Human Anatomy at Colby

Entries Tagged as 'Grand Rounds'

Grand Rounds Bi265 013019: HIV and Antiretroviral Resistance

February 7th, 2019 · Comments Off on Grand Rounds Bi265 013019: HIV and Antiretroviral Resistance

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Laurel Edington: Grand Rounds – Celiac Disease

February 23rd, 2015 · Comments Off on Laurel Edington: Grand Rounds – Celiac Disease

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During the last week of class, we presented our grand rounds talks that we’ve been working on all semester. This was a great experience because it allowed us to practice giving a grand rounds lecture, which is a common presentation in the medical community. Each group of three picked a topic, which could be a case study or an overview of a disease or medical treatment, and then presented as if they were doctors talking about an interesting patient, new procedure that they’re performing, etc.

This year, the weather didn’t exactly cooperate with us. We were supposed to have a practice session during class on Tuesday and then go to Augusta to present our talks along with Kents Hill students at Maine General. Because of the snow day and horrible driving conditions, neither of these events happened and we had to present our final product with little group practice. Thankfully, my group was able to practice together before the weather was too bad, but practicing during class and at Maine General would have been helpful.

My group decided to present a case study on a 42 year old man with chest and abdominal pain. We found this study through the New England Journal of Medicine and it was used as a hugely teaching moment instead of a typical grand rounds talk. In this case study, the man’s symptoms were textbook for celiac disease but physicians performed a number of tests, including an invasive and non-diagnostic procedure, before even thinking of the possibility of celiac disease. This case study was not used to teach medical students and medical professionals about a rare disease or an interesting case, it was used to enforce the fact that celiac disease is becoming increasingly common and physicians need to be aware of it and perform the simple diagnostic blood test for the disease when a patient comes in presenting characteristic symptoms.

Through this presentation, we learned the difference between celiac disease and non-celiac gluten sensitivity. With celiac disease, there is damage to the intestines and an IgA tissue transglutaminase and IgA endomysial antibody tests can be performed to diagnose the condition, this is not the case with a gluten sensitivity. Both conditions, however, are treated with a strict gluten-free diet. This is becoming a popular new diet in people who don’t suffer from celiac disease or non-celiac gluten sensitivity. People who are using this fad diet and who don’t have celiac disease or a gluten intolerance are at risk for developing new gastrointestingal problems.

This project was a great way to expose us to this sort of presentation since the majority of the class is interested in the medical profession and grand rounds are a common occurrence. This was an especially interesting experience because we were able to present in front of nurses and doctors, which made the experience that much more real. It also reinforced the material we had learned throughout the class because we had to explain the disease based on the anatomy and physiology. I’ve been to multiple grand rounds during my summer internships and I never thought that I would be able to understand a case as well as those doctors, but this experience showed me that I am more than capable and therefore, was an awesome experience.

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Allison O’Connor: Grand Rounds Presentations

February 22nd, 2015 · Comments Off on Allison O’Connor: Grand Rounds Presentations

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As a part of our Anatomy and Physiology course this Jan Plan, we worked in small groups to research and present a case study to our peers and a few health care professionals during a mock Grand Rounds presentation. Grand Rounds is a tradition in the medical field in which physicians present case studies to their peers, other medical professionals and medical students on a medical topic to share things that they learned in particular cases, so that others can learn from these cases. The Grand Rounds presentations were a highlight for me this JanPlan. Not only was it interesting to explore a case study of our choosing and get to learn about a particular medical condition, but it also exposed me to the format of Grand Rounds presentation and gave me the opportunity to practice my public speaking skills (which is something that is very anxiety provoking for me).

 

My group used the New England Journal of Medicine’s database to find a case study that we all found interesting. After reading through various case studies, we settled on the case of a 32 year old female, who three weeks post partum presented to the emergency department with substernal chest pain that radiated to her jaw. Substernal chest pain can be a result of many different complications including: cardiovascular complications, respiratory problems, gastrointestinal complications and musculoskeletal problems. Although cardiovascular complications are the most common cause of chest pain, it is not typically a complication that is expected in an otherwise healthy 32-year-old female. However, the fact that this patient was postpartum increases the index of suspicion for myocardial infarction, pulmonary embolism and coronary artery dissection because of the hormones present during pregnancy. An angiogram in the emergency department revealed a left anterior descending coronary artery dissection with a 35mm segment of narrowing and 90% stenosis.

 

Coronary artery dissections occur when the inner and outer layer of the coronary artery separate and blood pools in the area between the layers, causing decreased blood flow to the heart. There are two major types of coronary artery dissections, those that are spontaneous and those that are mechanically precipitated. Given this patient’s postpartum status and the events that precipitated her dissection, her coronary artery dissection would be classified as spontaneous. Within spontaneous coronary artery dissections, there are four sub-classifications, however only two of those are relevant to this case: postpartum coronary artery dissections and idiopathic spontaneous coronary artery dissections, which are dissections that are result of increased hemodynamic pressure caused by shear stress. Based upon test results, the patient’s postpartum status and the lack of disease in her other arteries, the patient was diagnosed with a spontaneous postpartum coronary artery dissection. Since postpartum spontaneous coronary artery dissections are relatively rare, there is not a universal treatment protocol. Conservative treatment is preferred, however sometime more invasive measures are required. In this case, conservative treatment was the most appropriate plan since the patient was stable, was experiencing very little pain and only had slight cardiac ischemia. The patient was treated with an intra-aortic balloon pump for two days to make her coronary artery more patent and was also given β-blockers, aspirin (an antiplatelet agent) and heparin (an anticoagulation agent). After two days, the patient was showing significant signs of improvement and was discharged from the hospital after eight days. The patient was able to return to life as normal and at the time that the case was presented had no further complications.

 

Since we had used the New England Journal of Medicine database to find our case study, we were actually able to get our hands on the PowerPoint that was used in the original Grand Rounds presentation given at Massachusetts General Hospital. The PowerPoint contained videos from the angiograms done in the hospital as well as other helpful pictures and background details of the case that we would not have had access to if we had not been able to obtain this PowerPoint. Having the actual angiogram videos from this patient enhanced our presentation immensely and made the case study feel more real.

 

I found this topic to be especially intriguing because it combined two of my clinical interests: women’s health and cardiology. I have always been drawn to women’s health issues particularly pregnancy and birth and for a while now have considered becoming an OBGYN or midwife. Spontaneous coronary artery dissections (SCAD) are a rare complication of pregnancy, so it was really valuable to learn about the presentation and treatment options for SCAD and this knowledge could potentially be useful in my future career, which made the information feel very relevant. This JanPlan I discovered a new interest in the heart and cardiology. I had never considered cardiology to be a field I was particularly interested in, but the cardiovascular unit in this class really opened my eyes to the wonders and intricacies of the heart and has left me wanting to learn more. This topic fit my interests perfectly and I thought it was really cool that we got the opportunity to study a case and explore our personal interests in an incredibly relevant way. Postpartum SCADs are very rare and are often overlooked, but now I know what to look out for which will hopefully help me provide the best care possible to my future patients. I also felt that I learned a lot of important and relevant information from my peers presentations. It was really fun to get to watch my classmates present topics that they were passionate about. Grand Rounds was a very rewarding and interesting endeavor and was definitely a highlight of my month.

 

 

Tags: Bi265j · Grand Rounds

Alexandria Lucas: Grand Rounds / Oligoastrocytoma

February 22nd, 2015 · Comments Off on Alexandria Lucas: Grand Rounds / Oligoastrocytoma

Alexandria Lucas_237129_assignsubmission_file_ALucasSophMajorPic

The grand rounds project, which consists of research on a particular topic and a final group presentation that is open to the public, I think was perhaps one of the most valuable parts of this class, for it really did require a lot of individual learning and the students really had to take things into their own hands, be independent, and put a final product together all outside of class, much like the way things will happen in medical school. I very much appreciate that Dr. K always pushed us to work hard in this way to prepare us for much harder tasks that are to come in the future in our post-Colby years, and the Grand Rounds project was easily one of those things.

My group wanted to do a case study for our project, so we first began by looking through a list of different case study articles when one caught our attention titled: “32 year old woman with episodes of unconsciousness.” We were very curious what was causing these episodes, because it really could be a wide range of things, so we choose this as our topic because of its very intriguing symptoms.

The next part of the project consisted of breaking up the material into sections, such as symptoms, differential diagnosis, diagnostics tests, and more, and then each group member doing research on their assigned sections. We then worked on putting together a PowerPoint presentation and a one-page synopsis on the topic. Some groups did a lot of this work together, but it is always hard to find a time that everyone can meet, so we ended up doing most of this work alone and communicating over email and Google docs which I think actually worked really well.

On the second to last day of class, each group presented their PowerPoint on their topic for about 15 minutes. I found this to be one of my favorite class times throughout the whole semester. I really enjoyed hearing about medical cases that I know nothing about, as well as see the different groups be so intrigued and excited about the topic they choose to research, and in addition seeing how much knowledge we had all gained over the past few weeks.

Alexandria Lucas_237129_assignsubmission_file_headrespiratory

It was, however, a little nerve-racking to be put in front of the class speaking about something that is often quite advanced and perhaps a little over a college students’ head, but having the class there and Dr. K in front being very supportive, the presentation did not end up being as scary as I thought it was going to be. Our case, of the 32 year old woman with episodes of unconsciousness, was mainly a result of an Oligoastrocytoma, which is a tumor consisting of mixed cells. It was located in the temporal part of her brain, which was causing her unconscious episodes. However, what makes this case even more interesting is that she had a genetic predisposition to neurocardiogenic syncope (fainting, loss of muscle both due to abnormal control of the brain over the heart), which led to her case being complicated by ictal asystole (stopping of the heart during her epileptic seizures, which is very rare). Not only during this Grand Rounds project did I have the opportunity to be an independent learner as well as a group member, but I also learned a significant amount about this woman’s case and Oligoastrocytoma’s, as well as recognizing the fact that although certain medical cases can easily explained by one disease, that does not mean that is always the only thing going on.

