A rare occurrence of Anaplasma-associated peritonitis.

Anaplasmosis or human granulocytic anaplasmosis is a tick-borne illness caused by the bacteria, Anaplasma phagocytophilum, resulting from an infected tick bite. Examination of a blood smear within the first week of exposure may show microcolonies of anaplasmae (morulae) in the cytoplasm of neutrophils that are highly suggestive of anaplasmosis but not definitive. We present the first case describing Anaplasma-related peritonitis and morulae in peritoneal fluid granulocytes in a peritoneal dialysis patient who developed anaplasmosis.

Disseminated Mycobacterium avium Complex Myositis in a Patient With Graft-Versus-Host Disease.

Mycobacterium avium complex (MAC) is a ubiquitous environmental pathogen that was infrequently reported as a cause of disease before the human immunodeficiency virus (HIV)/acquired immune deficiency syndrome epidemic. We present a case of MAC pyomyositis and bacteremia in a 59-year-old man with chronic lymphocytic leukemia in remission after an allogenic stem cell transplant. His posttransplant course was complicated by graft-versus-host disease, requiring treatment with oral steroids and ruxolitinib. In this report, we review the literature on disseminated MAC infection in patients with and without HIV. We also propose a potential mechanism by which this patient may have developed disseminated disease. Disseminated MAC myositis is uncommon in persons without HIV and requires a high index of suspicion for timely diagnosis.

Creation of an ex-vivo bovine kidney flow model for testing embolic agents: work in progress.

OBJECTIVES: To develop an ex- vivo perfusion flow model using a bovine kidney for future testing of embolic agents in an inexpensive and easy way. METHODS: Six bovine adult kidneys were used for this study. Kidneys were cannulated and perfused via a roller pump. Three embolic agents, coils, Gelfoam, and a glue mixture of Histoacryl + Lipiodol, were deployed by targeting three secondary segmental arteries per kidney via a 5Fr catheter under fluoroscopic guidance. Cannulation time, success rate of segmental artery selection and embolic agent deployment, total operational time, and fluoroscopy dose were recorded. RESULTS: Average kidney weight was 0.752 +/- 0.094 kg. All six bovine kidneys were successfully cannulated in 21.6 min +/- 3.0 min. Deployment of coils and glue was achieved in every case (12/12); however, Gelfoam injection was not successful in one instance (5/6, 83%). Coil deployment demonstrated no embolic effect while Gelfoam and glue injections demonstrated decreased distal contrast filling post-embolization. Mean dose area product was 12.9 ± 1.8 Gy·cm2, fluoroscopy time was 10 ± 4 min and operational time was 27 ± 8 min. CONCLUSIONS: We describe the creation of an ex vivo bovine kidney flow model for the preclinical evaluation of different embolic materials. The flow model can be modified to provide extensive bench testing and it is a promising tool for hands -on training in basic and advanced embolization techniques .

Evaluation of Integrated Interventional Radiology Residency Websites.

RATIONALE AND OBJECTIVES: In the transition to the integrated interventional radiology residency model, residency websites are important resources of program information for prospective applicants. The objective of this investigation was to evaluate the availability and comprehensiveness of integrated interventional radiology residency websites. MATERIALS AND METHODS: A complete list of programs participating in the 2018 integrated interventional radiology match was collected using the online Fellowship and Residency Electronic Interactive Database and Electronic Residency Application Service. Residency program websites were evaluated for the presence of 19 variables related to resident education and recruitment, and the percent comprehensiveness of each website was calculated based on the number of variables present. The effect of program size and geographic region on website availability and comprehensiveness was assessed. RESULTS: Of the 69 programs participating in the 2018 match, 18 (26%) programs did not have any locatable website. Of the 51 programs with websites, 30 (59%) had stand-alone interventional radiology websites distinct from the associated diagnostic radiology website. Large programs were more likely to have a residency website than small programs (91% versus 54%, p=0.001). Across all categories, the mean website comprehensiveness was 33%. Mean website comprehensiveness of programs in the Midwest (43%) and Northeast (37%) was significantly greater than mean website comprehensiveness of programs in the West (19%) (p=0.005). CONCLUSION: Overall, 1 in 4 integrated interventional radiology residency programs did not have locatable websites. Many integrated interventional radiology residency websites lack important content variables. Efforts should be made to improve the residency websites and digital training resources for prospective interventional radiology applicants and to help showcase programs in the best light.

Development of a Multidisciplinary Pediatric Surgery Fellowship.

With the rapidly changing landscape of medicine, physician assistants (PAs) have solidified their role as integral members of nearly every medical field. As PAs become leaders in smaller, more specialized fields, their duties encompass skills that they had not been exposed to in the broad, comprehensive, standard PA education. Consequently, participation in postgraduate PA education has rapidly expanded to keep up with the demand for additional training. Postgraduate PA education, frequently called "residencies" or "fellowships," offers additional specialized, hands-on, supervised clinical training along with continued didactic teaching on advanced topics. These programs offer distinct training advantages over on-the-job training. This article discusses the process of developing the Texas Children's Hospital Surgery Physician Assistant Fellowship Program and provides a framework for the development of similar programs around the country. Topics include the rationale for conception, curriculum development, applicant recruitment, and challenges along the way.

