Indolent T-cell lymphoproliferative disorder of the gastrointestinal tract managed conservatively with corticosteroids

An 82-year-old female presented with a 4-week history of abdominal pain, weight loss, diarrhea, and nausea. A complete infectious workup was negative. Her computed tomography (CT) scan showed no pathologic changes and her esophagogastroduodenoscopy (EGD) showed erosive damage in the duodenum. Her duodenal biopsy showed inflammation with a marked increase in intra-epithelial lymphocytes and her immunohistochemistry was consistent with indolent T-cell lymphoproliferative disorder of the gastrointestinal tract. She was started on high dose steroids three months after the onset of her symptoms. She gradually improved with complete resolution of erosive changes on her repeat EGD.

Ceteris Paribus: An Epistemological Error with Ethical Consequences

Herein I call into question a common epistemological justification for placebo controls, and thereby problematize the use of placebo in many modern clinical trials. I demonstrate both the ethical harm and epistemic inferiority of placebo controls in certain knowledge contexts, arguing the standard of care should be the more acceptable comparator for novel treatments in such contexts.

The Natural History of Medical Waste

As per publication guidelines we did not write an abstract for our commentary.

Lateral vs. Supine Positioning for Femoral Intramedullary Nailing: A Systematic Review of Comparative Studies

Femoral shaft fractures are devastating injuries that usually result from high-energy mechanisms in victims of poly-trauma. Reamed and statically locked intramedullary nailing (IMN) is the definitive treatment modality for femoral shaft fractures. Patients are most commonly positioned either supine or lateral decubitus. There remains considerable concern regarding the safety of lateral positioning in the traumatized patient, particularly in the management of a potentially difficult airway or concomitant C-spine injuries. We therefore undertook a systematic review of intraoperative positioning among patients with femoral shaft fractures following PRISMA guidelines. Title and abstract screening, full text screening, and data abstraction were all completed in duplicate. Methodological Index for Nonrandomized Studies (MINORS) scores were used to evaluate methodological quality. Results: 3018 studies were included in initial screening, with three studies ultimately meeting all inclusion criteria. A total of 1,949 patients were analyzed, with 684 patients treated in lateral positioning and 1,215 patients in supine positioning. Level of agreement was strong across title (κ = 0.872; 95% CI 0.794 to 0.951), abstract (κ = 0.801; 95% CI 0.585 to 1.000), and full-text screening (κ = 1.000). The consensus mean MINORS score of included studies was 17.67 ± 0.58, indicating good to high quality of evidence. Neither patient positioning offered obvious benefits such as fewer complications or shorter operative time. Furthermore, length of admission, days in ICU or on ventilator, and overall morbidity were not found to be significantly different between positions. Lateral positioning for intramedullary nailing of mid-shaft femur fractures appears to be a safe alternative to the standard supine positioning. There is a lack of both prospective and retrospective comparative studies investigating functional clinical outcomes in the literature.

Universal Vaccines against Influenza Viruses: Overview of the Past, Present, and Prospective

Influenza is a common disease caused by influenza virus infections. There are an estimated 3 to 5 million annual cases of severe illness and 290 000 to 650 000 respiratory deaths caused by influenza virus infections worldwide (1). Transmission can occur in three ways: direct contact with an infected person, through fomites, or by inhaling aerosolized infectious particles (2). Systemic manifestations of uncomplicated influenza include fever, fatigue, and headaches, and symptoms of upper respiratory tract infection including sore throat, nasal discharge, and non-productive cough (3). Although antiviral drugs are available to treat influenza, vaccination remains the best way to prevent infection. This article will provide an overview of influenza virus biology, as well as current methods and those in development to treat and prevent influenza.

systematic review of clinical decision rules used for diagnosing pulmonary embolism in the pediatric opulation

Objective: This review aims to evaluate the diagnostic accuracy of existing, adult clinical decision tools for pulmonary embolism, in the pediatric population. Methods: A systematic search and screening of the Pubmed, Embase, CINAHL, and Cochrane databases was done in January 2018. Studies evaluating the diagnostic accuracy of clinical decision tools and/or risk factors and clinical features for pulmonary embolism in the pediatric population were included. The measures of diagnostic accuracy of clinical decision tools were calculated. The pooled sensitivity and specificity of risk factors were calculated using a bivariate random effects model. All included studies were assessed for quality using QUADAS-2. Results: Six studies were included: three case-control and three retrospective cohort studies. We found that no standard clinical decision tool for pulmonary embolism has been evaluated in the pediatric population. As well, adult clinical decision tools have low diagnostic utility in pediatrics. Conclusion: Adult clinical decision tools should not be used for pediatric patients. There was no single risk factor or clinical feature displaying reliable sensitivity; however, a central venous line, a recent surgery, or the finding of hemoptysis, all have a positive likelihood ratio greater than two, demonstrating their potential diagnostic utility. Large, prospective cohort studies are needed.

