Common Medical Causes Research Articles

Depressive disorders and their pharmacotherapy in routine clinical practice

Depression is one of the most common medical causes of disability and mortality in patients of all ages. Depressive disorders are common in the practice of physicians of a variety of specialties, including psychiatrists, neurologists, and physicians. This paper provides a summary review of the literature on modern ideas about the epidemiology, classification, and clinical picture of depression. Current approaches to the diagnosis and treatment of depressive disorders in neurological and psychiatric practice are discussed. Modern pharmacotherapeutic strategies for the treatment of depression in various patient populations are described in detail. Current clinical practice indicates the high importance of an interdisciplinary approach in the diagnosis and management of patients with depressive symptoms in Russia. The paper suggests organizational and educational strategies that can be recommended to improve the effectiveness of medical care for patients with depressive disorders.

Medical Causes of Death’s Profile Based on ICD-10 Standards in Confirmed Covid-19 Patients in Tertiary Hospital in Padang, Indonesia

Medical causes of death written by a doctor are important to be documented for each death, especially in relation to public health, research, surveys, epidemiology, prevention programs, public safety, medicine, and health administration. This is a retrospective descriptive study that aims to describe the causes of medical death in confirmed Covid-19 deaths, as well as compare the writing of causes of medical death based on the WHO International Classification of Disease (ICD) 10 standard. From this study, it is known that more than half of the information on the medical cause of death form written by doctors still does not comply with the WHO ICD-10 standard. The most common medical causes of death that have a direct impact on the death of confirmed Covid-19 patients was acute respiratory distress syndrome. Writing the cause of death according to the WHO ICD 10 standard is very necessary in obtaining accurate information on deaths related to COVID-19.

Incidence and risk factors for acute kidney injury after total joint arthroplasty

BackgroundAcute kidney injury (AKI) is one of the most common medical causes for readmission following total joint arthroplasty (TJA). This study aimed to (1) examine whether the incidence of AKI has changed over the past decade with the adoption of modern perioperative care pathways and (2) identify the risk factors and concomitant adverse events (AEs) associated with AKI.Methods535,291 primary TJA procedures from the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2018 were retrospectively reviewed. The annual incidence of AKI was analyzed for significant changes over time. Matched cohort analyses were performed to identify the risk factors and AEs associated with AKI using multivariate logistic regression.ResultsThe mean incidence of AKI was 0.051%, which remained unchanged during the study period (P = 0.121). Factors associated with AKI were diabetes (OR 1.96, P = 0.009), bilateral procedure (OR 6.93, P = 0.030), lower preoperative hematocrit level (OR 1.09, P = 0.015), body mass index (OR 1.04, P = 0.025), and higher preoperative BUN (OR 1.03, P = 0.043). AKI was associated with length of stay (LOS) > 2 days (OR 4.73, P < 0.001), non-home discharge (OR 0.25, P < 0.001), 30-day readmission (OR 12.29, P < 0.001), and mortality (OR 130.7, P < 0.001).ConclusionsThe incidence of AKI has not changed over the past decade, and it remains a major bundle buster resulting in greater LOS, non-home discharge, readmissions, and mortality. Avoidance of bilateral TJA in patients with DM and high BMI as well as preoperative optimization of anemia and BUN levels are advised.

Exercise Related Respiratory Problems in the Young-Is It Exercise-Induced Bronchoconstriction or Laryngeal Obstruction?

Complaints of breathlessness during heavy exercise is common in children and adolescents, and represent expressions of a subjective feeling that may be difficult to verify and to link with specific diagnoses through objective tests. Exercise-induced asthma and exercise-induced laryngeal obstruction are two common medical causes of breathing difficulities in children and adolescents that can be challenging to distinguish between, based only on the complaints presented by patients. However, by applying a systematic clinical approach that includes rational use of tests, both conditions can usually be diagnosed reliably. In this invited mini-review, we suggest an approach we find feasible in our everyday clinical work.

Management of Psychiatric Disorders in Patients with Respiratory Diseases.

Management of Psychiatric Disorders in Patients with Respiratory Diseases.

