Atypical Presentation and Diagnosis of Multiple Myeloma: A Case Report

Chronic neck pain is a common, seemingly benign condition that typically does not warrant an urgent workup, in contrast to acute onset neck pain. Vertebral artery dissection (VAD) is a relatively rare presentation of acute onset neck pain and often presents in the context of blunt trauma. Due to the risk of subsequent clot formation and stroke, patients who present with symptoms suggestive of VAD must be promptly screened, most often first with computed tomography angiography (CTA) followed by magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) for further evaluation. We present a case of a 69-year-old male with a history of chronic neck pain who was seen in the emergency department due to acute, severe neck pain with initial CTA imaging that suggested left VAD. However, follow-up MRI of his cervical spine identified that what seemed to be a left VAD was instead multiple myeloma. This case demonstrates the utility of using multiple imaging modalities, including CT, CTA, MRI, and MRA, in diagnosing an atypical presentation of multiple myeloma and the consequences of physician implicit biases that are often involved when treating patients with chronic pain.

Site Readiness Framework to Improve Health System Preparedness for a Potential New Alzheimer’s Disease Treatment Paradigm

New therapies that address the underlying pathophysiology of Alzheimer’s Disease (AD), coupled with the growth of the AD population, will transform the AD care pathway and present significant challenges to health systems. We explored real-world challenges health systems may face in delivering potential new AD therapies with diverse stakeholders. Key challenges in care included integrating primary care providers into assessment and management, availability of memory care specialists, understanding payment and coverage issues and training mid-level providers to help coordinate care and serve as a shared resource across the system. This input informed a novel Site Readiness Framework for AD, comprising self-assessment exercises to identify health system capabilities and gaps and a framework of core strategies and responsive tools to help prepare to integrate new AD therapies. These resources may help health systems improve readiness to modify care pathways to integrate new therapies for AD.

Assessment of Emergency Medicine Resident Performance in a Pediatric In Situ Simulation Using Multi-Source Feedback

Introduction

Multi-source feedback (MSF) is an evaluation method mandated by the Accreditation Council for Graduate Medical Education (ACGME). The Queen’s Simulation Assessment Tool (QSAT) has been validated as being able to distinguish between resident performances in a simulation setting. The QSAT has also been demonstrated to have excellent MSF agreement when used in an adult simulation performed in a simulation lab. Using the QSAT, this study sought to determine the degree of agreement of MSF in a single pediatric (Peds) simulation case conducted in situ in a Peds emergency department (ED).

Methods

This Institutional Review Board-approved study was conducted in a four-year emergency medicine residency. A Peds resuscitation case was developed with specific behavioral anchors on the QSAT, which uses a 1-5 scale in each of five categories: Primary Assessment, Diagnostic Actions, Therapeutic Actions, Communication, and Overall Assessment. Data was gathered from six participants for each simulation. The lead resident self-evaluated and received MSF from a junior peer resident, a fixed Peds ED nurse, a random ED nurse, and two faculty (one fixed, the other from a dyad). The agreement was calculated with intraclass correlation coefficients (ICC).

Results

The simulation was performed on 35 separate days over two academic years. A total of 106 MSF participants were enrolled. Enrollees included three faculty members, 35 team leaders, 34 peers, 33 ED registered nurses (RN), and one Peds RN; 50% of the enrollees were female (n=53). Mean QSAT scores ranged from 20.7 to 23.4. A fair agreement was demonstrated via ICC; there was no statistically significant difference between sources of MSF. Removing self-evaluation led to the highest ICC. ICC for any single or grouped non-faculty source of MSF was poor.

Conclusion

Using the QSAT, the findings from this single-site cohort suggest that faculty must be included in MSF. Self-evaluation appears to be of limited value in MSF with the QSAT. The degree of MSF agreement as gathered by the QSAT was lower in this cohort than previously reported for adult simulation cases performed in the simulation lab. This may be due to either the pediatric nature of the case, the location of the simulation, or both.

