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Tolerability of electrodiagnostic studies in patients: a prospective study.
No full textINTRODUCTION: Nerve conduction study (NCS) and electromyography (EMG) are electrodiagnostic studies that are highly tolerated by patients despite their nature of causing pain and discomfort. However, few studies have focused on the true tolerability of these procedures in patients. This study aimed to determine the true tolerance rate of NCS and EMG in patient populations and the factors that might be associated with them.
METHODS: Participants scheduled for electrodiagnostic studies were prospectively recruited between March 2023 and September 2023. After completion of the study, the physicians completed a questionnaire on each patient\u27s tolerance of the studies.
RESULTS: Of the 103 patients enrolled in the study, 98 were able to tolerate both tests, and 5 patients were intolerant to 1 or both tests. The overall tolerance rate of NCS and EMG was 95.1% (0.951, 95% CI 0.897 to 0.981). Age, sex, ethnicity, the type of NCS performed and the type of EMG performed were not associated with NCS or EMG intolerance.
CONCLUSION: Most patients tolerated the NCS and EMG; however, a small percentage of patients were intolerant. Clinicians should recognise the intolerance of certain patients when introducing and performing electrodiagnostic tests
An Unusual Presentation of Erythrodermic Psoriasis
Get PDFIntroduction
Erythrodermic psoriasis is a rare form of psoriasis, occurring in less than 3% of patients with psoriasis. Limited information is known regarding diagnosis and treatment for this form of psoriasis, with most studies involving small groups or single patients. This unusual case of erythrodermic psoriasis outlines the presentation, diagnosis, and treatment that occurred in a 53-year-old patient who initially presented with dyspnea and a fever.
Case Presentation
The 53-year-old patient was originally admitted for dyspnea and a fever. A maculopapular rash developed diffusely on the upper extremities, lower extremities, trunk, and face. The rash then desquamated over several days, appearing as exfoliating and scaling skin. The patient underwent two punch biopsies for diagnosis and was treated with Hydrocortisone (2.5%) cream for the face and inguinal regions and Triamcinolone for the trunk. The patient continued this regimen daily for 2 weeks, and then alternated days for the following 2 weeks.
Discussion
There are many different causes and potential risk factors for a flare of erythrodermic psoriasis: history of psoriasis, systemic corticosteroids and excessive use of topical steroids, phototherapy complications, severe emotional stress, and preceding illness. The patient in this study had several precipitating factors worth noting, including recent diagnosis of colorectal cancer and infection with evidence of leukocytosis. She was also under a fair amount of emotional stress given her health issues and prolonged hospital stay. The patient was also receiving several medications that may have increased her risk of a flare, most notably being Vancomycin. Initial treatment is the use of topical corticosteroids and systemic therapy is considered if this does not improve symptoms. Prior case reports have shown that difficult to manage cases can be treated with Acitretin or systemic therapies such as Methotrexate.
Key Words
Erythroderma, psoriasis, dermatolog
Association Between Limited English Proficiency and Operative Vaginal Birth
No full textOBJECTIVES: Limited English proficiency (LEP) is a risk factor for adverse health care outcomes and may contribute to disparities in obstetrical care. Prior research has shown an association between LEP and obstetric anal sphincter injuries (OASIS); however, the underlying causes remain uncertain. For patients with LEP, language barriers may affect the process of obtaining consent and conducting shared decision-making for obstetrical operative instrumentation (ie, vacuum and forceps), the most significant risk factor for OASIS. The objective of this study was to evaluate if LEP is associated with increased risk of operative vaginal delivery in a cohort in which prior analysis has shown an association between LEP and increased risk of OASIS. METHODS: A secondary analysis of a prior retrospective study investigating the association between LEP and OASIS was performed. All patients who underwent term vaginal cephalic births between January 2016 and July 2023 at a single hospital center were included. The following variables were extracted from the electronic medical record: preferred language, OASIS injury, age, height, pre-gravid BMI, race, ethnicity, insurance type, parity, gestational age at birth, oxytocin use, epidural analgesia receipt, length of second stage of labor, any forceps or vacuum assistance, fetal position, birth weight, and maternal blood loss. Patients with LEP were defined as those with a non-English primary language. Binary logistic regression was used assess odds of operative versus spontaneous vaginal birth, adjusting for LEP, age, pre-gravid BMI, parity, and birth weight of fetus. Statistical analysis was performed in SPSS. RESULTS: A total of 15,736 patients were included in the study, of which 13,977 patients were English speaking and 1759 patients had LEP. There was