Oral food challenge failures among foods restricted because of atopic dermatitis

Background

Recent studies have suggested that removing foods from the diet to manage atopic dermatitis (AD), based on positive allergy test results, may lead to immediate allergic reactions on reintroduction of that food.

Anterior abdominal wall ‘peritoneal recess’: cause for pseudoherniation of small bowel resulting in chronic abdominal pain

A middle-aged patient presented with intermittent chronic abdominal pain without any obvious cause. Computed tomography detected a hernia (presumed to be the cause of the patient’s symptoms) without any obvious lump on examination. A laparoscopy was performed to repair the hernia. This revealed a left-sided unilateral ‘peritoneal recess’ at the level of the arcuate line extending medial to the linea semilunaris. No extraperitoneal sac or defect was noted in the rectus sheath or in the muscle, nor were any contents present in the recess at the time of the laparoscopy. We believe the bowel was being trapped intermittently in this space, causing the abdominal symptoms.     

The AIDS patient with abdominal pain: a new challenge for the emergency physician

As the prevalence of HIV infection continues to increase, EPs will be called upon to evaluate increasing numbers of AIDS patients who have abdominal pain, some of whom will require emergent surgical intervention. In addition to the myriad causes of abdominal pain in the nonimmunocompromised patient, the differential diagnosis in the AIDS patient includes a wide variety of opportunistic infections and neoplasms (Table 5). Evaluation frequently requires extensive laboratory studies and cultures and advanced imaging (CT, ultrasound, and so forth). A low threshold for surgical and other subspecialty consultation should be in place because of the often subtle presentation of surgical emergencies in AIDS patients.     

Predictors of ovarian malignancy in children: Overcoming clinical barriers of ovarian preservation

Background/Purpose

Ovarian preservation is desirable in girls with benign ovarian masses. We aimed to 1) identify clinical predictors of malignant ovarian masses, 2) investigate how often ovarian tissue is present to preserve in benign masses, and 3) identify factors associated with successful ovarian preservation.

Methods

Retrospective analysis (1997–2012) of girls age 1–18 years with an ovarian mass managed operatively. Data on presenting symptoms, imaging, biochemical markers, treatment, outcome, and pathology were extracted.

Results

We identified 150 patients. Large mass size, solid components, and elevated tumor markers (AFP, βHCG, and/or LDH) were significantly predictive of malignancy. All masses < 10 cm, predominantly cystic, and with negative tumor markers were benign. Masses with all three of these characteristics would decrease a 20% malignancy pretest probability to a posttest probability of 0.25%. Benign masses managed by oophorectomy contained normal ovarian tissue in 76% of the specimens. For benign masses, successful ovarian preservation was significantly associated with size < 10 cm, predominantly cystic, laparoscopy, and absence of torsion or calcifications.

Conclusion

Ovarian masses that are < 10 cm, primarily cystic, and have negative tumor markers are most likely benign. Viable ovarian tissue is frequently present in benign masses, so significant efforts should be made for ovarian preservation.     

Validating administratively derived frailty scores for use in Veterans Health Administration emergency departments

Objectives

Frailty is a clinical syndrome characterized by decreased physiologic reserve that diminishes the ability to respond to stressors such as acute illness. Veterans Health Administration (VA) emergency departments (ED) are the primary venue of care for Veterans with acute illness and represent key sites for frailty recognition. As questionnaire-based frailty instruments can be cumbersome to implement in the ED, we examined two administratively derived frailty scores for use among VA ED patients.

Methods

This national retrospective cohort study included all VA ED visits (2017–2020). We evaluated two administratively derived scores: the Care Assessment Needs (CAN) score and the VA Frailty Index (VA-FI). We categorized all ED visits across four frailty groups and examined associations with outcomes of 30-day and 90-day hospitalization and 30-day, 90-day, and 1-year mortality. We used logistic regression to assess the model performance of the CAN score and the VA-FI.

Results

The cohort included 9,213,571 ED visits. With the CAN score, 28.7% of the cohort were classified as severely frail; by VA-FI, 13.2% were severely frail. All outcome rates increased with progressive frailty (p-values for all comparisons < 0.001). For example, for 1-year mortality based on the CAN score frailty was determined as: robust, 1.4%; prefrail, 3.4%; moderately frail, 7.0%; and severely frail, 20.2%. Similarly, for 90-day hospitalization based on VA-FI, frailty was determined as prefrail, 8.3%; mildly frail, 15.3%; moderately frail, 29.5%; and severely frail, 55.4%. The c-statistics for CAN score models were higher than for VA-FI models across all outcomes (e.g., 1-year mortality, 0.721 vs. 0.659).

Conclusions

Frailty was common among VA ED patients. Increased frailty, whether measured by CAN score or VA-FI, was strongly associated with hospitalization and mortality and both can be used in the ED to identify Veterans at high risk for adverse outcomes. Having an effective automatic score in VA EDs to identify frail Veterans may allow for better targeting of scarce resources.     

Rotation of the Sacrum During Bellyboard Pelvic Radiotherapy

Patients with cervical, uterine, and rectal carcinomas are usually treated in the prone position using the bellyboard positioning device. Specific and uncomfortable prone position gives rise to uncertainties in the daily set-up of patients during the treatment. During investigation of translational movements, rotational movements of the pelvis are observed and investigated. The film portal imaging is used to discover patient positioning errors during treatment. We defined the rotational set-up errors by angle deviations of the sacrum. Thirty-six patients were included in the study; 15 patients were followed during the whole treatment and 21 during the first 5 consecutive treatment days. The image acquisitions were completed in 84%. Systematic and random positioning errors were analyzed in 725 images. Approximately half of the patients had adjusted to the bellyboard in the first few fractions, with sacrum angles remaining the same for the rest of the treatment. The other half had drifts of the sacrum angle during the whole treatment. The rotation of the sacrum during treatment ranged up to 14°, causing the usual set-up verification and correction procedure to result in errors up to 15 mm. Rotational movements of the patient pelvis during bellyboard pelvis radiotherapy can introduce considerable patient position error.