Physiopathology of Extrapulmonary Tuberculosis: A Literature Review

Please enjoy this new addition to our Fall Issue!

Introduction: Extrapulmonary tuberculosis (EPTB) is an infection by mycobacteria in any part of the body other than the lungs. There is information on tuberculosis infection from more than 3,000 years ago, and despite the knowledge that there is about the disease, nowadays, it is estimated that a quarter of the world population is infected and 15% of the cases are extrapulmonary.

Aims: This literature review aims to present the physiopathology of the most common EPTB, update and summarize the current diagnostic and therapeutic advances for the EPTB reviewed, as well as describe the physiopathological implications of coinfection with human immunodeficiency virus (HIV).

Methods: A literature review was performed for which PubMed, Cochrane Library, and Google Scholar databases were consulted using the following keywords: Tuberculosis, Epidemiology, Physiopathology, Diagnosis, and Therapy. Only articles published from 2016 to 2022, evaluated with a score ≥ 10 based on the Scale for the Assessment of Narrative Review Articles (SANRA) score were included, obtaining a total of 38 bibliographic sources.

Discussion: Depending on the system or organ affected, it is how the physiopathological process is carried through as well as how the clinical features manifest and the diagnostic approach is made. The diagnostic and therapeutic strategies of each type of EPTB have been widely studied; however, although technological innovation has contributed to the development of new diagnostic techniques, the treatment of almost all EPTB has remained the same over time, which consists of the same 6-month regimen of therapy as in pulmonary tuberculosis. Furthermore, tuberculosis treatment has been severely affected by rifampicin resistance and concomitant HIV infection.

Conclusion: The physiopathology of the different EPTBs is well described; nevertheless, a better understanding of how the disease spreads and develops will allow us to create new diagnostic resources and improve therapeutic targets for this disease, which still has a substantial presence worldwide.

Impact of Imposter Phenomenon on Medical Learners and Clinicians: A Scoping Review

Please enjoy this new addition to our Fall Issue!

Objective: The imposter phenomenon (IP) is the belief that one does not deserve success. Medical students, residents, and physicians experience IP at significant rates, often due to the stress of mastering the extensive diagnostic information and treatment modalities as well as the competitive nature of medicine. We aimed to identify the main factors of IP in medical students, residents, and physicians in the available literature to increase awareness of IP in medical education.

Methods: In this scoping review, PubMed, PsycINFO, Cochrane Library, Embase, Scopus, Web of Science, Google Scholar, Northern Lights Conference Abstracts, and Dissertations & Theses databases were systematically searched for relevant studies published before June 2020. Articles that examined IP in medical students, residents, and attending physicians were retained. References were hand- searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach. Extracted data were tabulated to summarize characteristics and main findings from each study. Content analysis of this table identified major themes in the available literature.

Results: Twenty-four journal articles published between 1978 and 2020 were included. Three main themes were identified, including specific demographic characteristics of IP (n = 14), the professional impact (n = 10), and the psychological impact (n = 17) of IP. For demographic characteristics, IP was higher in older individuals (n = 3), racial and/or ethnic minorities (n = 2), and women (n = 12). Married individuals experienced less IP (n = 2). For professional impact, IP increased during career transitions or professional challenges (n = 8). For psychological impact, IP was associated with reduced self-esteem (n = 7), a negative self-concept (n = 2), increased self-doubt (n = 3), and perfectionism (n = 3). Depression, anxiety (n = 3), and burnout (n = 6) were also heightened with IP.

Conclusion: Results revealed a multitude of factors influencing IP. Increased awareness of the presence, impact, and severity of IP assists medical educators to combat its negative effects. Further research is needed to improve treatments for IP in this population and to better understand the impact of IP on diversity, career trajectory, and career satisfaction in medicine.

Use of telehealth for cancer screening in primary care during COVID-19: an analysis of the Council of Academic Family Medicine Educational Research Alliance Survey 2022

Please enjoy this new addition to our Fall Issue!

Background: The COVID-19 pandemic caused rapid uptake of telemedicine in primary care settings affecting cancer screening.

Objective: This study aimed to understand provider perception of future cancer incidence and telehealth feasibility in cancer screening.

