A Case Report of Fournier's Gangrene

Early identification and intervention of Fournier's gangrene in the Emergency Department (ED) requires a high index of suspicion and is critical in improved patient outcomes. We present a case of a 64-year-old male with two months of progressively worsening buttock and rectal pain found to have extensive black eschar and ecchymosis on exam. In addition, this patient displayed marked leukocytosis, lactic acidosis, and elevated inflammatory markers. A preoperative computed tomography (CT) scan of the abdomen and pelvis revealed multiple perirectal abscesses and subcutaneous fluid and gas in the perineum and scrotum concerning for Fournier's Gangrene. He was started on broad spectrum antibiotics while in the ED and taken to the operating room for urgent surgical debridement with clinical improvement and was discharged home on day nine. This case report reviews the clinical presentation and interventional modalities, and aims to provide new images to better help visualize a diagnosis of Fournier's Gangrene.

Topics

Fournier's gangrene, necrotizing soft tissue infection, necrotizing fasciitis.

An Anomalous Cause of Deep Venous Thrombosis: A Case Report

Introduction

Lower extremity deep venous thrombosis (DVT) is a common diagnosis in the emergency department (ED). Deep venous thromboses can be the result of anatomical variation in the vasculature that predisposes the patient to thrombosis. May-Thurner syndrome (MTS) is one such anatomic variant defined by extrinsic compression of the left common iliac vein between the right common iliac artery and lumbar vertebrae.

Case Report

We report such a case of a 39-year-old woman with no risk factors for thromboembolic disease who presented to the ED with extensive unilateral leg swelling and was ultimately diagnosed with MTS.

Conclusion

This diagnosis is an important consideration particularly in patients who are young, female, have scoliosis or spinal abnormalities, or are at low risk for DVT yet who present with extensive lower extremity swelling and are found to have proximal thrombus burden. Often further imaging, anticoagulation, angioplasty, or thrombectomy are indicated to prevent morbidity and post-thrombotic syndrome in these patients.

Benchmark Performance of Emergency Medicine Residents in Pediatric Resuscitation: Are We Optimizing Pediatric Education for Emergency Medicine Trainees?

BACKGROUND

The majority of children in the United States seek emergency care at community-based general emergency departments (GEDs); however, the quality of GED pediatric emergency care varies widely. This may be explained by a number of factors, including residency training environments and postgraduate knowledge decay. Emergency medicine (EM) residents train in academic pediatric EDs, but didactic and clinical experience vary widely between programs, and little is known about the pediatric skills of these EM residents. This study aimed to assess the performance of senior EM residents in treating simulated pediatric patients at the end of their training.

METHODS

This was a prospective, cross-sectional, simulation-based cohort study assessing the simulated performance of senior EM resident physicians from two Massachusetts programs leading medical teams caring for three critically ill patients. Sessions were video recorded and scored separately by three reviewers using a previously published simulation assessment tool. Self-efficacy surveys were completed prior to each session. The primary outcome was a median total performance score (TPS), calculated by the mean of individualized domain scores (IDS) for each case. Each IDS was calculated as a percentage of items performed on a checklist-based instrument.

RESULTS

A total of 18 EM resident physicians participated (PGY-3 = 8, PGY-4 = 10). Median TPS for the cohort was 61% (IQR = 56%-70%). Median IDSs by case were as follows: sepsis 67% (IQR = 50%-67%), seizure 67% (IQR = 50%-83%), and cardiac arrest 67% (IQR = 43%-70%). The overall cohort self-efficacy for pediatric EM (PEM) was 64% (IQR = 60%-70%).

CONCLUSIONS

This study has begun the process of benchmarking clinical performance of graduating EM resident physicians. Overall, the EM resident cohort in this study performed similar to prior GED teams. Self-efficacy related to PEM correlated well with performance, with the exception of knowledge relative to intravenous fluid and vasopressor administration in pediatric septic shock. A significant area of discrepancy and missed checklist items were those related to cardiopulmonary resuscitation and basic life support maneuvers.

Phase II Trial of Oral Tegafur and Folinic Acid with Mitoxantrone as First-Line Regimen in Patients with Metastatic Breast Cancer

Background

Tegafur acts as a deport form of 5-fluorouracil when administered orally for longs periods of time, since it is an active drug in metastatic breast cancer, with response rates of 29-44%. Biochemical modulation with folinic acid and the addition of mitoxantrone could increase the efficacy of tegafur in patients with metastatic breast cancer.

