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Transcript: British Medical Journal Annals of Rheumatoid Disease Synovial membrane inflamed and thickened. Bones and cartilage gradually begin to erode Stratification Change in MRI Erosion Score from baseline to week 24 with the use of Rituximab! Progression of osseous tissue formation, causing fusion of the bones, this reducing mobility and in resulting in pain Other Signs and Symptoms of RA Baseline MRI scan 14 days before 1st infusion. Images scored by 2 independent radiologists In fact, data presents joint improvement! All secondary outcomes lead to development of primary outcome (Joint erosion) van Elteren test Used to determine primary endpoint Percent change from baseline Study did not have true 'normal' Each patient's baseline was their individual 'normal' ANOVA cannot be used Test is considered inferior to others with a true 'normal' What if they're biologically naive? Randomized 1:1:1 Loss of energy Loss of appetite Low fever Dry eyes/mouth (sjorgren's syndrome) Rheumatoid nodules (elbows/hands) To evaluate the effect of Rituximab + MTX in reducing structural damage and joint inflammation vs. MTX alone in patients with active RA. Progression of RA 3. Fibrous Ankylosis MRI assessment of suppression of structural damage in patients with rheumatoid arthritis receiving rituximab: results from the randomised, placebo-controlled, double-blind RA-SCORE study Impact Factor: 10.38 Authors Professor Charles Peterfy MD, PhD 1. DiCarlo J. Julie Camille DiCarlo - Publications. Researchgatenet. 2015. Available at: http://www.researchgate.net/profile/Julie_Dicarlo2/publications. Accessed December 1, 2015. 2. Clinicaltrials.gov. A Study of Rituximab (MabThera®/Rituxan®) in Patients With Rheumatoid Arthritis and Inadequate Response to Methotrexate - Full Text View - ClinicalTrials.gov. 2015. Available at: https://clinicaltrials.gov/ct2/show/NCT00578305?term=00578305&rank=1. Accessed December 1, 2015. 3. Peterfy C, Emery P, Tak P et al. MRI assessment of suppression of structural damage in patients with rheumatoid arthritis receiving rituximab: results from the randomised, placebo-controlled, double-blind RA-SCORE study. Annals of the Rheumatic Diseases. 2014. doi:10.1136/annrheumdis-2014-206015. 4. Vimeo. MabThera (Rituximab) – Mode of action and the role of B cells in rheumatoid arthritis (RA) (1). 2014. Available at: https://vimeo.com/91432523. Accessed December 1, 2015. 5. Netter F, Iannotti J, Parker R. Musculoskeletal System. Philadelphia: Elsevier Saunders; 2013. Significant finding: Rituximab 1000 mg exhibited slower progression of joint erosion. Inclusion Criteria Study Objective American Rheumatology Criteria for ≥3 months and ≤10 years Erosion/signs/symptoms of synovitis in a single joint (MRI) IR to MTX at dose 12.5-25mg/wk ≥ 12wks More Analysis Interactive Voice Response System (IVRS) RA RA! Rituximab Against Rheumatoid Arthritis Discussion History of rheumatic autoimmune disease other than RA or significant systemic involvement secondary to RA Previously on another biologic agent that depletes B-cells. Progression of RA 2. Pannus Formation Founder and CEO of Spire Sciences. Attending radiologist at UCSF for 7 years Director of Arthritis Research for the Osteoporosis and Arthritis Research Group. Developed the WOMRS system and co-developed the RAMRIS (Rheumatoid Arthritis MRI Score) and PsAMRIS (Psoriatic Arthritis MRI Score) methods. - Spire Sciences’ mission is to improve world health by helping bring new and better therapies into clinical use faster. They are focused exclusively on central image analysis. <6 months MTX therapy ≥ 6 months MTX therapy +Bone erosion No bone erosion Primary Outcome Article Post-Hoc Analysis CARLOS TDS TIS week 12, 24, and 52 Health Assessment Questionaire Disability Index (HAQ-DI) Antibody to CD-20, which is found on the surface of B-cells Progression of RA 4. Bony Ankylosis Non-Biologic Hydroxychloroquine Sulfasalazine Leflunomide Methotrexate - Drug of Choice for non-biologic DMARDs Folate antimetabolite (anti-inflammatory and immunosuppressive) Most common type of autoimmune arthritis Progression of RA 1. Synovitis Statistical Analysis for Secondary Outcomes Efficacy Assessment Sponsors & Collaborators: Hoffmann-La Roche Rheumatoid Arthritis Symptoms Clinical significance: Rituximab+MTX prevents joint damage in MTX-IR patients with active RA Reductions in synovitis and osteitis --> reduction in erosion and cartilage loss. Will Rituximab slow the progression of joint erosion in patients with active RA, biologically naive, and failed MTX treatment? 75% of those affected are women Preparation Randomization Rheumatoid Arthritis (RA) Genant-Modified Sharp radiographic scoring Range is too narrow (0-4) Study only used biologically naive patients Possible author bias. He co-developed RAMRIS score Research facility focuses on Central Image Analysis Discrepancies between text, tables, and charts. Insignificant p-value in table, while chart and text indicate statistical significance.

