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Arterial Thoracic Outlet Syndrome

    • Arterial thoracic outlet syndrome (TOS) is the least common form of TOS in adults.
    • Arterial TOS is usually a result of a bony anomaly causing compression of the subclavian artery at the scalene triangle.
    • Clinical presentation is similar to arterial insufficiency in any extremity.
    • Surgical treatment involves thromboembolectomy or thrombolysis depending on viability of the limb, arterial reconstruction, and first rib resection.

Overview of Psychotherapy in Psychiatry

    • The beginning of the twentieth century saw the rise of psychosocial interventions through the work of Sigmund Freud and other psychoanalysts and the advent of behaviorism. They offered novel approaches to patients with mental illness.
    • To be certified, psychiatry residencies must abide by the regulations of the Accreditation Council for Graduate Medical Education (ACGME). The ACGME requires that all psychiatry residents demonstrate competence in “managing and treating patients using both brief and long-term supportive, psychodynamic, and cognitive-behavioral psychotherapies.”
    • Data from office-based psychiatrists in the National Ambulatory Medical Care Survey (NAMCS) have been mixed. Between 1996–1997 and 2004–2005, the percentage of psychiatric office visits that involved psychotherapy fell from 44.4% to 28.9%. The number of psychiatrists who reported that they provide psychotherapy to all of their patients fell from 19.1% to 10.8% during that time.

Subjective Cognitive Impairment and Mild Cognitive Impairment (Predementias)

    • One in seven Americans is above the age of 65, and in the next 40 years, that number is expected to jump to nearly one in four. Older adulthood is a period when many individuals begin to exhibit difficulties in cognitive functioning, especially with memory and performing activities of daily living.
    • With the introduction of the DSM-5, changes were made to the nomenclature of the NCDs, as highlighted here. Mild cognitive impairment (MCI) was replaced by the new term mild neurocognitive disorder. Dementia was replaced by the new term major neurocognitive disorder.
    • AD is the most prevalent variant of the major NCDs, comprising 60 to 80% of all cases. In addition to the NIA/AA and DSM-5 criteria for dementia or major NCD, patients with AD need to exhibit evidence of a causative genetic mutation from family history/genetic testing or present with all of the following: (1) clear evidence of decline in memory and learning and at least one other cognitive domain, (2) steady, progressive decline in cognition without extended plateaus, and (3) no evidence of mixed etiology.

Pediatric Orthopedic Emergencies

    • Given the differences between pediatric bone characteristics compared with adults’, fractures are much more likely than sprains or strains and must be managed in light of open or partially open growth plates.
    • For pediatric fractures, thorough neurovascular assessment is vital and should be performed frequently during the emergency department visit, including before and after any splint placement or manipulation.
    • Nonaccidental trauma should be considered in cases where a patient’s injury is not consistent with either the history provided or the patient’s developmental age.
    • In children and adolescents with joint pain, careful consideration should be given to septic arthritis and osteomyelitis as presentations may range from indolent symptoms to septic shock.
    • In adolescents presenting with limp, slipped capital femoral epiphysis should be considered. Once the diagnosis is made, the patient should remain non–weight bearing until surgical correction is accomplished.

Pediatric Orthopedic Emergencies

    • Given the differences between pediatric bone characteristics compared with adults’, fractures are much more likely than sprains or strains and must be managed in light of open or partially open growth plates.
    • For pediatric fractures, thorough neurovascular assessment is vital and should be performed frequently during the emergency department visit, including before and after any splint placement or manipulation.
    • Nonaccidental trauma should be considered in cases where a patient’s injury is not consistent with either the history provided or the patient’s developmental age.
    • In children and adolescents with joint pain, careful consideration should be given to septic arthritis and osteomyelitis as presentations may range from indolent symptoms to septic shock.
    • In adolescents presenting with limp, slipped capital femoral epiphysis should be considered. Once the diagnosis is made, the patient should remain non–weight bearing until surgical correction is accomplished.

Pediatric Orthopedic Emergencies

    • Given the differences between pediatric bone characteristics compared with adults’, fractures are much more likely than sprains or strains and must be managed in light of open or partially open growth plates.
    • For pediatric fractures, thorough neurovascular assessment is vital and should be performed frequently during the emergency department visit, including before and after any splint placement or manipulation.
    • Nonaccidental trauma should be considered in cases where a patient’s injury is not consistent with either the history provided or the patient’s developmental age.
    • In children and adolescents with joint pain, careful consideration should be given to septic arthritis and osteomyelitis as presentations may range from indolent symptoms to septic shock.
    • In adolescents presenting with limp, slipped capital femoral epiphysis should be considered. Once the diagnosis is made, the patient should remain non–weight bearing until surgical correction is accomplished.

Pediatric Orthopedic Emergencies

    • Given the differences between pediatric bone characteristics compared with adults’, fractures are much more likely than sprains or strains and must be managed in light of open or partially open growth plates.
    • For pediatric fractures, thorough neurovascular assessment is vital and should be performed frequently during the emergency department visit, including before and after any splint placement or manipulation.
    • Nonaccidental trauma should be considered in cases where a patient’s injury is not consistent with either the history provided or the patient’s developmental age.
    • In children and adolescents with joint pain, careful consideration should be given to septic arthritis and osteomyelitis as presentations may range from indolent symptoms to septic shock.
    • In adolescents presenting with limp, slipped capital femoral epiphysis should be considered. Once the diagnosis is made, the patient should remain non–weight bearing until surgical correction is accomplished.

Patient with Lumbar Spondylosis and Diskogenic Pain

    • Studies suggest that early and gradual physical and behavioral therapies in combination with pharmacologic therapies should be encouraged in all patients as the initial treatment for patients with diskogenic low back pain (LBP).
    • Recent studies have found an association between microbial infection and symptomatic disk degeneration. Low-virulence microorganisms, in particular Propionibacterium acnes, might be causing a chronic low-grade infection in the lower intervertebral disks. A subset of patients with Modic type I changes in magnetic resonance imaging may benefit antibiotic therapy directed at the infected disks by P. acnes and other low-virulence microorganisms. 
    • There is accumulating evidence to support several interventional therapies for chronic diskogenic LBP. Biacuplasty is supported by level Ib evidence. Epidural steroid injection and gray ramus communicans radiofrequency ablation are supported by level II evidence. Intradiskal injections with methylene blue, ozone, or steroid have variable levels of evidence.
    • Regenerative strategies using cell-based therapies have shown promise to provide equal or even better outcomes compared with surgical spinal fusion or total disk replacement with an artificial disk.
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