Gallstone ileus 30 years after cholecystectomy and hepaticojejunostomy

Gallstone ileus occurs when the small or large intestine is obstructed by a gallstone and is a rare occurrence in a post-cholecystectomy patient. Non-specific clinical symptoms and inconsistent imaging results often lead to a delay in diagnosis. Complex anatomy, such as a Roux-en-Y biliary-enteric anastomosis, can increase the risk of stone formation and further confound a potential case of gallstone ileus. Here, we present a rare case of gallstone ileus at the anastomosis site of a Roux-en-Y hepaticojejunostomy done 30 years prior for a common bile duct injury during a cholecystectomy. The possibility of negative CT findings, pattern of presentation on imaging as intussusception, and potential pathomechanism of gallstone formation in post-cholecystectomy patients are discussed. Through this case and review of similar cases, we emphasise the need for further study of post-cholecystectomy gallstone ileus and the importance of clinical suspicion during diagnosis.

Pathway-Based Reduction of Repeat Head Computed Tomography for Patients With Complicated Mild Traumatic Brain Injury: Implementation and Outcomes

BACKGROUND

Routine follow-up head imaging in complicated mild traumatic brain injury (cmTBI) patients has not been shown to alter treatment, improve outcomes, or identify patients in need of neurosurgical intervention. We developed a follow-up head computed tomography (CT) triage algorithm for cmTBI patients to decrease the number of routine follow-up head CT scans obtained in this population.

OBJECTIVE

To report our experience with protocol implications and patient outcome.

METHODS

Data on all cmTBI patients presenting from July 1, 2018 to June 31, 2019, to our level 1, tertiary, academic medical center were collected prospectively and analyzed retrospectively. Descriptive analysis was performed.

RESULTS

Of the 178 patients enrolled, 52 (29%) received a follow-up head CT. A total of 27 patients (15%) were scanned because of initial presentation and triaged to the group to receive a routine follow-up head CT. A total of 151 patients (85%) were triaged to the group without routine follow-up head CT scan. Protocol adherence was 89% with 17 violations.

CONCLUSION

Utilizing this protocol, we were able to safely decrease the use of routine follow-up head CT scans in cmTBI patients by 71% without any missed injuries or delayed surgery. Adoption of the protocol was high among all services managing TBI patients.

ST Segment Elevation Caused by Artifact From Cylindrical Battery Ingestion

BACKGROUND

Ingestion of cylindrical batteries is uncommon. Management can include removal via upper endoscopy, surgical excision, or observation. This case demonstrates the rare phenomenon of cylindrical battery ingestion causing an electrocardiogram (ECG) artifact that mimics ST segment myocardial infarction (STEMI).

CASE REPORT

A 51-year-old man who ingested 13 small pencils and 18 AA batteries was found to have ST segment elevation in the inferior leads of the ECG. Further cardiac workup including cardiac biomarkers and transthoracic echocardiogram was negative, and his ECG changes resolved after extraction of the batteries. The ST segment changes were most likely caused by electrical artifact from battery ingestion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When faced with an ECG finding that is unexpected and that does not fit the patient's overall clinical picture, emergency physicians should consider artifact as a possible cause. Recognition of artifact as the cause of an ECG abnormality can obviate the need for a prolonged and potentially invasive cardiac workup.

WE-E-211-01: Medical Physics in Federal and State Governments

In 2010, FDA's Center for Devices and Radiological Health (CDRH) launched an "Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging" and held a public meeting on "Device Improvements to Reduce Unnecessary Radiation Exposure from Medical Imaging" March 30- 31, 2010). In follow-up, FDA is pursuing efforts using its regulatory authority as it applies to imaging equipment and manufacturers and also partnering with professional organizations such as AAPM, industry and other governmental agencies to incorporate radiation protection principles into facility quality assurance, personnel credentialing, and training requirements.The current U.S. Federal guidance on medical x-rays was published in 1976 and addresses film imaging for radiographie and dental modalities. The Medical Workgroup of the Interagency Steering Committee on Radiation Standards (ISCORS) has modernized that document to address both diagnostic and interventional approaches, film and digital imaging, and the broad range of modalities that include radiography, computed tomography, interventional fluoroscopy, dentistry, bone densitometry, and veterinary practice. The current scope and status of the document will be presented.The Military Health System is committed to providing state-of- the-art care to its beneficiaries; both at home and abroad. Personnel constraints and the continuing wars oversees have created obstacles to this objective. In the past decade, tremendous advances have occurred in Electronic Health Records (EHR) and Teleradiology. Military Radiology seeks to leverage these advances as a means of surmounting many of the challenges it faces. In this talk, the current status of DoD teleradiology and EHR will be presented.

