Respiratory Distress with Minimal Exertion: A Case of 2019 Novel Coronavirus (COVID-19) Pneumonia

Description COVID-19 is a new coronavirus that can cause severe respiratory distress. Interestingly, patients can present with COVID-19 and appear relatively well but with significant hypoxia, even with minimal movement. The authors present the case of a well-appearing gentleman who became acutely short of breath while undergoing chest imaging, stating he could not breathe. He tested positive for COVID-19 and recovered. His presentation, clinical course and imaging findings are discussed.

Hypercoagulable State in COVID-19: A Case Series of Three Patients

The novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that originated in China in late 2019, has caused significant morbidity and mortality worldwide. Although fever, cough, and shortness of breath have been recognized as hallmark symptoms, other lesser known complications continue to be described. We report a series of three patients who presented to the emergency department, who tested positive for COVID-19, and were found to have or subsequently developed thromboembolic complications. 

Ingested Fish Bone Lodged in the Vallecula

Although foreign body ingestions are less common in adults than children, when they do occur, it is often due to a fish or chicken bone. The authors present a case of a fish bone ingestion, and highlight its appearance on imaging.

Delta Lactate (Three-hour Lactate Minus Initial Lactate) Prediction of In-hospital Death in Sepsis Patients

This study examines the relationship between serial serum lactate levels and in-hospital mortality in an adult cohort of emergency department patients with severe sepsis or septic shock. Of the 164 patients in the cohort, 130 also got three-hour lactate in addition to the initial one. The median initial lactate was 3.01 (interquartile range [IQR]: 1.71-4.62). The median repeat lactate was 2.58 (IQR: 1.4-3.9). The in-hospital death rate was 23% for men and 29% for women. The delta lactate was significantly higher in women (P=0.0070), driven by a lower initial lactate (P=0.0277). In a multivariate regression model controlled for age and gender, a statistically significant correlation was noted between an increase in the delta lactate and in-hospital death (P=0.0323; R²=11.3%). The results of this single-center study suggest that an increase in serum lactic acid is significantly associated with higher in-hospital death.

Serum Procalcitonin Level Is Associated with Positive Blood Cultures, In-hospital Mortality, and Septic Shock in Emergency Department Sepsis Patients

This study examines the accuracy of initial and subsequent serum procalcitonin (PCT) levels in predicting positive blood cultures, in-hospital mortality, and development of septic shock in emergency department (ED) patients with severe sepsis. This study includes all patients who presented to our ED with an admission diagnosis of severe sepsis over a period of nine months. The median initial PCT was 0.58 ng/mL, interquartile range (IQR) 0.16-5.39. The median subsequent serum PCT was 2.1 ng/mL, with an IQR of 0.3-11.1. The PCT trend over the initial three hours increased in 67% of the study population. Blood cultures were positive in 38% of the cohort. The median maximum PCT in those with a negative blood culture was 1.06 ng/mL compared to 4.19 ng/mL in those with a positive blood culture (p=0.0116). Serum PCT levels >2.0 ng/mL display significant correlation with positive blood cultures, in-hospital mortality, and development of septic shock and as such may serve as a biomarker for more serious infections.

Ruptured Hepatic Artery Aneurysm

Aneurysmal ruptures are a life-threatening pathology, and while the aorta is the principal location, any aneurysmal rupture can be fatal. Most result from chronic diseases, such as hypertension, diabetes, and vasculitis. Nevertheless, a rupture can result in acute decompensation and must be recognized and addressed quickly to limit morbidity and mortality. The authors describe a case of a 66-year-old female who presented to the emergency department (ED) for abdominal pain and syncope. Even though imaging did not explicitly show the specific site of rupture of the hepatic artery, the positive Rapid Ultrasound for Shock and Hypotension (RUSH) exam and aortic dissection on computed tomography angiography along with her clinical picture (hypotension, abdominal pain, decreased capillary refill, grey skin) raised our suspicions for critical pathology. Exploratory laparotomy revealed a ruptured hepatic artery aneurysm. Her hospital course was complicated by ischemic necrosis of the gallbladder, spleen, and liver, requiring cholecystectomy, splenectomy, and partial hepatectomy, but she was discharged to rehabilitation and expected to make a recovery. This case displays the importance of using ultrasonography early to aid in expedited diagnosis and treatment as well as maintaining a high suspicion for vascular pathology in the setting of hemorrhagic shock.

