Polyarticular Septic Arthritis Secondary to Septic Thrombophlebitis of the Brachiocephalic Vein: A Rare Case Report.

BACKGROUND: Polyarticular septic arthritis (PASA) accounts for approximately 15% of all septic arthritides and is rare in immunocompetent adults. Even with appropriate therapy PASA's mortality rate is nearly 50%. CASE REPORT: We report a rare presentation of PASA caused by idiopathic septic thrombophlebitis of the brachiocephalic vein in an immunocompetent adult female patient who presented with symptoms of right clavicular, left wrist, and right hip pain associated with fevers. Methicillin-sensitive Staphylococcus aureus was isolated in blood cultures and joint aspiration of one of the affected hips. Transesophageal echocardiogram was negative for valvular vegetations and computed tomography chest with contrast revealed thrombi in the brachiocephalic and subclavian veins extending to the superior vena cava. It also showed bilateral pulmonary nodules consistent with septic pulmonary emboli. No clear precipitant for the underlying septic thrombophlebitis was identified. Management was conservative, with systemic anticoagulation and IV antibiotics. The patient's symptoms improved, and she was discharged to subacute rehabilitation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early diagnosis and treatment of PASA in the emergency department is imperative to reducing overall morbidity and mortality associated with this condition. To the best of our knowledge, this is the only case report of idiopathic septic thrombophlebitis of the subclavian vein causing PASA in an immunocompetent adult.

Can a Woman of Color Trust Medical Education?

In this Invited Commentary, the author-a second-generation immigrant, a first-generation college graduate, and a woman of color-reflects on the experiences during medical school that shaped her trust in the medical education system. She describes her reasons for entering medicine-to become the kind of doctor she wished she had had growing up. Then she considers how the words physicians use with patients and to talk about patients, which can reinforce problematic narratives and indicate complicity with structural injustices, negatively affect the care they provide. Trainees learn what is acceptable behavior from this hidden curriculum, perpetuating these harmful practices. The author challenges readers to consider how leaders in medical education can work to change this culture to create an education system that trains a physician workforce that keeps patients' voices and experiences at the center of their care and serves the needs of all patients, regardless of their identities.

Hospital-based maternity care practitioners' perceptions of doulas.

INTRODUCTION: A birth doula provides continuous informational, physical, and emotional support during pregnancy, labor, and immediately postpartum. Existing data on the benefits of doulas, especially for low-resource, high-need patients, do not address how and why individual practitioners decide to recommend this model of care. This project aims to describe best practices of integrating doulas into hospital-based maternity care teams to facilitate access to this evidence-based service for improving maternal health outcomes. METHODS: Semi-structured interviews using open-ended questions were conducted in person with 47 maternity care practitioners-OB/GYNs, family medicine physicians, RNs, and nurse-midwives-across three hospitals. Interview analysis was conducted using the Template Organizing Style qualitative analysis approach. RESULTS: Results demonstrated varied support for doula care given practitioners' experiences. Positive experiences centered on doulas' supportive role and strong relationships with patients. Some conflicts between practitioners and doulas may stem from a cross-cultural divide between mainstream obstetric/physician culture and a natural birth "counter culture." Suggestions to facilitate good working relationships centered on three overlapping themes: mutual respect between doulas and hospital staff, education about doulas' training, and clarification of roles on maternity care teams especially among staff with overlapping roles. CONCLUSIONS: Among maternity care practitioners, some frustration, anger, and resentment persist with respect to work with doulas. Adequate staff training in the doula model of care, explicit role definition, and increasing practitioner exposure to doulas may promote effective integration of doulas into hospital maternity care teams.