United States

Background: Myasthenia gravis, the most common autoimmune disease affecting the neuromuscular junction, is characterized by generalized muscle weakness. Myasthenia is easily treated, yet social determinants of health can complicate a patient’s access to treatment, prolonging symptoms and increasing patient suffering. Further, residents of rural Maine struggle with healthcare access, as 40% of Mainers live in rural areas and 6% of Mainers are uninsured. 

Case Presentation: A 29-year-old female presented to our hospital’s emergency department from her neurologist’s office. She presented with four months of neck and limb weakness and dysphagia; these symptoms worsened throughout the day. She recently had left her job, as she could no longer perform her duties due to weakness. A resident of rural Maine without health insurance who did not qualify for Medicaid, this patient had not seen a primary care provider (PCP) in five years. She was previously evaluated in an urgent care for similar symptoms and was advised to consult a PCP for further work-up. It took two months for the patient to secure a PCP; she was referred to a neurologist who immediately sent her to the emergency department.

On examination, the patient’s strength was globally 3/5. She was hyporeflexive. She ambulated with a walker. A workup for a neuromuscular syndrome was started. A chest CT did not show a thymoma. The patient was admitted to the hospital, where she was seen by neurology and started on pyridostigmine; she demonstrated immediate improvement. She was discharged one day later with a diagnosis of myasthenia and inflammatory motor neuropathy.

On follow-up with her neurologist one month later, the patient reported mild improvement with pyridostigmine. IV immunoglobulin (IVIG) therapy was ordered to treat her motor neuropathy. However, the patient was still unable to secure insurance, and IVIG therapy was delayed two months. Three months post-discharge, the patient secured insurance and began treatment with IVIG infusions. 

Discussion: The most salient aspect of this case is the patient’s social determinants of health – specifically lack of health care access. This case highlights the disparities that exist for underinsured adults and the great need for PCPs, especially in rural areas. Further, myasthenia is easily treated, yet the patient’s delay in treatment played an enormous impact on her physical and social wellbeing. This case serves to underline the consequences of limited PCP availability and insurance access which prolongs physical and social suffering for conditions with clear treatment, such as the myasthenia demonstrated in this case. 


AMA Research Challenge 2023

Myasthenia Gravis Complicated by Lack of Healthcare Access in Rural Maine

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Background:
Amiodarone-induced thyrotoxicosis (AIT) is one of the many side effects of the antiarrhythmic amiodarone. It can manifest in two forms: type 1 and type 2. Type 1 AIT occurs in patients with preexisting thyroid disease and is caused by excess thyroid hormone synthesis due to amiodarone’s high iodine content. Type 2 AIT is a destructive thyroiditis resulting from amiodarone’s direct toxicity on the thyroid gland causing the release thyroid hormone. Differentiating between these two is challenging due to overlapping clinical features and laboratory findings. However, it may be advantageous to differentiate between type 1 and type 2 AIT as the treatment approaches vary. A collaborative approach involving endocrinology, cardiology and the primary team is essential for accurate diagnosis and timely management.

Case Presentation:
A 67-year-old male with a past medical history of hypertension, hyperlipidemia, atrial fibrillation, coronary artery disease status post coronary bypass, and plaque psoriasis presented to our ER complaining of chest pain during bowel movements. Home medications included apixaban, amiodarone, lisinopril, carvedilol, atorvastatin, and isosorbide mononitrate. He was accepted to the ICU due refractory atrial fibrillation with rapid ventricular rate (A-fib with RVR).

