Poor Historian Research Articles

Sociocultural aspects of the medicalisation of infertility: a comparative reading of two illness narratives

This paper is a comparative reading of variations in the medicalisation of infertility caused by sociocultural aspects, in two illness narratives by patients: Elizabeth Katkin’s Conceivability (2018), a story of...

Depressive Disorder in Primary Hyperparathyroidism and Effects of Surgery in Elderly Patients: Case Series

Background: Patients with primary hyperparathyroidism (PHPT) often present nonspecific symptoms such as major depressive disorder and psychosis. Calcium plays a role in the pathogenesis of psychiatric symptoms by determining changes in monoamine metabolism in the central nervous system, thereby modifying neurotransmission and resulting in mood and cognitive alterations. Case series: This report presents a case series of 3 patients; 70-year-old, 78 year- old and 94 year-old women with PHPT and severe depression symptoms and its response to parathyroidectomy. The patients were a poor historian. Results of preoperative laboratory tests showed an increased serum calcium level (11.15mg/dL, 10.9 mg/dL and 11.4 mg/dL- reference range 8.4-10.2 mg/dL). A repeat serum calcium test confirmed hypercalcemia with concurrent elevated intact parathyroid hormone level. Two patients were undergone at parathyroidectomy. A 94 year-old patient refuse surgical approach and was efficacy treated with a single dose of zoledronic acid. Therefore, the patients underwent parathyroidectomy two months after procedure had a clinical improvement on depressive symptoms. There was any recurrent laryngeal nerve injury or recurrent PHTP. Conclusion: The presence of a long-standing depressive disorder unresponsive to medical therapy may suggest an organic disorder such as chronic hypercalcemia which may be secondary to PHPT. Surgical intervention in these selected cases can assist medical therapy in the improvement of depressive symptoms.

CLINICIAN AND STAFF PERSPECTIVES IN TRANSITIONS OF CARE FOR DUAL-USE VETERANS LIVING WITH DEMENTIA

Abstract The Veterans Administration (VA) has partnered with non-VA hospitals to improve access to care. However, older Veterans living with dementia (VLWD) who use both VA and non-VA care may experience gaps in care, placing them at risk of adverse health outcomes during transitions. This research aims to understand the barriers and facilitators in transitions of care for VLWD following non-VA hospitalization. We conducted 23 interviews with VA and non-VA clinicians involved in transitions of care for VLWD. Snowball sampling was used to identify participants, and rapid analysis identified themes. VA Participants faced significant challenges in receiving timely discharge communication from non-VA stakeholders, relying on VLWD, who are poor historians, for information about their non-VA hospitalization. Inadequate staffing for care coordination was also a barrier to timely care, resulting in frustration for VLWD and their families when tests had to be redone due to a lack of appropriate documentation from non-VA hospitals. Both VA and non-VA stakeholders experienced similar care coordination challenges for VLWD, their families, and clinicians. Non-VA stakeholders described the VA as a “black box” due to a lack of communication and collaboration. However, stakeholders expressed a desire to provide quality care, improve care coordination, and give timely care to veterans. These findings highlight the barriers experienced by VA and non-VA stakeholders and provide opportunities for improvement in coordinating care for VLWD. Implementing care coordination programs and improving communication and collaboration between VA and non-VA stakeholders can improve the quality of care for VLWD and their families during transitions.

S3338 An Unusual Case of a Large Cell Neuroendocrine Carcinoma and Acute Liver Failure

