An Unusual Case of Sinusitis in a Flight Attendant

Foreign body sinusitis is a rare but important condition that should be taken into account when considering differential diagnoses. In this case report, we present a unique case of sinusitis caused by a foreign body originating from a dental procedure. Additionally, the complexity of the case was compounded by the patient's occupation as a flight attendant. A 49-year-old female flight attendant presented with a two-month history of facial pressure exacerbated by flying. A computed tomography (CT) of her paranasal sinuses confirmed the presence of a radiopaque foreign body near the left maxillary infundibulum, with minimal left ethmoid sinus mucosal thickening. Initially, she elected for non-operative management due to schedule conflicts. Upon follow-up over the next year, she complains of recurring severe facial swelling and congestion. A repeat CT scan shows that she has a dental amalgam that migrated from her left maxilla to the ethmoid infundibulum, lodged between her uncinate process and ethmoid bulla. The patient subsequently underwent foreign body removal. The patient recovered well, and a follow-up CT confirmed the complete removal of the foreign body. This case provides excellent insight into the mechanism of foreign body migration and sinusitis complicated by the unique circumstances of barotrauma associated with regular air travel.

Differentiating Giant Bullous Emphysema From Tension Pneumothorax: A Case Report

Giant bullous emphysema (GBE) is a progressive disease that commonly presents with severe progressive dyspnea attributed to the progressive destruction of alveolar walls and the formation of large air pockets, resulting in impaired gas exchange. This presentation is most commonly seen in young, thin male smokers. GBE poses an interesting and unique clinical challenge due to its radiologic findings, which can be easily mistaken for tension pneumothorax. Despite the decreased acuity of GBE as compared to tension pneumothorax, inadequate treatment in a severe case can lead to spontaneous pneumothorax, infection, and/or respiratory failure. In this report, we highlight a case of severe GBE that presents similarly to tension pneumothorax in both symptomatology and radiologic findings. The case at hand is of a 50-year-old male patient with a history of chronic obstructive pulmonary disease (COPD) with complaints of dyspnea and subsequent findings of tachycardia, tachypnea, and hypoxemia with significantly decreased breath sounds in the right lung. Radiologic findings showed increased lucency of the right hemithorax and a mass effect with a mediastinal shift to the left. History and further imaging with CT led to an ultimate diagnosis of severe GBE and COPD exacerbations. The patient was treated with non-invasive medical management. With the challenges of overlapping presentations, landing on the correct diagnosis is imperative to accurately and adequately treat the patient since GBE and tension pneumothorax significantly differ in acuity and overall management, hence the need for a high level of suspicion based on the clinical picture and the use of high-resolution CT.

Immune checkpoint inhibitor-induced neurotoxicity is not associated with seroprevalence of neurotropic infections

BACKGROUND

Immune checkpoint inhibitors (ICI) substantially improve outcome for patients with cancer. However, the majority of patients develops immune-related adverse events (irAEs), which can be persistent and significantly reduce quality of life. Neurological irAEs occur in 1-5% of patients and can induce severe, permanent sequelae or even be fatal. In order to improve the diagnosis and treatment of neurological irAEs and to better understand their pathogenesis, we assessed whether previous neurotropic infections are associated with neurological irAEs.

METHODS

Neurotropic infections that might predispose to ICI-induced neurological irAEs were analyzed in 61 melanoma patients from 3 countries, the Netherlands, Australia and Germany, including 24 patients with neurotoxicity and 37 control patients. In total, 14 viral, 6 bacterial, and 1 protozoal infections previously reported to trigger neurological pathologies were assessed using routine serology testing. The Dutch and Australian cohorts (NL) included pre-treatment plasma samples of patients treated with neoadjuvant ICI therapy (OpACIN-neo and PRADO trials; NCT02977052). In the Dutch/Australian cohort a total of 11 patients with neurological irAEs were compared to 27 control patients (patients without neurological irAEs). The German cohort (LMU) consisted of serum samples of 13 patients with neurological irAE and 10 control patients without any documented irAE under ICI therapy.

