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Presence of Microscopic Hematuria Does Not Predict Clinically Important Intra-Abdominal Injury in Children.
No full textOBJECTIVE: Screening for blunt intra-abdominal injury in children often includes directed laboratory evaluation that guides need for computed tomography. We sought to evaluate the use of urinalysis in identifying patients with clinically important intraabdominal injury (ci-IAI).
METHODS: A retrospective chart review was performed for all patients less than 18 years who presented with blunt mechanisms at a level I trauma center between 2016 and 2019. Exclusion criteria included transfer from an outside facility, physical abuse, and death within thirty minutes of arrival. Demographics, physical exam findings, serum chemistries, urinalysis, and imaging were reviewed. Clinically important intraabdominal injury was defined as injury requiring ≥2 nights admission, blood transfusion, angiography with embolization, or therapeutic surgery.
RESULTS: Two hundred forty patients were identified. One hundred sixty-five had a completed urinalysis. For all patients an abnormal chemistry panel and abnormal physical exam had a sensitivity of 88.9% and a negative predictive value of 99.3%. Nine patients had a ci-IAI. Patients with a ci-IAI were more likely to have abdominal pain, tenderness on exam, and elevated hepatic enzymes. When patients were stratified by the presence of an abnormal chemistry or physical exam with or without microscopic hematuria, urinalysis did not improve the ability to identify patients with a ci-IAI. In fact, presence of microscopic hematuria increased the rate of false positives by 12%.
CONCLUSIONS: Microscopic hematuria was not a useful marker for ci-IAI and may lead to falsely assuming a more serious injury
A Case of Atypical Scleroderma Renal Crisis.
No full textWe present the case of a 63-year-old female diagnosed with atypical SSc in the setting of acute SRC. She was undergoing work-up for progressive dyspnoea in the outpatient setting when she was found to have newly diagnosed restrictive lung pathology and worsening renal function, thus prompting acute hospital admission. Given multisystem involvement of the pulmonary and renal systems, the differential diagnosis included autoimmune and connective tissue disorders. Although serologies were non-specific, renal biopsy confirmed scleroderma renal disease, and she was started on treatment with captopril. This case highlights the importance of clinical judgment and timely diagnosis, even when laboratory data might indicate otherwise.
LEARNING POINTS: Scleroderma renal crisis (SRC) remains an important cause of morbidity and mortality in systemic sclerosis (SSc), and clinicians should have a high index of suspicion to diagnose it.The absence of specific serologic markers makes SSc diagnosis challenging and necessitates reliance on clinical findings and additional diagnostic tools such as imaging studies and tissue sampling
Heart Disease and Heart Failure: Trends and Disparities in Mortality Rates in the United States from 2000 to 2020
No full textStudy objective: To describe the age, sex and racial disparities in mortality rates for heart disease (HD) and heart failure (HF) in the United States (US) between 2000 and 2020. Design: This was an ecological study with trend analysis of mortality rates. Setting: United States. Participants: Adults aged 18 years and above. Main outcomes measures: Mortality rates per 100,000 for HD and HF. Results: There was a significant decrease in the age-standardized mortality rate for HD over the past two decades (from 343.5 per 100,000 cases to 215.1 per 100,000 cases, p \u3c 0.001). HD mortality rates were significantly higher in males (p \u3c 0.001), non-Hispanic blacks (p \u3c 0.001) and in adults aged 65+ (p \u3c 0.001) and 75+ (p \u3c 0.001). There was no significant change in the age-standardized mortality rate for HF (from 26.9 per 100,000 cases to 25.7 per 100,000 cases (p = 0.706)) due to a reversal in the trend beyond 2011. Though the HF mortality rates were significantly lower in males (p = 0.001), and not significantly different in non-Hispanic blacks and non-Hispanic whites, there were shifts in trends beyond 2016, with higher rates in males and in non-Hispanic blacks compared to non-Hispanic whites. Conclusions: In summary, this study underscores significant reductions in heart disease mortality rates over the past two decades, alongside persistent disparities among different demographic groups. It also highlights emerging trends in heart failure mortality rates in particular population subgroups in recent years, necessitating further exploration to inform targeted interventions and policies
Catastrophic Spontaneous Uterine and Bladder Rupture in an Unscarred Uterus
Get PDFIntroduction:
Uterine rupture during pregnancy is a rare event which can be life-threatening for both the patient and the fetus. This case report describes a rare complication of uterine rupture which ultimately required a hysterectomy and extensive urologic reconstruction.
Case Description:
A 36-year-old patient presented to the hospital after term pre-labor rupture of membranes. The patient underwent induction of labor which ultimately resulted in a uterine rupture in an unscarred uterus. The rupture extended into the posterior bladder wall, right ureter, urethra, and anterior vaginal wall, resulting in a vesicovaginal fistula. The patient required a cesarean hysterectomy due to the uterine damage. Cystorrhaphy with right percutaneous nephrostomy tube and suprapubic catheter placement were performed due to the extensive urologic sequelae. Months later, the patient underwent ureteroneocystostomy for definitive urologic management.
