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Cutaneous oncology is currently a rapidly evolving field. Dermoscopy, total body photography, biomarkers, and artificial intelligence are affecting the way skin cancers, especially melanoma, are diagnosed and monitored. The medical management of locally advanced and metastatic skin cancer is also changing. In this article, we will discuss recent developments in cutaneous oncology with a particular focus on treatment of advanced cancers.

The optimal dose of physical activity and best types of exercise for improving cardiovascular (CV) durability and optimizing longevity are unknown. The purpose of this article is to review the recent literature on the effects of duration and intensity of exercise, physical fitness, and specific types of training/sports on long-term CV health and life expectancy. A systematic review of recent studies (2011 to 2022) was conducted using PubMed. Studies were included if they addressed the topic of fitness and/or exercise dose/type and CV health and/or life expectancy. Epidemiological studies show that cardiorespiratory fitness (is inversely related to risk of all-cause mortality, with no increased mortality risk in the most fit cohort. Being unfit is among most potent risk factors for all-cause mortality. Moderate PA (MPA) and vigorous PA (VPA) were associated with reduced CV and all-cause mortality in a recent definitive study. Paradoxically, high doses of MPA reduced both CV and all-cause mortality better than did high doses of VPA. A large meta-analysis showed that strength training was independently associated with lower rates of all-cause mortality and CV disease, though the best outcomes were associated with a cumulative dose of about 60 minutes/week. Physical interactive play is strongly associated with improved life expectancy. Physical fitness is a key determinant of CV health and life expectancy. Moderate to vigorous exercise, strength training and interactive sports are associated with improved life expectancy. Very large volumes of strenuous exercise and/or weightlifting may not be the ideal for optimizing longevity.

Infantile hemangiomas (IHs) are identified in about 5–12% of infants, making them the most common benign tumor of childhood (Figure 1). IHs are vascular growths characterized by an abnormal proliferation of endothelial cells and aberrant blood vessel architecture.1 IHs commonly involute after proliferation, traditionally leading to a non-interventional or “wait and see” management approach. However, a large subset of these growths can become problematic causing morbidities such as ulceration and scarring, disfigurement, or functional impairment. Another subset of these cutaneous hemangiomas may also be markers for visceral involvement or other underlying abnormalities. Historically, treatment options were often rife with unwanted side effects and modest results. However, with newer established treatments which are both safe and effective, there is a time-sensitive need for early identification of high-risk hemangiomas to ensure prompt delivery of treatment for best outcomes. Despite a more recent dissemination of awareness of IHs and these newer treatments, there remains a large subset of infants who still experience a delay in care and poor outcomes which are likely avoidable. There may be some avenues in Missouri to help mitigate these delays.

BACKGROUND: Next generation sequencing (NGS) has become standard practice for identification and treatment of targetable driver mutations in advanced cancer. However, NGS interpretation of clinical applicability can be challenging to clinician, with potential impact on patient’s outcome. Specialized precision medicine services are poised to bridge this gap by creating collaborative frameworks to formulate and deliver genomic patient care plans. METHODS: Saint Luke’s Cancer Institute in Kansas City, Missouri, (SLCI) instituted the Center for Precision Oncology (CPO) in 2017. The program accepts patient referrals for a multidisciplinary molecular tumor board and offers CPO clinic visits. An Institutional Review Board-approved molecular registry was initiated. It catalogues genomic files along with patient demographics, treatment and outcomes. CPO patient volumes, recommendation acceptance, clinical trial matriculation and funding for drug procurement were closely tracked. RESULTS: In 2020 there were 93 referrals to the CPO with 29 patient clinic visits. 20 patients matriculated to CPO-recommended therapies. Two patients were successfully enrolled in Expanded Access Programs (EAPs). CPO successfully procured eight off-label treatments. Treatments initiated per CPO recommendations totaled over $1 million in drug costs. CONCLUSION: Precision medicine services are essential tool for oncology clinicians. In addition to expert NGS analysis interpretation, precision medicine programs provide crucial multidisciplinary support for patients to understand the implications of their genomic report and pursue targeted treatment as indicated. Molecular registries associated with these services offer valuable opportunities for research.

Awareness with recall is an uncommon but potentially devastating neurological complication following perioperative care. End-tidal anesthetic gas concentration alarms can supplement usual care to reduce risk. Processed electroencephalographic (EEG) measures provided by depth-of-anesthesia monitors may be helpful, particularly for high-risk patients. Interpretation of EEG waveforms may supplement these processed EEG metrics to minimize risk of awareness with recall.