Tags: Bi265j · Grand Rounds · Human Health

Danielle Levine: Grand Rounds

January 31st, 2015 · Comments Off on Danielle Levine: Grand Rounds

Danielle Levine (’15, Biology)

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One of the opportunities I had during this Jan Plan course was to participate in a Grand Rounds Presentation; Grand Rounds, in which physicians give lectures to their peers, including other physicians and medical students, on a medical topic is a common tradition in medical education. In groups of three students, we were able to pick any topic of interest for a fifteen minute oral presentation that we would present at the end of the semester. Given the vast array of medical topics that could be picked for a presentation, we looked to academic medical sources, including the New England Journal of Medicine, for possible past case studies that we could research and discuss. After scrolling through dozens of case studies, and clicking on articles with titles that seemed very interesting and then reading the articles’ summaries, we finally settled on an interesting case subject, one about celiac disease or gluten-induced enteropathy, that we considered particularly relevant given the current emphasis on the effects of gluten in the diet in popular culture.

In this case study, a 42-year old man presented to the emergency room with the chief complaint of chest and abdominal discomfort; given his additional history of unintentional weight loss and chronic diarrhea for ten years following coronary artery bypass grafting, an inflammatory disorder or a cancer of the chest or abdomen were differential diagnostic considerations. After multiple tests were performed, including an invasive exploratory laparotomy done after a CT scan showed enlarged jejunal lymph nodes, a small bowel biopsy revealed the diagnosis of celiac disease given the presence of flattened villi and intraepithelial lymphocytes. Today, celiac disease can be diagnosed via a simple blood test for IgA tissue transglutaminase and IgA endomysial antibodies. This case study demonstrates the importance for physicians, especially given the increasing incidence of celiac disease, to test for it non-invasively when a patient’s symptoms may be suggestive of it.

The diagnosis of celiac disease has been increasing in the developed world, at least in part due to the availability of new non-invasive tests to diagnose the autoimmune disorder. Also, there has been an increase in the diagnosis of non-celiac gluten sensitivity, which has been an even more significant factor in the increase in the number of people now adhering to a gluten free diet in the developed world. Unfortunately, some people do not have a true gluten-related disease or sensitivity, but are adopting a gluten free diet in a fad-like way. This is unfortunate because a gluten free diet can cause its own problems, such as nutritional (in particular, certain vitamins) deficiencies, and a lack of fiber in the diet leading to bowel-related issues.

Given the occurrence of a generalized increase in autoimmune disorders today, the hygiene hypothesis has been offered as a possible explanation, the basic tenet of which is that given increasingly prevalent strict hygienic practices, children today are exposed to fewer pathogens, and as a result can develop autoimmune disorders in which their own immune systems attack self antigens. Given the increasing numbers of people diagnosed with autoimmune disorders, it is hoped that research into celiac disease as well as other autoimmune disorders will lead to improved treatments of and ways to prevent them.

This Grand Rounds presentation was very informational as it allowed us to research a current topic of interest and, in so doing, learn the signs and symptoms that may exist at presentation of a certain disease (in this case, celiac disease), and how that disease may ultimately be diagnosed. As celiac disease is likely to continue to be a relatively common disease in the developed world, I believe this experience will be helpful to me, since I hope to become a physician someday. Being able to present our research to our peers as well as physicians and nurse practitioners, that is, to emulate something a real physician might engage in, was a wonderful experience. Furthermore, my mom, as a physician, talks about attending Grand Rounds Presentations every week at a hospital in New Jersey, and for me to be able to present a case study in the same manner was a fun and great opportunity.

 

 

Tags: Grand Rounds · Human Health

Grand Rounds: Atypical Hyperplasia of the Breast

January 28th, 2015 · Comments Off on Grand Rounds: Atypical Hyperplasia of the Breast

Ariel Oppong, Jay Lee, Rebecca Gray

Grand Rounds _Hyperplasia powerpoint pdf

Grand Rounds Synopsis- Atypical Hyperplasia of the Breast

Hyperplasia occurs when an organ or tissue becomes enlarged because the cells within it begin to proliferate more quickly than usual, resulting in an abnormally large population of cells in one, concentrated area of the body. We categorize hyperplasia in two ways: (1) “simple” or “complex”, and (2) “usual” or “atypical”. The research we will explore focuses on complex, atypical hyperplasia. This refers to hyperplastic tissue that both engorges the tissue around it and contains deformed, non-uniform cells.

Hyperplasia of the breast falls into two categories: lobular and ductal. Within the fatty tissue of a healthy breast are mammary glands, and within those lie lobular clusters of alveoli. The cuboidal cells that line these alveoli secrete milk, which moves through milk ducts to reach the nipple, where it is excreted during breastfeeding. When hyperplasia occurs in the breast, it is usually found in either the lobules of the mammary gland or the associated milk ducts.

Usually, hyperplasia within the breast is relatively harmless. Because change in breast size and shape occurs normally over the course of a woman’s life, her body is designed to handle minor engorgement of the tissue there. This condition becomes concerning when hyperplastic cells within the breast become atypical; this is characterized by misshapen cytosol, nuclei, and membrane organization. When this occurs, the hyperplastic cells take on characteristics startlingly similar to those of tumors: they are clumped, proliferating rapidly, and lacking functionality. For this reason, atypical hyperplasia of the breast is linked with breast cancer and considered premalignant.

Usually if a lump or an abnormal mass is found during a female’s mammogram then a health professional will usually suggest a biopsy. During the biopsy tissue cells are removed for analysis by a pathologist.  If the pathologist can not make a definite decision as to if the excision is cancerous or not.

A 2014 report published by the New England Journal of Medicine published a new meta-analysis of the associated risk of breast cancer associated with atypical hyperplasia. The conclusions of the meta-analysis suggested that a women with a atypical hyperplasia has a least a 30% increased risk of having breast cancer within a 25 year follow-up. Due to this new information we ( the anatomy group) as well as the authors of this newly published report agree that there needs to be a reform in women’s health policies so that women are more aware of their risk and are also more informed about some preventative medicine including screening techniques, and treatment or surgical options if signs of breast cancer are already apparent.

Some of the current commonly used treatments are different types of SERMS. SERMS are selective estrogen receptor modulators. The most widely used antiestrogen for management of breast cancer is Tamoxifen. However, prolonged use of Tamoxifen does increase one’s risk for endometrial (uterine) cancer.

Another important issue is the health disparities in breast cancer diagnosis, quality of treatment, and mortality rates among different socio-economic groups, geographic locations, the unemployed and employed, and racial groups. Based of off data from the 2014 Racial Disparity in Breast Cancer Mortality Study in areas such as Memphis, Tennessee, black women are more than two times more likely to die of breast cancer than their white counterparts. Overall, our research indicates that we as a country need to implement new screening methods, need to promote more education initiatives, need to enact new policies to decrease health disparities, and need to stress the powerful conclusions that meta-analysis provide.

 

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Grand Rounds: Oligoastrocytoma

January 28th, 2015 · Comments Off on Grand Rounds: Oligoastrocytoma

Grand Rounds: Oligoastrocytoma

Alex Lucas, Yvette Qu, Rachel Bird

 

Grand Rounds_Oligoastrocytoma_powerpoint pdf

Oligoastrocytoma

Oligoastrocytomas are brain tumors that consist of oligodendrocytes and astrocytes, the two cell types in the brain that support and insulate nerve cells. Unlike many brain tumors, which typically present initially with headaches, seizures are a common initial symptom of oligoastrocytomas.

The patient presented with episodes of “a feeling of walking through a cloud,” receptive, or Wernicke’s aphasia (the inability to understand spoken words), Aphasia (inability to speak), and vertigo. She also suffered from brief seizures, which worsened in severity over the course of the next eight years, and began to involve loss of consciousness and muscle tone, occasional incontinence, and overwhelming confusion. Three months prior to admittance, the patient struck her head during an episode, but MRI, ECG, echocardiography, Holter monitoring, EEG and multiple blood tests all appeared normal. The patient did not respond to triptans or beta-blockers, but the frequency of her seizures increased to at least one per day.

An MRI was performed on the patient, which showed a mass in the left occipitotemporal region of the brain. A biopsy helped to determine the grade of the tumor – grade II, which is a low grade tumor – and also presents the pathology which helps to determine the growth patterns of the tumor cells. Fluorescence in situ hybridization (FISH), which allows for reliable and accurate detection of chromosomal deletions, showed deletions in 1p and 19q tumors.

Similar to most tumors, the exact cause of an oligoastrocytoma is unknown. It is understood that normal cells become abnormal in the sense that they may produce the wrong number of proteins or enzymes or be lacking certain genetic material. In the case of an oligoastrocytoma, deletions of genetic information in chromosomes 1p and 19q are the reason for the tumor cell’s abnormalities. This certain type of tumor is a result of a mixture of oligodendrocytes and astrocytes. Genetic material losses in 19q occur in 60-80% of oligodendrogliomas and 30-40% in astrocytomas, which demonstrate that there may be a shared variation in the formation of gliomas. Losses in the 1p chromosome are frequent with oligodendrogliomas at about 50-80%, however are less apparent with astrocytomas, which is detected only 10-18% of the time. However, the combination of genetic material losses of the 1p and 19q chromosomes is detected in 60-80% of oligoastrocytoma cases.

