Carotid ultrasound is not helpful in simple syncope

A critical appraisal and clinical application of Scott JW, Schwartz AL, Gates JD, Gerhard-Herman M, Havens JM. Choosing wisely for syncope: low-value carotid ultrasound use. J Am Heart Assoc. 2014 Aug 13;3(4). pii: e001063. doi: 10.1161/JAHA.114.00106

Chronic Renal Failure, But Why? A Case Report.

Renal failure, both acute and chronic, can present from many different etiologies and if diagnosed with diabetes mellitus, it is commonly assumed to be due to diabetic nephropathy. Monoclonal gammopathy of renal significance (MGRS) is a disorder that combines monoclonal gammopathy of undetermined significance with end stage renal disease. Monoclonal immunoglobulins are secreted by B or plasma cells leading to deposition in the kidney causing end organ damage. Several different subtypes fall under this category of renal diseases including, but not limited to, amyloidosis, C3 glomeruopathy, and light chain proximal tubulopathy, or better known as Fanconi syndrome1. Fanconi syndrome, which can be acquired or inherited, occurs due to toxicity of the proximal renal tubule in the kidney which leads to hypophosphatemia, hypokalemia, metabolic acidosis due to impaired bicarbonate absorption, impaired glucose and uric acid absorption, and proteinuria. In this case, an 84 year old Caucasian male presented with shortness of breath and weakness. He denied chest pain, hemoptysis, polyuria, and hematuria. His past medical history includes chronic renal disease secondary to well-controlled type II diabetes mellitus (DM), perirenal lymphangiectasis, pulmonary fibrosis, hypertension, atrial fibrillation, hyperlipidemia, and anemia. He had a left radiocephalic AV fistula Permacath placement prior to admission for dialysis. A combined effort from general internal medicine, nephrology, hematology/oncology, cardiology, pulmonary, vascular, infectious disease, radiology, and pathology was made to investigate the patient’s illness over the course of his one-month stay. Though type II DM played a role in the development of this patient’s chronic kidney disease, MGRS is a significant causal factor of the progression to end stage renal disease. Currently, treatment with chemotherapy that targets plasma or B cells can be used for MGRS. Several case studies reported improvement or stabilization of renal function in those treated with chemotherapeutic agents vs. no therapy. (4,5) Though renal transplantation can be done, recurrence post-transplantation is common. (6) The main goal in managing MGRS with Fanconi syndrome is slowing the progression of renal disease and preventing associated extra-renal complications. (7) This case demonstrates the complexities of medical diagnostics and the step-wise progression involved in caring for a patient. It displays the value of interdisciplinary collaboration among different medical specialties to accurately provide patients with an etiology and treatment for their illness and related symptoms

Ultrasound-guided out-of-plane (OOP) adductor canal continuous catheter placement compared to in-plane (IP) placement in total knee arthroplasty: a randomized, single blinded, pilot clinical trial

Background: Adductor canal continuous catheters (ACCCs) have largely replaced femoral nerve continuous catheters for providing analgesia after total knee arthroplasty. Both have similar analgesic efficacy, but ACCCs preserve quadricep strength and facilitate patient mobility more quickly. We hypothesized that placing the ACCC using an out of-plane (OOP) technique would decrease pain scores and opioid use due to parallel alignment with the saphenous nerve when compared to the in-plane (IP) technique. Methods: Sixty-nine patients undergoing total knee arthroplasty were randomized to either the IP or OOP technique for ultrasound-guided ACCC. The primary outcomes of the investigation were hospital length of stay, total opioid consumption, and average post-operative pain score. Secondary outcomes included total ondansetron consumption, total acetaminophen consumption, and the incidence of anti-emetic drug use. Results: There were no significant differences between the IP and the OOP groups for any of the measured variables: hospital length of stay, pre-operative pain score, average post-operative pain score, total opioid consumption, total ondansetron consumption, total acetaminophen consumption, and the incidence of anti-emetic drug administration. Conclusion: The OOP ACCC technique did not provide superior analgesia or decrease opioid consumption when compared to the IP ACCC technique. Both techniques can be used interchangeably for analgesia status-post TKA

