Gastric Electrical Stimulation as a New Treatment Modality for Refractory Nausea and Vomiting with Normal Gastric Emptying.

Nausea and vomiting are cardinal symptoms affecting many patients with delayed or normal gastric emptying. The current therapies are very limited and less than optimal. Therefore, gastrointestinal symptoms persist despite using all the standard approaches for gastroparesis, functional dyspepsia, or unexplained nausea and vomiting. It is well established that gastric electrical stimulation (GES) is effective in reducing nausea and vomiting in gastroparesis, but there are essentially no data available that detail the efficacy of GES in symptomatic patients without gastroparesis. We present a unique case of a female patient diagnosed with functional dyspepsia, whose nausea and vomiting which were refractory to all standard therapies were successfully addressed with the implantation of a GES system.

The Clot Thickens: COVID-19-Related ST-Elevation Myocardial Infarction in the Setting of Recent Boosters.

The coronavirus disease of 2019 (COVID-19) has an array of pathological effects that continue to be discovered. Vaccines against COVID-19 have quickly emerged as our main tool. However, the thrombotic risk of both the virus and the vaccine is yet to be established, let alone together. In this case report, we present a case involving a recently diagnosed COVID-19 patient who developed an ST-elevated myocardial infarction (STEMI) after receiving his booster shot. Our aim is to highlight the standard of treatment outcomes in COVID-19-associated clots, familiarize ourselves with the complexity of the clot burden in a COVID-19-associated STEMI, and illustrate the potential role of the cumulative pro-thrombotic effects of a recent COVID-19 booster with a concomitant symptomatic COVID-19 infection.

COVID-19-Associated Superior Mesenteric Artery Thrombosis and Acute Intestinal Ischemia.

The prothrombotic nature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been well-established since the start of the global coronavirus disease 2019 (COVID-19) pandemic. Mesenteric artery thrombosis and acute mesenteric ischemia are, on their own, rare occurrences and often present with fatal gastrointestinal (GI) pathologies requiring quick identification and intervention by the clinician to improve clinical outcomes. SARS-CoV-2 infection can present with acute GI pathologies and warrants further investigation regarding anticoagulation therapy in COVID-19 positive patients. We report on a 64-year-old woman infected with SARS-CoV-2 who presented with superior mesenteric artery thrombosis and acute intestinal ischemia.

Colorectal Carcinoma in the Background of Pelvic Inflammatory Disease.

Colorectal carcinoma (CRC) is a common malignancy with steadily declining incidence rates and mortality, secondary to improved screening and lifestyle changes (eg, decreased smoking rates). The association between pelvic inflammatory disease (PID) and CRC has been unclear in the past. However, multiple studies showed a positive association between PID and underlying malignancy (gynecologic and pelvic primarily). Several studies evaluated the relation between PID and CRC, but the results were conflicting. We describe a case of a 33-year-old female patient, with a history of PID and recurrent pelvic abscesses, who was found to have CRC. Of note, the patient's diagnosis was based on abnormal computed tomography findings, which were further investigated (by colonoscopy and biopsy), rather than on symptoms suggestive of CRC, such as rectal bleeding, constipation, symptomatic anemia, or abdominal pain.

A Perfect Storm: Abdominal Pain and Ileus Explained by Acute Intermittent Porphyria Caused by Prehospitalization and Intrahospitalization Factors.

Acute intermittent porphyria (AIP) is a rare autosomal dominant inherited disease, predominantly seen in female patients, caused by mutations in the hydroxymethylbilane synthase gene. When impaired, elevated heme biosynthesis precursor levels accumulate in the liver, resulting in neurological symptoms, psychiatric disturbances, darkened urine color, abdominal pain, nausea, vomiting, and ileus. We present a 22-year-old Hispanic female with diffuse abdominal pain and no bowel movements for 8 days. She reported recent antibiotic and oral contraceptive pill use. Computerized tomography of her abdomen revealed a dilated small bowel and marked colonic distension. A colonoscopy found mild nonspecific inflammation in the rectosigmoid and terminal ileum. Her abdominal pain persisted despite interventions and improvements in appetite, bowel movements, abdominal imaging, and treatment of an identified Clostridium difficile infection. A random urine porphobilinogen was then obtained and found to be elevated. Fractionation of plasma and urine porphyrins was suggestive of AIP. Her symptoms improved with 3 days of intravenous (IV) hematin and IV dextrose. This is a unique case of a rare disease due to her clinical presentation with ileus, unremarkable past medical history, family history, and the prehospitalization and intrahospitalization factors that likely exacerbated the patient AIP.

