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Objective: This article assesses the application of the Royal College of Obstetricians and Gynaecologists (RCOG) venous thromboembolism (VTE) risk model on a cohort of postpartum patients with a history of systemic lupus erythematosus (SLE)., Study Design: This is a secondary analysis of an ongoing patient registry of women with SLE from 2016 to 2022. There were 49 SLE patients with 55 pregnancies using the Definitions of Remission in SLE (DORIS) criteria to determine SLE disease activity. RCOG risk assessment model scoring was calculated for each patient prior to and after delivery. The primary outcome was the qualification of "active SLE" by standard rheumatologic criteria and assessment of recommendations for VTE prophylaxis based on RCOG VTE risk assessment scoring. Data were analyzed using Fisher's exact test, chi-square test, and Mann-Whitney U test with significance defined as p  < 0.05., Results: In the study cohort, 34 pregnancies (61.8%) were in DORIS remission at delivery. Twenty-one pregnancies (38.2%) were not and scored 3 points on the RCOG VTE risk model. Of these pregnancies, only 19% ( n  = 4) were recommended for VTE prophylaxis by the obstetrical provider despite RCOG score ≥3. Only 35.7% ( n  = 5) of pregnancies in DORIS remission, but with 3 points for non-SLE-related VTE risk factors ( n  = 14), were recommended for VTE prophylaxis. Of the 20 pregnancies in remission with an RCOG score < 3 after assessing all risk factors, 15% ( n  = 3) were nevertheless recommended for VTE prophylaxis. No patients had a postpartum VTE regardless of therapy., Conclusion: These data reveal a need to improve upon providing postpartum VTE prophylaxis to SLE patients not in remission while also recognizing a diagnosis of SLE alone should not equate with active disease. Moreover, SLE patients in remission may still warrant VTE prophylaxis if other non-SLE-related risk factors are present., Key Points: · Those with SLE are at increased risk for VTE postpartum.. · VTE prophylaxis should be instituted when clinically appropriate.. · Caution should be exercised in broadly assigning disease activity for SLE diagnosis only.. · This study supports VTE prophylaxis use in postpartum patients with SLE.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: A previously healthy young male of Southeast Asian descent presented with 6 weeks of fevers, cough, mucocutaneous ulcers, arthritis, and myalgias. Initial workup revealed positive Mycoplasma pneumoniae immunoglobulin M, and the patient was treated with antibiotics without relief of symptoms. Rheumatologic workup revealed highly positive melanoma differentiation-associated gene 5 antibody. Viral infections are thought to potentially trigger loss of self tolerance, and prompt the autoimmunity cascade that can result in conditions such as dermatomyositis. To our knowledge, this is the first case report demonstrating a non-viral infection, specifically Mycoplasma pneumoniae, as the inciting infectious trigger for the anti-melanoma differentiation-associated gene 5 dermatomyositis subtype., Case Presentation: A 20-year-old southeast Asian-American male with no significant past medical history presented with symptoms of intermittent fevers, nonproductive cough, dry eyes, oral ulcers, rash, arthritis, and myalgias. The patient was noted to have erythematous papules across the bilateral hands along the lateral digits and palms, as well as synovitis involving the bilateral hands and feet. Immunoglobulin M antibodies were positive for Mycoplasma pneumoniae. The patient was diagnosed with mycoplasma pneumonia. The patient did not respond to a course of antibiotics, leading to rheumatological testing that found highly positive melanoma differentiation-associated gene 5 autoantibody. Muscle enzyme and electromyography testing were normal, indicating clinically amyopathic disease. Methylprednisolone was initiated, with resolution of fevers and improvement of arthritis and myalgias. The cutaneous lesions on the digits and palms improved., Conclusions: This patient presented with symptoms of fever, cough, oral ulcers, rashes, and arthritis, and blood work demonstrated the presence of immunoglobulin M antibodies to Mycoplasma pneumoniae. Despite antibiotic treatment for the presumed diagnosis of Mycoplasma pneumoniae infection, the patient did not improve, prompting rheumatological workup and revealing melanoma differentiation-associated gene 5 autoantibodies. This case suggests that infections, other than viral, can trigger the autoinflammatory cascade, leading to the development of amyopathic melanoma differentiation-associated gene 5 dermatomyositis., (© 2022. The Author(s).)

