General Medicine

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    (2019-03-05) Nguyen, David; Lee, Janet; Kichena, Sanketh; Nwachukwu, Dexter; Kway, Kristi; Lammers, Cara; Mirochnitchenko, Alissa; Fisher, Cara; Vo, Russell
    The kidneys are paired retroperitoneal organs that receive 20-25% of cardiac output and function in the filtration of blood and maintenance of homeostasis. In 70% of the population, each kidney is perfused by a single renal artery that branches off the abdominal aorta at L1-2 vertebrae. This leaves 30% of individuals with either accessory or aberrant renal arteries. (1) Accessory renal arteries are auxiliary to the main renal artery and both travel together through the hilum to perfuse the kidney. Meanwhile aberrant renal arteries are the sole source of kidney perfusion and typically branch directly from the abdominal aorta, entering the kidney outside of the hilum. (2) During a routine dissection of an 82-year-old female cadaver, a unilateral accessory renal artery was identified on the right side. This accessory artery was identified entering the inferior pole of the right kidney, branching directly from the anterolateral aspect of the abdominal aorta prior to its bifurcation. This accessory artery passed under the ureter and gonadal vessels. Accessory renal arteries and renal stenosis both produce similar symptoms and effects including systemic hypertension and hydronephrosis of the implicated kidney. (3) It is pertinent that these vascular anomalies be identified prior to medical procedures and surgeries such that adequate perfusion is maintained to prevent ischemia and kidney loss. Methods to identify accessory or aberrant renal arteries prior to surgical approaches, radiological interventions, and kidney transplants must be considered to prevent or mitigate the risk of complications.
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    Does Tobacco Use Differ by Metropolitan Status in Young Adults Ages 18-24?
    (2019-03-05) McMahon, Meghan; Morgan, Mary; O'Rourke, Valerie; Hartos, Jessica; Mankus, Katherine
    Purpose: Prior research shows conflicting findings for the relationship between tobacco use and metropolitan status. The purpose of this study is to determine whether tobacco use, including smoking and chewing tobacco, differs by metropolitan status among young adults ages 18-34 years old. Methods: This is a cross sectional analysis using 2016 BRFSS data for Florida (N=752), Michigan (N=182), New York (N=1112), and Washington (N=285). Ordered logistic regression was performed for combined state data to assess patterns in relationships between tobacco use and metropolitan status while controlling for demographic and socioeconomic factors, health status, and alcohol use. Results: Across states, most people reported no tobacco use (77%), about one-fifth reported only smoking tobacco (19%), and very few people reported only chewing tobacco (3%) or both chewing and smoking tobacco (2%). For metropolitan status, about one-quarter reported living in a urban area (26%) and about one-third reported living in a suburban area (39%) or rural area (34%). The results of the adjusted analysis indicated that each successive level of tobacco use was moderately related to living in a rural or suburban area and highly related to alcohol use. Conclusion: The results of this study indicate that each successive level of tobacco use is moderately related to living in a suburban and rural area, compared to living in an urban area, and to alcohol use in young adults ages 18-34 years old. For primary care providers, it is recommended to screen for tobacco and alcohol use in all young adults, especially those living in rural and suburban communities. Clinicians should provide education for substance use and resources for substance abuse programs as needed.
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    Supraclavicular Course of Left External Jugular Vein
    (2019-03-05) Laborde, Alfred; Fisher, Cara Ph.D; Blackwood, Taylor
    Background: The external jugular vein is formed by the union of posterior division of retromandibular vein and posterior auricular vein. Variant drainage of the venous system is common and has been discussed at length in anatomical journals and textbooks. However, variations in the drainage of the EJV is uncommon and as such there are limited reports of this specific anomaly. We report a rare case of unilateral left EJV drainage that coursed superficial to the left clavicle and then proceeded to drain into the left subclavian vein. Case Information: During routine dissection of a 70-year-old African-American male cadaver, a unilateral variation in the left external jugular vein (EJV) was noted. This variant EJV was found to descend superficial to the left clavicle and then proceeded to drain into the left subclavian vein. This is a deviation from the typical left EJV path which normally courses posterior and deep to the clavicle before draining into the left subclavian vein. This cadaver was an African-American male and as such the variant was not noted on pre-dissection integumentary exam. It is unclear whether he possessed knowledge of his anomaly. We were unable to obtain a full medical history for the cadaver; however, the cause of death was determined to be metastatic esophageal cancer. Conclusions: Anatomical variations of the EJV may pose certain health risks increase the complexity of various surgical procedures. The EJV is commonly used as an indicator for increased central venous pressure which can be used concordantly with other symptoms for the diagnosis of: right-sided heart failure, pulmonary hypertension, or tricuspid valve stenosis. Knowledge of the EJV and its common variants is important for clinicians and surgical specialists. Surgeons performing placement of pacemaker leads or implantable cardioverter defibrillators should be acutely aware of the EJV and its variants to reduce complications and improve patient outcomes. Patients and individuals possessing this EJV variation may be at increased risk of adverse outcomes in the event they were to fracture their clavicle. The clavicle is the most commonly fractured bone in the body and the middle third is the most fractured segment, where this variant was noted. Notching of the clavicle was noted where the EJV passed superficial to it. We postulate this may be due to increased pressure from its tortuous path as well as aberrant development due to the mobility of the clavicle.
