Unilateral Anomalous Origin of Dorsalis Pedis Artery From Peroneal Artery in a Cadaver.

In normal anatomy, the anterior tibial artery is typically the first branch of the popliteal artery before it becomes the tibioperoneal trunk. The normal course of the anterior tibial artery includes piercing through the interosseus membrane and continuing through the anterior compartment. It then continues onto the dorsum of the foot as the dorsalis pedis artery at the level of the malleoli. We describe a unique case of an anomalous origin of the dorsalis pedis artery from the peroneal artery. It is important for vascular surgeons to be aware of this variant while interpreting arteriograms of the lower extremity. It can be easily misinterpreted as an occluded distal anterior tibial artery with reconstitution of the dorsalis pedis artery from the collaterals.

Susceptibility Magnetic Resonance Imaging Correlates with Glial Density and Tau in the Substantia Nigra Pars Compacta.

BACKGROUND: Susceptibility magnetic resonance imaging (MRI) is sensitive to iron-related changes in the substantia nigra pars compacta (SNc), the key pathologic locus of parkinsonisms. It is unclear, however, if iron deposition in the SNc is associated with its neurodegeneration. OBJECTIVE: The objective of this study was to test whether susceptibility MRI metrics in parkinsonisms are associated with SNc neuropathologic features of dopaminergic neuron loss, gliosis, and α-synuclein and tau burden. METHODS: This retrospective study included 27 subjects with both in vivo MRI and postmortem data. Multigradient echo imaging was used to derive the apparent transverse relaxation rate (R2*) and quantitative susceptibility mapping (QSM) in the SNc. Archived midbrain slides that were stained with hematoxylin and eosin, anti-α-synuclein, and anti-tau were digitized to quantify neuromelanin-positive neuron density, glial density, and the percentages of area occupied by positive α-synuclein and tau staining. MRI-histology associations were examined using Pearson correlations and regression. RESULTS: Twenty-four subjects had postmortem parkinsonism diagnoses (Lewy body disorder, progressive supranuclear palsy, multiple system atrophy, and corticobasal degeneration), two had only Alzheimer's neuropathology, and one exhibited only mild atrophy. Among all subjects, both R2* and QSM were associated with glial density (r ≥ 0.67; P < 0.001) and log-transformed tau burden (r ≥ 0.53; P ≤ 0.007). Multiple linear regression identified glial density and log-transformed tau as determinants for both MRI metrics (R2 ≥ 0.580; P < 0.0001). Neither MRI metric was associated with neuron density or α-synuclein burden. CONCLUSIONS: R2* and QSM are associated with both glial density and tau burden, key neuropathologic features in the parkinsonism SNc. © 2023 International Parkinson and Movement Disorder Society.

Pelvic and central nervous system tuberculosis complicated by a paradoxical response manifesting as a spinal tuberculoma: a case report.

BACKGROUND: The post-partum period is a risk factor for tuberculosis (TB), possibly including the period after miscarriage as illustrated here. This case demonstrates how non-specific symptoms can hide widely disseminated TB. CASE PRESENTATION: A healthy 26-year-old female with a history of recent miscarriage presented to the emergency department with non-specific symptoms of headache, abdominal pain, and sub-acute fevers. She had immigrated to the United States from the Marshall Islands 9 years prior. Two months prior to presentation she had a miscarriage at 18 weeks of pregnancy. On admission, transvaginal ultrasound revealed retained products of conception and abdominal computed tomography revealed findings consistent with tubo-ovarian abscesses and peritonitis. The obstetrics and gynecology service performed dilation and curettage (D&C) to remove retained products of conception. Acid-fast bacilli cultures from cerebrospinal fluid as well as specimens from D&C and intra-abdominal abscesses subsequently all grew TB. She was diagnosed with TB meningitis, peritonitis, endometritis, and tubo-ovarian abscesses. Her treatment course was complicated by a paradoxical response resulting in a spinal tuberculoma causing lower extremity weakness. The tuberculoma was treated with surgical decompression as well as continuation of treatment with anti-tubercular chemotherapy and steroids. CONCLUSION: Disseminated and extrapulmonary TB can present with non-specific symptoms. Recognition of risk factors for TB is critical for prompt diagnostic evaluation and treatment of this deadly disease. A paradoxical reaction needs to be taken into consideration when any new neurological symptoms occur during TB treatment.

