Showing papers by "Lincoln Hospital published in 2010"

Protein Tyrosine Phosphatase PTPN14 Is a Regulator of Lymphatic Function and Choanal Development in Humans

Abstract: The lymphatic vasculature is essential for the recirculation of extracellular fluid, fat absorption, and immune function and as a route of tumor metastasis. The dissection of molecular mechanisms underlying lymphangiogenesis has been accelerated by the identification of tissue-specific lymphatic endothelial markers and the study of congenital lymphedema syndromes. We report the results of genetic analyses of a kindred inheriting a unique autosomal-recessive lymphedema-choanal atresia syndrome. These studies establish linkage of the trait to chromosome 1q32-q41 and identify a loss-of-function mutation in PTPN14, which encodes a nonreceptor tyrosine phosphatase. The causal role of PTPN14 deficiency was confirmed by the generation of a murine Ptpn14 gene trap model that manifested lymphatic hyperplasia with lymphedema. Biochemical studies revealed a potential interaction between PTPN14 and the vascular endothelial growth factor receptor 3 (VEGFR3), a receptor tyrosine kinase essential for lymphangiogenesis. These results suggest a unique and conserved role for PTPN14 in the regulation of lymphatic development in mammals and a nonconserved role in choanal development in humans.

Complementary and alternative medicine in rheumatoid arthritis: no longer the last resort!

Abstract: Complementary and alternative medicine (CAM) has become popular with consumers worldwide and accounts for significant private and public health expenditures. According to earlier reports, the prevalence of CAM use by rheumatoid arthritis (RA) patients in the United States is anywhere between 28% and 90%. Extensive use among RA patients and the limited knowledge among physicians had confirmed the need to evaluate the increasing prevalence of various CAM modalities. The primary aim of this study was to identify the incidence of CAM usage among our RA patients. Additionally, we aimed to correlate patient demographics and disease characteristics with the use of specific CAM modalities. An analysis of data extracted from our institution’s RA longitudinal registry was performed. The patients were asked to select from a list the modalities they were currently using and/or had used in the past. Of patients, 75.9% reported current or past use of CAM with >10% using 12 different modalities. Nutritional supplements and touch therapies were the most widely used overall, with mind–body therapies more prevalent among younger patients. CAM users were found to have more extra-articular manifestations and fewer comorbidities than non-CAM users. The use of CAM among RA patients is widespread with a broad spectrum of CAM modalities being used in early stages of the disease, frequently in conjunction with mainstream conventional treatments. Therefore, CAM may no longer be considered the rheumatoid patients’ last resort.

Shared decision-making in the primary care treatment of late-life major depression: a needed new intervention?

Abstract: Objective We suggest that clinicians consider models of shared decision-making (SDM) for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions. Methods We explore the characteristics and techniques of patient–clinician SDM, with particular emphasis on this model's relevance to the unique treatment concerns of depressed older adults. Results We describe a SDM intervention to engage older adults in depression treatment in the primary care sector. Conclusions It is timely to examine SDM models for elderly depressed primary care patients given their potential ability to improve treatment adherence and clinical outcomes. Copyright © 2009 John Wiley & Sons, Ltd.

Cholinergic crisis after rodenticide poisoning.

Abstract: Rodenticides have historically been common agents in attempted suicides. As most rodenticides in the United States (U.S.) are superwarfarins, these ingestions are generally managed conservatively with close monitoring for coagulopathy, and if necessary, correction of any resulting coagulopathy. However, alternate forms of rodenticides are imported illegally into the U.S. and may be ingested either accidentally or in suicide attempts. We present an unusual case of poisoning by the illegally imported rodenticide, "Tres Pasitos." The main ingredient of this rat poison is aldicarb, a potent carbamate pesticide that causes fulminant cholinergic crisis. This case is relevant and timely because carbamates and organophosphates are still used as insecticides and emergency physicians (EP) working in rural areas may have to evaluate and manage patients with these poisonings. As international travel and immigration have increased, so has the possibility of encountering patients who have ingested toxic substances from other countries. In addition, there has been increased concern about the possibility of acts of terrorism using chemical substances that cause cholinergic toxidromes. EPs must be able to recognize and manage these poisonings. This report describes the mechanism of action, clinical manifestations, laboratory evaluation and management of this type of poisoning. The pertinent medical literature on poisoning with aldicarb and similar substances is reviewed. Language: en

