Calcium Disorders.

This article provides a comprehensive overview of calcium physiology, clinical presentation with physical examination findings, laboratory assessment, differential diagnosis, and management of hypocalcemia and hypercalcemia for the primary care provider.

Preventive Care for Men Who Have Sex With Men.

Men who have sex with men (MSM) is an inclusive term used to refer to phenotypic males who have insertive or receptive sex (penile-anal or penile-oral) with other phenotypic males, including people who are transgender or have other gender identities. MSM may report their sexual orientation as homosexual, bisexual, heterosexual, or something else, but this stated sexual orientation may not align with their sexual attraction or behaviors. Several health conditions disproportionately affect MSM compared with age-matched heterosexual men, including HIV infection, anal cancer, syphilis, and depression. Clinicians should use culturally sensitive questions to obtain a comprehensive sexual history and assess sexual risk. MSM should receive regular screening for HIV, hepatitis B and C, gonorrhea, chlamydia, and syphilis. Vaccinations for hepatitis A and B and human papillomavirus should be offered. MSM may benefit from preexposure prophylaxis to prevent HIV infection, postexposure prophylaxis to reduce the risk of HIV transmission, and counseling on safer sexual practices. Screening for anal cancer associated with human papillomavirus may be performed by digital anal rectal examination, although the optimal screening strategy has yet to be determined. Clinicians should also consider more frequent screenings for mental health issues in the MSM population because the rates of depression, suicide, substance use, and other psychosocial issues are higher than those of the general population.

Iatrogenic Arteriovenous Fistula Following Routine Venipuncture in an Adult Without Coagulopathy: An Uncommon Consequence of a Common Procedure.

Background: According to Tonnessen BH (2011),1 iatrogenic arteriovenous (AV) fistulas in adults most commonly occur due to endovascular access and procedures. Rarely, AV fistulas have been reported in low birth weight neonates following repeating venipuncture. This complication is extremely uncommon in adults, but has been reported after routine venipuncture for blood transfusion. Case presentation: We report the case of an elderly female patient who presented to the office for evaluation of left upper extremity swelling, ecchymosis, and dilated vessels after routine venipuncture at an outpatient laboratory. She was subsequently found to have an acquired AV fistula from her left cephalic vein to a small branch artery. Conclusion: This case demonstrates the rare but relevant risk in routine venipuncture and may underscore the benefit of using ultrasound guidance in high-risk populations, such as patients with coagulopathies, or thin, fragile veins, like the elderly or neonates.

Cervical Spine Evaluation by Telephone and Video Visit.

As telecommunication technologies advance, efforts are being made to mitigate direct patient contact in the COVID-19 pandemic due to the risk of contagion. The ability to host telephone and video visits within patient portals within health care institutions will only become increasingly valuable. Neck pain, a common complaint seen in primary care clinics, is well-suited to telemedicine evaluation, as related etiologies are often comparatively straightforward. A good assessment of the cervical spine by telephone or video is possible with the right knowledge and practice. The purpose of this article is to propose questions and maneuvers that can be used to evaluate the cervical spine via telephone or video, as well as likely diagnoses that can be reached through these. Phone and video evaluation of the cervical spine can result in valuable data regarding symmetry, range of motion, functional movement patterns, modified strength testing, and provocative testing. The skill set necessary to do telephone and video visits should be included in the curriculum of physician learners.

Polybrominated diphenyl ethers in fish and wastewater samples from an area of the Penobscot River in central Maine.

Polybrominated diphenyl ethers (PBDEs) are one class of flame retardants commonly used in textiles, foams and plastics. They are similar in behavior to the well-studied polychlorinated biphenyls and growing evidence suggests they are widespread global environmental pollutants that are capable of bioaccumulation. Fish tissue samples were collected from sites along the Penobscot River in central Maine. The total concentration of tetra- to hepta-PBDEs in these samples were calculated and generally increased from upstream to downstream locations ranging from 800 to 1810 ng/g lipid at the northernmost site to 5750-29000 ng/g at the downstream sampling site. BDE-47, 99 and 100 were the predominant congeners found in the fish tissue. Wastewater treatment plants (WWTPs) are one of the potential sources of these compounds to the environment through effluent discharge and landspreading of biosolids. Influent, effluent, activated sludge and dewatered biosolids were collected and analyzed for PBDE congeners from a WWTP at Orono, Maine. PBDE congeners were detectable in effluent samples at concentrations from 0.31 to 0.90 microg/l, in the activated sludge at 1.32-3.8 microg/l and in the influent at 4.2-4.3 microg/l, but the majority of the material was concentrated in the biosolids. Total concentration in the biosolids was 2320-3530 microg/kg dry weight.

