Acute Medical Diagnoses Are Common in "Found Down" Adult Patients Presenting to the Emergency Department as Trauma.

BACKGROUND: Patients often present to the emergency department (ED) as "found down," with limited history to suggest a primary traumatic or medical etiology. OBJECTIVE: The study objective was to describe the characteristics of "found down" adult patients presenting to the ED as trauma, specifically the incidence of acute medical diagnoses and major trauma. METHODS: Using an institutional trauma registry, we reviewed trauma activations with the cause of injury "found down" between January 2008 and December 2012. We excluded patients with cardiac arrest, transfers from other hospitals, and patients with a more than likely (>50%) traumatic or medical etiology on initial ED presentation. Inclusion and exclusion criteria were reviewed by two independent abstractors. We abstracted demographic, clinical, injury severity, and outcomes variables. Major trauma was defined as Injury Severity Score ≥ 16. RESULTS: There were 659 patients identified with the cause of injury "found down." A total of 207 (31%) patients met inclusion criteria; median age was 67 years (interquartile range 50-82 years), and 110 (53%) were male. Among the included patients, 137 (66%, 95% confidence interval [Cl] 59-73%) had a discharge diagnosis of an acute medical condition, 14 (7%, 95% Cl 4-11%) with major trauma alone, 21 (10%, 95% Cl 6-15) with both an acute medical condition and major trauma, and 35 (17%, 95% Cl 12-23%) with minor trauma. The most common acute medical diagnoses were toxicological (56 patients, 35%; 95% Cl 28-43%) and infectious (32 patients, 20%; 95% Cl 14-27%). CONCLUSION: Acute medical diagnoses were common in undifferentiated ED patients "found down" in an institutional trauma registry. Clinicians should maintain a broad differential diagnosis in the workup of the undifferentiated "found down" patient.

DORNRÖSCHEN-LIKE expression marks Arabidopsis floral organ founder cells and precedes auxin response maxima.

Live imaging during floral development revealed that expression of the DORNRÖSCHEN-LIKE (DRNL) gene encoding an AP2-like transcription factor, marks all organ founder cells. Transcription precedes the perception of auxin response maxima as measured by the DR5 reporter and is unaffected in early organogenesis, by mutation of four canonical auxin response elements (AuxREs) in the DRNL promoter. DRNL expression identifies discrete modes of organ initiation in the four floral whorls, from individual or pairs of organ anlagen in the outer whorl of sepals to two morphogenetic fields pre-patterning petals and lateral stamens, or a ring-shaped field giving rise to the medial stamens before carpel primordia are specified. DRNL function only overlaps in the central stem cell zone with that of its paralogue, DORNRÖSCHEN (DRN). drnl mutants are affected in floral organ outgrowth, which functionally interplays with boundary specification as organ fusions are sensitized by loss of CUP-SHAPED COTYLEDON (CUC) gene activity, and synergistic interactions exist with mutants in local auxin biosynthesis and polar transport. DRNL apparently monitors and contributes to cellular decisions in the SAM and thus provides a novel molecular access to the interplay of founder cell specification, organ anlage and organogenesis in the SAM peripheral zone.

Genetic integration of DORNRÖSCHEN and DORNRÖSCHEN-LIKE reveals hierarchical interactions in auxin signalling and patterning of the Arabidopsis apical embryo.

DORNRÖSCHEN (DRN) and DORNRÖSCHEN-LIKE (DRNL) encode AP2-domain transcription factors, which act redundantly in cotyledon organogenesis. A more detailed genetic study now integrates DRN and DRNL into the CUP-SHAPED COTYLEDON (CUC) regulatory network and places DRN and DRNL differentially within the auxin signalling network: DRNL function overlaps with that of PIN-FORMED1, and DRN with PINOID. DRN and DRNL act cell-autonomously and are co-expressed in the early globular embryo, whereas expression patterns diverge during later stages of embryogeny. Both genes synergize to provide essential patterning information in the apical embryo domain, to establish correct CUC, SHOOTMERISTEMLESS and WUSCHEL expression domains, which relates to the patterning of SAM anlagen to a central apical position to create two planes of bilateral symmetry in wild type Arabidopsis thaliana embryos.

DORNROSCHEN is a direct target of the auxin response factor MONOPTEROS in the Arabidopsis embryo.

DORNROSCHEN (DRN), which encodes a member of the AP2-type transcription factor family, contributes to auxin transport and perception in the Arabidopsis embryo. Live imaging performed with transcriptional or translational GFP fusions shows DRN to be activated in the apical cell after the first zygotic division, to act cell-autonomously and to be expressed in single cells extending laterally from the apical shoot stem-cell zone at the position of incipient leaf primordia. Here, we show that the Auxin response factor (ARF) MONOPTEROS (MP) directly controls DRN transcription in the tips of the embryonic cotyledons, which depends on the presence of canonical Auxin response elements (AuxREs), potential ARF-binding sites flanking the DRN transcription unit. Chromatin immunoprecipitation experiments show that MP binds in vivo to two AuxRE-spanning fragments in the DRN promoter, and that MP is required for expression of DRN in cotyledon tips. Hence, DRN represents a direct target of MP and functions downstream of MP in cotyledon development.

Evolution of C(4) phosphoenolpyruvate carboxylase in Flaveria: determinants for high tolerance towards the inhibitor L-malate.

During the evolution of angiosperms, C4 phosphoenolpyruvate carboxylases have evolved several times independently from ancestral non-photosynthetic isoforms. They show distinct kinetic and regulatory properties when compared with the C3 isozymes. To identify the evolutionary alterations which are responsible for C4-specific properties, particularly the increased tolerance towards the allosteric inhibitor L-malate, the photosynthetic phosphoenolpyruvate carboxylase of Flaveria trinervia Mohr C4 and its ortholog from the closely related C3 plant Flaveria pringlei Gand. were examined using reciprocal enzyme chimeras. The main determinants for a high tolerance towards L-malate were located in the C-terminal region of the C4 enzyme. The effect of interchanging the region between amino acids 296 and 437 was strongly dependent upon the activation of the enzyme by glucose-6-phosphate. This confirms earlier observations that this region is important for the regulation of the enzyme by glucose-6-phosphate and that it harbours determinants for the different response of the C3 and the C4 enzyme towards this allosteric activator. In addition, it was possible to demonstrate that the only C4-specific amino acid, a serine in the C-terminal part of the enzyme, is not involved in conferring an increased L-malate tolerance to the C4 enzyme.