How to write up something scholarly in a weekend

Transcription

1 OR How to write up something scholarly in a weekend Deb Houry, MD, MPH Associate Professor Vice Chair for Research, Emergency Medicine Clinical Research Bootcamp February 28, 2014

2 Goals and Objectives To determine what patient presentations are good opportunities to write up To identify the elements of a worthwhile image and case reports For you to be able to write up a case or image in a weekend!

3 A different type of scholarship Designed for quicker consumption High yield rather than comprehensive coverage Expand clinical skills Demonstrate approaches, thinking, and procedures

4 Anatomy of a good case report Dr Houry, would this be a good patient to write up?

5 A case report should: Review a classical presentation of a rare disease Review a rare presentation (or cause) of a common disease (or finding) Present a new disease (or new presentation) Demonstrate an adverse response to drug therapies or presumed cause-and-effect presentations that have not been detected or reported before

6 Elements to include Abstract Introduction Case history/description Discussion with literature review Conclusions/recommendations

7 Abstract words Is not the same as Introduction section Allow for easier retrieval from PubMed Should include case presentation, discussion, and conclusion

8 Example We report a case of perforation of a walled off appendiceal abscess in a 5-year-old boy who sustained blunt abdominal trauma. The past medical history was significant only for a 4-day episode of abdominal pain 1 month prior to this presentation. Initial laboratory studies were unremarkable, and radiographic studies showed free fluid in the pelvis with no evidence of solid organ injury, but inflammation of the right colon. The final diagnosis was made at laparotomy. We emphasize this unique presentation and review the literature on traumatic appendicitis in children.

9 Example Uterine artery pseudoaneurysm rupture is a rare, yet life-threatening, cause of postpartum hemorrhage. Prompt recognition and management are critical in severe vaginal bleeding. In this case, diagnosis by bedside ultrasonography and initial management with vaginal packing and fluid resuscitation were performed in the emergency department. Definitive treatment by selective arterial embolization was performed to achieve hemostasis. This article discusses options available in the diagnosis, management, and treatment of uterine artery pseudoaneurysm hemorrhage.

10 Introduction No more than 3 paragraphs; usually just 1 Brief overview of topic Why the case report is novel or merits review

11 Example Appendicitis and traumatic injury are two of the most common presenting complaints in children in the Emergency Department (ED) that result in surgical consultation (1). Forty cases of an association between blunt abdominal trauma and appendicitis have been previously reported in the medical literature, with less than one fourth of these in children [2], [3], [4], [5], [6], [7], [8] and [9]. In these cases, it has been theorized that direct trauma to the appendix causes subserosal hemorrhage and local inflammatory changes that lead to traumatic appendicitis (2). To our knowledge, no case of a patient with perforation of the appendix after blunt abdominal trauma with a recent prior episode of abdominal pain presumed secondary to undiagnosed appendicitis has been reported. We present the case of a young child with blunt abdominal trauma resulting in perforation of a walled off appendiceal abscess.

12 Example Postpartum hemorrhage is a leading cause of maternal mortality. 1 Defined as blood loss greater than 500 ml with vaginal delivery or greater than 1,000 ml with cesarean section, postpartum hemorrhage requires prompt attention and management. 2 Early, or primary, postpartum hemorrhage occurs within the first 24 hours postpartum. Uterine atony (approximately 70% of cases), lacerations, retained placenta, uterine inversion, and coagulation disorders compose the majority of primary causes. Delayed postpartum hemorrhage, affecting 1% to 3% of deliveries, occurs 24 hours to 6 weeks postpartum and is usually due to retained products of conception, endometritis, or sloughing of the placental site eschar. 3 We present a case of delayed postpartum hemorrhage and then discuss the diagnosis, management, and treatment of our patient.

13 Case History No more than 5 paragraphs Should follow logical patient course HPI and PE Labs, xrays Differential dx Expected and actual outcome

14 Discussion Significance- why you are writing this! What about this patient was striking or unusual? What will your colleagues learn? Literature search MEDLINE/other database Search terms Results of search (# relevant, citations, what you learned) Discussion (significance, why you re writing this) Other conflicting outcomes/observations

15 Conclusion Depending on journal, may not be separate sectionjust final paragraph of discussion Summarizes case and topic And, what you needed to learn from this presentation

16 Example Cases of traumatic appendicitis and traumatic perforated appendicitis as discussed above have been reported, but no prior cases of a perforated appendiceal abscess secondary to blunt abdominal trauma have been reported. With the delayed and often initially missed diagnosis of appendicitis in children, perforation of an appendiceal abscess secondary to blunt abdominal trauma is probably rare, but possible (10). Physicians are unlikely to consider appendicitis in patients with a history of blunt abdominal trauma, but need to keep appendicitis in the differential in patients with persistent abdominal pain, particularly right lower quadrant pain.

