Aerococcus Viridans

Aerococcus Viridans Infectious Endocarditis Complicated by Splenic Infarction

Author: Joshua Budhu M.S, Dorian Wood B.S, Marvin Crawford M.D, Khuram Ashraf M.D, Frederick Doamekpor M.D, Olufunke Akinbobuyi M.D

Author Affiliations: Morehouse School of Medicine, GA, USA

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Corresponding Author: Joshua Budhu,

Key Words: splenic infarct, infectious endocarditis, aercoccus viridans, HIV, immunocompromised, hemodialysis


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.


Published on date: September, 2017

DOI: 10.15404/msrj/07.2017.0002

Citation: : Budhu, J., Wood, D., Crawford, M., Ashraf, K., Doamekpor, F., & Akinbobuyi, O. Aerococcus Viridans Infectious Endocarditis Complicated by Splenic Infarction, Medical Student Research Journal (2017). doi:10.15404/msrj/07.2017.0002


  1. Baddour M., Wilson  W.R., Bayer  A.S.; Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation. 111 2005:e394-e434.
  2. Sanfilippo AJ, Picard MH, Newell JB, Rosas E, Davidoff R, Thomas JD, Weyman AE. Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications.J Am Coll Cardiol. 1991; 18:1191–1199. CrossRefMedline.
  3. Fauci, A.S., Braunwald, E., Kasper, D.L., Hauser, S.L., Longo, D.L., Jameson, J.L., Loscalzo, J. (Eds.). Harrison’s principles of internal medicine (18th ed.) (2011). New York: McGraw Hill.
  4. Vilacosta I, Graupner C, San Roman JA, Sarria C, Ronderos R, Fernandez C, Mancini L, Sanz O, Sanmartin JV, Stoermann W. Risk of embolization after institution of antibiotic therapy for infective endocarditis.J Am Coll Cardiol.2002; 39: 1489–1495.
  5. Nucifora G, Badano LP,Viale P,et al. Infective endocarditis in chronic haemodialysis patients: an increasing clinical challenge. Eur Heart J2007;28:2307-2312.
  6. Zhou W, Nanci V, Jean A, Salehi AH, Altuwaijri F, Cecere R, et al. Aerococcus viridans native valve endocarditis. Can J Infect Dis Med Microbiol. 2013;24(3):155-8.
  7. Uh, Y., J. S. Son, I. H. Jang, K. J. Yoon, and S. I. Hong. 2002. Penicillin-resistant Aerococcus viridans bacteremia associated with granulocytopenia. J. Korean Med. Sci. 17:113-115


MRI vs. CT in Diagnosing Acute Appendicitis in Children

Systematic review of the accuracy of magnetic resonance imaging in the diagnosis of acute appendicitis in children: comparison with computed tomography

Author: Benjamin Whitt

Author Affiliations: Saba University School of Medicine, MA, USA

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Corresponding Author: Benjamin Whitt,

Key Words: Appendicitis; Diagnostic Imaging; Sensitivity; Specificity; Children



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.


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.


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.


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.


Published on date: September, 2017

DOI: 10.15404/msrj/07.2017.0001

Citation: Whitt, Benjamin. Systematic review of the accuracy of magnetic resonance imaging in the diagnosis of acute appendicitis in children: comparison with computed tomography, Medical Student Research Journal (2015), 4(3), 54-58. doi:10.15404/msrj/07.2017.0001