Discussion:
The diagnosis was AIT causing refractory Afib w/RVR, however uncertainty remains regarding the type of AIT and complicating management. We suspected type II AIT as the patient lacks Graves’ disease or nodular goiter. Unfortunately, guidelines providing a clear distinction between type I and type II are limited, contributing to the lack of standard treatment approaches.
Clinical criteria used to differentiate between type I and type II AIT include timing, onset, underlying thyroid disease, thyroid hormone levels, and thyroid scintigraphy. There is also color flow doppler sonography (CFDS) which is a real time technique that depicts intrathyroidal blood flow giving physician information on thyroid morphology and hyperfunction. While these tools provide insight it is important to note that these criteria may overlap, and atypical presentations make the differentiation challenging. One aspect of contention revolves around the continuation or discontinuation of amiodarone. Some clinicians argue that if the type of AIT remains uncertain, continuing amiodarone for rhythm and rate control in atrial fibrillation does not significantly prolong the patient’s hospital stay. Conversely, others advocate for discontinuing amiodarone unless there is a life-threatening ventricular arrhythmia. Establishing a consensus to differentiate the types of AIT would improve treatment approaches and reduce the need for more invasive measures like thyroidectomy.


Amoidarone-induced Thyrotoxicosis (AIT): Subtype Differentiation and Management

Chat Generative Pretrained Transformer (ChatGPT) is a new language model developed to learn and converse interactively with users. Current medical research using ChatGPT has been done through the allopathic lens. Our research project shifts this viewpoint to focus on the Osteopathic holistic beliefs by asking ChatGPT questions about Osteopathic Manipulative Medicine (OMM). This research project will add to ChatGPT's knowledge base and provide physicians with more insight into ChatGPTs abilities.

Analyzing ChatGPT’s Proficiency In Multiple Choice Osteopathic Manipulative Medicine Questions: Insights and Implications

Background
Amphetamines are the first line treatment for ADHD in adults. There are many cardiac pathologies associated with amphetamine use such as hypertension, atrial fibrillation, and cardiomyopathy. A known complication of amphetamine abuse is that it can induce thoracic aortic dissection by facilitating the breakdown of elastin, medial cells, and degeneration of the blood vessel. Another proposed etiology for the association of amphetamine use and aortic dissection is hypertensive-mediated aortic dissection secondary to amphetamine use. Marfan’s syndrome is a congenital defect in fibrillin 1 which leads to impaired elastin formation. The leading cause of death in patients with Marfan’s syndrome is aortic pathology, specifically aortic dissection. The association between Marfan’s syndrome and amphetamine use is something not well described in the literature. 
Case Presentation
A 21-year-old man with a history of ADHD and Marfan’s syndrome presents to his primary care physician requesting medications to help him “focus” and “concentrate”. He had no other complaints and his physical exam showed a tall and lanky man, with arms disproportionally longer than his body. No cardiac abnormalities were heard on auscultation and no cataracts were visible on fundoscopy. His physician reviewed his previous EKG from three months prior and administered another EKG in clinic. Both EKG’s showed sinus rhythm with no indications of any heart defects or atrial fibrillations. Echocardiography from his cardiologist showed no aortic root dilation or cardiomyopathy. The patient was prescribed amphetamines, informed of the potential risks, and told to follow up in 4 weeks. 
Discussion
Marfan’s syndrome presents with variable expressivity, with some phenotypes being milder than others. This patient presented with a marfanoid body habitus but showed no cardiovascular or ocular abnormalities. Physicians should consider the risks associated with prescribing amphetamines for ADHD in patients with Marfan’s Syndrome. The literature only describes one reported case of amphetamine induced aortic dissection in a Marfan’s patient. Other papers claim undiagnosed Marfan Syndrome to be the culprit as to why there hasn’t been a clear established relationship between the two, pushing that every atypical aortic dissection in young people should be biopsied for connective tissue diseases. Nevertheless, reason compels physicians to complete a full cardiac workup of patients with Marfan’s syndrome to evaluate for any cardiac or aortic manifestation of disease that would push them to try a safer alternative for their patient. 


