Subchorionic Hemorrhage Appearing as Twin Gestation on Endovaginal Ultrasound

This case study describes a pregnant patient with vaginal bleeding who had a bedside endovaginal ultrasound in the emergency department (ED). The emergency physician identified a live intra-uterine pregnancy (IUP) with another structure that appeared to be a second gestational sac. The patient subsequently had an endovaginal ultrasound in the radiology department 46 minutes later. The attending radiologist described one live IUP and a subchorionic hemorrhage. Comparison of the ED and radiology ultrasound showed that the second structure, identified as a subchorionic hemorrhage, had significantly decreased in size. Endovaginal ultrasound in the evaluation of possible ectopic pregnancy is a useful bedside tool in the ED. We discuss a pitfall that can occur with endocavitary ultrasound when a twin gestation is presumed

New Onset Thyrotoxicosis Presenting as Vomiting, Abdominal Pain and Transaminitis in the Emergency Department

This case report describes an unusual presentation of an emergency department (ED) patient with nausea, vomiting, and epigastric pain, who was initially suspected of having viral hepatitis. The patient returned to the ED seven days later with persistent tachycardia and was diagnosed with new onset thyrotoxicosis

Implications and Approach to Incidental Findings in Live Ultrasound Models

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Ileocecal Intussusception in the Adult Population: Case Series of Two Patients

Background: Intussusception is a condition found primarily in the pediatric population. In the adult population, however, intussusception is usually due to a pathological process, with a higher risk of bowel obstruction, vascular compromise, inflammatory changes, ischemia, and necrosis. Radiographic and sonographic evidence can aid in the diagnosis. Surgical intervention involving resection of affected bowel is the standard of care in adult cases of intussusception. Case Reports: We present the case of a 21-year-old female who presented to the Emergency Department with diffuse cramping abdominal pain and distention. Workup revealed ileocecal intussusception, with a prior appendectomy scar serving as the lead point discovered during exploratory laparotomy. We also present the case of a 66-year-old male, who presented with one week of intermittent lower abdominal pain associated with several episodes of nausea and vomiting. Workup revealed ileocolic intussusception secondary to adenocarcinoma of the right colon, confirmed upon exploratory laparotomy with subsequent right hemicolectomy. Conclusion: In the adult population, intussusception is usually caused by a lead point, with subsequent telescoping of one part of the bowel into an adjacent segment. While intussusception can occur in any part of the bowel, it usually occurs between a freely moving segment and eithe

NMR-based assignment of isoleucine vs allo-isoleucine stereochemistry

A simple 1H and 13C NMR spectrometric analysis is demonstrated that permits differentiation of isoleucine and allo-isoleucine residues by inspection of the chemical shift and coupling constants of the signals associated with the proton and carbon at the α-stereocentre. This is applied to the estimation of epimerisation during metal-free N-arylation and peptide coupling reactions

Comparison of Pressures Applied by Digital Tourniquets in the Emergency Department

Background: Digital tourniquets used in the emergency department have been scrutinized due to complications associated with their use, including neurovascular injury secondary to excessive tourniquet pressure and digital ischemia caused by a forgotten tourniquet. To minimize these risks, a conspicuous tourniquet that applies the least amount of pressure necessary to maintain hemostasis is recommended.Objective: To evaluate the commonly used tourniquet methods, the Penrose drain, rolled glove, the Tourni-cot and the T-Ring, to determine which applies the lowest pressure while consistently preventing digital perfusion.Methods: We measured the circumference of selected digits of 200 adult males and 200 adult females to determine the adult finger size range. We then measured the pressure applied to four representative finger sizes using a pressure monitor and assessed the ability of each method to prevent digital blood flow with a pulse oximeter.Results: We selected four representative finger sizes: 45mm, 65mm, 70mm, and 85mm to test the different tourniquet methods. All methods consistently prevented digital perfusion. The highest pressure recorded for the Penrose drain was 727 mmHg, the clamped rolled glove 439, the unclamped rolled glove 267, Tourni-cot 246, while the T-Ring had the lowest at 151 mmHg and least variable pressures of all methods.Conclusion: All tested methods provided adequate hemostasis. Only the Tourni-cot and T-Ring provided hemostasis at safe pressures across all digit sizes with the T-Ring having a lower overall average pressure. [West J Emerg Med. 2011;12(2):242-249.

Nuclear Glycolytic Enzyme Enolase of Toxoplasma Gondii Functions as a Transcriptional Regulator

Apicomplexan parasites including Toxoplasma gondii have complex life cycles within different hosts and their infectivity relies on their capacity to regulate gene expression. However, little is known about the nuclear factors that regulate gene expression in these pathogens. Here, we report that T. gondii enolase TgENO2 is targeted to the nucleus of actively replicating parasites, where it specifically binds to nuclear chromatin in vivo. Using a ChIP-Seq technique, we provide evidence for TgENO2 enrichment at the 5′ untranslated gene regions containing the putative promoters of 241 nuclear genes. Ectopic expression of HA-tagged TgENO1 or TgENO2 led to changes in transcript levels of numerous gene targets. Targeted disruption of TgENO1 gene results in a decrease in brain cyst burden of chronically infected mice and in changes in transcript levels of several nuclear genes. Complementation of this knockout mutant with ectopic TgENO1-HA fully restored normal transcript levels. Our findings reveal that enolase functions extend beyond glycolytic activity and include a direct role in coordinating gene regulation in T. gondii

A Gene Expression Fingerprint of C. Elegans Embryonic Motor Neurons

Differential gene expression specifies the highly diverse cell types that constitute the nervous system. With its sequenced genome and simple, well-defined neuroanatomy, the nematode C. elegans is a useful model system in which to correlate gene expression with neuron identity. The UNC-4 transcription factor is expressed in thirteen embryonic motor neurons where it specifies axonal morphology and synaptic function. These cells can be marked with an unc-4::GFP reporter transgene. Here we describe a powerful strategy, Micro-Array Profiling of C. elegans cells (MAPCeL), and confirm that this approach provides a comprehensive gene expression profile of unc-4::GFP motor neurons in vivo.

Effect of a Medical Student Emergency Ultrasound Clerkship on Number of Emergency Department Ultrasounds

Objective: To determine whether a medical student emergency ultrasound clerkship has an effect on the number of patients undergoing ultrasonography and the number of total scans in the emergency department.Methods: We conducted a prospective, single-blinded study of scanning by emergency medicine residents and attendings with and without medical students. Rotating ultrasound medical students were assigned to work equally on all days of the week. We collected the number of patients scanned and the number of scans, as well as participation of resident and faculty.Results: In seven months 2,186 scans were done on the 109 days with students and 707 scans on the 72 days without them. Data on 22 days was not recorded. A median of 13 patients per day were scanned with medical students (CI 12-15) versus seven (CI 6-9) when not. In addition, the median number of scans was 18 per day with medical students (CI 16-20) versus eight (CI 6-10) without them.Conclusion: There were significantly more patients scanned and scans done when ultrasound medical students were present. [West J Emerg Med. 2010; 11:31-34]