Patients in rural and underserved areas face significant barriers in accessing specialty care due to unavailability of services, geographic isolation, travel burden, and other cultural and socioeconomic factors.1 Pediatric dermatology is among the top three subspecialties that provides routine care for pediatric patients, however, shortage and maldistribution of pediatric dermatologists have remained a major hurdle for those living in remote and isolated areas.2 Pediatric dermatologists cluster in urban areas with high-patient volume and estimated wait times for new patients that often exceed 13 weeks, making access one of the major drivers of inequity for rural patients.2–4

Fibromyalgia is a chronic pain syndrome with diffuse pain, muscle weakness, and other symptoms. A relationship between the severity of symptoms and obesity has been observed. OBJECTIVE: To determine the relationship between weight and the severity of fibromyalgia. MATERIAL AND METHODS: 42 patients with fibromyalgia were studied. BMI and fibromyalgia severity are classified weight by FIQR. Results: The mean age was 47.3 ± 9.4 years, 78% presented severe and extreme fibromyalgia, and 88% were overweight or obese. There was a positive correlation between the severity of the symptoms and the BMI (r = 0. 309). The reliability test for FIQR presented a Cronbach’s α of 0.94. CONCLUSION: About 80% of the participants do not show controlled symptoms, and their prevalence of obesity is high, observing a positive correlation between both.

Sepsis is a major health care burden with significant contribution to morbidity, mortality, and hospital resource utilization. Monocyte Distribution Width (MDW), the novel hematological biomarker, was clinically implemented in our laboratory for early detection of sepsis (ESId) in 2019. When COVID-19 pandemic hit in 2020, we noticed some similarities of the laboratory data of the COVID patients with patients previously diagnosed with sepsis. The aim of this study was to evaluate the value of the hematological data including MDW in predicting COVID disease severity and outcome. A retrospective study was conducted on 130 COVID-infected patients who presented at our hospital during March and April 2020. Collected data included clinical, laboratory, and radiological findings. This study demonstrates a unique pattern of three hematological biomarkers that predicted severity and outcome in COVID patients at their initial presentation in the Emergency Room (ER): higher absolute neutrophil count (ANC), lower absolute lymphocyte count (ALC), and higher MDW.

Since the start of the 21st Century, the use of opioids for pain management in primary care has increased along with a concomitant rise in opioid associated deaths. The use of opioids is associated with risks of addiction, respiratory depression, sedation, and death. There is no checklist available in electronic medical records to guide safe prescribing of non-opioid pain management options prior to opioids in primary care. Our quality improvement project pilot study aimed to reduce unnecessary opioid prescribing in an urban academic internal medicine clinic by incorporating a checklist of five first-line non-opioid therapy suggestions into electronic medical records. Following its implementation, opioid prescribing dropped by an average of 38.4 percent per month.

As our population ages, there is interest in delaying or intervening in cognitive decline. While newer agents are under development, agents in mainstream use do not impact the course of diseases that cause cognitive decline. This increases interest in alternative strategies. Even as we welcome possible new disease-modifying agents, they are likely to remain costly. Herein, we review the evidence behind other complementary and alternative strategies for cognitive enhancement and prevention of cognitive decline.

A number of chronic skin diseases, such as vitiligo and alopecia areata, are historically resistant to or respond poorly to treatment. Additionally, disorders such as atopic dermatitis and psoriasis have subtypes that are inadequately treated by current medications. Lastly, in the field of dermatology there are a number of conditions, some genetic (such as Darier’s disease and Hailey-Hailey disease) and others caused by aberrant inflammatory responses (macrophage-driven conditions such as sarcoidosis and autoimmune conditions such as localized scleroderma) where effective treatments have been limited to date. A new class of anti-inflammatory medications that inhibit the Janus Kinase-Signal transducer and activator of transcription pathway (JAK-STAT) show great promise in providing new and effective treatment of these formerly recalcitrant conditions. This brief review will cover inhibitors of the JAK-STAT pathway (JAK inhibitors) currently approved for use in treating dermatologic diseases including several very recently approved medications. It will also touch on additional conditions under study or where early reports of efficacy are promising.