Acute Vestibular Syndrome.

This article provides a practical approach to acute vestibular syndrome while highlighting recent research advances. Acute vestibular syndrome is defined as sudden-onset, continuous vertigo lasting longer than 24 hours with associated nausea and vomiting, all of which are worsened with head movement. Acute vestibular syndrome is provoked by a variety of central and peripheral causes, the most common of which are vestibular neuritis and acute stroke (posterior circulation). A clinical approach focusing on timing, associated history, and ocular motor findings can improve diagnostic accuracy and is more sensitive and specific than early neuroimaging. Because of the shared neurovascular supply, both peripheral and central vestibular disorders can manifest overlapping signs previously considered solely peripheral or central, including vertical skew, nystagmus, abnormal vestibular ocular reflex, hearing loss, and gait instability. Although acute vestibular syndrome is typically benign, stroke should be considered in every person with acute vestibular syndrome because it can act as a harbinger of stroke or impending cerebellar herniation. Treatment is focused on physical therapy because the evidence is minimal for the long-term use of medication. The diagnosis of acute vestibular syndrome first requires the elimination of common medical causes for dizziness. Next, underlying pathology must be determined by distinguishing between the most common causes of acute vestibular syndrome: central and peripheral vestibular disorders. Central vestibular disorders are most often the result of ischemic stroke affecting the cerebellar arteries. Peripheral vestibular disorders are assumed to be caused mostly by inflammatory sources, but ischemia of the peripheral vestibular apparatus may be underappreciated. By using the HINTS Plus (Head Impulse test, Nystagmus, Test of Skew with Plus referring to hearing loss assessment) examination in addition to a comprehensive neurologic examination, strokes are unlikely to be missed. For nearly all acute vestibular disorders, vestibular physical therapy contributes to recovery.

Community Acquired AKI: A Prospective Observational Study from a Tertiary Level Hospital in Southern India.

Introduction:Pattern of acute kidney injury (AKI) differs vastly from region to region in India. Moreover, prospective data on community-acquired AKI (CAAKI) using the KDIGO criteria for AKI are limited. Our objective was to study the etiology, clinical characteristics, and short-term outcome of CAAKI in adults.Methods:This was a prospective observational study in the medical wards of a tertiary care hospital. Patients fulfilling the 2012 KDIGO AKI criteria of community acquired acute kidney injury (CAAKI) were included. Patients who developed AKI 48 hours after admission, those hospitalized >48 hours elsewhere, and patients with chronic kidney disease were excluded. The study did not include obstetric or surgical cases of AKI. Serum creatinine and urine output was monitored. Daily progress, in particular development of hypotension, oliguria, acute respiratory distress syndrome, sepsis, and renal replacement therapy, was noted.Results:Of 186 CAAKI patients (mean age, 46.13 ± 15.2 years), 86/186 was infective etiology, 93/186 was non-infective etiology, 7/186 was due to intrinsic renal pathology. Pyelonephritis 33/186 (17.7%) was the most common infective etiology, and snakebite in 49 (26.3%) was the most common non-infective etiology; 28/186 (15.1%) died. On logistic regression, hypotension, mechanical ventilation, thrombocytopenia, and anuria were associated with mortality.Conclusions:Acute pyelonephritis and snakebite-related AKI emerged as the two most common medical causes of CAAKI in our region. Such environmental and infectious causes that largely are preventable causes of AKI are also associated with significant morbidity and mortality.

Increased risk of hospital admission for mood disorders following admission for epilepsy.