  1. Guthery, S.L., Hutchings, C., Dean, J.M., & Hoff, C. (2004). National estimates of hospital utilization by children with gastrointestinal disorders: analysis of the 1997 kids’ inpatient database. The Journal of Pediatrics, 144(5), 589-94.
  2. Addiss, D.G., Shaffer, N., Fowler, B.S., & Tauxe, R.V. (1990). The epidemiology of appendicitis and appendectomy in the United States. American Journal of  Epidemiology, 132 (5), 910-25.
  3. Seetahal, S.A., Bolorunduro, O.B., & Sookdeo, T.C. et al. (2011). Negative appendectomy: a 10-year review of a nationally representative sample. American Journal of Surgery, 201(4), 433-7.
  4. Saito, J.M., Yan, Y., Evashwick, T.W., Warner, B.W., & Tarr, P.I. (2013). Use and accuracy of diagnostic imaging by hospital type in pediatric appendicitis. Pediatrics, 131(1), 37-44.
  5. Fahimi, J., Herring, A., Harries, A., Gonzales, R., & Alter, H. (2012). Computed tomography use among children presenting to emergency departments with abdominal pain. Pediatrics, 130(5), 1069-75.
  6. Hernanz-Schulman, M. (2010). CT and US in the diagnosis of appendicitis: an argument for CT. Radiology, 255(1), 3-7.
  7. Raja, A.S., Wright, C., & Sodickson, A.D. et al. (2010). Negative appendectomy rates in the era of CT: an 18-year perspective. Radiology, 256(2), 460-65.
  8. Charfi, S., Sellami, A., Affes, A., Yaich, K., Mzali, R., & Boudawara, T.S. (2014) Histopathological findings in appendectomy specimens: a study of 24,697 cases. International Journal of Colorectal Disease, 29(8), 1009-12.
  9. Doria, A.S., Moineddin, R., & Kellenberger, C.J. et al. (2006). US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Radiology, 241(1), 83-94.
  10. Brenner, D.J. & Hall, E.J. (2007). Computed tomography—an increasing source of radiation exposure. New England Journal of Medicine, 357(22), 2277-84.
  11. Mathews, J.D., Forsythe, A.V., & Brady, Z. et al. (2013). Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ, 346.
  12. Pearce, M.S., Salotti, J.A., & Little, M.P. et al. (2012). Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet, 380(9840), 499-505.
  13. Nash, K., Hafeez, A., & Hou, S. (2002). Hospital-acquired renal insufficiency. American Journal of Kidney Diseases, 39(5), 930-36.
  14. Laroche, D., Aimone-Gastin, I., & Dubois, F. et al. (1998). Mechanisms of severe, immediate reactions to iodinated contrast material. Radiology, 209(1), 183-90.
  15. Cogley, J.R., O’Connor, S.C., Houshyar, R., & Al Dulaimy, K. (2012). Emergent pediatric US: what every radiologist should know. Radiographics, 32(3), 651-65.
  16. van Randen, A., Bipat, S., Zwinderman, A.H., Ubbink, D.T., Stoker, J., & Boermeester, M.A. (2008). Acute appendicitis: meta-analysis of diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology, 249(1), 97-106.
  17. Lowe, L.H., Penney, M.W., & Stein, S.M. et al. (2001). Unenhanced limited CT of the abdomen in the diagnosis of appendicitis in children: comparison with sonography. American Journal of Roentgenology, 176(1), 31-35.
  18. Krishnamoorthi, R., Ramarajan, N., & Wang, N.E. et al. (2011). Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology, 259(1), 231-39.
  19. Poletti, P.A., Platon, A., & De Perrot, T. et al. (2011). Acute appendicitis: prospective evaluation of a diagnostic algorithm integrating ultrasound and low-dose CT to reduce the need of standard CT. European Radiology, 21(12), 2558-66.
  20. Rosen, M.P., Ding, A., & Blake, M.A. et al. (2011). ACR Appropriateness Criteria® right lower quadrant pain—suspected appendicitis. Journal of the American College of Radiology, 8(11), 749-55.
  21. Pedrosa, I. & Rofsky, N.M. (2003). MR imaging in abdominal emergencies. Radiologic Clinics of North America, 41(6), 1243-73.
  22. Barger Jr, R.L. & Nandalur, K.R. (2010). Diagnostic performance of magnetic resonance imaging in the detection of appendicitis in adults: a meta-analysis. Academic Radiology, 17(10), 1211-16.
  23. Dillman, J.R., Gadepalli, S., & Sroufe, N.S. et al. (2016). Equivocal Pediatric Appendicitis: Unenhanced MR Imaging Protocol for Nonsedated Children-A Clinical Effectiveness Study. Radiology, 279(1), 216-25.
  24. Thieme, M.E., Leeuwenburgh, M.M., & Valdehueza, Z.D. et al. (2014). Diagnostic accuracy and patient acceptance of MRI in children with suspected appendicitis. European Radiology, 24(3), 630-37.
  25. Herliczek, T.W., Swenson, D.W., & Mayo-Smith, W.W. (2013). Utility of MRI after inconclusive ultrasound in pediatric patients with suspected appendicitis: retrospective review of 60 consecutive patients. American Journal of Roentgenology, 200(5), 969-73.
  26. Rosines, L.A., Chow, D.S., & Lampl, B.S. et al. (2014) Value of gadolinium-enhanced MRI in detection of acute appendicitis in children and adolescents. American Journal of Roentgenology, 203(5), 543-48.
  27. Kulaylat, A.N., Moore, M.M., & Engbrecht, B.W. et al. (2015). An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis. Journal of Pediatric Surgery, 50(8), 1359-63.
  28. Moore, M.M., Gustas, C.N., & Choudhary, A.K. et al. (2012). MRI for clinically suspected pediatric appendicitis: an implemented program. Pediatric Radiology, 42(9), 1056-63.
  29. Orth, R.C., Guillerman, R.P., Zhang, W., Masand, P., & Bisset III, G.S. (2014). Prospective comparison of MR imaging and US for the diagnosis of pediatric appendicitis. Radiology, 272(1), 233-40.
  30. Bayraktutan, U., Oral, A., & Kantarci, M. et al. (2014). Diagnostic performance of diffusion-weighted MR imaging in detecting acute appendicitis in children: comparison with conventional MRI and surgical findings. Journal of Magnetic Resonance Imaging, 39(6), 1518-24.
  31. Koning, J.L., Naheedy, J.H., & Kruk, P.G. (2014). Diagnostic performance of contrast enhanced MR for acute appendicitis and alternative causes of abdominal pain in Pediatric Radiology, 44(8), 948-55.
  32. Cobben, L., Groot, I., Kingma, L., Coerkamp, E., Puylaert, J., & Blickman, J. (2009). A simple MRI protocol in patients with clinically suspected appendicitis: results in 138 patients and effect on outcome of appendectomy. European Radiology, 19(5), 1175-83.
  33. Heverhagen, J.T., Pfestroff, K., Heverhagen A.E., Klose, K.J., Kessler, K., & Sitter, H. (2012). Diagnostic accuracy of magnetic resonance imaging: a prospective evaluation of patients with suspected appendicitis (diamond). Journal of Magnetic Resonance Imaging, 35(3), 617-23.
  34. Leeuwenburgh, M.M., Wiarda, B.M., & Jensch, S. et al. (2014). Accuracy and interobserver agreement between MR-non-expert radiologists and MR-experts in reading MRI for suspected appendicitis. European Journal of Radiology, 83(1), 103-10.

