General Medicine

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    A Case of Treatment-Resistant Catamenial Disease: Insufficiency in Mainstay Treatment Options
    (2021) Faisal, Annum; Ratnani, Iqbal; Fatima, Sahar
    Introduction:Thoracic endometriosis syndrome (TES) is characterized by presence of ectopic endometrial tissue within the thoracic cavity, mainly the lung parenchyma and pleura. TES presents as catamenial pneumothorax (CP), catamenial hemothorax (CH), pulmonary nodules or hemoptysis. Hormonal therapy is considered first line treatment followed by operative thoracoscopy for removal of ectopic endometrial implants. Description:A 37-year-old G4P0040 female presented to the emergency department (ED) with worsening shortness of breath for 5 days. Associated symptoms included cough and right-sided chest pain localized to the lateral right mid-lower rib cage. Her past medical history is significant for hypertension, obesity, iron deficiency anemia, severe endometriosis and TES manifesting as recurrent, right sided pleural effusions, CPs and CHs requiring surgical treatment. Her current medications include leuprolide 11.25mg injection/30 days, norethindrone and ferrous sulfate daily. She appeared in distress with a BP of 166/102. Physical examination revealed tachypnea, accessory muscle usage, and respiratory distress. Chest x-ray and CT were consistent with findings for right tension hemothorax. CBC revealed Hb of 5.7g/dl. She was initially started on BiPAP and a tube thoracostomy was performed to place a chest tube. She was transfused 4 units pRBC and admitted to the ICU for further monitoring. Leuprolide was administered to prevent recurrence of hemothorax, and patient was discharged after resolution of symptoms confirmed by imaging. Conclusion:This unique case illustrates the insufficiency in surgical and hormonal mainstay treatments. Novel treatments and multidisciplinary team approach should be used in conjunction to effectively treat TES and prevent disease relapse.
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    Improving Fall Risk Assessment in a Rural Primary Care Clinic
    (2021) Fischer, Joseph; Qualls, James; Gibson, John; Hadley, Lesca
    Purpose: The Athens Family Medicine clinic serves many elderly patients with a history of falls. The practice does not have any screening tools that assess a patient's risk for future falls. This project aims to see if increasing or diversifying screening services will lead to an increased screening for future fall risks in adults ages 65 and older. Methods: In this project two established fall assessment tools, the 4-Stage Balance Test and a modified Chair Stand test, were used to assess the fall risk of the patients. A "high risk" or "moderate risk" or "no increased risk" determination was assigned based on the assessment findings. Results: There was a total of 52 patients seen in the clinic during the assessment period that were greater than or equal to 65 years old. 40 patients out of the 52 patients had their fall risk assessed; an improvement of 77% compared to prior to the start of the survey. Of the patients surveyed 15 (38%) were found to have no increased fall risk, 9 (22%) had a moderate fall risk, and 16 (40%) had a high fall risk. Conclusions: The project showed that the fall risk screening method used allowed for the majority of eligible patients to be screened during the screening period, showing an increase in screening services in patients ages 65 and older. The next step is to then have a more personalized patient conversation about fall risk and preventing falls for those at increased risk.
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    Beneficial effects of dietary methionine restriction in aging and disease
    (2021) Hatch, Jonathan; Yan, Liang-Jun
    Purpose: Methionine is an essential amino acid, meaning the body cannot synthesize it de novo. It must be obtained in the diet. Methionine plays a role in many biochemical processes but is most well-known for its role in DNA methylation. Although methionine is classified as an essential amino acid, recent studies have suggested that methionine excess may contribute to cancer, shortened lifespans, and other undesirable conditions. As such, investigators have hypothesized the benefits of methionine restriction. In this poster presentation, we will outline the various benefits of methionine restriction and the mechanism by which these benefits manifest. Methods: We searched PubMed with the keywords "methionine restriction," then analyzed articles pertaining to the usage of methionine restriction in disease prevention or treatment. Results: Methionine restriction has several benefits in animal and human models. These benefits include improved skeletal muscle and metabolic health, prolonged cognitive health, improved gut microbiome, reduced cancer growth, reduced reperfusion-induced myocardial injury, prolonged life expectancy, etc. Conclusion: As research into methionine restriction grows, methionine restricted diets may be adopted as a health maintenance strategy or as adjunctive targeted therapy for cancer treatment, treatment of cognitive disorders, disorders of metabolic health, etc.
