Successful Management of Acute Streptococcal Meningoencephalitis Complicated by Bilateral Third-Nerve Palsies, Wall-Eyed Bilateral Internuclear Ophthalmoplegia, Blindness, and Deafness: Case Report.

Introduction: Streptococcal meningoencephalitis (SME) is a rare, and frequently lethal, acute infection, and inflammation of the central nervous system parenchyma, with associated meningeal involvement. Bacterial meningoencephalitis is generally associated with high rates of morbidity and mortality, despite available antimicrobial and corticosteroid treatments. While Streptococcus pneumoniae is well recognised to cause bacterial meningitis, direct extension into the central nervous system parenchyma is rare. Case Presentation: A previously well 49-year-old man presented with sudden onset severe headache, fevers, neck stiffness, and reduced consciousness. The manifestations of SME in this patient were bilateral pupil-involving third-nerve palsies, wall-eyed bilateral internuclear ophthalmoplegia (WEBINO), bilateral blindness, bilateral deafness, a right lower motor neuron facial palsy, and upper motor neuron signs in his limbs. Initially, a partial response to high dose intravenous antibiotics occurred, but with administration of intravenous corticosteroids, further substantial resolution of the patient's neurological and neuro-ophthalmological deficits occurred. Conclusion: This case highlights the benefit of multidisciplinary diagnostic and therapeutic interventions in a case of SME complicated by bilateral pupil-involving third-nerve palsies, WEBINO, bilateral blindness, bilateral deafness, a right lower motor neuron facial palsy, and upper motor neuron signs. It appears to be the first reported case of SME with this rare collection of neuro-ophthalmological abnormalities.

Recovery From Homonymous Hemianopia in Hyperglycemia-Induced Occipital Lobe Electroclinical Seizures Following Glycemic Control.

BACKGROUND: Visual changes due to hyperglycemia in diabetes are not uncommon. While blurred vision is a well-established sequela of chronic hyperglycemia, homonymous hemianopia with or without electroclinical seizures is much rarer and can be mistaken for migraine, temporal arteritis, or ischemia of the central nervous system. METHODS: This article analyzed case studies for 3 patients (67M, 68M, 52F) presenting with complex visual phenomena, from 3 to 42 days duration, including pathogenesis, clinical findings, management, and follow-up. RESULTS: Examinations demonstrated dense left homonymous hemianopias in 2 patients and a left inferior homonymous quadrantanopia in one, with no other abnormalities. Patients described vivid, nonstereotyped intermittent hallucinations in the affected fields. Blood glucose levels ranged from 13.5 to 35.0 mmol/L (243-630 mg/dL) without ketosis and HbA1c from 14.6% to 16.8%. Computed tomography of the brain showed no acute intracranial pathology. MRI of the brain either detected no abnormalities or demonstrated changes consistent with seizure activity. Electroencephalogram (EEG) demonstrated seizures over the right occipital region in each patient. EEG seizures coincided with patients' hallucinations, while they remained otherwise conscious. Oral hypoglycemic and antiepileptic medications were commenced with rapid and complete reversal of the seizures and visual field deficits, confirmed by repeat Automated 30-2 and MRI. CONCLUSIONS: Hyperglycemia-induced occipital lobe seizures with visual hallucinations and interictal homonymous visual field defects represent a rare but clinically important diagnosis. This article highlights the importance of prompt recognition and treatment to facilitate recovery.

Lacrimal gland sinus generated by a retained cilium: case report and literature review.

Lacrimal gland stone(s) (LGSs) are rare and usually asymptomatic. LGSs should be distinguished from dacryoliths, as the former arise in the lacrimal gland. The aetiology of LGSs in many cases is likely related to a reaction to a hair within the palpebral lobe of lacrimal gland. Eye rubbing may contribute to the migration of the hair into the lacrimal gland. This case report describes the rare occurrence of an LGS with a central hair shaft (cilium) and associated sinus formation in a 39-year-old male presenting with persistent redness of, and discharge from the right eye for 4 weeks. Examination revealed a sinus opening onto the inferonasal surface of the palpebral lobe of the right lacrimal gland. The patient was treated with surgical excision of the sinus, with rapid and complete resolution of his symptoms.