The prevalence of Attention Deficit Hyperactivity Disorder (ADHD) has seen a consistent rise in recent years. These numbers spark a debate over the reason for the observed trends, with some concerned about over diagnosis and over prescription of stimulant medications, and others raising the issue of diagnostic disparities, particularly in underrepresented populations. In this paper we look at both sides, starting with the history of ADHD and its diagnostic criteria changes, from early concepts of alterations in attention and hyperactivity in the 19th and 20th century, to its introduction in the Diagnostical and Statistical Manual of Mental Disorders (DSM), and its evolution into how it is defined today. The general broadening of ADHD diagnostically over time plays a role in the increased prevalence over the years, but it is not the only reason. Increased awareness of physicians and the public is also believed to play a big role, particularly in underrepresented minorities and women. However, there continues to be disparities in detection of ADHD in these groups. There are significant consequences to a patient’s social, interpersonal, and professional life when ADHD is left unrecognized and untreated. Thoughtful evaluation, accurate diagnosis, and adequate treatment can make a big difference.

Thyroid nodules are a common clinical finding. Approximately 4–7% of the population have a palpable nodule on physical exam,1 while up to 70% of the population have a nodule detected incidentally on ultrasound.2 The vast majority of nodules are benign, however, approximately 5–13% of thyroid nodules detected on imaging are at risk of malignancy.3 Some malignant nodules, especially those smaller than 1 cm, can exhibit indolent behavior and do not require aggressive treatment.4 Therefore, thyroid nodules need to be accurately assessed to avoid overdiagnosis and overtreatment of nodules which would not otherwise affect patient morbidity. The American Thyroid Association (ATA) addressed this challenge by developing a set of ultrasound pattern-based guidelines for thyroid nodule management in 2009, which were updated in 2015.5 Other societies have since published similar guidelines, such as the Thyroid Imaging Reporting & Data System (TI-RADS) by the American College of Radiology in 2017. TI-RADS was similarly intended to risk-stratify nodules based on ultrasound appearance, but uses a points-based approach. The purpose of this review is to provide an overview of thyroid nodule evaluation and management through a case-based comparison using the ATA and TI-RADS guidelines.

The field of genetics has evolved rapidly over the last few decades, from testing methods to genetic diagnoses, bringing new genetic testing guidelines and considerations for health care providers. Overall geneticists are limited in number and availability, particularly in non-academic settings, and many patients first present to a primary care provider. Here, we aim to review various modalities of genetic testing, their indications, limitations, and other pretest considerations for the primary care provider. In addition, we comment on the limitations of direct-to-consumer (DTC) genetic testing, which has seen a rise in popularity among the general population.

Much of the focus on the current opioid crisis remains on how we arrived here and who is to blame. Despite having effective treatments for the management of patients with opioid use disorder (OUD), rates of overdose deaths continue to increase. As such, the focus needs to shift to increasing access to medications for OUD and better incorporation of harm reduction strategies to decrease not just the mortality but also the morbidity associated with OUD and other substance use disorders. Unfortunately, significant barriers rooted in misunderstanding and bias still limit access and prevent patients with OUD from seeking and staying in treatment. Until these are overcome and medical practice changes, both physicians and patients will continue to struggle to overcome this problem.

Cannabis legalization may increase the rates of emergency department presentations and hospitalizations from Cannabinoid Hyperemesis Syndrome (CHS). This syndrome was first described nearly 20 years ago and has become increasingly common. Yet, for a variety of reasons, CHS is still an underrecognized cause of recurrent abdominal pain, nausea, and vomiting. All physicians must be prepared to diagnose, manage, and counsel patients on this condition, regardless of their state’s current or future cannabis legislation.

For over 40 years saturated fat, the fat found primarily in animal foods, was thought to be the main culprit for increasing cholesterol levels and causing heart disease. During this same time vegetable oils were promoted as being heart healthy because they could lower cholesterol. However, recently the evidence implicating saturated fat as being harmful to heart health has been challenged and more studies are beginning to show the harms from consuming industrially produced vegetable oils. Furthermore, monounsaturated fats, found in olives, olive oil, certain nuts and avocadoes have been promoted as being part of a healthy Mediterranean diet. This paper will provide a brief review comparing the effects of saturated fat to monounsaturated fat.

