Uroplakin IIIb, a urothelial differentiation marker, dimerizes with uroplakin Ib as an early step of urothelial plaque assembly

Urothelial plaques consist of four major uroplakins (Ia, Ib, II, and III) that form two-dimensional crystals covering the apical surface of urothelium, and provide unique opportunities for studying membrane protein assembly. Here, we describe a novel 35-kD urothelial plaque-associated glycoprotein that is closely related to uroplakin III: they have a similar overall type 1 transmembrane topology; their amino acid sequences are 34% identical; they share an extracellular juxtamembrane stretch of 19 amino acids; their exit from the ER requires their forming a heterodimer with uroplakin Ib, but not with any other uroplakins; and UPIII-knockout leads to p35 up-regulation, possibly as a compensatory mechanism. Interestingly, p35 contains a stretch of 80 amino acid residues homologous to a hypothetical human DNA mismatch repair enzyme-related protein. Human p35 gene is mapped to chromosome 7q11.23 near the telomeric duplicated region of Williams-Beuren syndrome, a developmental disorder affecting multiple organs including the urinary tract. These results indicate that p35 (uroplakin IIIb) is a urothelial differentiation product structurally and functionally related to uroplakin III, and that p35–UPIb interaction in the ER is an important early step in urothelial plaque assembly

An Unusual Case of Right Lower Quadrant Pain: A Case Report

Introduction: The perforation of a cecal diverticulum is a rare and challenging condition for the emergency physician.Case Report: A 47-year-old man with a past surgical history of bilateral inguinal hernia repair presented to the emergency department (ED) with acute abdominal pain of three days’ duration. Pain was localized to the right lower quadrant (RLQ), with anorexia as the only associated symptom. Upon arrival to the ED, his exam demonstrated focal RLQ tenderness to palpation, rebound tenderness, and guarding. Labs did not show any elevation in inflammatory markers, liver enzymes, or lipase. Computed tomography showed no evidence of acute appendicitis, colitis, or hernia recurrence. After morphine and reassessment, the patient still had a focal peritoneal exam in the RLQ. Surgical consultation was obtained and recommended additional non-opioid analgesia as well as serial abdominal exams. After several repeat abdominal exams, there was no change in the focality of the patient’s pain. Surgery was reconsulted and opted to take the patient to the operating room for exploratory laparoscopy with “appendicitis” as the presumptive diagnosis. Pathology report revealed a perforated cecal diverticulum that was adherent to the abdominal wall. The patient did well and was discharged on his third postoperative day.Conclusion: This case further underlines that even in the era of sensitive imaging tools, the diagnostic value of a targeted physical exam with clinical re-evaluation can never be overestimated

Elusive cardiac dysrhythmia in high-risk syncope

Emergency department presentations of syncope can vary from benign to life-threatening etiologies. Older patients are at increased risk of cardiac causes of syncope. Ventricular standstill is a rare phenomenon that can manifest as syncope and must be correctly identified and promptly treated to prevent sudden cardiac arrest. We report the case of a 70-year old man with dizziness and convulsive syncope whose initial ECG showed a right bundle branch block, but then developed ventricular standstill and intermittent high-grade AV block while still in the ED. He was transferred to the ICU and underwent pacemaker implantation. A high index of suspicion for dysrhythmias should be maintained for any patient presenting to the ED with high-risk syncope

An Unusual Case of Right Lower Quadrant Pain: A Case Report

Introduction: The perforation of a cecal diverticulum is a rare and challenging condition for the emergency physician. Case Report: A 47-year-old man with a past surgical history of bilateral inguinal hernia repair presented to the emergency department (ED) with acute abdominal pain of three days’ duration. Pain was localized to the right lower quadrant (RLQ), with anorexia as the only associated symptom. Upon arrival to the ED, his exam demonstrated focal RLQ tenderness to palpation, rebound tenderness, and guarding. Labs did not show any elevation in inflammatory markers, liver enzymes, or lipase. Computed tomography showed no evidence of acute appendicitis, colitis, or hernia recurrence. After morphine and reassessment, the patient still had a focal peritoneal exam in the RLQ. Surgical consultation was obtained and recommended additional non-opioid analgesia as well as serial abdominal exams. After several repeat abdominal exams, there was no change in the focality of the patient’s pain. Surgery was reconsulted and opted to take the patient to the operating room for exploratory laparoscopy with “appendicitis” as the presumptive diagnosis. Pathology report revealed a perforated cecal diverticulum that was adherent to the abdominal wall. The patient did well and was discharged on his third postoperative day. Conclusion: This case further underlines that even in the era of sensitive imaging tools, the diagnostic value of a targeted physical exam with clinical re-evaluation can never be overestimated

Reversal of Dabigatran with Idarucizumab in Acute Subarachnoid Hemorrhage

Dabigatran etexilate mesylate is a direct thrombin inhibitor used for reducing the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation. Dabigatran belongs to a new generation of oral agents for anticoagulation – the direct oral anticoagulants (DOACs). The DOACs also include the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban. In the case of major or life-threatening bleeding and/or the need for emergent invasive procedures, a reversal agent is needed if a patient is taking one of these medications. Research has shown the efficacy of idarucizumab as an antidote in healthy volunteers, but data in the case of life-threatening bleeds remains limited. We report a case of a patient who suffered a traumatic subarachnoid hemorrhage and received effective treatment with idarucizumab. Along with other reports, our case demonstrates that dabigatran-related major and/or life-threatening bleeds may be effectively counteracted by idarucizumab. This provides an option to emergency department providers in managing clinically significant bleeds in patients taking dabigatran

Reversal of Dabigatran with Idarucizumab in Acute Subarachnoid Hemorrhage

Dabigatran etexilate mesylate is a direct thrombin inhibitor used for reducing the risk of stroke andsystemic embolism in patients with non-valvular atrial fibrillation. Dabigatran belongs to a new generationof oral agents for anticoagulation – the direct oral anticoagulants (DOACs). The DOACs also includethe factor Xa inhibitors rivaroxaban, apixaban, and edoxaban. In the case of major or life-threateningbleeding and/or the need for emergent invasive procedures, a reversal agent is needed if a patient istaking one of these medications. Research has shown the efficacy of idarucizumab as an antidote inhealthy volunteers, but data in the case of life-threatening bleeds remains limited. We report a caseof a patient who suffered a traumatic subarachnoid hemorrhage and received effective treatment withidarucizumab. Along with other reports, our case demonstrates that dabigatran-related major and/orlife-threatening bleeds may be effectively counteracted by idarucizumab. This provides an option toemergency department providers in managing clinically significant bleeds in patients taking dabigatran