Purpose: To assess the effect of adrenocorticotropic hormone (ACTH) on plasma vascular endothelial growth factor (VEGF) levels in healthy children and adolescents and to inform future work on the effects of ACTH on VEGF in bone. Methods: An Institutional Review Board-approved prospective study of 10 healthy subjects, ages 9–17, was conducted to assess the effect of ACTH on plasma VEGF levels. VEGF levels were collected at baseline and every 30 minutes for 3 hours. Cosyntropin (a synthetic ACTH analogue) was administered at a low-dose (1 μg) given at t=0 minutes and a high-dose (250 μg) given at t=60 minutes. A Friedman test was performed comparing baseline to peak VEGF levels after stimulation with low-dose and high-dose cosyntropin. Results: Peak plasma VEGF levels significantly increased after high-dose cosyntropin compared with baseline (P=0.042). Peak plasma VEGF levels did not significantly increase after low-dose cosyntropin compared to baseline. Conclusion To our knowledge, this is the first study to demonstrate that ACTH administration causes a significant increase in plasma VEGF levels in humans. This finding may have important implications in the protective effects of ACTH on bone. Decreased bone mineral density and adrenal suppression are common side effects of glucocorticoid use in pediatrics. VEGF increases vascularity and may play a role in reducing glucocorticoid-induced bone disease. Animal studies have shown that ACTH stimulates release of VEGF in osteoblasts, though this effect has yet to be evaluated in humans.

Purpose: To assess the effect of adrenocorticotropic hormone (ACTH) on plasma vascular endothelial growth factor (VEGF) levels in healthy children and adolescents and to inform future work on the effects of ACTH on VEGF in bone. Methods: An Institutional Review Board-approved prospective study of 10 healthy subjects, ages 9–17, was conducted to assess the effect of ACTH on plasma VEGF levels. VEGF levels were collected at baseline and every 30 minutes for 3 hours. Cosyntropin (a synthetic ACTH analogue) was administered at a low-dose (1 μg) given at t=0 minutes and a high-dose (250 μg) given at t=60 minutes. A Friedman test was performed comparing baseline to peak VEGF levels after stimulation with low-dose and high-dose cosyntropin. Results: Peak plasma VEGF levels significantly increased after high-dose cosyntropin compared with baseline (P=0.042). Peak plasma VEGF levels did not significantly increase after low-dose cosyntropin compared to baseline. Conclusion To our knowledge, this is the first study to demonstrate that ACTH administration causes a significant increase in plasma VEGF levels in humans. This finding may have important implications in the protective effects of ACTH on bone. Decreased bone mineral density and adrenal suppression are common side effects of glucocorticoid use in pediatrics. VEGF increases vascularity and may play a role in reducing glucocorticoid-induced bone disease. Animal studies have shown that ACTH stimulates release of VEGF in osteoblasts, though this effect has yet to be evaluated in humans.

As medical students enter the role of physician, clinical outcomes not only rely on their mastery of clinical knowledge, but also on the effectiveness in which they can communicate with patients and family members. While students typically have numerous opportunities to practice clinical communication with adult patients, such practice in pediatric settings is limited. This study examines if simulated patient (SP) encounters strengthen third-year medical students' communication skills during the pediatrics clerkship. During 2011-2013, three SP encounters (comprising 3 pediatric scenarios) were incorporated into a pediatrics clerkship at one United States medical school to give students a safe venue to practice advanced communication with observation and direct feedback. Third-year medical students engaged in the scenarios and received both written and oral feedback from an evaluator observing the encounter. With IRB approval, students' self-perceived confidence and abilities at performing the advanced communication skills were measured using an eight-item, Likert scale questionnaire administered pre and post the SP encounter. Pre- and post-questionnaires (n=215; response rate, 96%) analyzed using a Wilcoxon-matched pairs signed-rank test demonstrated statistically significant increases in students' perception of their confidence and abilities regarding their performance (P<0.05; Bonferroni correction, P<0.006). There was an increases in student confidence and self-perceived ability in: first, communicating with children and family members of young patients; second, managing confrontational situations involving parents; third, performing a thorough psychosocial history with an adolescent; and fourth, using Evidence Based Medicine to motivate parents.
Adolescent ; Adult ; Child ; Ethics Committees, Research ; Evidence-Based Medicine ; Humans ; Parents ; Pediatrics ; Schools, Medical ; Students, Medical ; United States ; Surveys and Questionnaires

Surgical site infection (SSI) is a potentially devastating complication of spinal surgery that increases patient morbidity and healthcare costs. SSIs have complex and multifactorial etiologies; therefore, there are numerous opportunities for prevention and risk mitigation. The aim of this narrative review was to describe the incidence, risk factors, and outcomes of SSIs in spine surgery with an emphasis on postoperative wound care. We list and describe the preoperative, intraoperative, and postoperative evidence-based interventions that can be applied to potentially prevent SSI after spinal surgery.