Discussion:
Bladder rupture is a rare complication of uterine rupture and can occur in an unscarred uterus. Intrapartum bladder rupture should be considered in patients who develop gross hematuria or anterior vaginal wall laceration in the setting of uterine rupture. Maternal morbidity and mortality due to uterine rupture is decreased when care is provided at a tertiary referral or trauma center. This should be taken into consideration when planning deliveries with an increased risk of uterine rupture. Furthermore, providers performing vaginal deliveries should be aware of this rare complication to optimize maternal and neonatal outcomes
The Impact of Anterior Vertebral Body Tethering on Pulmonary Function.
No full textSTUDY DESIGN: Retrospective, single-center study.
OBJECTIVE: To examine pulmonary function tests (PFTs) in patients undergoing anterior vertebral body tethering (AVBT).
SUMMARY OF BACKGROUND DATA: The effect of AVBT on pulmonary status remains unclear.
METHODS: We examined preoperative and postoperative PFTs following AVBT in a retrospective, single-center cohort of patients. Outcomes were compared using percent predicted values as continuous and categorical variables (using 10% change as significant) and divided into categorical values based on the American Thoracic Society (ATS) standards.
RESULTS: 58 patients with adolescent idiopathic scoliosis were included with a mean age of 12.5±1.4 years and follow-up of 4.2±1.1 years. The mean thoracic curve was 47°±9°, which improved to 21°±12°. At baseline, the mean FEV1% and FVC% values were 79% and 82%, respectively. Four patients had normal FEV1% (≥100%), 67% had mild restrictive disease (70-99%), and the rest had worse FEV1%. Mean FEV1 improved from 2.2 to 2.6 L (P0.05) with mean postoperative PFTs at 37±12 months postoperative. The use of mini-open thoracotomy was not associated with worsening PFTs, but extension of the lowest instrumented vertebra below T12 was correlated with decreasing FEV1% in the bivariate analysis (P
CONCLUSION: Pulmonary function in most patients undergoing AVBT remained stable (76%) or improved (14%); however, a subset may worsen (10%). Further studies are needed to identify the risk factors for this group, but worse preoperative PFTs and extension below T12 may be risk factors for worsening pulmonary function
Geriatric Motorcycle-Related Outcomes: A Pennsylvania Multicenter Study.
No full textINTRODUCTION: Geriatric patients (GeP) often experience increased morbidity and mortality following traumatic insult and as a result, require more specialized care due to lower physiologic reserve and underlying medical comorbidities. Motorcycle injuries (MCCI) occur across all age groups; however, no large-scale studies evaluating outcomes of GeP exist for this particular subset of patients. Data thus far are limited to elderly participation in recreational activities such as water and alpine skiing, snowboarding, equestrian, snowmobiles, bicycles, and all-terrain vehicles. We hypothesized that GeP with MCCI will have a higher rate of mortality when compared with their younger counterparts despite increased helmet usage.
METHODS: We performed a multicenter retrospective review of MCCI patients at three Pennsylvania level I trauma centers from January 2016 to December 2020. Data were extracted from each institution\u27s electronic medical records and trauma registry. GeP were defined as patients aged more than or equal to 65 y. The primary outcome was mortality. Secondary outcomes included ventilator days; hospital, intensive care unit, and intermediate unit length of stays; complications; and helmet use. 3:1 nongeriatric patients (NGeP) to GeP propensity score matching (PSM) was based on sex, abbreviated injury scale (AIS), and injury severity score (ISS). P ≤ 0.05 was considered significant.
RESULTS: One thousand five hundred thirty eight patients were included (GeP: 7% [n = 113]; NGP: 93% [n = 1425]). Prior to PSM, GeP had higher median Charlson Comorbidity Index (GeP: 3.0 versus NGeP: 0.0; P ≤ 0.001) and greater helmet usage (GeP: 73.5% versus NGeP: 54.6%; P = 0.001). There was a statistically significant difference between age cohorts in terms of ISS (GeP: 10.0 versus NGeP: 6.0, P = 0.43). There was no significant difference for any AIS body region. Mortality rates were similar between groups (GeP: 1.7% versus NGeP: 2.6%; P = 0.99). After PSM matching for sex, AIS, and ISS, GeP had significantly more comorbidities than NGeP (P ≤ 0.05). There was no difference in trauma bay interventions or complications between cohorts. Mortality rates were similar (GeP: 1.8% versus NGeP: 3.2%; P = 0.417). Differences in ventilator days as well as intensive care unit length of stay, intermediate unit length of stay, and hospital length of stay were negligible. Helmet usage between groups were similar (GeP: 64.5% versus NGeP: 66.8%; P = 0.649).
