Teaching & Learning Tips 11: Teaching a procedure.

Challenge: Balancing patient-centered clinical care with learner-centered teaching in a clinical setting becomes particularly challenging when it comes to teaching procedures to trainees (e.g. biopsies, excisions, etc.). How can procedures be taught in a way that reinforces repetition and mastery without compromising patient safety, care, and comfort?

Severe Human Granulocytic Anaplasmosis With Significantly Elevated Ferritin Levels in an Immunocompetent Host in Pennsylvania: A Case Report.

Human granulocytic anaplasmosis (HGA) is a tick-borne, infectious disease caused by Anaplasma phagocytophilum that generally presents with nonspecific symptoms such as fever, chills, headache, malaise, and myalgia. If not treated immediately, HGA can cause hemophagocytic lymphohistiocytosis (HLH), a well-documented but underrecognized sequela of severe HGA. In this article, we report a case of severe HGA with hyperferritinemia in a 74-year-old male from Central Pennsylvania who initially presented with recurrent fevers, nausea, and malaise to our emergency department and was subsequently discharged home that same day. Ten days later, the patient returned with acute kidney injury, elevated liver transaminases, and profound hyperferritinemia to 5130 ng/mL. Empiric doxycycline was administered for suspected tick-borne disease and serologies eventually came back positive for anti-Anaplasma phagocytophilum antibodies. The patient returned to baseline status 15 days after discharge. Our case shows the challenges in the timely diagnosis of HGA and highlights the role of serum ferritin in aiding this diagnosis. Although our patient did not fulfill the HLH diagnostic criteria, our report demonstrates the importance of recognizing HGA as a reversible cause of HLH.

Treatment of multiple unresectable basal cell carcinomas from Gorlin-Goltz syndrome: a case report.

BACKGROUND: Nevoid basal cell carcinoma syndrome (NBCCS), which is also known by other names, including Gorlin-Goltz syndrome and multiple basal-cell carcinoma (BCC) syndrome, is a rare multi-systemic disease inherited in a dominant autosomal manner with complete penetrance and variable expressivity. The main clinical manifestations include multiple BCCs, odontogenic keratocysts of the jaw, hyperkeratosis of the palms and soles, skeletal abnormalities, intracranial calcifications and facial deformities. PATIENTS AND METHODS: A 31-year-old male diagnosed with Gorlin-Goltz syndrome with multiple unresectable facial BCCs was treated with the Hedgehog inhibitor vismodegib. RESULTS: After one month of therapy on vismodegib, there were significant reductions in the size of multiple BCCs on the patient's face. The patient remains on this therapy. CONCLUSION: Hedgehog pathway inhibition is an effective strategy to treat unresectable BCCs from Gorlin-Goltz syndrome. Although vismodegib shows some promising clinical results in the early phase of its use, there are concerns of possible resistance developing within months. Duration of therapy, role of maintenance treatment and drug modification to reduce resistance need to be explored in future case studies.

Seizure incidence by treatment pressure in patients undergoing hyperbaric oxygen therapy.

INTRODUCTION: Hyperbaric oxygen (HBO2) therapy uses different maximum treatment pressures. A side effect of HBO2 is oxygen toxicity seizure. The purpose of this study was to determine the overall incidence of oxygen toxicity seizure and assess risk at different treatment pressures. METHOD: A retrospective chart review was performed on patients who underwent HBO2 at a university hospital and at an outpatient center. Statistical analysis was performed to determine overall incidence of seizure and identify risk factors including maximum treatment pressure. RESULTS: A total of 931 patients were identified representing a total of 23,328 treatments. The overall incidence of seizure was one in 2,121 treatments (five per 10,000). There were zero per 10,000 at 2.0 atmospheres absolute/atm abs (0/16,430), 15 per 10,000 at 2.4/2.5 atm abs (1/669) and 51 per 10,000 at 2.8 atm abs (1/197). There was a statistically significant difference for seizure between the different pressures (χ2 (2, 23,540) = 31.38, p < .001). DISCUSSION: The overall incidence of oxygen toxicity seizure in this study is consistent with recent reports. This study demonstrated a statistically significant increased risk of seizure with increasing treatment pressure. Treatment at higher pressure should be chosen based on demonstrable benefit with a clear understanding of increased risk with higher pressure.