Twinkle Artifact Observed During POCUS of a Human Myiasis Caused by the Dermatobia hominisBotfly.

An 81-year-old man presented to urgent care for assessment of an area of erythema and tenderness on his right thigh after recent travel to Belize. Point of care ultrasound (POCUS) revealed a hyperechoic structure with acoustic shadowing in the subcutaneous tissue. Colour Doppler assessment of the structure produced a twinkle artifact. The structure was removed and pathology identified the object as a Dermatobia hominis larva (human botfly). The use of POCUS helped identify and localize the subcutaneous foreign body. The use of colour Doppler produced the twinkle artifact, which has not been previously reported as a finding produced during ultrasonographic assessment of botfly larvae.

Call of the wild: creating a formal wilderness medicine elective for Canadian pre-clerkship medical students.

Wilderness medicine education is interesting to medical students, yet not widely implemented in Canadian medical curricula. We describe a curriculum for a pre-clerkship wilderness medicine elective at a Canadian medical school. Our study reports increased student awareness of career opportunities in wilderness medicine after elective completion, and interest in hands-on learning for wilderness medicine topics. Medical schools may benefit from incorporating feedback from our elective towards a successful wilderness medicine curriculum in their own programs.

La médecine en milieu sauvage est un domaine que les étudiants trouvent intéressant, mais dont l'enseignement est peu répandu dans les programmes d'études médicales au Canada. Nous décrivons le contenu d'un stage au choix de médecine en milieu sauvage offert au pré-externat dans une faculté de médecine canadienne. Notre étude montre qu'à la suite du stage, les étudiants sont mieux informés des possibilités de carrière en médecine en milieu sauvage et qu'ils manifestent un intérêt pour l'apprentissage pratique dans ce domaine médical. Les commentaires recueillis sur notre stage peuvent être utiles à d'autres facultés souhaitant introduire une formation en médecine en milieu sauvage dans leur programme.

An assessment of mass casualty triage systems using the Alberta trauma registry.

OBJECTIVE: Triage is the process of identifying patients with both the greatest clinical need and the greatest likelihood of benefit in the setting of limited clinical resources. The primary objective of this study was to assess the ability of formal mass casualty incident triage tools to identify patients requiring urgent lifesaving interventions. METHODS: Data from the Alberta Trauma Registry (ATR) was used to assess seven triage tools: START, JumpSTART, SALT, RAMP, MPTT, BCD and MITT. Clinical data captured in the ATR was used to determine which triage category each of the seven tools would have applied to each patient. These categorizations were compared to a reference standard definition based on the patients' need for specific urgent lifesaving interventions. RESULTS: Of the 9448 records that were captured 8652 were included in our analysis. The most sensitive triage tool was MPTT, which demonstrated a sensitivity of 0.76 (0.75, 0.78). Four of the seven triage tools evaluated had sensitivities below 0.45. JumpSTART had the lowest sensitivity and the highest under-triage rate for pediatric patients. All the triage tools evaluated had a moderate to high positive predictive value (> 0.67) for patients who had experienced penetrating trauma. CONCLUSIONS: There was a wide range in the sensitivity of triage tools to identify patients requiring urgent lifesaving interventions. MPTT, BCD and MITT were the most sensitive triage tools assessed. All of the triage tools assessed should be employed with caution during mass casualty incidents as they may fail to identify a large proportion of patients requiring urgent lifesaving interventions.

ABSTRAIT: OBJECTIFS: Le triage est le processus qui consiste à identifier les patients qui ont à la fois les besoins cliniques les plus importants et les avantages les plus probables dans le contexte de ressources cliniques limitées. Le principal objectif de cette étude était d'évaluer la capacité des outils formels de triage des incidents impliquant des blessés de masse à identifier les patients nécessitant des interventions urgentes de sauvetage. MéTHODES: Les données du Alberta Trauma Registry (ATR) ont été utilisées pour évaluer sept outils de triage : START, JumpSTART, SALT, RAMP, MPTT, BCD et MITT. Les données cliniques saisies dans l'AR ont servi à déterminer la catégorie de triage que chacun des sept outils aurait appliquée à chaque patient. Ces catégories ont été comparées à une définition standard de référence fondée sur le besoin des patients d'interventions de sauvetage urgentes. RéSULTATS: Sur les 9448 enregistrements saisis, 8652 ont été inclus dans notre analyse. L'outil de triage le plus sensible était le TPMD, qui présentait une sensibilité de 0,76 (0,75, 0,78). Quatre des sept outils de triage évalués présentaient une sensibilité inférieure à 0,45. JumpSTART avait la sensibilité la plus faible et le taux de sous-triage le plus élevé chez les patients pédiatriques. Tous les outils de triage évalués avaient une valeur prédictive positive modérée à élevée (>0,67) pour les patients qui avaient subi un traumatisme pénétrant. CONCLUSION: La sensibilité des outils de triage pour identifier les patients nécessitant des interventions de sauvetage urgentes variait grandement. Les outils de triage les plus sensibles ont été le TCPR, le BCD et le MITT. Tous les outils de triage évalués doivent être utilisés avec prudence lors d'incidents impliquant des pertes massives, car ils peuvent ne pas identifier une grande proportion de patients nécessitant des interventions de sauvetage urgentes.