Aortic Complications to Consider in the Management of ADHD 
in Marfan’s Patients

This case details a unique fatal outcome of myocarditis in a 17-year-old Black male. The young patient initially displayed symptoms resembling stomach flu. A rapid decline in his health led to sudden death. Postmortem findings and CDC evaluation revealed ischemic myocarditis as the cause. Two positive post-mortem COVID tests suggest emphasizing the need for broader diagnostic perspectives, vigilance in monitoring symptom evolution, and understanding of COVID-19's varied impacts on the pediatric population


Fatal Case of Myocarditis in a 17-Year-Old Black Male with COVID-19

Background. Cocaine abuse is a major worldwide health problem with an estimated 5 million users in the USA. Crack cocaine inhalation causes serious pulmonary complications, which may progress to respiratory failure, leading to in-hospital mortality ranging from 20% to 100% [1]. Pulmonary complications include: diffuse alveolar damage and hemorrhagic alveolitis, pulmonary edema, eosinophilic pneumonia, foreign body granulomas, cocaine related pulmonary infection, obliterative bronchiolitis, asthma, pneumothorax, thromboembolic disease and persistent gas-exchange abnormalities. Respiratory manifestations are nonspecific and include shortness of breath, fever, cough, wheezing, hemoptysis, and chest pains. 
Case Presentation. A 42-year-old male was found unresponsive on the street with a crack pipe on him. He had pinpoint pupils and was breathing inadequately with respiratory rate (RR) of 7-8 per minute. After he was given naloxone, he started reacting to noxious stimuli. He was placed on a non-rebreather mask (NRBM) and was transferred to the hospital. In the emergency room, the patient was hypertensive, tachycardic, and desaturating to the 50s, which together with low Glasgow Coma Scale (GCS) prompted intubation and mechanical ventilation with settings of FiO2 100%, VT 460 ml, RR 24, and PEEP 12. The patient became hypotensive, requiring two vasopressors. On a physical exam, a large amount of blood was noted in the endotracheal tube. Initial labs showed pH 7.16, pCO2 59, pO2 53, elevated lactate and neutrophilic leukocytosis. Urine toxicology was positive for cocaine. EKG showed sinus tachycardia. Chest X-ray demonstrated bilateral infiltrates. CT-chest revealed extensive bilateral airspace opacities suggesting ARDS versus diffuse pulmonary hemorrhage. The patient was admitted to ICU for acute hypoxemic hypercapnic respiratory failure, circulatory shock due to ARDS vs diffuse alveolar hemorrhage and septic shock due to aspiration pneumonia. The management included antibiotics, IV fluids, vasopressors and supportive care. During a course of ICU stay for four days, the patient’s needs for vasopressors decreased and mental status improved. On day 4, the patient extubated himself. He was placed on a high flow nasal cannula. His vital signs remained stable, and he was alert and oriented to person, place and time. On repeat chest X-ray, diffuse bilateral airspace opacities decreased in size. Thus, the patient was downgraded to the floor.
Conclusion. The present case highlights pulmonary complications of cocaine use. Clinicians must consider various pulmonary complications in the differential diagnosis of respiratory failure when evaluating critically ill patients with history of cocaine use.


Pulmonary Complications of Crack Cocaine Inhalation

Background
Pitt Hopkins Syndrome (PHS) is a rare genetic condition (~1:35,000 births) involving pathologic variants of the TCF4 gene. Manifestations of PHS include developmental delay, seizures, gastro-esophageal reflux (GERD), and autonomic dysfunction (e.g., hyperventilation, constipation). There is limited understanding of disease progression into later adulthood. We here-in present the case of the oldest reported patient with exome sequencing confirmed PHS with recurrent fevers and orange urine.
Case Presentation
A 35-year-old male with diagnosed PHS presents to primary care clinic for recurrent fevers and discolored urine. The patient is non-verbal at baseline with global developmental delays. His main PHS symptoms include hyperventilation spells, severe GERD requiring fundoplication, seizures, and dysautonomia. Three months prior, he was hospitalized with fever, malaise, and breakthrough seizures. Workup was notable for Influenza A and radiographic evidence of aspiration pneumonia and a bladder calcification. He received phenobarbital, anti- microbials, and supportive care and was discharged home once stabilized. Since discharge he has experienced nightly fevers up to 101 oF with intermittent evanescent rash. Associated symptoms included poor oral intake, aggression, malaise, and increased seizure frequency. He also had fluorescent orange, malodorous urine and was diagnosed with multiple UTIs that recurred after treatment, and fevers persisted.
© 2023 American Medical Association. All rights reserved.
A broad differential for recurrent fever was considered. Autoimmune/inflammatory diseases, such as Still’s disease, were effectively excluded with an unremarkable rheumatologic workup. Malignancy was considered less likely with normal imaging and blood counts. Infectious disease specialists found no evidence of chronic infectious process or Lyme disease. However, recurrent aspiration pneumonia was considered given severe GERD. Initial urologic evaluation showed non-specific signs of dehydration. His previously identified bladder calcification was thought to be consistent with urachal remnant. Because a urachal remnant could be a nidus of infection, he underwent cystoscopy which was unremarkable. Ultimately, his abnormal urinary color and nightly fevers resolved, although the patient has continued to struggle with UTIs and failure to thrive.
Discussion
This is an unusual case of the oldest reported patient with PHS who completed months of evaluation for recurrent fever without identification of a clear cause. Considering the known role of TCF4 in neuronal development, these symptoms may represent additional autonomic features of PHS in adults. Further, this may highlight the impact of recurrent UTIs, severe GERD and aspiration pneumonias on disease morbidity and mortality. We present this case as to report additional under-recognized clinical features in adult PHS and begin to characterize the lifetime disease process.