A gross resection was performed to remove the patient’s low-grade oligoastrocytoma tumor. Standard radiotherapy and antiepileptic medications were given after the resection. Lifelong MRI was suggested instead of permanent pacemaker due to the low-grade of the tumor. Following MRI shows only postsurgical changes, implying good prognosis. During the 24-month following the resection, no seizure has occurred with reduction in medication, indicating great possibility of freedom from seizure in 10 years and absence of intractability.

The patient’s case is complicated by ictal asystole (stopping of the heart during her epileptic seizures, which is very rare) in a patient with a predisposition to neurocardiogenic syncope (fainting, loss of consciousness, loss of muscle tone due to an abnormal control mechanism of the brain over the heart) due to a genetic disorder, and with the asystole being triggered by the seizures caused by her oligoastrocytoma make this case very interesting and unique. The important information the case conveys is that a patient’s symptoms are not always indications of a single disease, and sometimes the symptoms need to be closely examined and can suggest more than one disease. Perhaps screening for relationships between cardiac dysfunction and neurologic mechanisms could help identify rare cases such as this one, which would allow for earlier diagnosis and treatment.

References:

(1) Paleologos, N A, ed. Oligodendroglioma and Oligoastrocytoma. Am Br Tum Assoc 2014: 3-8.

(2) Oligoastrocytoma. Univ CO Sch of Med Neusrgy 2015.

(3) Meenakshi G, MD, Azita Djalilvand, MD, Daniel J. Brat, MD, PhD. Clarifying the Diffuse Gliomas. Am J Clin Pathol. 2005;124(5):755-768.

(4) Cole, AJ, M.D., Eskandar, E. M.D., Mela, T, M.D., Noebels, J.L. M.D., Ph.D., Gonzalez, R.G. M.D., Ph.D., McGuone, D, M.B., Ch.B. Case 18-2013 — A 32-Year-Old Woman with Recurrent Episodes of Altered Consciousness. N Engl J Med 2013; 368:2304-2312.

(5) Ucdenver.edu. Department of Neurosurgery [Internet]. 2015 [cited 2015 Jan 15]; Available from:http://www.ucdenver.edu/academics/colleges/medicalschool/departments/Neurosurgery/patientcare/multi-disciplinaryprograms/AdultBrainTumorProgram/Pages/Oligoastrocytoma.aspx

 

 

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Grand Rounds: Postpartum Coronary Artery Dissection

January 28th, 2015 · Comments Off on Grand Rounds: Postpartum Coronary Artery Dissection

Lauren Shirley, Allison O’Connor, Cal Robbins

Grand Rounds Synopsis

Case 28-2010 A 32-Year-Old, 3 Weeks Postpartum with Substernal Chest Pain

Grand Rounds Case Presentation powerpoint pdf

Onset

A 32-year old woman had an uncomplicated, spontaneous vaginal delivery after 39 weeks of gestation. This was the patient’s second pregnancy. During her first pregnancy, she was diagnosed with preeclamptic toxemia which was treated with magnesium sulfate. Mild hypertension (systolic 120-140 mm Hg) was reported during the first and third trimesters of her second pregnancy followed by a return to normal blood pressure. Upon delivery, it was noted that her placenta weighed 340 g (below the fifth percentile for gestational age, mean 540 g) with increased amounts of perivillous fibrin (suggesting placental ischemia- lack of blood and thus oxygen and glucose to tissue).

The patient was admitted three weeks post partum when she developed pain in the left jaw and substernal area. The patient called EMS and was given oxygen which resolved her symptoms after 20 minutes and EMS personnel left. The pain returned shortly and EMS returned whereupon the pt scored her pain as a 7 out of 10. Blood pressure was noted as 148/74 and an electrocardiogram (ECG) revealed normal sinus rhythm of 90-100 bpm and ST-segment elevation of 4 mm in leads V2 and V3 (Abnormalities in ECG). Oxygen, acetyl-salicylic acid, nitroglycerin and morphine were administered. When examined at the hospital, the pt’s blood pressure was 143/92 mm Hg in her left arm and 137/81 mm Hg in her right arm with a pulse of 83-92 bpm.

Diagnosis

With a chief complaint of chest pain the patient could have been experiencing cardiovascular, pulmonary, gastrointestinal or musculoskeletal complications. Since the patient was 32 years old, cardiovascular complications would seem unlikely, however, since the patient was three weeks postpartum cardiovascular complications need to be considered more carefully since the risk of acute myocardial infarction is increased during pregnancy and the postpartum period and since pregnancy is a risk factor for aortic dissection. The risk of pulmonary embolism (a blockage of an artery in the lungs) is also increased during the postpartum period.

Since the patient’s ECG showed ST-segment elevation in conjunction with chest pain, an acute myocardial infarction would be suspected. Approximately 35% of postpartum women who present with myocardial infarction have a coronary artery dissection. There are two main types of coronary artery dissections, those that are caused by mechanical precipitation and those that are spontaneous. A spontaneous dissection is a tear in the artery where the tunica media and tunica externa separate, allowing blood to pool in between these layers. SCAD are rare, however 75% of patients who present with spontaneous aortic dissections are women and 30%  of those women are peripartum, suggesting that this patient’s coronary artery dissection was spontaneous. There are four subgroups of spontaneous coronary artery dissections, however peripartum status and idiopathic spontaneous coronary-artery dissections or those caused by coronary shear stress are the two subgroups relevant to this case. Since the chest pain began after the patient picked up her toddler, there is a high index of suspicion that this dissection may have been caused by the patient’s peripartum status and coronary shear stress caused by lifting her toddler. Angiographic projections showed 35mm long segment of narrowing in the left anterior descending coronary artery.  The lack of vascular disease in other coronary arteries along with the patient’s postpartum status as well as her test results are consistent with the diagnosis of a postpartum coronary-artery dissection.

Treatment Options

Unlike aortic dissections, the usual chest pain drugs (asprin, nitroglycerin, etc) which thin the blood can actually help, keeping the true lamen patent. Beta-blockers and nitrates are often used to prevent superimposed vapospasm.  In cases of myocardial ischemia or compromised coronary flow, reperfusion therapy is used.  In patients with severe ischemia, coronary-artery bypass  grafting is done. In this case, the patient was given an intra aortic balloon pump which helps to increase myocardial oxygen supply by being placed in the aorta where it inflates and decreases based on the heart beat.  Since the patient had no pain and the Percutaneous Coronary Intervention could have entered the false lumen, and since coronary dissections can heal by themselves, the balloon pump makes the most sense.  This increased blood flow to the coronary artery.  Aspirin as an antiplatelet, ß-blockers, and statins were used in case of intramural hematoma in the coronary vessel.  Because of the potential for emergency cardiac surgery, the patient was not given glycoprotein IIb/IIIa inhibitors.

 

After 2 days a significant improvement was noted, the pump was terminated, and since surgery was now unlikely, glycoprotein inhibitors were initiated  for a minor myocardial infarction discovered during treatment of the aortic dissection. This would be discontinued in a year, while aspirin was recommended indefinitely. The patient was able to return to her normal life with no further complications.

 

Little evidence exist in terms of the cause of spontaneous coronary artery dissections, but the current theory is that  inflammation is caused by hormones, which explains the prevalence in post partum women.  Several studies also included women taking oral contraceptives as being at risk for coronary artery dissections.  The eosinophils release the histolytic agents between the tunica media and the tunica adventitia, which cause dissections in coronary arteries.

 

References

  1. Sabatine, Marc S., Farouc A. Jaffer, Paul N. Statts, and James R. Stone. “Case 28-2010: A 32-Year-Old Woman, 3 Weeks Post Partum, with Substernal Chest Pain.”The New England Journal of Medicine (2010): n. pag. Web.
  2. James, A. H. “Acute Myocardial Infarction in Pregnancy: A United States Population-Based Study.” Circulation 113.12 (2006): 1564-571. Web.
  3. Koul, Ashok K., Gerald Hollander, Norbert Moskovits, Robert Frankel, Leo Herrera, and Jacob Shani. “Coronary Artery Dissection during Pregnancy and the Postpartum Period: Two Case Reports and Review of Literature.” Catheterization and Cardiovascular Interventions 52.1 (2001): 88-94. Web.
  4. Mcintyre-Spatar, Leslie, and Kevin H. Silver. “Spontaneous Coronary Artery Dissection in a Postpartum Woman: Literature Review.” The Journal for Nurse Practitioners 7.9 (2011): 770-73.
  5. Oliveira Marta Silvia, Goncalves Alexandra, Dias Paula, Maciel Júlia Maria. “Spontaneous Coronary Artery Dissection: a Diagnosis to consider in Acute Coronary Artery Syndromes” Artigos de Revisão. (2009): 28 (6): 707-713
  6. Heart Assist Devices. Texas Heart Institute, 2015. (Accessed January 20, 2015 at http://www.texasheart.org/Research/Devices/iabp.cfm)
  7. CBC. MedlinePlus, 2015. (Accessed Janury 25, 2015 at http://www.nlm.nih.gov/medlineplus/ency/article/003642.htm)
  8. Placental Pathology. University of Chicago. (Accessed January 20, 2015 at https://pathology.uchicago.edu/sites/pathology.uchicago.edu/files/uploads/PDFs/Placental%20Pathology%20Notes%20Aspen%202014%20-Fritsch%20final.pdf)
  9. Electrolytes. AACC, 2013. (Accessed January 25, 2015 at http://labtestsonline.org/understanding/analytes/electrolytes/tab/test/)
  10. CK-MB. AACC, 2013. (Accessed January 25, 2015 at http://labtestsonline.org/understanding/analytes/ckmb/tab/sample/)

 

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Grand Rounds: CABG v. PCI Stenting

January 28th, 2015 · Comments Off on Grand Rounds: CABG v. PCI Stenting

CABG vs. Stenting in Multi-vessel Procedures: A Synopsis

Mayra Arroyo, Chris Lee, Ivan Yang

Coronary artery disease is caused by atherosclerosis, or the accumulation of fatty deposits, known as plaque, along the innermost layer of the coronary arteries. There are three main coronary arteries: the right coronary artery, circumflex artery, and the left anterior descending artery.  Atherosclerosis causes the afflicted coronary artery’s wall to thicken and lose elasticity, ultimately narrowing or blocking the artery. This can reduce the oxygen flow to the myocardium. Treatment of coronary artery disease is complex and depends on several factors, but typically comprises of risk factor management, medication, and interventional techniques, such as coronary artery bypass grafting (CABG) and stenting.

