Physical Findings Research Articles

Incidence of an Identifiable Organism in Children Who Underwent a Surgical Procedure for Granulomatous Cervical Lymphadenopathy.

Objectives: The incidence of cervical lymphadenopathy due to nontuberculous mycobacteria is rising in the pediatric population. Our goal with this study was to review the number of pediatric patients with granulomatous cervical adenitis and determine the incidence of identification of a specific organism as both healthcare providers and parents are interested in identifying the causative pathogen. Methods: A retrospective chart review was conducted of patients at a high-volume tertiary care children's hospital between 2017 and 2023. Children were included if they underwent a surgical procedure for lymphadenopathy. Pathology, microbiology, and other laboratory reports were reviewed to document the presence of granulomatous cervical adenitis and the incidence of identification of a specific organism. Additional data collected included patient demographics and type of procedure. Results: Of the 1538 charts reviewed, 163 patients underwent an inclusionary procedure. Mean patient age was 10.7 years (range 2.4 months-20 years), 70 (43%) were female, 25 (15%) had granulomatous cervical adenitis, and a specific organism was identified in 9 of these. Conclusion: Despite the availability of a number of ancillary tests, our data demonstrate that the identification of a specific pathogen in cases of granulomatous cervical lymphadenitis is rare. As a result, physicians should be prepared to rely primarily on the history and physical exam findings to determine a working diagnosis as well as a medical and/or surgical treatment plan.

9202 Characterizing The Physiological Side-Effects Of Over-The-Counter Arthritis Supplements

Abstract Disclosure: K.S. Wei: None. M.O. De La Torre: None. A. Flores: None. C.E. Chiu: None. T.E. Angell: None. Introduction: Over the counter (OTC) health supplements are commonly used by patients for a variety of ailments but may contain active ingredients that are not stated, such as glucocorticoids. Here, we present a case series of 12 patients seen by the Endocrinology Consult service at an urban safety net hospital during 2022-2023 and determined to have iatrogenic adrenal insufficiency (AI) from specific OTC supplements that surreptitiously contained glucocorticoids. Clinical Cases:12 patients using OTC arthritis supplements [Artri King (n=8), Ardosons (n=3), and Ajo Rey (n=1)] were identified. Median age was 52 years and 33.3% were female. All started using the supplements because of joint pain. Median length of use prior to cessation was 6 months. The most common presenting symptoms were nausea/vomiting (42%), fatigue (42%), abdominal pain (33%), and dizziness (17%). The most common physical exam findings of steroid excess included moon facies (66%), central adiposity (66%), abdominal striae (50%), dorsocervical fat pad (33%), and bruising (33%). 3/12 patients required ICU admission. Cortisol assessment was performed in 11/12 patients, which showed normal cortisol level in 1 patient (cortisol ≥16 mcg/dL), AI in 3 patients (cortisol ≤3 mcg/dL), and an equivocal level (cortisol 3-16 mcg/dL) in 7 patients. Cosyntropin stimulation testing in 6/7 patients with equivocal cortisol levels suggested AI in 4 (cortisol level <16 mcg/dL at 60 minutes after ACTH stimulation), whereas 2 showed lower but normal response (cortisol levels 18.2 mcg/dL and 18.4 mcg/dL). In total, 10/12 patients were prescribed glucocorticoid tapering replacements to avoid precipitating adrenal crisis. The most common regimens were hydrocortisone 20mg qAM/10mg qPM (33%) and hydrocortisone 5mg qAM/5mg qPM (17%). To date, 2/10 patients have successfully discontinued steroid replacement. Conclusion: These cases demonstrate possible Cushing’s syndrome and/or adrenal insufficiency after unintentional exposure to glucocorticoids in these OTC arthritis supplements, which has only previously been reported in a small number of case reports (1). This series collected over a 2-year period offers important clinical insights: Because patients may not identify or recall a supplement, possible use of OTC medications for arthritis or other anti-inflammatory purposes should be specifically assessed in patients presenting with adrenal insufficiency (especially with concomitant findings suggesting Cushing’s syndrome). For patients on such supplements, immediate discontinuation may not be possible without cortisol replacement and should be done with caution. 1)Boncompagni A.C. et al. A case of iatrogenic Cushing syndrome and subsequent adrenal insufficiency from a hidden ingredient in the supplement Artri Ajo King. J Am Coll Emerg Physicians Open. 2023;4(4):e13007. Presentation: 6/1/2024

