PURPOSE:To describe patterns of fluid flow through locking pigtail and biliary catheters in patients that underwent biliary and abdominopelvic fluid drainage. METHODS:Contrast movement through catheter sideholes in pigtail and biliary catheters was evaluated retrospectively using sinograms and cholangiograms at 7-10 days post insertion. Dilute contrast injected through the catheter was evaluated by following flow through the catheter shaft and exit from side holes within the body cavity. Exit of contrast through side holes was appreciated and recorded. Included patients underwent biliary and abdominopelvic fluid drainage using 10.2-F catheters. Exclusion criteria included masking of contrast flow through sideholes by catheter angulation, contrast pooling or other imaging artifacts. RESULTS:A total of 99 patients meeting inclusion criteria underwent evaluation of contrast flow through pigtail (n = 81) and biliary (n = 18) catheters. For pigtail and biliary catheters, 91/99 cases (91.9%) showed contrast exiting the catheter from only the sidehole located most proximally to the catheter hub. In 6/99 cases (6.1%) contrast exited no further than the second most proximal sidehole. In 2/99 cases (2.0%) contrast exited no further than the third most proximal sidehole. In no cases was contrast observed exiting from distal sideholes beyond the third most proximal sidehole. CONCLUSION:Retrograde contrast injection through catheters suggests that the majority of the contribution to total output in drainage catheters comes from the most proximal side hole. Contribution of distal side holes to total drainage is negligible or non-existent, therefore the distal segment of the catheter may be considered non-functional.
Acute myeloid leukemia (AML) developing in patients with chronic lymphocytic leukemia (CLL) is very uncommon and usually associated with prior treatment. Acute promyelocytic leukemia (APL) accounts for a very small proportion of treatment-associated AML. So far, there has been only one reported case of APL occurring post radiation for prostate cancer in a patient with CLL. We report herein the first case of APL and CLL presenting concomitantly in an untreated patient. Evaluation of peripheral blood and bone marrow aspirate with immunohistochemistry, flow cytometry, and FISH to confirm two morphologically, molecularly and genetically distinct leukemic populations characteristic of APL and CLL is required. APL is a hematologic emergency, and aggressive management is vital to a successful therapeutic outcome. Standard treatment is with All-trans retinoic acid (ATRA) and anthracycline-based regimen, whether the process is de novo or therapy-related. Due to increased incidence of secondary malignancies in CLL patients, active surveillance is necessary.
To determine the level of knowledge of HPV related oropharyngeal cancer and practice patterns of HPV vaccine use by pediatricians.IRB approved 18-question survey was administered to members of the Louisiana Chapter of the American Academy of Pediatrics.We received 116 responses (response rate: 15.9 percent );. 104 respondents (89.66 percent ); routinely recommend/offer HPV vaccine, 6 (5.17 percent ); occasionally or only at caregiver request, and 6 (5.17 percent ); do not offer the vaccine. 17 (15.5 percent ); reported having no awareness of the link between oropharyngeal cancer and HPV, and only 50 (45.9 percent ); had knowledge that HPV-related oropharyngeal cancer incidence was increasing. Strength of recommendation for males and knowledge of HPV-related oropharyngeal cancer were not associated with years in practice, practice type or patient population served.Increased awareness regarding HPV-related oropharyngeal cancers among primary care providers may increase HPV immunization rates, especially in males.
A 72-year-old man presents with left knee pain and swelling over several days. The pain and swelling started after he felt a "pop" when bending to pick up an object off the floor. His past medical history is significant for type 2 diabetes mellitus. Physical exam revealed significant ecchymosis on the anterolateral aspect of the thigh. There was a minimal amount pain upon knee flexion.