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    A Comparison of Autism Spectrum Disorder (ASD) and a dual diagnosis of ASD + Developmental Coordination Disorder (DCD): A Case Study
    (2019-03-05) Kata, Karolina; Ganesh, Abhinaya; Mauk, Joyce; Bowman, Paul; Bailey, Laurie; Hamby, Tyler; Miller, Haylie; Chang, Shannon
    Background: Autism Spectrum Disorder (ASD), Developmental Coordination Disorder (DCD), and the dual diagnosis of ASD+DCD often have longer diagnostic trajectories given the complexity of their symptom profiles and associated difficulty with differential diagnosis. While first concerns may originate from parents, schools, or medical professionals, it may take years of waiting and assessments to reach a final diagnosis. Patients with co-occurring disorders can undergo a lengthier process as symptoms of 1 disorder may mask symptoms of another and create confusions within a care team. By understanding differences in the lines of service visited, symptoms, and parent concerns exist for patients with and without a dual diagnosis, we aim to identify potential targets for improvement in the diagnostic process. Case Information: Patient 1 (ASD+DCD) is a Caucasian female who presented with first concerns at 2 years and reached an ASD diagnosis at 6.25 years and a DCD diagnosis at 2 years. She was recommended and utilized speech therapy (ST), occupational therapy (OT), and physical therapy (PT). She had 9 visits with professionals and was assessed with the Ages and Stages Questionnaire (ASQ), Modified Checklist for Autism in Toddlers (M-CHAT), and the Autism Diagnostic Observation Schedule (ADOS). Patient 2 (ASD) is a Hispanic male with first concerns at 2 years and reached a final diagnosis at 6.5 years. While he was recommended ST, OT, and PT, he only utilized ST. He had 10 visits with professionals before reaching his diagnosis and was assessed with the ASQ, ADOS, and Social Communication Questionnaire (SCQ). Both were first seen by Pediatrics and were given a final diagnosis at Child Study Center. Conclusions: The age when a reliable diagnosis for ASD or DCD can be made is 1.5 and 5 years, respectively. However, the average age of diagnosis for ASD or DCD is 4.9 and 7.8 years. While patient 1 reached her DCD diagnosis at 2 years, both patients received their ASD diagnoses later than average. Several factors, such as the physician’s knowledge, clinical resources, sex, socioeconomic status, cultural and language barriers, and co-occurrence with ADHD may play a role in explaining this delay in diagnosis.
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    Assessing the Relation Between Weight Status and Sleep Status in 18-24 year old Females
    (2019-03-05) Benner, Ryan; Hartos, Jessica; Avila, Audrey; Herrera-Vazquez, Daisy
    Purpose: Obesity and sleep deprivation are prevalent within the United States. The purpose of this study was to determine whether weight status differs by sleep duration in 18-24 year old females. Methods: This sample includes women age 18-24 years old in Louisiana (N=100), Mississippi (N=118), and Texas (N=215). Descriptive statistics for each category by state and multiple logistic regression for each category by combined states were used for analysis using StataIC 15.1. Cross sectional analysis was performed using data obtained from the 2016 Behavioral Risk Factor Surveillance System conducted by the Center for Disease Control and Prevention. Results: Results indicated that approximately 40% of participants were either overweight or obese and approximately 20% had either long or short sleep duration. BMI was not significantly related to sleep duration in participants; however, physical activity was inversely related to weight status. Conclusion: The purpose of this study was to determine whether weight status differed by sleep duration in 18-24 year olds and it was found that there was no significant relation in this demographic. Results did, however, find that physical activity was highly related to weight status. Thus, in primary care practice, women age 18-24 with a higher BMI should be screened for their physical activity level. Those who do not participate in physical activity should be encouraged to participate, and possibly be referred to physical therapy to find appropriate exercises.
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    Depersonalization Disorder Following Medication Withdrawal
    (2019-03-05) Nguyen, Huan; Ripley, Zachary
    Background: Migraine headaches affects nearly 15% or roughly one billion people worldwide and are more common in women. Annually our country spends $78 billion on medical costs (both preventative and abortive) and lost wages. Symptoms can diminish quality of life and often last for several hours and even days. This case follows a 29-year-old Caucasian female with past medical history of migraine headaches that was admitted to the hospital for depersonalization secondary to Topamax withdrawals. Case information: A 29-year-old Caucasian female with a past medical history of migraine diagnosed many years ago who was admitted to the hospital with the complaint of confusion, unsteady gait, drowsiness and a feeling of being “disconnected from my body. Upon questioning, the patient takes propranolol 20 mg/day and Topamax 100 mg/day for migraine prophylaxis, but that she was forced to discontinue her Topamax 2 weeks prior due to change in her health insurance. She was diagnosed with depersonalization due to Topamax withdrawal. Topamax was restarted and her mentation returned to baseline. The patient was discharged from the hospital in stable condition. Conclusions: The goals of migraine preventive therapy include; reducing frequency, severity, and duration, improving responsiveness to treatment of acute attacks, improving function, and preventing progression of episodic to chronic occurrences. Treatment options should be individualized. In 2004, the Food and Drug Administration approved Topamax for the prevention of migraine in adult. Topamax is associated with various psychiatric and neurocognitive side effects and withdrawal symptoms secondary to abrupt discontinuation. Depersonalization is a period of feeling disconnected or detached from one’s body and thought while maintaining reality. The disorder belongs to a group of disorders called dissociative disorders. Depersonalization disorder can be precipitated by trauma, seizures, substance abuse, and medication withdrawal.