no difference in odds of operative vaginal birth between patients with LEP and their English speaking counterparts (aOR 1.10, 95% CI 0.85-1.42). Prior parity (aOR 0.20, 95% CI 0.17-0.24) and increased pre-gravid BMI (aOR: 0.98, 95% CI 0.97-0.995) were significantly associated with decreased risk of operative vaginal delivery. Age (aOR: 1.07, 95% CI 1.06-1.09) was significantly associated with increased risk of operative delivery. The adjusted logistic regression model predicted an overall 94.0% of outcomes and explained 8.8% (Nagel kerke R2) of the variance in operative vaginal delivery, with the Hosmer-Lemeshow test calculating goodness-of-fit at 0.344. CONCLUSIONS: Among patients with term vaginal deliveries, patients with LEP had a similar likelihood of undergoing operative vaginal birth compared to their English-speaking counterparts. However, in a previous analysis of this cohort, patients with LEP were more likely to sustain OASIS. Further research is needed to understand the association between of language barriers and OASIS, including any potential adverse impacts arising from impaired communication between health care providers and patients during labor
Paraganglioma Masquerading as Neurological Symptoms: A Rare Case Presentation
No full textIntroduction: Paragangliomas (PG) are rare tumors of neural crest origin. We report an unusual case of a PG wherein the patient presented to the hospital with complaints of bilateral numbness, tingling, and intermittent difficulty in grasping objects. Case presentation: A 51-year-old female with a prior history of Guillain-Barre Syndrome and hypertension presented to the hospital due to bilateral numbness, tingling, and intermittent difficulty grasping objects in her hands for four weeks. At presentation, her vitals were stable, and her physical examination was positive, only for diminished sensation in her upper extremities. Lab work, including TSH, B12/Folic Acid/ANA, was unremarkable at presentation. CT head and MRI brain were negative for acute intracranial pathology. MRI of the cervical spine showed multilevel degenerative changes (C5-6) and a 1.9 cm soft tissue mass just above the left carotid bifurcation. CTA of the neck revealed a 2.7 x 1.6 x 1.7 cm enhancing mass at the left carotid bifurcation and a contralateral 5 x 3 mm lesion at the right carotid bifurcation. EMG/NCS was performed, which did not meet the diagnostic criteria for Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP/GBS) or cervical radiculopathy. Biochemical workup with plasma metanephrine, 24-hour urine catecholamines/metanephrine/normetanephrine, and 24-hour vanillylmandelic acid was normal. She underwent resection of the left carotid body tumor. The histopathology was consistent with PG. Following the diagnosis, blood tests with PTH, calcium, and calcitonin were performed and were normal. The thyroid ultrasound did not show any thyroid nodules. The patient is scheduled to follow up with Endocrinology as an outpatient to complete genetic testing. Discussion: PG of the head and neck are rare. PG are benign in most cases, but 10% are reported to be malignant. PG may occur sporadically or as inherited familial tumors. Classic tumor syndromes associated with PG include MEN 2A and 2B, von Hippel-Lindau disease, Neurofibromatosis type 1 (NF-1), and Carney-Stratakis dyad. Most cases are non-functional, and symptoms result from mass effects. A preoperative diagnosis usually involves biochemical and radiographic (CT/MRI/PET/MIBG) testing. Biochemical evaluation with measurement of urinary and/or plasma fractionated metanephrines and catecholamines is indicated for all PG, even if clinically non-functional. The definitive diagnosis is histopathological. Treatment options include surgical resection, radiation, and stereotactic radiosurgery
Clinical characteristics, treatment, and outcomes of provoked acute cerebral sinovenous thrombosis in patients \u3c21 years old: findings from the Kids-DOTT Multinational Trial.
No full textBACKGROUND: Prospective multicenter data on the treatment and outcomes of children with cerebral sinovenous thrombosis (CSVT) are limited. We aimed to describe the clinical characteristics, treatment strategies, and outcomes of patients with a first-episode of provoked acute CSVT enrolled in the Kids-DOTT trial and compare these features with those of participants with non-CSVT venous thromboembolism (VTE).
METHODS: This was a subgroup analysis from the Kids-DOTT trial, a multinational randomized clinical trial on duration of anticoagulation for provoked acute VTE in patients younger than 21 years. Patient and thrombus characteristics, treatments, and outcomes of patients diagnosed with CSVT were compared with those of patients with non-CSVT VTE.
RESULTS: CSVT was diagnosed in 75 of the 532 (14%), 25 of whom received 6 weeks of anticoagulant treatment and 50 received 3 or more months. When compared with non-CSVT VTE, CSVT was more likely to occur in neonates and young children, associated with infection in general and acute head/neck infection in particular, and less likely to be related to central venous catheter. No patient in either group developed symptomatic recurrent VTE or clinically relevant bleeding, and there was no significant difference in rates of complete thrombus resolution between the 2 treatment durations.
