Volume 3
Number 1
Proceedings of ARMC Research Conference Vol. 3
Editor David Lanum, MD Co-Editor Edward W. Lee, MD, PhD Editorial
Board Emily Ebert, MD, MPH Andrew Lowe, PharmD Dan Miulli, DO
3
- Preface -
It is my pleasure to
welcome you to Arrowhead Regional
Medical
Center’s Third Annual Research Day.
My thanks to each one whose research
and commitment is illustrated in these Proceedings. It is my sincere hope that
the submissions from today may
go on to help shape and
focus
future
developments in medical care.
I encourage you to read through the Proceedings and engage the various au
thors in discussion.
Perhaps some of the articles will provide
inspiration for
further studies and projects.
A special thanks, again, to Dr. Edward Lee who
has perpetually lent his expertise and enthusiasm to make this event a reality
for the past three years. I am also grateful to the ARMC Foundation for their
financial support of this year’s endeavor. As we launch our third year of show
casing the research done here
at ARMC by our residents, I
salute
the
dedication and diligence exemplified by
those whose work is demonstrated
on the following pages.
David Lanum, M.D.
Editor
4
- Contents -
PREFACE…………….…………………………………………………..……………………………… 3
1. Ajay Amin, WeiPing Lin, Guillermo J. Valenzuela
DELIVERY OUTCOME WHEN ESTIMATED FETAL WEIGHT OF > 4000G AND COM
PARISON WITH DELIVERIES COMPLICATED BY SHOUDER DYSTOCIA
…………………………………..……………………………………………………….……………… 7
2. Sarkis Arabian, Roozehra Khan, Kambiz Raoufi
A CASE REPORT AND REVIEW OF CARDIAC MANIFESTATIONS OF CHAGAS’ DIS
EASE AFFECTING A HISPANIC MALE
………………………………………..……………………………………………………….………… 7
3. Sarkis Arabian, Joe Maissian, Kristina Angelo, Kambiz Raoufi
PREVALENCE OF METHAMPHETAMINE INDUCED CARDIOMYOPATHY
………………………………………………..…………………………………….…………………… 8
4. Shawn Couture, Martha Melendez
WOUND CARE MANAGEMENT IN A PRIMARY CARE SETTING
…………………………………………..……………………………………………….……………… 8
5. Phuongdoan L. Doan, Pooja Gupta
CASE REPORT: WEGENER’S GRANULOMATOSIS IN A 19YEAROLD MALE
…………………………………………………………..…………………………………….………… 9
6. Khaled El Said, Mark Shiu
DIABETIC MYONECROSIS
……………………………………..………………………………………………………….………… 9
7. Pat Kouwabunpat, Elaine MillerKaras, Deborah Small
SOMATIC EXPERIENCING TREATMENT IN AN 8YEAR OLD BOY SUFFERING FROM
PTSD: A CASE REPORT
………………………..………………………………………………………………………….……… 10
8. Paul Wisniewski, Angelica Loza, Katie Huynh, Fariborz Lalezarzadeh
EVALUATION OF PREHOSPITAL AND EMERGENCY DEPARTMENT SYSTOLIC
BLOOD PRESSURE AS A PREDICTOR OF INHOSPITAL MORTALITY
……………………………...…………………………………………………………………………… 10
5
- Contents -
6
- Contents -
17. Stephanie L. Tang, Arthur B. Dublin
INTRACRANIAL ARTERIAL FENESTRATION AND ASSOCIATION WITH ANEURYSM:
A CASECONTROL RETROSPECTIVE STUDY AND REVIEW OF LITERATURE
……………………………………………….…..……………………………………………………… 15
18. Jennifer D. Ward, Niren Raval
THE EFFECTIVENESS OF THE FOUR COMPONENT STUDY PLAN ON RESIDENT
SCORES ON THE AMERICAN BOARD OF FAMILY MEDICINE INTRAINING EXAM.
……………………………………...….…………………..………………………….………………… 15
19. Nanfei Zhang, JJ Peairs, P. Yang, J. Roberts, R. Kole and GJ Jaffe
THE IMPORTANCE OF BCLXL IN THE SURVIVAL OF HUMAN RPE CELLS
……………………………………………….……………………………….………….……………… 16
7
DELIVERY OUTCOME WHEN
ESTIMATED FETAL WEIGHT OF
> 4000G AND COMPARISON WITH
DELIVERIES COMPLICATED BY
SHOUDER DYSTOCIA
Ajay Amin, DO, MPH. WeiPing Lin, OMSIV. and
Guillermo J. Valenzuela, MD, MBA
Department of OB/GYN, Arrowhead
Regional Medical Center,
Colton, CA,
Objective: We decided to compare the characteristics of deliver
ies in which the estimated fetal weight was known before delivery
versus deliveries in patients that suffered shoulder dystocia at the
time of delivery.