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    Nontypical presentation of scurvy in a previously healthy child without risk factors
    (2019-03-05) Perez, Maria; Destin, Giovanny
    Background: Scurvy has been reported to be the cause of death for about two million sailors between 1500 to 1700 AD. It is a disease caused by a prolonged deficiency in Vitamin C. It is an especially rare disease in children in developed countries. It often presents with irritability, failure to thrive, muscle/joint pain, and mucocutaneous features in infants and older children. A modern interest in the subject has risen due to an increase in reports of the disease in recent years. These cases are often of children with underlying medical conditions. Very few cases have been reported in otherwise healthy children. We report a rare case of scurvy in a previously healthy 3-year-old patient from a middle-class family who presented without mucosal bleeding or odd dietary habits. Case information: A previously healthy 3-year-old male presented to rheumatology clinic for evaluation of a limp. He had no prior hospitalizations or surgeries, and had no chronic medical problems. Mom reported a development of a nonspecific limp and a refusal to jump that began three months prior to presentation. Physical exam revealed full range of motion of all joints without swelling or tenderness. He had no epistaxis, gingival bleeding, or petechiae. Patient had extensive workup done to rule out malignancies and autoimmune disorders. Post-streptococcal glomerulonephritis, inflammatory arthropathy, axial spondyloarthropathy, leukemia, and chronic recurrent multifocal osteomyelitis were all considered during the workup for this patient due to the atypical patient presentation and nonspecific lab findings. The x-ray of the leg showed some stress fractures which raised concerns for possible vitamin deficiency. Labs showed low vitamin D levels and Vitamin C levels. A diagnosis of scurvy was made. Patient was placed on vitamin C and D supplements with rapid improvement in his condition. Conclusion: Scurvy can have a vague presentation and can often mimic other diseases such as malignancies, osteomyelitis, septic arthritis, rheumatologic conditions, and bleeding disorders. Because of its rarity in America, a nontypical case can make it very challenging to derive this diagnosis. Although cases of scurvy in patients without underlying medical conditions have been reported, the lack of gingival and skin findings and odd nutritional habits make this a very rare and unusual case.
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    Does Alcohol Use Increase the Risk for Obesity in Middle Aged Males?
    (2019-03-05) Amir, Rija; Alford, Hailey; Mohan, Sonya; Hartos, Jessica; Mathew, Merin
    Purpose: Alcohol misuse is a serious public health issue within the general population, but there are conflicting findings regarding its relationship to obesity. The purpose of this study was to determine whether alcohol use increases the risk for obesity in middle aged males in the general population. Methods: This cross sectional analysis used 2016 Behavioral Risk Factor Surveillance System (BRFSS) data for males ages 45 to 64 from Maine (N=1,667), North Dakota (N=1,060), South Carolina (N=1,669), and Wisconsin (N=998). Multiple logistic regression analyses conducted by state were utilized to examine the relationship between alcohol use and obesity while controlling for health related and demographic factors. Results: Across states, about one third of the sample was obese (35-38%) and about half to two thirds reported alcohol use (55-69%). Adjusted results indicated that weight status was inversely related to excessive alcohol use in three of four states. In addition, weight status was positively related to health conditions while inversely related to physical activity and tobacco use. Conclusions: Overall, alcohol use was inversely related to obesity in representative samples of 45-64 year old males. As there is likely low to moderate prevalence of both obesity and alcohol use in middle aged males, it is recommended that providers screen for obesity and alcohol use separately. Adequate nutrition should be evaluated in individuals with excessive alcohol use and referrals to addiction specialists should be made as needed. In addition, there may be moderate to high prevalence of smoking, physical activity, and more than two health conditions, and these may be moderately related to obesity. Providers should screen middle aged males for smoking and physical activity during all visits and specifically screen for health conditions in individuals with an obese weight status as these were directly related. In addition, encouragement and education should be provided on the benefits of exercise and referrals to a fitness instructor or dietician should be provided as needed.
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    Medial periarticular clavicle fracture repair using inverted distal clavicle plate and sternal fixation: a case study
    (2019-03-05) Barcak, Eric; Schultz, Matthew
    Background: Fractures of the medial third of the clavicle are rare, comprising less than 3% of all clavicle fractures. Available studies regarding medial clavicle fractures report frequent poor outcomes with traditionally-accepted nonoperative management, especially in cases of complete displacement. The medial periarticular clavicle fracture presents a distinct therapeutic challenge as the medial fragment may be too small for adequate screw fixation. We report a favorable outcome following surgical repair of a fully displaced medial periarticular clavicle fracture using an inverted distal clavicle plate and sternal fixation. Case information: A 29-year-old male presented with left shoulder pain and visible deformity along the left medial clavicle following a motor vehicle collision. Radiographs demonstrated a medial clavicle fracture with greater than 100% displacement and shortening of approximately 2 cm. The surgeon opted to perform open reduction and internal fixation due to significant displacement, shortening and cosmetic deformity. Upon reduction, it was determined that the medial fracture fragment was too small for adequate screw fixation. Instead, a distal clavicle plate normally used for the right shoulder was inverted, placed along the fracture site, and utilized to obtain multiple fixation points in the clavicle and sternum. Final imaging showed adequate fracture reduction and restoration of shoulder length. The patient was placed in a shoulder immobilizer and later discharged with instructions for physical therapy. His plate was removed 6 months after surgery. 8 months after surgery, the patient had full range of motion, strength comparable to the contralateral side, and returned to work without complication. Conclusions: This case describes the unique surgical repair of a medial periarticular clavicle fracture. Traditional management of this injury has been nonoperative, but available literature reports frequent unsatisfactory results, including symptomatic non-union and continued pain. Despite the severity of this case, the patient accomplished a full recovery with no complications. The findings of this case study support surgical intervention for displaced medial periarticular clavicle fractures and suggests that fixation to the sternum is appropriate in cases where the medial fracture fragment is too small for adequate screw fixation.
