Risk for emerging bipolar disorder, variants, and symptoms in children with attention deficit hyperactivity disorder, now grown up

AIM: To determine the prevalence of bipolar disorder(BD) and sub-threshold symptoms in children with attention deficit hyperactivity disorder(ADHD) through 14 years' follow-up, when participants were between 21-24 years old.METHODS: First, we examined rates of BD type Ⅰ?and Ⅱ diagnoses in youth participating in the NIMH-funded Multimodal Treatment Study of ADHD(MTA). We used the diagnostic interview schedule for children(DISC), administered to both parents(DISC-P) and youth(DISCY). We compared the MTA study subjects with ADHD(n = 579) to a local normative comparison group(LNCG, n = 289) at 4 different assessment points: 6, 8, 12, and 14 years of follow-ups. To evaluate the bipolar variants, we compared total symptom counts(TSC) of DSM manic and hypomanic symptoms that were generated by DISC in ADHD and LNCG subjects. Then we sub-divided the TSC into pathognomonic manic(PM) and non-specific manic(NSM) symptoms. We compared the PM and NSM in ADHD and LNCG at each assessment point and over time. We also evaluated the irritability as category A2 manic symptom in both groups and over time. Finally, we studied the irritability symptom in correlation with PM and NSM in ADHD and LNCG subjects.RESULTS: DISC-generated BD diagnosis did not differ significantly in rates between ADHD(1.89%) and LNCG 1.38%). Interestingly, no participant met BD diagnosis more than once in the 4 assessment points in 14 years. However, on the symptom level, ADHD subjects reported significantly higher mean TSC scores: ADHD 3.0; LNCG 1.7; P < 0.001. ADHD status was associated with higher mean NSM: ADHD 2.0 vs LNCG 1.1; P < 0.0001. Also, ADHD subjects had higher PM symptoms than LNCG, with PM means over all time points of 1.3 ADHD; 0.9 LNCG; P = 0.0001. Examining both NSM and PM, ADHD status associated with greater NSM than PM. However, Over 14 years, the NSM symptoms declined and changed to PM over time(df 3, 2523; F = 20.1; P < 0.0001). Finally, Irritability(BD DSM criterion-A2) rates were significantly higher in ADHD than LNCG(χ2 = 122.2, P < 0.0001), but irritability was associated more strongly with NSM than PM(df 3, 2538; F = 43.2; P < 0.0001).CONCLUSION: Individuals with ADHD do not appear to be at significantly greater risk for developing BD, but do show higher rates of BD symptoms, especially NSM. The greater linkage of irritability to NSM than to PM suggests caution when making BD diagnoses based on irritability alone as one of 2(A-level) symptoms for BD diagnosis, particularly in view of its frequent presentation with other psychopathologies.

Correlation between the proportion of breast volume involved by locally advanced tumors and invasion of the skin and posterior structures

AIM: To evaluate any differences between the percentages of involved breast volume, pathologic attributes,and tumor marker expression of T3 and T4a-c tumors in locally advanced breast cancers(BC).METHODS: All patients with T3 N > 0 and T4a-c BC without evidence of distant metastasis(M0), presenting to the Breast Clinic from 1980 to 2010, were examinedto determine whether their BC's involved ≥ 50% of their breast volumes, defined by gross replacement of at least one hemisphere. Core needle biopsy or postmastectomy specimens from tumors involving a known percent of breast volume were evaluated for:(1)pathological grades and lympho-vascular invasion(LVI);(2) hormone receptor(ER/PR) expression > 0; and(3)epidermoid growth factor 2(her2) over-expression(3+)by immune-histochemical staining or fluorescent in situ hybridization.RESULTS: The data base included 98 patients with T3N> 0 M0 and 120 with T4a-c, any N disease, M0 disease. T3 tumor masses involved 50% or more of the breast in 23/98(24%), and T4a-c tumors 65/120(54%)(P < 0.001). Only 1% of T3 tumors and 23% of T4a-c tumors presented with total breast replacement. There were no significant differences between the pathological attributes and marker expression of the T3 and T4a-c tumors.CONCLUSION: These data suggest that erosion of the overlying skin or underlying chest wall by some BC may be due to neglect and delay, rather than inherent biological aggressiveness.

Using Poisson Modeling and Queuing Theory to Optimize Staffing and Decrease Patient Wait Time in the Emergency Department

Introduction: Studies have shown Emergency Department (ED) crowding contributes to reduced quality of patient care, delays in starting treatments, and increased number of patients leaving without being seen. This analysis shows how to theoretically and optimally align staffing to demand. Methods: The ED value stream was identified and mapped. Patients were stratified into three resource-driven care flow cells based on the severity indices. Time observations were conducted for each of the key care team members and the manual cycle times and service rate were calculated and stratified by severity indices. Using X32 Healthcare’s Online Staffing Optimization (OSO) tool, staffing inefficiencies were identified and an optimal schedule was created for each provider group. Results: Lower Severity Indices (higher acuity patient) led to longer times for providers, nurses, patient care assistants, and clerks. The patient length of stay varied from under one hour to over five hours. The flow of patients varied considerably over the 24 hours’ period but was similar by day of the week. Using flow data, we showed that we needed more nurses, more care team members during peak times of patient flow. Eight hour shifts would allow better flexibility. We showed that the additional salary hours added to the budget would be made up for by increased revenue recognized by decreasing the number of patients who leave without being seen. Conclusion: If implemented, these changes will improve ED flow by using lean tools and principles, ultimately leading to timeliness of care, reduced waits, and improved patient experience.