Falls from Tree Stands Have Become the Leading Cause of Deer Hunting Accidents in Pennsylvania.

OBJECTIVES: This study aimed to describe, using a statewide trauma registry, the incidence, trends, and injuries for tree stand falls while deer hunting in Pennsylvania. METHODS: Falls from tree stands were abstracted from the Pennsylvania Trauma Systems Foundation registry (1990-2017) and combined with the number of licensed deer hunters, deer hunting days, and deer hunting-related shooting incidents (HRSIs) provided by the Pennsylvania Game Commission to calculate tree stand fall and HRSI rates (per 1 million deer hunting days) and age-group specific fall rates (per 100,000 licensed deer hunters). Poisson regression was used to assess the significance of the annual and age group rate trends (significance P < 0.05). Case fatality rate (percentage of number of deaths per number of injured hunters) also was calculated. RESULTS: There were 1229 victims of tree stand falls and 560 victims of HRSIs between 1990 and 2017. Fall rates increased from 1.5 to 10.4 (P < 0.0001), and HRSI rates decreased from 4.9 to 1.2 (P = 0.001). Fall rates surpassed HRSI rates in 1999 and increased with advancing age (P = 0.007), peaking at 7.2 for hunters aged 50 to 59 years. Most (77%) injured hunters sustained multiple injuries. The case fatality rate was only 0.8%, but 26% of the injured hunters had a dependent functional limitation at hospital discharge. CONCLUSIONS: Tree stand falls are now the leading cause of Pennsylvania deer hunting accidents. Fall victims usually sustain multiple nonfatal but often disabling injuries. Study findings support the need for surveillance of these accidents and additional tree stand safety education.

A compact cold-atom interferometer with a high data-rate grating magneto-optical trap and a photonic-integrated-circuit-compatible laser system.

The extreme miniaturization of a cold-atom interferometer accelerometer requires the development of novel technologies and architectures for the interferometer subsystems. Here, we describe several component technologies and a laser system architecture to enable a path to such miniaturization. We developed a custom, compact titanium vacuum package containing a microfabricated grating chip for a tetrahedral grating magneto-optical trap (GMOT) using a single cooling beam. In addition, we designed a multi-channel photonic-integrated-circuit-compatible laser system implemented with a single seed laser and single sideband modulators in a time-multiplexed manner, reducing the number of optical channels connected to the sensor head. In a compact sensor head containing the vacuum package, sub-Doppler cooling in the GMOT produces 15 µK temperatures, and the GMOT can operate at a 20 Hz data rate. We validated the atomic coherence with Ramsey interferometry using microwave spectroscopy, then demonstrated a light-pulse atom interferometer in a gravimeter configuration for a 10 Hz measurement data rate and T = 0-4.5 ms interrogation time, resulting in Δg/g = 2.0 × 10-6. This work represents a significant step towards deployable cold-atom inertial sensors under large amplitude motional dynamics.

Admitting Service and Outcome for Small Bowel Obstruction.

INTRODUCTION: Small bowel obstruction (SBO) is a common admission diagnosis. Prior research has shown improved length of stay and time to operation for SBO patients on surgical services (SS) compared to medical services (MS). This study evaluates the impact of admitting service on readmission and mortality. METHODS: A 12-year retrospective cohort study of patients ≥18 years old, admitted with SBO to either a MS or SS within one health care system was performed. Clinicodemographic characteristics and admission details were extracted and reviewed. Statistical analyses performed included the Student's t-test, chi-square, and multivariable regression. RESULTS: The study included 7921 patients, of which 3862 (48.8%) were admitted to a SS. No significant clinicodemographic differences existed between the groups except SS patients were more likely to have cancer (23.3% vs 15.2%, P < .0001) and to be within a 30-day post-operative period (9.4% vs 1.8%, P < .0001). On multivariable analysis, admission to a SS was associated with a decreased admission mortality (OR .70), 30-day mortality (OR .42), and 180-day mortality (OR .42). 30-day readmissions (OR .54) and 180-day readmission (OR .43) were also significantly decreased for SS patients. In patients requiring a procedure during admission, there was significantly decreased admission mortality (OR .684), 30-day mortality (OR .470), 180-day mortality (OR .431), 30-day readmission (OR .63), and 180-day readmission (OR .50). CONCLUSION: In patients with SBO, admission to a SS confers decreased odds of readmission and mortality compared to MS. Future studies are needed to understand the management decisions potentially underlying these differences. These findings may help better define admission pathways and improve outcomes.

