Intravenous fluid therapy: a multi-national, cross-sectional survey of common medical student resources.

BACKGROUND: Inappropriate prescription of intravenous fluid therapy is highly prevalent in hospitals, with up to 1 in 5 patients suffering from preventable, additional morbidity. Since trainee physicians are frequently responsible for prescribing intravenous fluids, it is possible that common medical student resources do not sufficiently cover the topic. There is a paucity of recent literature on this issue, which this study was designed to address. METHODS: Two original evaluation tools were created by the authors to evaluate reference books, official guidelines, and online reference sources commonly used by medical students in the United States of America, Australia, and the United Kingdom on their coverage of foundational and clinically relevant principles of intravenous fluid prescription. The choice of student resources was guided by a literature search and personal experience. A total of 10 resources was assessed. RESULTS: Resources were generally deficit in their coverage of basic intravenous fluid topics. The total points each topic accumulated ranged from 0.5 (5%) to 7.5 (75%), with the median score being 4.5 (45%), on a scale from 0 to 10 points. CONCLUSIONS: Popular medical student resources poorly cover intravenous fluid therapy topics. This may be contributing to inadequate fluid prescribing practices.

Recurrent Optic Neuritis and Perineuritis Followed by an Unexpected Discovery: From the National Multiple Sclerosis Society Case Conference Proceedings.

We describe a woman with a history of relapsing acute optic neuritis and perineuritis. Testing failed to confirm a specific diagnosis; hence, she was diagnosed with seronegative neuromyelitis optica spectrum disorder and treated with the immunotherapy rituximab, later in conjunction with mycophenolate mofetil. She achieved a durable remission for 9 years until she presented with paresthesia affecting her left fifth digit, right proximal thigh, and left foot, while also reporting a 25-pound weight loss over the prior 3 months. New imaging demonstrated a longitudinally extensive and enhancing optic nerve, in conjunction with multifocal enhancing lesions within the spinal cord, in a skip-like distribution. The differential diagnosis is discussed.

Dyad learning versus individual learning under medical simulation conditions: a systematic review.

Background: Dyad learning is a two-person learning dynamic in which one student observes the other performing tasks, with their roles then being reversed such that both students experience the observer and the performer role. The efficacy of dyad learning has been tested in medical education contexts, such as in medical simulation. To our knowledge, this is the first systematic review that has evaluated the efficacy of dyad learning in a medical simulation context. Methods: PubMed, Google Scholar, Cochrane Library databases were searched in September 2021 and January 2022. Prospective studies of randomized design that compared dyad learning to a single medical student or physician learning in a medical simulation were included. Non-English language studies, secondary literature papers, non-human based studies, and papers that were published prior to 2000 were excluded. The methodological quality of these studies was assessed using the Medical Education Research Study Quality Instrument (MERSQI). The Kirkpatrick model was used to conceptualize study outcomes. Results: The identified papers included eight studies from four countries that totaled 475 participants. Students reported positively on their experiences as dyads, especially regarding the social aspects of it. Studies showed non-inferior learning outcomes for dyads. As most studies were one or two days long, there is limited evidence that this non-inferiority extends to longer term training modules. There is some evidence to suggest that dyad learning outcomes may be replicable in a clinical context following simulation training. Conclusions: Dyad learning in medical simulation is a pleasant experience for students and may be as effective as conventional learning. These findings set the foundation for future studies of longer duration, which is needed to determine the efficacy of dyad learning in lengthier curriculums and long-term knowledge retention. While cost-reduction is an implied benefit, studies that explicate cost reduction are needed to formalize this.

Increased Surveillance or Increased Scrutiny: Curbing Inappropriate Screening of Endometrial Cancer in Transgender Men.

Objective: The transgender male body is often considered a "black box" by even the most senior of attending physicians. Because of the stigma and fear associated with the utilization of Hormone Replacement Therapy (HRT) and the lack of clinical knowledge surrounding the subject, many transgender men will experience unnecessary testing for endometrial cancers. Materials and methods: This narrative review looked through publicly available PubMed and GoogleScholar articles on the topic of the use of pelvic ultrasounds in gynecological screening in transgendered males. 18,000 articles were filtered by relevance, date, clarity of the topic, and clinical recommendations. Of these articles 37 were included for discussion. Results: Of these 18,000 articles, only 37 were included for discussion. The resulting table, diagnostic tree, and discussion section are included within. Conclusion: Herein, the authors discuss the current understanding of the role of imaging in the diagnosis and treatment of gynecological cancers in transgendered men and how unnecessary imaging studies can be curbed for the benefit of the patient and the medical system at large.

