An undifferentiated cause of rhabdomyolysis: a case report.

BACKGROUND: Rhabdomyolysis can occur secondary to infections, trauma, or myotoxic substances. Rhabdomyolysis secondary to autoimmune myositis occurs rarely. Distinguishing autoimmune rhabdomyolysis from rhabdomyolysis secondary to other causes is paramount in considering the long-term management of autoimmune rhabdomyolysis. It is further important to continue close follow-up and further testing to completely understand the extent of this disease as diagnoses may be ever-changing. CASE PRESENTATION: A previously healthy female presented to the hospital with myalgias and myoglobinuria following a respiratory infection treated with azithromycin and promethazine. Labs demonstrating elevated creatine kinase (CK) prompted treatment for rhabdomyolysis and rheumatology consultation. The patient was given 3 l of intravenous (IV) 0.9% sodium chloride in the Emergency Department. Upon admission, the patient was placed on a continuous IV drip of 0.9% sodium chloride running at 300 cc/hour for all 8 days of her hospital admission. The rheumatology autoantibody panel pointed towards autoimmune myositis as a potential cause of her rhabdomyolysis. The patient was discharged to follow up with rheumatology for further testing. CONCLUSION: Autoimmune myositis, although less common than other etiologies of rhabdomyolysis, is important to consider as the long-term management of autoimmune myositis includes the use of immunosuppressants, antimalarials, or IV immunoglobulins, which may be inappropriate for other etiologies of rhabdomyolysis.

Ovarian vein thrombosis: A rare cause of abdominal pain as a complication of an elective abortion.

Ovarian vein thrombosis (OVT) is a rare diagnosis. Patients can appear to be very uncomfortable on presentation with a physical examination that can mimic an acute abdomen. OVT is most often diagnosed during the postpartum period [Jenayah et al., 2015] and not typically seen during pregnancy or after procedures such as dilation and curettage (D&C). The complications from an OVT are significant and include sepsis, thrombophlebitis and pulmonary embolism [Harris et al., 2012]. Here we describe a case of OVT with an atypical presentation, diagnosed twenty-four hours after an elective D&C for a second trimester abortion.

Mesh for Hernia Repair as Cause of Bowel Obstruction.

Ventral hernia repairs are commonly treated by abdominal wall repair where a prosthetic mesh is placed over the hernia site, to prevent future hernia recurrences. Risks of a ventral hernia repair include urinary retention, seroma, recurrence, and in rare cases, bowel injury or obstruction. Our patient's clinical presentation and history, supported by an abdominal X-ray and CT findings, were consistent with the diagnosis of small bowel obstruction (SBO) due to adhesions between the patient's small bowel and the mesh used for abdominal wall hernia repair. Our patient underwent an exploratory laparotomy due to exquisite abdominal wall tenderness and evidence of SBO. Appropriate identification of the cause of our patient's SBO, careful and meticulous treatment, and appropriate inpatient monitoring all contributed to a successful outcome.

A Comprehensive Review of Pharmaceutical and Surgical Interventions of Prostate Cancer.

As the second most common cause of death amongst men in the United States, prostate cancer is a type of cancer that is known to develop and originate in the prostate gland. The main function of the prostate gland is to produce seminal fluid in which the sperm bathes. The seminal fluids are necessary for allowing the sperm to move easily through the urethra and also allows successful fertilization by providing an alkaline environment for the sperm in the acidic nature of the vagina. The seminal vesicles are two smaller glands that are attached to either side of the prostate gland and in radical prostatectomies, can get removed. In the event that the seminal vesicles are removed during a radical prostatectomy, the individual is unable to produce any seminal fluids and thus, becoming infertile. Prostate cancer is most commonly seen in patients over the age of 66 years, however, in the presence of predisposing risk factors, may occur as early as in the late 40s. Certain risk factors may speed the presentation of prostate cancer in individuals and thus, mandatory screening is recommended around the age of 45. If no risk factors are present, screening is recommended to begin after the age of 50 years. Screening for prostate cancer is focused on looking for prostate-specific antigen (PSA) in a blood test, though this may not be the most reliable method. The method of diagnosis stems from further testing done following an abnormal PSA test. A digital rectal examination and ultrasonography may also be used to assist with the diagnosis of prostate cancer. Though there are several different types of pharmaceutical interventions currently present in the eradication of prostate cancer, with androgen deprivation therapy being the most commonly used, surgical interventions may be utilized to completely resect cancer from an individual. Different radical prostatectomies are used; the appropriate approach utilized is dependent on the extensiveness of cancer and the type of cancer that is present.