Modeling carbamazepine transport in wastewater-irrigated soil under different land uses.

The pharmaceutical compound carbamazepine (CBZ) is a contaminant of emerging concern. Wastewater irrigation can be a long-term, frequent source of CBZ; therefore, understanding the fate and transport of CBZ as a result of wastewater reuse practices has important environmental implications. The objective of this study was to estimate long-term soil transport of CBZ originating from treated wastewater irrigation on plots under different land uses. Field data from a previous study comparing CBZ concentrations in soil under different land uses were used in numerical modeling with HYDRUS-2D for the estimation of CBZ soil transport during 20 yr of irrigation with treated wastewater. This study showed high CBZ retention in soil under all investigated land uses. Adequate modeling results were obtained by using soil organic carbon-water partitioning coefficient (Koc ) for the CBZ linear sorption coefficient (Kd ) estimation, yet an underestimation of CBZ concentration in soil was still noted. Thus, results suggest that, although highly important, organic carbon content is probably not the only soil property governing CBZ sorption at this site, indicating the potential research perspective. Modeling results showed wastewater irrigation containing CBZ for 20 yr increased the CBZ concentration in the soil profile and its vertical movement, with the slowest vertical transport rate occurring on the forested plots. Overall results suggest that a beneficial management practice could be to increase soil organic carbon (e.g., compost addition) when using treated wastewater for irrigation in order to retain CBZ in the surface soil and thus limit its leaching through the soil profile.

The Genome of the Softshell Clam Mya arenaria and the Evolution of Apoptosis.

Apoptosis is a fundamental feature of multicellular animals and is best understood in mammals, flies, and nematodes, with the invertebrate models being thought to represent a condition of ancestral simplicity. However, the existence of a leukemia-like cancer in the softshell clam Mya arenaria provides an opportunity to re-evaluate the evolution of the genetic machinery of apoptosis. Here, we report the whole-genome sequence for M. arenaria which we leverage with existing data to test evolutionary hypotheses on the origins of apoptosis in animals. We show that the ancestral bilaterian p53 locus, a master regulator of apoptosis, possessed a complex domain structure, in contrast to that of extant ecdysozoan p53s. Further, ecdysozoan taxa, but not chordates or lophotrochozoans like M. arenaria, show a widespread reduction in apoptosis gene copy number. Finally, phylogenetic exploration of apoptosis gene copy number reveals a striking linkage with p53 domain complexity across species. Our results challenge the current understanding of the evolution of apoptosis and highlight the ancestral complexity of the bilaterian apoptotic tool kit and its subsequent dismantlement during the ecdysozoan radiation.

Factors Associated with Failure of Nonoperative Management for Complicated Appendicitis.

In recent years, nonoperative management of complicated appendicitis has become more common. Patients managed nonoperatively do well, but there is a paucity of literature on patients who fail nonoperative management. The purpose of this study was to examine the overall failure rate, morbidity associated with failure, and potential predictors of failure in nonop management of appendicitis. This is a descriptive retrospective review of patients from a single hospital system who were diagnosed with advanced appendicitis and underwent nonop management between January 1, 2007, and November of 2017. The data were obtained through review of patient charts from the electronic medical record. Failure was defined as requirement of an operation due to ongoing infection secondary to appendicitis. There were 183 patients initially managed nonoperatively, with 70 patients failing nonoperative management. Patients failing nonoperative management experienced longer hospitalization (6.2 vs 2.9 days, P < 0.0001), and more patients in the failure group required admission to the ICU (10.0% vs 1.8%, P = 0.028). Multivariate analysis revealed that longer duration of symptoms reduced the likelihood of failure (odds ratio: 0.77 [0.64-0.92]). In this retrospective review, 38 per cent of patients failed nonop management of appendicitis. Symptom duration could provide insight for clinicians in assessing the role of nonoperative management because increasing symptom duration reduced the likelihood of failure.

