Medical Specialties Commons^™

Cervical Fractures: Does Injury Level Impact The Incidence Of Dysphagia In Elderly Patients?, Jill Pattison, Michelle Kincaid, Urmil Pandya

Trauma and Acute Care Articles

Dysphagia is common in the elderly with significant consequences such as aspiration and malnutrition. This study seeks to investigate oropharyngeal dysphagia in elderly patients with cervical fractures and determine whether the level of cervical fracture impacts the incidence of swallowing dysfunction. Records of trauma patients ≥65 admitted with cervical fractures over a 76-month period to a level 1 trauma center were reviewed. History of dysphagia, stroke, tracheostomy or spinal cord injury were excluded criteria, leaving 161 patients for analysis. Evaluation of swallowing function was performed to identify dysphagia and variables were analyzed. A total of 161 patients met inclusion criteria …

B-Cell Lymphoma Presenting As Multiple Nerve Sheath Tumors., Jason Milton, Julie Renner, Victor Awuor

Oncology Articles

BACKGROUND: Diffuse Large B-cell Lymphoma (DLBCL) is the most common form of Non-Hodgkin lymphoma (NHL), accounting for 25-30 percent of cases in the United States.1 Extranodal sites are involved in approximately 40% of cases of DLBCL.

CASE DESCRIPTION: In this report, we discuss the case of a patient with extranodal DLBCL within the cervical nerve roots that underwent surgical intervention due to the presence of cervical radiculopathy.

CONCLUSION: The diagnosis of DLBCL was surprising given the appearance of the masses on MRI being similar to that of a neurofibroma or schwannoma. Surgical decompression provided a tissue sample for biopsy as …

The Role Of Central Neck Lymph Node Dissection In The Management Of Papillary Thyroid Cancer., Lawrence A Shirley, Natalie B Jones, John E Phay

Oncology Articles

Papillary thyroid cancer (PTC) is the most common thyroid malignancy, and cervical nodal metastases are frequent at presentation. The most common site for nodal metastases from PTC is the central compartment of the ipsilateral neck in the paratracheal and pretracheal regions. The decision to resect these lymph nodes at the time of thyroidectomy often depends on if nodes with suspected malignancy can be identified preoperatively. If nodal spread to the central neck nodes is known, then the consensus is to remove all nodes in this area. However, there remains significant controversy regarding the utility of removing central neck lymph nodes …

A Case-Based Review Of The Management Of Penetrating Brain Trauma., Jason Milton, Alex Rugino, Kailash Narayan, Chris Karas, Victor Awuor

Trauma and Acute Care Articles

Principles of penetrating head trauma management were established by Harvey Cushing in relation to the management of penetrating brain injuries of World War One. Cushing radically debrided the scalp and skull and aggressively irrigated wound tracks to remove foreign bodies. He would then obtain water-tight closure. Cushing significantly decreased infection rates which reportedly limited the major cause of mortality due to penetrating head injuries. Many advances have been made by contributions from World War Two, Korean War, Vietnam War, and Iran/Iraq conflicts. Early radical decompression, with conservative debridement and duraplasty applied to blast-induced penetrating injuries during Operation Iraqi Freedom, has …

A Unique Presentation Of An Intracranial Abscess Secondary To Retained Projectile After Debridement With Dural Closure., Jason Milton, Victor Awuor

Trauma and Acute Care Articles

Patients with penetrating head trauma with retained projectiles develop intracranial abscesses as a common complication. The most common presentation is a suddenly worsening headache. The most common pathogen identified is staphylococcus. Outcomes are related to adherence of Matson's tenets. This case study details the presentation of a 19-year-old patient that presented to the neurological surgery clinic without neurologic deficits. Further questioning revealed complaints of intermittent diffuse headaches with bilateral upper extremity shock-like sensation for two weeks. Eight weeks prior he had undergone right craniotomy, after a gunshot wound, for debridement and watertight dural closure. The patient denied symptoms of fever, …

Adenocarcinoma In A Koff Urinary Ileal Diversion., Bradley Sherman, Frederick Taylor

Oncology Articles

The use of an ileal conduit as a means of treatment for bladder cancer or dysfunction is widely used and understood. However, long term surveillance of that conduit has not been strongly established and set forth as a means of screening. We present a 76yo female with a history of neurogenic bladder secondary to paraplegia who underwent the formation of a "Koff" pouch as a conduit. Nineteen years later she presents with hematuria and was found to have adenocarcinoma originating in her conduit.

