Simultaneous duodenal stenosis and duodenal web in a newborn.

Failure of duodenal recanalization results in a spectrum of proximal bowel obstruction from stenosis to atresia. Associations between congenital duodenal obstruction and other congenital anomalies have been well documented although the coincidence of duodenal stenosis and duodenal web is incredibly rare, posing a unique diagnostic challenge. We report a case of a full-term 4-day-old female child presented with forceful, bilious emesis and poor oral intake with decreased frequency of urination, and stooling whose initial abdominal radiograph showed several loops of gas-filled bowel in the distal stomach and proximal duodenum mimicking the classic "double-bubble" sign. An upper gastrointestinal barium contrast study revealed distention of the duodenal bulb with an abrupt narrowing and subsequent dilation at the second portion of the duodenum raising the suggestion of multiple duodenal obstructions. Ladd's procedure was performed, and the stenotic and webbed segments were bypassed with a Kimura diamond-shaped duodenoduodenostomy.

Microglial Acid Sensing Regulates Carbon Dioxide-Evoked Fear.

BACKGROUND: Carbon dioxide (CO2) inhalation, a biological challenge and pathologic marker in panic disorder, evokes intense fear and panic attacks in susceptible individuals. The molecular identity and anatomic location of CO2-sensing systems that translate CO2-evoked fear remain unclear. We investigated contributions of microglial acid sensor T cell death-associated gene-8 (TDAG8) and microglial proinflammatory responses in CO2-evoked behavioral and physiological responses. METHODS: CO2-evoked freezing, autonomic, and respiratory responses were assessed in TDAG8-deficient ((-/-)) and wild-type ((+/+)) mice. Involvement of TDAG8-dependent microglial activation and proinflammatory cytokine interleukin (IL)-1ß with CO2-evoked responses was investigated using microglial blocker, minocycline, and IL-1ß antagonist IL-1RA. CO2-chemosensitive firing responses using single-cell patch clamping were measured in TDAG8(-/-) and TDAG8(+/+) mice to gain functional insights. RESULTS: TDAG8 expression was localized in microglia enriched within the sensory circumventricular organs. TDAG8(-/-) mice displayed attenuated CO2-evoked freezing and sympathetic responses. TDAG8 deficiency was associated with reduced microglial activation and proinflammatory cytokine IL-1ß within the subfornical organ. Central infusion of microglial activation blocker minocycline and IL-1ß antagonist IL-1RA attenuated CO2-evoked freezing. Finally, CO2-evoked neuronal firing in patch-clamped subfornical organ neurons was dependent on acid sensor TDAG8 and IL-1ß. CONCLUSIONS: Our data identify TDAG8-dependent microglial acid sensing as a unique chemosensor for detecting and translating hypercapnia to fear-associated behavioral and physiological responses, providing a novel mechanism for homeostatic threat detection of relevance to psychiatric conditions such as panic disorder.

Neuropeptide Y Impairs Retrieval of Extinguished Fear and Modulates Excitability of Neurons in the Infralimbic Prefrontal Cortex.

Neuropeptide Y (NPY), a 36 aa peptide, regulates stress and emotional behaviors. Preclinical and clinical studies support an association of NPY with trauma-evoked syndromes such as posttraumatic stress disorder (PTSD), although the exact contribution of NPY is not clear. In the current study, we examined functional attributes of NPY in the infralimbic (IL) cortex, an area that regulates fear memories and is reported to be hypoactive in PTSD. Carriers of NPY gene polymorphism rs16147 have been reported to have elevated prefrontal NPY expression. Infusion of NPY into the IL cortex in rats significantly impaired fear extinction memory without affecting conditioned fear expression or acquisition of extinction. Neuroendocrine stress response, depression-like behavior, and working memory performance were not affected by NPY infusion into the IL. The NPY Y1 receptor antagonist BIBO3304 completely abolished NPY effects on fear extinction retrieval. Y1 receptor expression was localized on CaMKII-positive pyramidal projection neurons and GAD67-positive interneurons in the IL. Patch-clamp recordings revealed increased inhibitory synaptic transmission onto IL projection neurons in the presence of NPY. Thus, NPY dampens excitability of IL projection neurons and impairs retrieval of extinction memory by inhibiting consolidation of extinction. Of relevance to PTSD, elevation of prefrontal NPY attributable to the genetic polymorphism rs16147 may contribute to IL hypoactivity, resulting in impaired extinction memory and susceptibility to the disorder. SIGNIFICANCE STATEMENT: Neuropeptide Y (NPY), a stress modulatory transmitter, is associated with posttraumatic stress disorder (PTSD). Contribution of NPY to PTSD symptomology is unclear. PTSD patients have reduced activity in the infralimbic (IL) subdivision of the medial prefrontal cortex (mPFC), associated with compromised extinction memory. No information exists on fear modulation by NPY in the IL cortex, although NPY and NPY receptors are abundant in these areas. This study shows that IL NPY inhibits consolidation of extinction, resulting in impaired retrieval of extinction memory and modulates excitability of IL projection neurons. In addition to providing a novel perspective on extinction memory modulation by NPY, our findings suggest that elevated mPFC NPY in gene polymorphism rs16147 carriers or after chronic stress could increase susceptibility to PTSD.

