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Biomedical subjects

R A Schwab

Publications and source records attributed to R A Schwab.

At least 19 recordsLinked to original sources

The Akt/PKB pathway is constitutively activated in Theileria-transformed leucocytes, but does not directly control constitutive NF-kappaB activation.

The intracellular protozoan parasites Theileria parva and Theileria annulata transform leucocytes by interfering with host cell signal transduction pathways. They differ from tumour cells, however, in that the transformation process can be entirely reversed by elimination of the parasite from the host cell cytoplasm using a specific parasiticidal drug. We investigated the state of activation of Akt/PKB, a downstream target of PI3-K-generated phosphoinositides, in Theileria-transformed leucocytes. Akt/PKB is constitutively activated in a PI3-K- and parasite-dependent manner, as judged by the specific phosphorylation of key residues, in vitro kinase assays and its cellular distribution. In previous work, we demonstrated that the parasite induces constitutive activation of the transcription factor NF-kappaB, providing protection against spontaneous apoptosis that accompanies transformation. In a number of other systems, a link has been established between the PI3-K-Akt/PKB pathway and NF-kappaB activation, resulting in protection against apoptosis. In Theileria-transformed leucocytes, activation of the NF-kappaB and the PI3-K-Akt/PKB pathways are not directly linked. The PI3-K-Akt/PKB pathway does not contribute to the persistent induction of IkappaBalpha phosphorylation, NF-kappaB DNA-binding or transcriptional activity. We show that the two pathways are downregulated with different kinetics when the parasite is eliminated from the host cell cytoplasm and that NF-kappaB-dependent protection against apoptosis is not dependent on a functional PI3-K-Akt/PKB pathway. We also demonstrate that Akt/PKB contributes, at least in part, to the proliferation of Theileria-transformed T cells.

Animals↗

Acquired vulvar lymphangiomas: a sequela of radiation therapy.

Lymphangiomas of the vulva are rare clinical entities. Acquired or secondary lymphangiomas have characteristically been reported after radiation therapy for cervical carcinoma and appear on the vulva years after this treatment. Local surgery, scrofuloderma, and Crohn's disease may also damage vulvar lymphatic flow and lead to the development of vulvar lymphangiomas. We report a case of acquired vulvar lymphangiomas that occurred in a patient 15 years after she received radiation therapy for squamous cell carcinoma of the uterine cervix.

Aged↗

Topical imiquimod for recalcitrant facial flat warts.

Imiquimod is a unique topical therapeutic agent useful in the treatment of external genital and perianal warts (condyloma acuminata) in adults. The authors report a case of a 21-year-old woman who experienced complete clearance of recalcitrant facial flat warts after 3 weeks of therapy with topical imiquimod 5% cream.

Adjuvants, Immunologic↗

Clindamycin-induced acute generalized exanthematous pustulosis.

Acute generalized exanthematous pustulosis is a rare but distinctive entity that may be associated with various etiologies. Drug exposure is the most common cause. We present the first report of acute generalized exanthematous pustulosis induced by the drug clindamycin.

Aged↗

Baby steps.

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Emergency Treatment↗

Emergency medicine resident choice of practice location.

STUDY OBJECTIVE: To describe the geographic distribution of practice locations for 1995 emergency medicine residency graduates and factors that are important to residents in their choice of practice location. METHODS: Self-administered questionnaires were distributed to Emergency medicine residents who graduated in 1995. The survey ascertained practice city and state, resident employment characteristics, and the importance of factors that influenced the residents' selection of employment. RESULTS: Eighty-six of 87 programs and 441 (69.4%) of 635 eligible residents participated. Forty-three percent of graduates chose to practice in the city or metropolitan area in which they trained; 46% of these had no personal tie to the area before their residency training. Liking the city was cited as being more important (P<.001) than other factors in picking practice location. Group personality and coworkers' credentials were more important (P< or =.01) than contract and salary arrangement. Twenty percent of respondents were not practicing in the city or area of their first choice. CONCLUSION: Residency training location, regardless of prior ties to the geographical area, appears to be a major factor in the choice of practice location of emergency medicine residency graduates. Coworkers' personalities and credentials are more important factors in job selection than salary and employment arrangements.

Adult↗

Clinical predictors of mandibular fractures.