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    Review: A 15-Year-Old Boy with Abdominal Pain, Hematochezia, and Anemia
    (2021) Nguyen, Ly; Modi, Saman; Huang, Clifton
    Background: Intussusception is the telescoping of part of the intestine into a more distal segment. It can cause abdominal pain and hematochezia. Intussusception typically presents between 6 and 36 months of age, however, 3-4% of cases can occur in children over 10 years of age and are usually associated with a pathologic lead point. Case information: A 15-year-old male presented to the emergency department with recurrent abdominal pain, diarrhea, and hematochezia. The painless rectal bleeding was first noted when the patient was 9 years old. At that time, abdominal and colonoscopy exams and stool cultures were normal. Laboratory studies were consistent with iron deficiency and β-thalassemia (low Hb, Hct, MCV, elevated TIBC, low ferritin, low serum iron, elevated HbA2), but were otherwise unremarkable. The abdominal pain began 8 weeks prior to admission. The patient has a history significant for iron-deficiency anemia, β-thalassemia minor, and allergic rhinitis with nasal polyps, and a family history of Peutz-Jeghers syndrome with nasal polyposis in two siblings. Prior to admission, an abdominal and pelvic CT scan revealed an ileocolonic intussusception without a distinct mass. A diagnostic procedure and surgical resection revealed a resolved intussusception with a dysplastic polyp as the lead point. No evidence of carcinoma was noted. Conclusions: This case highlights a unique presentation of intussusception with a pathologic lead point in an atypical age group.
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    Nasopleural Drainage of Empyema via Esophago-Pleural Fistula: A Novel Endoscopic Rescue Technique
    (2021) Salim, Hamza; Gajula, Prianka; Raza, Ali
    Background: Esophago-pleural fistulas (EPF) are rare entities. These can occur spontaneously or following surgical manipulation and can result in empyema formation. Treatment of empyema in this patient population is difficult, and a variety of techniques have been described. Here, we present a novel rescue technique for empyema management via endoscopy, when percutaneous and surgical techniques were not feasible. Case Information: A 90-year-old female presented with acute gastric volvulus requiring emergent partial gastrectomy and gastrostomy tube placement. Her clinical course was complicated by necrosis of the gastric cardia resulting in perforation and contamination of the mediastinum, requiring distal esophageal stump creation and multiple washouts. She was started on long term antimicrobial agents, with plans of maintaining esophageal discontinuity for six months prior to considering re-anastomosis. She was unstable for surgical drainage. An urgent transnasal endoscopy was performed using an ultra-slim scope. A small fistulous connection was noted between the distal esophageal stump and the left pleural cavity. She had a remarkable clinical improvement within 24 hours. A week after conservative management, a percutaneous drain placement was successfully performed. Conclusion: Empyema management ranges from conservative chest tube placement to aggressive surgical management. Endoscopic drainage is another option when percutaneous and surgical options are not possible. Our case demonstrates a novel rescue technique for the management of empyema in patients who already have an EPF and are not good candidates for conventional treatment. This technique can only be used short-term, as a bridge to definitive treatment.
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    A Presentation of a Rare Disorder: Hereditary Hemorrhagic Telangiectasia
    (2021) Kannan, Srijaa; Elmore, Stephanie; Smith, Michael
    Background: The purpose of this case study is to describe a presentation of a rare disorder called Hereditary Hemorrhagic Telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome. HHT is a rare autosomal dominant disorder that leads to malformed blood vessels in various body organs. Patients may be asymptomatic or have a wide range of clinical manifestations, thus making diagnosis of this condition difficult. Case Information: A 53-year-old Caucasian female with a history of intermittent epistaxis and multiple family members with HHT presented for a well woman visit and was found to be anemic with an H&H of 10.2 and 32.9 respectively. She was referred for a bidirectional endoscopy and was found to have multiple telangiectasias and polyps in her stomach and duodenum, some treated with argon plasma coagulation (APC). Since then, she has seen an HHT specialist biannually to rule out brain, heart, and lung involvement. She has had multiple colonoscopies and endoscopies with treatment of telangiectasias and arteriovenous malformations (AVMs) with APC since then. In 2018, she was treated for a left lower lung AVM. She requires parenteral iron therapy for her anemia every 3 months. Clinically, this patient presented with recurrent nosebleeds and anemia; however, her family history indicated a strong likelihood of HHT. Conclusion: Here I discuss the clinical features of this particular presentation of HHT as well as diagnostic criteria, management, and treatment with hopes of creating awareness in the scientific and medical community about how to diagnose and manage this rare condition.