Recurrent fever in an adult with Pitt-Hopkins Syndrome: A challenging case in a rare patient

The median nerve maintains a close relationship with the brachial artery in the upper limb. Variability in the formation and distribution of upper extremity vessels is frequently encountered during donor body dissections. This case presents a rare anatomical variation of the brachial artery emerging through an opening in the median nerve. The median nerve formed a small opening without the contribution from additional nerve roots, and the remaining vasculature of the upper limb was otherwise normal. An abnormal arrangement of a neurovascular bundle in the arm can cause sensory and motor issues, as well as vascular implications. This variation has potential clinical significance in surgical interventions. To our knowledge, this is the first reported case of a small median nerve opening pierced by the brachial artery.

Variation of the Brachial Artery Emerging through an Opening in the Median Nerve: A Case Report

Background
Geminus Head Start is a federal program that works with children under five years old from low-income communities to promote school readiness. The organization in Northwest Indiana provided anecdotal data on delayed social and emotional development of children during the pandemic. Studies have shown that adverse childhood development can have a severe psychological and physiological impact on health outcomes into adulthood. However, there has been a lack of research on quantifying the extent of damage from the pandemic on our Head Start children, who mainly identify as Black/African American. 

Methods
Geminus Head Start provided demographic data including race, postal codes and DECA for over 4650 students from 2019-2023. DECA, Devereux Early Childhood Assessment, is used by educators to evaluate children’s social emotional competence for early intervention. In this study, we are investigating the DECA categories, including initiative, self control, and attachment/relationships. We analyzed DECA scores via ANOVA along with listening into the teacher focus groups. 

Results
Students had increased attachment/relationship scores from the 2019-2020 school year to the 2020-2021 school year (36.69 to 44.59). However, following COVID-19 to the 2021-2022 and 2022-2023 school years, these scores dropped to 23.51. When looking at the second protective factor, self regulation, the opposite trend was found. The scores went from 18.79 in 2019-2020 down to 14.68 in 2020-2021 and eventually up to 23.51 in 2021-2022.

Conclusion

Like most institutions, the pandemic has created a time of isolation and instability for our children and their families. In particular, these children have not been able to access adequate conditions to develop emotional and social maturity. Lacking this development can lead to several negative health outcomes as it may impact mental health and the ability to create healthy supportive networks.


Retrospective Analysis of COVID-19 Impact on Social & Emotional Development in Children of Low-Income Communities from Head Start 


Background:
Mobile health (mHealth) is a rapidly evolving technological field determined to assist healthcare professionals and users in monitoring their health status through biometrics collected on internet of things (IoTs). Recent advancements in IoTs increase user access to protected/personal health information (PHI) and streamline data analysis for healthcare professionals to perform occupational responsibilities. While IoTs involve gathering individual health data, which some may see as violating the rights of privacy and security, implementing effective policies and regulations can ensure that confidentiality is maintained. Although the utilization of IoTs in healthcare is evolving rapidly, there is still limited exploration regarding how it can benefit individuals in high-risk occupations, such as first responders, who are frequently exposed to dangerous conditions.

