Showing papers by "Lincoln Hospital published in 2014"

Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: A systematic review and meta-analysis

Abstract: BACKGROUNDTraumatic injury in the United States is the Number 1 cause of mortality for patients 1 year to 44 years of age. Studies suggest that early identification of major injury leads to better outcomes for patients. Imaging, such as computed tomography (CT), is routinely used to help determine t

Life-threatening complications of adult-onset Still's disease.

Abstract: Adult-onset Still’s Disease (AOSD) since its description in 1971 has proven to be a very complex and challenging disease entity. This rare auto-inflammatory disease is classically described by the “Still’s triad” of fever, rash, and arthritis, although the atypical cases frequently outnumber the typical ones. The exact pathogenesis and etiologic factors responsible for the clinical features remain largely obscure, despite recent suggestive cytokine biology findings. Diagnosis is made on clinical grounds, following the exclusion of mimickers of infectious, autoimmune or neoplastic etiology, with the additional consideration of non-specific laboratory abnormalities such as peripheral leukocytosis and elevation of serum ferritin and other acute phase reactants. The disease manifestations are protean and can include diverse complications, affecting multiple organ systems. Moreover, the severity of the organ involvement can vary considerably, representing a wide spectrum from the self-limited to severe. The mainstay of therapy has evolved from the traditional use of corticosteroids and oral immunosupressants to the newer targeted treatments with biologic agents. The scope of this review is to alert the clinician to the existence of life-threatening AOSD complications, namely the macrophage activation syndrome, disseminated intravascular coagulopathy, thrombotic thrombocytopenic purpura, diffuse alveolar hemorrhage, and pulmonary arterial hypertension. Such knowledge may lead in earlier recognition, prompt treatment, and, ideally, improved patient outcomes.

Can traumatic injury trigger psoriatic arthritis? A review of the literature.

Abstract: Traumatic injury as a trigger for the subsequent development of psoriatic arthritis (PsA) has been implicated by several case reports and case series. However, it is still unclear whether trauma is the inciting event or just an incidental finding. It is thought that the interplay of genetic, immunologic, and environmental factors, such as trauma, may trigger the development of PsA. At least two hypotheses of how trauma may be linked to the development of PsA have surfaced and involve a "deep Koebner effect," the concept of a synovio-entheseal complex and activation of the innate immune system by biomechanical factors. The role of neuropeptides such as substance P and vasoactive intestinal peptide has been highlighted in the synovium after trauma. Better understanding of this phenomenon would shed light into the pathophysiology of Psa and help the development of preventive and therapeutic strategies.

Anticoagulant therapy during primary percutaneous coronary intervention for acute myocardial infarction: a meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors

Abstract: Objectives To investigate the relative benefits of unfractionated heparin, low molecular weight heparin(LMWH), fondaparinux, and bivalirudin as treatment options for patients with ST segment elevation myocardial infarction undergoing percutaneous coronary intervention (PCI). Design Mixed treatment comparison and direct comparison meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors. Data sources and study selection A search of Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) for randomized trials comparing unfractionated heparin plus glycoprotein IIb/IIIa inhibitor(GpIIb/IIIa inhibitor), unfractionated heparin, bivalirudin, fondaparinux, or LMWH plus GpIIb/IIIa inhibitor for patients undergoing primary PCI. Outcomes The primary efficacy outcome was short term (in hospital or within 30 days) major adverse cardiovascular event; the primary safety outcome was short term major bleeding. Results We identified 22 randomized trials that enrolled 22 434 patients. In the mixed treatment comparison models, when compared with unfractionated heparin plus GpIIb/IIIa inhibitor, unfractionated heparin was associated with a higher risk of major adverse cardiovascular events (relative risk 1.49 (95% confidence interval 1.21 to 1.84), as were bivalirudin (relative risk 1.34 (1.01 to 1.78)) and fondaparinux (1.78 (1.01 to 3.14)). LMWH plus GpIIb/IIIa inhibitor showed highest treatment efficacy, followed (in order) by unfractionated heparin plus GpIIb/IIIa inhibitor, bivalirudin, unfractionated heparin, and fondaparinux. Bivalirudin was associated with lower major bleeding risk compared with unfractionated heparin plus GpIIb/IIIa inhibitor (relative risk 0.47 (0.30 to 0.74)) or unfractionated heparin (0.58 (0.37 to 0.90)). Bivalirudin, followed by unfractionated heparin, LMWH plus GpIIb/IIIa inhibitor, unfractionated heparin plus GpIIb/IIIa inhibitor, and fondaparinux were the hierarchy for treatment safety. Results were similar in direct comparison meta-analyses: bivalirudin was associated with a 39%, 44%, and 65% higher risk of myocardial infarction, urgent revascularization, and stent thrombosis respectively when compared with unfractionated heparin with or without GpIIb/IIIa inhibitor. However, bivalirudin was associated with a 48% lower risk of major bleeding compared with unfractionated heparin plus GpIIb/IIIa inhibitor and 32% lower compared with unfractionated heparin alone. Conclusions In patients undergoing primary PCI, unfractionated heparin plus GpIIb/IIIa inhibitor and LMWH plus GpIIb/IIIa inhibitor were most efficacious, with the lowest rate of major adverse cardiovascular events, whereas bivalirudin was safest, with the lowest bleeding. These relationships should be considered in selecting anticoagulant therapies in patients undergoing primary PCI.

