A Case Report Evaluating Gastric Emphysema versus Emphysematous Gastritis.

Gastric emphysema (GE) and emphysematous gastritis (EG) share similar clinical presentations but exhibit drastically different prognoses. While GE is generally benign, EG is associated with mortality rates up to 60%. Here, we present the case of a 29-year-old female patient who presented to the emergency department (ED) with symptoms of nausea, vomiting, and epigastric abdominal pain. Clinical evaluation revealed tachycardia, pain out of proportion, leukocytosis, and metabolic acidosis. Computed tomography (CT) scan unveiled the presence of air within the gastric wall, and a presumptive diagnosis of gastric emphysema was made. The patient responded positively to conservative management and was discharged after a two-day hospitalization. This case report emphasizes the need for physicians to adeptly distinguish between GE and EG. Timely identification and precise differentiation of the two conditions allow for timely and tailored management, ultimately leading to improved clinical outcomes in patients. By providing insights into the etiologies, clinical presentations, and imaging findings for the two pathologies, we aim to empower clinicians to make informed decisions for optimal patient care. Topics: Gastric emphysema, emphysematous gastritis, gastric pneumatosis.

A Case Report of Invasive Mucormycosis in a COVID-19 Positive and Newly-Diagnosed Diabetic Patient.

This is a case report of a 46-year-old female with undiagnosed diabetes, COVID-19, and mucormycosis. Mucormycosis is a rare, rapidly progressive disease process characterized by an insidious onset of vague symptoms and is associated with a high mortality rate. The patient initially presented at two outside ophthalmology clinics due to right eye pain and was prescribed steroids. Upon presentation to our institution's Emergency Department, the patient's pain had significantly increased along with new symptoms of ptosis and failure to adduct the right eye. Laboratory results demonstrated leukocytosis, hyperglycemia, and a positive SARS-CoV-2 test. Magnetic resonance imaging confirmed a diagnosis of mucormycosis and the patient underwent surgery and began intravenous antifungal therapy. This discussion addresses the presenting features of mucormycosis in the emergency department while highlighting the need for immediate investigation due to the fungi's rapidly progressive nature. Topics: Mucormycosis, mucor, diabetes, COVID-19, ROCM.

The Continued Rise of Syphilis: A Case Report to Aid in Identification of the Great Imitator.

Syphilis is a progressive sexually transmitted infection that has a wide variety of presentations depending on the disease stage. These variable presentations can make it difficult to differentiate syphilis from other diseases. While tertiary syphilis is less common in the United States compared to primary or secondary syphilis, recognition of the varied manifestations of advanced syphilis can help providers accurately diagnose this disease to help prevent continued spread. In this case report, we present a patient with a history of bilateral palmar wounds. The patient had presented to multiple emergency departments without a diagnosis of syphilis. Upon subsequent emergency department visits, the patient was diagnosed with tertiary syphilis, started on a course of penicillin, and evaluated by dermatology. However, the patient left against medical advice prior to further evaluation and treatment. From this case report, we have learned the importance of considering tertiary syphilis gummas in the differential diagnosis of atypical skin wounds. Topics: Sexually transmitted infection (sti), syphilis, tertiary syphilis, gummas, dermatologic lesions.

Strengthening of enterococcal biofilms by Esp.

Multidrug-resistant (MDR) Enterococcus faecalis are major causes of hospital-acquired infections. Numerous clinical strains of E. faecalis harbor a large pathogenicity island that encodes enterococcal surface protein (Esp), which is suggested to promote biofilm production and virulence, but this remains controversial. To resolve this issue, we characterized the Esp N-terminal region, the portion implicated in biofilm production. Small angle X-ray scattering indicated that the N-terminal region had a globular head, which consisted of two DEv-Ig domains as visualized by X-ray crystallography, followed by an extended tail. The N-terminal region was not required for biofilm production but instead significantly strengthened biofilms against mechanical or degradative disruption, greatly increasing retention of Enterococcus within biofilms. Biofilm strengthening required low pH, which resulted in Esp unfolding, aggregating, and forming amyloid-like structures. The pH threshold for biofilm strengthening depended on protein stability. A truncated fragment of the first DEv-Ig domain, plausibly generated by a host protease, was the least stable and sufficient to strengthen biofilms at pH ≤ 5.0, while the entire N-terminal region and intact Esp on the enterococcal surface was more stable and required a pH ≤ 4.3. These results suggested a virulence role of Esp in strengthening enterococcal biofilms in acidic abiotic or host environments.

