Carilion Roanoke Community Hospital

Attention is called to a hitherto largely overlooked manifestation of fibrous dysplasia. Nine previous cases and 2 new cases of intramuscular myxomas in cases of fibrous dysplasia are reviewed. Ten of the 11 cases had multiple intramuscular myxomas, usually on the right side, and all near but distinct from the bony lesions. All were benign. In 5 cases with Albright's syndrome, the multiple myxomas occurred on the same side as the cutaneous pigmentations. Characteristically, the myxomas made their appearance considerably later in life than the fibrous dysplasia. The literature is reviewed, and the probable pathogenic relationship between myxomas and fibrous dysplasia is discussed.

Opsoclonus-myoclonus syndrome (OMS) is an autoimmune disorder with serious neurodevelopmental morbidity and limited treatment options. We treated a toddler with moderately severe OMS with rituximab, a monoclonal anti-B cell antibody. The patient's clinical response was documented on videotape and scored with the OMS Evaluation Scale. Cerebrospinal fluid lymphocyte subsets were evaluated by flow-cytometric immunophenotyping, with a comprehensive panel of monoclonal antibodies. Eradication of cerebrospinal fluid B cells, which previously were expanded, was associated with dramatic clinical improvement. There also were secondary changes in other lymphocyte subsets that might be relevant to the clinical response and lack of serious infections. In addition to clarifying the immune response to B-cell depletion, these data reveal a promising new therapy for OMS that warrants a phase I clinical trial.

A single report of brothers born to first-cousin parents with a form of acute spinal muscular atrophy (SMA) and congenital fractures suggested that this combination represented a distinct form of autosomal recessive SMA. We describe a boy with hypotonia and congenital fractures whose sural nerve and muscle biopsies were consistent with a form of spinal muscular atrophy. Molecular studies identified no abnormality of the SMN(T) gene on chromosome 5. This case serves to validate the suggestion of a distinct and rare form of spinal muscular atrophy while not excluding possible X-linked inheritance.

This report describes the sonographic diagnosis of the Pena-Shokeir syndrome type 1 during the second trimester of a pregnancy which was electively terminated. The mother had previously delivered a macerated, hydropic infant with multiple congenital anomalies. The diagnosis was based on the recurrence of hydramnios and nonimmune hydrops in a fetus with normal chromosomes, normal amniotic fluid alpha-fetoprotein, normal fetal echocardiography, and lack of evidence of a lysosomal storage disease. These observations suggest that serial sonography during the second trimester in pregnancies at risk may allow for the prenatal diagnosis of the Pena-Shokeir syndrome type 1. Without further experience, it would not be prudent to suggest to couples at risk that the prenatal diagnosis of a recurrence can be assured with a high degree of accuracy.

OBJECTIVE: To determine whether the distribution of peripheral blood mononuclear cells (PBMCs) is altered in paraneoplastic opsoclonus-myoclonus (POM). METHODS: PBMCs from 17 children with POM, 17 children with OM but no tumor, and 17 controls were immunophenotyped using a comprehensive panel of surface markers by dual-laser flow cytometry. All groups were matched for age and gender; POM and OM patients were matched for treatment. RESULTS: In the POM patients, the CD4+ T-cell subset was smaller in both relative size (-18%, P = 0.02) and absolute size (-41%, P = 0.03) compared with controls. The CD4/CD8 ratio also was less (-29% to -44%) and was related to POM duration (P = 0.03). The absolute but not relative size of the gammadelta T-cell subset was reduced (-44%, P = 0.02). There were no significant abnormalities of CD19+ B-cells, CD3- or CD3+ NK cells, HLA-DR+ or CD25+ T-cells, or CD45RA+ or CD45RO+ T-cells. Prior tumor chemotherapy, which was associated with a higher percentage but not number of CD8+ T-cells, did not restore the CD4+ T-cell subset. When the POM and OM groups, which were not significantly different, were combined, chemotherapy decreased both the relative and absolute size of the CD19+ B-cell pool and had small effects on other lymphocyte subsets. CONCLUSIONS: POM is characterized by T-cell abnormalities of PBMCs, the most robust of which is reduction of the CD4+ T-cell subset and the CD4/CD8 ratio. Although this reduction was found previously in cerebrospinal fluid in POM patients, PBMC subsets did not otherwise reflect cerebrospinal fluid abnormalities. Longitudinal studies will be necessary to determine whether PBMC abnormalities could serve as treatment markers.

