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"text": "The correct action implies inescapably the personal and direct contact between the doctor and the patient."
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} | There is no doubt that the doctor-patient relationship today transcends the physical environment of the consultation room. But we must not forget that we must maintain the same ethical and professional codes as in the real environment. The code of ethics Article 26-3. The clinical practice of medicine by means of consultations exclusively by letter, telephone, radio, press or internet, is contrary to the deontological norms. The correct action implies inescapably the personal and direct contact between the doctor and the patient. | There is no doubt that the doctor-patient relationship today transcends the physical environment of the consultation room. But we must not forget that we must maintain the same ethical and professional codes as in the real environment. The code of ethics Article 26-3. The clinical practice of medicine by means of consultations exclusively by letter, telephone, radio, press or internet, is contrary to the deontological norms. [HIDDEN] the personal and direct contact between the doctor and the patient. | Juan, a second year resident, attends Sofia, a 15 year old girl in the emergency room, who apparently fainted at school without losing consciousness. The patient says that she was due to take an exam, which caused her a lot of anxiety. From the interrogation, it appears that she was being bullied by her classmates and that she may have an eating disorder. Vital signs and neurological examination are normal. Juan keeps Sofia under observation while waiting for her parents to come to the service, periodically taking a look at how the patient is doing. After the initial scare, the patient seems to be increasingly animated and is very friendly. On one occasion, Juan finds her actively chatting on her cell phone. Juan tells her that it would be better for her to put the cell phone down and rest and to reassure her, he tells her that he also uses social networks a lot since college. Sofia apologizes for not knowing that she should have her cell phone turned off, and after turning it off, asks if she can make a friend request on Facebook. What do you think is Juan's best response? | 402 | en | {
"1": "Tell him to make the friend request and that he will accept it, as he is sure that there are no inappropriate items on his page for a girl of Sofia's age.",
"2": "Because you consider Sofia a vulnerable patient and are concerned that she may misinterpret a rejection, agree to let her make the request but only allow her access to certain content on your page.",
"3": "Answer that it is important to maintain certain professional boundaries between patients and physicians and that, unfortunately, if you make the request you will not be able to accept it, so it is better not to do so.",
"4": "Tell him to make the request but without any intention of accepting it.",
"5": null
} | 183 | PRIMARY CARE AND SOCIAL NETWORKS | 2,016 | {
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{
"id": "pubmed23n0091_3667",
"title": "[Telling the patient the diagnosis of cancer].",
"score": 0.009988023952095809,
"content": "Four cases are presented for discussion. In the first case, the patient believed the doctor for a while when his suspicion of cancer was forcibly denied. But when radiotherapy followed the operation, he became convinced that he had been deceived and confronted the doctor aggressively to force him into a confession. In the second case, the patient, a resident of the U.S. for many years, was told on completion of tests the true diagnosis even before his American wife learned of it. He became very depressed, while his wife kept urging him to fight the cancer. In the third case, the doctor thought better of the earlier decision by another doctor not to tell the truth. The doctor called the patient's relatives to discuss the advisability of telling the truth and when he secured their confidence, he visited the patient with them and told him the true diagnosis. The patient recovered from the initial shock and lived peacefully for several months enjoying the new union he felt with his wife. In the fourth case, it is as if there were a kind of silent conspiracy between the doctor and the patient's relatives who kept her in the dark about her condition. When her illness went downhill, she became completely withdrawn, though she accepted religious ministering to the end. It is cruel to deceive the patient with false hopes. But to tell the patient the truth needs tact. The doctor in the third case gives a very good model of it. First, he assesses the patient's personality. Second, he convinces the patient's relatives of the advisability of truth-telling. Third, he assures the patient that he is in charge no matter what happens to him. Perhaps it was easier to tell the patient the diagnosis of cancer or its poor prognosis in bygone days than nowadays, when the wonders of modern medicine are too much publicized."
},
{
"id": "pubmed23n0648_15276",
"title": "Who rules the roost?",
"score": 0.009900990099009901,
"content": "Adam's mother was concerned about her 3-year-old son's hyperactivity, violence, and activity level. Adam and his mom had recently moved into a shelter for pregnant women. The rest of the residents are primarily in their early 20s, whereas Adam's mom is 42. She had found about 3 months ago that she was pregnant. This was her fourth pregnancy, second with this father, and he had recently left her when she refused an abortion. Her other children are 22 and 24 and live out of state. She has a history of opioid addiction. She had been on methadone during Adam's gestation and had recently started on buprenorphine to treat her addiction during this pregnancy as well. Adam is here today for his 3-year-old checkup and you had not seen him for a year. Mom states that he has been healthy but has become progressively active over the last year. He is very angry about his dad leaving, and according to Adam's mother \"blames her\" for sending him away. They are living in 1 room at the shelter, and mom is finding it increasingly difficult to keep him busy all day. When she goes out looking for a job, he is very challenging at the shelter, and she constantly receives complaints that he is \"too loud\" in the common rooms. She feels like she is at the end of her rope with him, he is constantly climbing, bolting from her, and taking risks.When you examine Adam, you find a robust, healthy young boy. His eye contact is good, and he is socially related but does actively explore your office. When he begins taking the instruments off your wall, his mother sits passively watching him. When he begins playing with the faucet, she half heartedly tells him to \"stop\" but he looks at her and continues splashing. He then begins flicking the light switch on and off in the room with no response from mom. When you ask about discipline, mom states \"nothing works.\" When you ask about supports, she states \"I have nobody except Adam and the new baby now.\"Adam was born after an uneventful full-term pregnancy with his mother on 100 mg methadone daily. She denies cigarette smoking, drugs, alcohol, or other medications. Urine testing throughout was positive only for opioids. Motor milestones were achieved at the appropriate time. Language milestones at the 2-year-old visit consisted of 10 single words. Now, he has a 50 single-word vocabulary but no 2-word combinations. He primarily takes whatever he wants and has a tantrum if mom cannot figure out what he desires. Adam's medical history is unremarkable. Family history is significant for drug abuse by her father and mother; mental illness in the father's family consisting of bipolar disorder in several uncles. Where do you go from here?"
},
{
"id": "wiki20220301en046_12836",
"title": "Letter of appointment",
"score": 0.009900990099009901,
"content": "Other critics assert that the outer sheet containing the postmark and address is of different stock than the first two pages, however this is disputed. This theory infers that Strang disposed of the first two pages, retaining the last page with the post mark and composed his own partial letter containing the appointment. Analysis indicates that the handwriting on all three pages is the same. Vague references to Strang's appointment appear throughout the letter. On page one: \"The faith which thou hast in the Shepherd, the stone of Israel [Joseph Smith], hath been repaid to thee a thousandfold, and thou shalt be like unto him; but the flock shall find rest with thee, and God shall reveal to thee his will concerning them.\" Page two continues: \"[H]e [Strang] had faith in thee [Smith], the Shepherd and Stone of Israel, and to him shall the gathering of the people be.\" Page three: \"Thy [Strang] duty is made plain . ... [I]f evil befall me [Smith], thou shalt lead the flock to pleasant"
},
{
"id": "pubmed23n1027_22858",
"title": "Questioning a Previous Autism Spectrum Disorder Diagnosis: Can You \"Lose\" the Diagnosis?",
"score": 0.00980392156862745,
"content": "Heidi is an almost 6-year-old girl presenting to your primary care office to establish care because of a change in insurance status. You review her previous medical records before seeing her.She was diagnosed with autism spectrum disorder (ASD) when she was 25 months old. Her parents were initially concerned about language delay. Through a comprehensive evaluation by a developmental-behavioral pediatrician and a child psychologist, including administration of the Bayley Scales of Infant and Toddler Development and the Autism Diagnostic Observation Schedule, she was diagnosed with ASD. Her cognitive skills were reported to be within the average range. Soon after the diagnosis, she began receiving 20 hours of applied behavioral analysis (ABA) per week, as well as music therapy, occupational therapy, and a toddler playgroup through early intervention. Four months after the initial diagnosis, her parents reported that she had started making small improvements in her behavior, used more eye contact, and seemed more socially engaged. Approximately 1 year after the diagnosis, she was receiving 6 hours of ABA per week in addition to starting preschool with an Individualized Education Program. She reportedly continued to show progress with social communication and pretend play skills.At the age of 3 years, 8 months, neuropsychological testing was completed at her parent's request, and her cognitive skills and adaptive skills were reported to be within the average range. She continued to meet the diagnostic criteria for ASD, given her challenges with social awareness, communication, delayed play skills, decreased flexibility, and tendency toward subtle self-direction. She continued to receive speech/language therapy and attended an integrated preschool program within the school district because of her social and communication challenges. She also received ABA 4 hours weekly at home.During your first visit with Heidi, her parents report that she has continued to make progress in all areas, including social skills. She can engage in imaginary play with her friends, ask strangers questions, and comprehend the perspective of others, and she is no longer \"rigid.\" She is not receiving services outside of school and is only receiving once weekly speech/language therapy in school. Her parents no longer believe that she meets the criteria for ASD, and they are interested in further evaluation. Her parents ask if it is possible to \"lose\" the diagnosis of ASD. They also want to know if there are other things to be concerned about for her future. How do you respond?"
},
{
"id": "wiki20220301en388_21724",
"title": "Aidan Foster",
"score": 0.00980392156862745,
"content": "Chris' friendship with Natasha starts to affect his relationship with Aidan, who asks him to choose between them. When Natasha's party is ruined, Chris rushes straight to her aid. Natasha also steals Chris' attention from Aidan and he often drops everything for her, even though she would not do the same for him. Aidan, who has become tired of Chris always making excuses for Natasha, tells him to start asserting himself instead. Morley explained to a TV Soap writer, \"It's not that Aidan doesn't approve of Tash, rather it's the way that she has been treating Chris that Aidan doesn't agree with. This, coupled with the fact that Chris isn't standing up for himself, sends Aidan over the edge.\" Chris feels \"shattered\" at having to choose between his boyfriend and best friend. Mason commented that his character just needed to learn how to handle them both. Aidan feels the situation is just part of the \"getting to know each other\" phase, but Chris panics and assumes his relationship is about"
},
{
"id": "pubmed23n0900_12777",
"title": "Supporting a Youth with Cerebellar Ataxia into Adolescence.",
"score": 0.009708737864077669,
"content": "Zoe, a 13-year-old white girl, presents as a new patient to your pediatric clinic with complaints of frequent emesis, anxiety, and learning problems, and previous diagnosis of cerebellar ataxia. Parents accompany Zoe and state, \"it is really hard for her to go out, she gets sick and falls easily.\" She was born full term by vaginal delivery without complications. Given globally delayed milestones, she received early intervention services. Feeding problems began at infancy, including gastroesophageal reflux and aspiration pneumonia.At age 2, Zoe saw a neurologist and brain MRI revealed cerebellar atrophy. She recently saw a geneticist and genetic studies are pending. Parents report receiving \"little\" information regarding prognosis; through their own research, they read about individuals having similar symptoms in adulthood, with a degenerative pattern. They worry that Zoe is \"still very young and we do not know what her future will be like.\"Despite ongoing speech and feeding challenges, the parents report difficulty finding a speech and language therapist in their area. Zoe does see an otolaryngologist for frequent otitis media and hearing loss and an ophthalmologist for vision problems. Still, she continues to fall further behind in school. Furthermore, she is intensely afraid of falling at school and has few friends, resulting in the family being at a loss regarding \"what to do about school.\"She lives with both parents and 2 healthy older sisters. Her mother has Crohn's disease and has been unable to work. Her maternal aunt is close to Zoe and has hypothyroidism. Her father works as an insurance agent and resources have been \"tight.\" Zoe's mother describes \"making\" Zoe go out to the movies, \"otherwise she just stays home.\" Zoe usually needs assistance to walk in public, to keep from stumbling. Parents share that simply being in a public place or meeting a new physician may trigger emesis. Zoe does enjoy interacting with neighborhood children and says she wants to be \"normal,\" wear nail polish, and date. She seeks independence, often refusing to use her wheelchair. Parents feel she requires more intensive occupational and physical therapy.On examination, she is very slender with hypertelorism and nystagmus. Holding an emesis bag, she gags intermittently, producing clear secretions. She has a notable tremor and walks slightly stooped with wide-based gait. Her few words demonstrate articulation differences and cognitive expression characteristic of a younger child. She wears light make-up and age-appropriate clothes. She asks, \"When can I go home?\"At the end of the visit, parents share their worry that Zoe is \"so young and we do not know anything, what to expect, or what to tell her.\" As the family's new medical home, they ask you to weigh in on what to do next to best support her? Where do you begin?"
},
{
"id": "wiki20220301en419_7457",
"title": "The Clique (duo)",
"score": 0.009708737864077669,
"content": "For the Judges' Choice-themed first live show, Third Degree sang \"thatPower\" by will.i.am and received positive feedback from the judges. In week six of the live shows, Third Degree fell into the bottom two alongside JTR but was saved after Keating, Minogue and Redfoo all opted to eliminate JTR. Following the eliminations of Adira-Belle and JTR, Third Degree became the only remaining act in the Groups category. In week eight of the live shows, Third Degree fell into the bottom two alongside Jiordan Tolli. The judges' vote went to deadlock, and Tolli was eliminated after it was revealed she received the fewest votes. In the semi-finals, Third Degree sang \"Give Me Everything\" by Pitbull and \"Pound the Alarm\" by Nicki Minaj, gaining positive reviews from the judges. Despite this, they fell into the bottom two alongside Taylor Henderson. The judges' vote went to deadlock, and Henderson advanced to the grand final after it was revealed he received the most public votes, leading to Third"
},
{
"id": "pubmed23n1132_11877",
"title": "Let Me Spell It Out: The Impact of Microaggression on the Health Care Professional.",
"score": 0.009615384615384616,
"content": "Rachel is a 10-year-old White girl with attention-deficit/hyperactivity disorder and a history of trauma who presented for evaluation by Dr. Narayanaswamy, a developmental-behavioral pediatrician. A pediatric resident observed the visit with permission from Rachel's parents.During the visit, Dr. Narayanaswamy spoke to Rachel's case manager over the phone to advocate for a trauma-based day treatment program at her school. At the end of the call, the case manager asked the physician for her full name. Dr. Narayanaswamy responded with her name and asked the case manager, \"Would you like me to spell it?\" At that time, Rachel's father began to laugh, shook his head, and incredulously remarked, \"Ugh, yeah you need to spell it.\" Dr. Narayanaswamy ignored the comment and completed the phone call.After the visit, Dr. Narayanaswamy explained to the resident that the father's derisive laughter was a microaggression. The resident appreciated the observation and, after a pause, asked why she chose not to defend herself when the microaggression occurred. Dr. Narayanaswamy reflected that she had refrained from responding to Rachel's father over concern that he would retaliate by providing low ratings on the postvisit patient satisfaction survey sent to all patients who received care at the institution. The granular survey results, comprising ratings in each survey subheading category for each clinician, are made public to members of her division each quarter, and low ratings are scrutinized by the leadership. Dr. Narayanaswamy thought it unfortunate that she felt inhibited in her response because this deprived the resident of observing ways to address microaggressions during an encounter, deprived herself the opportunity to respond directly to Rachel's father, and deprived Rachel from an instructive moment about racial empathy.Dr. Narayanaswamy wrote a letter about the incident to the chief of clinical affairs to inquire what recourse clinicians had in these situations and whether certain patient encounters could be flagged to prevent the postvisit patient survey from being automatically sent. The chief responded that the incident was unfortunate and praised Dr. Narayanaswamy's restraint and professionalism but denied her request to have postvisit surveys blocked for certain encounters. He shared that if a clinician were to be dissatisfied with a visit satisfaction rating, the clinician could petition for a review, and a committee would subsequently determine whether the review could be removed.How can health care professionals respond to microaggressions while maintaining a therapeutic alliance with the patient/family members and how can institutions support health care professionals in this endeavor?"