LEARNING OBJECTIVES

1. To provide a venue in which physicists working in the public sector can interface and discuss specific issues related to supporting the federal and state governments 2. To provide a venue for medical physicists to voice specific concerns with federal/state programs where medical physics should be involved in and/or more effective. 3. To educate audience on federal or state new or updated guidelines.

Effects of polychlorinated biphenyls on development and reproduction

As part of its mandate, the Agency for Toxic Substances and Disease Registry (ATSDR) prepares toxicological profiles on hazardous chemicals found at Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) National Priorities List (NPL) sites that have the greatest public health impact. These profiles comprehensively summarize toxicological and environmental information. This article, which constitutes the release of an important section of the Toxicological Profile for Polychlorinated Biphenyls (ATSDR 2000) into the scientific literature, focuses on the developmental and reproductive effects of this group of synthetic organic chemicals (PCBs) in humans and animals. Information on other health effects, toxicokinetics, mechanisms of toxicity, biomarkers, interactions, chemical and physical properties, potential for human exposure, and regulations and advisories is detailed in the profile. Interested readers are encouraged to consult the original toxicological profile for more information. Profiles can be requested from ATSDR's Information Center by telephone (1-888-42-ATSDR [1-888-422-8737] or E-mail: (atsdric@cdc.gov).

Carcinogenic effects of polychlorinated biphenyls

As part of its mandate, the Agency for Toxic Substances and Disease Registry (ATSDR) prepares toxicological profiles on hazardous chemicals found at Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) National Priorities List (NPL) sites that have the greatest public health impact. These profiles comprehensively summarize toxicological and environmental information. This article constitutes the release of an important section of the Toxicological profile for polychlorinated biphenyls [ATSDR. 2000: Toxicological profile for polychlorinated biphenyls. Atlanta, GA: US Department of Health and Human Services, Agency for Toxic Substances and Disease Registry.] into the scientific literature. This article focuses on the carcinogenic effects of this group of synthetic organic chemicals (polychlorinated biphenyls) in humans and animals. Information on other health effects, toxicokinetics, mechanisms of toxicity, biomarkers, interactions, chemical and physical properties, potential for human exposure, and regulations and advisories is detailed in the profile.

The psychosocial treatment of schizophrenia: an update

OBJECTIVE

The authors sought to update the randomized controlled trial literature of psychosocial treatments for schizophrenia.

METHOD

Computerized literature searches were conducted to identify randomized controlled trials of various psychosocial interventions, with emphasis on studies published since a previous review of psychosocial treatments for schizophrenia in 1996.

RESULTS

Family therapy and assertive community treatment have clear effects on the prevention of psychotic relapse and rehospitalization. However, these treatments have no consistent effects on other outcome measures (e.g., pervasive positive and negative symptoms, overall social functioning, and ability to obtain competitive employment). Social skills training improves social skills but has no clear effects on relapse prevention, psychopathology, or employment status. Supportive employment programs that use the place-and-train vocational model have important effects on obtaining competitive employment. Some studies have shown improvements in delusions and hallucinations following cognitive behavior therapy. Preliminary research indicates that personal therapy may improve social functioning.

CONCLUSIONS

Relatively simple, long-term psychoeducational family therapy should be available to the majority of persons suffering from schizophrenia. Assertive community training programs ought to be offered to patients with frequent relapses and hospitalizations, especially if they have limited family support. Patients with schizophrenia can clearly improve their social competence with social skills training, which may translate into a more adaptive functioning in the community. For patients interested in working, rapid placement with ongoing support offers the best opportunity for maintaining a regular job in the community. Cognitive behavior therapy may benefit the large number of patients who continue to experience disabling psychotic symptoms despite optimal pharmacological treatment.

Relative validity of a food frequency questionnaire among tin miners in China: 1992/93 and 1995/96 diet validation studies

OBJECTIVE

Diet validation research was conducted to compare the respondents' reporting of dietary intake in a food frequency questionnaire (FFQ) with intake reported in food recalls. Because the population received annual salary increments that could modify food intake, diet validation studies (DVSs) were conducted during two time intervals.

DESIGN

A 99-item FFQ was administered by an interviewer twice in a 1-year interval, and responses to each FFQ item were compared with 28 days of interviewer-administered food recalls that were collected in four 1-week intervals during each season of 1992/93. The second validation study in 1995/96 had a similar design to the earlier one.

SETTING

A prospective cohort study of lung cancer among tin miners in China was initiated in 1992, with dietary and other risk factors updated annually.

SUBJECTS

Among a cohort of high risk tin miners for lung cancer, two different samples (n = 141 in 1992/93, and n = 113 in 1995/96) for each diet validation study were randomly selected from four mine units, that were representative of all worker units.