A Modified Delphi Study to Prioritize Content for a Simulation-based Pediatric Curriculum for Emergency Medicine Residency Training Programs

OBJECTIVES

Pediatric training is an essential component of emergency medicine (EM) residency. The heterogeneity of pediatric experiences poses a significant challenge to training programs. A national simulation curriculum can assist in providing a standardized foundation of pediatric training experience to all EM trainees. Previously, a consensus-derived set of content for a pediatric curriculum for EM was published. This study aimed to prioritize that content to establish a pediatric simulation-based curriculum for all EM residency programs.

METHODS

Seventy-three participants were recruited to participate in a three-round modified Delphi project from 10 stakeholder organizations. In round 1, participants ranked 275 content items from a published set of pediatric curricular items for EM residents into one of four categories: definitely must, probably should, possibly could, or should not be taught using simulation in all residency programs. Additionally, in round 1 participants were asked to contribute additional items. These items were then added to the survey in round 2. In round 2, participants were provided the ratings of the entire panel and asked to rerank the items. Round 3 involved participants dichotomously rating the items.

RESULTS

A total of 73 participants participated and 98% completed all three rounds. Round 1 resulted in 61 items rated as definitely must, 72 as probably should, 56 as possibly could, 17 as should not, and 99 new items were suggested. Round 2 resulted in 52 items rated as definitely must, 91 as probably should, 120 as possibly could, and 42 as should not. Round 3 resulted in 56 items rated as definitely must be taught using simulation in all programs.

CONCLUSIONS

The completed modified Delphi process developed a consensus on 56 pediatric items that definitely must be taught using simulation in all EM residency programs (20 resuscitation, nine nonresuscitation, and 26 skills). These data will serve as a targeted needs assessment to inform the development of a standard pediatric simulation curriculum for all EM residency programs.

Alternative Markers of Performance in Simulation: Where We Are and Where We Need To Go

This article on alternative markers of performance in simulation is the product of a session held during the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes." There is a dearth of research on the use of performance markers other than checklists, holistic ratings, and behaviorally anchored rating scales in the simulation environment. Through literature review, group discussion, and consultation with experts prior to the conference, the working group defined five topics for discussion: 1) establishing a working definition for alternative markers of performance, 2) defining goals for using alternative performance markers, 3) implications for measurement when using alternative markers, identifying practical concerns related to the use of alternative performance markers, and 5) identifying potential for alternative markers of performance to validate simulation scenarios. Five research propositions also emerged and are summarized.

Perceived Fall Risk and Functional Decline: Gender Differences in Patient's Willingness to Discuss Fall Risk, Fall History, or to Have a Home Safety Evaluation

The CDC reports that among older adults, falls are the leading cause of injury-related death and rates of fall-related fractures among older women are twice those of men. We set out to 1) determine patient perceptions (analyzed by gender) about their perceived fall risk compared to their actual risk for functional decline and death and 2) to report their comfort level in discussing their fall history or a home safety plan with their provider. Elders who presented to the Emergency Department (ED†) were surveyed. The survey included demographics, the Falls Efficacy Scale (FES) and the Vulnerable Elders Survey (VES); both validated surveys measuring fall concern and functional decline. Females had higher FES scores (mean 12.3, SD 5.9) than males (mean 9.7, SD 5.9 p = .007) in the 146 surveys analyzed. Females were more likely to report an increased fear of falling, and almost three times more likely to have a VES score of 3 or greater than males (OR = 2.86, 95% CI: 1.17-7.00, p = .02). A strong correlation was observed between FES and VES scores (r = 0.80, p < .001). No difference in correlation was observed between males and females, p = .26. Participants (77 percent) reported they would be comfortable discussing their fall risk with a provider; there was no difference between genders (p = .57). In this study, irrespective of gender, there appears to be a high association between subjects' perceived fall risk and risk for functional decline and death. The majority of patients are likely willing to discuss their fall risk with their provider. These findings may suggest a meaningful opportunity for fall risk mitigation in this setting.

