Increased 18F-FDG-PET Uptake in Granulomatosis with Polyangiitis: Case Report and Review of the Literature

We present an unusual case of granulomatosis with polyangiitis (GPA), which initially presented as a large lung mass, without renal or other systemic features. The lung mass was most concerning for malignancy, and positron emission tomography (PET) further supported this concern, with intense uptake in the mass as well as in mediastinal and hilar lymph nodes. Biopsies however were non-diagnostic, and the patient developed acute kidney injury with active urinary sediment, leading to a definitive diagnosis of GPA. With supportive care and treatment directed at GPA, she was ultimately able to discontinue hemodialysis, and the lung mass resolved. This case demonstrates that GPA can present with PET-positive lymphadenopathy which may be initially suspected to be a malignancy, especially in the absence of renal abnormalities

Using Design Thinking to Spread iPACE™: An Interprofessional Medical Education Innovation in an Academic Medical Center

Problem Statement: The Interprofessional Partnership to Advance Care and Education (iPACE™) model and its core principles are spreading across the MaineHealth system. Thus, there is a need for a standardized approach that is adaptable and incorporates the requirements of diverse patient care settings. Background: In 2017, the original iPACE™ model was designed and piloted on a new teaching unit for adult internal medicine at Maine Medical Center. Analysis of the pilot data showed improved teaming, care team experiences, interprofessional collaborations, and patient satisfaction. Because the pilot model will require adaptation to be successfully implemented in other disciplines, the authors sought a framework to facilitate implementation of core iPACE™ principles in diverse clinical care settings. Application/Recommendation: The Design Thinking (DT) framework was selected as a structured, standardized approach to accelerate innovation and implementation of the iPACE™ model in a new patient care setting. The DT framework consists of 6 consecutive process steps and iteration loops: Understand, Observe, Point of View, Ideate, Prototype, and Test. This paper outlines specific metrics and activities in each step, as well as opportunities for tailoring each step based on the care setting

Endocannabinoids mediate muscarine-induced synaptic depression at the vertebrate neuromuscular junction

Endocannabinoids (eCBs) inhibit neurotransmitter release throughout the central nervous system. Using the Ceratomandibularis muscle from the lizard Anolis carolinensis we asked whether eCBs play a similar role at the vertebrate neuromuscular junction. We report here that the CB1 cannabinoid receptor is concentrated on motor terminals and that eCBs mediate the inhibition of neurotransmitter release induced by the activation of M3 muscarinic acetylcholine (ACh) receptors. N-(piperidin-1-yl)-5-(4-iodophenyl)-1-(2,4-dichlorophenyl)-4-methyl-1H-pyrazole-3-carboxamide, a CB1 antagonist, prevents muscarine from inhibiting release and arachidonylcyclopropylamide (ACPA), a CB1 receptor agonist, mimics M3 activation and occludes the effect of muscarine. As for its mechanism of action, ACPA reduces the action-potential-evoked calcium transient in the nerve terminal and this decrease is more than sufficient to account for the observed inhibition of neurotransmitter release. Similar to muscarine, the inhibition of synaptic transmission by ACPA requires nitric oxide, acting via the synthesis of cGMP and the activation of cGMP-dependent protein kinase. 2-Arachidonoylglycerol (2-AG) is responsible for the majority of the effects of eCB as inhibitors of phospholipase C and diacylglycerol lipase, two enzymes responsible for synthesis of 2-AG, significantly limit muscarine-induced inhibition of neurotransmitter release. Lastly, the injection of (5Z,8Z,11Z,14Z)-N-(4-hydroxy-2-methylphenyl)-5,8,11,14-eicosatetraenamide (an inhibitor of eCB transport) into the muscle prevents muscarine, but not ACPA, from inhibiting ACh release. These results collectively lead to a model of the vertebrate neuromuscular junction whereby 2-AG mediates the muscarine-induced inhibition of ACh release. To demonstrate the physiological relevance of this model we show that the CB1 antagonist N-(piperidin-1-yl)-5-(4-iodophenyl)-1-(2,4-dichlorophenyl)-4-methyl-1H-pyrazole-3-carboxamide prevents synaptic inhibition induced by 20 min of 1-Hz stimulation

Methods of cooling: practical aspects of therapeutic temperature management.

OBJECTIVES: To review traditional and newer means of inducing, maintaining, and withdrawing therapeutic hypothermia and normothermia. To suggest treatment algorithms for temperature modulation and review neuromonitoring options. DESIGN: A review of current literature describing methods of performing therapeutic temperature management and neuromonitoring during the cooling, maintenance, and decooling periods. Algorithms for performing therapeutic temperature management are suggested. RESULTS: Temperature management can be safely and effectively performed using traditional or newer modalities. Although traditional means of cooling are feasible and efficacious, modern devices utilizing feedback loops to maintain steady body temperature and prevent overcooling have advantages in ease of application, patient safety, maintenance of target temperature, and control of decooling. Neuromonitoring options should be adapted to an individual patient and situation. CONCLUSIONS: Intensivists should be familiar with techniques to induce, maintain, and withdraw therapeutic temperature management, and select the most appropriate method for a given patient and situation

Oxygenation Response to a Recruitment Maneuver during Supine and Prone Positions in an Oleic Acid–Induced Lung Injury Model

Prone position and recruitment maneuvers (RM) are proposed as adjuncts to mechanical ventilation to open up the lung and keep it open. We studied the oxygenation response to a RM (composed of a 30-s sustained inflation at 60 cm H2O airway pressure) performed in prone and supine positions in dogs after oleic acid-induced lung injury using an inspired O-2 fraction of 0.60. In one group (n = 6) first supine then prone positions were examined after a RM at 8 cm H2O and 15 cm H2O of positive end-expiratory pressure (PEEP). In the second group (n = 6) the sequence of positions was reversed. Prone positioning after supine position always improved oxygenation, whereas the decrement in Pa-O2 was relatively small when dogs were returned to the supine position. Oxygenation improved in both groups after a RM, and the improvement was sustained (after 15 min) in the prone position at 8 cm H2O of PEEP, but 15 cm H2O of PEEP was required in supine position. Our results suggest that a RM improves oxygenation more effectively with a decreased PEEP requirement for the preservation of the oxygenation response in prone compared with supine position