Concerns are rising regarding the quality, validity, and reliability of clinical research findings in medical literature. This investigation sought to identify the most cited orthopedic clinical studies and assess the replicability of the findings reported. Web of Science was used to identify the top ten orthopedic surgery journals by impact factor from which primary comparative studies cited at least 250 times were identified. A second literature search identified follow-up studies relevant to the respective primary studies. Studies investigating the same intervention via parallel methodology were summarized and their conclusions compared to their respective highly cited primary study. Seven primary highly cited clinical studies met inclusion criteria. A literature search identified and screened 1163 follow-up articles, of which 79 met inclusion criteria. Of these, 70.9% (56/79) of studies were randomized clinical trials, 7.6% (6/79) were multicenter in nature, and 67% (53/79) were classified as level I evidence. Average subject cohort size in the follow-up studies was 365 patients (range, 10-4564). The rate of coming to the same conclusion as the primary study was 45.5% (36/79). The rate of different conclusions from the primary studies was 26.6% (21/79). Additionally, 16.5% (13/79) found a weaker correlation, and 11.4% (9/79) neither agreed nor disagreed with the primary study. No significant association existed between study design, level of evidence, or study size and agreement or disagreement with the original paper (P > .05). Less than 50% of replicating follow-up studies support the effects demonstrated by highly cited comparative studies in orthopedic literature, which is a lower rate than that reported by other areas of medicine. Difficulty performing large, high-level-of-evidence studies and publication bias likely contribute to this observation. Based on these findings we believe that replication of prior research, emphasis on research quality, and conscious awareness of the limitations of clinical research are critical to the quality of orthopedic literature.
Experiencing meaning and fulfillment in healthcare work is recognized as important for those in nursing, medicine, respiratory therapy, social work, and other health disciplines. Critically, moral distress, compassion fatigue, staff burnout, and individual health have all been linked as related phenomena when such experiences are compromised. And yet, we may question whether we truly understand the meaning of meaningfulness and fulfillment. What calls health providers to come to work, again and again, despite the complex and difficult situations that they have to deal with? What are sources of meaning and fulfillment? How do we understand these phenomena? The context of newborn intensive care deserves special consideration as healthcare providers manage clinical acuity, respond to infant illness, support stressed families, navigate ethical decision-making, and work through complex team dynamics. In this paper, we explore and reflect on anecdotes of meaning and fulfillment as described by healthcare providers to explicate these phenomena.
Traumatic brain injuries (TBI) are a significant and growing health issue, leading to over 200 000 hospitalizations annually in the United States. Cranial nerve (CN) injuries accompanying TBI can severely impact patients' quality of life. This review aims to address the gap in research regarding the severity, mechanisms of injury, and associated intracranial injuries, emphasizing the importance of early detection and intervention. A comprehensive literature search was conducted across databases such as PubMed and Ovid using key terms, including "cranial nerve injury," "cranial nerve palsy," "traumatic brain injury," and "Glasgow Coma Scale." Inclusion criteria encompassed studies reporting CN injuries with TBI, categorized by Glasgow Coma Scale (GCS) scores, and the mechanisms of injury. A total of 14 studies were reviewed, integrating data from adult and pediatric populations. The incidence of CN injuries in TBI patients varies in the literature, with studies reporting rates between 5%-23%. Data revealed significant occurrences of CN injuries in mild (GCS scores 13-15), moderate (GCS scores 9-12), and severe (GCS scores < 9) TBI. Common mechanisms of injury included automobile accidents and falls; crush injuries were a notably common mechanism of injury in pediatric patients with TBI. Associated injuries included skull base fractures (38.9%), subdural hematomas (16.6%), epidural hematomas (18.9%), and subarachnoid hemorrhage (25.6%). Early detection and intervention were found to be critical in improving patient outcomes, with delays leading to increased disability and poor prognosis. The high prevalence of CN injuries in even mild cases of TBIs emphasizes the need for physicians to be equipped to assess, diagnose, and treat CN deficits in all forms of neurological trauma. By acknowledging common mechanisms of injury and associated intracranial injuries, we can elucidate the possibility of CN damage in order to facilitate early recognition and treatment. The identification of CN injury also suggests the importance of investigating other intracranial injuries such as skull base fractures, epidural or subdural hematomas, and hemorrhage.
