Not All Back Pain Is Muscle Strain: A Case of Epidural Abscess.

Epidural abscesses are rare suppurative abscesses of the central nervous system that can expand and lead to severe neurologic complications and even death. Here we describe the case of a 68-year-old female who developed a spinal epidural abscess one month following cervical spinal decompression and fusion. The patient presented with decreased grip strength, flaccid paralysis of the lower extremities with hyporeflexia, urinary incontinence, and decreased sensation in the bilateral lower extremities. A cervical spine MRI revealed a large cervical spinal epidural abscess causing multilevel spinal cord compression that was treated with surgical evacuation and antibiotics. Due to the complications of epidural abscess, we as clinicians must have high clinical suspicion to initiate the correct treatment. In addition, patients without neurological symptoms or symptoms lasting less than 36 hours have the best recovery rate. Our case highlights the importance of timely diagnosis, management, and intervention, which can lead to restored functionality and the prevention of permanent neurologic sequelae.

Safety and efficacy of a COVID-19 treatment with nebulized and/or intravenous neutral electrolyzed saline combined with usual medical care vs. usual medical care alone: A randomized, open-label, controlled trial.

Coronavirus disease 2019 (COVID-19) is currently the major public health problem worldwide. Neutral electrolyzed saline solution that contains reactive chlorine and oxygen species may be an effective therapeutic. In the present study, the treatment efficacy of intravenous and/or nebulized neutral electrolyzed saline combined with usual medical care vs. usual medical care alone was evaluated in ambulatory patients with COVID-19. A prospective, 2-arm, parallel-group, randomized, open-label, multi-center, phase I-II clinical trial including 214 patients was performed. The following two outcomes were evaluated during the 20-day follow-up: i) The number of patients with disease progression; and ii) the patient acceptable symptom state. Serial severe acute respiratory syndrome coronavirus 2 naso/oro-pharyngeal detection by reverse transcription-quantitative (RT-q) PCR was performed in certain patients of the experimental group. Biochemical and hematologic parameters, as well as adverse effects, were also evaluated in the experimental group. The experimental treatment decreased the risk of hospitalization by 89% [adjusted relative risk (RR)=0.11, 95% confidence interval (CI): 0.03-0.37, P<0.001] and the risk of death by 96% (adjusted RR=0.04, 95% CI: 0.01-0.42, P=0.007) and also resulted in an 18-fold higher probability of achieving an acceptable symptom state on day 5 (adjusted RR=18.14, 95% CI: 7.29-45.09, P<0.001), compared with usual medical care alone. Overall, neutral electrolyzed saline solution was better than usual medical care alone. Of the patients analyzed, >50% were negative for the virus as detected by RT-qPCR in naso/oro-pharyngeal samples on day 4, with only a small number of positive patients on day 6. Clinical improvement correlated with a decrease in C-reactive protein, aberrant monocytes and increased lymphocytes and platelets. Cortisol and testosterone levels were also evaluated and a decrease in cortisol levels and an increase in the testosterone-cortisol ratio were observed on days 2 and 4. The experimental treatment produced no serious adverse effects. In conclusion, neutral electrolyzed saline solution markedly reduced the symptomatology and risk of progression in ambulatory patients with COVID-19. The present clinical trial was registered in the Cuban public registry of clinical trials (RPCEC) database (May 5, 2020; no. TX-COVID19: RPCEC00000309).

Influence of BMI, Age, and Gender on the Thickness of Most Common Thinned Flaps.

BACKGROUND: Since the description of superficial fascia flap harvesting, a new window of opportunity has been open in obese patients, where a higher subcutaneous thickness of tissue is present. To our knowledge, the impact of body mass index on superficial fascial flaps has not been reported. METHODS: We recruited 122 patients from April 2019 to January 2020. From these patients, the 3 most common thinned flaps were selected: the superficial circumflex iliac perforator flap; the anterolateral thigh flap at the perforator A, B, and C; and the thoracodorsal flap. Two vertical measures were registered: the distance from the skin to the superficial fascia, and from this point to the deep fascia. RESULTS: The average flap measurement presented here was within the range, as previous clinical studies. The superficial fatty layer thickness in the superficial circumflex iliac perforator and anterolateral thigh flap was somewhat similar in thickness between overweight and obese patients, showing a minimal increase with higher body mass index. The anterolateral thigh flap was found thicker among women, and no statistical difference was shown between age groups in any of the flaps. CONCLUSIONS: A better understanding of the fat layers' thickness will result in better planning, minimizing secondary debulking procedures, decreasing operative time, and reducing general complications among obese patients. Thus, a better understanding of flap structure and physiology in obese patients will lower complications and give more predictable results.