Introduction: Large cell neuroendocrine carcinomas (LCNECs) are characterized as large cells with areas of necrosis, neuroendocrine traits (palisading, trabeculae, etc.), ample cytoplasm and high mitotic rates. LCNECs are a rare, aggressive form of neuroendocrine tumor known to have high rates of metastasis. Our case highlights acute liver failure with rapid progression to death due to metastatic spread of LCNEC. Case Description/Methods: 71-year-old male with a history of prostate cancer requiring prostatectomy, hypertension, hyperlipidemia, and tobacco use, presented for shortness of breath and abdominal pain for 3 days. He was a poor historian and was unable to provide much history. Of note, the patient reported that he had imaging performed in spring 2021 to further evaluate his degenerative disc disease and was told there was concern for a cancerous process. Initial laboratory studies showed an elevated AST and ALT (over 300), and thrombocytopenia, but were otherwise unremarkable. Further imaging was performed, given the patient's history of reported malignancy. Initial chest X-ray was negative for acute findings and an abdominal ultrasound revealed a markedly abnormal appearance of the liver, suggestive of possible hepatic metastatic disease. Computed tomography scan of the chest/abdomen/pelvis showed a left hilar mass measuring 5.5 x 6cm with regional lymphadenopathy. The patient underwent a biopsy of the liver, and was later noted to have worsening liver enzymes, platelets, INR, and renal function, along with a lactic acid. He was transferred to the intensive care unit for further monitoring. Bowel ischemia and portal vein thrombosis were ruled out, and the patient became continually more acidotic, and had a pulseless electrical activity (PEA) arrest. He was revived and intubated, and placed on pressor support and continuous renal replacement therapy. His family decided to change his code status to “do not resuscitate” and the patient was made comfortable. Final results of the liver biopsy were obtained 2 days later, and showed findings consistent with high grade large cell neuroendocrine carcinoma. Immunohistochemical staining was positive for CD56, synaptophysin, CK7 and CK5/6. (Figure) Discussion: Liver metastasis has been documented throughout the literature for other carcinomas, however very few in regards to LCNEC. Acute liver failure in such a short span of time, as in our case, highlights the mortality associated with LCNECs, and the difficulty in diagnosing the condition early in the disease course.Figure 1.: CT abdomen/pelvis showing diffuse heterogeneity of the liver.

S1892 A Double Take on a 20-Year Double J-Stent

Introduction: The double J biliary stent is commonly used to relieve obstructions and aid in draining of pancreatic fluid. Indwelling or forgotten stents are rarely seen and their sequelae are unknown. We present the case of a patient who was lost to follow-up over twenty years ago following cholecystectomy and placement of double J stent. A routine esophagogastroduodenoscopy (EGD) for variceal surveillance was performed and discovered an ampullary fungating mass. Case Description/Methods: A 79 y/o female with a history of hypertension presented to the ED with worsening abdominal distention. She was a poor historian but denied alcohol use, drug use, or any history of liver disease. Her workup included an abdominal paracentesis removing greater than 7 liters of fluid with a SAAG indicating portal hypertension. She had abnormal liver function tests (LFTs) and CT imaging was consistent with cirrhotic morphology of the liver and a double-J stent present in CBD (Figure A). An EGD for further evaluation and for variceal vein monitoring was done revealing grade 2 varices but more significantly, at the site of ampulla of vater a large fungating mass was noted. The mass was medium-sized and polypoid with no bleeding. The CBD stent was in place with noted hyperproliferation of the tissue of the ampulla vs a periampullar duodenal mass (Figure B). A repeat EDG with EUS was performed, finding the hypoechoic non-circumferential mass endosonographically within the ampulla. The mass measured 24 mm by 14 mm in maximal cross-sectional diameter (Figure C). The lesion extended from the mucosa to the muscularis mucosa. The endosonographic borders were well-defined. There was sonographic evidence suggesting invasion into the deep mucosa (Layer 2). Filamentous microorganisms were identified on HE and GMS stain. No individual atypical AE1/AE3 positive epithelial cells were identified. Discussion: This case highlights the unusual sequelae of a retained double-J stent in a patient who was lost to follow up. It’s unknown why the stent was placed, likely during an intraoperative cholangiogram, and the patient did not recall her follow-up instructions. Several questions arise surrounding the mass such as, did it have malignant potential and what role, if any, did the stent have in the formation of the mass? Did colonization represent an increased risk of ascending cholangitis? The stent was left in at the conclusion of the case and the patient was extensively educated about follow-up and maintenance endoscopy.Figure 1.: CT evidence of pneumobilia, ampullary fungating mass, and EUS imaging.

