Stroke Secondary to Air Embolism Following Laparoscopic Nissen Fundoplication.

An air embolism is characterized by the entry of gas bubbles into the circulatory system, which can lead to the possible occlusion of blood vessels, posing a potentially life-threatening risk. While commonly associated with lung trauma or decompression sickness, it can also result from medical procedures such as central venous catheter insertion or, in our case, gas insufflation for laparoscopic surgery. We present the case of a 65-year-old female who suffered from a stroke secondary to an air embolism after undergoing a laparoscopic Nissen fundoplication in which carbon dioxide insufflation of the abdominal cavity was utilized. We also will discuss the elusive etiology of this complication as well as diagnosis, treatment, and proposed preventative measures.  A 65-year-old female with gastroesophageal reflux disease and a hiatal hernia elected to undergo a laparoscopic Nissen fundoplication for hernia repair. After a successful surgery, the patient was found with significant neurological deficits, including left-sided hemiplegia, numbness in the left hand, hemianopsia, dysarthria, and a National Institutes of Health Stroke Scale score of 20. CT head imaging revealed several low-density foci in the right frontal lobe, while CT neck and chest imaging revealed subcutaneous emphysema and pneumomediastinum. Subsequent labs were significant for an elevated lactate at 7.6 mmol/L. MRI of the brain depicted evidence of an acute infarct in the right frontal lobe with diffusion-weighted imaging (DWI) sequences. The imaging results were correlated with the patient's clinical presentation to establish the diagnosis of a nondominant hemisphere stroke, localized to an anterior branch of the right middle cerebral artery (MCA). After intubation and supportive treatment for three days, the patient was extubated and able to follow commands but had left facial weakness and diminished strength in the left upper and lower extremities. At the two-month follow-up visit, the patient no longer had any focal neurological deficits. Air emboli, though very rare, can occur as a complication in laparoscopic surgeries that utilize CO2 for body cavity insufflation. Patients may be asymptomatic with small, self-limiting emboli, while others may exhibit pulmonary symptoms, cardiac arrest, or focal neurologic changes, depending on the emoji's size and location. Given the wide range of patient presentations, the elevated mortality of laparoscopic procedures complicated by air emboli, and the rare occurrence of focal neurological symptoms as depicted in this case, rapid diagnosis and close postoperative observation and treatment are vital for both short-term and long-term patient outcomes.

Sleeping with technology: cognitive, affective, and technology usage predictors of sleep problems among college students.

OBJECTIVES: Sleep problems related to technology affect college students through several potential mechanisms including displacement of sleep due to technology use, executive functioning abilities, and the impact of emotional states related to stress and anxiety about technology availability. DESIGN: In the present study, cognitive and affective factors that influence technology usage were examined for their impact upon sleep problems. PARTICIPANTS AND MEASUREMENTS: More than 700 US college students completed an online questionnaire addressing technology usage, anxiety/dependence, executive functioning, nighttime phone usage, bedtime phone location, and sleep problems. RESULTS: A path model controlling for background variables was tested using the data. The results showed that executive dysfunction directly predicted sleep problems as well as affected sleep problems through nighttime awakenings. In addition, anxiety/dependence increased daily smartphone usage and also increased nighttime awakenings, which, in turn, affected sleep problems. CONCLUSIONS: Thus, both the affective and cognitive factors that influence technology usage affected sleep problems.

Overview of nine computerized, home-based auditory-training programs for adult cochlear implant recipients.

BACKGROUND: Computerized, home-based auditory-training programs could be attractive to cochlear implant (CI) recipients who cannot obtain direct intensive training services and also to busy clinicians who would like to enable CI recipients to benefit from these programs. However, it is difficult for either group to know which of the many programs available might best suit individual needs. PURPOSE: Selecting a computerized home-based program can be challenging because each offers different features. This article provides an overview of currently available programs to help clinicians and recipients choose one that is most suitable. DATA COLLECTION AND ANALYSIS: A narrative literature review and an advanced Google search of Web sites linked to auditory-training programs were conducted. This overview builds on and updates information from previous literature. RESULTS: Nine computerized, home-based auditory-training programs were identified for overview. Twenty-nine information items and features for each of the nine programs are presented, categorized by general product and purchase information, design features of the training paradigm, and auditory and communication targets. CONCLUSIONS: This article provides a descriptive overview of computerized, home-based auditory-training programs for the use of clinicians, CI recipients, researchers, and hearing aid users.

Tablet-based screening of depressive symptoms in quito, ecuador: efficiency in primary care.

Depression is a frequent yet overlooked occurrence in primary health care clinics worldwide. Depression and related health screening instruments are available but are rarely used consistently. The availability of technologically based instruments in the assessments offers novel approaches for gathering, storing, and assessing data that includes self-reported symptom severity from the patients themselves as well as clinician recorded information. In a suburban primary health care clinic in Quito, Ecuador, we tested the feasibility and utility of computer tablet-based assessments to evaluate clinic attendees for depression symptoms with the goal of developing effective screening and monitoring tools in the primary care clinics. We assessed individuals using the 9-item Patient Health Questionnaire, the Quick Inventory of Depressive Symptoms-Self-Report, the 12-item General Health Questionnaire, the Clinical Global Impression Severity, and a DSM-IV checklist of symptoms. We found that 20% of individuals had a PHQ9 of 8 or greater. There was good correlation between the symptom severity assessments. We conclude that the tablet-based PHQ9 is an excellent and efficient method of screening for depression in attendees at primary health care clinics and that one in five people should be assessed further for depressive illness and possible intervention.

