Harrison's Principles Research Articles

Performance of Publicly Available Large Language Models on Internal Medicine Board-style Questions.

Ongoing research attempts to benchmark large language models (LLM) against physicians' fund of knowledge by assessing LLM performance on medical examinations. No prior study has assessed LLM performance on internal medicine (IM) board examination questions. Limited data exists on how knowledge supplied to the models, derived from medical texts improves LLM performance. The performance of GPT-3.5, GPT-4.0, LaMDA and Llama 2, with and without additional model input augmentation, was assessed on 240 randomly selected IM board-style questions. Questions were sourced from the Medical Knowledge Self-Assessment Program released by the American College of Physicians with each question serving as part of the LLM prompt. When available, LLMs were accessed both through their application programming interface (API) and their corresponding chatbot. Mode inputs were augmented with Harrison's Principles of Internal Medicine using the method of Retrieval Augmented Generation. LLM-generated explanations to 25 correctly answered questions were presented in a blinded fashion alongside the MKSAP explanation to an IM board-certified physician tasked with selecting the human generated response. GPT-4.0, accessed either through Bing Chat or its API, scored 77.5-80.7% outperforming GPT-3.5, human respondents, LaMDA and Llama 2 in that order. GPT-4.0 outperformed human MKSAP users on every tested IM subject with its highest and lowest percentile scores in Infectious Disease (80th) and Rheumatology (99.7th), respectively. There is a 3.2-5.3% decrease in performance of both GPT-3.5 and GPT-4.0 when accessing the LLM through its API instead of its online chatbot. There is 4.5-7.5% increase in performance of both GPT-3.5 and GPT-4.0 accessed through their APIs after additional input augmentation. The blinded reviewer correctly identified the human generated MKSAP response in 72% of the 25-question sample set. GPT-4.0 performed best on IM board-style questions outperforming human respondents. Augmenting with domain-specific information improved performance rendering Retrieval Augmented Generation a possible technique for improving accuracy in medical examination LLM responses.

COCAINE INTOXICATION LEADING TO HYPERTHERMIA, DISSEMINATED INTRAVASCULAR COAGULATION, AND ACUTE RENAL FAILURE

COCAINE INTOXICATION LEADING TO HYPERTHERMIA, DISSEMINATED INTRAVASCULAR COAGULATION, AND ACUTE RENAL FAILURE

INTERESTING RADIOGRAPHIC FINDING OF SVC SYNDROME DUE TO PRIMARY LARGE B-CELL LYMPHOMA

INTERESTING RADIOGRAPHIC FINDING OF SVC SYNDROME DUE TO PRIMARY LARGE B-CELL LYMPHOMA

E-health as a sine qua non for modern healthcare

In each era we need to balance between being able to provide care with our “technical skill, scientific knowledge, and human understanding” (Harrison's Principles of Internal Medicine, 1950) to the...

Comparative analysis of the effectiveness of the alternatives current treatments in Meniere’s disease

<p class="abstract">The objective is to compare the efficacy of the treatments currently used in Ménière's disease, assessing their advantages and disadvantages. A bibliographic review was carried out with 11 original articles, of which 10 are in English and 1 in Spanish, from 3 years to date in Journal of Vestibular Research, Otology & Neurotology, European Archives Oto-Rhino-Laryngology, American Journal of Otolaryngology, Laryngoscope Investigative Otolaryngology, Journal of Neurology, Iranian Journal of Otorhinolaryngology, Revista Ciencia y Salud, respectively. The following books were consulted Harrison's Principles of Internal Medicine; Oído, nariz, garganta y cirugía de cabeza y cuello; Diagnóstico y tratamiento en otorrinolaringología. Cirugía de cabeza y cuello; and, Tratado de otorrinolaringología y patología cervicofacial. Medical treatment with dexamethasone, gentamicin, betahistine and diuretics was evaluated, as well as surgical treatment with endolymphatic sac surgery, vestibular neurectomy and labyrinthectomy. Treatment is individualized, however, betahistine is recommended as the first option, followed by IT gentamicin for the control of vertigo.</p>

