Sternoclavicular joint arthropathy mimicking radiculopathy in a patient with concurrent C4-5 disc herniation

Background Patients with sternoclavicular joint arthropathy, which can result from septic arthritis, often present with localized sternoclavicular pain as well as shoulder pain. Such pain may be similar to the presenting symptoms of cervical intervertebral disc herniation. Clinical presentation A 47-year-old female presented with 1 month of significant pain in the neck as well as right anterior chest and deltoid. The patient was found to have reduced strength in the right deltoid muscle on physical examination. MRI revealed a C4-C5 herniated nucleus pulposus. The patient underwent successful C4-C5 anterior cervical discectomy, but subsequently developed painful swelling in the region of the right sternoclavicular joint with limited motor strength in the right shoulder and arm. A needle biopsy of the mass yielded negative results, but her erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) numbers did respond to antibiotics, consistent with infection of the sternoclavicular joint. A follow-up CT scan (6.5 months postoperatively) revealed apparent resolution right sternoclavicular joint arthropathy, thought the patient continued to experience pain. 15 months postoperatively, the patient was prescribed methotrexate due to persistent pain and mild weakness arising from a possible rheumatologic inflammation. 19 months postoperatively, the patient had full strength of the right shoulder and arm and visible decrease in swelling at the sternoclavicular joint. More than three years postoperatively, the patient was diagnosed with multiple myeloma, which was appropriately treated. At follow-up four years postoperatively, the patient had an MRI showing new C6-C7 herniated nucleus pulposus, but no longer had any right shoulder or chest pain or associated weakness. Conclusion This case demonstrates that sternoclavicular joint arthropathy results in symptoms that can mimic the presenting symptoms of shoulder or cervical spine pathology, such as shoulder and neck pain, necessitating careful diagnosis and management

Emil Zuckerkandl, M.D. (1849-1910): Bridging Anatomic Study and the Operating Room Table.

In the mid-19th century, the Vienna School of Anatomy was at the epicenter of the rapidly growing field of anatomy. One of the school’s most distinguished professors, Hungarian-born anatomist Emil Zuckerkandl was instrumental in transforming anatomy from a descriptive science to one of practical and clinical value. A prolific researcher interested in nearly all areas of morphology and most famously, the chromaffin system, Zuckerkandl’s discoveries from more than a century ago still provide a foundation for surgeons to this day

Quality Improvement for the JeffMD Clinical Experience Program

Introduction: The JeffMD curriculum at Sidney Kimmel Medical College, which completed its inaugural year in the spring of 2018, aims to prepare future physicians to “thrive in the landscape of modern healthcare.” The curriculum is based upon the knowledge that human health exists interdependently with all aspects of life, including but not limited to social, health care system, behavioral, and biological factors. The JeffMD Clinical Experience Program (CE) is a mandatory, experiential, value-added component of the curriculum. Through the CE course, which spans the 21-month preclinical period, students work with a Community Health Worker to screen patients for social needs and connect them to community resources. Objective: The purpose of this Quality Improvement study was twofold. First, we sought to evaluate the extent to which the first year of the CE program (1) contributed to student learning, and (2) added value to the clinical sites. Second, we sought to implement site-specific improvements based upon our results. Methods: We followed the Plan-Do-Study-Act (PDSA) model. We measured the current performance of the CE program through electronic surveys administered to the 260 first-year medical students who participated. The surveys included free response and Likert scale questions. We also conducted small group interviews with key stakeholders from four of the clinical sites using a questionnaire adapted from Penn State. Results: Students valued the opportunity to interact with patients and learn about social determinants of health; however, they did not find the CE program to be an effective learning experience. Key themes from the clinical site interviews included lack of student initiative, physical space constraints, communication barriers, and the positive contribution of Community Health Workers. Conclusion: We performed cause analyses and implemented clinical site-specific changes based upon our results. We believe that the student experience will improve from year-to-year so long as we continue to incorporate feedback from students and other stakeholders

Remnant cholesterol predicts progression of diabetic nephropathy and retinopathy in type 1 diabetes

Background We aimed to assess whether remnant cholesterol concentration and variability predict the progression of diabetic nephropathy (DN) and severe diabetic retinopathy (SDR) in type 1 diabetes. Methods This observational prospective study covered 5150 FinnDiane Study participants. Remnant cholesterol was calculated as total cholesterol - LDL cholesterol - HDL cholesterol and variability as the coefficient of variation. DN category was based on consensus albuminuria reference limits and the progression status was confirmed from medical files. SDR was defined as retinal laser treatment. For 1338 individuals, the severity of diabetic retinopathy (DR) was graded using the ETDRS classification protocol. Median (IQR) follow-up time was 8.0 (4.9-13.7) years for DN and 14.3 (10.4-16.3) for SDR. Results Remnant cholesterol (mmol L-1) was higher with increasing baseline DN category (P < 0.001). A difference was also seen comparing non-progressors (0.41 [0.32-0.55]) with progressors (0.55 [0.40-0.85]), P < 0.001. In a Cox regression analysis, remnant cholesterol predicted DN progression, independently of diabetes duration, sex, HbA(1c), systolic blood pressure, smoking, BMI, estimated glucose disposal rate and estimated glomerular filtration rate (HR: 1.51 [1.27-1.79]). Remnant cholesterol was also higher in those who developed SDR (0.47 [0.36-0.66]) than those who did not (0.40 [0.32-0.53]), P < 0.001, and the concentration increased stepwise with increasing DR severity (P < 0.001). Regarding SDR, the HR for remnant cholesterol was 1.52 (1.26-1.83) with the most stringent adjustment. However, remnant cholesterol variability was not independently associated with the outcomes. Conclusions Remnant cholesterol concentration, but not variability, predicts DN progression and development of SDR. However, it remains to be elucidated whether the associations are causal or not.Peer reviewe