Sexually transmitted diseases are a growing threat to public health, but are often underrecognized, due to the often nonspecific (or absent) signs and symptoms, the myriad diseases, and the possibility of co-infection. Emergency clinicians play a critical role in improving healthcare outcomes for both patients and their partners. Optimizing the history and physical examination, ordering appropriate testing, and prescribing antimicrobial therapies, when required, will improve outcomes for men, women, and pregnant women and their babies. This issue reviews the latest evidence in the diagnosis and treatment of sexually transmitted diseases, focusing on efficient and safe strategies to optimize outcomes. [Points & Pearls is a digest of Emergency Medicine Practice.]

Blunt cardiac injury describes a range of cardiac injury patterns resulting from blunt force trauma to the chest. Due to the multitude of potential anatomical injuries blunt force trauma can cause, the clinical manifestations may range from simple ectopic beats to fulminant cardiac failure and death. Because there is no definitive, gold-standard diagnostic test for cardiac injury, the emergency clinician must utilize an enhanced index of suspicion in the clinical setting combined with an evidence-based diagnostic testing approach in order to arrive at the diagnosis. This review focuses on the clinical cues, diagnostic testing, and clinical manifestations of blunt cardiac injury as well as best-practice management strategies. [Points & Pearls is a digest of Emergency Medicine Practice.]

Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches --migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening. This issue details the important pathophysiologic features of the most common types of life-threatening headaches, the key historical and physical examination information emergency clinicians must obtain, the red flags that cannot be missed, and the current evidence for best-practice testing, imaging, treatment, and disposition. [Points & Pearls is a digest of Emergency Medicine Practice.]

Timely management of patients presenting to the ED while in their first trimester of pregnancy can improve outcomes for both the patient and the fetus. Common obstetric problems encountered include vaginal bleeding and miscarriage, ectopic pregnancy and pregnancy of undetermined location, and nausea and vomiting of pregnancy, including hyperemesis gravidarum. Optimal diagnostic approaches and management strategies are covered, including which antiemetics are safe to give in pregnancy. Common nonobstetric problems include asymptomatic bacteriuria, urinary tract infections including pyelonephritis, and acute appendicitis. This article also reviews the various imaging modalities available for pregnant patients and reviews the risks of ionizing radiation as well as various contrast media.[Points & Pearls is a digest of Emergency Medicine Practice.]

Electrical injuries can be caused by exposure to current from low-voltage and high-voltage sources as well as lightning strikes, and the circumstances of the exposure will dictate management strategies. Human tissues have varying resistance characteristics and susceptibility to damage, so injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury. This issue reviews the types of trauma seen with electrical injury and how body systems can be affected by occult or delayed effects, and the optimal evidence-based resuscitation and management strategies associated with each. [Points & Pearls is a digest of Emergency Medicine Practice.]

Sepsis is a common and life-threatening condition that requires early recognition and swift initial management. Diagnosis and treatment of sepsis and septic shock are fundamental for emergency clinicians, and include knowledge of clinical and laboratory indicators of subtle and overt organ dysfunction, infection source control, and protocols for prompt identification of the early signs of septic shock. [Points & Pearls is a digest of Emergency Medicine Practice.]

There are approximately 10,000 emergency department visits in the United States for snakebites every year, and one-third of those involve venomous species. Venomous North American indigenous snakes include species from the Crotalinae (pit vipers) and Elapidae (coral snakes) subfamilies. Treatment relies on supportive care, plus antivenom for select cases. While certain principles of management are widely accepted, controversies exist with regard to prehospital use of pressure immobilization, antivenom use, coagulation testing after copperhead envenomation, and fasciotomy. An evidence-based approach to management of North American venomous snakes will be discussed, along with a review of the current controversies. [Points & Pearls is a digest of Emergency Medicine Practice.]

Despite current legal and medical controversies surrounding cannabinoids, it is a fact that emergency departments are seeing an increasing number of patients presenting with symptoms associated with the use of these drugs. This review outlines the pathophysiology of cannabinoids, the potential clinical findings associated with their use, and the current evidence for best-practice management of patients who present to the emergency department with signs of acute intoxication and chronic use. Differences between natural and synthetic cannabinoids are discussed, along with the latest evidence for diagnosing and managing patients presenting with the intractable vomiting of cannabinoid hyperemesis syndrome.Emerging treatments for cannabinoid hyperemesis syndrome are presented, including hot water bathing, early haloperidol administration, and topical capsaicin, in addition to an update on the legal status of medical cannabinoid substances. [Points & Pearls is a digest of Emergency Medicine Practice.