Editorial Staff 2017-2018

Introducing the new 2017 – 2018 editorial staff for the MSRJ! We are thrilled to welcome many new junior editors to our experienced MSRJ team. The journal has been making exciting new changes with the start of e-publication and we look forward to another productive year of publishing, editing, and supporting medical student research efforts around the world!

Continue reading

Hardware Repair

Re-fracture of Distal Radius and Hardware Repair in the Setting of Trauma

Authors: Brandon P. Lucke-Wold, PhD1*, Patrick C. Bonasso, MD2, and Glen Jacob, MD3

Author Affiliations:

1 Department of Surgery, West Virginia University School of Medicine.  Medical student author.

2 Dept. of Surgery, West Virginia University School of Medicine. Co-author,

3 Dept. of Surgery, West Virginia University School of Medicine. Faculty author,

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Corresponding Author: Brandon Lucke-Wold, PhD,

Key Words: Volar locking plate-distal radius fracture-open reduction-internal fixation



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.


Published on date: December, 2016


DOI: 10.15404/msrj/11.2016.0009

Citation: Lucke-Wold B, Bonasso P, Jacob G. Re-fracture of Distal Radius and Hardware Repair in the Setting of Trauma. Medical Student Research Journal (2016). doi:10.15404/msrj/11.2016.0009


