Showing papers by "Lincoln Hospital published in 2015"

Adult-onset Still's disease-pathogenesis, clinical manifestations, and new treatment options.

Abstract: Adult-onset Still's disease (AOSD), a systemic inflammatory disorder, is often considered a part of the spectrum of the better-known systemic-onset juvenile idiopathic arthritis, with later age onset. The diagnosis is primarily clinical and necessitates the exclusion of a wide range of mimicking disorders. AOSD is a heterogeneous entity, usually presenting with high fever, arthralgia, skin rash, lymphadenopathy, and hepatosplenomegaly accompanied by systemic manifestations. The diagnosis is clinical and empirical, where patients are required to meet inclusion and exclusion criteria with negative immunoserological results. There are no clear-cut diagnostic radiological or laboratory signs. Complications of AOSD include transient pulmonary hypertension, macrophage activation syndrome, diffuse alveolar hemorrhage, thrombotic thrombocytopenic purpura and amyloidosis. Common laboratory abnormalities include neutrophilic leukocytosis, abnormal liver function tests, and elevated acute-phase reactants (ESR, CRP, ferritin). Treatment consists of anti-inflammatory medications. Non-steroidal anti-inflammatory drugs have limited efficacy, and corticosteroid therapy and disease-modifying anti-rheumatic drugs are usually required. Recent advances have revealed a pivotal role of proinflammatory cytokines such as tumor necrosis factor-α (TNF-α), interleukin (IL)-1, IL-6, IL-8, and IL-18 in disease pathogenesis, giving rise to the development of novel targeted therapies aiming at optimal disease control. The review aims to summarize recent advances in pathophysiology and potential therapeutic strategies in AOSD.

Trauma-associated pneumonia: time to redefine ventilator-associated pneumonia in trauma patients

Abstract: Background The high prevalence of ventilator-associated pneumonia (VAP) in trauma patients has been reported in the literature, but the reasons for this observation remain unclear. We hypothesize that trauma factors play critical roles in VAP etiology. Methods In this retrospective study, 1,044 ventilated trauma patients were identified from December 2010 to December 2013. Patient-level trauma factors were used to predict pneumonia as study endpoint. Results Ninety-five of the 1,044 ventilated trauma patients developed pneumonia. Rib fractures, pulmonary contusion, and failed prehospital intubation were significant predictors of pneumonia in a multivariate model. Conclusions It is time to redefine VAP in trauma patients based on the effect of rib fractures, pulmonary contusions, and failed prehospital intubations. The Centers for Disease Control and Prevention definition of VAP needs to be modified to reflect the effect of trauma factors in the etiology of trauma-associated pneumonia.

Didelphys Uterus: A Case Report and Review of the Literature.

Abstract: Background. Mullerian duct anomalies (MDAs) are congenital defects of the female genital system that arise from abnormal embryological development of the Mullerian ducts. A didelphys uterus, also known as a “double uterus,” is one of the least common amongst MDAs. This report discusses a case of didelphys uterus that successfully conceived, carried her pregnancy to term, and delivered vaginally without any significant complications. Case. Patient is a 29-year-old G2P0010 from Bangladesh, initially came a year prior in her first pregnancy, with spontaneous abortion (SAB). Pelvic Sonogram at that time showed a diagnosis of bicornuate versus didelphys uterus. There were no renal anomalies on subsequent abdominal CT scan. Patient presented with the second pregnancy and had uncomplicated prenatal care and did not have signs of preterm labor; fetus showed appropriate growth and the pregnancy was carried in the left uterus. Patient presented at 38 4/7 wks with Premature Rupture of Membrane and underwent induction of labor with Cytotec. Antibiotics were started for chorioamnionitis. Patient had a vaginal delivery with left mediolateral episiotomy and complete tear of vaginal septum. Third stage of labor was complicated with retained placenta, which was removed manually in the operating room with total EBL of 600 cc.