Material and Methods.
We reviewed medical records of all pa
tients delivered in a 10 months
period. All reported cases of
shoulder dystocia in four years were reviewed retrospectively for
comparison. Results. 212 of
2442 deliveries (8.68%) patients
received ultra
sound with EFW within 1 week of delivery.
Fortyone patients
were found to have EFW >4000, and all were offered delivery by
cesarean section.
Nine patients went through
trial of labor, and
five (55.6%) failed. Analysis of data showed EFW vs. actual birth
weight > 4000g has sensitivity of 65.6%, specificity of 89%, posi
tive predictive value of 51%,
and negative predictive value of
94.15%. If the threshold of
detection is changed to 4500g,
the
sensitivity becomes 43%, specificity 97%, positive predictive value
33%, and negative predictive value 98%. Of total of 12,965 deliv
eries documented over a period of 4 years,
there were 58 cases
(0.45% National average is 0.5~1.5%) shoulder dystocia reported,
with associated 7 cases (0.054%) of clavicular fracture and 6 cases
(0.05%) brachial plexus injury. Of the 58 cases of shoulder dysto
cia only 7
(12.1%) received ultrasound with EFW within 1 week
before birth, despite some of them being diabetics.
Conclusions. In patients that had an EFW > 4,000 g and chose to
have a trial of labor, none suffered shoulder dystocia. The major
ity of patients with shoulder dystocia had not an USEFW.
We
think that the knowledge of a large baby entering labor influenced
decision making process by which many of those who tried labor,
had a cesarean section for failure
to progress. We changed our
policy to include an estimation of fetal weight in all patient with
diabetes mellitus and anyone with large fundal height (regardless
of maternal weight).
A CASE REPORT AND REVIEW OF
CARDIAC MANIFESTATIONS OF
CHAGAS’ DISEASE AFFECTING A
HISPANIC MALE
Sarkis Arabian D.O., Roozehra Khan, B.S., Kambiz
Raoufi M.D.
Department of Internal Medicine, ARMC
Chagas’ Disease (CD) is a vector borne illness caused
by the parasite Trypanosoma cruzi (T.cruzi), and can manifest as
both acute and chronic illness. CD has been a significant health
concern in South and Central American countries, affecting 10 –
12 million people worldwide. In the chronic phase, morbidity
and mortality is high from complications of cardiomyopathy
such as heart failure, arrhythmias, and thromboembolism. In
United States, CD remains an exotic infectious disease, which can
remain undiagnosed for many years. However, increase in Latin
American population over the recent decades requires physicians
to be aware of the clinical features of this important infection.
In this report, we describe the case of a 43yearold
Hispanic male with history of multiple ischemic strokes and right
bundle branch block, who presented with sudden cardiac arrest
due to pulseless ventricular tachycardia. Further diagnostic test
ing revealed a characteristic dilated left ventricle with poor sys
tolic function and an apical aneurysm on coronary angiography.
Serologic evaluation confirmed the presence of anti Trypanosoma
cruzi antibody.
Chagas’ heart disease and its prevalence in Northern America.
1 2
8
PREVALENCE OF METH AMPHETAMINE INDUCED CARDIO
MYOPATHY Sarkis Arabian D.O., Joe
Maissian D.O., Kristina
Angelo B.S., Kambiz Raoufi M.D.
Department of Internal Medicine, ARMC
Introduction: It is well known that there is high prevalence of
methamphetamine abuse in San Bernardino County. Chronic
methamphetamine use can induce dilated cardiomyopathy.
There have been no studies that we could find looking at extent
and prevalence of cardiomyopathy in this group of patients. We
hypothesize that there is a significantly higher prevalence of
cardiomyopathy in chronic methamphetamine abusers leading to
heart failure contributing to increased morbidity and mortality in
this group of patients.
Methods: This study is a retrospective review of methampheta
mine abusers younger than 50 years old who were admitted to
Arrowhead Regional Medical Center between June 2005 and
December 2006. The echocardiogram results were compared to a
control group during the same time period. The 2 groups were
matched for other cardiac risk factors such as diabetes, hyperten
sion, and renal failure. Data was obtained through chart review,
echocardiogram logs, and computer records.
Results: Total of 210 patients was chosen for analysis. The aver
age cardiac ejection fraction (EF) among methamphetamine abus
ers and control group was 45% and 55% respectively. Further
more, methamphetamine abusers older than 35 years old were
more likely to have EF of less than 40% than those younger than
35 years old (29% vs. 14% respectively).
Conclusion: The results of this study support our hypothesis that
patients with methamphetamine abuse have lower ejection frac
tions and significantly higher rates of cardiomyopathy compared
to the general population. Older methamphetamine abusers
were more likely to have severe dilated cardiomyopathy. Further
prospective data is needed to better understand the pathophysi
ology and treatment of methamphetamine induced cardiomyopa
thy.