The use of topical hemostatic agents has become common during surgical interventions. There is a wide variety of substances available to augment clotting, ranging from physical agents to topical thrombin combinations. Application of these agents in gynecologic surgery in patients with existing coagulopathies has not been studied. A 62-year-old woman with an inferior vena cava filter and a history of multiple deep vein thromboses presented to the clinic with pelvic pain, stress urinary incontinence, and uterovaginal prolapse. She underwent a total vaginal hysterectomy, sacral colpopexy, tension-free vaginal tape sling, and cystourethroscopy. Warfarin was cross titrated to enoxaparin prior to surgery. Patient had a 10-week sized uterus, normal appearing adnexa, and postoperatively bleeding was identified at the vaginal cuff. Preoperative hemoglobin was 9.0, and postoperative hemoglobin was 8.0 with normal coagulation factors. Several hemostatic techniques were used intraoperatively including combined gelatin-thrombin and gelatin-based agents. The procedure was complicated by a cystotomy which was repaired intraoperatively. The patient had postoperative bleeding from the incision site within the first 2 hours of recovery requiring a revision procedure. Exploration laparotomy was performed identifying the source of hemorrhage as a vaginal cuff hematoma. Suture and additional gelatin-thrombin sealant was applied to the pedicles and thrombin-soaked packing was placed in the vagina. Total estimated blood loss was 800 mL. The patient was transfused 2 units of packed red blood cells, 1 unit of platelets, and 1 unit of fresh frozen plasma. The patient made an uneventful recovery, and routine follow-up was conducted with no apparent complications. This case illustrates special considerations for intraoperative topical hemostatic agent use for gynecologic patients taking chemoprophylaxis for history of thrombosis and the value of the material composition for timely activity. Fibrin sealants have more rapid hemostasis than an oxidized regenerated dry matrix of cellulose. Because of the proximity of the reproductive organs to the bladder and urinary system, procedures complicated by cystotomy may result in mild leakage of sanguineous urine. This leakage can reduce the efficacy of combined gelatin-thrombin spray by disrupting its chemical components, compared with other hemostatic agents.
Although chronic obstructive pulmonary disease (COPD) increasingly affects women, they remain under-represented in randomized controlled trials (RCTs). Understanding enrollment patterns is essential to ensure the generalizability of COPD therapeutic evidence. We systematically identified RCTs of pharmacologic interventions for COPD published between 2010 and 2024. For each trial, we calculated the Enrollment Disparity Difference (EDD)-defined as the trial's percentage of women minus the Global Burden of Disease (GBD) sex-specific prevalence. Random-effects meta-analyses were conducted to pool EDD across trials; heterogeneity was explored using subgroup analyses (region, sample size, therapy class, age group, funding source) and meta-regression models. Temporal trends were evaluated, and a weighted annual EDD trajectory with forecasted values through 2026 was generated. A total of 190 RCTs were included. Women comprised 31.7% of enrolled participants. Pooled EDD was -0.21 (95% CI, -0.22 to -0.19), indicating relative underrepresentation. Heterogeneity was very high (I2 = 100%). Underrepresentation varied significantly across regions, with the greatest gaps observed in Asia and Africa and the smallest in North and South America. Age was a significant moderator (β = -0.0070 per year, p = 0.0006), with greater disparities in trials enrolling older patients. Industry funding, sample size, and therapy class were not significant predictors. A continuous-year meta-regression demonstrated an improvement in female representation over time (β = 0.0068 per year, p = 0.0269). Women remain underrepresented in COPD RCTs. Although modest improvements have occurred, significant gaps persist. Ensuring equitable representation is essential for generating evidence that reflects the COPD population. Chronic obstructive pulmonary disease (COPD) affects both men and women, but women are often underrepresented in medical research. This underrepresentation matters because women often experience COPD differently than men. They may have more shortness of breath, different types of lung disease, different responses to inhalers, and higher rates of anxiety and depression related to their illness. To understand how well women are included in COPD clinical trials, we reviewed 190 randomized controlled trials that tested medications for COPD. We found that women were consistently underrepresented: on average, trials enrolled about 20% fewer women than expected based on real-world disease patterns. When trials do not include enough women, the results may not fully reflect how well treatments work for everyone. This can affect how confidently doctors can use evidence from trial to guide treatment decisions for their patients specifically women. We also found that women’s representation in trials has slowly improved over time, especially after 2020, but there is still a substantial gap. Overall, our findings highlight the need for more inclusive research practices, such as broader eligibility criteria, targeted recruitment of women, and routine reporting of trial results separately for men and women. Ensuring that clinical trials reflect the real-world population with COPD is essential for developing treatments that work for everyone.