A novel therapeutic approach in pulmonary arterial hypertension as a complication of adult-onset Still's disease: targeting IL-6

Abstract: Adult-onset Still's Disease (AOSD), often though as the adult variant of systemic juvenile idiopathic arthritis (JIA), has an incidence of 1-3 cases per 1 million. Cardinal manifestations include fever, arthritis, skin rash, sore throat, hepatosplenomegaly and lymphadenopathy. Prolongation in diagnosing this disease results from its similarity to infectious, malignant and rheumatic diseases and lack of biomarkers. Pulmonary arterial hypertension (PAH) is a rare pulmonary complication of AOSD, and we are aware of only six cases reported in literature to date. Here we present a patient with AOSD who has developed pulmonary hypertension as a complication. We report a case of AOSD complicated by PAH treated successfully with tocilizumab, a humanized monoclonal antibody to human interleukin (IL)-6 receptor. A Pubmed and Medline search for evidence of pulmonary hypertension in AOSD and use of IL-6 inhibition in management was performed. Data for this study was collected from the patient's chart records. No infectious or neoplastic cause of her disease was identified and after extensive diagnostic workup, the patient was diagnosed with AOSD fulfilling Yamaguchi criteria. After initiation of IL-6 therapy the patient was followed over time to monitor the hemodynamic changes in pulmonary vasculature. Following treatment with Tocilizumab, the patient showed dramatic improvement in her clinical symptoms and remains in remission, through combination of tocilizumab (8 mg/kg), methotrexate and prednisone. Improvement of systemic symptoms, right heart catheterization (RHC) findings and the VECTRA-DA score served as a measure of treatment response. Tocilizumab has been effective in demonstrating marked improvement in both the clinical and laboratory parameters. Tocilizumab is an effective novel treatment for AOSD with PAH. This is the first documented report of successful use of tocilizumab in AOSD patients presenting with PAH. Prospective comparative studies could help validate its efficacy and safety.

Multiple deployments and combat trauma: do homefront stressors increase the risk for posttraumatic stress symptoms?

Abstract: Multiple deployments are common among military personnel who served in Operation Enduring Freedom and Operation Iraqi Freedom and are associated with greater posttraumatic stress symptoms (PTSS). Homefront stressors (i.e., family, occupational problems) resulting from deployments may increase the risk of PTSS. Moreover, with multiple deployments, a new deployment may occur while still experiencing homefront stressors from previous tours. This prospective study assessed whether homefront stressors from a previous tour increased the risk of PTSS after a new deployment. It also examined the effects of homefront stressors at postdeployment. Survey data were obtained from U.S. National Guard soldiers with previous deployments prior to (Wave 1) and after (Wave 2) a new deployment to Iraq (N = 196). Homefront stressors reported at Wave 1 (β = .154, p = .015) and Wave 2 (β = .214, p = .002) were both significantly predictive of PTSS at postdeployment, even after adjusting for warzone stressors, predeployment PTSS, and other variables. A pattern of chronic homefront stressors (i.e., homefront stressors at pre- and postdeployment) was associated with higher levels of PTSS at postdeployment (β = .220, p = .002). Service members with multiple deployments are at greater risk for PTSS if deployed with homefront stressors from previous tours and/or face these stressors at postdeployment.

