Extensive longitudinal acute transverse myelitis complicated by pulseless ventricular tachycardia and recent shingles vaccination.

This case describes a 50-year-old male with a history of psoriatic arthritis who presented to the emergency department with a chief complaint of ascending bilateral lower extremity paresthesia one week following a shingles vaccine. MRI of the patient's spine was significant for longitudinally extensive T2 hyperintensity involving the lower cervical spine with extension into the upper thoracic spine suggestive of acute transverse myelitis (ATM). The patient's hospital course was complicated by a self-limiting episode of pulseless ventricular tachycardia accompanied by a brief loss of consciousness. Initial treatment included IV solumedrol, however due to lack of clinical improvement after a 5-day steroid treatment, plasmapheresis was initiated. The patient's condition improved with plasmapheresis and he was subsequently discharged to a rehab facility with a diagnosis of ATM of unclear etiology. Extensive serology, cardiac and CSF studies failed to determine the cause of this patient's myelitis or pulseless ventricular tachycardia. The following case report explores the potential factors that may have contributed to this patient's symptoms.

Digestive organ in the female reproductive tract borrows genes from multiple organ systems to adopt critical functions.

Persistent adaptive challenges are often met with the evolution of novel physiological traits. Although there are specific examples of single genes providing new physiological functions, studies on the origin of complex organ functions are lacking. One such derived set of complex functions is found in the Lepidopteran bursa copulatrix, an organ within the female reproductive tract that digests nutrients from the male ejaculate or spermatophore. Here, we characterized bursa physiology and the evolutionary mechanisms by which it was equipped with digestive and absorptive functionality. By studying the transcriptome of the bursa and eight other tissues, we revealed a suite of highly expressed and secreted gene products providing the bursa with a combination of stomach-like traits for mechanical and enzymatic digestion of the male spermatophore. By subsequently placing these bursa genes in an evolutionary framework, we found that the vast majority of their novel digestive functions were co-opted by borrowing genes that continue to be expressed in nonreproductive tissues. However, a number of bursa-specific genes have also arisen, some of which represent unique gene families restricted to Lepidoptera and may provide novel bursa-specific functions. This pattern of promiscuous gene borrowing and relatively infrequent evolution of tissue-specific duplicates stands in contrast to studies of the evolution of novelty via single gene co-option. Our results suggest that the evolution of complex organ-level phenotypes may often be enabled (and subsequently constrained) by changes in tissue specificity that allow expression of existing genes in novel contexts, such as reproduction. The extent to which the selective pressures encountered in these novel roles require resolution via duplication and sub/neofunctionalization is likely to be determined by the need for specialized reproductive functionality. Thus, complex physiological phenotypes such as that found in the bursa offer important opportunities for understanding the relative role of pleiotropy and specialization in adaptive evolution.

Dynamic digestive physiology of a female reproductive organ in a polyandrous butterfly.

Reproductive traits experience high levels of selection because of their direct ties to fitness, often resulting in rapid adaptive evolution. Much of the work in this area has focused on male reproductive traits. However, a more comprehensive understanding of female reproductive adaptations and their relationship to male characters is crucial to uncover the relative roles of sexual cooperation and conflict in driving co-evolutionary dynamics between the sexes. We focus on the physiology of a complex female reproductive adaptation in butterflies and moths: a stomach-like organ in the female reproductive tract called the bursa copulatrix that digests the male ejaculate (spermatophore). Little is known about how the bursa digests the spermatophore. We characterized bursa proteolytic capacity in relation to female state in the polyandrous butterfly Pieris rapae. We found that the virgin bursa exhibits extremely high levels of proteolytic activity. Furthermore, in virgin females, bursal proteolytic capacity increases with time since eclosion and ambient temperature, but is not sensitive to the pre-mating social environment. Post copulation, bursal proteolytic activity decreases rapidly before rebounding toward the end of a mating cycle, suggesting active female regulation of proteolysis and/or potential quenching of proteolysis by male ejaculate constituents. Using transcriptomic and proteomic approaches, we report identities for nine proteases actively transcribed by bursal tissue and/or expressed in the bursal lumen that may contribute to observed bursal proteolysis. We discuss how these dynamic physiological characteristics may function as female adaptations resulting from sexual conflict over female remating rate in this polyandrous butterfly.