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    Impact of Smoking on Opioid Use in Patients with Chronic Low Back Pain
    (2021) Chen, Easlie; Licciardone, John C.
    Purpose: Low back pain is a leading cause of disability and healthcare costs. The costs to society are estimated to be up to $100 billion per year in the United States. Current cigarette smoking has been linked to physical impairment and severe chronic pain and studies have shown that daily smoking increases the risk of low back pain in a dose-dependent fashion. However, few studies have closely examined smoking cessation as a possible intervention for chronic low back pain and reduction of opioid use. Methods: This cross-sectional study utilized data from the PRECISION Pain Research Registry to examine the quantity of opioids used daily by patients with chronic low back pain according to smoking status (either current of former smokers). Reported daily opioid use was converted into morphine milligram equivalents (MMEs) using guidelines established by the Centers for Disease control and Prevention. Multiple linear regression was used to study the relationship between smoking status and opioid MMEs, including adjustment for age and gender as potential confounders. Results: There were 923 patients (264 male, 659 female). A total of 164 patients reported specific opioid drug use for MME conversion. Smoking status was not significantly associated with opioid MMEs (standardized beta coefficient= 0.062; P= 0.55). Neither age nor gender were associated with opioid MMEs. Conclusion: These findings show that smoking status may have little effect on the opioid MMEs used to treat chronic low back pain. However, smoking cessation may still provide substantial health benefits and reduce cancer risks.
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    Telehealth Education for Geriatric Populations
    (2021) Wilder, Alyssa; Jenkins, Joseph; Gibson, John; Hadley, Lesca
    Introduction The acceptance and use of telehealth by geriatric patients are a result of many factors, including perceived value, attitude, perceived behavior control, and resistance. Technology anxiety is often a large contributor to the negative reception of telehealth by geriatric patients. Will educational handouts lead to increased usage of telehealth services among geriatric patients? Methods Geriatrics patients were informed about the clinics telehealth services and offered two educational handouts about the telehealth service. The handouts were provided to patients over the course of a month as well as given to the medical assistant for reference when speaking to patients over the phone. The electronic health record was used to record the number of visits. Results The table shows that the number of geriatric patients utilizing the telehealth services decreased from 10.3% to 8.7% during the course of the project. Upon further investigation, the number of telehealth visits for the entire clinic had decreased in the month of August. This appears to be correlated with the declining number of COVID-19 cases in Port Lavaca during this time frame. Conclusions Though the number of telehealth visits decreased, patients felt more informed about what to expect. The medical assistant used the handouts to determine which patients could use the service. For this project the intent was to provide physical handouts could refer to after an in-person visit. Moving forward, it would be beneficial to add the flyers or other instructions to the patient portal, for easy access to all patients.
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    Treatment Resistant Cellulitis Complicated by COVID-19: A Case Study
    (2021) Hall, Marshall; Lim, Henry; Surve, Sajid
    Cellulitis is a common dermatological condition that affects nearly 1 in every 20 individuals. This disease places a significant burden on both patients and the healthcare system. In this case report, we present a 70-year-old male who had a chief complaint of arm pain following a fall from ground level. The patient was diagnosed with cellulitis and placed on multiple empiric antibiotic treatments for several weeks without success in reducing symptoms. In conjunction with the patient's treatments, during the patient's stay, the patient developed acute dyspnea and tested positive for COVID-19 pneumonia. The patient was successfully treated for COVID-19 pneumonia and cellulitis through a combined effort of surgical and medical interventions. Recognizing treatment-resistant cellulitis and how COVID-19 may affect patient outcomes with dermatological conditions may help patients in the future when encountered with similar medical conditions.
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    The use of Telemedicine in primary care setting.