Fusobacterium Nucleatum: Atypical Organism of Pyogenic Liver Abscess Might be Related to Sigmoid Diverticulitis.

CONTEXT: Pyogenic liver abscesses (PLAs) are the most common form of liver abscesses in the United States. Most cases are caused by enteric bacteria and anaerobes. We report a case of PLA caused by a rare pathogen, Fusobacterium nucleatum, from an unusual primary site of infection. CASE REPORT: A 60-year-old male presented with subacute fever. Initial work-up revealed leukocytosis and elevated alkaline phosphatase (ALP). Dental examination and Panorex x-ray were normal. Imaging of the liver with abdominal computed tomography demonstrated a 5.5 cm abscess in the right lobe of the liver. Culture of the aspirate grew Fusobacterium nucleatum. He improved with abscess drainage and antibiotic therapy with moxifloxacin and metronidazole. Colonoscopy performed a few weeks later, demonstrated sigmoid ulceration most likely from the previous diverticulitis. CONCLUSION: PLAs can be a complication of sigmoid diverticulitis and as a result of occult dental disease as well. The clinical presentation of Fusobacterium infection is diverse and can be fatal if diagnosis is delayed. Therefore, early diagnosis and treatment are the keys to preventing serious complications.

Prenatal Identification of Pierre Robin Sequence: A Review of the Literature and Look towards the Future.

Fetal ultrasonography is an important tool used to prenatally diagnose many craniofacial conditions. Pierre Robin sequence (PRS) is a rare congenital deformation characterized by micrognathia, glossoptosis, and airway obstruction. PRS can present as a perinatal emergency when the retropositioned tongue obstructs the airway leading to respiratory compromise. More predictable and reliable diagnostic studies could help the treating medical team as well as families prepare for these early airway emergencies. The medical literature was reviewed for different techniques used to prenatally diagnose PRS radiologically. We have reviewed these techniques and suggested a possible diagnostic pathway to consistently identify patients with PRS prenatally.

False positivity of monospot test in an immunocompetent elderly woman with acute cytomegalovirus infection.

A 75-year-old woman presented with altered mental status, septic picture, and influenza-like symptoms. Initial investigations revealed atypical lymphocytosis, thrombocytopenia, elevated liver enzymes, and a positive monospot test result. Further investigation showed the Epstein-Barr virus viral capsid antibody IgM/IgG and Epstein-Barr virus DNA by polymerase chain reaction to be negative; however, interestingly her cytomegalovirus (CMV) IgM and IgG were positive, suggesting that her mononucleosis-like syndrome was due to acute CMV infection. Herein, we report the first case of a heterophile-positive mononucleosis syndrome caused by acute CMV infection in an elderly immunocompetent woman. This case conveys that monospot test can yield false-positive result in the setting of acute CMV infection.

A systematic examination of the effect of tissue glues on rhytidectomy complications.

BACKGROUND: Fibrin glue has widespread use in multiple fields of surgery. There have been numerous studies on the use of fibrin glue in facelifts, with no consensus regarding differences in outcomes. OBJECTIVES: This study compared the risk of hematoma, seroma, and the 24-hour drainage volume in all published prospective controlled trials. METHODS: A MEDLINE search of English-language articles on fibrin glue and rhytidectomy published up to July 2013 yielded 49 citations. After screening, we examined 7 relevant controlled trials. The DerSimonian and Laird random-effects model was used to perform the meta-analysis. RESULTS: Seven controlled trials measuring the outcomes of fibrin glue in facelifts were used to estimate the pooled relative risk of complications and confidence intervals. Hematoma formation was four times less likely with the use of fibrin glue (relative risk 0.25, P = .002). There was no significant reduction in seroma formation (relative risk 0.56, P = .19). There was not enough data to properly measure 24-hour drainage and ecchymoses. CONCLUSIONS: This analysis suggests that fibrin glue reduces the rates of hematoma formation, but does not significantly reduce the rates of seroma development. LEVEL OF EVIDENCE: 3 Therapeutic.

Unveiling the hidden eagle: acute parotitis-induced eagle syndrome.

CONTEXT: A cervicofacial pain and foreign body sensation in pharynx associated with styloid process elongation is called Eagle syndrome. Typically, this syndrome is provoked by tonsillectomy or trauma. We report the first case of acute parotitis-induced Eagle syndrome. CASE REPORT: A 65-year-old woman presented with right facial pain. CT scan of neck revealed asymmetric enhancement of the right parotid gland compatible with acute parotitis. All inflammation was resolved with antibiotics. However, the patient complained of pain in right mandibular region out of proportion to inflammation. Review CT found to have an asymmetrically long right styloid process measures. The diagnosis of acute parotitis-induced Eagle syndrome was established. CONCLUSION: Physicians should have a high index of suspicion for Eagle syndrome in patients with atypical neck pain and elongated styloid process since another significant manifestation of Eagle syndrome is carotid artery compression leading to recurrent syncope or stroke.