Carotid artery stenosis and coronary artery disease are often co-morbid, with a prevalence of concurrent carotid and coronary artery stenosis approaching 50%. The optimal treatment for these patients has long been debated, with open carotid revascularization generally reserved for those with severe symptomatic carotid disease that precludes cardiac surgery. In this scenario, the role of less-invasive carotid artery stenting, particularly transcarotid arterial revascularization (TCAR), remains controversial and is not yet well studied. This study aims to present our outcomes and methodology for treating severe carotid stenosis with TCAR prior to cardiac surgery. A retrospective chart review of the previous 656 TCAR procedures performed from 2013 to 2024 identified 15 TCAR procedures conducted during the same hospital admission before cardiac surgery. The primary endpoint was 30-day stroke and myocardial infarction (MI). Secondary endpoints included operative time, cranial nerve (CN) injury, neck hematoma, length of stay, arterial dissection, and death. Fifteen patients underwent TCAR before cardiac surgery. Of these, 73.33% were men, with a median age of 65.98 years. Eighty percent of the cohort was asymptomatic, and the majority of the cohort had greater than 80% stenosis. Bridging anticoagulation treatment included aspirin and either heparin infusion (60.0%, n = 9), intravenous antiplatelet therapy such as cangrelor or eptifibatide (33.33%, n = 5), or subcutaneous enoxaparin (6.67%, n = 1). No patients experienced MI, stroke, CN injury, neck hematoma, or arterial dissection within 30 days. There were no deaths within 30 days. In our initial experience with TCAR prior to cardiac surgery, there were no cerebrovascular complications, suggesting the feasibility of same admission TCAR and cardiac surgery. In our experience, a range of anticoagulation bridging therapies did not result in apparent stent thrombosis and can be employed until the cardiac surgeon deems it safe to initiate oral dual antiplatelet therapy. Further studies with larger datasets are required to support the broader adoption of TCAR prior to heart surgery in patients with concurrent, severe cardiac and carotid disease.
We present a rare case of Sweet syndrome with underlying monoclonal gammopathy of unknown significance (MGUS) which initially presented as upper respiratory tract infection. A 52-year-old woman presented with a complaint of sore throat for 6 days, productive cough and fever for 5 days, and red, pruritic, circular, tender rashes on face, arms and trunk for 2 days. There was a past history of similar self-limiting rashes presenting intermittently for 1.5 years. She also reported to be taking tablet ibuprofen, as required for the past 1-2 years, for cervical spondylosis. On integumentary examination, widespread, red, tender, annular plaques (2.5-5 cm in diameter) were noted over the face, back, and arms, with old, healed lesions having hyper-pigmented margins. A blood test revealed leukocytosis (13.6 x 109/L), high neutrophil count (9.6 x 109/L), elevated C-reactive protein of 108.7 mg/dL, abnormal monoclonal protein level (1.9 g/dL), high immunoglobulin G count (19.78 g/L) and high erythrocyte sedimentation rate (64 mm/hr). A histological examination showed skin with hyperkeratosis, parakeratosis and acanthosis of the epidermis, and scattered intra-epidermal neutrophils with occasional eosinophils and florid interstitial infiltrate of neutrophil in dermis. A diagnosis of Sweet syndrome due to possible use of ibuprofen and underlying MGUS was suspected, and the patient was started on a tapering dose of prednisolone. At a 2-week follow-up, the patient reported significant improvement in her health, which confirmed our diagnosis of Sweet syndrome. It is crucial to investigate Sweet syndrome patients for malignant and premalignant conditions due to their common association. In this case, the patient was diagnosed with MGUS, a clinical condition with 1% risk of conversion into lymphoma or myeloma.