IT'S BEEN ON MY NECK FOR YEARS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Initial patient encounters with patients who are poor historians can be extremely challenging. Physical exam is of utmost importance. The nature, history and prognosis of exophytic melanoma has been extremely controversial and uncertain. CASE PRESENTATION: A 91 year old Caucasian female with no apparent medical comorbidities who had not seen a physician in 30 years presented to the emergency department after her family stated they could no longer care for her. Initial chest X-ray revealed a large mass like opacity over the left lung apex. She also had a urinary tract infection. She was started on Ceftriaxone and admitted to internal medicine. Upon our exam, after examining her neck and removing her bandage, we found an external exophytic, pedunculated mass from the inferior lateral left neck measuring 4.6 x 3.7 x 5.7 cm which was concerning for malignancy. The mass was pulsatile and bleeding from certain areas without evidence of frank hemorrhage. A CT scan was then pursued which reinforced our physical exam findings. Upon further questioning of the patient and her family, it was reported that said mass had been present for 10 + years and they had always covered it up with abdominal pads without seeking medical attention. There was no white blood cell count elevation indicating infectious foci. General surgery was consulted for excision and pathology. She was taken to the operating room the next day and the lesion was excised at skin zone 2 of the neck with a margin of skin and normal subcutaneous tissue around it. The excised mass measured 15 x 15 x 20 cm (L x W x H). The patient was discharged to a nursing home in a stable fashion. Her pathology came back for ulcerated malignant melanoma with negative margins. Histologic type was nodular melanoma. Maximum Breslow thickness of 17mm with no microsatellites. The distance of invasive melanoma from closest peripheral margin of 10mmwith mitotic rate of 8 per mm2. Tumor infiltrating lymphocytes were present with no tumor regression. The tumor cells demonstrated strong positivity for SOX10 and Melan-A stain and focally positive for HMB-45. DISCUSSION: Nodular melanoma accounts for less than 15% of all melanomas. Usual prognostic indicators in melanoma are driven by histologic subtype with thickness being neglected. Nodular melanoma, however, has been known to include thickness as a prognostic factor. Majority of these cases have reported metastasis and poor prognosis. CONCLUSIONS: With our patient being neglected, she still had only local disease and after tumor removal, no adjunctive therapy was needed. Clinicians should be made aware and on the lookout for different types of melanomas and their respective presentations. REFERENCE #1: Clark WH, Elder DE, Guerry D, Epstein MN, Greene MH, Van Horn M. A study of tumor progression: The precursor lesions of superficial spreading and nodular melanoma. Hum Pathol. 1984;15(12):1147-1165. doi:10.1016/S0046-8177(84)80310-X REFERENCE #2: Shaikh WR. The Contribution of Nodular Subtype to Melanoma Mortality in the United States, 1978 to 2007. Arch Dermatol. 2012;148(1):30. doi:10.1001/archdermatol.2011.264 DISCLOSURES: No relevant relationships by Ahmad Abu Hashyeh, source=Web Response No relevant relationships by Mohamed Suliman, source=Web Response no disclosure on file for Toufeeq Suliman

ISOLATED UNILATERAL ABSENCE OF THE PULMONARY ARTERY PRESENTING IN ADULTHOOD: A CASE REPORT

TOPIC: Lung Pathology TYPE: Fellow Case Reports INTRODUCTION: Isolated unilateral absence of the pulmonary artery (IUAPA) may rarely go undiagnosed into adulthood (1). CASE PRESENTATION: We report the case of a 44-year-old frequently homeless male with known history of chronic obstructive pulmonary disease (COPD) and pulmonary arterial hypertension (PAH), whose findings on computed tomography (CT) of the chest were consistent with IUAPA. DISCUSSION: This patient was referred to our advanced lung disease center following an episode of acute-onset hemoptysis, concurrent with long-standing history of progressive dyspnea. Infant and early childhood history was significant for pyloric stenosis, cryptorchidism, and scoliosis, but otherwise the patient reported being 'relatively healthy' through adolescence to early adulthood in exception of 5-6 hospitalizations for 'bronchitis treatments'. The patient was diagnosed with COPD in 2010 after complaints of increased dyspnea on exertion. Treatment with supplementary oxygen, tiotropium, and budesonide/formoterol was initiated with successful disease mitigation. In late 2019, the patient was hospitalized for the episode of hemoptysis, where he revealed non-adherence to oxygen and medical therapy, albeit infrequently, attributed to challenge in continued medication use. The patient was otherwise a poor historian, but reported frequent homelessness over the course of the last 9 years. At our center, CT of the chest revealed moderate cardiomegaly (Figure A, blue), bilateral subsegmental atelectasis, hypoplasia of the right lung with emphysematous changes and increased bronchial collateral circulation (Figure A-B, green), and absence of the right main pulmonary artery (Figure B, red). The patient is undergoing evaluation for lung transplantation at this time. CONCLUSIONS: This anomaly should be suspected if imaging reveals asymmetric lung fields, lung hypoplasia, or hyperinflation of the contralateral lung. Early recognition and management of IUAPA is important for preventing more serious complications such as PAH. REFERENCE #1: Jariwala P, Maturu VN, Christopher J, Jadhav KP. Congenital isolated unilateral agenesis of pulmonary arteries in adults: case series and review. Indian J Thorac Cardiovasc Surg. 2021 Jan;37(Suppl 1):144-154. doi: 10.1007/s12055-020-01032-w. Epub 2020 Sep 23. PMID: 33584030; PMCID: PMC7859122. DISCLOSURES: No relevant relationships by Ashwini Arjuna, source=Web Response No relevant relationships by Michael Olson, source=Web Response No relevant relationships by Tejus Walia, source=Web Response