Dyspnea is one of the most distressing symptoms experienced by dying patients, and it is a common reason for such patients to seek care in the emergency department. Many underlying disease states and acute illnesses cause shortness of breath at the end of life, and management tends to be symptomatic rather than diagnostic, particularly in those for whom comfort is the most important goal. Opioids are the most effective and widely studied agents available for palliation of dyspnea in this population, while adjuvant therapies such as oxygen, noninvasive positive pressure ventilation, and hand-held fans may also be used. Benzodiazepines may also be helpful in select patients. The early involvement of palliative medicine specialists and/or hospice services for dying patients can facilitate optimal symptom management and transitions of care. [Points & Pearls is a digest of Emergency Medicine Practice.]

With population shifts, increased travel, and climate change, the spread of emerging and re-emerging infections is increasing. Although encountering a patient with an emerging infection on any given emergency department shift is unlikely, missing a diagnosis could have profound consequences for the patient, healthcare workers, and the patient's close contacts. This review provides a framework to evaluate, diagnose, and treat a returning traveler with suspected Middle East respiratory syndrome, chikungunya virus, or Zika virus-3 recently emerged infections. All may present with nonspecific viral-like symptoms and are easily missed if an appropriate travel history is not obtained. A high level of vigilance and proper disposition will enable the emergency clinician to effectively diagnose, manage, and contain these diseases. [Points & Pearls is a digest of Emergency Medicine Practice.].

There are approximately 52,000 visits a year to emergency departments for patients presenting with jaundice. While many of these patients will not have immediately life-threatening pathology, it is essential that the emergency clinician understands the pathophysiology of jaundice, as this will guide the appropriate workup to detect critical diagnoses. Patients who present with jaundice could require intravenous antibiotics, emergent surgery, and, in severe cases, organ transplantation. This issue will focus on the challenge of evaluating and treating the jaundiced patient in the ED using the best available evidence from the literature. [Points & Pearls is a digest of Emergency Medicine Practice.].

Smoke inhalation injury portends increased morbidity and mortality in fire-exposed patients. Upper airway thermal burns, inflammation from lower airway irritants, and systemic effects of carbon monoxide and cyanide can contribute to injury. A standardized diagnostic protocol for inhalation injury is lacking, and management remains mostly supportive. Clinicians should maintain a high index of suspicion for concomitant traumatic injuries. Diagnosis is mostly clinical, aided by bronchoscopy and other supplementary tests. Treatment includes airway and respiratory support, lung protective ventilation, 100% oxygen or hyperbaric oxygen therapy for carbon monoxide poisoning, and hydroxocobalamin for cyanide toxicity. Due to its progressive nature, many patients with smoke inhalation injury warrant close monitoring for development of airway compromise. [Points & Pearls is a digest of Emergency Medicine Practice.].

Unexpected peptide deformylase (PDF) genes were recently retrieved in numerous marine phage genomes. While various hypotheses dealing with the occurrence of these intriguing sequences have been made, no further characterization and functional studies have been described thus far. In this study, we characterize the bacteriophage Vp16 PDF enzyme, as representative member of the newly identified C-terminally truncated viral PDFs. We show here that conditions classically used for bacterial PDFs lead to an enzyme exhibiting weak activity. Nonetheless, our integrated biophysical and biochemical approaches reveal specific effects of pH and metals on Vp16 PDF stability and activity. A novel purification protocol taking in account these data allowed strong improvement of Vp16 PDF specific activity to values similar to those of bacterial PDFs. We next show that Vp16 PDF is as sensitive to the natural inhibitor compound of PDFs, actinonin, as bacterial PDFs. Comparison of the 3D structures of Vp16 and E. coli PDFs bound to actinonin also reveals that both PDFs display identical substrate binding mode. We conclude that bacteriophage Vp16 PDF protein has functional peptide deformylase activity and we suggest that encoded phage PDFs might be important for viral fitness., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Thermal burn injuries are a significant cause of morbidity and mortality worldwide. In addition to treatment of the burns, emergency clinicians must assess for inhalation injury, exposure to toxic gases, and related traumatic injuries. Priorities for emergency resuscitation include stabilization of airway and breathing, intravenous fluid administration, pain control, and local wound care. Special populations, including children and pregnant women, require additional treatment considerations. Referral to specialized burn care for select patients is necessary to improve long-term outcomes. This article reviews thermal burn classification and evidence-based treatment strategies. [Points & Pearls is a digest of Emergency Medicine Practice.].