Integrating palliative care into intensive care unit (ICU) practice is an essential component of comprehensive patient management, ensuring that critical interventions are aligned with patient-centered care objectives. This study aims to evaluate the impact of palliative care consultation (PCC) on clinical interventions, patient outcomes, and decision-making processes in a community-based medical-surgical ICUs. We conducted a prospective, observational, single-center cohort study of critically ill adult patients in a community-based medical-surgical ICU. Patients were grouped by the presence (PCCP) or absence (PCCA) of palliative care consultation. Primary outcomes included differences in clinical interventions (mechanical ventilation, vasoactive medications, renal replacement therapy, family meetings, code status changes, pain management, and comfort care directives). Secondary outcomes included ICU clinical course (Sequential Organ Failure Assessment (SOFA) score at 72 hours, length of ICU/hospital stay, ICU readmission, discharge disposition). Logistic regression was used to identify predictors for PCC involvement. Of 387 patients included, 27.6% (n = 107) received PCC. The PCCP group exhibited significantly higher use of non-invasive (46.7% vs 27.5%, P < .001) and invasive mechanical ventilation (62.6% vs 28.6%, P < .001), vasoactive medications (37.4% vs 20.4%, P < .05), and renal replacement therapy (9.3% vs 3.2%, P < .05). Additionally, PCCP patients more frequently underwent family meetings within 72 hours (75% vs 62.6%, P < .05), adopted DNR status (46.7% vs 7.9%, P < .001), and transitioned to comfort care and palliative extubation measures. Multivariate analysis identified higher SOFA scores within 24 hours of admission (odds ratio (OR) 1.16; 95% confidence interval (CI) 1.05-1.28) and age 85 or older (OR 0.19; 95% CI 0.05-0.72) as independent predictors of PCC involvement. Palliative care consultations in critically ill patients are associated with intensified clinical interventions, increased morbidity and mortality, and more frequent discussions regarding advanced directives and comfort-oriented care measures in a community-based mixed ICU. Future research should further elucidate the impact of PCC on patient and family satisfaction within ICU contexts.
This article provides surgical trainees with a ranked list of the foundational literature that guides the contemporary surgical management of colorectal cancer and shows the evolution of surgical techniques in the field. We assessed the surgical literature using the Web of Science and other ranking systems to create a ranked list of published articles on colorectal cancer surgery. We compiled a ranked list of the top 25 articles in the surgical management of colorectal cancer, based on the citation density score (mean number of citations per year) and the individual author H-index. The mean density score of the 25 papers was 29.9, and the journal most frequently represented on our list was the Annals of Surgery (36% of top papers). The Web of Science (primary) and alternative databases (secondary) H-index values for each author were identified. The range, mean, and median of the primary H-index values were 7.0-84.0, 31.8, and 29.0, respectively. The range, mean, and median of secondary H-index values were 4.0-108.0, 48.6, and 45.0, respectively. A 2-tailed, unpaired t-test was used to determine whether a significant difference existed between the primary and secondary H-index values for primary authors; P = .0376 (95% confidence interval, 1.02-32.58). A citation density score was calculated for each article, which represented the mean number of citations per year. We provided a ranked list (citation density score) of the top-cited 25 articles in colorectal cancer surgery, a ranking of the associated primary authors by H-index, and a comparison of H-index scores between primary and secondary database sources. We believe this list is a useful resource for surgical trainees and researchers in colorectal cancer field and provides easy access to the top papers in this discipline.
