Thyrotoxicosis and bilateral internal carotid artery dissections.

Cervical artery dissection is a rare but important diagnosis to consider in young patients presenting with stroke. Multiple etiologies of cervical artery dissections have been previously reported, but the association with thyrotoxicosis is extremely rare. A previously healthy 43-year-old female presented to the emergency department with new symptoms related to thyrotoxicosis and bilateral internal carotid artery dissections. Her atrial fibrillation and hypertension resolved by treating the underlying hyperthyroidism with methimazole and propranolol. The bilateral internal carotid artery dissections were managed conservatively with acetylsalicylic acid. Despite an initially poor prognosis, the patient made a complete recovery with resolution of her neurological symptoms.

Routine creatine kinase testing does not provide clinical utility in the emergency department for diagnosis of acute coronary syndromes.

BACKGROUND: Despite the high sensitivity and negative predictive value of contemporary high-sensitivity troponin T assays (hsTnT), creatine kinase (CK) continues to be routinely tested for the diagnosis of acute coronary syndrome (ACS). We conducted a study to identify the clinical utility of routine CK measurement, its relevance in clinical decision making in the era of hsTnT, and the potential cost-savings achievable by limiting its use. METHODS: We conducted a retrospective review of all adult patients presenting to a tertiary care center in the year 2017. We identified patients presenting with cardiac complaints who had non-diagnostic hsTnT and positive CK. These patients underwent chart review to determine whether a diagnosis of AMI was made. RESULTS: A total of 36,251 presentations were reviewed. 9951 had cardiac complaints and 8150 had CK measured. 82% of these patients had hsTnT and CK measured; 2012 of these patients had non-diagnostic hsTnT with positive CK. Of these 2012 patients, only 1 was subsequently diagnosed with AMI (0.012%). CK provided no diagnostic benefit over hsTnT alone in > 99.9% of cases. With a cost for CK of $4/test, we estimated that routine CK testing costs at least $32,000 per year in our center, and over $100,000 per year across the region. CONCLUSION: Routine CK testing does not provide a significant benefit to patient care and therefore represents an unnecessary system cost. Routine CK testing for the diagnosis of AMI should be eliminated from emergency departments in the era of hsTnT assays.

Cadaveric Dissection in Relation to Problem-Based Learning Case Sequencing: A Report of Medical Student Musculoskeletal Examination Performances and Self-Confidence.

Mercer University School of Medicine utilizes a problem-based learning (PBL) curriculum for educating medical students in the basic clinical sciences. In 2014, an adjustment was piloted that enabled PBL cases to align with their corresponding cadaver dissection that reviewed the content of anatomy contained in the PBL cases. Faculty had the option of giving PBL cases in sequence with the cadaveric dissection schedule (sequential group) or maintaining PBL cases out of sequence with dissections (traditional group). During this adjustment, students' academic performances were compared. Students' perception of their own preparedness for cadaveric dissection, their perceived utility of the cadaver dissections, and free-response comments were solicited via an online survey. There were no statistically significant differences when comparing student mean examination score values between the sequential and traditional groups on both multidisciplinary examinations (79.39 ± 7.63 vs. 79.88 ± 7.31, P = 0.738) and gross anatomy questions alone (78.15 ± 10.31 vs. 79.98 ± 9.31, P = 0.314). A statistically significant difference was found between the sequential group's and traditional group's (63% vs. 29%; P = 0.005) self-perceived preparedness for cadaveric dissections in the 2017 class. Analysis of free-response comments found that students in the traditional group believed their performance in PBL group, participation in PBL group and examination performance was adversely affected when compared to students with the sequential schedule. This study provides evidence that cadaveric dissections scheduled in sequence with PBL cases can lead to increased student self-confidence with learning anatomy but may not lead to improved examination scores.

A case of tetanus secondary to an odontogenic infection.

Tetanus is a life-threatening clinical syndrome that commonly presents with muscular spasms, rigidity, and autonomic instability. It is considered rare in industrialized countries, and tetanus occurring secondary to dental abscesses, procedures, or infections has been infrequently reported. We describe the case of a patient inadequately immunized for tetanus, who presented to the emergency department with muscular spasms, rigidity, and autonomic instability in the setting of an odontogenic infection. A clinical diagnosis of tetanus was made and subsequently managed successfully.

Comparison of community-associated and health care-associated methicillin-resistant Staphylococcus aureus in Canada: results of the CANWARD 2007-2009 study.

This study assessed the demographics, antimicrobial susceptibility, and molecular epidemiology of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) and health care-associated MRSA (HA-MRSA) in Canadian hospitals between 2007 and 2009. Among 3589 S. aureus, 889 (24.8%) were MRSA; 224 (25.2%) were CA-MRSA genotypes and 644 (72.4%) were HA-MRSA genotypes. The prevalence of CA-MRSA genotypes increased from 19.5% in 2007 to 31.9% in 2009 (P < .001). CMRSA10/USA300 (73.7%) was the predominant CA-MRSA epidemic type; the most common HA-MRSA epidemic type was CMRSA2/USA100/800 (83.5%). CA-MRSA genotypes carried SCCmec type IVa (98.2%) and were largely agr type I (73.2%). Most HA-MRSA genotypes were SCCmec type II (81.2%) and agr type II (83.4%). Panton-Valentine leukocidin was detected in 201/224 (89.7%) CA-MRSA genotypes and 3/644 (0.5%) HA-MRSA genotypes. An increase in vancomycin minimum inhibitory concentration (MIC) was observed in HA-MRSA genotypes overall, with 1.3% (4/305) of strains in 2007 and 4.6% (7/152) in 2009 exhibiting vancomycin MICs of 2 µg/mL. No MRSA resistance occurred with linezolid, daptomycin, or tigecycline. In conclusion, CA-MRSA genotypes represented 25.2% of all MRSA and continue to increase in prevalence in Canadian hospitals.