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    Retrospective analysis of the patients referred to the pediatric nephrology clinic at Cook Children's for evaluation of hypertension
    (2019-03-05) Brzezny, Jordan; Razzouk, Randa; Hamby, Tyler; Barrow, Julie; Pueringer, Matthew
    Background/Significant Aims/ Purpose: There is increasing evidence that hypertension and pre-hypertension are becoming more prevalent in the pediatric population and may contribute to premature atherosclerosis and the early development of cardiovascular disease and kidney disease. Higher blood pressure in childhood correlates with higher blood pressure in adulthood and the onset of hypertension in young adulthood. Despite the awareness of this increasing prevalence, pediatric hypertension is often unrecognized. The purpose of this study was to quantify the proportion of patients, referred to pediatric nephrology clinics for hypertension, who first had elevated blood pressure (EBP) ≥1 year prior to referral. Methods: This study was a single center retrospective chart review of patients aged 3-18 years and referred to the outpatient nephrology clinic at Cook Children's for the evaluation of hypertension, pre-hypertension, or EBP between July 1st 2016 and July 1st 2017. We excluded patients referred for diagnoses other than hypertension, patients previously seen by nephrology, and patients lacking appropriate documentation. We examined patients’ numbers of appointments with EBP (systolic and/or diastolic BP ≥95th percentile) prior to referral and the proportion of patients with ≥1 year between EBP and referral to nephrology. Additionally, we examined the source of the appointments with EBP, looking at the clinics from specialty versus primary care. Results: Of the 135 charts reviewed, 46 patients met inclusion criteria. Of these, only 5 (11%) were referred within the first year of documented EBP. The median time to referral in years was 3.54 for the population studied. The median number of visits prior to referral with documented EBP was 5, and 9 (20%) patients had ≥10 visits with EBP prior to referral. Cardiology and neurology had high and low rates of referral, respectively. Conclusion: Hypertension, considered a silent killer, is associated with premature atherosclerosis and early-onset vascular disease manifestations. Early diagnosis and management are crucial, and preventative measures to limit further development should be taken. For the present data, both the duration of time and number of visits from first EBP to referral to nephrology are concerning from a prevention standpoint. Further data acquisition and analysis are required but the awareness on this topic is essential.
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    Radiofrequency ablation (RFA) for the treatment of refractory gastric antral vascular ectasia: a systematic review and meta-analysis
    (2019-03-05) Komandur, Thrupthi; Shah, Usman; Turab, Mohammed; Patil, Pritvhi; Thosani, Nirav; Salim, Hamza
    Abstract Purpose: Gastric antral vascular ectasia (GAVE) is an uncommon cause of upper GI bleeding characterized by mucosal and submucosal vascular ectasia that commonly manifests as occult bleeding and chronic anemia. Argon Plasma Coagulation (APC) is frequently used as initial treatment for symptomatic GAVE. APC often requires multiple endoscopies and patients may not have full resolution of symptoms. Radiofrequency ablation (RFA) has emerged as a successful alternative. This study aims to conduct a systematic review and meta-analysis to evaluate the safety and efficacy of RFA in the treatment of GAVE. Methods: A comprehensive search of Pubmed, EMBASE, and Web of Science databases was performed, which focused on reviewing titles/abstracts, choosing relevant studies, and conducting necessary data extrapolation. This search was done on literature from 2008 up until June 2018 and studies with less than 5 patients were excluded. The measured parameters included improved hemoglobin levels, transfusion dependence, RFA treatment modality, adverse events, and number of RFA treatments. Results: We identified a total of 8 studies (N=128 patients) that used RFA for refractory GAVE. The HALO-90 or HALO-ULTRA ablation catheter (Covidien, GI Solutions, Sunnyvale, CA, USA), with a power capacity of 10-15 J/cm2, were the treatment modalities used. The overall clinical success rate for RFA in treatment for refractory GAVE was 68% (59%-76%, I2 value for heterogeneity 0). Average pre-treatment Hb value increased significantly from 8.03 (6.88-9.18, I2 94) to 10.38 (9.49-11.27, I2 77) after the RFA treatment. This difference was statistically significant: Standardize difference in mean 1.92 (0.50-3.35, p Conclusions: RFA can be an effective alternative in treatment for GAVE refractory to APC. While long-term data is limited, the evidence shows improved Hemoglobin levels and decreased transfusion dependence in treated patients. Further controlled trials are needed to compare the long-term safety, efficacy, and cost-effectiveness between RFA and APC in the treatment of GAVE and CRP.