},
{
"id": "wiki20220301en404_14293",
"title": "List of Person of Interest characters",
"score": 0.009615384615384616,
"content": "(5.12 \".exe\") In a simulated world where the Machine never existed, Cole is shown to have survived and to still be partnered with Shaw. Henry Peck Henry Peck (played by Jacob Pitts) is a former NSA Analyst and Person of Interest. (1.22 \"No Good Deed\") When Peck discovers the existence of the mass surveillance program, \"Operation Northern Lights\", an ISA team is sent to kill him. Peck still refuses to stop investigating, so Finch is forced to tell him the truth and give him a new identity so he can escape the threat. Alicia Corwin secretly records their conversation and learns of Finch's involvement. (5.12 \".exe\") In a simulated world where the Machine never existed, Peck uncovers the existence of Samaritan. He presents his evidence to a member of the Office of Special Counsel, revealed to be Shaw. After she verifies that Peck hasn't told anyone else about his theory, she assassinates him."
},
{
"id": "pubmed23n1007_19220",
"title": "Maintaining Safety and Planning for the Future.",
"score": 0.009523809523809525,
"content": "Kevin is a 12-year-old boy with autism spectrum disorder, intellectual disability (nonverbal IQ scores in mid-40s), and attention-deficit/hyperactivity disorder who has been followed up by a developmental-behavioral pediatrician (DBP) and a child psychologist for medication and behavioral management since he was 4 years old. Kevin was placed in the care of his great-great-aunt shortly after he turned 2 years of age because of concerns of neglect. She is now his legal guardian.Kevin is predominately nonverbal but does use a few single words to make requests or label items. He attends a public school and receives full-time special education support. He has a personal care assistant (PCA) who provides in-home support 5 to 6 days/wk for 3 to 4 hours at a time. The PCA is working on toilet training, using a \"clock-training\" approach, and also takes Kevin outdoors to play or on short outings during her visits. In his free time, Kevin prefers to watch cooking shows on television.Over the past year, Kevin's behaviors have become more concerning. There have been several episodes of Kevin waking up during the early morning hours and going to the kitchen to \"cook.\" After one of these episodes, his guardian was not aware that Kevin had woken up until the next morning when she found a concoction of corn starch, coffee grounds, cottage cheese, and powdered drink mix in the blender. Kevin had also woken up during the night and ventured out of the house into the back yard. His guardian had woken up immediately as the alarm system sounded when he opened the outer door from the house to the yard.A door alarm was added to Kevin's bedroom door so that his guardian would be alerted when he leaves his bedroom; however, the alarm is not used consistently because there are times when the alarm cannot be found at bedtime. Kevin's guardian was able to obtain a GPS device for him to wear on his shoe from the local police department. He wears this without resistance every day.Kevin's guardian is in her mid-70s, and she has had several health issues over the past 2 to 3 years. There are no other family members who are willing or able to care for Kevin if his guardian were no longer able to. The DBP and child psychologist have encouraged Kevin's guardian to explore long-term residential care options with the state agency that provides support for individuals with intellectual disabilities and with Kevin's insurance provider, but the guardian is very reluctant to do this. She fears that Kevin will be removed from her care or placed in a \"home\" where someone will \"do bad things to him.\"What else would you recommend or actions would you take to support Kevin's guardian in ensuring Kevin's safety and planning for his future care?"
},
{
"id": "wiki20220301en442_27108",
"title": "Something There",
"score": 0.009523809523809525,
"content": "In his biography I'm Not Dead... Yet!, actor Robby Benson, voice of the Beast, revealed that it was co-star Paige O'Hara's idea to have Benson's character duet with O'Hara's Belle in \"Something There\". According to Benson, the actress \"explained to Ashman and Menken that [Benson] had made records and sang in Broadway musicals.\" O'Hara briefly struggled to record one of the song's lines – \"a bit alarming\" – to which an ailing Ashman, who was forced to communicate with O'Hara and the studio via telephone from his hospital bed in New York due to his illness, simply responded \"Streisand.\" By this, Ashman meant that he wanted O'Hara to impersonate singer and actress Barbra Streisand, and by doing so O'Hara finally recorded the song successfully. \"Something There\" was recorded by O'Hara and Benson accompanied by a live orchestra."
},
{
"id": "pubmed23n0895_1202",
"title": "Bullying and ADHD: Which Came First and Does it Matter?",
"score": 0.009433962264150943,
"content": "Aiden, a 13-year-old boy in the sixth grade who is relatively new to your practice, is seen for follow-up after his routine physical last month when you noted concerns for possible attention-deficit hyperactivity disorder (ADHD) and gave the family Vanderbilt Scales to complete. Aiden has a family history of ADHD, specific learning disabilities, and mood disorder.His mother reports that she is concerned about how Aiden is doing at school; his teachers are complaining that he is not doing his work, and she is worried that he may be kept back in school. Aiden first began having trouble in the third grade. He was retained in the fourth grade for academic and behavioral reasons. Now his mother has been receiving calls about him not paying attention, distracting others, and staring at his paper. At home, he does not want to do homework and gets very frustrated. In fifth grade, he had a psychoeducational evaluation and was found not eligible for services. His achievement testing showed average scores in reading, math, and writing. Cognitive testing demonstrated average scores for verbal and nonverbal abilities and memory but was significantly below average for processing speed. Aiden continues to have problems now in into the sixth grade.You speak with Aiden in the office and ask him about school. He says, \"It's bad. I'm failing.\" He believes his major problems at school are that he is not doing his homework, he easily becomes frustrated, and he argues with the teachers. He has supportive relationships with his family and friends at school. He gets along well with some of his teachers, noting that he loves his science teacher even though she is tough and \"gives hard homework.\" He describes his history teacher as \"annoying.\" When you ask what he means he states this teacher \"Can be not nice and says mean things. She picks on me a lot.\" His description is consistent with the use of shaming as a behavior he experiences at school.You review the completed parent and teacher Vanderbilt forms; both are consistent and concerning for combined type ADHD. You discuss the diagnosis of ADHD with his mother and both agree to revisit pharmacotherapy in September when the school year resumes. You give her resources on ADHD and classroom accommodations and discuss requesting a 504 plan at school. You also discuss behavioral therapy to better address his self-regulation skills.A week later, you receive a telephone call from Aiden's mother. \"Aiden got home today and he is more upset than I have ever seen him! His teacher told him in front of the class that he would probably stay back a year and now he is saying there is no point in going to school.\" She is not aware if retention has been recommended for Aiden.What would you say to Aiden's mother? What would you do next?"
},
{
"id": "wiki20220301en113_36728",
"title": "Re'eh",
"score": 0.009433962264150943,
"content": "repayment would surely cause the person to decline assistance on a second occasion, Rav Papa explained that the community exacts repayment from the person's estate upon the person's death. Rabbi Simeon taught that the community need not become involved if a person who has the means for self-support chooses not to do so. Rabbi Simeon taught that if a person has no means but does not wish to receive support from the community's charity fund, then the community should ask for a pledge in exchange for a loan, so as thereby to raise the person's self-esteem. The Rabbis taught in a Baraita that the instruction to \"lend\" in refers to the person who has no means and is unwilling to receive assistance from the community's charity fund, and to whom the community must thus offer assistance as a loan and then give it as a gift. Rabbi Judah taught that the words \"you . . . shall surely lend him\" in refer to the person who has the means for self-support but chooses rather to rely on the"
},
{
"id": "pubmed23n0772_17523",
"title": "Bullying and ADHD: which came first and does it matter?",
"score": 0.009345794392523364,
"content": "Aiden, a 13-year-old boy in the sixth grade who is relatively new to your practice, is seen for follow-up after his routine physical last month when you noted concerns for possible attention-deficit hyperactivity disorder (ADHD) and gave the family Vanderbilt Scales to complete. Aiden has a family history of ADHD, specific learning disabilities, and mood disorder.His mother reports that she is concerned about how Aiden is doing at school; his teachers are complaining that he is not doing his work, and she is worried that he may be kept back in school. Aiden first began having trouble in the third grade. He was retained in the fourth grade for academic and behavioral reasons. Now his mother has been receiving calls about him not paying attention, distracting others, and staring at his paper. At home, he does not want to do homework and gets very frustrated. In fifth grade, he had a psychoeducational evaluation and was found not eligible for services. His achievement testing showed average scores in reading, math, and writing. Cognitive testing demonstrated average scores for verbal and nonverbal abilities and memory but was significantly below average for processing speed. Aiden continues to have problems now in into the sixth grade.You speak with Aiden in the office and ask him about school. He says, \"It's bad. I'm failing.\" He believes his major problems at school are that he is not doing his homework, he easily becomes frustrated, and he argues with the teachers. He has supportive relationships with his family and friends at school. He gets along well with some of his teachers, noting that he loves his science teacher even though she is tough and \"gives hard homework.\" He describes his history teacher as \"annoying.\" When you ask what he means he states this teacher \"Can be not nice and says mean things. She picks on me a lot.\" His description is consistent with the use of shaming as a behavior he experiences at school.You review the completed parent and teacher Vanderbilt forms; both are consistent and concerning for combined type ADHD. You discuss the diagnosis of ADHD with his mother and both agree to revisit pharmacotherapy in September when the school year resumes. You give her resources on ADHD and classroom accommodations and discuss requesting a 504 plan at school. You also discuss behavioral therapy to better address his self-regulation skills.A week later, you receive a telephone call from Aiden's mother. \"Aiden got home today and he is more upset than I have ever seen him! His teacher told him in front of the class that he would probably stay back a year and now he is saying there is no point in going to school.\" She is not aware if retention has been recommended for Aiden.What would you say to Aiden's mother? What would you do next?"
},
{
"id": "wiki20220301en357_27411",
"title": "That Darn Priest",
"score": 0.009345794392523364,
"content": "On February 28, 2011, during a national television interview in his home, Sheen publicly demanded a 50% raise for the show. Already the highest-paid actor on television, Sheen demanded $3 million per episode, claiming that in comparison to the amount that the series was making, he was \"underpaid.\" He later retracted that demand. A March 3, 2011, telephone survey of 1,000 people found that 71% of them had an unfavorable impression of Sheen and 16% had a positive opinion of him. On March 7, 2011, CBS and Warner Bros. officially fired Sheen from the show after eight seasons. The official statement read: \"After careful consideration, Warner Bros. Television has terminated Charlie Sheen's services on Two and a Half Men effective immediately.\" In the aftermath of his dismissal, Sheen remained vocally critical of Lorre, and repeatedly attacked him in an eight-minute Ustream video. On May 13, 2011, CBS and Warner Bros. announced that Ashton Kutcher would replace Sheen on the show."
},
{
"id": "pubmed23n0713_17582",
"title": "[Power of personal goal sharing--treatment plan using personal goal maps for patients with mental disorders].",
"score": 0.009259259259259259,
"content": "A female patient in her sixties with schizophrenia had secretly disposed of all her medication and was not cooperating with hospital staff for about four months. During one of our consultations she mentioned that she wanted to be out of hospital by a certain date. That date happened to be her grandchild's birthday. It was at this point that she shared her goals with us, and voluntarily started having treatment. She was able to return home three months later, just in time to celebrate her grandchild's birthday with her family. A male patient in his sixties was able to leave the seclusion room after 10 years. The first doctor in charge and other hospital staff had firmly believed that releasing him from the seclusion room wasn't a possibility. However the patient decided he wanted to be discharged and was interested in finding out how to go about it. The moment he realized it was possible, his outlook changed immensely. He gradually started to open up and communicate better with his new doctor in charge, and was able to work towards his newly found goals. Staff members were also surprised when he was able to leave the seclusion room. They realized this patient was another person like them who had dreams and goals, and stopped stereotyping patients who seemed to be 'difficult to handle'. I have always experienced the power of goal sharing at clinical scenes, and have noticed its importance for patients making a start on the road to recovery. In order to discuss goals and the way to go about achieving them, I use a simple drawing of a mountain. I call this mountain 'A Personal Goal Map'. I like to think of myself (the doctor) as the mountain guide, and my patient as the mountain climber. The three key philosophies are acknowledging individuality, diversity and freedom. These are important when we think about where we are now, where we are going, and where we want to be. Firstly at the start point, we need to define the patient's problem and discuss ideas and goals, which help us along the Trust Path. The more patients and staff trust and understand each other the easier it is to climb up the Initial Treatment Path. We need to build up trustful relations so we can share personal goals and make a proper assessment and diagnosis, and talk about the safety, efficacy, cost and suitability of the initial treatment. Secondly, we need to take a rest and make more plans for the Recovery Path. It is on this path that we decide on comprehensive treatment together. We may be able to improve the patient's cognitive functions by using atypical anti-psychotic agents. We can then give them information, instructions and warnings about medicine usage so the patient is able to understand their condition. It is only after the patient can understand these things fully and act positively that we can start to climb the final path, the Achievement Path. We should review the suitability and efficacy of the treatment again, and it is at this stage that the mountain guide steps back and watches the mountain climber take the final steps towards the mountain peak goal. Lastly, the patient will feel elation and a sense of fulfillment and self-pride, and no doubt will be ready to look for the next mountain peak to climb. In order for you to enjoy the benefits at the clinical scene, all you need is a piece of paper, a pen, and a limitless imagination for better personal goal sharing. At Meisei hospital we promote the 'Minotake Team Approach', which calls for flexible management so we hospital staff can help each other as professionals. We treat patients as individuals using words and expressions they understand (such as local dialect and nonmedical terms), and give them access to easy to understand resources such as leaflets delivered by universities or pharmaceutical companies. We ask our staff to act naturally with the patients, and to just do what they can do to help the patients work towards their personal goals."