A critical review of the classic metaphyseal lesion: traumatic or metabolic?

OBJECTIVE: The purpose of this study was to review the hypothesis that classic metaphyseal lesions represent traumatic changes in abused infants and compare these lesions with healing rickets. MATERIALS AND METHODS: Using a PubMed search, a multidisciplinary team reviewed studies that reported the histopathologic correlation of classic metaphyseal lesions. Selective studies of growth plate injury and rickets were cross-referenced. RESULTS: Nine identified classic metaphyseal lesion studies were performed by the same principal investigator. Control subjects were inadequate. Details of abuse determination and metabolic bone disease exclusion were lacking. The presence of only a single radiology reviewer prevented establishment of interobserver variability. Microscopy was performed by two researchers who were not pathologists. Classic metaphyseal lesions have not been experimentally reproduced and are unrecognized in the accidental trauma literature. The proposed primary spongiosa location is inconsistent with the variable radiographic appearances. Classic metaphyseal lesions were not differentiated from tissue processing artifacts. Bleeding and callus were uncommon in spite of the vascular nature of the metaphysis. The conclusion that excessive hypertrophic chondrocytes secondary to vascular disruption were indicative of fracture healing contradicts the paucity of bleeding, callus, and periosteal reaction. Several similarities exist between classic metaphyseal lesions and healing rickets, including excessive hypertrophic chondrocytes. "Bucket-handle" and "corner fracture" classic metaphyseal lesions resemble healing rickets within the growth plate and the perichondrial ring, respectively. The age of presentation was more typical of bone fragility disorders, including rickets, than reported in prior child abuse series. CONCLUSION: The hypothesis that classic metaphyseal lesions are secondary to child abuse is poorly supported. Their histologic and radiographic features are similar to healing infantile rickets. Until classic metaphyseal lesions are experimentally replicated and independently validated, their traumatic origin remains unsubstantiated.

Hospitalized Patients' Perceptions of Resident Fatigue, Duty Hours, and Continuity of Care.

BACKGROUND: Physicians' perceptions of duty hour regulations have been closely examined, yet patient opinions have been largely unstudied to date. OBJECTIVE: We studied patient perceptions of residency duty hours, fatigue, and continuity of care following implementation of the Accreditation Council for Graduate Medical Education 2011 Common Program Requirements. METHODS: A cross-sectional survey was administered between June and August 2013 to inpatients at a large academic medical center and an affiliated community hospital. Adult inpatients on teaching medical and surgical services were eligible for inclusion in the study. RESULTS: Survey response rate was 71.3% (513 of 720). Most respondents (57.1%, 293 of 513) believed residents should not be assigned to shifts longer than 12 hours, and nearly half (49.7%, 255 of 513) wanted to be notified if a resident caring for them had worked longer than 12 hours. Most patients (63.2%, 324 of 513) believed medical errors commonly occurred because of fatigue, and fewer (37.4%, 192 of 513; odds ratio, 0.56; P < .01) believed medical errors commonly occurred as a result of transfers of care. Given the choice between a familiar physician who "may be tired from a long shift" or a "fresh" physician who had received sign-out, more patients chose the fresh but unfamiliar physician (57.1% [293 of 513] versus 42.7% [219 of 513], P < .01). CONCLUSIONS: In a survey about physician attributes relevant to medical errors and patient safety, adult inpatients in a large and diverse sample reported greater concern about fatigue and working hours than about continuity of care.

Report of a family with idiopathic knuckle pads and review of idiopathic and disease-associated knuckle pads.

Knuckle pads are a rare, frequently overlooked, thickening of the skin usually overlying the extensor surface of the proximal interphalangeal joints. They are well- circumscribed, benign lesions that generally do not require treatment. Idiopathic knuckle pads must be differentiated from similar appearing lesions or trauma-induced pseudo-knuckle pads. Knuckle pads have been observed in association with autosomal dominant conditions such as Bart-Pumphrey syndrome, Dupuytren's contracture, Ledderhose disease, and Peyronie's disease. To the best of our knowledge, idiopathic familial knuckle pads have not previously been described in the English language literature. We describe a sister and brother with familial idiopathic knuckle pads with no associated conditions.

Pulmonary blastomycosis: a new endemic area in New York state.

We describe three cases of pulmonary blastomycosis in patients from central New York State (NYS). Two of these cases occurred in 2012, and in patients who resided in the same county. Moreover, two of these cases manifested with acute respiratory distress syndrome and survived. Interestingly, one of the two received corticosteroids and was extubated within 1 week. To the best of our knowledge, these are the first cases of human blastomycosis to be reported from NYS and we propose that corticosteroids administration might reduce hospitalisation time and ventilator-associated complications, even though it is not currently recommended in standard treatment.