    (2021) Di Le, Minh
    Purpose: During the COVID-19 pandemic, telemedicine has become a valuable tool for physicians to remotely care for patients. Limited quality of care has been a major barrier of telemedicine. This project attempts to resolve this barrier through the use of home visit and Eko Stethoscope device as parts of telemedicine. The hypothesis is that there is an improvement in the number of use of telemedicine in the elderly patients, 65 of ages or more, with the intervention. Methods: In this project, the number of patients, who is 65 years old or more and use at least one time of telemedicine, is documented through 2 designated periods, the months of April and June. The April period is prior to intervention and June period is the after. Results: The data shows there is 17 telemedicine used out of 84 patients who are eligible for the service during the period of April. The data also shows 38 calls out of 111 patients during June period. This is a rise of 14% in the number of telemedicine use in one period. Conclusions The data shows positive result in number of telemedicine use with intervention. Many patients prefer the in-office visit because of its quality and trust physician-patient relationship. The intervention has improved the telemedicine quality of care, thus, motivates patient to use the service. The next step would be training more nurses who are capable of home visit. In addition, an in-office advertisement of telemedicine could be beneficial.
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    Eosinophilic Gastritis: An Imposter of Gastric Malignancy
    (2021) Salim, Hamza; Gajula, Prianka; Raza, Ali
    Introduction: Eosinophilic gastroenteritis (EGE) is an uncommon condition characterized by eosinophilic infiltration into the lining of the GI tract with a predilection for the stomach and proximal small bowel. Symptoms are non-specific, and the disease is known to take a chronic, relapsing/remitting course. To date, approximately 300 cases are described in literature. Here, we present a case of EGE closely mimicking gastric malignancy. Case Description: A 57-year-old male with a past medical history of DM II, HTN, GERD, and ESRD was admitted to the hospital with 30 lbs weight loss, postprandial fullness, and intractable vomiting. Physical examination showed moderate tenderness to deep palpation in the upper abdomen. CT scan revealed gastric outlet obstruction from an incidental finding of gastric antrum mass. An EGD was performed and revealed a malignant appearing mass in the pre-pyloric region of the stomach. Biopsies showed peptic duodenitis without any evidence of malignancy or H. Pylori infection. After a multi-disciplinary discussion, the decision was made to perform diagnostic laparoscopy, followed by gastrojejunostomy, for the gastric outlet obstruction. Discussion The pathogenesis of EGE is not well understood. Available evidence suggests that it is a hypersensitivity reaction. Histopathological analysis can confirm the diagnosis. Eosinophilic infiltration can involve any layer of the stomach (mucosa, muscularis propria, or serosa), which impacts clinical presentation. The treatment is primarily based on dietary modifications and systemic steroids. In conclusion, eosinophilic gastroenteritis should remain on the differential diagnosis in appropriate clinical cases where the diagnosis of cancer is unclear.
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    Ultrasound and Computerized Tomography in Managing Cellulitis: A Case Study
    (2021) Hall, Marshall; Hurley, Kara; Lim, Henry; Hatch, Jonathan; Surve, Sajid
    Cellulitis is a common cutaneous tissue infection that affects approximately 14.5 million people in the United States each year. This skin disease is usually a clinical diagnosis. With the development of technology, especially bedside ultrasound, imaging techniques have become integrated into the physical exam, diagnosis, and treatment of disease. Ultrasound and computerized tomography (CT) have become part of the management of cutaneous infections such as cellulitis, abscess, and necrotizing fasciitis. However, it is still not clear what role these imaging techniques hold. In this case report, we present a patient with cellulitis refractory to standard antibiotic regimens. Ultrasound and CT scan were performed which showed soft-tissue edema, phlegmon without drainable abscess. Without improvement, the patient underwent incision and drainage for possible abscess. Following the surgical procedures, the patient's symptoms resolved, and the patient was discharged. This case raises to the surface limitations that may still exist in imaging studies in the treatment of soft tissue infections. Further research, training, and perhaps technological development are necessary to assist in using imaging studies in the diagnosis of soft tissue infection.