What's New In Critical Illness And Injury Science? We Must Lead By Hope…., Michael Shay O'Mara

Trauma and Acute Care Articles

No abstract provided.

Ventilator-Associated Pneumonia: New Definitions., M Chance Spalding, Michael W Cripps, Christian T Minshall

Trauma and Acute Care Articles

The National Healthcare Safety Network's new classification characterizes all adverse ventilator-associated events (VAE) into a tiered system designed to shift the focus away from ventilator-associated pneumonia as the only important cause or morbidity in ventilated patients. This new surveillance definition of VAE eliminates subjectivity by using clearly defined criteria and facilitates the automated collection of data. This allows for easier comparison and analysis of factors affecting rates of VAE. Numerous studies have been published that demonstrate its clinical application. This article presents the VAE criteria, contrasts the difference from the previous ventilator-associated pneumonia definition, and discusses its implementation over the …

State Emergency Department Opioid Guidelines: Current Status., Robert I Broida, Tanner Gronowski, Andrew F Kalnow, Andrew G Little, Christopher M Lloyd

Trauma and Acute Care Articles

INTRODUCTION: The purpose of this study was to evaluate and categorize current state-sponsored opioid guidelines for the practice of emergency medicine (EM).

METHODS: We conducted a comprehensive search of EM-specific opioid prescribing guidelines and/or policies in each state to determine current state involvement in EM opioid prescribing, as well as to evaluate some of the specifics of each guideline or policy. The search was conducted using an online query and a follow-up email request to each state chapter of ACEP.

RESULTS: We found that 17 states had emergency department-specific guidelines. We further organized the guidelines into four categories: limiting prescriptions …

Trends In Management Of Radial Head And Olecranon Fractures., Matthew Motisi, Jennifer Kurowicki, Derek D Berglund, Jacob J Triplet, Shanell Disla, Timothy Niedzielak, Jonathan C Levy

Surgery Articles

BACKGROUND: Advancement in surgical techniques and implants has improved the ability to manage radial head and olecranon fractures. However, trends in management of these fractures are largely unstudied.

OBJECTIVE: This purpose of this study is to evaluate management trends for these common fractures.

METHODS: A retrospective review of a comprehensive Humana database was performed using Pearl Diver supercomputer (Warsaw, IN, USA) for radial head and neck (RHNF) and olecranon fractures (OF) between 2007 and 2014. Treatment methods including open reduction internal fixation (ORIF), radial head arthroplasty (RHA), and non-operative treatment were reviewed. Total reported incidence of office visits and utilization …

A Case Of Spontaneous Transdiaphragmatic Intercostal Hernia With Contralateral Injury, And Review Of The Literature., Alexander A Chapman, Steven B Duff

Surgery Articles

This case report discusses the diagnosis and management of a 67-year-old male presenting with a spontaneous transdiaphragmatic intercostal hernia with contralateral intercostal hernia. The patient had a history of chronic obstructive pulmonary disease (COPD) exacerbations requiring multiple prolonged courses of steroids. The patient was ultimately diagnosed with computed tomography (CT) and underwent surgical repair via thoracotomy with primary repair of the diaphragmatic defect. The patient's postoperative course was uncomplicated. A review of the literature since the first similar case in 1977 recognizes the propensity of this injury to be found in patients with COPD and chronic steroid usage, as well …

Angioembolization Is Necessary With Any Volume Of Contrast Extravasation In Blunt Trauma., Ankur Bhakta, David S Magee, Matthew S Peterson, Michael Shay O'Mara

Trauma and Acute Care Articles

INTRODUCTION: Reduction of nonessential angiogram and embolization for patients sustaining blunt abdominal and pelvic trauma would allow improved utilization and decreased morbidity related to nontherapeutic embolization. We hypothesized that the nature of intravenous contrast extravasation (IVCE) on computed tomography (CT) would be directly related to the finding of extravasation on angiogram and need for embolization.