A retrospective analysis of the utility of an artificial neural network to predict ED volume.

Abstract: Objective The objectives of this study are to design an artificial neural network (ANN) and to test it retrospectively to determine if it may be used to predict emergency department (ED) volume. Methods We conducted a retrospective review of patient registry data from February 4, 2007, to December 31, 2009, from an inner city, tertiary care hospital. We harvested data regarding weather, days of week, air quality, and special events to train the ANN. The ANN belongs to a class of neural networks called multilayer perceptrons. We designed an ANN composed of 37 input neurons, 22 hidden neurons, and 1 output neuron designed to predict the daily number of ED visits. The training method is a supervised backpropagation algorithm that uses mean squared error to minimize the average squared error between the ANN's output and the number of ED visits over all the example pairs. Results A linear regression between the predicted and actual ED visits demonstrated an R 2 of 0.957 with a slope of 0.997. Ninety-five percent of the time, the ANN was within 20 visits. Conclusion The results of this study show that a properly designed ANN is an effective tool that may be used to predict ED volume. The scatterplot demonstrates that the ANN is least predictive at the extreme ends of the spectrum suggesting that the ANN may be missing important variables. A properly calibrated ANN may have the potential to allow ED administrators to staff their units more appropriately in an effort to reduce patient wait times, decrease ED physician burnout rates, and increase the ability of caregivers to provide quality patient care. A prospective is needed to validate the utility of the ANN.

“Looking out for each other”: a qualitative study on the role of social network interactions in asthma management among adult Latino patients presenting to an emergency department

Abstract: Objective: The objective of this study was to identify the types of interactions between asthma patients and their social networks such as close family and friends that influence the management of asthma. Methods: Participants were Latino adults presenting for a repeat visit to the emergency department for asthma treatment. Qualitative interviews were conducted with 76 participants. They were asked to describe the experiences of their social networks that have asthma and how interactions with these individuals influenced their own asthma management. Responses were transcribed and analyzed using Grounded Theory as a qualitative analytic approach. Responses were assigned codes; similar codes were grouped into concepts and then categorized to form overarching themes. Results: Four themes emerged: (1) Perceptions of severity of asthma may be based on the experiences of social networks; (2) Economic factors may contribute to the sharing and borrowing of asthma medications between patients and their soc...

Can a Simple Urinalysis Predict the Causative Agent and the Antibiotic Sensitivities

Abstract: OBJECTIVES The objective of this study was (1) to determine the reliability of urinalysis (UA) for predicting urinary tract infection (UTI) in febrile children, (2) to determine whether UA findings can predict Escherichia coli versus non-E. coli urinary tract infection, and (3) to determine if empiric antibiotics should be selected based on E. coli versus non-E. coli infection predictions. METHODS This was a retrospective chart review of children from 2 months to 2 years of age who presented to the emergency department with fever (rectal temperature >100.4°F) and had a positive urine culture. This study was conducted between January 2004 and December 2007. Negative UA was defined as urine white blood cell count less than 5 per high-power field, negative leukocyte esterase, and negative nitrites. Urine cultures were classified into E. coli and non-E. coli groups. These groups were compared for sex, race, and UA findings. Multivariate forward logistic regression, using the Wald test, was performed to calculate the likelihood ratio (LR) of each variable (eg, sex, race, UA parameters) in predicting UTI. In addition, antibiotic sensitivities between both groups were compared. RESULTS Of 749 medical records reviewed, 608 were included; negative UA(-) was present in 183 cases, and positive UA(+) was observed in 425 cases. Furthermore, 424 cases were caused by E. coli, and 184 were due to non-E. coli organisms. Among 425 UA(+) cases, E. coli was identified in 349 (82.1%), whereas non-E. coli organisms were present in 76 (17.9%); in contrast, in 183 UA(-) cases, 108 (59%) were due to non-E. coli organisms versus 75 (41%), which were caused by E. coli. Urinalysis results were shown to be associated with organism group (P < 0.001). Positive leukocytes esterase had an LR of 2.5 (95% confidence interval [CI], 1.5-4.2), positive nitrites had an LR of 2.8 (95% CI, 1.4-5.5), and urine white blood cell count had an LR of 1.8 (95% CI, 1.3-2.4) in predicting E. coli versus non-E. coli infections. Antibiotic sensitivity compared between UA groups demonstrated equivalent superiority of cefazolin (94.7% sensitive in UA(+) vs 84.0% in UA(-) group; P < 0.0001), cefuroxime (98.2% vs 91.7%; P < 0.001), and nitrofurantoin (96.1% vs 82.2%; P < 0.0001) in the UA(+) group. In contrast, the UA(-) group showed significant sensitivity to trimethoprim-sulfamethoxazole (82.2% vs 71.3% in UA(+); P = 0.008). CONCLUSIONS Urinalysis is not an accurate predictor of UTI. A positive urine culture in the presence of negative UA most likely grew non-E. coli organisms, whereas most UA(+) results were associated with E. coli. This study also highlighted local patterns of antibiotic resistance between E. coli and non-E. coli groups. Negative UA results in the presence of strong suspicion of a UTI suggest a non-E. coli organism, which may be best treated with trimethoprim-sulfamethoxazole. Conversely, UA(+) results suggest E. coli, which calls for treatment with cefazolin or cefuroxime.