Noncommutative Conformally Coupled Scalar Field Cosmology and its Commutative Counterpart

We study the implications of a noncommutative geometry of the minisuperspace variables for the FRW universe with a conformally coupled scalar field. The investigation is carried out by means of a comparative study of the universe evolution in four different scenarios: classical commutative, classical noncommutative, quantum commutative, and quantum noncommutative, the last two employing the Bohmian formalism of quantum trajectories. The role of noncommutativity is discussed by drawing a parallel between its realizations in two possible frameworks for physical interpretation: the NC-frame, where it is manifest in the universe degrees of freedom, and in the C-frame, where it is manifest through theta-dependent terms in the Hamiltonian. As a result of our comparative analysis, we find that noncommutative geometry can remove singularities in the classical context for sufficiently large values of theta. Moreover, under special conditions, the classical noncommutative model can admit bouncing solutions characteristic of the commutative quantum FRW universe. In the quantum context, we find non-singular universe solutions containing bounces or being periodic in the quantum commutative model. When noncommutativity effects are turned on in the quantum scenario, they can introduce significant modifications that change the singular behavior of the universe solutions or that render them dynamical whenever they are static in the commutative case. The effects of noncommutativity are completely specified only when one of the frames for its realization is adopted as the physical one. Non-singular solutions in the NC-frame can be mapped into singular ones in the C-frame.Comment: explanations added, references include

Persistent Genital Arousal Disorder (PGAD): case report of long-term symptomatic management with electroconvulsive therapy

Introduction. This is the second case report of a woman with bipolar disorder type I who noted the onset of persistent genital arousal disorder (PGAD) symptoms after abrupt cessation of paroxetine. With the worsening of PGAD symptoms, she developed severe depression and suicidal thoughts, resulting in her undergoing electroconvulsive therapy (ECT) as management. Aim. To describe a case of PGAD and develop hypotheses to explain the beneficial actions of ECT on PGAD based on 4 years of ECT administration. Methods. Patient self-report after obtaining consent, as well as literature review. Results. After the fourth ECT, the patient&apos;s PGAD symptoms abated serendipitously. She was placed on ECT on demand for the treatment of her PGAD. With each ECT treatment, PGAD symptoms immediately disappeared, relapsing slowly over time until the next ECT was administered. The patient has, thus far, received a total of 30 treatments of ECT. Side effects continue to be minimal and include brief short-term memory loss, headache, and muscle aches. Conclusion. ECT is known to induce cerebral excitatory and inhibitory neurotransmitter changes after acute and chronic administration. Sexual arousal is stimulated by the action of hypothalamic and limbic dopamine, noradrenaline, melanocortin, and oxytocin, and inhibited by serotonin, cerebral opioids, and endocannabinoids. Based on the patient&apos;s bipolar disorder, the mechanism of action of ECT and the observation of ECT effectiveness on her PGAD, we hypothesize the following: (i) bipolar disorder led to central hyperactive dopamine release, an important component in the pathophysiology of her PGAD; (ii) central serotonin deficiency after selective serotonin-reuptake inhibitor (SSRI) withdrawal resulted in a lack of inhibition of sexual excitement; (iii) ECT resulted in lowering of the hyperstimulated central dopamine release; and (iv) ECT led to an increase in sexual inhibition by stimulating serotonin activity

Accurate computation of quaternions from rotation matrices

The final publication is available at link.springer.comThe main non-singular alternative to 3×3 proper orthogonal matrices, for representing rotations in R3, is quaternions. Thus, it is important to have reliable methods to pass from one representation to the other. While passing from a quaternion to the corresponding rotation matrix is given by Euler-Rodrigues formula, the other way round can be performed in many different ways. Although all of them are algebraically equivalent, their numerical behavior can be quite different. In 1978, Shepperd proposed a method for computing the quaternion corresponding to a rotation matrix which is considered the most reliable method to date. Shepperd’s method, thanks to a voting scheme between four possible solutions, always works far from formulation singularities. In this paper, we propose a new method which outperforms Shepperd’s method without increasing the computational cost.Peer ReviewedPostprint (author's final draft

Interprofessional Student Hotspotting Project

Background: IPE and Practice-based Learning It is well established that there is a need for Interprofessional Education (IPE) in the current landscape of health education1 and students that participate in IPE enjoy these experiences and develop skills in interprofessional teamwork that prepare them for future team-based practice.2,3,4 IPE, however, is not standardized. It ranges from programs that teach theoretical frameworks in a classroom setting to others that allow interprofessional teams of students to work together in a clinical setting.5,6 The second form is referred to as practice-based learning (PrBL).3 PrBL is now considered by experts as one of the most effective teaching methods.3,6 Unfortunately, due to the lack of consistency of IPE programs and the lack of standardization in IPE research, there is inconsistency in data regarding the best IPE method.6,