},
{
"id": "wiki20220301en113_36729",
"title": "Re'eh",
"score": 0.009259259259259259,
"content": "as a loan and then give it as a gift. Rabbi Judah taught that the words \"you . . . shall surely lend him\" in refer to the person who has the means for self-support but chooses rather to rely on the community, to whom the community should give what the person needs as a gift, and then exact repayment from the person's estate upon the person's death. The Sages, however, said that the community has no obligation to help the person who has the means of self-support. According to the Sages, the use of the emphatic words \"you . . . shall surely lend him\" in (in which the Hebrew verb for \"lend\" is doubled, וְהַעֲבֵט, תַּעֲבִיטֶנּוּ) is merely stylistic and without legal significance."
},
{
"id": "pubmed23n0659_1449",
"title": "A dominating imaginary friend, cruelty to animals, social withdrawal, and growth deficiency in a 7-year-old girl with parents with schizophrenia.",
"score": 0.009174311926605505,
"content": "Tessa is a 7-year-old girl with odd behaviors, worsening over the preceding year. She spends a significant amount of time alone in her room, talking to \"Richard.\" Her father observed that Tessa is \"in her own world.\" In school, she often glares at the teacher and refuses to work. She is alone at recess without any real friends. Her father reports that she eats little and only after he tastes the food. She is increasingly cruel to both real and toy animals. She tied a string around her cat's neck and swung it around, saying she wanted to punish it. She was heard to say to her stuffed cat, \"Die, b ... .; die.\" Richard told her to do this and other \"bad\" things. Tessa has not had chronic health problems or developmental concerns. During the first 18 months of life, her height was between the 5th and 10th percentiles; it declined to below the 3rd percentile over the past 2 years. Weight has been consistently between the 3rd and 5th percentiles. Tessa's parents both have been diagnosed with schizophrenia. There are at least 7 first- and second-degree relatives with the same diagnosis. Both parents cared for Tessa for 4 years with a lot of support. Then, her father left the home, but he was in contact with her while managing his own illness. When the mother's illness and compliance worsened, Tessa was removed for neglect at 5 (1/2) years old. Two foster homes preceded Dad's award of sole custody 13 months ago. Mother's weekly visitations are quite upsetting to Tessa. Tessa is a verbal, solemn, small, well-dressed girl with no physical abnormalities. She talks with advanced vocabulary and syntax, with normal prosody and good conversational skills. She says Richard is a bad boy who gets her into trouble at school. She equivocates when asked if he is real or imagined or if others can see him. She says that she misses her mother."
},
{
"id": "wiki20220301en545_26208",
"title": "List of last words",
"score": 0.009174311926605505,
"content": "\"On a certain occasion, I chanced to be one of three who sat in judgment on one of my own good friends, who, according to the laws, should have been punished with death. I was greatly embarrassed. One of two things was inevitable—either to violate the law or condemn my friend. After careful consideration, I devised this expedient. I delivered with such address all the most plausible arguments in behalf of the accused, that my two colleagues found no difficulty in acquitting him, and yet I, myself, condemned him to death without assigning any reason for my conduct. Thus I discharged two duties, those of friend and judge; yet I feel in my conscience something which makes me doubt whether my conduct was not criminal.\" — Chilon of Sparta, philosopher (6th century BCE), speaking to his friends before his death"
},
{
"id": "pubmed23n0712_25047",
"title": "Diagnosis and management of carbon monoxide poisoning in the emergency department.",
"score": 0.00909090909090909,
"content": "An 89-year-old female is found by her family, lying unconscious on her kitchen floor after they had been unable to reach her by phone for several hours. EMS is activated and when the paramedics arrive, they note that the gas oven is on, and there is thin, gray smoke coming from around the door. The house gas supply is turned off, windows are opened, and the family and the patient are immediately evacuated from the home. En route to the hospital, the patient is placed on high-flow oxygen at 15 liters per minute by non-rebreather mask. Her bedside glucose determination is 229 mg/dL. Vital signs are within normal limits during transport. She opens her eyes to sternal rub, and makes spontaneous movements of all extremities. Upon arrival to the ED, the patient becomes more alert and is able to respond to your questions. She tells you that she remembers putting a tray of calzones into the oven, after which she has no recall of the day's events. She has a past medical history of \"well-controlled\" hypertension, hyperlipidemia, and non-insulin-dependent diabetes. Her medications include hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, simvastatin 20 mg daily, and metformin 1000 mg twice daily. On physical examination, weight is 65 kg, blood pressure is 97/50 mm Hg, heart rate is 113 beats per minute, respiratory rate is 22 breaths per minute, temperature is 37.1 degrees C (98.8 degrees F), and oxygen saturation is 99% on 15 liters per minute via non-rebreather mask. She appears her stated age. Cardiopulmonary examination is remarkable only for tachycardia. Her abdomen is soft and non-tender with normal bowel sounds. Her skin is warm and dry, and there is no peripheral edema. Her cranial nerves are intact, with briskly reactive, symmetric pupils. Motor and sensory examination is non-focal, and cerebellar testing is notable only for an intention tremor on finger-nose-finger test. Gait is normal and speech is fluent and without errors. Laboratory testing shows a hemoglobin of 10.3 g/dL and a leukocyte count of 11.7 x 10(9)/L. Electrolyte results fall within the normal range, and her serum creatinine is 1.7 mg/dL. Qualitative CK-MB and troponin I tests are positive, and the sample has been sent to the STAT lab for quantitative testing. Serum carboxyhemoglobin level is 15% with normal serum pH on an arterial blood gas. An ECG reveals deep, down-sloping inferior and lateral ST-segment depressions which were not present on a routine cardiogram 1 month prior. You have many questions about this patient's care. What symptoms and physical signs need to be addressed and treated? What additional diagnostic testing should be performed? What treatment regimen is appropriate and what should be avoided? What are the risks or delayed complications from her illness? Are there special considerations for this or other patient populations?"
},
{
"id": "wiki20220301en248_19884",
"title": "Elizabeth Needham",
"score": 0.00909090909090909,
"content": "Needham was taken from the pillory alive, but died on 3 May 1731, the day before she was due to stand in the pillory (this time at New Palace Yard) for the second time. With her last words she apparently expressed great fear at having to stand in the pillory again after the severe punishment she had received the first time. The Grub Street Journal, the satirical journal allied with Alexander Pope and others of Hogarth's friends, sardonically reported that the populace \"acted very ungratefully, considering how much she had done to oblige them\". Her demise was celebrated in a mocking rhyme: Ye Ladies of Drury, now weep Your voices in howling now raise For Old Mother Needham's laid deep And bitter will be all your Days. She who drest you in Sattins so fine Who trained you up for the Game Who Bail, on occasion would find And keep you from Dolly and Shame Now is laid low in her Grave..."
},
{
"id": "pubmed23n0385_3037",
"title": "Case vignette: unanticipated propinquity.",
"score": 0.009009009009009009,
"content": "UNANTICIPATED PROPINQUITY. Dr. Marge N. O'Vera has a reputation in the community as a thoughtful, caring, and highly ethical psychotherapist. For more than a year she has been treating Greta Grievance, helping her to cope with emotional and financial insecurities in the aftermath of a highly contentious divorce. During a therapy session, Ms. Grievance tells Dr. O'Vera that she has decided to sue the attorney who represented her during the divorce. Ms. Grievance believes that he did not represent her interests effectively and that she foolishly took his advice in accepting a very inferior settlement. She has retained another attorney who, she tells O'Vera, will soon be calling to request information on the stress of the divorce and Ms. Grievance's continuing need for therapy. Dr. O'Vera will be asked to testify as to the harm caused to her client and resulting treatment expenses. As Ms. Grievance gets up to leave, she tells Dr. O'Vera, \"I'm so glad you'll help me teach that awful Tom Tort a lesson.\" As she hears the name of Attorney Tort for the first time, Dr. O'Vera begins to sweat. Thomas Tort, attorney at law, is also a client of hers. She had no idea that he had been Ms. Grievance's divorce lawyer. She has treated him for recurring major depression over several years and knows that he probably was sufficiently depressed so as to compromise his professional work at the time he represented Ms. Grievance. When she is named as an expert witness for the plaintiff, Attorney Tort will learn that his therapist was also treating Ms. Grievance. At the same time, her duty of confidentiality precludes her informing others that Tort is also her client. What is Dr. O'Vera to do?"
},
{
"id": "wiki20220301en455_24915",
"title": "Family Business (Once Upon a Time)",
"score": 0.009009009009009009,
"content": "Mr. Gold locates Ingrid and calls her out. Ingrid, knowing how well Gold works, tells him that she wanted Emma to find out about their past as part of her plan. Gold says he's there to offer her a deal, saying that if she declined, she'd better watch out. Then, Ingrid replies by saying that if there was something that he wanted from her, he should just take it, but she knows that he can't and needs leverage to make her accept the deal, so she turns him down, and warns Mr. Gold to stay out of her way. As Belle helps Elsa at the library, Elsa is convinced that everyone doesn't know if Anna is in Storybrooke, but Belle says otherwise and decides to seek out the answer back at the pawn shop. When Gold returns, she \"uses\" the fake dagger on him to take her to the Snow Queen's lair. After they find it, Belle orders Gold to stay outside while she goes in, but there is no sign of the Snow Queen anywhere. Belle then hears a voice, which draws her to a mirror, where an image of Belle taunts her"
},
{
"id": "pubmed23n0663_3305",
"title": "Test your skills: a worsening rash.",
"score": 0.008928571428571428,
"content": "A mother brings her 5-year-old boy in to your office because she is concerned about a rash on his legs that seems to be worsening. She tells you that he had a runny nose and a mild cough a week earlier, but that those symptoms resolved before the rash developed. He has also complained of \"belly pain.\" The boy's mother says he has been less active and more irritable since the onset of the rash, and that he is hardly eating. She also tells you that earlier in the day, her son told her that it hurts to walk. A complete review of systems is otherwise negative. The 5-year-old was born at term without complication. He has met all developmental milestones and his immunizations are up to date. He takes no medications. The boy's vital signs are normal. He has an erythematous maculopapular rash distributed on his legs symmetrically; it is palpable, nontender, and nonblanching. You detect no abnormalities in abdominal, neurologic, or musculoskeletal examinations. A complete blood count (CBC) and basic metabolic panel (BMP) reveal mild leukocytosis with a normal differential. Urinalysis shows moderate blood and trace protein. Laboratory results are otherwise normal. What's your diagnosis?"
},
{
"id": "wiki20220301en113_36722",
"title": "Re'eh",
"score": 0.008928571428571428,
"content": "Rabbi Shila of Nawha (a place east of Gadara in the Galilee) interpreted the word \"needy\" (, evyon) in to teach that one should give to the poor person from one's wealth, for that wealth is the poor person's, given to you in trust. Rabbi Abin observed that when a poor person stands at one's door, God stands at the person's right, as says: \"Because He stands at the right hand of the needy.\" If one gives something to a poor person, one should reflect that the One who stands at the poor person's right will reward the giver. And if one does not give anything to a poor person, one should reflect that the One who stands at the poor person's right will punish the one who did not give, as says: \"He stands at the right hand of the needy, to save him from them that judge his soul.\""
},
{
"id": "pubmed23n0712_25046",
"title": "An evidence-based approach to managing the anticoagulated patient in the emergency department.",
"score": 0.008849557522123894,
"content": "You start another busy shift with a double row of charts waiting to be seen. Your first patient is an elderly man who fell 1 hour prior to presentation. He did not lose consciousness, but he was dazed for a few minutes. He complains of a mild headache but denies any neck pain. He takes warfarin for valvular heart disease. He looks good and has no focal neurological complaints. His mental status is normal, he has a negative head CT scan, and his INR is 3.9. His family wants to take him home, which would help relieve some of the congestion in the ED, but you wonder what would be best. To observe and repeat imaging? Reverse his anticoagulation? Change his dosing regimen of warfarin? In the next room, you quickly evaluate a 51-year-old obese woman with nonspecific back and abdominal pain that started 24 hours before and has slowly progressed to become intolerable. She denies fever, chills, nausea, or vomiting. She is on the last day of a 5-day course of ciprofloxacin for a UTI. She takes warfarin for a pulmonary embolus that occurred 2 months prior. Her hematocrit is mildly decreased, and her white blood count is normal; however, the INR is 6.8. You wonder if her abdominal pain is related to the UTI, or if it could be somehow related to the prolonged INR. In fact, you wonder why her INR is so prolonged..."
},
{
"id": "wiki20220301en404_14291",
"title": "List of Person of Interest characters",
"score": 0.008849557522123894,
"content": "Devon Grice Devon Grice (played by Nick Tarabay) is a Crimson 6 agent who was trained by Sameen Shaw herself when she was still working as an ISA operative. When they meet in New York whilst both on different ends of the same mission, Grice lets her live. When a Samaritan representative refuses to allow Control to review the contents of a relevant threat's laptop, she secretly enlists Grice's help to continue the investigation. When Control discovers the impending \"Correction\" and labels it as a Samaritan-sanctioned terrorist attack, she has Grice investigate the supposed target: the Supreme Court. When the \"Correction\" is revealed to be a purging of persons seen as threats to Samaritan, Grice is executed by an operative for his previous betrayal. Brooks Brooks (played by Theodora Miranne) is another Crimson 6 agent and Grice's partner."
},
{
"id": "pubmed23n0659_1457",
"title": "Juan: a 9-year-old Latino boy with ADHD.",
"score": 0.008771929824561403,
"content": "Juan, a 9-year-old Latino male, was referred to a community clinic by his third-grade teacher for evaluation of classroom behavior problems. He is an only child and lives with both parents. At home, Juan speaks Spanish with his parents although he occasionally speaks English with his father. His father came to the U.S. from Mexico as a small child and completed the 12 grade in the U.S. Juan's mother completed 8 grade in Mexico and immigrated to the U.S. as a teenager.Juan's mother reported that he has had no significant medical problems. Her report of his behavior included an inability to focus on tasks at hand and easy distractibility. She was concerned that the principal of the school mentioned that Juan may be asked to repeat the 3 grade or change schools. In the clinic, Juan sat quietly but appeared to be daydreaming and attentive to the conversation. The pediatrician called the principal who expressed frustration with Juan's behavior. In class, he was very fidgety, did not pay attention and usually did not answer questions. He also bothered other students when they were working. The principal explained that because Juan's school was a Spanish language immersion school, there were no special education services available. If a student at the school required special education services, he or she would be transferred to another school in the same school district. An evaluation for an Individualized Education Plan (IEP) indicated that Juan had above average cognitive ability (90 percentile), with superior ability to problem solve and process information simultaneously (99 percentile). The Woodcock Johnson III (Spanish version) indicated average achievement in academic skills, with low average in reading fluency, comprehension and spelling. On the Test of Auditory-Perceptual Skills, Juan tested generally low average in all domains, and was at the 14 percentile for both auditory number and auditory word memory. On the Test of Visual-Perceptual Skills, Juan scored above the 92 percentile. Juan did not qualify for special education services on the basis on the standardized tests. However, because of the individual attention required by Juan, a transfer to another school was considered inevitable if his classroom behaviors did not improve. Juan's mother and teacher filled-out the NICHQ Vanderbilt Assessment Scale. Their responses were consistent with the diagnosis of ADHD, inattentive type. In discussion of treatment options with the family, the possibility of stimulant medication use was raised. Juan's mother was opposed to the medication because of what she had heard from her friends-that these medications had bad side effects and did not work most of the time. Juan's father, however, was in favor of the medication because it might assist Juan to stay at the school. After several clinical visits that included further information about ADHD, behavioral treatment, and reviewing information from the school, Juan's parents agreed to a trial of medication. Juan was evaluated for a follow-up visit 2 weeks after starting fourth grade; he had been taking a stimulant medication for one month. He seemed much happier about school and was proud to report that he has completed all of his assignments in school as well as homework assignments, and he did well on a math quiz. Juan's mother was also pleased with his progress. The pediatrician called the principal, who reported that Juan was an entirely different student. He now sat at his desk and wrote down the assignments. He seemed eager to learn and able to be attentive in the classroom. The principal was amazed at the difference."