RESULTS

The association of neurological irAEs with 21 possible preceding infections was assessed by measuring specific antibodies against investigated agents. The seroprevalence of all the tested viral (cytomegalovirus, Epstein-Barr-Virus, varicella-zoster virus, measles, rubella, influenza A and B, human herpes virus 6 and 7, herpes simplex virus 1 and 2, parvovirus B19, hepatitis A and E and human T-lymphotropic virus type 1 and 2), bacterial (Borrelia burgdorferi sensu lato, Campylobacter jejuni, Mycoplasma pneumoniae, Coxiella burnetti, Helicobacter pylori, Yersinia enterocolitica and Y. pseudotuberculosis) and protozoal (Toxoplasma gondii) infections was similar for patients who developed neurological irAEs as compared to control patients. Thus, the analysis provided no evidence for an association of described agents tested for seroprevalence with ICI induced neurotoxicity.

CONCLUSION

Previous viral, bacterial and protozoal neurotropic infections appear not to be associated with the development of neurological irAEs in melanoma patients who underwent therapy with ICI across 3 countries. Further efforts are needed to unravel the factors underlying neurological irAEs in order to identify risk factors for these toxicities, especially with the increasing use of ICI in earlier stage disease.

Running for the Runs: Intermittent Intussusception From Vanek Tumor Manifesting as Constipation Improved With Exercise

Constipation commonly affects adults and most often results from benign conditions. Certain associated symptoms (e.g., rectal bleeding or weight loss) raise concern for structural pathology and prompt further evaluation. Intussusception uncommonly affects adults and typically presents with abdominal pain and vomiting. Rarely, intussusception manifests with constipation as the primary symptom. We present a case of a patient with new onset constipation who was only able to induce bowel movements after exercising, a compensatory behavior in the setting of recurrent intussusception because of a Vanek tumor.

Let the river erode! Enabling lateral migration increases geomorphic unit diversity

River restoration practice frequently employs conservative designs that create and maintain prescribed, static morphology. Such approaches ignore an emerging understanding of resilient river systems that typically adjust their morphology in response to hydrologic, vegetative and sediment supply changes. As such, using increased dynamism as a restoration design objective will arguably yield more diverse and productive habitats, better managed expectations, and more self-sustaining outcomes. Here, we answer the following question: does restoring lateral migration in a channelised river that was once a wandering gravel-bed river, result in more diverse in-channel geomorphology? We acquired pre- and post-restoration topographic surveys on a segment of the Allt Lorgy, Scotland to quantify morphodynamics and systematically map geomorphic units, using Geomorphic Unit Tool (GUT) software. GUT implements topographic definitions to discriminate between a taxonomy of fluvial landforms that have been developed from an extension of the River Styles framework, using 3-tiered hierarchy: (1) differentiation based on stage or elevation relative to channel; (2) classification of form based on shape (mound, bowl, trough, saddle, plane, wall); and (3) mapping geomorphic units based on attributes (e.g., position and orientation). Results showed restoration increased geomorphic unit diversity, with the Shannon Diversity Index increasing from 1.40 pre-restoration (2012) to 2.04 (2014) and 2.05 (2016) after restoration. Channel widening, due to bank erosion, caused aerial coverage of in-channel geomorphic units to increase 23% after restoration and 6% further in the two-years following restoration. Once bank protection was removed, allowing bank erosion yieled a local supply of sediment to enable the formation and maintenance of lateral and point bars, riffles and diagonal bar complexes, and instream wood created structurally-forced pools and riffles. The methodology used systematically quantifies how geomorphic unit diversity increases when a river is given back its freedom space. The framework allows for testing restoration design hypotheses in post-project appraisal.