Assembly Line Education: A Novel Educational Technique for Today's Learners

Background

Education is undergoing a transformation. The traditional passive lectures are failing to capture and inspire the new generation of learners who value more active and collaborative learning techniques.

Objective

We sought to create a novel educational technique to integrate into our curriculum that would be more personalized, employ more active learning and collaboration, and allow for an effective assessment of resident strengths and weaknesses.

Discussion

We created a monthly assembly line education academic half-day that evolved to replace one of the typical in-classroom didactics each month. Faculty run small-group simulation rooms, procedure workshops, competitive ultrasound, and wellness stations through which residents and medical students rotate.

Conclusion

This novel education technique resulted in a more personalized approach that increased resident interest, sparked the creation of a very popular MedEd-Simulation elective, and allowed the faculty to gain a better sense of resident strengths and deficiencies.

Sources of elevated heavy metal concentrations in sediments and benthic marine invertebrates of the western Antarctic Peninsula

Antarctica is one of the least anthropogenically-impacted areas of the world. Metal sources to the marine environment include localised activities of research stations and glacial meltwater containing metals of lithogenic origin. In this study, concentrations of nine metals (Cd, Co, Cr, Cu, Fe, Mn, Ni, Pb, Zn) were examined in three species of benthic invertebrates collected from four locations near Rothera Research Station on the western Antarctic Peninsula: Laternula elliptica (mudclam, filter feeder), Nacella concinna (limpet, grazer) and Odontaster validus (seastar, predator and scavenger). In addition, metals were evaluated in sediments at the same locations. Metal concentrations in different body tissues of invertebrates were equivalent to values recorded in industrialized non-polar sites and were attributed to natural sources including sediment input resulting from glacial erosion of local granodioritic rocks. Anthropogenic activities at Rothera Research Station appeared to have some impact on metal concentrations in the sampled invertebrates, with concentrations of several metals higher in L. elliptica near the runway and aircraft activities, but this was not a trend that was detected in the other species. Sediment analysis from two sites near the station showed lower metal concentrations than the control site 5 km distant and was attributed to differences in bedrock metal content. Differences in metal concentrations between organisms were attributed to feeding mechanisms and habitat, as well as depuration routes. L. elliptica kidneys showed significantly higher concentrations of eight metals, with some an order of magnitude greater than other organs, and the internal structure of O. validus had significantly higher Ni. This study supports previous assessments of N. concinna and L. elliptica as good biomonitors of metal concentrations and suggests O. validus as an additional biomonitor for use in future Antarctic metal monitoring programs.

Symptomatic May-Thurner Syndrome Without Deep Venous Thrombosis

The authors present a case of symptomatic May-Thurner syndrome in the absence of a deep venous thrombosis. This is an unusual case, as most cases are diagnosed with a deep venous thrombosis as the underlying finding. The clinical presentation and suggested diagnostic workup are discussed. A key point is the need to consider this frequently under-diagnosed condition. Optimal management is often with a stent, but if not diagnosed, the patient can develop unnecessary clot burden, be placed on lifelong anticoagulation, or both. 

Radial Head Dislocation with Elbow Subluxation in an Adult

Isolated radial head subluxation without fracture, commonly referred to as "nursemaid's elbow," is one of the most common pediatric upper extremity injuries. Radial head dislocation without an associated fracture is rarely seen in adults. They are usually associated with ulnar fractures or an elbow dislocation. We present a case of an adult female presenting with a radial head dislocation and an elbow subluxation sustained while dressing, which was successfully reduced using the techniques commonly used to reduce nursemaid's elbow in pediatric patients.

Effect of a Novel Engagement Strategy Using Twitter on Test Performance

INTRODUCTION

Medical educators in recent years have been using social media for more penetrance to technologically-savvy learners. The utility of using Twitter for curriculum content delivery has not been studied. We sought to determine if participation in a social media-based educational supplement would improve student performance on a test of clinical images at the end of the semester.

METHODS

116 second-year medical students were enrolled in a lecture-based clinical medicine course, in which images of common clinical exam findings were presented. An additional, optional assessment was performed on Twitter. Each week, a clinical presentation and physical exam image (not covered in course lectures) were distributed via Twitter, and students were invited to guess the exam finding or diagnosis. After the completion of the course, students were asked to participate in a slideshow "quiz" with 24 clinical images, half from lecture and half from Twitter.