RATIONALE: Predicted increases in heat-related weather phenomena will result in increasing heat exposures and heat injuries, like heat stroke. Prompt recognition, early intervention, and evidence-based management are necessary to optimize outcomes. OBJECTIVES: The objective of these guidelines was to develop evidence-based recommendations for the treatment of patients with heat stroke. DESIGN: The Society of Critical Care Medicine convened a multidisciplinary panel of 18 international clinicians, comprising expertise in critical care, emergency medicine, neurocritical care, surgery, trauma/burn surgery, sports medicine, athletic training, military medicine, nursing, pharmacy, respiratory therapy, and one patient representative. The panel also included a guidelines methodologist specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guidelines development including panel selection and voting. METHODS: The panel members identified Patient, Intervention, Comparison, and Outcomes questions in two main areas: cooling modalities and medications that affect temperature. A systematic review for each question was conducted to identify the best available evidence, statistically analyze the evidence, and assess the certainty of the evidence using the GRADE methodology. The GRADE evidence-to-decision framework was used to formulate the recommendations. Good practice statements were included to provide additional clinical guidance. RESULTS: The panel generated two strong recommendations, five good practice statements and one "only-in-the-context of research" statement. Active cooling measures are recommended over passive cooling methods, with cold- or ice-water immersion achieving the fastest cooling rate. This method should be prioritized where available. In heat stroke patients, there is no evidence to support pharmacological interventions that affect temperature control and they should be avoided. CONCLUSIONS: The guidelines task force provided recommendations for the management of patients with heat stroke. These recommendations should be considered along with the patient's clinical status and available resources.

Recurrent episodes of endoscope contamination with nontuberculous mycobacterium and Pseudomonas species, coupled with employee concerns about exposure to 2% glutaraldehyde and the requirement for rapid scope turnover time, led to the investigation of an alternative method for endoscope processing. A prospective evaluation of 220 bronchoscopy procedures was carried out. Endoscope culture surveillance was performed twice a month for a 12 month period on all endoscopes. In addition, the deliberate inoculation of bronchoscopes with Mycobacterium gordonae was carried out. No indications of cross contamination were noted among the 220 bronchoscopy procedures after processing the scopes by the studied liquid chemical sterilization system using peracetic acid. Ongoing patient surveillance did not reveal any indications of cross contamination for nearly 15,000 patients diagnostic or surgical endoscopic procedures using instruments processed by this liquid chemical sterilization system. Twice a month for 12 months, bronchoscopes, colonoscopes, and gastroscopes were cultured for bacterium, fungi, and acid fast bacilli and showed no growth. Deliberate inoculation of bronchoscopes with M. gordonae showed the scopes were rendered sterile. No unusual occurrences of occupational chemical exposure were found in 11 individuals working with this liquid chemical sterilization system. The peracetic acid based sterilization system studied proved to be an effective, safe, and economical alternative to the glutaraldehyde method.

OBJECTIVE: The objective of this study was to determine the feasibility (i.e., limited efficacy testing, practicality, and acceptability) of a 6-week smartphone game-based applications program for promoting physical activity (PA) in adolescents in an afterschool program. MATERIALS AND METHODS: This mixed-method, quasi-experimental design study included 27 adolescents who evaluated four smartphone PA game-based applications in two Boys & Girls Clubs of America. After an initial baseline week (i.e., usual activity during their visit to the Club), adolescents played each game for 1 week. During a final week, the participants could choose to play any combination of the four games. An established conceptual framework was used to assess feasibility. Efficacy was assessed by changes in PA via wrist-worn accelerometers (model GT3x+; ActiGraph LLC, Pensacola, FL). Practicality was measured through field notes, the number of players attending each session, and the proportion of attendees who played the games. Acceptability was measured using poststudy focus groups. RESULTS: Compared with baseline (3.22 metabolic equivalents [METs]), mean accelerometer values were significantly (P<0.05) higher during "Space Rayders" (4.33 METs) and "Color Hunt" (3.67 METs). Attendance did not differ among games, and weekly number of players averaged 12 of 27 participants. Qualitative findings indicated that participants perceived "Space Rayders" as the most acceptable game. Overall, participants found the games to be enjoyable and easy to use, although they had suggestions to improve graphics and sounds. CONCLUSIONS: Smartphone games can be feasible for adolescents to use for PA. Lessons learned will be used to provide improvements for future game development and evaluation.