Delta Lactate (Three-hour Lactate Minus Initial Lactate) Prediction of In-hospital Death in Sepsis Patients

This study examines the relationship between serial serum lactate levels and in-hospital mortality in an adult cohort of emergency department patients with severe sepsis or septic shock. Of the 164 patients in the cohort, 130 also got three-hour lactate in addition to the initial one. The median initial lactate was 3.01 (interquartile range [IQR]: 1.71-4.62). The median repeat lactate was 2.58 (IQR: 1.4-3.9). The in-hospital death rate was 23% for men and 29% for women. The delta lactate was significantly higher in women (P=0.0070), driven by a lower initial lactate (P=0.0277). In a multivariate regression model controlled for age and gender, a statistically significant correlation was noted between an increase in the delta lactate and in-hospital death (P=0.0323; R²=11.3%). The results of this single-center study suggest that an increase in serum lactic acid is significantly associated with higher in-hospital death.

Serum Procalcitonin Level Is Associated with Positive Blood Cultures, In-hospital Mortality, and Septic Shock in Emergency Department Sepsis Patients

This study examines the accuracy of initial and subsequent serum procalcitonin (PCT) levels in predicting positive blood cultures, in-hospital mortality, and development of septic shock in emergency department (ED) patients with severe sepsis. This study includes all patients who presented to our ED with an admission diagnosis of severe sepsis over a period of nine months. The median initial PCT was 0.58 ng/mL, interquartile range (IQR) 0.16-5.39. The median subsequent serum PCT was 2.1 ng/mL, with an IQR of 0.3-11.1. The PCT trend over the initial three hours increased in 67% of the study population. Blood cultures were positive in 38% of the cohort. The median maximum PCT in those with a negative blood culture was 1.06 ng/mL compared to 4.19 ng/mL in those with a positive blood culture (p=0.0116). Serum PCT levels >2.0 ng/mL display significant correlation with positive blood cultures, in-hospital mortality, and development of septic shock and as such may serve as a biomarker for more serious infections.

Quality assurance of rifampicin-containing fixed-drug combinations in South Africa: dosing implications

SETTING:

Rifampicin (RMP) drives treatment response in drug-susceptible tuberculosis. Low RMP concentrations increase the risk of poor outcomes, and drug quality needs to be excluded as a contributor to low RMP exposure.

OBJECTIVES AND DESIGN:

We performed an open-label, three-way cross-over study of three licensed RMP-containing formulations widely used in South Africa to evaluate the bioavailability of RMP in a two-drug fixed-dose combination tablet (2FDC) and a four-drug FDC (4FDC) against a single-drug reference. RMP dosed at 600 mg was administered 2 weeks apart in random sequence. Plasma RMP concentrations were measured pre-dose and 1, 2, 3, 4, 6, 8 and 12 h post-dose. The area under the concentration-time curve (AUC_0–12) of the FDCs was compared to the single drug reference. Simulations were used to predict the impact of our findings.

RESULTS:

Twenty healthy volunteers (median age 22.8 years, body mass index 24.2 kg/m²) completed the study. The AUC_0–12 of the 4FDC/reference (geometric mean ratio [GMR] 78%, 90%CI 69–89) indicated an average 20% reduction in RMP bioavailability in the 4FDC. The 2FDC/reference (GMR 104%, 90%CI 97–111) was bioequivalent. Simulations suggested dose adjustments to compensate for the poor bioavailability of RMP with the 4FDC, and revised weight-band doses to prevent systematic underdosing of low-weight patients.

CONCLUSION:

Post-marketing surveillance of in vivo bioavailability of RMP and improved weight band-based dosing are recommended.

Back to Basics: A Case of Adult Epiglottitis

The authors report a case of a 69-year-old female with difficulty swallowing and neck swelling and review the clinical presentation, radiographic features and treatment of adult epiglottitis. Epiglottitis remains a medical emergency, with the potential for airway compromise. The authors present this case because it is a potentially life-threatening infection that warrants prompt diagnosis and management. This case is worth reporting because epiglottis in adults can have a milder and less classic presentation that sometimes results in delayed recognition.

Sepsis Cards and Facts: A Simple Way to Increase Sepsis Bundle Compliance

Objective

The objective of this study was to improve sepsis bundle compliance via an educational intervention in our emergency department (ED).