No-shows in primary care clinics prevent patients from receiving essential care and decrease clinic productivity. The COVID-19 pandemic forced physicians to adjust to telemedicine as a necessary method to provide care. In this study no-show patients were converted to telehealth visits thereby allowing physicians to care for their patients and maintain hospital revenue. The most common reasons for “no-shows” were found to be forgetting appointments and transportation issues.

A computerized tomography (CT) scan is the current advanced imaging standard of care for evaluation and preoperative planning for tibial plateau fractures, but magnetic resonance imaging (MRI) is emerging as a better method to identify soft tissue injuries. This study compares MRI and CT for fracture classification, associated soft tissue injuries, and preoperative planning for tibial plateau fractures. MRI offers lack of radiation and enhanced soft tissue evaluation, and as a result improved preoperative planning. MRI was favored among survey respondents for preoperative planning, Schatzker classification, and surgical approach planning.

Maternal thyroid disease, with both an excess or deficiency of thyroid hormone, raises the risk profile of affected pregnancies with regards to preeclampsia, preterm birth, placental problems, thyroid derangement of the fetus and neonate, and neurodevelopment of exposed fetuses later in life. Fortunately, close and tight management of thyroid disease within the fluctuating physiologic milieu of pregnancy offers opportunities to significantly improve perinatal outcomes. However, despite guidelines offered by American College of Obstetrics and Gynecology (ACOG) and American Thyroid Association (ATA), controversy persists regarding interpretation of thyroid labs, screening for disease, surveillance, fetal and placental thyroid physiology, and optimal medication and management strategies. This is a brief overview of what is known and unknown regarding thyroid disease and its impact on maternal, fetal, and pregnancy health.

INTRODUCTION: Posterior spinal fusion (PSF) is the gold standard procedure for curve correction in Adolescent Idiopathic Scoliosis (AIS). Enhanced recovery protocols (ERPs) have been found to decrease pain and hospital length of stay (LOS) resulting in decreased total hospital charges. METHODS: We identified all adolescent idiopathic scoliosis patients treated with a posterior spinal fusion at our children’s hospital between 2015–2019. Length of stay, pain scores, and hospital direct costs were calculated to determine the pathway’s efficacy. RESULTS: Hospital LOS was reduced by 26% and post-op pain scores did not significantly change when using the Team Integrated Enhanced Recovery (TIGER) protocol (P

Rates of burnout among clinicians have been exacerbated by the COVID-19 (COVID)pandemic. A survey of Missouri primary care professionals at federally qualified health centers was conducted during a COVID surge in August 2021 to assess burnout, stress, and job satisfaction as well as if respondents had sought assistance for burnout or attended resiliency training. Despite respondents reporting rates of burnout (56%) that exceed those reported nationally (48%), only 17% sought help for burnout. Most (81%) had not attended resiliency training; of those who did, 16% said sessions "make me feel less alone," while an equivalent number found sessions not useful, identifying an absence of resources within their organization. Comments focused on the need for dedicated time to receive support, including time to seek assistance during working hours, time to take breaks, and time for self-care. The data suggest one path forward to remediate burnout: provide the workforce with time to access support.

Posterior fossa lesions can occur in patients of all ages. Patients present with subtle findings of hearing loss, tinnitus, headache, cranial neuropathies, imbalance, vertigo, nausea, and vomiting depending on the location and type of lesion. The presentation can be particularly insidious as the most common symptom is slowly progressive hearing loss. Posterior fossa lesions should be included in the differential diagnosis for patients with this presentation and appropriate audiologic testing and imaging should be performed. Management involves collaboration between multiple subspecialties and has evolved significantly over the years leading to increased patient involvement and improved outcomes.

Thyroid disease is common in older adults. Increasing numbers of older persons will present to physicians for care in the United States as the U.S. and world populations age. It is expected that by the year 2030 that 19-20% of the U.S. population will be over 65-years old and by 2040 that 25% of the U.S. population will be over 65-years old. It is important for clinicians to be familiar with thyroid disease in this population because of its impact on the patient's functional and cognitive state. Thyroid disease often presents in older adults with nonspecific presentations such as falls, weakness, or cognitive impairment. Thyroid abnormalities may also be detected with routine testing.

Thyroid storm is a severe manifestation of thyrotoxicosis. Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid stimulating hormone (TSH) (

The many health benefits of exercise are well-known. Conversely, the pathologies associated with a sedentary lifestyle are also well-documented. However, science and medicine have only recently begun to explain how exercise does what it does. Here, I discuss recent insight into the biochemical mechanisms underlying the benefits of exercise and the pathologies of inactivity.