Methods: Data were gathered and analyzed as part of the 2020 Council of Academic Family Medicine’s (CAFM) Educational Research Alliance (CERA) survey for primary analysis. The 2020 General Member COVID Survey examined demographics, the impact of faculty isolation, E-learning experience, cancer screening during COVID-19, and outpatient prenatal care. Survey participants were practicing family medicine physicians who were members of one of the CAFM organizations, with a response rate of 14.5%. Descriptive statistics were calculated. Analysis of Variance (ANOVA) was used to evaluate the relationship between telehealth sufficiency and provider age or year they earned their highest degree. Logistic regression evaluated the relationship between telehealth sufficiency and institution type.

Results: 54% of respondents believe that there will be an increase in late-stage cancer. Respondents whose practice settings were not affiliated with medical schools were 1.94 times more likely to feel that telehealth would not be sufficient for cancer screenings in the future (odds ratio [OR] = 1.94, 95% confidence interval [CI]: 1.28, 2.93).

Conclusion: While our study shows that in light of the COVID-19 pandemic, primary care physicians believe there will be an increase in later stage cancer; they can also use telehealth to adequately maintain cancer screening practices. This research serves as a starting point to understanding where, in cancer screening, telehealth can be useful and how practitioners can provide high-quality hybrid care.

When Cannabis Use Goes Wrong: An Epidemiologic Study of Cardiopulmonary Symptoms in Patients That Present to Emergency Departments

Please enjoy this new addition to our Fall Issue!

Background: Increased availability and use of cannabis in Michigan have led to a marked increase in emergency department (ED) visits associated with the drug’s adverse cardiopulmonary effects. However, few people are aware of these potential cardiopulmonary side effects. Recognition of these presenting symptoms is critical for emergency clinicians to provide timely and effective care, make accurate diagnoses, and safeguard the health of patients who may be experiencing toxic effects from cannabis use.

Study objective: To describe the prevalence, clinical features, and disposition of cannabis cardiopulmonary toxicity in a community- based study.

Methods: This was a retrospective cohort analysis of all patients diagnosed with toxicity related to cannabis use. Patients were seen at eight EDs over a 26-month study period (November 2018–December 2020). Affiliated institutions included three university-affiliated hospitals, a children’s tertiary care facility, and four rural medical centers. Data collected included demographics, clinical features, and treatment outcomes in patients presenting to the ED with cardiopulmonary symptoms (CPS) versus those experiencing other forms of cannabis toxicity.

Results: During the study period, 1,174 patients were evaluated for cannabis toxicity. A total of 318 patients (27.1%) had a cardiopulmonary chief complaint (CPS group) and 856 (72.9%) experienced other forms of cannabis toxicity, predominantly symptoms of intoxication, cannabis hyperemesis syndrome, or neuropsychiatric complaints. The CPS group presented with tachycardia (36.5%), dyspnea (34.3%), chest tightness (28.6%), palpitations (17.9%), and hypertension (8.2%). CPS patients were more likely to be older (32.6 vs. 24.3 years, p < 0.001), ingested edible cannabis (36.8% vs. 9.2%, p < 0.001), and have a history of polysubstance abuse (17.6 vs. 12.0%, p = 0.013). These patients also had a longer ED length of stay (4.9 vs. 3.8 h, p < 0.001) and significantly more hospital admissions (10.1% vs. 6.3%, p = 0.027).

Conclusions: Cardiopulmonary toxicity is common after acute or chronic cannabis exposures, occurring in over one-quarter of ED patients in this community-based study. These troublesome findings highlight the risks associated with using cannabis for recreational or therapeutic purposes.

Do Probiotics Prevent Gestational Diabetes in Obese/Overweight patients? A Systematic Review

The final article to be included in our Spring 2023 issue is linked below. Enjoy!

Introduction: While some studies suggest probiotic supplements may prevent Gestational Diabetes Mellitus (GDM), it is unclear if probiotics effectively prevent GDM among overweight and obese patients. This systematic review synthesizes recommendations for clinical practice and future research by evaluating the quality of evidence regarding Lactobacillus and Bifidobacterium containing probiotics to prevent GDM among obese and overweight patients. 