The Impact of a Population-Based System of Care Intervention on Enhanced Prenatal Care and Service Utilization Among Medicaid-Insured Pregnant Women.

INTRODUCTION: Enhanced prenatal/postnatal care home visiting programs for Medicaid-insured women have significant positive impacts on care and health outcomes. However, enhanced prenatal care participation rates are typically low, enrolling <30% of eligible women. This study investigates the impacts of a population-based systems approach on timely enhanced prenatal care participation and other healthcare utilization. METHODS: This quasi-experimental, population-based, difference-in-differences study used linked birth certificates, Medicaid claims, and enhanced prenatal care data from complete statewide Medicaid birth cohorts (2009 to 2015), and was analyzed in 2019-2020. The population-based system intervention included cross-agency leadership and work groups, delivery system redesign with clinical-community linkages, increased enhanced prenatal care-Community Health Worker care, and patient empowerment. Outcomes included enhanced prenatal care participation and early participation, prenatal care adequacy, emergency department contact, and postpartum care. RESULTS: Enhanced prenatal care (7.4 percentage points, 95% CI=6.3, 8.5) and first trimester enhanced prenatal care (12.4 percentage points, 95% CI=10.2, 14.5) increased among women served by practices with established clincial-community linkages, relative to that among the comparator group. First trimester enhanced prenatal care improved in the county (17.9, 95% CI=15.7, 20.0), emergency department contact decreased in the practices (-11.1, 95% CI= -12.3, -9.9), and postpartum care improved in the county (7.1, 95% CI=6.0, 8.2). Enhanced prenatal care participation for Black women served by the practices improved (4.4, 95% CI=2.2, 6.6) as well as early enhanced prenatal care (12.3, 95% CI=9.0, 15.6) and use of postpartum care (10.4, 95% CI=8.3, 12.4). CONCLUSIONS: A population systems approach improved selected enhanced prenatal care participation and service utilization for Medicaid-insured women in a county population, those in practices with established clinical-community linkages, and Black women.

Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis.

OBJECTIVE: Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST). METHODS: To identify studies, the following databases were systematically searched on October 14th, 2018 and repeated on September 12th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review. RESULTS: Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I2 = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I2 = 36%). CONCLUSION: This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.

Impetigo.

Impetigo is a common superficial bacterial infection of the skin, with a global disease burden of greater than 140 million. Children are more affected than adults and incidence decreases with age. Principal pathogens implicated include Staphylococcus aureus and Streptococcus pyogenes. There are two common variants of impetigo: nonbullous (70%) and bullous (30%). Nonbullous impetigo is caused by S. aureus and S. pyogenes whereas bullous impetigo is caused by S. aureus. The classic appearance of distinctive honey-colored, crusted legions aids in diagnosis, which is most often based on clinical presentation. The disease is generally mild and felt to be self-limited; however, antimicrobial treatment is often initiated to reduce spread and shorten clinical course. Treatment for limited impetigo is topical whereas oral therapy is recommended for extensive cases. Rising rates of bacterial resistance to standard treatment regimens should inform treatment decisions. Complications, while rare, can occur.

Efficacy and Usability of Intranasal Glucagon for the Management of Hypoglycemia in Patients With Diabetes: A Systematic Review.