A general deep learning model for bird detection in high-resolution airborne imagery.

Advances in artificial intelligence for computer vision hold great promise for increasing the scales at which ecological systems can be studied. The distribution and behavior of individuals is central to ecology, and computer vision using deep neural networks can learn to detect individual objects in imagery. However, developing supervised models for ecological monitoring is challenging because it requires large amounts of human-labeled training data, requires advanced technical expertise and computational infrastructure, and is prone to overfitting. This limits application across space and time. One solution is developing generalized models that can be applied across species and ecosystems. Using over 250,000 annotations from 13 projects from around the world, we develop a general bird detection model that achieves over 65% recall and 50% precision on novel aerial data without any local training despite differences in species, habitat, and imaging methodology. Fine-tuning this model with only 1000 local annotations increases these values to an average of 84% recall and 69% precision by building on the general features learned from other data sources. Retraining from the general model improves local predictions even when moderately large annotation sets are available and makes model training faster and more stable. Our results demonstrate that general models for detecting broad classes of organisms using airborne imagery are achievable. These models can reduce the effort, expertise, and computational resources necessary for automating the detection of individual organisms across large scales, helping to transform the scale of data collection in ecology and the questions that can be addressed.

Another Sherlock Holmes Mystery: Abdominal Pain Explained by Median Arcuate Ligament Syndrome.

Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome, is a rare gastrointestinal condition with an estimated incidence of 2 per 100 000 population. Predominantly in female patients, this syndrome is characterized by the compression of the celiac artery at its origin from the aorta by the median arcuate ligament, which at the same time is entrapping the celiac plexus, causing upper abdominal pain, notably postprandial pain, as well as nausea, vomiting, food aversion, and weight loss. We present a case of abdominal pain secondary to MALS that was appropriately diagnosed after requiring narcotic medication, which responded to surgical therapy.

When Worlds Collide: An Interesting Case of Rhinocerebral Mucormycosis Exacerbated by COVID-19 and Diabetic Ketoacidosis Complicated by Intraorbital Hematoma.

Mucormycosis is a devastating fungal infection seen in patients who are immunosuppressed or in severe inflammatory states. Mucormycosis has been increasingly seen in the setting of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. We describe a 68-year-old male with a past medical history of uncontrolled diabetes mellitus who presented with acute vision loss and was found to have concomitant diabetic ketoacidosis (DKA) and coronavirus disease 2019 (COVID-19) infection on presentation. Rhinocerebral mucormycosis was suspected given the patient's presentation and was confirmed with an ethmoidal sinus biopsy. Our case was further complicated by the presence of cavernous sinus thrombosis, cerebral infarcts, and, later, the development of a left orbital hematoma following therapeutic anticoagulation. This case report aims to address the rare but now increasing incidence of rhinocerebral mucormycosis in the setting of COVID-19, further complicated by DKA, cerebral thrombosis, and intraorbital hematoma.

Cefepime-Induced Encephalopathy in a High-Risk Patient With Renal Insufficiency and Cirrhosis.