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    Atypical Case of Post Cholecystectomy Patient with Chronic Diarrhea
    (2021) Bhachawat, Neal; Trinh, Jennifer
    Introduction: Diarrhea is a common gastrointestinal complaint. One culprit that may often go overlooked is bile induced diarrhea, which is often proceeded by a prior cholecystectomy. There are approximately 300,000cholecystectomies performed annually in the U.S. Up to 20%of people undergoing gallbladder surgery develop diarrhea however this normally stops soon after the surgery. Rarely, will it last for years. Cholestyramine, a bile acid binder, has proven to be an effective medication for bile acid induced diarrhea. Here we present a case of post cholecystectomy diarrhea.Case: 70-year-old female with a past medical history of mixed hyperlipidemia, diverticulitis, and post-cholecystectomy 38years ago developed episodes of diarrhea 29years post-procedure. She had been having ongoing episodes of diarrhea and abdominal pain with some episodes being so intense it caused her to lose consciousness and one resulted in a fractured femur. She reports losing up to 50pounds due to her diarrhea. Patient had tried Imodium and dicyclomine in the past with minor relief. Patient was started on Cholestyramine 4gram packets daily as needed which resolved her symptoms of diarrhea and abdominal pain. Conclusion: With cholecystectomies being common procedures in the U.S., it is important for physicians to keep bile acid induced diarrhea in the differential diagnosis when treating chronic diarrhea in patients. Our case presented unusually in the aspect that the patient's diarrhea episodes occurred years after her cholecystectomy with such a long duration spanning over years however like the majority of bile acid induced diarrhea, it responded well to cholestyramine.
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    Impact of Failed Back Surgery Syndrome on Health-Related Quality of Life
    (2021) Ly, Colin; Licciardone, John C.
    Purpose: Failed back surgery syndrome (FBSS) is a complex condition often described as persistent, residual, and neuropathic back pain of unknown origin following surgical intervention. The FBSS has proven to be troublesome for patients who experience symptoms and for clinicians tasked with providing effective treatment. As treatment options are still being explored, the progression of FBSS remains uncertain. The aim of this study was to determine the impact of FBSS on health-related quality of life. Methods: The PRECISION Pain Research Registry collects data from participants with chronic low back pain. Registry data were accessed for the Patient-Reported Outcomes Measurement Information System with 29 items (PROMIS-29) to compare a FBSS group with a control group without FBSS over 6 months. Results: A total of 30 participants had surgery following enrollment in the registry, including 14 in the FBSS group and 16 in the control group. The FBSS group reported worse outcomes than the control group at various intervals in the domains of depression (3 month mean: 61.0 vs 53.5, p=.04), sleep disturbance (3 month mean: 60.5 vs 54.9, p=0.04; 6 month: 61.5 vs 55.9, p=0.04), participation in social roles and activities (6 month mean: 37.4 vs 44.4, p=0.04), and pain interference with activities (3 month mean: 68.7 vs 61.5, p=0.01; 6 month: 68.5 vs 61.3, p=0.003). Conclusion: These findings provide insight on the longitudinal impact of FBSS on health-related quality of life, particularly depression, sleep disturbance, participation in social roles and activities, and pain interference with activities.
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    Development of COVID Respiratory Failure in a Patient with B-cell Lymphoma: A Case Report
    (2021) Oh, James; Lin, Annie; Gaudet, Ellen; Mejia, Daniel; Lukose, Emily; Agajyelleh, Yordanos; Ghebrekristos, Robel; Fowler, Grant; Martin, Joseph
    Background: Few studies examine the care for patients with hematological malignancy complicated by COVID-19 and sequelae of treatment. Case description: A 60 yo Caucasian male presented to the ED with chest discomfort and dyspnea. He had a history of HTN, HFrEF, T2DM, Stage 3 CKD, and morbid obesity. CXR revealed a large mediastinal mass, prompting biopsy. One week later, he returned to the ED with worsening dyspnea, chest pain and edema. CXR revealed a right pleural effusion and ECG showed AFib. He was diagnosed with acute-on-chronic respiratory failure with hypoxia; O2 nasal cannula, a thoracentesis, and antibiotics were started. The hospital course was complicated by multifactorial decompensation, tracheostomy placement, ICU admission for hospital-acquired pneumonia, septic shock, ATN, and AFib with RVR. Medical stabilization was achieved with combination therapy including antibiotics, supplemental O2, anti-arrhythmics, and antiplatelets. Mediastinal mass biopsy demonstrated low grade B-cell non-Hodgkin's lymphoma and cyclophosphamide, vincristine, with prednisone were initiated. However, severe hyperglycemia ensued requiring an insulin drip and chemotherapy discontinuation. He later developed persistent diarrhea and tested positive for recurrent C.difficile; vancomycin was started. On day 34, he was again transferred to the ICU for respiratory distress and tested positive for COVID-19. High flow O2, convalescent plasma, decadron and remdesivir were started. Eventually, the patient reached medical clearance on day 61 and was discharged with home health for rehabilitation and care. Conclusions: This case report presents the complex management required for patients with lymphoma and COVID-19.