To determine if epilepsy admissions, compared to admissions for other medical causes, are associated with a higher readmission risk for mood disorders. The Nationwide Readmissions Database is a nationally representative dataset comprising 49% of US hospitalizations in 2013. In this retrospective cohort study, we used ICD-9-CM codes to identify medical conditions. Index admissions for epilepsy (n = 58,278) were compared against index admissions for stroke (n = 215,821) and common medical causes (n = 973,078). Readmission rates (per 100,000 index admissions) for depression or bipolar disorders within 90 days from discharge for index hospitalization were calculated. Cox regression was used to test for associations between admission type (defined in 3 categories as above) and readmission for depression or bipolar disorder up to 1 year after index admission, in univariate models and adjusted for age, sex, psychiatric history, drug abuse, income quartile of patient's zip code, and index hospitalization characteristics. The adjusted hazard ratio (HR) for readmission for depression in the epilepsy group was elevated at 2.80 compared to the stroke group (95% confidence interval [CI] 2.39-3.27, p < 2 × 10-16), and 2.09 compared to the medical group (95% CI 1.88-2.32, p < 2 × 10-16). The adjusted HR for readmission for bipolar disorder in the epilepsy group was elevated at 5.84 compared to the stroke group (95% CI 4.56-7.48, p < 2 × 10-16), and 2.46 compared to the medical group (95% CI 2.16-2.81, p < 2 × 10-16). Admission for epilepsy was independently associated with subsequent hospital readmission for mood disorders. The magnitude of elevated risk in this population suggests that patients admitted with epilepsy may warrant targeted psychiatric screening during their hospital admission.

Increased risk of hospital admission for ICD-9-CM psychotic episodes following admission for epilepsy.

To determine whether epilepsy admissions are associated with a higher readmission risk for psychotic episodes compared to admissions for other medical causes. The Nationwide Readmissions Database is a nationally representative dataset from 2013. We used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify medical conditions. There were 58278 index admissions for epilepsy, and this group was compared against admissions for stroke (n=215821) and common medical causes (pneumonia, urinary tract infection [UTI], congestive heart failure [CHF], and chronic obstructive pulmonary disease [COPD], n=973078). Readmission rates for psychotic episodes within 90days from discharge for index hospitalizations were calculated. Cox regression was used to test for associations between admission type and readmission for psychotic episodes up to 1year after index admission, in univariate models and adjusted for multiple medical, social, and psychiatric variables. Up to 90days from index admission, there were 683/100000 readmissions for psychotic episodes in the epilepsy group, 92/100000 in the stroke group, and 58-206/100000 in the medical group. The relative rate of readmission in the epilepsy group was highest in the first 30days following index admission (311/100000). Unadjusted hazard ratio (HR) for readmission for psychotic episodes within 1year in the epilepsy group compared to the stroke group was 6.58 (95% confidence interval [CI] 5.69-7.61, P<2×10-16 ), and 4.41 compared to the medical group (95% CI 4.00-4.85, P<2×10-16 ). The fully adjusted HR for readmission in the epilepsy group remained elevated at 3.63 compared to the stroke group (95% CI 3.08-4.28, P<2×10-16 ), and 1.95 compared to the medical group (95% CI 1.76-2.15, P<2×10-16 ). Confounding factors most strongly associated with psychosis readmission were documented psychosis history at the time of index admission, younger age, and lower income quartile. An epilepsy admission was independently associated with subsequent hospital readmission for psychotic episodes, even after adjustment for confounding variables.

Jaundice in infants and children: causes, diagnosis and management

Jaundice is caused by an accumulation of bilirubin in the blood. The presentation in infants and children can be indicative of a wide range of conditions, with some self-limiting and others potentially life-threatening. This article aims to provide a concise review of the common medical and surgical causes in children and discuss their diagnosis and management.

Risk of readmission for suicide attempt after epilepsy hospitalization

The objective of this study was to examine if epilepsy admissions are associated with a higher readmission risk for suicide attempt, independent of psychiatric comorbidity, compared with index admissions for other medical causes. The Nationwide Readmissions Database is a nationally representative dataset containing data from roughly 15 million hospital discharges. Analysis of International Classification of Disease Clinical Modification 9 (ICD-9-CM) codes in the year 2013 revealed 58,278 index admissions for epilepsy; this group was compared with admissions for stroke (N=215,821) and common medical causes (N=973,078). Ninety-day readmission rates for suicide attempts were calculated. Cox regression tested for associations between admission type and suicide attempt readmissions up to 1year following index admission. There were 402/100,000 readmissions for suicide attempt within 90days from index admission in the group with epilepsy; 43/100,000 in the stroke group; and between 37 and 89/100,000 in the medical group. Unadjusted hazard ratios (HR) for suicide readmissions within 1year in the group with epilepsy compared with the stroke group were 9.61 (95% confidence interval (CI): 7.69-11.90, p<2.0×10-16) and 5.02 compared with the medical group (95% CI: 4.40-5.73, p<2.0×10-16). The HR for readmission in the group with epilepsy, after adjustment for sociodemographic and psychiatric variables, were elevated at 4.91 compared with the stroke group (95% CI: 3.83-6.27, p<2.0×10-16), and 2.66 compared with the medical group (95% CI: 2.32-3.05, p<2.0×10-16). Independent of psychiatric comorbidities, epilepsy admissions may be independently associated with more than a threefold increased risk of hospital readmission for suicide in the year following index admission in comparison with patients recently hospitalized because of stroke or other common medical disorders.