Cancel that PICC line order; cholecystostomy tube and short course of antibiotics.

BACKGROUND: Current guidelines do not specifically address optimal antibiotic duration following cholecystostomy. This study compares outcomes for short-course (<7 days) and long-course (≥7 days) antibiotics post-cholecystostomy. METHODS: This was a retrospective review of cholecystostomy patients (≥18 years) admitted (1/1/2007-12/31/2017) to one healthcare system. RESULTS: Overall, 214 patients were studied. Demographics were similar, except short-course patients had higher Charlson Comorbidity Index (p < 0.0001). There were no intergroup differences in tachycardia (22.5%[short-course] vs 23.3%[long-course]) or leukocytosis (67.1%[short-course] vs 64.4%[long-course]) at drain placement nor time to normalization for pulse, temperature or leukocytosis. There were no differences regarding Clostridium Difficile infection (5.0%[short-course] vs 1.6%[long-course]) or cholecystitis recurrence (8.8%[short-course] vs 10.9%[long-course]). No differences were observed regarding gallbladder-related unplanned readmissions (30-day:18.8%[short-course] vs 17.2%[long-course]; 90-day: 20.0%[short-course] vs 25.8%[long-course]). There were no 30- or 90-day mortality differences (overall mortality: 18.3%). CONCLUSION: Post-cholecystostomy outcomes were comparable between short-course and long-course antibiotics, consistent with emerging literature supporting short-course antibiotics for intra-abdominal infection with source control.

Adherence to Treatment by African Americans Undergoing Hemodialysis.

End stage renal disease (ESRD) affects African Americans more than any other ethnic group. Adherence is a challenge. Patients with ESRD must adhere to medication, diet, fluid restrictions, and dialysis treatment schedules if they do not receive a kidney transplant. The purpose of this exploratory, descriptive study was to assess adherence in 120 African Americans with ESRD undergoing hemodialysis (HD). Participants completed a demographic questionnaire and the ESRD Adherence Questionnaire (ESRD-AQ). Biomarkers were collected from medical records. Few participants (24%) adhered to dietary restrictions; however, fluid restriction was reported as the most difficult to manage, which was consistent with the interdialytic weight gain biomarker. Older participants were more adherent. Participants were adherent with HD attendance and medication. Participants reported frequent communication with the healthcare team, but a more formal process needs to be implemented with follow up to ensure understanding and reinforce adherence.

Sarcopenia predicts poor outcomes in urgent exploratory laparotomy.

BACKGROUND: Emergent laparotomies are associated with higher rates of morbidity and mortality. Recent studies suggest sarcopenia predicts worse outcomes in elective operations. The purpose of this study is to examine outcomes following urgent exploratory laparotomy in sarcopenic patients. METHODS: This was a retrospective review of patients in a rural tertiary care facility between 2010 and 2014. Patients underwent a laparotomy within 72 h of admission and had an abdomen/pelvis CT scan were included. Primary outcomes were predictors of morbidity and mortality. Sarcopenia is the lowest quartile cross sectional area of the psoas muscles. RESULTS: Multivariate analysis of 967 patients found that sarcopenic patients had higher mortality, complication rate, were less likely to be discharged home, were more likely to undergo unplanned re-operation, and had a longer length of stay. Increasing abdominal wall fat has favorable outcomes in mortality, discharge destination, and complications. CONCLUSIONS: Sarcopenia is measured from CT scans, making it an accessible outcome predictor. In urgent laparotomies, sarcopenia was associated with higher morbidity, mortality, length of stay, and worse discharge destination.

Evaluation and Management of Erectile Dysfunction in the Hypertensive Patient.