Testicular Infarction Becoming Apparent After Hernia Reduction

Abstract: Background: Testicular infarction from an incarcerated inguinal hernia is a rare event in children, often not considered in the initial evaluation. Objective: To report a case that describes the presentation, diagnosis, and management of testicular infarction in the setting of an incarcerated inguinal hernia. Case Report: A 2-month old boy was brought to the Emergency Department (ED) by his parents for vomiting, crying, and a left-sided scrotal swelling. An inguinal hernia was manually reduced successfully in the ED. Subsequently, scrotal ultrasound with color Doppler was obtained, demonstrating no blood flow to the left testis. The patient underwent a left orchiectomy and right orchiopexy with hernia repair. Discussion: Testicular injury can occur from torsion due to the effect of an incarcerated hernia or due to ischemia from cord compression. Delay in diagnosis and surgery risks testicular viability, therefore, surgery should not be delayed for imaging in the presence of strong suspicion of torsion. Conclusions: The diagnosis of testicular torsion is not always straightforward because many conditions may have a similar clinical presentation or may compromise testicular blood supply. This case is an unusual presentation of testicular infarction in the setting of an incarcerated inguinal hernia.

Actinomycosis of the Pancreas: A Case Report and Review.

Abstract: Actinomyces is a normal commensal of the upper aerodigestive tract, colon and female reproductive tract. It can give rise to invasive disease in case of any breach in mucosal integrity, as well as, in patients with immunosuppression. Rarely, actinomycosis can involve the pancreas especially after episodes of pancreatitis or in post operative patients. We observed a case of actinomycosis affecting recurrent intraductal papillary mucinous neoplasm (IPMN) of pancreatic remnant, 5 years after a Whipple's procedure. Our patient, a 66 years old male with a history of Whipple's procedure for IPMN of pancreatic uncinate process, presented with repeated episodes of acute pancreatitis. Repeated radiological investigations (CT, MRI and EUS) revealed resolving pancreatitis with recurrent IPMN of the pancreatic tail. The patient underwent laparobotic assisted resection of the remnant pancreas and spleen 3 months later. Intraoperatively, in addition to the recurrent IPMN of pancreatic tail, we found a dense peripancreatic desmoplastic reaction with areas of thick yellow pus pockets in the remnant pancreatic body. Bacteriology and histopathology revealed it as a recurrent IPMN associated with actinomycosis of pancreas with chronic xanthogranulomatous changes. We conclude that actinomycosis of the pancreas is a rare entity with only 5 cases reported in English literature to the best of our knowledge. If diagnosed preoperatively, early institution of antibiotics can improve the surgical outcome. Fortunately, after diagnosis, we were able to start antibiotics in early postoperative period with successful outcome.

Serum inhibin A concentration in women with polycystic ovarian syndrome and the correlation to ethnicity, androgens and insulin resistance

Abstract: A prospective case-series in an academic hospital clinic was performed to determine whether there is a relationship between polycystic ovarian syndrome (PCOS) and ethnicity. Also, serum inhibin A concentrations were compared between PCOS and normal-ovulatory women. The possibility of a correlation between inhibin A, androgens and insulin resistance in PCOS women was evaluated. Serum inhibin A concentrations were measured in anovulatory PCOS patients (n=32) and in control women of reproductive age (n=16). Statistical analysis was performed using the Mann-Whitney U-test. Serum concentrations of inhibin A, follicle-stimulating hormone, LH, prolactin, thyroid-stimulating hormone, fasting glucose, insulin, testosterone, 17-hydroxyprogesterone (17-OHP) and dehydroepiandrosterone sulphate (DHEAS) were measured. Inhibin A concentrations were significantly lower (4.5+/-4.8 pg/ml) when compared with the control group (13.2+/-14.4 pg/ml; P=0.003) and were not significantly different between Hispanic and Caucasian women diagnosed with PCOS. There was no correlation between inhibin A concentrations and insulin, testosterone, free testosterone, 17-OHP, or DHEAS concentrations. In PCOS women, inhibin A concentrations are similar between Hispanic and Caucasian women; however, women with PCOS, regardless of ethnicity, have a lower inhibin A concentration compared with normal-ovulatory women. No correlation was observed between inhibin A androgens and insulin resistance in women diagnosed with PCOS.