Pandemic influenza-implications for critical care resources in Australia and New Zealand.

OBJECTIVES: To quantify resource requirements (additional beds and ventilator capacity), for critical care services in the event of pandemic influenza. MATERIALS AND METHODS: Cross-sectional survey about existing and potential critical care resources. Participants comprised 156 of the 176 Australasian (Australia and New Zealand) critical care units on the database of the Australian and New Zealand Intensive Care Society (ANZICS) Research Centre for Critical Care Resources. The Meltzer, Cox and Fukuda model was adapted to map a range of influenza attack rate estimates for hospitalisation and episodes likely to require intensive care and to predict critical care admission rates and bed day requirements. Estimations of ventilation rates were based on those for community-acquired pneumonia. RESULTS: The estimated extra number of persons requiring hospitalisation ranged from 8,455 (10% attack rate) to 150,087 (45% attack rate). The estimated number of additional admissions to critical care units ranged from 423 (5% admission rate, 10% attack rate) to 37,522 (25% admission rate, 45% attack rate). The potential number of required intensive care bed days ranged from 846 bed days (2 day length of stay, 10% attack rate) to 375,220 bed days (10 day length of stay, 45% attack rate). The number of persons likely to require mechanical ventilation ranged from 106 (25% of projected critical care admissions, 10% attack rate) to 28,142 (75% of projected critical care admissions, 45% attack rate). An additional 1,195 emergency ventilator beds were identified in public sector and 248 in private sector hospitals. Cancellation of elective surgery could release a potential 76,402 intensive care bed days (per annum), but in the event of pandemic influenza, 31,150 bed days could be required over an 8- to 12-week period. CONCLUSION: Australasian critical care services would be overwhelmed in the event of pandemic influenza. More work is required in relation to modelling, contingency plans, and resource allocation.

Orphan nuclear receptor Nurr1 directly transactivates the promoter activity of the tyrosine hydroxylase gene in a cell-specific manner.

Tyrosine hydroxylase (TH) catalyzes the first and rate-limiting step of catecholamine synthesis and its expression is necessary for neurotransmitter specification of all catecholaminergic neurons, while dopamine beta-hydroxylase (DBH) is essential for the noradrenergic phenotype. In the present study, we show that Nurr1, an orphan nuclear receptor critical for dopaminergic (DA) neuron development, directly transactivates the promoter activity of the TH gene in a cell type-dependent manner, while it does not regulate the DBH promoter. Consistent with these results, only the TH promoter contains multiple sequence motifs homologous to the known Nurr1-binding motif, NBRE. TH promoter deletional analysis indicates that < 1.0 kb upstream sequences, encompassing three NBRE-like motifs (i.e. NL1, NL2 and NL3) are mostly responsible for the effects of Nurr1. Among these potential motifs, site-directed mutational analysis showed that NL1, residing from - 35 to - 28 bp, was most critical for mediating the transactivation by Nurr1. Strikingly, however, both DNase I footprinting and electrophoretic mobility shift assays showed that NL3, but not NL1 or NL2, has high binding affinity to Nurr1. To determine whether the proximity of these motifs may be important for transactivation by Nurr1 in the transient transfection assay, we generated reporter gene constructs in which NL3 is immediately proximal to the TATA box. Indeed, NL3 was more efficient in this position than NL1 or NL2 for mediating the transactivation by Nurr1. Our results suggest that Nurr1 may play a direct role for specification of DA neurotransmitter identity by activating TH gene transcription in a cell context-dependent manner.