7550 Case Report On Concurrent Metastases To The Pituitary And Adrenal From A Primary Breast Cancer

Abstract Disclosure: M.V. David-santos: None. M.C. Isidro: None. Background: Metastatic Cancer to the pituitary gland is a rare condition accounting for 0.5% of all pituitary tumors. It rarely manifests clinically and is often found incidentally. Endocrine dysfunction usually arise, with 38.4% of cases presenting with Diabetes Insipidus, while 37.7% as Panhypopituitarism. On the other hand, prevalence of adrenal metastases is at 0.5 to 3.8% with 43% occurring bilaterally. Primary adrenal insufficiency occurs at 12.4% among those with bilateral metastases. Case: A 32-year old Chinese woman was diagnosed with Stage 4 breast adenocarcinoma ER PR Her2 Neu positive with metastases to the axillary lymph nodes, bone and right adrenal in July 2021. She underwent chemotherapy with Paclitaxel and Trastuzumab then radical mastectomy of the left breast in April 2022.5 months post op, PET scan was done which showed a 11 x 18 x 21 mm pituitary mass. In light of the primary malignancy, lesion was considered a metastatic focus. At that time, patient did not exhibit any neurologic symptoms such as blurring of vision or headaches. No polyuria, polydipsia, nocturia, easy fatigability, nausea or vomiting. Physical examination findings were normal. A hormonal panel showed the following: elevated Prolactin at 150 ng/ml (NV 3-20), normal plasma ACTH IRMA 10 pg/ml (NV < 50 pg/ml), low 8AM plasma cortisol at 1.55 ug/dL (Ref 5- 25 ug/dL), TSH was low at 0.15iIU/ml (0.27-3.75) while FT4 was normal at 0.87 ng/dl (NV 0.68 - 2.56).ACTH stimulation showed low cortisol at the 30th minute and 1st hour post ACTH infusion. Serum sodium and urine Osmolality were both normal. The hyperprolactinemia was attributed to Stalk effect, while the decreased cortisol was considered as central adrenal insufficiency. She was then started on Prednisone 5mg tab daily. Repeat TSH and FT4 5 months after showed normal TSH at 1.209, low FT4 at 5.97 pmol/L (NV 9.01-19.05). She was started on Levothyroxine 50mcg daily for the central hypothyroidism.Repeat Cranial MRI 4 months post diagnosis of the pituitary mass showed increased in its size. An endoscopic transsphenoidal resection and biopsy of the pituitary mass showed metastatic carcinoma of the pituitary gland. Staining of the sellar tumor were compatible with a metastatic carcinoma of breast origin. Intensity-modulated radiation therapy (IMRT) at 400 gray was done for 5 fractions and Trastuzumab was continued. Cranial MRI done 6 months post IMRT showed decreasing size of the pituitary mass to its latest size of 6 x 9 x 13 mm as of November 2023. Latest Whole abdominal CT scan of the adrenals showed clearing of the right adrenal Nodule. Conclusion: Breast cancer may also metastasize to endocrine organs causing hormonal dysfunction. Although curative treatment is no longer the goal for Metastatic breast cancer, prolongation of the quality of life is an important aspect to consider. Hormonal work up, surveillance and hormonal replacement can help in attaining this goal. Presentation: 6/3/2024

6619 An Unlikely Cause of Oligomenorrhea: Acromegaly Secondary to a Sparsely Granulated, Somatotroph-Lactotroph Adenoma

Abstract Disclosure: S.I. Alicea: None. Y. Wu: None. J. Marquez: None. C.S. Botero Suarez: None. M. Kinaan: None. Introduction: Acromegaly most commonly presents as a pituitary tumor that causes excessive production ofgrowth hormone (GH); and rarely due to excess of GHRH or ectopic production of GH. Approximately 15% of surgically removed pituitary adenomas represent GH-producing neoplasms, and about 5% are bihormonal, secreting both GH and prolactin (PRL). We present a case of an unexpected presentation of oligomenorrhea which ended up with the diagnosis of acromegaly secondary to plurihormonal mixed somatotroph-lactotroph sparsely granulated adenoma. Case Description A 32-year-old female with history of prediabetes was referred to our clinic by her gynecologistfor evaluation of oligomenorrhea which was initially attributed to polycystic ovarian syndrome.She reported menarche at age 10 and has experienced irregular menses and periods of amenorrhea over the years. Physical exam revealed macroglossia, a widened thickened nose, acanthosis nigricans in the neck skin folds, facial hair thickening, and significant thickening of all fingers, toes and soft tissues. Given physical exam findings, we evaluated the patient for acromegaly and lab testing revealed markedly high IGF I, mildly elevated prolactin, and hemoglobin A1C of 5.7%. An MRI of the brain with IV contrast revealed a heterogeneously enhancing pituitary macroadenoma measuring 2.9 x 2.9 x 2.2 cm with suprasellar extension resulting in mass effect on the optic chiasm without definite cavernous sinus extension. She was started on Cabergoline 0.5mg twice weekly temporarily and underwent pituitary transsphenoidal resection. Pathology results revealed tumor cells that were positive for Chromogranin and Cam5.2. About 10% of cells showed immunoreactivity for Prolactin and negative for TSH, ACTH, FSH, LH and immunostains. There was also weak focal (about 2%) immunoreactivity for GH. Occasional mitotic figures were present. The MIB-1 proliferation index was 3%. The reticulin stain demonstrates loss of acinar architecture, supporting the diagnosis. Aside from transient sodium fluctuations consistent with triphasic response, she had no long-lasting postoperative complications. One month after her surgery, her IGF I level and hemoglobin A1C are trending down and she reports symptomatic relief. She continues follow up in our clinic. Discussion This patient has acromegaly secondary to a mixed somatotroph-lactotroph sparsely granulated adenoma. Sparsely granulated adenomas are more common in younger populations, can be more aggressive, and are less responsive to somatostatin analogs. Early detection and treatment is imperative in the prevention of complications secondary to the disease. Our case will closely examine the differences in the clinical, prognostic, and pathologic features of sparsely- vs. densely granulated adenomas. We will also discuss the effects of acromegaly on gonadal function. Presentation: 6/1/2024