This rapid review aims to elucidate the impact of coronavirus 2 (SARS-CoV-2) (COVID) disease-both in the acute phase and the "long-hauler" syndrome-on sleep health. Literature regarding the direct physiologic impact of COVID disease on sleep is sparse but has illuminated a toxic synergy between the immune response to COVID disease and the pro-inflammatory state brought on by obstructive sleep apnea (OSA). Primary care physicians and sleep medicine specialists should aggressively screen for OSA in COVID patients.

The rate of maternal mortality in the United States (U.S.) is higher than any other industrialized nation, at 23.8 per 100,000 deliveries from 2000–2014. Although maternal mortality ratios decreased by 44% globally from 1990 to 2015, emerging evidence suggests that maternal mortality in the U.S. has been increasing.2–4 One study quotes 700 maternal deaths every year, with 50,000 “near misses.”1 By one metric, Missouri ranks as the 44(th)-worst state for maternal mortality in the U.S.5

Chronic obstructive pulmonary disease (COPD) is not merely a lung disease as the name indicates. Patients with COPD experience associated complications with systemic inflammation, heart strain, muscle wasting, poor functional performance, and psychological issues. An assessment of these patients based only on lung function tests or functional capacity would be inadequate. Many studies have reported the significance and prognostic value of several laboratory tests. Troponin, C-reactive protein (CRP), hemoglobin, and carbon dioxide are older tests but compared with the newly developed tests, they are relatively inexpensive to measure and widely available. This article will review laboratory tests used for COPD and discuss their prognostic value. The laboratory tests that can identify high-risk patients will be discussed. We will explore the role of these tests in clinical practice.

Food insecurity affects fourteen million American households. Due to the impact on health outcomes and costs of care, food insecurity is one of the leading health and nutrition issues in the U.S. In this article, we provide an overview of food and nutrition insecurity and how it is measured, followed by health consequences of food insecurity, and then discuss ways that physicians and health professionals can help address food and nutrition security in clinical setting.

Understanding of the spondyloarthritis diseases has changed significantly in the last 15 years. It is now clear that there are patients with and without radiographic changes and the terminology has changed to reflect that: radiographic axial spondyloarthritis and non-radiographic axial spondyloarthritis. In addition, the importance of the presence of inflammatory back pain with spondyloarthritis in making the diagnosis is now well established. It is also clear that women are much more likely to develop axial spondyloarthritis than previously thought. Finally, there are treatments now available to treat axial spondyloarthritis and more hopefully to be approved in the next year.

Таърих ва фаъолияти бемористонҳо ва мадориси тиббии қуруни вустои Хуросону Мовароуннаҳр баррасӣ шудааст. Ташкили мадориси тиббию бемористонҳо, инчунин тарзи гузаронидани озмунҳои довталабони соҳаи тиб, дастмузди пизишкон дар китоби Авесто, сабабҳои сохтмони бемористонҳо мавриди таҳлилу баррасӣ қарор гирифтааст. Инчунин маънои вожаи бемористон, сабабҳои сохтмони шаҳри Ҷундишопур, вожаи Ҷундишопур, бино намудани мадрасаю бемористони Ҷундишопур, густариш ва ташаккули бемористони номбурда, раисону табибони ин бемористон мавриди омӯзиш қарор дода шудаанд. Ба ғайр аз ин нақши дастпарварони бемористони Ҷундишопур дар Хилофати Араб, намудҳои бемористонҳои он давра: собит ва сайѐр, аввалин бор дар ҷаҳон пайдоиши омӯзиши бемориҳои хусусияти баҳрнавардидошта дар бемористони Ҷундишопур ба риштаи таҳқиқ кашида шудаанд. Бар замми масъалаҳои бемористони Рашид, бемористони Бармакӣ, бемористонҳои Мовароуннаҳру Хуросон дар давраи ҳукмронии Сомониѐн,,, бемористонҳои Низомия ва хусусиятҳои онҳо таҳқиқ гардидаанд. Ҳамчунин доир ба сарпастони бемористонҳо низ маълумот дода шудааст., The article dwells on the history of creating hospitals and special medical educational establishments in Maverannahr and Khorasan in Middle Ages. Such issues are highlighted as launching of hospitals, methods of conducting competitions among a future medical staff and also the reasons associated with the enterprises in question. The author analyzes the sense of the notion ―hospital‖, the reasons accounting for the creation of Jundishapur-city with its medical schools and hospitals and also for the assignment of their chiefs. He discloses the role of the graduates of medical institutions in medicine development through the period of Arabian khalifate, presents the types of hospital which existed at that time, both permanent and mobile ones; diseases beset with navigation being described as well. Into the bargain, there are canvassed the problems of mediaeval hospitals named after Rashid, Barmaki, the hospitals of Maverannahr and Khorasan in the period of the Somonids, Nizomiya hospitals with their peculiarities of functioning, medicinal properties of bath-houses. Information about Maecenases of the medical institutions enumerated is given.