Vitamin C Premedication Reduces Postoperative Rescue Analgesic Requirement after Laparoscopic Surgeries

Background & Objectives: Pain is one of the common medical causes of delayed discharge from hospital. It causes adverse effect such as tachycardia, hypertension, myocardial ischemia, decrease alveolar ventilation, and poor wound healing. The reduction of pain may prevent these adverse effects and enhance early discharge from hospital. The premedication with oral vitamin C was assumed to reduce postoperative pain and rescue analgesic requirement in patients after laparoscopic surgeries. Material and Methods: After approval from ethical committee and informed written consent, study was conducted on 200 patients of ASA physical status 1 and 2, who were scheduled for laparoscopic surgery. All the selected patients were divided in to 2 groups. Group 1 received oral vitamin C 2 gram and group 2 patients received placebo tablets in night and 2 hour before surgery. After premedication Patients were explained about surgical procedure and visual analogue pain scale (VAS 0: no pain and VAS 10: worst pain). Anesthesia was induced with propofol 2mg/kg and vecuronium bromide 0.1mg/kg as muscle relaxant and maintained with oxygen, nitrous oxide (50:50) and isoflurane. Patients in both group received injection paracetamol 10mg/kg body weight 30 minutes before skin closure. Neuromuscular blockade was reversed and patients were shifted in postoperative recovery room. The data were recorded and analyzed. Results: The physical variables of both group patients were statistically comparable. Mean heart rate, blood pressure VAS score were statistically different in early part of postoperative period. The postoperative analgesic consumption in group 1 patients were significantly low. Conclusion: We concluded that use of vitamin C reduces early postoperative pain and consumption of fentanyl as rescue analgesic in postoperative period.

What Are the 30-day Readmission Rates Across Orthopaedic Subspecialties?

The Centers for Medicare & Medicaid Services (CMS) now include hip and knee replacements in the Hospital Readmission Reduction Program. The 30-day readmission rate is an important quality metric; however, the incidence has not yet been defined across the numerous orthopaedic subspecialties. Elucidating the readmission rate for each subspecialty may indicate that certain services are being disincentivized by the CMS reimbursement program. Furthermore, the "planned" and "unplanned" definitions of readmission have not been well examined to determine their clinical relevance and representation of safe patient care. Therefore, reducing the 30-day readmission rate has become a top priority in orthopaedic quality assurance. (1) What are the 30-day readmission rates for the different orthopaedic subspecialties? (2) What are the risk factors associated with readmission within 30 days? (3) What are the causes of 30-day readmissions? (4) What is the interrater agreement among CMS, hospital, and clinician definitions of planned and unplanned readmissions? We retrospectively examined one tertiary care academic hospital's quality improvement database and identified 4792 discharges from the department of orthopaedics during a continuous 24-month period. Discharges were divided and analyzed according to the subspecialty of orthopaedic care. Demographics and comorbidities were extracted from the database and subjected to univariate and multivariate analysis to determine risk factors for 30-day readmission. Further chart review was conducted on all cases of 30-day readmission to identify causes. The authors' determination of planned versus unplanned was compared with two other definitions (hospital and CMS) and analyzed for agreement by using Fleiss' kappa for multiple rater. The all-cause 30-day readmission rate was 4% (95% confidence interval [CI], 3.8-4.8). The unplanned readmission rate was 3% (95% CI, 2.8-3.8). After controlling for relevant confounding variables, we found that length of stay (odds ratio [OR], 1.10 per day; p < 0.001), American Society of Anesthesiologists score (OR, 1.89 per point; p < 0.001), and care under trauma (OR, 2.55; p < 0.001) or "other" (OR, 1.65; p = 0.009) as compared with joint subspecialty were associated with increased risk of readmission. Of the 160 unplanned readmissions, 93 (58%) were surgical and 67 (42%) were medical. The most common surgical cause was surgical site infection (38% of surgical readmissions) and the most common medical causes were gastrointestinal bleed, pulmonary embolus, and unrelated trauma (each 9% of medical readmissions). There was poor agreement (Fleiss' kappa = 0.120) among the three definitions of planned readmission. There are important differences in the risk of readmission by subspecialty across orthopaedics and the CMS-driven disincentives may be applied unequally across these subspecialties. This could result in hospitals deemphasizing those service lines and could potentially limit access to care for the patients most in need. Avenues of readmission reduction should be further studied including telephone followup programs and outpatient management of threatened wounds. Clinical, hospital, and CMS definitions of planned readmission have poor agreement, suggesting that hospitals are being unnecessarily penalized. The CMS should develop a more clinically relevant definition of 30-day readmission to more accurately evaluate the rate of readmissions. Level III, therapeutic study.