Diferencia de presentación del síndrome coronario agudo por género en pacientes llevados al laboratorio de cateterismo en población dominicana: un estudio retrospectivo / Acute Coronary Syndrome presentation difference by gender in patients taken to catheterization laboratory in Dominican population: A retrospective study

Introducción: el síndrome coronario agudo (SCA) es una serie de signos y síntomas que se refieren a isquemia miocárdica repentina. Estas condiciones clínicas son Síndrome Coronario agudo sin Elevación del Segmento ST (SCASEST) y Síndrome Coronario Agudo con Elevación del Segmento ST (SCACEST). A nivel mundial hay hallazgos controversiales con respecto a la diferencia de presentación de SCA en hombres y mujeres. Objetivo: determinar las diferencias en presentación del síndrome coronario agudo según el género en República Dominicana. Métodos: en este estudio observacional retrospectivo unicéntrico, 3,548 pacientes con SCA llevados al laboratorio de cateterismo fueron observados durante el período de agosto de 2016 a septiembre de 2019. Resultados: la edad promedio de presentación fue mayor en las mujeres, con una media de 63 años (DE ± 12.2). El SCACEST fue más frecuente en hombres (69.35 %) y la Angina Inestable en mujeres (50.14 %, p <0.0001). Angiográficamente, la enfermedad coronaria multivascular fue más común en hombres y la angiografía coronaria normal en mujeres (41.30 % y 35.37 %, p < 0.0001). Conclusión: dentro de la población dominicana, la mujer tiende a ser mayor al momento de presentación de SCA, con menor tendencia a someterse a intervención coronaria terapéutica.

Introduction: Acute Coronary Syndrome (ACS) is a series of signs and symptoms referring to sudden myocardial ischemia. These clinical conditions are: Non-ST-Acute Coronary Syndromes (NST-ACS) and ST-segment Elevation Myocardial Infarction (STEMI). Globally there are controversial findings regarding the difference in SCA presentation in both men and women. Objective: Determine differences in presentation of acute coronary syndrome by gender in the Dominican Republic. Methods: In this retrospective single-centered observational study 3,548 patients with ACS taken to the catheterization laboratory underwent observation, during the time frame of August 2016 to September 2019. Results: The average age of presentation was higher in females, with a mean of 63 years old (SD ± 12.2). STEMI was greater in males (69.35%) and females presented more with UA (50.14%, p<0.0001). Angiography findings showed that multi-vascular coronary artery disease was more common in males and normal coronary angiography more frequent in females (41.30% and 35.37%, p<0.0001). Conclusion: Within the Dominican population, females tend to be older at the time of appearance of ACS with a lower tendency of undergoing coronary intervention.

Spontaneous Gastrojejunal Fistulization after Roux-en-Y Bypass Surgery: A Case Report and Review of Literature.

Fistula development is an uncommon but well-recognized complication following Roux-en-Y gastric bypass (RYGB). The broad spectrum of clinical presentation represents a challenge at the time of diagnosis. We present the case of a patient who developed gastrojejunal fistulization after gastric bypass surgery.

Elevated International Normalized Ratio: A Risk Factor for Portal Vein Thrombosis in Cirrhotic Patients.

