis, in all patients in the 3 age groups. The system-based conditions most often managed with OMT were respiratory and neurologic conditions. Various OMT techniques were used to treat patients in the 3 age groups; however, high-velocity, low-amplitude (HVLA) was usually avoided in patients aged 65 years or older. CONCLUSION: Osteopathic physicians who used OMT in their practice administered OMT for a variety of musculoskeletal and system-based conditions in patients of all ages. Various OMT techniques were used by these physicians for patients of all ages, with the exception of HVLA, which was mainly used in patients younger than 65 years.

Minimal genomes, maximal productivity: comparative genomics of the photosystem and light-harvesting complexes in the marine cyanobacterium, Prochlorococcus.

Although Prochlorococcus isolates possess the smallest genomes of any extant photosynthetic organism, this genus numerically dominates vast regions of the world's subtropical and tropical open oceans and has evolved to become an important contributor to global biogeochemical cycles. The sequencing of 12 Prochlorococcus genomes provides a glimpse of the extensive genetic heterogeneity and, thus, physiological potential of the lineage. In this study, we present an up-to-date comparative analysis of major proteins of the photosynthetic apparatus in 12 Prochlorococcus genomes. Our analyses reveal a striking diversity within the Prochlorococcus lineage in the major protein complexes of the photosynthetic apparatus. The heterogeneity that has evolved in the photosynthetic apparatus suggests versatility in strategies for optimizing photosynthesis under conditions of environmental variability and stress. This diversity could be particularly important in ensuring the survival of a lineage whose individuals have evolved minimal genomes and, thus, relatively limited repertoires for responding to environmental challenges.

Enhanced susceptibility to kainate-induced seizures, neuronal apoptosis, and death in mice lacking gangliotetraose gangliosides: protection with LIGA 20, a membrane-permeant analog of GM1.

Knock-out (KO) mice lacking gangliotetraose gangliosides attributable to disruption of the gene for GM2/GD2 synthase [GalNAcT (UDP-N-acetylgalactosamine:GM3/GD3 beta-1,4-N-acetylgalactosaminyltransferase; EC 2.4.1.92 [EC])] are revealing key neural functions for the complex gangliosides of brain. This study has found such animals to be highly susceptible to kainic acid (KA)-induced seizures in terms of both seizure severity and duration. Intraperitoneal injection of 25 mg/kg KA produced status epilepticus for approximately 200 min in normal mice or heterozygotes and more than four times longer in the KO mice. The latter group suffered approximately 30% mortality, which increased to approximately 75% at dosage of 30 mg/kg KA, compared with 10-14% for the other two genotypes at the latter dosage. Nissl staining and terminal deoxynucleotidyl transferase-mediated biotinylated UTP nick end labeling assay revealed substantial deterioration of pyramidal neurons attributable to apoptosis in the KO hippocampus, especially the CA3 region. Seizure activity in the KO mouse was only moderately diminished by intraperitoneal injection of GM1 ganglioside, whereas LIGA 20, a semisynthetic analog of GM1, substantially reduced both seizure severity and cell damage. The potency of LIGA 20 was correlated with its enhanced membrane permeability (compared with GM1), as seen in the increased uptake of [3H]LIGA 20 into the subcellular fractions of brain including cell nuclei. The latter finding is consonant with LIGA 20-induced restoration of the Na+/Ca2+ exchanger located at the inner membrane of the nuclear envelope in KO mice, an exchanger dependent on tight association with GM1 or its analog for optimal activity. These results point to a neuroprotective role for GM1 and its associated exchanger in the nucleus, based on regulation of Ca2+ flux between nucleoplasm and nuclear envelope.