Comparison of Urinary Tract Infection Rates Among 2- to 12-Month-Old Febrile Infants With RSV Infections Using 1999 and 2011 AAP Diagnostic Criteria

Abstract: Background. Infants with RSV infections have been found to have a clinically significant rate of urinary tract infections (UTIs). The American Academy of Pediatrics (AAP) published a revised Clinical Practice Guideline on UTIs in 2011, which includes major changes in diagnostic criteria for UTIs. Past research has been done using previous diagnostic criteria. The objective of the study is to assess the rate of UTIs in febrile infants with respiratory syncytial virus (RSV) infections according to the 2011 revised AAP Diagnostic Criteria and compare the rate of UTIs against the 1999 AAP Diagnostic Criteria. Methods. A retrospective comparative study of febrile infants (2-12 months) with RSV infections admitted to the Inpatient Pediatric unit of Lincoln Medical and Mental Center, Bronx, NY, from September through April 2006 to 2012. We applied the AAP’s 1999 and 2011 diagnostic criteria for UTIs separately to assess the rates of UTIs. Results. A total of 359 RSV-positive febrile patients who were investigate...

Characteristics of asthmatic patients with and without repeat emergency department visits at an inner city hospital

Abstract: Objective: The objective of this study was to document the frequency and clinical characteristics associated with repeat emergency department (ED) visits for asthma in an inner city population with a high burden of asthma. Methods: During an ED visit for asthma in an inner city hospital (‘index visit’), patients completed a valid survey addressing disease and behavioral factors. Hospital records were reviewed for information about ED visits and hospitalizations for asthma during the 12 months before and the 90 days after the index visit. Results: One hundred and ninety-two patients were enrolled; the mean age was 42 years, 69% were women, 36% were black, 54% were Latino, 69% had Medicaid, and 17% were uninsured. 100 patients (52%) were treated and released from the ED, 88 patients (46%) were hospitalized, and 4 patients (2%) left against medical advice. During the subsequent 90 days, 64 patients (33%) had at least one repeat ED visit for asthma and 27 (14%) were hospitalized for asthma. In a multi...

Partial Hydatidiform Mole With False-Negative Urine Human Chorionic Gonadatropin Test in the Emergency Department

Abstract: Background Hydatidiform mole (molar pregnancy) is a benign tumor of placental trophoblastic cells, which release human chorionic gonadotropin (hCG). Several case reports have described complete hydatidiform moles with false-negative urine qualitative hCG tests. These negative pregnancy tests have been attributed to the hook effect. We report an unusual presentation of a partial mole and review an alternative explanation for the negative hCG test. As partial moles are usually not associated with a large proliferation of trophoblastic cells, levels of hCG are commonly Objective In a pregnant patient, vaginal bleeding and abdominal pain are common presentations. Molar pregnancy is an uncommon cause of abdominal pain and vaginal bleeding that should be considered. Case Report A 47-year-old female presented to the emergency department with abdominal pain and vaginal bleeding. Urine qualitative hCG was negative and serum quantitative hCG was 1,094,950 mIU/mL. Pelvic ultrasonography showed a uterine cavity containing a soft-tissue mass with multiple cystic lesions and the hydatidiform mole was extracted with suction curettage. Tissue pathology confirmed partial hydatidiform mole. Conclusions In addition to the hook effect, we present another possible explanation for the false-negative test; namely the inability of some assays to detect hCG-degradation products, which may be higher in clinical samples from patients with hydatidiform mole. This case underscores the importance of knowing the limitations of the commonly used hCG assays.