},
{
"id": "wiki20220301en104_14073",
"title": "Who Do You Trust?",
"score": 0.008771929824561403,
"content": "After a brief chat with Bergen (and his dummies \"Charlie McCarthy\", \"Mortimer Snerd\" and \"Effie Klinker\") the couples would try to answer four questions. The first was a match question, where the spouses tried to match each other's answer to a question about their married life. The remaining questions were of general knowledge, where after the category was revealed, the husband chose whether to answer himself or \"trust\" his wife to do so, hence the name of the show. The first correct answer won $100, the second added $200, and the third $300. For the fourth question they could wager any of their winnings by answering a question from one of six categories ranging in value and difficulty from $100 to $600. If the couple won no money, they would answer a very easy $100 question. The couple with the most money competed with the winners from the previous week's show to name as many items as possible in a category with the couple coming up with the most answers receiving $100 a week for a"
},
{
"id": "pubmed23n1092_16507",
"title": "Disproportionate Representation of Children of Color and Parents with Disabilities in the Child Welfare System: The Intersection of Race/Ethnicity, Immigration Status, and Disability.",
"score": 0.008695652173913044,
"content": "An almost 5-year-old girl is referred to a developmental-behavioral clinician for developmental evaluation because of language and learning concerns. Her developmental screening in the primary pediatrics office showed scores concerning for delays in communication, social-emotional, gross, and fine motor domains. Her mother has concerns about her language. Her mother's primary language is Spanish, but the patient and her siblings speak primarily English. She speaks in short phrases and sentences with grammatical errors. Her mother understands approximately 75% of what she says, and strangers understand approximately 50%. She uses gestures and facial expression, is social and friendly, demonstrates pretend play, and plays well with her siblings and other children her age. She has occasional meltdowns, but there are no other major behavioral concerns. She feeds herself with utensils and is able to dress herself. She toilet trained recently, at about age 4.5 years.She did not receive early intervention before age 3 years and had no previous evaluations. She did not attend preschool or child care. Her mother reported that they were referred to the school district twice, but she had trouble requesting the evaluation.She lives with her parents and 2 brothers. The patient's parents immigrated to the United States from Mexico 7 years ago. They are both farm workers, and extended family members are in Mexico. On reviewing family history, the clinician learns that the patient's mother had trouble learning and attended school until she was 12 years old. She did not receive extra help at school. The child's mother said that she forgets things and \"has trouble with reading and writing fast.\" The patient's 10-year-old brother has an individualized education plan and is in a substantially separate classroom. He has inclusion activities of recess, art, and music. He receives speech-language therapy and academic support for reading and writing. The patient's mother becomes tearful and shares that Child Protective Services was notified because of her inability to request the school evaluation, but a case was not opened.Developmental evaluation reveals expressive language at a 33-month-old level and receptive language at a 39-month-old level. Cognitive testing shows extremely low verbal comprehension, borderline visual spatial skills, and fluid reasoning in the low average range. Working memory and processing speed fall in the borderline range. The clinician learns at a follow-up visit that the patient's mother was evaluated by state disability services and has mild intellectual disability.What is your next step in management? What feedback or resources would you provide to the pediatric clinician and family?"
},
{
"id": "wiki20220301en113_36727",
"title": "Re'eh",
"score": 0.008695652173913044,
"content": "The Gemara turned to how the community should convey assistance to the pauper. Rabbi Meir taught that if a person has no means but does not wish to receive support from the community's charity fund, then the community should give the person what the person requires as a loan and then convert the loan into a gift by not collecting repayment. The Sages, however, said (as Rava explained their position) that the community should offer the pauper assistance as a gift, and then if the pauper declines the gift, the community should extend funds to the pauper as a loan. The Gemara taught that if a person has the means for self-support but chooses rather to rely on the community, then the community may give the person what the person needs as a gift, and then make the person repay it. As requiring repayment would surely cause the person to decline assistance on a second occasion, Rav Papa explained that the community exacts repayment from the person's estate upon the person's death. Rabbi"
},
{
"id": "pubmed23n0592_3030",
"title": "Drug-facilitated sexual assault: educating women about the risks.",
"score": 0.008620689655172414,
"content": "\"Andrea,\" an 18-year-old college freshman, walked into her first fraternity party with a few of her sorority sisters. As she walked through the crowded house, one of the fraternity boys handed the girls large plastic cups. Another boy circulated through the crowd, filling up the cups of all guests from two pitchers of beer. When he filled Andrea's cup, he smiled and was polite and charming. She thought his act of filling her cup was kind and gentlemanly, and was flattered by his attention. She didn't notice he used a different pitcher for her than he had for her friends. She and her friends continued to mill through the crowd, sipping their beer. About 20 minutes later, Andrea suddenly had trouble focusing her vision. She felt disoriented and \"drunk\" even though she had only consumed a third of her beer. She started feeling nauseated, and tried to find her friends. The polite boy who had poured her beer asked her if she was all right, and offered to take her up to his room so she could rest. She followed him, grateful to be able to lie down. Forty-five minutes later, her concerned friends searched the house for Andrea. They found her upstairs passed out in a bedroom, lying on her side; she had vomited and her clothes were disheveled. Suspecting only alcohol intoxication; they picked her up, and walked her out of the party. After Andrea slept for about two hours, she woke up and told her friends something wasn't right. She had only drunk a small amount of her beer, and had no recollection after she walked up the stairs with the boy. She burst into tears, stating she feels some vaginal discomfort, and is afraid she may have been raped. Her friends looked at each other, thinking, \"How did this happen and what are we supposed to do?\""
}
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"text": "Diffuse axonal injury produces an early and sustained deterioration of the level of consciousness (as mentioned in the case statement) without a lesion on CT scan to justify the picture."
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} | Diffuse axonal injury produces an early and sustained deterioration of the level of consciousness (as mentioned in the case statement) without a lesion on CT scan to justify the picture. Sometimes, punctate hemorrhages at the level of the corpus callosum, corticosubcortical junction and dorsolateral portion of the brainstem are evidenced in this imaging test. | Diffuse axonal injury produces an early and sustained deterioration of the level of consciousness (as mentioned in the case statement) without a lesion on CT scan to justify the picture. Sometimes, punctate hemorrhages at the level of the corpus callosum, corticosubcortical junction and dorsolateral portion of the brainstem are evidenced in this imaging test. | After a traffic accident a 38-year-old patient is admitted to the ICU in coma. After several days the patient does not improve neurologically and a CT scan shows hemorrhagic punctate lesions in the corpus callosum and cortico-subcortical junction. What is the diagnosis? | 237 | en | {
"1": "Acute subdural hematoma.",
"2": "Trobocytopenic purpura.",
"3": "Cerebral hemorrhagic contusion.",
"4": "Severe diffuse axonal injury.",
"5": "Hypoxic-ischemic encephalopathy."
} | 144 | NEUROLOGY | 2,014 | {
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{
"id": "pubmed23n0113_8474",
"title": "[Clinicopathological studies of diffuse axonal injury--five autopsy cases].",
"score": 0.01890999910801891,
"content": "In severe head injuries, delayed intracerebral hematoma appearing lately is noted due to the spread use of serial CT scan. The authors experienced the autopsy of 5 cases who presented diffuse axonal injury (DAI) among these new lesions in repeated CT scan findings and report the pathohistological findings. Subjects were as follows: The age range of the patients was 15 to 25 years. The consciousness levels of the 5 cases on admission were 6 or less by the Glasgow coma scale. CT findings of DAI were revealed hemorrhage of the corpus callosum, basal ganglia, tegmentum of pons, intraventricular, and acute brain swelling. Total clinical courses were 2 to 29 days, but most of them were 9 or less days. In the macroscopic findings, marked congestion and edema revealed mainly in deep part of the white matter of the frontal lobe in all 5 cases. Callosal disruption and hematoma adjacent the corpus callosum revealed in 4 out of 5 cases. Cerebral contusion with hemorrhage revealed in 3 out of 5 cases. Intraventricular hemorrhage and traumatic subarachnoid hemorrhage revealed in 2 out of 5 cases. Hemorrhage of basal ganglia and base of pons revealed in 2 cases. Microscopic examination of all 5 cases revealed pallor of myelin in the corpus callosum and white matter surrounding hemorrhagic lesion, and abnormal tortuous, swelling and fragmentation of axons in stained preparation. Axonal retraction ball was recognized in 3 out of 5 cases. In conclusion, five autopsied cases who presented acute brain swelling and hemorrhage of corpus callosum and tegmentum of pons in serial CT scan were examined.(ABSTRACT TRUNCATED AT 250 WORDS)"
},
{
"id": "pubmed23n0311_20846",
"title": "[Clinical features and CT diagnostic criteria for diffuse axonal brain injury].",
"score": 0.01731893837156995,
"content": "The clinical and computed tomographic features of 117 patients with severe closed head injury were analysed. We put forward the CT diagnostic criteria of diffuse axonal injury (DAD)i.e. (1) single or multiple small intraparenchymal hemorrhages in the cerebral hemispheres (< 2 cm in diameter); (2) intraventricular hemorrhage; (3) hemorrhage in the corpus callosum; (4) small focal areas of hemorrhage adjacent to the third ventricle (< 2 cm in diameter); (5) brain stem hemorrhage. Our patients were divided into DAI group and non-DAI group according to the set of criteria. Traffic accidents were the main injury cause in patients with DAI. GCS on admission in patients with DAI were significantly lower than those in patients without DAI. The incidence of diffuse brain swelling in patients with DAI significantly higher than that in non-DAI patients, whereas the incidences of skull fracture and epidual hematoma were respectively significantly lower than those in non-DAI patients. There was no significant difference between the incidences of subarachnoid hemorrhage and subdual hematoma in the two groups. The incidence of poor outcome in DAI group was significantly higher than that in non-DAI group, although there was no significant difference between the mortalities in the two groups. Because DAI is a very important factor worsening the outcome of head-injured patient, it is very important to make a diagnosis as soon as we can. However, the clinical manifestations of DAI are not specific and DAI does not show directly on CT, so it is difficult to make a diagnosis. The CT diagnostic criteria of DAI we put forward now are practicable, though they are not perfect."
},
{
"id": "pubmed23n0257_9566",
"title": "[An autopsy case of traumatic subdural hematoma from arterio-venous malformation with diffuse axonal injury].",
"score": 0.01717142443124185,
"content": "Diffuse axonal injury (DAI) is defined as widespread damage to axons in the white matter of the brain without focal injury such as contusion and acute subdural hematoma. A case of traumatic subdural hematoma from arterio-venous malformation accompanied by DAI is reported. A 58-year-old man was assaulted, and immediately lost consciousness, and remained unconscious during about 44 hours until his death. The autopsy revealed acute subdural hematoma (about 160 g) on left temporal lobe and left cingular, uncal and cerebellar tonsillar herniation, and tear and hemorrhage of the corpus callosum. Under this subdural hematoma, gray-whitish vascular lesion with subarachnoid hemorrhage was found. Histologically, this lesion was diagnosed as the arterio-venous malformation. Neuropathological examination of the corpus callosum, dorsolateral part of midbrain and superior cerebellar peduncle revealed DAI findings, such as swelling and ballooning of the myelin fibers, swelling and waving of axons, and retraction balls. Axon degenerations were also observed immunohistochemically by anti-200 kD neurofilament antibody. From the results, his unconsciousness from the moment of impact might be occurred from not only subdural hematoma but also DAI."
},
{
"id": "pubmed23n0304_5257",
"title": "[Two cases of delayed posttraumatic vasospasm followed by brain SPECT].",
"score": 0.01632680261228842,
"content": "This is a report of two cases of delayed posttraumatic vasospasm. In case 1, a 68-year-old male was injured by falling. He did not show any neurological deficits on admission. CT scan revealed a diffuse subarachnoid hemorrhage (SAH) without brain contusion. Aneurysm was not disclosed by angiography. On the 7th day after admission, he presented disorientation. Reviewed angiography revealed diffuse delayed vasospasm. 123I-IMP brain SPECT showed an extensive low perfusion area in the bilateral parietal portion. In case 2, a 71-year-old female experienced immediate development of a deep comatose state after head injury. CT scan on admission disclosed a massive acute left subdural hematoma and the severe compression of the left cerebral hemisphere by the hematoma. But traumatic SAH was not diffuse and was restricted to the left basal cistern. After emergency operation, her consciousness level improved and the mass effect of the subdural hematoma was diminished. On the 7th day after the operation, her neurological condition worsened. CT scan showed some infarction lesions in the left cerebral hemisphere and mild left cerebral swelling. Angiography on the same day revealed vasospasm in M2-M3 portion of left middle cerebral artery. HM-PAO brain SPECT disclosed low perfusion in the left parietal region, but a state of high perfusion in the other region. In case 1, vasospasm might have been derived from diffuse clots of traumatic SAH caused by the same process as postruptured aneurysmal vasospasm. In case 2, the region of vasospasm was not associated with traumatic SAH. It corresponded to the site of the brain contusion. It was suggested that the cause of vasospasm might have been the direct mechanical injury to the arterial wall and chemical substances deriving from the contused brain tissues. We conclude that SPECT or transcranial Doppler monitoring should be used for the early detection of posttraumatic vasospasm."