A novel nutrition medicine education model: the Boston University experience.

Most deaths in the United States are preventable and related to nutrition. Although physicians are expected to counsel their patients about nutrition-related health conditions, a recent survey reported minimal improvements in nutrition medicine education in US medical schools in the past decade. Starting in 2006, we have developed an educational plan using a novel student-centered model of nutrition medicine education at Boston University School of Medicine that focuses on medical student-mentored extracurricular activities to develop, evaluate, and sustain nutrition medicine education. The medical school uses a team-based approach focusing on case-based learning in the classroom, practice-based learning in the clinical setting, extracurricular activities, and a virtual curriculum to improve medical students' knowledge, attitudes, and practice skills across their 4-y period of training. We have been using objectives from the NIH National Academy Awards guide and tools from the Association of American Medical Colleges to detect new areas of nutrition medicine taught at the medical school. Although we were only able to identify 20.5 h of teaching in the preclerkship years, we observed that most preclerkship nutrition medicine objectives were covered during the course of the 4-y teaching period, and extracurricular activities provided new opportunities for student leadership and partnership with other health professionals. These observations are very encouraging as new assessment tools are being developed. Future plans include further evaluation and dissemination of lessons learned using this model to improve public health wellness with support from academia, government, industry, and foundations.

Cytoplasmic inositol hexakisphosphate production is sufficient for mediating the Gle1-mRNA export pathway.

Production of inositol hexakisphosphate (IP6) by Ipk1, the inositol-1,3,4,5,6-pentakisphosphate 2-kinase, is required for Gle1-mediated mRNA export in Saccharomyces cerevisiae cells. To examine the network of interactions that require IP6 production, an analysis of fitness defects was conducted in mutants harboring both an ipk1 null allele and a mutant allele in genes encoding nucleoporins or transport factors. Enhanced lethality was observed with a specific subset of mutants, including nup42, nup116, nup159, dbp5, and gle2, all of which had been previously connected to Gle1 function. Complementation of the nup116Deltaipk1Delta and nup42Deltaipk1Delta double mutants did not require the Phe-Gly repeat domains in the respective nucleoporins, suggesting that IP6 was acting subsequent to heterogeneous nuclear ribonucleoprotein targeting to the nuclear pore complex. With Nup42 and Nup159 localized exclusively to the nuclear pore complex cytoplasmic side, we speculated that IP6 may regulate a cytoplasmic step in mRNA export. To test this prediction, the spatial requirements for the production of IP6 were investigated. Restriction of Ipk1 to the cytoplasm did not block IP6 production. Moreover, coincident sequestering of both Ipk1 and Mss4 (an enzyme required for phosphatidylinositol 4,5-bisphosphate production) to the cytoplasm also did not block IP6 production. Given that the kinase required for inositol 1,3,4,5,6-pentakisphosphate production (Ipk2) is localized in the nucleus, these results indicated that soluble inositides were diffusing between the nucleus and the cytoplasm. Additionally, the cytoplasmic production of IP6 by plasma membrane-anchored Ipk1 rescued a gle1-2 ipk1-4 synthetic lethal mutant. Thus, cytoplasmic IP6 production is sufficient for mediating the Gle1-mRNA export pathway.

Regulation of chromatin remodeling by inositol polyphosphates.

Chromatin remodeling is required for efficient transcription of eukaryotic genes. In a genetic selection for budding yeast mutants that were defective in induction of the phosphate-responsive PHO5 gene, we identified mutations in ARG82/IPK2, which encodes a nuclear inositol polyphosphate kinase. In arg82 mutant strains, remodeling of PHO5 promoter chromatin is impaired, and the adenosine triphosphate-dependent chromatin-remodeling complexes SWI/SNF and INO80 are not efficiently recruited to phosphate-responsive promoters. These results suggest a role for the small molecule inositol polyphosphate in the regulation of chromatin remodeling and transcription.

The human homolog of the rat inositol phosphate multikinase is an inositol 1,3,4,6-tetrakisphosphate 5-kinase.

We have demonstrated that the human homolog of the rat inositol phosphate multikinase is an inositol 1,3,4,6-tetrakisphosphate 5-kinase (InsP(4) 5-kinase). The cDNA of the human gene contained a putative open reading frame of 1251 bp encoding 416 amino acids with 83.6% identity compared with the rat protein. The substrate specificity of the recombinant human protein demonstrated preference for Ins(1,3,4,6)P(4) with a catalytic efficiency (V(max)/K(m)) 43-fold greater than that of Ins(1,3,4,5)P(4) and 2-fold greater than that of Ins(1,4,5)P(3). The apparent V(max) was 114 nmol of Ins(1,3,4,5,6)P(5) formed/min/mg of protein, and the apparent K(m) was 0.3 microm Ins(1,3,4,6)P(4). The functional homolog in yeast is Ipk2p, and ipk2-null yeast strains do not synthesize Ins(1,3,4,5,6)P(5) or InsP(6). Synthesis of these compounds was restored by transformation with wild-type yeast IPK2 but not with human InsP(4) 5-kinase. Thus the human gene does not complement for the loss of the yeast gene because yeast cells do not contain the substrate Ins(1,3,4,6)P(4), and the reaction of the human protein with Ins(1,3,4,5)P(4) is insufficient to effect rescue or synthesis of InsP(5) and InsP(6). Therefore the major activity of human InsP(4) 5-kinase is phosphorylation at the D-5 position, and the pathways for synthesis of Ins(1,3,4,5,6)P(5) in yeast versus humans are different.