A Novel Dynamic Rigidizing Overtube Significantly Eases Difficult Colonoscopy

Colonoscopy is a common procedure for colorectal cancer screening and evaluation of large intestinal pathology such as inflammatory bowel disease and lower gastrointestinal bleeding 1 Kasper DL Fauci AS Hauser SL et al. Harrison's principles of internal medicine 19/E (Vol.1 & Vol.2). 19th ed. McGraw-Hill Professional, 2015 Google Scholar . Colonoscopy allows both viewing of the large intestine up to the cecum and performance of procedures such as polypectomy and control of GI bleeding. 2 Haycock A Cohen J Saunders BP et al. Cotton and Williams’ practical gastrointestinal endoscopy: the fundamentals. John Wiley & Sons, Ltd, 2014 Google Scholar A successful screening colonoscopy involves viewing the entire colon including the cecum and being able to safely perform therapeutic procedures such as polypectomy and control of bleeding. 3 Rees CJ Bevan R Zimmermann-Fraedrich K et al. Expert opinions and scientific evidence for colonoscopy key performance indicators. Gut. 2016; 65: 2045-2060 Google Scholar There are various barriers to successfully completing a colonoscopy including colon looping, poor bowel prep, and patient intolerance of the procedure. 4 Wong JYY Ho KY. Robotics for advanced therapeutic colonoscopy. Clin Endosc. 2018; 51: 552-557 Google Scholar , 5 Serper M Gawron AJ Smith SG et al. Patient factors that affect quality of colonoscopy preparation. Clin Gastroenterol Hepatol. 2014; 12: 451-457 Google Scholar For the practicing endoscopist, looping of the colon can be a significant barrier to successful completion of colonoscopy. This often leads to suboptimal outcomes including prolonged anesthesia, limited examination and therapy, and overall diminished patient care.

LISTERIA BACTEREMIA PRESENTING WITH CEREBRAL ABSCESS AND ENDOCARDITIS IN AN ELDERLY PATIENT WITH CHRONIC IMMUNE THROMBOCYTOPENIA

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Listeria monocytogenes, an intracellular gram-positive bacillus, is a ubiquitous foodborne pathogen that causes Listeriosis. Its clinical spectrum ranges from mild, self-limiting gastroenteritis in immunocompetent individuals to severe, life-threatening, invasive disease affecting persons at the extremes of age, pregnant women, and individuals with cell-mediated immunodeficiencies. Central nervous system involvement by is common – presenting as meningitis, meningoencephalitis or, less frequently, rhombencephalitis. Listerial brain abscesses are rare. Moreover, only 5-8% of these infections are complicated by infective endocarditis (IE). CASE PRESENTATION: A 70-year-old Caucasian man with chronic immune thrombocytopenia (ITP) presented to the ED with acute onset of altered mental status and right-sided weakness. He was afebrile, with no heart murmurs or peripheral stigmata of IE. Neurologic exam findings included disorientation, expressive aphasia, and right-sided hemiparesis. Laboratory findings were unremarkable except for leukocytosis and hyponatremia. Brain MRI showed an irregular rim-enhancing lesion in the left frontal lobe with surrounding edema and midline shift. The lesion was excised with adjacent necrotic tissue and frozen sections were highly suspicious for a high-grade glial neoplasm. He was started empirically on vancomycin, ceftriaxone and metronidazole. Eventually, the organism was identified as Listeria monocytogenes from two sets of blood cultures; hence, antibiotics were de-escalated to ampicillin and gentamicin. Transesophageal echocardiography (TEE) showed mitral valve vegetation. The patient developed fever on day 4; by day 6, he began to defervesce and showed improvement in mental status. On day 9, he was discharged to the inpatient rehabilitation center to complete a total of 6 weeks on IV ampicillin and IV gentamicin. Pathology of the brain mass was subsequently reported as listerial brain abscess with no evidence of malignancy. DISCUSSION: Chronic treatment with high-dose oral glucocorticoids and pre-existing ITP have been independently implicated as predisposing factors in listerial brain abscess. There is a propensity to misdiagnose listerial brain abscess as an intracranial neoplasm due to similar clinical/imaging findings, especially when fever is absent at presentation. In addition, Listeria monocytogenes is an atypical cause of IE. Our patient had no pre-existing structural or valvular heart disease, but he satisfied two major diagnostic criteria for IE – two separate positive blood cultures of Listeria monocytogenes and a TEE demonstrating mitral valve vegetation. CONCLUSIONS: A high index of suspicion is necessary for early recognition and successful treatment of listerial brain abscess and listerial endocarditis in high-risk patients. REFERENCE #1: Tiri B, Priante G, Saraca LM, Martella LA, Cappanera S, Francisci D. Listeria monocytogenes brain abscess: controversial issues for the treatment—two cases and literature review. Case Rep Infect Dis. 2018;2018(6549496):1-9. REFERENCE #2: Hohmann EL, Portnoy DA. Listeria monocytogenes infections. In: Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill Education; 2018:1100-1102. REFERENCE #3: Garcia-Granja PE, Lopez J, Vilacosta I, Olmos C, Sarria C, Roman JAS. Infective endocarditis due to Listeria monocytogenes: a report of 4 patients. Cardiol. 2016;69(7):699–709. DISCLOSURES: No relevant relationships by Nili Gujadhur, source=Web Response no disclosure on file for Vanessa Karimi; No relevant relationships by Olushola Ogunleye, source=Web Response