Methods

A prospective phase II trial in patients with previously untreated metastatic breast cancer was carried out. The scheme consisted of mitoxantrone, 12 mg/m2 intravenous day 1, oral tegafur, 750 mg/m2/day divided in three equal doses, and leucovorin 15 mg/8 h orally for days 1-21, given in a 4-week schedule. None patient had received chemotherapy for metastatic breast cancer, although 16 patients had received previous adjuvant chemotherapy.

Results

Thirty-four patients were included. Objective responses were achieved in 20 of 32 patients assessable for response, with 1 complete response and 19 partial responses. The objective response rate was 62.5% (95% confidence intervals, 48-76%). The median duration of response was 10 months. Grade III-IV toxicity according to WHO criteria was digestive (nausea/vomiting) in 12.5%, diarrhea in 25% and stomatitis in 25% of patients. Other toxicities were low. Eight patients required dose-reduction.

Conclusions

We achieved a significant response rate with the scheme, which was administered on an outpatient basis. It seems to be safe and effective as first-line treatment in metastatic breast cancer, with a short median response duration. The size of the trial does not permit definitive conclusions, and the role of biochemical modulation of tegafur in combination with mitoxantrone remains to be defined.

Using Photovoice and Asset Mapping to Inform a Community-Based Diabetes Intervention, Boston, Massachusetts, 2015

Introduction

Diabetes self-management takes place within a complex social and environmental context.  This study’s objective was to examine the perceived and actual presence of community assets that may aid in diabetes control.

Methods

We conducted one 6-hour photovoice session with 11 adults with poorly controlled diabetes in Boston, Massachusetts.  Participants were recruited from census tracts with high numbers of people with poorly controlled diabetes (diabetes “hot spots”).  We coded the discussions and identified relevant themes.  We further explored themes related to the built environment through community asset mapping.  Through walking surveys, we evaluated 5 diabetes hot spots related to physical activity resources, walking environment, and availability of food choices in restaurants and food stores.

Results

Community themes from the photovoice session were access to healthy food, restaurants, and prepared foods; food assistance programs; exercise facilities; and church.  Asset mapping identified 114 community assets including 22 food stores, 22 restaurants, and 5 exercise facilities.  Each diabetes hot spot contained at least 1 food store with 5 to 9 varieties of fruits and vegetables.  Only 1 of the exercise facilities had signage regarding hours or services.  Memberships ranged from free to $9.95 per month.  Overall, these findings were inconsistent with participants’ reports in the photovoice group.

Conclusion

We identified a mismatch between perceptions of community assets and built environment and the objective reality of that environment. Incorporating photovoice and community asset mapping into a community-based diabetes intervention may bring awareness to underused neighborhood resources that can help people control their diabetes.

Abstract P3-07-39: CASCADE study: Treatment and clinical outcomes of metastatic breast cancer by tumor immunophenotypes

BACKGROUND: Currently available therapeutic armamentarium for locally advanced and/or metastatic breast cancer (LA/MBC) allows an increasing tailored approach for each of the major tumor immunophenotypes. Nevertheless, there is scarce information about how these subgroups fare and how the alternative therapeutic approaches are actually being used during the disease course. CASCADE is an epidemiological, retrospective, and multicenter study aimed to retrieve demographic and clinical information from a representative cohort of LA/MBC patients treated within the Spanish National Healthcare System.

MATERIALS AND METHODS: Several strategies were used to identify patients diagnosed with LA/MBC for the first time between 01/2007 and 12/2008 in 13 Spanish public hospitals covering nearly 5'000'000 inhabitants (>10% of the national population) and followed throughout their metastatic lifetime until death, lost to follow-up, or until December 2013. Data collected included demographical and clinical information for each line of treatment. Descriptive statistics were applied to analyze the information.

RESULTS: We identified 443 LA/MBC patients. Median age at diagnosis was 59 years (CI95%: 49.5 - 71.6). Significant differences in dropout rates per line of treatment were found according to the tumor intrinsic immunophenotype. Patients reaching a 4th line were: whole study population 38.4%, HER2-/HR+ 42.8%, HER2+/HR- 41.5%, HER2+/HR+ 39.5%, and Triple-negative 31.9%. Median Overall survival (OS) and per line Progression Free Survival (PFS) for each line of treatment by tumor subtype were:

Median OS and per line PFS by tumor subtype Subtype (%)OS (months)PFS (months)PFS (months)PFS (months)PFS (months)PFS (months)Treatment line--1L2L3L4L5LWhole PopulationAll33.57.25.94.33.73.0HER2-/HR+43.838.68.85.84.43.33.0HER2+/HR-12.036.37.46.74.34.03.0HER2+/HR+17.234.411.27.94.95.83.5Triple-negative16.319.04.03.52.43.32.9