METHODS: A 5-year retrospective evaluation of trauma patients with IVCE on CT. Demographics, hemodynamics, and IVCE location and maximal dimension/volume were examined for relationship to IVCE on angiography and need for embolization. Primary complications were defined as nephropathy and acute respiratory distress syndrome.

RESULTS: A …

Analysis Of The Final Denali Trial Data: A Prospective, Multicenter Study Of The Denali Inferior Vena Cava Filter., S William Stavropoulos, James X Chen, Ronald F Sing, Fakhir Elmasri, Mitchell J Silver, Alex Powell, Frank C Lynch, Ahmed Kamel Abdel Aal, Alexandra Lansky, Bart E Muhs

Heart and Vascular Articles

PURPOSE: To report the final 2-year data on the efficacy and safety of a nitinol retrievable inferior vena cava (IVC) filter for protection against pulmonary embolism (PE).

MATERIALS AND METHODS: This was a prospective multicenter trial of 200 patients with temporary indications for caval filtration who underwent implantation of the Denali IVC filter. After filter placement, all patients were followed for 2 years after placement or 30 days after filter retrieval. The primary endpoints were technical success of filter implantation in the intended location and clinical success of filter placement and retrieval. Secondary endpoints were incidence of clinically symptomatic recurrent …

A Unique Case Of Pulmonary Embolism Presenting As A Paroxysmal Atrial Tachycardia Instigated Only By Recumbency And Stooping., Nagesh Chopra

Heart and Vascular Articles

No abstract provided.

3-Year Outcomes In High-Risk Patients Who Underwent Surgical Or Transcatheter Aortic Valve Replacement., G Michael Deeb, Michael J Reardon, Stan Chetcuti, Himanshu J Patel, P Michael Grossman, Steven J Yakubov, Neal S Kleiman, Joseph S Coselli, Thomas G Gleason, Joon Sup Lee, James B Hermiller, John Heiser, William Merhi, George L Zorn, Peter Tadros, Newell Robinson, George Petrossian, G Chad Hughes, J Kevin Harrison, Brijeshwar Maini, Mubashir Mumtaz, John Conte, Jon Resar, Vicken Aharonian, Thomas Pfeffer, Jae K Oh, Hongyan Qiao, David H Adams, Jeffrey J Popma

Heart and Vascular Articles

BACKGROUND: In patients with severe aortic stenosis at increased risk for surgery, self-expanding transcatheter aortic valve replacement (TAVR) is associated with improved 2-year survival compared with surgery.

OBJECTIVES: This study sought to determine whether this clinical benefit was sustained over time.

METHODS: Patients with severe aortic stenosis deemed at increased risk for surgery by a multidisciplinary heart team were randomized 1:1 to TAVR or open surgical valve replacement (SAVR). Three-year clinical and echocardiographic outcomes were obtained in those patients with an attempted procedure.

RESULTS: A total of 797 patients underwent randomization at 45 U.S. centers; 750 patients underwent an attempted …

Durable Clinical Effectiveness With Paclitaxel-Eluting Stents In The Femoropopliteal Artery: 5-Year Results Of The Zilver Ptx Randomized Trial., Michael D Dake, Gary M Ansel, Michael R Jaff, Takao Ohki, Richard R Saxon, H Bob Smouse, Lindsay S Machan, Scott A Snyder, Erin E O'Leary, Anthony O Ragheb, Thomas Zeller

Heart and Vascular Articles

BACKGROUND: This randomized controlled trial evaluated clinical durability of Zilver PTX, a paclitaxel-coated drug-eluting stent (DES), for femoropopliteal artery lesions. Outcomes compare primary DES versus percutaneous transluminal angioplasty (PTA), overall DES (primary and provisional) versus standard care (PTA and provisional Zilver bare metal stent [BMS]), and provisional DES versus provisional BMS.

