Technology and Transplants: Troubleshooting Insulin Pumps and Pancreas Transplants in the Emergency Department.

Diabetes management has continued to evolve with new treatments and technology. This article discusses the approach to evaluation and management of two distinctive subsets of patients: (1) patients who manage their diabetes with an insulin pump (artificial pancreas) and (2) patients who have received a pancreas transplant. The most current literature is reviewed and pearls and pitfalls distinctive to these two patient populations are discussed. Relevant diagnostics are reviewed with emphasis on recognition of complications faced in the emergency department management of these unique patient populations.

Medical Cannabis in the Treatment of Parkinson's Disease.

OBJECTIVES: Medical cannabis (MC) has recently garnered interest as a potential treatment for neurologic diseases, including Parkinson's disease (PD). A retrospective chart review was conducted to explore the impact of MC on the symptomatic treatment of patients with PD. METHODS: Patients with PD treated with MC in the normal course of clinical practice were included (n = 69). Data collected from patient charts included MC ratio/formulation changes, PD symptom changes after initiation of MC, and adverse events (AEs) from MC use. Information regarding changes in concomitant medications after MC initiation, including opioids, benzodiazepines, muscle relaxants, and PD medications, was also collected. RESULTS: Most patients were initially certified for a 1:1 (∆ 9 -tetrahydrocannabinol:cannabidiol) tincture. Eight-seven percent of patients (n = 60) were noted to exhibit an improvement in any PD symptom after starting MC. Symptoms with the highest incidence of improvement included cramping/dystonia, pain, spasticity, lack of appetite, dyskinesia, and tremor. After starting MC, 56% of opioid users (n = 14) were able to decrease or discontinue opioid use with an average daily morphine milligram equivalent change from 31 at baseline to 22 at the last follow-up visit. The MC was well-tolerated with no severe AEs reported and low rate of MC discontinuation due to AEs (n = 4). CONCLUSIONS: The MC may improve motor and nonmotor symptoms in patients with PD and may allow for reduction of concomitant opioid medication use. Large, placebo-controlled, randomized studies of MC use in patients with PD are required.

Clinical Characteristics of Pediatric Patients With Carbon Monoxide Poisoning.

OBJECTIVES: Carbon monoxide (CO) poisoning is a common and deadly form of poisoning that is often treated with hyperbaric oxygen. The characteristics of children exposed to CO and then treated with hyperbaric oxygen have not been delineated. The purpose of this study was to describe the clinical characteristics of children treated with hyperbaric oxygen therapy for CO poisoning at a regional hyperbaric referral center. METHODS: The study is based on a retrospective review of data extracted from the medical records of children (age <19 years) who were referred to our center for hyperbaric oxygen therapy for CO poisoning between 2008 and 2013. Inferential analyses were used to compare demographic characteristics, serum carboxyhemoglobin (COHb) levels, and presenting symptoms. RESULTS: Forty-seven children met our study criteria. Their mean age was 8.9 years, and their mean COHb level was 14.3% (range, 3.4%-30.1%). Severity of symptoms did not correlate with serum COHb levels; however, neurologic symptoms at presentation were more common in patients with a COHb level greater than 25%. There was a correlation between increasing age and higher COHb levels and between COHb and lactate levels. CONCLUSIONS: Our retrospective review of patients' records showed no correlation of serum COHb levels with symptoms on presentation; however, a correlation was found between increasing age and COHb level as well as lactate level and COHb level.

Profiling the Targets of Protective CD8+ T Cell Responses to Infection.

T cells are critical effectors of host immunity that target intracellular pathogens, such as the causative agents of HIV, tuberculosis, and malaria. The development of vaccines that induce effective cell-mediated immunity against such pathogens has proved challenging; for tuberculosis and malaria, many of the antigens targeted by protective T cells are not known. Here, we report a novel approach for screening large numbers of antigens as potential targets of T cells. Malaria provides an excellent model to test this antigen discovery platform because T cells are critical mediators of protection following immunization with live sporozoite vaccines and the specific antigen targets are unknown. We generated an adenovirus array by cloning 312 highly expressed pre-erythrocytic Plasmodium yoelii antigens into adenovirus vectors using high-throughput methodologies. The array was screened to identify antigen-specific CD8+ T cells induced by a live sporozoite vaccine regimen known to provide high levels of sterile protection mediated by CD8+ T cells. We identified 69 antigens that were targeted by CD8+ T cells induced by this vaccine regimen. The antigen that recalled the highest frequency of CD8+ T cells, PY02605, induced protective responses in mice, demonstrating proof of principle for this approach in identifying antigens for vaccine development.