A 17 year old girl with active Crohn's colitis developed idiopathic thrombocytopenic purpura that was managed with intravenous immune globulins and cyclosporin A. The possible association between Crohn's disease and immune thrombocytopenia is explored.

Recurrent episodes of endoscope contamination with nontuberculous mycobacterium andPseudomonasspecies, coupled with employee concerns about exposure to 2% glutaraldehyde and the requirement for rapid scope turnover time, led to the investigation of an alternative method for endoscope processing. A prospective evaluation of 220 bronchoscopy procedures was carried out. Endoscope culture surveillance was performed twice a month for a 12 month period on all endoscopes. In addition, the deliberate inoculation of bronchoscopes withMycobacterium gordonaewas carried out. No indications of cross contamination were noted among the 220 bronchoscopy procedures after processing the scopes by the studied liquid chemical sterilization system using peracetic acid. Ongoing patient surveillance did not reveal any indications of cross contamination for nearly 15,000 patient diagnostic or surgical endoscopic procedures using instruments processed by this liquid chemical sterilization system. Twice a month for 12 months, bronchoscopes, colonoscopes, and gastroscopes were cultured for bacterium, fungi, and acid fast bacilli and showed no growth. Deliberate inoculation of bronchoscopes withM. gordonaeshowed the scopes were rendered sterile. No unusual occurrences of occupational chemical exposure were found in 11 individuals working with this liquid chemical sterilization system. The peracetic acid based sterilization system studied proved to be an effective, safe, and economical alternative to the glutaraldehyde method.ASAIO Journal1995;41:151-154.

We have found in reviewing our vascular cases that the Fogarty embolectomy is definitive treatment in only certain types of cases; in most it is an adjunct to more complex vascular surgery. In our cases, an embolectomy catheter was used as an integral part of the procedure in 130 (18%) cases. In 96 (74%) cases, an embolectomy alone was performed with a success rate of only 48% (46 cases). In 50 (52%) cases, the embolectomy was not adequate, requiring reoperation, a new bypass, or amputation within 7 to 10 days. Mortality rate for the series of 130 patients was 7.0%, and limb loss rate was 5.0%. The majority of cases (92) in this review were diagnosed with an acute exacerbation of diffuse peripheral vascular disease or a clotted graft, and it is in these patients that the success rate was so poor (17%) if embolectomy alone was performed. The population of patients presenting with suspected acute arterial insufficiency has changed over the past 30 years. Now it is the elderly who have an acute exacerbation of their peripheral vascular disease. It is this change in the population that has made the Simple Fogarty Embolectomy an operation of the past--mandating angiography, Fogarty embolectomy, and complex vascular reconstruction for limb salvage.

Iliac artery aneurysm rupture can be rapidly fatal if not diagnosed immediately. These aneurysms usually present in patients with other aneurysmal diseases of the aortoiliac arterial system. If not diagnosed and surgically repaired, iliac artery aneurysms can proceed to expand and ultimately rupture, usually presenting with back, flank, or abdominal pain and, possibly, signs of systemic shock. We present an unusual case report of a common iliac artery aneurysm rupture presenting as gross hematuria due to an arteriovesical fistula. Only three other cases of arteriovesical fistulae have been reported previously. Unlike the case presented, all three of these cases involved trauma or surgical instrumentation or manipulation of the bladder.

Carotid endarterectomy has recently become one of the more controversial operations. The tremendous increase in the number of endarterectomies performed, coupled with the apparent increase in morbidity and mortality associated with this operation in some studies, have brought into question the indications and results of the procedure. The potential for complications from the procedure itself, as well as increased morbidity and mortality from surgery on the elderly, make carotid endarterectomy a dangerous operation that must be done carefully and thoughtfully. The authors have performed carotid endarterectomies exclusively under local anesthesia to more closely evaluate the neurologic status of the patient. They believe that the operation performed in this manner obviates the use of a shunt and its inherent complications in greater than 80 per cent of the patients. This, coupled with the fact that many of the patients also have severe cardiac disease and the use of local anesthesia causes less hemodynamic changes and stress, should make carotid endarterectomy under local anesthesia the preferred approach.