Medical Case Presentation

Transcript: Medical Case Presentation Timeline A 5-Day Timeline of Events Timeline 5 Timeline 2. 4. 2. 4. 4 2. 4. Future Considerations Complications Encountered Revised Diagnosis Looking forward, this case highlights the need for improved protocols in patient monitoring and a more integrated approach to multidisciplinary care. Future practices should focus on leveraging technology for better tracking of patient conditions and enhancing communication among medical teams. Further Testing The patient exhibited signs of respiratory distress and electrolyte imbalance, indicating potential complications from treatment. These issues necessitated immediate reassessment of the patient’s condition to prevent further deterioration. The results from Day 2 testing indicated an evolving clinical picture, leading to a revised diagnosis of a potential systemic infection. This shift underscored the importance of adaptability in medical diagnoses and treatment protocols when patient conditions change. In response to the patient’s declining status, further diagnostic tests were conducted, including blood cultures and imaging studies. These investigations aimed to identify underlying causes of the patient's deterioration and to tailor an effective treatment strategy. Demographics Day 4 Events: Complications and Responses 3 Key Learnings Conclusion Patient Profile Critical insights from this case emphasize the importance of timely interventions, comprehensive assessments, and collaboration among healthcare professionals. The evolving nature of patient conditions necessitates continuous monitoring and adaptability in treatment approaches. This section encapsulates the timeline of events, highlighting the critical insights gained throughout the medical case presentation over five days. The patient is a 45-year-old male, presenting with no known allergies. He lives alone and works as an accountant, leading a sedentary lifestyle. This demographic information provides insights into potential health risks and lifestyle-related conditions. Adjustments in Treatment Understanding the patient profile is essential for effective diagnosis and treatment. This section summarizes crucial demographic information, medical history, and current medications for a holistic view of the patient's health. Day 2 Events On Day 4, the patient experienced unexpected complications, altering the treatment trajectory. Prompt adjustments were necessary to effectively address new clinical challenges and ensure patient safety. In response to the complications, the treatment plan was modified to include supplemental oxygen and intravenous fluids for rehydration. This prompted close monitoring to evaluate effectiveness and mitigate further risks. Current Medications Changes in Patient Condition Medical History Consultations with Specialists Summary of Timeline On Day 2 of the case trajectory, significant changes in the patient's condition prompted immediate reevaluation. This set the stage for a series of critical tests and a necessary revision of the initial diagnosis, illustrating the evolving nature of medical assessments. Currently, the patient is on Lisinopril for hypertension. Additionally, he takes a multivitamin daily but reports no use of over-the-counter medications or supplements, which is critical for medication reconciliation. By Day 2, the patient exhibited noticeable alterations in vital signs, including elevated heart rate and fluctuating blood pressure. Symptoms such as increased discomfort and altered consciousness levels were reported, necessitating reassessment of the treatment plan. The patient has a medical history of hypertension diagnosed 5 years ago, managed with lifestyle changes. There is no significant surgical history or family history of chronic diseases, which influences the treatment options available. With the emergence of complications, consultations with pulmonology and nephrology specialists were initiated. Their insights guided the medical team in refining the treatment strategy and ensuring comprehensive care. The timeline of this case illustrates a series of pivotal events leading from initial symptoms to final assessments over five days. Key decisions and interventions shaped both the patient’s experience and outcomes, reinforcing the value of structured medical timelines in patient care. 2 3. 1. 1 Overview of Medical Case Discharge Planning Outcome of Treatment The medical case involves a patient who presented with multiple symptoms requiring a systematic analysis. Over five days, various diagnostic tests, treatments, and responses will be chronologically detailed to illustrate the clinical journey and decision-making process. 3. 1. Discharge planning involved a multidisciplinary team assessing the patient's needs for home care, follow-up appointments, and medication instructions. Effective communication and coordination ensured the patient understood their post-discharge care, minimizing the risk of complications. The treatment plan