8162 A Unique Presentation of Ovarian Steroid Cell Tumor Causing Hyperandrogenism in a Postmenopausal Woman

Abstract Disclosure: A. Rehan: None. M. Pandey: None. I. Goyal: None. E. Punni: None. N. Shakir: None. Background:­­­ Steroid cell tumors of the ovary are a rare entity, constituting less than 0.1% of all ovarian tumors. These tumors can present with diverse endocrine and paraneoplastic effects, including androgen excess and polycythemia. Hyperandrogenism in females can lead to hirsutism, virilization, alopecia, menstrual irregularities, acne, and emotional changes, with complications including hyperlipidemia and insulin resistance. There are various causes of androgen excess in a female including polycystic ovary syndrome (PCOS), androgen-secreting tumors, Cushing’s syndrome, and congenital adrenal hyperplasia. In a postmenopausal woman displaying signs of androgen excess, one must consider androgen-secreting tumors, and even the rare ovarian steroid cell tumor as a possible cause. Clinical Case: A 62-year-old female with type 2 diabetes mellites, obstructive sleep apnea, anxiety and depression initially presented to her primary care provider with fatigue, light-headedness, and weight loss. Initial blood work done revealed a hemoglobin greater than 20 g/dL (NR 12-16) and hematocrit greater than 60% (NR 36-48), requiring several sessions of phlebotomy. Symptoms persisted and she was finally referred to a hematologist who noted physical exam findings of hirsutism and virilization, including temporal hair loss and excess facial/body hair growth. Other concerning signs included clitoromegaly, decrease in chest size, and deepening voice. Menopause had occurred at age 50, and the patient did not have any issues with fertility during her reproductive years. Biochemical evaluation revealed testosterone level of greater than 1500 ng/dL (NR 19-82) with normal sex hormone binding globulin level, DHEA-S 652 ug/dL (NR 29-220), appropriately suppressed FSH/ LH, and normal salivary cortisol levels. Tumor markers showed normal CEA, and alpha fetoprotein but elevated CA 125 to 80.5 U/ml (NR < 38.1). Pelvic ultrasound demonstrated a 12 cm heterogeneously echoic, vascular right adnexal mass concerning for ovarian malignancy. Pelvic MRI showed a 9.8 cm right sided cystic and solid adnexal mass. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, peritoneal biopsies, and omentectomy. Pathology revealed a stage IA steroid cell tumor measuring 11.4 cm. After resection, the patient reported improvement in facial hair and fatigue. Labs showed normalization of hemoglobin, hematocrit, and testosterone levels. Conclusion: This rare case highlights the importance of considering steroid cell tumor as a cause of polycythemia with hyperandrogenism. Timely diagnosis and intervention play a critical role in preventing irreversible virilization, mitigating malignant risks, and, in certain instances, preserving fertility. Generally, the prognosis is favorable, and symptom and lab normalization is often achieved through surgical resection. Presentation: 6/2/2024