WOUND CARE MANAGEMENT IN A
PRIMARY CARE SETTING
Shawn Couture, MD and Martha Melendez, MD
Department of Family Medicine, ARMC
An overall assessment, analysis, and summary of the literature
pertaining to wound care and management was performed and
reported in a concise, organized, and educational format. The
details were arranged to pertain to a primary care setting.
Wound healing has been described by Sussman et al. as,
“a cascade of overlapping series of events that occurs in a rea
sonably predictable fashion.” These events can be classified into
phases; inflammation, epithelialization, proliferation, remodeling.
To properly treat and care for a wound, a comprehensive analysis
of intrinsic and extrinsic factors is necessary. Such factors include
but are not limited to age, presence of chronic disease, tissue
perfusion, oxygenation, immunologic response, wound protec
tion, medications, nutritional deficits, irradiation, chemotherapy,
wound necrosis, infection, quality of wound care, whole patient
care, etc.
Assessing the wound is a thorough and detailed step,
which guides any and all future treatment decisions. There are
numerous methods and systems developed to classify wounds
based on either the level of tissue involvement or encompassing
specific wound etiologies (Sussman et al. p.89). Examining and
describing the wound attributes include location, age of wound
(days/weeks/months), size (length and width), stage or depth,
evaluation for undermining or tunneling, presence or absence of
characteristics that would hinder or aid wound healing (eg. ne
crotic tissue/escar, erythema, edema, infection, condition of
wound edges, granulation tissue, epithelialization, etc.), and a
description of exudate if present (color/type, volume, odor, con
sistency). One must not overlook the examination of the sur
rounding tissue or periwound environment as this may provide
detailed clues that can identify the health of the skin, phase of
wound healing and the patient’s overall health status. These
attributes include skin texture, scar tissue, callus, maceration,
edema, color, sensation, temperature, hair distribution, toenails,
and blisters. The assessment should be updated on every en
counter.
Continuing with wound characterization, one must
determine the current stage of wound healing as well as clarify
the wound healing status. This may be as simple as acute or
chronic terminology. In addition, the etiology of a wound needs
to be uncovered to be able to treat the source of the wound. Here,
one takes into consideration the need for additional testing to
assess woundhealing capabilities. These tests can include the
anklebrachial index (ABI), continuous wave doppler, duplex
ultrasound, roentgenographs, magnetic resonance imaging/
angiography, and transcutaneous tissue oxygen measurements.
Finally, the decision for treatment can be made which includes
the utilization of referrals. The goal of applying a dressing is to
improve the wound’s overall healing abilities by providing a
moist environment.
Wound management is a comprehensive, multidiscipli
nary approach to care for the patient and the healing wound.
This includes a clear understanding and knowledge of wound
(Abstract truncated due to its length)
3 4
9
DIABETIC MYONECROSIS
Khaled El Said, MD, and Mark Shiu, DO
Department of Family Medicine, ARMC
Introduction: Diabetic Myonecrosis is
an uncommon complica tion of (DM),
presenting with severe pain in
the medial thigh. Diabetic myonecrosis
is often misdiagnosed as
a Neoplasm, an abscess,
or myositis. Significant proportions
of patients do not
comply with their insulin regimen and as a result have poor dia
betic control for 5 to 30 years (mean, 15 years).
Diabetic myonecrosis is unique as it occurs in young adult (Mean
age, 37 years) and is more common in Females. The etiology may
be atheroembolism or Arteriosclerosis
obliterans. The patho
physiologic Pathway of Diabetic myonecrosis is controversial.
Some
investigators propose, a compartmental Syndrome exacer
bating Ischemia versus abnormalities in the clotting cascade or in
Fibrinolytic Pathways. Case
Presentation: Patient is a 46
y/o African American Male
with h/o longstanding Diabetes Mellitus
type II (HgA1c: 13.6)
With Retinopathy and Peripheral Neuropathy and HTN, present
ing With few months history of
right leg pain and swelling.
Movement Makes the pain worse, No associated trauma to the leg,
or fever & Chills.
Conclusion: Diabetic Myonecrosis is an uncommon, missed sign
Of underlying chronic vascular disease. Most patients reported in
Literatures are relatively young with
a mean 15 yr history of
diabetes With poor chronic control. The pathophysiology is not
understood yet. With an appropriate clinical history and typical
MRI findings, a Diagnosis of DMI can often be made, permitting
conservative Management. In atypical
cases, or where clinical
doubt persists Regarding the diagnosis, biopsy can be performed.