Recrudescence of Plasmodium malariae after Quinine

Abstract: Plasmodium malariae causes uncommon benign malaria found in the malaria endemic regions mostly of Sub-Saharan Africa. As Plasmodium malariae does not have a continued liver stage in humans the only way to have reinfection without reexposure is through recrudescence. However, reports of its recrudescence after antimalarials are rare with only a handful of case reports in the literature. Research in this field to date has not been able to establish definitively an emergence of resistance in Plasmodium malariae to commonly used antimalarials. In the presented case, patient had a recrudescence of P. malariae after full treatment with quinine and clindamycin. This recrudescence was treated with full course of chloroquine with clearance of parasite from blood immediately after treatment and at two months' follow up. The recrudescence in this case cannot be explained by mechanisms explained in prior articles. We propose that the indolence of some of the Plasmodium malariae trophozoites in the blood can shield them from the effect of the toxic effects of antimalarials and enable them to produce recrudescence later. However, when recrudescence happens, this should not be considered a case of development of resistance and a course of chloroquine should be considered.

A Case Report of Hairy Cell Leukemia Presenting Concomitantly with Sweet Syndrome

Abstract: Hairy cell leukemia and Sweet syndrome are both uncommon hematological diagnoses. We present a patient who was admitted with fevers, pancytopenia, pneumonia, and rash. Diagnostic bone marrow biopsy demonstrates Hairy cell Leukemia and skin biopsy demonstrates neutrophils infiltration consistent with Sweet syndrome. The patient was treated with purine analogs with resolution of the cytopenias, infection, and rash.

Occipital condyle fracture in a patient with neck pain

Abstract: Occipital condyle fractures (OCF) are rare traumatic injuries and are of critical clinical importance because of the anatomic considerations of the occipitoatlantoaxial joint complex. OCF can be a diagnostic challenge because of the inability to diagnose this injury with plain radiographs. This is especially true in the emergency department (ED) setting. A high degree of clinical suspicion and careful investigation of the craniocervical junction is warranted in patients presenting to the ED with head and cervical trauma. We present a case of a 45-year-old male who presented to the ED with complaints of neck pain and headache four days after an assault. The classification, clinical presentation, diagnosis, and management of his injury are discussed, and pertinent literature is reviewed. OCF can be easily overlooked due to multiple factors; including the conscious state of the patient or the inability to diagnose it through plain radiographs. Early recognition and diagnosis of OCF is crucial to prevent neurological involvement.

SAT0211 14-3-3 ETA Protein: A Novel Biomarker for the Diagnosis of Rheumatoid Arthritis

Abstract: Background Serum 14-3-3 eta has been described to have diagnostic utility and in established RA an association has been established between the levels of this marker and the degree of joint damage. The η isoform of 14-3-3 is expressed extracellularly in much higher concentration than the Υ isoform or MMP 1 and 3 levels in the synovial fluid and serum of patients with rheumatoid arthritis compared to the normal population. Rheumatoid factor (RF) is known to be sensitive and anti CCP highly specific for RA, but a high number of patients remain seronegative. There is a need for a biomarker to prevent underdiagnosis in this subset. Objectives The purpose of the study was to investigate if serum 14-3-3 η enhanced the detection of RA over RF or anti CCP in RA patients. We also studied the utility of 14-3-3 eta as a diagnostic test by comparing presence of this protein in RA v/s non-RA patients. Methods A retrospective chart review study was conducted in RA patients at an outpatient rheumatology clinic in an inner city population at a community teaching hospital serving a large immigrant population. 91 RA patients were identified who satisfied the 2010 ACR diagnostic criteria and 37 non RA patients seen in the clinic for other rheumatologic conditions were chosen as the control group. Serum 14-3-3η protein was measured by ELISA. The positive threshold range using Quest Diagnostic for RF was 15 International Unit/ml, Anti CCP was 20 Units and for 14-3-3 eta was 0.2 ng/mL. The chi-square goodness-of-fit test was used to analyze the frequency of eta positivity in the RA population while kappa was calculated to compare the RA and non RA patients. Results Of the 91 RA patients, 75.8% were females and mean age was 58 (range 28- 90) years. The population was predominantly Hispanic (75%). In the non-RA group, 9% had psoriatic arthritis and 14% lupus, 73% were females,76% Hispanic and the mean age was 54 (range 19-93) years. In the RA population, none of group without RF or anti-CCP was positive for eta. For those with either RF or anti-CCP, the prevalence of eta positivity was 11.1% (95%CI 2.8-35.2%). For those with both RF and anti-CCP, the prevalence of eta positivity was 81.0% (95% CI 68.9-89.2%). All comparisons between groups were significant at p Conclusions Measurement of 14-3-3η complements RF and anti-CCP antibody tests in RA and may improve diagnostic sensitivity. Used in combination with other serological markers, 14-3-3 eta can increase identification of patients with RA. *Equal Contribution Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5776