Gestational Gigantomastia Complicating Pregnancy: A Case Report and Review of the Literature

Abstract: Background. Gestational gigantomastia is a rare disorder without clear etiology or well-established risk factors. Several pathogenic mechanisms contributing to the disease process have been proposed, all of which can lead to a similar phenotype of breast hypertrophy. Case. A 28-year-old Guinean woman presented at 37 weeks of gestation with bilateral gigantomastia, mastalgia, peau d’orange, and back pain. Prolactin levels were 103.3 μg/L (with a normal reference value for prolactin in pregnancy being 36–372 μg/L). The patient was treated with bromocriptine (2.5 mg twice daily), scheduled for a repeat cesarean, and referred to surgery for bilateral mammoplasty. Conclusion. Gestational gigantomastia is a rare disorder, characterized by enlargement and hypertrophy of breast tissue. Our patient presented with no endocrine or hematological abnormalities, adding to a review of the literature for differential diagnoses, workup, and management of cases of gestational gigantomastia with normal hormone levels.

Comparing biomarkers of traumatic shock: the utility of anion gap, base excess, and serum lactate in the ED ☆,☆☆

Abstract: Background Biomarkers such as serum lactate, anion gap (AG), and base excess (BE) have been shown to be of use in determining shock in patients with seemingly normal vital signs. We seek to determine if these biomarkers can be used interchangeably in patients with trauma in the emergency setting based on their test characteristics and correlation to each other. Methods A prospective observational cohort study was undertaken at an urban level 1 trauma center. Baseline vital signs, point-of-care BE, AG, and serum lactate were recorded in all patients who presented for trauma. Correlation was determined by linear regression model. Overall test characteristics and relative risk were calculated. Results One hundred patients were enrolled. The median age was 30 years (interquartile range, 24-42 years), and 89% were male. Fifty-three percent of injuries were blunt trauma. Pearson correlation of serum lactate to BE was −0.81 ( r 2 = 0.66; 95% confidence interval [CI], 0.53-0.75; P r 2 = 0.5; 95% CI, −0.80 to −0.57; P r 2 = 0.5; 95% CI, 0.57-0.80; P Conclusions This study demonstrates that the biomarkers have similar test characteristics which may make them interchangeable as indicators for the presence of occult shock in patients with trauma. Lactate and BE correlate well with each other; however, AG was not as strongly correlated with either.

Tolerability of Antihypertensive Medications in Older Adults

Abstract: Several guidelines for hypertension have recently undergone revisions to incorporate an approach providing choices of medications based on age, race, and specific situations where hypertension may co-exist with disorders such as diabetes, coronary artery disease, heart failure and chronic kidney disease. Initial recommendations include diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers; beta blockers are favored in some guidelines and are a choice in specific settings. Within the classes of drugs, several antihypertensive agents provide options. This review discusses antihypertensive drugs by class, including adverse effects and tolerability, with preferences in older adults and specific settings. Adverse drug events from antihypertensive medications are discussed by class and where applicable for specific agents. Data from select studies pertinent to tolerability and adverse effects are presented in tables for several classes of drugs. The rationale for nonadherence to medication is reviewed, including the roles played by tolerability and adverse drug effects. Antihypertensive therapy in typical settings in older adults is discussed; they include hypertension in association with impaired cognition, depression, diabetes, sexual dysfunction, and falls. The key to successful therapy and tolerability is to promote a healthy lifestyle in conjunction with medications as the approach, thereby also lowering the adverse drug effects. The eventual choice of the specific drug(s) is based on risks, benefits, and patient preferences, and is best tailored for each older adult.

Essure Microinsert Abdominal Migration after Hysteroscopic Tubal Sterilization of an Appropriately Placed Essure Device: Dual Case Reports and Review of the Literature

Abstract: Background. The Essure device is a method of permanent sterilization widely used in the US that has proven to be safe and effective in most cases. However, there have been reports of device migration that have led to failed tubal occlusion as well as several other serious complications resulting from the presence of the device in the abdominal cavity. Case. This paper represents two cases of failed tubal occlusion by an appropriately placed Essure device without signs or symptoms of further complications related to device migration. Conclusion. Although there have only been 13 reported cases of abdominal device migration since November 2014, this case indicates that the actual number may be higher than reported since it is possible for migration to occur without additional complications. In the majority of reported cases of abdominal migration a major complication requiring surgical correction occurred, such as adhesions, small bowel obstruction, bowel perforation, or persistent pelvic pain. To avoid these complications it is recommended that migrating implants be removed; however, this case also represents an example of when a migrating device may remain in situ in an asymptomatic patient.