},
{
"id": "pubmed23n0092_12125",
"title": "[A clinical and pathological study of diffuse axonal injury].",
"score": 0.015970668655232414,
"content": "There is increasing evidence from human and experimental studies that the most important factor governing the outcome in head injury is the severity of diffuse axonal injuries. The authors have experienced 18 cases of severe diffuse axonal injury which showed post-traumatic coma for more than 24 hours and CT findings resembling those of shearing injuries of the cerebral white matter such as have been presented by Zimmerman et al. (1978). The consciousness levels on admission were 6 or less on the Glasgow Coma Scale and all cases were shown clinically to have primary brain stem injury. The main type of head trauma resulted from road traffic accidents (83%). Skull fractures were found in only 5 cases (28%). These findings suggested that acceleration/deceleration injury produce in the patients severe diffuse axonal injury. Initial ICP was below 20 mmHg in 11 cases out of 13 (85%). Parenchymal small hemorrhagic lesions of initial CT were basal ganglia (7 cases), corpus callosum (4 cases), pons (4 cases), midbrain (3 cases) and thalamus (2 cases). Extraparenchymal hemorrhagic lesions included intraventricular hemorrhage (6 cases) and subarachnoid hemorrhage (6 cases). Two autopsied cases of severe diffuse axonal injury (acute case and chronic case) showed remarkable congestion and edema in the deep part of the frontal white matter. Microscopic examination revealed marked axonal degeneration including axonal retraction ball in the corpus callosum, in the internal capsule and in the white matter of the brain stem. Glasgow Outcome Scale of the 18 patients at 3 months after the trauma made us concerned that no patients indicated good recovery or even only moderate disability.(ABSTRACT TRUNCATED AT 250 WORDS)"
},
{
"id": "pubmed23n0342_6378",
"title": "Clinical studies on diffuse axonal injury in patients with severe closed head injury.",
"score": 0.015201976794155567,
"content": "To discuss the clinical criteria for diagnosing diffuse axonal injury (DAI). Clinical and computed tomographic features of 117 patients with severe closed head injury were analyzed. The authors preliminarily put forward CT diagnostic criteria of DAI, that is, 1) single or multiple small intraparenchymal hemorrhages in the cerebral hemispheres (< 2 cm in diameter); 2) intraventricular hemorrhage; 3) hemorrhage in the corpus callosum; 4) small focal areas of hemorrhage adjacent to the third ventricle (< 2 cm in diameter); and 5) brain stem hemorrhage. All patients were divided into two groups, DAI and non-DAI group, according to the criteria. There were 42 patients in the DAI group and 75 patients in the non-DAI group. The injury causes, Glasgow coma scale (GCS) scores on admission, coexisting injuries and outcomes were compared between the two groups. The relationship between DAI and the outcomes in the patients with severe head injury was analyzed. Traffic accident was the main injury cause in the cases of DAI. GCS scores on admission in patients with DAI were significantly lower than those in patients without DAI. The incidence of diffuse brain swelling (DBS) in the DAI group was significantly higher than that in the non-DAI group, whereas the incidences of both skull fracture and epidural hematoma (EDH) in the DAI group were significantly lower than those in non-DAI group. There was no significant difference between the incidence of subarachnoid hemorrhage (SAH) and subdural hematoma (SDH) in the two groups. The incidence of poor outcome in the DAI group was significantly higher than that in the non-DAI group, although there was no significant difference between the mortalities in the two groups. Because DAI is a very important factor worsening the outcome of patients with head injury, it is essential to make a diagnosis as soon as possible. The clinical manifestations of DAI, however, are not specific and DAI does not show directly on CT scans, so it is difficult to make a definite diagnosis. The CT diagnostic criteria of DAI put forward in this article are practicable, though they are by no means perfect."
},
{
"id": "pubmed23n0047_4944",
"title": "[Epidemiology of head traumas. \"Barcelona\" data base. Objectives, design and analysis of 584 cases].",
"score": 0.014894795127353266,
"content": "Descriptive analysis of some features in patients with cranio-encephalic traumatisms (CET) admitted to our hospital and collected in a data base, in order to establish the prognosis of the lesions and apply the most appropriate diagnostic and therapeutic procedures. Since July 1987 to June 1989 we collected data on 584 patients with CET who presented the following selection criteria: consciousness level lower than 13 points in the Glasgow scale and/or pathologic computerized tomography. According to the consciousness level (Glasgow scale) on admission, patients were classified into three groups: slight CET (Glasgow 15-13), moderate CET (Glasgow 12-9), and severe CET (Glasgow < 9). The traumatic mechanisms were divided into 8 categories (occupant, pedestrian, motorbike, aggression, labor, drop, sporting, cyclist). According to the main lesion we considered the following diagnoses: subdural hematoma, epidural hematoma, cerebral contusion (s), diffuse lesion with normal computerized tomography and/or subarachnoid hemorrhage, cerebral congestion, and diffuse axonal lesion. Results were evaluated six months after using the Glasgow scale. The mean age of patients with slight CET was 37.7 +/- 22.1 years, those with moderate CET 31.7 +/- 22.6 years, and those with severe CET 30.8 +/- 21.6 years. Four hundred and forty-two were men (75.6%). The time period between the accident and hospital admission could be determined in 512 cases (87.6%). Severe CET arrived to the hospital (4.8 +/- 7.3 hours) earlier than the other groups (6.6 +/- 11.9 hours in moderate CET and 14.2 +/- 23 hours in slight CET). Most of patients, 488 (83.5%), were referred from another hospital, whereas the remaining cases came directly from the accident place. Traumatic mechanisms according to the previous categories were: occupant 145 (25%), pedestrian 112 (20%), motorbike 104 (18%), cyclist 2 (0.003%), labor 39 (7%), drop 154 (27%), sporting 7 (1%), aggression 10 (2%). Percentage of traffic accident was higher in patients with severe CET (74.6, 64, and 47% in severe moderate, and slight CET, respectively). The main lesions were: acute subdural hematoma, 72 (12.3%); cerebral contusion, 207 (35.4%); epidural hematoma, 88 (15%); normal computerized tomography/subarachnoid hemorrhage, 87 (14.8%); swelling, 17 (2.9%); diffuse axonal injury, 74 (12.6%); and the remaining, 39 (6.6%) had other lesions such as hydrocephalus fracture-sinking, etc. Mortality was 44.2, 12.2, and 3.7% respectively in severe, moderate, and slight CET. Data base may contribute to establish the prognosis of CET and to determine the efficacy of therapeutic procedures as well as that of diagnostic and investigational methods."
},
{
"id": "pubmed23n0068_8932",
"title": "[Bilateral traumatic hemorrhage in the basal ganglia: report of two cases].",
"score": 0.014810306350172449,
"content": "Hematomas of the basal ganglia in head injury have long been recognized by pathologists with an interest in head injury but their mechanism has not been revealed clearly. We report two cases of bilateral traumatic hemorrhage in the basal ganglia. Case #1, a 17-year-old male was admitted to our hospital immediately after a traffic accident. Neurological examination revealed that the patient was comatose and had right hemiparesis. CT scan showed bilateral hemorrhage of the basal ganglia and subarachnoid hemorrhage in the perimesencephalic cistern. MRI showed high signal intensity areas in the bilateral basal ganglia, perimesencephalic cistern, cerebral white matter and corpus callosum. The patient was diagnosed as having diffuse axonal injury coinciding with bilateral hemorrhage of the basal ganglia. Stereotactic aspiration for the hematoma of the left basal ganglia was carried out. Case #2, a 75-year-old male was admitted immediately after falling from the roof of his house. Neurological examination revealed no neurological deficit except for headache and nausea. CT scan on the day of injury revealed no abnormality. But CT scan 12 hours following the injury showed bilateral hemorrhage of the basal ganglia. Blood pressure of the patient was within normal range and he was diagnosed as having traumatic bilateral intracerebral hematoma. Conservative treatment was carried out and the patient was discharged 7 days after injury with no neurological deficit. The mechanism of traumatic hemorrhage of the basal ganglia has not been clear. In case #1, diffuse axonal injury (DAI) may have played an important role in the bilateral hemorrhage. But in case #2, non-DAI factor such as vasoparalysis syndrome may have existed.(ABSTRACT TRUNCATED AT 250 WORDS)"
},
{
"id": "pubmed23n0953_10680",
"title": "Development of Delayed Posttraumatic Acute Subdural Hematoma.",
"score": 0.014390344543016298,
"content": "Prior studies have shown that most patients with mild traumatic brain injury or negative computed tomography (CT) scans of the head rarely decline or require neurosurgical interventions. One common reason for a delayed decline is an intracranial hemorrhage that presents within 24-48 hours. This is typically seen in elderly patients and/or patients on antiplatelet or anticoagulation agents. We describe a case of a delayed subdural hemorrhage presenting in a young adult not on any antiplatelet or anticoagulation therapy. A 19-year-old male presented to the emergency department after being involved in a motor vehicle accident. He had a Glasgow Coma Scale of 15, and an initial CT was negative for any intracranial hemorrhage or pathology, so he was then admitted to the intensive care unit for further care. The patient received 1 dose of aspirin 325 mg the following day for treatment of blunt cerebrovascular injury. Six hours later he reported a severe headache and had an episode of emesis with a subsequent rapid neurologic decline. Repeat CT showed an acute right subdural hematoma, and he underwent an emergent right decompressive hemicraniectomy. In rare cases, patients with negative initial head CT scans neurologically deteriorate as a result of a delayed acute subdural hematoma. We present an unusual case of a young patient on no medications with no CT findings of an intracranial injury who neurologically declined due to a delayed acute subdural hematoma."
},
{
"id": "pubmed23n0477_18777",
"title": "Acute subdural hematoma and diffuse axonal injury in fatal road traffic accident victims: a clinico-pathological study of 15 patients.",
"score": 0.014216843762298308,
"content": "Although acute subdural hematoma (ASDH) and diffuse axonal injury (DAI) are commonly associated in victims of head injury due to road traffic accidents, there are only two clinico-pathological studies of this association. We report a clinical and pathological study of 15 patients with ASDH associated with DAI. The patients were victims of road traffic accidents and were randomly chosen. The state of consciousness on hospital admission was evaluated by the Glasgow coma scale. For the identification of axons the histological sections of the brain were stained with anti-neurofilament proteins. Twelve of the 15 patients were admitted to hospital in a state of coma; in three patients, the level of consciousness was not evaluated, as they died before hospital admission. The poorer prognosis in patients with ASDH who lapse into coma immediately after sustaining a head injury, as described by several authors, can be explained by the almost constant association between ASDH and DAI in victims of fatal road traffic accidents."
},
{
"id": "wiki20220301en070_31317",
"title": "Cerebral contusion",
"score": 0.014196706720071207,
"content": "Multiple petechial hemorrhages Numerous small contusions from broken capillaries that occur in grey matter under the cortex are called multiple petechial hemorrhages or multifocal hemorrhagic contusion. Caused by shearing injuries at the time of impact, these contusions occur especially at the junction between grey and white matter and in the upper brain stem, basal ganglia, thalamus and areas near the third ventricle. The hemorrhages can occur as the result of brain herniation, which can cause arteries to tear and bleed. A type of diffuse brain injury, multiple petechial hemorrhages are not always visible using current imaging techniques like CT and MRI scans. This may be the case even if the injury is quite severe, though these may show up days after the injury. Hemorrhages may be larger than in normal contusions if the injury is quite severe. This type of injury has a poor prognosis if the patient is comatose, even with no apparent causes for the coma. Treatment"
},
{
"id": "pubmed23n0052_12018",
"title": "[Acute subdural hematoma caused by mild head trauma in the aged].",
"score": 0.01411519514967791,
"content": "We encountered 8 cases of acute subdural hematoma caused by mild head trauma in the aged. In this report, these cases were analyzed, taking into consideration clinical symptoms, CT scan, operative findings and outcome. The age ranged from 70 to 92 years (mean age of 79.7 years). 4 patients were male and 4 female. Head trauma was caused by falls in 4 patients, but in the other 4 patients the causes were unknown. Initial symptoms were headache, nausea and vomiting in 5 patients and mild disturbance of consciousness with lucid intervals in 3 patients. Seven patients had more than 100 on JCS and less than 9 on GCS on admission. Small craniotomy (HITT) was performed in 4 patients. Large craniotomy was performed in 2 patients, and decompressive craniectomy was carried out in 2 patients. The bleeding focus came from the cortical artery of the middle cerebral artery in 4 patients, cerebral contusion in 2 patients, and was unknown in 2 patients for HITT. CT scan on admission showed mixed density area of acute subdural hematoma in all of the patients, and intraventricular hemorrhage, intracerebral hemorrhage and subarachnoid hemorrhage in 3 patients. CT scan after operation revealed a new area of cerebral contusion in 3 patients, delayed traumatic intracerebral hematoma (DTICH) in 2 patients, and hypertensive intracerebral hemorrhage in 1 patient. Two patients recovered to good and fair without general complication. But the outcome in 5 patients with general complication was poor for 3 patients and fatal for 2 patients. In conclusion, large craniotomy is recommended because of bleeding from the cortical artery of the middle cerebral artery.(ABSTRACT TRUNCATED AT 250 WORDS)"
},
{
"id": "wiki20220301en026_55411",
"title": "Subdural hematoma",
"score": 0.013141240413967687,
"content": "Classification Subdural hematomas are classified as acute, subacute, or chronic, depending on the speed of their onset. Acute bleeds often develop after high-speed acceleration or deceleration injuries. They are most severe if associated with cerebral contusions. Though much faster than chronic subdural bleeds, acute subdural bleeding is usually venous and therefore slower than the arterial bleeding of an epidural hemorrhage. Acute subdural hematomas due to trauma are the most lethal of all head injuries and have a high mortality rate if they are not rapidly treated with surgical decompression. The mortality rate is higher than that of epidural hematomas and diffuse brain injuries because the force required to cause subdural hematomas tends to cause other severe injuries as well."
},
{
"id": "wiki20220301en028_66084",
"title": "Intracranial hemorrhage",
"score": 0.012930023783204368,
"content": "Subdural hematoma Subdural hematoma occurs when there is tearing of the bridging vein between the cerebral cortex and a draining venous sinus. At times they may be caused by arterial lacerations on the brain surface. Acute subdural hematoma are usually associated with cerebral cortex injury as well and hence the prognosis is not as good as extra dural hematoma. Clinical features depend on the site of injury and severity of injury. Patients may have a history of loss of consciousness but they recover and do not relapse. Clinical onset occurs over hours. A crescent shaped hemorrhage compressing the brain that does cross suture lines will be noted on CT of the head. Craniotomy and surgical evacuation is required if there is significant pressure effect on the brain. Complications include focal neurologic deficits depending on the site of hematoma and brain injury, increased intracranial pressure leading to herniation of brain and ischemia due to reduced blood supply and seizures."
