Worrisome Symptoms Research Articles

Health Datapalooza 2012

The goal of the Health Datapalooza 2012 is liberate data. IT IS A great time to be an innovator at the intersection of data and healthcare according to the panelists at the 2012 Health Data Initiative Forum—aka the Health Datapalooza—which was held in Washington DC at the Convention Center on June 5–6, 2012. The Health Data Initiative, originally launched in 2010 by the Institute of Medicine and the U.S. Department of Health and Human Services, is a public–private collaboration that encourages innovators to utilize health data to develop applications that raise awareness of health and health system performance and spark community action to improve health. The 2012 Forum is the third annual event and is the largest one yet. The goal of the Health Datapalooza is to showcase the best and brightest new applications using data from government and other sources. Innovators presented their technologies to the audience, describing how it uses health data and makes a meaningful impact on health. This year the attendees included over 1600 leaders from the White House, federal agencies, investment and venture capital sectors, academia, social service organizations, public health communities, information technology firms, business and health care delivery systems who came together to make data actionable. Over 100 applications and Web sites, all powered by open data were presented. Here are some of the best new applications featured at the forums, in breakout sessions, or in the exhibit hall. Although some of the sites require users to register, most are free and easy to use. Symcat (http://symcat.com/) is an application designed by two Johns Hopkins Medical School classmates to help cyberchondriacs—or people who search the Internet about worrisome symptoms (most of us) understand what conditions might be causing those symptoms and provide immediate, customized information for those searchers. It is

Gastroesophageal Reflux

Gastroesophageal Reflux

Natural History of Cervical Paragangliomas<subtitle>Outcomes of Observation of 43 Patients</subtitle><alt-title>Natural History of Cervical Paragangliomas</alt-title>

To evaluate the outcomes, growth rate, and symptoms of nonoperated cervical paragangliomas. Retrospective review of clinical and radiologic records and images. Tertiary academic medical center. We studied all patients presenting with cervical paragangliomas between 1993 and 2010 who were observed rather than operated on. Growth of tumors and need for surgical removal. Forty-three patients with 47 tumors were identified. Mean patient age was 56 years (age range, 17-86 years). Thirty patients were asymptomatic (70%) (22 diagnosed by imaging for other reasons and 8 for workup of a neck mass), and only 5 presented with cranial nerve abnormalities (12%). No patients presented with lymphadenopathy, rapid growth, or pain. Reasons for observation were patient preference (n=15; 35%), advanced age of patient (n=12; 28%), and preexisting contralateral cranial nerve deficits (n=11; 26%). Twenty-eight of the 47 tumors were suspected carotid body tumors based on imaging (60%), and 19 were suspected vagal tumors (40%). The mean greatest dimension at presentation was 2.6 cm (range, 1-7.2 cm). During a mean follow-up of 5 years (range, 1-17 years), 19 tumors remained stable in size (42%); 17 grew (38%); and 9 regressed (20%). Of the 17 tumors that grew, the mean growth was 0.2 cm/y. Observation of cervical paragangliomas is an option in selected patients who do not present with worrisome symptoms. The natural history of paragangliomas in these patients is typically little to no growth over time. Regular follow-up is important to ensure minimal change and stable symptoms.

Ophthalmic manifestation of skull base metastasis from breast cancer

SummaryBackgroundThere is a vast discrepancy between the incidence of skull base metastases reported in vivo and at autopsy. Asymptomatic character or unspecific symptoms make the diagnosis difficult, particularly in patients with no history of cancer. Our case illustrates a skull base metastasis from breast cancer, detected in a diagnostic process initiated by ophthalmologic examination.Case ReportWe report the case of a 53-year-old woman complaining of ptosis and diplopia, with concomitant loss of skin sensation within the right half of the forehead, and without any other worrisome symptoms or signs. Ophthalmic examination revealed impairment in eye movements, slight proptosis and corneal hypoesthesia on the right side, with normal pupillary light reflexes. The anterior and posterior segments of the eye were normal. Based on CT and MRI, an extensive tumor was detected, infiltrating the right orbit and the frontotemporal region of the skull base, and producing edema of the adjacent aspects of the brain. Aside from partial palsy of the oculomotor nerve and the ophthalmic division of the trigeminal nerve, no abnormalities were found on neurological examination. Explorative craniotomy and histopathological findings revealed a skull base metastasis from breast cancer.ConclusionsDiplopia, ptosis, proptosis, and ophthalmic nerve sensory loss may be the only manifestation of a skull base metastasis. Careful ophthalmologic examination is crucial in early detection of this life-threatening condition.