CASE REPORT: WEGENER’S GRANU
LOMATOSIS IN A 19YEAROLD MALE
Phuongdoan L Doan, DO, Pooja Gupta, DO
Department of Family Medicine, ARMC
This is the case of a 19yearold male who presented
with newonset Wegener’s granulomatosis, a rare disease in
which delay in diagnosis would mean dire consequences for the
patient. Advances in medicine have shed better understanding
on this disease and resulted in improved outcomes for patients
diagnosed with Wegener’s granulomatosis.
5 6
10
EVALUATION OF PREHOSPITAL AND
EMERGENCY DEPARTMENT
SYSTOLIC BLOOD PRESSURE AS A
PREDICTOR OF INHOSPITAL
MORTALITY Paul Wisniewski, DO,
Angelica Loza, MD, Katie
Huynh, MS4 and Fariborz Lalezarzadeh, DO
Department of Family Medicine, ARMC
Department of Surgery, ARMC
Trauma patients need an organized team of profession
als in a specialized trauma center to receive efficient medical care.
Trauma activation at Arrowhead Regional Medical Center
(ARMC) is well established and primarily focuses on mechanism
of injury, anatomy, and physiology. Hospitals nationwide typi
cally follow the guidelines established by the American College
of Surgeons Committee on Trauma to create trauma activation
criteria. Some of these variables have been scientifically vali
dated; however, they have not been studied as independent pre
dictors of mortality. The present study focuses on prehospital
systolic blood pressure (SBP) with emergency room SBP as one
variable used to predict inhospital mortality at ARMC. The goal
is to assist in the triage and prognosis of trauma patients that fall
within the systolic blood pressure categories.
This is a retrospective observational analysis of all
trauma patients seen at ARMC over a 5year period. Patients who
were dead on arrival, those transferred to another facility for
higher level of care, or with incomplete data in the emergency
room were excluded. A total of 6,964 patients were analyzed.
Patients were categorized into 4 different groups based on their
prehospital systolic blood pressure readings. Severe hypoten
sion, defined as SBP ≤ 80 mmHg; moderate hypotension, defined
as SBP 81100 mmHg; mild hypotension, defined as SBP 101120
mmHg; and normotension, defined as SBP >120 mmHg. Each of
the 4 groups was further subcategorized based on whether the
patients were hypotensive or not in the emergency department,
defined as systolic blood pressure ≤ 90mmHg. The overall mor
tality for patients with severe prehospital hypotension was
18.1%. Patients who had both severe prehospital hypotension as
well as ER hypotension had mortality of 50%. Odds ratio analysis
demonstrated that there was a 9fold increase in mortality in
patients with severe prehospital hypotension compared to all
other patients with a prehospital systolic blood pressure >80
mmHg.
The data illustrated a physiologic expectation; a low
blood pressure in the field and a low blood pressure in the emer
gency department is associated with poor prognosis. However,
this study elucidated the severity of the expected poor outcome.
The odds ratios consistently depict that prehospital hypotension
and ED hypotension show a decreased in hospital survival. This
information is important for the ARMC trauma team in order to
have a higher index of suspicion about the severity of a traumati
cally injured patient based on severe prehospital hypotension.
SOMATIC EXPERIENCING
TREATMENT IN AN 8YEAR OLD BOY
SUFFERING FROM PTSD: A CASE
REPORT
Pat Kouwabunpat, MD, Elaine MillerKaras, LCSW,
and Deborah Small, MD
Department of Family Medicine, ARMC
Somatic experiencing (SE) is an emerging therapeutic modality
that shows promise in being able to treat posttraumatic stress
disorder (PTSD). PTSD is a debilitating condition that is com
monly treated through two psychotherapy techniques called
cognitive behavioral therapy (CBT) and eye movement desensiti
zation and reprocessing (EMDR). However, preliminary obser
vations suggest that SE may be an effective, singletreatment
option in lieu of the more extensive traditional therapies. This
case report describes implementation of the SE technique in a
family medicine clinic setting, on an eight year old child suffering
from PTSD as a result of being bitten by a dog. The outcome of
this SE implementation, occurring within a twenty minute office
visit, resulted in immediate and full resolution of symptoms.
This case report lends further evidence to the burgeoning SE
technique as a viable modality in trauma therapy alongside CBT
and EMDR. Additionally, this case report demonstrates that SE
can be implemented effectively and in a timely manner in the
medical setting, including outpatient offices and emergency
rooms.