Expanded criteria donor kidneys for retransplantation United Network for Organ Sharing update: proceed with caution.

Abstract: Summary This study analyzed outcomes of retransplantation from expanded criteria donors (ECD) over the last two decades to determine the benefits and risks of using ECD kidneys for retransplantation. Data from the United Network for Organ Sharing database were collected and analyzed. Graft survival, death-censored graft survival, and patient survival for retransplantation with ECD kidneys (re-ECD) were reported and compared with primary transplantation with ECD kidneys (prim-ECD) and retransplantation with standard criteria donor kidneys (re-SCD). Re-ECD kidneys had higher risk of graft failure compared with prim-ECD (hazard ratio [HR] = 1.19) and to re-SCD (HR = 1.76). Patient survival was better in re-ECD compared with prim-ECD (HR = 0.89) but was worse than re-SCD (HR = 1.82). After censoring the patients who died with a functioning graft, re-ECD had a higher mortality risk compared with prim-ECD (HR = 1.45) and re-SCD (HR = 1.79). Transplantation improves quality of life and reduces healthcare costs, and due to the risk associated with resumption of hemodialysis and the longer waiting list times for SCD kidneys, there is a benefit to accepting ECD kidneys for select patients requiring retransplantation. Although this benefit exists for select patients, retransplantation with ECD kidneys should be undertaken with trepidation, and appropriate informed consent should be obtained.

Acute myopericarditis in an adolescent mimicking acute myocardial infarction.

Abstract: Acute myopericarditis is primarily a pericarditic syndrome with variable myocardial involvement, as evidenced by elevated cardiac enzymes. It is a rare entity, exclusively seen in male adolescents and accounts for less than 2% of the cases of inpatient admissions for chest pain/pericarditis in the pediatric age group. The electrocardiographic changes of pericarditis include J point/ST segment elevation, which needs to be differentiated from the benign early repolarization pattern that is common in young adolescents and the subtle anterior ST segment elevation myocardial infarction. Differentiating acute myopericarditis from acute coronary syndromes can be challenging because they share the presenting triad of acute chest pain, ST segment changes, and elevated cardiac enzymes. The accurate distinction of myopericarditis from acute myocarditis or acute coronary syndrome is important because of their differences in risk for specific complications, prognosis, and treatment implications. We present a case of acute myopericarditis in an adolescent who presented with atypical precordial chest pain, accompanied by inferolateral focal electrocardiographic changes and significant elevation of cardiac enzymes. The differential diagnosis and management of myopericarditis is reviewed with a focus on electrocardiographic changes and troponin assays.

Promoting an obesity education program among minority patients in a single urban pediatric Emergency Department (ED)

Abstract: Background The purpose of this study was to assess the feasibility of the Emergency Department (ED) as a place for obesity education and to evaluate its impact on patient’s lifestyle modification.

Pleural mycobacterium avium complex infection in an immunocompetent female with no risk factors.

Abstract: Mycobacterium avium complex (MAC) infections rarely affect the pleura, accounting for 5–15% of pulmonary MAC. We report a case of MAC pleural effusion in an otherwise immunocompetent young patient. A 37-year-old healthy female with no past medical history was admitted to the hospital with two weeks of right sided pleuritic chest pain, productive cough, and fever. She was febrile, tachycardic, and tachypneic with signs of right sided pleural effusion which were confirmed by chest X-ray and chest CT. Thoracentesis revealed lymphocytic predominant exudative fluid. The patient underwent pleural biopsy, bronchoscopy with bronchoalveolar lavage, and video assisted thoracoscopic surgery (VATS), all of which failed to identify the causative organism. Six weeks later, MAC was identified in the pleural fluid and pleural biopsy by DNA hybridization and culture. The patient was started on clarithromycin, ethambutol, and rifampin. After six months of treatment, she was asymptomatic with complete radiological resolution of the effusion. The presence of lymphocytic effusion should raise the suspicion for both tuberculous and nontuberculous mycobacterial disease. Pleural biopsy must be considered to make the diagnosis. Clinicians must maintain a high index of suspicion of MAC infection in an otherwise immunocompetent patient presenting with a unilateral lymphocytic exudative effusion.

