Diagnostic Dilemma in a Case of Necrotizing Lymphadenitis With Macrophage Activation Syndrome.

Necrotizing lymphadenitis is a histological diagnosis that can arise from various conditions, including lupus lymphadenitis (LL), Kikuchi disease (KD), and infectious causes. Distinguishing between Kikuchi disease and lupus lymphadenitis can be challenging in clinical practice. In this report, we present the clinical scenario of a young female patient with lymphadenopathy and elucidate the process through which we ultimately arrived at a diagnosis of systemic lupus erythematosus (SLE) with macrophage activation syndrome. This case underscores the significance of recognizing Kikuchi disease as a condition that can mimic lupus and sheds light on the distinguishing features of necrotizing lymphadenitis, with a particular focus on Kikuchi disease and lupus lymphadenitis.

An innovative approach to comprehensive communication skills training for residents: A resident-led communication curriculum.

Innovations to enhance residency training in interpersonal and communication skills are needed and a resident-led strategy has not been well-described. In this study, we explored a resident-led comprehensive communication skills curriculum for internal medicine residents. Residents and faculty prepared the curriculum as part of an Accreditation Council for Graduate Medical Education (ACGME) Back to Bedside Project and with "The language of caring guide for physicians." Employing active learning techniques, three residents led 43 internal medicine residents in seven 1 h sessions from 2019 to 2020. Using a 35-question survey, we assessed pre and post self-reported competence in: mindful practice, collaboration and teamwork, effective openings and closing, communicating with empathy, effective explanations, engaging patients and families as partners, and hard conversations. A Wilcoxon signed rank test was employed to explore differences in median scores after matching each person's pretest and posttest score. The median score for aggregate communication and the scores for all seven competencies assessed improved from pre to post (p < 0.05). This indicates that residents reported higher incidences of performing patient-centered communication skills after the curriculum compared to before. Using a five-point Likert scale, 100% of participants agreed the program improved their communication skills and improved confidence in bedside patient-centered communications. A resident-led comprehensive communication skills curriculum for internal medicine residents was implemented showing improvement in skills over the course of the curriculum. The curriculum was well-accepted by post-survey evaluation and was feasible with motivated resident-leaders, use of an existing guide to communication, and reserved didactic time to implement the program.

Pharmacist Medication Management of Adults with Attention Deficit: An Alternative Clinical Structure.

INTRODUCTION: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common psychiatric conditions in youth. This disorder can persist into adulthood, with an estimated prevalence of 4.4% to 5.2% in the US. OBJECTIVE: To review adult ADHD diagnostic criteria, adult clinical presentation, and resulting impairments in function and to describe our adult psychiatry clinic's pharmacist-comanaged ADHD medication management program as a model to provide safe and effective care that is accessible, efficient, and well monitored. METHODS: The program consists of 1) screening (urine toxicology, diagnostic evaluation, data collection) by physicians, 2) program participation and treatment agreement with establishment of care goals, and 3) patient maintenance and monitoring. Pharmacists in the Department of Psychiatry manage refills, distributing the clinical caseload among a broader clinician base. RESULTS: This program created a standardized protocol for assessment, referral, and follow-up of adult patients with ADHD, with close monitoring and titration of controlled medications, systematic use of screening measures, and a stimulant treatment contract. DISCUSSION: Development of this program and workflow model could increase care delivery efficiency, potentially improving patient satisfaction and outcomes. There is a great need to use alternative patient management strategies such as this to maintain access to high-quality care while there is a nationwide need for more psychiatric clinicians. CONCLUSION: We believe this program offers a solution to a component of this growing problem, and other clinical sites would benefit from such a program. Next steps include analysis and publication of results of implementation, including patient outcomes, engagement in treatment, and satisfaction.

Effect of intervention on decision making of treatment for disease progression, prostate-specific antigen biochemical failure and prostate cancer death.