BACKGROUND: Portal vein thrombosis (PVT) is a complication that is commonly seen in patients with cirrhosis and an entity that leads to increased mortality in patients who undergo liver transplantation. This study aims to establish a link between an elevated international normalized ratio (INR) and the presence of PVT in a cohort of cirrhotic patients. METHODS: We retrospectively reviewed the electronic medical records of all patients diagnosed with cirrhosis in SBH Health System from 2013 to 2018. Among these patients we extracted baseline demographic data, laboratory results, co-morbidities and the presence of PVT. RESULTS: In total there were 268 patients who met our inclusion criteria. Twenty-two patients had PVT, while 246 patients did not. Of the 22 patients with PVT there was a statistically significant increase in INR when compared to patients without PVT. There was also a statistically significant increase in total bilirubin, alkaline phosphatase and platelet count. CONCLUSIONS: Elevated INR levels are associated with the presence of PVT in patients with cirrhosis. These findings suggest a hypercoagulable state and could assist clinicians in risk-stratifying patients when making the decision to initiate anti-coagulation therapy.

Dynamical modeling of liver Aquaporin-9 expression and glycerol permeability in hepatic glucose metabolism.

Liver is crucial in the homeostasis of glycerol, an important metabolic intermediate. Plasma glycerol is imported by hepatocytes mainly through Aquaporin-9 (AQP9), an aquaglyceroporin channel negatively regulated by insulin in rodents. AQP9 is of critical importance in glycerol metabolism since hepatic glycerol utilization is rate-limited at the hepatocyte membrane permeation step. Glycerol kinase catalyzes the initial step for the conversion of the imported glycerol into glycerol-3-phosphate, a major substrate for de novo synthesis of glucose (gluconeogenesis) and/or triacyglycerols (lipogenesis). A model addressing the glucose-insulin system to describe the hepatic glycerol import and metabolism and the correlation with the glucose homeostasis is lacking so far. Here we consider a system of first-order ordinary differential equations delineating the relevance of hepatocyte AQP9 in liver glycerol permeability. Assuming the hepatic glycerol permeability as depending on the protein levels of AQP9, a mathematical function is designed describing the time course of the involvement of AQP9 in mouse hepatic glycerol metabolism in different nutritional states. The resulting theoretical relationship is derived fitting experimental data obtained with murine models at the fed, fasted or re-fed condition. While providing useful insights into the dynamics of liver AQP9 involvement in male rodent glycerol homeostasis our model may be adapted to the human liver serving as an important module of a whole body-model of the glucose metabolism both in health and metabolic diseases.

Influence of recent immobilization or surgery on mortality in cancer patients with venous thromboembolism.

BACKGROUND: The influence of recent immobilization or surgery on mortality in cancer patients with venous thromboembolism (VTE) has not been thoroughly studied. METHODS: We used the RIETE Registry data to compare the 3-month mortality rate in cancer patients with VTE, with patients categorized according to the presence of recent immobilization, surgery or neither. The major outcomes were fatal pulmonary embolism (PE) and fatal bleeding within the first 3 months. RESULTS: Of 6,746 patients with active cancer and acute VTE, 1,224 (18%) had recent immobilization, 1,055 (16%) recent surgery, and 4,467 (66%) had neither. The all-cause mortality was 23.4% (95% CI: 22.4-24.5), and the PE-related mortality: 2.5% (95% CI: 2.1-2.9). Four in every ten patients dying of PE had recent immobilization (37%) or surgery (5.4%). Only 28% of patients with immobilization had received prophylaxis, as compared with 67% of the surgical. Fatal PE was more common in patients with recent immobilization (5.0%; 95% CI: 3.9-6.3) than in those with surgery (0.8%; 95% CI: 0.4-1.6) or neither (2.2%; 95% CI: 1.8-2.6). On multivariate analysis, patients with immobilization were at an increased risk for fatal PE (odds ratio: 1.8; 95% CI: 1.2-2.5). CONCLUSIONS: One in every three cancer patients dying of PE had recent immobilization for ≥ 4 days. Many of these deaths could have been prevented with adequate thromboprophylaxis.

Venous thromboembolism during pregnancy or postpartum: findings from the RIETE Registry.

