Accidental Botulism Poisoning: A Case of Pickled Herring

INTRODUCTION: Botulism is a rare cause of neuromuscular weakness that presents a diagnostic challenge in the face of respiratory collapse. Pupil and bulbar paralysis aid prompt recognition and treatment, as clinical confirmation can be time intensive and limited by sample integrity. Early treatment can halt paralysis and prevent ICU and ventilator days. CASE DESCRIPTION: A 74-year-old male with hypertension and DVT presented with acute weakness and respiratory failure after three days of cough and diarrhea. Upon ICU admission for mechanical ventilation, we discovered sluggish pupils, mild ptosis, and proximal muscle weakness. Symptoms then progressed to unresponsive pupils, complete ptosis, and complete paralysis. While we suspected a neuromuscular cause, no single cause was identified despite extensive workup and neurology consultation. Our differential was narrowed after electromyogram (EMG) demonstrated a pre-synaptic defect, indicating either Lambert Eaton or Botulism as culprits. Empiric treatment with botulism anti-toxin resulted in clinical improvement of ptosis and proximal weakness. While ventilated, he wrote of recent pickeled herring ingestion, possibly left unrefrigerated for a week. He ultimately received tracheostomy and transfer to long-term assisted care, and at discharge stool and serum testing for botulism toxin was still pending. While state-run testing finally returned negative, his illness was ultimately attributed to accidental botulism poisoning. DATA: Differential and WorkupMyasthenia Gravis • CT Chest: no mediastinal/thymic mass (thymoma) • Acetylcholine Receptor Ab: negative • Striated Muscle and Titin Ab: negative Lambert Eaton • Pre-synaptic defect on EMG: low motor amplitudes that increased with sustained exercise • Voltage Gated Calcium Chanel Ab: negative • CT Chest: no nodules or masses (paraneoplastic SCLC in 50%) Demyelinating Polyneuropathy • LP: Glucose 76, protein 53, WBC 0, RBC 0, lymphocytes 67% • CSF: Ganglioside GM1 Ab negative Botulism • Stool: rejected, poor specimen quality • Serum: small sample size, Endopep-MS assay negative Central and Infectious • MRI brain and C-spine normal Infectious • Treponemal Ab negative • Lyme Ab negative Botulism Key Features Exam • Respiratory collapse • Proximal then distal paralysis, rapid progression • Preserved sensation, reflexes • Bulbar Paralysis with pupil involvement, nystagmus Workup • Botulism Neurotoxin (BoNT) of fluid, serum samples • Mouse Bioassay Treatment • Botulism equine anti-toxin, early administration can reduce ventilator and ICU days RESULTS / DISCUSSION: Yearly US incidence of botulism is 100 cases, and early treatment with equine anti-toxin reduces mortality and ventilation time1. Timely diagnosis is challenging as respiratory collapse overshadows subtle pupil and bulbar paralysis unique to botulism2. Lab diagnosis with Endopep-MS assay is not FDA approved and can be falsely negative with small samples3 while verified sacrificial mouse bioassays are rarely used2. Early suspicion should prompt anti-toxin treatment and discussion with the CDC’s botulism consultation service, who will supply anti-toxin and provide assistance with workup in conjunction with state health laboratories.https://digitalcommons.psjhealth.org/psv_internal/1012/thumbnail.jp

Battling the Stigma: HIV Screening in Resident Primary Care Clinic

INTRODUCTION: HIV affects ~1.2 million in the US, with 25% unaware of their statusand annual incidence of 50,000. Early detection and treatment reduces risk of AIDS-related deaths and transmission. Both the CDC and the US Preventative Service Task Force recommend routine HIV screening. The Providence Medical Group at St Vincent (PMG-STV) resident clinic has no routine screening protocol. • 24% (757/3139) of all clinic patients have ever been screened. • Of active clinic patients seen quarterly, 5% are offered screening with only 3% completing screening. We implemented and measured a clinic-wide HIV screening protocol leveraging existing clinic workflows. We aimed to increase screening of active clinic patients from 3% to 25% at one year. METHODS: Using a time-series design we measured quarterly rates of HIV screening tests ordered and resulted in active clinic patients, ages 18-65 and seen in office, during the study period. We utilized a pre-existing preventative healthcare workflow for routine cancer screening, influenza vaccines, etc. We introduced this workflow to residents and staff prior to our go-live date. RESULTS / DISCUSSION: Our primary outcome was to increase quarterly HIV screening rate of active patients, with a secondary outcome to increase overall clinic HIV screening rate. We increased the quarterly screening rate of active patients from 3.34% to 9.19% (Phttps://digitalcommons.psjhealth.org/psv_internal/1011/thumbnail.jp