BACKGROUND: Patient preference for the choice of treatment modality for prostate cancer has increasingly gained attention. OBJECTIVE: To assess the impact of client-oriented decision on long-term mortality, disease progression and biochemical failure compared with standard treatment protocol (TP). METHODS: With data from a Finnish multicentre, randomized controlled trial with two arms [104 in the enhanced patient participation (EPP) arm and 106 in the TP arm], disease-specific and disease-free survival, biochemical failure with elevated prostate-specific antigen (PSA) level and disease progression were compared between the two arms using Wilcoxon test and also Cox proportional hazards regression model. RESULTS: Patients in the EPP arm had a higher risk of death by 37% [HR, 1.37 (0.87-2.17)] compared with those in the TP arm. Patients in the EPP arm were at increased risk of having biochemical failure by 14% [HR, 1.14 (0.72-1.79)] and for having disease progression by 2% [HR, 1.02 (0.61-1.70)] compared with those in the TP arm. All the differences were non-significant. CONCLUSIONS: Patients actively involved in the choice of treatment had higher risk of prostate cancer death but only slightly increased risk of biochemical failure and clinical disease progression. These findings would provide a good reference when patient autonomy for the choice of treatment modality is addressed.

Connexin43 antisense oligodeoxynucleotide treatment down-regulates the inflammatory response in an in vitro interphase organotypic culture model of optic nerve ischaemia.

Using a model of optic nerve ischaemia, this study investigated oxygen-glucose deprivation (OGD) on isolated rat optic nerve segments cultured in vitro. Thereafter, the effect of antisense oligodeoxynucleotides (ASODN) specific to the gap junction protein connexin43 (Cx43) was evaluated in this same model. Following exposure to OGD for 2 hours, optic nerves were maintained in interphase organotypic culture with and without exposure to Cx43 ASODN. Optic nerves were sectioned at 2 hours, 6 hours, and at days 1, 2, 3 and 6 following culture. Cell death was quantified using propidium iodide (PI) staining and specific markers for Cx43, capillaries (von Willebrand factor), astrocytes (glial fibrillary acidic protein), microglia and endothelial cells (isolectin B4) were used to evaluate these parameters in conjunction with digital light and confocal microscopy. In this model, up-regulation of Cx43 was seen at 2 hours following exposure of the optic nerve to OGD and peaked at day 3. Cx43 ASODN treatment dampened this up-regulation. Additionally, more PI labeled cells were found in the centre of control optic nerve segments than in treated nerves (p<0.01). Controls also showed evidence of capillary breakdown and increased numbers of astrocytes and activated microglia compared to Cx43 ASODN treated nerves (p<0.05). Thus, the application of Cx43 ASODN to post-ischaemic optic nerve segments significantly reduced the up-regulation of Cx43 and, subsequently, the spread of injury and a resultant inflammatory response. Cx43 up-regulation may play an important role in optic nerve injury, offering a potential avenue for treatment in optic neuropathy.

Persistence of posttraumatic stress in violently injured youth seen in the emergency department.

OBJECTIVE: To determine if symptoms of posttraumatic stress, initially evaluated in the emergency department (ED) setting, persist over time. DESIGN: Prospective cohort study. SETTING: Two urban, academic medical center EDs. PATIENTS: Sixty-nine injured patients, aged 12 to 24 years, were assessed for acute posttraumatic stress symptoms at the time of their enrollment in an ongoing ED-based study of intentional youth violence, and assessed for posttraumatic stress symptoms up to 5 months later. MAIN OUTCOME MEASURES: The Immediate Stress Reaction Checklist, administered during the ED visit, and the Symptom Checklist of the Child and Adolescent Trauma Survey, administered during routine telephone follow-up. RESULTS: Patients in the emergency department reported a range of acute stress symptoms on the Immediate Stress Reaction Checklist, with 25% reporting clinically significant distress. On follow-up assessment, 15% reported significant posttraumatic stress symptoms. The severity of acute stress symptoms was strongly associated with the severity of posttraumatic stress symptoms at follow-up (r = 0.55, P<.005). Age, sex, injury type, and time from injury to follow-up were not associated with the degree of acute stress or posttraumatic stress symptom severity at initial or follow-up assessment. CONCLUSION: This study provides preliminary evidence that acute stress symptoms, assessed in the ED in the immediate aftermath of a traumatic injury, are useful indicators of risk for later posttraumatic stress.