To evaluate the diagnostic accuracy of clinical signs and symptoms of mandibular fracture, a prospective study of emergency department patients presenting with mandibular trauma was undertaken. Patients with airway compromise, who were edentulous, or could not cooperate with the physical examination were excluded. Over a 1-year period, 119 patients were studied. The presence of malocclusion, trismus, facial asymmetry, or a positive result on the tongue blade test (inability to grasp and hold a tongue blade between the teeth) was significantly associated with a mandibular fracture. Malocclusion and facial asymmetry were strong predictors of fracture, and a negative result on the tongue blade test was a strong predictor of nonfracture.

Diagnosis, Differential↗

Emergency medicine credentials in St Louis and Kansas City: does the presence of an emergency medicine residency program have a geographic difference?

STUDY OBJECTIVE: To compare emergency physician (EP) credentialing characteristics in two metropolitan areas of Missouri: Kansas City, which has had an emergency medicine (EM) residency program since 1973, and St Louis, which is without a program approved by the Accreditation Council for Graduate Medical Education. METHODS: A cross-sectional, descriptive survey concerning EP training, certification, and practice characteristics was administered by standardized telephone interviews. Participants were all emergency department directors in Kansas City and St Louis general hospital EDs serving more than 10,000 patients annually. RESULTS: Twenty Kansas City EDs, with an annual census of 20,250 +/- 7,200; and 30 St Louis EDs, with an annual census of 27,100 +/- 13,800, were surveyed. In Kansas City, 68% of practicing EPs were EM trained, versus 10% in St. Louis (P < .0005). The percentage of board-certified EPs was also greater in Kansas City than in St Louis (82% versus 42%, P < .0005). Eighty-six percent of ED directors in St Louis, compared with 30% in Kansas City, reported that they did not attempt to recruit EM-trained staff or that recruitment was difficult (P < .0005). CONCLUSION: The presence of an EM residency training program is associated with favorable EP credentialing characteristics in the Kansas City metropolitan area. This information may prove useful to institutions attempting to establish EM training programs in areas where none currently exist.

Certification↗

Patient understanding of emergency department discharge instructions.

Patients were interviewed immediately after discharge outside the emergency department to determine whether they could read their discharge instructions and recall their diagnosis and treatment plan. The association between frequency of correct responses and various characteristics of the patients was assessed. Of the patients completing the interview, 72% could read the discharge instructions. The illiteracy rate was higher for patients with less than 9 years of education and for patients aged 50 to 59 years. There was no association between patient race, sex, or literacy. The correct diagnosis was given by 79% of patients, correct treatment information by 49%, and correct follow-up information by 82%. Overall, 37% of patients answered all questions correctly and 8% answered all questions incorrectly. No association was found between frequency of correct responses and variables examined. Miscommunication of discharge information occurs frequently; illiteracy does not completely account for the observed low rates of recall.

Adolescent↗

Impact of emergency medicine residency program on rotators' emergency medicine education.

STUDY OBJECTIVE: To assess the perceived impact of emergency medicine residency programs on other program directors' perceptions of emergency medicine as a distinct service and educational entity. DESIGN: Self-administered questionnaire. TYPE OF PARTICIPANTS: Residency directors in medicine, surgery, pediatrics, and obstetrics and gynecology at sites containing emergency medicine residency programs. RESULTS: Two hundred twenty-four of 372 questionnaires (60.1%) were returned completed, with equal distributions among all specialties. Respondents stated that the presence of the emergency medicine training program has positively influenced their attitude toward emergency medicine as a specialty (61% agree, 26% neutral), improved their residents' training in emergency medicine (47% agree, 31% neutral), and improved emergency care at their institution (65% agree, 26% neutral). Fifty-seven percent think emergency physicians should teach emergency medicine (27% were neutral). There were statistically significant associations between age of the emergency medicine program and perceived improvement in rotating residents' education and institutional delivery of emergency care. CONCLUSION: Residency directors in other specialties have a generally positive view of emergency medicine as a specialty and as an important component of their residents' education. The presence of an emergency medicine training program appears to have positively influenced their attitudes, improved their residents' education, and improved emergency care. Older programs have positively influenced attitudes to a greater degree than have newer programs.

Attitude of Health Personnel↗

Prevalence of folate deficiency in emergency department patients with alcohol-related illness or injury.