Neurological Consequences of 2019-nCoV Infection: A Comprehensive Literature Review.

First identified in November 2019 in Hubei Province, the coronavirus disease of 2019 (COVID-19) caused by SARS-CoV-2 soon spread worldwide to become a global health pandemic. The COVID-19 preferentially damages the respiratory system that produces symptoms such as fever, cough, and shortness of breath. However, the infection often tends to disseminate to involve various organ systems. Recent evidence indicates that SARS-CoV-2 can cause significant neurological damage and resultant neurological symptoms and complications. Here, we provide a comprehensive and thorough review of original articles, case reports, and case series to delineate the possible mechanisms of nervous system invasion and damage by SARS-CoV-2 and subsequent consequences. We divided the neurological manifestations into three categories: (1) Central Nervous System involvement, (2) Peripheral Nervous System manifestations, and (3) Skeletal Muscle Injury. Headache and dizziness were found to be the most prevalent symptoms followed by impaired consciousness. Among the symptoms indicating peripheral nervous system invasion, anosmia and dysgeusia were commonly reported. Skeletal muscle injury predominantly presents as myalgia. In addition, encephalitis, myelitis, cerebrovascular disease, Guillain-Barre syndrome, and Miller Fischer syndrome were among the commonly noted complications. We also emphasized the association of pre-existing comorbidities with neurological manifestations. The aim of this review is to provide a deeper understanding of the potential neurological implications to help neurologists have a high index of clinical suspicion allowing them to manage the patient appropriately.

Neuromuscular Junction Disorders and Floppy Infant Syndrome: A Comprehensive Review.

Floppy infant syndrome, also sometimes referred to as rag-doll syndrome, is characterized by hypotonia that could present as either peripheral hypotonia or central. Depending on the origin of hypotonia, the infant will present with different symptoms that ultimately have the characteristic feature of hypotonia. The clinical examination is crucial in diagnosing floppy infant syndrome in the neonate period, but the most critical factor is investigating and diagnosing the underlying cause of hypotonia. Regardless of whether the underlying cause of hypotonia is peripheral or central in origin, the presentation of floppy infant syndrome focuses on observing for the presence or absence of specific signs such as 'frog-leg' posture, significant head lag on traction or pull-to-sit maneuver, or the feeling of 'slipping through the hands' when the infant is held under the arms. Infantile botulism, transient neonatal myasthenia gravis, congenital myasthenia gravis, hypermagnesemia, and aminoglycoside toxicity are all neuromuscular junction disorders that are considered to be a differential diagnosis of floppy infant syndrome. These neuromuscular junction disorders ultimately impact the presence of acetylcholine within the neuromuscular junction. While some of these disorders may impact the acetylcholine receptors, others may cause a depletion within the end-plate anticholinesterase enzyme. A deficiency within the anticholinesterase deficiency may cause desensitization to acetylcholine, which could also cause present with floppy infant syndrome as well. Depending on the underlying causative disorder leading to the presence of floppy infant syndrome, the treatment will vary considerably. Treatment of the underlying causative syndrome resulting in the presentation of floppy infant syndrome deals with the symptoms of hypotonia, and as a result, the decreased muscle tone, diminished tendon reflexes, any feeding or respiratory difficulties diminish.

Curricula for empathy and compassion training in medical education: A systematic review.