12465 Unraveling The Enigma: A Multifaceted Presentation Of Hormonal Dysregulation In A 37-year-old Woman

Abstract Disclosure: S.Y. Rizvi: None. N. Ahmad: None. Title: Unraveling the Enigma: A Multifaceted Presentation of Hormonal Dysregulation in a 37-Year-Old Woman Background: Leydig cell tumors (LCTs) are rare gonadal tumors, arising from the interstitial cells of the testis or, less commonly, the ovary, 0.1%. These tumors are known for their potential to produce androgens, leading to virilization symptoms such as hirsutism. While LCTs are typically benign, they can occasionally exhibit malignant features. Accurate diagnosis and appropriate management are crucial to prevent complications and ensure favorable outcomes. Clinical Case: A 37-year-old, G3P3A0 woman, presented to our endocrinology clinic for a follow-up visit following the removal of a malignant thyroid nodule. During the visit, her endocrinologist noted elevated testosterone levels and worsening hirsutism. She reported mild abdominal pressure but denied other symptoms. She also complained of pain in the lower abdomen, although physical examination findings were limited due to type II obesity. Diagnostic investigations revealed a history of imaging studies, including CT scans and pelvic ultrasounds, demonstrating various findings such as a fibroid uterus, ovarian abnormalities, and a heterogeneous mass in the left adnexa. Laboratory evaluations over time showed fluctuations in androgen levels, with notable values including DHEA-sulfate (137.5 ug/dL), total testosterone (309.6 NG/dL), and free testosterone (12.85 NG/dL). Tumor markers, including CA 19-9= 16 U/mL, CA 125= 23.3 U/mL, CEA = 1.7 NG/mL, and HCG, were unremarkable. Gynae/Oncology was consulted, and she underwent surgical exploration with laparoscopic left oophorectomy. It revealed a Leydig cell tumor without overt malignant features, as confirmed by histopathological examination and immunohistochemical analysis. Her testosterone improved since oophorectomy. Patient undergoes frequent post-op follow up of her testosterone, free+total lc/MS to monitor for hyperandrogenism. Conclusion: This case highlights the importance of considering Leydig cell tumors in the differential diagnosis of hirsutism, particularly in the presence of elevated androgen levels. Multidisciplinary collaboration involving endocrinologists, gynecologists, oncologists, radiologists, and pathologists is essential for accurate diagnosis and optimal management. Surgical resection remains the cornerstone of treatment for Leydig cell tumors, with careful histopathological evaluation necessary to assess for potential malignancy. Long-term follow-up is warranted to monitor for recurrence or metastasis, although the prognosis for benign Leydig cell tumors is generally favorable. Patients with large body habitus may present challenges in physical examination, necessitating reliance on imaging and laboratory studies for diagnostic evaluation. Keywords: hirsutism, testosterone, ovary Presentation: 6/2/2024

6941 Congenital Generalized Lipodystrophy - An Undiagnosed Case in an Underserved Border Community

Abstract Disclosure: D. Evans: None. A. Gutierrez: None. S. Echetebu: None. M. Zerah: None. Introduction: Congenital Generalized Lipodystrophy (Berardinelli-Seip Syndrome) is estimated to occur 1-10/10 million people1. Patients may present with specific clinical features and/or hormonal imbalances such as hyperinsulinemia and hypertriglyceridemia. Complications of CGL result in a decreased average life expectancy of 51.2 years2. Here we present a case of a female from a medically underserved city in Mexico who was not diagnosed until the age of 16, three years after immigration to the United States. Case Presentation: The patient lived in Mexico and had little medical care. After she immigrated, she was referred to Pediatric Endocrinology due to an elevated hemoglobin A1c, hypertriglyceridemia, and elevated liver enzymes. At birth and in adolescence, the patient did not resemble any of her five fully biological siblings, had little adipose tissue, and had well-defined musculature. Physical exam findings included generalized absence of adipose tissue and prominent musculature, large hands and feet, acromegaloid features, acanthosis nigricans, hirsutism, and phlebomegaly. Breast development was Tanner Stage IV, and genitalia was Tanner Stage V, without clitoromegaly. Patient is currently being treated by psychiatry for Major Depressive Disorder and suicidal ideation. Results: She was diagnosed with diabetes mellitus due to elevated glucose on OGGT and hypertriglyceridemia. She was then started on a low carbohydrate diet, Metformin, and Atorvastatin. After treatment a significant improvement in labs were observed. Triglyceride levels decreased from 1112 mg/dL to 392 mg/dL(35-150 mg/dL), A1c from 8.5% to 5.8%(<5.8%), AST from 36 U/L to 16 U/L(12-32U/L), and ALT from 51 U/L to 20 U/L(5-32U/L). OGGT levels measured after treatment began were as follows: fasting: 95 mg/dL (70-100mg/dL), 1 hour: 242 mg/dL (130-140 mg/dL), and 2 hours: 229 mg/dL(<155 mg/dL). A liver ultrasound was normal. Genetic testing, Echocardiogram, EKG, and Leptin levels are all pending. Discussion/Conclusion: This case of an adolescent with CGL, who was not diagnosed until 16 years of age, demonstrates not only the health disparities and challenges faced by patients in border communities, but it also demonstrates the lack of knowledge of CGL in healthcare. By presenting this case, we hope to increase awareness of CGL within the medical community at large, and to improve the quality of life of our patients.