CASE:A 54 year old woman with hypothyroidism presented with right flank pain that began acutely one week prior to presentation. She was told initially she had a urinary tract infection and treatment resulted in mild symptomatic improvement. The pain returned and she presented to another Emergency Department (ED); and was told the pain was due to constipation. She returned to the ED the next day when her pain worsened and her labs were notable for WBC of 19,000/uL, BUN/Cr of 28/0.75 mg/dL, AST of 31 U/L, ALT of 92 U/L and total bilirubin of 0.6 mg/dL. RUQ ultrasound was notable for dilation of the common bile duct. Given concern for choledocholithiasis, she was started on cefepime and metronidazole. MRCP demonstrated a distended gallbladder without stones and a small amount of pericholecystic fluid. Also noted were two areas of increased signal in the right kidney, concerning for neoplasia or infarction. Contrasted abdominal Computed tomography showed a moderate size area of hypodensity, consistent with renal infarct. Workup for embolic source of the infarction was unrevealing. Renal artery angiogram demonstrated a spontaneous dissection of the superior branch of the right renal artery. PCI was not performed due to risk of jeopardizing the other vessels and so she was managed medically with rivaroxaban along with hydrochlorothiazide and metoprolol succinate to keep her systolic blood pressure below 140 mmHg. The morning after the procedure, the patient told the treatment team that her grandson liked to jump from a height and she would catch him on her right side. This was felt to be a likely etiology of her spontaneous dissection. At the time of discharge, her pain was improved and repeat angiogram performed eight weeks later noted healing of the dissection.DISCUSSION:Spontaneous renal artery dissection is a rare cause of abdominal pain and often presents a diagnostic and therapeutic challenge. This case highlights the importance of considering alternate etiologies of localized abdominal pain when other common pathologies have been excluded.
A 61-year-old man presented to the emergency department with second degree burns along his right arm and hand. He reported that his knees suddenly gave out while holding a pot of soup resulting in the scalding liquid spilling over his arm. His medical history is significant for alcohol abuse, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure with preserved ejection fraction, chronic knee instability, and degenerative joint disease of the spine.
CASE:A 50 year old African-American woman with diabetes, hypertension, and hyperlipidemia presented with progressively worsening retro-sternal chest pain, exacerbated by activity and relieved by rest. She also endorsed a thirty-pound unintentional weight loss, and dysphagia. She was dysarthric with left-sided Bell's Palsy and a palpable left axillary lymph node. She had been evaluated at several hospitals in the previous months for similar typical chest pain. Her troponin values were normal, and an EKG showed T-wave inversions in leads I and aVL. On echocardiography, her ejection fraction was 45 percent with anterolateral hypokinesis. She was treated for NSTEMI, and an angiogram showed 95 percent stenosis of the right coronary artery. A modified barium swallow study revealed weakened swallowing with aspiration of thin liquids. An MRI Brain demonstrated scattered T2/ FLAIR hyper-intense foci in the subcortical white matter and focal meningeal thickening. ANA, dsDNA, ANCA, and Lyme antibodies were all negative, and a chest CT showed hilar lymphadenopathy. Cardiac MRI demonstrated scattered foci of delayed enhancement in the mid-myocardium and sub-epicardium without infarction. An endobronchial biopsy of hilar lymph nodes showed two small epithelioid granulomas, consistent with Sarcoidosis. She was started on high-dose corticosteroids with rapid improvement. A repeat modified barium swallow study was normal and a repeat echocardiogram demonstrated recovered ejection fraction of 55 percent with improved wall motion in the septum and apex. Additionally, her left-sided Bell's Palsy and dysarthria improved after several days of therapy.DISCUSSION:To our knowledge, this report is the third case of multi-organ Sarcoidosis presenting as ACS. This case depicts the simultaneous presentation of neurologic, pharyngeal, pulmonary, and cardiac Sarcoidosis. Myocardial involvement in Sarcoidosis is rare and usually presents as conduction abnormalities with arrhythmia rather than ACS. Though her symptoms were consistent with Sarcoidosis, she had multiple risk factors for coronary atherosclerosis including diabetes, hypertension, and hyperlipidemia. This case highlights the importance of including Sarcoidosis in the differential diagnosis for patients with recurrent typical chest pain of uncertain etiology.