Myxedema Coma Disguised as Alcohol Withdrawal

Introduction: Myxedema coma is a medical emergency whose symptoms may sometimes mimic other diseases such as alcohol withdrawal.Case: A 64-year-old male with a history of alcohol abuse and bipolar disorder (on no medications) presented to the emergency department after being found on the floor surrounded by multiple open alcohol bottles. He was a poor historian but reported a previous fall. Vitals on presentation were BP 109/70, HR 110, RR 22, SpO2 of 90% on room air, and rectal temperature of 97.6 F. The remainder of the exam revealed he was alert and oriented to self and place but not time; his neck was supple and no thyroid masses were palpated; he had tremors, head swelling and abdominal tenderness. Labs demonstrated CPK 1300 U/L, Creatinine 1.0 mg/dl, glucose 120 mg/dl, and sodium 142 mmol; urine toxicology was negative and alcohol level was not elevated. He was admitted and treated for suspected alcohol withdrawal and rhabdomyolysis with intravenous fluids and benzodiazepines. However, his mental status continued to decline; he became obtunded and was hypothermic and bradycardic. Thyroid function tests (TFT) revealed TSH 98.9 uIU/mL with free T4 0.27 ng/dl. He was subsequently managed for myxedema coma and given IV levothyroxine and hydrocortisone. He improved clinically after initiation of therapy and was transitioned to oral thyroid replacement. The patient was pending discharge to sub-acute rehab however his hospital course was later complicated by aspiration pneumonia.Discussion: Myxedema coma is a medical emergency as severe hypothyroidism leads to slowed functioning of multiple organs. Risk factors include female gender and age above 60 years; it is seen more commonly in colder months. Symptoms include decreased mental status, feelings of cold and tongue swelling while physical exam may reveal hypothermia, hypoventilation, bradycardia, an enlarged goiter, thinning hair and non-pitting edema. Lab studies usually reveal an elevated TSH with low T4; there may also be hyponatremia and hypoglycemia. Myxedema coma is a clinical and laboratory diagnosis; if there is clinical suspicion for myxedema coma, IV thyroid replacement should be administered promptly without waiting for lab results. Stress-dose steroids should also be administered and TFTs should be monitored every 48 hours. Clinical symptoms usually improve over one week of treatment. Mortality of myxedema coma is reported to be up to 40% in hospitalized patients. Our patient’s presentation of suspected alcohol withdrawal masked his diagnosis of myxedema coma.Conclusion: Physicians should keep myxedema coma in the differential for patients who present with suspected alcohol withdrawal and develop worsening mental status and hypothermia.Reference: DynaMed. (2020, October 22). Myxedema Coma. Retrieved October 23, 2020, from https://www-dynamed-com.arktos.nyit.edu/topics/dmp~AN~T1584563697784.

Anchoring Bias – A Barrier to the Art of Healing

“Patient A” is a 25-year-old male with a history of type 1 diabetes mellitus complicated by presumed diabetic gastroparesis, who presents to the hospital with intractable nausea and vomiting. Upon first impression, the patient is agitated and hostile. “Patient A” is a poor historian, exhibiting limited medical insight and providing a contradictory history. A quick review of his chart details a longstanding history of drug abuse with multiple hospital visits in the last 2 years for similar presenting complaints of refractory vomiting totaling 15-20 episodes per day. “Patient A” is requesting medications to help with the burning discomfort associated with his nausea and vomiting; however, clinicians cautiously treat his pain due to his extensive history of substance abuse. The current provider forgoes another comprehensive work-up, as his symptoms were previously investigated at prior presentations for the same complaints. A repeat hemoglobin A1C is deemed unnecessary because of known poorly-controlled diabetes. Additionally, further inquiry into the patient’s medical compliance is disregarded, given his chart previously classified him as a “non-compliant patient.” During hospitalization, “Patient A” is managed with strict glucose control, carbohydrate-controlled diet, antiemetics with gradual resolution of presenting symptoms, and repeated conversations emphasizing diabetic medical compliance which were poorly received by the patient.

