Brain metastasis in a patient with multiple malignancies.

ABSTRACT: Brain metastases originate from other primary cancers within the body, most commonly lung, breast, and melanoma. Because patients with brain metastasis, stroke, or intracranial hemorrhage may present with similar acute neurologic symptoms, clinicians must have a high suspicion for brain metastasis and perform an immediate workup to rule out life-threatening conditions. This case report focuses on the clinical symptoms, diagnostics, and treatment options for brain metastasis in a patient with multiple malignancies.

Understanding resistant hypertension.

ABSTRACT: Resistant hypertension affects about 17% of the US population. However, it is difficult to diagnose because of multiple factors that influence adequate treatment of BP, including patient lifestyle and comorbidities, improper therapeutic regimens, and secondary mechanisms. Possible causes of resistant hypertension include nonmodulator hypertension, which affects patients who have an inappropriate response to elevated sodium through the renin-angiotensin-aldosterone system. Early identification and frequent follow-up can help patients achieve BP goals more rapidly and may reduce morbidity and mortality associated with complications of hypertension, including cerebrovascular accident, cardiovascular disease, and kidney disease.

Screening for hypertrophic cardiomyopathy.

ABSTRACT: Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiomyopathy and causes changes in the cardiac muscle affecting ventricular, valvular, and cellular functions. Because HCM is an inherited disorder, all age groups are affected; however, it commonly presents in adolescents, especially athletes. Many patients are asymptomatic and undiagnosed, putting them at risk for sudden cardiac death. This article describes screening and management of patients with HCM.

Adult attention deficit/hyperactivity disorder in the ambulatory care setting.

Adult attention deficit/hyperactivity disorder (ADHD) is a significant and prevalent disorder. ADHD can impair adults' quality of life, so clinicians in multiple specialties should be able to recognize and treat the disorder. Much of the current literature has focused on childhood ADHD. However, adult ADHD is a common comorbidity in patients with mental illness, and it is essential that patients diagnosed with the disorder are treated appropriately, which can significantly improve outcomes. Adults with untreated ADHD are more likely to have substance dependence, job instability, and an overall poorer quality of life. This article reviews the screening and assessment for adult ADHD along with pharmacologic and nonpharmacologic recommendations for the management of the disorder.

Kawasaki disease: Shedding light on a mysterious diagnosis.

Kawasaki disease is an acute systemic febrile vasculitis of medium and small arteries, most often occurring in children under age 5 years. This condition is the most common cause of acquired heart disease in children in the developed world. The cause is unclear but is thought to be a hyperimmune reaction to an infectious agent. Diagnosis is clinical; the classic presentation includes persistent fever, lymphadenopathy, oral mucosal changes, conjunctivitis, and rash. Although the disease technically is self-limiting, treatment with IV immunoglobulin (IVIG) and high-dose aspirin is necessary to prevent cardiac complications, such as coronary artery aneurysm, pericarditis, or myocarditis. This article reviews the pathophysiology, clinical presentation, diagnosis, and treatment of Kawasaki disease.

Trigger finger: An overview of the treatment options.

Stenosing flexor tenosynovitis, more commonly known as trigger finger, is one of the most common causes of hand pain and dysfunction. Clinicians must be able to identify the disorder, know the broad range of treatment options, and counsel patients on the treatment best suited for their condition. Awareness of the economic burden each option entails is central to optimizing treatment outcomes and patient satisfaction.

Opioid use disorder during pregnancy: An overview.

Women with opioid use disorder who become pregnant are a particularly vulnerable population and require a comprehensive treatment approach for mother and fetus. Research is continuing on opioid use disorder, effects of opioid use on the fetus, and best treatment approaches. This article reviews current recommendations and guidelines for treatment.

An overview of reactive arthritis.

Reactive arthritis, also known as Reiter syndrome, is a spondyloarthropathy that typically follows a urogenital or gastrointestinal infection, and is characterized by conjunctivitis, urethritis, and arthritis. The frequency of reactive arthritis in the United States is estimated at 3.5 to 5 patients per 100,000. Physician assistants (PAs) can manage the condition; therefore, they should be familiar with the disease's signs and symptoms, diagnostic criteria, and treatment regimens. Without proper management, reactive arthritis can progress to a chronic destructive arthritis. Prompt recognition of the condition is key to early intervention and a better patient outcome with fewer complications.

Isolated left homonymous hemianopia secondary to a pericatheter cyst-a rare presentation of a ventriculoperitoneal shunt failure.