Uncovering the significance of expanded CD8+ large granular lymphocytes in inclusion body myositis: Insights into T cell phenotype and functional alterations, and disease severity.

Introduction: Inclusion body myositis (IBM) is a progressive inflammatory myopathy characterised by skeletal muscle infiltration and myofibre invasion by CD8+ T lymphocytes. In some cases, IBM has been reported to be associated with a systemic lymphoproliferative disorder of CD8+ T cells exhibiting a highly differentiated effector phenotype known as T cell Large Granular Lymphocytic Leukemia (T-LGLL). Methods: We investigated the incidence of a CD8+ T-LGL lymphoproliferative disorder in 85 IBM patients and an aged-matched group of 56 Healthy Controls (HC). Further, we analysed the phenotypical characteristics of the expanded T-LGLs and investigated whether their occurrence was associated with any particular HLA alleles or clinical characteristics. Results: Blood cell analysis by flow cytometry revealed expansion of T-LGLs in 34 of the 85 (40%) IBM patients. The T cell immunophenotype of T-LGLHIGH patients was characterised by increased expression of surface molecules including CD57 and KLRG1, and to a lesser extent of CD94 and CD56 predominantly in CD8+ T cells, although we also observed modest changes in CD4+ T cells and γδ T cells. Analysis of Ki67 in CD57+ KLRG1+ T cells revealed that only a small proportion of these cells was proliferating. Comparative analysis of CD8+ and CD4+ T cells isolated from matched blood and muscle samples donated by three patients indicated a consistent pattern of more pronounced alterations in muscles, although not significant due to small sample size. In the T-LGLHIGH patient group, we found increased frequencies of perforin-producing CD8+ and CD4+ T cells that were moderately correlated to combined CD57 and KLRG1 expression. Investigation of the HLA haplotypes of 75 IBM patients identified that carriage of the HLA-C*14:02:01 allele was significantly higher in T-LGLHIGH compared to T-LGLLOW individuals. Expansion of T-LGL was not significantly associated with seropositivity patient status for anti-cytosolic 5'-nucleotidase 1A autoantibodies. Clinically, the age at disease onset and disease duration were similar in the T-LGLHIGH and T-LGLLOW patient groups. However, metadata analysis of functional alterations indicated that patients with expanded T-LGL more frequently relied on mobility aids than T-LGLLOW patients indicating greater disease severity. Conclusion: Altogether, these results suggest that T-LGL expansion occurring in IBM patients is correlated with exacerbated immune dysregulation and increased disease burden.

Randomized Controlled Trial on Combined Percutaneous Release and Steroid Injection Versus Percutaneous Release Alone for Trigger Finger in Adults

@#INTRODUCTION: Trigger finger is one of the most common causes of hand pain and disability. Surgical treatment consists of release of the A-1 pulley by open or percutaneous techniques. Many authors have noted that percutaneous release is convenient and cost-effective with a low complication rate. Only few studies have published results on combination of percutaneous release and steroid injection. OBJECTIVE: To compare the differences of outcomes in adults with trigger finger treated with combination of percutaneous release and corticosteroid injection to those treated with percutaneous release alone METHODS: We included all patients older than 18 years old in the UP-PGH Department of Orthopedics with a diagnosis of trigger finger who have consented to participate in this study. They were randomized into two treatment groups. One group was treated with percutaneous release only and the other group was treated with combined percutaneous release and corticosteroid injection. Outcomes measured were total active motion (TAM), postoperative pain, time to return-to-work, patient satisfaction, and complications. RESULTS: Post-procedure, both groups showed significant improvement in motion of the fingers (p = 0.034) and pain relief (p = 0.001). TAM scores of the combination group were better compared to the control at all time intervals (p = 0.03, 0.008, 0.004, 0.019) and better pain VAS scores in the 1st week (p = 0.009). Patients who received the combination treatment showed a trend toward better patient satisfaction, shorter duration of post-release pain and earlier return-to-work. CONCLUSION: significantly improves TAM and pain VAS scores.