  1. Sebastin SJ, Chung KC. An Asian perspective on the management of distal radius fractures. Hand Clin. 2012;28(2):151-156.
  1. Kose A, Aydin A, Ezirmik N, Topal M, Can CE, Yilar S. Intramedullary nailing of adult isolated diaphyseal radius fractures. Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTES. 2016;22(2):184-191.
  1. Berglund LM, Messer TM. Complications of volar plate fixation for managing distal radius fractures. The Journal of the American Academy of Orthopaedic Surgeons. 2009;17(6):369-377.
  1. Lattmann T, Meier C, Dietrich M, Forberger J, Platz A. Results of volar locking plate osteosynthesis for distal radial fractures. Journal of trauma. 2011;70(6):1510-1518.
  1. Harness NG. Fixation Options for the Volar Lunate Facet Fracture: Thinking Outside the Box. J Wrist Surg. 2016;5(1):9-16.
  1. Ezzat A, Baliga S, Carnegie C, Johnstone A. Volar locking plate fixation for distal radius fractures: Does age affect outcome? J Orthop. 2016;13(2):76-80.
  1. Dasari CR, Sandhu M, Wisner DH, Wong MS. Approaches to Distal Upper-Extremity Trauma: A Comparison of Plastic, Orthopedic, and Hand Surgeons in Academic Practice. Ann Plast Surg. 2016;76 Suppl 3:S162-164.
  1. Geissler WB, Clark SM. Fragment-Specific Fixation for Fractures of the Distal Radius. J Wrist Surg. 2016;5(1):22-30.
  1. Pillukat T, Fuhrmann R, Windolf J, van Schoonhoven J. [The volar locking plate for extension fractures of the distal radius]. Oper Orthop Traumatol. 2016;28(1):47-64.
  1. Korpelainen R, Korpelainen J, Heikkinen J, Vaananen K, Keinanen-Kiukaanniemi S. Lifelong risk factors for osteoporosis and fractures in elderly women with low body mass index–a population-based study. Bone. 2006;39(2):385-391.
  1. Gyuricza C, Carlson MG, Weiland AJ, Wolfe SW, Hotchkiss RN, Daluiski A. Removal of locked volar plates after distal radius fractures. The Journal of hand surgery. 2011;36(6):982-985.
  1. De Baere T, Lecouvet F, Barbier O. Breakage of a volar locking plate after delayed union of a distal radius fracture. Acta orthopaedica Belgica. 2007;73(6):785-790.
  1. Naito K, Zemirline A, Sugiyama Y, Obata H, Liverneaux P, Kaneko K. Possibility of Fixation of a Distal Radius Fracture With a Volar Locking Plate Through a 10 mm Approach. Tech Hand Up Extrem Surg. 2016;20(2):71-76.
  2. Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. The Journal of hand surgery. 2011;36(5):824-835 e822.
  1. Cao J, Ozer K. Failure of volar locking plate fixation of an extraarticular distal radius fracture: A case report. Patient safety in surgery. 2010;4(1):19.
  1. Yukata K, Doi K, Hattori Y, Sakamoto S. Early breakage of a titanium volar locking plate for fixation of a distal radius fracture: case report. The Journal of hand surgery. 2009;34(5):907-909.
  1. Wall LB, Brodt MD, Silva MJ, Boyer MI, Calfee RP. The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates. The Journal of hand surgery. 2012;37(3):446-453.
  1. Arora R, Gabl M, Erhart S, Schmidle G, Dallapozza C, Lutz M. Aspects of current management of distal radius fractures in the elderly individuals. Geriatric orthopaedic surgery & rehabilitation. 2011;2(5-6):187-194.
  1. Chung KC, Squitieri L, Kim HM. Comparative outcomes study using the volar locking plating system for distal radius fractures in both young adults and adults older than 60 years. The Journal of hand surgery. 2008;33(6):809-819.
  1. Sugun TS, Gurbuz Y, Ozaksar K, Toros T, Bal E, Kayalar M. A new complication in volar locking plating of the distal radius: longitudinal fractures of the near cortex. Acta Orthop Traumatol Turc. 2016;50(2):147-152.
  1. Yu YR, Makhni MC, Tabrizi S, Rozental TD, Mundanthanam G, Day CS. Complications of low-profile dorsal versus volar locking plates in the distal radius: a comparative study. The Journal of hand surgery. 2011;36(7):1135-1141.

Scrotal Rupture

Scrotal Rupture in a Premature Neonate with Cystic Fibrosis as a Consequence of Meconium Periorchitis

Authors: Michael Bedgood1* BS, Christine Cortelyou1 MD, Cynthia Blanco1, MD, MSc, Rafael Fonseca2, MD, Alvaro Moreira1, MD

Author Affiliations:

1University of Texas Health Science Center (UTHSC), San Antonio, TX;

2University of Texas Medial Branch (UTMB), Galveston, TX

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Corresponding Author: Michael Bedgood BS,

Key Words: neonate, meconium peritonitis, meconium periorchitis



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.


Published on date: December, 2016


DOI: 10.15404/msrj/11.2016.0008

Citation: Bedgood M, Cortelyou C, Blanco C, Fonseca R, & Moreira A. Scrotal Rupture in a Premature Neonate with Cystic Fibrosis as a Consequence of Meconium Periorchitis. Medical Student Research Journal (2016). doi:10.15404/msrj/11.2016.0008