6724 A Broken Heart Due to Excess Thyroid

Abstract Disclosure: R. Subramani: None. R. Subramani: None. V. Zeykan: None. Introduction: Tachycardia-induced cardiomyopathy related to thyrotoxicosis is an uncommon yet serious complication affecting fewer than 1% of individuals with hyperthyroidism. Restoring a euthyroid state can potentially reverse the abnormal cardiac structure and function. Here we report a case of tachycardia-induced cardiomyopathy secondary to thyrotoxicosis Case Summary: A 52-year-old woman with a history of hypertension presented with recent-onset exertional dyspnea, a nonproductive cough, and paroxysmal nocturnal dyspnea. On examination, she exhibited tachycardia (heart rate: 150/min), tachypnea, hypertension, and was afebrile. Physical findings included a mildly enlarged, firm, non-tender thyroid gland bilaterally, without exophthalmos or tremors. Auscultation revealed bilateral crackles in the left lower lung fields. Laboratory analysis revealed undetectable TSH (<0.02 uIU/mL), elevated free T4 (5.3 ng/dL), free T3 (16.30 pg/mL), thyroid stimulating immunoglobulin (TSI) at 216%, and NT proBNP at 8528 pg/mL. Neck ultrasound and CT confirmed diffuse enlargement of the thyroid gland. Transthoracic echocardiography (TTE) displayed severely depressed left ventricular systolic function, estimating an ejection fraction (EF) of 25-30%. Initial management involved intravenous beta-blockers for heart rate control, IV Lasix, and IV hydrocortisone. Subsequently, the patient received propylthiouracil, propranolol, and prednisone, resulting in symptomatic improvement. A follow-up TTE after 6 months revealed an improved EF of 50%. Discussion: The pathophysiologic mechanisms underlying thyrotoxic cardiomyopathy encompass several factors, including tachycardia-induced cardiomyopathy, direct myopathic effects induced by the T3 hormone, and concurrent autoimmune myocarditis associated with Graves' disease. Thyroid hormone exerts a comprehensive impact on nearly all tissue and organ systems, heightening basal metabolic rate and subsequently increasing preload, myocardial contractility, and cardiac output. While thyrotoxicosis-related congestive heart failure (CHF) is relatively uncommon among patients hospitalized for acute CHF, addressing hyperthyroidism and CHF through definitive treatment yields a more favorable prognosis compared to cases of acute CHF stemming from other etiologies. The intricate interplay of these mechanisms highlights the importance of a comprehensive approach in managing thyrotoxic cardiomyopathy, emphasizing the need for targeted interventions to address both the underlying thyroid dysfunction and associated cardiac manifestations. Presentation: 6/3/2024

Cold Environment-Associated Extremity Lesions or Severe Hypothermia Help Differentiate Between Frostbitten and Trench Foot (Immersion Foot).

Cold associated foot injuries, such as frostbite and trench foot (immersion foot) are relatively common in cold environments. The former is classified as a freezing cold injury, and the latter as a nonfreezing cold injury. Trench foot is sometimes misdiagnosed as frostbite, and rapid rewarming exacerbates the condition. This paper aims to help differentiate between frostbitten foot and trench foot. This study included patients with frostbitten foot or trench foot treated at our hospital between December 2005 and May 2023. The differences in sex, age, month of injury, conditions at the time of injury, injury distribution, foot lesion laterality, other complications upon arrival (finger frostbite, immersion hand, or hypothermia), and presence and distribution of sensory disturbance at discharge were noted among the groups. A total of 16 patients (14 men) with frostbitten foot and 3 patients (3 men) with trench foot were identified. Finger frostbite observed in nine and zero patients with frostbitten foot and trench foot, respectively; and severe hypothermia on arrival observed in five and zero patients with frostbitten foot and trench foot, respectively. Physical findings at the initial examination showed that the frostbitten feet were dry, and the lesions were distal and clearly demarcated, whereas feet with trench foot were wet, and the lesions covered the entire sole and were not clearly demarcated. Accurate differentiation between frostbitten foot and trench foot and appropriate initial treatment are important. The presence of finger frostbite, immersion hand or severe hypothermia may help to differentiate between frostbitten foot and trench foot.

Clinical features of tularemia in cats: a retrospective study from 2000 to 2021.

The objectives of this study were to describe the clinical features of cats diagnosed with tularemia, and to compare the clinical features of cats with and without tularemia and identify characteristics increasing the likelihood of a tularemia diagnosis. Diagnostic laboratory data and medical records were retrospectively reviewed of cats tested for tularemia between 2000 and 2021. Clinical features including signalment, presenting complaint(s), physical examination findings and clinicopathologic data were described for cats with tularemia diagnosed by culture and/or PCR. Clinical features were also compared between PCR+ vs PCR- cats and logistic regression was used to identify features that predicted PCR+ status. A total of 18 cats were diagnosed with tularemia. The affected cats had a mean age of 5.8 ± 4.9 years, with a slight male predominance. Most were domestic shorthair cats and had outdoor access. Common presenting complaints included lethargy and anorexia, while physical examination findings frequently revealed fever, peripheral lymphadenomegaly and oral ulcers. Laboratory findings varied, with notable abnormalities including neutrophilic inflammation observed on cytology and widespread acute systemic pathologic changes in necropsy results. Leukopenia and neutropenia were more common in PCR+ vs PCR- cats, and these factors were 7.4 times (confidence interval [CI] 1.2-62.3) and 10.0 times (CI 1.4-83.2) more likely to occur in PCR+ vs PCR- cats, respectively. There were no significant differences between the groups in other parameters including anemia, thrombocytopenia, band neutrophilia and hyperbilirubinemia. This study provides a more comprehensive description of tularemia in cats than has been available to date. In particular, leukopenia and neutropenia are significantly associated with tularemia-positive cats. These clinical features should be considered and raise suspicion for tularemia in cats. These findings may be valuable for the timely diagnosis, treatment and prevention of tularemia outbreaks in cats and humans.