Approach to diagnosis and management of childhood attention deficit hyperactivity disorder.

OBJECTIVE: To provide primary care clinicians with an approach to the diagnosis and management of attention deficit hyperactivity disorder (ADHD) by reviewing and summarizing the relevant practice guidelines and recent evidence from the literature. SOURCES OF INFORMATION: Published guidelines on the management of ADHD were reviewed. A PubMed search was conducted with the MeSH terms attention deficit disorder and family practice. Results were limited to articles published in English within the past 15 years. MAIN MESSAGE: Attention deficit hyperactivity disorder is a common neurodevelopmental disorder. Guidelines agree that diagnosis and management of ADHD is appropriate within primary care. Attention deficit hyperactivity disorder is diagnosed by applying the criteria defined within the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, and is supplemented by validated rating scales. Behavioural management is first-line management in all patients, and stimulant medications are first-line management in patients 6 years of age and older. The Canadian ADHD Resource Alliance provides free resources to help clinicians care for patients with ADHD. CONCLUSION: Most patients with ADHD can be managed by family physicians. It is a chronic condition that requires ongoing follow-up. Attention deficit hyperactivity disorder that is complicated by comorbidities might require referral to a specialist.

Approche diagnostique et de prise en charge du trouble déficitaire de l'attention avec hyperactivité chez l'enfant.

OBJECTIF: Proposer aux médecins de première ligne une approche diagnostique et de prise en charge du trouble déficitaire de l'attention avec hyperactivité (TDAH) en examinant et en résumant les lignes directrices pertinentes de pratique clinique et les données récentes relevées dans les publications scientifiques. SOURCES D'INFORMATION: Nous avons examiné les lignes directrices publiées sur la prise en charge du TDAH. Une recherche a été réalisée dans PubMed à l'aide des motsclés anglais attention deficit disorder et family practice. Les résultats étaient limités aux articles publiés en anglais au cours des 15 dernières années. MESSAGE PRINCIPAL: Le trouble déficitaire de l'attention avec hyperactivité est un trouble neurodéveloppemental courant. Les lignes directrices s'entendent pour dire qu'il est approprié de poser un diagnostic et d'entreprendre la prise en charge du TDAH en première ligne. Le trouble déficitaire de l'attention avec hyperactivité est diagnostiqué en appliquant les critères définis dans le Manuel diagnostique et statistique des troubles mentaux, 5e édition, qu'on complète avec les scores aux échelles validées. La prise en charge comportementale est l'intervention de première intention chez tous les patients, et les stimulants sont l'intervention de première intention chez les patients de 6 ans et plus. La Canadian ADHD Resource Alliance fournit gratuitement des ressources aux médecins pour les aider à soigner les patients atteints du TDAH. CONCLUSION: La plupart des patients atteints du TDAH peuvent être pris en charge par les médecins de famille. Le TDAH est une affection chronique qui exige un suivi continuel. Les cas de trouble déficitaire de l'attention avec hyperactivité qui sont compliqués par des comorbidités pourraient nécessiter une recommandation à un spécialiste.

Randomized phase III trial to evaluate radiopharmaceuticals and zoledronic acid in the palliation of osteoblastic metastases from lung, breast, and prostate cancer: report of the NRG Oncology RTOG 0517 trial.

BACKGROUND: Skeletal-related events (SREs), common sequelae of metastatic cancer, are reduced by bisphosphonates. In this study, it was postulated that radiopharmaceuticals, added to bisphosphonates, could further decrease the incidence of SREs. METHODS: NRG Oncology RTOG 0517 randomized patients with breast, lung, and prostate cancer and blastic bone metastases to either zoledronic acid (ZA) alone or ZA plus radiopharmaceuticals (Sr-89 or Sm-153). The primary endpoint was time to development of SREs. Secondary objectives included quality of life (QOL), pain control, overall survival (OS), and toxicity. RESULTS: 261 patients (median age 68; 62% male; 55% prostate, 35% breast, 10% lung) were accrued between July 2006 and February 2011. The study closed early due to a lower than expected rate of SREs. 52 (42%) patients in the ZA arm and 49 (40%) in the radiopharmaceutical arm experienced an SRE. Median time free of SREs was 29.9 and 27.4 months, respectively (p = 0.84). Median OS in the ZA arm and radiopharmaceutical arms was 32.1 and 26.9 months, respectively (p = 0.37). Cox proportional hazards regression model showed that primary disease site (lung) and number of bone metastases (> 2) had a negative impact on OS (p < 0.0001, p = 0.01, respectively). The addition of radiopharmaceuticals to ZA led to a significant reduction in pain at 1 month based on BPI worst score (p = 0.02). No other group differences were noted for QOL or toxicity. CONCLUSION: The addition of radiopharmaceuticals to bisphosphonates did not alter time to SREs or OS for patients with breast, lung, prostate cancers and blastic bone metastases, although it was associated with significant pain reduction at 1 month. CLINICAL TRIAL REGISTRY: This protocol (RTOG 0517) is registered with ClinicalTrials.gov (NCT00365105), and may be viewed online at http://www.clinicaltrials.gov/ct2/show/NCT00365105?term=RTOG+0517&rank=1 .

