Diffuse Alveolar Hemorrhage Synergistically Induced by Amiodarone and Rheumatoid Arthritis.

Diffuse alveolar hemorrhage (DAH) syndrome is characterized by bleeding into the alveolar spaces of the lungs and occurs when there is an injury to the alveolar microcirculation that leads to hemorrhage from the alveolar capillaries. We report a case of an 82-year-old woman who presented with acute respiratory distress. The patient had a history of rheumatoid arthritis (RA) and was on amiodarone for atrial fibrillation therapy. Initial diagnostic workup, including bronchoscopy and imaging studies, revealed diffuse opacities and the bronchoalveolar lavage fluid consistent with DAH. The patient required aggressive management with supportive care and corticosteroids. Laboratory work showed a synergistic effect between amiodarone and RA in inducing DAH. This makes the report unique as no reports in the literature described a synergic effect of amiodarone and RA in inducing DAH. The primary objective of this report is to guide physicians and remind them to keep DAH at the top of their differential diagnosis in the setting of an RA patient taking amiodarone.

High-Efficiency Ultrasound-Guided Regional Nerve Block Workshop for Emergency Medicine Residents.

Audience: This small-group workshop is designed for emergency medicine residents. This workshop can also be offered to medical students or faculty interested in reviewing and practicing ultrasound-guided regional nerve blocks. Introduction: Ultrasound-guided regional nerve block (UGRNB) is a method used to administer local anesthesia to otherwise unreachable locations on the body and may be used in the management of various painful conditions seen in the emergency department. The ultrasound curriculum of our residency program is longitudinal. All residents spend time with the ultrasound director throughout their training, engage in daily bedside ultrasound, and have regular skills training on the various clinical applications of ultrasound. Additionally, all residents have a required ultrasound rotation dedicated to performing bedside ultrasound in the Emergency Department. Although others have outlined approaches to teaching emergency medicine residents the techniques needed to perform UGRNBs, the value of taking a one-day, high-efficiency teaching strategy with a narrow focus on practical application has yet to be appreciated. Educational Objectives: The objective of this workshop is to provide emergency medicine residents the confidence and skill sets needed to effectively perform five commonly used UGRNBs for conditions encountered in the emergency department. Through this one-day, accelerated workshop, residents will be given an opportunity to sharpen their UGRNB technique prior to applying them in the clinical environment. By the end of this workshop, learners will be able to: 1) recognize the clinical situations in which UGRNBs can be utilized and understand the associated risks, 2) list the commonly used local anesthetic medications and their proper dosing in respect to regional nerve blocks, 3) demonstrate proper ultrasound probe positioning and identify relevant anatomical landmarks for each nerve block on both standardized patients and cadavers, 4) describe the common steps involved to perform each nerve block, 5) perform the five UGRNB techniques outlined in this workshop. Educational Methods: Small group activity combining didactic learning, case-based learning, and procedural simulation. The didactic component may be delivered in an asynchronous learning or "flipped classroom" format. Research Methods: In-person interviews of the learners were obtained following the debriefing session during which they were asked about their enjoyment and satisfaction with the workshop. In addition, learners were asked about the value of the activities for their clinical practices and to provide formative feedback regarding the design of the workshop. Results: Overall, participants reported high levels of enjoyment, and many verbalized their satisfaction with the expeditious and pragmatic nature of the workshop. Some participants commented that they were looking forward to future workshops of similar design. Participants also stated that they felt more confident performing nerve blocks and looked forward to applying these skills in the clinical setting. Discussion: A focused small-group workshop directed towards developing the confidence and skill set necessary to perform UGRNBs can be successfully offered to emergency medicine residents in a single-day workshop. Topics: Ultrasound, nerve block, local anesthesia, injection, pain, resident, workshop.

Heparan Sulfate Structure Affects Autophagy, Lifespan, Responses to Oxidative Stress, and Cell Degeneration in Drosophila parkin Mutants.

Autophagy is a catabolic process that provides cells with energy and molecular building blocks during nutritional stress. Autophagy also removes misfolded proteins and damaged organelles, a critical mechanism for cellular repair. Earlier work demonstrated that heparan sulfate proteoglycans, an abundant class of carbohydrate-modified proteins found on cell surfaces and in the extracellular matrix, suppress basal levels of autophagy in several cell types during development in Drosophila melanogaster In studies reported here, we examined the capacity of heparan sulfate synthesis to influence events affected by autophagy, including lifespan, resistance to reactive oxygen species (ROS) stress, and accumulation of ubiquitin-modified proteins in the brain. Compromising heparan sulfate synthesis increased autophagy-dependent processes, evident by extended lifespan, increased resistance to ROS, and reduced accumulation of ubiquitin-modified proteins in the brains of ROS exposed adults. The capacity of altering heparan sulfate biosynthesis to protect cells from injury was also evaluated in two different models of neurodegeneration, overexpression of Presenilin and parkin mutants. Presenilin overexpression in the retina produces cell loss, and compromising heparan sulfate biosynthesis rescued retinal patterning and size abnormalities in these animals. parkin is the fly homolog of human PARK2, one of the genes responsible for juvenile onset Parkinson's Disease. Parkin is involved in mitochondrial surveillance and compromising parkin function results in degeneration of both flight muscle and dopaminergic neurons in Drosophila Altering heparan sulfate biosynthesis suppressed flight muscle degeneration and mitochondrial dysmorphology, indicating that activation of autophagy-mediated removal of mitochondria (mitophagy) is potentiated in these animals. These findings provide in vivo evidence that altering the levels of heparan sulfate synthesis activates autophagy and can provide protection from a variety of cellular stressors.