Kissing choroidal sign: A case report.

Choroidal detachment (CD) is a rare and potentially vision-threatening complication of glaucoma surgery. Inflammation and prolonged ocular hypotony can promote fluid accumulation between the choroid and sclera. Risk factors include trauma, advanced age, use of anticoagulant medications, systemic hypertension, atherosclerosis, and diabetes. CD ultrasound findings will show 2 layers, detaching as far anteriorly as the ciliary bodies, that protrude convexly into the vitreous without extending to the optic disc, often described as the appositional or kissing choroidal sign. In contrast, retinal detachments will show a distinct "V" shape due to the retina's fixation to the optic nerve head posteriorly. In the case of hemorrhagic CD, therapy should be targeted at reducing intraocular pressure. In this case, the patient was started on atropine and prednisolone drops and discontinued on all glaucoma medications in the left eye. While serous choroidal detachments are usually benign, persistent choroidal effusions may cause significant morbidity with hemorrhagic CD having a worse prognosis. Point of care ultrasound can help emergency physicians quickly distinguish between choroidal and retinal detachments and thus guide management in a safe and timely manner.

Novel Use of Clonidine Patch to Treat Tizanidine Withdrawal.

Tizanidine is commonly prescribed for muscle spasticity and pain. Yet, withdrawal is rarely reported. Tizanidine stimulates presynaptic α-2 adrenergic and imidazoline receptors decreasing norepinephrine release. Abrupt cessation can cause withdrawal. Current treatment strategies include tapering oral tizanidine or substituting oral clonidine. A 52-year-old male with a history of hypertension, diabetes, coronary artery disease, and chronic back pain presented with altered mental status, agitation, hypertensive emergency (blood pressure: 250/145 mmHg), and tachycardia. The patient had been prescribed tizanidine for chronic back pain for two years and had recently run out with suspicion of misuse. Tizanidine withdrawal was diagnosed, and he improved with 0.1 mg oral clonidine three times daily weaned over five days while hospitalized. One month later the patient was admitted for persistent hypertension, tachycardia, diaphoresis, and anxiety. Alpha-2 agonist withdrawal was again diagnosed. Utilizing a clonidine patch taper may offer a reasonable approach in patients with tizanidine withdrawal.

Evaluation of an Intravenous Acetaminophen Protocol in the Emergency Department.

BACKGROUND: Acute pain is a leading reason for Emergency Department (ED) evaluation, accounting for nearly half of all ED visits. Therefore, providing effective non-opioid analgesics in the ED is critical. Oral acetaminophen (APAP) is commonly administered in the ED but is limited to patients tolerating oral intake. Intravenous (IV) APAP provides significant pain reduction parenterally. The purpose of this quality assessment project was to evaluate the frequency of opioid use in patients receiving IV APAP, the safety of IV APAP, and compliance with an ED IV APAP protocol. METHODS: This study included all patients who received IV APAP in the ED of a tertiary care, level I trauma center, during a three-month period. The protocol required ED patients to be NPO (nil per os), 18 years or older, and administered with a single 1000 mg dose. The adverse reactions within 24 hours post-IV APAP, ED length of stay (LOS), and opioid administration within four hours post-IV APAP were assessed. RESULTS: Ninety-four patients received IV APAP. All patients received a 1000 mg dose. One patient received more than one dose, but this patient had a 22-hour ED LOS. Two patients received oral medications within one hour of IV APAP (one received an antacid, and the other received carbamazepine and lamotrigine). An opioid was administered to 22 of the 94 (23.4%) patients during the four-hour protocol period. There were no reports of adverse reactions. CONCLUSIONS: The results show excellent compliance with the protocol. IV APAP was safe and well-tolerated. Notably, most patients did not receive an opioid within four hours of IV APAP. IV APAP can be safely and effectively utilized as an analgesic and lessen ED opioid use.