Law Office Originalism

Originalism as practiced by Supreme Court Justices has long been described as “law office history,” or cherry picking shallow historical evidence to achieve pre-determined, political results. However, none has provided a systematic review of these claims, including the Supreme Court’s historical methodology and its purchase power to cabin judicial will. This empirical study—which canvases the entire universe of the Court’s 299 references to the Constitutional Convention—is the first to supply that deficiency. To test both normative historical methodology and Originalism’s constraint function, this study hypothesizes that 1) the Court’s historical methodology is generally bad, 2) that Originalist Justices’ historical methodology was no better; and 3) that Justices’ engagement in better historical methodology would result in significant political deviations. Results of this study show that the Court references the Convention without having looked at the primary record or, indeed, any source nearly half of the time, over-relies on non-historical secondary sources for context, and fails to cite to both primary and secondary sources in all but a small minority of its references. In all this, the first hypothesis was confirmed: the Court is a poor historian according to history’s standards. Likewise, based on a comparison of eight Justices—three Originalist Justices, three with non-Originalist jurisprudential commitments, and two “index” Justices—to all Justices since 1935, Originalist Justices proved they were no better at historical methodology than their peers, confirming the second hypothesis. Finally, through adding an interactive variable of political deviation to the previous test, the third hypothesis was rejected in large part: deeper historical methodology did not result in consistent significant political deviations. Originalism may thus appropriately be deemed “law office history.” However, using deeper historical methodology did result in significant political deviations for the two “index” Justices who lacked previous interpretive commitments, and a non-significant deviating trend for all other Justices but Justice Thomas, who deviated not at all. These results suggest that it is better history, not better theory, which constrains judicial will. Herein lies history’s promise for the Court: better historical methodology grounded in primary sources can have the power to constrain Justices, perhaps providing hope for a methodology with bite. To capitalize on its constraint function, this article concludes by making multiple practical suggestions for improving the historical methodology for the Supreme Court bench and bar.

God Is My Roommate? Tax Exemptions for Parsonages Yesterday, Today, and (if Constitutional) Tomorrow

In 2019, the Seventh Circuit decided an Establishment Clause question that had been percolating through the courts for two decades. It held that the parsonage allowance, which permits “ministers of the gospel” to receive an untaxed housing allowance, does not violate the Establishment Clause of the Constitution. It grounded its conclusion in part on the “historical significance” test the Supreme Court established in its Town of Greece v. Galloway decision. In coming to that conclusion, the Seventh Circuit cited a 200-year unbroken history of property tax exemptions for religious property. According to the Seventh Circuit, that history demonstrated that both the Founders and subsequent generations of Americans recognized that there was no constitutional problem with exempting parsonages. The court’s historical significance analysis was fundamentally flawed, however. Had the court actually engaged with this history, rather than made the conclusory assertion of consistent and uncontroversial exemption, it would have seen at least two things that complicated its facile conclusion. Significantly, in treating the history of religious property tax exemptions as unbroken and consistent, the court elides the actual history, which was messy and varied. The actual history provides no support for the proposition that the Framers and those who followed viewed property tax exemptions as constitutional. Even if the history were as clean as the Seventh Circuit portrayed it, that history would have been irrelevant to the question of the constitutionality of the parsonage allowance. The Supreme Court did not incorporate the Establishment Clause against the states until 1947, so states faced no Establishment Clause bar to exempting for religious property. And the federal government only made four attempts at taxing property, none of which expressly exempted religious property. In this Article, I explore the historical and current tax exemptions for parsonages, and trace how states arrived at their current exemptions. Ultimately, I conclude that the historical significance test, as applied by the Seventh Circuit, does not support the constitutionality of the parsonage allowance. I further conclude that, given its complexity and the fact that attorneys and judges tend to be poor historians, the historical significance test is not well suited as a jurisprudential tool for analyzing Establishment Clause questions, and that courts should not adopt it.