Percutaneous Coronary Intervention (PCI) or Stenting is a minimally invasive process in which a doctor inflates a stent (mesh steel tube) with a balloon to open up a clogged artery. This restores normal blood flow. A catheter is inserted through the groin, neck, or arm to move the stent to the affected area.  In recent years, newer types of stents such as drug-eluting stents and biodegradable ones have been developed. Before choosing stenting as a treatment option, one should consider risks involved with stenting such as damage to the vessels or arteries.

CABG is a surgical procedure where a vein or artery (usually from the inner thigh) is used to form a path around a blocked coronary artery. Over the years, there have been changes to the techniques used to carry out CABG. One such example is Totally Endoscopic CABG, which uses a robot equipped with a camera and surgical instruments in its arms. It is important to note that this procedure is highly invasive and risky, which is why it is usually used after more conservative treatments have been attempted.

In the three studies discussed, we compared long-term outcomes of CABG and stenting in multi-vessel disease in diabetics and in combined subgroups by looking at death rates, adverse event rates, and repeat revascularization rates.  Multi-vessel disease is defined as the occlusion of two or more of the three main coronary arteries, and revascularization is a procedure that returns blood flow to a low-oxygen area.

In diabetics, we found that CABG ultimately has better long-term outcomes in multi-vessel treatment.  Primary outcome (death, heart attack, or stroke) rates and all-cause mortality rates were lower in CABG diabetic patients than in diabetic patients who underwent drug-eluting stent procedures.

A study published in 2001 observed the effects that CABG and stent had on patients one year after treatment. The patients’ quality of life (survival and freedom from stroke, heart attack, or repeat revascularization) was examined after one year. It was found that there were no significant differences between the number of CABG and stent patients who did not die or have heart attacks or strokes. However, CABG patients had lower rates of repeat revascularizations than stent patients. In light of this study, it is important to remember that it was conducted in a time before drug-eluting stents and other newer treatment options.

Another study published in January of 2013 found that, compared to CABG patients, a greater percentage of people who underwent PCI with drug-eluting stents underwent repeat revascularization. The study concluded that in people with less complex disease, it is acceptable to undergo PCI. On the other hand, people with multi-vessel problems should choose CABG.

In conclusion, though CABG has proven to have better long-term outcomes than stenting in multi-vessel disease treatment, better studies should be conducted to verify this.   Future studies should include more patients, cover modern CABG and stent techniques, and be extended for several years after revascularization.  For now, it appears that CABG does have an advantage over stenting and drug-eluting stents, mostly due to reduced rates of repeat revascularization.

 

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Grand Rounds: Celiac Disease

January 28th, 2015 · Comments Off on Grand Rounds: Celiac Disease

Ari Thomas, Laurel Edington and Danielle Levine

Grand_Rounds_Celiac_Disease powerpoint_pdf

Grand Rounds Synopsis

A 42-year-old man presented with a chief complaint of chest and abdominal discomfort that had begun suddenly two days before as a sharp left upper quadrant pain radiating to his back, associated with nausea and early satiety, and that increased in intensity over the next two days. The next day, he experienced substernal chest pressure consistent with his usual angina, but which did not respond to a single sublingual nitroglycerin tablet; it only resolved completely after IV morphine, ketorolac (an NSAID), chewable aspirin, and three more sublingual nitroglycerin tablets. He had experienced no recent abdominal trauma, vomiting, rectal bleeding or black stools.1

The patient’s past medical history includes hypertension, hyperlipidemia (excess blood lipids), and coronary artery disease (myocardial infarction at 32 years of age, with coronary artery angioplasty with stent placement, and subsequent bypass grafting).1,2 For more than ten years before presentation (since the coronary-artery bypass surgery), he has experienced chronic diarrhea that has worsened since his cholesterol-lowering medication was increased 6 months ago.1  During the past six months, he has experienced daily headaches, nocturia (excessive urination at night), feeling warm at night, an unintentional weight loss of 35 lbs, and occasional early satiety.1,2  Although he has a family history of colon cancer, a colonoscopy performed 4 months prior was unremarkable.1

The abdominal and chest pain, weight loss, and history of gastrointestinal symptoms suggested an acute chest syndrome, acute abdominal syndrome, inflammatory disorder, or cancer. An acute coronary syndrome was unlikely and an echocardiogram and chest radiography confirmed this. The physical exam ruled out acute chest syndromes, but sensitivity in the upper right quadrant suggested an upper abdominal disorder. Lipase, aminotransferase, and amylase levels were elevated, suggesting pancreatitis, liver injury (from an infection or drug use) or disease, or liver cancer. A CT scan of the abdomen ruled out pancreatitis and colon and small bowel disorders, but showed enlarged jejunal lymph nodes. An exploratory laparotomy was performed and the lymph nodes showed reactive follicular and interfollicular hyperplasia and lipogranulomas, suggesting an inflammatory abdominal disorder. Evidence of lymphoproliferative disorders was absent, ruling out cancer. A small-bowel biopsy showed flattened villi and intraepithelial lymphocytes, which suggested celiac disease. Positive IgA tissue transglutaminas and IgA endomysial antibody tests, the most specific and sensitive tests for celiac disease, were positive and confirmed the final diagnosis.1

The patient was advised to follow a gluten-free diet with an intramuscular iron supplementation as well as a multivitamin for general vitamin and mineral deficiencies.3 The gluten-free diet includes avoiding foods made out of wheat, rye, barley, oats, and processed foods that may contain wheat flour.4

Based on the patient’s symptoms, doctors diagnosed the patient with celiac disease. This disease is an autoimmune disorder that is provoked by intaking various forms of gluten and affects the small bowel. The intestinal symptoms of this disease include abdominal pain, diarrhea, a mild elevation of aminotransferase levels, and an increased risk of pancreatitis. Abdominal pain in the patient may have been due to transient intussusception related to celiac enteropathy.  Celiac disease also has extragastrointestinal system effects such as rashes, arthralgias, neurologic and psychiatric effects, fatigue, and infertility.4 Patients also suffer from malabsorption of nutrients which can lead to weight loss, iron-deficiency, and osteoporosis. Patients have an abnormal immune response to the gliadin component of the gluten protein, where type 1 helper T cells cause inflammation in the epithelium and lamina propria of the small intestine, which alters the structures of the intestinal villi and therefore causes malabsorption.3 Celiac disease may also accompany type 1 diabetes, thyroiditis, and hepatitis.1

Celiac disease is different than a gluten sensitivity.5 Although the symptoms are similar, a person with a gluten sensitivity does not have the intestinal damage that a person with celiac disease has. Patients with a gluten sensitivity also do not have the IgA tissue transglutaminase or IgA endomysial antibodies that patients with celiac disease have.6 Since blood tests and intestinal biopsies will not diagnose a gluten sensitivity, using a process of exclusion helps to diagnose the sensitivity.5 Both disorders are treated by following a strict gluten-free diet.5,6

References:

  1. Ole-Petter Riksfjord Hamnvik, M.D., Fidencio Saldana, M.D., Bruce D. Levy, M.D., and Joseph Loscalzo, M.D., Ph.D. N Engl J Med 2014; 371:1333-1338.
  1. Medline Plus: Medical Dictionary. Besthesda, MD: U.S. National Library of Medicine, 2012. (Accessed January 13, 2015 at http://www.nlm.nih.gov/medlineplus/mplusdictionary.html.)
  1. Leffler, D. Celiac Disease Diagnosis and Management: A 46-Year-Old Woman With Anemia. Jama 2011; 306:1582–1592.
  1. Rubio-Tapia, A., Hill, I. D., Kelly, C. P., Calderwood, A. H., & Murray, J. A. American College of Gastroenterology Clinical Guideline: Diagnosis and Management of Celiac Disease. The American Journal of Gastroenterology 2013, 108:656–677.
  1. Non-Celiac Gluten Sensitivity.  Ambler, PA.: National Foundation for Celiac Awareness, 2015. (Accessed January 25, at http://www.celiaccentral.org/non-celiac-gluten-sensitivity/).
  1. Gluten Sensitivity.  Woodland Hills, CA.: Celiac Disease Foundation, 2015.  (Accessed January 25, at http://celiac.org/celiac-disease/non-celiac-gluten-sensitivity/).

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Human A&P Grand Rounds Presentations

January 23rd, 2015 · Comments Off on Human A&P Grand Rounds Presentations

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Our Human Anatomy and Physiology class will be presenting a series of talks on various diseases this coming Wendesday, January 28th 2015 from 9 until 11 AM on Colby’s campus in the Olin 01 auditorium, beneath the Olin Science Library. Each of the five 15 minute talks will be followed by a brief Q&A and will cover the following topics:

  • Celiac Disease
  • Oligoastrocytoma
  • Atypical Hyperplasia of the Breast
  • Postpartum Coronary Artery Dissection
  • Coronary Artery Bypass Grafting vs. Stent Implantation

The presentation is free and open to the public and light refreshments will be served.