Endometriosis is a common condition in which endometrial glands and stroma are implanted outside the uterine cavity. Rarely, the skin can be involved. We describe a case of a 41-year-old woman who presented to the dermatology clinic complaining of a brown umbilical nodule with slight erythema. It was occasionally painful and hemorrhagic. She denied a history of endometriosis and abdominal surgeries. A shave biopsy of the nodule was consistent with a diagnosis of cutaneous endometriosis. The patient was referred to her gynecologist for further evaluation and treatment. This unique case demonstrates primary cutaneous endometriosis in the umbilicus of a female patient. Cutaneous endometriosis can be classified as primary or secondary. Primary cutaneous endometriosis is rarer and has an unclear etiology, developing seemingly spontaneously without history of surgical interventions. Secondary cutaneous endometriosis typically arises within surgical scars following abdominal operations, which is believed to be a result of iatrogenic implantation of endometrial cells. Definitive treatment involves surgery. This case highlights the importance of considering cutaneous endometriosis in the differential diagnosis of a female patient with painful and intermittently hemorrhagic skin nodules.
Lower limb amputations significantly impair the mobility and activities of daily living (ADLs) and frequently require inpatient rehabilitation with opioid analgesics to control pain. Largescale studies of clinical characteristics specific to rehabilitation outcomes after lower limb amputations are limited in the current literature. Identifying the associations between specific clinical characteristics and opioid analgesic use with home versus non-home discharge can help improve care for patients undergoing inpatient rehabilitation after lower-limb amputations. In this retrospective study, we examined 1611 patients from 58 inpatient rehabilitation units who underwent transfemoral or transtibial amputations between January 2021 and December 2022, identified using International Classification of Diseases (ICD) codes. Multivariable logistic regression was used to identify patient characteristics, including opioid use, associated with home discharge after inpatient rehabilitation for lower-limb amputation. There were 1124 (69.8%) patients with transtibial amputations and 487 (30.2%) patients with transfemoral amputations. When compared with transtibial amputees, opioids were used more frequently (86.5% vs 82.1%, P = .032) and at higher oral morphine milligram equivalents (356 mg vs 241 mg, P = .019) at admission among transfemoral amputees. A total of 1223 patients (75.9%) were discharged home after inpatient rehabilitation. Patient characteristics independently associated with a lower likelihood of home discharge included a higher medical comorbidity index, adverse events during inpatient rehabilitation, intravenous (IV) opioid use at admission, and lower initial functional levels. Early identification of patients with clinical characteristics associated with a lower likelihood of returning home may facilitate the development of targeted rehabilitation strategies during inpatient rehabilitation.
Ketamine is a powerful and rapid-acting antidepressant but has no regulatory authorization for any psychiatric illness. The S-enantiomer of ketamine, esketamine, was approved by the FDA in 2019 as adjunctive therapy for treatment-resistant depression. Substantial controversy exists as to whether there is a significant clinical difference between intravenous (IV) ketamine racemate and intranasal esketamine. The EQUIVALENCE protocol will directly compare these therapies for treatment-resistant depression (TRD). Patients with TRD are randomized (1:1) to receive 8 treatments of IV ketamine or IN esketamine over a 4-week period. The primary outcome is change in depression severity as measured by a patient-reported outcome, the Quick Inventory of Depressive Symptomatology (QIDS) after 4 weeks of treatment. The study is designed as a non-inferiority study, with the FDA-approved therapy, esketamine, considered the standard. With a sample size of 400 total (200 per group), the study is powered to declare non-inferiority within a margin of 1.6 on the QIDS. If IV ketamine is found to be non-inferior to esketamine, a subsequent statistical test will examine whether ketamine is superior. Secondary outcomes include response and remission rates, anxiety severity, quality of life, and patient satisfaction, acceptability, and tolerability. We will also examine whether TRD with anxious distress responds differentially to one treatment or the other and the role that patient preference plays in outcomes. Results of the EQUIVALENCE study will have important implications for patient choice, health insurance coverage policies, and clinical care for TRD.