Safe Haven Laws: lack of awareness, misinformation, and shortfalls in resident education.

Abstract: Infanticide is defined as the killing of a child in the first 12 months of life, while neonaticide refers to the killing of a child in the first 24 hours of life [1,2]. The tragedy of abandoned or murdered newborns continues to be a reality in our society [3-7]. The Centers for Disease Control report that a person is 10 times more likely to die of homicide on the day they are born than at any other time during their life [8,9]. About 150 to 300 cases of neonaticide occur per year in the United States with an incidence to be 2.1 per 100000 live births per year [3,4]. The stories behind these abandoned newborns are varied but typically involve an unplanned, unwanted, and concealed pregnancy [1,5,6,10-12]. The mother is generally the perpetrator, though paternal neonaticide had been reported [13-15]. The most common Fig. 2. Measurements of the alpha and beta angles and the base of the triangle do not coincide with those established for the Brugada pattern.

When to perform urine cultures in respiratory syncytial virus-positive febrile older infants?

Abstract: Background Respiratory syncytial virus (RSV) infections are associated with clinically significant rate of urinary tract infections (UTIs) in young infants. Previous research investigating RSV infections and UTIs has been performed mainly in infants younger than 2 to 3 months and has not focused on the risk of UTI in infants 3 to 12 months. Objective This study aimed to assess the rate of UTIs in febrile RSV-positive older infants admitted as inpatients and identify predictors of UTI in febrile RSV-positive older infants. Methods This is a retrospective comparative study of febrile RSV-positive infants 0 to 12 months of age admitted to the inpatient pediatric unit of Lincoln Medical and Mental Health Center, Bronx, from September through April 2006 to 2012. Infants 3 to 12 months were considered the cases, and infants 0 to 3 months were the comparative group. The rate of UTIs between the 2 groups was compared. Univariate tests and multiple logistic regression were used to identify demographic/clinical factors associated with UTI in febrile RSV-positive older infants. Results A total of 414 RSV-positive febrile infants were enrolled including 297 infants 3 to 12 months of age. The rate of UTI in older infants was 6.1% compared with 6.8% in infants younger than 3 months. Positive urinalysis finding was an independent predictor of UTI (P = 0.003) in older infants. All 11 boys with UTI were uncircumcised, and none of the 51 circumcised boys had UTI. Demographic (race, sex, and age) and clinical factors (temperature, white blood cell count, and absolute neutrophil count) were not associated with UTI. Conclusions Febrile older infants who are RSV positive have a clinically significant rate of UTIs. It seems prudent to examine the urine of these older infants. Positive urinalysis finding was a predictive factor of UTI. Circumcised boys are at a decreased risk of UTI, compared with uncircumcised boys.

Perspectives on bullying among children who present to the emergency department with behavioral misconduct: a qualitative study.

