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Case Report of Glanzmann Thrombasthenia

Posted by on Sep 18, 2017 in Articles, ePubs | 0 comments

Background

Glanzmann Thrombasthenia (GT) is a rare inherited genetic platelet disorder characterized by a qualitative, or quantitative mutation in GPIIb/IIIa receptor; which results in defective platelet aggregation and diminished clot retraction.

Case

A 19-year-old Arab descent female presented to emergency department with severe menorrhagia. On examination an ill looking pale patient in addition to generalized fatigue of one-week duration.

Conclusion

Acquired platelet disorders are more frequently encountered in practice than inherited ones, usually due to medical therapy or an underlying medical condition. GT, was previously known as hereditary hemorrhagic thrombasthenia, is an autosomal recessive disorder that is often disregarded as it has many clinical and laboratory findings similar to some acquired platelet disorders.

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Three Wishes Survey

Posted by on Sep 18, 2017 in Articles, ePubs | 0 comments

Purpose

In this study we assessed the underlying values and goals of current medical students by examining personal wishes. The authors also aimed to determine the impact of the increased financial burden of medical training on students‟ motivations by comparing current wishes to those of students from 1999. We also examined the relationships between types of wishes, choice of future medical specialty, and demographic characteristics.

Methods

An anonymous survey with the question: “If you had three wishes, what would you wish for?”, and items pertaining to specialization choice and demographics was completed by 418 medical students. Wishes were coded into seventeen categories. Results were compared to a previous survey conducted in 1999.

Results

The largest category of wishes was altruism (40% of students) followed by achievement (36%), and money (34%). Significantly more medical students in 2015 had altruistic and achievement wishes compared to 1999. However, there was no significant increase in money-related wishes in the 2015 cohort compared to students from 1999. Final year students were more likely to report power-related wishes and male medical students had significantly more wishes related to power, money, and self-esteem. Students who aspired to be surgeons had more affiliation wishes and fewer knowledge-related aspirations. Conversely, medical students planning to enter internal medicine training were more likely to have wishes related to power and self-esteem. Achievement wishes were more common among individuals wanting to enter family medicine.

Conclusion

There was no evidence that medical students are becoming less altruistic and more money-orientated. Further, individuals did not appear to become less altruistic or increasingly financially driven as they progressed through the medical course.

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Aerococcus Viridans

Posted by on Sep 17, 2017 in Articles, ePubs | 0 comments

In this case report we discuss splenic infarction as a presentation for infectious endocarditis. While not unheard of, splenic infarctions are usually incidental findings and are not usually used to diagnose infectious endocarditis. Since our patient was on hemodialysis, had AIDS and blood cultures tested positive for Aerococcus viridans and Streptococcus parasanguis, we propose that atypical presentations of IE should be considered in immunocompromised patients.

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MRI vs. CT in Diagnosing Acute Appendicitis in Children

Posted by on Sep 17, 2017 in Articles, ePubs | 0 comments

Purpose

Computed tomography (CT) has emerged as the gold standard test for the evaluation of suspected appendicitis in pediatric patients. It has been shown to have excellent accuracy and to decrease negative appendectomy rates. However, CT scans expose patients to ionizing radiation, which is of especially high concern in children. Magnetic resonance imaging (MRI) is a potential alternative that could be used to evaluate children while eliminating exposure to radiation. This systematic review tests the hypothesis that the sensitivity and specificity of MRI are not inferior to that of CT in the evaluation of suspected appendicitis in children.

Methods

A search of the Medline database was conducted to identify articles that used MRI to evaluate children with suspected appendicitis. Articles that focused on pediatric subjects and reported sensitivity and specificity of MRI in these subjects were included. Data for the calculation of sensitivity, specificity, and 95% confidence intervals for each were extracted from each study included. Pooled data for sensitivity and specificity of MRI were calculated and tested for significance compared to sensitivity and specificity of CT using Fisher’s exact test.