CONCLUSIONS: After matching for sex, ISS, and AIS, age more than 65 y was not associated with increased mortality following MCCI. There was also no significant difference in helmet use between groups. Further studies are needed to investigate the effects of other potential risk factors in the aging patient, such as frailty and anticoagulation use, before any recommendations regarding management of motorcycle-related injuries in GeP can be made
A Short Adverse Experiences Measure Among Mothers of Young Children.
No full textOBJECTIVES: Screening for parental adverse childhood experiences (ACEs) in pediatric settings can be burdensome because of the questionnaire\u27s length and sensitive nature. Rapid screening tools may help address these challenges. We evaluated a 2-item short ACE measure developed for adults in a cross-sectional sample of mothers of young children in an urban pediatric emergency department.
METHODS: From January 2011 to March 2020, we administered the ACE questionnaire in English or Spanish to 3999 biological mothers of children agedPhiladelphia, Pennsylvania. We assessed sensitivity and specificity of a shortened 2-item ACE measure defined as report of childhood emotional abuse and/or household substance use, using 4+ ACEs on the full questionnaire as the standard. We assessed convergent validity by comparing associations of the 2-item and standard measures with maternal, household, and child outcomes using adjusted log-binomial regression.
RESULTS: Mothers were racially and ethnically diverse (54% Latina, 35% Black non-Latina); 94% of children were publicly insured. Thirteen percent of mothers reported childhood emotional abuse and 16% childhood household substance use; 23% reported at least 1 of these and 6% both. Compared with 4+ ACEs on the full questionnaire, the 2-item measure had sensitivity 88% and specificity 90%. In adjusted models, high adversity was associated with poor maternal, household, and child outcomes.
CONCLUSIONS: A 2-item ACE measure assessing childhood emotional abuse and household substance use may be useful in pediatric settings to identify mothers who may have experienced significant child adversity and inform development, testing, or provision of comprehensive family supports
A Case of Omeprazole-Associated Acute Interstitial Nephritis.
No full textAcute interstitial nephritis (AIN) is characterized by an inflammatory infiltrate of the interstitium of the kidney, typically causing a decline in kidney function. Drug-induced AIN (also called allergic AIN) is a type of AIN. Common drugs associated with AIN are antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitors (PPIs). A 59-year-old male with a history of recent laparoscopic robotic sleeve gastrectomy presented to the emergency department with five weeks of progressively worsening fatigue, nausea, and lightheadedness. Postoperatively, he was prescribed omeprazole 20 mg daily for gastric ulcer prophylaxis. His other home medications were amlodipine, atorvastatin, ursodiol, and budesonide-formoterol fumarate nebulizer. His physical examination was normal. Laboratory studies revealed elevated creatinine of 4.19 mg/dL from a baseline of 0.9 mg/dL two months ago and the presence of urine eosinophils. The etiology of this elevated creatinine was unclear, prompting CT-guided left renal biopsy. The biopsy showed diffuse interstitial inflammatory infiltration with numerous lymphocytes, a large number of neutrophils, and scattered eosinophils, consistent with the allergic type of AIN. Omeprazole was discontinued and the patient received a seven-day course of prednisone. Despite treatment, permanent renal damage occurred, and the patient\u27s new baseline creatinine was 2.3 mg/dL. AIN caused by PPIs should be considered in the differential diagnosis of acute kidney injury (AKI). AIN can be difficult to diagnose, presenting with nonspecific symptoms, such as oliguria, malaise, nausea, and vomiting. An accurate and timely diagnosis can help prevent and treat worsening renal failure
Cognitive Impairment in a 64-Year-Old Male: Dilemmas With Differential Diagnosis for Patients With Dementia.
No full textDementia is characterized by cognitive impairment and difficulties in executive functioning. It is an umbrella term for different subtypes that should be differentiated using a meticulous review of the patient\u27s history, physical exam, and work-up. Posing difficulties in diagnosis, findings at times may be inconclusive. We report a case of a depressed patient on hemodialysis for end-stage renal disease (ESRD) who presents with an acute agitated episode following a visual hallucination that he has been experiencing intermittently for six months, along with a three- to four-year history of cognitive impairments. Our differential diagnosis includes vascular dementia, dementia with Lewy bodies, pseudodementia, dialysis dementia, and early-onset Alzheimer\u27s. In this case, the findings of a normal mini-mental status exam (MMSE) and mental status exam (MSE) do not correlate with a working diagnosis. Due to persistent dilemmas in diagnosing early neurocognitive impairment, continued monitoring and re-assessment are necessitated for efficient management of psychiatric patients with cognitive decline