Is Clinical Medicine Dying?

Recently, I came across a few discussions and write-ups on the dying art of clinical medicine caused by rapid advances in technology, which is replacing previously indispensable instruments such as stethoscope. Fred has interestingly termed it "Hyposkillia."1 Multiple editorials have decried the loss of clinical skills, and medical educators justify not only teaching but also using basic history-taking and physical examination skills in routine patient care.2-4 However, some skeptics suggest that emphasis on clinical skills is from a bygone era and that the availability of advanced imaging techniques and laboratory tests has supplanted ambiguous history and physical findings.5,6 Here is what I think.

Descriptive and content analysis of breast cancer vlogs on YouTube.

258 Background: Vlogs, or “video blogs,” are personally-created experiential videos based on wide-ranging topics, usually posted to YouTube. Many women with breast cancer (BC) document their cancer experiences in YouTube vlogs. These may have the potential to serve as peer-to-peer support and provide community. This study provides a descriptive and content analysis of vlogs by women with BC. Methods: YouTube was searched in incognito mode in 11/2023 using the search terms “breast cancer vlog.” A maximum of 10 videos/creator were included based on viewership and date created.Video characteristics collected included: title, length, number of views, likes, comments, and playlist inclusion. Videos were assessed for sponsorship, presence of explanation and discussion on BC, type of content, and themes. Creator characteristics included age, location, and engagement approaches. Descriptive and content analysis were performed to assess and analyze video content and potential areas where peer-to-peer support may be provided. Results: 90 vlogs by 13 creators were included, all originating from personal accounts. Mean video length, number of views, and number of comments were 21.4 minutes (SD 9.1), 266,780 (SD 534,465), and 1485 (SD 3422), respectively. 38.9% included hashtags. 12.2% included paid sponsorships. Most common filming location was at home (96.7%), followed by the hospital (31.1%), or in the car (21.1%). Home vlogs were most often set in the living room (44.3%), bedroom (33.0%), or kitchen (20.6%). 56.7% included visuals of treatment as well as physical findings. Creators addressed motivation for vlogging in 48.9%; the two most common reasons were wanting to build a community and helping others in a similar situation. In 46.7%, creators explicitly expressed emotion. Most common themes were treatment (85.6%), mental health (81.1%), side effects (72.2%), appearance (63.3%), and family relationships (36.7%). Subthemes included young age, finances, and the importance of online community support. Patient-directed advice was offered in 60.0%, mostly on treatment-related issues. In 56.7%,creators provided explicit treatment definitions. Chemotherapy was discussed in 70.0%; surgery in 57.8%, primarily mastectomy; radiation in 30.0%; general side effects in 71.1%. 24.4% were about a new diagnosis. When mentioned (44.4%), most common creator location was the USA. When mentioned (30.0%), most common age demographic was 20-29 years old. Conclusions: Vlogs by women with BC receive significant levels of engagement. The dedication to building community demonstrated by vlog creators, and the personal nature of their storytelling, advice, and suggestions, may make these vlogs a potential resource for peer-to-peer support.

Diagnostic strategies for chronic lateral ankle instability: a narrative review.

Diagnosing chronic lateral ankle instability (CLAI) involves a comprehensive evaluation encompassing medical history, physical findings, and imaging examination. The optimal method of diagnosis of CLAI remains controversial. Therefore, the objective of this review was to summarize the current literatures regarding recent evolution and technical improvement of diagnostic methods for CLAI. A literature regarding the diagnosis of CLAI was reviewed on PubMed, including articles written in English until May 2024. In the manual examination for the diagnosis of CLAI, the anterior drawer test is the standard evaluation for lateral ligament insufficiency. The anterolateral drawer test, meanwhile, which focuses more on lateral instability biomechanically, has also been performed. Ultrasonography is a point-of-care tool that is less invasive than stress radiography and can dynamically assess ligament integrity, making the diagnosis of CLAI more accurate and convenient. Magnetic resonance imaging (MRI) is a useful modality that allows extensive preoperative evaluation of ligamentous properties and associated osteochondral damage, and it is essential in the preoperative diagnosis of CLAI. A combination of physical examination and imaging studies is especially important to more accurately diagnose CLAI. Future research should focus on standardizing testing and measurement methods to objectively define CLAI.

Comprehensive evaluation of deep neck infections: A retrospective analysis of 111 cases.