Benign transient hyperphosphatasemia (BTH) in children is characterized by temporary highly elevated serum alkaline phosphatase (ALP) activity in the absence of liver or bone disease and a return to normal within 3 to 4 months. Since its first description in the 1950s, several cases of BTH in infants and children have been reported. Although there is no known etiology for this illness, it has been associated with viral infections. This condition has rarely been seen in the adult population, and there is scarce available information. The sialylation of the ALP isoenzymes decreases their renal clearance from the circulation; however, the pathophysiology behind the increased sialylation of the ALP is uncertain. This is a 62-year-old female with a history of hypertension who was seen for a routine checkup and was found to have elevated ALP. The patient reports a family history of primary biliary cirrhosis. Routine labs showed an isolated elevation of ALP at 1496 U/L (normal range is 44 to 147 U/L). A physical examination and review of systems revealed no evidence of liver disease or bone abnormalities. Lipase, thyroid-stimulating hormone (TSH), T3, T4, parathyroid hormone, vitamin D, electrolytes, and markers for autoimmunity and tumors were found within normal limits. The abdominal ultrasound, the computerized tomography (CT) with contrast of the abdomen, and the bone survey were unremarkable. Alkaline phosphatase electrophoresis showed equally elevated liver and bone isoenzymes with a typical pattern of BTH. Serial ALP levels showed normalization by week 8 from the initial abnormal level. Benign transient hyperphosphatasemia is a rare condition mostly seen in children, and it is even rarer for it to present in adults. It is speculated that BTH is caused by a transient decrease in the clearance of ALP. The adult presentation of BTH is poorly described in medical literature, limiting the ability of medical providers to make an early diagnosis and avoiding extensive investigations.
Atrial flutter is a common arrhythmia, and catheter ablation offers a potentially curative intervention. However, there is a continued desire to enhance the procedure's efficiency and safety to optimize patient outcomes. Recently, local impedance (LI) has garnered attention as a novel approach to optimizing ablation procedures. The parameters of LI change when associated with durable ablation lesions for cavo-tricuspid isthmus (CTI) which remains poorly defined. This study aims to address this gap through analysis of gathered data. We conducted a retrospective data analysis of 121 consecutive patients who underwent local impedance-guided catheter ablation of the CTI for typical atrial flutter. The durability of the ablated lesions was assessed using high-resolution activation and voltage mapping to detect conduction gaps. The maximum LI drop was calculated for each ablation point. Each point was assessed by 3-dimensional electroanatomic mapping with binary categorization denoting either durable/successful ablation lesion or non-durable/unsuccessful ablation lesion. In addition, subjective evaluation of catheter-tissue contact was assessed by a single proceduralist using intracardiac echocardiography (ICE) and was then stratified as high-level contact, intermediate-level contact, and low-level contact. A total of 1814 ablation points were analyzed. The mean maximum drop in LI was significantly different (P < .0001) between the -16.38 ohms (95% confidence interval [CI], -17.54 to -15.23) for unsuccessful lesions and -20.79 ohms (95% CI, -21.20 to -20.38) for successful lesions. Among patients with at least 1 unsuccessful lesion, the maximum drop in LI was -16.38 for those that were unsuccessful in comparison to -19.81 for successful lesions (95% CI [-20.56, -19.06], P < .0001). The mean maximum drop in LI was progressively smaller moving from the high-level contact group (-25.93 ± 9.35), to the intermediate-level contact group (-19.04 ± 7.64), and again for the low-level contact group (-13.84 ± 6.93). Our results give insight into the relationship between maximal local impedance change and the achievement of a durable block along the CTI.