Acute Chest Pain

Chest pain is a worrisome symptom that often causes parents to bring their child to emergency department(ED) for evaluation. In the majority of cases, the etiology of the chest pain is benign, but in one-fourth of the cases symptoms are distressing enough to cause children to miss school. The clinician's primary goal in ED evaluation of chest pain is to identify serious causes and rule out organic pathology. The diagnostic evaluation includes a thorough history and physical examination. Younger children are more likely to have a cardiorespiratory source for their chest pain, whereas an adolescent is more likely to have a psychogenic cause. Children having an organic cause of chest pain are more likely to have acute pain, sleep disturbance due to pain and associated fever or abnormal examination findings, whereas those with non-organic chest pain are more likely to have pain for a longer duration. Chest radiograph is required in some, especially in patients with history of trauma . In children, myocardial ischemia is rare, thus routine ECG is not required on every patient. However, both pericarditis and myocarditis can present with chest pain and fever. Musculoskeletal chest pain, such as caused by costochondritis and trauma, is generally reproducible on palpation and is exaggerated by physical activity or breathing. Pneumonia with or without pleural effusion, usually presents with fever and tachypnea; chest pain may be presenting symptom sometimes. In asthmatic children bronchospasm and persistent coughing can lead to excess use of chest wall muscles and chest pain. Patients' who report acute pain and subsequent respiratory distress should raise suspicion of a spontaneous pneumothorax or pneumomediastinum. ED management includes analgesics, specific treatment directed at underlying etiology and appropriate referral.

Acute Vision Loss

Sudden loss of vision is a very uncommon but extremely worrisome symptom. The management of children with acute vision loss in the emergency department requires timely recognition, a focused assessment, and referral to the appropriate subspecialty care provider for further evaluation and definitive care. In this article, we will review the clinical manifestations and early management of traumatic and nontraumatic causes of acute vision loss in children.

Favorable internal hernia rate achieved using retrocolic, retrogastric alimentary limb in laparoscopic Roux-en- Y gastric bypass

Background The present study was performed at a tertiary care university hospital. The present study examined the incidence of internal hernia (IH) in our series of laparoscopic Roux-en- Y gastric bypass (LRYGB) with retrocolic, retrogastric routing of the alimentary limb accompanied by routine secure closure of all mesenteric defects. Methods During a 4-year period, 847 patients underwent LRYGB. Our operative technique included retrocolic, retrogastric placement of the alimentary limb. The enteroenterostomy mesenteric defect, mesocolic defect, and Petersen defect were routinely closed in running fashion with nonabsorbable suture. Results The study population had a mean age of 42.4 ± 9.3 years and a mean preoperative body mass index of 45.3 ± 5.6 kg/m 2. The mean operative time was 154 ± 25 minutes. The mean excess body weight loss at 1 year was 70%. The incidence of IH among this large study population was 0%. A total of 11 patients (1.3%) presented with symptoms concerning for IH, most commonly nausea, vomiting, and crampy abdominal pain, from 1 month to 6 years after the initial surgery. On re-exploration, 4 patients had adhesive small bowel obstruction, 4 had adhesions without obstruction, 1 had small bowel intussusception, and 2 patients had negative findings. Conclusion IH is a serious complication of LRYGB that can lead to catastrophic morbidity and mortality. We advocate vigilant screening for this complication and laparoscopic exploration for patients with worrisome symptoms. Our data have indicated that a routine and consistent technique to securely close the mesenteric defects can significantly reduce the risk of IH associated with retrocolic, retrogastric placement of the alimentary limb during LRYGB.

