Approach to Treatment of Cervical Pregnancy: A Case Report

CASE: A 25yo G1 at 11wk4d dated by LMP and confirmed with a 10 week ultrasound presents with a possible cervical ectopic pregnancy. Past medical, surgical, and OBGYN histories are unremarkable. A cervical pregnancy was suspected on ultrasound due to low implantation of the gestational sac, and a significant posterior bulge with an hourglass shaped uterus. MRI suggested implantation of the placenta in the posterior uterine and cervical wall due to extreme thinning of these structures. Our institution had previously created a protocol for multidisciplinary management of cesarean scar and cervical pregnancies. She desires fertility preservation, and so consented to combined local and systemic treatment with Methotrexate (MTX). Preprocedural Beta-hCG was 81,514.8 mU/mL. Ultrasound-guided transvaginal intra-gestational sac injection of MTX was performed without complication, though cardiac activity was still present at the conclusion of the procedure. The patient also received an IM injection of MTX before discharge. Serial Beta-hCG are still being followed, and are trending towards zero. CONCLUSION: The optimal management for cervical pregnancies is not known, and decisions around type of management are informed by the patient’s desire for fertility preservation. In this case, a protocol created by a multidisciplinary team was used to guide treatment. This protocol using MTX successfully treated the cervical pregnancy at 11wk4d and avoided a surgery that could complicate future fertility. CLINICAL SIGNIFICANCE: Due to the rare occurrence of cervical pregnancy, there is not a universally accepted treatment protocol. This case shows that medical management can be successful for cervical pregnancies. Clear guidelines must be established for cervical pregnancies to optimize outcomes, and decrease maternal morbidity and mortality and to preserve future fertility

Adamantane-Resistant Influenza Infection During the 2004–05 Season

Adamantane-resistant influenza A is an emerging problem, but infections caused by resistant and susceptible viruses have not been compared. We identified adamantane resistance in 47% of 152 influenza A virus (H3N2) isolates collected during 2005. Resistant and susceptible viruses caused similar symptoms and illness duration. The prevalence of resistance was highest in children

Presentations of patients of poisoning and predictors of poisoning-related fatality: Findings from a hospital-based prospective study

<p>Abstract</p> <p>Background</p> <p>Poisoning is a significant public health problem worldwide and is one of the most common reasons for visiting emergency departments (EDs), but factors that help to predict overall poisoning-related fatality have rarely been elucidated. Using 1512 subjects from a hospital-based study, we sought to describe the demographic and clinical characteristics of poisoning patients and to identify predictors for poisoning-related fatality.</p> <p>Methods</p> <p>Between January 2001 and December 2002 we prospectively recruited poisoning patients through the EDs of two medical centers in southwest Taiwan. Interviews were conducted with patients within 24 hours after admission to collect relevant information. We made comparisons between survival and fatality cases, and used logistic regressions to identify predictors of fatality.</p> <p>Results</p> <p>A total of 1512 poisoning cases were recorded at the EDs during the study period, corresponding to an average of 4.2 poisonings per 1000 ED visits. These cases involved 828 women and 684 men with a mean age of 38.8 years, although most patients were between 19 and 50 years old (66.8%), and 29.4% were 19 to 30 years. Drugs were the dominant poisoning agents involved (49.9%), followed by pesticides (14.5%). Of the 1512 patients, 63 fatalities (4.2%) occurred. Paraquat exposure was associated with an extremely high fatality rate (72.1%). The significant predictors for fatality included age over 61 years, insufficient respiration, shock status, abnormal heart rate, abnormal body temperature, suicidal intent and paraquat exposure.</p> <p>Conclusion</p> <p>In addition to well-recognized risk factors for fatality in clinical settings, such as old age and abnormal vital signs, we found that suicidal intent and ingestion of paraquat were significant predictors of poisoning-related fatality. Identification of these predictors may help risk stratification and the development of preventive interventions.</p

Phytoplankton dynamics in an urbanizing south Texas estuary, Corpus Christi Bay, Texas