To assess the prevalence of folate deficiency in emergency department patients with alcohol-related illness or injury, a prospective, nonconsecutive case series with nonrandomized controls was used. All patients presenting to a 60,000-visit public hospital emergency department with alcohol-related illness or injury were eligible; patients were excluded if they had received folate in our health care facility within the previous 4 months. An alcohol and brief dietary history was obtained, and a complete blood cell count and red blood cell folate level was performed on each patient. Analysis was undertaken by chi 2 to evaluate the prevalence of folate deficiency in the alcohol-related versus the control population. One hundred three patients were entered into the study. Three patients were subsequently excluded from analysis. Of 52 study patients, three (5.8%) were found to be folate deficient. Of 48 controls, two (4.2%) were found to be folate deficient. This difference is not statistically significant (P greater than .05, chi 2; mean difference 1.6%, 95% confidence interval -6.9% to 10.1%). The prevalence of folate deficiency in patients presenting to this emergency department with alcohol-related illness or injury is low, and does not differ from the general emergency department population. Empiric folate therapy in these patients is not indicated.

Adult↗

Delirium and lactic acidosis caused by ethanol and niacin coingestion.

A 44-year-old male presented to the emergency department with altered mental status. He was receiving niacin therapy for hypercholesterolemia, and 16 hours earlier had ingested a large quantity of wine. Past medical history was otherwise unremarkable; physical examination revealed paranoid ideation and asterixis. Laboratory evaluation was significant for metabolic acidosis with a calculated anion gap of 39. Liver enzymes were elevated, and lactic acid level was 9.5 mmol/L (normal: 0.5 to 2.2 mmol/L). White blood cell count was 23,100, but all cultures were negative, and all other diagnostic studies, including bilirubin, prothrombin time, and ammonia were normal. The patient recovered rapidly with hydration and administration of thiamine and magnesium. After psychiatric evaluation, a diagnosis of toxic delirium due to niacin and ethanol coingestion was made. This is the first case reporting toxic delirium and lactic acidosis due to niacin and ethanol coingestion. This occurred in the absence of significant hepatic impairment. Possible mechanisms for the observed derangements are discussed.

Acid-Base Equilibrium↗

Contribution of sorbitol combined with activated charcoal in prevention of salicylate absorption.

The use of cathartics and activated charcoal in treating toxic ingestions has become a standard treatment modality. Sorbitol has been shown to be the most rapidly acting cathartic, but its therapeutic significance has been debated. Using a previously described aspirin overdose model, ten healthy volunteers participated in a crossover design study that investigated the effect of activated charcoal alone versus that of activated charcoal and sorbitol in preventing salicylate absorption. In phase 1 of the study, subjects consumed 2.5 g aspirin followed by 25 g activated charcoal one hour later. Urine was collected for 48 hours and analyzed for quantitative salicylate metabolites. Phase 2 was identical except that 1.5 g/kg sorbitol was consumed with the activated charcoal. The mean amount of aspirin absorbed without the use of sorbitol was 1.26 +/- 0.15 g, whereas the mean absorption was 0.912 +/- 0.18 g with the addition of sorbitol. This is a 28% decrease in absorption of salicylates attributable to the use of sorbitol. The difference is significant at P less than .05 by the paired Student's t test. This study demonstrates that the addition of sorbitol significantly decreases drug absorption in a simulated drug overdose model. Effects on absorption in actual overdose situations and on patient outcome should be the subjects of further study.

Adult↗

Ultrasound versus culdocentesis in the evaluation of early and late ectopic pregnancy.

A retrospective study of patients found to have ectopic pregnancy was undertaken to determine the relative usefulness of culdocentesis and ultrasound in the evaluation of early and late presentations. The patient's history was used as the sole determinant of gestational age, and results of culdocentesis and/or ultrasound were reviewed. In early presentations (less than 42 days gestation), 38% of ultrasound examinations and 89% of culdocenteses performed were positive. In late presentations, 93% of ultrasound examinations and 70% of culdocenteses performed were positive. The difference between the modalities' performance was significant (P less than .05) for both early and late presentations. These data could provide the basis for a prospective study to test the hypothesis that culdocentesis is the diagnostic test of choice in early suspected ectopic pregnancy, whereas ultrasound is more likely to yield clinically useful information in patients presenting after six weeks gestation.

Douglas' Pouch↗