A 26-year-old woman developed a left homonymous hemianopia 1 week after placement of a ventriculoperitoneal shunt through a right parieto-occipital approach. Computed tomography demonstrated a parenchymal cyst in the right occipital lobe. After shunt revision, there was concomitant resolution of the cyst and visual field defect over 1 month. The literature is reviewed regarding this unusual complication of ventriculoperitoneal shunt failure.

A double-blind placebo-controlled trial of N-acetylcysteine in the treatment of cocaine dependence.

BACKGROUND: There remains no FDA approved medication for the treatment of cocaine dependence. Preclinical studies and early pilot clinical investigations have suggested that N-acetylcysteine (NAC) may be useful in the treatment of the disorder. OBJECTIVE: The present report assessed the efficacy of NAC in the treatment of cocaine dependence. METHODS: Cocaine-dependent volunteers (n = 111) were randomized to receive daily doses of 1,200 mg of NAC, 2,400 mg of NAC, or placebo. Participants were followed for 8 weeks (up to three visits weekly). At each of these visits, urine samples were collected, along with self-reports of cocaine use. Urine samples were assessed for quantitative levels of benzoylecognine (ie, cocaine metabolite). RESULTS: Overall, the primary results for the clinical trial were negative. However, when considering only subjects who entered the trial having already achieved abstinence, results favored the 2,400 mg NAC group relative to placebo, with the 2,400 mg group having longer times to relapse and lower craving ratings. CONCLUSION: While the present trial failed to demonstrate that NAC reduces cocaine use in cocaine-dependent individuals actively using, there was some evidence it prevented return to cocaine use in individuals who had already achieved abstinence from cocaine. SCIENTIFIC SIGNIFICANCE: N-acetylcysteine may be useful as a relapse prevention agent in abstinent cocaine-dependent individuals.

Biomaterial-based interventions for neuronal regeneration and functional recovery in rodent model of spinal cord injury: a systematic review.

CONTEXT: There is considerable interest in translating laboratory advances in neuronal regeneration following spinal cord injury (SCI). A multimodality approach has been advocated for successful functional neuronal regeneration. With this goal in mind several biomaterials have been employed as neuronal bridges either to support cellular transplants, to release neurotrophic factors, or to do both. A systematic review of this literature is lacking. Such a review may provide insight to strategies with a high potential for further investigation and potential clinical application. OBJECTIVE: To systematically review the design strategies and outcomes after biomaterial-based multimodal interventions for neuronal regeneration in rodent SCI model. To analyse functional outcomes after implantation of biomaterial-based multimodal interventions and to identify predictors of functional outcomes. METHODS: A broad PubMed, CINHAL, and a manual search of relevant literature databases yielded data from 24 publications; 14 of these articles included functional outcome information. Studies reporting behavioral data in rat model of SCI and employing biodegradable polymer-based multimodal intervention were included. For behavioral recovery, studies using severe injury models (transection or severe clip compression (>16.9 g) or contusion (50 g/cm)) were categorized separately from those investigating partial injury models (hemisection or moderate-to-severe clip compression or contusion). RESULTS: The cumulative mean improvements in Basso, Beattie, and Bresnahan scores after biomaterial-based interventions are 5.93 (95% CI = 2.41 - 9.45) and 4.44 (95% CI = 2.65 - 6.24) for transection and hemisection models, respectively. Factors associated with improved outcomes include the type of polymer used and a follow-up period greater than 6 weeks. CONCLUSION: The functional improvement after implantation of biopolymer-based multimodal implants is modest. The relationship with neuronal regeneration and functional outcome, the effects of inflammation at the site of injury, the prolonged survival of supporting cells, the differentiation of stem cells, the effective delivery of neurotrophic factors, and longer follow-up periods are all topics for future elucidation. Future investigations should strive to further define specific factors associated with improved functional outcomes in clinically relevant models.

Prevalence, characteristics, and poverty status of Supplemental Security Income multirecipients.

"Multirecipients" are people who receive Supplemental Security Income (SSI) payments while living with other recipients (not including an SSI-eligible spouse). Using Social Security Administration records matched to Current Population Survey data for 2005, this article examines multirecipients' personal, family, household, and economic characteristics. I find that no more than 20 percent of the 2005 SSI population were multirecipients. Most multirecipients were adults, lived with one other recipient, and/or shared their homes with related recipients. Multirecipients were generally less likely to be poor than SSI recipients as a whole; but those who were children, lived with one other recipient, and/or shared their homes with a nonrecipient were more likely to be poor. Implementing sliding-scale SSI benefit reductions for children in multirecipient households would affect about 23 percent of multirecipients, or about 5 percent of all SSI recipients.