A CASE OF NON-RESOLVING PNEUMONIA

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Non-resolving pneumonia is defined as pneumonia with slow or incomplete resolution despite adequate appropriate antibiotic treatment. It is a common reason for pulmonary consultations & bronchoscopies in the hospital. Though occurrence is relatively rare, there are many reasons non-resolving pneumonia may develop. Often, they are caused by resistant organisms, mechanical airway obstructions, inappropriate antibiotic treatment, & inadequate duration of treatment. We present a rare case of non-resolving pneumonia, which led to irreversible respiratory failure. CASE PRESENTATION: A 68-year-old male with no significant past medical history presented with worsening dyspnea on exertion & cough productive of yellowish sputum for 5 weeks. In the ER, he reported fevers, night sweats, & unintentional 10-lb weight loss. Vitals showed tachycardia & hypoxia. Physical exam was positive for decreased breath sounds on the right with rhonchi. The patient had not seen a physician for many years. He reported smoking 1 pack per day for 50 years. Chest X-ray showed extensive opacification of the right hemithorax with a small pleural effusion, which suggested multi-lobar right lung pneumonia. The patient was started on empiric piperacillin-tazobactam & vancomycin. Sputum culture grew normal respiratory flora. Blood cultures remained negative. Extensive infectious workup was performed with all tests being negative. CTPA revealed airspace opacities within the right lung & fluid density within the right lung apex which is consistent with early lung necrosis. Bronchoscopy showed a normal bronchial tree. Bronchoalveolar lavage cytology showed no malignant cells. After 10 days of no clinical improvement, a repeat CT chest showed worsening right lung opacification, ground-glass opacities within the left upper lobe, & enlarged mediastinal lymph nodes. The patient continued to worsen clinically therefore underwent right limited thoracotomy & lung biopsy, which showed extensive adhesions with pleural & lung implants. Pathology revealed lung adenocarcinoma. The patient declined therapeutic chemotherapy treatment & opted to go home with hospice. DISCUSSION: This case emphasizes the importance of early recognition of non-resolving pneumonia, the proper diagnostic approach, & when to initiate further invasive workup. Evaluation of a patient with a slowly or incompletely resolved pneumonia starts with a careful history, physical examination, & review of the medical record CONCLUSIONS: Consideration of risk factors for delayed resolution should include age, comorbidities, the severity of pneumonia, & specific pathogens. If indicated, further evaluation should include CT chest to assess for findings suggestive of an alternative diagnosis. When pneumonia fails to resolve, bronchoscopy should be considered. Patients with a negative bronchoscopy examination should undergo further evaluation with lung biopsy to assess for malignancy REFERENCE #1: Jameson, J. L., Kasper, D. L., Longo, D. L., Fauci, A. S., Hauser, S. L., & Loscalzo, J. (2018). Harrison's principles of internal medicine. New York: McGraw-Hill Education. DISCLOSURES: No relevant relationships by Luqman Baloch, source=Web Response No relevant relationships by Luqman Baloch, source=Web Response No relevant relationships by Adrienne DaGue, source=Web Response No relevant relationships by ayobami olaleye, source=Web Response