Applying a perceptions and practicalities approach to understanding nonadherence to antiepileptic drugs.

OBJECTIVE: Nonadherence to antiepileptic drugs (AEDs) is a common cause of poor seizure control. This study examines whether reported adherence to AEDs is related to variables identified in the National Institute for Health and Clinical Excellence (NICE) Medicines Adherence Guidelines as being important to adherence: perceptual factors (AED necessity beliefs and concerns), practical factors (limitations in capability and resources), and perceptions of involvement in treatment decisions. METHODS: This was a cross-sectional study of people with epilepsy receiving AEDs. Participants completed an online survey hosted by the Epilepsy Society (n = 1,010), or as an audit during inpatient admission (n = 118). Validated questionnaires, adapted for epilepsy, assessed reported adherence to AEDs (Medication Adherence Report Scale [MARS]), perceptions of AEDs (Beliefs about Medicines Questionnaire [BMQ]), and patient perceptions of involvement in treatment decisions (Treatment Empowerment Scale [TES]). RESULTS: Low adherence was related to AED beliefs (doubts about necessity: t(577) = 3.90, p < 0.001; and concerns: t(995) = 3.45, p = 0.001), reported limitations in capability and resources (t(589) = 7.78, p < 0.001), and to perceptions of a lack of involvement in treatment decisions (t(623) = 4.48, p < 0.001). In multiple logistic regression analyses, these factors significantly (p < 0.001) increased variance in reported adherence, above that which could be explained by age and clinical variables (seizure frequency, type, epilepsy duration, number of AEDs prescribed). SIGNIFICANCE: Variables identified in the NICE Medicines Adherence Guidelines as potentially important factors for adherence were found to be related to adherence to AEDs. These factors are potentially modifiable. Interventions to support optimal adherence to AEDs should be tailored to address doubts about AED necessity and concerns about harm, and to overcome practical difficulties, while engaging patients in treatment decisions.

History of chronic stress modifies acute stress-evoked fear memory and acoustic startle in male rats.

Chronicity of trauma exposure plays an important role in the pathophysiology of posttraumatic stress disorder (PTSD). Thus, exposure to multiple traumas on a chronic scale leads to worse outcomes than acute events. The rationale for the current study was to investigate the effects of a single adverse event versus the same event on a background of chronic stress. We hypothesized that a history of chronic stress would lead to worse behavioral outcomes than a single event alone. Male rats (n = 14/group) were exposed to either a single traumatic event in the form of electric foot shocks (acute shock, AS), or to footshocks on a background of chronic stress (chronic variable stress-shock, CVS-S). PTSD-relevant behaviors (fear memory and acoustic startle responses) were measured following 7 d recovery. In line with our hypothesis, CVS-S elicited significant increases in fear acquisition and conditioning versus the AS group. Unexpectedly, CVS-S elicited reduced startle reactivity to an acoustic stimulus in comparison with the AS group. Significant increase in FosB/ΔFosB-like immunostaining was observed in the dentate gyrus, basolateral amygdala and medial prefrontal cortex of CVS-S rats. Assessments of neuropeptide Y (NPY), a stress-regulatory transmitter associated with chronic PTSD, revealed selective reduction in the hippocampus of CVS-S rats. Collectively, our data show that cumulative stress potentiates delayed fear memory and impacts defensive responding. Altered neuronal activation in forebrain limbic regions and reduced NPY may contribute to these phenomena. Our preclinical studies support clinical findings reporting worse PTSD outcomes stemming from cumulative traumatization in contrast to acute trauma.