Results

Nine studies were found to be relevant to the question posed by this systematic review and met the inclusion criteria. The pooled sensitivity and specificity of MRI for the diagnosis of appendicitis were 0.96 (95% CI: 0.94-0.98) and 0.97 (95% CI: 0.96-0.98) as opposed to values of 0.94 (95% CI: 0.92-0.97) and 0.95 (95% CI: 0.94-0.97) for CT. The difference between MRI and CT was not statistically significant for sensitivity (p=0.11) or specificity (p=0.06) in the evaluation of suspected appendicitis in children.

Conclusion

In children with suspected appendicitis, the sensitivity and specificity of MRI are comparable to those of CT in terms of sensitivity and specificity. MRI is a viable choice for imaging in these patients and limits exposure to radiation.

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Hardware Repair

Posted by on Dec 16, 2016 in Articles, ePubs | 0 comments

Distal radius fractures are one of the most common fractures in the elderly. Falls and motor vehicle collisions lead to increased risk for this type of fracture. A seventy-three year-old female had a previous history of distal radius fracture with repair by open reduction and internal fixation. She was involved in a motor vehicle collision that re- fractured the distal radius. The plate was bent and required removal, which is a very rare but potentially serious complication. Surgery was done to fix the open reduction and internal fixation with volar locking plates while removing damaged hardware. Only a select few cases have reported hardware failure as a cause of complications. Among those cases, high-energy activities and maintained stress on the hardware were likely causes. Distal radius fractures are the most common upper extremity fracture in the elderly. We highlight a unique case of re-fracture in the setting of trauma with prior hardware failure and describe the strategy for hardware repair.

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Scrotal Rupture

Posted by on Dec 16, 2016 in Articles, ePubs | 0 comments

Neonatal meconium periorchitis is a rare condition, with less than 60 cases described in the literature. Of the reported cases, only one describes the complication of a congenital rupture of the scrotum. We present a case of a Hispanic preterm neonate who was diagnosed with cystic fibrosis after scrotal rupture secondary to meconium periorchitis. The neonate was taken to the operating room for exploratory laparotomy and scrotal exploration. No calcification was noted and the patient’s left scrotum was surgically packed as well as creating a colostomy. The surgery proved successful and the patient was discharged home on day of life 79. This case of a neonate presenting with meconium periorchitis and scrotal rupture notes the varying degree of initial presentations for cystic fibrosis in a neonate. Successful outcomes for neonates presenting with a ruptured scrotum depend on early clinical assessment.

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Tonsillar Ectopia

Posted by on Aug 29, 2016 in Articles, ePubs | 0 comments

Purpose

Chiari Malformation Type I (CM I) is characterized by cerebellar tonsil ectopia and has varying symptomatology . Previous research has shown a relationship between tonsillar dominance and related conditions but few examined association with symptomatology. This study attempts to elucidate a relationship between cerebellar tonsil dominance, age, and symptomatology.

Methods

Data from CM I patients were extracted from the Conquer Chiari Patient Registry. Tonsillar dominance was determined using a ratio of right-to-left herniation length. Pearson’s correlation and one-tailed Student’s T-test were used for analysis.

Results

Length of tonsillar descent appears to be negatively correlated to age of onset (r = -0.266; p < 0.001; n = 113) and diagnosis (r = -0.323; p < 0.001; n = 113). No correlation was found between tonsillar dominance and symptom location, nor between tonsillar dominance and symptom severity bilaterally (p > 0.05). Symptom location and severity ratios appear to be correlated (r = 0.666; p < 0.001). Tonsillar descent length appears to be strongly correlated bilaterally (r = 0.972; p < 0.001; n = 50). Conclusion Inconsistency between tonsillar dominance as related to symptomatology suggests a multifactorial contribution to clinical presentation. The inverse relationship between tonsillar herniation length and age of symptom onset and diagnosis suggests herniation length may be an important predictor for clinical outcomes. Further research is needed to elucidate additional contributing factors and tonsillar dominance and symptomatology association.

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Wallis Implant

Posted by on Aug 29, 2016 in Articles, ePubs | 0 comments

Introduction: Degeneration of the lumbar motion segment is the primary cause of low back pain in many individuals. Therefore, new minimally invasive treatments are being sought.