Hughes-Stovin Syndrome (HSS) is a rare vasculitis characterized by pulmonary artery aneurysms (PAAs) and peripheral venous thrombosis. Anticoagulation, the standard treatment for venous thrombosis, is often contraindicated in HSS due to the risk of fatal pulmonary hemorrhage, especially since mortality rates of patients with a history of hemoptysis are reported at 50%-100% from PAA ruptures, yet treatment guidelines are limited due to the condition's rarity with fewer than 90 reported cases globally. This report highlights the complex management decisions required. A 24-year-old man with a 3-month history of PAAs, left lower extremity deep vein thrombosis (DVT), and hemoptysis presented with worsening right lower extremity DVT after discontinuing apixaban due to the hemoptysis. He was initially evaluated for chest pain potentially signaling myocardial infarction, which was ruled out. Imaging confirmed extensive new bilateral lower extremity DVTs and a chronic infrarenal inferior vena cava (IVC) occlusion with collateralization. Importantly, the PAAs remained stable without imaging signs suggesting impending rupture. HSS was diagnosed based on the constellation of PAAs, recurrent DVT, and the patient's history of hemoptysis. Despite the inherent risks associated with anticoagulation in HSS, the decision was made to resume apixaban due to the patient's significant thrombotic burden and stable PAAs, alongside continued immunosuppression and close monitoring. This case underscores the necessity of individualized treatment in HSS, balancing thrombotic versus hemorrhagic risk in the absence of definitive guidelines. Further research is crucial to establish evidence-based strategies for managing anticoagulation in this complex patient population.
Description This article draws attention to Winnicott's concept of the "good enough mother" and how it can be applied to those in medicine. It emphasizes that no one is perfect, and our children learn best from our imperfections. I was reminded of that while kayaking on the Lost Spring Lake in Ocala, FL, and took this picture. If we can find beauty in nature's imperfections, we can also find it within our own imperfections.
Spontaneous pneumomediastinum (SPM) is a rare condition defined by the presence of air in the mediastinum in patients without an observable traumatic cause. Pneumomediastinum is a somewhat rare condition that occurs 1 in every 25 000 individuals, aged 5 to 34 years old, with 76% occurring in men. Pneumomediastinum can further be divided into 2 categories: SPM and traumatic pneumomediastinum. Traumatic pneumomediastinum is most commonly seen with blunt force trauma or any iatrogenic procedures to the chest wall. Spontaneous pneumomediastinum frequently occurs due to air leaking through small alveolar sacs, which rupture within the surrounding bronchovascular sheath. Spontaneous pneumomediastinum can be further divided into primary and secondary causes; the main difference is that secondary SPM requires a preexisting condition (ie, lung disease). Primary SPM is considered when trauma or any iatrogenic causes are ruled out. Secondary SPM, which is more common, is usually seen with esophageal perforation. Few case reports have been published connecting the inhalation of marijuana, cocaine, and the use of opioids to SPM, and, until now, no published data links the ingestion of cleaning products to SPM. This case report presents a 28-year-old White man who developed a SPM following the ingestion of bleach, dish soap, and laundry detergent and the inhalation of methamphetamines. This case report highlights the potential for chemical-induced pneumomediastinum and emphasizes the importance of considering unusual etiologies in patients presenting with acute chest pain and respiratory distress after chemical exposures with a suicide attempt. Spontaneous pneumomediastinum is due to a pressure change within the thoracic cavity as a result of air leakage. This has been commonly seen with certain risk factors, such as cystic fibrosis, chronic obstructive pulmonary disease, and, most commonly, Boerhaave's syndrome. However, there are other less commonly known risk factors that can predispose a patient to or contribute to them developing SPM, including methamphetamine use and inhalation of laundry chemicals.
Description Keratosis pilaris (KP) is a common benign disorder involving hyperkeratosis of the skin. It is associated with other common dry skin disorders such as atopic dermatitis and ichthyosis vulgaris. Lesions are clinically characterized as symmetrically distributed, monomorphic, folliculocentric, hyperkeratotic papules with a variable degree of perifollicular erythema. The appearance can be likened to spikey bumps that are commonly located on the arms, legs, and buttocks. Awareness of KP is important as every primary care clinician will see patients with this disorder. Identification can support the diagnosis of other associated skin diseases. Education about KP and its treatment may alleviate psychological distress and reduce symptoms. Common mimicking diagnoses include folliculitis, acne vulgaris, and milia. There are also uncommon atrophic variants of KP that result in scarring and alopecia. The clinical images in this review focus on identifying KP across the spectrum of skin tones.