Q fever is a zoonotic infection caused by Coxiella burnetii. Acute Q fever usually develops as a self-limited flu-like illness, atypical pneumonia, or hepatitis. We experienced a case of Q fever in a 50-year-old male who had a prolonged fever. The bone marrow and lymph node biopsy revealed fibrin-ring granulomas, which is a distinct finding of Q fever. The diagnosis was proven by high titers of C. burnetii anti-phase II antibody (IgM 1:512 and IgG >,048) and positive nested PCR for the com-1 gene. Q fever is rare in Korea, but should be considered in the differential diagnosis of fever of unknown origin
Biopsy ; Bone Marrow ; Coxiella burnetii ; Diagnosis, Differential ; Fever ; Fever of Unknown Origin ; Granuloma ; Hepatitis ; Humans ; Immunoglobulin G ; Korea ; Lymph Nodes ; Male ; Middle Aged ; Pneumonia ; Polymerase Chain Reaction ; Q Fever

Nocardiosis is well-known opportunistic infection in immunocompromised patients. The timely diagnosis and treatment, however, is still a difficult problem. Recently, as newer molecular techniques, particularly 16S rRNA sequencing, are implemented, the diagnosis and management of the infection are improving. We report a case of lung abscess in a 39-year-old-man who underwent kidney transplantation. He was diagnosed of Nocardia elegans by 16S rRNA sequencing and was cured of the infection with appropriate antibiotic therapy.
Immunocompromised Host ; Kidney ; Kidney Transplantation ; Lung ; Lung Abscess ; Nocardia ; Nocardia Infections ; Opportunistic Infections

Nocardiosis is well-known opportunistic infection in immunocompromised patients. The timely diagnosis and treatment, however, is still a difficult problem. Recently, as newer molecular techniques, particularly 16S rRNA sequencing, are implemented, the diagnosis and management of the infection are improving. We report a case of lung abscess in a 39-year-old-man who underwent kidney transplantation. He was diagnosed of Nocardia elegans by 16S rRNA sequencing and was cured of the infection with appropriate antibiotic therapy.
Immunocompromised Host ; Kidney ; Kidney Transplantation ; Lung ; Lung Abscess ; Nocardia ; Nocardia Infections ; Opportunistic Infections

Septic arthritis is an uncommon finding of invasive Aspergillosis. It can be caused by direct inoculation, post-surgical infection, and hematogenous spread. Articular aspergillosis often involves the knee. A 49-year-old man who received a liver transplant in China on two months ago, due to liver cirrhosis caused by hepatitis B virus was admitted because of left side hip pain. Hip MRI showed joint effusion and bony destruction of the left hip and acetabulum. Incision and drainage was done and Aspergillus fumigatus was isolated from the resected tissue. After eight weeks of amphotericin B therapy, total hip replacement arthroplasty was done. Oral itraconazole 400mg/day was prescribed for six months after operation. The patient is now doing well without physical restriction
Acetabulum ; Amphotericin B ; Arthritis ; Arthritis, Infectious ; Arthroplasty ; Arthroplasty, Replacement, Hip ; Aspergillosis ; Aspergillus ; Aspergillus fumigatus ; China ; Drainage ; Hepatitis B virus ; Hip ; Humans ; Itraconazole ; Joints ; Knee ; Liver ; Liver Cirrhosis ; Liver Transplantation ; Middle Aged ; Transplants

Septic arthritis is an uncommon finding of invasive Aspergillosis. It can be caused by direct inoculation, post-surgical infection, and hematogenous spread. Articular aspergillosis often involves the knee. A 49-year-old man who received a liver transplant in China on two months ago, due to liver cirrhosis caused by hepatitis B virus was admitted because of left side hip pain. Hip MRI showed joint effusion and bony destruction of the left hip and acetabulum. Incision and drainage was done and Aspergillus fumigatus was isolated from the resected tissue. After eight weeks of amphotericin B therapy, total hip replacement arthroplasty was done. Oral itraconazole 400mg/day was prescribed for six months after operation. The patient is now doing well without physical restriction
Acetabulum ; Amphotericin B ; Arthritis ; Arthritis, Infectious ; Arthroplasty ; Arthroplasty, Replacement, Hip ; Aspergillosis ; Aspergillus ; Aspergillus fumigatus ; China ; Drainage ; Hepatitis B virus ; Hip ; Humans ; Itraconazole ; Joints ; Knee ; Liver ; Liver Cirrhosis ; Liver Transplantation ; Middle Aged ; Transplants

Cryptococcosis is a disseminated infection caused by Cryptococcus neoformans. It usually causes pulmonary infection and meningitis in immunocompromised patients. However, osteomyelitis due to C. neoformans is extremely rare. It is generally known that cryptococcal osteomyelitis is a complication of disseminated cryptococcosis, appearing in 5-10%. We experienced a case of cryptococcal osteomyelitis with paraspinal abscess in a liver transplant patient.
Abscess ; Cryptococcosis ; Cryptococcus neoformans ; Humans ; Immunocompromised Host ; Liver ; Meningitis ; Osteomyelitis ; Transplants