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.
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.
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.
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.
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.
Click the link below to view the full manuscript.
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.
Check out the link below to see an early release from our Spring 2023 issue.
Introduction: This study aims to assess the impact of various teaching methods including role play, didactic lectures, and case studies on the history taking and communication skills of second year Bachelor of Medicine and Surgery (MBBS) students. The goal is to help students become better doctors by arriving at diagnoses quicker through asking relevant questions in their history taking. A secondary goal is to improve the doctor-patient relationship through better communication skills.
Methods: The students were assessed on their history taking and communication skills before and after the application of specific teaching methods. The teaching methods were chosen according to efficacy and impact as shown by other research articles, in addition to the convenience of applying them to our study and the curriculum of similar schools. The improvement was scored by the faculty at KEM Hospital in Mumbai, India, where the study was conducted, using a checklist which includes the main aspects of communication and general history taking. We tested the students on their communication skills, completeness of their history taking with regards to history of the presenting illness, history of past illnesses, personal history, family history, and mental status report. The results of the pre- and post- intervention scores were analyzed using paired t-tests.
Results: Fifteen students were assessed in this study. The results showed improvement in their mean scores after the teaching methods were applied. Using the student t-test, we statistically analyzed the students pre- and post-intervention. The p-value was found to be statistically significant (<0.05) in communication skills, completeness of their history taking with regards to history of the presenting illness, history of past illnesses, family history, and mental status report. It was found to be non- significant with regards to personal history taking.
Conclusions: The students benefited from the teaching sessions conducted during their surgical rotations. Applying these teaching tools helped students come to diagnoses better through history taking alone. Their communication skills were also found to be significantly improved, which has shown to positively impact physician-patient rapport and treatment compliance. We have concluded that it would be meaningful to incorporate these teaching tools in the curriculum of second year undergraduate students with the goal of making them better physicians in the future.
Check out this interesting article for our upcoming Fall 2022 issue!
Background: Little is known about the ethical issues confronting medical students during their first exposure to emergency medicine (EM). The aim of this study was to review student narratives to determine the type and frequency of ethical issues that beginning students confront in the ED.
Methods: This was a prospective, qualitative observational study of consecutive first- and second-year medical students electing to do a pre-clinical clerkship in Emergency Medicine (EM) at five university- affiliated hospitals. Students were asked to write a short description of three cases that had the greatest impact on them during the month-long clerkship. Each essay was independently analyzed by five members of the research team. Descriptive and kappa statistics were used to summarize the data.
Results: During the four-year study period, 292 consecutive student essays were evaluated from 103 medical students. A total of 194 specific incidents were coded across 15 categories of ethical standards. Overall, 71.1% (138/194) were depictions of exemplary instances of ethical issues, 13.9% (27/194) were considered normal interactions, and 14.9% (29/194) were categorized as unethical behavior. While generally impressed by the admirable behavior of faculty and staff, students were quick to describe instances of improper treatment of patients, such as poor communication, discrimination, improper pain management, or a perceived lack of empathy.
Conclusions: Narrative essays describe a wide variety of interesting ethical situations that beginning medical students confront during their clerkships. Many of these ethical interactions seem to be connected to the student’s role as an observer of the health care team and how that role can lead to ethical tension. As educators, we need to shine a light on the subtle ethical issues that clerkship students struggle with daily and give them practical tools to deal with moral decisions required of them in medical practice.
Check out this early release of the latest article for our Fall 2022 issue!
Quadricuspid aortic valves (QAVs) are a rare congenital anomaly associated with increased risk of aortic insufficiency. This case presents the incidental finding of a quadricuspid aortic valve on intraoperative transesophageal echocardiography after going undetected on transthoracic echocardiography multiple times, suggesting that transesophageal echocardiography may be a superior imaging modality for the identification of this defect. This patient with a history of coronary artery disease presented with sudden onset moderate to severe aortic insufficiency and required subsequent aortic valve replacement (AVR).
Another new and interesting article! Click the link below to view the full case study.
We aim to add to the literature regarding Petit (inferior lumbar) hernias. The presence and location of lower back masses may have a deeper origin than initially apparent. We urge the surgical community to keep in mind the differential diagnosis of lumbar hernia, although rare, when evaluating subcutaneous masses and lipomata in this region. Simple excision may address the mass but not the cause and will lead to early recurrence of the presenting problem.