},
{
"id": "pubmed23n0542_16034",
"title": "[Traumatic subarachnoid hemorrhage: a prospective study of 58 cases].",
"score": 0.01243894993894994,
"content": "We evaluated the prognostic factors in traumatic subarachnoid hemorrhage (tSAH). This study was conducted with 58 patients (44 males, 14 females; mean age 39.2; range 17 to 79 years) with tSAH, between 2001 and 2003. The patients who were admitted to the hospital within in the first 6 hours of head injury were included, whereas patients with gun shot wounds, multiple injured patients and postoperative patients were excluded. Fifty-eight patients with tSAH were prospectively followed. The neurological status of the patients and the outcomes were evaluated using Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS), respectively and computed tomography (CT) examinations were done according to the grading criteria by Hijdra and Fisher. The etiology of tSAH included traffic accidents (73%), falls (20%) and others (7%). The GCS scores of patients at admission were mild (9%), moderate (39%) and severe (52%). In the CT scans, the amount and distribution of bleeding was grade 1 (small SAH) in 21 patients, grade 2 (moderate SAH) in 17 patients, and grade 3 (extensive SAH) in 20 patients according to Hijdra grading system and according to Fisher's criteria. The thickness of blood layer was grade 1 (no blood) in 6 patients, grade 2 (bleeding layer less than 1 mm) in 21 patients, grade 3 (bleeding layer more than 1 mm) in 15 patients and grade 4 (ventricular bleeding) in 16 patients. Neurological outcomes of patients were favorable (good recovery or moderate disability) in 59%, and unfavorable (severe disability, persistent vegetative state or death) in 41% according to GOS. We have found in our series that the prognosis was poor in patients with poor admission scores of GCS, cysternal or fissural hemorrhage, tSAH with cerebral contusion or acute subdural hematoma, higher than 13 points according to Hidjra's classification and patients of grade 3 or 4 in Fisher's criteria."
},
{
"id": "wiki20220301en082_15099",
"title": "Blunt trauma",
"score": 0.011921127244608642,
"content": "Most patients with more severe traumatic brain injury have of a combination of intracranial injuries, which can include diffuse axonal injury, cerebral contusions, and intracranial bleeding, including subarachnoid hemorrhage, subdural hematoma, epidural hematoma, and intraparenchymal hemorrhage. The recovery of brain function following a traumatic accident is highly variable and depends upon the specific intracranial injuries that occur, however there is significant correlation between the severity of the initial insult as well as the level of neurologic function during the initial assessment and the level of lasting neurologic deficits. Initial treatment may be targeted at reducing the intracranial pressure if there is concern for swelling or bleeding within this skull, which may require surgery such as a hemicraniectomy, in which part of the skull is removed. Blunt trauma to extremities"
},
{
"id": "pubmed23n0930_22057",
"title": "[Surgical Treatment for Traumatic Acute Subdural Hemorrhage in the Posterior Cranial Fossa:Three Cases Reports and Review of the Literature].",
"score": 0.011847046773642882,
"content": "Acute subdural hemorrhage(ASDH)in the posterior cranial fossa is rare. Extremely unfavorable outcomes are reported among cases accompanied by supratentorial hematoma, brainstem contusion, or intracerebellar contusion. We report three cases surgically evacuated several times for traumatic ASDH in the posterior cranial fossa simultaneously accompanied by supratentorial hematomas. In our three presented cases, the mean age was 72.3 years, and all patients were male. The mechanisms of injury included traffic accidents in two cases and fall in one. The median Glasgow Coma Scale score on admission was 6. On admission, the patients had traumatic ASDH in the posterior cranial fossa accompanied by supratentorial hematoma, so they first underwent external decompression or ICP sensor insertion for the supratentorial lesions. However, after their first surgery, all patients developed upward herniation, and subsequently underwent suboccipital craniotomy and evacuation of hematomas. Glasgow Outcome Scales were death in one case, persistent vegetable state in one case, and severe disability in one case. The patients with ASDH in the posterior cranial fossa accompanied by supratentorial hematoma should immediately undergo suboccipital craniotomy and supratentorial decompression simultaneously when the hematomas compress the brainstem and upward herniation develops."
},
{
"id": "pubmed23n0755_1137",
"title": "A case of traumatic hematoma in the basal ganglia that showed deterioration after arrival at the hospital.",
"score": 0.011680988184747582,
"content": "A case of traumatic hematoma in the basal ganglia that showed deterioration after arrival at the hospital was reported. A 65-year-old man crashed into the wall while riding a motorcycle. His Glasgow coma scale was E3V4M6 and showed retrograde amnesia and slight right motor weakness. Because head CT in the secondary trauma survey showed subarachnoid hemorrhage in the right Sylvian fissure and multiple gliding contusions in the left frontal and parietal lobe, he was entered into the intensive care unit for diagnosis of diffuse brain injury. He showed complete muscle weakness of left upper and lower limbs 5 h after the accident. Head CT newly showed hematoma, 2 cm in diameter, in the right basal ganglia. The patient vomited following the CT scan, and so his consciousness suddenly deteriorated into a stupor. We performed head CT again. The hematoma had enlarged to 5 cm at the same lesion and partially expanded into midbrain. The patient died on the 13th day of trauma. Based on retrospective interpretation, we conclude that clinical examinations, follow-up CT scans and blood examinations should be performed frequently as part of ICU management for all TBI patients in the early phase after trauma."
},
{
"id": "wiki20220301en100_5740",
"title": "List of MeSH codes (C10)",
"score": 0.011655011655011654,
"content": "– craniocerebral trauma – brain injuries – brain concussion – post-concussion syndrome – brain hemorrhage, traumatic – brain stem hemorrhage, traumatic – cerebral hemorrhage, traumatic – brain injury, chronic – diffuse axonal injury – epilepsy, post-traumatic – pneumocephalus – shaken baby syndrome – cerebrospinal fluid otorrhea – cerebrospinal fluid rhinorrhea – coma, post-head injury – cranial nerve injuries – abducens nerve injury – facial nerve injuries – optic nerve injuries – head injuries, closed – brain concussion – post-concussion syndrome – head injuries, penetrating – intracranial hemorrhage, traumatic – brain hemorrhage, traumatic – brain stem hemorrhage, traumatic – cerebral hemorrhage, traumatic – hematoma, epidural, cranial – hematoma, subdural – hematoma, subdural, acute – hematoma, subdural, chronic – hematoma, subdural, intracranial – subarachnoid hemorrhage, traumatic – skull fractures"
},
{
"id": "wiki20220301en026_55414",
"title": "Subdural hematoma",
"score": 0.011594202898550725,
"content": "Prognosis Acute subdural hematomas have one of the highest mortality rates of all head injuries, with 50 to 90 percent of cases resulting in death. About 20 to 30 percent of patients recover brain function. See also Concussion Diffuse axonal injury Extra-axial hemorrhage Intra-axial hemorrhage References External links Imaging and Mechanism of Subdural Hematoma - MedPix Neurotrauma Cerebrovascular diseases zh:硬膜下血肿"
},
{
"id": "wiki20220301en100_5488",
"title": "List of MeSH codes (C21)",
"score": 0.011213675213675214,
"content": "– trauma, nervous system – cerebrovascular trauma – carotid artery injuries – carotid artery, internal, dissection – carotid-cavernous sinus fistula – vertebral artery dissection – craniocerebral trauma – brain injuries – brain concussion – post-concussion syndrome – brain hemorrhage, traumatic – brain stem hemorrhage, traumatic – cerebral hemorrhage, traumatic – brain injury, chronic – diffuse axonal injury – epilepsy, post-traumatic – pneumocephalus – shaken baby syndrome – cerebrospinal fluid otorrhea – cerebrospinal fluid rhinorrhea – coma, post-head injury – cranial nerve injuries – abducens nerve injury – facial nerve injuries – optic nerve injuries – head injuries, closed – head injuries, penetrating – intracranial hemorrhage, traumatic – brain hemorrhage, traumatic – brain stem hemorrhage, traumatic – cerebral hemorrhage, traumatic – hematoma, epidural, cranial – hematoma, subdural – hematoma, subdural, acute"
},
{
"id": "InternalMed_Harrison_30887",
"title": "InternalMed_Harrison",
"score": 0.010830545810557233,
"content": "Acute Subdural Hematoma (Fig. 457e-3) Direct cranial trauma may be minor and is not required for acute subdural hemorrhage to occur, especially in the elderly and those taking anticoagulant medications. Acceleration forces alone, as from whiplash, are sometimes sufficient to produce subdural hematoma. Up to one-third of patients have a lucid interval lasting minutes to hours before coma supervenes, but most are drowsy or comatose from the moment of injury. A unilateral headache and slightly enlarged pupil on the side of the hematoma are frequently, but not invariably, present. Stupor or coma, hemiparesis, and unilateral pupillary enlargement are signs of larger hematomas. In an acutely deteriorating patient, burr (drainage) holes or an emergency craniotomy are required. Small subdural hematomas may be asymptomatic and usually do not require evacuation if they do not enlarge."
},
{
"id": "pubmed23n1024_1420",
"title": "Early computed tomography for acute post-traumatic diffuse axonal injury: a systematic review.",
"score": 0.010439605252426393,
"content": "Diffuse axonal injury (DAI) is the rupture of multiple axons due to acceleration and deceleration forces during a closed head injury. Most traumatic brain injuries (TBI) have some degree of DAI, especially severe TBI. Computed tomography (CT) remains the first imaging test performed in the acute phase of TBI, but has low sensitivity for detecting DAI, since DAI is a cellular lesion. The aim of this study is to search in the literature for CT signs, in the first 24 h after TBI, that may help to differentiate patients in groups with a better versus worst prognosis. We searched for primary scientific articles in the PubMed database, in English, indexed since January 1st, 2000. Five articles were selected for review. In the DAI group, traffic accidents accounted 70% of the cases, 79% were male, and the mean age was 41 years. There was an association between DAI and intraventricular hemorrhage (IVH) and traumatic subarachnoid hemorrhage (tSAH); an association between the IVH grade and number of corpus callosum lesions; and an association between blood in the interpeduncular cisterns (IPC) and brainstem lesions. In closed TBI with no tSAH, severe DAI is unlikely. Similarly, in the absence of IVH, any DAI is unlikely. If there is IVH, patients generally are clinically worse; and the more ventricles affected, the worse the prognosis."
},
{
"id": "pubmed23n0050_10203",
"title": "[Rapid resolution of acute subdural hematoma; report of two cases].",
"score": 0.009900990099009901,
"content": "We reported two cases of rapid resolution of acute subdural hematoma. Case 1, a 21-year-old female, sustained head trauma and became unconscious for about 15 min. Probably she was suffering from posttraumatic amnesia for about 1 day. On admission J.C.S and G.C.S were 20 and 9 (2 + 2 + 5) points, respectively. Neurological examination showed no abnormalities. An initial computed tomography (CT) scan taken 2 hours after the injury showed a high dense subdural hematoma on the left cerebral hemisphere and hemispheric swelling. She was conservatively treated. A follow up CT scan taken 8 hours after the injury disclosed rapid disappearance of the hematoma and cerebral swelling. Case 2a 23-year-old male, sustained head trauma and became unconscious for about 30 min. On admission J.C.S and G.C.S were 1 and 14 (4 + 4 + 6) points, respectively, and slight right hemiparesis was noted. An initial CT scan taken 2 hours after the injury showed subdural hematoma of the left cerebral hemisphere and hemispheric swelling. He was conservatively treated. A follow up CT scan taken 24 hours after the injury revealed almost complete disappearance of the subdural hematoma and cerebral swelling. It was suggested that the rapid resolution of acute subdural hematoma was attributable to redistribution due to decrease of ICP, and washing out by cerebrospinal fluid."
},
{
"id": "pubmed23n0052_2762",
"title": "[MRI findings of closed head injury in children; with special reference to the effect of central shearing force].",
"score": 0.00980392156862745,
"content": "It is considered that shearing effect as introduced by Holbourn may produce central concussion, diffuse brain swelling and diffuse axonal injury according to its grade of force. MRI was performed in 38 children who had been admitted to our hospital during the previous 1 year for the treatment of closed head injury of varying severity. In 8 out of 38 cases, abnormal high signal intensity was observed in the medial and para-medial brain parenchyma on MRI. All of these 8 cases suffered from head trauma caused by motor vehicle accidents. They included 2 cases of cerebral concussion, 1 of diffuse brain swelling, and 5 cases of diffuse axonal injury. In 2 cases of cerebral concussion, MRI (T2 weighted) revealed only localized high intensity in the corpus callosum, while CT showed normal and subarachnoid hemorrhage only at the interposium. These two children had been unconscious for periods of 20 to 30 minutes. In one case of diffuse brain swelling, MRI (T2W) showed a slightly obscure border between gray and white matter due to generally increased intensity. In 5 cases of diffuse axonal injury, most of these cases manifested lesions at the corpus callosum, deep white matter, periventricular gray matter, pons, midbrain and the cerebellum as demonstrated by high signal intensity on MRI (T2W) while CT in the acute stage showed small hemorrhage at the corpus callosum, corticomedullary junction and mid-brain and in the ventricles. Among these, two cases also demonstrated subdural hematoma and cortical contusional hemorrhage. At 3-4 weeks after injury, the area of high intensity previously demonstrated in the deep white matter and the corpus callosum on MRI (T2W) was reduced.(ABSTRACT TRUNCATED AT 250 WORDS)"
},
{
"id": "pubmed23n0366_9056",
"title": "Postraumatic intracranial hematomas in infancy. a 16-year experience.",
"score": 0.00980392156862745,
"content": "The objective of this study is to analyze some of the epidemiological aspects in patients with post-traumatic intracranial hematomas (post-traumatic ICH) in infancy. These patients were treated at the Hospital Infantil Municipal de Córdoba, Argentina, between April 1980 and April 1996. A retrospective descriptive analysis was conducted on the 113 case histories of children with post-traumatic ICH, all of whom required surgical intervention during this period. Relevant information such as age, sex, mechanism of injury causing craniocerebral trauma (CCT), and data on clinical presentation on admission, diagnosis, morbidity and mortality rates were collected. The series revealed a greater incidence of post-traumatic ICH in boys (73.5%), whose average age was 6 years 5 months +/- 4 years 10 months (range 1 day to 15 years). Fifty-three percent of the girls suffered post-traumatic ICH before the age of 3, while 54% of the children were 7 years of age or older (P<0.05). Falls were the most frequent mechanism of injury causing CCT (36.3%), followed by vehicle accidents (33.6%) and unknown causes (15.9%), the latter mainly in children under 3 years old (31%). The most frequent symptoms were vomiting (58.6%), loss of consciousness (47.1%) and headaches (24.1%). Of all these children, 93.8% presented signs and symptoms at the time of hospital admission, alterations in the level of consciousness (66%), vomiting (47.2%) and headaches (26.4%) being among the most frequent. The hemorrhagic complications observed in the 113 patients took the form of extradural hematomas (EDH) in 75 (66.4%), of subdural hematomas (SDH) in 35 (31.0%), of hemorrhagic contusions (Hc) in 19 (16.8%), and of intracerebral hematomas (Ich) in 11 (9.7%). In 13 patients the site of the hematoma was the posterior cranial fossa (11.5%), and 22.1% of patients presented more than one type of hemorrhagic complication. Morbidity rates were 9.7% and mortality rates 17.7%."