Low inflow estuaries are thought to be susceptible to cultural eutrophication due to lack of flushing and increased residence times, allowing for accumulation of phytoplankton. Corpus Christi Bay is a low inflow estuary located on the south Texas coast that has a rapidly urbanizing watershed and is subject to near annual occurrence of K. brevis red tides. Increasing demands for freshwater and a shift to a warmer and drier climate predicted for this region have the potential to further decrease freshwater inflows to the estuary, resulting in decreased nutrient inputs, increased salinity, and increased water residence time. To date, however, there has been little work to quantify patterns in phytoplankton biovolume, community composition, or their environmental drivers. This dissertation provides an assessment of phytoplankton dynamics in Corpus Christi Bay and furthers our understanding of how urbanization and global climate change are likely to impact the estuary. Results of a two-year field study indicate that phytoplankton biomass in Corpus Christi Bay displayed relationships with nutrients, precipitation, and temperature. Accumulation of phytoplankton biovolume during the spring and summer were limited by the availability of nutrients, whereas hydraulic flushing and decreased temperatures were also important during the fall and winter, respectively. A site located in a man-made canal system demonstrated relatively high phytoplankton biovolume and the occurrence of high biovolume blooms following precipitation-derived nutrient inputs. In contrast, regions closer to freshwater sources demonstrated lower overall phytoplankton biovolume despite relatively high concentrations of precipitation-derived nutrients, likely due to flushing effects. This indicates that projected decreases in precipitation and increases in temperature may create an environment more susceptible to phytoplankton blooms and earlier timing of the spring bloom. Phytoplankton community composition also varied in relation to nutrients, precipitation, and temperature. Diatoms were dominant during periods of cooler temperatures and higher nutrients, followed by a shift to dinoflagellate and picocyanobacteria dominance as temperatures warmed and nutrients were depleted. Dinoflagellates and picocyanobacteria were also dominant in the man-made canal site, where higher residence times and recycled nutrients were important factors supporting dominance of these groups. Given projections for a drier, warmer climate and increased water residence times, these findings indicate that there is potential for a prolonged increase in mean phytoplankton standing crops and a potential shift to more persistent dominance by dinoflagellates and picocyanobacteria in Corpus Christi Bay. Nutrient addition bioassays showed that nitrogen was the primary limiting nutrient. In spring, summer, and fall, phytoplankton growth rates increased with nitrogen additions indicating that future increases in the availability of nitrogen due to increased urbanization will influence the accumulation of phytoplankton in Corpus Christi Bay. The short duration of the experiments tended to favor diatoms in comparison to other taxonomic groups. This may indicate that when nutrients are pulsed, as is common in this region due to the flashy nature of rainfall, the Corpus Christi Bay system is buffered against negative impacts of nutrient loading on community composition (i.e., dominance of dinoflagellates and HABs) that have been observed elsewhere. Lastly, this study quantified K. brevis red tide frequency, duration, and environmental drivers. Results show a long-term increase in K. brevis frequency in the Nueces Estuary, which correlated with increased salinity and decreased precipitation during non-El Niño periods and the negative phase of the North Atlantic Oscillation. Additionally, duration was inversely related to temperature and wind speed, with fall-like temperatures and calm water conditions conducive to prolonging red tides. Given projections for warmer and drier conditions in south Texas, these results indicate the potential for continued increases in the occurrence of red tides, a potential shift to occurrence later in the year, and the potential for blooms to extend longer into winter months. Together, this research improves our understanding of factors driving phytoplankton dynamics in a rapidly urbanizing, low-inflow estuary. Results suggest that Corpus Christi Bay may currently be buffered against the occurrence of large, nutrient-driven phytoplankton blooms due to the opposing influences of nutrient availability and increased flushing (during rain events). Evidence presented here suggests that future changes in climate patterns, such as overall decreased precipitation and warmer temperatures, are likely to result in changes in both the frequency, timing and composition of phytoplankton blooms, and this study provides the basis for additional hypothesis-based studies to address these issues.Life SciencesCollege of Science and Engineerin

Comparing Syndromic Surveillance and Poison Center Data for Snake Bites in Missouri

OBJECTIVE: This study intends to use two different surveillance systems available in Missouri to explore snake bite frequency and geographic distribution. INTRODUCTION: In 2010, there were 4,796 snake bite exposures reported to Poison Centers nationwide (1). Health care providers frequently request help from poison centers regarding snake envenomations due to the unpredictability and complexity of prognosis and treatment. The Missouri Poison Center (MoPC) maintains a surveillance database keeping track of every phone call received. ESSENCE, a syndromic surveillance system used in Missouri, enables surveillance by chief complaint of 84 different emergency departments (ED) in Missouri (accounting for approximately 90% of all ED visits statewide). Since calling a poison center is voluntary for health care providers, poison center data is most likely an underestimation of the true frequency of snake envenomations. Comparing MoPC and ESSENCE data for snake envenomations would enable the MoPC to have a more accurate depiction of snake bite frequency in Missouri and to see where future outreach of poison center awareness should be focused. METHODS: Archived data from Toxicall®, the MoPC surveillance system, was used to query the total number of snake bite cases from 01/01/2007 until 12/31/2011 called into the MoPC center by hospitals that also participate ESSENCE. Next, ESSENCE data was used to estimate the total number of snake envenomations presenting to EDs in Missouri. This was accomplished using the same date range as well as searching for key terms in the chief complaints that would signify a snake bite. The results of each datasearch were compared and contrasted by Missouri region. RESULTS: The Toxicall® search showed a total of 324 snake bite cases. The initial ESSENCE data query showed a total of 1983 snake bite cases. After certain data exclusions, there was a total of 1763 ESSENCE snake bite visits. This suggests that approximately 18% of all snake bite visits reported in Missouri ESSENCE were called into the MoPC. The results are demonstrated by Missouri region in Figure 1. This figure also shows that the greatest number of ESSENCE visits for snake bites were reported by Southwest region hospitals whereas the Eastern region hospitals placed the greatest number of calls to MoPC regarding snake bites. CONCLUSIONS: The total number of snake bite cases from Missouri ESSENCE ED visits is much greater than the number of snake bites cases called into the MoPC by ESSENCE participating hospitals. This underutilization of the poison center demonstrates the increased need for awareness of the MoPC’s free services. In Missouri, the MoPC should target hospitals in the Southwest region for outreach in particular based on these findings. Poison centers are staffed by individuals trained in all types of poisonings and maintain a list of consulting physicians throughout the United States experienced in management and treatment of venomous snake bites (2). Any healthcare facility would benefit from MoPC assistance. Finally, syndromic surveillance allows for quick and easy data compilation, however there are some difficulties when attempting to search for a particular condition. Communication and partnership between two different public health organizations will be beneficial toward future public health studies

Comparing Syndromic Surveillance and Poison Center Data for Snake Bites in Missouri

Snake envenomations can lead to complex disease progression in humans. Health care providers often use the Missouri Poison Center (MoPC) to assist with treatment protocols. Missouri ESSENCE, a syndromic surveillance system, and Toxicallå¨, the data system used by the MoPC, were used to compare the frequencies of snake bite cases in Missouri for the past 5 years. The total number of snake bite visits recorded by ESSENCE was 1763, compared to 324 cases from MoPC data. These results suggest that the MoPC should increase awareness of their resources to hospitals in certain regions in Missouri