  1. Lange, M. Meconium peritonitis presenting in scrotal hydroceles. J. Surg. 1964; 51(12): 942-4
  2. Varkonyi I, Fliegel C, Rosslein R, Jenny P, Ohnacker H. Meconium periorchitis: Case report and literature review. Eur J Pediatr Surg. 1998; 10: 404-407
  3. Regev RH, Markovich O, Arnon S, Bauer S, Dolfin T, Litmanovitz I. Meconium periorchitis: Intrauterine diagnosis and neonatal outcome: case reports and review of the literature. Journal of Perinatology. 2009: 29; 585-7
  4. Salle JLP, Fraga JCS, Wojciechowski M, Antunes CRH. Congenital rupture of scrotum: An unusual complication of meconium peritonitis. The Journal of Urology. 1992; 148: 1242-43
  5. Jeanty C, Bircher A, Turner C. Prenatal Diagnosis of Meconium Periorchitis and Review of the Literature. J Ultrasound Med.2009; 28: 1729-1734.
  6. Williams HJ, Abernethy LJ, Losty PD, Kotiloglu E. Meconium periorchitis – a rare cause of paratesticular mass. Pediatr Radiol. 2004; 34: 421-423
  7. Soferman R, Ben-Sira L, Jurgenson U. Cystic fibrosis and neonatal calcified scrotal mass. Journal of Cystic Fibrosis. 2003; 2: 214-216
  8. Wax JR, Pinette MG, Cartin A, Blackstone J. Prenatal sonographic diagnosis of meconium periorchitis. J Ultrasound Med. 2007; 26: 415-417
  9. Herman TE, Siegel MJ. Meconium Periorchitis. Journal of Perinatology. 2004; 24: 188-190
  10. Alanbuki, Ammar Hameed, Ashwith Bandi, and Nick Blackford. “Meconium Periorchitis: A Case Report and Literature Review.” Canadian Urological Association Journal 7.7-8 (2013): E495–E498. PMC. Web. 27 Apr. 2016.

Editorial Staff 2016-2017

Introducing the new 2016 – 2017 editorial staff for the MSRJ! We are thrilled to welcome 20+ junior editors to our experienced MSRJ team. The journal has been making exciting new changes with the start of e-publication and we look forward to another productive year of publishing, editing, and supporting medical student research efforts around the world!

Continue reading

Tonsillar Ectopia

Determining if a Relationship Exists Between Tonsillar Ectopia and Symptom Presentation in Chiari Malformation Patients

Author: Julia R. Saling, B.S.1, Paige Marty, B.S.2, Rebecca Fischbein, Ph.D3, Michelle Chyatte, Dr.PH., MPH4

Author Affiliations:

1 Student Research Fellow, Northeast Ohio Medical University

2 Student Research Fellow, Northeast Ohio Medical University

Research Coordinator and Assistant Professor of Family and Community Medicine, Northeast Ohio Medical University

4 Assistant Professor of Family and Community Medicine, Northeast Ohio Medical University

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Corresponding Author: Julia R. Saling,

Key Words: Chiari Malformation Type I, Tonsillar Ectopia, Symptom Presentation




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.


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.


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).

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.


Published on date: August, 2016


DOI: 10.15404/msrj/08.2016.0007

Citation: Saling et al. Determining if a Relationship Exists Between Tonsillar Ectopia and Symptom Presentation in Chiari Malformation Patients Medical Student Research Journal (2016). doi:10.15404/msrj/08.2016.0007