Patient Profile: A 47-year old man presented with severe low back pain and radicular symptoms of several years duration. Lumbar MRI revealed severe desiccation, loss of disc height, and an annular tear with right lateral disc protrusion at L4-5.

Interventions/Outcomes: After conservative treatment failed, the patient received a Wallis® interspinous spacer at the affected level. 100% subjective pain relief was obtained at 3 months post-op. Nucleus pulposus rehydration on MRI was observed.

Discussion: Controversy exists over whether disc dehydration is a reliable indicator of low back pain; however, interspinous spacers seem to alter abnormal motion segment’s biomechanics in a way that results in alleviation of low back pain and increased range of motion. With the advent of biologic therapy, this may provide an intriguing minimally invasive treatment modality, although further research is needed.

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Time to Neurological Deterioration

Posted by on Mar 17, 2016 in Articles, ePubs | 0 comments

Background: Neurological deterioration (ND) is common, with nearly one-half of ND patients deteriorating within the first 24 to 48 hours of stroke. The timing of ND with respect to ND etiology and reversibility has not been investigated.

Methods: At our center, we define ND as an increase of 2 or more points in the National Institutes of Health Stroke Scale (NIHSS) score within 24 hours and categorize etiologies of ND according to clinical reversibility. ND etiologies were considered non-reversible if such causes may have produced or extended any areas of ischemic neurologic injury due to temporary or permanent impairment in cerebral perfusion.

Results: Seventy-one of 350 ischemic stroke patients experienced ND. Over half (54.9%) of the patients who experienced ND did so within the 48 hours of last seen normal. The median time to ND for non-reversible causes was 1.5 days (IQR 0.9, 2.4 days) versus 2.6 days for reversible causes (IQR 1.4, 5.5 days, p=0.011). After adjusting for NIHSS and hematocrit on admission, the log-normal survival model demonstrated that for each 1-year increase in a patient’s age, we expect a 3.9% shorter time to ND (p=0.0257). In addition, adjusting for age and hematocrit on admission, we found that that for each 1-point increase in the admission NIHSS, we expect a 3.1% shorter time to ND (p=0.0034).

Conclusions: We found that despite having similar stroke severity and age, patients with nonreversible causes of ND had significantly shorter median time to ND when compared to patients with reversible causes of ND.

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Does Traditional Chinese Medicine Matter?

Posted by on Mar 17, 2016 in Articles, ePubs | 0 comments

Introduction: With an aging, urbanizing population, China is home to the world’s largest number of adult diabetics. Although more diabetic patients currently live in cities, the prevalence of pre-diabetes is greater in the rural population due to changing dietary and physical habits, as well as the relative poverty. This demographic is thus an important target for public health intervention. As Traditional Chinese Medicine (TCM) is viewed in China as useful for treating chronic diseases and widely accepted, we sought to explore its use for rural diabetic patients.

Methods: The study population included 63 diabetic patients and two village doctors from four rural villages near Changsha, China. An initial survey was orally conducted with all 63 participants to collect demographics, financial situation, health-seeking behaviors, treatment beliefs, and medical expenditure. Three focus groups of six rural patients each were subsequently held at village health centers. For analysis, questionnaire data was summarized using means and standard deviations or medians and quartiles. Focus group sessions were voice-recorded and transcripts were coded for thematic analysis.

Results/Conclusions: Questionnaire data revealed that for the majority of participants, seeing a doctor is costly in terms of time and money. Patients often do not have the luxury of choosing their medical provider. Despite the benefits of TCM, its slow speed and cumbersome preparation methods do not fit a need for immediate results. Furthermore, TCM doctors are not as available or accessible as Western medicine doctors. As such, although 20% of rural patients rated higher trust in TCM than WM, no patient solely used TCM for their treatment. Instead, almost 40% of patients try to use both TCM and WM. Village practitioners similarly believed that although diabetes treatment should go towards integrative treatment, TCM’s development is hindered by its slow onset and inconvenience coupled with a more systemic lack of TCM infrastructure and research in China. In summary, the continued trust that rural patients place in TCM supports further research for better understanding the true economic, social, and health benefits of having combined TCM-WM treatment be part of diabetes standard of care.

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