RESULTS

We conducted a one-way analysis of variance to determine the effect Twitter participation had on total, Twitter-only, and lecture-only scores. Twitter participation data was collected from the end-of-course survey and was defined as submitting answers to the Twitter-only questions "all or most of the time", "about half of the time", and "little or none of the time." We found a significant difference in overall scores (p<0.001) and in Twitter-only scores (p<0.001). There was not enough evidence to conclude a significant difference in lecture-only scores (p=0.124). Students who submitted answers to Twitter "all or most of the time" or "about half the time" had significantly higher overall scores and Twitter-only scores (p<0.001 and p<0.001, respectively) than those students who only submitted answers "little or none of the time."

CONCLUSION

While students retained less information from Twitter than from traditional classroom lecture, some retention was noted. Future research on social media in medical education would benefit from clear control and experimental groups in settings where quantitative use of social media could be measured. Ultimately, it is unlikely for social media to replace lecture in medical curriculum; however, there is a reasonable role for social media as an adjunct to traditional medical education.

Optimising outcome assessment of voice interventions, I: reliability and validity of three self-reported scales

Background:

There is an increasing choice of voice outcome research tools, but good comparative data are lacking.

Objective:

To evaluate the reliability and validity of three voice-specific, self-reported scales.

Design:

Longitudinal, cohort comparison study.

Setting:

Two UK voice clinics: the Freeman Hospital, Newcastle upon Tyne, and the Glasgow Royal Infirmary.

Participants:

One hundred and eighty-one patients presenting with dysphonia.

Main outcome measures:

All patients completed the vocal performance questionnaire, the voice handicap index and the voice symptom scale. For comparison, each patient's voice was recorded and assessed perceptually using the grade–roughness–breathiness–aesthenia–strain scale. The reliability and validity of the three self-reported vocal performance measures were assessed in all subjects, while 50 completed the questionnaires again to assess repeatability.

Results:

The results of the 170 participants with completed data sets showed that all three questionnaires had high levels of internal consistency (Cronbach's alpha = 0.81–0.95) and repeatability (voice handicap index = 0.83; vocal performance questionnaire = 0.75; voice symptom scale = 0.63). Concurrent and criterion validity were also good, although, of the grade–roughness–breathiness–aesthenia–strain subscales, roughness was the least well correlated with the self-reported measures.

Conclusion:

The vocal performance questionnaire, the voice handicap index and the voice symptom scale are all reliable and valid instruments for measuring the patient-perceived impact of a voice disorder.

The reliability of three perceptual evaluation scales for dysphonia

Perceptual rating scales are widely used in voice quality assessment, yet apart from the GRBAS scale, their reliability has been poorly demonstrated. There are no studies that have compared the optimal reliability of experienced judges using different auditory rating scales in a controlled experimental environment. This study aimed to assess the reliability of three common scales (The Buffalo Voice Profile, The Vocal Profile Analysis Scheme (VPA) and GRBAS. Sixty-five varyingly dysphonic and five normal voices were recorded onto CD in random order. Thirty voices were recorded twice. Seven experienced and trained speech and language therapists rated all voices on the three scales. Only the overall grade was found to be reliable for the Buffalo Voice Profile. The reliability of the VPA scheme was found to be poor to moderate. The VPA may have a use as a multi-dimensional and in-depth evaluation of voice types, but its greater scope is at the expense of reliability. The GRBAS was reliable across all parameters except Strain. Our detailed reliability analysis comparing performance of three commonly used rating scales provides further evidence to support the GRBAS as a simple reliable measure for clinical use.

Lithium levels and toxicity among hospitalized patients

OBJECTIVE

Although psychiatrists in the United States have used lithium for nearly 30 years, toxicity still occurs frequently. The authors report an attempt to reduce the incidence of lithium toxicity in hospitalized psychiatric patients and to identify factors associated with toxicity.

METHODS

Serum lithium levels were monitored by the drug use evaluation committee at a psychiatric hospital between 1990 and 1996. Each laboratory result showing a serum lithium level of 1.5 mmol/L or more was promptly investigated, and the results were reported quarterly to the hospital staff association.

RESULTS

The study found that in 6.8 percent of the 2,210 admissions during which lithium was administered, patients had serum levels of 1.5 mmol/L or higher. The number of excessive serum lithium levels decreased over the course of the study period. Only 27.8 percent of patients with excessive levels had signs and symptoms of toxicity. Of the excessive serum lithium levels that were investigated, 43.3 percent were detected in blood samples drawn at the time of admission. Women and elderly persons were significantly more likely to have excessive serum levels. Psychiatric diagnosis was not significantly associated with excessive serum levels.