Percent use of the four major pharmacological families per line of LA/MBC treatment was:

Pharmacological families used per line of LA/MBC treatmentTreatment line1L2L3L4L5L6L7LChemotherapy75.463.075.979.487.976.178.6Anti-HER219.721.919.420.618.720.921.4Hormone therapy37.939.225.318.811.217.916.7Other targeted therapy13.09.612.212.47.511.914.3

CONCLUSION: Our study identifies differences in OS and PFS among BC immunophenotypes, with Triple-negatives faring the poorest. Among therapeutic families, chemotherapy clearly prevails along the disease lifetime, with hormone therapy being primarily used during the initial lines of treatment.

Citation Format: Zamora P, Servitja S, Santaballa A, García J, de Paz L, Plata Y, Garau I, Florian J, Chacón I, de la Haba J, García P, Artime E, Rodríguez-Villanueva J, Velasco A, Martínez E, Segui MA. CASCADE study: Treatment and clinical outcomes of metastatic breast cancer by tumor immunophenotypes. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-39.

Abstract P5-08-43: CASCADE study: Longer overall survival in the novo versus recidivant patients with locally advanced/metastatic breast cancer

BACKGROUND: Current treatment strategies for locally advanced and/or metastatic breast cancer (LA/MBC) are meant to prolong survival while maintaining or improving the quality of life. Nevertheless, there is a lack of recent data regarding the actual clinical management and its impact on the prognosis of these patients. It is unknown whether prior diagnosis and treatment of early breast cancer (EBC) make any difference in the outcome of the advanced disease. CASCADE is an epidemiological, retrospective, and multicenter study aimed at retrieving this information from a representative cohort of LA/MBC patients treated within the Spanish National Healthcare System.

MATERIALS AND METHODS: Thirteen Spanish public hospitals covering nearly 5'000'000 inhabitants (>10% of the national population) applied several combined systematic strategies to identify patients firstly diagnosed with LA/MBC between 01/2007 and 12/2008. Once identified, patients were followed throughout their metastatic lifetime until death, lost to follow-up, or until December 2013, whichever occurs first. Data collected included demographical, pathological, diagnostic, and therapeutic information for each line of treatment. Descriptive statistics were applied.

RESULTS: We identified 443 LA/MBC patients; median age at diagnosis was 59 years (CI95%: 49.5 - 71.6). Previous history of early BC was reported in 69.3% of them with a median disease-free interval of 38 months. Median Overall Survival (OS) for the whole study population was 33.5 months, while numbers for advanced cases originally diagnosed as EBC or the novo LA/MBC were 31.7 (CI95%: 26.8 - 36.0) and 38.8 months (CI95% 32.8 - 45.3; p = 0.0138) respectively. Main tumor immunohistochemical subtypes for EBC and the novo LA/MBC were: HER2+/HR- 11.3% and 15.3%, HER2+/HR+ 16.2% and 19.1%, HER2-/HR+ 41.2% and 51.1%, and Triple-negative 17.9% and 11.5%, respectively.

At the end of the study follow-up (Dec 2013) 78.2% of the patients had died. Breakdown of the decaying percentage and OS for the entire study population, early-, and the novo diagnosed LA/MBC from the beginning of each line of treatment was:

OS according to the type of diagnosisTreatment line1L2L3L4L5L6L7LWhole pulation Patients (%)95.370.253.538.424.215.19.5Whole pulation OS (months)32.622.616.613.513.312.48.5Early diag. LA/MBC OS (months))30.921.015.612.912.49.17.5The novo diag. LA/MBC OS (months)37.625.921.618.714.016.913.8

CONCLUSION: Our study's OS data supports the hypothesis that highly effective current neo/adjuvant treatment may cure most treatment-sensitive early tumors, allowing only those more aggressive to develop to LA/MBC, which then will fare worse than those of the novo metastatic diagnosis.

Citation Format: Servitja S, Zamora P, Santaballa A, García J, de Paz L, Plata Y, Garau I, Florian J, Chacón I, de la Haba J, García P, San José B, Rodríguez-Villanueva J, Orcajo L, Martínez E, Segui MA. CASCADE study: Longer overall survival in the novo versus recidivant patients with locally advanced/metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-43.