Acute myeloid leukemia (AML) developing in patients with chronic lymphocytic leukemia (CLL) is very uncommon and usually associated with prior treatment. Acute promyelocytic leukemia (APL) accounts for a very small proportion of treatment-associated AML. So far, there has been only one reported case of APL occurring post radiation for prostate cancer in a patient with CLL. We report herein the first case of APL and CLL presenting concomitantly in an untreated patient. Evaluation of peripheral blood and bone marrow aspirate with immunohistochemistry, flow cytometry, and FISH to confirm two morphologically, molecularly and genetically distinct leukemic populations characteristic of APL and CLL is required. APL is a hematologic emergency, and aggressive management is vital to a successful therapeutic outcome. Standard treatment is with All-trans retinoic acid (ATRA) and anthracycline-based regimen, whether the process is de novo or therapy-related. Due to increased incidence of secondary malignancies in CLL patients, active surveillance is necessary.
A 56 year old African-American man presented to the emergency department with dyspnea and dysphagia with drooling. On his initial evaluation, disproportionate obesity of the face, neck and shoulders were noted. The patient's history was significant for obstructive sleep apnea, end-stage renal disease, alcoholic liver disease, pulmonary hypertension and alcoholic cardiomyopathy. He had multi-decade history of heavy alcohol abuse, but quit drinking two years previously.
INTRODUCTION:Immunotherapy has been approved for treatment of melanoma. Autoimmune endocrinopathies have been reported in trials involving immunotherapy but autoimmune diabetes has not been definitively linked to them. Here we describe a case of autoimmune diabetes presenting with DKA after receiving combined immunotherapy with anti-CTLA4 and anti-PD1 monoclonal antibodies.CASE:A 47year old gentleman with metastatic melanoma presented to our institution with confusion, abdominal pain and decreased oral intake. The patient had a history of diabetes on metformin which was discontinued two years prior. He was started on Novilumab/Iplimumab for metastatic melanoma. He had received two cycles of immunotherapy and treatment was initially well tolerated. However, eight days after the second cycle the patient developed lethargy, confusion, vomiting and abdominal pain. CT of the head was negative for intracranial abnormalities and without evidence of brain metastasis. His laboratory results included: serum sodium 126 mmol/L, potassium 6.7 mmol/L, BUN 55 mg/dL, creatinine 3.5, bicarbonate 5 mmol/L, chloride 94 mmol/L, albumin 3.2 g/dL. Serum beta-hydroxybuterate was elevated (4.7 mmol/L, N: 0.0-0.5 mmol/L) and the calculated anion gap was 43 mmol/L. Serum lipase elevated (535 u/L, N: 4-60 u/L). The diagnosis of diabetic ketoacidosis was made and he was started on intravenous fluids and insulin therapy. Given his history of metastatic melanoma, his DKA was initially thought to be secondary to pancreatic metastasis especially considering the elevated lipase level. A non-contrast CT of the abdomen showed no evidence of pancreatic metastasis. Interestingly, further investigation identified high serum titers of anti-glutamic acid decarboxylase (anti-GAD) antibodies (0.43 nmol/L, N: less than 0.02 nmol/L), a low C-peptide level (0.2 ng/ml, N: 0.9-5.5 ng/ml), supporting an autoimmune etiology of the diabetes. Other islet autoantibodies were not elevated and his Hemoglobin A1C was 8.0 percent .DISCUSSION:There are few case reports about diabetes and immunotherapy. Autoimmune mechanism was suggested as the culprit, although not all cases reported with positive antibodies. Moreover, it is unlikely that patient developed latent autoimmune diabetes (LADA); and not related to immunotherapy due to the course of LADA is quite more gradual and our patient presented with acute DKA few days post the second cycle. Physicians and patients should be aware that autoimmune disorder such as DKA may be a rare but important immunotherapy related adverse events.