LINAC-Based Stereotactic Body Radiation Therapy for Benign Tumors of the Skull Base

https://openworks.mdanderson.org/sumexp23/1072/thumbnail.jp

Listening as medicine: A thematic analysis

Realizations of the importance of “the art of medicine” in trust-building and patient satisfaction have resulted in the incorporation of narrative medicine programs into training curricula. By learning how to respond to patient stories as well as communicate their own, healthcare providers can ensure that their patients feel heard and respected. This study seeks to define what constitutes empathetic listening through a qualitative analysis of personal narratives collected from patients, caregivers, and providers across an urban academic healthcare system. Stories (n=41) underwent thematic analysis to note common experiences related to listening during a health system encounter. Eighteen grounded codes were identified which were abstracted to the following five themes: (1) connection and trust, (2) emotion and vulnerability, (3) objectives and experiences, (4) interaction and opportunity, and (5) challenges of listening. The most common theme of “connection and trust” indicated that active listening and person-centered care were key drivers of patient satisfaction and medical adherence. Encouraging patients and providers to become more comfortable verbalizing vulnerability also provided emotional relief. Taking the time to listen to patient needs and values advanced shared-decision making and facilitated the establishment of care objectives. Storytellers also conveyed the challenges inherent to the listening process. By helping to define empathetic listening, these results may enable the development of healthcare training programs centered on improving clinician communication and patient experience. We hope this study encourages future research devoted to quantifying subjective features such as “connection and trust” and “emotion and vulnerability” utilizing psychometrically validated instruments. Experience Framework This article is associated with the Patient, Family & Community Engagement lens of The Beryl Institute Experience Framework (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens

Shigatoxin E. coli (STEC) in Public Park at Different Seasons of the Year

BACKGROUND: In the U.S. STEC HUS is the most common cause of acute renal failure in children. In TN from 1996-2017 there were 2008 STEC cases were reported. Every year in the U.S, there 36 reported mortality each year. At our local children’s hospital, 4-5 children are hospitalized with STEC infection each year. Some of these children had no history of ingesting food items that could have placed them at risk to develop STEC infection; however, there are other ways that humans could get infected, such as exposure to contaminated water from cattle farms. GOALS: To determine if there are differences in the presence of STEC at a local park at different seasons of the year. METHODS: Fifty (50) ml of water samples were collected from a creek in 2 areas of public park in Johnson City, TN. Samples were inoculated to Sorbitol McConkey Agar (SMAC) plates under sterile techniques & incubated at 36C for 18 hours under aerobic conditions. RESULTS: Table demonstrating presence of STEC from water samples at different seasons of the year. SEASON OF THE YEAR # COLONIES FOUNDERS PARK # COLONIES LIBRARY PARK SUMMER JUNE 2018 A:1 B:1 C:2 TOTAL: 4 A: 3 B: 2 C: 1 TOTAL: 6 FALL SEPT 2018 A: 1 B: 3 C: 2 TOTAL: 6 A: 1 B:2 C:4 TOTAL: 7 WINTER DEC 2018 A: 1 B: 0 C: 1 TOTAL: 2 A: 0 B: 1 C: 1 TOTAL: 2 SPRING MARCH 2019 A: 2 B: 2 C:1 TOTAL: 5 A: 0 B: 0 C: 0 TOTAL: 0 DISCUSSION/ CONCLUSION: STEC was present at almost every season of the year. Public health measures should be undertaken to inform the community that these waters around public parks are contaminated with STEC to prevent STEC infection. References: TN Dept of Health CEDEP report CDC websit

Statewide declines in myocardial infarction and stroke emergency department visits during COVID-19 restrictions in North Carolina