COMING OUT AFTER A DECADE OF HIDING: A 35-YEAR-OLD FEMALE WITH CHRONIC COUGH AND UNINTENTIONAL WEIGHT LOSS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tuberculosis is one of the oldest infectious causes of death in adults, with archeological evidence of Potts disease in bones 9,000 years old. Incidence of tuberculosis in the United States continues to decline even though the pace of decline has slowed in the recent years. Most infections are diagnosed with exposures in the highly endemic, homeless, or prison population. Here we present a case of tuberculosis after a decade of possible exposure CASE PRESENTATION: A 35-year-old female with no prior medical history presented with one-year history of chronic productive cough with brown sputum associated with generalized weakness, dizziness, and shortness of breath. At an outside hospital, she was treated for bacterial pneumonia with continued worsening of symptoms. She also endorsed about 80 pounds of unintentional weight loss in the past year. She denied fever, chills, night sweat, chest pain, palpitations, heartburn, sick contacts, or hemoptysis. She denied any prior or current alcohol or illicit drug and was employed at a convenience store. She denied international traveling but admitted that she was incarcerated in 2010 for six months. She was born at term in the United States without any significant childhood illness. She denied family history of lung disease, tuberculosis, or malignancy. Work up showed extensive cavitary lesions in the left upper lobe and left lower lobe and some bronchiectasis. Sputum acid fact bacilli culture was positive. Human immunodeficiency was negative. Patient was diagnosed with pulmonary tuberculosis and started on appropriate treatment. DISCUSSION: Mycobacterium tuberculosis is most commonly transmitted by droplet nuclei from an infected person. The intimacy, duration of contact, the degree of infectiousness, and the shared environment in which contact takes place are all important determinants of the likelihood of transmission. The majority of active tuberculosis cases manifest soon after infection, rarely occurring more than two years of infection. Reactivation of latent tuberculosis is thought to occur later in life, when immunity wanes from natural aging or immunocompromised states. In our patient, the distinction between primary and reactivation tuberculosis is challenging as she has no recent risk of acquiring tuberculosis and reactivation in relatively young patient with no significant underlying medical problems is uncommon. CONCLUSIONS: In low transmission countries such as the United States, we usually see tuberculosis disease in elderly or in immigrants from high transmission area. Detecting and treating all tuberculosis patients is important to prevent outbreaks and untreated tuberculosis is often fatal. This case illustrates the importance of a wide differential during patient assessment. REFERENCE #1: Behr MA, Edelstein PH, Ramakrishnan L. Revisiting the timetable of tuberculosis. BMJ 2018; 362:k2738. REFERENCE #2: Cain KP, Haley CA, Armstrong LR, et al. Tuberculosis among foreign-born persons in the United States: achieving tuberculosis elimination. Am J Respir Crit Care Med 2007; 175:75. REFERENCE #3: Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J. (2015). Harrison's principles of internal medicine (19th edition.). New York: McGraw Hill Education. DISCLOSURES: No relevant relationships by Samapon Duangkham, source=Web Response No relevant relationships by Megan Hughes, source=Web Response No relevant relationships by Kenneth Iwuji, source=Web Response No relevant relationships by Cristina Morataya, source=Web Response No relevant relationships by Upama Sharma, source=Web Response No relevant relationships by Divya Vangipuram, source=Web Response No relevant relationships by Alexandra Wichmann, source=Web Response