7 8
11
FONTANA HEALTH CLINIC PATIENT
SAFETY CULTURE SURVEY
Gerardo B. Martin, MD and Emily Ebert, MD
Department of Family Medicine, ARMC
Objective: The survey
instrument used in this study was
taken from the Agency
for Healthcare Research Quality (AHRQ),
the lead Federal agency
charged with conducting and supporting
research to improve patient safety and health care quality for all
Americans. The purpose of the
study was to gauge the patient
safety mindset of the staff at the Fontana Health Clinic. The sur
vey was designed to1) provide a view of the current patient safety
climate at the clinic, 2) provide an assessment of employee opin
ions, attitudes, and concerns, 3)
communicate key messages to employees
about what is important, 4)
document frequency of events
reported, 5) provide a release
valve for employees (to speak
their minds),6) communicate results
to clinic and hospital
administrators to determine areas of priority and improvement in
patient safety, 7) serve as a baseline survey and comparison
for progress over time against
opportunity areas, 8) compare our
results to the AHRQ’s national database average.
RESULTS: In November, 2007, a total of 40 clinic staff at Fontana
Health Clinic participated
in the survey instrument.
The results of the survey
items were found to populate
the desired positive
categories except for staffing. Most of the people in the clinic feel
that there is not enough staff to handle the workload. Nurses feel
that their mistakes are held
against them and are kept in
their personal file. Clinic
assistants disagreed to the statement
that
“staff feel free to question decisions or actions of those with more
authority”. Resident physicians
disagree to the statement that
“staff in this unit work longer hours that is best for patient care”.
Frequency of error reporting was
also an area of concern and
showed the clinic was below the national average.
CONCLUSION: The survey
instrument educated the staff and
built awareness about issues of concern related to patient safety at
the clinic. The survey provided a
glimpse of the patient safety
culture at the Fontana Health Clinic and it also provided a release
valve for staff to voice out opinions. It is intended to reduce any
“climate of blame” in the clinic and to encourage error reporting
which has been a constant problem according to literature. There
is evidently a climate of blame
that exists at the Fontana Health
Clinic and this needs to be
improved upon. Staffing is
also a
major problem identified. If staff feels that their mistakes are not
held against them, more errors would be reported, hence, safety
problems would be identified and
actions plans can be imple
mented to prevent patients from harm. This survey would hope
fully not be the end but the beginning of action planning to
im
prove the safety culture in the clinic and would serve as baseline
for comparison for future surveys.
DRESS SYNDROME AFTER THERAPY
WITH LITHIUM Janiene Luke, MD
Department of Family Medicine, ARMC
Drug Rash with Eosinophilia and Systemic Symptoms
(DRESS), also known
as Hypersensitivity Syndrome is a
severe adverse drug reaction
clinically characterized by fever,
cutaneous mani festations that range
from a morbilliform eruption
to exfoliative dermatitis, eosinophilia,
lymphadenopathy and visceral involve
ment most commonly being hepatitis, but can include myocarditis,
nephritis, pneumonitis and thyroiditis. The differential diagnosis
includes: other cutaneous drug eruptions, acute viral
infections, idiopathic hypereosinophic
syndrome, lymphoma and pseudo
lymphoma. Removal of the offending
agent and corticosteroids
are firstline therapy for DRESS syndrome, however, milder cases
can be treated topically with a highpotency corticosteroid.
This case report describes an 18 year old female with manifesta
tions of DRESS syndrome soon after initiating therapy with lith
ium for Bipolar
disorder. Although DRESS syndrome is
com monly reported
in patients after use of anticonvulsants
such as
carbamazepine, phenytoin, and phenobarbital, to my knowledge
there have been no reports
of DRESS syndrome in association
with lithium use.
9 10
12
ULNATOSTATURE RATIO AS A PRE
DICTOR OF BREAST CANCER
Wildred Rico, MD, James Martin, COMP and Vivian
Davis, DO
Department of Family Medicine, ARMC
Department of Surgery, ARMC
Introduction: Recent epidemiologic studies have investigated the
possibility that exposure during very
early life to hormones or their
analogues increases adult cancer
risk. A highly estrogenic intrauterine
environment may lead to a
greater risk for breast
cancer in adulthood.
Objectives: Estrogens and androgens are two of several hormone
groups that regulate long bone
growth during childhood and
adolescence. Rising estrogen levels at the onset of adolescence are
thought to stimulate long bone growth in girls. Later at the end of
adolescence, an estrogen signal is responsible for the end of long
bone growth. Some portion of
the variance in long bone lengths
may be due to variable amounts of estrogen exposure. Long bone
to stature ratios have not been systematically examined in breast
cancer patients. We propose to examine women with breast can
cer to determine if they have ulna to stature ratios and other an
thropometric traits that differ from control populations.
Methods: We conducted a retrospective
study recruiting breast
cancer patients (n=138) and control subjects (n=192). Women over
18 and under 75 years of age were enrolled from white, black, and
Hispanic ethnic groups from 5 local Southern California hospitals.
Subjects designated as
the breast cancer group or control group
were recruited from a pool of inpatients, outpatients and visitors.
Ulna length was determined using an osteometric board with the
elbow seated against the back of the board; the edge of the styloid
process was marked on a paper
recording sheet on the board.