Methods: PubMed, Embase, CINAHL, and Web of Science were searched using appropriate MeSH terms. Results were limited to randomized controlled trials published between 2011-2021. Titles and abstracts were screened for relevance after duplicates were removed. Included studies diagnosed GDM according to by International Association of Diabetes and Pregnancy Study Group criteria, suspended probiotic use prior to intervention, excluded participants with altered glucose metabolism, included participants with a BMI ≥25kg/m2, and provided a specified dose of probiotic supplements. Articles without statistical analysis were excluded. Resulting articles were critically appraised using Version 2 of the Cochrane Risk of Bias tool.

Results: This search strategy resulted in 24 articles after duplicates were removed. Five double- blind randomized controlled trials found the incidence of GDM during the third trimester was not significantly different between probiotic and control groups. There was wide variation in the bacterial species, dose and duration of probiotic treatments used. All studies have a high risk of bias due to non-adherence to the treatment.

Discussion: This review used a highly sensitive criteria for GDM diagnosis that may mask a preventative effect of probiotics. Non-compliance may bias results towards the null given insufficient analysis of the effect of adhering to the intervention. No patterns between length of probiotic intervention or probiotic species and improved glucose tolerance were noted.

Conclusions: Current evidence is not sufficient to recommend probiotic supplements to prevent GDM in overweight and obese patients. Future evidence should address the effect of adhering to probiotic interventions and develop consistent probiotic intervention protocols.

Vulvovaginal Lacerations Following Consensual Versus Non-consensual Sexual Intercourse

We are pleased to share another manuscript that will be included in our Spring 2023 issue.

Background: The medical literature on vulvovaginal lacerations following consensual versus nonconsensual sexual intercourse is sparse and conflicting.

Objectives: To compare the predisposing factors, injury location and severity, as well as treatment of vulvovaginal lacerations sustained during consensual versus nonconsensual sexual intercourse, in adult women within a community-based cohort.

Methods: This is a retrospective comparative analysis of adult women presenting to the emergency departments of five hospitals and a free-standing nurse examiner clinic during a seven-year study period. All patients had documented vulvovaginal lacerations and reported vaginal penetration via consensual sexual intercourse (CSI) or nonconsensual sexual intercourse (NCSI) within 72 hours of presentation.

Results: A total of 598 cases were identified: 81 (14%) reported CSI, and 517 (87%) reported NCSI. CSI patients were younger (21.3 vs 25.7, p <0.001) and reported a greater incidence of penile penetration (97.5% vs 75.9%, p <0.001). While NCSI subjects had a higher incidence of vulvovaginal lacerations overall (1.7 vs. 1.0, p<0.001), their injuries were smaller (1.1 cm vs. 4.3 cm, p<0.001) and more likely to be located on the posterior vulva (83% vs. 69%, p=0.003) when compared to the CSI group. Additionally, all the lacerations in the NCSI group were superficial. In contrast, 27 (33%) of CSI subjects had lacerations sutured in the ED; six (7%) required aggressive fluid resuscitation and ten (12%) required surgical intervention.

Conclusions: In this community-based population, more severe vulvovaginal lacerations were noted in women following CSI. The predisposing factors, injury location, and subsequent treatment in this group were significantly different when compared with women reporting NCSI.

Diffusion Tensor Imaging: A Step-by-Step Guide for Radiology and Neurology Clerkship Students, Residents, and Graduate Students Using Clinical Research Examples

We are pleased to share our latest manuscript for our Spring 2023 issue.


Diffusion-tensor imaging has become common practice in radiology and imaging research due to its many applications in brain connectivity and neurodevelopment as well as for pathologies including tumors, ischemia, trauma, and neurodegeneration. However, its novelty compared to other neuroimaging techniques has meant that graduate programs, particularly medical schools, have not included opportunities to learn how diffusion tensor imaging can visualize the brain and interpretation of the data clinically and in research. Diffusion tensor imaging can be a challenging utility to understand for newcomers and is subject to wide interpretation. We offer for medical and graduate students as well as residents a step-by-step guide in interpreting diffusion tensor imaging results for clinical analysis using simple explanations of physics and neuroscience and its application in clinical and translational research.

Just like the simulations: Improving medical student confidence with simulated emergency medicine scenarios

Check out our latest article below.

Background: Incoming emergency medicine residents may feel unsure of their ability to handle common emergency department scenarios, even if they are well educated on the proper steps to take in those scenarios. This may not stem from a lack of skill so much as a lack of confidence in their ability to perform with skills they have. 