BACKGROUND: Empathy and compassion are vital components of health care quality; however, physicians frequently miss opportunities for empathy and compassion in patient care. Despite evidence that empathy and compassion training can be effective, the specific behaviors that should be taught remain unclear. We synthesized the biomedical literature on empathy and compassion training in medical education to find the specific curricula components (skills and behaviors) demonstrated to be effective. METHODS: We searched CENTRAL, MEDLINE, EMBASE, and CINAHL using a previously published comprehensive search strategy. We screened reference lists of the articles meeting inclusion criteria to identify additional studies for potential inclusion. Study inclusion criteria were: (1) intervention arm in which subjects underwent an educational curriculum aimed at enhancing empathy and/or compassion; (2) clearly defined control arm in which subjects did not receive the curriculum; (3) curriculum was tested on physicians (or physicians-in-training); and (4) outcome measure assessing the effect of the curriculum on physician empathy and/or compassion. We performed a qualitative analysis to collate and tabulate effects of tested curricula according to recommended methodology from the Cochrane Handbook. We used the Cochrane Collaboration's tool for assessing risk of bias. RESULTS: Fifty-two studies (total n = 5,316) met inclusion criteria. Most (75%) studies found that the tested curricula improved physician empathy and/or compassion on at least one outcome measure. We identified the following key behaviors to be effective: (1) sitting (versus standing) during the interview; (2) detecting patients' non-verbal cues of emotion; (3) recognizing and responding to opportunities for compassion; (4) non-verbal communication of caring (e.g. eye contact); and (5) verbal statements of acknowledgement, validation, and support. These behaviors were found to improve patient perception of physician empathy and/or compassion. CONCLUSION: Evidence suggests that training can enhance physician empathy and compassion. Training curricula should incorporate the specific behaviors identified in this report.

Curricula and methods for physician compassion training: protocol for a systematic review.

INTRODUCTION: Compassionate patient care has been associated with improved clinical outcomes for patients. However, current evidence suggests that healthcare is experiencing a compassion crisis, with physicians frequently overlooking opportunities to treat patients with compassion. Although there is evidence that compassionate care can be enhanced through training interventions, it is currently unclear what specific skills and behaviours ought to be taught and how best to transfer this information to the learner. The objectives of this systematic review are to collate the world's literature on compassion training to determine (1) the specific skills and behaviours that should be taught (curriculum), and (2) the methods of training that are most effective at improving compassionate patient care. METHODS AND ANALYSIS: We will perform a qualitative systematic review of studies aimed at improving compassionate patient care among physicians and physicians in training. We will comprehensively search CENTRAL, MEDLINE, EMBASE and CINAHL. Additional recommended techniques for systematic reviews of complex evidence will be performed including pursuing selected 'references of references', electronic citation tracking and consulting experts in the field. Two investigators will independently review all search results. After identification and inclusion of papers, we will use a standardised form for data extraction. We will use tables to describe the study populations, interventions tested (including specific skill/behaviours taught and training methods used), outcome measures and effects of interventions on outcome measures compared with control groups. Where appropriate, meta-analysis will be used for quantitative analysis of the data. ETHICS AND DISSEMINATION: The proposed systematic review does not require ethical approval since no individual patient-level data will be collected. Results of this study will contribute to the understanding of compassion training and help inform the development of compassion training curricula. PROSPERO REGISTRATION NUMBER: CRD42018095040.

Medical Student Perception of Resident Versus Attending Contributions to Education on Co-Supervised Shifts During the Emergency Medicine Clerkship.

OBJECTIVE: The objective was to assess medical student perception of resident and attending contributions to nine Accreditation Council for Graduate Medical Education educational objectives during their emergency medicine (EM) clerkship. METHODS: This was a prospective survey study of fourth-year medical students during their EM clerkship in a single academic emergency department. Students anonymously completed end-of-shift surveys if supervised by both resident and attending physicians. Students estimated the relative educational contribution from resident and attending on a 100-point visual analog scale (-50 to 50) with -50 = 100% resident contribution, +50 = 100% attending contribution, and 0 = equal contributions by resident and attendings. Nine educational objectives were surveyed: evidence-based medicine (EBM), clinical knowledge, chart documentation, bedside teaching, patient throughput, interpersonal communication, oral patient presentations, efficiency, and procedural instruction. RESULTS: We collected 274 surveys from 65 students. Of the nine objectives, students perceived that residents contributed more than attendings in eight of nine (results reported as mean values with 95% confidence intervals): clinical knowledge -4.5 (-7.3 to -1.7), chart documentation -8.0 (-12.0 to -4.0), bedside teaching -8.6 (-12.0 to -5.2), throughput -13.0 (-16.4 to -9.6), oral presentations -14.2 (-17.3 to -11), efficiency -14.4 (-17.6 to -11.3), procedural instruction -20.2 (-24.0 to -16.5), and interpersonal communication -13.5 (-17.7 to -9.4). The sole outlier favoring attendings was EBM: 5.5 (1.9 to 9.1). CONCLUSIONS: Medical students perceive resident physicians to contribute more than attendings for most of their EM educational objectives, with faculty providing the greatest contribution to their EBM training.