METHODS AND RESULTS: Patients with symptomatic femoropopliteal artery disease were randomly assigned to DES (n=236) or PTA (n=238). Approximately 91% had claudication; 9% had critical limb ischemia. Patients experiencing acute PTA failure underwent secondary randomization to provisional BMS (n=59) or DES (n=61). The 1-year primary end points of event-free …

The Liberty Study: Design Of A Prospective, Observational, Multicenter Trial To Evaluate The Acute And Long-Term Clinical And Economic Outcomes Of Real-World Endovascular Device Interventions In Treating Peripheral Artery Disease., George L Adams, Jihad Mustapha, William Gray, Nick J Hargus, Brad J Martinsen, Gary Ansel, Michael R Jaff

Heart and Vascular Articles

Background: Most peripheral artery disease (PAD) clinical device trials are supported by commercial manufacturers and designed for regulatory device approval, with extensive inclusion/exclusion criteria to support homogeneous patient populations. High-risk patients with advanced disease, including critical limb ischemia (CLI), are often excluded leading to difficulty in translating trial results into real-world clinical practice. As a result, physicians have no direct guidance regarding the use of endovascular devices. There is a need for objectively assessed studies to evaluate clinical, functional, and economic outcomes in PAD patient populations.

Study design: LIBERTY is a prospective, observational, multicenter study sponsored by Cardiovascular Systems Inc …

The Association Between Cognitive Function And Objective Adherence To Dietary Sodium Guidelines In Patients With Heart Failure., Mary A Dolansky, Julie T Schaefer, Misty Aw Hawkins, John Gunstad, Anup Basuray, Joseph D Redle, James C Fang, Richard A Josephson, Shirley M Moore, Joel W Hughes

Heart and Vascular Articles

BACKGROUND: Although cognitive impairment is common in heart failure (HF) patients, its effects on sodium adherence recommendations are unknown.

PURPOSE: Our aim is to examine if cognitive function is associated with patient sodium adherence.

METHODS: Sodium collection/excretion and cognitive function were assessed for 339 HF patients over a 5-8-week period. Neuropsychological testing was performed at baseline (Visit 1), whereas two 24-hour urine samples were collected within 7 weeks postbaseline. The ability to collect two 24-hour urine samples and the estimation of sodium excretion levels from these samples were used to estimate sodium adherence recommendations.

RESULTS: Nearly half (47%) of the …

Central Retinal Artery Occlusion Following Laser Treatment For Ocular Ischemic Aortic Arch Syndrome., Payal J Shah, Brian Ellis, Lauren R Digiovine, Jeffery P Hogg, Monique J Leys

Heart and Vascular Articles

Objective: Ocular ischemic syndrome is a rare blinding condition generally caused by disease of the carotid artery. We describe a 69-year-old female with a 50 pack-year smoking history with aortic arch syndrome causing bilateral ocular ischemic syndrome.

Methods: The patient presented with progressive visual loss and temple pain. Slit lamp biomicroscopy revealed bilateral iris neovascularization. This finding prompted a cardiovascular work up. Panretinal photocoagulation with retrobulbar block was performed in the right eye.

Results: A temporal artery biopsy was negative. The carotid duplex ultrasound showed only a 1-39% stenosis. MRA revealed a more proximal occlusion of the aortic branch for …

Effects Of Agitation And Storage Temperature On Measurements Of Hydration Status., Heather M Adams, Lindsey E Eberman, Susan W Yeargin, Andrew J Niemann, Heather L Mata, David J Dziedzicki

Ambulatory and Primary Care Articles

BACKGROUND: Hypohydration can have significant implications on normal physiological functions of the body.

OBJECTIVES: This study aimed to determine the impact of agitation, storage temperature, and storage time on urine osmolality compared to the criterion control.