Injury due to mechanical falls: future directions in gender-specific surveillance, screening, and interventions in emergency department patients

The Centers for Disease Control and Prevention report that among older adults (≥65 years), falls are the leading cause of injury-related death. Fall-related fractures among older women are more than twice as frequent as those for men. Gender-specific evidence-based fall prevention strategy and intervention studies show that improved patient-centered outcomes are elusive. There is a paucity of emergency medicine literature on the topic. As part of the 2014 Academic Emergency Medicine (AEM) consensus conference on "Gender-Specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes," a breakout group convened to generate a research agenda on priority questions to be answered on this topic. The consensus-based priority research agenda is presented in this article.

Exploring the structural complexity of intermetallic compounds by an adaptive genetic algorithm

Solving the crystal structures of novel phases with nanoscale dimensions resulting from rapid quenching is difficult due to disorder and competing polymorphic phases. Advances in computer speed and algorithm sophistication have now made it feasible to predict the crystal structure of an unknown phase without any assumptions on the Bravais lattice type, atom basis, or unit cell dimensions, providing a novel approach to aid experiments in exploring complex materials with nanoscale grains. This approach is demonstrated by solving a long-standing puzzle in the complex crystal structures of the orthorhombic, rhombohedral, and hexagonal polymorphs close to the Zr2Co11 intermetallic compound. From our calculations, we identified the hard magnetic phase and the origin of high coercivity in this compound, thus guiding further development of these materials for use as high performance permanent magnets without rare-earth elements.

An adaptive genetic algorithm for crystal structure prediction

We present a genetic algorithm (GA) for structural search that combines the speed of structure exploration by classical potentials with the accuracy of density functional theory (DFT) calculations in an adaptive and iterative way. This strategy increases the efficiency of the DFT-based GA by several orders of magnitude. This gain allows a considerable increase in the size and complexity of systems that can be studied by first principles. The performance of the method is illustrated by successful structure identifications of complex binary and ternary intermetallic compounds with 36 and 54 atoms per cell, respectively. The discovery of a multi-TPa Mg-silicate phase with unit cell containing up to 56 atoms is also reported. Such a phase is likely to be an essential component of terrestrial exoplanetary mantles.

Effect of coronary target lesion revascularization on late cardiac events after insertion of sirolimus-eluting or bare metal stents

Restenosis is associated with acute myocardial infarction (MI) either at presentation or related to complications of target lesion revascularization (TLR). The cumulative late effect of TLR after drug-eluting or bare metal stent placement on cardiac death or MI is uncertain. Of the 1,057 patients with one native coronary lesion randomized to a sirolimus-eluting stent or bare metal stent in the Sirolimus-Eluting Stent in De Novo Native Coronary Lesions (SIRIUS) trial, the 983 who survived free of MI for the first 30 days were evaluated for the primary outcome of cardiac death or MI for 5 years. Patients with events occurring at or after TLR were assigned to TLR group. Cox proportional hazards regression analysis with TLR as a time-dependent variable and adjustment for baseline clinical and demographic covariates was used to assess the independent effect of TLR on the primary outcome. TLR occurred in 160 patients (16.3%) and was an independent predictor of the primary end point (hazard ratio 2.8, 95% confidence interval 1.7 to 4.5). This association was significant for sirolimus-eluting stents and bare metal stents. TLR was also associated with an increased risk of subsequent stent thrombosis and nontarget vessel revascularization. Intracoronary brachytherapy in the TLR group was associated with an increased risk of cardiac death or MI. In conclusion, restenosis requiring TLR was associated with an increased risk of cardiac death or MI occurring at TLR and during the subsequent 5 years.

Management of a renal artery aneurysm with coil embolization

We describe a case of a 51-year-old female who was incidentally noted to have a renal artery aneurysm on computed tomography (CT). The aneurysm was not seen on an abdominal CT performed 4 years prior, so the patient underwent successful percutaneous coil embolization. The indications for repair of such aneurysms are unknown, and there are a myriad of surgical and percutaneous management options. Because of the increase in abdominal imaging, the incidence of renal artery aneurysms is likely to rise. We describe the case and review the literature surrounding the epidemiology, outcome and management of renal artery aneurysms.