Our study will analyze patients' clinical characteristics, treatment strategies, and complications with deep neck infection (DNI) using their medical records for five years. The present study included 111 patients diagnosed with DNI in our clinic between January 2018 and March 2023. The patients' complaints at admission, sociodemographic characteristics, season of diagnosis, findings from laboratory tests, radiological imaging performed at the time of first diagnosis, abscess localization, medical and surgical treatment methods used, and complications developing during follow-up were retrospectively examined. The mean age of the patients included in the study was 38.51 ± 16.92 (6-87 years). There was a significant correlation between chronic disease, smoking behaviours, oral hygiene, and DNI among patients based on their sociodemographic characteristics and medical history (p < .005). DNI development did not differ by season (p > .005). Physical examination findings predominantly revealed neck masses (39.6%) and peritonsillar abscesses (32.4%), and patients with peritonsillar abscesses had a shorter length of hospital stay than those with other localizations. No severe complications occurred during the clinical follow-up. Chronic diseases, smoking, and poor oral hygiene are the primary risk factors for developing DNIs. If an abscess is located in a critical area, it may require extended hospitalization and surgery under general anesthesia. Therefore, addressing these risk factors and encouraging good oral hygiene practices are crucial to preventing DNIs and reducing the need for intensive treatment.

Erosive pustular dermatosis of the scalp

This case of an elderly woman with a rapidly growing lesion of her scalp that developed several months after treatment of a squamous cell carcinoma with Mohs micrographic surgery illustrates a known precipitating trigger of erosive pustular dermatosis of the scalp. This report describes the clinical stages of the disease and their corresponding histologic findings. It reviews the epidemiology and proposed etiology of this erosive pustular dermatosis of the scalp. The differential diagnoses of scalp disease are extensive. An approach to evaluating scalp dermatoses through physical examination, laboratory testing and pathology findings will be discussed. Finally, treatment of this chronic condition, including both patient education and medical management, is detailed.

Clinical Effects of Additional Platelet-Rich Plasma Application to Exercise Therapy in Patients with Subacromial Impingement Syndrome: A Double-Blind Randomized Controlled Trial.

Exercise therapy (ET) is the main and initial treatment modality for treating subacromial impingement syndrome (SIS). The isolated or combined use of platelet-rich plasma (PRP) applications in treating SIS is increasing and promising. A comparison was made on the effectiveness of ET alone and in combination with PRP on pain, functionality, and quality of life (QoL) in patients with SIS. The purposes of this study were to (1) investigate the possible positive effects of PRP injections combined with ET in treating SIS on pain, functionality, and QoL and (2) propose an alternative treatment protocol. It was hypothesized that the group receiving PRP applications in addition to ET would have a better QoL due to less pain and higher functionality 6 months after treatment. Randomized controlled trial; Level of evidence, 2. Volunteer patients diagnosed with SIS were included based on history and physical examination findings. All participants underwent magnetic resonance imaging to confirm the diagnosis and exclude possible accompanying pathologies. The patients were randomly divided into 2 groups. The first group underwent ET at home for 8 weeks (ET group), and the second group received the same ET program and an additional 2 PRP injections, at the beginning of the study and the end of the fourth week (PRP group). Patients were evaluated initially and 6 months after the treatment using the visual analog scale (VAS) for pain score, Constant-Murley Score (CMS), and the 36-Item Short Form Health Survey (SF-36). The Kolmogorov-Smirnov test determined the conformity of the data to a normal distribution, chi-square analysis was used to compare categorical variables between groups, and the Mann-Whitney U test was used to compare continuous and intergroup variables. Intragroup changes before and after treatment were evaluated with the Wilcoxon signed-rank test. P < .05 was considered statistically significant. A total of 67 patients were initially enrolled; 5 were excluded and 6 were lost to follow-up (1 because of a COVID diagnosis). Thus, 56 patients (56 shoulders) were included for analysis. There were 28 patients in the ET group and 28 patients in the PRP group. There were no statistical differences between groups regarding participant characteristics and clinical evaluations before treatment. A statistically significant improvement was observed in pain (VAS subgroups), functionality (CMS subgroups), and QoL (SF-36 subgroups) evaluations of patients in both the ET and the PRP groups compared with before the treatment and 6 months after treatment (P < .05). At the 6-month posttreatment evaluation, the PRP group was statistically significantly superior to isolated ET in terms of VAS rest (P = .001) and night (P = .004) scores. This superiority was also in favor of the PRP group in flexion strength (P = .001), abduction strength (P = .046), and abduction degree (P = .041) measurements. There was no significant difference between ET and PRP groups regarding VAS activity, CMS, and SF-36 scores (P > .05) at 6 months. Our study showed that both isolated ET and additional PRP application to ET are effective methods in SIS treatment regarding pain, function, and QoL. Combining ET with PRP was superior in reducing pain and improving abduction degree and strength.

A Whodunit Gamified Flipped Classroom For High Yield Bite Injuries And Envenomation.