Measurements were made in triplicate to the nearest 0.1 mm.
Results: We performed an ANOVA
analysis to compare ulna stature ratio
in breast cancer versus control
in Hispanics, whites and blacks.
In the black population,
the ulnastature ratio in the
breast cancer group was significantly higher
than in the control
group with p= .04. A similar trend was observed in whites, p > .05.
However, in Hispanics,
the breast cancer group was not signifi
cantly different from the control group, p > 10. In all ethnic groups
breast cancer patients were older
than controls. This raises the
question of whether age might be a
factor in any difference ob
served between groups. A regression
analysis of age and ulna stature
ratios showed no significant
difference between breast cancer and
control groups for any of the
three ethnic groups.
Other factors might also have contributed to variation in the ulna
to stature ratio. Since the maternal gestational hormone environ
ment may vary systematically for different sibship positions, we
examined how birth order may potentially influence ulna to stat
ure ratio in breast cancer and
controls. Over all ethnic groups,
birth order was a significant source of variation in ulna to stature
ratios (F3,256 = 3.95, p = .0089). However, the interaction of birth
order and disease was not significant.
Conclusion: The results of this study do not provide strong evi
dence to support the hypothesis that increased estrogen exposure
early in life can lead to future development of breast cancer. If one
assumes that ulna:stature ratios are inversely
related to early
A RETROSPECTIVE STUDY OF
MATERNAL ICU ADMISSION IN A
COUNTY HOSPITAL SETTING FROM
20042007 AND REVIEW OF
LITERATURE Lauren Prewitt, DO, Lony
Castro, MD and Nina Agarwal, BS
Department of OB/GYN, ARMC
Objectives: Pregnancy increases a woman’s chance of morbidity
or death. We used maternal ICU admissions as a proxy for
severe maternal morbidity. Our goals were to describe the major
diagnoses and hospital course leading to a maternal ICU admis
sion in a county hospital setting.
Methods: We performed a retrospective review of all ICU ad
missions involving pregnant or postpartum women at a subur
ban county hospital over a 3 year period (20042007). Charts
were abstracted and underwent a two tier review. Each case was
summarized. We focused on outpatient and inpatient medical
care, in addition to the hospital course once in critical care.
Results: We identified 50 cases (1 maternal ICU admission/ 200
deliveries). The main diagnostic categories are listed in the table
below. There was one maternal death from cardiac disease (non
preventable) and 3 cases of longterm major morbidity. 80% of
patients had either one or more contributing comorbidities
(maternal substance use, chronic hypertension, diabetes, obesity,
renal disease, pancreatitis, previous cesarean, psychiatric disease
and cardiac disease predominated). 70% of these ICU admissions
involved morbidity which was directly pregnancy related. 30%
involved severe medical complications which were only indi
rectly related to the pregnancy.
Conclusions: Our rate of ICU admissions is similar to other
estimates (approx 1/200) of severe maternal morbidity in preg
nancy. The major diagnoses are also consistent with the litera
ture. The presence of multiple comorbidities contributed to the
severity of illness and created diagnostic and therapeutic chal
lenges for the managing physicians. Attempts at decreasing
severe morbidity in patients like these require frequent and com
prehensive evaluations.
14 cases of postpartum hemorrhage
12 cases of severe preeclampsia/HELLP
8 cases of pulmonary disease
4 cases of CNS morbidity
4 cases of sepsis
3 cases endocrine/metabolic disorders
3 cases of cardiac disease
2 cases of adverse drug reactions
11 12
13
SENSITIVITY OF ULTRASOUND IN
SCREENING FOR ENDOMETRIAL
PATHOLOGY IN PATIENTS WITH
ABNORMAL UTERINE BLEEDING Dawn
RileyCavner, DO and Guillermo J.
Valenzuela, MD, MBA
Department of OB/GYN, ARMC
Objective: The purpose of this study was to evaluate whether
determination of endometrial thickness and endometrial biopsy
are both necessary to adequately assess patients with abnormal
uterine bleeding. The null hypothesis is that endometrial biopsy
is not necessary if the endometrial thickness is normal on ultra
sound examination. The alternative hypothesis is that abnormal
endometrial thickness will detect endometrial abnormalities,
making biopsy unnecessary.
Material and Methods: Medical records from patients that un
derwent endometrial biopsy and their concomitant endometrial
thickness measured by ultrasound were reviewed. A total of 402
charts met inclusion criteria (abnormal uterine bleeding, pelvic
sonogram, pathology report). Data collected included age, endo
metrial thickness expressed in millimeters, and endometrial bi
opsy results (stratified into benign, atypical, insufficient, and
malignant).