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    A Previously Unreported Combination of Mutations and its Unexpected Outcome in a Patient with Type 1a Rickets: A Case Study
    (2019-03-05) Swanson, Larry MD; Sridhar, Swathi
    Background: Type 1a rickets is a rare autosomal recessive condition in which the enzyme 1-alpha-hydroxylase is not fully active. The result of this mutated enzyme is the inability to convert vitamin D from 25-hydroxyvitamin D to its active form, 1,25-dihydroxyvitamin D. This form of rickets classically presents with low 1,25 (OH)2 vitamin D, hypocalcemia, elevated parathyroid hormone (PTH), and distinct radiographic findings such as bowing of the legs and widening of the growth plates1,2. There are a number of mutations of the CYPB27B1 gene that are known to cause impaired enzymatic activity. Individuals with homozygous and compound heterozygous mutations have been described. Correlations between specific mutations and varying degrees of enzymatic impairment have been made. Case Information: A 14-year-old male was referred to endocrinology after experiencing a pathologic femur fracture. His mobility was severely limited secondary to bowing of his legs and pain with weight bearing. He was 48.4” tall (z = -4.8). He had pronounced bowing of his extremities and wide wrists. Labwork revealed the following: serum Ca 6.3 mg/dL, serum Phos 4.4 mg/dL, PTH 265 pg/mL, 25-hydroxyvitamin D 29 ng/mL, and 1,25 (OH)2 vitamin D 33 pg/mL (19-83). He was then admitted to the inpatient endocrine service and treated with oral and IV calcium, ergocaliciferol, and calcitriol. Later, whole exome sequencing revealed compound heterozygous variants of the CYP27B1 gene: c1319_1325dupCCCACCC (p.P443fs) and c.1226C [greater than] T (p.T409l). The normal level of 1,25-(OH)2 vitamin D concentration was surprising, given that both of the mutations in this patient were previously believed to cause complete enzymatic inactivity. The P443fs variant has been found in combination with other mutations, resulting in phenotypic variability3. The T409l variant appears less frequently in the literature, but is also believed to cause complete enzymatic inactivity. The P443fs and T409l mutations, however, have not previously been described together. Conclusion: The normal 1,25 (OH)2 vitamin D concentration in this patient suggests that at least one of these two CYP27B1 variants does not universally cause complete enzymatic inactivity, which is a departure from the current evidence base. Further use of genetic testing in Type 1a Rickets may result in improved understanding of the connection between genotype and phenotype in this rare condition.
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    Bilateral Pulmonary Embolism as Initial Presentation of Invasive Adenocarcinoma of the Colon
    (2019-03-05) Burgess, Lauren; Salas, Gabriel; Subramaniam, Smita; Gnasigamany, Jason
    Background:Venous thromboembolism (VTE) is a frequently encountered diagnosis, and there are numerous genetic and acquired risk factors for this affliction. Thromboembolism due to hypercoagulability in cancer is well-known, and it is a common cause of death in these patients. Thrombosis represents the second most frequent cause of death in cancer patients, and cancer accounts for almost 20% of all VTE events. The highest incidence of VTE is in mucin-producing pancreatic, lung, and ovarian carcinomas. Although pulmonary embolism (PE) incidence in colon cancer is not as high as other malignancies, VTE may reflect more aggressive cancer and is a predictor of death within one year of diagnosis. In this report, we present a patient with syncope and anemia, a common scenario which uncovered the diagnosis of PE and subsequently colon adenocarcinoma. Case Information:A 43-year-old male presented with syncope, and had experienced fatigue, chest pain and dyspnea for a week. Aside from hypertension, there is no significant history. Vitals showed tachycardia, tachypnea and decreased oxygen saturation. Physical exam was unremarkable, and labs revealed severe microcytic anemia and a BNP of 2,285 ( Conclusions:Cancer patients treated with anticoagulation have lower mortality, and guidelines recommend low-molecular-weight heparin (LMWH) for cancer-associated thromboembolism. However, new evidence suggests that direct oral anticoagulants (DOACs) are reasonable alternatives. For our patient, we decided to give Apixaban for its ease of use over LMWH, and recent approval of DOACs is increasing the confidence regarding their safety. The unique aspects of this case involving anemia and bleeding risk with the need for anticoagulation raise the awareness of the varied co-existing disorders that can impact the diagnosis and treatment of cancer patients.
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    Gender Differences in Chronic Low Back Pain Perception and Chosen Treatment Modalities
    (2019-03-05) Licciardone, John C.; Hammack, Lilly
    Background: Differences in perceptions and reported levels of pain intensity between men and women are poorly understood. Current evidence indicates an increased prevalence of chronic pain syndromes in women. However, relationships among gender, reported pain and related clinical outcomes, and pain treatment modalities have not been adequately studied. Purpose: The purpose of this research was to examine differences between men and women in pain intensity and its clinical impact, including differences in pain treatment modalities according to gender. Hypotheses: Women are more likely to report higher levels of pain intensity than men, and thereby also experience greater back-related disability and poorer quality of life. Women are more likely to use non-pharmacological approaches to manage pain in addition to, or in place of, opioids and nonsteroidal anti-inflammatory agents (NSAIDs). Methods: 452 patients aged 21 to 79 years with chronic low back pain were selected from the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION Pain Research Registry). Patient data at registry enrollment included sociodemographic and clinical characteristics, including pharmacological and non-pharmacological treatments used. Clinical status measures included a numerical rating scale for pain intensity (NRS), the Roland-Morris Disability Questionnaire (RMDQ), and quality of life deficits on the SPADE cluster (sleep disturbance, pain interference with activities, anxiety, depression, and low energy/fatigue). Contingency table methods and t-tests were used for analysis. Results: No statistically significant differences between genders with respect to NRS, RMDQ, and SPADE scores (p= 0.75, 0.27, and 0.23, respectively). A statistically significant relationship was observed between females and NSAID usage (p=0.03). However, no significant relationships were observed between gender and use of opioids or other non-pharmacological pain treatment modalities. Conclusions: Women were not more likely to report higher levels of pain, nor to report higher levels of pain-related disability or quality of life deficits. Women were more likely than men to use NSAIDs for their low back pain, but were not more likely to use opioid therapy or other non-pharmacological pain treatment modalities. Further research is needed to determine what other factors might play into women using NSAIDs more frequently.