Clerkship-level medical students, sub-interns, junior and senior residents, attending physicians. Bite injuries and envenomation are core content found in the model of the clinical practice of emergency medicine.1 However, depending on the geographic location of training or clinical practice, physicians may or may not be exposed to these pathologies. For example, a qualitative analysis conducted in 2022 discovered a significant range in emergency medicine (EM) physician perception of snake antivenom use and level of comfort, noting that experiences with its use ranged from hundreds of cases treated to purely didactic understanding.2 Such discrepancies necessitate supplemental education and activities to bridge the knowledge gap. Ideally, these activities would utilize tenets of experiential learning to allow learner processing comparable to that of clinical experience.3 Flipped classroom and audience participation promote engagement and active learning when compared to the passive learning of lectures.4 In that vein, there is a growing body of gamified resources in medical education which utilize pattern recognition and problem solving skills that can be analogous to clinical practice.5,6. By the end of this activity, learners will be able to: 1) identify and name species responsible for bite/sting/envenomation injuries, 2) recognize associated signs, symptoms, physical exam findings and complications associated with bites/stings/envenomations by certain species, 3) discuss management such as antibiotics, antivenom, and supportive care. We designed a small group activity asking residents to identify, research, and present the "culprits" implicated in environmental exposures to animals and insects, and match them to corresponding clinical scenarios. Participants anonymously answered electronic multiple-choice quizzes before and after completing the activity to gauge its effectiveness in conveying the material. They also completed an additional anonymous, electronic survey regarding their attitudes towards this activity and the possibility of other gamified didactics within the curriculum. Each resident class showed an upward trend in their average multiple-choice score, the greatest of which was seen in the post-graduate year (PGY) 1 class. The residency demonstrated a statistically significant improvement in their ability to answer multiple choice questions (MCQs), with an average pre-activity score of 67.14%, and post-activity score of 87.14%. Participants showed determination and enthusiasm to engage with the material when presented in a gamified format, and 100% of post-activity survey respondents wanted to participate in further gamified activities. Gamified small group activities are a fun and effective method of supplementing residency and medical student education for both common and esoteric clinical presentations that they may not encounter in the clinical environment. Toxicology, bite injury, envenomation, gamification.

Intravenous pyogenic granuloma of the external jugular vein

AbstractIntravenous pyogenic granuloma (IVPG) represents a subset of lobular capillary haemangioma. The preoperative diagnosis is complex due to the absence of distinct features specific to a particular diagnosis in the clinical presentation. Physical examination findings closely mimic those of other soft tissue growths. Ultrasound should be the preferred modality for preoperative diagnostic imaging, as the lesion typically exhibits consistent ultrasound characteristics. This knowledge is imperative for an accurate and timely diagnosis. This case report presents a histologically confirmed IVPG localised in the right external jugular vein, which has been present for 2 years and is progressively enlarging.

A Picture Paints a Thousand Words: Perspectives of the Use of Images and Videos of Physical Findings in Virtual OSCE Teaching Sessions.

The COVID-19 pandemic has resulted in medical students' education being disrupted and a new direction of learning towards the online classroom, with students frequently learning to identify clinical signs via online conferencing platforms. Given this shift in student study techniques in the pandemic and post-pandemic era, we set out to analyse the confidence levels of students recognizing clinical signs in patients and the opinions and patterns of resources students would use to build up the knowledge and confidence for their future clinical practice. OSCEazy, a student-led medical education organisation, delivered an online teaching session and disseminated a questionnaire containing ten-point Likert scales, multiple-choice questions and free text options. The majority (over 75%) of respondents reported using digital resources to learn physical examinations. Most respondents were somewhat confident with recognising clinical signs during physical examinations (Median 7, IQR 6-8). Kruskal-Wallis H-test on students' impression of the quality of current OSCE materials showed a statistically significant difference between cohorts (X2(2) = 14.209, p = 0.014). A large proportion of students (98.41%) agreed that an online resources bank would be beneficial for their learning. Wilcoxon rank test showed a statistically significant preference for learning physical examinations using clinical images rather than videos (p = 0.014). A 29% of respondents mentioned the use of physical textbooks as a resource, while online platforms such as OSCE revision websites, YouTube and Google Images had become the mainstream platforms. The findings reported here suggest that there needs to be a greater emphasis on providing online image-based resources to support medical students in learning clinical signs. A resource containing these clinical signs would prove to be of benefit for students to access high-quality self-directed learning to identify and verify clinical signs.

The greatest physics discovery of the 20th century

Abstract My claim is that the greatest physics discovery of the 20th century is the realisation that the experimental predictions of quantum mechanics are under certain conditions inconsistent with those of any theory of the so-called “objective local” class and the subsequent experimental falsification of all such theories. This paper briefly examines the implications of this discovery for our conception of nature not only at the microscopic level of photons and electrons, but at the level of everyday life; in particular I conclude that even at this level counterfactual statements cannot always possess truth values.