Anterior ischemic optic neuropathy precipitated by acute primary angle closure

A 59-year-old man with a history of longstanding systemic hypotension developed asymmetric non-arteritic anterior ischemic optic neuropathy (NAION) apparently precipitated by bilateral sequential acute primary angle closure. NAION is very rarely reported in association with raised intraocular pressure. In contrast to optical coherence tomography, the failure of scanning laser polarimetry to detect axonal swelling was another interesting finding. Possible reasoning for these observations is discussed.     

Opening of Psychiatric Observation Unit Eases Boarding Crisis

Objectives

The objective of this study was to evaluate the effect of a psychiatric observation unit in reducing emergency department (ED) boarding and length of stay (LOS) for patients presenting with primary psychiatric chief complaints. A secondary outcome was to determine the effect of a psychiatric observation unit on inpatient psychiatric bed utilization.

Methods

This study was a before‐and‐after analysis conducted in a 1,541‐bed tertiary care academic medical center including an adult ED with annual census over 90,000 between February 2013 and July 2014. All adult patients (age > 17 years) requiring evaluation by the acute psychiatry service in the crisis intervention unit (CIU) within the ED were included. Patients who left without being seen, left against medical advice, or were dispositioned to the pediatric hospital, hospice, or court/law enforcement were excluded. In December 2013, a 12‐bed locked psychiatric observation unit was opened that included dedicated behavioral health staff and was intended for psychiatric patients requiring up to 48 hours of care. The primary outcomes were ED LOS, CIU LOS, and total LOS. Secondary outcomes included the hold rate defined as the proportion of acute psychiatry patients requiring subsequent observation or inpatient admission and the inpatient psychiatric admission rate. For the primary analysis we constructed ARIMA regression models that account for secular changes in the primary outcomes. We conducted two sensitivity analyses, first replicating the primary analysis after excluding patients with concurrent acute intoxication and second by comparing the 3‐month period postintervention to the identical 3‐month period of the prior year to account for seasonality.

Results

A total of 3,501 patients were included before intervention and 3,798 after intervention. The median ED LOS for the preintervention period was 155 minutes (interquartile range [IQR] = 19–346 minutes), lower than the median ED LOS for the postintervention period of 35 minutes (IQR = 9–209 minutes, p < 0.0001). Similar reductions were observed in CIU LOS (865 minutes vs. 379 minutes, p < 0.0001) and total LOS (1,112 minutes vs. 920 minutes, p = 0.003). The psychiatric hold rate was statistically higher after intervention (before = 42%, after = 50%, p < 0.0001), however, coupled with a statistically lower psychiatric admission rate (before = 42%, after = 25%, p < 0.0001).

Conclusions

Creation of an acute psychiatric observation improves ED and acute psychiatric service throughput while supporting the efficient allocation of scare inpatient psychiatric beds. This novel approach demonstrates the promise of extending successful observation care models from medical to psychiatric illness with the potential to improve the value of acute psychiatric care while minimizing the harms of ED crowding.

     

Molecular modeling studies and in vitro screening of dihydrorugosaflavonoid and its derivatives against Mycobacterium tuberculosis

Novel drug regimens against tuberculosis (TB) are urgently needed and may be developed by targeting essential enzymes of Mtb that sustain the pathogenicity of tuberculosis. In the present investigation, series of compounds (5a–f and 6a–f) based on a naturally occurring rugosaflavonoid moiety were evaluated by in silico molecular modeling studies against β-ketoacyl-ACP reductase (MabA) (PDB ID: IUZN) and pantothenate kinase (PanK) (PDB ID: 3AF3). Compounds 5a, 5c, 5d, and 6c, which had docking scores of −8.29, −8.36, −8.17 and −7.39 kcal mol⁻¹, respectively, displayed interactions with MabA that were better than those of isoniazid (−6.81 kcal mol⁻¹). Similarly, compounds 5a, 5c, 5d, and 6c, which had docking scores of −7.55, −7.64, −7.40 and −6.7 kcal mol⁻¹, respectively, displayed interactions with PanK that were comparable to those of isoniazid (−7.64 kcal mol⁻¹). Because of their docking scores, these compounds were screened in vitro against Mycobacterium tuberculosis H37Ra (Mtb) using an XRMA protocol. Among the screened compounds, the dihydrorugosaflavonoid derivatives 5a, 5c, and 5d had IC₅₀ values of 12.93, 8.43 and 11.3 μg mL⁻¹, respectively, and exhibited better inhibitory activity than the parent rugosaflavonoid derivatives. The rugosaflavonoid derivative 6c had an IC₅₀ value of 17.57 μg mL⁻¹. The synthesized compounds also displayed inhibitory activity against the Gram-positive bacteria Bacillus subtilis and Staphylococcus aureus. The present study will be helpful for the further development of these molecules into antitubercular lead candidates.

Novel drug regimens against tuberculosis (TB) are urgently needed and may be developed by targeting essential enzymes of Mtb that sustain the pathogenicity of tuberculosis. Dihydrorugosaflavonoid interacted with the active pocket of MabA and PanK.     

Quadruple vessel involvement at root entry zone in trigeminal neuralgia

The author describes a rare case of trigeminal neuralgia where four major named vessels of the posterior circulation were detected to be in close approximation to the trigeminal nerve. The quadruple vessel compression included a tortuous dilated basilar trunk, ipsilateral anterior inferior cerebellar artery, a superior cerebellar artery and superior petrosal vein. All vessels were related to the root entry zone of the nerve. Significance of such a multiple vessel neuovascular conflict at the root entry zone is discussed, highlighting technical implications during surgical management and its prognostic relevance.     

Carotid "trifurcation" aneurysm: surgical anatomy and management

The authors describe a rare case of internal carotid artery (ICA) trifurcation aneurysm and its surgical management. Carotid trifurcation is a unique anatomical variant where three arterial branches arise from the carotid termination than the usual two. Aneurysm arising from the trifurcation, due to its rarity, is difficult to treat. The anatomy, embryological basis and significance of such an anomaly during surgical management are discussed.     

Spontaneous extrusion of guglielmi detachable coils from anterior communicating artery aneurysm

Recurrence of coiled aneurysm usually due to coil compaction is a known phenomenon. Extent of recurrence and its relation to re-bleeding is not known. The authors report a case of spontaneous asymptomatic extrusion of guglielmi detachable coils from the dome of a previously ruptured anterior communicating artery aneurysm two years after the initial endovascular obliteration. The initial aneurysm had a suitable neck-aspect ratio for endovascular obliteration with uncomplicated coiling procedure. Extreme degree of coil compaction with subsequent expulsion of the coils from the dome due to water-hammer effect of blood flow is thought to be the main pathogenic mechanism of this rare but worrying complication. Surgical management includes clipping at the neck ensuring complete obliteration of the aneurysm. Postoperative angiogram to confirm its satisfactory obliteration is advised.