Methods

This was a before and after study. Historical data on sepsis bundle compliance was obtained from our quality officer. Data were collected for 30 consecutive days to compare sepsis bundle compliance rates before and after the intervention. Descriptive statistics were compiled, and the z-test for proportions was used to calculate statistical significance.

The intervention was two-fold: 1) a bright yellow card with sepsis criteria listed was posted on all ED workstation computers and 2) there was a daily email blast for one month with “sepsis facts.” These email blasts were short pearls that highlighted the importance of recognizing and treating sepsis.

Results

The sepsis bundle compliance rates in the month prior to the intervention was 38%. In the month during the targeted intervention, the compliance rate increased to 56%. There was a statistically significant increase in bundle compliance rates during the intervention (p=0.0399).

We also administered a survey to the ED attendings and residents following the completion of the study to assess whether they perceived that our intervention was helping them increase compliance with ordering the sepsis bundle. The response rate was 94%. To the question “Did you feel the sepsis cards placed on the workstations make you more likely to consider sepsis earlier in patients under your care in the emergency department?” 70% answered agree or strongly agree. To the question “Were you more likely to order the sepsis bundle after receiving the daily "Sepsis Facts"?” 29% were neutral while 59% answered agree or strongly agree. Finally, to the question “Did you feel the sepsis cards and "sepsis facts" help you improve the care of Septic patients in the emergency department?” 76% answered agree or strongly agree.

Conclusion

Sepsis criteria reminders and email blasts highlighting the importance of treating and recognizing sepsis can improve compliance with sepsis bundle ordering within the emergency department.

Rapid Sequence Intubation in Traumatic Brain-injured Adults

Deciding on proper medication administration for the traumatic brain injury (TBI) patient undergoing intubation can be daunting and confusing. Pretreatment with lidocaine and/or vecuronium is no longer recommended; however, high-dose fentanyl can be utilized to help blunt the sympathetic stimulation of intubation. Induction with etomidate is recommended; however, ketamine can be considered in the proper patient population, such as those with hypotension. Paralysis can be performed with either succinylcholine or rocuronium, with the caveat that rocuronium can lead to delays in proper neurological examinations due to prolonged paralysis. Recommendations for post-intubation continuous sedation medications include a combination propofol and fentanyl in the normotensive/hypertensive patient population. A combination midazolam and fentanyl or ketamine alone can be considered in the hypotensive patient.

Early Versus Late Weight-Bearing Protocols for Surgically Managed Posterior Wall Acetabular Fractures

Despite overall improved outcomes with open reduction and internal fixation of acetabular fractures, posterior wall fractures show disproportionately poor results. The effect of weight bearing on outcomes of fracture management has been investigated in many lower extremity fractures, but evidence-based recommendations in posterior wall acetabular fractures are lacking. The authors systematically reviewed the current literature to determine if a difference in outcome exists between early and late postoperative weight-bearing protocols for surgically managed posterior wall acetabular fractures. PubMed and MEDLINE were searched for posterior wall acetabular fracture studies that included weight-bearing protocols and Merle d'Aubigné functional scores. Twelve studies were identified. Each study was classified as either early or late weight bearing. Early weight bearing was defined as full, unrestricted weight bearing at or before 12 weeks postoperatively. Late weight bearing was defined as restricted weight bearing for greater than 12 weeks postoperatively. The 2 categories were then compared by functional score using a 2-tailed t test and by complication rate using chi-square analysis. Six studies (152 fractures) were placed in the early weight-bearing category. Six studies (302 fractures) were placed in the late weight-bearing category. No significant difference in Merle d'Aubigné functional scores was found between the 2 groups. No difference was found regarding heterotopic ossification, avascular necrosis, superficial infections, total infections, or osteoarthritis. This systematic review found no difference in functional outcome scores or complication rates between early and late weight-bearing protocols for surgically treated posterior wall fractures. [Orthopedics. 2017: 40(4):e652-e657.].