Endovenous Laser Ablation of the Small Saphenous Vein Sparing the Saphenopopliteal Junction

Abstract: To assess outcomes after endovenous laser ablation (EVLA) of the small saphenous vein (SSV). Retrospective review was performed of all consecutive EVLA procedures performed over a 39-month period at three neighboring vein practices for symptomatic, duplex ultrasound-proven incompetence of the SSV. EVLA was performed under ultrasound guidance with an 810- or 980-nm diode laser in continuous mode using the pullback method while sparing the deep, most cephalad segment of the SSV near the saphenopopliteal junction. Follow-up after EVLA included patient symptoms, physical examination, and duplex ultrasound. Pretreatment variables were similar across all three practices. EVLA was performed to treat 67 incompetent SSVs in 63 patients (86% women; mean age and 95% confidence interval, 50 ± 3 years; range, 20–82 years). Average energy delivered was 92 J/cm. Immediate technical success and occlusion of the treated vein at 1–2 weeks was 100%. Imaging follow-up length was 243 ± 65 days (range, 3–893 days). Clinical follow-up (243 ± 66 days) showed symptomatic improvement in 66 (99%) of 67 patients; one patient had recanalization with recurrent reflux by ultrasound (2%). Complications included one case of paresthesias lasting beyond 1 month of follow-up (2%) and three cases of superficial phlebitis (4%), but no deep vein thrombosis, skin burns, or other complications. Although ablation involved only the superficial portion of the SSV and spared its deep segment in the popliteal fossa, SSV occlusion typically extended up to the saphenopopliteal junction or to a gastrocnemial collateral, without popliteal vein involvement. EVLA of the SSV is safe and effective when the saphenopopliteal junction and popliteal fossa are avoided. This approach may help reduce the risk of paresthesias or other complications while maintaining low recanalization rates.

Hip pain in a child: myositis or appendicitis?

Abstract: Hip pain is a common presenting complaint in the pediatric emergency department, which can be attributed to many possible causes. It may be due to a benign "growing pain" or a potentially serious illness requiring urgent evaluation. At times, hip pain can be a manifestation of an underlying appendicitis in a child; thus, it can be confused with many other conditions. Children can be at particular risk for misdiagnosis or delayed diagnosis of appendicitis as it often can have an uncommon presentation with atypical signs and symptoms. Early identification, however, is important to prevent potential complications of delaying the diagnosis. We present a case that illustrates an atypical presentation of acute appendicitis. This report also highlights the diagnostic dilemma encountered during the evaluation of hip pain in children.

A penetrating neck injury: trivial trauma with serious consequences.

Abstract: Life-threatening complications due to apparently minor penetrating neck injuries can occur. We present the case of a 16-year-old boy, who had what initially appeared to be a superficial stab wound to his neck. After further evaluation, he was found to have major injuries to his larynx and esophagus. This case underscores the importance of a careful evaluation after any penetrating neck injury, even one that initially appears to be trivial. The pertinent literature regarding penetrating neck trauma is reviewed.

Ear acupuncture in Addiction Treatment.

Abstract: Acupuncture is currently used in the treatment of addictions by approximately 2,500 addiction treatment programs. Clinical evidence supports that it is effective in ameliorating withdrawal and craving symptoms associated with alcohol, opiate, and cocaine dependence, as well as symptoms associated with most other addictions. Acupuncture for cocaine dependence has been particularly recognized as an important innovation, since there are presently no established pharmaceutical treatments for cocaine dependence. Acupuncture is used by programs as a foundation for later psychosocial recovery. It is a non-verbal, non-threatening, “first-step” intervention that has an immediate calming effect on clients regardless of the specific substance used and regardless of whether a coexisting psychiatric disorder has been diagnosed. Initial participation with acupuncture has been found to improve participants’ overall treatment retention, and to facilitate their subsequent involvement. In most programs, clients receive 3–5 ear acupuncture points while seated together in a large group room so that a substantial number of individuals can be treated conveniently. This safe and cost-efficient procedure has gained increasing acceptance from agencies responsible for overseeing addiction treatment. Evidence for the benefit of acupuncture in coexisting psychiatric conditions and other behavioral health settings also will be presented. This chapter will describe the practical use and research findings related to acupuncture for addiction. Mechanisms of action that involve physiology and psychosocial process will be covered.

Headache from cavernous sinus thrombosis in Adamantiades-Behçet disease.

Abstract: A 24-year-old Russian man with a history of recurrent aphthous oral ulcers and a recent episode of genital ulcers presented with severe head and neck pain. Two days after the onset of his symptoms, the patient developed a fever (39-C) and sore throat and was treated for presumed pharyngitis. Four days before presentation, the patient noticed painful genital ulcers (Fig. A) and a rash on his forearm (Fig. B) consistent with folliculitis. The diagnosis of Adamantiades-Beh0et disease was made. A lumbar puncture was performed and was remarkable for an opening pressure of 540 mm Hg with normal cell count. Magnetic resonance venogram (Fig. C; arrowhead depicts lack of flow in transverse sinus) confirmed the diagnosis. The patient was treated with corticosteroids, colchicine, and azathioprine, and his symptoms resolved within weeks.