Correction: Fever of Unknown Origin: The Workup and Diagnosis of Pel-Ebstein Fever.

[This corrects the article DOI: 10.7759/cureus.21959.].

Fever of Unknown Origin: The Workup and Diagnosis of Pel-Ebstein Fever.

The clinical and diagnostic workup of fever of unknown origin (FUO) is key in the treatment of patients on the internal medicine service. In this article, the authors present a case of fever of unknown origin, walk through the differential diagnosis, explain the laboratory testing ordered in the workup of the patient as well as the resulting values of said testing, and discuss the pathophysiology and diagnostic criteria for the diagnosis of Pel-Ebstein fever. The authors also discuss a clinical pearl when working with electronic health records to ensure that the needs of the patient in question are met.

Hearing abnormalities in multiple sclerosis: clinical semiology and pathophysiologic mechanisms.

Auditory manifestations from multiple sclerosis (MS) are not as common as the well-recognized sentinel exacerbations of optic neuritis, partial myelitis, motor weakness, vertiginous episodes, heat intolerance, and eye movement abnormalities. This paper discusses four cases of auditory changes, secondary to MS, and describes the first case, to our knowledge, of palinacousis, the perseveration of hearing, despite cessation of the sound stimulus. For each we characterize the initial complaint, the diagnostic work up, and ultimately, underscore the individualized treatment interventions, that allowed us to achieve a remission in all four cases. Individually codifying the treatment regimens served to mitigate, if not to abolish, the clinical derangements in hearing. Special attention is focused upon examination of the clinical manifestations and the pathophysiologic mechanisms which are responsible for them. We further emphasize the differential diagnostic considerations, and physical exam findings, along with the results of laboratory testing, neuro-imaging sequences, and lesion localization. Taken together, such information is germane to organizing cogently coherent strategic treatment plan(s). We believe that this small case series represents a clinically pragmatic example of 'precision medicine'; a principal theme and goal throughout this paper, the achievement of such in MS, but also as an illustration for the assessment and management schema for neuroimmunologic disorders in general.

Lend Me a Hand: A Value-Based Care Case Study on Pan Plexopathy of Unknown Origin.

This paper discusses an interesting case of pan plexopathy and the difficulties associated with the diagnostic processes based on patient-specific circumstances. It walks through the major differential of the etiology of the patient's particular presenting symptoms and the associated diagnostic and therapeutic process by which this particular patient was treated. In the discussion, the relevant anatomy of the brachial plexus and the surrounding structures in both the cervical and the axillary regions is discussed and key clinical pearls that became apparent throughout the diagnostic workup that was significant for a hematoma and therapeutic process aimed at providing symptomatic relief until recovery to baseline. This case study discusses the benefits, drawbacks, and financial costs of utilizing the major different imaging modalities such as CT, MRI, or Point of Care Ultrasound (POCUS). Finally, this study provides a new diagnostic algorithm for the selection of the imaging modality based on the major principles of value-based care as detailed by both the Radiological Society of North America and the European Society of Radiology.

Schizoaffective Disorder and Concurrent Rhabdomyolysis.

The authors present a unique case of schizoaffective disorder exacerbation, complicated by substance misuse, rhabdomyolysis, and acute renal injury. The patient had been recently released from jail and was not on any psychiatric medications aside. His family reported bizarre behavior involving the patient spending a significant amount of time in an outdoor hot tub exposed to extreme heat, which the patient justified as necessary to protect him from snakes. The patient was diagnosed with severe dehydration and rhabdomyolysis, both of which were managed by the primary care team in a hospital setting with specialist input from the psychiatry and renal departments. The patient exhibited paranoid ideations toward the medical team and at times was agitated and combative. Resolution of this distrust was pivotal to successful treatment and was made possible through trilateral communication between the patient, the police officers, and medical staff.

Application of an evidence-based, out-patient treatment strategy for COVID-19: Multidisciplinary medical practice principles to prevent severe disease.

