Primary brain calcification: an international study reporting novel variants and associated phenotypes

Primary familial brain calcification (PFBC) is a rare cerebral microvascular calcifying disorder with a wide spectrum of motor, cognitive, and neuropsychiatric symptoms. It is typically inherited as an autosomal-dominant trait with four causative genes identified so far: SLC20A2, PDGFRB, PDGFB, and XPR1. Our study aimed at screening the coding regions of these genes in a series of 177 unrelated probands that fulfilled the diagnostic criteria for primary brain calcification regardless of their family history. Sequence variants were classified as pathogenic, likely pathogenic, or of uncertain significance (VUS), based on the ACMG-AMP recommendations. We identified 45 probands (25.4%) carrying either pathogenic or likely pathogenic variants (n = 34, 19.2%) or VUS (n = 11, 6.2%). SLC20A2 provided the highest contribution (16.9%), followed by XPR1 and PDGFB (3.4% each), and PDGFRB (1.7%). A total of 81.5% of carriers were symptomatic and the most recurrent symptoms were parkinsonism, cognitive impairment, and psychiatric disturbances (52.3%, 40.9%, and 38.6% of symptomatic individuals, respectively), with a wide range of age at onset (from childhood to 81 years). While the pathogenic and likely pathogenic variants identified in this study can be used for genetic counseling, the VUS will require additional evidence, such as recurrence in unrelated patients, in order to be classified as pathogenic.

De Mello's Single Incision for Combined Liver-kidney Transplantation, Keeping the Kidney Retroperitoneal: A Case Report

The combined liver-kidney transplantation (cLKT) is the procedure of choice for patients with end-stage liver and kidney disease. In cLKT we can usually accommodate the grafts in two different ways, varying the kidney placement. The retroperitoneal kidney implant has some advantages, such as the easy access or avoiding vascular complications. We propose a new single incision, not yet reported, maintaining an extraperitoneal kidney, with excellent surgical field for cLKT and possible reduction of the impact of wound complications.

Therapy of paraneoplastic pemphigus with Rituximab: a case report and review of literature

Paraneoplastic pemphigus (PNP) is an autoimmune blistering disease with poor prognosis when associated with malignant neoplasm. We report the case of a patient with PNP associated with a CD20+ non-Hodgkin follicular lymphoma who was treated with Rituximab plus corticosteroids and short courses of cyclosporin. One and a half years after Rituximab therapy, oral ulcerations had cleared and oral methylprednisolone was slowly tapered down without further recurrences. In the course of the disease, the patient developed sepsis due to Listeria monocytogenes and viral infections by human herpes virus 1 and 3. At the end-stage of the disease she developed a cutaneous infection from Mycobacterium chelonae. The patient died 2 years and 7 months after the onset of PNP. Rituximab may be useful for PNP therapy, but further studies are necessary to confirm this hypothesis.

Non-steroidal anti-inflammatory drugs inhibit epinephrine- and cAMP-mediated lipolysis in isolated rat adipocytes

Acute ethanol intoxication increased triacylglycerides (TAG) and thiobarbituric acid reactive substances (TBARS) in liver and promoted the liberation of epinephrine. Four non-steroidal anti-inflammatory drugs (NSAIDs)--aspirin, naproxen, nimesulide and piroxicam--prevented this increase in TAG and TBARS. Because fatty acids provided by adipose tissue contribute substantially to elevated hepatic TAG in ethanol-intoxicated rats, it was thought that the NSAIDs might reduce epinephrine-stimulated lipolysis in these rats. Isolated rat adipocytes were activated with epinephrine in the presence or absence of the NSAIDs. The NSAIDs inhibited epinephrine-stimulated lipolysis. These drugs did not modify the binding of dihydroalprenolol (beta-adrenergic agonist) to their receptors in isolated guinea-pig liver membranes. The NSAIDs, at concentrations 3,000-fold lower than that of cAMP, inhibited stimulated lipolysis by this messenger. In conclusion, aspirin, naproxen, nimesulide and piroxicam reduce the release of fatty acids from adipose tissue to the liver by inhibiting the epinephrine-stimulated lipolysis, and this, in part, explains the protective action of these NSAIDs against hepatic signs of acute ethanol intoxication.