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    Rectal perforation injury following high pressure water penetrating trauma: a case report
    (2019-03-05) Dillard, Robert; Kim, Elizabeth MD
    Abstract Background: Injuries to the rectum and perineal regions secondary to jet-ski and watercraft vessels are uncommon and unique, presenting a potentially complicated clinical scenario. While this injury pattern has been described before, severity, intervention and hospital course has varied among cases¹. Additional descriptions of these trauma types may be necessary to establish a standardized approach to the treatment of such injuries. Case information: The patient is a 16-year-old female with a past medical history of asthma that was a transfer from an outside medical facility. She presented following a trauma sustained after falling off a jet-ski. She reports being the third individual seated at the rear of the watercraft when the wake created by another vessel caused her to be thrown from the back. She states that she fell backwards onto the water being propelled from the back of the jet-ski and felt a sudden sharp burst of pain. She described her pain as moderate, located in the lower pelvis, radiating to her abdomen and back. The patient was brought to an outside hospital where she was found to have several small lacerations in the perianal region and rectal bleeding. On presentation to our institution approximately 8 hours after injury, she was neurologically intact (GCS 15), blood pressure 128/73, heart rate 120s, febrile 101.5F. Primary trauma survey was intact and the secondary survey revealed two small superficial lacerations at the anterior and posterior aspects of her anus, good sphincter tone, and malodorous dark rectal discharge mixed with blood. Abdominal examination revealed tenderness to palpation over the lower quadrants with guarding. Given the above findings, the patient was taken to the operating room for surgical evaluation and treatment. She was placed in the lithotomy position and proctoscopy performed. Visualization was difficult secondary to a large amount of dark, watery anal discharge but a large posterior rectal defect was appreciated on examination, about 6 cm from the anal verge. The surgical team proceeded to perform a diagnostic laparoscopy which was converted to an exploratory laparotomy after confirmation of intra-abdominal extension of contaminated water. Upon evaluation of the pelvis, the presacral space was found to be dissected with underlying exposure of the sacrum and rupture of the retroperitoneum near the bifurcation of the aorta. Additionally, large amounts of contaminated water were found throughout the bilateral paracolic gutters and between the small bowel loops. The rectum also demonstrated a 5 cm anterior vertical serosal tear. Surgical intervention involved stapling and transection of the rectosigmoid junction leaving ~15cm rectal stump and providing colonic diversion, rectal serosal repair, abdominal washout, drain placement within the presacral space exiting the right lower abdominal quadrant, and temporary abdominal closure. She remained intubated and was admitted to the trauma surgical intensive care unit. Planned takeback occurred 24 hours later. Proctoscopy was repeated with better visualization. The rectal defect was found to involve approximately 40% of the posterior circumference. The celiotomy was reopened and explored, no residual fluid collections were noted, all observed bowel was viable. The abdominal cavity and presacral space were irrigated once more and a second drain placed exiting the left lower abdominal quadrant. An end sigmoid colostomy was created and the abdominal fascia closed. A subcutaneous wound vacuum device was placed. The patient was extubated and returned to the ICU. Postoperative care included empiric broad spectrum antibiotic coverage for freshwater organisms. The initial regimen included Levaquin and Flagyl for anaerobic/gram-negative bowel flora contamination and Clindamycin with Fluconazole for possible endemic organisms present within the water contamination. This antibiotic combination was continued from the time of admission until 24 hours after final closure when Clindamycin and Flagyl were discontinued. Intraoperative cultures resulted negative and all antibiotics were discontinued after a total of nine days. On postoperative day fourteen, the patient began to experience intermittent fevers with moderately elevated leukocytosis. Computed tomography of the pelvis showed an abscess collection present within the presacral space. Interventional radiology was consulted for percutaneous drain placement. Drain cultures were taken and yielded a specimen positive for multi-drug resistant Staph epidermidis, Streptococcus viridans, and Gardnerella vaginalis, for which she was treated with Cefepime, Flagyl, and Vancomycin. On postoperative day nineteen, the patient continued to experience intermittent fevers. Repeat imaging of the pelvis showed an abscess collection present despite the surgical drains in place. The patient was returned to the operating room for surgical drainage. She was placed in the lithotomy position and proctoscopy was performed with the rectal defect irrigated with two liters normal saline to drain the presacral abscess. A large penrose drain was left in place through the defect. Antibiotic coverage was continued until the patient’s discharge to an ancillary facility. Conclusions: The above case presents several points of interest. Rectal injuries and perforations from high pressure water exposure is an uncommonly reported incident and the subsequent management less defined. The initial approach to such an injury first requires recognition of the potential sequelae of the mechanism and appropriate evaluation of the patient’s clinical status. A prior case report acknowledged the benefits of a multimodal assessment with the use of imaging and non-operative interventions as warranted in hemodynamically stable patients in whom peritonitis was not present¹. For more severe cases, where further intra-abdominal involvement is suspected, imaging becomes more selected as surgical intervention will most likely be warranted. Close examination of the entire perineal region should be performed, including both the genital and anal areas. Proctoscopy is beneficial in identifying the proximity and circumference extent of the rectal injury, which may be difficult to assess during laparotomy, especially if present on the posterior/retroperitoneal surface. Frequently, however, frank watery discharge is present in excess and impedes visualization of the injury. When intra-abdominal extension is likely, laparoscopy/laparotomy is indicated for presacral drainage. In the case above, exposure of this area showed a large dead space created by the pressure injury, denoting a difficult area to control surgically and subsequently abscesses occurred despite multiple drains in place. As commonly documented in previously reported cases, an end diverting colostomy was created. After adequate drainage and diversion, the rectal injury is allow to heal without attempts at