Results are expressed in the table below:
Endo metrial thickness + std error
41 + 5 42 + 3 23 + 4
29 + 7
Atypical or Malig nant (%)
1.2 2.5 1.2 8.6
N 83 199 84 35
EFFICIENCY OF ANTEPARTUM NON
STRESS TESTING AT ARROWHEAD
REGIONAL MEDICAL CENTER
Kristina Roloff, DO, and Guillermo J. Valenzuela,
MD, MBA Department of OB/GYN, ARMC
Objective. The purpose of this study was to establish the average
time to fetal heart rate reactivity and whether present resources
utilization are maximized.
Methods. To assess the time interval between an NST becoming
reactive and the interval at which the NST was discontinued, a
prospective review of chart, not randomized, was performed in a
prospective manner (as not to be influenced by outcome). The
time to reactivity, defined as the length of time for fetal heart rate
tracing to demonstrate two 15 beat by 15 second duration accel
erations, was measured. Additionally, total time monitored, ges
tational age, indication for NST, amniotic fluid index (AFI), pres
ence of contractions, and presence of fetal heart rate decelerations
were noted.
Results. The average time interval from reactive to discontinua
tion of NST was 19.1 min + 1.2 (SEM). There was no trend no
ticed in the time of the day and the length to discontinuation of
the test.
Conclusion. From this sample is seems that there is opportunities
to become more efficient with the performance of NST. This
could contribute to overall patient satisfaction
13 14
14
DO INCREASED AMOUNT OF OMEGA
3 FATTY ACIDS IMPROVE
SYMPTOMS OF DEPRESSION?
Dannette Saguan, DO and Martha Meledez, MD
Department of Family Medicine, ARMC
Objective In patients with Major Depressive disorders (MDD),
lower serum levels of eicosapentaenoic acid (EPA) were found
compared to controls [1, 9]. Moreover, most of the EPAs in the
brain are of the 3 type and its deficiency was observed to be
related to the serotonergic or catecholaminergic disturbances in
MDD [8]. The objective of this study is to compare the symptoms
of depression at baseline and the same after increasing oral intake
of foods high in Omega3 FA.
Study Design A prospective clinical study in a group practice
county Family Health Clinic setting.
Results In more than 50% of the patients with Major Depressive
Disorder assessed over at least a 24 month period, 24 symptoms
were reported to have improved after increased intake of foods
high in Omega3 FA. Statistical significance is still to be deter
mined.
Conclusion Although there may have been a subjective improve
ment in the symptoms of depression, many other factors can
confound this simple correlational relation. The number of sub
jects, the amount of Omega3 FA intake, and the use of anti
depressant medications alls need to be accounted for. The exact
benefit of an increased intake of foods high in Omega3 FA re
mains to be determined.
EXTRACRANIAL CAROTID ARTERY
ANEURYSMS: A CASE REPORT
Ravi Shah, DO, and Jeffrey Hsu, MD
Department of Surgery, ARMC
Department of Surgery, Kaiser Permanente, Fontana, CA
Introduction
Extracranial carotid artery (ECA) aneurysms are ex
tremely rare, as only about 2600 of them have been reported.
Therefore it is impossible to define their true incidence and infor
mation about immediate and long term results of surgical ther
apy is sparse. However, with the increasingly widespread use of
technology, such as ultrasound, angiography, and other modali
ties, ECAs are recognized more often than before. The etiology of
these aneurysms include atherosclerotic disease, trauma
(penetrating and blunt), infection, congenital aneurysms, and
pseudoaneurysms resulting from prior carotid surgery. The pri
mary complications of untreated ECAs are rupture, thrombosis,
and embolism, resulting in vast array of neurologic deficits.
Treatment includes surgical resection of the aneurysm and resto
ration of arterial continuity.
Case Report
A 79 year old male with HTN, hyperlipidemia and a
right carotid bruit underwent a screening carotid ultrasound. He
had no history of strokes, weakness, numbness or tingling. The
ultrasound showed bilateral internal carotid artery stenosis of 50
79%, and a small focal outpouching of the proximal left internal
carotid bulb. A CT angiogram of the neck depicted a saccular
aneurysm (12x9x8 mm) of the proximal left internal carotid artery
just above the bifurcation. Due to the risk of neurologic events
and rupture, the patient underwent successful left carotid en
darterectomy with patch angioplasty and excision of carotid
aneurysm. There were no operative complications and the pa
tient was discharged home the following day.
Conclusion
Satisfactory longterm results with surgery have been
reported in the current literature, and due to the potential risks of
cerebral ischemia and rupture, surgical repair is warranted in the
treatment of ECA aneurysms.