Gaining insight into the prevention of maternal death using narrative analysis: an experience from kerman, iran.

Reduction in maternal mortality requires an in-depth knowledge of the causes of death. This study was conducted to explore the circumstances and events leading to maternal mortality through a holistic approach. Using narrative text analysis, all documents related to maternal deaths occurred from 2007 to 2011 in Kerman province/Iran were reviewed thoroughly by an expert panel. A 93-item chart abstraction instrument was developed according to the expert panel and literature. The instrument consisted of demographic and pregnancy related variables, underlying and contributing causes of death, and type of delays regarding public health aspects, medical and system performance issues. A total of 64 maternal deaths were examined. One third of deaths occurred in women less than 18 or higher than 35 years. Nearly 95% of them lived in a low or mid socioeconomic status. In half of the cases, inappropriate or nonuse of contraceptives was seen. Delay in the provision of any adequate treatment after arrival at the health facility was seen in 59% of cases. The most common medical causes of death were preeclampsia/eclampsia (15.6%), postpartum hemorrhage (12.5%) and deep phlebothrombosis (10.9%), respectively. Negligence was accounted for 95% of maternal deaths. To overcome the root causes of maternal death, more emphasis should be devoted to system failures and patient safety rather than the underlying causes of death and medical issues solely.

Gabapentinoids: Gabapentin and Pregabalin for Postoperative Pain Management

Editorial Postsurgical pain is normally perceived as nociceptive pain. Surgical trauma has been known to induce central and peripheral sensitization and hyperalgesia, which in untreated cases could lead to chronic postoperative pain after surgery. Indeed pain is one of the three most common medical causes of delayed discharge after ambulatory surgery, the other two being drowsiness and nausea/ vomiting. Antihyperalgesic drugs improve postoperative pain by preventing the development of central sensitization (1). The development of newer agents available for postoperative pain control create possibilities for better combinations in multimodal analgesia. The recent advances in postoperative pain management can be specifically grouped in the following areas: Finding exact molecular mechanisms, new pharmaceutical products and other routes and modes of analgesic delivery. For the years, opioids have been the mainstay of postoperative pain management but they have side effects. For this purpose the multimodal approach and non-opioid drugs have been suggested to improve postoperative analgesia and to reduce opioid related side effects (2). Gabapentinoids (gabapentin and pregabalin) were originally introduced as antiepileptics but have analgesic, anticonvulsant, and anxiolytic effects also. These easily tolerable drugs by patients have limited side-effects. Gabapentin an anti-epileptic drug binds to the alpha-2 delta subunit of the presynaptic voltage gated-calcium channels and inhibits calcium release so prevents the release of excitatory neurotransmitters involved in the pain pathways (2, 3). Gabapentin has demonstrated analgesic effect in diabetic neuropathy, post-herpetic neuralgia, and neuropathic pain. Several meta-analyses reveal that perioperative gabapentin helps to produce a significant opioid-sparing effect and probably decreses postoperative pain score relative to the control group (4, 5). Pregabalin is a structural analog of gamma-aminobutyric acid (GABA). It acts by presynaptic binding to the α -2-λ subunit of voltage-gated calcium channels that are widely distributed in the spinal cord and brain6. By this mechanism, pregabalin modulates the release of several excitatory neurotransmitters, such as glutamate, norepinephrine, substance