primary closure². A colorectal consultation may be beneficial, both at the onset of treatment and for further long-term followup. Empiric antibiotic coverage should be initiated to include specimens both present within the gastrointestinal tract and water source. Freshwater exposure includes Aeromonas, Edwardsiella, Erysipelothrix, Vibrio, and Mycobacterium species. A third or fourth generation cephalosporin, fluoroquinolone or clindamycin is appropriate for gram-negative coverage in addition to Vancomycin for gram-positive organisms. Metronidazole should be added for anaerobic coverage. Antibiotics can then be tailored once cultures have speciated³⁻⁴. Multidisciplinary care is advantageous in a unique case such as this and should follow the tenants of safe surgical diversion and drainage. Awareness of rectal injuries associated with watercraft vessels can aid in prompt identification and effective management. References Wyatt SN, Lockhart ME, Richter HE. Hydrostatic injury surgical planning. J Low Genit Tract Dis. 2015;19(2):e40-2. Gill, Richdeep S. et al. Hydrostatic rectosigmoid perforation: a rare personal watercraft injury, Journal of Pediatric Surgery, Volume 46, Issue 2, 402-404 Collier DN. Cutaneous infections from coastal and marine bacteria. Dermatol Ther 2002; 15:1. Noonburg, GE., Management of extremity trauma and related infections occurring in the aquatic environment. J Am Acad Ortho Surg., 2005 July-Aug;13(4):243-53
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    Rapidly Progressive Glomerulonephritis in an Otherwise Healthy Elderly Female
    (2019-03-05) Vu, Michael
    Background: Rapidly progressive glomerulonephritis describes a clinical syndrome that is characterized by a rapid loss of renal function in a relatively short period of time, ranging from days to months, that can ultimately lead to complete renal failure. The histologic hallmark of RPGN presents as proliferating crescents found within the kidney glomeruli which are induced by inflammatory cytokines and made of fibrin, cellular components, and differentiating antibodies. RPGN can present as a wide variety of symptoms associated with severe acute kidney injury such as uremia, gross hematuria, edema, fatigue, hypertension, and oliguria. Case Information: A 73-year-old female with a past medical history of well-controlled hypertension, hyperlipidemia, and type 2 diabetes mellitus along with chronic kidney disease stage 3 and chronic heart failure with preserved ejection fraction (50-55%) presented after a ground level fall at home. Traumatic injury or loss of consciousness could not be ruled out. Reported symptoms included shortness of breath, oliguria, and generalized weakness. With extensive workup and evaluation, patient exhibited markedly elevated creatinine from baseline, elevated inflammatory markers, fractional sodium excretion indicative of intra-renal disease, crescent formation on renal biopsy, and blood work positive for cytoplasmic anti-neutrophil cytoplasmic and myeloperoxidase antibodies. Treatment was initiated with aggressive steroid therapy, therapeutic plasmapheresis, and immunosuppressant therapy with Rituximab. Conclusions: If left untreated, RPGN can be a severe syndrome that can lead to end-stage renal failure, subsequent infection, and/or massive pulmonary hemorrhage. Hallmark of treatment is centered around high-dose steroid therapy and immunosuppression. Expectations of said treatment are focused on decreasing the degree of irreversible renal injury rather than complete remission. Outcomes remain largely dependent of time of diagnosis or clinical suspicion. Even though clear diagnostic findings are outlined along with treatment guidelines, a large deal remains to be discovered regarding definitive pharmacologic options. Treatment plans should include extension discussion with the patient and family remembers regarding quality of life, side-effects and burden of aggressive immunosuppressive therapy, and degree of irreversible renal damage.
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    Skeletal dysplasia and growth failure in congenital hypothyroidism due to a novel form generalized thyroid hormone resistance.
    (2019-03-05) Gongidi, Preetam; Wilson, Don; Hamilton, Luke; Steelman, Joel; Mitts, Matthew
    Background: Thyroid hormone exerts systemic actions mediated by its specific receptors. These actions encompass a wide array of functions, including energy homeostasis, skeletal growth, neural development, cardiac function, and gastrointestinal function. There are two thyroid hormone receptors, thyroid hormone receptor alpha (THRA) and thyroid hormone receptor beta (THRB) which are encoded by genes on two different chromosomes and with differing tissue distributions. Only mutations in THRB were known until recently with a reported incidence of 1 in ~40,000. Mutations in thyroid receptor THRA have recently been discovered and are is exceedingly rare, with 14 cases documented in the past five years. We report a case of a patient with generalized thyroid hormone resistance due to THRA mutation. Clinical Case: Patient was born to non-consanguineous parents at term and was appropriate for gestational age. Prenatal ultrasound was suspect for shortened long bones. Congenital heart disease (ASD and VSD) were detected at birth. Genetics consultation confirmed ultrasound concern with finding of mild rhizomelia. Patient had coarse facial features, macroglossia, and dysmorphic appearance. Initial genetics work-up showed normal chromosomes, normal newborn screening, and normal metabolic studies. Genetics was concerned for possible mucopolysaccharidosis, but further testing ordered did not show definite results of this diagnosis. Patient exhibited post-natal growth failure after birth with length well below 3rdpercentile by 18 months old. Delayed developmental milestones (verbal [greater than] motor) was seen. Thyroid function tests between birth and 11 months old were normal. Thyroid function testing at 11 months old were suspect for central hypothyroidism with free T4 0.6 ng/dl (0.6-1.3) and TSH 1.07 uIU/ml (0.71-5.81). Cranial MRI scan showed no abnormalities in hypothalamic-pituitary area. Levothyroxine 37.5 mcg was started, and thyroid function tests normalized. However, little change was seen clinically in patient’s growth pattern or development. Whole exome screening performed in 2013 demonstrated a heterozygous mutation in the THRA gene consistent with generalized thyroid hormone resistance from this mutation. Liothyronine treatment was added in 2014. Growth has continued to be extremely slow with current height standard deviation score of -4.2. Patient is developmentally delayed and non-verbal. Conclusions: A constellation of findings including post-natal growth failure, skeletal findings, and prominent verbal developmental delays are seen in generalized thyroid hormone resistance due to THRA mutation. The subtle presentation of this condition is different from congenital hypothyroidism or generalized thyroid hormone resistance due to THRB mutation. This case will help geneticists and endocrinologist recognize this condition.