Unexpected separation of functions at the level of miR-146a targets regulates immune cell activation and malignant transformation

microRNA-146a (miR-146a) has been previously implicated as an essential molecular brake that prevents immune overreaction and malignant transformation by attenuating NF-κB signaling. miR-146a−/− mice display an autoimmune disorder, and also develop frank tumors in secondary lymphoid organs and a progressive myelodysplastic syndrome (MDS) as they age. miR-146a was proposed to exert its regulatory activity by targeting Traf6 and Irak1, genes which encode two key adapter proteins that function upstream of NF-κB activation. The exact contribution of miR-146a-mediated silencing of Traf6 and Irak1 to the control of immune activation is currently unknown. Therefore, we defined the role of the miR-146a-Traf6 axis in the regulation of immune homeostasis using mouse genetic epistasis analysis. Our studies have uncovered a unique separation of functions at the level of miR-146a targets. Lowering the Traf6 gene dose and consequent attenuation of NF-κB activation rescued many significant miR-146a−/− phenotypes such as splenomegaly, aberrant myeloproliferation, and excessive inflammatory responses. In contrast, decreasing Traf6 expression had no effect on the development of the MDS-like phenotype in aged miR-146a−/− mice, indicating that miR-146a controls hematopoietic stem cell (HSC) homeostasis through a different molecular mechanism. Our genetic data implicate excessive IFNγ production as the main driver of HSC exhaustion and bone marrow failure in miR-146a−/− mice. Furthermore, our findings suggest that control of the Traf6-NF-κB regulatory axis by miR-146a is not essential for its tumor suppressor activity, because lowering the Traf6 gene dose did not affect the rate of development of miR-146a-deficient lymphomas.

Control of mammalian hematopoiesis and humoral immune response by microRNA-142 (IRM10P.617)

MicroRNAs (miRNAs) are a class of powerful post-transcriptional regulators implicated in the control of diverse biological processes, including regulation of hematopoiesis and the immune response. To define the biological functions of miR-142, which is specifically and abundantly expressed in immune cells, we created a mouse line with targeted deletion of this gene. Our analysis of miR-142-/- mice revealed a critical role for this miRNA in the development and homeostasis of lymphocytes. Marginal zone B cells expand in the knockout spleen, while the number of T and B1 B cells in the periphery is reduced. Abnormal development of hematopoietic lineages in miR-142-/- animals is accompanied by a profound immunodeficiency, manifested by hypoimmunoglobulinemia and failure to mount a productive immune response to soluble antigens and virus. miR-142-/- B cells express elevated levels of BAFF receptor (BAFF-R) and as a result proliferate more robustly in response to BAFF stimulation. Lowering the BAFF-R gene dose in miR-142-/- mice rescued the B cell expansion defect, suggesting that BAFF-R is a bona fide miR-142 target through which it controls B cell homeostasis. Collectively, our results uncover miR-142 as an essential regulator of lymphocyte ontogenesis and suggest that lesions in this miRNA gene may lead to primary immunodeficiency.

Prececal digestibility of various sources of starch in minipigs with or without experimentally induced exocrine pancreatic insufficiency

Low prececal digestibility of starch leads to a higher starch flux into the hindgut, causing a forced microbial fermentation, energy losses, and meteorism. For exocrine pancreatic insufficiency (EPI), lack of pancreatic amylase can be compensated mostly by hindgut fermentation of starch. Even in pigs with complete loss of pancreatic secretion, starch digestibility over the entire tract is reaching levels of controls. To optimize diets for human patients with EPI, the proportion of starch that is digested by the ileum is important. Minipigs were fitted with an ileocecal reentrant fistula (n = 8) to determine prececal digestibility of starch. In 5 minipigs the pancreatic duct was ligated (PL) to induce EPI; 3 minipigs served as controls (Con). Various starch sources were tested in a 1-d screening test; therefore, disappearance rate (DR) instead of digestibility was used. Test meals consisted of 169 g DM of a basal diet plus 67.5 g DM of the starch (without thermal treatment; purified; starch content of 89 to 94.5%) and Cr(2)O(3). The test meal contained (% of DM) starch, 67; crude fat, 1.69; CP, 15; crude fiber, 2.0; and Cr(2)O(3), 0.25. In PL, prececal DR of starch was lower than in Con (P < 0.05) for all starch sources. In Con, prececal DR of starch was almost complete (>90%) but was lower (P < 0.05) for potato (Solanum tuberosum) starch (75.4%). In PL, prececal DR of starch was higher (P < 0.05) for wheat (Triticum aestivum) starch (61.2%) than corn (Zea mays) starch (43.0%) and rice (Oryza sativa) starch (29.2%) and intermediate for potato and field pea (Pisum sativum) starch. For patients with EPI, wheat starch seems favorable due to the higher prececal digestibility whereas raw corn and rice starch should be avoided.