Response to disease modifying therapies in African Americans with multiple sclerosis.

BACKGROUND: The African American (AA) population has a lower risk for developing multiple sclerosis (MS) than Caucasian (CA) population; however, the disease tends to be more severe with early disability in AA. The reason underlying the discrepancy in disease severity is not yet understood, and it could be caused by different response to disease modifying therapies (DMTs). OBJECTIVE: To evaluate whether there are significant differences in profile of response to disease modifying therapies related to ethnicity, while controlling for disease characteristics. DESIGN: We performed a retrospective chart analysis of MS patients undergoing treatment with DMTs. Rating of disease progression was based on expanded disability status score (EDSS) difference at the time of first and last visit. PATIENTS: AA and CA patients with MS. RESULTS: Sex and age at the time of diagnosis did not differ significantly between AA and CA. There was statistically significant difference in disease duration, which was longer among CA patients (P < .001). Median of EDSS difference was higher in AA population than in CA population (P < .001). Increased EDSS difference suggests poorer response to DMTs among AA patients in our study. CONCLUSIONS: AA patients showed poorer response to DMTs when compared with CA patients. This suggests a trend, however, further prospective studies on the response of AA patients to DMTs are warranted.

Comparison of Methods for Identifying Phenotype Subgroups Using Categorical Features Data With Application to Autism Spectrum Disorder.

We evaluate the performance of the Dirichlet process mixture (DPM) and the latent class model (LCM) in identifying autism phenotype subgroups based on categorical autism spectrum disorder (ASD) diagnostic features from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision. A simulation study is designed to mimic the diagnostic features in the ASD dataset in order to evaluate the LCM and DPM methods in this context. Likelihood based information criteria and DPM partitioning are used to identify the best fitting models. The Rand statistic is used to compare the performance of the methods in recovering simulated phenotype subgroups. Our results indicate excellent recovery of the simulated subgroup structure for both methods. The LCM performs slightly better than DPM when the correct number of latent subgroups is selected a priori. The DPM method utilizes a maximum a posteriori (MAP) criterion to estimate the number of classes, and yielded results in fair agreement with the LCM method. Comparison of model fit indices in identifying the best fitting LCM showed that adjusted Bayesian information criteria (ABIC) picks the correct number of classes over 90% of the time. Thus, when diagnostic features are categorical and there is some prior information regarding the number of latent classes, LCM in conjunction with ABIC is preferred.

Methodology Applied by a Physician Assistant Program to Evaluate the New ARC-PA 5 th Edition Diversity and Inclusion Standard.

ABSTRACT: Diversity and inclusion in higher education are a top priority for institutions. In 2020, the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), in its 5 th edition of the Accreditation Standards for Physician Assistant Education, implemented a standard specifically designed to require programs to demonstrate their commitment to diversity and inclusion. Through a protocol-driven methodology, consistent with the ARC-PA's 4 key elements of analysis, one PA program demonstrates and explains how it examines ongoing compliance with diversity and inclusion within their program.

Application of beta regression to analyze ischemic stroke volume in NINDS rt-PA clinical trials.

BACKGROUND AND PURPOSE: Ischemic stroke lesion volumes have proven difficult to analyze due to the extremely skewed shape of their underlying distribution. We introduce an extension of generalized linear models, beta regression, as a possible method of modeling extremely skewed distributions as evidenced in ischemic stroke lesion volumes. METHODS: The NINDS rt-PA clinical trials measured ischemic stroke lesion volume as a secondary trial outcome. Three-month lesion volumes from these trials were analyzed using beta regression. A multi-variable regression model associating explanatory variables with ischemic stroke lesion volumes was constructed using accepted model building strategies and compared with the previously published volumetric analysis. RESULTS: Beta regression produced a similar model when compared to the previous analysis published by the study group. All previously identified variables of importance were detected in the model building process. The age by treatment interaction described in previous studies was also found in this analysis, confirming the strong effect age has on stroke outcomes. Further, a treatment effect was elicited in terms of odds ratios, yielding a previously unknown quantification of the effect of rt-PA on lesion volumes. CONCLUSIONS: Beta regression proved adept in modeling ischemic stroke lesions and offered the interpretation of covariates in terms of odds ratios. Beta regression is seen as a legitimate alternative to analyze ischemic stroke volumes.

Osmotherapy: use among neurointensivists.