Tags: Grand Rounds · Human Health · Special Activities · Uncategorized

Breanna Davis: My January Experience

February 14th, 2014 · Comments Off on Breanna Davis: My January Experience

Breanna Davis: 2/14/14

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This Jan Plan, 2014, I was given the opportunity to take an Introduction to Anatomy and Physiology class with Dr. Thom Klepach. I have always loved Anatomy and Physiology and I hope to be a medical doctor some day, so it seemed necessary to take a class about the human body in College. Going in to the class, I had expected that I would be in class for around 3 hours, 4 days a week. I also expected that I would do really well on the quizzes and tests because I did very well in Anatomy and Physiology in High School. However, I did not expect what actually happened, which was to be pushed to my limits, learn about myself when under stress, and learn how to present a case-study.

I am a student-athlete at Colby and a student-worker. This allows for less time in my day that can be spent freely as I choose. I am a sophomore, so I have learned how to keep a healthy lifestyle and balance all my commitments in the past year. However, this January was something I haven’t quite experienced yet. In the Anatomy and Physiology class at Colby, I learned so much more than the names of the body and how the systems of the body work. I learned how to communicate with my boss, my coach, and my teacher in ways I haven’t yet done.

Our hockey schedule switches away games to home games each year. Last year, we had only one weekend away during Jan Plan, Connecticut College. This year, of the four JanPlan weekends, we had three away games, Trinity, Amherst, and Williams. We didn’t get back before 12 on any of those Saturdays because it was snowing every night when we came back. The one weekend home was our Alumni Weekend, which ended up being just as time consuming as an away trip. Some people would say, “Why put yourself through that?” My answer would be because we love our team and the sport. We aren’t quite ready to give up competing at a high level.

Having multiple commitments makes it hard to prevent them from ever overlapping. If you miss practice, you won’t get as much playing time. If you miss school, your grade will go down. If you miss work, you don’t make money. I managed to only miss work 3 times and practice once because of class. I realized that being a student-athlete may make things more complicated and may take away from the classroom, but I realized in this class that learning how to balance many commitments and keep my stress levels down will be a very important skill in Medical School.

Because I found a balance, I was able to go on the trip to Boston to see the Body World Museum, take a tour of MaineGeneral by 3rd year Medical Students, and present a case on Strokes in young adults to Doctors. With just those field trips, I would have felt like my Month of January was a success. For me, those trips helped me learn more about Medical School, anatomy, and presenting to a crowd than sitting in a lecture could. The lecture is necessary to get knowledge, but I believe the real learning is done by trying, practicing, touching, and taking what is learned in lecture to real life situations. The reason why I would recommend this class to anyone, even though it did put me in over my head, is because of the field trips and projects we did. This class did a great job teaching beyond the classroom.

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My coach came to our group’s presentation and learned about Ischemic Strokes in Young Adults. The other day when she sent me an article about a professional hockey player, age 28, that had a recent stroke, I realized that my grand rounds talk had made a difference. Our group’s main focus was to raise awareness of strokes in young adults because they have increased in recent years. In the article, the hockey player happened to say almost the exact same thing. He listed symptoms, as we did, and said to get checked immediately instead of trying to stick it out. I felt accomplished that I made my coach aware enough to notice the news. It was fascinating to see that something I had created in “class” could be so important and relevant to today.

As a whole, the class affected me in a positive way and taught me important knowledge, taught me useful life skills, and it allowed me to create connections with people I may work with in the future.

 

Tags: Body Worlds Vital · Grand Rounds · Maine General

Peter Wirth: MaineGeneral Augusta

February 14th, 2014 · Comments Off on Peter Wirth: MaineGeneral Augusta

Peter Wirth

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Our class had the opportunity to visit the new Augusta campus of Maine General. Medical students first gave us tours of the new hospital. Many of the students were from the University of New England, while some were from other schools on rotation at MaineGeneral. Three students, none of which were from UNE, showed Emma and me around. Each student brought a unique perspective to medical school; one student went to Dartmouth, one was at the University of Oklahoma, and one was Canadian at medical school in the Caribbean. They were all very helpful and honest in giving Emma and me answers about the process of applying and attending medical school.

Both Emma and I are pre-med, so we found their advice to be especially helpful. Since they each had taken a very different route to end up in medical school, their advice underscored the importance of studying what we enjoy during undergraduate years. In addition they told us that at many of their interviews it was not MCAT scores that were discussed; rather, they were asked about their hobbies, their aspirations, and their reasons for becoming a doctor. These students greatly reduced my anxiety and showed me how they all made it work.

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While talking to these students, we were showed around the hospital. We were able to see several wards, as well as the ER, library, and several rooms for residents and students. The hospital is beautiful, new, and state-of-the-art. The hospital rooms were large, comfortable, and inviting. Each room had its own bathroom attached. Some parts of the hospital reminded me more of a hotel than a medical facility.

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Following the tour we began listening to presentations from fellow Colby students, as well as Kent’s Hill high school students. Each topic was very unique and all the students did an incredible job presenting. Some groups presented an interesting case study from the New England Journal of Medicine, while others presented a disease or disorder. Our group presented on a case of a college student who developed a brain infection following a diagnosis of mononucleosis. The audience of students and doctors was kind in their assessment of our presentations and complemented our ability to make sense of a very complex case.

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This trip was helpful for me because it gave us the opportunity to interact with medical professionals (and those in training) in a relaxed environment. All of my questions were well answered and clarified many aspects of the medical school application process. In addition, being able to see these students interact with doctors and other hospital staff was insightful as to how the students were integrated into the healthcare profession.

Overall, this trip reminded me why I was pre-med; it is all too easy for me to get caught up in GPA, lab reports, and exams and forget the main reason why I’m doing it in the first place. Seeing patients and being able to provide a benefit to them and their families is an incredible opportunity that people in the medical profession get to do. Visiting MaineGeneral definitely reminded me why I am pursuing this career path and allowed me to meet students who are like-minded individuals on their way to becoming doctors.

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Tags: Grand Rounds · Maine General

Grand Rounds: Creutzfeldt-Jakob Disease – An 80-Year-Old Man with Fatigue, Unsteady Gait, and Confusion

January 29th, 2014 · Comments Off on Grand Rounds: Creutzfeldt-Jakob Disease – An 80-Year-Old Man with Fatigue, Unsteady Gait, and Confusion

By: Kasey Kirschner, Jenna Passaggio, Phoebe Hughes

Four weeks before admission an eighty year old man presented with fatigue, insomnia, confusion, and difficulty walking. These symptoms may seem normal for elderly, but they were very uncharacteristic for him.  As his symptoms worsened, he was admitted to the hospital.  However, all tests conducted showed normal results. The test for 14-3-3 protein, which could indicate Creutzfeldt-Jakob, came back negative.  An MRI showed loss of brain volume and changes in his white matter. He was given multiple drugs for insomnia, and he was released three days later.  Cognitive abilities continued to decline, and he began experiencing tremors in his left arm and leg.  He was readmitted to the hospital fifteen days later. Though many tests were done, all returned normal. Nevertheless, his symptoms continued to worsen, and he died after twenty third day of readmission.

The diagnosis was sporadic Creutzfeldt-Jakob disease with MM1. This diagnosis is most likely because of the rapid progression of the patient’s myoclonic jerking and dementia. Additionally, the patient presented with multiple symptoms consistent with other patients diagnosed with Creutzfeldt-Jakobs, including confusion, insomnia, and cerebral ataxia. Despite this, other tests which may indicate Creutzfeldt-Jakobs, such as an MRI or tests for the 14-3-3 protein did not confirm the diagnosis. Upon autopsy, a loss of neurons on the thalamus and spongiform changes of the cerebral cortex were found. This, combined with other symptoms, is indicative of sporadic Creutzfeldt-Jakob disease. However, the patient’s visit to England may suggest the variant form of Creutzfeldt-Jakobs. Only the brain was autopsied, and no other tissues were searched for presence of the PrPSc protein. The PRNP gene was sequenced and showed no mutations, which ruled out familial Creutzfeldt-Jakob disease.  Ultimately, the final diagnosis was sporadic Creutzfeldt-Jakob disease.

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Creutzfeldt-Jakob is hard to diagnose because there is no single test to confirm it, and the tests available can sometimes be misleading.  There are a few which may help indicate the disease such as MRI’s, tests of the cerebrospinal fluid, and EEG’s. The presence of the 14-3-3 protein in the cerebrospinal fluid, high signal intensity on an MRI of T2 weighted images in the basal ganglia, or triphasic spikes on EEG can signify Creutzfeldt-Jakobs. In this case study, none of these tests showed signs of the disease.  An autopsy of the brain and spinal cord may be done to see spongiform changes and neuronal loss.

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Creutzfeldt-Jakob disease is a rare disease affecting approximately one in a million people. It is caused by an infectious prion misfolding. This prion in its active state causes other proteins to misfold as well.  Prions are resistant to proteinase K, which breaks down proteins.  This makes them hard to destroy.  It can be transmitted through transfusions or transplants.  However, the sporadic form of Creutzfeldt-Jakobs disease causes the prions to misfold and become infectious spontaneously. The accumulation of misfolded prions causes holes in the brain which degenerate the brain matter. The neurodegeneration causes numerous and various problems in the patient.

Although some clinical trials are underway, no cure is currently available.  Various treatments have been tested, and some patients have shown very brief periods of improvement, but nothing is available that stops CJD completely.  This disease is treated by alleviating symptoms of the disease to make the patient more comfortable prior to death.