2447 A Case of Daptomycin Causing Drug-Induced Liver Injury

INTRODUCTION: Drug-induced liver injury (DILI) is the most common cause of acute liver failure. DILI is rare and characterized by elevated creatinine kinase (CK) and liver enzymes without associated end-organ damage. We present a rare case of daptomycin associated hepatotoxicity without corresponding elevation in CK. CASE DESCRIPTION/METHODS: A 87-year-old man with a history of hypertension, hyperlipidemia, benign prostate hyperplasia, closed fracture of distal lateral malleolus of left ankle, and atrial fibrillation on apixaban presented to the ED from rehab facility with complaints of one day of shortness of breath, cough, diarrhea, and nausea. Patient was a poor historian. He also has had poor oral intake. He was unable to state if he had any prior gastrointestinal problems. No tobacco, alcohol, illicit drug use. On physical examination, patient was noted to have mild purulent drainage on plantar surface of right fifth metatarsal phalangeal joint. A CT scan of foot ruled out osteomyelitis. On admission, labs revealed elevated transaminases with AST 113, likely due to congestive hepatopathy, as per echocardiogram with elevated right ventricular systolic pressure. All other liver enzymes were within normal limits. Blood cultures resulted in Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and he was subsequently started on vancomycin (due to penicillin allergy). After 7 days of vancomycin therapy, he was switched to daptomycin due to the rising creatinine levels. Next 5 days, LFTs trended up dramatically with the initiation of daptomycin. All non-essential medications were discontinued at this time. LFTs peaked at total bilirubin 1.4, AST 432, ALT 535 and alkaline phosphatase (AP) 161. CK was normal. At this time, daptomycin was discontinued. LFTs started a steep downtrend one day after cessation of daptomycin (Figure 1). The rise in creatinine, total bilirubin, and initial CK levels were temporally related to the initiation of vancomycin infusions (Figure 2). Autoimmune work up and hepatitis panel were all negative. An abdominal ultrasound showed hepatomegaly (16.5 cm) with diffuse hypoechoic texture. Liver doppler showed normal flow. DISCUSSION: Daptomycin induced hepatotoxicity without evidence of elevated CK levels is rare. The pathophysiology is unclear. There is limited literature on DILI without renal failure or rhabdomyolysis in setting of daptomycin use. We only found one case in literature. The long-term sequela has not been fully studied, thus liver enzymes should be monitored closely.

How to avoid ever having to write 'poor historian'.

How to avoid ever having to write 'poor historian'.

On Shoulders of Giants: A Message from an Elder Fellow to New Diplomates

On Shoulders of Giants: A Message from an Elder Fellow to New Diplomates

A Case of the Missing Ring

Introduction: The ingestion of foreign bodies is most frequently observed in children and in adults with underlying psychiatric disease. Foreign bodies generally cause little morbidity if properly managed. Roughly 90% of foreign bodies pass through the gastrointestinal tract with 10-20% requiring endoscopic removal and up to 1% requiring surgical intervention. The diagnosis is usually apparent from a patient's clinical history; however, radiographs of the neck, chest and abdomen may be required in the case of patients that are poor historians. Case: The patient is a 51 year old asymptomatic man status post appendectomy in 2000 who presented for outpatient index average risk colorectal cancer screening in June 2017. He subsequently underwent a colonoscopy during which a stricture was found to be causing moderate obstruction in the ascending colon that was not traversable with an adult colonoscope. There was evidence of mucosal scarring at the site. Several cold forcep biopsies were taken, revealing colonic mucosa with rare focal active colitis and prominent lymphoid aggregates. A CT scan of the abdomen/pelvis with IV contrast was performed which revealed moderate stool burden and an indeterminate 2.5 cm metallic ring in the lumen of the terminal ileum at the ileocecal valve with associated small amounts of mural edema and inflammation involving the ileocecal valve and adjacent terminal ileum. The patient was subsequently admitted and colorectal surgery was consulted. Given the risk for erosion and obstruction, the patient was taken to the operating room for surgical resection. An ileocecectomy was performed, in which 12.5 cm of a single segment of bowel was resected and a side to side ileo-colonic anastomosis was created. Discussion: The treatment of foreign bodies is largely dependent on the foreign body ingested, location, and time since ingestion. The vast majority of foreign bodies will pass on their own; however, some do require endoscopic or surgical intervention given the risk of obstruction or erosion with subsequent perforation. The case as described above is a classic example of foreign body ingestion in which surgical intervention was indicated.1618_A Figure 1. Stricture- Stellate scar1618_B Figure 2. CT abdomen- ring at ileocecal junction