Abstract The purpose of this study was to explore the relationship between tactile defensiveness and self‐esteem in typical children attending a state school. Thirty‐two children aged 8–11 were administered the Touch Inventory for Elementary School Aged Children to measure tactile defensiveness, and the Piers Harris Self Concept Scale to measure self‐esteem. A Spearman rank order correlation coefficient revealed a negative correlation (−0.429) which was statistically significant (p=0.014). These findings suggest that there is an inverse relationship between self‐esteem and behaviours associated with tactile defensiveness in elementary‐school‐aged children. Continued research in this area is recommended. Copyright © 1998 Whurr Publishers Ltd.

OBJECTIVES: The charge of the newly formed Society of Critical Care Medicine Sustainability Task Force is to describe actionable items supporting environmental stewardship for ICUs, to discuss barriers associated with sustainability initiatives and outline opportunities for future impact. DATA SOURCES: Ovid Medline, EBSCOhost CINAHL, Elsevier Embase, and Scopus databases were searched through to March 2024 for studies reporting on environmental sustainability and critical care. STUDY SELECTION: Systematic reviews, narrative reviews, quality improvement projects, randomized clinical trials, and observational studies were prioritized for review. Bibliographies from retrieved articles were scanned for articles that may have been missed. DATA EXTRACTION: Data regarding environmental sustainability initiatives that aimed to quantify, manage, or mitigate pollution and/or carbon emissions with a focus on ICUs, barriers to change, and opportunities for development were qualitatively assessed. DATA SYNTHESIS: ICUs are resource-intensive and as such, methods to attenuate carbon emissions and waste can play a substantial role in mitigating the sizable burden of healthcare-related pollution and greenhouse gas emissions. Several initiatives and strategies exist for clinicians and providers to engage in environmental stewardship, with specific attention to avoiding low-value care while maintaining or improving patient safety and high-quality care. Increased focus on sustainability can be met with resistance to change, including institutional, financial, and behavioral barriers. Collaboration and innovative thinking create valuable opportunities for clinicians, patients, families, and policymakers to advocate for patient and planetary health. CONCLUSIONS: Within the healthcare system, ICUs are well positioned to lead sustainability action, policy, and practice. Critical care teams have the capability and the moral responsibility to mitigate the negative impact of critical care medicine upon our environment and become change agents promoting sustainable healthcare for the benefit of human health.

The duplex scan has become the definitive test in the diagnosis of carotid arterial disease. Its significance, however, has been diminished its extensive use for inappropriate indications. We performed a retrospective study over a four year period at two major hospitals to evaluate the different indications for carotid duplex scans. Symptoms which prompted the test, associated diseases, the type of physician ordering the test, and demographic data were recorded on all patients. Statistical analysis was used to indicate which symptoms and associated diseases were significant in predicting carotid disease. A total of 4,764 scans were reviewed. There were 4,289 studies (90%) which were negative for disease requiring surgery. There were a total of 12 indications for the carotid duplex scan in this study; the most common indications were dizziness, (20%) transient ischemic attack symptoms (19%) and a bruit (16%). Vascular surgeons (28%), Internal Medicine physicians (27%) and Family practice physicians (15%) ordered the duplex scan most frequently, but 39% of the positive scans were ordered by vascular surgeons. A history of seizures, confusion, stroke and as a preoperative evaluation all had a very low yield and should not be used as an indication for a duplex scan. However, a long smoking history, a history of known carotid disease, and peripheral vascular disease all had a statistical correlation with an abnormal duplex scan. The use of the duplex scan to rule out carotid arterial disease for patients with vague, uncommon symptoms is inappropriate and wasteful.

Acute septic arthritis, or septic joint, results from bacterial invasion of the joint space. Infecting organisms can invade any joint through the blood-stream, from adjacent osteomyelltis, or through direct inoculation of the wound. Although this can occur at any age, children are particularly susceptible and must be treated rapidly by joint aspiration, arthrotomy, or by a combination of procedures.