P, and calcitonin gene-related peptide. It leads to inhibitory modulation of “overexcited” neurons and returning them to a “normal” state. Centrally, pregabalin could reduce the hyperexcitability of dorsal horn neurons that is induced by tissue damage (6). To sum up, pregabalin has a more appropriate pharmacokinetic profile than gabapentin, including dose-independent absorption and far more potent than gabapentin while producing fewer adverse effects (7-9). Pregabalin has efficacy of varying degree in neuropathic pain conditions such as postherpetic neuralgia, painful diabetic neuropathy, central neuropathic pain, and fibromyalgia. While some surveys do not demonstrate a significant analgesic effect in the acute, including postoperative pain control (9, 10), other studies suggest pregabalin to have effective sedative and opioid-sparing effects (11-13), and emphasize on its effectiveness in acute pain control. Since safe postoperative pain control is nessecary, established role of pregabalin as an analgesic adjuvant as a part of multimodal analgesia for acute pain control is in progress (7, 8, 14, 15). Its unique potency in reducing opioid requirements, prevention of opioid tolerance, enhancement the quality of opioid analgesia, decreased respiratory depression and anxiolysis, make it an attractive drug to consider for control of pain in the post-operative setting (15-17). Lots of meta-analyses and clinical trials show that perioperative pregabaline helps to produce a significant opioid-sparing effect and probably improves postoperative pain score relative to the control group (18-21). Having looked at these two drugs from different angles and aspects, one comes to this understanding that these multi-purpose drugs have found a strong and reliable place in acute pain service setting. So, Gabapentinoids are an effective tool in the treatment of postoperative pain.

Trends in maternal mortality at the University of Calabar Teaching Hospital, Nigeria, 1999-2009.

Maternal mortality remains a major public health challenge, not only at the University of Calabar Teaching Hospital, but in the developing world in general. The objective of this study was to assess trends in maternal mortality in a tertiary health facility, the maternal mortality ratio, the impact of sociodemographic factors in the deaths, and common medical and social causes of these deaths at the hospital. This was a retrospective review of obstetric service delivery records of all maternal deaths over an 11-year period (01 January 1999 to 31 December 2009). All pregnancy-related deaths of patients managed at the hospital were included in the study. A total of 15,264 live births and 231 maternal deaths were recorded during the period under review, giving a maternal mortality ratio of 1513.4 per 100,000 live births. In the last two years, there was a downward trend in maternal deaths of about 69.0% from the 1999 value. Most (63.3%) of the deaths were in women aged 20-34 years, 33.33% had completed at least primary education, and about 55.41% were unemployed. Eight had tertiary education. Two-thirds of the women were married. Obstetric hemorrhage was the leading cause of death (32.23%), followed by hypertensive disorders of pregnancy. Type III delay accounted for 48.48% of the deaths, followed by Type I delay (35.5%). About 69.26% of these women had no antenatal care. The majority (61.04%) died within the first 48 hours of admission. Although there was a downward trend in maternal mortality over the study period, the extent of the reduction is deemed inadequate. The medical and social causes of maternal deaths identified in this study are preventable, especially Type III delay. Efforts must be put in place by government, hospital management, and society to reduce these figures further. Above all, there must be an attitudinal change towards obstetric emergencies by health care providers.