Barriers to effective communication between family physicians and patients in walk-in centre setting in Dubai: a cross-sectional survey

BackgroundEffective communication between family physicians and their patients is crucial to improving healthcare outcomes and patients’ satisfaction. However, the barriers to effective communication have been weakly studied in the Gulf region with no reported studies in Dubai. This study aims to identify the main perceived barriers to effective communication between patients and their family physicians in Dubai from both the physicians’ and the patients’ viewpoints.MethodsThe study was conducted at 12 primary healthcare centres in Dubai between October 2016 – July 2017. Two self-administered questionnaires were used, one measuring the patients’ perceived frequency of encounters with barriers to communication, while the other was for the family physicians’ perceived level of risk to communication posed by the barriers. The barriers were assessed in the following four domains: personal characteristics and attitudes, organisational factors, communication of information, and linguistic and cultural factors.ResultsThere were a total of 1122 patients and 170 family physicians, with 75% and 85% response rates, respectively. Having a time limitation was the highest ranking barrier, with 23.4% of patients encountering it half of the time-always, and 50.6% of physicians perceiving it as moderate-very high risk. This was followed by barriers in the communication of information domain, especially not checking the patient’s understanding and not educating the patient (16.0–16.9%) from the patients’ perception and presentation with multiple problems and not following with a treatment plan (51.2% and 35.9%, respectively), from the physicians’ perception. Preoccupation with medical records ranked in the second pentile for the physicians, and in the lowest pentile for the patients. Barriers related to the failure of rapport building and linguistic/cultural factors ranked in the fourth and fifth pentiles for both patients and physicians.ConclusionTime pressure is the major perceived barrier to communication between patients and family physicians. In addition, a greater focus needs to be placed on training the physicians to convey their messages to the patients clearly, checking their understanding and managing poor historians.

Conspiracy as Plot Type in Herodian’s Roman History

AbstractDespite positioning himself as a contemporary eyewitness and heir to Thucydides, Herodian has generally been judged to be a poor historian prone to the use of compression, formulaic scenes, and even free invention. This paper examines Herodian’s application of a specific plot type to conspiracies against the emperor by praetorian prefects. The use of this plot type reveals something of Herodian’s understanding of history and historical methodology, while also serving an important narrative function in his text.

'The poor historian': Heart sink? Or time for a re-think?

In this commentary article, the oft-heard expression, 'the poor historian', will be discussed. We will consider who the poor historian is and reflect on medical training to speculate how and why the expression has entered the medical lexicon. The potential negative impact of this terminology on patients and junior learners will be considered and strategies for re-framing this concept, for both clinical teachers and learners, will be presented.

The Case Files

The Case Files

P265 – 1749 A novel suspicion index tool to aid diagnosis of Niemann-Pick disease type C (NP-C) in paediatric patients

afebrile multifocal epilepsy. CT brain revealed calcification in the basal ganglia bilaterally, thalami and white matter of cerebral hemispheres. This was extensively investigated and no abnormalities were detected. Parents are very poor historians and were reluctant to disclose family history. His five siblings all have a diagnosis of ADHD. Recently his behaviour has deteriorated and he is being investigated for ADHD. Of note the patient’s mother had a previous CT brain which demonstrated striking calcification in the basal ganglia, cerebellum and white matter felt to be consistent with the rare diagnosis of Fahr’s disease. Case report 2: A 13 year old girl was referred to tertiary neurology with focal seizures. She had a background history of delayed motor milestones, stereotypical movements and marked Obsessive Compulsive Disorder manifestations. CT brain revealed bilateral basal ganglia calcification. Discussion: None of these children had significant neurological signs or symptoms but both have neuropsychiatric comorbidities; OCD and ADHD. In case two a heterozygous mutation o SLC20A2 gene has been identified, known to be associated with autosomal dominant intracranial calcification. This same mutation has also been identified in her father. Gene testing is currently awaited in case one. We conclude that CT brain scanning should be considered in all children with psychiatric co-morbidities, seizures and a family history of neuropsychiatric/neurological disorders to look for calcification.