Medical Case Presentation

Transcript: Boulanger David medicine student Medical case presentation Identity Identity Name: Johnson Forname: William DOB: 24th September 1979 Occupation: Teacher (school director) Social status: Married Child: 2 (girl: 12 boy: 8) Live in: Grenoble (France) Symptom(s) Symptom(s) - Dizziness - Headache - Muscle aches - Insomnia - Nausea and vomiting - Irritability - Loss of appetite - Swelling of the hands, feet, and face - Rapid heartbeat - shortness of breath with physical exertion - Coughing - Chest congestion - Pale complexion and skin discoloration - Inability to walk or lack of balance - Social withdrawal Family history (FH) Family history (FH) TIME FATHER: myocardial infarction (67) MOTHER: Diabetes (32) Siblings: NAD Past medical history Past medical history TIME appendectomy (14) tonsillectomy (15) withdrawal of wisdom teeth (18) Broken leg (23) Social history (SH) Social history (SH) TIME Walking Trekking Climbing Swimming Skiing Examination (O/E) Examination (O/E) examination (O/E) examination (O/E) Weight: 70 Size: 1.75 Weight: 70 Size: 1.75 BP: 140/80 BP: 140/80 P: 180 P: 180 Respiratory frequency 20 / Min Respiratory frequency 20 / Min P02: 92% P02: 92% T: 37.5°C T: 37.5°C DIAGNOSIS DIAGNOSIS Acute Mountain Sickness (AMS) ? Acute Mountain Sickness (AMS) Treatment Treatment Medications : acetazolamide, to correct breathing problems blood pressure medicine lung inhalers dexamethasone, to decrease brain swelling aspirin, for headache relief Other treatments Lower altitude Lower altitude At rest At rest Water Water