Methods:
To explore this knowledge gap, our team has performed a literature review on the development of mHealth & IoTs in high-exposure occupations. High-exposure occupations were defined as those who experienced increased trauma, environmental hazards, chemicals, and stress (e.g., emergency medicine, firefighters, police officers, etc.). We reviewed previous implementations of IoTs in high-exposure occupations, evaluated statistics of work-related illnesses/injuries that were identified as preventable, and recognized challenges of IoTs utilization in such occupations.

Results:
Our literature review concluded there is a significant opportunity for the current utilization of IoTs in physician-patient relationships to expand toward such careers. Implementing non-obstructive wearable devices in high-exposure careers while abiding by the Health Information Technology for Economic and Clinical Health (HITECH) Act can minimize work-related mortalities, improve situational awareness, aid in the early detection of occupational illnesses/injuries, and facilitate safer working conditions. The Swiss cheese model developed by James Reason supports these claims through the addition of another systemic barrier to reduce unnecessary risk. Such an idea could be promoted by real-time monitoring and analysis of biometric data (heart rate, electrocardiogram, pulse oximetry, etc.) and environmental data for the user and a potential third-party analyst. The third-party analyst would interpret live biometrics for the users of the IoTs and send an alert if any abnormalities were identified compared to baseline measurements.

Conclusion:
mHealth and IoTs have become common since the COVID-19 pandemic and increased development encourages further utilization. Implementation of non-obstructive wearable devices in high-exposure occupations is one such way. Here we present a solution to promote work-related safety for preventable illnesses/injuries. Our literature review establishes an opportunity for the expansion of mHealth and IoTs to high-exposure occupations to promote overall safety.

IoTs Expansion and their Opportunity to Promote Safety in High-Exposure Occupations

Background
Emergency department (ED) visits for preventable dental conditions are substantially increasing. 

Methods
A retrospective chart review of prospectively maintained data was used. We reviewed 275 children who presented to the ED between July 2019 and January 2021. The inclusion criteria were children under the age of 18 years with odontogenic pain, demographics, insurance status, primary diagnosis, services provided in the ED, prescriptions given, total ED length of stay, and disposition. We classified these visits as necessary and unnecessary based on the treatment given. Data were analyzed using chi-square and student t-test.

Results
Among these patients, 52% were males with ages 9.3±4.7 years and a median of 9 years old. The primary diagnoses were dental caries (27%), tooth pain (26%), tooth infections (17%), traumatic tooth fracture (11%), and others comprising cavities, gingivitis, and oral mucosal infections (19%). Most patients were under Medicaid-managed care (67%), followed by those without insurance (17%). After ED evaluation, 70% of patients received non-steroidal anti-inflammatory drugs (NSAIDs), 55% had dental referrals, 28% had OMFS referrals, and 27% received antibiotics. This cohort was subdivided into necessary versus unnecessary ED visitation––with the majority of patients having tooth pain (17% vs. 33%) and dental caries (21% vs. 31%) that required NSAIDs (35% vs. 34%) and home discharge (98% vs. 99%).

Conclusion
The cost of 1 ED visit in New York City averages from 1400$ to 1600$, so avoiding these 155 unnecessary ED visits, about 250,000$ could be saved. Dental pain is highly prevalent among children, with a substantial increase in ED visits for atraumatic dental problems. The fact is that dental conditions can be treated more effectively in a dental clinic due to the availability of definitive care and the likelihood of continuity of care than in a hospital. Multiple strategies are required to reduce this usage and relieve the healthcare system pressure. Reducing barriers like lack of insurance, sociocultural deterrents, and language barriers improves access to optimal dental care. Efforts should be made to raise dental health awareness and improve access and utilization of oral health care services. These will benefit the patient and decrease the reliance on hospital ED for non-traumatic dental issues.


Next from AMA Research Challenge 2023

Amoidarone-induced Thyrotoxicosis (AIT): Subtype Differentiation and Management