Thomas, Alexa

AbstractObjectivesMany guidelines for septic olecranon bursitis recommend aspiration of the bursa prior to initiation of antimicrobial therapy despite the absence of robust clinical data to support this practice and known risk of aspiration complications. Our objective was to describe outcomes associated with empiric antibiotic therapy without bursal aspiration among emergency department (ED) patients with suspected septic olecranon bursitis.MethodsWe conducted a retrospective observational cohort study of patients presenting to an academic ED from January 1, 2011, to December 31, 2018, with olecranon bursitis. The health record was reviewed to assess patient characteristics and outcomes within 6 months of the ED visit. Olecranon bursitis was considered “suspected septic” if the patient was treated with antibiotics. The primary outcome of interest was complicated versus uncomplicated bursitis resolution. Uncomplicated resolution was defined as bursitis resolution without subsequent bursal aspiration, surgery, or hospitalization.ResultsDuring the study period, 264 ED patients were evaluated for 266 cases of olecranon bursitis. The median age was 57 years and 85% were men. Four (1.5%) patients had bursal aspiration during their ED visit, 39 (14.7%) were admitted to the hospital, 76 (28.6%) were dismissed without antibiotic therapy, and 147 (55.3%) were dismissed with empiric antibiotic therapy for suspected septic olecranon bursitis. Among these 147 patients, 134 had follow‐up available including 118 (88.1%, 95% confidence interval [CI] = 81.1%–92.8%) with an uncomplicated resolution, eight (6.0%, 95% CI = 2.8%–11.8%) who underwent subsequent bursal aspiration, and nine (6.7%, 95% CI = 3.3%–12.7%) who were subsequently admitted for inpatient antibiotics.ConclusionsEighty‐eight percent of ED patients with suspected septic olecranon bursitis treated with empiric antibiotics without aspiration had resolution without need for subsequent bursal aspiration, hospitalization, or surgery. Our findings suggest that empiric antibiotics without bursal aspiration may be a reasonable initial approach to ED management of select patients with suspected septic olecranon bursitis.

In recent years, the use of point of care ultrasound (POCUS) in clinical practice has increased substantially . Many medical schools have introduced ultrasound skills training into their curriculum which starts early in anatomy courses . Few, if any, of these programs assess students’ ultrasound knowledge and skills in a simulated clinical team environment. Anatomy Ultrasound Objective Structural Practical Examination (OSPE) implemented as a part of practical examination provides such an opportunity to asses both traditional and non‐traditional discipline‐independent skills, competencies and attributes. As part of the seven‐week anatomy course at Mayo Clinic Alix School of Medicine, first‐year medical students attended four ultrasound sessions. Each session included a short didactic module followed by hands‐on practice guided by near‐peer teachers. For the final examination, four‐member student teams were required to work collaboratively to perform four different scans during which students interacted with multiple standardized patients and rotated responsibility for obtaining an image, orienting the image, and identifying assigned structures. Students were graded using a rubric and received a team‐score based on tasks associated with individual roles of team members. In addition to ultrasound skills, the nature of their professional interactions with patient, communication skills, and situational awareness were assessed. The average team score was 96%. The students completed a survey at the conclusion of the anatomy course in which they rated the OSPE experience very positively. Team‐based OSPE examination was a clinically relevant and effective mechanism to simultaneously evaluate anatomic knowledge, clinical skills, and non‐traditional discipline‐independent skills that were emphasized during the anatomy course. Support or Funding Information

The nasoseptal flap is a well‐recognized “work‐horse” flap for anterior skull base reconstruction. The sphenopalatine artery (SPA), which accounts for a large portion of the arterial supply in the nasal cavity, forms a basis for the flap pedicle. In addition, the identification of the SPA as it emerges from the pterygopalatine fossa into the nasal cavity via the sphenopalatine foramen (SPF) is useful during the transpterygoidal approach to the infratemporal fossa. This identification is also useful for treatment of epistaxis in the nasal cavity, and aids in the prevention of vascular complications in a surgical setting. Previous studies have shown the relationship of the sphenopalatine foramen to the floor of the nasal cavity, choanal arch, and maxillary line. To enhance endoscopic visualization this study set out to identify the relationship of the anteroinferior bony border of the sphenoid sinus, the superior nasal concha, and the middle nasal concha as anatomical landmarks to the SPF. A total of n = 33 cadaveric hemisections were studied. In addition, the SPF was identified in coronal computerized tomography (CT) scans of the dissected cadavers acquired from the Anatomical Bequest Program at the Mayo Clinic (IRB approval #19‐010471), n = 8. Nasal mucosa was reflected from the lateral nasal wall where the SPF was located. The exit of the SPA’s main arterial trunk at the SPF was measured in relation to the sphenoid sinus, superior nasal concha, and middle nasal concha and the number of branches was recorded. Measurements on CT imaging were taken posterior to the ostiomeatal unit and maxillary sinus at initial visualization of the sphenoid sinus. Measurements of the SPF in relation to the inferior bony boundary of the sphenoid sinus were recorded (mm). All radiologic images were collected, and measurements were taken using Association for Quality Imaging (AQI) software. Images were analyzed and processed using Fiji ImageJ software. Results of this study showed the immediate surgical relationship of the sphenoid sinus, superior nasal concha, and middle nasal concha to the SPA as it traverses the SPF into the nasal cavity. Average distance from the SPF to the anterior‐inferior bony boundary of the sphenoid sinus was 2.5mm, the superior nasal concha was 4.12mm, and the middle nasal concha was 2.86mm. Radiological measurements taken in coronal CT images from the inferior bony boundary of the SPF to the inferior bony boundary of the sphenoid sinus was on average 4.94mm. Number of primary branches off of the SPA arterial trunk, and branching patterns varied between 2–3 with instances of a single long SPA arterial trunk traveling more than 3 mm followed by two small branches inferiorly. These relationships can be used to safely identify the SPA as it exits the SPF during surgery to prevent vascular complications due to occluded visualization of the region. Support or Funding Information American Association of Anatomists Short‐Term Visiting Scholarship Award

Background Premature coronary artery disease ( CAD ) is common in patients with coarctation of aorta ( COA ), but there are limited data about any direct relationship (or lack thereof) between COA and CAD . We hypothesized that atherosclerotic cardiovascular disease risk factors, rather than COA diagnosis, was the primary determinant of CAD occurrence in patients with COA . Methods and Results This is a retrospective study of 654 COA patients and a control group of 876 patients with valvular pulmonic stenosis and tetralogy of Fallot to determine prevalence and independent risk factors for CAD . There was no evidence of a difference in the unadjusted CAD prevalence between the COA and control groups (7.8% versus 6.3%, P =0.247), but premature CAD was more common in COA patients (4.4% versus 1.8%, P =0.002). In the analysis of a propensity‐matched cohort of 126 COA and 126 control patients, there was no evidence of a difference in overall CAD prevalence (6.3% versus 5.6% versus P =0.742) and premature CAD prevalence (4.8% versus 3.2%, P =0.518). The multivariable risk factors for CAD were hypertension (odds ratio [ OR ] 2.14; 95% CI 1.36–3.38), hyperlipidemia ( OR 3.33; 95% CI 2.02–5.47), diabetes mellitus ( OR 1.98; 95% CI 1.31–3.61), male sex ( OR 2.05; 95% CI 1.33–3.17), and older age per year ( OR 1.06; 95% CI 1.04–1.07). Conclusions After adjusting for atherosclerotic cardiovascular disease risk factors, we did not find evidence of a difference in CAD risk between the patients with COA and other patients with congenital heart disease.