PURPOSE OF REVIEW: The prevalence of hypertension and erectile dysfunction has steadily increased, and greater than 40% of men with erectile dysfunction concurrently share a diagnosis of hypertension. The treatment of the patient with both diseases poses a clinical challenge as both are closely correlated and share multiple overlapping risk factors.To address the recognized knowledge gap among clinicians who care for these patients, we will review the current literature on the diagnosis and treatment of erectile dysfunction in the hypertensive patient and will provide recommendations for the management of this challenging patient population. RECENT FINDINGS: The pharmacological treatment of hypertension may adversely affect sexual function, and certain treatments for erectile dysfunction are contraindicated or cautioned against with certain antihypertensive agents. In review of the literature, we find that the clinician should opt to use an angiotensin-receptor blocker followed by an angiotensin-converting enzyme inhibitor or calcium channel blocker for the treatment of hypertension in patients with erectile dysfunction. Other agents require careful consideration for adverse effects on sexual function. Men with erectile dysfunction should be assessed for cardiovascular fitness for sexual activity, and PDE-5 inhibitors remain the first-line treatment for erectile dysfunction.

Effects of metformin on endothelial health and erectile dysfunction.

Erectile dysfunction (ED) affects approximately 18 million American men. ED may be attributed to several etiologies, including arteriogenic, psychogenic, neurogenic, hormonal, drug-induced, and systemic disease or aging related factors. Specific to arteriogenic ED, three major mechanisms have been identified: (I) endothelium-dependent vasodilatory impairment; (II) sympathetic nerve activity elevation; (III) atherosclerotic luminal narrowing. Additionally, these insults have been linked to the insulin resistant state, which in turn is comorbid with obesity, dyslipidemia, diabetes, and hypertension. In this review, we summarize the evidence regarding the impact of metformin-an insulin sensitizer-on the three mechanisms of arteriogenic ED. We report that metformin treatment positively affects two of three pathways, specifically through enhanced endothelium-dependent vasodilation and sympathetic nerve activity attenuation, but does not seem to have a significant impact on hypertension regulation. Given the encouraging data found in both animal and clinical studies, we advocate for further studies on metformin use in ED.

Minimal adverse effects profile following implantation of periauricular percutaneous electrical nerve field stimulators: a retrospective cohort study.

The periauricular percutaneous implantation of the Neuro-Stim System™ family of devices EAD, MFS, and BRIDGE is a procedure involving the use of a non-opiate, neuromodulation analgesic for relieving acute and chronic pain. It has been approved as a minimal-risk procedure by multiple governmental and institutional facilities. This retrospective report of findings will help quantify the incidence of clinically observed bleeding, localized dermatitis, and infections at the implantation sites of the electrode/needle arrays, dermatitis at the site of the generator, and patient syncope. A total of 1,207 devices, each producing up to 16 percutaneous punctures, for a total of 19,312 punctures were monitored for adverse effects, based on retrospective chart audits conducted at six clinical facilities over a 1-year period.

Vitamin D3 Treatment Influences PGE2 and TGFß in Normal and Increased Breast Cancer Risk Women.

BACKGROUND/AIM: We reported that vitamin D3 increased transforming growth factor (TGF)ß2 and decreased prostaglandin (PG)E2 in the breast of normal-risk women, suggesting a protective effect. We determined if the findings held for higher risk women. PATIENTS AND METHODS: Seventy-eight women received daily for one month/menstrual cycle: placebo, 400 international units (IU) vitamin D3, 2,000 IU vitamin D3 or 2,000 IU vitamin D3/400 mg celecoxib. Nipple aspirate fluid (NAF) and/or serum were analyzed for PGE2, TGFß1,-2, vitaminD binding protein (DBP) 25(OH)D; and plasma for celecoxib. RESULTS: 25(OH)D increased (p<0.001) in women receiving 2,000 IU vitamin D3. Two thousand IU vitamin D3 lowered NAF PGE2 in normal-risk women (p=0.029), whereas 2,000 IU vitamin D3/celecoxib lowered NAF PGE2 in high-risk women (p=0.063). Serum TGFß1 was influenced by treatment (p=0.011). NAF TGFß2 increase correlated with increase in 25(OH)D. DBP serum levels were higher than matched NAF, regardless of race, and did not appreciably change with treatment. CONCLUSION: Vitamin D3 influenced TGFß1 and -ß2 expression. PGE2 response to vitamin D3 treatment was influenced by a participant's breast cancer risk. The implications of these observations regarding breast cancer risk should be further evaluated.