Nascent and rapidly growing research into defining the concept of "food addiction" (FA) in relation to obesity is currently underway. Food addiction is present in a subset of patients who are overweight or have obesity, and its presence is associated with other psychosocial disorders such as depression, anxiety, eating disorders, impulse control disorders, and lower quality of life. Food addiction is associated with higher intake of and preference for highly processed foods that have addictive-like properties such as cravings, reward sensitivity, and impaired control. Food addiction is associated with less weight loss in patients with obesity utilizing diet and lifestyle-related interventions. In clinical practice, identifying the subset of patients with obesity with FA-related psychosocial constraints and continued emphasis on avoiding highly processed foods may improve obesity and weight management outcomes. Food addiction is thought to be an addictive-like phenotype.Food addiction is noted to have significant overlap with substance use disorder (SUD) and other eating disorders, but is currently not classified a diagnosis by DSM-IV and DSM-V criteria.Food addiction has similarities to SUD, such as cravings, reduced control over intake, increased impulsivity and altered reward-sensitivity.The Yale Food Addiction Scale, which is a clinical scale modeled by the DSM-IV and DSM-V criteria for SUD, has been used to quantify and study FA.

Thyroid eye disease, although rare, is the most common inflammatory orbital disorder and is associated with autoimmune thyroid dysfunction. It is a progressive disorder with symptoms and signs that may cause significant facial disfigurement, visual disability, but rarely blindness. We will review the diagnostic criteria, immunologic basis, clinical course, and medical and surgical treatments for thyroid eye disease. Recent developments in the use of biologic agents to treat this disorder appear to be changing its progression curve and offer the first specific and preventative therapeutic options.

Cancer continues to be one of the leading causes of death. Although survival rates have improved with current treatments for hematological malignancies, relapsed and refractory cases have poor prognosis. Immunotherapy against cancer cells offer new hope for curative response in these patients. Of those, Chimeric Antigen Receptor (CAR) T-cells are emerging as promising therapy for hematological malignancies, where T-lymphocytes are genetically engineered with CAR to recognize and eliminate specific tumor cells. The efficacy of CAR T-cell therapy is also being studied in solid tumors. In this review, the basic principles of CAR T-cell therapy are discussed.

One of the cornerstones of treatment after acute coronary syndromes is cardiac rehabilitation (CR). However, traditional CR remains underused in the United States due to comorbidities and geographical limitations. To evaluate feasibility and safety of our individually tailored CR program, we evaluated twelve weeks of tele-monitored home-based arm ergometer and weight training exercises in seven Veterans. Prior to beginning our CR program, all Veterans underwent an arm ergometer stress test and training in the proper techniques for arm exercises and weight training. Seattle Angina Questionnaire (SAQ) and the MacNew Heart Disease Health-related Quality of Life (MacNew) questionnaire were administered at the beginning and conclusion of the program. Six patients completed the study. One withdrew due to generalized weakness. There were no adverse events during the study period. There was a perceived improvement in heart disease related global (4.47 to 4.61), physical, emotional, and social well-being by the MacNew questionnaire. The SAQ showed improvement in physical limitation, angina frequency, treatment satisfaction, and overall quality of life (36.1 to 51.7) after completion of our tailored CR program. There was a decrease in average blood pressure and patients were able to exercise seven minutes longer and workload increased eight additional watts. This pilot study demonstrates the safety and feasibility of a home-based arm cardiac rehabilitation program. These tailored programs may improve quality of life in coronary artery disease patients with disabilities.