Recent advances in atherectomy and devices for treatment of infra-inguinal arterial occlusive disease

The prevalence of peripheral arterial disease (PAD) continues to rise in an ever ageing society and consumes a significant part of health resources. Percutaneous revascularization has revolutionized the treatment of lower extremity peripheral vascular disease over the past 10 years. Additionally, novel devices have allowed improved endovascular treatment of femoropopliteal as well as infrapopliteal disease. Although percutaneous transluminal angioplasty (PTA) can be an effective modality for focal lesions in the iliac arteries, the results for complex infra-inguinal arterial disease have been disappointing. One class of new technology has concentrated on debulking the plaque, while others focus to improve safety (distal embolic protection devices) or are directed to specific clinical challenges such as chronic total occlusions. However, the lack of uniform performance criteria and reporting standards for these and other devices has resulted in heterogeneous study end points, making comparative efficacy difficult. Here we review the current data for atherectomy and atheroablative technologies as well as other adjunctive devices in the treatment of lower extremity peripheral arterial disease.

Combining warfarin and antiplatelet therapy after coronary stenting in the Global Registry of Acute Coronary Events: is it safe and effective to use just one antiplatelet agent?

AIMS

To identify factors associated with the use of single or dual antiplatelet therapy in patients prescribed warfarin following coronary stenting and to investigate whether single (aspirin or thienopyridine) vs. dual antiplatelet therapy plus warfarin leads to an excess of adverse outcomes.

METHODS AND RESULTS

We analysed data from 800 patients with an acute coronary syndrome who underwent coronary stenting (130 patients received a drug-eluting stent) and were discharged on warfarin and either dual (n = 580) or single (n = 220) antiplatelet therapy. The use of single antiplatelet therapy was more common in Europe than in the USA (34 vs. 17%, P < 0.001). There was no difference in major bleeding in hospital or in 6-month mortality or myocardial infarction. In the single antiplatelet group, the use of either aspirin or thienopyridine (clopidogrel or ticlopidine) in combination with warfarin resulted in similar outcomes.

CONCLUSION

Use of single vs. dual antiplatelet therapy and warfarin following stenting is common. In this observational study, there was no difference in mortality or myocardial infarction at 6 months; however, larger trials are needed to assert any firm recommendations.

Simple approaches towards the design of an attached-growth sponge bioreactor (AGSB) for wastewater treatment and reuse

Wastewater treatment and reuse is being emphasized due to the shortage of water sources and the continuous deterioration of the aquatic environment. In this study, a novel sponge bioreactor was studied as a low cost, high efficiency alternative for an attached growth biological system. This was designed by combining of number of sponge trays. This emerging technology has many beneficial properties in wastewater treatment and reuse. The approaches towards the conditions for system design were: (i) selection of sponge types; (ii) selection of sponge shapes; and (iii) selection of designated slope of sponge tray. They were determined through a series of experiments using a laboratory-scale unit with synthetic wastewater. It was then tested with a pilot-scale unit at the predetermined optimum conditions. The results indicate that the highest biomass growth was found at the sponge type with a cell count of 70-90 cells/in(2) (6.45 cm(2)) The relationship between biomass growth and biological oxygen consumption was well established. The prism-shaped sponge (triangular polyurethane sponge of 70-90 cells/in(2) with designated slope of sponge tray at 10 degrees) led to the best performance in terms of both organic and nutrient removal efficiency.