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    A Case of Fever of Unknown Origin in the Setting of an Uncommon Exposure History & Nonspecific Symptoms
    (2021) Tomasco, Olivia; Yen, Kyle; Desai, Shivani
    Background: This case of fever of unknown origin with a broad differential illustrates the potential for multiple diseases to co-occur. Case Presentation: A 46-year-old female with a past medical history of malaria and TB presented with cough, shortness of breath, cyclical fever up to 103°F, diffuse rash, BRBPR, joint pain, multiple liver nodules, night sweats, and 20-lb weight loss following travel to Burma 6 months prior. Physical exam revealed tachycardia with irregular rhythm and a holosystolic murmur, suprapubic tenderness, 2+ lower extremity edema, and scattered small, round pruritic, erythematous rashes throughout all 4 extremities. Several fungal, parasitic, viral, and bacterial infectious etiologies were considered. Labs were significant for the following etiologies: infectious- EBV DNA and Brucellosis, Bartonella Hensleae, Coccidioides, and hepatitis A antibodies; Malignancy- protein gap IgG 2x upper limit; Autoimmune- anti-dsDNA 1:640, CRP 9.7, protein:creatinine ratio 62.1 with decreased C3/C4, positive Coombs, positive ANA, elevated ACE-I levels, and anti-smooth muscle/anti-cardiolipin/anti-RNP/myeloperoxidase antibodies, leading to a broad autoimmune differential. Imaging showed multiple liver nodules, and liver biopsy revealed extramedullary hematopoiesis and diagnosis of stage III High Grade B Cell Lymphoma with CD20+, BCL-2+, Myc+, Ki67>90% cytology. Despite this diagnosis, there was clear concurrent autoimmune manifestation and the treatment team suspected rheumatologic etiology over malignancy prior to diagnosis. Conclusion: This unusual case shows how autoimmune and malignant symptomatology can co-occur, generating a clinical picture that is persistently nonspecific. This case also raises the question of how autoimmune disease can trigger malignancy.
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    Dermatitis in Stringed Instrumentalists
    (2021) Lim, Henry; Hall, Marshall; Surve, Sajid
    Purpose: Up to 25% of stringed instrumentalists suffer from dermatological issues. Although occupational contact dermatitis alone has been estimated to cost the United States a billion dollars in economic burdens there has yet to be a focused review of dermatologic diseases in stringed instrumentalists. The objective of this systematic literature review is to identify dermatologic diseases of stringed musicians and summarize the available treatment options. Methods: A literature search of PubMed, Scopus, and Medline were conducted for articles relevant to skin diseases in musicians. Two investigators independently reviewed and narrowed the search to 32 articles based on the inclusion criteria of stringed instruments. Data was then abstracted with a focus on violin, viola, cello, bass, guitar, and harp. Results: Stringed instrumentalists commonly had the highest practice frequencies (p=0.0.31). This was associated with instrument-related skin disorders (p=0.022) such as callosities. Fiddler's Neck was the most commonly reported finding in violinists and violists. the most common cause of allergic contact dermatitis were nickel and colophony. Mastitis was reported in guitarists and finger trauma in harpists. Beginner status made individuals more susceptible to dermatologic issues. Data on cello and bass players is lacking. Non-pharmacological treatments included cessation of playing, proper posture, modified instrument set-ups, and physical barriers between the instrument and skin. Conclusions: Stringed instrumentalists have a unique set of dermatological conditions. Further research is needed to investigate the local musician populations, promote proper body mechanics, and develop instrument set-ups that do not cause dermatological conditions.