Nouvelle technique endovasculaire pour le traitement des ruptures traumatiques bilatérales des artères axillaires et suivi à long terme

Abstract: Nous rapportons un cas de technique endovasculaire innovante utilisee pour la reparation d’une rupture traumatique bilaterale de l’artere axillaire. Un patient de 36 ans travaillant dans le Bbtiment fit une chute d’un echafaudage d’une hauteur de huit etages et presentait des lesions traumatiques bilaterales des arteres axillaires. La continuite entre les arteres brachiales et axillaires etait retablie en utilisant de longs stents nus auto expansibles (Zilver). A notre connaissance, il s’agit d’un cas original d’utilisation des techniques endovasculaires dans un trauma center de niveau 1 pour le traitement de lesions traumatiques bilaterales des arteres axillaires, avec un suivi a long terme.

An analysis of the robustness and fragility of the coagulation system

Abstract: The coagulation system (CS) is a complex, inter-connected biological system with major physiological and pathological roles. Adaptive mechanisms such as ubiquitous feedback and feedforward loops create non-linear relationships among its individual components and render the study of this biology at a molecular and cellular level nearly impossible. Computational modeling aims to overcome limitations of current analytical methods through in silico simulation of these complex interplays. We present herein an Agent Based Modeling and Simulation (ABMS) approach for simulating these complex interactions. Our ABMS approach utilizes a subset of 48 rules to define the interactions among 24 enzymes and factors of the CS. These rules simulate the interaction of each “agent”, such as substrates, enzymes, and cofactors, on a two-dimensional grid of ~3,000 cells and ~500,000 agents. Our ABMS method demonstrates the robustness of the physiologic CS system over large ranges of tissue factor (TF) concentrations. The system also demonstrates fragility as complete coagulation occurs at sufficiently high concentrations of TF. Removal of individual coagulation inhibitors from the physiologic system results in system fragility at relatively lower TF concentrations. The complete removal of coagulation inhibitors leads to a system that is incapable of controlling coagulation at all TF concentrations. The synergistic effects of the inhibitory pathways create an intricate regulatory mechanism that allows sufficient clot formation while preventing system wide activation of the CS; a robust system emerges. Introduction

Index of suspicion. Case 1: abdominal pain, vomiting, and weakness in an obese adolescent. Case 2: bowlegs in a toddler. Case 3: cyclical abdominal pain and urinary symptoms in a teenage girl.

Abstract: A 15-year-old girl is hospitalized with right upper quadrant abdominal pain, vomiting, and weakness of 3 days' duration. She has a history of hyperlipidemia, polycystic ovary syndrome (PCOS), metabolic syndrome, and left ovarian cystadenectomy. She has been taking oral contraceptives (OCPs) and metformin for the past 2 years and started spironolactone 8 weeks ago. She experienced menarche at age 12 years and had one menstrual cycle for the whole first year. There is no history of dysmenorrhea or menorrhagia. Her family history is positive for type 2 diabetes mellitus (DM), obesity, and gallstones. On physical examination, her body mass index (BMI) is 28.0 kg/m2 (95th percentile), and she is in mild distress due to pain. Her blood pressure is 128/76 mm Hg (90th percentile for age and height); the remainder of her vital signs are normal. She has acanthosis nigricans and hirsutism. She is at Sexual Maturity Rating 5. She has mild tenderness in the right upper abdominal quadrant, but there is no organomegaly or rigidity. The rest of the physical findings are normal. Laboratory results reveal serum amylase of 660 units/L, lipase of 263 units/L, AST of 868 units/L, ALT of 1,573 units/L, cholesterol of 216 mg/dL (5.6 mmol/L), triglycerides of 181 mg/dL (2.0 mmol/L), high-density lipoprotein (HDL) cholesterol of 33 mg/dL (0.9 mmol/L), and glucose ranging from 120 to 148 mg/dL (6.7 to 8.2 mmol/L). Ultrasonography shows multiple cholesterol gallstones and a thickened gall bladder. Additional investigation reveals the diagnosis. A healthy 2-year-old girl presents to the clinic for evaluation of bowlegs. She was born at term and had a birthweight of 6 lb 11 oz. Her development has been normal, and she eats a regular diet. However, the bowing of her legs has increased progressively since she started walking at 1 year of age. There is …