Acute Genital Edema during Peritoneal Dialysis: A Review for Surgeons.

Abstract: Acute genital edema (AGE) is an infrequent but disruptive complication in patients on continuous ambulatory peritoneal dialysis. It is a common manifestation of dialysate leakage caused by inguinal, umbilical, femoral, or incisional hernias; peritoneal tears; leaks around the dialysis catheter; trauma; fluid overload; and malignancy. The evaluation of AGE begins with a history and physical exam. However, the physical exam in these patients is often indeterminate. Several diagnostic measures exist to evaluate and guide management of AGE occurring during continuous ambulatory peritoneal dialysis but little agreement exists on an optimum method. We have conducted a review of the literature on the evaluation and management of AGE and present a summary of the data. CT peritoneography and peritoneal scintigraphy have been used extensively to evaluate AGE although no comparative studies exist. MRI peritoneography has also been described. CT peritoneography offers more anatomical detail but may not be as sensitive as peritoneal scintigraphy in detecting a peritoneal fluid leak as the cause for AGE. CT is also more costly and subjects the patient to more radiation. MRI is a noncontrast study without radiation risk, but has not been studied to the same degree. If testing is equivocal or bilateral hernias are suspected, diagnostic laparoscopy is helpful and can be combined with hernia repair. Whether the etiology is a leak or tear, low-volume peritoneal dialysis (PD) or cessation of PD for two to four weeks will allow closure. However, hernias almost always require operative repair with mesh usually without disrupting PD.

Determining the Utility of Metabolic Acidosis for Trauma Patients in the Emergency Department

Abstract: Background Metabolic acidosis has been proposed as the gold standard to define shock in trauma patients. Other studies determine the presence of shock by use of serum lactate. However, not all medical centers have the ability to utilize point-of-care lactate at bedside. Objective This study seeks to determine the relationship between serum lactate and metabolic acidemia in trauma patients, and if metabolic acidemia can be used to guide therapy. We hypothesized that acidemia would be strongly correlated with lactate levels and would be associated with activation of massive transfusion (MT) in the presence of shock in trauma. Methods This was a prospective observational cohort study, level II evidence; this study aids in decision-making. Setting was a Level I academic, urban trauma center. The study took place from July 1, 2012 to March 1, 2013 and included patients who were ≥18 years old and required trauma team activation. Observations included baseline demographics (age, gender, type of injury), vital signs, point-of-care arterial blood gas, lactate, and need for MT. Results One hundred patients were enrolled over the study period. The average age was 34 years, and 82% were male. Forty patients were acidemic (pH p r s = −0.38, t = −4.03, p p = 0.002). Conclusion This is a prospective observational cohort study with level II evidence. This study demonstrates that acidemia was strongly correlated to serum lactate, lactate levels were higher in the acidemic group, and metabolic acidemia was associated with the activation of MT for trauma patients at our institution.

Marchiafava-Bignami disease in a trauma patient

Abstract: Marchiafava-Bignami disease (MBD) is a rare pathological condition affecting the corpus callosum (CC), characterized by progressive demyelination and necrosis. While usually found in patients with chronic alcoholism, it has rarely been characterized in non-alcoholics. We describe a trauma patient with an unknown mechanism of injury, who was found to have MBD after remaining comatose for a prolonged period of time. Magnetic resonance imaging (MRI) demonstrated restricted diffusion involving the genu, body, and splenium of the CC. The patient eventually awoke but was non-communicative and uncomprehending prior to discharge to a nursing facility. We reviewed the literature and report here the first case of MBD encountered in a trauma patient. In conclusion, MBD is an extremely rare condition in non-alcoholic patients, and the use of MRI is crucial for its identification.