As the prevalence of cancer continues to increase in the general population and improvements in cancer treatment prolong survival, the incidence of patients presenting to the emergency department with oncologic complications will, similarly, continue to rise. This issue reviews 3 of the more common presentations of oncology patients to the emergency department: metastatic spinal cord compression, tumor lysis syndrome, and febrile neutropenia. Signs and symptoms of these conditions can be varied and nonspecific, and may be related to the malignancy itself or to an adverse effect of the cancer treatment. Timely evidence-based decisions in the emergency department regarding diagnostic testing, medications, and arrangement of disposition and oncology follow-up can significantly improve a cancer patient's quality of life. [Points & Pearls is a digest of Emergency Medicine Practice.].

Dislocation of the major joints of the lower extremities--hip, knee, and ankle--can occur due to motor-vehicle crashes, falls, and sports injuries. Hip dislocations are the most common, and they require emergent management to prevent avascular necrosis of the femoral head. Knee dislocations are uncommon but potentially dangerous injuries that can result in amputation due to the potential for missed secondary injury, especially if they are reduced spontaneously. Isolated ankle dislocations are relatively rare, as most ankle dislocations involve an associated fracture. This review presents an algorithmic approach to management that ensures that pain relief, imaging, reduction, vascular monitoring, and emergent orthopedic consultation are carried out in a timely fashion. [Points & Pearls is a digest of Emergency Medicine Practice.].

Because of the chronic relapsing nature of inflammatory bowel disease (IBD), emergency clinicians frequently manage patients with acute flares and complications. IBD patients present with an often-broad range of nonspecific signs and symptoms, and it is essential to differentiate a mild flare from a life-threatening intra-abdominal process. Recognizing extraintestinal manifestations and the presence of infection are critical. This issue reviews the literature on management of IBD flares in the emergency department, including laboratory testing, imaging, and identification of surgical emergencies, emphasizing the importance of coordination of care with specialists on treatment plans and offering patients resources for ongoing support. [Points & Pearls is a digest of Emergency Medicine Practice.].

Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a clinical diagnosis that is based on changes in dyspnea, cough, and/or sputum production in a COPD patient; however, patients presenting with an acute exacerbation may be undiagnosed or have a variety of comorbid conditions that can complicate diagnosis. This issue presents strategies and algorithms for the early use of evidence-based interventions, including appropriate use of antibiotics, bronchodilators, and corticosteroids, along with noninvasive ventilation with capnography, to minimize morbidity and mortality associated with this disease. [Points & Pearls is a digest of Emergency Medicine Practice.].

Prokaryotic proteins must be deformylated before the removal of their first methionine. Peptide deformylase (PDF) is indispensable and guarantees this mechanism. Recent metagenomics studies revealed new idiosyncratic PDF forms as the most abundant family of viral sequences. Little is known regarding these viral PDFs, including the capacity of the corresponding encoded proteins to ensure deformylase activity. We provide here the first evidence that viral PDFs, including the shortest PDF identified to date, Vp16 PDF, display deformylase activity in vivo, despite the absence of the key ribosome-interacting C-terminal region. Moreover, characterization of phage Vp16 PDF underscores unexpected structural and molecular features with the C-terminal Isoleucine residue significantly contributing to deformylase activity both in vitro and in vivo. This residue fully compensates for the absence of the usual long C-domain. Taken together, these data elucidate an unexpected mechanism of enzyme natural evolution and adaptation within viral sequences.