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    Is Sleep Duration Related to Weight Status in Young Adults With Asthma?
    (2019-03-05) Esbayhat, Leanne; Graham, Dylan; Ruggiano, April; Hartos, Jessica; Parupia, Iqra
    Purpose. Sleep duration and weight status have been found to be related in prior studies in healthy populations; however, there are conflicting findings and limited research for young adults with asthma. The purpose of this study was to determine whether sleep duration is related to weight status in young adults with asthma. Methods. This cross-sectional analysis used 2016 data from the BRFSS for males (N=116) and females (N=212) ages 18-34 years with asthma in Alaska, Arizona, Arkansas, and Maine. The relationship between sleep duration and weight status was assessed by gender with combined state data using multiple logistic regression analysis while controlling for mental and physical health, physical activity, alcohol and tobacco use, ethnicity, age, income level, educational level, employment status, and state. Results. Across states, the majority of male and female participants with asthma reported being overweight or obese (57-59%) and a relatively low amount reported averaging more than 8 hours of sleep (7-11%). The results of adjusted analysis indicated that male participants who averaged more than 8 hours of sleep per night were less likely to be overweight or obese compared to those who averaged 6-8 hours per night. Weight status was not related to sleep in females. Conclusions. After assessing the relationship between sleep duration and weight status in young adults with asthma, results indicated that males who slept more than 8 hours per night were less likely to be overweight or obese. Primary care clinicians might expect to find a moderate prevalence of obesity and a low prevalence of a sleep duration of more than 8 hours in males and females with asthma. If young adult males with asthma have symptoms of either obesity or short sleep duration, providers should screen for both and provide education and treatment. There was no significant relationship in females.
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    Risk factors for QTc Interval Prolongation in the Ambulatory Setting
    (2019-03-05) Elrod, Shara; Lopez, Gladys
    Purpose: Prolongation of the QT interval through acquired characteristics or congenital abnormalities can lead to Torsades de Pointes (TdP), a life-threatening arrhythmia. A number of clinical characteristics and medications have an association with acquired QT prolongation, with some having a higher risk than others. The objective of our study was to identify patients seen by University of North Texas Health Science Center (UNTHSC) providers at risk for QT interval prolongation and to describe the most common QT-prolonging clinical characteristics and medications in this patient population. Methods: A retrospective analysis for those aged 18 to 99 years seen by UNTHSC providers between July 1st through October 1st, 2018 was conducted. Records were obtained for: diagnoses, laboratory values, vitals, most recent medication list, and presence of completed electrocardiogram (EKG). Clinical characteristics were filtered for those with high quality evidence for clinical association with increased QT interval. Medications were classified, based on published evidence of prolonging the QT interval via, as: ‘Known Risk of TdP’, ‘Possible Risk of TdP’, and ‘Conditional Risk of TdP’. Collected data were analyzed using descriptive statistics. Results: A total of 11,759 patients were identified for inclusion. Patients were mostly female and White with 15% of patients identifying themselves as Hispanic or Latino. The median age was 60 years, and 40% were at least 65 years of age. The median BMI was 29.44 kg/m2. Twenty-one patients had a calcium level below 8.5 mg/dL; with 28 having a potassium level below 3.5 mmol/L. Twenty-five patients had an eGFR (if African American) below 30 mL/min/1.73m2, and 35 patients had an eGFR (if non-African American) below 30 mL/min/1.73m2. A total of 1,359 patients had a documented EKG. The five most commonly prescribed medications in the ‘Known Risk of TdP’ category were escitalopram, donepezil, citalopram, ondansetron, and fluconazole. Conclusions: Our findings highlight the importance of reviewing both medications, some of which only pose a risk under certain conditions, and clinical characteristics. Future studies can aid providers in more easily identifying patients at risk for life-threatening arrhythmias.
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    Is Sleep Related to Mental Health in Middle Aged Males & Females?
    (2019-03-05) Roman, Madison; Thornhill, Kayla; Callahan, Jamie; Hartos, Jessica; Reynolds, Julia; Rozell, Laura
    Purpose: Studies have related sleep disturbances and mental health disorders, but not sleep duration and current general mental health. Therefore, this study aims to determine whether sleep duration is related to current general mental health in middle aged males and females in the general population. Methods: This cross-sectional analysis used 2016 BRFSS data for males and females ages 35 to 54 in Alabama (N=2000), Arkansas (N=1118), Kentucky (N=2890), Oregon (N=1578), and West Virginia (N=2087). Ordered logistic regression analysis was conducted separately by state and gender to assess the relationship between sleep duration and mental health while controlling for health-related and demographic factors. Results: About one-third to one-half of male and female participants reported low to moderate mental health (31-51%) and less than one-fourth reported short sleep duration (11-21%). Mental health was significantly related to sleep and health conditions for both genders as well as to smoking status, alcohol use, and physical activity for females. Conclusion: Mental health was related to sleep duration and health conditions for both genders. Therefore, clinicians should screen for mental health status, sleep issues, and health conditions if symptoms of any present. For females, mental health is also related to smoking status, alcohol use, and physical activity, so clinicians should screen for all if symptoms of any present. Clinicians should address each of these factors concurrently with mental health.