Portal Hypertension and Ascites Due to an Arterioportal Fistula: Sequela of a Remote Traumatic Liver Laceration

Arterioportal fistulas (APFs) are a group of vascular disorders, in which systemic arteries communicate with the portal circulation, presenting as a congenital syndrome or more commonly acquired from iatrogenic instrumentation or abdominal trauma. We report the case of a 58-year-old man who developed ascites without underlying risk factors for portal hypertension, which was attributed to an APF found on imaging, manifesting 43 years after sustaining a liver laceration. After angiographic embolization of the APF, the patient's ascites resolved completely. The prolonged latent period between the patient's abdominal trauma and eventual presentation with ascites highlights the need to consider vascular malformations in the differential diagnosis of unexplained noncirrhotic portal hypertension

What is the best beta-blocker for systolic heart failure?

Q: What is the best beta-blocker for systolic heart failure? Evidence-based answer: Three beta-blockers--carvedilol, metoprolol succinate, and bisoprolol--reduce mortality equally (by about 30% over one year) in patients with Class III or IV systolic heart failure. Insufficient evidence exists comparing equipotent doses of these medications head-to-head to recommend any one over the others (strength of recommendation [SOR]: A, systematic review/meta-analysis)

Does surgery relieve the pain of a herniated disc?

Patients with an acute episode of low back pain, radicular symptoms, and evidence of a herniated disc on imaging may experience short-term pain relief from discectomy if their symptoms haven�۪t improved after initial conservative therapy (strength of recommendation [SOR]: A, multiple randomized, controlled trials [RCTs]). Although surgery may enhance pain relief initially, no evidence supports a long-term benefit for surgery over conservative management (SOR: A, multiple RCTs)

From Sacrilege to Privilege: The Tale of Body Procurement for Anatomical Dissection in the United States

Anatomical dissection remains an integral part of most medical schools’ curricula, and in order to meet their educationalneeds, schools turn to a mixture of donated and unclaimed bodies. However, the procurement of bodies foranatomical dissection has not always been a simple task. The history of the cadaver supply in the United States, asin many other countries, is a story of crime, punishment, and legal dilemmas. The method by which medical schoolsobtain cadavers has affected not only anatomists and medical students, but all members of society. Methods of procurementthrough the centuries have been able to change only along with concurrent changes in societal perceptionsof death and dissection. An appreciation of this history and these societal changes may benefit students in theirstruggles to come to terms with how their cadavers were obtained and how society has granted them the privilegeto dissect a fellow human’s body

What are the benefits and risks of daily low-dose aspirin for primary prevention of CV events?

Q: What are the benefits and risks of daily low-dose aspirin for primary prevention of CV events? A: One nonfatal myocardial infarction (MI) will be avoided for every 126 to 138 adults who take daily aspirin for 10 years (strength of recommendation [SOR]: A, systematic reviews and meta-analyses of multiple randomized controlled trials [RCTs]). Taking low-dose aspirin for primary prevention shows no clear mortality benefit. A benefit for primary prevention of stroke is less certain. Although no evidence establishes increased risk of hemorrhagic stroke from daily low-dose aspirin, one gastrointestinal hemorrhage will occur for every 72 to 357 adults who take aspirin for longer than 10 years (SOR: A, systematic reviews and meta-analyses of multiple RCTs and cohort studies).Authors: Justin Mutter, MD, MSc University of Virginia School of Medicine, Charlottesville; Rebecca Grandy, PharmD, BCACP, CPP Mountain Area Health Education Center, Asheville, NC, and Eshelman School of Pharmacy, University of North Carolina-Chapel Hill, Asheville; Stephen Hulkower, MD Mountain Area Health Education Center, Asheville, NC; Sue Stigleman, MLS Mountain Area Health Education Center, Asheville

The History of the Hippocratic Oath: Outdated, Inauthentic, and Yet Still Relevant

Nearly all medical schools incorporate some form of professional medical oath into their graduation ceremo- nies. The oldest and most popular of these oaths is the Hippocratic Oath, composed more than 2,400 years ago. In modern times, especially during the twentieth century, the Hippocratic Oath has had its content changed and its authorship challenged. This article discusses the history of the Hippocratic Oath from its traditional form to its modern adaptations. Additionally, this article seeks to explain the Hippocratic Oath’s endurance despite these challenges, based upon the historical importance of Hippocrates and the Hippocratic tradition in Western medicine.

Inactivation of Surrogate Coronaviruses on Hard Surfaces by Healthcare Germicides