BACKGROUND: The duplex scan with its improved technology has allowed clinicians to visualize noninvasively the carotid bifurcation. We investigated whether the duplex scan, with its ability to visualize plaque structure, can reliably predict the major components of different plaques seen in pathologic studies. Furthermore, we studied whether it could correlate these findings with the presenting symptoms of patients and predict which patients would benefit from early endarterectomy. METHODS: We performed a retrospective study of 84 patients during a 43-month period. The arteriogram, duplex scans, symptoms, and pathologic examination of the carotid atheroma in each patient were reviewed. The specimens were divided into three categories depending on the major component found in pathologic studies. One group consisted of calcific plaques, another was predominantly fibrosis and cholesterol, and the third was plaques with intramural hemorrhage. The angiograms and duplex scans were separately interpreted. Patients with symptoms (81%) were divided into those with amaurosis fugax (19%), transient ischemic attacks (58%), and cerebral vascular accidents (3%). RESULTS: The agreement between duplex scan findings and arteriograms concerning the percent stenosis was 95%. There was no correlation, however, between the presence or type of symptoms and the plaque structure as seen in pathologic studies or on the duplex scan. CONCLUSIONS: At this stage of technology the duplex scan is most reliable in detecting hemodynamically significant lesions. Its ability to predict symptoms or findings at surgery and possibly to alter treatment is at best limited.

Timely follow-up care after an abnormal cervical cancer screening test result is critical to the prevention and early diagnosis of cervical cancer. The current inadequate and inequitable delivery of these potentially life-saving services is attributed to several factors, including patient out-of-pocket costs. Waiving of consumer cost-sharing for follow-up testing (e.g., colposcopy and related cervical services) is likely to improve access and uptake, especially among underserved populations. One approach to defray the incremental costs of providing more generous coverage for follow-up testing is reducing expenditures on "low-value" cervical cancer screening services. To explore the potential fiscal implications of a policy that redirects cervical cancer screening resources from potentially low- to high-value clinical scenarios, we analyzed 2019 claims from the Virginia All-Payer Claims Database to quantify (i) total spending on low-value cervical cancer screening and (ii) out-of-pocket costs associated with colposcopy and related cervical services among commercially insured Virginians. In a cohort of 1,806,921 female patients (ages 48.1 ± 24.8 years), 295,193 claims for cervical cancer screening were reported, 100,567 (34.0%) of which were determined to be low-value ($4,394,361 total; $4,172,777 for payers and $221,584 out-of-pocket [$2/patient]). Claims for 52,369 colposcopy and related cervical services were reported ($40,994,016 total; $33,457,518 for payers and $7,536,498 out-of-pocket [$144/patient]). These findings suggest that reallocating savings incurred from unnecessary spending to fund more generous coverage of necessary follow-up care is a feasible approach to enhancing cervical cancer prevention equity and outcomes. PREVENTION RELEVANCE: Out-of-pocket fees are a barrier to follow-up care after an abnormal cervical cancer screening test. Among commercially insured Virginians, out-of-pocket costs for follow-up services averaged $144/patient; 34% of cervical cancer screenings were classified as low value. Reallocating low-value cervical cancer screening expenditures to enhance coverage for follow-up care can improve screening outcomes. See related Spotlight, p. 363.

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones as a tool to aid trainee assessment based on the framework of the six core competencies of practice. Variability in the interpretation and application of the original Milestones prompted the ACGME to convene work groups within the different specialties and subspecialties to update the Milestones. The Geriatric Medicine work group was convened in 2019 with the goal of clarifying and simplifying the language of the Milestones, revising content to be specific to geriatrics, and developing supplemental resources to aid in implementation and use. We suggest using a practical, four-step process to implement the updated Milestones, called the Milestones 2.0, in fellowship programs by: (1) training faculty in the use of the Milestones 2.0, including an overview of the background and updates, (2) mapping the Milestones 2.0 to existing assessments, (3) educating fellows about the Milestones 2.0 and (4) presenting and discussing the Milestones 2.0 at Clinical Competency Committee meetings. This systematic approach promotes the development of a shared mental model for trainee assessments.