Circular dichroism tensor of a triarylmethyl propeller in sodium chlorate crystals

In 1919, Perucca reported anomalous optical rotatory dispersion from chiral NaClO(3) crystals that were colored by having been grown from a solution containing an equilibrium racemic mixture of a triarylmethane dye (Perucca, E. Nuovo Cimento 1919, 18, 112-154). Perucca's chiroptical observations are apparently consistent with a resolution of the propeller-shaped dye molecules by NaClO(3) crystals. This implies that Perucca achieved the first enantioselective adsorption of a racemic mixture on an inorganic crystal, providing evidence of the resolution of a triarylmethyl propeller compound lacking bulky ortho substituents. Following the earlier report, NaClO(3) crystals dyed with aniline blue are described herein. The rich linear optical properties of (001), (110), and (111) sections of these mixed crystals are described via their absorbance spectra in polarized light as well as images related to linear dichroism, linear birefringence, circular dichroism, and anomalous circular extinction. The linear dichroism fixes the transition electric dipole moments in the aromatic plane with respect to the growth faces of the NaClO(3) cubes. Likewise, circular dichroism measurements of four orientations of aniline blue in NaClO(3) fix a bisignate tensor with respect to the crystal growth faces. Electronic transition moments and circular dichroism tensors were computed ab initio for aniline blue. These calculations, in conjunction with the crystal-optical properties, establish a consistent mixed-crystal model. The nature of the circular extinction depends upon the crystallographic direction along which the crystals are examined. Along 100, the crystals evidence circular dichroism. Along 110, the crystals evidence mainly anomalous circular extinction. These two properties, while measured by the differential transmission of left and right circularly polarized light, are easily distinguished in their transformation properties with respect to reorientations of the sample plates. Circular dichroism is symmetric with respect to the wave vector, whereas anomalous circular extinction is antisymmetric. Analysis of Perucca's raw data reveals that he was observing a convolution of linear and circular optical properties. The relatively large circular dichroism should in principle establish the absolute configuration of the propeller-shaped molecules associated with d- or l-NaClO(3) crystals. However, this determination was not as straightforward as it appeared at the outset. In the solid state, unlike in solution, a strong chiroptical response is not in and of itself evidence of enantiomeric resolution. It is shown how it is possible to have a poor resolution-even an equal population of P and M propellers-within a given chiral NaClO(3) crystal and still have a large circular dichroism.

The prevalence of insulin receptor antibodies in patients with systemic lupus erythematosus and related conditions

Autoantibodies to the insulin receptor have been demonstrated to antagonize the physiologic actions of insulin, most often resulting in hyperglycemia unresponsive to massive doses of insulin (type B insulin resistance). Patients with these anti-insulin receptor antibodies typically have a coexistent autoimmune disorder, most commonly systemic lupus erythematosus (SLE) or undifferentiated autoimmune syndromes. Attempting to determine the prevalence and significance of anti-insulin receptor antibodies, sera from consecutive patients with SLE and early undifferentiated connective tissue disease (UCTD) were tested for the presence of anti-insulin receptor antibodies by radio-immuno assay. Thirty-eight patients participated in the study. Twenty-six had SLE and 12 had UCTD. One patient with SLE (2.6%) was positive for anti-insulin receptor antibodies. None of the patients demonstrated evidence of insulin resistance, hypoglycemia, ovarian hyperandrogenism, or acanthosis nigricans, findings commonly linked with the presence of anti-insulin receptor antibodies. The results presented here indicate that the incidence of anti-insulin receptor antibodies in patients with SLE or UCTD, without associated history of altered glucose metabolism, is quite low. Because in most cases the disturbance of glucose metabolism dominates the clinical picture at presentation and the associated systemic autoimmune syndrome presents either simultaneously with or subsequent to the diagnosis of diabetes, the measurement of anti-insulin receptor antibodies should be reserved for patients with indications of disordered glucose homeostasis.