Secondary acute angle closure glaucoma: a complication of AIDS

A 58-year-old man with advanced AIDS presented to the emergency department complaining of headache and decreased vision bilaterally. On evaluation, he was found to have intraocular pressures of 69 and 65 mm Hg. After topical treatment with miotics and apraclonidine, he was given intravenous acetazolamide (Diamox) and peripheral iridotomy was performed. The pressures did not improve significantly. Secondary acute angle closure glaucoma was diagnosed. Emergency physicians should consider this diagnosis when evaluating AIDS patients with visual complaints.

Cyclic antidepressant overdoses. A review

Cyclic antidepressant drug toxicity is a common cause of death from prescription drug overdose in the United States. The pathophysiologic features include cardiac, neurologic, and gastrointestinal effects. Major signs of toxicity are identifiable in the emergency department. Treatment includes aggressive supportive care, activated charcoal, alkalinization therapy, and management of arrhythmias, hypotension, and seizures. Outcomes are generally good when early appropriate treatment is initiated.

Prognostic value of the emergency department cardiogram for in-hospital complications of acute myocardial infarction [corrected]

STUDY OBJECTIVE

To identify patients who are admitted from the emergency department with chest discomfort who are at low risk for life-threatening complications.

DESIGN

Retrospective chart review.

SETTING

A 450-bed military medical center providing active duty and military beneficiaries.

TYPE OF PARTICIPANTS

Six hundred twenty-one patients admitted to an ICU from the ED with the chief compliant of chest discomfort.

MEASUREMENTS AND MAIN RESULTS

Study participants were placed into low- and high-risk groups based on clinical criteria and ECGs. The groups were compared with respect to occurrence of life-threatening complications during the hospital course. Three of the 262 patients in the low-risk group experienced life-threatening events; two died. Twenty-nine of the 224 high-risk patients experienced life-threatening events; 17 died . Results were statistically evaluated using Fisher's exact test. Significance was achieved at a value of P < .01.

CONCLUSION

Patients who meet low-risk group criteria have a low likelihood of immediate life-threatening events and could be admitted to an intermediate care unit.

Medical complications of oncologic disease

Oncologic patients in urgent medical crises frequently are seen in the Emergency Department. Hypercalcemia, tumor lysis syndrome, hyperviscosity syndrome, and the syndrome of inappropriate antidiuretic hormone are four metabolic complications that have life-threatening implications. This article reviews these conditions from the perspective of the emergency physician. Clinical presentation, pathophysiology, and management specific to each entity are discussed.

Mother and child. Trauma in pregnancy

The role of the emergency physician in optimizing outcome for the maternal and fetal victims of trauma is pivotal. Knowledge of the anatomic and physiologic changes of pregnancy aid in understanding the nuances of care of the pregnant trauma patient. Both catastrophic and noncatastrophic trauma can be managed with confidence and expertise by recalling the maternal and fetal pathophysiologic responses to trauma. Burns and electrical injuries carry significant fetal risks, which may be minimized by rapid and knowledgeable emergency care.

Chlamydial antigen testing on female patients presenting to the emergency department

We prospectively determined the prevalence of Chlamydia trachomatis infection in patients presenting to an emergency department over a 4-month period who received pelvic exams. We compared the percentage of cases of Chlamydia diagnosed by the Chlamydiazyme immunoassay with the percentage diagnosed clinically by emergency physicians. Over the study period, 326 pelvic exams were performed. Of 36 patients (11%) with positive tests, 16 (44%) were treated clinically for pelvic inflammatory disease. Twenty (56%) received neither appropriate antibiotic treatment nor a gynecology referral based on clinical exam alone. We statistically evaluated the data using the hypothesis test for two proportions from one group. The difference was significant (Z = 4.6, p less than 0.001).

Amantadine toxicity presenting with complex ventricular ectopy and hallucinations

Amantadine hydrochloride is a commonly prescribed drug with a narrow therapeutic-to-toxic range. Toxicity is related to the anticholinergic properties of the drug and primarily affects the cardiovascular, central nervous, and respiratory systems. We report the case of an adolescent who ingested 1.3 grams of amantadine and developed complex ventricular arrhythmias and altered mental status. The arrhythmias were completely suppressed with intravenous lidocaine. This case supports the hypothesis that lidocaine is effective for treatment of ventricular arrhythmias secondary to amantadine toxicity.