 

 

References:

1. “Creutzfeldt-Jakob Disease Fact Sheet.” National Institute of Neurological Disorders and Stroke. National Institutes of Health, 31 Dec 2013. Web. 12 Jan 2014. <http://www.ninds.nih.gov/disorders/cjd/detail_cjd.htm>.

2. Richard T. Johnson, M.D., R. Gilberto Gonzalez, M.D., and Matthew P. Frosch, M.D., Ph.D. Case 27-2005 — An 80-Year-Old Man with Fatigue, Unsteady Gait, and Confusion. N Engl J Med 2005; 353:1042-1050.September 8, 2005.DOI: 10.1056/NEJMcpc059024

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Grand Rounds: History and Advances in Kidney Transplantation

January 29th, 2014 · Comments Off on Grand Rounds: History and Advances in Kidney Transplantation

By: Kumba Seddu, Sophie Suechting, Blake McCartney

As of June 21, 2013 96,645 people in the United States await kidney transplants.  Last year, 4,903 patients died while awaiting a kidney transplant. These patients suffer from very advanced chronic kidney disease, which requires dialysis or a kidney transplant to maintain life. The two main causes of chronic kidney disease are diabetes and high blood pressure, which are responsible for up to two-thirds of the cases.

Experimentation with renal transplantation started in humans around 1906. There were many failed attempts using kidneys (and other organs) from animals; this method resulted in tissue rejection and was ultimately fatal. In 1954 Murray performed the first successful transplant with a donor on the identical Herrick twins – the kidney started producing urine immediately. Shortly after, in 1960, Murray performed another successful transplant on twelve year-old twins Johanna and Lana Nightingale. Murray was unable to perform advanced tissue and blood typing, but the transplants worked because the twins were an exact match. Later, advancements for non-twin donor pairs developed. Research also continued in the field of immunology, improving transplantation success rates and decreasing cases of tissue rejection.

Dr. Murray (left) and the Herrick twins.

Dr. Murray (center) and the Nightengale twins.

The kidneys are located in the back of the abdominal cavity in the retroperitoneum. Their function is to filter blood and remove waste from the body. If the kidneys are unable to adequately filter waste products from the blood, the body can enter renal failure. Renal failure requires regular dialysis or a kidney transplant to maintain proper bodily functions.

Scientists have always been fascinated with discovering a way to preserve organs for transplantation. It was discovered that there is a reversible effect of hypothermia on the metabolic processes of isolated tissues and that when the tissues are rewarmed their function returns to normal. There are currently two main methods of organ preservation that both freeze the tissues: machine perfusion and simple cold storage. Machine perfusion was researched first as it seemed to most effectively mimic the actual physiology of the organ. Cold storage was discovered soon after and became the primary method of organ storage due to its simplicity, quality of organ preservation, and cost effectiveness. There still remains a debate today as to which preservation method is best, but cold storage continues to be the method of choice due to its simplicity and a lack of clinical evidence advocating for machine perfusion instead.

Due to the increased rate of surgical morbidities, the diseased kidney is usually left in its position. The transplanted kidney is placed in a different position, usually the iliac fossa, using a different blood supply. The renal artery of the kidney, branching from the donor’s abdominal aorta is connected to the recipient’s external iliac artery. The renal vein initially connected to the donor’s inferior vena cava is joined to the recipient’s external iliac vein.

The optimization of the Paired Donor Schema helps to increase the degree of compatibility in recipient and donor antigens. Blood test, Tissue test and cross matching are done on both recipient and donor and the results are then computed into an algorithm from graph theory. A random permutation is done and compatible matches are identified. This reduces rejection and helps better the transplant procedure.

 

 

 

Sources:

 

“About Chronic Kidney Disease.” The National Kidney Foundation: Kidney Disease. N.p., n.d.

Web. 14 Jan. 2014. <http://www.kidney.org/kidneydisease/aboutckd.cfm>.

 

Moers, Cyril, Jacques Pirenne, Andreas Paul, and Rutger J. Ploeg. “Machine Perfusion or Cold

Storage in Deceased-Donor Kidney Transplantation.” The New England Journal of Medicine (2012): n. pag. Web. 15 Jan. 2014.

 

Petechuck, David. “Organ Transplantation .” Google Books. N.p., n.d. Web. 15 Jan. 2014.

<http://books.google.com/books?id=POQB4YIjAnoC>.

 

Smith, Rebecca. “Breakthrough in Kidney Transplant ‘could Cut Waiting List'” The Telegraph.

Telegraph Media Group, 30 June 2008. Web. 15 Jan. 2014.

 

Smith, Susan.  “Immunologic Aspect of Organ Transplant.” Medscape Log In. N.p., n.d. Web. 15

Jan. 2014. <http://www.medscape.com/viewarticle/436533_11>.

 

Terasaki, Connolly, and Jeffrey L. Veale “The New England Journal of Medicine.” Kidney Paired

Donation. N.p., n.d. Web. 15 Jan. 2014. <http://www.nejm.org/doi/full/10.1056/NEJMc1106996>.

Tags: Grand Rounds

Grand Rounds: Bath Salt Subtance Abuse – A 36-Year-Old Man with Agitation and Paranoia

January 29th, 2014 · Comments Off on Grand Rounds: Bath Salt Subtance Abuse – A 36-Year-Old Man with Agitation and Paranoia

By: Thomas Kader and Michael Chiu

Background

Our case study focused on the case of a 36 year old man who was rushed to the hospital after his girlfriend called EMT.  He was initially reported to be running naked through the streets, tachycardic, was extremely agitated, paranoid, and lacked the ability to communicate.  He also had a high body temperature and was diaphoretic.  In terms of pertinent medical history, the man suffered from depression, and had just recently been laid off from his job.  In addition, he had a history of alcohol and drug abuse, and was smoking tobacco at the time. He had no known allergies to medications but was but was lactose intolerant and allergic to shellfish.  His family had a history of hypertension, coronary disease, and diabetes mellitus.  His only medication was fluoxetine, an antidepressant, which he hadn’t taken for 2 weeks.  He also had taken bath salts intranasally for the prior 3 days.  Initially, the patient was given midazolam and Lorazepam via IV, intubated for airway protection, and sedated with Propofol.  A CT scan was taken with no acute pathology.  The patient was then transported to the ICU, where he was given benzodiazepines and neuroleptics, as well as endotracheal intubation.

Commercially available methcathinone “bath salts”

Man chewing khat leaves, a naturally occurring source of cathinone.

 

Differential Diagnosis

A clinical differential diagnosis was then conducted with clinical presentation showing: agitated delirium, aggressive violent behavior, hallucinations, paranoia, possible seizure, mydriasis, tachycardia, hypertension, and tachypnea, and diaphoresis.  The diagnosis could either be toxic/metabolic, infectious, psychiatric, traumatic, or hemorrhagic/ischemic.  It was determined that the symptoms most likely showed a toxic/metabolic cause because the patient had ingested a “bath salt” drug and was showing symptoms related to a toxic cause.  For a toxic cause, there are many possible toxidromes that can be caused by different types of toxins.  These toxins include anticholinergics, sympathomimetics, analgesics, toxic alcohols.  Other possible toxidromes are sedative/hypnotic withdrawal, hemoglobinopathies, and serotonin syndrome or neuroleptic malignant syndrome.  Doctors narrowed down the diagnosis to be caused by a sympathoimetic toxidrome, which is caused by ingestion of amphetamines, cocaine, or other sympathomimetics.  Common symptoms associated with sympathomimetic toxidromes are hypertension, tachycardia, psychomotor agitation, diaphoresis, mydriasis, psychotic behavior, seizures, and coronary ischemia.  It was known that the patient had ingested bath salts, which is a sympathomimetic toxin.  The symptoms the patient was presenting also corresponded with the symptoms associated with those who have a sympathomimetic toxidrome.  An initial CBC, or complete blood count test/blood panel test was conducted.  The concentration of lactic acid in the patient’s blood was extremely high and the pH was very low.  There was also a high concentration of creatinine and creatine kinase.  These results suggested that the patient had metabolic acidosis, or high levels of acidity in the body, as well as rhabdomyolysis, or breakdown of skeletal muscle that can cause renal failure.  The final diagnosis was acute ingestion of a synthetic cathinoine (Bath Salts) causing a sympathomimetic toxidrome with psychotic features and an acute lactic acidosis with acute renal failure.

Diagnostic Procedures

     A serum test, a blood test using blood plasma with fibrinogens removed, using liquid chromatography with photodiode array detection (LC-PDA) was conducted, and it was positive for Lorazepam, Fluoxetine, Norfluoxetine, and Methcathinone.  It was negative for common stimulants such as amphetamines and cocaine.  A urine test using class-specific immunoassays was also conducted and was positive for amphetamines and benzodiazepines.  The positive reading for amphetamine, however, was a false positive reading caused by Methcathinone cross-reacting in the amphetamine immunoassay conducted.

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Treatment

The patient showed symptoms of cathinone toxicity: agitation, hyperthermia, metabolic acidosis, hyperthermia, rhabdomyolysis, tachycardia, hypertension, renal dysfunction, and oxidation by reactive oxidation species.  To address these symptoms, GABA agonists as well as α-agonists were given to sedate the patient, and dopamine antagonists were given to attempt to reverse psychotic symptoms.  To treat hypertension, the drug needed to be expelled.  In addition, standard cooling measures were used and mechanical ventilation through endotracheal intubation was applied.