Nonoperative Management of Blunt Splenic Injury: A 5-Year Experience

OBJECTIVES

The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization.

METHODS

We conducted a retrospective review of all patients admitted to a Level I trauma center with blunt splenic injury. Data review included patient demographics, computed tomographic (CT) scan results, management technique, and patient outcomes.

RESULTS

A total of 648 patients with blunt splenic injury were admitted, 280 of whom underwent immediate surgical management. Three hundred sixty-eight underwent planned nonoperative management, and 70 patients were treated with observation, serial abdominal examination, and follow-up abdominal CT scanning. All were hemodynamically stable, with a 100% salvage rate. One hundred sixty-six patients had a negative angiogram, with a nonoperative salvage rate of 94%, and 132 patients underwent embolization, with a nonoperative salvage rate of 90%. Overall salvage rates decreased with increasing injury grade; however, over 80% of grade 4 and 5 injuries were successfully managed nonoperatively. The salvage rate was similar for main coil embolization versus selective or combined embolization techniques. Admission abdominal CT scan correlated with splenic salvage rates. Significant hemoperitoneum, extravasation, and pseudoaneurysm had acceptable salvage rates, whereas arteriovenous fistula had a high failure rate, even after embolization.

CONCLUSION

Splenic embolization is a valuable adjunct to splenic salvage in our experience, allowing for the increased use of nonoperative management and higher salvage rates for American Association for the Surgery of Trauma splenic injury grades when compared with prior studies. Main coil embolization has a similar salvage rate when compared with other angiographic techniques. An arteriovenous fistula as a CT finding was predictive of a 40% nonoperative failure rate.

Comparison of the effects of ketoprofen on platelet function in the presence and absence of aspirin

PURPOSE

Although aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) exert inhibitory effects on platelets in vitro and in vivo, there are insufficient data to substantiate the use of NSAIDs alone as antiplatelet drugs in patients already taking aspirin. We therefore sought to determine whether aspirin, added to NSAID therapy, further suppresses platelet function.

SUBJECTS AND METHODS

We enrolled 25 healthy adult volunteers who were administered ketoprofen (extended-release capsules, 200 mg daily) for 1 week, followed by ketoprofen (200 mg daily) and aspirin (325 mg daily) or ketoprofen (200 mg daily) alone during the second week. Platelet aggregation, stimulated by epinephrine and arachidonic acid, and cyclooxygenase activity, measured by thromboxane B(2), were measured at baseline, on day 8, and on day 15.

RESULTS

On day 8, all subjects demonstrated abnormal platelet aggregation (>50% inhibition), which persisted at day 15 in both the aspirin and no aspirin groups. One week of ketoprofen treatment reduced thromboxane B(2) levels by 84% in the aspirin group and by 85% in the no aspirin group (P = 0.8), without any further inhibition measured on day 15.

CONCLUSION

Extended-release ketoprofen significantly inhibited platelet aggregation and thromboxane B(2) production in healthy volunteers. Addition of aspirin had no additional effect. Trials are warranted to determine whether these in vitro effects result in clinical antiplatelet activity in patients who require chronic treatment with NSAIDs, thereby avoiding the toxicity of NSAID/aspirin combination therapy.