Medical Case Presentation

Transcript: O God, that men should put an enemy in their mouths to steal away their brains! That we should with joy, pleasance, revel, and applause transform ourselves into beasts! William Shakespeare (1564-1616) British poet and playwright. 48 year old Caucasian female "My stomach is really hurting" HPI 48 y/o lady with a PMH of alcoholic liver cirrhosis, and esophageal varices "My stomach really hurts" She's been having abdominal pain for the past 6 days. Describes the pain as dull (constant and diffuse) 8/10 in severity starting from the epigastrium moving to the lower part of the belly. She feels relief when she lies down and worse sitting up. She also mentions that she noticed gradual distention of her belly for the past three weeks. She denies any nausea, vomiting, weight loss, or fever but notices some swelling in her left leg. In addition, she has recently been experiening some shortness of breath. She has dyspnea on exertion but denies orthopnea and paroxysmal nocturnal dyspnea. Of note, she mentions that she had similar belly pain 2 weeks ago which was associated with episodes of bloody vomiting. She went to Eastern Shore Hospital, admitted for upper GI bleed, underwent a panel of tests that included an endoscopy, ultrasound, and ascitic tapping and diagnosed with liver dx. She also mentions that she felt a lot better after that and hoped to get tapping done at SAH. Past Medical History Alcoholic liver cirrhosis Grade one esophageal varices Anemia Hx of thrombocytopenia Anxiety disorder GERD Cholecystitis Alcohol abuse Past Surgical History Rhinoplasty Allergies Acetaminophen (rash) Oxycodone (nausea) Medications Propanolol 10 mg po BID Pantoprazole 40 mg po BID Lactulose 15 mg po Qday Spironolactone 25 mg po Qday Sertraline 100 mg po Qday Clonazepam 1 mg po BID Review of Systems General: Muscle weakness, fatigue, and chills HEENT: No headaches, vision change, hearing changes, sinus troubles, bleeding gums, swollen glands Cardiac: No chest pain, palpitations Resp: Cough (non productive) and wheezing Breasts: No lumps, pain, nipple discharge GI: per HPI GU: No trouble urinating, no pain on urination, no hematuria, LMP was three years ago Extremities: per HPI Skin: No rashes, lesions, or color changes Endocrine: No heat or cold intolerance, excessive thirst or hunger Neuro: No seizures, numbness, or tingling Hematologic: No easy bruising or past transfusions Physical Exam 99.0 T 76 P 18 RR 115/60 BP 97% on 2L nasal cannula Weight: 70.307 kg General: Middle aged lady, in obvious pain but no acute respiratory distress, alert and oriented to person, place, and time. HEENT: Scalp normal, pupils equally round and reactive to light and accomodation. Fundoscopic exam reveals normal vessels, tympanic membranes are normal, oral pharynx is normal, neck is supple, no abnormal adenopathy in cervical or supraclavicular areas, thyroid is normal without any masses. Cardio: No murmurs/rubs, heart sounds S1 and S2 are present. Resp: Decreased air entry over the rt lower lung field, some expiratory wheezing bilaterally. GI: The abdomen is distended and bulging at the flanks but not tense, diffuse tenderness to palpation exquisitely over the epigastrium, Murphy's sign not present, bowel sounds are present, positive for shifting dullness, liver palpable 2 fingers below the subcostal margin, unable to appreciate exact size of liver or any splenomegaly MS: No cyanosis, clubbing, or edema noted. Peripheal pulses in the dorsalis pedis, and radial arms are normal. Skin: Multiple spider angiomas over subclavicular region, face and shoulders Neuro: Alert, oriented x3, CN II-XII intact, power 5/5 all extremities. March 10: Hypoxic requiring 100%FIO2 and PEEP of 12. March 11: Breathing improving requiring PEEP of 5 and FiO2 of 40%. Renal function improving with the CVVHD March 12: Breathing treatment the same, worsening encephalopathy, sedated but arousable, does not follow commands this am, eye opening present. CT of abdmn showed mild ascites, possible ascending colitis. Displaying multiorgan failure. March 13: Family decides to change code to DNI/DNR and request pt to be extubated with pastoral services present. March 14: Pt displays agonal breathing, no longer arousable. On morphine drip for pain. March 15: Worsening agonal breathing, no longer arousable. On morphine drip for pain. March 16: Pt passes away at 6:21pm. SBP Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection in the peritoneum and severe consequence of ascites. Patients with cirrhosis who are in a decompensated state are at the highest risk of developing spontaneous bacterial peritonitis. Patients at greatest risk for spontaneous bacterial peritonitis have decreased hepatic synthetic function with associated low total protein level or prolonged prothrombin time (PT). The diagnosis is established by a positive ascitic fluid bacterial culture and an elevated ascitic fluid PMN count >250 cells/mm3 SBP Fever and chills occur in as many as 80% of patients.

Template For Students

Transcript: Stories & Legends Winter 1. Powerful Central Image with an inquiry question to guide your thinking 2. Three main idea subtopics to refine your thinking: 1) Geography/Topography - 10 pictures (5 for land, 5 for water) relating to geographical terms with definitions for each 2) Natural Resources - Food: What types were available? - Where did they get it from? - How did they get it? - Transportation - What natural resources did they use for travel? - Natural waterways? - Did they make vessels or tools to aid their travel? - Clothing - How did the seasons/climate change what they wore? - What was the clothing made of and why? - Housing: 5 Facts - Did they change/move depending on season? - What were they made of? - How many people/families did they support? 3) Lifestyle & Cultural Practices: At least two of each: - Stories/Legends (2) - Ceremonies (2) - Beliefs (2) 3. At least 3 short video clips (less than 5 minutes; one for each main idea) Transportation/Tools From Resources Picture Hunting From the Land Agriculture What is it made of? Canoes? Snowshoes? Different styles? Using the Land as a Lifeline Spring Summer Fishing How does where one lives, affect how they live? Beliefs Clothing From Resources Picture Hunting How do the seasons/climate change the clothing? Food From Resources Picture Women were usually the ones that gathered the berrys Criteria Ceremonies From the Natural Waterways Geography/Topography Picture of Land Housing From Resources Picture Fall Lifestyle & Culture Natural Waterways Gathering Quoted From: http://www.aitc.sk.ca/saskschools/firstnations/beliefs.html Geography/Topography Using the Land as a Lifeline Picture of Water First Peoples of Canada Prezi What resources helped them travel? Lifestyle & Culture INSERT CENTRAL IMAGE

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