25-year-old woman • abdominal pain • urticarial rash • recent influenza immunization • Dx?

► Abdominal pain ►Urticarial rash ► Recent influenza immunization.

Work Group Report: Perspectives in Diagnosis and Management of Exercise-Induced Bronchoconstriction in Athletes.

Exercise-induced bronchoconstriction, otherwise known as exercise-induced bronchoconstriction with asthma or without asthma, is an acute airway narrowing that occurs as a result of exercise and can occur in patients with asthma. A panel of members from the American Academy of Allergy, Asthma & Immunology Sports, Exercise, & Fitness Committee reviewed the diagnosis and management of exercise-induced bronchoconstriction in athletes of all skill levels including recreational athletes, high school and college athletes, and professional athletes. A special emphasis was placed on the recommendations and regulations set forth by professional athletic organizations after a detailed review of their collective bargaining agreements, substance abuse policies, antidoping program manuals, and the World Anti-Doping Agency antidoping code. The recommendations in this review are based on currently available evidence in addition to providing guidance for athletes of all skill levels as well as their treating physicians to better understand which pharmaceutical and nonpharmaceutical management options are appropriate as well as which medications are permitted or prohibited, and the proper documentation required to remain compliant.

Diagnosis and Management of Rhinosinusitis: Highlights from the 2015 Practice Parameter.

Rhinosinusitis is a commonly diagnosed disease in the USA. Rhinosinusitis is classified as acute, recurrent, or chronic (with or without nasal polyps). While acute rhinosinusitis is diagnosed by history and physical examination, chronic rhinosinusitis and recurrent acute rhinosinusitis are diagnosed based on symptoms and the presence of disease on either a sinus CT scan and/or endoscopy. Management of uncomplicated acute rhinosinusitis includes analgesics, saline irrigation, and/or intranasal steroids. Antibiotics and intranasal steroids are recommended for acute bacterial rhinosinusitis. Intranasal and oral steroids with antibiotics are recommended to treat chronic rhinosinusitis although the evidence for antibiotics is weak. Biologics such as omalizumab and mepolizumab are being investigated for the treatment of chronic rhinosinusitis with nasal polyps. Surgery may be indicated in management of refractory chronic rhinosinusitis and rarely for acute bacterial rhinosinusitis. This review discusses highlights of the updated 2014 practice parameter and up-to-date evidence from other literature sources.

Characterization of the syndrome of UGI bleeding from a Mallory-Weiss tear associated with transesophageal echocardiography.

AIM: To quantitatively describe the syndrome of Mallory-Weiss tears associated (MWa) with antecedent transesophageal echocardiography (TEE) as a distinct syndrome. METHODS: Cases of MWa were identified by comprehensive, computerized literature search via PubMed and review of textbooks and monographs on TEE and gastroenterology. Statistical comparison of 17 identified MWa cases versus previously published series of 73 cases of Mallory-Weiss tears unassociated with TEE (MWu) was performed. A new illustrative case is also currently reported. RESULTS: Comparison between these two groups revealed the following: MWa patients were significantly older (67.1 vs. 52.6 years, p = .0002, assuming equal variance), likely due to MWa patients having preexisting cardiovascular disease for which the TEE was indicated. The two groups had similar sex distributions (60 vs. 76% male, p = .32). MWa patients were significantly, more frequently anticoagulated at the time of bleeding (90.9 vs. 9.6%, p < .00001, OR = 94.3, 95%-OR CI: 9.56-2293), likely because of anticoagulation for underlying cardiac disease for which TEE was indicated. MWa patients tended to more frequently rebleed and more frequently require endoscopic therapy (both parameters: 4/17 vs. 8/73, p = .23) and tended to more frequently require surgery or angiography to control bleeding (3/17 vs. 3/73, p = .08). MWa patients had significantly higher mortality (23.5 vs. 2.7%, p = .01, OR = 10.9, 95%-OR CI 1.48-97.8), likely because of their older age, concomitant heart disease, and administered anticoagulation. A new case of MWa is reported with notable features that extend the clinical spectrum of this syndrome: (1) tear associated with hiatal hernia, (2) presentation with severe, fatal UGI bleeding, and (3) no anticoagulation during bleeding episode. CONCLUSIONS: Patients with MWa represent a distinct clinical subset from patients with MWu, with significantly older mean age, more frequent concomitant anticoagulation, and higher mortality. They also tend to have more severe bleeding. These characteristics are important in clinically managing this syndrome.

Development of anatomic science in the late middle ages: the roles played by Mondino de Liuzzi and Guido da Vigevano.

Medical historians generally consider anatomic science, as we know it today, to have been established through the pioneering work of Vesalius during the Renaissance. Although this is largely true, detailed assessment of the scientific advances made in the late Middle Ages, though not as spectacular as those made during the Renaissance period, did pave the way and form a foundation for subsequent progress. During the two centuries of AD 1300 to 1500, several worthwhile advances occurred. Many universities, centers of learning excellence, were established throughout Europe, most notably in Italy. King Frederick II, the Holy Roman Emperor, established guidelines for medical education and practice that seem to parallel current regulations. Human cadaveric dissection was performed, after a hiatus of over 1700 years, as the foundation for the study of anatomy. Observation of human dissection became a requirement for medical students. A manual for anatomic dissection was written, printed, and published for the first time in history by Mondino de Liuzzi. His student, Guido da Vigevano, who also had an engineering background, established two "firsts" of his own: providing illustrations of anatomy and designing the first automobile in history. The authors believe that the contributions of these two key anatomists in the late Middle Ages should not be forgotten.

Evolving role of uPA/uPAR system in human cancers.

Recent advancements in cancer research have led to some major breakthroughs; however, the impact on overall cancer-related death rate remains unacceptable, suggesting that further insight into tumor markers and development of targeted therapies is urgently needed. The urokinase plasminogen activator (uPA) system represents a family of serine proteases that are involved in the degradation of basement membrane and the extracellular matrix, leading to tumor cell invasion and metastasis. In this review, we have provided an overview of emerging data, from basic research as well as clinical studies, highlighting the evolving role of uPA/uPAR system in tumor progression. It is currently believed that the expression and activation of uPA plays an important role in tumorigenicity, and high endogenous levels of uPA and uPAR are associated with advanced metastatic cancers. The endogenous inhibitors of this system, PAI-1 and PAI-2, regulate uPA-uPAR activity by either direct inhibition or affecting cell surface expression and internalization. PAI-1's role in cancers is rather unusual; on one hand, it inhibits uPA-uPAR leading to inhibition of invasion and metastasis and on the other it has been reported to facilitate tumor growth and angiogenesis. Individual components of uPA/uPAR system are reported to be differentially expressed in cancer tissues compared to normal tissues and, thus, have the potential to be developed as prognostic and/or therapeutic targets. Therefore, this system represents a highly attractive target that warrants further in-depth studies. Such studies are likely to contribute towards the development of molecularly-driven targeted therapies in the near future.