PURPOSE: Hypoglycemia is a common and sometimes life-threatening adverse event associated with insulin, sulfonylurea, and meglitinide therapies. In patients who are disoriented or unconscious, treatment with injectable glucagon is recommended, along with a call for emergency medical assistance. However, limitations of this formulation include difficulty with reconstitution and an unwillingness to administer an injection. In July 2019, intranasal glucagon was approved for use in the acute treatment of severe hypoglycemia in patients ≥4 years of age with diabetes. The purpose of this systematic review was to describe the efficacy, usability, and tolerability of intranasal glucagon 3 mg in patients with diabetes. METHODS: To identify studies, the following databases were systematically searched: Ovid MEDLINE, Embase, CINAHL, Web of Science Core Collection, Cochrane CENTRAL (EBSCO), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform, from inception to March 3, 2020. Comparative studies included patients with diabetes and an active comparator. Usability studies enrolled participants who used a device for glucagon administration. FINDINGS: Ten studies met the inclusion criteria. In 5 comparative studies in insulin-induced hypoglycemia (intranasal vs injectable glucagon), the criteria for successful treatment varied. In 3 studies, it was defined as an increase in blood glucose of ≥70 mg/dL (3.9 mmol/L) or an increase of ≥20 mg/dL (1.1 mmol/L) within 30 min of glucagon administration. In 1 study, the criteria were stricter, with success defined as an increase in blood glucose of ≥27 mg/dL (≥1.5 mmol/L) within 15 min. In the pediatrics study, success was defined as an increase in blood glucose of ≥25 mg/dL (1.4 mmol/L) within 20 min. In 2 studies of intranasal glucagon monotherapy in clinical practice, the primary end point was the percentage of patients who awakened or returned to normal status within 30 min of intranasal glucagon administration. In these 7 studies, almost all of the participants met the criteria for success as defined in their respective studies. The mean time to treatment success was between 10 and 20 min with intranasal and injectable glucagon. Nausea and vomiting were common adverse events with both formulations; watery eyes and runny nose occurred more frequently with intranasal glucagon. In 3 simulation studies, caregivers and noncaregivers administered intranasal glucagon within 1 min versus 1.3-5 min with IM glucagon. IMPLICATIONS: In patients who are disoriented or unconscious, treatment with injectable or ready-to-use intranasal glucagon increases blood glucose within 15-30 min. Intranasal glucagon was preferred by most caregivers and noncaregivers due to its ease of use. Additional studies of intranasal glucagon in younger patients (1-<3 years of age), pregnant women, and in comparison with SC glucagon are needed to further clarify bioavailability, efficacy, and tolerability.

Nursemaid's Elbow Reduction.

Nursemaid's elbow, also known as radial head subluxation, is a common childhood orthopedic injury that can easily be diagnosed and reduced by the advanced practice nurse. It is most common in children 1-4 years of age and typically occurs as the result of a pulling mechanism on an outstretched arm. This leads to subluxation of the radial head at the annular ligament. The child subsequently refuses to use the affected arm, leading the caregiver to present for evaluation. This article explores epidemiology, pathophysiology, clinical presentation, reduction techniques, and parent education.

Intra-individual assessment of speech and music perception in cochlear implant users with contralateral Cochlear™ and MED-EL™ systems.

CONCLUSION: Whilst objective testing on music perception showed no individual differences between cochlear implant (CI) devices, subjective music perception was found to be superior with the MED-EL device in the majority of cases evaluated. OBJECTIVE: To compare speech and music perception through two different CI systems in the same individuals. METHODS: Six post-lingually deaf patients, who had been implanted with a Cochlear™ Nucleus(®) device in one ear and a MED-EL SONATATI(100) on the contralateral side were evaluated. One subject was excluded from group analysis because of significant differences in performance between ears. Subjects completed a questionnaire designed to assess implant users' listening habits. Subjective assessments of each subject were made for comparison of speech and music perception with each system and preferences of system. The subjects consecutively used each system with the contralateral device turned off, and were objectively assessed for specific musical skills. Speech perception in quiet and in noise was tested. RESULTS: For all objective tests of music discrimination and speech perception in noise, there were no statistically significant differences between MED-EL and Cochlear CI systems. Subjectively, four subjects thought their MED-EL device was better than their Cochlear device for music appreciation. Four thought that music sounded more natural, less tinny and more reverberant with their MED-EL CI than with their Cochlear CI. One subject rated all these to be equal.

Evaluation of time required for water-only decontamination of an oil-based agent.

STUDY OBJECTIVE: The objective was to evaluate the time to decontaminate an area of skin exposed to an oil-based agent using a water-only decontamination protocol. METHODS: A fluorescent mock chemical/biological agent was created. Each of 20 subjects had his/her forearm sprayed with the agent. Each subject placed his/her arm under a decontamination shower, which provided water at a pressure of 60-70 psi and 35 degrees C. After 30 sec a black light was used by three evaluators to determine whether the agent was removed. The process of 30 sec decontamination and re-evaluation was repeated for a total of 5 min. The primary endpoint was proportion decontaminated over time. RESULTS: After 90 sec, 100% of subjects were decontaminated. CONCLUSION: Whereas the data suggest the possibility of rapid water-only decontamination, the applicability of this data in current form is doubtful, but provides a model as a basis for future study.