Large ulcerated cecal lipoma mimicking malignancy

Colonic lipomas are relatively uncommon tumors of mesenchymal origin,composed of well-differentiated adipose tissue supported by fibrous tissue,that usually occur in cecum and ascending colon.Colonic lipomas rarely cause symptoms and are usually detected incidentally. However,if the lesion is large,it may produce symptoms, such as abdominal pain,rectal bleeding,obstruction, intussusception,and even weight loss.Large colonic lipomas can be mistaken for malignancy,which may result in extensive surgical operations.We report a large broadbased ulcerated cecal lipoma in a 68-year-old woman, who presented with abdominal pain and weight loss.The ulcerated lesion was highly suspicious for malignancy radiologically and endoscopically.The patient underwent laparoscopic right-hemicolectomy,and the lesion was diagnosed as a cecal submucosal lipoma.The surgical approach remains the treatment of choice for large and complicated cases.

Screening for asymptomatic chlamydia and gonorrhea in adolescent males in an urban pediatric emergency department

AIM To determine the prevalence of Chlamydia trachomatis(CT) and Neisseria gonorrhea(GC) in young men seeking care in the emergency department(ED) for non-sexually transmitted infection(STI) related symptoms.METHODS This was a prospective, cross-sectional study in an urban ED. The main outcome was the rate of positive CT and GC on urine nucleic acid amplification testing in males aged 16-21 presenting with non-STI related complaints. RESULTS Two hundred and eighty-four patients were enrolled, 271 were included in the final data analysis [age range 16-21, median: 18(quartiles 16-18, 19-21)]. Overall, 17(6.3%, 95%CI: 4%-10%) tested positive for CT and 0%(95%CI: 0%-2%) were found to have GC. The proportion of sexually active subjects was 71%(95%CI: 65%-76%) and 2%(95%CI: 0.6%-4%) reported sex with men. Previous STI testing was reported in 46%(95%CI: 43%-54%) and 13%(95%CI: 8%-20%) of those patients previously tested had a history of STI. Of the patients who tested positive for CT in the ED, 88%(95%CI: 64%-98%) were successfully followed up. CONCLUSION The prevalence of CT infection found by screening was 6.3%. Screening and follow-up from the ED was successful. The findings justify routine STI screening in male adolescents presenting to the ED with non-STI related complaints.

A Review: Embedding a Simulation Training Program in Labor and Delivery to Improve Healthcare Quality, Clinical Outcomes, and Patient Satisfaction

In response to maternal deaths being three-fold higher for black women than other races in New York City, Governor Andrew M. Cuomo created a taskforce which met for a year. In March 2019, the taskforce published ten recommendations to address the current healthcare disparities. The taskforce recommended utilizing medical simulation training to improve skills and communication. Peer-reviewed literature was explored for evidentiary support for embedding a simulation program in a NYC public hospital. In addition, obstacles to and advantages of in-situ simulation programs were discussed. Steps for garnering executive leadership support, improving teamwork, defining outcome measures, and identifying beneficiaries of in-situ simulation programs were explored.

Accessory Breast Tissue in Pregnancy

Accessory breast tissue development frequently occurs in addition to physiologic breast development and is a common congenital condition with an occurrence of 0.4% to 6% in women and 1% - 3% in men. A 31-year-old G1P0 female presented to our triage at 20 + 4 weeks gestation with a one-week history of painful bilateral axillary lumps. Her last menstrual period was consistent with an estimated gestational age of 39 + 3 weeks by LMP. She had emigrated from Bengal three years earlier with no other gynecological complaints and knew of no abnormalities on physical exam. The painful axillary lumps were found to be accessory breast tissue. This entity is presented as a palpable thickening that is most prevalent along the milk line in the region immediately below the breasts, along the abdomen, in the axilla and in the groin region adjacent to the vulva. Affected individuals may undergo premenstrual changes such as tenderness, swelling, and difficulty with shoulder range of motion and irritation. The onset of pregnancy stimulates the tissue and makes it more evident as it did with our patient.

