About Lisa

I have been a Clinical Informationist (aka Medical Librarian) for Emory University since September 2013. Prior to that, I was a Medical Librarian for Lincoln Memorial University (LMU) from March 2007 to August 2013 and served its DeBusk College of Osteopathic Medicine, Caylor School of Nursing, and allied health programs. From January 2002 - March 2007, I served the Medical Assisting (MA), Occupational Therapy Assistant, Physical Therapy Assistant, Radiologic Technologist, and Nursing programs at South College in Knoxville, Tennessee. I graduated from The University of Tennessee School of Information Sciences with a Master of Science degree in December 2000.

EUH Krakow Conference: Review of Kikuchi-Fujimoto Disease

Bottom line: “Kikuchi–Fujimoto disease, or Kikuchi’s disease, also known as histiocytic necrotizing lymphadenitis, is a rare, benign, self‐limiting condition characterized by cervical lymphadenopathy and fever….symptoms usually resolve spontaneously within 1–4 months. However, cervical lymphadenopathy can persist for up to 6 months and even 1 year. There is a possibility of recurrence, yet rates of only 3–4% have been reported. The treatment of Kikuchi’s disease is primarily supportive and aims to facilitate the relief of symptoms with the use of analgesics, antipyretics, and rest. In a more severe or protracted disease course, short‐duration oral corticosteroid therapy is the treatment of choice. There are no specific guidelines regarding the dosage or length of treatment. Hydroxychloroquine is another therapeutic option that has been used to achieve rapid clinical improvement in Kikuchi’s disease. The safety profile of hydroxychloroquine may make it a better alternative to long‐term, high‐dose corticosteroids as it has fewer adverse effects. Despite a lack of recommendation, intravenous immunoglobulin, given its immunomodulatory nature, has also been used successfully in patients with severe disease. The mortality rate with Kikuchi’s disease was calculated to be 2.1%. Patients diagnosed with Kikuchi’s disease should be subject to close long‐term monitoring for the possible development of SLE [systemic lupus erythematosus]. Kikuchi’s disease can precede the onset of SLE by years.”1 Review articles provides several histopathological and dermatological images of patients with the condition.

ReferenceMathew LM, Kapila R, Schwartz RA. Kikuchi-Fujimoto disease: a diagnostic dilemmaInt J Dermatol. 2016 Oct;55(10):1069-75. doi: 10.1111/ijd.13314. Epub 2016 May 21. 

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EUH Krakow Conference: Review of Lemierre’s Syndrome

Bottom Line: Vijay and Fattah1 state that Lemierre’s syndrome typically presents in young adults who were previously healthy. In a case series of 222 patients who fit the “Lemierre’s syndrome case presentation, the median age was 19 years and 89% of patients were aged 10 to 35 years.”2 Its four key elements are “primary oropharyngeal infection within 4 weeks, suppurative thrombophlebitis of the internal jugular (IJ) vein, metastatic septic emboli, and [a] causal association with F necrophorum.” It should be “suspected in those with a recent history of oropharyngeal infection presenting with fever and rigors, with or without evidence of metastatic lesions, particularly respiratory symptoms (pleuritic chest pain, dyspnoea, haemoptysis).” Penicillin/beta-lactamase inhibitor, penicillin plus metronidazole, and carbapenem” are “appropriate empirical antibiotic regimens….There are no controlled trials to guide management, but most sources recommend between 2–6 weeks of antibiotics in total.” Review article provides four computed tomography pulmonary angiogram (CTPA) images with red arrows that indicate locations of multiple peripheral nodular lesions.

References:

1. Vijay V, Fattah Z. Lesson of the month 1: Lemierre‘s syndrome: a reminder of the ‘forgotten disease.’ Clin Med (Lond). 2018 Feb;18(1):100-102. doi:10.7861/clinmedicine.18-1-100.

2. Riordan T. Human infection with Fusobacterium necrophorum (Necrobacillosis), with a focuson Lemierre’s syndrome. Clin Microbiol Rev. 2007 Oct;20(4):622-59. doi:10.1128/CMR.00011-07.

EUH Morning Report: Review of microscopic colitis

Bottom Line: “Microscopic colitis is a common cause of chronic watery diarrhea, particularly in the elderly. The accompanying symptoms, which include abdominal pain and fatigue, can markedly impair patients’ quality of life. Diagnosis is based upon characteristic histologic findings of the colonic mucosa….Two recent randomized studies have confirmed the effectiveness of oral budesonide for both induction and maintenance treatment of microscopic colitis and is now endorsed by the American Gastroenterological Association as first-line treatment.”