17 Example Uterine arterial pseudoaneurysm rupture is an infrequent, yet life-threatening, cause of delayed postpartum hemorrhage, requiring prompt diagnosis and treatment. Postpartum patients presenting with severe vaginal bleeding and lower pelvic pain should heighten one's clinical suspicion. In skilled hands, bedside transabdominal sonography has been shown to be highly sensitive and specific for pseudoaneurysm detection. Early crystalloid and blood product resuscitation are essential. Vaginal packing often helps to tamponade hemorrhage, but other forms of therapy, including balloon compression and blood pressure cuff tamponade, should be considered. Arterial embolization should be considered first-line treatment if this modality is rapidly available, and surgical options such as arterial ligation and hysterectomy should be reserved as alternative therapies.

18 Anatomy of a good image case

19 The patient A 60-year-old woman presented to the emergency department (ED) after being treated earlier in the day in the Express Care area for a 5-day history of ear pain and sore throat. At that time, she was prescribed antibiotics and analgesics for presumed otitis media. Approximately 5 hours later, she re-presented for difficulty swallowing, hoarseness, and shortness of breath. Her vital signs were blood pressure 155/84 mm Hg, pulse 103 beats/min, respirations 20 breaths/min, temperature 37.7 C (orally), and room air oxygen saturation 98%.

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21 Continued The patient was given dexamethasone, albuterol, famotidine, diphenhydramine, clindamycin, and ceftriaxone on arrival for presumed epiglottitis. The radiograph demonstrated epiglottic and aryepiglottic swelling (Figure 1). Subsequent fiberoptic laryngoscopy performed in the ED revealed a large, inflamed epiglottis (Figure 2).

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23 DIAGNOSIS: Adult epiglottitis. Adult epiglottitis is an increasingly common phenomenon. However, the clinical presentation may differ slightly from that of the classic drooling, tripoding child. In one review, Frantz et al found that sore throat and odynophagia were present in 95% and 94% of cases, respectively. Nakamura et al found that sore throat was actually the chief complaint in 75% of cases. Additionally, both Frantz et al and Katori and Tsukuda found that the presence of stridor significantly increased the relative risk of need for an airway intervention. Microbiologically, although classically epiglottitis is associated with Haemophilus influenza, the advent of an effective vaccine has caused a decrease in H influenza associated epiglottitis. In adults, although antibiotic therapy must be directed toward coverage for H influenza, it must also adequately cover Staphylococcus aureus, Streptococcus pneumoniae, and Streptococcus pyogenes. REFERENCES 1. Berger G, Landau T, Berger S, et al. The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol.2003;24: Frantz TD, Rasgon BM, Quesenberry CP Jr. Epiglottitis in adults: analysis of 129 cases. JAMA. 1994;272: Nakamura H, Tanaka H, Matsuda A, et al. Acute epiglottitis: a review of 80 patients. J Laryngol Otol. 2001; 115: Katori H, Tsukuda M. Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol. 2005;119:

24 Why was that a good image case? Relevance: immediately apparent that the patient had a condition a physician should be able to recognize and treat It was clearly written and illustrated classic findings It focused on high yield information Diagnosis Important PE findings, historical clues Key management responsibilities, prognosis, next steps

25 What makes a good image? Something you should recognize on physical exam Rash- syphilis; cutaneous anthrax Neuro findings- facial droop, uneven pupils EKGs, etc you can find in a textbook Diagnostic imaging? Should be something a physician should be able to do or read

26 Why makes a good image write up? SHORT 1-2 paragraphs before and after the image <5 references Diagnosable in your setting Classic cases

27 Testicular pain! Published in Urology

28 Further reading Cohen H: How to write a patient case report. Am J Health-Syst Pharm. 2006; 63: McCarthy LH, Reilly K: How to Write a Case Report. Fam Med 2000;32(3):190-5.

29 Cited Examples Houry D, Colwell C, Ott C. Abdominal pain in a child after blunt abdominal trauma: an unusual injury. J Emerg Med Oct;21(3): Bhatt A, Odujebe O, Bhatt S, Houry D. Uterine artery pseudoaneurysm rupture: a life-threatening presentation of vaginal bleeding. Ann Emerg Med May;55(5): Epub 2010 Feb 20. Bitner MD, Capes JP, Houry DE. Images in emergency medicine. Adult epiglottitis. Ann Emerg Med May;49(5):560, 563.

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