e-EVN radio detection of Aql X-1 in outburst

The neutron star X-ray binary Aql X-1 is currently in outburst. Using the European VLBI Network (e-EVN) we observed Aql X-1 at 5 GHz in two time-slots: 2013 June 18 between 19:48 - 20:36 UT (MJD 56461.825 - 56461.858), and 2013 June 19 between 02:53 - 05:54 UT (MJD 56462.120 - 56462.246). The two datasets were combined together and then calibrated

Major and minor flares on Cygnus X-3 revisited

Intense flares at cm-wavelengths reaching levels of tens of Jy have been observed from Cygnus X-3 for many years. This active high mass X-ray binary also has periods of quenching before major outbursts, and has minor flares at levels of a few hundred mJy. In this paper we show that the minor flares have much shorter rise times and durations suggesting more rapid expansion of the synchrotron radiation emitting material than in the strong flares. They also appear closer to the binary, whereas the large flares form a more developed jet. Calculations of physical conditions show that the minor out-bursts have lower minimum power but have larger magnetic fields and energy densities than the major flares. Minor flares can occur while a major flare is in progress, suggesting an indirect coupling between them. The spectral evolution of the minor flares can be explained by either an expanding synchrotron source or a shock model. The possibility that there is a brightening zone as in SS433 is explored

Wine production in classical Asia Minor

Ankara : The Institute of Economics and Social Sciences of Bilkent Univ., 2001.Thesis (Master's) -- Bilkent University, 2001.Includes bibliographical references.Garrett, Spencer HoytM.S

An outburst of SS 433 observed on milliarcsecond scale

SS 433 is a high-mass X-ray binary system (XRB) and one of the most persistent sources of relativistic jets in the Milky Way. The object has been intensively studied in radio at arcsecond scales, however the high-resolution observations (i.e. VLBI) are relatively scarce. In 2008 November the system was in outburst. Using the e-VLBI capabilities of the European VLBI Network (EVN) we observed SS 433 for three epochs during the active phase. The data offered a detailed view of the system’s behaviour in outburst at milliarcsecond scales. We used the “kinematic model" (which predicts the position along the jet of any knot ejected at some particular time in the past) to investigate the dynamic parameters of SS 433 and we examined the polarization properties of the ejected material. We report here the preliminary results

First e-VLBI observations of GRS 1915+105

We present results from the first successful open call e-VLBI science run, observing the X-ray binary GRS 1915+105. e-VLBI science allows the rapid production of VLBI radio maps, within hours of an observation rather than weeks, facilitating a decision for follow-up observations. A total of 6 telescopes observing at 5 GHz across the European VLBI Network (EVN) were correlated in real time at the Joint Institute for VLBI in Europe (JIVE). Constant data rates of 128 Mbps were transferred from each telescope, giving 4 TB of raw sampled data over the 12 hours of the whole experiment. Throughout this, GRS 1915+105 was observed for a total of 5.5 hours, producing 2.8 GB of visibilities of correlated data. A weak flare occurred during our observations, and we detected a slightly resolved component of 2.7 x 1.2 milliarcsecond with a position angle of 140 (+/-2) degrees. The peak brightness was 10.2 mJy per beam, with a total integrated radio flux of 11.1 mJy.Comment: Accepted for publication in MNRAS 4 pages, 3 figure

Modulation of TRPV4 protects against degeneration induced by sustained loading and promotes matrix synthesis in the intervertebral disc

While it is well known that mechanical signals can either promote or disrupt intervertebral disc (IVD) homeostasis, the molecular mechanisms for transducing mechanical stimuli are not fully understood. The transient receptor potential vanilloid 4 (TRPV4) ion channel activated in isolated IVD cells initiates extracellular matrix (ECM) gene expression, while TRPV4 ablation reduces cytokine production in response to circumferential stretching. However, the role of TRPV4 on ECM maintenance during tissue-level mechanical loading remains unknown. Using an organ culture model, we modulated TRPV4 function over both short- (hours) and long-term (days) and evaluated the IVDs\u27 response. Activating TRPV4 with the agonist GSK101 resulted in a C