CASE:A 51 year old African American Man without significant past history presented with three weeks of persistent cough productive of copious yellow sputum. He denied fevers, chills, hemoptysis, dyspnea, weight or appetite changes, sick contacts, recent travel. On physical examination, the patient was afebrile and appeared comfortable. He had decreased air entry of the left lower lobe with dullness to percussion. A 5x3 cm fluctuant mass was incidentally found on the left anterior chest wall at the level of the 11th rib with yellow expressible exudate at which time the patient reported a minor trauma sustained 3 weeks prior. WBC count was 17,300/mcL. CT chest identified a peripherally enhancing fluid-attenuation structure in the left lower lung measuring 11.8 cm x 11.3 cm x 9.6 cm. The collection appeared to be tracking out from the pleural space to the exterior skin that corresponded to the site of the chest wall swelling. There was also a focal lytic lesion of the adjacent ribs. He was empirically started on Vancomycin, clindamycin and piperacillin-tazobactam. CTguided aspiration failed because the material was too viscous to be aspirated; a chest tube drained copious yellow exudate. Blood cultures and respiratory cultures were negative. Gram stain of the purulent material demonstrated clusters of branching gram positive rods. Pathology showed necrotic debris with clusters of filamentous gram negative organism. Acid fast and Kinyoun stains were negative. He was started on empiric Penicillin G for empyema necessitans with a presumed etiology of actinomyces. Due to development of hypersensitivity drug eruption from PCN, intravenous doxycycline was started for total of 14 days followed by 6 months of oral therapy. Imaging four weeks after treatment showed significant reduction in size of the lesion. Culture confirmed Actinomyces israelii.DISCUSSION:Actinomyces are anaerobic gram positive commensals of the oral cavity notorious to breach though tissue planes. Thoracic manifestations are varied and can mimic malignancy. Astute microbiology and pathology tests are necessary to make an early diagnosis and prevent invasive surgery as the organism is a slow growing anaerobic bacteria. Excellent clinical and radiologic response were noted in our case following treatment with chest wall drainage and antibiotics thus avoiding invasive thoracic surgery.
INTRODUCTION:Tuberous sclerosis complex (TSC); is an autosomal dominant disorder characterized by the formation of hamartomatous lesions in multiple organs, with a birth incidence of around one in 10,000. Although it usually manifests itself in early life, we present a case of an adult woman who we diagnosed with TSC.CASE:A 27 year old woman presented to Emergency Department with worsening right flank pain and progressive dyspnea. Physical examination findings revealed Shagreen patches and multiple angiomyolipomas of the skin. Computed tomography scan of the chest and abdomen was remarkable for pulmonary lymphangioleiomyomatosis and renal angiomyolipomas. Brain imaging revealed multiple subependymal nodules and cortical dysplasias. Subsequent genetic testing later confirmed pathogenic mutation in the TSC2 gene and patient was referred for Genetic counseling and further management.DISCUSSION:Clinical features of TSC continue to be the principal means of diagnosis, with the inclusion of identification of a pathogenic mutation in TSC1 and TSC2 as an independent diagnostic criterion. Affected patients may present early in life with the classic triad of seizures, intellectual disability, and cutaneous angiofibromas, but some findings, notably renal angiomyolipomas and pulmonary lymphangioleiomyomatosis (LAM);, emerge later, placing adults with undiagnosed TSC at increased risk for morbidity and mortality. Recent advances in the treatment of TSC highlight.
CASE:A 48 year-old man with no past medical history was sent to our emergency department (ED); from a primary care clinic for hypertensive urgency of 200/130. The man reported an intermittent non-productive cough of approximately one year's duration and worsening dyspnea on exertion and orthopnea over the last month with lower extremity swelling. Of note, he emigrated from Honduras twenty years ago. Blood pressure normalized with administration of Lasix in the ED. Physical exam revealed rales in lung bases bilaterally, jugular venous distension, lower extremity pitting edema with serpiginous patches of erythema and excoriation, and a cardiac gallop. Labs showed peripheral eosinophilia, thrombocytopenia, elevated creatinine, hyperbilirubinemia, hyperglycemia, and mild transaminitis. Transthoracic echocardiogram revealed a dilated left ventricle with global hypokinesis and severely depressed systolic function with an ejection fraction less than 15 percent . The patient was diuresed, and subsequent left and right heart catheterizations were normal. CT chest showed a small nodule in the right upper lobe. Tests for Coccidiosis, Trypanosoma cruzi, and Mycobacterium tuberculosis were negative; however the acid fast bacilli culture grew Mycobacterium fortuitum. A Strongyloides stercoralis antibody test was positive, and the patient was treated with two doses of oral ivermectin with one dose of intravenous ceftriaxone, and discharged. Two months later, his eosinophilia resolved, but he remained symptomatic with productive cough and weight loss, and was started on an outpatient course of oral ciprofloxacin and trimethoprim-sulfamethozole for M. fortuitum.DISSCUSION:Strongyloides-infected patients may carry the parasite for years without prominent symptoms. Endemic throughout South America, Strongyloides persists in its hosts through a lifecycle of autoinfection, which, over time, increases parasite burden and can lead to a hyperinfection syndrome whereby filiariform larvae penetrate organ tissue, most commonly: heart, central nervous system, lungs and liver. We suspect chronic eosinophilia and disseminated filiaria to be the etiology of the non-ischemic dilated cardiomyopathy in this patient. Standard treatment of strongyloidiasis is ivermectin, however, mortality owing to transient bacteremia in the setting of hyperinfection syndrome is high. Therefore, bacteremia prophylaxis with gram negative rod coverage should be considered before antiparasitic agent initiation.