ATYPICAL PRESENTATION OF LEMIERRE'S SYNDROME WITH ISOLATED INVOLVEMENT OF THE EXTERNAL JUGULAR VEIN

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lemierre’s syndrome is a life-threatening complication of pharyngitis leading to internal jugular vein (IJV) thrombophlebitis with pulmonary septic embolisation. Isolated external jugular vein (EJV) thrombophlebitis is rare. CASE PRESENTATION: A 35-year-old woman presented with one day of acute pleuritic chest pain. She had fever, chills, throat pain, dysphagia, malaise, and headache for 2 weeks. On presentation, she had trismus, extensive tender cervical lymphadenopathy with swelling on the left side of the neck, erythematous posterior pharynx and left enlarged erythematous tonsillar pillars without exudates. Blood showed leucocytosis with neutrophil predominance, elevated D-dimer, CRP, elevated bilirubin with normal liver enzymes, low platelets, low albumin, and blood culture revealed Fusobacterium necrophorum. Contrast CT scan soft tissue of the neck showed left tonsillar pillar enlargement with micro-abscesses and extension of inflammation into the left submandibular, parotid, and cervical space with thrombosis of the left EJV. Extension of inflammation into the retro-pharyngeal space was noted. CT Angiogram of Chest revealed bilateral peripheral opacities with cavitation in the right upper lobe and left lower lobe consistent with septic emboli. IJV revealed no thrombosis. A diagnosis of Lemierre’s syndrome was made. The patient improved on antibiotic therapy. DISCUSSION: Lemierre’s syndrome is a rare potentially lethal complication of oropharyngeal infection occurring mainly in young adults characterised by septic thrombophlebitis of the IJV with embolisation to lungs. It is rare (3.6 cases/million/year) with a mortality rate of >15%. 1,2. The common causative organisms are anaerobic gram-negative bacilli from the genus Fusobacterium mainly F. necrophorum.3 The oropharyngeal infection spreads to IJV from local oropharyngeal veins. Lymphatic spread and direct extension of infection also occur. However, in some patients, the venous drainage allows direct propagation of thrombophlebitis into the EJV.3 Patients present with fever, sore throat, neck swelling, pleuritic chest pain with cervical lymphadenopathy. Leucocytosis, elevated ESR, CRP, bilirubin and thrombophilia are seen. CT scan of the soft tissue of the neck and chest with contrast is required for diagnosis. CONCLUSIONS: In patients with severe pharyngitis and pulmonary septic emboli Lemierre’s syndrome must be suspected and the venous system of the neck should be closely visualised for evidence of thrombophlebitis of both IJV and EJV. Reference #1: Nall RW. Sore Throat. In: Stern SC, Cifu AS, Altkorn D. eds. Symptom to Diagnosis: An Evidence-Based Guide, 4e New York, NY: McGraw-Hill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2715§ionid=228250877. Accessed May 28, 2020.2. Reference #2: Barlam TF, Kasper DL. Approach to the Acutely Ill Infected Febrile Patient. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 20e New York, NY: McGraw-Hill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=183880456. Accessed May 28, 2020 Reference #3: Format:Reicher J, Brooke S, Arnold D, Counter P, Abdelgalil A. An unusual case of cavitating pulmonary nodules: Lemierre's syndrome with isolated involvement of the external jugular vein. BJR Case Rep. 2018;4(3):20170093. Published 2018 Feb 22. doi:10.1259/bjrcr.20170093 DISCLOSURES: No relevant relationships by Anomadarshi Barua, source=Web Response No relevant relationships by padmanabhan krishnan, source=Web Response No relevant relationships by Litty Mathews, source=Web Response No relevant relationships by Qasim Sheikh, source=Web Response No relevant relationships by Sarita Singh, source=Web Response

Assessment of the effect of education on correct prophylaxis of deep vein thrombosis among patients admitted to intensive care unit