},
{
"id": "pubmed23n0391_2817",
"title": "[A postmortem view on \"pure\" subdural hemorrhages in infants and toddlers].",
"score": 0.009615384615384616,
"content": "In the last years, the discussion concerning the causes of infantile subdural hemorrhages became controversial. Many authors still suppose that child abuse is the predominant cause of such cases. On the other hand, reports presenting series of accidental cases were published, and the fear of an overdiagnosis of the shaken baby syndrome has been expressed. Our autopsy material concerning all lethal head injuries of infants and toddlers from 2 decades was reviewed. 17 of these 64 cases were characterized by the following: history of no trauma or only an insignificant event; children found dead or apnoic or in coma; no skull fractures; no focal brain injury; ruptures of several bridging veins but only minimal subdural bleeding. 11 victims were infants (1st year of life) and either 3 were 2 years resp. 3 - 6 years old; 50 % off all lethal head injuries of infants were of this type, while only 25 % resp. 10 % of the following age groups. None of these 17 cases was a result of a minor accident witnessed by unrelated persons. Abuse could be ascertained with a high degree of probability in most cases and remained quite likely in the others. Two different types of subdural hemorrhages should be kept from another: a) patients suffering a moderate head injury from a minor accident which results in a subdural bleeding (from a small intracranial lesion) often do not deteriorate soon after the impact, develop a hemorrhage of significant volume, respond well to therapy and have a good prognosis. b) cases with a history of no or only of an insignificant trauma, infants dead or nearly dead on clinical presentation, often a poor outcome in cases of survival. There is typically no significant subdural bleeding despite multiple bridging vein ruptures in the majority of these cases: the subdural hemorrhage is here only a visible sign of a much more serious and general cerebral alteration, resulting in a rapid increase of intracranial pressure (often complicated by respiratory arrest) which prevents a signifant bleeding into the subdural space. This combination of findings is typically found in victims of massive events (car occupants in high-velocity crashes) and not compatible with a supposition of a minor fall causing this."
},
{
"id": "pubmed23n0381_21594",
"title": "Acute interhemispheric subdural hematomas. Report of nine cases.",
"score": 0.009523809523809525,
"content": "Nine male patients with acute interhemispheric subdural hematoma (ISH) are presented. The etiologic factor was trauma for all patients (traffic accident and falling down). The young adult cases and one child had bad prognosis due to severe clinical findings and high mortality. The asymptomatic patients were treated conservatively. In this report, we discussed etiologic factors, presentation of age groups, whether an ISH progresses to a chronic convexity subdural hematoma (SH), and real mortality rates for ISH with relevant literature knowledge. As a result, ISHs can present in all age groups including shaken babies, severely injured young adults as well as low velocity trauma striken elderly patients (especially those under anticoagulant medication). We believe that an acute ISH does not change to chronic convexity SH; in fact they present as simultaneous acute thin convexity SH and acute ISH. It is also concluded that in contrast to previous literature ISH and acute SH patients of similar neurological status have similar mortality rates."
},
{
"id": "pubmed23n0299_4934",
"title": "[Acute traumatic subdural haematomas: study of 110 cases].",
"score": 0.009433962264150943,
"content": "We report a series of 110 patients with acute traumatic subdural hematoma (ASDH) admitted at HBDF emergency within 1994 (January 1st to December 1st). All patients were treated according to the same protocol. There was a predominance of males (79%), with ages ranging from 14 to 70, being car accidents (20%) and car-pedestrian accidents (34%) the most frequent causes. The majority of patients (85.7%) was admitted in very serious condition, with a score of 8 points on the Glasgow Coma Scale (GCS) or lesser, which directly influenced the mortality rates. CT scan was the diagnostic procedure of choice, and it showed contusion and brain swelling to be the most frequent associated intracranial lesions. Surgery was carried out in 45.1% of cases and, in most instances, through an ample fronto-temporo-parietal craniotomy, with hematoma drainage and dural reconstitution. In 54.9% of cases, clinical conditions did not allow surgery and in this group, 69.6%."
},
{
"id": "article-20077_13",
"title": "Contrecoup Brain Injury -- Differential Diagnosis",
"score": 0.00940603700097371,
"content": "The main differential for contrecoup injury is the condition of diffuse axonal injury (DAI). In DAI, petechial hemorrhages forms at the gray-white matter junction, corpus callosum, and brainstem. It is the result of traumatic acceleration/deceleration or rotational injuries, not attributed to a direct impact to the skull. It is a frequent cause of persistent vegetative state in patients. [20] [21]"
},
{
"id": "pubmed23n0135_15341",
"title": "[Traumatic hemorrhage in the basal ganglia in the child. Five cases].",
"score": 0.009345794392523364,
"content": "Traumatic hemorrhages in the basal ganglia were seen in five children. The CT findings and the characteristics of these injuries were discussed. All of children were injured in car accidents. They ranged in age from 3 to 13 years. The patients comprised 3 boys and 2 girls. On admission, case 1 was conscious and case 2 was in a stupor. Case 1 and 2 were mild cases in which spotty hematomas were seen in the ganglionic region. They recovered fully. Case 3-5 were severe cases in which massive hematomas were seen in the ganglionic region. On admission, their consciousness ranged from stupor to coma. We performed operations on two of them but their recoveries were unsatisfactory. Their results were as follows. One had residual hemiparesis and dysarthria, one experienced tetraparesis and dysarthria and the last went from coma to a vegetative state. Concerning the directions of the impacts, 4 were hit in the frontal region or face and the last one received blows on the occipital region. Skull fractures were seen in two cases. Mandibula and clavicula fractures were seen in the other two cases. Only one child had no fractures. We conclude that pediatric traumatic hemorrhages in the basal ganglia are induced by severe impact on the frontal or occipital regions. The size of hematomas in this injury is spotty or massive. The massive type has a poor prognosis. On the other hand, the spotty type's prognosis is good. We speculate that impact to the head causes a shear strain in the ganglionic region. At that time, vessels in the area are injured."
},
{
"id": "pubmed23n0054_14141",
"title": "[A case of acute subdural hematoma in the posterior fossa with idiopathic thrombocytopenic purpura].",
"score": 0.009259259259259259,
"content": "Intracranial bleeding is one of fatal complications in idiopathic thrombocytopenic purpura although its reported incidence is low. A case of spontaneous acute subdural hematoma complicated with idiopathic thrombocytopenic purpura was reported. He was hospitalized complaining of sudden onset of headache and nasal bleeding without neurological deficit. CT scan revealed subdural hematoma in the posterior fossa especially below the tentorium cerebelli. Further hematological examination proved very low platelet count (1,000/mm3) and antiplatelet antibody in confirmation of a diagnosis of idiopathic thrombocytopenic purpura. As his neurological status was good, he was treated medically. His symptoms and platelet count improved gradually with corticosteroid therapy. Reviewing the literature, acute subdural hematoma with idiopathic thrombocytopenic purpura was quite rare and only three cases reported."
}
]
}
}
} |
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"text": "In osteoporosis, one of the main risks associated with the increased risk of fracture is low adherence to treatment, so answer 1 is correct."
},
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"text": "correct. Answer 2 is found in the SER guidelines, which confirm that some studies conclude that bone remodeling markers can be useful for early monitoring of adherence and response to treatment."
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"text": "Therefore, the correct answer to this question is option 3. Patients on pharmacological treatment for OP should use calcium and vitamin D supplements because practically all clinical trials that have demonstrated efficacy of antiosteoporotic drugs routinely include calcium supplements and cholecalciferol (vitamin D3), but not in monotherapy."
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"text": "Answer 4 is correct because again in the SER 2019 guidelines they quote: \"The current scientific evidence allows us to affirm that neither increasing dietary calcium nor taking calcium supplements alone protects against the appearance of fractures\"."
},
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}
} | In osteoporosis, one of the main risks associated with the increased risk of fracture is low adherence to treatment, so answer 1 is correct. Answer 2 is found in the SER guidelines, which confirm that some studies conclude that bone remodeling markers can be useful for early monitoring of adherence and response to treatment. Answer 4 is correct because again in the SER 2019 guidelines they quote: "The current scientific evidence allows us to affirm that neither increasing dietary calcium nor taking calcium supplements alone protects against the appearance of fractures". Therefore, the correct answer to this question is option 3. Patients on pharmacological treatment for OP should use calcium and vitamin D supplements because practically all clinical trials that have demonstrated efficacy of antiosteoporotic drugs routinely include calcium supplements and cholecalciferol (vitamin D3), but not in monotherapy. | In osteoporosis, one of the main risks associated with the increased risk of fracture is low adherence to treatment, so [HIDDEN]. Answer 2 is found in the SER guidelines, which confirm that some studies conclude that bone remodeling markers can be useful for early monitoring of adherence and response to treatment. [HIDDEN] because again in the SER 2019 guidelines they quote: "The current scientific evidence allows us to affirm that neither increasing dietary calcium nor taking calcium supplements alone protects against the appearance of fractures". Therefore, [HIDDEN]. Patients on pharmacological treatment for OP should use calcium and vitamin D supplements because practically all clinical trials that have demonstrated efficacy of antiosteoporotic drugs routinely include calcium supplements and cholecalciferol (vitamin D3), but not in monotherapy. | 79-year-old woman admitted for an osteoporotic hip fracture. Regarding secondary prevention of fragility fractures, point out the WRONG answer: | 620 | en | {
"1": "Low adherence to treatment is associated with an increased risk of fracture.",
"2": "Bone remodeling markers may be useful for early monitoring of treatment response.",
"3": "Vitamin D monotherapy is effective in reducing these fractures in non-institutionalized elderly people.",
"4": "Increasing dietary calcium or taking calcium supplements in isolation does not protect against the appearance of fractures.",
"5": null
} | 121 | TRAUMATOLOGY | 2,022 | {
"clinical_case_options": {
"MedCorp": {
"RRF-2": [
{
"id": "pubmed23n0298_13589",
"title": "Prevention of hip fractures by correcting calcium and vitamin D insufficiencies in elderly people.",
"score": 0.018311036789297658,
"content": "For a 50-year old caucasian woman today, the risk of a hip fracture over her remaining lifetime is about 17%. Tomorrow the situation will clearly be worse because the continual increase in life expectancy will cause a 3-fold rise in worldwide fracture incidence over the next 60 years, particularly in women, but also in men. In addition, a secular increase in the incidence of hip fractures in individuals of the same age has been noted in both sexes by several investigators, and the cost of hip fractures is expected to dramatically increase in the next decades. Consequently, preventive strategies are urgently required. A great deal has been learned in recent years about the risk factors for hip fracture, the pathophysiology of this fracture, and the prediction of fracture risk, particularly through bone mass measurements on the hip and biochemical evaluations of parathyroid and vitamin D status. The two main determinants of hip fractures are falls and bone loss leading to an intrinsic femoral fragility. A substantial femoral bone loss continues throughout the old age, with a continuous and exponential increase in the risk of hip fracture, and any reduction or arrest of this loss will induce an important reduction in the incidence of hip fractures. A preventive effect on the risk of hip fracture may be partly achieved by using long term estrogen replacement therapy after menopause, but also by using vitamin D and calcium supplements for a late prevention in elderly people. Vitamin D insufficiency and deficit in calcium intake are very common in elderly people living either in institutions or at home, particularly in Europe where dairy products are not fortified with vitamin D. The cumulative response to this deficit in calcium intake and low vitamin D status is a negative calcium balance which stimulates parathyroid hormone secretion. In 300 residents of nursing homes, we recently found a significant negative correlation between serum 25 OHD and log serum PTH after age-adjustment. In addition, in 446 elderly women living at home in 5 French cities and selected from the voting lists, we also found an age-adjusted relationship between serum 25 OHD and PTH concentrations. This senile secondary hyperparathyroidism is one of the determinants of femoral bone loss and can be reversed by calcium and vitamin D supplements. We have shown in a 3-year controlled prospective study that the daily use of these supplements (1.2 g of calcium and 800 IU of vitamin D3) given in a large population of 3270 elderly ambulatory women living in nursing homes reduced of 23% (intention-to-treat analysis) the number of hip fractures and other non vertebral fractures. In parallel, serum perathyroid hormone concentration was reduced of 28% and low serum 25-hydroxyvitamin D concentration returned to normal values. After 18 months of treatment the bone density of the total proximal femoral region had increased 2.7% the vitamin D3-calcium group and decreased 4.6% in the placebo group (p < 0.001). This prevention is safe and can be recommended in people living in institutions. It could be also useful in other elderly subjects particularly at risk because of a low calcium intake, an absence of solar exposure and a previous history of falls. From the data of our study we assessed the economic consequences in terms of medical cost of this prevention. In case of treatment of all women living in nursing homes in France, this would saved FF 150000000 per year, the economic balance of prevention becoming positive as soon as the age of the beginning of the prevention reaches 73.5 years. It is now possible to partly stop bone loss in elderly people and it is never too late to prevent hip fractures with calcium and vitamin D supplements."
},
{
"id": "pubmed23n0396_7604",
"title": "Combined calcium and vitamin D3 supplementation in elderly women: confirmation of reversal of secondary hyperparathyroidism and hip fracture risk: the Decalyos II study.",
"score": 0.017067550050410486,
"content": "Vitamin D insufficiency and low calcium intake contribute to increase parathyroid function and bone fragility in elderly people. Calcium and vitamin D supplements can reverse secondary hyperparathyroidism thus preventing hip fractures, as proved by Decalyos I. Decalyos II is a 2-year, multicenter, randomized, double-masked, placebo-controlled confirmatory study. The intention-to-treat population consisted of 583 ambulatory institutionalized women (mean age 85.2 years, SD = 7.1) randomized to the calcium-vitamin D3 fixed combination group (n = 199); the calcium plus vitamin D3 separate combination group (n = 190) and the placebo group (n = 194). Fixed and separate combination groups received the same daily amount of calcium (1200 mg) and vitamin D3 (800 IU), which had similar pharmacodynamic effects. Both types of calcium-vitamin D3 regimens increased serum 25-hydroxyvitamin D and decreased serum intact parathyroid hormone to a similar extent, with levels returning within the normal range after 6 months. In a subgroup of 114 patients, femoral neck bone mineral density (BMD) decreased in the placebo group (mean = -2.36% per year, SD = 4.92), while remaining unchanged in women treated with calcium-vitamin D3 (mean = 0.29% per year, SD = 8.63). The difference between the two groups was 2.65% (95% CI = -0.44, 5.75%) with a trend in favor of the active treatment group. No significant difference between groups was found for changes in distal radius BMD and quantitative ultrasonic parameters at the os calcis. The relative risk (RR) of HF in the placebo group compared with the active treatment group was 1.69 (95% CI = 0.96, 3.0), which is similar to that found in Decalyos I (RR = 1.7; 95% CI = 1.0, 2.8). Thus, these data are in agreement with those of Decalyos I and indicate that calcium and vitamin D3 in combination reverse senile secondary hyperparathyroidism and reduce both hip bone loss and the risk of hip fracture in elderly institutionalized women."