INTRODUCTIONPyomyositis has traditionally been considered a tropical disease. Increasing prevalence has been observed in more northern climates, especially with HIV, immunosuppression, and IV drug abuse as predisposing factors. Pyomyositis has the tendency to mimic other conditions, such as muscle contusion, necrotizing fasciitis, or septic arthritis. The rarity of this disease and non-specificity of its symptoms often lead to delay in appropriate diagnosis and treatment.CASE24-year-old man, seen 2 days prior in orthopedics clinic and the Emergency Department for persistent gluteal pain thought to be due to right-sided sciatica, was admitted following worsening pain, diffuse generalized weakness with polyarthralgias and myalgias These symptoms were associated with night sweats, shaking chills, and difficulty walking. Prior to onset of symptoms, the patient vacationed in Cayman Islands and experienced a stingray bite on his right hand as well as numerous cuts on rocks in stagnant waters. He was febrile with WBC count of 18.7 K/ μL and was found to have methicillin-sensitive Staphylococcus aureus (MSSA); bacteremia. Magnetic resonance imaging (MRI); of his lumbar spine on admission was unremarkable. Repeat MRI 4 days later showed extensive inflammation within musculature with multiple abscesses around right sciatic foramen and septic arthritis of the sacroiliac joint. The patient was subsequently diagnosed with MSSA septic polyarthritis and required several orthopedic procedures. Infectious and oncologic work up was unremarkable. Transesophageal echocardiogram showed 0.3 cm x 0.5 cm aortic valve vegetation, which was managed medically. Repeat MRI 11 days after initiation of appropriate antibiotics and surgeries showed improvement in muscular edema. Based on the MSSA susceptibilities, the patient was treated with 6 weeks of intravenous cefazolin and 2 weeks of oral cephalexin thereafter.DISCUSSIONAwareness of tropical pyomyositis in colder climates remains scarce, although cases have been reported in immunosuppressed patients. However, in healthy patients, accurate history of travel and trauma is important in evaluation for predisposing factors for pyomyositis. Early antibiotic and appropriate surgical interventions are imperative for management of this disease in order to prevent systemic toxicity, dissemination of infection, and long-term debility.
A family brought their 61-year-old mother to the emergency department because for 4 days she had been confused, incoherent, and somnolent. She also had dysphagia, dysarthria, diplopia, and had fallen out of bed. She had been in the hospital 3 weeks earlier for atrial fibrillation and an exacerbation of congestive heart failure. She also carried a diagnosis of chronic obstructive pulmonary disease and used an albuterol inhaler. She was obese (BMI of 45); and had adult-onset diabetes mellitus. She had a 43 pack-year history of cigarette smoking but had recently quit. Soon after arriving in the emergency department, she had an ECG (Figure);.