Noninvasive ventilation during procedural sedation in the ED: a case series

Abstract: Given this information, although the authors reported that 100% of patients had elevated CRP and the elevated CRP was used to rule in serositis, we propose that, in SLE, the CRP level is not as sensitive as it would appear here. Thus, the physicianmust be aware of this complex relationship, knowing that the predictive value of an elevated conventional CRP assay on SLE disease activity and cardiovascular risk is still limited at present. Secondly, we comment on the frequent occurrence of coexisting pericardial and pleural effusions in SLE disease presentation. This correlation was explained by the authors as a generalized serositis. In SLE, the pathogenesis of serositis is thought to involve immune complex deposition stimulating an inflammatory reaction [5]. Although this can simultaneously affect both the pleura and pericardium, we draw attention to the fact that outside of autoimmune serositis, there is a strong link between pericardial disease and pleural effusion, in particular, a predominantly left-sided effusion [6,7]. It would be interesting for the authors to have reported if the coexistent pleural effusions were predominantly left sided. This little-known association is clinically important for emergency physicians. The finding of increased transverse cardiac diameter and a left-sided pleural effusion on imaging should arouse suspicion of pericardial disease. This can be an early clue to a pericardial effusion, which can otherwise be silently progressing to tamponade physiology. Furthermore, this association is important to recognize as a small pericardial effusion in existence with a large pleural effusion can produce cardiac tamponade, which may actually resolve with pleural tap [8,9]. In conclusion, physicians must always consider SLE as a differential in patients presentingwith cardiac symptoms in the appropriate clinical context. This involves appropriate laboratory investigations, with cautious interpretation of CRP levels, and remembering the link between pericardial and pleural effusions when interpreting imaging and instituting management.

Do all children with suicidal ideation receive a significant psychiatric intervention

Abstract: BACKGROUND: In most physicians' minds, suicidal ideation carries with it an ominous prognosis requiring intensive evaluation and treatment. We evaluated the hypothesis by first defining what an intensive psychiatric intervention would be, then determining what percentage of suicidal children received this intervention. OBJECTIVES: To determine the proportion of children identified with suicide ideation, who received a significant psychiatric intervention. METHODS: Medical records were reviewed for psychiatric interventions of all children presenting to the Emergency Department (ED) with behavioral disorders between 2004 and 2007, for which a psychiatry consultation was obtained. Suicidal children were those who had expressed suicidal ideation. We defined a significant psychiatric intervention as one of the following: hospitalization in a psychiatric facility, a period of observation in the ED (>12 hours), use of restraints, and prescribing a psychiatric medication. Suicidal labeling was considered "appropriate" if one or more of the above interventions were recommended by a psychiatrist. The presence of psychiatric intervention was compared with children who presented with a behavioral disorder, not labeled as suicidal. Chi-square or Fisher's Exact Test, whenever appropriate, was used to evaluate the association between suicide status and interventions. RESULTS: We identified 160 (27.1%) children who were labeled suicidal and 431 (72.9%) children with a behavioral disorder, who were classified as non-suicidal. 244/431 (56.6%) in the non-suicidal group had a significant psychiatric intervention compared to 79/160 (49.4%) of children with suicidal ideation (P=0.116). This 49.4% is significantly different from an a priori assumption that 100% of children with suicidal ideation would have a significant psychiatric intervention. CONCLUSION: Over half (50.6%) of the children presenting with a label of suicidal ideation did not receive significant psychiatric intervention. This study calls into question the accuracy of suicide labeling in children referred to the ED. Language: en

Midcareer Transition in Radiology: Threat or Opportunity?

Abstract: Midcareer job transitions are occurring for many reasons other than individual radiologists' professional performance quality, affability, and desire for geographic change. New causes seem to be related to the present health care environment. All radiologists should be aware of this disruptive change to the profession and of the resources available to help job seekers find new positions.

Triple Negative Breast Cancer in Pregnancy and Postpartum: Two Case Reports in Hispanic Women

Abstract: Objective. Despite studies suggesting that triple negative breast cancer is more often seen in women of African ancestry, we report here two cases of pregnancy associated triple negative breast cancer in Hispanic women. Cases. Case one is a 37-year-old female para 2-0-0-2, who presented with a left breast mass, at 19 weeks of gestation, the biopsy of which reported an invasive ductal carcinoma, found to be triple receptor negative. The patient underwent chemotherapy during the pregnancy and was delivered with a cesarean at 37 weeks for obstetric indication. After delivery, the patient completed her chemotherapy that was followed by radical mastectomy and radiotherapy. Case two is a 28-year-old female para 6-0-1-5, who presented while breast-feeding with signs and symptoms of mastitis, and an engorged and tender right breast, five months postpartum. However, the sonogram revealed a fluid filled cavity. Aspiration and cytology did not reflect an infection and were negative for malignancy. High suspicion and lack of improvement led to biopsy that identified an invasive ductal carcinoma, found to be triple negative. The patient underwent chemotherapy followed by modified radical mastectomy. Conclusions. Triple negative breast cancer, during pregnancy or postpartum, poses a unique challenge and requires a multidisciplinary team to optimize treatment for these women.

