Postoperative Pharmacologic Anticoagulation following Temporal Lobe Resection of a Gliosarcoma in a Hypercoagulable Patient

Gliosarcomas are a rare subtype of glioblastomas associated with high rates of malignancy-associated venous thromboembolism (VTE). VTE risk is further increased in hypercoagulable patients upon discontinuing pharmacologic anticoagulation for surgery. We present a 60-year old obese male with history of hypercoagulability on apixaban who developed extensive thrombosis following resection of a gliosarcoma. Prior to temporal lobe resection, apixaban was discontinued and an IVC filter placed. On postoperative day 4, imaging revealed thrombosis above the IVC filter extending to the bilateral common, internal and external iliac, and femoral veins, requiring immediate anticoagulation and suction thrombectomy. Clinicians must balance the risk of VTE and intracerebral hemorrhage following neurosurgical. While withholding pharmacologic VTE is standard, hypercoagulable patients may benefit from pharmacologic prophylaxis postoperatively. Patients with multiple risk factors including malignancies with high rates VTE, like gliosarcomas, medical and hematological conditions, including idiopathic erythrocytosis, and history of VTE may benefit from earlier pharmacologic prophylaxis.

Knowledge, Attitudes, and Barriers to Breastfeeding in Adolescent Mothers: a Review

Introduction: Despite the proven benefits of breastfeeding, there are a variety of reasons why many women do not, or cannot, breastfeed their children. Adolescent mothers are even less likely to breastfeed than non-adolescent mothers. The aim of this review was to synthesize the current literature on breastfeeding practices in adolescent mothers and explore the factors influencing their breastfeeding decisions. Methods: A literature search was conducted in January 2018 using PubMed. Studies were included in the review if they discussed adolescent mothers’ views and experiences of breastfeeding or if they reporting breastfeeding rates among adolescent mothers. For this review, adolescence was defined as the ages between 13 and 21. Results: Of the 19 studies selected, each study was summarized and analyzed to determine that the proportion of adolescent mothers who breastfeed is lower than non-adolescent mothers: 31-100% initiated breastfeeding, 17-64% breastfed exclusively, and more than half stopped within the first month. Intention to breastfeed, social support and maternity care support were positive predictors of breastfeeding behaviors. Although significant effects of the interventions aimed at improving breastfeeding rates was revealed by this review, findings also indicated analytical themes related to adolescents’ breastfeeding knowledge, attitudes, and barriers that are unique to their age group. Conclusions: This review highlights that adolescents have limited breastfeeding knowledge, unique attitudes, and face a variety of barriers to breastfeeding, including returning to school, social stigma, the physical demands of breastfeeding and unease with the act of breastfeeding. These findings indicate that developmentally sensitive education and support is fundamental to effective interventions aimed to increase breastfeeding rates among adolescent mothers.

Acupuncture and its Effects on Chronic Pain

Acupuncture is an complementary form of medicine that has relatively recently become a component of traditional Chinese medicine (TCM). It involves the application of thin needles at specific points throughout the body, although initially, general areas instead of points were used. There are estimated to be about 395 different points that can be utilized, and the technique behind using these points can vary widely between practitioners. In addition to acupuncture points, TCM is said to use meridians or pathways along with qi, or energy flows. In terms of acupunctures’ utility, it has been known to treat a variety of ailments ranging from pain and headaches to sleep disturbances, but it's true benefits continue to be questioned. To date, thousands of studies have been performed in regards to its efficacy with varying conclusions. Once considered to be “pseudomedicine”, this ancient technique has been found to provide long-term benefits for patients with chronic pain. This manuscript aims at providing a brief history of acupuncture and examines studies in favor of its relief of chronic pain.

Treatment and Diagnostic Considerations in a Complex Psychiatric Case - a Case Report

A patient with a history of autism spectrum disorder and epilepsy was hospitalized for management of acute onset psychosis and agitation. The acuity of his behaviors warranted abrupt shifts in treatment and multiple pharmacologic interventions were ineffective. The atypical nature of his presentation and intense pressure from ancillary staff to consider organic etiologies drove frequent transitions of care within the hospital setting. Multiple diagnoses were considered including a primary psychosis, excited catatonia and antiepileptic drug-induced psychotic disorder. Ultimately the patient was diagnosed with bipolar disorder and effectively treated with quetiapine and valproic acid. The authors suggest that rapid consideration of comorbid bipolar disorder in autism spectrum disorder patients presenting with affective dysregulation may expedite trial of an anticonvulsant with mood stabilizing properties, which would have simplified this patient’s clinical course and limited potential for iatrogenic harm. This course of treatment should especially be considered when a history of epilepsy is present.

Multidisciplinary Approach to Diagnosing and Managing a Case of Peritoneal Mesothelioma

Peritoneal mesothelioma is a rare cause of a peritoneal mass in adults and can occur in malignant or benign forms. Compared to the pleural variant of mesothelioma, the peritoneal form is understudied due to the small number of reported cases. We present a case of an 84-year-old male with a history of asbestos exposure who initially presented for an aggravated hernia, was found to have an incidental mass on imaging, and ultimately was diagnosed with malignant peritoneal mesothelioma (MPM)1 likely related to prior asbestos exposure. This case study will provide a review of literature and discuss the role of imaging for MPM.