Balloon-assisted tracking: A practical solution to avoid radial access failure due to difficult anatomical challenges.

AIM: The balloon assisted tracking (BAT) technique is utilised to overcome various anatomical difficulties during radial procedures when standard measures such as adequate sedation, pain relief, vasodilators and use of hydrophilic guidewires, fail. The aim of this study was to evaluate the success rates of the BAT technique in overcoming anatomical difficulties during radial coronary interventional procedures. METHODS: We retrospectively reviewed 1100 consecutive patients undergoing coronary procedures from the transradial approach (TRA) between May 2015 and May 2017. Anatomic variations and equipment used were recorded from procedure logs. RESULTS: Overall 30 patients (2.72%) required the use of BAT. Mean age was 66.7years, with a range from 48 to 90years (53.3% female). Out of these 30 cases, 86.7% patients underwent percutaneous coronary intervention (PCI) while the remaining patients underwent coronary angiography alone. Acute coronary syndrome cases represented 63.3% of the cases while the remaining patients were elective procedures. Anatomical difficulties included severe, non-resolving radial spasm (66.6%), catheter induced radial or brachial perforation (16.6%), small calibre and/or diseased radial artery (10.0%), severe radial, branchial and/or subclavian tortuosity (3.0%) and radial loops (3.0%). Anatomical difficulties were overcome in all cases (100%). Coronary angiography and/or PCI were successfully completed in all 30 cases without the need for obtaining alternative arterial access. Mean added procedural time was 131s. There were no procedure related complications. CONCLUSION: Balloon assisted tracking is a highly successful and safe technique for overcoming various anatomical difficulties at the level of the radial, brachial or subclavian arteries, which minimises the need for alternative arterial access.

Early Disseminated Lyme Disease Masquerading as Mononucleosis: A Case Report.

BACKGROUND: Disseminated Lyme disease can be difficult to diagnose, as it begins with nonspecific signs and symptoms, which, if not treated correctly, can lead to atrioventricular conduction blocks and meningitis. In addition, the diagnosis can be further complicated by potentially false-positive test results. CASE REPORT: We report a case of early-disseminated Lyme disease presenting with Borrelia meningitis and concomitant Lyme carditis, which was misdiagnosed as mononucleosis. A young, previously healthy patient had been hiking in the woods of upstate New York and 4 weeks later developed fever, night sweats, and myalgias. He was diagnosed with mononucleosis via a positive rapid heterophile agglutination antibody test to the Epstein-Barr virus at a walk-in clinic and was started on medications, but then subsequently developed left hip pain, a facial droop, and a very long first-degree atrioventricular conduction block. He went to the Emergency Department, where he had testing that confirmed disseminated Lyme disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the difficulty in early diagnosis of disseminated Lyme disease and how a potentially false-positive laboratory test can lead to the complications of Borrelia meningitis and Lyme carditis in untreated young healthy patients. Emergency physicians need to consider Lyme disease in patients with nonspecific signs and symptoms, especially if they have been outdoors for prolonged periods of time in Lyme-endemic areas.

Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers.

INTRODUCTION: Electronic health records (EHR) have become ubiquitous in emergency departments. Medical students rotating on emergency medicine (EM) clerkships at these sites have constant exposure to EHRs as they learn essential skills. The Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have determined that documentation of the patient encounter in the medical record is an essential skill that all medical students must learn. However, little is known about the current practices or perceived barriers to student documentation in EHRs on EM clerkships. METHODS: We performed a cross-sectional study of EM clerkship directors at United States medical schools between March and May 2016. A 13-question IRB-approved electronic survey on student documentation was sent to all EM clerkship directors. Only one response from each institution was permitted. RESULTS: We received survey responses from 100 institutions, yielding a response rate of 86%. Currently, 63% of EM clerkships allow medical students to document a patient encounter in the EHR. The most common reasons cited for not permitting students to document a patient encounter were hospital or medical school rule forbidding student documentation (80%), concern for medical liability (60%), and inability of student notes to support medical billing (53%). Almost 95% of respondents provided feedback on student documentation with supervising faculty being the most common group to deliver feedback (92%), followed by residents (64%). CONCLUSION: Close to two-thirds of medical students are allowed to document in the EHR on EM clerkships. While this number is robust, many organizations such as the AAMC and ACE have issued statements and guidelines that would look to increase this number even further to ensure that students are prepared for residency as well as their future careers. Almost all EM clerkships provided feedback on student documentation indicating the importance for students to learn this skill.