Reference: Cotter TG, Pardi DS. Current approach to the evaluation and management of microscopic colitis. Curr Gastroenterol Rep. 2017 Feb;19(2):8.

EUH Dressler Case Conference: What is the definition of heart failure with mid-range ejection fraction (HFmrEF), which is also called intermediate ejection fraction and borderline heart failure with preserved left ventricular (LV) ejection fraction (HFpEF)? Do patients benefit from typical HFrEF therapies?

Bottom Line: In a meta-analysis, Zheng, Chan, Nabeebaccus, et al. state, “The latest European Society of Cardiology guidelines introduced the term heart failure with mid-range ejection fraction (HFmrEF), categorising an intermediate group of patients with an LV ejection fraction of between 40% and 49%, with HFpEF defined as an LV ejection fraction ≥50% with the same echocardiographic criteria. The American College of Cardiology defines HFpEF as an LV ejection fraction >40%, with anything from 41% to 49% as borderline HFpEF.” Dressler reviewed the aforementioned article and states, “In 6 randomized trials (≈1300 patients), β-blockers, compared with placebo, significantly lowered early mortality (18% vs. 20%). In 15 randomized trials (>13,000 patients), HFpEF patients who received any drug class that improves [heart failure with reduced ejection fraction (HFrEF) outcomes were significantly less likely to be hospitalized (14% vs. 16% with placebo; number needed to treat, 64), but no individual medication class yielded significant improvements.” Drug classes that are typically used to treat HFrEf and were evaluated in the meta-analysis include β-blockers, angiotensin-converting–enzyme inhibitors, angiotensin-receptor blockers, and mineralocorticoid-receptor antagonists.
References
Zheng SL, Chan FT, Nabeebaccus AA, et al. Drug treatment effects on outcomes in heart failure with preserved ejection fraction: a systematic review and meta-analysis. Heart. 2017 Aug 5.
Dressler DD. Do any meds improve outcomes in heart failure with preserved ejection fraction. N Engl J Med J Watch. 2018 Jan 16.

EUH Dressler Case Conference: In chest x-rays, what is the water bottle sign?

Bottom Line: In patients with pericardial effusion, the water bottle sign appears when the chest x-ray’s cardiac silhouette has a globular shape that looks like a water bottle as the result of slowly accumulating fluid. In the screenshot from YouTube below, the four images show a normal chest x-ray (top left corner), a patient with cardiomegaly (lower right corner), and a chest x-ray with a water bottle sign (lower right corner). The water bottle shape appears in the upper right corner.
water bottle sign

Reference for Image: Hammadshams. Chest X-Ray – Cardiomegaly or No Cardiomegaly – Water Bottle Sign. https://www.youtube.com/watch?v=oG_bE2x5LG8. Accessed January 23, 2018.

EUH Dressler Case Conference: Review of cardiac sarcoidosis

Bottom Line: Increased awareness and diagnostic techniques are the primary reasons for the exponential increase in the prevalence of cardiac sarcoidosis during the last decade. More evidence is needed to determine optimal management. First-line treatment is corticosteroids; authors recommend also using immunosuppressive therapy. For either primary or secondary prevention of ventricular arrhythmias and cardiac death, implantable-cardioverter defibrillators (ICDs) should be a consideration for all patients.

Reference: Young L, Sperry BW, Hachamovitch R. Update on treatment in cardiac sarcoidosisCurr Treat Options Cardiovasc Med. 2017 Jun.

EUH Hunt Conference: Residents’ “Pathways Service” to link patient care to scientific inquiry

Bottom Line: The authors created a “Pathways Service” to link patient care to scientific inquiry by attempting to fill gaps in knowledge regarding the biology behind patients’ medical problems. Residents refer patients on their service to the program “if they have an extreme or unusual disease phenotype that no one has been able to explain adequately and if the disease process appears to reflect a fundamental pathophysiological problem.” Patients are chosen if a determination is made that there is a “potential for elucidating the underlying pathophysiology.” Residents on the Pathways rotation, along with the faculty advisor, “meet the patient, review data, and formulate pathophysiological hypotheses that they discuss with basic and clinical scientists from around the world.” The residents present the case at a Pathways conference. “After debate about the possible underlying mechanisms and potential experiments, the team agrees on recommendations for further clinical workup and a road map outlining feasible scientific explorations that may advance understanding of the fundamental problem.”

Reference:
Armstrong K, Ranganathan R, Fishman M. Toward a culture of scientific inquiry – the role of medical teaching services N Engl J Med. 2018 Jan 4;378(1):1-3.