PATIENTS AND METHODS: We used a descriptive diagnostic validity test design. To investigate agitation, we recruited 75 healthy individuals (males = 41, females = 34; mean age = 22 ± 5 years; mean self-reported height = 172 ± 23 cm and mass = 77 ± 17 kg) who provided one or more samples (total = 81). The independent variables were agitation (vortex, hand shaken, …

Transarterial Chemoembolization Is Ineffective For Neuroendocrine Tumors Metastatic To The Caudate Lobe: A Single Institution Review., Lawrence A Shirley, Megan Mcnally, Ravi Chokshi, Natalie Jones, Patrick Tassone, Gregory Guy, Hooman Khabiri, Carl Schmidt, Manisha Shah, Mark Bloomston

Oncology Articles

BACKGROUND: Caudate lobe liver metastases occur commonly in patients with neuroendocrine tumors. It is unknown, however, how these lesions respond to regional therapy and how their presence impacts outcomes. We reviewed our experience treating these lesions using transarterial chemoembolization (TACE).

METHODS: We reviewed radiographic response to TACE in 86 patients with metastatic neuroendocrine tumors to the liver. We determined the impact of caudate lesions on outcomes in comparison to the cohort of patients without caudate lesions, as well as response of caudate lesions to TACE versus lesions elsewhere in the liver.

RESULTS: Caudate lesions were identified in 45 (52%) patients. …

Nasolacrimal System Aeration On Computed Tomographic Imaging: Effects Of Patient Positioning And Scan Orientation., Craig N Czyz, Thomas S Bacon, Andrew W Stacey, Eva N Cahill, Bryan R Costin, Boris I Karanfilov, Kenneth V Cahill

Ambulatory and Primary Care Articles

PURPOSE: To determine the impact of patient positioning and scan orientation on the appearance of air in the nasolacrimal drainage system on computed tomography (CT) imaging, and the repeatability of the observations.

METHODS: This was a retrospective analysis of CT images for 92 patients.

RESULTS: Air was found to be present more fully in the upright-position group as compared with the supine-position group. Comparing axial and coronal scan orientation, no difference in aeration was found, except for the nasolacrimal duct in the upright-position group.

CONCLUSION: Patient position should be accounted for in diagnostic conclusions and treatment decisions based on CT.

Prostate Cancer And Li-Fraumeni Syndrome: Implications For Screening And Therapy., Colleen K Spees, Kelly J Kelleher, Ronney Abaza, Steven K Clinton

Oncology Articles

Li-Fraumeni Syndrome (LFS) is an autosomal dominant genetic disorder associated with mutations in the TP53 gene and characterized by a propensity to develop a variety of malignancies resulting in a shortened lifespan. We report a case of prostate cancer in a 50 year old male with LFS. Experimental studies suggest that TP53 mutations in prostate cancer are associated with therapeutic resistance to radiation, chemotherapy, and anti-androgens, implying that LFS men may experience more aggressive cancer biology with implications for therapeutic decisions. The potential of prostate cancer to develop earlier in LFS favors institution of screening at earlier ages.

Cutaneous Manifestations Of Diabetes Mellitus., Michelle Duff, Olga Demidova, Stephanie Blackburn, Jay Shubrook

Ambulatory and Primary Care Articles

No abstract provided.

Palliative Care In Africa: A Global Challenge., Christian R Ntizimira, Jean Luc Nkurikiyimfura, Olive Mukeshimana, Scholastique Ngizwenayo, Diane Mukasahaha, Clare Clancy

Ambulatory and Primary Care Articles

We are often asked what challenges Rwanda has faced in the development of palliative care and its integration into the healthcare system. In the past, patients have been barred from accessing strong analgesics to treat moderate to severe pain, but thanks to health initiatives, this is slowly changing. Rwanda is an example of a country where only a few years ago, access to morphine was almost impossible. Albert Einsten said 'in the middle of difficulty lies opportunity' and this sentiment could not be more relevant to the development of palliative care programmes. Through advocacy, policy, and staunch commitment to compassion, …

The Denali Trial: An Interim Analysis Of A Prospective, Multicenter Study Of The Denali Retrievable Inferior Vena Cava Filter., S William Stavropoulos, Ronald F Sing, Fakhir Elmasri, Mitchell J Silver, Alex Powell, Frank C Lynch, Ahmed Kamel Abdel Aal, Alexandra J Lansky, Richard A Settlage, Bart E Muhs, Denali Trial Investigators

Heart and Vascular Articles

Purpose: To assess safety and effectiveness of a nitinol retrievable inferior vena cava (IVC) filter in patients who require caval interruption to protect against pulmonary embolism (PE).