Background: Thromboembolism is a serious complication in patients admitted to the intensive care unit. Education of the effective prophylaxis guidelines by physicians can be reduces the incidence of this illness in at-risk patients. The purpose of this study was to investigate the effect of education on the correct prophylaxis of deep vein thrombosis in patients admitted to the intensive care unit of Imam Khomeini Hospital in Urmia. Methods: This cross-sectional study was carried out on 252 patient records. In this study, the correct prophylaxis of deep vein thrombosis, according to the Harrison Principles of Internal Medicine Textbook, 19th edition (2015), was taught. This education was given to the physicians in the intensive care unit in terms of prophylaxis indications, proper dosage, type of prophylaxis and unnecessary prophylaxis. Results: Most of the patients were male (51.59%). Their age in pre and post intervention groups was 58.12 and 56.58 years respectively. After the training intervention, unnecessary prophylaxis (from 7.9% to 4.8% (p=0.54)], inappropriate administration of anticoagulant dose [from 51.6% to 18.2% (p = 0.025), and type of anticoagulant [from 10.3% to 4% (p=0.038)] were reduced. Correct prophylaxis frequency was increased from 30.2% to 73% (p= 0.045). Conclusion: Education sessions on the prophylaxis of venous thrombosis in high-risk patients can lead to the use of correct prophylaxis and maybe it reduces the frequency of deep vein thrombosis and its complications

A Multicenter Study Into Causes of Severe Acute Liver Injury

The differential diagnosis of an increase in alanine aminotransferase (ALT) level and/or aspartate aminotransferase (AST) level of ≥1000 IU/L often is stated to include 3 main etiologies: ischemic hepatitis, acute viral hepatitis (typically hepatitis A and hepatitis B), and drug-induced (more specifically, acetaminophen/paracetamol) liver injury (DILI).1 Unfortunately, there are a paucity of studies examining the most common causes of acute liver injury (ALI) and those that have been published have been small,2 single-center,2 or examined less severe increases in ALT or AST levels.3,4 We conducted a multicenter study of all patients with an ALT and/or AST level ≥1000 IU/L. Our study had 3 main goals: (1) to determine the most common causes of an ALT and/or AST level ≥1000 IU/L, along with their relative frequencies; (2) todetermine differences in etiology based on hospital type (liver transplant center, community hospital, Veterans Affairs hospital); and (3) to confirm or disprove the differential heuristic that ischemic hepatitis, acute viral hepatitis, and acetaminophen toxicity are the most common etiologies.

Undisclosed conflicts of interest among biomedical textbook authors

ABSTRACTBackground: Textbooks are a formative resource for health care providers during their education and are also an enduring reference for pathophysiology and treatment. Unlike the primary literature and clinical guidelines, biomedical textbook authors do not typically disclose potential financial conflicts of interest (pCoIs). The objective of this study was to evaluate whether the authors of textbooks used in the training of physicians, pharmacists, and dentists had appreciable undisclosed pCoIs in the form of patents or compensation received from pharmaceutical or biotechnology companies. Methods: The most recent editions of six medical textbooks, Harrison's Principles of Internal Medicine (HarPIM), Katzung and Trevor's Basic and Clinical Pharmacology (KatBCP), the American Osteopathic Association's Foundations of Osteopathic Medicine (AOAFOM), Remington: The Science and Practice of Pharmacy (RemSPP), Koda-Kimble and Young's Applied Therapeutics (KKYAT), and Yagiela's Pharmacology and Therapeutics for Dentistry (YagPTD), were selected after consulting biomedical educators for evaluation. Author names (N = 1,152, 29.2% female) were submitted to databases to examine patents (Google Scholar) and compensation (ProPublica's Dollars for Docs [PDD]). Results: Authors were listed as inventors on 677 patents (maximum/author = 23), with three-quarters (74.9%) to HarPIM authors. Females were significantly underrepresented among patent holders. The PDD 2009–2013 database revealed receipt of US$13.2 million, the majority to (83.9%) to HarPIM. The maximum compensation per author was $869,413. The PDD 2014 database identified receipt of $6.8 million, with 50.4% of eligible authors receiving compensation. The maximum compensation received by a single author was $560,021. Cardiovascular authors were most likely to have a PDD entry and neurologic disorders authors were least likely. Conclusion: An appreciable subset of biomedical authors have patents and have received remuneration from medical product companies and this information is not disclosed to readers. These findings indicate that full transparency of financial pCoI should become a standard practice among the authors of biomedical educational materials.