Lean Management in Obstetrics and Gynecology: Application in the Ambulatory Clinic Pre- and Post-Kaizen

OBJECTIVE: The ambulatory clinic was an important departmental problem. Providers hated working there and patients complained about the wait times there. It seemed there were equal numbers of patients and provider complaints. In the spirit of solving the problem, data was gathered, a LEAN intervention was planned, and data was collected. METHODS: We defined the service families in the clinic as registration, vital signs, provider or ultrasound visit, nursing visit, and registration for the return visit. We walked the Gemba engaging all the staff in the process. Many observations pointed to long waits between and among the five stations. In order to study the current state, time data was collected by attaching a sheet of paper to a folder that the patient would carry themselves to all the clinical steps. On the sheet of paper each station logged the time that patient appeared and the time the patient left their sight. Data was gathered each day and every day from October 2016 to the summer of 2017. The data was analyzed. Leadership met and identified value and waste in the process. A Kaizen event was scheduled after the first set of measurements engaging all the staff. After the data was thoroughly analyzed and digested, brainstorming occurred. Together we determined our future state. We created a vision and strategic goals to reach our future state. RESULTS: The data pre-Kaizen event showed that the process of arrival to leaving took 124 minutes. We discovered that not every patient passed through each station. We learned the patients were on time or early for their visit most of the time. The providers were late most of the time by 1 - 1.5 hours. We learned how long each station took from the patient’s point of view. There were no statistically significant differences between ultrasound and provider visits;there were no statistically significant differences between midwife and physician visits. Each day of the week was similar. The arrival rate was higher in the morning because of the template. After the event, the total time in clinic did not change however the variability in time between and among each station decreased in variance. We informed the staff of these findings so that they could take responsibility for their part in the process. The atmosphere in clinic changed dramatically and the complaints from both providers and patients stopped. CONCLUSION: LEAN management was used to improve the clinic. It yielded important results, got the staff engaged in the process, and provided a way for the patients to see the efforts made by staff to improve.

Uterine Didelphys in a Pregnant Mother

Background: Uterine Didelphys is a rare congenital condition and it can affect both mother and fetus. A 24 year-old patient presented to the emergency room with pelvic pain and a pelvic ultrasound confirmed the presence of Uterine Didelphys. She subsequently became pregnant and was first seen at 21 weeks gestation. She was designated as a high-risk patient during the second trimester when she experienced irregular contractions. She was monitored weekly with Non-Stress Tests and eventually was delivered by Cesarean Section. Uterine Didelphys can be detected in-utero in affected individuals, and clinical findings vary among individuals. Some may be asymptomatic, whereas others will experience dyspareunia, and still others may present with concurrent renal agenesis. Serial sonograms are performed throughout their pregnancy to evaluate fetal growth and well-being, as well as cervical length. Unlike many uterine anomalies, Uterine Didelphys does not affect fertility but can affect labor, fetal growth, placentation, fetal viability and fetal outcome. Uterine Didelphys frequently results in recurrent miscarriages and may cause preterm labor and necessitate cesarean section. The presentation, associated symptoms, methods of detection and management options for Uterine Didelphys will be discussed.

Effects of Metoclopramide Orally Disintegrating Tablet in Optimizing Late Outpatient Endoscopy: A Randomized Double-Blind Placebo-Controlled Clinical Trial

Aims: Metoclopramide has been used as a gastro-kinetic agent but the safety and effects of different preparations of metoclopramide on preparation for outpatient endoscopy are largely unknown. The study aimed to evaluate the (1) Safety of using ODT (orally disintegrating tablet) or TT (traditional tablet) metoclopramide pre-endoscopy in non-fasting patients compared with placebo (2) Impact of ODT or TT metoclopramide on sedation and recovery times compared with placebo. Methods: A double blind randomized placebo-controlled trial with 3 arms;Metoclopramide ODT (n = 43), Metoclopramide TT (n = 43) and Placebo (n = 43). Results: Metoclopramide ODT had fewer adverse events compared with TT or placebo. Recovery time was significantly shorter with use of either metoclopramide versus placebo (P < 0.001) & total sedation time was also significantly shorter in the metoclopramide groups versus placebo (P < 0.001). Conclusion: Metoclopramide ODT is safe and beneficial in endoscopic procedures requiring limited access to food and liquid.

Magnesium in Women’s Health and Gynecology

Magnesium is well known in the world of obstetrics for many important uses. It has been utilized in treating pre-eclampsia, eclampsia, and preventing preterm labor, though it has been found recently that prolonged magnesium administration in pregnant women may result in adverse outcomes to fetal bone metabolism, resulting in a new FDA warning [1]. Outside of obstetrics, magnesium is recommended for treating the arrhythmias torsades de pointes and rapid atrial fibrillation, treating severe acute asthma, improving migraine symptoms, and for treating dyspepsia and constipation [2]. Many women in our modern society are magnesium deficient due to low dietary intake, and low dietary magnesium intake resulting in hypomagnesaemia has recently been shown to have many deleterious effects. Magnesium’s uses are wide-reaching, touching many areas of women’s health and gynecology from pre-menstrual syndrome to menopause, PCOS to endometriosis, and beyond.