  1. Siasios J, Kapsalaki EZ, Fountas KN. Surgical Management of Patients with Chiari I Malformation. Int J Pediatr. 2012;2012:1-10. doi:10.1155/2012/640127.
  2. Heiss J. Epidemiology of the Chiari I Malformation. In: Tubbs RS, Oakes WJ, eds. The Chiari Malformations. New York: Springer Science + Business Media; 2013:83-92.
  3. Milhorat TH, Chou MW, Trinidad EM, et al. Chiari I malformation redefined: Clinical and radiographic findings for 364 symptomatic patients. Neurosurgery. 1999;44(5):1005-1017. doi:10.1097/00006123-199905000-00042.
  4. Deng X, Wang K, Wu L, et al. Asymmetry of tonsillar ectopia, syringomyelia and clinical manifestations in adult Chiari I malformation. Acta Neurochir (Wien). 2014;156(4):715-722. doi:10.1007/s00701-014-2000-5.
  5. Tubbs RS, Wellons JC, Oakes WJ. Asymmetry of tonsillar ectopia in Chiari I malformation. Pediatr Neurosurg. 2002;37(4):199-202. doi:10.1159/000065399.
  6. Wu T, Zhu Z, Sun X, et al. Is curve direction correlated with the side of dominant displacement of cerebellar tonsil and syrinx deviation in thoracic scoliosis secondary to Chiari malformation type I and syringomyelia? Stud Health Technol Inform. 2012;176(Cmi):286-290. doi:10.3233/978-1-61499-067-3-286.
  7. Kaplan Y, Oksuz E. Chronic migraine associated with the Chiari type 1 malformation. Clin Neurol Neurosurg. 2008;110(8):818-822. doi:10.1016/j.clineuro.2008.05.016.
  8. Lewis AR, Kline LB, Sharpe JA. Acquired esotropia due to Arnold-Chiari I malformation. J Neuro-Ophthalmology. 1996;16(1):49-54. <Go to ISI>://WOS:A1996UE52700012.
  9. Shamji MF, Ventureyra ECG, Baronia B, Nzau M, Vassilyadi M. Classification of symptomatic Chiari I malformation to guide surgical strategy. Can J Neurol Sci. 2010;37(4):482-487. doi:10.1017/S0317167100010507.
  10. Brandon W. Smith, M.D., M.S.C.R.1, Jennifer Strahle, M.D.1, J. Rajiv Bapuraj, M.D.2, Karin M. Muraszko, M.D.1, Hugh J. L. Garton, M.D., M.H.Sc.1, and Cormac O. Maher MD. Distribution of cerebellar tonsil position: implications for understanding Chiari malformation Clinical article. J Nerosurgery. 2013;119(3):812-819.
  11. Christophe C, Bernard D. Magnetic resonance imaging cranial and cerebral dimensions: Is there a relationship with Chiari I malformation? A preliminary report in children. Eur J Paediatr Neurol. 1999;3(1):15-24. doi:10.1053/ejpn.1999.0174.
  12. Fischbein R, Saling JR, Marty P, et al. Patient-reported Chiari malformation type I symptoms and diagnostic experiences: a report from the national Conquer Chiari Patient Registry database. Neurological Sciences. 2015.
  13. Meeker J, Amerine J, Kropp D, Chyatte M, Fischbein R. The impact of Chiari malformation on daily activities: A report from the national Conquer Chiari Patient Registry database. Disabil Health J. 2015;8(4):521-526. doi:10.1016/j.dhjo.2015.01.003.
  14. Aitken LA, Lindan CE, Sidney S, Gupta N, Barkovich AJ, SorelM et al (2009) Chiari type I malformation in a pediatric population. Pediatr Neurol 40(6):449–454
  15.  Speer MC, Enterline DS, Mehltretter L, Hammock P, Joseph J,Dickerson M et al (2014) Chiari type I malformation with or without syringomyelia: prevalence and genetics. J Genet Couns12(4):297–311

Wallis Implant

Pain Relief and Intervertebral Disc Rehydration Following Wallis® Interspinous Device Implantation: a Case Report.

Author: Carter R. Mohnssen, B.S.1,2, Kenneth Pettine, MD2, and Nicole Rittenhouse, MA, CCRC2

Author Affiliations:

1 Creighton University School of Medicine, Omaha, Nebraska, USA.

2 The Spine Institute, Loveland, Colorado, USA.

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Corresponding Author: Carter Mohnssen,

Key Words: intervertebral disc degeneration, case reports, orthopedics, therapeutics, biologics



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.


Published on date: August, 2016


DOI: 10.15404/msrj/04.2016.0006

Citation: Mohnssen, C. Pain relief and intervertebral disc rehydration following Wallis interspinous device implantation: a case report. Medical Student Research Journal (2016). doi: 10.15404/msrj/04.2016.0006