Abstract: The problem of bullying is an increasing public health threat encountered by emergency physicians especially in inner city emergency departments (EDs). Bullying may result in emotional disturbances and psychological trauma in children. Many children sent to the ED because of behavioral misconduct require immediate stabilization and treatment. The emergency physician performs an initial assessment and stabilization. Emergency departments are increasingly on the frontline of the bullying problem. OBJECTIVES: Our objective was to explore children's perspective of bullying and their views of potential solutions. METHODS: A qualitative study was conducted in a cohort of 50 children (age, 8-17 years), who were referred to the ED from school because of their behavioral misconduct. An interview survey tool about bullying was administered. It focused on what bullying meant to them and what advice they have for a child who is bullied. They were also asked what advice they would have for adults who try to help. We used grounded theory to analyze the data. Similar concepts were grouped, and the categories with similar properties and dimensions were defined. Common themes were then identified. RESULTS: We interviewed 50 children, of whom 27 were boys and 23 were girls. Their mean (SD) age was 12.5 (2.12) years (range, 8-17 years). Bullying was identified by children as including physical, verbal, and emotional actions. Several themes emerged. First, a power imbalance between a bully and victim may render an individual vulnerable to bullying. Being different and weak also increases the risk of being bullied. Second, bullying is wrong, and the bully should be punished. Third, children should learn how to handle bullying situations and develop resilience against bullying. Finally, adults need to be more proactive to prevent or stop bullying. CONCLUSIONS: Our results provide insights into the perceptions of children regarding bullying. We have garnered a better understanding of what these children feel adults should do to prevent bullying. Language: en

A Rare Case of β-hCG Production by a Solitary Fibrous Tumor of the Pleura

Abstract: Background Solitary fibrous tumors are rare tumors of mesenchymal origins, most commonly seen arising from the pleural lining of the lungs. These are generally benign tumors, which in rare cases have been identified to be associated with multiple para-neoplastic syndromes. Case report This is a case of a solitary fibrous tumor of the pleura in a 49 year old female which was found to be associated with elevated levels of serum beta human chorionic gonadotropin β-hCG). Due to the lack of plausible causes for elevated β-hCG in the patient, immune-histochemical staining of the tumor specimen for β-hCG was obtained. This confirmed the patient's solitary fibrous tumor as the source of the β-hCG. The patient was also found to have a possible paraneoplastic syndrome with irregular menstruation and hot flushes from the secreted β-hCG. Conclusions This is the first reported case of solitary fibrous tumors of the pleura producing {b-hCG. Multiple types of lung tumors have been associated with production of β-subunit of human chorionic gonadotropin. Production of β-hCG by these tumors has been associated with a poor prognosis. In this case, we find an aggressive form of solitary fibrous tumor associated with production of β-hCG and associated paraneoplastic syndrome secondary to the β-hCG. Further study is required to identify the frequency of this phenomenon and the implications of β-hCG production in the prognosis of the solitary fibrous tumors.

Opiate Withdrawal Complicated by Tetany and Cardiac Arrest

Abstract: Patients with symptoms of opiate withdrawal, after the administration of opiate antagonist by paramedics, are a common presentation in the emergency department of hospitals. Though most of opiate withdrawal symptoms are benign, rarely they can become life threatening. This case highlights how a benign opiate withdrawal symptom of hyperventilation led to severe respiratory alkalosis that degenerated into tetany and cardiac arrest. Though this patient was successfully resuscitated, it is imperative that severe withdrawal symptoms are timely identified and immediate steps are taken to prevent catastrophes. An easier way to reverse the severe opiate withdrawal symptom would be with either low dose methadone or partial opiate agonists like buprenorphine. However, if severe acid-base disorder is identified, it would be safer to electively intubate these patients for better control of their respiratory and acid-base status.

Prolonged survival in metastatic colorectal cancer following chemotherapy

Abstract: Key Clinical Message The cost of treating metastatic colorectal cancer has increased significantly after the introduction of targeted antivascular therapies. We report the unusual case of a patient with colorectal cancer with several large liver metastases at diagnosis, who was cured after removal of the primary tumor and treatment with 5-FU/LV only.

Noncontraceptive use of contraceptive agents.