Peripheral Neuropathy of the Upper Extremity

In the orthopedic patient, the diagnosis of a compression neuropathy may be straightforward. However, various medical comorbidities can obscure this diagnosis. It is paramount for the practicing orthopedic surgeon to have an appreciation for the medical pathology of common axonal neuropathies to properly diagnose, treat, and refer a patient with altered sensation in the upper extremity. The prevalence of diabetes in the United States is 10%, and roughly 20% of diabetic patients have peripheral neuropathy. In addition to diabetes, 32% of heavy alcohol users present with polyneuropathy. With advancements in the treatment of human immunodeficiency virus/acquired immunodeficiency syndrome clinicians may see the long-term effects of the virus manifested as axonal neuropathies and extreme allodynia. In some regions of the world, Hansen's disease usurps diabetes as the most common cause of polyneuropathy. Based on patient demographics and social habits, Lyme disease, multiple sclerosis, and syphilis can all manifest as polyneuropathies. Understanding the common medical causes of neuropathy will aid the orthopedic surgeon in differentiating simple compression neuropathies from diseases mimicking or confounding them.

Peripheral Neuropathy of the Upper Extremity: Medical Comorbidity That Confounds Common Orthopedic Pathology

In the orthopedic patient, the diagnosis of a compression neuropathy may be straightforward. However, various medical comorbidities can obscure this diagnosis. It is paramount for the practicing orthopedic surgeon to have an appreciation for the medical pathology of common axonal neuropathies to properly diagnose, treat, and refer a patient with altered sensation in the upper extremity. The prevalence of diabetes in the United States is 10%, and roughly 20% of diabetic patients have peripheral neuropathy. In addition to diabetes, 32% of heavy alcohol users present with polyneuropathy. With advancements in the treatment of human immunodeficiency virus/acquired immunodeficiency syndrome clinicians may see the long-term effects of the virus manifested as axonal neuropathies and extreme allodynia. In some regions of the world, Hansen's disease usurps diabetes as the most common cause of polyneuropathy. Based on patient demographics and social habits, Lyme disease, multiple sclerosis, and syphilis can all manifest as polyneuropathies. Understanding the common medical causes of neuropathy will aid the orthopedic surgeon in differentiating simple compression neuropathies from diseases mimicking or confounding them.

Medical Conditions Requiring Intensive Care

Patients who require critical care for internal medical conditions make up a small but significant proportion of those requiring evacuation to the Royal Centre for Defence Medicine in Birmingham, UK....

Clinical Reasoning: A child with pulsatile headache and vomiting

A child was born to nonconsanguineous, healthy parents. Pregnancy and delivery were uneventful, and psychomotor development was normal. At the age of 6 years and 10 months, he was admitted to a local hospital because of vomiting and nonfebrile unilateral headache. Neurologic examination had normal results. Blood tests (complete blood count, C-reactive protein, electrolytes, blood urea nitrogen, creatinine, glucose, serum bicarbonate and pH, anion gap, transaminase, and urine culture) were within normal limits. Abdominal x-ray and abdominal ultrasound imaging had normal results. Based on these results and on clinical observation, common medical and surgical causes (viral illness, gastroenteritis, diabetes, intestinal obstruction) were ruled out. Head CT scan had normal results. The EEG showed some irregular activity in the occipital regions, with rare sharp waves, more prevalent on the right side. One week later, a further awake EEG was performed and had normal results. A presumptive diagnosis of migraine with aura was made after 2 months by a pediatric neurologist because of several episodes of unilateral pulsatile headache and vomiting (one to two episodes per week). The episodes were preceded by a sensation of sickness, and lasted about 5–10 minutes each. Pallor, poorly defined abnormal ocular movements, and transitory unresponsiveness were also reported by his parents. After the episode, the child asked to sleep. Acetaminophen and ibuprofen were prescribed to control symptoms. Five months later, the patient was brought to the Emergency Department of our hospital because of recurrent and long-lasting episodes of headache beginning the same day. He had four episodes of nausea, vomiting, pallor, and unilateral (right-sided or left-sided) pulsatile headache, each one lasting from 5 to more than 30 minutes. The prescribed treatment was ineffective, and the child was considered to be in a migraine aura status by his pediatrician. A critical episode was observed during clinical examination: …