Assessment of the alveolar-arterial oxygen gradient as a screening test for pulmonary embolism in pregnancy.

OBJECTIVE: The objective of the study was to determine whether the alveolar-arterial (A-a) oxygen gradient is an adequate screening test for pulmonary embolism (PE) in pregnancy and postpartum. STUDY DESIGN: A chart review was performed at Tampa General Hospital. Patients who had a workup for a PE consisting of a computed tomography pulmonary angiogram and an arterial blood gas from 2002 to 2009 were included in the analysis. Sensitivity, specificity, and negative and positive predictive values were calculated. Additionally, common clinical signs and symptoms were assessed for their ability to accurately predict PE. RESULTS: Of 102 patients, there were 13 PEs (2 antepartum and 11 postpartum). The best sensitivity, specificity, and negative and positive predictive values for A-a gradients were 76.9%, 20.2%, 80.0%, and 11.5%, respectively. CONCLUSION: The A-a gradient is a poor screening test for PE in pregnancy and postpartum. Suspicion of PE should prompt early imaging studies to rapidly make the diagnosis and begin treatment.

Increased risk of placental abruption in underweight women.

We sought to determine if there is a relationship between prepregnancy underweight status and placental abruption. We utilized the Missouri maternally linked cohort data files covering the period 1989 through 1997. We estimated the association between prepregnancy underweight subtypes and placental abruption using adjusted odds ratios. Subanalyses were performed to determine whether the amount of weight gained during pregnancy could modify the association. A total of 439,235 singleton pregnancies with 3696 abruptions were analyzed. Underweight mothers had a 40% greater likelihood for placental abruption (odds ratio 1.4; 95% confidence interval 1.3 to 1.5). The risk increased with ascending severity of underweight status ( P for trend <0.01). There was a trend toward decreased risk for placental abruption among underweight women with adequate weight gain in pregnancy. Prepregnancy maternal underweight status is associated with placental abruption. This risk may be reduced with adequate weight gain during pregnancy.

Ultrasound to identify cord knotting in monoamniotic monochorionic twins.

This case report demonstrates the use of ultrasound and doppler flow in the management of mono-amniotic monochorionic (M/M) twins. M/M twinning is a rare but significant event. It is associated with high rates of fetal mortality, most commonly cited at anywhere from between 30% and 70%. A common cause of death is cord entanglement. The case presented is that of a 19-year-old gravida 1 at 30 weeks with M/M twins in which multiple cord knots were found by ultrasound color doppler flow after variable fetal heart rate decelerations occurred. This prompted a decision for immediate cesarean delivery with normal fetal outcomes. Improvements in perinatal imaging systems are therefore beneficial in the management of M/M twins.

Cesarean or vaginal delivery for the breech fetus at the threshold of viability: results from a maternal-fetal medicine specialists survey.

OBJECTIVE: To determine how United States Maternal-Fetal medicine specialists recommend delivery of a breech fetus at the threshold of viability. METHODS: U.S. Society for Maternal-Fetal Medicine (SMFM) members were surveyed about; geographic location, practice type, whether they performed deliveries, definition of threshold for viability, recommendations for delivery of a breech fetus at the threshold of viability, and if the current medical-legal climate had any bearing on their decisions. Chi-Square and Fisher's Exact tests were used for analysis. RESULTS: 510 SMFM members responded to the questionnaire. The highest percentage of respondents stated '23 weeks' (31%) as the cutoff for viability, followed by '24 weeks' (21%) and '23 weeks or 500 g' (10%). Seventy percent recommended cesarean delivery for a breech fetus at the threshold of viability. The majority of respondents based their decision on 'published data' or 'expert opinion', however, 58.6% reported they felt current medical evidence was inadequate to support a recommendation. Fifty-three percent stated their recommendations are affected by medical-legal concerns. CONCLUSION: The majority of U.S. maternal fetal-medicine specialists who responded would recommend cesarean delivery for a breech fetus at the threshold of viability, despite the belief that there is inadequate evidence in the literature to support this recommendation.