A Patient With Pancoast Tumor Presenting With Cervical Radiculopathy: A Case Report.

Objective: The purpose of this report was to describe a patient with a Pancoast tumor who presented for chiropractic care with neck and arm pain. Clinical Features: A 52-year-old male patient with right-sided cervicothoracic pain and numbness in the right upper extremity presented to a chiropractic office for care. The patient reported an occupational history of repetitive lifting motions and overuse injuries. The patient denied history of smoking at the time of presentation. Intervention and Outcome: Radiographic imaging revealed tracheal deviation. A chest computed tomography image demonstrated a large lesion in the apex of the right lung, suggestive of bronchogenic carcinoma. The patient was referred to an oncology clinic, where he admitted to having a 20-year history of smoking. The diagnosis of adenocarcinoma was made via biopsy, and the oncologist's evaluation confirmed the cancer to be stage IIIC. The patient received palliative care treatments, as the advanced state of his condition determined that he was not a candidate for surgical intervention. Conclusion: Chiropractors and other first-contact health care providers must keep in mind unusual presentations masquerading as common conditions. This case demonstrates the importance of including apical lung tumors in the differential diagnosis of unilateral arm and neck pain and neurologic deficits of the upper extremity. This case demonstrates the importance of thorough follow-up on images ordered, including the ordering clinicians viewing the images themselves.

An estimate of diapycnal nutrient fluxes to the euphotic zone in the Florida Straits.

A recent hydrographic survey of the Florida Current at 27°N revealed an enhanced upward flux of nutrients along the Florida coast. Geostrophic flow of the Gulf Stream through the narrow Florida Straits causes an uplift of the nutricline toward its western edge, shoaling the mixed layers into the base of the euphotic zone. At a nearshore station, nitrate, phosphate, and silicate concentrations reached 19, 1.4, and 10 µM, respectively, at a water depth of 27 m. Furthermore, nutrient vertical gradients below the mixed layer increased with decreasing seafloor depth toward the Florida coast. The estimated vertical eddy diffusive nutrient fluxes across diapycnal surfaces reached 0.40-83.7, 0.03-6.24, and 0.24-45.5 mmol m-2 d-1 for nitrate, phosphate, and silicate, respectively, along the shore. Estimated fluxes span a wide range due to the range of diffusivity measured. The lower end of estimated fluxes are comparable to open ocean values, but higher end of estimates are two orders of magnitude greater than those observed in open ocean. The diapycnal nutrient fluxes declined rapidly offshore as a result of decreasing vertical gradients of nutrient concentration.

Tumor imaging instruction and assessment at chiropractic colleges in North America: a pilot study with implications for National Board of Chiropractic Examiners content.

OBJECTIVE: This pilot study tested a survey instrument pertaining to the instruction and assessment of tumor imaging in chiropractic training programs. The secondary purpose was to gather data regarding credentials of lead instructors, textbook and resource use, and tumors taught and assessed. METHODS: An electronic survey was distributed to lead tumor imaging instructors at all chiropractic colleges in the United States and Canada. A focus group of tumor imaging instructors was conducted to clarify ambiguous data. RESULTS: Diplomate status with the American Chiropractic Board of Radiology was held by 87.5% of the instructor respondents. There were similarities in course content and assessment across institutions. A total of 26 tumors were considered clinically significant by more than 65% of instructors, 9 tumors were identified as not clinically significant by more than 65%, and 4 tumors were considered clinically significant by 35% to 65% of instructors. There was correlation between those instructors who evaluated on various tumors and those who feel it is important to evaluate such tumors (rS = 0.94, p < .001). The focus group addressed the 4 equivocal tumors and recommended 3 be added to the list of clinically insignificant tumors. CONCLUSION: The survey instrument is ready to be used to conduct a study of all clinical areas of the chiropractic curriculum. A total of 12 tumors were recommended for removal from National Board of Chiropractic Examiners tests. The authors recommend that the Academics Committee of the American Chiropractic Board of Radiology share information regarding learning libraries to allow for a richer learning experience across all campuses.

Presumptive Late-Onset Ankylosing Spondylitis Simulating Osteoblastic Skeletal Metastasis in a Patient With a History of Prostate Carcinoma: A Diagnostic Challenge.

OBJECTIVE: The purpose of this report is to present a presumptive case of ankylosing spondylitis with late stage progression that simulated osteoblastic metastasis in a patient with a history of prostate carcinoma. CLINICAL FEATURES: A 67-year-old white man presented to a chiropractic clinic complaining of severe and worsening acute low back pain and right foot "numbness." Further questioning also revealed a history of prostate carcinoma. INTERVENTION AND OUTCOME: Imaging examination revealed a sclerotic pedicle and increased uptake of radiopharmaceutical on a nuclear medicine bone scan highly suggestive of osteoblastic skeletal metastasis. Further evaluation, however, revealed that the bone sclerosis was not the result of skeletal metastasis, but more consistent with a seronegative spondyloarthritis such as ankylosing spondylitis. CONCLUSION: This report describes a presumptive case of ankylosing spondylitis simulating skeletal metastasis in a patient with a past medical history of prostate cancer. This atypical presentation illustrates the inherent uncertainty of diagnosis and how that uncertainty can be challenging in clinical practice. It also reinforces that it is critical for healthcare providers to consider a wide spectrum of differential diagnoses to avoid misdiagnoses and inappropriate interventions.

