N-Methyl-D-Aspartate Receptor-Negative Autoimmune Encephalitis in a Patient With an Ovarian Teratoma and an Associated Novel Cerebrospinal Fluid Autoantibody.

Autoimmune encephalitis is most commonly caused by autoantibodies against N-methyl-D-aspartate (NMDA) receptors, and the malignancy most often associated with anti-NMDA receptor autoimmune encephalitis is an ovarian teratoma. Here, we describe a case of autoimmune encephalitis caused by a newly discovered cerebrospinal fluid autoantibody that has not been previously described and is not anti-NMDA receptor-mediated, which has been associated with an ovarian teratoma. It was successfully treated with high-dose corticosteroids and plasmapheresis followed by rituximab and chemotherapy (paclitaxel, ifosfamide, and cisplatin) for her teratoma.

Emergency department management of pediatric patients with cyanotic heart disease and fever.

BACKGROUND: Children with cyanotic congenital heart disease (CCHD) are living longer and presenting to the Emergency Department (ED) in larger numbers. A greater understanding of their diagnoses and appropriate management strategies can improve outcomes. OBJECTIVE: Our objective was to describe the ED diagnoses, management, and dispositions of pediatric CCHD patients who present with fever. METHODS: We retrospectively analyzed pediatric ED patients age 18 years or younger with a previous diagnosis of CCHD who presented with a fever from January 2000 to December 2005. RESULTS: Of 809 total ED encounters, 248 (30.6%) were eligible for inclusion. Of those meeting inclusion criteria, 59 (23.8%) required supplemental oxygen and 67 (27%) received intravenous fluid. ED diagnoses were febrile illness in 120 (48.4%), pneumonia in 35 (14.1%), upper respiratory infection in 19 (7.7%), viral syndrome in 17 (6.9%), gastroenteritis in 17 (6.9%), otitis media in 10 (4.0%), bronchiolitis in 5 (2.0%), pharyngitis in 3 (1.2%), croup in 3 (1.2%), bronchitis in 3 (1.2%), urinary tract infection in 3 (1.2%), mononucleosis in 2 (0.8%), pericarditis in 2 (0.8%), influenza in 1 (0.4%), cellulitis in 1 (0.4%), bacteremia in 1 (0.4%), and potential endocarditis in 1 (0.4%). In terms of patient disposition, 53.2% were discharged, 44.4% were floor admissions, and 2.4% were intensive care unit admissions. CONCLUSIONS: A cardiac cause of fever in CCHD patients is rare. Because of limited cardiopulmonary reserve, they might require supplemental oxygen, intravenous fluids, and hospital admission.

Initial management of septic patients with hyperglycemia in the noncritical care inpatient setting.

BACKGROUND: Previous research on the management of hyperglycemia in patients with sepsis has focused primarily on those with established organ failure in the critical care setting. The impact of hyperglycemia and glycemic control in patients with infection before developing severe sepsis or shock remains undefined. METHODS: This observational, prospective, cohort study investigated the relationship between initial 72-hour time-weighted mean glucose concentrations and in-hospital mortality, intensive care unit transfer, and hospital length of stay in a cohort of patients with an acute infection who were admitted from the emergency department to a non-intensive care unit hospital ward. We used multivariate regression models adjusted for age, diabetes, and disease severity. RESULTS: A total of 1849 patients were included, of whom 29% had diabetes. In the 1310 nondiabetic patients, we observed hyperglycemia using time-weighted glucose concentrations: 121 to 150 mg/dL (n=204, 16%), 151 to 180 mg/dL (n=32, 2.4%), and greater than 180 mg/dL (n=21, 1.6%). Insulin treatment was infrequent in nondiabetic patients, with 9%, 13%, and 29% of nondiabetic patients in these ranges receiving insulin, respectively. As patient glucose values increased, in-hospital mortality increased in nondiabetic patients, with odds ratios (ORs) of 4.4 (95% confidence interval [CI], 1.8-11), 10.0 (95% CI, 2.5-40), and 9.3 (95% CI, 1.9-44.0). Conversely, hyperglycemia did not confer an increased risk of adverse outcomes in diabetic patients. Likewise, increased risk for unplanned intensive care unit admission from the floor demonstrated ORs of 2.2 (95% CI, 1.1-4.3), 2.0 (95% CI, 0.45-8.9), and 6.3 (95% CI, 1.9-20.6) in nondiabetic patients, whereas no increased risk was found in diabetic patients. CONCLUSIONS: In this cohort of acutely infected patients without established severe sepsis or shock, higher glucose concentrations within the first 72 hours in the nondiabetic population were associated with worse hospital outcomes and were less likely to be treated with insulin compared with diabetic patients.

Neurologic recovery after therapeutic hypothermia in patients with post-cardiac arrest myoclonus.

Early myoclonus in comatose survivors of cardiac arrest, even when it is not myoclonic status epilepticus (MSE), is considered a sign of severe global brain ischemia and has been associated with high rates of mortality and poor neurologic outcomes. We report on three survivors of primary circulatory cardiac arrests who had good neurologic outcomes (two patients with a CPC score=1 and one patient with a CPC score=2) after mild therapeutic hypothermia, despite exhibiting massive myoclonus within the first 4h after return of spontaneous circulation. The concept that early myoclonus heralds a uniformly poor prognosis may need to be reconsidered in the era of post-cardiac arrest mild therapeutic hypothermia.