Venous thromboembolism (VTE) occurs infrequently during pregnancy, and issues concerning its natural history, prevention and therapy remain unresolved. RIETE is an ongoing registry of consecutive patients with objectively confirmed, symptomatic acute VTE. In this analysis, we compared the clinical characteristics and outcome for all enrolled pregnant and postpartum women with acute VTE, and all non-pregnant women in the same age range. Up to May 2005, 11,630 patients were enrolled in RIETE, of whom 848 (7.3%) were women aged <47 years. Of them, 72 (8.5%) were pregnant, 64 (7.5%) postpartum. Pregnant women presented less often with symptomatic pulmonary embolism (11%) than non-pregnant women (39%). VTE developed during the first trimester in 29 (40%) pregnant patients; in the second in 13; in the third in 30. Thrombophilia tests were more often positive in women who had VTE during the first trimester (odds ratio [OR]: 4.4; 95% CI: 0.9-2.4; p=0.037). Most patients in all three groups were initially treated with low-molecular-weight heparin (LMWH). As for long-term therapy, 75% of pregnant women received LMWH until delivery. There were no maternal deaths, and no pregnant patient had recurrence or bled before delivery. However, after delivery one patient (1.4%) developed recurrent thrombosis, four (5.6%) had major bleeding. In conclusion, VTE developed during the first trimester in 40% of the pregnant women, thus suggesting that thromboprophylaxis, when indicated during pregnancy, should start in the first trimester. No patient showed recurrence or bled before delivery, but after delivery the risk of bleeding exceeded the risk of recurrences.

Which primary care resident is more likely to initiate the discussion of designating a healthcare proxy?

Despite widespread support for the concept of advance care planning, few Americans have a healthcare proxy. It is not known if certain physician characteristics make it less likely that the discussion of a healthcare proxy will be initiated, particularly in the case of physicians in training. The objective of this descriptive, cross-sectional study was to determine if resident characteristics (specialty, race, age, gender, and religion) affect his or her decision to initiate discussions with patients regarding designation of a healthcare proxy. Participants consisted of primary care residents employed at The Brooklyn Hospital Center, Brooklyn, New York, from the departments of Internal Medicine, Pediatrics, Obstetrics and Gynecology, and Family Practice. An anonymous 14-item questionnaire was distributed to all primary care residents (N = 151) at the hospital during their respective conferences and grand rounds. Seventy-eight residents returned the instrument for analysis. When compared to other primary care specialties (n = 40), internal medicine residents (n = 38) were more likely to initiate healthcare proxy discussions with patients (p < 0.05). Residents who were younger than 35 were more inclined to encourage decision-making by surrogates (p < 0.05). Of the total number of residents, 92 percent correctly defined a healthcare proxy, and 66 percent thought a physician should initiate patient selection of a healthcare proxy, yet only 55 percent of physicians did so. Our results indicated that a little over half of the physicians surveyed initiated discussion for a surrogate decision-maker, even though most thought it was their duty. Younger internal medicine residents are more likely to ask patients about healthcare proxies. Some residents were unable to correctly identify the definition of a healthcare proxy, and this lack of knowledge is likely to result in poor advance care planning.

La enseñanza de la patología médica, basada en procesos asistenciales, mejora el aprendizaje de los estudiantes de medicina / Assisted learning methods in the teaching of medical pathology improves medical students' learning

Fundamento: Las facultades de medicina deben definir las competencias que sus estudiantes han de adquirir a lo largo de su formación de pregrado, poner los medios necesarios para asegurar su adquisición y proceder a su evaluación. El objetivo de este estudio es determinar si la enseñanza clínica de la medicina interna, estructurada en objetivos específicos por procesos, mejora el nivel de aprendizaje, comparada con la enseñanza oportunista tradicional. Métodos: Incluimos a 40 estudiantes de la Facultad de Medicina de Córdoba. Al inicio del curso fueron sometidos a un examen, en el que se evaluaron sus conocimientos de medicina interna. Seguidamente, les explicamos los objetivos del 50 per cent de los procesos médicos más prevalentes. Seleccionamos los procesos siguiendo un modelo de aleatorización estratificada. Al final del período de prácticas todos los estudiantes hicieron un examen similar al inicial. El contenido de ambos exámenes se estableció al comienzo del curso de forma aleatoria. Resultados: Tras las prácticas se observó un mayor nivel de conocimientos de los 24 procesos: el número de preguntas correctas se incrementó en un 96 per cent (p < 0,001), y el de preguntas erróneas descendió en un 36 per cent (p < 0,001); la interpretación de las pruebas complementarias aumentó en un 95 per cent (p < 0,001).Conocer los objetivos de aprendizaje se reflejó en un mayor número de respuestas correctas (23 per cent; p < 0,01), y en un menor número de respuestas incorrectas (39 per cent; p < 0,01). Conclusión: La definición de unos objetivos de aprendizaje claros mejora sustancialmente el nivel de conocimientos clínicos que los estudiantes de medicina adquieren (AU)