Objective: We look to establish a link between completion of simulation- based training in common emergency medicine scenarios and learner self-reported confidence in their ability to perform competently in those scenarios. 

Methods: Fourth-year medical students who matched into an emergency medicine residency program participated in a Transitional Educational Program (TEP) at the Interprofessional Immersive Simulation Center at the University of Toledo in April 2021. Simulations of 16 procedural skills and clinical judgement cases were carried out using high-fidelity mannequins and real medical equipment in a hospital-based setting. Subjects were given pre- and post- TEP survey questionnaires assessing their self-reported confidence to competently perform in common emergency medicine clinical scenarios, using a 5-grade Likert scale. Data was analyzed using a one-tailed Wilcoxon signed-rank matched-pairs test. 

Results: Of 19 participating subjects, 16 (84.2%) consented and responded to the pre-survey. Of those 16 subjects, 10 (62.5%) completed the surveys at the correct time and order. The pre- and post- surveys consisted of the same 14 questions. In 11 of 14 survey questions, there was a significant increase in subject self-reported confidence (p<.05) between pre- and post-survey. 

Conclusions: Simulation-based training in the setting of high-fidelity equipment and faculty guidance improved the self-reported confidence of incoming emergency medicine residents to perform in common emergency medicine scenarios.

An Assessment of Knee Flexion in Lateral Knee X-rays

Purpose: Patient positioning plays a crucial role in the field of radiology. Lateral knee x-rays are a type of image that often has incorrect positioning of the angle of knee flexion. The ideal range is between 20-30 degrees. The goal of this study was to assess the angle of knee flexion at two different locations in a single hospital system while determining if several variables influence the angle.

Methods: This study is a retrospective chart review that assessed the angle of knee flexion in patients 18 years or older that underwent a lateral-mediolateral knee x-ray taken at an urgent care center and a general diagnostic center of a hospital within the same system between March 1 and December 1, 2021. Variables including age, sex, BMI, technologist, and location were collected from these patients’ charts and evaluated. MRI information was gathered for patients who underwent an MRI within 30 days of a lateral knee x-ray. The research team assessed effusions reported on x-ray compared to effusions reported on MRI for these patients.

Results: Among patients included in the study (n=665) the average angle of knee flexion was 51.28 degrees. Age, sex, BMI, and location were not significantly associated with the mean angle of knee flexion with p-values of 0.63, 0.13, 0.55, and 0.15 respectively. The radiology technologist taking the image did have an association with the angle of knee flexion with a p- value of 0.001. Differences in the mean angle of knee flexion between the groups of x-rays with effusions reported compared to the groups of x-rays where effusions were not reported but found on MRI resulted in a p-value of 0.83.

Conclusions: The technologist taking the image was the only variable of this study that had a significant difference in mean angle of knee flexion. Additional studies are needed to determine what technologist factors are most important in determining the angle of knee flexion. Using MRI information to evaluate if effusions were not reported due to the angle of knee flexion was limited in this study due to small sample size.

Etiology and Clinical Features of Optic Neuritis in Two Children: A Case Report

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Background: Optic neuritis (ON) is inflammation of the optic nerve that can occur in both adults and children. This disease is marked by a heterogeneous presentation in children and has clinical and epidemiologic characteristics that differ greatly from those found in adults. The purpose of this report is to illustrate the clinical features of ON that occur during childhood and to highlight the differences of ON in children versus adults. In doing so, we aim to add to the sparse current literature on this topic and help prevent the future misdiagnosis of ON in pediatric patients.

Case Presentations: An 11-year-old female presented with bilateral decreased visual acuity and significant ocular pain. The ophthalmic presentation and diagnostic workup led to the diagnosis of acute disseminated encephalomyelitis with ON. A second patient, a 12-year-old male, presented with decreased visual acuity and bilateral papilledema. Alongside a diagnosis of bilateral ON, a muscle biopsy confirmed mitochondrial cytopathy as the etiology of his presenting symptoms.

Conclusions: ON in children may be related to specific infections, autoimmune disorders, diseases of adjacent anatomical structures, or demyelinating disorders. Attacks may be acute or subacute with signs of reduced visual acuity, abnormal pupillary response, loss of color vision, impaired contrast sensitivity, and decreased peripheral vision. Awareness of this complex disease allows the clinician to initiate specific treatment and follow-up care that may reduce subsequent morbidity and the rate of recurrence.