Late sodium current block for drug-induced long QT syndrome: Results from a prospective clinical trial

Drug-induced long QT syndrome has resulted in many drugs being withdrawn from the market. At the same time, the current regulatory paradigm for screening new drugs causing long QT syndrome is preventing drugs from reaching the market, sometimes inappropriately. In this study, we report the results of a first-of-a-kind clinical trial studying late sodium (mexiletine and lidocaine) and calcium (diltiazem) current blocking drugs to counteract the effects of hERG potassium channel blocking drugs (dofetilide and moxifloxacin). We demonstrate that both mexiletine and lidocaine substantially reduce heart-rate corrected QT (QTc) prolongation from dofetilide by 20 ms. Furthermore, all QTc shortening occurs in the heart-rate corrected J-Tpeak (J-Tpeak c) interval, the biomarker we identified as a sign of late sodium current block. This clinical trial demonstrates that late sodium blocking drugs can substantially reduce QTc prolongation from hERG potassium channel block and assessment of J-Tpeak c may add value beyond only assessing QTc.

Trial geography, pharmacogenetics, and global drug development

Drug development is increasingly global. The benefits of multiregional trials include worldwide evaluation of safety and efficacy. However, clinical practice, environmental, and genetic factors can vary across geographic regions, significantly influencing trial outcomes within a specific geographic region or the global population relative to the United States (US). Genomic technologies and research discoveries continue to advance at a remarkable pace, offering opportunities to explore intrinsic factors that could account for regional variability in drug pharmacokinetics or response.

Inhibitory circuits and the nature of their interactions in the human motor cortex a pharmacological TMS study

Inhibitory circuits are crucial in modulating corticospinal output in the primary motor cortex (M1). Relatively little is known about how these inhibitory circuits interact. Here we measured three forms of inhibition in M1 by paired-pulse transcranial magnetic stimulation: short-interval intracortical inhibition (SICI), long-interval intracortical inhibition (LICI) and short-interval interhemispheric inhibition (SIHI). We specifically tested their interactions under pharmacological challenge with a single oral dose of diazepam, a positive allosteric modulator of the gamma-aminobutyric acid type A receptor (GABA A R), or baclofen, a specific agonist at the GABA type B receptor (GABA B R). Motor evoked potentials were recorded bilaterally from the first dorsal interosseous muscle in eight right-handed healthy volunteers. Diazepam enhanced SICI, and baclofen produced a trend towards enhanced LICI, corroborating the view that SICI reflects inhibition mediated by the GABA A R, and LICI very likely reflects inhibition mediated by the GABA B R. The pharmacology of SIHI was inconclusive and warrants further investigation. Findings strongly suggest that SICI, LICI and SIHI recruit three distinct inhibitory circuits in the human M1. The interactions between SIHI and SICI, LICI and SIHI, and LICI and SICI were all negative, that is SIHI suppressed SICI, and LICI suppressed both SIHI and SICI. Diazepam partially restored SICI in the presence of LICI, while all other interactions remained unaffected by diazepam or baclofen. It will be argued that the negative interactions between SIHI and SICI, LICI and SIHI, and LICI and SICI are most likely due to presynaptic GABA B R-mediated autoinhibition.

Insulin-like growth factor inhibits vascular contraction to 5-hydroxytryptamine: involvement of tyrosine phosphatase

This study tests the hypothesis that insulin-like growth factor 1 (IGF-1)-induced vasodilation is due to the stimulation of tyrosine phosphatase. Rat aortic segments (endothelium intact) were placed in muscle baths for force measurement. Segments were contracted to serotonin [5-hydroxytyptamine (5-HT), 10(-7)-10(-5) M] before and after incubation with IGF-1 (10-100 nM; 90 min). IGF-1 caused a 20% inhibition of 5-HT-induced contractions. This inhibition was reversed by the tyrosine phosphatase inhibitors sodium orthovanadate and molybdate. Orthovanadate did not alter inhibitory properties of the calcium channel antagonist verapamil, suggesting that the phosphatase inhibitors were relatively specific. IGF-1-induced inhibition was not altered by blockade of nitric oxide synthase. Western blot analysis confirmed that the 5-HT-induced stimulation of tyrosine phosphorylation of the 42-kDa extracellular signal-regulated mitogen-activated protein kinase protein was reduced by IGF-1 (52% inhibition), an inhibition that was attenuated by orthovanadate. These data are consistent with the hypothesis that the vasodilator activity of IGF-1 is mediated by the activation of a tyrosine phosphatase.

Mechanistic alternatives in phosphate monoester hydrolysis: what conclusions can be drawn from available experimental data?