PURPOSE OF STUDY: Plastic Bronchitis (PB) is a rare pulmonary condition characterized by the presence of casts in the trachea or bronchial tree. While there are many individual cases reported in pediatric and adult populations, no thorough reviews of pediatric and adult cases of PB exist in the literature. The purpose of this article is to conduct a comprehensive review of PB regarding presentation, diagnosis, pathophysiology, and treatments. ETIOLOGY: In the pediatric population, PB can be attributed to pediatric cardiothoracic surgeries such as Fontan procedures, infections, inflammatory processes, acute chest syndrome, or iatrogenic processes. In the adult population, PB can be idiopathic or due to infections, anatomic variations in lymphatic vessels, surgeries, medications, or other comorbidities. PATHOPHYSIOLOGY: The pathophysiology of PB is still widely unknown; however, associations with inflammatory diseases and cardiac surgery have been proposed. There are two types of cast formations found in plastic bronchitis: Type I casts are associated with inflammatory diseases and Type II casts are associated with surgical procedures. TREATMENT: Historically, PB has been treated by a variety of pharmacological methods including the use of corticosteroids and mucolytics. Recently, the treatment paradigm has shifted towards procedures such as lymphatic embolization, duct ligation, and stent grafting. CONCLUSIONS: The information available regarding PB is still sparse, hence future research is necessary for further understanding of the disease. Due to its numerous presentations and disease associations, awareness of plastic bronchitis, and its treatment options is essential for primary care providers and respiratory specialists.

Peripherally inserted central catheter (PICC) placement is necessary for delivery of intravenous (IV) antibiotics to treat bone and soft tissue infections. Upper extremity deep venous thrombosis (DVT) after PICC placement is a complication with unknown incidence in the orthopaedic literature. The major objectives of this study are Identifying the rate of upper extremity PICC-associated DVTs after orthopaedic procedures;Which orthopaedic subspecialties are most likely to encounter an upper extremity PICC-associated DVT?What surgeries or medical comorbidities are risk factors for upper extremity PICC-associated DVTs?Does type of DVT chemoprophylaxis decrease the risk of an upper extremity PICC-associated DVT?A retrospective review of electronic medical records (EMR) was performed to include all patients undergoing irrigation and debridement (ID) for treatment of orthopaedic surgery-related infections over a 10-year period. All patients with PICC placement were included for analyses. Age, sex, and medical comorbidities were extracted from the EMR. Mann-Whitney non-parametric tests, Fisher's exact tests, Chi-square tests, and Cochran-Mantel-Haenszel (CMH) tests were used to determine associations with DVT events for those with PICCs based on medical comorbidities, PICC lumen size, team placing the PICC, impact of implant removal, and protective effect of DVT chemoprophylaxis. Significance was set at p0.05.Twenty-one of 660 patients (3.18% rate) were found to have an upper extremity PICC-associated DVT. A history of DVT (OR=8.99 [95% CI: 3.39, 49.42]) was significantly associated with an upper extremity PICC-associated DVT. The greatest risk for an upper extremity PICC-associated DVT was intramedullary implant removal (OR=12.43 [95% CI: 3.13, 49.52]). The type of DVT chemoprophylaxis did not significantly affect the likelihood of an upper extremity PICC-associated DVT.Intramedullary implant removal and a history of DVT are risk factors for an upper extremity PICC-associated DVT. The results of this study should be of particular interest to surgeons who do not typically give DVT prophylaxis and plan to perform surgery on patients with CHF, a history of a DVT, or plan to manipulate the intramedullary canal.

Sleep fragmentation refers to the disruption of sleep architecture with poor quality of sleep despite optimal duration of sleep. Sleep fragmentation has been shown to have multiple effects on different body systems. This article reviews the effect of sleep fragmentation on the rate of atherosclerosis which has been linked to comorbidities like myocardial infarction, stroke, and coronary artery disease with an aim to educate patients regarding the importance of sleep hygiene and to incorporate a good amount and quality of sleep as life style modification along with diet and exercise.

Up until about 100 years ago, the omega-6/3 ratio has been around 4:1 or less. However, the typical Western diet now provides an omega-6/3 ratio of approximately 20:1 in favor of omega-6. This predisposes to supraphysiologic inflammatory responses and perpetuates chronic low-grade inflammation. The overconsumption of linoleic acid, mainly from industrial omega-6 seed oils, and the lack of long-chain omega-3s in the diet creates a pro-inflammatory, pro-allergic, pro-thrombotic state. Reducing the omega-6/3 ratio, particularly through reductions in the intake of refined omega-6 seed oil, and increasing the intake of marine omega-3s, either through dietary means or supplementation, may be an effective strategy for reducing inflammation, allergies, and autoimmune reactions.