Contrasting patient, family, provider, and societal goals at the end of life complicate decision making and induce variability of care after trauma.

BACKGROUND: End-of-life (EoL) decision making during critical illness and injury is important in facilitating compassionate care that is congruent with patient, family, and societal expectations. Herein, we evaluate factors that may effect and induce variability in practitioner EoL decision making, particularly years in practice, use of advance directives (ADs), and cost. METHODS: An anonymous, online survey was offered to all active members of the Eastern Association for the Surgery of Trauma (n = 1,359) in June 2012. Demographic information and a series of questions dealing with common potentially influential factors were included. Responses were 5-point Likert scale based. RESULTS: A total of 375 responses (27.6%) were received. Ninety-two percent of the respondents were physicians, 70% were male, and 77% were from Level 1 trauma centers. Of respondents, 65.8% rely on family to make EoL decisions most or all of the time, while 80.7% feel family members are rarely or only sometimes in appropriate emotional states to make such choices. A significant number of practitioners felt comfortable making decisions without family input at all, more so with experienced practitioners as compared with those in practice for less than 15 years (38.2% and 24.1% respectively, p < 0.01).Of the practitioners, 59.6% rely on ADs most or all of the time, only 61.1% agree or strongly agree that ADs are useful, and only 56.3% feel families follow their loved one's ADs most or all of the time. A patient's family support or ability to pay for aftercare was rarely or never considered important by 80.1% of the practitioners, despite 85.1% reporting that quality of life postillness/injury was important most or all of the time. CONCLUSION: Practitioner comfort and motivation to influence EoL decision making varies with experience level. ADs are not uniformly perceived to be helpful, and costs are uncommonly considered. To improve EoL quality, these factors need to be considered. LEVEL OF EVIDENCE: Care management study, level IV.

Carbon dynamics of Florida Bay: spatiotemporal patterns and biological control.

Carbon dynamics of Florida Bay is manifested by wide ranges of pH (7.65-8.61), dissolved inorganic carbon (DIC, 929-3223 µM) and partial pressure of CO2 (pCO2, 50-1313 µatm) observed over seven years. Despite the seasonal variation, a decline of -0.0066 pH per year was observed as a result of ocean acidification and the spatiotemporal patterns were consistent with known biological processes in the bay. Microbial respiration of organic matter produced high pCO2, resulting in Florida Bay being a CO2 source to the atmosphere during winter and spring. In summer, cyanobacteria blooms developed in the north central bay drew down pCO2, causing bloom waters to become a CO2 sink while the nonbloom waters shrunk but remained a CO2 source. The maxima local CO2 fluxes were 36.4 ± 10.5 and -14.0 ± 5.6 mmol m(-2) d(-1) for the source and sink region, respectively. Cyanobacteria blooms modulated the interannual variation in bay-wide CO2 net flux, which averaged 7.96 × 10(9) ± 1.84 × 10(9) mol yr(-1). Extensive cyanobacteria blooms in 2009 resulted in a 50% reduction in the net CO2 flux as compared with 2010 when a minimal cyanobacteria bloom occurred.

Evaluating the incidence of leukopenia and neutropenia with valproate, quetiapine, or the combination in children and adolescents.

BACKGROUND: At the Austin State Hospital, Austin, TX, a number of cases of neutropenia and leukopenia have been observed in children and adolescents who were treated with the combination of valproate and quetiapine. Use of this combination has raised concerns regarding an increased risk of hematologic toxicity. OBJECTIVE: To evaluate the incidence of leukopenia and neutropenia associated with the use of valproate, quetiapine, or the combination in the child and adolescent population. METHODS: This study was a retrospective evaluation of patients from the child and adolescent psychiatric service of the Austin State Hospital who were treated with valproate, quetiapine, or the combination. Subjects were selected from patients discharged between August 1, 2004, and August 31, 2007. Laboratory data were evaluated to determine the incidence and severity of leukopenia and neutropenia associated with valproate, quetiapine, and a combination of the 2. RESULTS: A total of 131 patients were included in the study. Analysis of the laboratory data revealed a combined incidence of neutropenia and/or leukopenia of 44%, 26%, and 6% in the combination group, valproate monotherapy group, and quetiapine monotherapy group, respectively. Differences in the incidence of neutropenia and/or leukopenia between the quetiapine monotherapy group and valproate monotherapy group, as well as the quetiapine monotherapy group and the combination group reached statistical significance. A significant difference was found among groups based on absolute neutrophil count Common Toxicity Criteria severity (p < 0.001). The combination group differed significantly in incidence of moderate-to-severe neutropenia (14 cases) from both the valproate (5 cases) and quetiapine (0 cases) monotherapy groups. A significantly greater number (44%) of African American patients experienced neutropenia and/or leukopenia than white (not Hispanic or Latino; 29%) or Hispanic or Latino (11%) patients. CONCLUSIONS: Patients treated with valproate or the combination of valproate and quetiapine should be monitored for the occurrence of leukopenia and neutropenia. Controlled studies are warranted to examine possible pharmacokinetic and pharmacodynamic interactions with the combination of valproate and quetiapine to further evaluate the hematologic findings of this study.