  1. Luoma K, Riihimaki H, Luukkonen R, Raininko R, Viikari-Juntura E, Lamminem A. Low back pain in relation to lumbar disc degeneration. Spine. February 2000; 25:487-92.
  2. Mooney V, Robertson J. The facet syndrome. Clinical Orthopedic Related Research. March-April 1976; 115:149-56.
  3. Kirkaldy-Willis WH, Wedge JH, Yong-Hing K, Reilly J. Pathology and pathogenesis of lumbar spondylosis and stenosis. Spine. December 1978; 3:319-27.
  4. Yang KH, King AI. Mechanism of facet load transmission as a hypothesis for low-back pain. Spine. September 1984; 9:557-65.
  5. Guyer RD, McAfee PC, Banco RJ, et al. Prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of total artificial disc replacement with the CHARITE artificial disc versus lumbar fusion: five year follow-up. Spine. May 2009; 9(5): 374-86.
  6. Zigler J, Delamarter R, Spivak JM, et al. Results of the prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of the ProDisc-L total disc replacement versus circumferential fusion for the treatment of 1-level degenerative disc disease. Spine. May 2007; 15;32(11): 1155-62.
  7. Sénégas J. Minimally invasive dynamic stabilisation of the lumbar motion segment with an interspinous implant. Minimally Invasive Spine Surgery: A Manual, edited by HM Mayer. 2005; 459-65.
  8. Sénégas J. Mechanical supplementation by non-rigid fixation in degenerative intervertebral lumbar segments: the Wallis system. European Spine Journal. October 2002; Suppl 2 S164-69.
  9. Sénégas J, Vital JM, Pointillart V, Mangione P. Clinical evaluation of a lumbar interpsinous dynamic stabilization device (the Wallis system) with a 13-year mean follow up. Neurosurgery Review. July 2009; 32:335-342.
  10. Boeree NR. Dynamic stabilization of the degenerative lumbar motion segment: the Wallis system. Spinal Arthroplasty Society Annual Meeting. May 2005; New York, New York.
  11. Sandu N, Schaller B, Arasho B, Orabi M. Wallis implantation to treat degenerative spine disease: description of the method and case series. Expert Review of  Neurotherapeutics. June 2011; 11(6):799-807.
  12. Gazzeri R, Galarza M, Alfieri A. Controversies about Interspinous Process Devices in the Treatment of Degenerative Lumbar Spine Diseases: Past, Present, and Future. Biomed Research International. Volume 2014 (2014); 15 pages.
  13. Lotz JC, Chin JR. Intervertebral disc cell death is dependent on the magnitude and duration of spinal loading. Spine. June 2000; 25:1477–1483.
  14. Zeiter S, Bishop NE, Ito K. Significance of the mechanical environment during regeneration of the intervertebral disc. European Spine Journal. November 2005; 14:874-79.
  15. Minns RJ, Walsh WK. Preliminary design and experimental studies of a novel soft implant for correcting sagittal plane instability in the lumbar spine. Spine. August 1997; 22(16):1819-25.
  16. Zucherman JF, Hsu KY, Hartjen CA, Mehalic TF, et al. A Multicenter, Prospective, Randomized Trial Evaluating the X STOP Interspinous Process Decompression System for the Treatment of Neurogenic Intermittent Claudication: Two-Year Follow-Up Results. Spine. June 2005; 30(12):1351-1358.
  17. DePalma M. Biologic Treatments for Discogenic Low Back Pain. SpineLine. April 2012; 19-26.
  18. Hohaus C, Ganey T, Minkus Y, Meisel H. Cell transplantation in lumbar spine disc degeneration disease. European Spine Journal. November 2008; 17(Suppl 4):S492-S503.

Time to Neurological Deterioration

Time to Neurological Deterioration in Ischemic Stroke.

Author: James E. Siegler, MD1†, Karen C. Albright, DO, MPH2,3,4,5†, Alexander J. George, BS1, Amelia K. Boehme, MSPH2, Michael A. Gillette, MPH 1, Andre D. Kumar, MD1, Monica Aswani MSPH6, Sheryl Martin-Schild, MD, PhD1

Author Affiliations:

1 Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA 70112.

2 Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 35294.

3 Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), University of Alabama at Birmingham, 35294.

4 Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities (CERED) Minority Health & Health Disparities Research Center (MHRC), University of Alabama at Birmingham, 35294.

5 Department of Neurology, School of Medicine, University of Alabama at Birmingham, 35294.

6 Department of Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL 35249.

Siegler and Albright contributed equally to this article as first authors.

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Corresponding Author: Sheryl Martin-Schild,

Key Words: Acute ischemic stroke, neurological deterioration, latency, time to event analysis



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.


Published on date: March, 2016


DOI: 10.15404/msrj/03.2016.0005

Citation: Siegler J, Albright K, et al. Time to Neurological Deterioration in Ischemic Stroke. Medical Student Research Journal (2016). doi:10.15404/msrj/03.2016.0005