Corneal sensitivity in chronic inflammatory demyelinating polyneuropathy.

PURPOSE: Neurotrophic keratitis may result from a variety of ocular or systemic diseases. Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune neuropathy that affects any nerve plexus but with no known association with corneal disease. We observed 2 patients with CIDP and visually compromising neurotrophic corneal ulcers. This study was performed to determine the prevalence of neurotrophic corneas in patients with CIDP to identify a subpopulation of asymptomatic patients who are at risk for vision loss. METHODS: This is an observational case series of 2 patients with CIDP with visually compromising neurotrophic corneal ulcers and a prospective clinical study comparing corneal sensitivity in 9 patients with CIDP versus 9 age- and sex-matched controls. Corneal sensitivity was tested with an esthesiometer. Statistical analyses were performed to determine patterns or significances in relation to the subject's age, gender, and duration and severity of the disease. RESULTS: The overall median corneal sensitivity was 5.7 for patients with CIDP and 6.0 for controls (P = 0.09). The mean corneal sensitivity was 5.6 ± 0.4 in patients with CIDP compared with 5.8 ± 0.3 in controls. No specific pattern was found with age, gender, or duration and severity of the disease among patients with CIDP. CONCLUSIONS: Although the case series demonstrated decreased corneal sensitivity in both patients with CIDP, the prospective study detected reduced corneal sensitivity in patients with CIDP when compared with controls, but did not reach statistical significance. Ophthalmic examinations with measurement of corneal sensitivity should be considered in the management of patients with CIDP.Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01379833.

Electrodiagnosis of ulnar neuropathy at the elbow (Une): a Bayesian approach.

INTRODUCTION: In ulnar neuropathy at the elbow (UNE), we determined how electrodiagnostic cutoffs [across-elbow ulnar motor conduction velocity slowing (AECV-slowing), drop in across-elbow vs. forearm CV (AECV-drop)] depend on pretest probability (PreTP). METHODS: Fifty clinically defined UNE patients and 50 controls underwent ulnar conduction testing recording abductor digiti minimi (ADM) and first dorsal interosseous (FDI), stimulating wrist, below-elbow, and 6-, 8-, and 10-cm more proximally. For various PreTPs of UNE, the cutoffs required to confirm UNE (defined as posttest probability = 95%) were determined with receiver operator characteristic (ROC) curves and Bayes Theorem. RESULTS: On ROC and Bayesian analyses, the ADM 10-cm montage was optimal. For PreTP = 0.25, the confirmatory cutoffs were >23 m/s (AECV-drop), and <38 m/s (AECV-slowing); for PreTP = 0.75, they were much less conservative: >14 m/s, and <47 m/s, respectively. CONCLUSIONS: (1) In UNE, electrodiagnostic cutoffs are critically dependent on PreTP; rigid cutoffs are problematic. (2) AE distances should be standardized and at least 10 cm.

MNGIE neuropathy: five cases mimicking chronic inflammatory demyelinating polyneuropathy.

We report five patients with mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) who had demyelinating peripheral neuropathy. The MNGIE neuropathy had clinical and electrodiagnostic features typical of acquired, rather than inherited, etiologies. In fact, three patients were actually treated for chronic inflammatory demyelinating polyneuropathy (CIDP). We discuss findings that may help distinguish patients with MNGIE from those with CIDP.

A case of combined orthostatic tremor and primary gait ignition failure.

We report a case of a woman with both orthostatic tremor and primary gait ignition failure, a novel combination. We review the literature on both of these conditions, and discuss possible neuroanatomic substrates.