Case Report of a Pelvic Kidney with Ureteral Obstruction from Inguinal Hernia Entrapment and Concurrent Cryptorchid Testis.

This is a case report of a ureteral obstruction from inguinal hernia entrapment with an ipsilateral cryptorchid testis in a 45-year-old male with an ectopic pelvic kidney. Ureteral herniation is unusual and to our knowledge has not been described in the setting of a patient with an ectopic pelvic kidney and undescended testis. The patient initially presented at an outside hospital with mild right lower quadrant abdominal pain and scrotal fullness, and initial computed tomography (CT) imaging demonstrated a pelvic right kidney with an indirect right inguinal hernia containing an entrapped ureter resulting in severe hydronephrosis. The CT also revealed an undescended testis on the patient's right side. A nephrostomy tube was then placed in the right kidney under interventional radiological (IR) guidance and subsequent CT urography showed resolution of hydronephrosis. Surgical hernia repair was followed up on a later date. The discussion addresses the unique pathological features of this case while highlighting the relevant complications of a ureteral herniation. Topics: Pelvic kidney, renal ectopia, ureteral obstruction, cryptorchidism, undescended testis.

A Case Report of Epiglottitis in an Adult Patient.

Epiglottitis is historically known to be a disease of childhood. However, since the implementation of the Haemophilus influenzae type B vaccination, there has been an increasing incidence within the adult population. This is a case report of a 36-year-old male who presented to the emergency department (ED) in severe respiratory distress with complaints of a sore throat, shortness of breath, odynophagia, dysphagia, and hoarseness. Physical exam revealed biphasic stridor, tachycardia, tachypnea, and an erythematous uvula. Imaging of his neck revealed findings consistent with epiglottitis containing nonspecific air. The patient was rapidly intubated, started on broad spectrum antibiotics and dexamethasone. He was admitted for intensive medical management with Otolaryngology consultation. This case report highlights the importance of rapid recognition and diagnosis of epiglottitis in an adult population to prevent morbidity and mortality. Topics: Epiglottitis, stridor, odynophagia, dysphagia, Haemophilus influenzae, group C streptococci, thumb-print sign, intubation.

Implementation of an Electronic Health Record-Based Messaging System in the Emergency Department: Effects on Physician Workflow and Resident Burnout.

INTRODUCTION: The traditional methods of communication between nurses and physicians through paging or phone calls have been known to cause patient care interruptions, increase stress and workload, and cause burnout. Our study assessed the impact of using an electronic health record-based messaging system (Epic Secure Chat) for nonemergent communication between nurses and physicians in the emergency department (ED). METHOD: This study was performed at a large urban academic ED. Surveys were distributed through e-mail using Google forms. Preimplementation and postimplementation surveys were performed from May 2019 (presurvey) to August 2019 (postsurvey). RESULT: The number of nonurgent phone calls from registered nurse staff decreased after intervention (P < 0.001). The frequency of nonurgent calls disrupting workflow decreased after the intervention (P = 0.029). The number of calls that were appropriately alerted to increased but was not significant (P = 0.120), whereas the degree of burnout from nonurgent calls remained relatively the same (P = 0.841). CONCLUSIONS: The findings provide insight into the implementation of an EMR messaging system in an ED setting. These findings suggest the messaging system can decrease unnecessary nonurgent calls from registered nurses and medical doctors, allowing for more efficient workflow in the ED. These findings suggest further research especially regarding burnout implemented on a larger scale and yield redesign suggestions in the ED.

The Effects of Implementing a "Waterfall" Emergency Physician Attending Schedule.

INTRODUCTION: Increases in emergency department (ED) crowding and boarding are a nationwide issue resulting in worsening patient care and throughput. To compensate, ED administrators often look to modifying staffing models to improve efficiencies. METHODS: This study evaluates the impact of implementing the waterfall model of physician staffing on door-to-doctor time (DDOC), door-to-disposition time (DDIS), left without being seen (LWBS) rate, elopement rate, and the number of patient sign-outs. We examined 9,082 pre-intervention ED visits and 8,983 post-intervention ED visits. RESULTS: The change in DDOC, LWBS rate, and elopement rate demonstrated statistically significant improvement from a mean of 65.1 to 35 minutes (P <0.001), 1.12% to 0.92% (P = 0.004), and 3.96% to 1.95% (P <0.001), respectively. The change in DDIS from 312 to 324.7 minutes was not statistically significant (P = 0.310). The number of patient sign-outs increased after the implementation of a waterfall schedule (P <0.001). CONCLUSION: Implementing a waterfall schedule improved DDOC time while decreasing the percentage of patients who LWBS and eloped. The DDIS and number of patient sign-outs appears to have increased post implementation, although this may have been confounded by the increase in patient volumes and ED boarding from the pre- to post-intervention period.