Effectiveness and tolerability of aripiprazole in child and adolescent inpatients: a retrospective evaluation.

The objective of this study was to evaluate the effectiveness and tolerability of aripiprazole use in child and adolescent psychiatric inpatients. This was a naturalistic, retrospective evaluation of the discharged patients treated with aripiprazole on the child and adolescent unit at the Austin State Hospital. To be included, patients had to be <18 years of age and treated with aripiprazole for at least two consecutive weeks during their hospital stay. We used a chart extracted Clinical Global Impression of Improvement, and a chart extracted Clinical Global Impression of Severity of Illness score to determine their effectiveness. Adverse events and side effects recorded in the physician or nursing notes were collected to establish tolerability. Forty-five patients met the criteria and were included in this analysis. Average clinical global impression of severity of illness scores at baseline and endpoint were 5.04+/-0.91 and 3.33+/-1.24 respectively. This difference was statistically significant (Wilcoxon's signed-rank test: Z=-5.179, P<0.001). Fifty-one percent of the youth had a clinical global impression of severity of illness score that was much improved or very much improved (clinical global impression of improvement score of 1 or 2). Significant reduction in clinical global impression of severity of illness scores suggests a decline in the symptom severity for patients treated with aripiprazole. On the basis of the reported adverse events and side effects, aripiprazole was generally well tolerated. Randomized controlled trials of aripiprazole in childhood mental disorders are warranted.

Quantitation of neurite growth parameters in explant cultures using a new image processing program.

An interactive image processing program was developed to quantify the effects of various biochemical and physical factors on cultured explants of nerve tissue. We used this method to obtain a growth curve of chick embryo dorsal root ganglia (DRG) in media containing various concentrations of nerve growth factor (NGF). In the past, neurite lengths and numbers were measured manually using collages of 35 mm color photographs or made directly under the microscope. Our new program makes it possible to quantify the growth of whole live, unstained DRG's on photograph collages or digital images with respect to center area, neurite area, total explant area, and the number and length of neurites almost exclusive of background artifacts. After comparing the old and new methods, we conclude that our analysis algorithm correlates well with previously accepted protocols for assessing stimulation and inhibition of growth. It rapidly measures several biologically-relevant properties and provides a means to obtain information on six parameters (neurite area, neurite length, neurite number, center area, total area, neurite density) using a single quantitative method. Neurite area in the presence of 10 ng/ml or 20 ng/ml NGF was the most significantly increased parameter as was expected from previous studies since it includes both neurite length and number as well as any crossing fibers.

Similarities and differences in the treatment of spine trauma between surgical specialties and location of practice.

STUDY DESIGN: Questionnaires administered to practicing orthopedic and neurosurgical spine surgeons from various regions of the United States and abroad. OBJECTIVES: To determine similarities and differences in the treatment of spinal trauma. SUMMARY OF BACKGROUND DATA: Spinal trauma is generally referred to subspecialists of orthopedic or neurosurgical training. Prior studies have suggested that there is significant variability in the management of such injuries. METHODS: Questionnaires based on eight clinical scenarios of commonly encountered cervical, thoracic, and lumbar injuries were administered to 35 experienced spinal surgeons. Surgeons completed profile information and answered approximately one dozen questions for each case. Data were analyzed with SPSS software to determine the levels of agreement and characteristics of respondents that might account for a lack of agreement on particular aspects of management. RESULTS: Of the 35 surgeons completing the questionnaire, 63% were orthopedists, 37% were neurosurgeons, and 80% had been in practice for more than 5 years. Considerable agreement was found in the majority of clinical decisions, including whether or not to operate and the timing of surgery. Of the differences noted, neurosurgeons were more likely to obtain a MRI, and orthopedists were more likely to use autograft as a sole graft material. Physicians from abroad were, in general, more likely to operate and to use an anterior approach during surgery than physicians from the northeastern United States. CONCLUSIONS: More commonalities were identified in the management of spinal trauma than previously reported. When found, variability in opinion was related to professional and regional differences.