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    Efficacy of two escalated enoxaparin dosing regimens in achieving target anti-factor Xa levels for venous thromboembolism prophylaxis among obese, hospitalized patients
    (2021) Gibson, Caitlin
    Purpose: Due due pharmacokinetic and pharmacodynamic differences, standard enoxaparin dosing regimens may not provide adequate venous thromboembolism prophylaxis in obese hospitalized patients. Both weight-based and fixed-dose escalated prophylaxis regimens have been compared to routine dosing, but no studies have compared the escalated approaches to each other. The purpose of this study is to compare the effects of a weight-based and a fixed-dose escalated enoxaparin dosing regimen on attainment of target anti-Factor Xa levels, a surrogate marker for anticoagulation. Methods: In this prospective, multi-center trial, enoxaparin 0.5 mg/kg daily (weight-based) and enoxaparin 40 mg twice daily (fixed dose) were compared to determine if either resulted in more frequent attainment of anti-Factor Xa levels within the goal range of 0.2-0.5 IU/mL. Patients with a BMI ≥ 40 kg/m2 were included. Exclusion criteria were pregnancy, creatinine clearance < 30 mL/min, and trauma during the index stay. Results: Eighty patients were enrolled in a 1:1 fashion between the weight-based and fixed-dose groups. There were no difference in percent of patients achieving target anti-Factor Xa levels (72.5% in weight-based versus 70.0% in fixed-dose). More patients had sub-therapeutic levels than supra-therapeutic levels. No bleeding or thrombotic events were observed. Conclusions: Both weight-based and fixed-dose escalated enoxaparin dosing regimens appear effective in attaining target anti-Factor Xa levels, and no safety events occurred. Future studies should examine the clinical significance of this finding.
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    An Unusual Case of Pyogenic Liver Abscesses Presenting with Obstructive Jaundice
    (2021) Brewer, Shannon; Patel, Pranav; Kesiry, Riad
    Background: Pyogenic liver abscesses (PLA) are an uncommon, but potentially life-threatening infection that occur in 2.3 cases per 100,000 hospital admissions. Although the link between amebic liver abscesses and obstructive jaundice is well documented, there are few cases of PLA leading to this complication. Case Presentation: We present the case of a 48-year-old immunocompetent Hispanic male with multiple massive PLAs and obstructive jaundice on initial presentation. The results of liver-function tests were indicative of obstructive jaundice: total bilirubin 14.0 mg/dL, direct bilirubin 11.35 mg/dL, AST 388 U/L, ALT 271 U/L, alkaline phosphatase 480 µ/L. Abdominal CT and triple phase MRI revealed innumerable masses throughout the liver, with the largest measuring up to 12 cm x 16 cm. Blood cultures grew Streptococcus constellatus and liver abscess cultures grew S. intermedius – commensal organisms most often found in the GI tract. The patient was treated in the hospital for six weeks with antibiotic therapy and two percutaneous drains were placed in the largest abscesses. After clinical improvement and the resolution of the hyperbilirubinemia, the drains were removed and the patient was discharged home. Conclusion: This case illustrates a unique presentation of PLA and secondary obstructive jaundice. This complication of PLA is rare and, to our knowledge, there are only two other reported cases of a similar nature. This case highlights the importance of clinician awareness of other etiologies when evaluating patients with signs and symptoms of painful obstructive jaundice.
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    Assessing Fall Risk in the Geriatric Population
    (2021) Nance, Callie; Hadley, Lesca; Gibson, John; Daley, Rebecca
    Purpose Falls in the geriatric population are a major cause of morbidity and mortality, and identifying patients at risk of falling can guide physicians in their next steps of preventative management. We implemented the Gait Speed Test into pre-wellness visits at the clinic to identify patients at greater risk of falling. Methods We tested the patients Gait Speed by having them sit in a chair, stand up and walk down a hallway that is marked on the side. When the patient passed the start line we began timing, and we stopped the timer when they walked 4 meters and passed the finish line. The time in seconds was divided by 4 meters, giving the "Gait Speed' which was recorded. Results were discussed at the wellness exam the following week. Results We tested 15 individuals during the month of November, which was 100% of the patients seen for pre-wellness exams. Of these, 5 were considered increased risk for fall (>5s/4m). We were able to counsel the patient on their individual situation and give them exercises to increase their strength and gait speed. Conclusions The Gait Speed Test proved to be a fast and efficient way to determine which patients need more time spent on education about fall prevention. The clinic is going to repeat the test annually to follow along with patients as they increase in age. This will hopefully be able to catch any decline in function in patients before it gets severe.