Development of archetypes for non-ranking classification and comparison of European National Health Technology Assessment systems.

INTRODUCTION: European countries are increasingly utilising health technology assessment (HTA) to inform reimbursement decision-making. However, the current European HTA environment is very diverse, and projects are already underway to initiate a more efficient and aligned HTA practice within Europe. This study aims to identify a non-ranking method for classifying the diversity of European HTA agencies process and the organisational architecture of the national regulatory review to reimbursement systems. METHOD/RESULTS: Using a previously developed mapping methodology, this research created process maps to describe national processes for regulatory review to reimbursement for 33 European jurisdictions. These process maps enabled the creation of 2 HTA taxonomic sets. The confluence of the two taxonomic sets was subsequently cross-referenced to identify 10 HTA archetype groups. DISCUSSION: HTA is a young, rapidly evolving field and it can be argued that optimal practices for performing HTA are yet to emerge. Therefore, a non-ranking classification approach could objectively characterise and compare the diversity observed in the current European HTA environment.

Disparities in children with otitis media: the effect of insurance status.

OBJECTIVES: To determine the difference between children with private and public insurance at the time of referral to a pediatric otolaryngologist. STUDY DESIGN: Prospective study. SETTING: Tertiary care hospital. SUBJECTS AND METHODS: Data relating to the severity of a patient's otitis media (number of infections, doctor visits, antibiotic courses) were collected by phone interview. All patients referred to a pediatric otolaryngologist at an urban tertiary care hospital over a 5-month period were included. RESULTS: One hundred eighty-three children were studied: 87 consecutive patients in the private third-party insurance group (PIN) and 96 patients in the state-based Medicaid insurance group (PA). During the 6 months prior to referral, children in the PIN group had a median 4 acute otitis media infections with 5 courses of oral antibiotics and 6 primary care visits compared to 3 infections with 3 courses of antibiotics and 4 primary care visits for the PA group (P = .0009, P ≤ .0001, P = .0003, respectively). For recurrent acute otitis media, the PA group had a significantly longer time with disease prior to referral than the PIN group (P = .0478). CONCLUSION: Children in this metropolitan area referred for tympanostomy tube placement with PIN are younger, have more episodes of acute otitis media, receive more antibiotic courses, and have more primary care visits in the 6 months prior to referral than their PA counterparts. Additional research is required to determine why these differences exist, especially in light of ongoing changes to the health care system.

Triple-vessel percutaneous coronary revascularization in situs inversus dextrocardia.

Dextrocardia with situs inversus occurs in approximately one in 10,000 individuals of whom 20% have primary ciliary dyskinesia inherited as an autosomal recessive trait. These patients have a high incidence of congenital cardiac disease but their risk of coronary artery disease is similar to that of the general population. We report what is, to our knowledge, the first case of total triple-vessel coronary revascularization by percutaneous stent implantation in a 79-year-old woman with situs inversus dextrocardia. We describe the successful use of standard diagnostic and interventional guide catheters with counter rotation and transversely inversed image acquisition techniques. The case also highlights that the right precordial pain may represent cardiac ischemia in this population.

Multicenter study of cigarette smoking among patients presenting to the emergency department with acute asthma.