We recently developed a protocol for the transcriptome-wide isolation of RNA recognition elements readily applicable to any protein or ribonucleoprotein complex directly contacting RNA (including RNA helicases, polymerases, or nucleases) expressed in cell culture models either naturally or ectopically (Hafner et al., 2010). Briefly, immunoprecipitation of the RNA-binding protein of interest is followed by isolation of the crosslinked and coimmunoprecipitated RNA. In the course of lysate preparation and immunoprecipitation, the mRNAs are partially degraded using Ribonuclease T1. The isolated crosslinked RNA fragments are converted into a cDNA library and deep-sequenced using Solexa technology (see Explanatory Chapter: Next Generation Sequencing). By introducing photoreactive nucleosides that generate characteristic sequence changes upon crosslinking (see below), our protocol allows one to separate RNA segments bound by the protein of interest from the background un-crosslinked RNAs., (© 2014 Elsevier Inc. All rights reserved.)

Ours is an age of unprecedented levels of environmental alteration and biodiversity loss. Beyond the exposure to environmental hazards, conditions such as environmental degradation, biotic impoverishment, climate change, and the loss of ecosystem services create important health threats by changing the ecology of many pathogens and increasing the incidence and/or severity of certain noncommunicable conditions. They also threaten health in the future by weakening the Earth's life support systems.Although physicians remain one of the most often accessed and most trusted sources of information about the environment, there is currently little emphasis on educating medical professionals about these environmental issues. This lack of training reduces the ability of most physicians to be efficient science-public interfaces and makes them ineffective at contributing to address the fundamental causes of environmental problems or participate in substantive environmental policy discussions. This is an important challenge facing medical education today.To turn medical students into effective physician-citizens, an already-overwhelmed medical school curriculum must make way for a thoughtful exploration of environmental stressors and their impacts on human health. The overarching question before medical educators is how to develop the competencies, standards, and curricula for this educational endeavor. To this end, the authors highlight some of the critical linkages between health and the environment and suggest a subset of key practical issues that need to be addressed in order to create environmental education standards for the physician of the future.

Background: Palliative wound care should be centered on symptom management and is a viable option for patients whose chronic wounds do not respond to standard interventions, or when the demands of treatment are beyond the patient's tolerance or stamina. Palliative wound care is the incorporation of strategies that prioritize symptomatic relief and wound improvement ahead of wound healing (total closure). Palliative wound care strategies must also work in conjunction with curative treatment objectives as wounds often heal completely in spite of serious illness and advanced disease. Palliative wound care is much more than pain, exudate and odor management. Common curative treatment goals such as physical correction of the underlying pathology, addressing nutrition and other supportive aspects of care, and sensible (nonharmful) local wound treatments should never be ignored., Objective: (1) To provide a fresh and effective approach to palliative wound care by integrating individual clinical expertise with clinical and laboratory evidence from the (curative) wound healing literature and (2) to share our (Calvary Hospital) experience and approach to palliative wound care in an inpatient, home, and outpatient setting. This approach can be summarized with the mnemonic S-P-E-C-I-A-L (S = stabilizing the wound, P = preventing new wounds, E = eliminate odor, C = control pain, I = infection prophylaxis, A = advanced, absorbent wound dressings, L = lessen dressing changes). Throughout this paper we will offer rationale, principles and recipes, for each of the steps of the "SPECIAL" approach in an effort to facilitate the caring for chronic wounds in palliative medicine., Conclusions: A practical marriage of wound palliation (symptom management) with current wound healing concepts to provide options for the palliative care provider and improve the practice of palliative medicine.

The transition of birthing practices in Greece from a homebirth culture, in which women deliver at home surrounded by family and under the supervision of a typically female birth attendant, to a biomedical birth model, in which women deliver in a hospital with numerous forms of medical intervention and under the control of a physician, has been unusually rapid. Today, Western biomedicine not only dominates the health care system in Greece but has an essential hegemony on women's health care. My research examines whether the pervasive utilization of biomedical environments for birthing can be explained by a lack of alternatives or by women's satisfaction with the technology and care available in hospitals. I also examine how women retain control over their experience of pregnancy and childbirth within the biomedical context and attempt to explain the emerging construction of a "natural" discourse on pregnancy and childbirth in Athens. Major themes that emerged from interviews with Athenian women were the lack of consent for medical intervention during birth, limited infrastructure to support women who seek non-medical alternatives, and limited emotional support and collective education for mothers in the urban environment of Athens. Also, women described choosing the right caregiver as essential to maintaining a sense of control over their pregnancy and, more generally, over their life. In light of women's apparent interest in improving women's experience of pregnancy and childbirth in Athens, it is recommended that researchers further explore the interaction of medical and non-medical discourses on pregnancy and childbirth.