Making the Most of Your Healthcare intervention for older adults with multiple chronic illnesses.

OBJECTIVE: This study tested the efficacy of a patient engagement intervention for older adults with multiple chronic illnesses. METHODS: Seventy-nine participants were randomly assigned to receive the intervention (Intervention Group), contacts on a different topic (Safety Group), or Usual Care. The Intervention and Safety Groups attended a 2-h workshop and participated in phone calls; one before and one after a naturally-occurring medical encounter. The Intervention Group discussed patient engagement concepts from publicly distributed content. The Safety Group discussed general safety (e.g., fire safety, identity theft). Self-report measures were gathered by telephone interview at Baseline and 6-months following Baseline. RESULTS: We did not find expected improvements in patient activation and health-related quality of life. However, the Intervention Group was the only group to show a statistically significant improvement in self-efficacy for self-management. CONCLUSION: The intervention shows promise for improving quality of life and/or health, but requires refinement to reach persons not already engaged in their healthcare and to strengthen its effects. PRACTICE IMPLICATIONS: Patient-directed skills training interventions may be a successful way to support clinicians' and others' efforts to encourage older patients to be actively involved in their care.

Quality assurance of HDR prostate plans: program implementation at a community hospital.

Adenocarcinoma of the prostate is currently the most commonly diagnosed cancer in men in the United States, and the second leading cause of cancer mortality. The utilization of radiation therapy is regarded as the definitive local therapy of choice for intermediate- and high-risk disease, in which there is increased risk for extracapsular extension, seminal vesicle invasion, or regional node involvement. High-dose-rate (HDR) brachytherapy is a logical treatment modality to deliver the boost dose to an external beam radiation therapy (EBRT) treatment to increase local control rates. From a treatment perspective, the utilization of a complicated treatment delivery system, the compressed time frame in which the procedure is performed, and the small number of large dose fractions make the implementation of a comprehensive quality assurance (QA) program imperative. One aspect of this program is the QA of the HDR treatment plan. Review of regulatory and medical physics professional publications shows that substantial general guidance is available. We provide some insight to the implementation of an HDR prostate plan program at a community hospital. One aspect addressed is the utilization of the low-dose-rate (LDR) planning system and the use of existing ultrasound image sets to familiarize the radiation therapy team with respect to acceptable HDR implant geometries. Additionally, the use of the LDR treatment planning system provided a means to prospectively determine the relationship between the treated isodose volume and the product of activity and time for the department's planning protocol prior to the first HDR implant. For the first 12 HDR prostate implants, the root-mean-square (RMS) deviation was 3.05% between the predicted product of activity and time vs. the actual plan values. Retrospective re-evaluation of the actual implant data reduced the RMS deviation to 2.36%.

Information sources accessed by parents following childhood poisoning.

OBJECTIVE: To ascertain the sources of information accessed by parents/caregivers following an incident of child poison ingestion, prior to their presentation to an ED. METHODS: A questionnaire based survey of the parents/caregivers of children presenting to the Mater Children's Hospital Emergency Department with poisoning from March to October 2001. RESULTS: A total of 121 parents/caregivers were surveyed. In 117 cases (97%), information was sought prior to presentation. The Poisons Information Centre (PIC) was the initial source of information in 39 cases (32%), the ED in 25 cases (21%) and the family doctor (by telephone or consultation) in 21 cases (17%). Poisons Information Centres, emergency departments and family doctors were the sole sources of information for 18%, 15% and 12% of cases, respectively. For 46% of cases multiple sources of information were accessed, and overall, in 57 cases (47%) the Poisons Information Centre was accessed, the ED in 38 cases (31%) and the family doctor in 34 cases (28%). CONCLUSIONS: Poisons Information Centres are under-utilized as the first point of contact after childhood poisoning but in nearly all cases of poison ingestion that presented to the ED, information was sought prior to presentation and in most cases this was from direct contact with a health professional.