EUH Hunt Conference: Review of Meigs’ Syndrome

Bottom Line: Meigs’ syndrome is also known as Meigs syndrome or Demons-Meigs syndrome. It is characterized by a triad of ascites, pleural effusion, and benign ovarian fibroma, which is a rare triad. “Meigs syndrome…is a diagnosis of exclusion only after ovarian carcinoma is ruled out. The presentation of symptoms and radiographic findings mimics that of metastatic ovarian cancer, creating a significant clinical challenge….The treatment is exploratory laparotomy that includes biopsy of the ovarian mass, lymph node biopsies, biopsy of omentum, and pelvic washings. Unilateral salpingo-oophorectomy is performed in women of reproductive age, whereas total hysterectomy is preferred in postmenopausal women. The prognosis of Meigs syndrome is good and <1% of fibromas progress to fibrosarcoma. The pleural effusion and ascites resolve within a few weeks after tumor resection. We favor the use of chest ultrasound to follow pleural effusion progression, as it is superior to chest x-rays in identifying residual pleural effusion and can detect amounts as small as 3 to 5 mL.” The article reports a case of a patient with recurrent pleural effusions and an ovarian mass. It describes the case in detail and reviews the literature on Meigs syndrome.

Reference:
Riker D, Goba D. Ovarian mass, pleural effusion, and ascites: revisiting Meigs syndrome. J Bronchology Interv Pulmonol. 2013 Jan;20(1):48-51.

EUH Hunt Conference: What is the sensitivity of cytology tests of pleural effusion and ascites?

Bottom Line: Sensitivity of ascitic cytology is approximately 60%, and the sensitivity of pleural effusion cytology is approximately 50%.

References:

Karoo RO, Lloyd TD, Garcea G, Redway HD, Robertson GS. How valuable is ascitic cytology in the detection and managent of malignancyPostgrad Med. 2003 May;79(931):292-294. Study included 276 samples.

Motherby H, Nadjari B, Friegel P, Kohaus J, Ramp U, Bocking A. Diagnostic accuracy of effusion cytology. Diagn Cytopathol. 1999 Jun;20(6):350-357. Study included 300 pleural effusions and 300 ascitic effusions and provides sensitivity for both types of effusions.

 

EUH Morning Report: In patients with acute alcoholic hepatitis, does steroid therapy increase the risk of GI bleeding compared to no use of steroids?

The Bottom Line: For patients with acute alcoholic hepatitis, there isn’t literature to answer the question of whether steroid therapy increases risk of GI bleeding compared to no use of steroids. For patients with non-acute alcoholic liver disease who do not have concomitant GI bleeding., use of steroids does not appear to increase risk of GI bleeding when compared to placebo or no intervention.

References:

O’Shea RS, Dasarathy S, McCullough AJ, et al. Alcoholic liver disease. Hepatology. 2010 Jan;51(1):307-328. PMID: 20034030. doi: 10.1002/hep.23258

Comment on above article by O’Shea, Dasarathy, and McCullough: Singal AK. Comments on AASLD practice guidelines for alcoholic liver disease. Hepatology. 2010 May;51(5):1860-1861. PMID: 20432268. doi: 10.1002/hep.23605

Rambaldi A, Saconato HH, Christensen E, Thorlund K, Wetterslev J, Gluud C. Systematic review: glucocorticosteroids for alcoholic hepatitis — a Cochrane Hepato-Biliary Group systematic review with meta-analyses and trial sequential analyses of randomized clinical trials. Aliment Pharmacol Ther. 2008 Jun;27(12):1167-1178. PMID: 18363896. doi: 10.1111/j.1365-2036.2008.03685.x

References were found in DynaMed Plus. See DynaMed Plus → alcoholic liver disease → treatment → medications → medication to treat acute inflammation for patients with severe alcoholic hepatitis → steroids

Summary of evidence on whether steroid therapy increases the risk of GI bleeding compared to no use of steroids in patients with alcoholic hepatitis (not acute alcoholic hepatitis):

DynaMed Plus states, “efficacy of steroids has not been evaluated in patients with severe alcoholic hepatitis and concomitant…gastrointestinal bleeding,” an “exclusion criteria in many of the early studies of alcoholic hepatitis.”

Only one of the systematic reviews cited in DynaMed Plus on use of steroids versus placebo or no intervention mentioned bleeding as an outcome measure. It states, “Combining the results of four trials providing data demonstrated no significant effects of glucocorticosteroids on…variceal bleeding….Combining the results of the eight trials reporting adverse events demonstrated a significantly higher proportion of patients with adverse events in the glucocorticosteroid group (RR 3.63, 95% CI 1.95–6.76).” The glucocorticosteroids group of 239 patients had “one suspicious of gastrointestinal bleeding.”