What a difference a day makes

With the availability of group A beta-hemolytic streptococcal (GABHS) antigen detection tests, the management of adult pharyngitis is being reassessed. A decision analytic model was developed which considered four strategies: immediate treatment, no treatment, performing a rapid antigen test, or obtaining a bacterial culture. Patient outcomes were expressed in “well” days, which were reduced by the “sick” days associated with adverse reactions to treatment or complications of GABHS infection. When immediate test results are available, testing is the optimal strategy for probabilities of GABHS between 1 and 49 per cent. This range includes almost all patients, using probability estimates based on clinical criteria. The absolute benefit of testing was 0.1 days. The major advantage of a rapid test is the avoidance of penicillin reactions. Variations in the symptomatic benefits of treatment had minimal effects on the analysis. The analysis supports the use of an antigen test for adult patients with pharyngitis. Received from the Division of General Medicine and Primary Care. Department of Internal Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond. Virginia. A preliminary version of this work was presented at the seventh annual meeting of the Society for Medical Decision Making, October 21, 1985.     

Report of a case of a giant phytobezoar in a patient with a duodenal bulb ulcer.

A case of a large phytobezoar (750 g weight and with the length of 29 cm) due to Khormalou (Persimmon) is being reported in a young patient with chief complaint of abdominal pains and concomitant duodenal ulcer. Review of the literature in this subject shows that bezoars of this size and weight are relatively rare in healthy individuals.     

Cryptogenic stroke in a patient with a PFO: a decision analysis

BACKGROUND: Octogenarian Israeli prime-minister Ariel Sharon recently sustained a mild, reversible stroke. A patent foramen ovale (PFO) was detected and anticoagulants were given pending PFO closure. A few days later, he sustained major intracerebral hemorrhage and has since remained in vegetative state. The events triggered serious criticism in the mass media, experts promoting one management option over others. Because knowledge of outcome and hindsight bias evaluation of appropriateness of care, we sought to systematically review the clinical case. METHODS: We performed a formal decision analysis to identify the preferred management between anticoagulation, antiplatelets, PFO closure, or no treatment. Using the best evidence available, we built a decision tree. Main outcomes: recurrent stroke and treatment complications within 1 year. RESULTS: Optimal decision was found to be critically sensitive to assumptions about etiology, efficacy and safety of treatments, recurrence risk, and to small changes in utilities. In multiway sensitivity analysis, when the risk of recurrent stroke was <0.12 per year, no treatment was the best management. PFO closure is dominant only when the risk of recurrent stroke is >0.12 per year closure effectiveness is assumed to be <0.28. When closure effectiveness is >0.6, it is inferior to anticoagulation and antiplatelet management. CONCLUSIONS: Uncertainties precluded a clear-cut answer and choice was found to be a "toss-up," often associated with much controversy. Use of novel therapies, such as PFO closure, outside clinical trials will not reduce uncertainty about efficacy.     

Ochronosis: a report of a case and a review of literature

A patient with alkaptonuria and ochronotic pigment deposited in articular cartilage and sclerae clinically manifested a serious osteoarthritis of the peripheral and axial joints and synchondrosis, typically involved in long lasting cases of this hereditary defect of homogentisic acid oxidase. This is the first patient with this disorder reported, where a non-cemented total knee prosthesis (PCAR) was applied on both knees. This was possible due to the good quality of the bone stock, which did not seem to be impaired by ochronosis. Our patient had no cardiac symptoms or murmurs, but had a slight calcification in the annulus of aorta observed with echocardiography, a useful new method for screening this disease manifestation. A third new aspect reported is the immunopathology of the synovial tissue. Small pieces of torn-off cartilage were seen embedded in the synovial stroma. This was associated with a slight hyperplasia of the C3bi-receptor positive and proline hydroxylase positive type A and B synovial lining cells. Perivenular infiltrates contained CD2 positive T lymphocytes, mostly belonging to the CD4 subset, and some C3bi-receptor positive monocytes. Activated CD25 positive and immunoglobulin light chain positive T and B lymphocytes were absent or few. Because modern medicine has much to offer to those suffering from this ancient inborn error of metabolism in the form of new specific diagnostic methods and new surgical modes of treatment, such as endoprosthesis surgery and cardiac valve replacement, we also present a literature overview of this interesting condition.     

Between a Clot and a Scarred Place

Immobilized orthopedic trauma patients face an elevated risk of venous thromboembolism (VTE). We present a case in which a patient undergoing staged repair of traumatic orthopedic injuries developed deep venous thrombosis (DVT) during hospitalization, prior to repair of a lower extremity injury for which delay in operation might result in poor functional outcome. We provide an overview of recommendations regarding pharmacologic prophylaxis of VTE in orthopedic patients. We review the importance of cultivating a high index of suspicion for VTE in such patients, even when receiving appropriate prophylaxis and lacking overt symptoms. Finally, we outline the multidisciplinary decision-making process regarding optimizing care for the patient in a precarious position of developing acute VTE while awaiting urgent surgery. Specifically, we review the safety, efficacy, and management of retrievable inferior vena cava filters (rIVCF) for this population.     

Between a Rock and a Hard Place

• SFA disease has unique challenges
• A myriad of interventional techniques have been proposed to treat calcific femoral disease
• It appears a combination of atherectomy and drug elution may be the procedure of choice in these patients
• New innovative therapies may be a viable option in the future

     

KBRE: a proposition of a reverse engineering process by a KBE system

This paper focuses on reverse engineering (RE) in a mechanical design domain. RE is an activity which consists in creating a full CAD model from a 3D points cloud. The aim of RE is to suggest an activity of redesign in order to improve, repair or update the case of study. According to the users, the CAD models of RE softwares are usually frozen and do not allow an activity of redesigning. This paper shows a RE methodology which allows defining, saving and reusing geometrical features defined by knowledge analysis of the case of study. This methodology called knowledge based reverse engineering (KBRE) supports the knowledge management. Knowledge is materialised by the features which are fitted in a points cloud.     

Transcatheter occlusion of a Blalock-Taussig shunt with a detachable balloon in a child

A case of transcatheter occlusion of a Blalock-Taussig shunt with a detachable silicone filled balloon is described. This 11 year old boy had previously had a repair of tetralogy of Fallot together with ligation of a large Blalock-Taussig shunt. Though there was a good surgical result, the shunt proved to be incompletely closed leaving a significant left to right shunt. As an alternative to a further operation a silicone filled balloon was detached in the Blalock-Taussig shunt and this successfully closed the fistula.     

Image of a left atrial mass after a cardiopulmonary bypass in a child

Invagination of an appendage into the left atrium is a rare complication. It occurs spontaneously or after open‐heart surgery. In our case, a postoperative transesophageal echocardiogram, after closure of a ventricular septal defect in a 5‐month‐old infant, revealed a large mass in the left atrium. A diagnosis of a left appendage inversion was confirmed after external examination of the heart. Herein, we provide echocardiographic images before, during, and after manual reversion of the left appendage. Misdiagnosis of this complication could have led to an additional unnecessary surgical procedure that could have impacted on the patient's morbidity.