New-onset seizure activity in a transplant patient on immunosuppressive therapy.

The evaluation of new-onset seizure activity must raise a much broader differential than just epilepsy. This case study highlights that broad differential and identifies an important, but less common, cause of seizure activity in specific patient populations. Information is summarized from recent primary research, case series, literature reviews, and meta-analyses. In the appropriate clinical context, the diagnosis of posterior reversible encephalopathy syndrome (PRES) should be considered as a cause of seizures. Posterior reversible encephalopathy syndrome is a neurotoxic syndrome characterized by posterior cerebral edema on imaging and triggered by a variety of inciting or predisposing factors. This article reviews suggestions for the identification and management of PRES. Because of the myriad factors, nurse practitioners should be familiar with PRES and may encounter it through primary care, emergency or urgent care, hospitalist medicine, or a variety of specialty roles.

Predictors of Perceived Educational Value in Emergency Medicine Residency Simulation Cases.

OBJECTIVES: This study was designed to identify characteristics associated with the perceived educational value of simulation cases in an emergency medicine residency curriculum. METHODS: Following 17 individual emergency medicine simulation cases, a standard feedback questionnaire was completed by emergency medicine residents. Multiple linear regression was performed to identify significant variables that predict perceived educational value. RESULTS: A total of 374 feedback responses were analyzed from 60 residents over a 2-year period. Complete data for inclusion in a regression analysis were available for 288 responses. The linear regression has an R2 value of 0.979, indicating that the model explains nearly 98% of the variation. The perceived usefulness of the simulation cases, PGY, and the reported the stressfulness of the exercise were all positively associated with perceived benefit. Familiarity with the clinical scenario, role of team leader, and perceived difficulty of the scenario did not influence the residents' perception of benefit. CONCLUSIONS: Multiple variables related to the scenario and the participants contribute to the perceived educational value of simulation cases in an emergency medicine residency curriculum. Specific predictors of educational value were PGY, stressfulness, and perceived utility. Being team leader, the familiarity of the scenario, or the perceived difficulty of the case did not influence the reported educational value. Recognition of these variables should help educators involved in the creation of educationally valuable simulation cases in the future.

Effort thrombosis (Paget-Schroetter syndrome) in a 16-year-old male.

PATIENT: Male, 16. FINAL DIAGNOSIS: Effort thrombosis (Paget-Schroetter Sydnrome). SYMPTOMS: Swollen arms. MEDICATION: -. CLINICAL PROCEDURE: -. SPECIALTY: Metabolic Disorders and Diabetics. OBJECTIVE: Rare disease. BACKGROUND: Thrombotic events in otherwise healthy pediatric patients are rare. In patients presenting with limb swelling, thrombosis must be considered in the differential diagnosis. In pediatric patients with thrombosis, there has been wide variability in the rates of associated thrombophilia. Many pediatric patients may instead have other contributors such as venous catheters or physical activity. CASE REPORT: We present a case of bilateral upper extremity deep venous thrombi in a previously healthy 16-year-old male. The patient presented with swelling and pain in both arms after several days of weight-bearing exercise. Following emergency department evaluation with ultrasound and laboratory testing, the patient was diagnosed with effort thrombosis - also known as Paget-Schroetter syndrome - and rhabdomyolysis. CONCLUSIONS: This case of Paget-Schroetter syndrome is distinguished by elevation in creatine kinase and transaminases. While these findings can be due to physical exertion and effort, effort thrombosis is not classically associated with laboratory abnormalities except an elevated D-dimer. The significance of these laboratory test result abnormalities remains unclear. Given the rarity of effort thrombosis, further epidemiological study is warranted to determine if these laboratory findings are seen in other cases, and, if so, what implications they may have for management and prognosis.

Intraosseous administration of thrombolytics for pulmonary embolism.

BACKGROUND: Massive pulmonary embolism is associated with cardiac dysfunction and ischemia, hemodynamic collapse, and significant potential for death. The American College of Chest Physicians and American College of Emergency Physicians each supports thrombolytic administration to hemodynamically unstable patients with acute pulmonary embolism. OBJECTIVES: In the resuscitation of patients with massive pulmonary embolism and obstructive shock, difficulty with vascular access can hinder care. Alternative options may facilitate delivery of thrombolytics and enhance patient management. CASE REPORT: The case presented is a 36-year-old woman with massive pulmonary embolism associated with hemodynamic instability. She was treated with thrombolytics through a tibial intraosseous line. CONCLUSIONS: To the best of our knowledge, this is the first identified case of a patient not in cardiac arrest in whom thrombolytics were administered via an intraosseous line. Similarly, we believe this is also the first reported case of thrombolytics delivered via an intraosseous line for massive pulmonary embolism in the United States.

The challenge of multiple chemical sensitivity.

Environmental health professionals frequently come across a health-related problem with no clear cause-and-effect relationship. A typical case occurs when a person complains of experiencing symptoms, often in an indoor setting, that may vary from vague to severe. Multiple Chemical Sensitivity (MCS) may be a factor at play in some of these situations. The condition is characterized by persistent symptoms that follow exposure to chemically unrelated compounds at doses well below those that have been established individually to cause harmful effects. An understanding of MCS among environmental health and medical professionals is encouraged. The following article provides a review of the current literature about MCS and discusses the difficulties, from various sources, in resolving health complaints that may be caused by. exposure to low doses of multiple chemicals

Enhanced fitness conferred by naturally occurring variation in the circadian clock.

Natural variation in clock parameters is necessary for the circadian clock to contribute to organismal fitness over a broad geographic range. Considerable variation is evident in the period, phase, and amplitude of 150 Arabidopsis accessions, and the period length is correlated with the day length at the latitude of origin, implying the adaptive significance of correctly regulated circadian timing. Quantitative trait loci analysis of recombinant inbred lines indicates that multiple loci interact to determine period, phase, and amplitude. The loss-of-function analysis of each member of the ARABIDOPSIS PSEUDO-RESPONSE REGULATOR family suggests that they are candidates for clock quantitative trait loci.