Diagnosis of spinal cord compression in nontrauma patients in the emergency department.

OBJECTIVES: The objectives were to evaluate the presenting signs and symptoms of spinal cord and cauda equina compression (SCC) and to determine the incidence of emergency department (ED) misdiagnosis. METHODS: This was a retrospective chart review at an urban, tertiary care hospital of patients discharged from an inpatient stay (April 2008 through July 2009) with an International Classification of Diseases, Ninth Revision (ICD-9) code indicating spinal disease, who had visited the ED for a related complaint within the previous 30 days, and who had a final diagnosis of new SCC. Trauma and transferred patients were excluded. The authors defined a misdiagnosis as no ED-documented diagnosis of SCC and failure to perform an appropriate diagnostic study either prior to arrival, in the ED, or immediately upon admission. RESULTS: Of 1,231 charts reviewed, 63 met inclusion criteria. The most common presenting symptoms in patients with SCC were pain (44, 70%), difficulty ambulating (38, 60%), and weakness (35, 56%). On physical examination, motor deficits (45, 71%) were more common than sensory deficits (27, 43%); however, 15 (24%) patients had no motor or sensory deficit, and 13 (23%) patients only had unilateral findings. Impaired gait was present in 14 patients of only 20 tested, three of whom had no associated motor or sensory deficit. SCC was misdiagnosed in 18 (29%, 95% confidence interval [CI] = 19% to 41%) cases, which resulted in a significant delay to diagnosis (median = 54 hours, interquartile range [IQR] = 38 to 77 vs. 5.3 hours, IQR = 3.0 to 15) in these patients. CONCLUSIONS: SCC can have a subtle presentation with absent or unilateral motor and sensory deficits, but gait ataxia may be an additional finding. ED misdiagnosis of SCC in nontrauma patients is common.

RhoB loss prevents streptozotocin-induced diabetes and ameliorates diabetic complications in mice.

RhoB is an early-response gene whose expression is elevated by multiple cellular stresses; this gene plays an important role in cancer, macrophage motility, and apoptosis. These factors are essential for the onset of type 1 diabetes mellitus and related complications. This study explores the role of RhoB in ß-cell depletion and hyperglycemia-associated complications and tests whether the pleiotropic effect of statins on glycemic control is RhoB dependent. We induced ß-cell depletion in RhoB(+/+), RhoB(+/-), and RhoB(-/-) mice with streptozotocin (STZ). Diabetic status was assessed by glucose tolerance and pancreatic islet loss. RhoB(-/-) mice showed a significant reduction in the severity of STZ-induced diabetes; only 13% of the STZ-treated RhoB-null animals became hyperglycemic, as opposed to 61% of the wild-type controls. Diabetes-related complications, such as wound healing rate and onset of nephropathy, were also assessed. Hyperglycemic RhoB(-/-) mice had fewer signs of nephropathy and showed faster wound healing than RhoB(+/+) animals. After assessing the diabetic status of mice treated simultaneously with STZ and simvastatin, we conclude that the effect of statins in improving glycemic control is RhoB independent. We propose that RhoB is a modifier of diabetes, important for the induction of ß-cell loss. Suppression of RhoB expression may have potential application in the treatment of diabetes and associated complications.

The role of cranial computed tomography in the immediate post-cardiac arrest period.

Patients who initially survive cardiac arrest are often admitted to an intensive care unit comatose and on mechanical ventilation. It is not clear whether or not a screening cranial computed tomography (CT scan) is necessary in the immediate post-arrest period. We hypothesized that there may be clinically relevant information gleaned from head CT scans obtained early in the post-arrest period that could affect immediate management of these patients, even when non-neurologic causes of cardiac arrest are suspected. A retrospective data analysis was conducted of all survivors (age >18 years) of non-traumatic out-of-hospital cardiac arrest (OHCA) who underwent non-contrast head CT (NCHCT) within the first 24 h of admission. A total of 84 patients were identified and 51 (60.7%) met the inclusion criteria. As much as 45 (88.2%) patients in the total cohort had an NCHCT negative for ICH or herniation; of this group, 39 (76.5%) had a normal NCHCT, while six (11.8%, 95% CI: 5.1-23.8%) demonstrated varying degrees of cerebral edema or loss of gray-white matter distinction consistent with anoxic brain injury, but without herniation. Six patients (11.8%, 95% CI: 5.1-23.8%) exhibited findings consistent with either an ICH (with or without herniation) or herniation without an ICH. Four (7.8%) of these patients had an ICH without herniation, one had an acute SAH with edema and herniation, and one had frank herniation due to massive cerebral edema. The overall incidence of any kind of intracranial hemorrhage in our cohort was 9.8% (95% CI: 3.8-21.4%). In this cohort of post-cardiac arrest patients who underwent cranial computed tomography, 11.8% of patients had clinically significant abnormalities identified. The exact role of neuroimaging in this population is still in evolution, and further prospective evaluation is warranted.