Abstract: 1. Monique Collier Nickles, MD* 2. Elizabeth Alderman, MD† 1. *Department of Pediatrics, Lincoln Medical and Mental Health Center, Bronx, NY. 2. †Department of Pediatrics, Division of Adolescent Medicine, Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY. * Abbreviations: CDC: : Centers for Disease Control and Prevention CHC: : combined hormonal contraceptive COCP: : combined oral contraceptive pill FDA: : Food and Drug Administration GnRH: : gonadotropin-releasing hormone LNG-IUS: : levonorgestrel intrauterine system NSAID: : nonsteroidal anti-inflammatory drug PCOS: : polycystic ovary syndrome PMDD: : premenstrual dysphoric disorder PMS: : premenstrual syndrome SCD: : sickle cell disease vWD: : von Willebrand disease vWF: : von Willebrand factor According to 2006-2008 National Survey of Family Growth data, 33% of adolescents ages 15 to 19 years using combined oral contraceptives do so solely for noncontraceptive reasons, mostly to alleviate problems and symptoms associated with menstrual periods. Consequently, it is necessary for physicians to become more knowledgeable of the known health benefits and noncontraceptive uses of contraceptive agents to enhance their treatment and care for adolescent patients. (1) After completing this article, readers should be able to: 1. Identify medical conditions treatable with hormonal contraception. 2. Identify noncontraceptive benefits of contraceptive agents for adolescents. 3. Recognize conditions and diseases for which menstrual regulation or suppression can benefit adolescents, improve disease outcome, and enhance quality of life. 4. List the relative and absolute contraindications to the use of combined hormonal contraceptives. 5. Describe different contraceptive methods available for use. Recent data have revealed that more than 30% of adolescent girls use contraceptive agents solely for noncontraceptive reasons, typically to alleviate symptoms associated with menstrual periods but also for acne and endometriosis. (1) Most noncontraceptive uses of these agents are off-label; however, they have been deemed appropriate secondary to research and Cochrane review. This represents a change from historical trends in which contraceptive agents, specifically, oral contraceptive pills, were typically used by adolescents primarily for prevention of unintended pregnancy. In addition to this shift, another important change during the past decade has been the introduction of several new hormonal contraceptive agents. Not only has direct advertising to the public through various media increased …

Focused Cardiac Ultrasound Diagnosis of Thoracic Aortic Aneurysm: Two Cases

Abstract: Background Thoracic aortic aneurysms (TAAs) are less prevalent than abdominal aortic aneurysms. Symptomatic TAAs need to be identified quickly by the emergency physician (EP) since mortality rates increase dramatically once complications such as rupture or dissection occur. Compared with validated EP-performed ultrasound of the abdominal aorta, EP-performed focused cardiac ultrasound that includes evaluation of the thoracic aorta is relatively unreported. Objective Two cases illustrate EP-performed focused cardiac ultrasound and evaluation of the thoracic aorta for aneurysmal dilation. Case Reports (1) A 60-year-old man presented to the emergency department (ED) after a blunt traumatic injury to his back while at work. During the focused cardiac ultrasound examination, the aortic outflow tract distal to the aortic valve appeared enlarged and the aortic root measured 5.49 cm. (2) An 82-year-old man with hypertension presented to the ED with 1 month of chest pain radiating to the back. The focused cardiac ultrasound examination demonstrated enlargement of the descending thoracic aorta at 4.82 cm. Conclusion EPs performing focused cardiac ultrasound can visualize regions of the thoracic aorta that may reveal an aneurysm, particularly in the parasternal long axis view.

A 20-year-old female with hemoptysis and high blood pressure: An unusual case of papillary renal cell carcinoma.

Abstract: Patient: Female, 20 Final Diagnosis: Papillary renal cell carcinoma Symptoms: Hemopthysis Medication: Sutent Clinical Procedure: CT guided biopsy Specialty: Oncology Objective: Rare disease Background: Papillary renal cell carcinoma (PRCC) is a rare disease and is a carcinoma of the renal tubular epithelium, comprising only 10–15% of all renal cell carcinoma cases. The majority of cases occur in the sixth decade of life. PRCC rarely occurs before the fourth decade in the absence of family history. This paper describes an aggressive, sporadic case of PRCC in a 20-year-old female without family history and no risk factors. Case Report: A 20-year-old African American female was admitted for hemoptysis with elevated blood pressure and was found to have left peri-hilar opacification on chest X-ray. Further radiological studies led to the discovery of a large complex left renal lesion within the collecting system, infiltrating the renal artery and causing severe hydronephrosis with para-aortic lymphadenopathy. An MRI also showed signal heterogeneity in the L2 and L3 vertebrae. Biopsies of the left renal mass and a right endobronchial lesion confirmed metastatic PRCC. Treatment was commenced with a tyrosine kinase inhibitor. Within a few weeks, the vertebral metastatic lesions progressed to cause spinal compression. After targeted radiotherapy, the patient was referred to Memorial Sloan Kettering Cancer Center for enrolment in a clinical trial. Conclusions: PRCC rarely occurs in the second decade of life and even then, most such early cases occur in family clusters. PRCC also has a relatively benign course, constituting less than 10% of all metastatic renal cell carcinomas, further making this case a unique presentation.