In the United States, efforts to control the coronavirus disease (COVID)-19 pandemic brought sweeping social change, with stay-at-home orders and physical distancing mandates in 43 of 50 states by April 2020. Although these public health measures were intended to curb the spread of COVID-19, their impact on individuals with other health conditions was largely unknown. Initial anecdotal reports described precipitous decreases in emergency department (ED) visits for acute cardiovascular outcomes and were replicated by the results of several larger observational analyses. However, these studies relied primarily on data from select health systems or medical groups and few reported on the impact of the pandemic past May 2020. Now, more than a year since the US confirmed its first case of COVID-19, our objective is to provide an understanding of the pandemic's longer-term impact on ED utilization for acute cardiovascular disease. We hypothesized that (1) acute myocardial infarction (AMI) and stroke/transient ischemic attack (TIA)-related ED visits in North Carolina (NC) decreased substantially after a statewide stay-at-home order was announced on March 27, 2020 and that (2) ED visits decreased considerably over the course of 2020 in comparison to 2019

Radiation damage tolerance of a novel metastable refractory high entropy alloy V2.5Cr1.2WMoCo0.04

A novel multicomponent alloy, V2.5Cr1.2WMoCo0.04, produced from elements expected to favour a BCC crystal structure, and to be suitable for high temperature environments, was fabricated by arc melting and found to exhibit a multiphase dendritic microstructure with W-rich dendrites and V–Cr segregated to the inter-dendritic cores. The as-cast alloy displayed an apparent single-phase XRD pattern. Following heat treatment at 1187 °C for 500 h the alloy transformed into three different distinct phases - BCC, orthorhombic, and tetragonal in crystal structure. This attests to the BCC crystal structure observed in the as-cast state being metastable. The radiation damage response was investigated through room temperature 5 MeV Au+ ion irradiation studies. Metastable as-cast V2.5Cr1.2WMoCo0.04 shows good resistance to radiation induced damage up to 40 displacements per atom (dpa). 96 wt% of the as-cast single-phase BCC crystal structure remained intact, as exhibited by grazing incidence X-ray diffraction (GI-XRD) patterns, whilst the remainder of the alloy transformed into an additional BCC crystal structure with a similar lattice parameter. The exceptional phase stability seen here is attributed to a combination of self-healing processes and the BCC structure, rather than a high configurational entropy, as has been suggested for some of these multicomponent “High Entropy Alloy” types. The importance of the stability of metastable high entropy alloy phases for behaviour under irradiation is for the first time highlighted and the findings thus challenge the current understanding of phase stability after irradiation of systems like the HEAs

Subtyping sub-Saharan esophageal squamous cell carcinoma by comprehensive molecular analysis

Esophageal squamous cell carcinoma (ESCC) is endemic in regions of sub-Saharan Africa (SSA), where it is the third most common cancer. Here, we describe whole-exome tumor/normal sequencing and RNA transcriptomic analysis of 59 patients with ESCC in Malawi. We observed similar genetic aberrations as reported in Asian and North American cohorts, including mutations of TP53, CDKN2A, NFE2L2, CHEK2, NOTCH1, FAT1, and FBXW7. Analyses for nonhuman sequences did not reveal evidence for infection with HPV or other occult pathogens. Mutational signature analysis revealed common signatures associated with aging, cytidine deaminase activity (APOBEC), and a third signature of unknown origin, but signatures of inhaled tobacco use, aflatoxin and mismatch repair were notably absent. Based on RNA expression analysis, ESCC could be divided into 3 distinct subtypes, which were distinguished by their expression of cell cycle and neural transcripts. This study demonstrates discrete subtypes of ESCC in SSA, and suggests that the endemic nature of this disease reflects exposure to a carcinogen other than tobacco and oncogenic viruses

Dimensional Dependence of Black Hole Formation in Self-Similar Collapse of Scalar Field

We study classical and quantum self-similar collapses of a massless scalar field in higher dimensions, and examine how the increase in the number of dimensions affects gravitational collapse and black hole formation. Higher dimensions seem to favor formation of black hole rather than other final states, in that the initial data space for black hole formation enlarges as dimension increases. On the other hand, the quantum gravity effect on the collapse lessens as dimension increases. We also discuss the gravitational collapse in a brane world with large but compact extra dimensions.Comment: Improved a few arguments and added a figur