Population-based epidemiology, risk factors and screening of intraductal papillary mucinous neoplasm patients

Intraductal papillary mucinous neoplasm (IPMN) was first recognized in the 1980s with increasing publications over the last decade as the incidence increased sharply, especially at tertiary-care referral centers. Population-based studies have estimated the age and sex-adjusted cumulative incidence of IPMN to be 2.04 per 100 000 person-years (95% confidence interval: 1.28-2.80). It is now understood that IPMN can be classified anywhere along the spectrum of the adenoma to carcinoma sequence and often harbors mutations in genes such as KRAS early in the disease process. Many patients are diagnosed incidentally after imaging of the abdomen for other diagnostic purposes. Patients that present with a history of symptoms such as pancreatitis and abdominal pain are at high risk of harboring a malignancy. Clinicopathologic features such as involvement of the main pancreatic duct, presence of mural nodules, and side branch disease > 3.0 cm in size may indicate that there is an underlying invasive component to the IPMN. In addition, the incidence of extra-pancreatic neoplasms is higher in patients with IPMN, with reported rates of 25% to 50%. There are no current screening recommendations to detect and diagnose IPMN but once the diagnosis is made, screening for extrapancreatic neoplasms such as colon polyps and colorectal cancer should be considered. Surgical resection is the recommend treatment for patients with high-risk features while close observation can be offered to patients without worrisome signs and symptoms of carcinoma.

Genome-wide association study of suicidal ideation emerging during citalopram treatment of depressed outpatients

Suicidal ideation is an uncommon but worrisome symptom than can emerge during antidepressant treatment. We have described earlier the association between treatment-emergent suicidal ideation (TESI) and markers in genes encoding glutamate receptor subunits GRIK2 and GRIA3. The present genome-wide association study was conducted to identify additional genetic markers associated with TESI that may help identify individuals at high risk who may benefit from closer monitoring, alternative treatments, and/or specialty care. A clinically representative cohort of outpatients with nonpsychotic major depressive disorder enrolled in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial were treated with citalopram under a standard protocol for up to 14 weeks. DNA samples from 90 White participants who developed TESI and a sex-matched and race-matched equal number of treated participants who denied any suicidal ideas were genotyped with 109 365 single nucleotide polymorphisms on the Illumina's Human-1 BeadChip. One marker was found to be associated with TESI in this sample at the experiment-wide adjusted P less than 0.05 level (marker rs11628713, allelic P = 6.2x10, odds ratio = 4.7, permutation P = 0.01). A second marker was associated at the experiment-wide adjusted P = 0.06 level (rs10903034, allelic P = 3.02x10, odds ratio = 2.7, permutation P = 0.06). These markers reside within the genes PAPLN and IL28RA, respectively. PAPLN encodes papilin, a protoglycan-like sulfated glycoprotein. IL28RA encodes an interleukin receptor. Together with our earlier report, these findings may shed light on the biological basis of TESI and may help identify patients at increased risk of this potentially serious adverse event.

Routine surveillance cystoscopy for patients with augmentation and substitution cystoplasty for benign urological conditions: is it necessary?

To evaluate screening cystoscopy as the long-term follow up in patients with an enterocystoplasty for > or =10 years. We performed a prospective analysis of 92 consecutive patients who attended our endoscopy suite for regular check cystoscopy as per standard follow-up. This is performed for all patients with cystoplasty performed at our institute after 10 years. The data were recorded on patient demographics, original diagnosis and type of cystoplasty. In all, 53 of these patients consented to undergo bladder biopsies at the same time. The median (range) follow-up was 15 (10-33) years. No cancer was identified with either surveillance cystoscopy or on routine biopsies. Chronic inflammation was identified in 25 biopsies (27%). Villous atrophy was present in 12 (55%) ileal patch and three (12.5%) colonic patch biopsies. During this study, the first and only case of malignancy in a cystoplasty at our institution was diagnosed in a symptomatic patient. She had intermittent haematuria and recurrent urinary tract infections (UTIs). She previously had a normal surveillance cystoscopy. We feel that it is not necessary to perform yearly check cystoscopies in patients with augmented bladders at least in the first 15 years, as cancer has not yet been detected with surveillance cystoscopy in this patient group. However, if the patient develops haematuria or other worrisome symptoms including suprapubic pain and recurrent unexplained UTIs a full evaluation, including cystoscopy and computerized tomography should be undertaken.