  1. Davalos A, Toni D, Iweins F, Lesaffre E, Bastianello S, Castillo J. Neurological deterioration in acute ischemic stroke: potential predictors and associated factors in the European cooperative acute stroke study (ECASS) I. Stroke; a journal of cerebral circulation. 1999;30(12):2631-6.
  2. Siegler JE, Martin-Schild S. Early Neurological Deterioration (END) after stroke: the END depends on the definition. International journal of stroke : official journal of the International Stroke Society. 2011;6(3):211-2.
  3. Siegler JE, Boehme AK, Kumar AD, Gillette MA, Albright KC, Martin-Schild S. What change in the National Institutes of Health Stroke Scale should define neurologic deterioration in acute ischemic stroke? Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2013;22(5):675-82.
  4. Kwan J, Hand P. Early neurological deterioration in acute stroke: clinical characteristics and impact on outcome. QJM : monthly journal of the Association of Physicians. 2006;99(9):625-33.
  5. DeGraba TJ, Hallenbeck JM, Pettigrew KD, Dutka AJ, Kelly BJ. Progression in acute stroke: value of the initial NIH stroke scale score on patient stratification in future trials. Stroke; a journal of cerebral circulation. 1999;30(6):1208-12.
  6. Siegler JE, Boehme AK, Kumar AD, Gillette MA, Albright KC, Beasley TM, et al. Identification of modifiable and nonmodifiable risk factors for neurologic deterioration after acute ischemic stroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2013;22(7):e207-13.
  7. Miyamoto N, Tanaka Y, Ueno Y, Kawamura M, Shimada Y, Tanaka R, et al. Demographic, clinical, and radiologic predictors of neurologic deterioration in patients with acute ischemic stroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2013;22(3):205-10.
  8. Tei H, Uchiyama S, Ohara K, Kobayashi M, Uchiyama Y, Fukuzawa M. Deteriorating ischemic stroke in 4 clinical categories classified by the Oxfordshire Community Stroke Project. Stroke; a journal of cerebral circulation. 2000;31(9):2049-54.
  9. Weimar C, Mieck T, Buchthal J, Ehrenfeld CE, Schmid E, Diener HC, et al. Neurologic worsening during the acute phase of ischemic stroke. Archives of neurology. 2005;62(3):393-7.
  10. Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Effect of blood pressure and diabetes on stroke in progression. Lancet. 1994;344(8916):156-9.
  11. Grotta JC, Welch KM, Fagan SC, Lu M, Frankel MR, Brott T, et al. Clinical deterioration following improvement in the NINDS rt-PA Stroke Trial. Stroke; a journal of cerebral circulation. 2001;32(3):661-8.
  12. Leigh R, Zaidat OO, Suri MF, Lynch G, Sundararajan S, Sunshine JL, et al. Predictors of hyperacute clinical worsening in ischemic stroke patients receiving thrombolytic therapy. Stroke; a journal of cerebral circulation. 2004;35(8):1903-7.
  13. Ogata T, Yasaka M, Wakugawa Y, Ibayashi S, Okada Y. Predisposing factors for acute deterioration of minor ischemic stroke. Journal of the neurological sciences. 2009;287(1-2):147-50.
  14. Toyoda K, Fujimoto S, Kamouchi M, Iida M, Okada Y. Acute blood pressure levels and neurological deterioration in different subtypes of ischemic stroke. Stroke. 2009;40(7):2585-8.
  15. Awadh M, MacDougall N, Santosh C, Teasdale E, Baird T, Muir KW. Early recurrent ischemic stroke complicating intravenous thrombolysis for stroke: incidence and association with atrial fibrillation. Stroke. 2010;41(9):1990-5.
  16. Georgiadis D, Engelter S, Tettenborn B, Hungerbuhler H, Luethy R, Muller F, et al. Early recurrent ischemic stroke in stroke patients undergoing intravenous thrombolysis. Circulation. 2006;114(3):237-41.
  17. Britton M, Roden A. Progression of stroke after arrival at hospital. Stroke. 1985;16(4):629-32.
  18. Davalos A, Cendra E, Teruel J, Martinez M, Genis D. Deteriorating ischemic stroke: risk factors and prognosis. Neurology. 1990;40(12):1865-9.
  19. Toni D, Fiorelli M, Gentile M, Bastianello S, Sacchetti ML, Argentino C, et al. Progressing neurological deficit secondary to acute ischemic stroke. A study on predictability, pathogenesis, and prognosis. Arch Neurol. 1995;52(7):670-5.
  20. Siegler JE, Boehme AK, Dorsey AM, Monlezun D, George AJ, Bockholt HJ, et al. A Comprehensive Stroke Center Patient Registry: Advantages, Limitations, and Lessons Learned. Med Stud Res J. 2013;1(2):21-9.
  21. Siegler JE, Boehme AK, Albright KC, George AJ, Monlezun DJ, Beasley TM, et al. A proposal for the classification of etiologies of neurologic deterioration after acute ischemic stroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2013;22(8):e549-56.
  22. Serena J, Rodriguez-Yanez M, Castellanos M. Deterioration in acute ischemic stroke as the target for neuroprotection. Cerebrovasc Dis. 2006;21 Suppl 2:80-8.
  23. Del Bene A, Palumbo V, Lamassa M, Saia V, Piccardi B, Inzitari D. Progressive lacunar stroke: review of mechanisms, prognostic features, and putative treatments. Int J Stroke. 2012;7(4):321-9.
  24. Adams HP, Jr., Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35-41.
  25. Albright KC, Martin-Schild S, Bockholt HJ, Howard G, Alexandrov A, Sline MR, et al. No consensus on definition criteria for stroke registry common data elements. Cerebrovasc Dis Extra. 2011;1(1):84-92.
  26. Bender R, Lange S. Adjusting for multiple testing–when and how? J Clin Epidemiol. 2001;54(4):343-9.