The COVID-19 pandemic has devastated individuals, families, and institutions throughout the world. Despite the breakneck speed of vaccine development, the human population remains at risk of further devastation. The decision to not become vaccinated, the protracted rollout of available vaccine, vaccine failure, mutational forms of the SARS virus, which may exhibit mounting resistance to our molecular strike at only one form of the viral family, and the rapid ability of the virus(es) to hitch a ride on our global transportation systems, means that we are will likely continue to confront an invisible, yet devastating foe. The enemy targets one of our human physiology's most important and vulnerable life-preserving body tissues, our broncho-alveolar gas exchange apparatus. Notwithstanding the fear and the fury of this microbe's potential to raise existential questions across the entire spectrum of human endeavor, the application of an early treatment intervention initiative may represent a crucial tool in our defensive strategy. This strategy is driven by evidence-based medical practice principles, those not likely to become antiquated, given the molecular diversity and mutational evolution of this very clever "world traveler".

Part II. high-dose methotrexate with leucovorin rescue for severe COVID-19: An immune stabilization strategy for SARS-CoV-2 induced 'PANIC' attack.

Here, in Part II of a duology on the characterization and potential treatment for COVID-19, we characterize the application of an innovative treatment regimen for the prevention of the transition from mild to severe COVID-19, as well as detail an intensive immunotherapy intervention hypothesis. We propose as a putative randomized controlled trial that high-dose methotrexate with leucovorin (HDMTX-LR) rescue can abolish 'PANIC', thereby 'left-shifting' severe COVID-19 patients to the group majority of those infected with SARS-CoV-2, who are designated as having mild, even asymptomatic, disease. HDMTX-LR is endowed with broadly pleiotropic properties and is a repurposed, generic, inexpensive, and widely available agent which can be administered early in the course of severe COVID-19 thus rescuing the critical and irreplaceable gas-exchange alveoli. Further, we describe a preventative treatment intervention regimen for those designated as having mild to moderate COVID-19 disease, but who exhibit features which herald the transition to the severe variant of this disease. Both of our proposed hypothesis-driven questions should be urgently subjected to rigorous assessment in the context of randomized controlled trials, in order to confirm or refute the contention that the approaches characterized herein, are in fact capable of exerting mitigating, if not abolishing, effects upon SARS-CoV-2 triggered 'PANIC Attack'. Confirmation of our immunotherapy hypothesis would have far-reaching ramifications for the current pandemic, along with yielding invaluable lessons which could be leveraged to more effectively prepare for the next challenge to global health.

Part I. SARS-CoV-2 triggered 'PANIC' attack in severe COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has produced a world-wide collapse of social and economic infrastructure, as well as constrained our freedom of movement. This respiratory tract infection is nefarious in how it targets the most distal and highly vulnerable aspect of the human bronchopulmonary tree, specifically, the delicate yet irreplaceable alveoli that are responsible for the loading of oxygen upon red cell hemoglobin for use by all of the body's tissues. In most symptomatic individuals, the disease is a mild immune-mediated syndrome, with limited damage to the lung tissues. About 20% of those affected experience a disease course characterized by a cataclysmic set of immune activation responses that can culminate in the diffuse and irreversible obliteration of the distal alveoli, leading to a virtual collapse of the gas-exchange apparatus. Here, in Part I of a duology on the characterization and potential treatment for COVID-19, we define severe COVID-19 as a consequence of the ability of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to trigger what we now designate for the first time as a 'Prolific Activation of a Network-Immune-Inflammatory Crisis', or 'PANIC' Attack, in the alveolar tree. In Part II we describe an immunotherapeutic hypothesis worthy of the organization of a randomized clinical trial in order to ascertain whether a repurposed, generic, inexpensive, and widely available agent is capable of abolishing 'PANIC'; thereby preventing or mitigating severe COVID-19, with monumental ramifications for world health, and the global pandemic that continues to threaten it.

B2 or Not B2: A Systematic Literature Review on Migraine Headaches and Riboflavin Deficiency / B2 ou não B2: uma revisão sistemática da literatura sobre enxaquecas e deficiência de riboflavina

Objective: To assess the prevalence of riboflavin deficiency in patients with migraines or headaches.Methods: Systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Two articles met the inclusion and exclusion criteria, and neither of these discussed riboflavin deficiency prevalence in those patients who suffer from migraines. Conclusion: The prevalence of riboflavin deficiency in migraineurs and in headache patients is unknown.

Objetivo: Avaliar a prevalência de deficiência de riboflavina em pacientes com enxaquecas ou dores de cabeça. Métodos :Revisão sistemática da literatura seguindo as diretrizes Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Resultados: Dois artigos preencheram os critérios de inclusão e exclusão, e nenhum deles discutiu a prevalência de deficiência de riboflavina em pacientes que sofrem de enxaqueca. Conclusão: A prevalência da deficiência de riboflavina em pacientes com enxaqueca e com dor de cabeça é desconhecida.