This is a retrospective chart review of 161 MICU patients who underwent tracheotomy by the Otolaryngology service at the University of Missouri Hospital from April 2015 through March 2018. The objectives of this study were to describe long term outcomes of patients who underwent tracheotomy, and identify any clinical variables associated with these outcomes. One-year mortality was 37% (50/161), and on multivariate analysis only age (p=0.001) was associated with mortality.

Cystic fibrosis (CF) is an autosomal recessive disease that was previously a fatal pediatric disease with no treatment; however, due to scientific advancements, the median age of survival for the CF population born in 2018 has increased from 29 in 1989 to 47.4 in 2018. This is an innovative era for the treatment of CF as advanced research continues to evolve and novel treatments for the disease and related illnesses are discovered.

Thunderbeat™ is a device that uses both ultrasonic and advanced bipolar energies to achieve hemostasis. It has been evaluated in a variety of clinical contexts, but no literature exists regarding its application to pancreatic surgery. Using a prospective, randomized controlled trial, we evaluated its safety and efficacy in the Whipple procedure. Thirty-two participants were enrolled in the study. The Thunderbeat™ device during the Whipple procedure showed similar safety profile compared to standard of care.

The author dilated 3,112 patients with esophageal strictures over 36 years. Most strictures were peptic, esophageal rings, cervical webs or eosinophilic. Strictures were assessed for presence of hiatal hernia, hernia size, stricture diameter, and type and size of dilator used. Complex strictures were present in 19.7% of patients. Re-dilation was needed in 30% of patients within five years. Three adverse reactions occurred, one perforation and two bleeds in 3,112 patients (0.1%) and 5,960 dilations (0.05%).

PURPOSE OF STUDY: EVALI has reached epidemic proportions. With the increasing prevalence, new information has come to light regarding the safety of electronic cigarettes. We investigate the impact of the recent EVALI epidemic on patient perception surrounding vaping. METHODS: An anonymous survey was developed to evaluate patient perception regarding vaping. The survey was administered to adult patients at various clinics at University of Missouri. A total of 287 survey responses were analyzed. RESULTS: In all, 81.5% of respondents reported that e-cigarettes are unsafe, 73.2% did not feel that the absence of THC oils or vitamin E acetate made e-cigarettes safer, and 55.1% felt that e-cigarettes are less safe than traditional cigarettes. A majority (76%) felt that e-cigarettes/vaping products should be more regulated and pose a public health concern. Most surprising, 67.6% of participants answered that they knew somebody who was negatively affected by EVALI. CONCLUSION: The survey responses suggest that the current EVALI epidemic is changing the public’s perception and the narrative surrounding safety of e-cigarettes and vaping products.

The majority of acute coronary syndromes are caused by the rupture of plaques rendered vulnerable by oxidized lipids, inflammation, and a thin fibrous cap with reduced collagen and smooth muscle cell content.2 Thus, stabilizing and reversing vulnerable atherosclerotic plaques can help to prevent cardiovascular events. In this regard, long-chain omega-3 fatty acids have a plethora of data for stabilizing vulnerable atherosclerotic plaques as well as reversing atherosclerosis. This review paper will summarize the observational data as well as animal and human studies supporting such a role and further discuss the current controversies around omega-3 supplementation.

Spontaneous coronary artery dissection (SCAD) is an uncommon and potentially fatal cause of acute coronary syndrome, myocardial infarction, and sudden death primarily affecting women. While the exact cause of SCAD is unknown, associated risk factors are emotional or physical stress, female gender, pregnancy-related factors including hormonal changes, fibromuscular dysplasia, mixed connective tissue disorders, and inflammatory disorders. In this report, we present a middle-aged female with ulcerative colitis and cirrhosis secondary to primary sclerosing cholangitis who was found to have SCAD on cardiac evaluation for liver transplantation workup.

We are reporting a 52-year-old female that developed documented vision impairing, large, bilateral nuclear and cortical cataracts during therapy after 46 treatments of a planned 60 treatment course of HBO(2) for a non-healing post-radiation leg wound. A review of the available literature makes this one of the earliest cases of cataract formation.