Extra Axial Chordoma of the Distal Femoral Metaphysis: A Case Report

Background Chordomas are malignant bone tumors that are derived from remnant embryonic tissue of the notochord and are typically found in the axial midline. When they are found outside of the axial skeleton, the diagnosis can be challenging and elusive. Often, they are overlooked on initial presentation in lieu of other more common lesions, including cartilage tumors (eg, enchondroma, chondrosarcoma, osteochondromatosis) due to their overlapping features. Case Report A 30-year-old female with a four-year history of intermittent left knee pain presented for initial evaluation. Physical exam of the knee was unremarkable except for moderate tenderness on palpation. Radiographs showed a lucent lesion with peripheral sclerosis, eccentrically located within the anteromedial femoral diaphysis. The patient was subsequently lost to follow-up. She presented again two years later with similar symptoms. Her physical exam remained unchanged, and repeat radiographs showed interval growth. She underwent open biopsy of the left distal femur, with pathology revealing tumor consisting predominantly of epithelioid cells set in an abundant myxoid matrix. Immunohistology showed cells that stained strongly for EMA, CK19, and brachyury. These findings support the diagnosis of extra-axial chordoma. Discussion Extra-axial chordomas remain a challenging diagnosis for clinicians due to their extreme rarity and overlapping features with other more common lesions. They are often misdiagnosed as extraskeletal myxoid chondrosarcomas or myoepitheliomas. Our patient’s insidious presentation and radiologic findings present a learning opportunity for clinicians to recognize extra-axial chordomas as a potential early diagnosis in someone presenting with a long history of intermittent and worsening knee pain.

Anesthetic Use In Status Epilepticus: A Concise Review

The purpose of this review is to summarize the recent literature focusing on intravenous (IV) administration of commonly used anesthetics, including midazolam, pentobarbital/ thiopental, propofol, and ketamine in the treatment of status epilepticus (SE). Anesthetics should be reserved as third-line therapy for the treatment of SE when benzodiazepines and other second-line agents fail to terminate the seizure. We have reviewed the literature related to the treatment of status epilepticus, refractory status epilepticus, super-refractory status epilepticus, anesthetics, midazolam, pentobarbital/thiopental, propofol, and ketamine. This paper focuses on the pharmacology, dosages, major side effects, and clinical use of IV anesthetics in the treatment of SE with an emphasis on the developing literature supporting the use of ketamine for this indication. Based on the available literature, we propose recommendations for third-line agent selection in the management of SE.

Medication Literacy Tool in a Student-Run Free Clinic

Introduction: Low medication literacy can lead to prescription non-adherence and medical errors. The goal of this study was to create an easy-to-use comprehensive medication literacy assessment tool to aid in identification of patients with trouble reading and interpreting medication labels in the primary care setting. The secondary goal was to evaluate the role of primary language and education level on medication literacy and determine if patient reported difficulty with reading labels correlated with a lower medication literacy. Methods: Forty-two patients of the Cooper Rowan Clinic, a student-run free clinic, were given a demographic survey and 7-item questionnaire based on a standard prescription label. The study was limited to patients over the age of 16 who were able to read in either English or Spanish. Results: A significant difference was noted in average scores between the English and Spanish-speaking groups. In addition, a positive correlation was found between education level and assessment scores. The assessment scores of participants who self-reported having trouble reading their label were lower but not significantly different from those who did not report difficulty reading a label. Conclusions: The assessment was easily administered in a student-run clinic and could be used for medication literacy evaluation and quality improvement in other clinics. This tool also shows that primary language and education play a role in the ability to interpret labels. Further testing could be performed to establish the validity of the assessment with longer, well-established health literacy tests.

Advancing Health Policy and Advocacy Education in Medical School through a Student-run Elective

Introduction: Training medical students in the policy topics of healthcare economics, delivery systems, disparities, and reform helps to prepare them for the growing role of advocacy in medicine. We used a near-peer educational model to create an elective to advance learners’ policy knowledge and advocacy skills, while simultaneously offering student directors hands-on experience in educational program development. Methods: The 4-week elective for fourth year medical students included weekly readings, policy seminars, advocacy workshops, and journal clubs. Longitudinally, students prepared for a policy debate and prepared a research project or Op-Ed article on a healthcare disparity topic of their choice. The elective was designed, coordinated, and implemented by a team of first, second, third, and fourth-year medical students with faculty adviser oversight. Pre- and post-surveys were utilized to assess student learners’ knowledge of subject material and their perceptions of the effectiveness of the curriculum. Student directors self-assessed their confidence with the subject material and acquired skill in educational program development. Results: Student learners (n=6) noted significant improvement in their knowledge of health policy (P=0.0002) and advocacy (P=0.0064). They also reported improvement in several subtopics under policy and advocacy, with significant improvements seen in healthcare reform (P=0.0131) and writing skills (P=0.0099). Student directors (n=4) reported improved skills in curriculum development, educational evaluation, and leadership. Discussion: This novel student-run elective provided effective training in health policy and advocacy that extends beyond traditional curricula in medical school. Employing a near-peer model, the elective offers a sustainable system to educate interested students in these subjects and provide student directors unique experience in medical education. Further evaluation of future iterations will help determine the effectiveness of the curriculum in advancing individual policy and advocacy subtopics to guide future curricular modifications.

Minding the Mindfulness Research in Healthcare: More Data on Diversity are Urgently Needed

Securing a residency position has become increasingly competitive, thereby making the interview crucial in matching successfully. In this commentary, what I consider “Ten Commandments” of a successful interview are elaborated. Although this is geared to those applying in dermatology, the principles are applicable for any medical student applying for a residency program.