Antimalarial compounds from Rhaphidophora decursiva

Bioassay-directed fractionation led to the isolation of 14 compounds, six of which possess antimalarial activity, from the dried leaves and stems of Rhaphidophora decursiva. Polysyphorin (1) and rhaphidecurperoxin (6) showed strong activities against Plasmodium falciparum. Rhaphidecursinol A (2), rhaphidecursinol B (3), grandisin (4), and epigrandisin (5) were less active against the same organism. Among the isolates, rhaphidecursinol A (2) and rhaphidecursinol B (3) were determined to be new neolignans, and rhaphidecurperoxin (6) is a new benzoperoxide. Known compounds isolated include polysyphorin (1), grandisin (4), epigrandisin (5), (+)-medioresinol, (-)-pinoresinol, (-)-syringaresinol, (+)-glaberide I, (+)-dehydrovomifoliol, (-)-liliolide, (-)-hydroxydihydrobovolide, and N-butylbenzamide, of which compound 1 appears worthy of further evaluation as an antimalarial agent. Structure elucidation and identification were accomplished by spectroscopic means including 1D and 2D NMR analyses.

Diagostic value of respiratory impedance measurements in elderly subjects

Obstructive lung disease (OLD) is highly prevalent in elderly subjects but markedly under-diagnosed. Indeed, only 40-50% of hospitalized elderly patients are able to adequately perform spirometric tests. This study aimed to evaluate, in an acute-care geriatric hospital, the diagnostic value of measuring airway impedance (Zrs) by the forced oscillation technique (FOT) for: (1) identifying OLD and (2) identifying responders vs. non-responders to bronchodilators. Sixty-seven patients (aged 82+/-8 years) underwent consecutive measurement of Zrs and forced expiratory volumes before and after bronchodilators. Zrs was measured by FOT at frequencies of 4-30 Hz. Correlations, ROC curves and logistic regression models were established to determine the sensitivity (Se) and specificity (Sp) of Zrs in identifying OLD. Significant correlations were found between spirometric and Zrs measurements. The Zrs parameters yielding the best Se and Sp for detecting OLD were: Fn (resonant frequency; Se: 76%; Sp: 78%) and R0 (resistance extrapolated for a frequency of 0: Se: 76%; Sp: 74%). Using the logistic regression models, 76% of the patients were correctly classified as having OLD or not. Zrs was however not contributive in identifying responders to bronchodilators. Zrs measurements by FOT are contributive to the diagnosis of OLD in elderly hospitalized patients.

Relationships between tamoxifen use, liver fat and body fat distribution in women with breast cancer

Tamoxifen is a nonsteroidal anti-estrogenic drug used for adjuvant treatment of breast cancer and recently as a chemopreventative agent for breast cancer and, on an investigational basis, for other cancers. To date there are case reports of hypertriglyceridemia and fatty liver disease in tamoxifen users. Fatty liver is associated with visceral obesity and other components of the metabolic syndrome. Here we evaluated steatosis and adipose tissue distribution by CT scan in a cross-sectional study of 32 women on tamoxifen and 39 control women. Tamoxifen users had more visceral adipose tissue (VAT) and more liver fat than controls. This is the first study to demonstrate that fatty liver and intra-abdominal fat accumulation are common in breast cancer patients receiving tamoxifen. Prospective studies of tamoxifen should monitor metabolic changes in obese women with or without breast cancer.

Delivering drugs, via microdialysis, into the environment of extracellularly recorded hippocampal neurons in behaving primates

Hippocampal neurons in primates have been extensively studied with electrophysiological and neuroanatomical methods. Much less effort has been devoted to examining these cells with contemporary pharmacological techniques. Therefore, we modified a recently developed integrative technique (N. Ludvig, P.E. Potter, S.E. Fox, Simultaneous single-cell recording and microdialysis within the same brain site in freely behaving rats: a novel neurobiological method, J. Neurosci. Methods 55 (1994) 31-40 [9] ) for cellular neuropharmacological studies in behaving monkeys. A driveable microelectrode-microdialysis probe guide assembly was implanted stereotaxically into the left hippocampus of squirrel monkeys (Saimiri sciureus) under isoflurane anesthesia. The assembly was covered with a protective cap. After 3 weeks of postsurgical recovery and behavioral training, the experimental subject was seated in a primate chair. For 4-5 h, single-cell recording and microdialysis were simultaneously performed in the hippocampal implantation site. The technique allowed the recording of both complex-spike cells and fast-firing neurons without the use of head restraint. The control microdialysis solution, artificial cerebrospinal fluid (ACSF), was replaced with either 1 M ethanol or 500 microM N-methyl-D-aspartate (NMDA) for 10-30 min intervals. The ethanol perfusions principally suppressed the firing of the neurons in the dialysis area. The NMDA perfusions initially increased the firing of local neurons, then caused electrical silence. These drug delivery/cell recording sessions were performed with 1-4 day intersession intervals over a 1-month period. The described method provides a tool to elaborate the pharmacology of primate hippocampal neurons during behavior and without the confounding effects of systemic drug administrations.