RESULTS

Miners reported a significantly higher average frequency of intake of foods in the food recalls than the FFQ, with few exceptions. Deattenuated Pearson correlation coefficients of the frequency of food intake between the FFQ and food recalls were in the range of -0.40 to 0.72 in both studies, with higher positive correlations for beverages and cereal staples than for animal protein sources, vegetables, fruits and legumes. The percentage of individuals with exact agreement in the extreme quartiles of intake in the food recalls and FFQ ranged from 0 to 100% in both studies.

CONCLUSIONS

Among Chinese miners, the range in correlations between the food recalls and the FFQ were due to: (i) market availability of foods during the food recall weeks compared to their annual reported intake in the FFQ; (ii) cultural perception of time; and (iii) differences in how the intake of mixed dishes and their multi-ingredient foods were reported in the recalls vs. the FFQ. The range in the percentage of agreement in the same quartiles and the changes in food intake over time may have implications for the analysis of the diet-disease relationship in this cohort.

The development of treatment resistance in patients with schizophrenia: a clinical and pathophysiologic perspective

The pathophysiologic process and clinical factors that contribute to the development of treatment resistance in schizophrenia are not well defined. This article describes data indicating that treatment resistance may evolve over the course of the patients' illness and maturational development. Data from multiepisode patients suggest that early effective intervention with clozapine can prevent treatment resistance. Early identification of patients with signs of treatment resistance is vital. Treatments must be effective and prevent relapse. At the first indication that a patient may be developing resistance (e.g., the emergence of extrapyramidal symptoms or increases in negative symptomatology) or may not be complying with treatment, clozapine therapy should be considered.

High prevalence of adeno-associated virus (AAV) type 2 rep DNA in cervical materials: AAV may be sexually transmitted

Adeno-associated virus (AAV) is a human parvovirus that in laboratory and animal models has the ability to suppress the oncogenic phenotype of a variety of viruses and cellular derived oncogenes. The inhibitory effects of AAV have been mapped to its rap gene (Rep78 protein). Furthermore, seroepidemiologic data indicate that AAV infection is linked to reduced cervical cancer rates in humans. Because of AAV's inverse relationship with cervical cancer, we attempted to identify AAV rep sequences within DNA derived from cervical brushings taken from nondiseased middle class patients at a Little Rock clinic. Polymerase chain reaction (PCR) amplification was carried out with primers designed to amplify a specific segment of the endogenous human beta-globin gene or the AAV rep gene. Of those cervical samples that were positive for beta-globin DNA, 50% were also found to be positive for AAV rep DNA when analyzed by either ethidium bromide staining or dot-blot hybridization with an internal probe. These data strongly suggest that AAV is commonly carried in the genital region and further raise the possibility that AAV can be sexually transmitted.

Progressive and imaginal relaxation training for elderly persons with subjective anxiety

Elders exposed to either progressive or imaginal relaxation procedures reported significant relaxation effects and showed improvement on measures of personal functioning. The results of the Physical Assessment Scale of the Relaxation Inventory indicated that relaxation responses were acquired within and across sessions. Large, consistent changes in relaxation occurred in all 4 sessions. The Symptom Checklist-90-R, which measures self-reported personal adjustment, showed significant positive changes following relaxation training and at 1-month follow-up. Elders who imagined muscle tension release profited as much as those engaged in actual muscle tension-release activities. This finding is of importance for older adults who may experience physical limitations that contraindicate muscle-tension-release procedures.

Progressive and imaginal relaxation training for elderly persons with subjective anxiety

Elders exposed to either progressive or imaginal relaxation procedures reported significant relaxation effects and showed improvement on measures of personal functioning. The results of the Physical Assessment Scale of the Relaxation Inventory indicated that relaxation responses were acquired within and across sessions. Large, consistent changes in relaxation occurred in all 4 sessions. The Symptom Checklist-90-R, which measures self-reported personal adjustment, showed significant positive changes following relaxation training and at 1-month follow-up. Elders who imagined muscle tension release profited as much as those engaged in actual muscle tension-release activities. This finding is of importance for older adults who may experience physical limitations that contraindicate muscle-tension-release procedures.

The effects of bile on the locomotory cycle of Fasciola hepatica

The rate of production of locomotory cycles in juvenile Fasciola hepatica was significantly decreased following treatment with conjugated chenodeoxycholic acids and significantly increased following treatment with dehydrocholic acid or whole bovine bile. Deoxycholic acid caused death and lysis of the parasites in less than 30 min. These results suggest that bile components act as a specific stimulus for a fixed action pattern (the locomotory cycle) in this parasite.