INTRODUCTIONChronic pancreatitis by definition is a recurrent episode of acute pancreatitis and is commonly associated with alcoholism in the US. Another cause of chronic pancreatitis is hypertriglyceridemia (HTGP);, occurring in 1-5 percent of cases. The incidence of HTGP is higher in patients with diabetes and HIV, usually requiring triglyceride levels > 1000 mg/dL.CASEA 33 year old man with uncontrolled type 1 diabetes and recurrent pancreatitis, first diagnosed 5 years prior, presented as a transfer from an outside hospital for a recurrent episode of HTGP. He reported recurrent pain episodes, requiring 6-9 hospitalizations within the last year for pancreatitis. He reported poor compliance with his insulin regiment at home. Other home medications included gemfibrozil, lisinopril, niacin, and omega-3 fatty acid. On transfer, his glucose was 296, triglyceride level was >3600, and A1C of 12.4. Transfer report lab work showed a triglyceride level >7000 and a lipase of 600. The patient had severe, diffuse abdominal tenderness on examination. He was diagnosed with pancreatitis secondary to hypertriglyceridemia due to a lipoprotein metabolism disorder and long-standing uncontrolled DM1. An intensive insulin drip was started on this patient, with goals of correcting his TG to less than 500 along with lowering his glucose. After 13 days, mostly on insulin drip, his TG decreased to 995 and pain was controlled, eventually tolerating a diabetic diet. He was encouraged to modify his diet and take his medications as directed at discharge.DISCUSSIONThe relationship between hypertriglyceridemia and pancreatitis is poorly understood. In HTGP, a decrease in triglyceride concentration is a management priority. Rapid triglyceride concentration lowering is managed by insulin or plasmapheresis. As HTGP often presents in patient with uncontrolled diabetes, insulin is frequently used as treatment to lower both blood glucose and triglycerides; insulin decreases serum triglyceride levels by enhancing lipoprotein lipase activity and inhibiting hormone sensitive lipase, accelerating metabolism and decreasing adipocyte breakdown. Patients should be educated on the importance of compliance with drug therapy and lifestyle modifications.
INTRODUCTION:The prevalence of sarcoidosis varies as much as 1-40 cases per 100,000 depending on region and population. Sarcoid typically occurs in people younger than 50 years old, with a peak incidence with ages between 20 and 40 years old. African Americans are 3 times more likely to develop sarcoidosis than Caucasian Americans, and woman are more likely than men to develop sarcoidosis in any ethnic group; nonetheless, it remains a valid differential across any population. CASE:A 32 year old Hispanic man presented to the Emergency Department with night sweats, fatigue, and 35 pound unintentional weight loss over the last several weeks. He also reported a sore throat, occasional cough w/ yellowish sputum, and new onset dyspnea with exertion. He moved from Mexico to the U.S. 20 years prior and last visited the country 7 yrs ago. He never smoked and denied any TB exposure. His vitals at admit demonstrated tachycardia (pulse 108); and temperature of 99.4 ᴼF. He had coarse bilateral breath sounds on exam. Serum chemistries were unremarkable. Chest radiograph demonstrated perihilar fullness. Chest CT revealed enlarged mediastinal and perihilar LAD and airspace consolidation in right middle and lower lobes bilaterally. The patient was admitted to a negative pressure room w/ airborne precautions and RIPE therapy was initiated. PPD and AFB's were negative. He underwent bronchoscopy and was discharged on RIPE. Lung biopsy showed non-caseating granulomas. RIPE therapy was stopped, and he was referred to ophthalmology to rule out uveitis. Cultures from the procedure were negative for fungal growth, and he was started on prednisone 40 mg daily with taper 6 weeks later as his weight returned, night sweats subsided, and dyspnea on exertion improved. DISCUSSION:Sarcoidosis should be considered as a diagnosis in any gender of any racial or ethnic group. Sarcoid is a great mimicker of many serious illnesses including malignancies such as lymphomas, TB and atypical mycoplasma, fungal infections, and other granulomatous diseases, and other autoimmune disorders such a hypersensitivity pneumonitis. Diagnosis requires patient investigation and careful analysis of these differentials.