Mechanisms of disease

Based on the presented symptoms, doctors determined that the patient was undergoing malignant catatonia induced by Serotonin syndrome as well as Excited Delirium syndrome.  Malignant catatonia is a variant of catatonia that is characterized by autonomic instability consisting of fever, tachycardia, and hypertension and is associated with psychiatric illness and drug ingestion.  Serotonin syndrome is characterized by mental-status changes, autonomic hyperactivity, and neuromuscular abnormalities.  Excited Delirium Syndrome is characterized by delirium, agitation, acidosis, and hyperadrenergic autonomic dysfunction, and is typically seen in drug abuse or mental illness.  Serotonin syndrome occurs when there is an excess activity of serotonin at the serotonergic receptors of central and peripheral nervous systems.  Excess serotonergic activity may be due to a combination of monoamine oxidase inhibitors and serotonin selective reuptake inhibitors, which prevent breakdown and reuptake of monoamine neurotransmitters including serotonin.

 

References

Benzer TI, Nejad SH, Flood JA, et al. Case 40-2013: A 36-Year-Old Man with Agitation and Paranoia. N Engl J Med 103; 369;26.

Singerman, Burton; Raheja, Ram. Malignant Catatonia: A Continuing Reality. Annals of Clinical Psychiatry. Vol 6(4),  259-266.     http://psycnet.apa.org/psycinfo/1995-43892-001

Sporer KA. The Serotonin syndrome. Implicated drugs, pathophysiology, and management. US Library of Medicine, National Institutes of Health. Drug Saf. 1995 Aug;13(2):94-104.http://www.ncbi.nlm.nih.gov/pubmed/7576268

Tags: Grand Rounds

Grand Rounds: Adolescent Stroke

January 29th, 2014 · Comments Off on Grand Rounds: Adolescent Stroke

By:   Breanna Davis, Emmie Lai, and Adam Lavertu

Rather than focusing on the specific case, we intend to discuss the incidence of ischemic strokes in adolescents drawing support from the case worked on by Phoebe H. Yager, M.D., Aneesh B. Singhal, M.D., and Raul G. Nogueira, M.D. Strokes in young adults are frequently misdiagnosed or not even recognized.

 

 

 

Pretreatment

 

 

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Pretreatment (above) and posttreatment (below) angiography

An ischemic stroke results from a blockage of a blood vessel that supplies the brain. This lack of blood results in oxygen deprivation of the brain; this is what we know as a stroke. There are two main types, cerebral thrombosis and embolisms. Thromboses are formed at the site of the blockage and while embolisms originate somewhere else in the body and travel to the site of the blockage. Some identifying risk factors of stroke include hypertension, diabetes and lipid issues. Many other diseases and conditions can also increase the risk of stroke, for instance patent foramen ovales (PFO) have a high correlation with strokes.

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Retrieved thrombus and MERSI retriever.

PFOs result from a failure of the neonatal hole in the heart between the right and left atrium to close post birth. Normally the closure of which results in what we know as the fossa ovalis. PFOs can allow clots to enter the aorta, where the clot has the potential to travel to the brain possibly resulting in ischemic strokes. A surprising 14% of all strokes occur in children and young adults (Yager et al.). The majority of which are ischemic strokes, with a lesser incidence of hemorrhagic strokes.

There are over 18 Cardiac causes of stroke in young adults. However, of all these causes of cardiac strokes in young adults, 37% of the patients have a PFO. Unlike many of the causes, PFO’s are source of low and uncertain risk because just having a PFO doesn’t directly relate to a person having a stroke, since 1 in 5 Americans have PFO’s and many of these people go through life with no cardiac issues. Along with a PFO, a person has to have clot form in their blood, and their blood pressure must be high in the right atrium to build enough pressure to push open the flap and send the clot through to the left atrium. This is relevant to our case because our patient had a PFO and got it closed and had no further issues with ischemic strokes. He has made a full recovery but did come very close to death due to the late diagnosis. This was not a surprise because people under 50 are often misdiagnosed since the general public and clinicians are unaware of how often young adults do have strokes and it is not their first assumption.

Common signs are numbness in face or extremities, trouble speaking, disturbed vision, trouble with motor control, dizziness, and headache. Our patient presented with ataxia or impaired motor control, blurred vision, and dysarthria or slurred speech. Initially receiving clinicians searched for a tumor and other sources due to the young age of the patient. After, the rapid onset of symptoms they began to search for other causes. Within 20 minutes of admission to the original receiving hospital, the patient progressed from difficulty walking to needing a wheelchair, within hours he entered into a coma and was promptly transferred to Mass General via airlift. Doctors at Mass General made the correct diagnosis of stroke after performing diagnostic tests including CT scans and MRIs, because the patient was diagnosed with a stroke past the three hour window, he was treated with an endovascular reperfusion, or a minimally invasive clot retrieval surgery. The other options were both made use of pharmacological agents and ran the risk of cerebral hemorrhage. This is due to the possible malignant interaction between the drug and the infarcted tissue surrounding the occlusion. A Merci retriever was guided into the femoral artery to the location of the clot. The retrieved thrombus was 1.8 cm in length. The patient made a full recovery and his PFO closed after a year. He now lives a normal life with an aspirin regimen.

Through this case study, we hope to raise clinician awareness of the rate of strokes in young adults. As clinicians become more aware hopefully there won’t be as many late and misdiagnoses that lead to fewer treatment options, higher risk of fatality and increased treatment costs. Incidence of strokes in people under 34 has increased in recent years, particularly in males. Therefore, it is important that clinicians become more aware and have better clinical cues in order to more quickly work up to the stroke diagnosis, as this problem will only increase.

 

Works cited:

 

George MG, Tong X, Kuklina EV, Labarthe DR. Trends in stroke hospitalizations and associated risk factors among children and young adults, 1995-2008. Ann Neurol2011;70:713-721. http://www.ncbi.nlm.nih.gov/pubmed/21898534?dopt=Abstract. Accessed 13 Jan 2014.

 

“Ischemic Strokes (Clots).” Ischemic Strokes (Clots). American Heart Association, American Stroke Association. N.p., n.d. Webhttp://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/IschemicClots/Ischemic-Strokes-Clots_UCM_310939_Article.jsp. Accessed 18 Jan. 2014.

 

Ji R, Schwamm LH, Muhammad P, Singhal AB. “Ischemic stroke and TIA in young adults: risk factors, diagnostic yield, neuroimaging and thrombolysis. Arch Neurol (in press).” JAMA Neurol. 2013 Jan;70(1):51-7. http://www.ncbi.nlm.nih.gov/pubmed/23108720. Accessed 14 Jan 2014.

 

Krasuski, R. M.D., Tuzcu, M. M.D., Kapadia, S., M.D. “Disease and conditions: Patent Foramen Ovale.” Clevelandclinic.org. Jan 2012. http://my.clevelandclinic.org/heart/disorders/congenital/pfo.aspx. Accessed 14 Jan 2014.

 

Yager, P.H., M.D., Singhal A.B., M.D., Nogueira, RG, M.D. “Case 31-2012: A Young Man with Neurologic Symptoms”. New England Journal of Medicine 368:2, 193-194. http://www.nejm.org/doi/full/10.1056/NEJMcpc1208150. Accessed 8 Jan 2014.

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Grand Rounds: 49-Year-Old Male with Adenocarcinoma of the Rectum and Novel Bacterial Therapy

January 29th, 2014 · Comments Off on Grand Rounds: 49-Year-Old Male with Adenocarcinoma of the Rectum and Novel Bacterial Therapy

By: Cameron, Lizzy, & Cody

Adenocarcinoma is cancerous disease that originates in mucus-secreting glandular tissues, most commonly in the lungs, pancreas, prostate, esophagus, colon/rectum. 95% of all colorectal cancers (CRC) are adenocarcinomas. Three months prior to diagnosis, the patient (Male, 49 years) notes blood in his stool. He went to his primary physician who found his physical examination to be normal. His father had colonic polyps, and his paternal grandmother had colon cancer in her 80s. Although family history of CRC is most significant in first degree family members, his father’s history of polyps may suggest a hereditary CRC predisposition in the patient. Six weeks before the patient’s presentation at MGH, he noted decreased stool caliber, and prolonged presence of blood and mucus in his feces. He went to see a gastroenterologist who performed a colonoscopy and discovered an exophytic mass 15 cm from the anal verge and 2 polyps in the descending colon.

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At higher magnification, small infiltrating glands in desmoplastic stroma are diagnostic of moderately differentiated adenocarcinoma. The depth of invasion cannot be assessed from this small biopsy specimen.

Biopsy of the mass revealed dense stroma covered by villiform dysplastic epithelium, with stromal hypertrophy and small infiltrating glands, a characteristic that is indicative of moderately-differentiated adenocarcinoma. An axial CT image of the abdomen/pelvis revealed a rectal mass causing abrupt narrowing of the rectal lumen (3.2×3.1×6.8 cm). An MRI image showed the rectal mass extending through the muscularis propria and into the outer layer (serosa) of the colon. Ultrasonography-guided fine-needle aspiration and core biopsy of the inguinal lymph node determined that the cancer had not spread into the lymph node and was still limited to the colon (although locally advanced). Final diagnosis of the case was moderately differentiated, invasive rectal adenocarcinoma (Stage IIA).

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An axial image from the CT study with oral and intravenous contrast material that was performed at the other hospital  shows a soft-tissue density in the rectum causing abrupt narrowing of the rectal lumen

The patient’s rectal cancer is advanced, and as such the first major treatment decision is whether to resect immediately or use preoperative (neoadjuvant) chemotherapy, radiation, and/or postoperative chemoradiation. The team of doctors recommended preoperative chemoradiation therapy with fluorouracil and radiation therapy. Stage I rectal cancer is often successfully treated with resection, but advanced rectal cancer cases such as Stage II or III typically need multiple treatment modalities (e.g. radiation). Lynch syndrome is an autosomal dominant disorder, and in this case is likely the cause of his colorectal cancer. According to the Amsterdam criteria, this patient did not qualify as having lynch syndrome. However, the Bethesda guidelines, which are more sensitive to subtle cases of Lynch syndrome, did suggest Lynch syndrome. Between 50 and 70% of people with Lynch Syndrome develop colon cancer in their lifetime, and the risk of syndrome is 50% to immediate family members–making clinical diagnosis important not only for the patient but for immediate family members as well. Postoperative treatment was complicated by a Superficial femoral-vein thrombosis which was treated with a 6 month course of heparin. The take down of his ileostomy was successful, with colon function being restored. He is now alive without recurrence more than 4 years after resection, and undergoes annual endoscopic surveillance and visits his doctor biannually.