15 16
15
INTRACRANIAL ARTERIAL FENES
TRATION AND ASSOCIATION WITH
ANEURYSM: A CASECONTROL RET
ROSPECTIVE STUDY AND REVIEW OF
LITERATURE
Stephanie L. Tang, DO and Arthur B. Dublin, MD
Department of Family Medicine, ARMC and UC Davis Medical
Center, Sacramento, CA
BACKGROUND AND PURPOSE: Cerebral artery fenestration is
rare but wellrecognized congenital anomaly that can occur any
where in
the anterior and posterior
cerebral arterial circulation.
Fenestration is believed to be a consequence of incomplete fusion
of bilateral primitive longitudinal neural arteries during the fetal
period [Padget et al]. Their clinical significance lies in their possi
ble association with arterial
aneurysms either at the site of
the
fenestration or in a separate location. Although their association
has been frequently mentioned
in many case reports, there are
only a small number of published studies done to evaluate their
association. The majority of published reports detected fenestra
tions using cerebral angiograms.
There are very few reports
studying the association of fenestration using CTA or MRA. This
is clinically
important as convention moves away
from cerebral
angiograms to MRA and CTA as the imaging modality of choice
of initial evaluation of the
cerebral vasculature. To our knowl
edge, this is the first casecontrol retrospective study on cerebral
artery fenestration and their association with aneurysm evaluated
by one of or
in any combination of the
following: cranial MRA,
CTA and cerebral angiography.
METHODS: We compiled a database of cerebral MRA, CTA, and
Angiography reports containing the key words fenestration and/
or aneurysm from July 1, 2001 to February 5, 2007. Each fenestra
tion case was retrospectively reviewed by a board certified radi
ologist for confirmation of fenestration
location and aneurysm if
present. The incidence and odds
ratio was then calculated from
this study population.
RESULT: Our study found the incidence of cerebral artery fenes
tration to be 0.60%. The
highest incidence of fenestration oc
curred in the basilar artery (0.36%), followed by anterior commu
nicating artery (0.13%), anterior
cerebral artery (0.07%), Middle
cerebral artery and vertebrobasilar junction (0.04%) and Posterior
cerebral artery (.02%) accordingly. We did not find any fenestra
tion along the internal carotid arteries. The odds ratio of a patient
with cerebral artery fenestration also having aneurysm was 1.18.
Of the 36 patients with
fenestration(s), twentyone was female
and fifteen were male. The
percentage of female fenestration
patients with aneurysm was 19% and male
fenestration patients
with aneurysm were 20%.
The odds ratio of
fenestration occur
ring with aneurysm is 1.18.
DICUSSION: As a tertiary referral center for stroke, trauma, and
oncology, we expected to
find a higher
incidence of cerebral ar
tery fenestration then other institutions. However, our incidence
was within the wide range of incidence reported in literature. The
incidence of fenestration occurring with
aneurysm either at the
same site of fenestration or at a satellite location was only 0.12%.
(Abstract truncated due to its length)
THE EFFECTIVENESS OF THE FOUR
COMPONENT STUDY PLAN ON
RESIDENT SCORES ON THE
AMERICAN BOARD OF FAMILY
MEDICINE INTRAINING EXAM.
Jennifer Ward, MD and Niren Raval, DO
Department of Family Medicine, ARMC
In an attempt to determine why some residents reach the mean
on the annual ABFM InTraining Exam (ITE) and others do not, a
survey was conducted to determine whether the number of com
ponents used of a Four Component Study Plan made a difference
in resident scores, and ultimately whether residents using the
Plan met the mean on the ITE or not. The survey found no signifi
cant difference in study components used between residents. The
data is inconclusive, though, as to whether the Four Component
Study Plan makes a difference on ITE scores. This is secondary to
faults in the survey design, which are discussed below. If, on
future surveys, it is found that the Four Component Study Plan
influences whether or not a resident does well on the ITE, it will
provide guidance as to how to set up study plans for residents on
the PIP.
17 18
16
1st Place
(Transitional Year)
2nd Place "A Prospective Study To Evaluate The Depth Of
Sedation
In Patients Undergoing Procedural Sedation" Jonathan Kelling,
M.D.
(Transitional Year)
3nd Place “Retrospective Study of Second Trimester Intrauterine
Fetal Demise (IUFD):
Methods of Induction” Lisa Barden, DO
(Department of OB/GYN)
1st Place
"Effectiveness of ARMC’s “Quit Clinic” for Smoking Cessation"
Hansie Wong, MD
(Department of Family Medicine)
2nd Place "Incidence of Abnormal Blood Gases Among Patients
Undergoing
Elective Cesarean Section" Nicole Adair, DO
(Department of OB/GYN)
3nd Place “Utilization of the Rapid HIV Test in the Emergency
Department”
Patricia Kahn, DO (Department of Emergency Medicine)
19
Dan Miulli, DO Ms. Rebecca Rivera
Departments of Anesthesiology
Surgery
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/HRV (Za stvaranje Adobe PDF dokumenata najpogodnijih za
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