Statin-induced rhabdomyolysis: a cautionary tale for high-dose rosuvastatin

Statins are a widely prescribed lipid-lowering agent for preventing adverse cardiovascular events. However, a major side effect is rhabdomyolysis, a breakdown of muscle tissue, which can cause acute kidney injury and death. We present a case of a 77-year-old Chinese woman who was started on 40 mg rosuvastatin post-percutaneous coronary intervention and ultimately developed rhabdomyolysis and acute kidney injury one month later. This case highlights the need to consider patient risk factors for developing statin-induced rhabdomyolysis when choosing the right dose of statin to prescribe.

Postoperative pain management education during the surgery core rotation at McMaster University, Waterloo Regional Campus.

Background: Opioid over-prescription continues to be a challenge in the postoperative setting for management of acute pain. Initiatives have been developed to standardize postoperative opioid prescribing with an emphasis on multimodal pain management. However, there is a concern medical education has not remained current on this topic. Objective: The aim of this study is to explore current teaching around postoperative pain management during the surgery core rotation at McMaster University, Waterloo Regional Campus (WRC), and identify any opportunities for improvement. Methods: A 13-item survey was developed to determine effectiveness of teaching around postoperative pain management during the surgery core and its alignment with current guidelines. The survey was disseminated to third year medical students at the WRC. Results: Seven of nine respondents indicated that teaching on postoperative pain management and opioid reduction strategies was provided during the surgery core. All respondents receiving this teaching also indicated learning about a multimodal pain control approach consistent with current guidelines. However, only three of seven respondents noted receiving teaching on providing patient and caregiver education around the pain management plan, despite a strong recommendation in guidelines in favour of this practice. Conclusions: Most students receive teaching on multimodal postoperative pain management and opioid reduction strategies during the surgery core at the WRC. Opportunities to strengthen the teaching include addressing the role of patient and caregiver education in the pain management plan as well as incorporating the topic into formal teaching such as classroom sessions or learning objectives in the surgery core. Keywords: postoperative; opioids; multimodal pain management; medical education; surgery

geospatial analysis of pertussis and its risk factors in southern Ontario from 2005–2016

Introduction: Pertussis, commonly known as whooping cough, is a bacterial respiratory tract infection caused by Bordetella pertussis. Pertussis affects more than 48 million people worldwide annually, most of whom are under the age of 5. Hypothesis & Objectives: The hypothesis being investigated is that pertussis incidence, between 2005 and 2016, is not equally distributed across public health units in southern Ontario. We aim to identify disease cluster locations and associate geospatial fluctuations in incidence rates with putative risk factors. Materials and Methods: Data was sourced from Public Health Ontario on pertussis incidence in southern Ontario for all ages, specifically for each public health unit’s geographical area. A choropleth map was generated using data smoothed by empirical Bayesian estimation in a spatial analysis context. Following the creation of an incidence map for southern Ontario, the spatial scan test was applied to elucidate the existence of any disease clusters at a public health unit level. Moran’s I was used to determine whether there was evidence of any spatial dependence in pertussis incidence. Finally, putative risk factors were assessed in Poisson regression models and spatial Poisson regression models as potential predictor variables. Results and Discussion: The flexible spatial scan test identified three spatial clusters where incidence rates of pertussis were higher than expected. A spatial Poisson regression model was fit that included predictor variables of socioeconomic status and population density. For every 100 people/km2 increase in population density there was a significant 6% increase in pertussis incidence (p=0.03). Interestingly, vaccination rates were not found to be predictive of pertussis incidence nor did the variable improve the model. This epidemiological study identifies where pertussis incidence is clustered and what variables it is associated with, both of which are valuable for public health purposes and as a reference for future research into pertussis.