CONCLUSION: CSVT is most common in neonates and young children and those with acute head and neck infections. A 6-week anticoagulation treatment course appears to be safe (no clinically relevant bleeding) and effective (no difference in symptomatic recurrent VTE) for provoked acute pediatric CSVT. Nevertheless, given the nature of a subpopulation analysis, these findings should be interpreted with caution
Direct Oral Anticoagulants: A Review for Health Care Providers
Get PDFDirect oral anticoagulants (DOACs) are a novel class of anticoagulants. They include rivaroxaban, apixaban, edoxaban, and dabigatran. Benefits of DOACs over many older anticoagulants include oral administration, quicker onset of action, less monitoring requirements, and fewer drug interactions. Since the DOACs were first introduced, their use has increased tremendously. This article aims to help providers become more familiar with DOACs and the specific factors that may impact prescribing practices. Several drugs used for the reversal of DOACs will also be discussed. Lastly, the article will describe certain situations in which warfarin is preferred over DOACs
Cracking the Code: A Case Report on Low-Renin Hypertension.
No full textLow-renin hypertension (LRH) is characterized by hypertension accompanied by low serum renin levels. LRH is a spectrum, including low-renin essential hypertension (LREH), primary hyperaldosteronism, and several acquired or familial secondary forms. Here, we present a case of LRH. A 57-year-old female with resistant hypertension on multiple antihypertensive medications presented for blood pressure management. Workup for secondary causes of hypertension revealed low renin levels with normal aldosterone. The patient was initiated on spironolactone and responded quickly with normal blood pressure on a follow-up visit. LRH is an under-recognized etiology for uncontrolled hypertension. It can be secondary to several different causes. Although treatment of LREH is essentially the same as regular patients, these patients tend to respond well to sodium-volume-depleting diuretics, mineralocorticoid receptor blockers, and epithelial sodium channels (ENaC) blockers
Gastrointestinal Amyloidosis as a Cause of Anemia: Rare and Rarely Considered.
No full textGastrointestinal involvement in amyloidosis is reported in 3% of cases, mostly associated with multiple myeloma. An elderly man with chronic kidney disease presented to the hospital after a large melenic bowel movement. The patient was tachycardic and anemic to 3.8 g/dL on admission and was transfused blood. Endoscopy and colonoscopy were unremarkable. Subsequently, the patient had 2 more admissions for severe anemia requiring blood transfusion. Repeat esophagoduodenoscopy with capsule endoscopy were unremarkable. The patient was diagnosed with monoclonal gammopathy of undetermined significance by hemoglobin electrophoresis, and endoscopy biopsy revealed intestinal amyloidosis in a duodenal specimen. The patient\u27s recurrent anemia was attributed to bleeding from gastrointestinal amyloidosis, in the absence of other identifiable sources of anemia, and was managed with intravenous iron infusions
Body Mass Index Does Not Predict Injury Pattern or Outcome After Motorcycle Crash.
No full textINTRODUCTION: The obesity epidemic plagues the United States, affecting approximately 42% of the population. The relationship of obesity with injury severity and outcomes has been poorly studied among motorcycle collisions (MCC). This study aimed to compare injury severity, mortality, injury regions, and hospital and intensive care unit length of stay (LOS) between obese and normal-weight MCC patients.
METHODS: Trauma registries from three Pennsylvania Level 1 trauma centers were queried for adult MCC patients (January 1, 2016, and December 31, 2020). Obesity was defined as adult patients with body mass index ≥ 30 kg/m
RESULTS: One thousand one hundred sixty-four patients met the inclusion criteria: 40% obese (n = 463) and 60% nonobese (n = 701). Comparison of ISS demonstrated no statistically significant difference between obese and normal-weight patients with median ISS (interquartile range) 9 (5-14) versus 9 (5-14), respectively (P = 0.29). Obese patients were older with median age 45 (32-55) y versus 38 (26-54) y, respectively (P \u3c 0.01). Comorbidities were equally distributed among both groups except for the incidence of hypertension (30 versus 13.8%, P \u3c 0.01) and diabetes (11 versus 4.4%, P \u3c 0.01). There was no statistically significant difference in Trauma Injury Severity Score or abbreviated injury score. Hospital LOS, intensive care unit LOS, and 30-day mortality among both groups were similar.
CONCLUSIONS: Obese patients experiencing MCC had no differences in distribution of injury, mortality, or injury severity, mortality, injury regions, and hospital compared to normal-weight adults. Our study differs from current data that obese motorcycle drivers may have different injury characteristics and increased LOS