Interaction of NMDA receptors and L-type calcium channels during early odor preference learning in rats.

Early odor preference learning in rats provides a simple model for studying learning and memory. Learning results in an enhanced output from mitral cells, which carry odor information from the olfactory bulb to the olfactory cortex. Mitral cell NMDA receptors (NMDARs) are critically involved in plasticity at the olfactory nerve to mitral cell synapse during odor learning. Here we provide evidence that L-type calcium channels (LTCCs) provide an additional and necessary source of calcium for learning induction. LTCCs are thought to act downstream of NMDARs to bridge synaptic activation and the transcription of the plasticity-related proteins necessary for 24-h learning and memory. Using immunohistochemistry, we have demonstrated that LTCCs are present in the mitral cell and are primarily located on mitral cell proximal dendrites in neonate rats. Behavioral experiments demonstrate that inhibiting the function of LTCCs via intrabulbar infusion of nimidopine successfully blocks learning induced by pairing isoproterenol infusion with odor, while activation of LTCCs via an intrabulbar infusion of BayK-8644 rescues isoproterenol-induced learning from a D-APV block. Interestingly, the infusion of BayK-8644 paired with odor is by itself not sufficient to induce learning. Synaptoneurosome Western blot and immunohistochemistry measurement of synapsin I phosphorylation following BayK-8644 infusion suggest LTCCs are involved in synaptic release. Finally, odor preference can be induced by gabazine disinhibition of mitral cells, and NMDAR opening is sufficient for the gabazine-induced learning. These results provide the first evidence that NMDARs and LTCCs interact to permit calcium-dependent mitral cell plasticity during early odor preference learning.

[Medium-term results of grade 3 and 4 cystocele repair by porcine xenograft matrix (pelvicol)]. / Résultats à moyen terme du traitement des cystoceles de grade 3 et 4 par plaque de xénogreffe porcine (pelvicol).

OBJECTIVE: To evaluate the medium-term results of grade 3 and 4 (Baden-Walker classification) cystocele repair by transvaginal porcine xenograft matrix (Pelvicol). MATERIALS: Between February 2002 and October 2005, fifty patients with grade 3 or 4 cystocele were treated by Pelvicol matrix. The preoperative grade of prolapse and symptoms (urinary and pelvic heaviness) were recorded and a sexuality questionnaire was completed retrospectively (BISF-W questionnaire). All patients were reviewed in the outpatients department at 1 month and at the date of last follow-up. The success of the surgical procedure was defined by postoperative grades 0 and 1. Preoperative and postoperative symptoms and sexuality were compared. The operative morbidity was recorded. The success of the surgical procedure was compared in patients operated for the first time and in redo patients. RESULTS: The mean age was 69.4 years; 29 patients had a grade 3 cystocele (58%), and 21 had a grade 4 cystocele (42%). Preoperative symptoms consisted of dysuria (32%) and symptoms of overactive bladder (22%), accompanied by symptomatic (36%) or asymptomatic (20%) stress urinary incontinence. Pelvic heaviness was present in 100% of cases. An associated procedure was necessary in 70% of cases (29 suburethral tapes, 6 rectocele repairs, 3 vaginal hysterectomies). Mean follow-up was 27.2 months (95%CI [23.3-31.1]). No intraoperative or postoperative complications were observed. During follow-up, no cases of rejection of material, vaginal erosion or delayed healing were observed. The surgical success rate was 94% (37 grade 0 and 10 grade 1). Dysuria and pelvic heaviness were significantly improved. None of the 10 women who were sexually active preoperatively reported postoperative discomfort. Among the 50 operated patients, 35 (70%) were treated by Pelvicol as first-line procedure and 15 were redo procedures (30%); no significant difference in surgical success rate was observed between these two groups (94.3% versus 93.4%). CONCLUSION: The use of a porcine xenograft matrix (Pelvicol) appears to be a safe and effective technique in the medium term for first-line treatment of grade 3 and 4 cystocele.