The Case Files

The Case Files

26-Year-Old Man With Nausea, Delirium, and Fever

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN (H.L.T.); Advisor to resident and Consultant in Infectious Diseases, Mayo Clinic, Rochester, MN (L.M.B.). A 26-year-old-man who had been living in Indonesia until 4 months previously presented to our hospital for evaluation of fever, agitation, and altered mental status. He had been seen previously at another facility for vague abdominal pain, nausea, and fever. He had become subacutely agitated and was transferred to our institution because of altered mental status and vomiting. On admission, he was febrile (temperature, 39.3 C) and tachycardic (heart rate, 118 beats/ min); his blood pressure was 134/96 mm Hg, and his oxygen saturation was 100% while breathing room air. Physical examination findings were notable for intermittent altered mental status with restlessness, agitation, inattention, and pain with neck flexion and posterior neck palpation. Findings on work-up at the outside facility included a sodium level of 118 mmol/L and no abnormalities detected on head computed tomography (CT) and chest radiography. His pupils were mildly constricted but responded to light. Admission laboratory studies yielded a normal white blood cell count of 10.1 10/L and an improved sodium concentration of 133 mmol/L.

Multi‐country outbreak of Shiga toxin‐producing Escherichia coli infection associated with haemolytic uraemic syndrome

EFSA Supporting PublicationsVolume 13, Issue 4 1017E Technical reportOpen Access Multi-country outbreak of Shiga toxin-producing Escherichia coli infection associated with haemolytic uraemic syndrome European Food Safety Authority and European Centre for Disease Prevention and Control, European Food Safety Authority and European Centre for Disease Prevention and ControlSearch for more papers by this author European Food Safety Authority and European Centre for Disease Prevention and Control, European Food Safety Authority and European Centre for Disease Prevention and ControlSearch for more papers by this author First published: 06 April 2016 https://doi.org/10.2903/sp.efsa.2016.EN-1017Citations: 3 Published date: 6 April 2016 Question number: EFSA-Q-2016-00232 AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL References Luna-Gierke RE, Wymore K, Sadlowski J, Clogher P, Gierke RW, Tobin-D'Angelo M, et al. Multiple-Aetiology Enteric Infections Involving Non-O157 Shiga Toxin-Producing Escherichia coli - FoodNet, 2001–2010. Zoonoses Public Hlth. 2014 Nov; 61(7): 492– 8. European Centre for Disease Prevention and Control. Escherichia coiifactsheet Stockholm: ECDC; [cited 2016 March 29]. Available from: http://ecdc.europa.eu/en/healthtopics/escherichia_coli/basic_facts/Pages/basic_facts.aspx. Fauci A, Braunwald E, Kasper D, Hauser S, Longo D, Jameson J, et al. Harrison's Principles of internal medicine. MH Medical, editor: McGraw Hill Medical; 2008. 1811– 5 p. EFSA (European Food Safety Authority) and ECDC (European Centre for Disease Prevention and Control). The European Union summary report on trends and sources of zoonoses, zoonotic agents and food-borne outbreaks in 2014. EFSA journal. 13(12): 4329,191. European Centre for Disease Prevention and Control. Surveillance Atlas of Infectious Diseases Stockholm: ECDC; 2016 [cited 2016 March 29]. Available from: http://atlas.ecdc.europa.eu/public/index.aspx. Espie E, Grimont F, Mariani-Kurkdjian P, Bouvet P, Haeghebaert S, Filliol I, et al. Surveillance of hemolytic uremic syndrome in children less than 15 years of age, a system to monitor O157 and non-O157 Shiga toxin-producing Escherichia coli infections in France, 1996–2006. Pediatr Infect Dis J. 2008 Jul; 27(7): 595– 601. Institut de Veille Sanitaire. Epidémie d'infections à E. coli producteurs de Shiga-toxines non 0157 liée à la consommation de camembert au lait cru, nord-ouest de la France, octobre-décembre 20052007 March 30. Available from: http://opac.invs.sante.fr/index.php2lvNnotice_display&id=9416. Ethelberg S, Smith B, Torpdahl M, Lisby M, Boel J, Jensen T, et al. Outbreak of non-O157 Shiga toxin-producing Escherichia coli infection from consumption of beef sausage. Clin Infect Dis. 2009 Apr 15; 48(8): e78– 81. Germinario C, Chironna M, CGallone M, Tafuri S, Desiante F, Calabrese G. Community-wide Outbreak of Haemolytic Uremic Syndrome Associated with Shiga Toxin 2-Producing Escherichia coli O26:H11 in Southern Italy, Summer 2013. Euro Surveill. 2016;(Forthcoming). International Organization for Standardization. ISO/TS 13136:2012 Microbiology of food and animal feed -Real-time polymerase chain reaction (PCR)-based method for the detection of food-borne pathogens -Horizontal method for the detection of Shiga toxin-producing Escherichia coli (STEC) and the determination of O157, O111, O26, O103 and O145 serogroups. Technical Specifications: ISO; 2012. p. 22. Peron E, Zaharia A, Zota L, Severi E, Mârdh O, Usein C, et al. Early findings in outbreak of haemolytic uraemic syndrome among young children caused by Shiga toxin-producing Escherichia coli, Romania, January to February 2016. Eurosurveillance. 2016; 21(11). Jenssen G, Hovland E, Bjerre A, Bangstad H-J, Nygard K, Vold L. Incidence and etiology of hemolytic-uremic syndrome in children in Norway, 1999–2008 - a retrospective study of hospital records to assess the sensitivity of surveillance. BMC Infectious Diseases. 2014; 14(1): 265. Nielsen EM, Andersen MT. Detection and characterization of verocytotoxin-producing Escherichia coli by automated 5' nuclease PCR assay. J Clin Microbiol. 2003 Jul; 41(7): 2884– 93. Citing Literature Volume13, Issue4April 20161017E ReferencesRelatedInformation