BACKGROUND: Cerebral edema and raised intracranial pressure are common problems in neurological intensive care. Osmotherapy, typically using mannitol or hypertonic saline (HTS), has become one of the first-line interventions. However, the literature on the use of these agents is heterogeneous and lacking in class I studies. The authors hypothesized that clinical practice would reflect this heterogeneity with respect to choice of agent, dosing strategy, and methods for monitoring therapy. METHODS: An on-line survey was administered by e-mail to members of the Neurocritical Care Society. Multiple-choice questions regarding use of mannitol and HTS were employed to gain insight into clinician practices. RESULTS: A total of 295 responses were received, 79.7% of which were from physicians. The majority (89.9%) reported using osmotherapy as needed for intracranial hypertension, though a minority reported initiating treatment prophylactically. Practitioners were fairly evenly split between those who preferred HTS (54.9%) and those who preferred mannitol (45.1%), with some respondents reserving HTS for patients with refractory intracranial hypertension. Respondents who preferred HTS were more likely to endorse prophylactic administration. Preferred dosing regimens for both agents varied considerably, as did monitoring parameters. CONCLUSIONS: Treatment of cerebral edema using osmotically active substances varies considerably between practitioners. This variation could hamper efforts to design and implement multicenter trials in neurocritical care.

The association of drinking water quality and sewage disposal with Helicobacter pylori incidence in infants: the potential role of water-borne transmission.

The mode of transmission of Helicobacter pylori, a bacterium causing gastric cancer and peptic ulcer disease, is unknown although waterborne transmission is a likely pathway. This study investigated the hypothesis that access to treated water and a sanitary sewerage system reduces the H. pylori incidence rate, using data from 472 participants in a cohort study that followed children in Juarez, Mexico, and El Paso, Texas, from April 1998, with caretaker interviews and the urea breath test for detecting H. pylori infection at target intervals of six months from birth through 24 months of age. The unadjusted hazard ratio comparing bottled/vending machine water to a municipal water supply was 0.71 (95% confidence interval (CI): 0.50, 1.01) and comparing a municipal sewer connection to a septic tank or cesspool, 0.85 (95% CI: 0.60, 1.20). After adjustment for maternal education and country, the hazard ratios decreased slightly to 0.70 (95% confidence interval: 0.49, 1.00) and 0.77 (95% confidence interval: 0.50, 1.21), respectively. These results provide moderate support for potential waterborne transmission of H. pylori.

Elderly poverty and supplemental security income, 2002-2005.

The Supplemental Security Income (SSI) program is the nation's safety net for the aged, blind, and disabled. SSI receipt is often not reported by individuals interviewed in the Current Population Survey (CPS), the statistical base for the Census Bureau's annual estimates of poverty rates. In an earlier article, we explored the effect on estimated poverty rates in 2002 of adjusting CPS income reports using administrative data on earnings and benefits from the SSI and Old-Age, Survivors, and Disability Insurance programs. We assessed poverty using both the official standard and a "relative" standard based on half of median pretax, posttransfer income. This article extends that work through 2005. We find that including administrative data presents challenges, but under the methodology we adopt, such adjustments lower estimated official poverty overall and increase estimated poverty rates for elderly SSI recipients. Relative poverty rates are much higher than official poverty rates. By any of the applied standards and procedures for income adjustment, poverty changed little over the 2002-2005 interval.

Racial/ethnic disparities in the identification of children with autism spectrum disorders.

OBJECTIVES: We sought to examine racial and ethnic disparities in the recognition of autism spectrum disorders (ASDs). METHODS: Within a multisite network, 2568 children aged 8 years were identified as meeting surveillance criteria for ASD through abstraction of evaluation records from multiple sources. Through logistic regression with random effects for site, we estimated the association between race/ethnicity and documented ASD, adjusting for gender, IQ, birthweight, and maternal education. RESULTS: Fifty-eight percent of children had a documented autism spectrum disorder. In adjusted analyses, children who were Black (odds ratio [OR] = 0.79; 95% confidence interval [CI] = 0.64, 0.96), Hispanic (OR = 0.76; CI = 0.56, 0.99), or of other race/ethnicity (OR = 0.65; CI = 0.43, 0.97) were less likely than were White children to have a documented ASD. This disparity persisted for Black children, regardless of IQ, and was concentrated for children of other ethnicities when IQ was lower than 70. CONCLUSIONS: Significant racial/ethnic disparities exist in the recognition of ASD. For some children in some racial/ethnic groups, the presence of intellectual disability may affect professionals' further assessment of developmental delay. Our findings suggest the need for continued professional education related to the heterogeneity of the presentation of ASD.