Proton therapy for pediatric cranial tumors: preliminary report on treatment and disease-related morbidities

PURPOSE

Accelerated protons were used in an attempt to limit treatment-related morbidity in children with tumors in or near the developing brain, by reducing the integral dose to adjacent normal tissues.

METHODS AND MATERIALS

Children treated with protons at Loma Linda University Medical Center between August 1991 and December 1994 were analyzed retrospectively. Twenty-eight children, aged 1 to 18 years, were identified as at risk for brain injury from treatment. Medical records, physical examinations, and correspondence with patients, their parents, and referring physicians were analyzed. The investigators tabulated post-treatment changes in pre-treatment signs and symptoms and made judgments as to whether improvement, no change, or worsening related to disease or treatment had supervened. Magnetic resonance images were correlated with clinical findings and radiographic impressions were tabulated.

RESULTS

Follow-up ranged from 7 to 49 months (median 25 months). Four instances of treatment-related morbidity were identified. Forty-one instances of site-specific, disease-related morbidity were identified: 15 improved or resolved and 26 remained unchanged after treatment. Four patients had radiographic evidence of local failure. Three of these patients, including two with high-grade glioma, have died.

CONCLUSION

Early treatment-related morbidity associated with proton therapy is low. Tumor progression remains a problem when treating certain histologies such as high-grade glioma. Escalating the dose delivered to target volumes may benefit children with tumors associated with poor rates of local control. Long-term follow-up, including neurocognitive testing, is in progress to assess integral-dose effects on cognitive, behavioral and developmental outcomes in children with cranial tumors.

Long-term compliance with nasal continuous positive airway pressure therapy of obstructive sleep apnea

In an attempt to identify predictors of long-term compliance with nasal continuous positive airway pressure (CPAP), we reviewed the records of 125 patients with obstructive sleep apnea (OSA) referred to our center for nasal CPAP trials. Severity of sleep apnea, sleep staging, daytime hypersomnolence, effectiveness of nasal CPAP, previous palatal surgery, and adverse reactions were compared in compliant and noncompliant patients. Nineteen patients did not tolerate a nasal CPAP trial in the laboratory or refused home nasal CPAP therapy. Ten patients were unavailable for follow-up. Of the remaining 96 patients, 23 (24 percent) had discontinued therapy, while 73 (76 percent) were still using nasal CPAP at 14.5 +/- 10.7 months (mean +/- SD). There were no statistically significant differences between the compliant and noncompliant patients in baseline apnea plus hypopnea index (AHI), baseline sleep staging, AHI while receiving nasal CPAP, sleep staging while receiving nasal CPAP, or frequency of adverse reactions during therapy. Severe daytime sleepiness was present in 65 of the 73 compliant patients and in 12 of the 23 noncompliant patients (p less than 0.05). Ten of 43 in the compliant group had previous palatal surgery compared with ten of 23 noncompliant patients (p less than 0.05). Our data confirm earlier observations in smaller samples that compliant and noncompliant patients have equally severe sleep apnea and good initial responses to nasal CPAP. Long-term compliance with nasal CPAP may be associated with the severity of daytime hypersomnolence on presentation. Previous palatal surgery was more frequent in patients who did not tolerate long-term nasal CPAP therapy.