Child and Adolescent Sleep Patterns and Early School Start Times: Recognizing the Role of the Pediatric Nurse

Child and Adolescent Sleep Patterns and Early School Start Times: Recognizing the Role of the Pediatric Nurse

Profiles in Science for Science Librarians: Anthony S. Fauci, M.D.

Tony Fauci is arguably America's best known clinical investigator and federal medical research administrator. He has authored a torrent of papers in research and professional journals (1,368 as of May 15, 2013) and has appeared well over 100 times on TV news shows explaining aspects of America's fight against autoimmune and infectious diseases, particularly AIDS. The vast majority of today's American medical students and their librarians will also recognize him as editor in chief of the best-selling textbook Harrison's Principles of Internal Medicine. He has been awarded honorary degrees by thirty-eight universities, including Harvard, Yale, Princeton, Penn, and Georgetown. His productivity and visibility have spanned three generations of Americans, and yet his work has probably had an even greater impact far beyond our borders. An analysis of the evolving assortment of journals in which he has been published over the course of his career discloses three major patterns: a progressively higher proportion of more prestigious titles as he tackled bigger and bigger scientific and clinical challenges; an extraordinary output of “big picture” papers (generally one in every twenty of his papers were invited review articles); as well as great willingness to publish in brand-new journals (twenty-six), most of which would go on to be highly successful.

The Case Files

The Case Files

Infectious diseases publications in leading medical journals—a comparative analysis

The representation of medical disciplines in leading journals may provide valuable information on their respective importance for both researchers and funding agencies. We were interested in the scientific contribution of infectious diseases to leading medical journals and their ranking compared to other medical disciplines. Original articles and short communications in three leading medical journals from 2003 to 2009 were analyzed by contributing medical discipline and by nation: The New England Journal of Medicine (NEJM), The Lancet, and the Journal of the American Medical Association (JAMA). The medical disciplines were selected according to a standard textbook (Harrison's Principles of Internal Medicine). Each article was categorized into one to three medical disciplines. The most frequently represented disciplines in 3,953 articles were cardiology (19.5 %), infectious diseases (18.6 %), and hematology/oncology (15.9 %). Each of the journals had another leading discipline: cardiology in JAMA, hematology/oncology in NEJM, and infectious diseases in The Lancet. In the American journals, contributions from US researchers dominated the field (52.6 % in NEJM, 73.6 % in JAMA), while the majority of papers in The Lancet originated from non-US residents (76.5 %). This study underlines the importance of infectious diseases as a medical discipline in clinical research.