Materials and methods: Two hundred patients with temporary indications for an IVC filter were enrolled in this prospective, multicenter clinical study. Patients undergoing filter implantation were to be followed for 2 years or for 30 days after filter retrieval. At the time of the present interim report, all 200 patients had been enrolled in the study, and 160 had undergone a retrieval attempt or been followed to 6 months with their filter in …

Proximal Biceps Tenodesis: An Anatomic Study And Comparison Of The Accuracy Of Arthroscopic And Open Techniques Using Interference Screws., Thomas J Kovack, John D Idoine, Paul B Jacob

Ambulatory and Primary Care Articles

PURPOSE: To (1) better define the anatomy of the proximal shoulder in relation to the long head of the biceps tendon, (2) compare the length-tension relationship of the biceps tendon in the native shoulder with that after arthroscopic and open tenodesis techniques using interference screws, and (3) provide surgical recommendations for both procedures based on study findings.

STUDY DESIGN: Descriptive laboratory study.

METHODS: Twenty fresh-frozen cadaveric shoulders were dissected for analysis. Initial anatomic measurements involving the proximal long head of the biceps tendon (BT) were made, which included: the labral origin to the superior bicipital groove (LO-SBG), the total tendon …

Age-Matched, Case-Controlled Comparison Of Clinical Indicators For Development Of Entropion And Ectropion., Kevin S Michels, Craig N Czyz, Kenneth V Cahill, Jill A Foster, John A Burns, Kelly R Everman

Ambulatory and Primary Care Articles

Purpose. To analyze the clinical findings associated with involutional entropion and ectropion and compare them to each other and to age-matched controls. Methods. Prospective, age-matched cohort study involving 30 lids with involutional entropion, 30 lids with involutional ectropion, and 52 age-matched control lids. Results. The statistically significant differences associated with both the entropion and ectropion groups compared to the control group were presence of a retractor dehiscence, presence of a "white line," occurrence of orbital fat prolapse in the cul-de-sac, decreased lower lid excursion, increased lid laxity by the snapback test, and an increased lower lid distraction. Entropion also differed …

Novel T(5;19) Translocation In A Patient With Pdgfrb Associated Chronic Leukemia: Implications For Treatment Strategy., Joel D Provenzano, J Phillip Kuebler

Oncology Articles

Myeloproliferative disorders are variable disorders, based on the genetic abnormality present and the cell line progenitors that are affected. In this case, we discuss a novel gene translocation in the subset of PDGFRB mutations, first seen with prominent hyperbasophilia. This case demonstrates the possibility for lower therapeutic doses of imatinib mesylate than previously reported, in order to control leukocyte counts and reverse the genetic mutation.

Intraorbital Foreign Body Projectile As A Consideration For Unilateral Pupillary Defect., Craig N Czyz, Thomas P Petrie, Jonathan D Harder, Kenneth V Cahill, Jill A Foster

Trauma and Acute Care Articles

Intraorbital foreign bodies are frequently the result of high-velocity injuries with varying clinical presentations. The resultant diagnosis, management, and outcome depend on the type of foreign body present, anatomical location, tissue disruption, and symptomatology. A patient who presented to the Emergency Department with a large intraorbital foreign body projectile that was not evident clinically, but found incidentally on computed tomography and subsequent plain films is reported. The emergency room physician needs to be aware of the differential diagnosis of a unilateral irregular pupil with or without visual acuity changes. The differential diagnosis for any trauma patient with an irregular pupil …