Physicians’ Duty to Be Aware of and Report Environmental Toxins

Case Miguel’s mother brought her 3-month-old son to a rural clinic for an urgent care visit. Miguel was vomiting and had diarrhea. Among his other worrisome symptoms were cyanosis, drowsiness, and rapid breathing. His physician told his mother he needed to go to the nearest ER by ambulance and she agreed. At the ER, they were rushed into an exam room, with the baby on oxygen.

The Impact of Acculturative Stress and Daily Hassles on Pre-adolescent Psychological Adjustment: Examining Anxiety Symptoms

Acculturative stress in relation to anxiety symptoms has not been examined empirically in young Hispanic populations. The present study, conducted with 138 pre-adolescent Hispanic youngsters, investigated this relationship. The findings suggested that acculturative stress was related to physiological, concentration, and worrisome symptoms of anxiety. After decomposing acculturative stress, it became evident that perceived discrimination accounted for a large proportion of the variance in the relationship between acculturative stress and anxiety. Immigration-related stress was mostly associated with worry symptoms. Finally, total daily hassles were an independent predictor of concentration and physiological anxiety symptoms. Implications for prevention interventions and future research are discussed.

Current Concepts: Recognition and Management of Common Activity-Related Gastrointestinal Disorders

Sports medicine clinicians may encounter a wide variety of activity-related gastrointestinal (GI) disorders. The advancing ages and burgeoning obesity rates of the US population have generally increased the prevalence of GI conditions among adults. However, conditioned younger athletes with normal body mass indices also may experience disquieting activity-related GI disorders. While often mild and transient, some of these GI conditions may disrupt exercise routines or pose significant health risks to affected individuals. Gastroesophageal reflux occurs frequently during physical activity and should be empirically treated with activity reduction and dietary modifications in conjunction with antisecretory agents. Persistent or worrisome symptoms merit upper endoscopy, a thorough evaluation for non-GI causes and, rarely, surgery. Altered GI motility commonly occurs during vigorous activities that use dynamic or fluctuating body positions. Dietary and exercise modifications are usually enough to resolve these symptoms. Physical activity may also precipitate GI bleeding from upper and/or lower sources. Although mild or occult bleeding is most common, significant bleeding merits a thorough diagnostic evaluation after stabilization and treatment. Adequate hydration and gradual exercise progression may be particularly helpful to prevent the recurrence of bleeding. The judicious use of medications in conjunction with nonsteroidal anti-inflammatory drug avoidance may also be necessary. Fortunately, most activity-related GI disorders are self-limited and can be managed conservatively. After a brief period of modified activity, clinically stable individuals may progress their activity levels as symptoms allow.

Out of Left Field

When a woman with a family history of premature coronary artery disease presented with worrisome symptoms, the findings were anything but typical. The 54-year-old patient reported several hours of palpitations and atypical chest pain. Her initial electrocardiogram revealed sinus tachycardia and an old left bundle branch block. Myocardial infarction was ruled out by serial measurements of cardiac biomarkers.