Pharmacological evidence for inhibition of ACTH secretion by a central adrenergic system in the dog

To obtain more information about the transmitter involved in catecholaminergic inhibition of ACTH secretion, the site of this inhibition, and the receptors involved, the secretion of ACTH was studied in pentobarbital-anesthetized dogs that were surgically stressed and treated with drugs which modify central catecholaminergic transmission. The index of ACTH secretion was adrenal venous output of corticoid hormones. Intravenous L-dopa inhibited ACTH secretion, and this inhibition was not modified by blockade of peripheral decarboxylation of L-dopa with carbidopa. Intravenous or centrally administered clonidine inhibited stress-induced ACTH secretion, whereas centrally administered apomorphine did not. When given into the third ventricle, phenoxybenzamine (but not phentolamine) blocked the inhibitory effect of L-dopa and clonidine. Pimozide had no effect. L-propranolol caused a small but significant decrease in stress-induced ACTH secretion. Intraventricular procaine blocked the stress response. The data support the conclusion that the site of catecholaminergic inhibition of ACTH secretion is central, 'inside the blood-brain barrier', instead of the pituitary or the median eminence. They indicate that dopamine is not the mediator involved, and suggest that it is probably norepinephrine, although epinephrine is not ruled out. The receptor on which the released catecholamines act, presumably on the surface of the cells that secrete the hypothalamic hormone that regulates ACTH secretion, appears to be a type of alpha-adrenergic receptor.

Giant cell myocarditis: most fatal of autoimmune diseases

OBJECTIVE

To increase awareness of giant cell myocarditis (GCM), its pathogenesis, and treatment.

METHODS

Review of relevant publications from the English-language literature.

RESULTS

GCM is a rare, frequently fatal inflammatory disorder of cardiac muscle of unknown origin, characterized by widespread degeneration and necrosis of myocardial fibers.Congestive heart failure and ventricular tachycardia are common clinical manifestations. GCM occurs primarily in previously healthy adults, although it is frequently associated with various systemic diseases, primarily of autoimmune causes. The inflammatory infiltrate is characterized by the presence of multinucleated giant cells and is distinct from cardiac sarcoidosis. Animal models of GCM are similar to models of other autoimmune disorders such as rheumatoid arthritis. The prognosis, which is poor despite partial responsiveness to immunosuppressive medications, is improved with cardiac transplantation.

CONCLUSIONS

The clinical and immunopathogenetic similarities with classical rheumatologic diseases, the differential diagnosis with sarcoidosis and other inflammatory conditions, and the use of standard immunosuppressive medications make GCM a disease process that should be added to the rheumatologist's expertise.

The shdA gene is restricted to serotypes of Salmonella enterica subspecies I and contributes to efficient and prolonged fecal shedding

Little is known about factors which enable Salmonella serotypes to circulate within populations of livestock and domestic fowl. We have identified a DNA region which is present in Salmonella serotypes commonly isolated from livestock and domestic fowl (S. enterica subspecies I) but absent from reptile-associated Salmonella serotypes (S. bongori and S. enterica subspecies II to VII). This DNA region was cloned from Salmonella serotype Typhimurium and sequence analysis revealed the presence of a 6,105-bp open reading frame, designated shdA, whose product's deduced amino acid sequence displayed homology to that of AIDA-I from diarrheagenic Escherichia coli, MisL of serotype Typhimurium, and IcsA of Shigella flexneri. The shdA gene was located adjacent to xseA at 52 min, in a 30-kb DNA region which is not present in Escherichia coli K-12. A serotype Typhimurium shdA mutant was shed with the feces in reduced numbers and for a shorter period of time compared to its isogenic parent. A possible role for the shdA gene during the expansion in host range of S. enterica subspecies I to include warm-blooded vertebrates is discussed.

Why I would not recommend complementary or alternative therapies: a physician's perspective

The use of complementary or alternative therapies by patients with rheumatic diseases is widespread and under-reported by patient to physician. The most commonly used forms of therapy are herbal/nutrient supplements, chiropractic, homeopathy, and acupuncture. The use of these therapies for treatment of rheumatic disease is not substantiated by review of the available medical literature. Furthermore, these therapies are expensive and potentially toxic. Incorporation of these treatments into the therapeutic armamentarium of the rheumatologist cannot be recommended until they are shown to be effective, safe, and affordable.