Endoscopia de la vía biliar y pancreatica

El desarrollo de la endoscopia digestiva ha permitido en los últimos 25 años un estudio detallado de las lesiones intraluminales del tubo digestivo, sobre todo la porcion alta (esófago,estómago y duodeno) así como del colon. Con el invento de la fibra óptica y la construcción de apartos cada vez más flexibles y de luz fría, con gran poder de resolución en la imagen, los avances en la precisión diagnostica y en las posibilidades terapeúticas han sido relevantes

Sangrado del tracto gastrointestinal / Gastrointestinal tract bleeding

Durante el período comprendido entre los años de 1985 y 1989 el servicio de endoscopia digestiva de la Clínica San Pedro Claver de Bogotá practicó un número importante de exámenes endoscópicos demostrándose en un 25 por ciento la presencia de una hemorragia digestiva alta. Confirmándose así la importancia de esta patología. Se revisan en este artículo las diversas causas de sangrado digestiva haciendo énfasis en la elaboración de una buena historia clínica que conduzca obviamente a establecer un diagnóstico acertado. Se enumeran las alternativas de tratamiento existentes de acuerdo al cuadro y sintomatología clínica presentados por el enfermo.

[Sudden deafness in patients undergoing cardiac surgery with extracorporeal circulation]. / Sordera súbita en enfermos sometidos a cirugía cardíaca con circulación extracorpórea.

Between January 1974 and December 1986, 5,975 patients underwent open heart surgery at National Institute of Cardiology "Ignacio Chávez". We reviewed all open heart cases carried out at this Center. Eleven patients (1.8/1000) presented unilateral sudden hearing loss following cardiopulmonary bypass surgery. Pure tone audiograms, speech reception threshold, discrimination testing, tympanometry and stapedius reflex testing were carried out. We then studied the relationship between the auditory deficit and the type of surgical procedure, length of time on the pump, preexisting ear disease, coexistence of diabetes, use of ototoxic drugs and occurrence of hemodynamic complications. There are 3 possible causes for hearing loss in cardiopulmonary bypass: 1) Microembolism from the cardiopulmonary bypass pump to the arteries that supply only the cochlea. 2) Decreasing cerebral flow, or 3) Microhemorrhage of the internal ear. Ototoxic drugs are used frequently, but the hallmark of these drugs is bilateral toxicity, and all the cases under discussion have been unilateral. Unilateral sudden deafness after open heart surgery constitutes another complication, fortunately rare and benign in most cases. Further studies should be undertaken to clarify the pathophysiology of this entity.

Endocarditis infecciosa por brucella en un caso de transposición corregida de las grandes arterias / Infective endocarditis due to Brucella in a case with corrected transposition of great vessels

Se describe el caso clínico de un paciente masculino de 14 años de edad, que desarrolló endocarditis infecciosa por Brucella sp; en presencia de una transposición corregida de las grandes arterias, con estenosis valvular pulmonar e insuficiencia mitral. Durante la evolución de la enfermedad desarrolló vegetaciones bacterianas en válvulas pulmonar y A-V izquierda demostrada por ecocardiograma. Con tratamiento antibacteriano sanó por completo. Dado a la rareza de asociación de brucelosis con endocarditis infecciosa y con presencia de vegetaciones en válvulas cardiacas, decidimos informar el presente caso

[Infectious Brucella endocarditis in a case of corrected transposition of the great arteries]. / Endocarditis infecciosa por brucella en un caso de transposición corregida de las grandes arterias.

We describe a case of a 14 year old male who developed infections endocarditis due to Brucella sp. He had a corrected transposition of great vessels with valvular pulmonary stenosis and mitral insufficiency. Vegetations were demonstrated by echocardiogram on the pulmonary valve as well as on left atrioventricular valve. He had also proliferative nephritis. Prolonged antimicrobial treatment results in complete healing. Because the rarity of this association we inform this observation.