BACKGROUND: Many studies have focused on smoking and chronic asthma severity. However, research on the relationship between smoking and acute asthma severity in an acute care setting is sparse. OBJECTIVES: To determine the smoking prevalence among emergency department (ED) patients with acute asthma and to investigate the relationships between smoking and acute asthma severity. METHODS: A 63-site medical record review study of ED patients, ages 14 to 54 years, with a principal diagnosis of acute asthma was performed. Patients with chronic obstructive pulmonary disease were excluded. Measurements for acute asthma severity included sociodemographic factors, asthma medical history, ED presentation, clinical course, medications administered, and return visit within 48 hours. RESULTS: A total of 4,052 patient medical records were reviewed. A total of 1,332 patients (33%; 95% confidence interval, 31%-34%) were documented as smokers. No statistically significant differences were found between smokers and nonsmokers in vital signs, oxygen saturation, peak expiratory flow, and administration of asthma medications. By contrast, smokers were more likely than nonsmokers to receive antibiotics in the ED (12% vs 9%, P < .001) or at discharge (23% vs 14%, P < .001). A multivariate analysis confirmed that smoking status was independently associated with antibiotic administration (odds ratio, 1.6; 95% confidence interval, 1.3-1.8). CONCLUSIONS: One-third of ED patients with acute asthma smoked cigarettes. Smokers and nonsmokers did not differ in their acute asthma severity. Asthmatic smokers, however, were more likely to receive antibiotics, even when adjusting for other possible confounders.

Lifesaving embolization of coronary artery perforation.

Coronary artery perforation remains one of the most fearsome complications during cardiac catheterization procedures. Although emergent bypass surgery is the preferred treatment for cases with uncontrollable perforation, endovascular vessel sealing and arrest of bleeding with a combination of balloons, covered stents, or embolic materials have also been proposed. The authors describe a case of emergent lifesaving microcoil embolization of the distal right coronary artery in a patient with uncontrollable grade III guidewire perforation resulting in cardiac tamponade. The relevant literature is reviewed and the merits and limitations of the endovascular approach are highlighted.

Transgenic mice expressing a cameleon fluorescent Ca2+ indicator in astrocytes and Schwann cells allow study of glial cell Ca2+ signals in situ and in vivo.

Glial cell Ca2+ signals play a key role in glial-neuronal and glial-glial network communication. Numerous studies have thus far utilized cell-permeant and injected Ca2+ indicator dyes to investigate glial Ca2+ signals in vitro and in situ. Genetically encoded fluorescent Ca2+ indicators have emerged as novel probes for investigating cellular Ca2+ signals. We have expressed one such indicator protein, the YC 3.60 cameleon, under the control of the S100beta promoter and directed its expression predominantly in astrocytes and Schwann cells. Expression of YC 3.60 extended into the entire cellular cytoplasmic compartment and the fine terminal processes of protoplasmic astrocytes and Schwann cell Cajal bands. In the brain, all the cells known to express S100beta in the adult or during development, expressed YC 3.60. While expression was most extensive in astrocytes, other glial cell types that express S100beta, such as NG2 and CNP-positive oligodendrocyte progenitor cells (OP cells), microglia, and some of the large motor neurons in the brain stem, also contained YC 3.60 fluorescence. Using a variety of known in situ and in vivo assays, we found that stimuli known to elicit Ca2+ signals in astrocytes caused substantial and rapid Ca2+ signals in the YC 3.60-expressing astrocytes. In addition, forepaw stimulation while imaging astrocytes through a cranial window in the somatosensory cortex in live mice, revealed robust evoked and spontaneous Ca2+ signals. These results, for the first time, show that genetically encoded reporter is capable of recording activity-dependent Ca2+ signals in the astrocyte processes, and networks.

Laryngeal electromyography findings in a patient with HIV, John Cunningham virus and bilateral true vocal fold motion impairment.

We present the findings from laryngeal electromyography (EMG) on a 33-year-old HIV-positive male who presented with decreased vocal endurance and a breathy voice. Management considerations were broadened by the history of John Cunningham (JC) virus recovered from his cerebrospinal fluid and the consequent diagnosis of progressive multifocal leukoencephalopathy. We reviewed the available literature on neuropathy, HIV, JC virus and how all these factors relate to voice disturbances. We present laryngeal EMG findings, discuss the benefit of electrodiagnostic studies, and offer an algorithm for interpreting this information and applying it to create the optimal care plan for these patients. As medical management of HIV-related diseases continues to improve, more patients may present with similar circumstances.