Scientists at Chonnam National University in South Korea have developed a way to selectively attach flagellar bacteria to polystyrene microbeads. The team modified Salmonella typhimurium with a selectively BSA (bovine serum albumin) pattered PS (polystyrene) microbead. S. typhimurium has been shown to aggregate around quiescent or necrotic tumors due to chemoattraction to tumor cell lysates and spheroids. The attached microbead can release the therapeutic compound inside of the tumor. The bacteria are also useful in detecting metastases and small tumors. One of the most significant challenges of chemotherapeutic treatments is the continuous, specific delivery of optimal quantities of drugs to target cells – which would allow the bacteriobot to shine in efficiency and selectivity of drug delivery. The advancement of this treatment could mean that a total colectomy may not be necessary if the cancer recurs in the colon. The treatment also could help eliminate the negative gastrointestinal issues associated with chemotherapy by reducing general cytotoxicity and negative body response to treatment.

bacteriobot2

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Ground Rounds: The Relationship Between Coronary Heart Disease and Childhood Obesity

January 29th, 2014 · Comments Off on Ground Rounds: The Relationship Between Coronary Heart Disease and Childhood Obesity

By: Amanda Millatt,  Michelle Daigle

    Coronary vasculature carry oxygen rich blood to the heart muscle and removes  oxygen depleted blood. The left and the right artery each supply blood to a different part of the heart. Atherosclerosis is a disease that causes plaque to build up in arteries. Plaque is a buildup that consists of fat, cholesterol, calcium and other substances that can be found in blood. This plaque buildup can harden and narrow the arteries over the years, which limits the blood flow of oxygen-rich blood organs and other parts of the body. Atherosclerosis in the coronary arteries can completely block the flow of blood to the heart in some places or in others form a blood clot. This lack of blood to the heart tissues caused by a plaque buildup will cause  the heart muscle to die, thus causing a heart attack. The blockage of blood flow can cause angina, a symptom that simulates a discomfortable pressure in the chest area and sometimes can extend to other part of the body.

    A study published in the New England Journal of Medicine examined the effects of adolescent obesity on coronary heart disease in adults for the projected year 2020. Through a series of studies relying on the U.S. census, the National Hospital Discharge Survey and a few other studies along with computer programs they were able to project the percentage of overweight adolescents who will develop coronary heart disease as adults. Having an elevated Body Mass Index (BMI), a calculation of your height and weight to determine weight classes, creates many different risk factors for coronary heart disease, which include hypertension, dyslipidemia, and diabetes. To run this study researchers used the parameters of adult obesity being defined as a BMI of 30 or more and adolescent obesity as being in the 95th percentile on the growth charts. From this study done in 2000, researchers predicted that for the year 2020 the obesity rate for men and women is supposed to increase significantly. This elevates the risk of coronary heart disease by increasing the risk for plaque buildup in the blood, elevating diastolic blood pressure, cholesterol buildup in the blood and the risk for diabetes. They  also projected future obesity cases leading to coronary heart disease for the year 2035 and determined that the incidences of Coronary Heart Disease is expected to surpass 100,000 events for both their low, high, and average projections. Along these same lines they determined that through the use of treatment for high blood pressure and high cholesterol the rates of coronary heart disease due to obesity could be lowered.

Coronary Heart Disease  amillatt mdaigle

    Obesity has recently become prevalent in America because the increasing amount of sucrose in modern diets without fiber. Sucrose consist of glucose and fructose. America’s consumption of fructose went from 15g per day to now 75g per day. The explanation for obesity  starts with the increase of fructose which causes the pancreas to produce more insulin, hormone that signal cells to take sugar from the blood. Simultaneously glucose is metabolized by the whole body and stored as glycogen. Fructose can only be metabolized by the liver, however the body produced enough glycogen to suffice. Thus the liver converts the fructose into fat. The carbohydrates from the food consumed floods the tissues instantly turning into fat. This fat sends a hormone called leptin to the hypothalamus to tell the body to stop eating. The leptin is not received by the hypothalamus because the access insulin blocks the leptin. Thus causing the brain to think that the body needs more energy and the person continues eating.

Strategies to reduce childhood obesity are eat more fiber, reduce consumption of sugary drinks, wait 20 minute for a second plate of food and physical activity. The increase fiber consumption will cause a decrease in blood sugar level if three or more grams are consumed. The reduction of sugary drinks such as soda or orange juice, will decrease the amount of insulin produced. Food after being consumed will take 20 minutes to move completely through the intestine. At the end of the intestine is where hormones are produced to signal the brain that the stomach is full. Physical activity will reduce stress and stress induced eating. Through these lifestyle changes the adolescent will be decrease their risk for coronary heart disease.  Coronary Heart Disease  amillatt mdaigle -1

Resources

1.  Anatomy and Function of the Coronary Arteries. Stanford Hospital, 2014. (Accessed January 12, 2013, at http://stanfordhospital.org/healthLib/greystone/heartCenter/heartIllustrations/anatomyandFunctionoftheCoronaryArteries.html.)

2. Bibbins-Domingo K, Coxson P, Lightwood J, Goldman L. Adolescent Overweight and Future Adult Coronary Heart Disease. N Engl J Med 2007; 357:2371-2379.

3. The Complete Skinny on Obesity. Perf. Dr. Robert Lustig. YouTube. YouTube, 23 Oct. 2013. Web. 28 Jan. 2014.

4. What is Coronary Heart Disease?.National Heart, Lung and Blood Institute, 2012. (Accessed January 12, 2013, at http://www.nhlbi.nih.gov/health/health-topics/topics/cad/.)

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Grand Rounds: Epstein-Barr Virus and Infectious Mononucleosis Induced Acute Post-infectious Cerebellar Ataxia

January 29th, 2014 · Comments Off on Grand Rounds: Epstein-Barr Virus and Infectious Mononucleosis Induced Acute Post-infectious Cerebellar Ataxia

By:  Laurel W, Emma R, Peter W

One month before admission to Massachusetts General Hospital, a previously healthy 19 year old male presented with fatigue, fever, pharyngitis, and lymphadenopathy. A streptococcal pharyngitis (strep throat) test was found to be negative, and a heterophile antibody test (rapid test for mononucleosis) was found to be positive. The diagnosis of infectious mononucleosis due to Epstein-Barr virus (EBV) was made 17 days before admission.

Two weeks prior to admission, the patient presented with additional symptoms, including dysphagia and pain and difficulty hearing in the right ear. A diagnosis of otitis media was made and was treated with prednisone, amoxicillin, and azithromycin. 8 days prior to admission, the patient presented with severe ear pain, a perforated right tympanic membrane, and a bloody purulent in the external auditory meatus. The patient was treated with oral cefurozime and ciprofloxacin (antibiotics). Several days after visiting the ENT, the patient returned for a myringotomy (procedure to relieve pressure in ear by making incision in ear drum). Then, 6 days prior to admission, the patient experienced unsteadiness, slurred speech, and increasing gait imbalance.

Upon arrival the patient had experienced weight loss, decreased hearing, enlarged tonsils, falling, and truncal ataxia. Over the first four days of admission the patient was found to have opacification (indicating fluid in these areas) of right mastoid air cells and middle ear (as shown from MRI and CT scans), impaired ability to perform simple arithmetic, continued deterioration of speech, and balance. The CT scans of the cerebrum and cerebellum showed no abnormalities. The coordination test showed impairment in his motor functions. Slurred speech, clumsiness, ataxia (lack of coordination of movements) and otitis media led to the admission of the patient to neurology services.

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Although Guillian-Barre syndrome is the most common cause of post-infectious ataxia, it is accompanied by loss of reflexes, which were intact in this case. Although cerebral involvement due to executive dysfunction was considered, it could not explain all of the patient’s signs and symptoms. Hereditary and neurodegenerative diseases were ruled out due to lack of family history, normal imaging, and patient’s age. However, the patient’s symptoms, along with the diagnoses of infectious mononucleosis, led to the clinical diagnoses of an upper respiratory tract infection complicated by otitis media. The neurological symptoms also led to the diagnoses of post-infectious acute cerebellar ataxia (ACA) associated with Epstein-Barr virus. ACA is presumed to be an auto-immune response causing inflammation of the cerebellum leading to motor dysfunction.

Plasmapheresis and intravenous immunoglobulin (IVIG) were recommended for treatment as this course is directed at the immune response and therefore more effective. IVIG is administering a solution containing antibodies from the plasma of thousands of people and Plasmapheresis is the process of removing, treating, and returning blood plasma to a patient. Both techniques are common treatments for autoimmune disorders. On the fourth day in Massachusetts General Hospital a five day course of IVIG was begun; the patient responded rapidly and his symptoms improved. After the fifth day of treatment the patient had recovered 90% of his function. He then spent one day in a rehabilitation center and was discharged on the eighth day after admission with a full recovery.
Tracey A. Cho, M.D., Jeremy D. Schmahmann, M.D., and Mary E. Cunnane, M.D., et al. A 19-Year-Old Man with Otalgia, Slurred Speech, and Ataxia. N Engl J Med 2013;369:1253-1261

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