Cefepime is a fourth-generation, cephalosporin antibiotic commonly used as a first-line empirical treatment in a wide range of bacterial infections. It is predominantly excreted renally; therefore, a reduction in kidney function allows for the accumulation of cefepime to potentially toxic levels. Here we present a case of cefepime-induced encephalopathy (CIE) in a 67 years old male patient with advanced-stage renal insufficiency and cirrhosis who was admitted to our hospital for altered mental status (AMS). The patient was initially treated for hepatic encephalopathy (HE) given an elevated ammonia level (105 µg/dL), which had significantly improved. He was also placed on intravenous (IV) cefepime for Pseudomonas bacteremia. Four days later, the patient became drowsy and confused. A detailed workup for secondary causes of AMS was performed however no significant acute abnormalities were detected. The ammonia level remained within the normal range. There was no acute intracranial pathology reported on a head computerized tomography (CT). Furthermore, an electroencephalograph (EEG) was obtained which showed generalized periodic discharge with a tri-phasic wave pattern suggesting non-convulsive status epilepticus (NCSE). CIE was suspected at that point and cefepime administration was stopped. Following cefepime discontinuation, there was a remarkable improvement in the patient's mental status for several days after cefepime discontinuation that supported the diagnosis of CIE in our patient. Although the exact pathophysiology is unclear, CIE should be suspected in elderly patients, patients with renal dysfunction, and critical illness. Meanwhile, liver dysfunction can be an additional risk factor for CIE as it increases the permeability of the blood-brain barrier (BBB), altered neurotransmission, and neuro-inflammation.

Design of a Small Unmanned Aircraft System for Bridge Inspections.

Bridge inspections are an important procedure for maintaining the infrastructure vital to our economy and well-being. The current methodology of utilizing specialized equipment such as snooper trucks and scaffolding to support manned-inspections poses a significant financial cost, disrupts traffic, and is dangerous to the inspectors and public. The advent of unmanned aerial systems (UAS), more commonly called drones, presents a practical solution that promises reduced cost, enhanced safety, and is significantly less intrusive than previous methodologies. Current limitations in the implementation of UAS include the reliance on a skilled operator and/or the requirement for a UAS to operate in a cluttered, GPS-denied environment. A solution to these challenges is presented in this paper by utilizing commercial off-the-shelf (COTS) hardware including laser rangefinders, optical flow sensors, and live video telemetry. Included in the system is the obstacle avoidance equipped drone and a ground station intended to be manned by a pilot and bridge inspector. The proposed custom-fabricated UAS was implemented during eight inspections of Florida Department of Transportation (FDOT) bridges. The UAS was able to navigate under GPS-denied and obstacle-laden bridge decks with position-hold performance comparable to, if not better than, a COTS unit in an unobstructed environment. The position hold capability maintained an altitude of ±12.8 cm with a horizontal hold of ±435 cm. Details of the hardware, algorithm development, and suggestions for future research are discussed in this paper.

Nimbolide inhibits pancreatic cancer growth and metastasis through ROS-mediated apoptosis and inhibition of epithelial-to-mesenchymal transition.

The mortality and morbidity rates of pancreatic cancer are high because of its extremely invasive and metastatic nature. Its lack of symptoms, late diagnosis and chemo-resistance and the ineffective treatment modalities warrant the development of new chemo-therapeutic agents for pancreatic cancer. Agents from medicinal plants have demonstrated therapeutic benefits in various human cancers. Nimbolide, an active molecule isolated from Azadirachta indica, has been reported to exhibit several medicinal properties. This study assessed the anticancer properties of nimbolide against pancreatic cancer. Our data reveal that nimbolide induces excessive generation of reactive oxygen species (ROS), thereby regulating both apoptosis and autophagy in pancreatic cancer cells. Experiments with the autophagy inhibitors 3-methyladenine and chloroquine diphosphate salt and the apoptosis inhibitor z-VAD-fmk demonstrated that nimbolide-mediated ROS generation inhibited proliferation (through reduced PI3K/AKT/mTOR and ERK signaling) and metastasis (through decreased EMT, invasion, migration and colony forming abilities) via mitochondrial-mediated apoptotic cell death but not via autophagy. In vivo experiments also demonstrated that nimbolide was effective in inhibiting pancreatic cancer growth and metastasis. Overall, our data suggest that nimbolide can serve as a potential chemo-therapeutic agent for pancreatic cancer.