CONCLUSIONS

Education by the drug use evaluation committee may have helped to reduce the number of patients who experienced excessive lithium levels while hospitalized. Vigilance should be emphasized for women and elderly persons.

Prenatal diagnosis of mosaic trisomy 8 with investigations of the extent and origin of trisomic cells

A case of trisomy 8 mosaicism, which presented at obstetric ultrasound at 18 weeks' gestation with a distended bladder and absence of amniotic fluid, is described. Analysis of DNA microsatellite polymorphisms indicates that the trisomic cell line most likely arose as the result of a post-fertilization non-dysjunction event in early development of a chromosomally normal pre-implantation embryo. The distribution of normal and trisomy 8 cells suggests that in this pregnancy there has been either uneven allocation of abnormal cells to the extra-embryonic mesoderm, or selection against the proliferation of trisomic cells in trophoblast derived cell lineages. This prenatal detection of trisomy would not have been possible if only analysis of direct preparations had been undertaken.

Detection of mosaic and non-mosaic chromosome abnormalities in 6- to 8-day old human blastocysts

A reliable technique has been developed for the production of good quality G-banded chromosome preparations from 6- to 8-day-old human blastocysts (20-800 cell stage) from an in vitro fertilization programme. The technique involves a thymidine cell division synchronization step to reduce the exposure time to colcemid, in conjunction with a simple 70% acetic acid disaggregation procedure to produce discrete metaphases for analysis. Of 105 blastocysts processed by this technique, 9 were lost during handling and 10 showed no dividing cells. The remaining 86 produced useful separate metaphases with a mean mitotic activity of 6.5%. A full G-banded karyotype was obtained from 1-6 cells in 55 blastocysts (64%), incomplete G-banded analysis but with full information of ploidy was obtained from 18 blastocysts (21%), with 13 (15%) producing no useful cytogenetic results. Abnormalities observed included polyploidy, diploid/polyploid mosaicism, non-mosaic trisomy 16 (2 cases), 46,Xdel(X)-(q21)/46,XX (1 case) and several single cells with trisomies or structural anomalies in otherwise normal blastocysts. Variable levels of structural chromosome damage, with apparent interchanges, chromosome branching and anomalous chromatid pairing were also seen.

Maternal uniparental disomy for chromosome 2 in association with confined placental mosaicism for trisomy 2 and severe intrauterine growth retardation

We report a liveborn infant with severe intrauterine growth retardation and renal failure, delivered following detection of non-mosaic trisomy 2 by chorionic villus biopsy in the first trimester. Detailed analysis post-delivery indicated apparent complete trisomy 2 of the chorionic tissues, with a chromosomally normal infant demonstrating maternal uniparental disomy for chromosome 2.

Functional interactions between herpes simplex virus immediate-early proteins during infection: gene expression as a consequence of ICP27 and different domains of ICP4

Two of the five immediate-early gene products, ICP4 and ICP27, expressed by herpes simplex virus type 1 have profound effects on viral gene expression and are absolutely essential for virus replication. Functional interactions between ICP4 and ICP27 may contribute to establishing the program of viral gene expression that ensues during lytic infection. To evaluate this possibility, viral mutants simultaneously deleted for ICP27 and defined functional domains of ICP4 were constructed. These mutant viruses allowed a comparison of gene expression as a function of different domains of ICP4 in the presence and absence of ICP27. Gene expression in the absence of both ICP4 and ICP27 was also examined. The results of this study demonstrate a clear involvement for ICP27 in the induction of early genes, in addition to its known role in enhancing late gene expression during viral infection. In the absence of both ICP4 and ICP27, viral early gene expression, as measured by the accumulation of thymidine kinase and ICP6 messages was dramatically reduced relative to the amounts of these messages seen in the absence of only ICP4. Therefore, elevated levels of early gene expression as a consequence of ICP27 occurred in the absence of any ICP4 activity. Evidence is also presented regarding the modulation of the ICP4 repression function by ICP27. When synthesized in the absence of ICP27, a mutant ICP4 protein was impaired in its ability to repress transcription from the L/ST promoter in the context of viral infection and in vitro. This defect correlated with the loss of the ability of this mutant protein to bind to its recognition sequence when produced in infected cells in the absence of ICP27. These observations indicate that ICP27 can regulate the activity of at least one domain of the ICP4 protein as well as contribute to elevated early gene expression independently of ICP4.