Pediatric appendicitis (PA) is the most frequent cause of pediatric emergency surgery. Standard PA scoring systems incorporate inflammatory biomarkers (white blood cell count [WBC] or C-reactive protein [CRP]); however, the individual biomarker sensitivities have not been reported beyond single-center sites. We aimed to measure the individual and combined sensitivities of WBC and CRP to rule out PA in a large multicenter hospital system. We did a retrospective study of pediatric emergency department patients (age <18) with abdominal pain, using a deidentified electronic health database from a 175-hospital system in the United States, comparing PA versus non-PA patients. Pediatric appendicitis patients were identified by ICD-10 diagnosis codes and had advanced imaging, whereas non-PA patients had advanced imaging and were discharged home with the ICD-10 code for abdominal pain. Using matched propensity matching, we calculated receiver operator characteristics and Youden's index to find the optimal cutpoints. Sensitivity was calculated at the optimal and traditional cutpoints for each biomarker, also combined in parallel fashion. We identified 7414 subjects (3707 PA matched to 3707 controls). The WBC in PA patients was 14.99 ± 5.00 k/mm3 versus 9.63 ± 3.83 k/mm3 in non-PA patients (P < .001). The CRP in PA patients was 5.13 ± 6.43 mg/dL versus 1.22 ± 2.17 mg/dL in controls (P < .001). The optimal cutpoints (Youden's index) were 11.5 k/mm3 for WBC and 1.11 mg/dL for CRP. The sensitivity of WBC to rule out PA varied between 75.6%-83.9%, depending on the cutpoint (10.0-11.5 K/mm3). Similarly, the sensitivity of CRP to rule out PA varied from 64.9%-66.7%, depending on the cutpoint (1.0-1.11 mg/dL). Combined analysis showed that low WBC and CRP had a sensitivity of 90.0%-93.0%, yielding a negative predictive value of 99.2%-99.4% to rule out PA. The PA patients in our study had significantly higher inflammatory biomarkers than the non-PA patients. Combining WBC less than 10.0 k/mm3 and CRP less than 1.0 mg/dL was 93.0% sensitive to rule out PA. Researchers should consider this combination of biomarkers to rule out PA in future prospective studies.
The thin, vascularized skin of the eyelids makes them prone to irritation and discoloration, potentially revealing underlying issues, such as subcutaneous deposits, and an abundance of pigments like carotenoids and lipofuscins. First described in 2008 by Assouly et al, orange palpebral spots (OPS) present as painless orange-yellow lesions on the upper eyelids, primarily affecting White women with Fitzpatrick skin types I to III. Despite various hypotheses, the exact cause of OPS remains elusive, with no established links to malignancy or systemic illnesses. A 63-year-old woman, with a medical history including basal and squamous cell carcinoma, diabetes mellitus, hypertension, and hypercholesterolemia, was found to have asymptomatic orange-yellow patches on bilateral eyelids during a routine dermatological exam. There was no prior treatment for these lesions. A clinical diagnosis of OPS was made without obtaining biopsies. Orange-yellow discoloration of the eyelids suggests lipid deposition in the dermis, leading to differentials including xanthelasma and carotenoderma. Biopsies of OPS show increased lipid deposition without xanthelasma's characteristic lipid-laden macrophages, also described as foamy histiocytes. Carotenoderma primarily affects sweat and sebum, leading to pigmentation in specific areas, like palms, soles, and nasolabial folds. Though the cause of OPS is unknown, factors like microscopic fat cells, increased pigments, and local trauma, are implicated. However, further research is needed to determine the etiology. Orange palpebral spots remain poorly recognized, with no established treatments, underscoring the need for accurate diagnosis to avoid unnecessary biopsies and provide reassurance to patients.