CASE:A 44 year old woman with a history of stroke s/p aneurysm clipping, seizure, and substance abuse was brought to the hospital after a family member received a call from her friend saying she was acting unusual and may have had a seizure while hanging out on the street. At her baseline, she needed modest assistance in daily activities after her CVA and conversed without issue. Her mother died of a stroke. On exam the patient was afebrile, normotensive with mild tachycardia to 110. The patient moved all her extremities but was lethargic, agitated, responded to pain but would not follow commands and moaned nonsensical speech. Labs were unrevealing with mild leukocytosis (WBC: 11.7 × 109/L);, normal metabolic panel, ammonia, glucose, and a negative urine toxicology. Initial computed tomography (CT); of her head demonstrated atrophy with large area of encephalomalacia in Left middle cerebral artery (MCA); area. Repeat CT, 1 day later showed edema and sulcal effacement in the right occipital, posterior, temporal, and posterior parietal lobes with evolving infarct in right posterior cerebral artery (PCA); and right MCA territories. CT angiogram showed occlusion of the clinoid segments of both internal carotid arteries, consistent with Moyamoya pattern of collateral flow. Neurosurgery was consulted and recommended cerebral bypass. The patient was unable to consent for surgery and her closest relative refused surgery. The patient received supportive therapy with minimal improvements in word findings/ communication and no improvement in inability to perform daily activities. She was accepted to inpatient stroke rehab upon discharge.DISCUSSION:Moyamoya disease is a rare vascular condition which leads to progressive stenosis of the internal carotid arteries through wall thickening of the associated arteries which leads to progressive strokes and the development of collateral vessels. Moyamoya is a Japanese term for a "puff of smoke" which describes the appearance on imaging of the small collateral vessels that develop around the progressively blocked arteries. There is a hereditary association and our patient's mother likely had the disease as well. The prognosis is poor and the disease will lead to a cognitive decline with associated CVAs. Treatment includes cerebral revascularization or bypass. The case highlights the need for early diagnosis, as our patient was too debilitated to make medical decisions for treatment at the time of her diagnosis.
BACKGROUND:Cerebral venosinus thrombosis (CVT); is an uncommon, potentially fatal disease that is more common in young adults and children. Thrombophilia, elevated estrogenic states, and infections are the most common risk factors in patients who develop CVT.CASE:A 69-year-old man with a right-sided odontogenic infection presented with fever, headache, opthalmoplegia, and periorbital swelling. Imaging revealed evidence of meningitis and thrombosis of bilateral ophthalmic veins, the cavernous sinus, right internal jugular vein, and sigmoid sinus. The patient was treated with empiric antibiotic therapy and unfractionated heparin. He recovered with only mild impairment in right eye abduction.DISCUSSION:Early diagnosis and prompt treatment of CVT is vital in reducing the associated morbidity and mortality. Unfractionated or low molecular weight heparin may be safely used in CVT patients. Thrombolytic therapy is an option in clinically severe cases. Treatment also includes addressing the underlying cause and management of early complications.
INTRODUCTION:Abstinence-only sexuality education (AOSE); is required in the public school systems of many states, raising public health concerns and perpetuating health disparities through school systems. This study aimed to determine the correlations between state-mandated AOSE and the rates of adolescent HIV and teen pregnancy.METHODS:Using publicly available data on all 50 United States' laws and policies on AOSE, states were ranked according to their level of abstinence emphasis on sexuality education (Level 0 - Level 3);. We calculated the relative proportion of Black students in public schools and the proportion of families below the federal poverty line then ranked them by state. We compared the states' ranks to the incidence of adolescent HIV and teen pregnancy in those states to identify associations between variables.RESULTS:The majority of states (~44 percent ); have legally mandated AOSE policies (Level 3); and adolescent HIV and teen pregnancy rates were highest in these Level 3 states. There were significant, positive correlations between HIV incidence rates of 13-19 year olds, HIV rates of 20-24 year olds, teen pregnancy rates, and AOSE level, with the proportion of the population that lives below the federal poverty level, and whether they attended schools that had a greater than 50 percent of an African American population.DISCUSSION:These data show a clear association between state sexuality education policies and adolescent HIV and teen pregnancy rates not previously demonstrated. Our data further show that states that have higher proportions of at-risk populations, with higher adolescent HIV and teen pregnancy rates, are more likely to also have restrictive AOSE policies. These populations may be more likely to attend public schools where AOSE is taught, increasing their risk for HIV and teen pregnancy. The World Health Organization considers fact-based Comprehensive Sexuality Education a human right, and the authors believe it is past time to end harmful, discriminatory sexuality education policies in US public schools.