Phosphate monoester hydrolysis reactions in enzymes and solution are often discussed in terms of whether the reaction pathway is associative or dissociative. Although experimental results for solution reactions have usually been considered as evidence for the second alternative, a closer thermodynamic analysis of observed linear free energy relationships shows that experimental information is consistent with the associative, concerted and dissociative alternatives.

[Attention deficit in hyperactive children]

The most typical features of hyperactivity in children (ADHD) are deficient attention, impulsiveness and hyperactivity on which the present paper is focused. With this problem symptoms are associated such as sensomotor problems, intellectual questions, impaired sleep, emotional disorders and behavioural disorders. The part devoted to etiology analyzes the impact of the environment and of genetic factors on ADHD whereby the latter factor is dominant. As regards treatment, the authors discuss not only pharmacological treatment, but also counselling for parents and teachers of thus affected children.

[Effect of Aponeuron in the treatment of children with hyperkinetic syndrome]

The submitted original paper deals with hyperactivity of children (ADHD) and their treatment by means of the stimulant Aponeuron. The authors made a long-term, double blind, placebo controlled trial which comprised more than 20 hyperactive children. The applied methods are described in detail and the results of individual investigations are summarized. Moreover it is a subject to which in the local professional literature, contrary to that in other countries, little attention was paid, although it is a frequent disorder. Administration of Aponeuron (and stimulations in general) proved useful in the treatment of this disorder. The subtle and crude motorics improved, symptoms of hyperactivity disappeared and the general school performance of the child improved.

[Stimulants]

The authors present a comprehensive account of stimulants from chemical structure to clinical use. They analyze in detail the function and pharmacokinetic properties of stimulants but also their clinical and undesirable side-effects. The section on the interaction of stimulants and other drugs and other types of treatment is very important. The second part of the paper deals with indications and contraindications of stimulants, incl. the possible risk of the development of dependence. There are many indications for stimulants in clinical (in particular paedopsychiatric) practice.

Ab initio investigation of the molecular structure of methyl methoxymethyl phosphonate, a promising nuclease-resistant alternative of the phosphodiester linkage

Conformational flexibility of the methyl methoxymethyl phosphonate anion (CH3-O-PO2-CH2-O-CH3)-, a nuclease resistant alternative to the phosphodiester linkage in DNA, have been investigated by ab initio quantum mechanical calculations. The potential of backbone torsional degrees of freedom of methyl methoxymethyl phosphonate anion (MMP) was determined at the Hartree-Fock (HF) 3-21G* level using the adiabatic mapping technique. Energies, geometries, and effective atomic charges of different conformers were calculated at HF/6-31G* and MP2/6-31G* levels of theory. These were compared to the results obtained for dimethyl phosphate calculated at the same level. The impact on DNA structure from inserting a methylene group between phosphorus and oxygen of the nucleoside sugar moiety was examined via distance and angle-constrained geometry optimizations. Due to its high flexibility, MMP has been shown to be compatible with both A and B forms of DNA.

The isolated perfused kidney of the pig: new model to evaluate shock wave-induced lesions

Little is known about the mechanisms and determining factors of shock wave-induced kidney trauma. After classification of the renal lesion in a canine model, we attempted to establish an ex vivo model using the isolated kidney of the pig perfused by Tyrode's solution under physiologic conditions. After shock wave application on the Modulith SL 20, vessel lesions were evaluated by microangiography to determine the size and frequency of dye extravasation in the different areas of the organ. Variation of the focus localization caused different patterns of lesions that characterized the pathway of the shock wave. In particular, constant petechial extravasation in the cortex was observed. The generator voltage correlated with the diameter and the frequency of the lesion area. The number of shock waves primarily affected the incidence of vessel rupture in the regions adjacent to the focal zone. Light microscopy revealed dose-dependent necrosis of tubular cells up to gap-like parenchymal defects. Even after application of the minimal shock wave doses, electron microscopy demonstrated vacuolization of tubular cells in the shock wave focus. Traumatic junctions between capillaries and the tubulur system can explain clinically observed macrohematuria without renal hematomas. With this model, it was possible to evaluate localization and dose dependence of shock wave-induced kidney trauma with high sensitivity and reproducibility. Further advantages of the model were easy availability and the fact that studies on living animals were not necessary. Therefore, standardization and comparison of different lithotripters becomes possible.

An Early Human Embryo (No. 1285, Manchester Collection), with Capsular Attachment of the Connecting Stalk

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The Formation of the Connecting Stalk and the Extension of the Amniotic Cavity towards the Tissue of the Connecting Stalk in Young Human Embryos

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