Utilization of Anti-RhD in the Emergency Department After Blunt Trauma

In the United States, trauma occurs in 6% to 7% of pregnancies. Its severity may range from critical injuries where the mother's life is at risk, to apparently minor injuries, which might not be associated with any worrisome symptoms. One of the risks associated with a traumatic event is fetomaternal hemorrhage--the transfer of fetal blood cells into the maternal circulation. If the maternal blood type is rhesus negative and the fetus is rhesus positive, even a small amount of blood can cause the mother to develop antibodies against the fetal Rho D antigen, thus becoming sensitized. In subsequent pregnancies, this can lead to hemolytic disease of the fetus or newborn, which, if severe, is associated with total body edema, hepatosplenomegaly and heart failure, and intrauterine death. Although there are no published studies specific to the US population, poor awareness of the risk of sensitization following trauma and underutilization of anti-RhD in the emergency department has been reported in countries such as Canada and the United Kingdom. This article reminds caregivers of the risk of rhesus sensitization following blunt trauma, in order that they can administer anti-RhD appropriately and hemolytic disease of the fetus or newborn can be prevented.

The Genetic Information Nondiscrimination Act: Fear Factor or Fantasy Island?

The Genetic Information Nondiscrimination Act, or GINA, was signed into law on May 21, 2008.1 Its implications are hard to predict for a variety of reasons--for example, the scope of the law is limited to employment and health insurance; regulations for implementing it have yet to be written; and its power to protect will only be appreciated once it is challenged. More importantly, however, its implications are difficult to assess because of the Alice in Wonderland dimension of the genetic landscape--risks and benefits may be distorted, appearing to be different from what they actually are. And arriving at the hoped-for destination--personalized genetic medicine, where knowledge is power and health care is safer, more affordable, more equitable, and more effective--may require a trip down the proverbial rabbit hole. The first version of GINA legislation was introduced in 1995, shortly after the Human Genome Project bore its first fruits. The genes for cystic fibrosis, Huntington Disease, and breast cancer had recently been identified. Many of the psychosocial concerns about genetic information could be addressed through education, a better informed consent process, and counseling. However, the problem of discrimination seemed to require a regulatory approach. Examples of genetic discrimination are both apocryphal and anecdotal. Yet concern about discrimination is cited as an important reason that people forgo either clinical genetic testing or participation in genetic research. (2) The hope is that GINA will be a necessary step on the way to individualized based on genetics--even if it is not a sufficient one--because it addresses this perceived barrier of genetic discrimination. 3 However, the very idea of GINA has been criticized because it reinforces a exceptionalism--the concept that genetic information is somehow different from other kinds of medical information--rather than addressing the underlying problem, which is that health care coverage is limited for those who are ill. Some critics also fear that GINA may mislead people into thinking that untested protections are more robust than they really are. (4) Predicting what impact GINA will have or should have on the public's behavior regarding either clinical genetics or genetics research is a difficult task. Will it provide enough reassurance to alter the behavior of people whose fear of discrimination has influenced a decision to avoid genetic research or clinical genetic tests? Even if it does allay these fears, it may still have limited impact on their decisions. In some cases, people may have other concerns about genetic research and testing--for example, they may be ambivalent about whether they want to know their risk of future disease, or they may worry about its impact on their family relationships--but discrimination is a more socially acceptable explanation. For others, their concerns may be inchoate, but genetic discrimination provides a concept for them to get behind that is easy to understand and articulate. It is difficult for most of us to appreciate the complex mix of reasons, emotions, and circumstances that influence our own decisions and behaviors, let alone those of others. For example, people who decide not to seek medical care for a worrisome symptom offer a variety of explanations: don't like doctors, was worried I might have cancer, or medicine is simply about taking advantage of sick people to make money, to name a few. Clearly, these explanations should be taken seriously because they point to genuine concerns that require a concerted response. Yet behavioral scientists who study the complex nature of health care decision-making and behavior appreciate that behavior may only be partially related to factors people are aware of and talk about. (5) As a result, whether GINA will indeed result in people making different decisions about health care or participation in research is far from clear. …

The International Economics of Natural Resources and Growth

This article is in three parts. First, it briefly describes the contribution of natural resources to economic growth around the world, pondering the question whether an abundance of natural resources is a blessing or a curse. Secondly, an attempt is made to provide a glimpse of recent empirical evidence that can be brought to bear on this question. Thirdly, the article discusses the experience of Norway, the world's third largest oil exporter. To date, Norway has appeared to be mostly free of the worrisome symptoms, such as the Dutch disease, that have afflicted many other countries with abundant natural resources.