A strategy for dual inhibition of the proteasome and fatty acid synthase with belactosin C-orlistat hybrids.

The proteasome, a validated cellular target for cancer, is central for maintaining cellular homeostasis, while fatty acid synthase (FAS), a novel target for numerous cancers, is responsible for palmitic acid biosynthesis. Perturbation of either enzymatic machine results in decreased proliferation and ultimately cellular apoptosis. Based on structural similarities, we hypothesized that hybrid molecules of belactosin C, a known proteasome inhibitor, and orlistat, a known inhibitor of the thioesterase domain of FAS, could inhibit both enzymes. Herein, we describe proof-of-principle studies leading to the design, synthesis and enzymatic activity of several novel, ß-lactone-based, dual inhibitors of these two enzymes. Validation of dual enzyme targeting through activity-based proteome profiling with an alkyne probe modeled after the most potent inhibitor, and preliminary serum stability studies of selected derivatives are also described. These results provide proof of concept for dual targeting of the proteasome and fatty acid synthase-thioesterase (FAS-TE) enabling a new approach for the development of drug-candidates with potential to overcome resistance.

Distinct Roles for CdtA and CdtC during Intoxication by Cytolethal Distending Toxins.

Cytolethal distending toxins (CDTs) are heterotrimeric protein exotoxins produced by a diverse array of Gram-negative pathogens. The enzymatic subunit, CdtB, possesses DNase and phosphatidylinositol 3-4-5 trisphosphate phosphatase activities that induce host cell cycle arrest, cellular distension and apoptosis. To exert cyclomodulatory and cytotoxic effects CDTs must be taken up from the host cell surface and transported intracellularly in a manner that ultimately results in localization of CdtB to the nucleus. However, the molecular details and mechanism by which CDTs bind to host cells and exploit existing uptake and transport pathways to gain access to the nucleus are poorly understood. Here, we report that CdtA and CdtC subunits of CDTs derived from Haemophilus ducreyi (Hd-CDT) and enteropathogenic E. coli (Ec-CDT) are independently sufficient to support intoxication by their respective CdtB subunits. CdtA supported CdtB-mediated killing of T-cells and epithelial cells that was nearly as efficient as that observed with holotoxin. In contrast, the efficiency by which CdtC supported intoxication was dependent on the source of the toxin as well as the target cell type. Further, CdtC was found to alter the subcellular trafficking of Ec-CDT as determined by sensitivity to EGA, an inhibitor of endosomal trafficking, colocalization with markers of early and late endosomes, and the kinetics of DNA damage response. Finally, host cellular cholesterol was found to influence sensitivity to intoxication mediated by Ec-CdtA, revealing a role for cholesterol or cholesterol-rich membrane domains in intoxication mediated by this subunit. In summary, data presented here support a model in which CdtA and CdtC each bind distinct receptors on host cell surfaces that direct alternate intracellular uptake and/or trafficking pathways.

What is the risk of infecting a cerebrospinal fluid-diverting shunt with percutaneous tapping?

OBJECT: Most CSF-diverting shunt systems have an access port that can be percutaneously tapped. Tapping the shunt can yield valuable information as to its function and whether an infection is present. The fear of causing a shunt infection by tapping may limit the physician's willingness to do so. The authors of this study investigate the risk of infecting a shunt secondary to percutaneous tapping. METHODS: Following institutional review board approval, CSF specimens obtained from tapping an indwelling CSF-diverting shunt during the 2011 and 2012 calendar years were identified and matched with clinical information. A culture-positive CSF sample was defined as an infection. If results were equivocal, such as a broth-only-positive culture, a repeat CSF specimen was examined. The CSF was obtained by tapping the shunt access port with a 25-gauge butterfly needle after prepping the unshaven skin with chlorhexidine. RESULTS: During the study period, 266 children underwent 542 shunt taps. With 541 taps, no clinical evidence of a subsequent shunt infection was found. One child's CSF went from sterile to infected 11 days later; however, this patient had redness along the shunt tract at the time of the initial sterile tap. CONCLUSIONS: The risk of infection from tapping a shunt is remote if the procedure is done correctly.