The SARS coronavirus (SARS-CoV) was identified as the cause of severe acute respiratory syndrome (SARS) following the worldwide 2003 outbreak. The spread of SARS in healthcare settings and the presence of SARS CoV nucleic acids on hospital surfaces in outbreak settings suggest that surfaces could potentially play a role in the spread of SARS in healthcare environments. Disinfection of hospital surfaces may interrupt virus transmission, but there are little data on the effectiveness of germicides commonly used in healthcare against corona viruses on surfaces. The goal of this research was to test the efficacy of six standard healthcare germicides for inactivation of surrogate corona viruses on environmental surfaces. The germicides tested were (1) Steris Vesphene® IIse Non-sterile Disinfectant Cleaner (9.09% o-phenylphenol, 7.66% p-tertiary amylphenol), (2) 70% ethanol, (3) chlorine bleach (6.0% sodium hypochlorite), (4) Cidex® OPA (ortho-phthalaldehyde), (5) Purell® Instant Hand Sanitizer (62% ethanol), (6) Clorox® Anywhere Hand Sanitizing Spray (71% ethanol). These were tested for virucidal activity against two surrogate coronaviruses, Mouse Hepatitis Virus (MHV) and Transmissible Gastroenteritis Virus (TGEV). MHV and TGEV were dried onto stainless steel surfaces, exposed to a germicide at its use dilution for one-minute contact time, and assayed for infectivity in cell culture. For TGEV, log[10] infectivity reductions were: 70% ethanol=3.2; phenolic=2.0; Cidex OPA=2.3; 1:100 chlorine bleach=0.35; 62% ethanol=4.0; and 71% ethanol=3.5. For MHV, they were: 70% ethanol=3.9; phenolic,=1.3; Cidex OPA=1.7; 1:100 chlorine bleach=0.62; 62% ethanol=2.7; and 71% ethanol=2.0. Of the healthcare germicides tested, only the ethanol effectively reduced infectivity of the two coronaviruses by >3 log[10] after an exposure time of one minute. Cidex OPA was somewhat effective, with >2 log[10] reduction, and 1:100 chlorine bleach was ineffective, with <1 log[10] reduction. MHV and TGEV were reduced to a similar extent (within 0.5 log[10]) by the germicide tested. The results of this study suggest the need for care in choosing effective germicides against viruses like SARS CoV.Master of Science in Public Healt

Do preparticipation clinical exams reduce morbidity and mortality for athletes?

Though clinical preparticipation exams (PPE) are recommended by experts and required in most states, we found no medium- or better-quality evidence that demonstrates they reduce mortality or morbidity. PPEs detect only a very small percentage of cardiac abnormalities among athletes who subsequently die suddenly (strength of recommendation [SOR]: C, case series study). PPEs are also unable to accurately identify athletes with exercise-induced bronchospasm (SOR: C, small cross-sectional study) and are poorly predictive of which athletes are at increased risk of orthopedic injuries (SOR: C, cross-sectional study)

The effects of regulation on the performance of nuclear power in the United States and the Federal Republic of Germany

Thesis (M.S.)--Massachusetts Institute of Technology, Technology and Policy Program, 1986The nuclear power industry of the Federal Republic of Germany has achieved consistently better reactor operating performance than has the U.S. industry. Earlier work has suggested that a major source of the difference is in capacity factor losses caused by regulatory practices. An investigation of the problems attributed to regulation in the United States, which caused losses from 1975 to 1984, was performed. Fifteen major issues were identified, which comprised 85 percent of all regulatory losses. The performance of the German industry then was analyzed to discover differences in regulatory practices. Most of the U.S. regulatory losses were found to be associated with steam generators, reactor coolant systems, and containment systems. The regulatory losses in the Federal Republic of Germany included the retraining of a plant staff after an accident, a long-term derating of a plant because of inadequate backup safety systems, and several smaller problems. The German industry applies inspection and repair standards for steam generators that equal or exceed U.S regulations, and it treats these losses as part of normal plant maintenance. However, the German industry also assigned the largest single cause of capacity loss in BWRs--recirculation pipe replacement--to the voluntary maintenance category because they weren't strictly ordered to shut down, only pressured with the threat of stringent inspection standards. When the BWR pipe replacement outages were added to the Federal Republic of Germany's total regulatory loss, and the steam generator losses were subtracted from the U.S. total, the Federal Republic of Germany was found to have greater regulatory losses. It can therefore be concluded that the sources of poor U.S. performance relative to the Federal Republic of Germany come from areas other than regulation.US Department of Energy, the Westinghouse Electric Corporation, Kraftwerk Union AG, and the Center for Energy Policy Research at MI

Effect of corticosteroids on pain and function in knee osteoarthritis patients

Clinical Inquiries question: Does the type of corticosteroid have an effect on pain and functional status of the knee in osteoarthritis (OA) patients receiving intra-articular injections? Evidence-based answer: In patients with knee OA, the type of injected steroid does not appear to alter pain and functional response, based on 3 head-to-head trials comparing intra-articular injection of different corticosteroid formulations for relief of knee pain and improvement of functional status (strength of recommendation A: based on small randomized controlled trials with consistent results).Luke Beggs, MD, PhD; Sue Stigleman, MLS; Aaron Vaughan, MD; Josh Pacious, DO; Stephen Hulkower, MDDr Beggs is a resident in the Family Medicine Residency Program at Mountain Area Health Education Center (MAHEC) in Asheville, NC. Ms Stigleman is a medical librarian for University of North Carolina Health Sciences at MAHEC. Dr Vaughan is Fellowship Program Director of Primary Care Sports Medicine at MAHEC. Dr Pacious is a resident in the Family Medicine Residency Program at MAHEC. Dr Hulkower is Chair of the Department of Family Medicine for University of North Carolina Health Sciences at MAHEC.Includes bibliographical reference