Untreated Active Tuberculosis in Pregnancy with Intraocular Dissemination: A Case Report and Review of the Literature.

Abstract: Background. Tuberculosis (TB) is a disease that affects hundreds of millions of people across the world. However, the incidence in developed countries has decreased over the past decades causing physicians to become unfamiliar with its unspecific symptoms. Pregnant individuals are especially difficult because many symptoms of active TB can mimic normal physiological changes of pregnancy. We present a case report of a 26-year-old multiparous woman, G4P3003, at 38-week gestation with a history of positive PPD who emigrated from Ghana 6 years ago. She came to the hospital with an initial complaint of suprapubic pain, pressure, and possible leakage of amniotic fluid for the past week. Patient also complained of a productive cough for the past 3 to 4 months with a decrease in vision occurring with the start of pregnancy. Visual acuity was worse than 20/200 in both eyes. Definitive diagnosis of active TB was delayed due to patient refusal of chest X-ray. Fortunately, delay in diagnosis was minimized since patient delivered within 24 hours of admission. Active TB was confirmed with intraocular dissemination. Patient had optic atrophy OS (left eye) and papillitis, choroiditis, and uveitis OD (right eye) due to TB infiltration. Fetus was asymptomatic and anti-TB therapy was started for both patients.

Use of B lymphocyte stimulator inhibitor belimumab may be associated with a decrease in the serum concentration of epidermal growth factor in patients with primary Sjögren's syndrome.

Abstract: B cell activating factor (BAFF), also called the B lymphocyte stimulator, has been known to show increased expression in primary Sjogren’s syndrome (pSS) which could explain increased B cell activation characteristic of this disease. Belimumab, a fully human IgG1λ recombinant monoclonal antibody directed against B lymphocyte stimulator (Blys), has been reported to be efficacious in systemic lupus erythematosus (SLE) through its B cell-mediated action. Randomized controlled trials of belimumab in a selected target population of pSS patients are further warranted.

Rhombencephalosynapsis: a rare congenital anomaly presenting with seizure and developmental delay

Abstract: A 6-year-old boy with past medical history of attention deficit/hyperactivity disorder (ADHD) and developmental delay was admitted for a first episode of partial seizure with secondary generalization. The patient was born at 36 weeks gestation via cesarean section due to low birth weight. After birth, he was briefly admitted to the neonatal acute care unit for treatment of hydrocephalus. Past surgical history was significant for bilateral hamstring release due to spasticity. Physical examination was significant for macrocephaly with protuberance of the posterior part of the head, mild hypertelorism, and a small mouth with high arched palate. Patient had bilateral 4/5 strength in upper extremities and spastic diplegia in both lower extremities. He began crawling and speaking at the age of three. At the time of admission, he was unable to walk but able to pull to stand and had no limitation using his upper extremities. He was able to form 3–4 words sentences and had adequate comprehension to follow one-step commands. Brain CT was significant for complete fusion of the cerebellar hemispheres, consistent with the diagnosis of rhombencephalosynapsis. Associated supratentorial anomalies included absence of corpus callosum, absence of the septum pellucidum, and ventriculomegaly (Figs. 1, 2).

Comment on Hughes et al. An Early Pregnancy HbA1c ≥5.9% (41 mmol/mol) Is Optimal for Detecting Diabetes and Identifies Women at Increased Risk of Adverse Pregnancy Outcomes. Diabetes Care 2014;37:2953–2959

Abstract: We welcome the article by Hughes et al. (1) on glycosylated hemoglobin A1c (HbA1c) as a readily available screening tool that the authors propose be used to identify undiagnosed diabetes during the early prenatal period. However, we submit that the low subject participation rate of 23% severely limits the validity of their findings. Data obtained from only 23% of the study participants do not allow one to have confidence that the selected 5.9% (41 mmol/mol) HbA1c cutoff correlates …