The International Economics of Natural Resources and Growth

This article is in three parts. First, it briefly describes the contribution of natural resources to economic growth around the world, pondering the question whether an abundance of natural resources is a blessing or a curse. Second, an attempt is made to provide a glimpse of recent empirical evidence that can be brought to bear on this question. Third, the article discusses the experience of Norway, the world's third largest oil exporter. To date, Norway has appeared to be mostly free of the worrisome symptoms, such as the Dutch disease, that have afflicted many other countries with abundant natural resources.

Gender Differences in Symptom Experiences of Patients with Acute Coronary Syndromes

To compare the symptom experiences between men and women with acute coronary syndromes (ACS), we surveyed a convenience sample of 112 subjects with a final diagnosis of ACS in four hospitals. Our study found that after adjusting for cardiac diagnosis, diabetes, and age, women were more likely than men to experience chest discomfort rather than chest pain; pain/discomfort only in areas of the body other than the chest; pain/discomfort that started first either in the arm(s) or in areas of the body other than the chest; and unexplained anxiety. Women were less likely than men to experience chest pain/discomfort, pain/discomfort in the left side of the chest, and chest pain/discomfort as the most worrisome symptom. Significant gender differences were observed in the reports of several symptoms associated with ACS. This study is the first to identify different pain/discomfort referral patterns between men and women that require further validation.

Pneumatosis Intestinalis Due to Mycobacterium avium intracellulaire in an AIDS Patient

Pneumatosis intestinalis (PI) is characterized by the presence of multiple submucosal and subserosal blood-filled cysts in the small or large intestine. PI associated with AIDS is usually asymptomatic, but uncommonly causes life-threatening disorders potentially producing bowel necrosis or perforation. We report a patient with Mycobacterium avium intracellulaire (MAI) and complicated PI to alert clinicians to consider this rare and potentially misleading cause of abdominal complaints when evaluating clinical symptoms in AIDS. Case report: A 41 y.o. man with AIDS (CD4 = 7) presented to the ER with 2 months of diffuse upper abdominal pain, diarrhea and weight loss. On exam, he was afebrile and had a distended, tender upper abdomen without signs of peritonitis. WBC = 2500 with 85% polys. Abdominal CT scan = widespread lymphadenopathy consistent with disseminated MAI, diagnosed previously. Abdominal pain decreased over several days, but loose, watery diarrhea persisted. On hospital day 10, his pain worsened acutely and new diffuse abdominal tenderness was detected; he remained afebrile with no change in WBC. Repeat CT scan demonstrated extraluminal, submucosal air consistent with pneumatosis of the right colon and sigmoid; a small amount of free intraperitoneal air indicative of intestinal perforation was suggested. He underwent exploratory laparotomy, sub-total colectomy and small bowel resection with ileostomy for severe colitis. Pathology revealed MAI of the ileum, colon and pericolonic mesenteric lymph nodes. No perforation was present. Discussion: PI has been reported in AIDS and other immunosuppressed settings, including solid organ transplantation, chemotherapy, and high-dose corticosteroid treament. Opportunistic infections such as CMV, toxoplasmosis, MAI and cryptosporidium are the most common associations of PI in AIDS which may represent as many as 10–25% of all PI cases. Most frequently, PI in AIDS is incidental and resolves or stabilizes with conservative mangement. Our patient, however, developed worrisome signs and symptoms requiring laparotomy. Clinicians must be aware that the spectrum of MAI-associated PI in AIDS is diverse. This rare disorder may manifest as an incidental imaging finding, or as unexplained digestive symptoms which may be innocuous or life-threatening. Free intraperitoneal air in this setting may be due to rupture of a subserosal bleb resulting in non-surgical pneumoperitoneum or reflect an intra-abdominal emergency.