},
{
"id": "pubmed23n0655_3344",
"title": "Efficacy of vitamin D3 supplementation in preventing fractures in elderly women: a meta-analysis.",
"score": 0.016817410966647822,
"content": "The efficacy of vitamin D(3) in preventing fractures and falls has been explored in a number of clinical trials. However, recent evidence revealed new questions about the adequate doses of vitamin D(3) supplementation and its efficacy in fracture prevention independent of calcium supplements for various types of fractures. To conduct a meta-analysis to estimate the effectiveness of 800 IU daily vitamin D(3) supplementation for increasing bone mineral density (BMD) and preventing fractures in postmenopausal women. Medline and EMBASE were searched for controlled trials comparing the effectiveness of cholecalciferol (vitamin D(3)) against placebo with or without background calcium supplementation in the treatment of postmenopausal women. Eight controlled trials evaluating the effect of vitamin D(3) supplementation with or without calcium were assessed. Of 12 658 women included in a Bayesian meta-analysis, 6089 received vitamin D(3) (with or without calcium) and 6569 received placebo (with or without calcium). Compared to placebo, vitamin D(3) with calcium supplementation showed beneficial effects on the incidence of non-vertebral (odds ratio [OR] 0.77, 95% credibility limit [CL] 0.6-0.93) and hip (OR 0.70, 95% CL 0.53-0.90) fractures, while the effects on non-vertebral-non-hip fractures (OR 0.84, 95% CL 0.67-1.04) % point increase) were associated with more uncertainty. Vitamin D(3) supplementation showed a 70% probability of being a better treatment than placebo for the prevention of non-vertebral fractures, hip fractures, and non-vertebral, non-hip fractures. Compared to calcium supplementation, vitamin D(3) plus calcium reduced non-vertebral fractures (OR 0.68, 95% CL 0.43-1.01) and non-vertebral, non-hip fractures (OR 0.64, 95% CL 0.38-0.99), but did not reduce hip fractures (OR 1.03, 95% CL 0.39-2.25). Key limitations to this analysis include a small number of studies and heterogeneity in the study populations. This meta-analysis supports the use of vitamin D3 of 800 IU daily to reduce the incidence of osteoporotic non-vertebral, hip, and non-vertebral-non-hip fractures in elderly women. Vitamin D(3) with calcium appears to achieve benefits above those attained with calcium supplementation alone for non-vertebral and non-vertebral-non-hip fractures."
},
{
"id": "pubmed23n0275_4712",
"title": "Prevention of hip fractures.",
"score": 0.016391257995735608,
"content": "For a 50-year old Caucasian woman today, the risk of a hip fracture over her remaining life-time is about 17%. Tomorrow the situation will clearly be worse because the continuous increase in life expectancy will cause a three-fold increase in worldwide fracture incidence over the next 60 years. Through diagnostic bone mass measurements at the hip and assessment of biochemical parameters, a great deal has been learned in recent years about reduction of hip fracture risk. Preventive strategies are based on prevention of falls, use of hip protectors, and prevention of bone fragility. The latter includes the optimization of peak bone mass during childhood, postmenopausal estrogen replacement therapy, and also late prevention consisting in reversing senile secondary hyperparathyroidism, which plays an important role in the decrease of skeletal strength. This secondary hyperparathyroidism, which results from both vitamin D insufficiency and low calcium intake, is preventable with vitamin D3 and calcium supplements. They have recently been shown capable of providing effective prevention of hip fractures in elderly women living in nursing homes, with a reduction of about 25% in the number of hip fractures noted in a 3-year controlled study in 3,270 women (intention-to-treat analysis). In conclusion, it is never too early to reduce the risk of osteoporosis and never too late to prevent hip fractures."
},
{
"id": "pubmed23n0567_4693",
"title": "Where do we stand on vitamin D?",
"score": 0.016297428062133947,
"content": "A meta-analysis of primary prevention high-quality trials published in 2005 found that oral cholecalciferol (D3) in a daily dose of 700-800 IU or intermittently 100,000 IU every 4 months with or without calcium, should reduce both hip and non-vertebral fracture risk significantly compared to placebo. Trials that administered 400 IU vitamin D did not achieve fracture efficacy. Notably, there was a significant association between higher achieved 25-hydroxyvitamin D levels (25(OH)D) in the treatment groups and fracture efficacy: The minimal mean level where fracture efficacy was observed was 74 nmol/l (25(OH)D). Epidemiological data for bone density and lower extremity strength support this threshold, and high-quality trials that used 700 to 800 IU D3 suggested fall risk reduction by 35 to 65% in institutionalized and community-dwelling older individuals. However, since the 2005 meta-analysis, benefits of vitamin D on fracture and fall reduction have been questioned by results from several recent trials. This review proposes that the interpretation of these recent trials is hindered by different doses of vitamin D, different types of supplemental vitamin D (D3 or ergocalciferol D2), low adherence, concurrent use of supplements outside the study protocol, open study design, short follow-up, and/or different patient risk profiles including primary and secondary fracture prevention. In most recent trials, low adherence, the use of the relatively less potent D2, or a too low dose of D3 (400 IU) may have prohibited a shift of (25(OH)D) levels in the treatment groups to the desirable range of at least 75 nmol/l. In summary, from recent trials, two lesson may be learned: (1) Adherence less than 60% is insufficient to achieve fracture efficacy with daily 800 IU D3 plus calcium, (2) D2 in any application or any previously studied dose may not reduce fractures in institutionalized or community-dwelling older individuals."
},
{
"id": "pubmed23n0671_592",
"title": "Reducing fracture risk with calcium and vitamin D.",
"score": 0.016242346116661296,
"content": "Studies of vitamin D and calcium for fracture prevention have produced inconsistent results, as a result of different vitamin D status and calcium intake at baseline, different doses and poor to adequate compliance. This study tries to define the types of patients, both at risk of osteoporosis and with established disease, who may benefit from calcium and vitamin D supplementation. The importance of adequate compliance in these individuals is also discussed. Calcium and vitamin D therapy has been recommended for older persons, either frail and institutionalized or independent, with key risk factors including decreased bone mineral density (BMD), osteoporotic fractures, increased bone remodelling as a result of secondary hyperparathyroidism and increased propensity to falls. In addition, treatment of osteoporosis with a bisphosphonate was less effective in patients with vitamin D deficiency. Calcium and vitamin D supplementation is a key component of prevention and treatment of osteoporosis unless calcium intake and vitamin D status are optimal. For primary disease prevention, supplementation should be targeted to those with dietary insufficiencies. Several serum 25-hydroxyvitamin D (25(OH)D) cut-offs have been proposed to define vitamin D insufficiency (as opposed to adequate vitamin D status), ranging from 30 to 100 nmol/l. Based on the relationship between serum 25(OH)D, BMD, bone turnover, lower extremity function and falls, we suggest that 50 nmol/l is the appropriate serum 25(OH)D threshold to define vitamin D insufficiency. Supplementation should therefore generally aim to increase 25(OH)D levels within the 50-75 nmol/l range. This level can be achieved with a dose of 800 IU/day vitamin D, the dose that was used in successful fracture prevention studies to date; a randomized clinical trial assessing whether higher vitamin D doses achieve a greater reduction of fracture incidence would be of considerable interest. As calcium balance is not only affected by vitamin D status but also by calcium intake, recommendations for adequate calcium intake should also be met. The findings of community-based clinical trials with vitamin D and calcium supplementation in which compliance was moderate or less have often been negative, whereas studies in institutionalized patients in whom medication administration was supervised ensuring adequate compliance demonstrated significant benefits."
},
{
"id": "pubmed23n0667_6165",
"title": "Treatment for osteoporosis in Australian residential aged care facilities: consensus recommendations for fracture prevention.",
"score": 0.01605126253013577,
"content": "Older people living in residential aged care facilities (RACFs) are at considerably higher risk of suffering fractures than older people living in the community. When admitted to RACFs, patients should be assessed for fracture risk to ensure early implementation of effective fracture prevention measures. Routine or regular determination of calcium and phosphate serum levels in institutionalised older people is not indicated. Opinion is divided about the value of routine measurements of serum concentrations of 25-hydroxyvitamin D, parathyroid hormone and bone turnover markers. The non-pharmacological approach to fracture prevention includes multifactorial programs of falls prevention and the use of hip protectors. Vitamin D supplementation is recommended for all patients in RACFs. Dietary calcium intake should be optimised (1200-1500 mg per day is recommended) and supplementation offered to those with inadequate intake. The decision to prescribe calcium supplements should be guided by patients' tolerance, whether or not they have a history of kidney stones, and emerging data about its cardiovascular safety. Bisphosphonates are the first-choice pharmacological agents for fracture prevention in older persons at high risk. Intravenous administration is as efficient as oral and has the significant advantage of better adherence. Use of strontium ranelate has not been tested on people in RACFs, but evidence in the \"old-old\" (those aged 75 years and older) suggests it could be a therapeutic option for fracture prevention in this setting. In general, teriparatide should not be considered as a first-line treatment for fracture prevention, particularly for people in RACFs."
},
{
"id": "pubmed23n0575_244",
"title": "Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis.",
"score": 0.015198408312147674,
"content": "Whether calcium supplementation can reduce osteoporotic fractures is uncertain. We did a meta-analysis to include all the randomised trials in which calcium, or calcium in combination with vitamin D, was used to prevent fracture and osteoporotic bone loss. We identified 29 randomised trials (n=63 897) using electronic databases, supplemented by a hand-search of reference lists, review articles, and conference abstracts. All randomised trials that recruited people aged 50 years or older were eligible. The main outcomes were fractures of all types and percentage change of bone-mineral density from baseline. Data were pooled by use of a random-effect model. In trials that reported fracture as an outcome (17 trials, n=52 625), treatment was associated with a 12% risk reduction in fractures of all types (risk ratio 0.88, 95% CI 0.83-0.95; p=0.0004). In trials that reported bone-mineral density as an outcome (23 trials, n=41 419), the treatment was associated with a reduced rate of bone loss of 0.54% (0.35-0.73; p<0.0001) at the hip and 1.19% (0.76-1.61%; p<0.0001) in the spine. The fracture risk reduction was significantly greater (24%) in trials in which the compliance rate was high (p<0.0001). The treatment effect was better with calcium doses of 1200 mg or more than with doses less than 1200 mg (0.80 vs 0.94; p=0.006), and with vitamin D doses of 800 IU or more than with doses less than 800 IU (0.84 vs 0.87; p=0.03). Evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, in the preventive treatment of osteoporosis in people aged 50 years or older. For best therapeutic effect, we recommend minimum doses of 1200 mg of calcium, and 800 IU of vitamin D (for combined calcium plus vitamin D supplementation)."
},
{
"id": "pubmed23n0359_17457",
"title": "Effects of a short-term vitamin D and calcium supplementation on body sway and secondary hyperparathyroidism in elderly women.",
"score": 0.014863387978142076,
"content": "Long-term vitamin D and calcium supplementation is effective in reducing nonvertebral fractures in elderly people. Increased bone fragility caused by secondary hyperparathyroidism (sHPT) and impaired balance are known risk factors for hip fractures. The hypothesis is that short-term therapy with calcium and vitamin D may improve body sway as well as sHPT more effectively than calcium monotherapy. The effects of 8 weeks of supplementation with vitamin D (cholecalciferol) and calcium on body sway and biochemical measures of bone metabolism were measured. The sample consisted of 148 women (mean [+/-SD] age, 74 +/- 1 years) with a 25-hydroxycholecalciferol level below 50 nmol/liter. They received either 1200 mg of calcium plus 800 IU of vitamin D or 1200 mg of calcium per day. We measured intact parathyroid hormone (PTH), markers of bone turnover, and body sway before and after treatment. Falls and fractures among the participants were followed over a 1-year period. Compared with calcium mono, supplementation with vitamin D and calcium resulted in an increase in serum 25-hydroxyvitamin D of 72% (p < 0.0001), a decrease in the serum PTH of 18% ( p = 0.0432), and a decrease in body sway of 9% (p = 0.0435). The mean number of falls per subject during a 1-year follow-up period was 0.45 for the calcium mono group and 0.24 for the calcium and vitamin D group (p = 0.0346). Short-term supplementation with vitamin D and calcium improves sHPT and body sway and therefore may prevent falls and subsequent nonvertebral fractures in elderly women."
},
{
"id": "pubmed23n0705_13552",
"title": "[Are calcium and vitamin D supplements for everyone?: Pro].",
"score": 0.014732475268588448,
"content": "Calcium and vitamin D are essential for the health of our bones and various scientific societies recommend an intake of 1,000 mg of calcium and 800 IU of vitamin D daily. Most people with osteoporosis do not eat food with this amount of calcium and also have insufficient levels of vitamin D, so supplements are recommended to provide osteoporotic patients with these amounts. Calcium supplements and vitamin D improve the effectiveness of anabolic and anti-catabolic agents and may have a small effect in reducing the number of fractures. Calcium supplements alone have not shown efficacy preventing fractures in patients with osteoporosis and may increase cardiovascular risk in healthy elderly women and is therefore not recommended for widespread use. Vitamin D supplements are recommended in persons with 25-OH vitamin D levels below 30 ng/ml, in particular the elderly and osteoporotic patients, due to its ability to halt the remodeling resulting from secondary hyperparathyroidism and reduce the loss of bone mass. Vitamin D supplements could help reduce falls and fractures in the institutionalized elderly. In addition, supplements of vitamin D may have other beneficial effects due to extra-osseous regulatory functions on the immune response and cell differentiation and proliferation that is associated with vitamin D. Trials begun in recent years clearly indicate a beneficial effect of vitamin D supplements on mortality, cardiovascular risk,development of tumors and prevention of infections."
},
{
"id": "wiki20220301en001_33041",
"title": "Osteoporosis",
"score": 0.014611613876319759,
"content": "Studies of the benefits of supplementation with calcium and vitamin D are conflicting, possibly because most studies did not have people with low dietary intakes. A 2018 review by the USPSTF found low-quality evidence that the routine use of calcium and vitamin D supplements (or both supplements together) did not reduce the risk of having an osteoporotic fracture in male and female adults living in the community who had no known history of vitamin D deficiency, osteoporosis, or a fracture. The USPSTF does not recommend low dose supplementation (less than 1 g of calcium and 400 IU of vitamin D) in postmenopausal women as there does not appear to be a difference in fracture risk. A 2015 review found little data that supplementation of calcium decreases the risk of fractures. While some meta-analyses have found a benefit of vitamin D supplements combined with calcium for fractures, they did not find a benefit of vitamin D supplements (800 IU/day or less) alone. While supplementation does"
},
{
"id": "wiki20220301en289_2170",
"title": "Vitamin D",
"score": 0.014446444644464446,
"content": "Bone health In general, no good evidence supports the commonly held belief that vitamin D supplements can help prevent osteoporosis. Its general use for prevention of this disease in those without vitamin D deficiency is thus likely not needed. For older people with osteoporosis, taking vitamin D with calcium may help prevent hip fractures, but it also slightly increases the risk of stomach and kidney problems. A study found that supplementation with 800 IU or more daily, in those older than 65 years was \"somewhat favorable in the prevention of hip fracture and non-vertebral fracture\". The effect is small or none for people living independently. Low serum vitamin D levels have been associated with falls, and low bone mineral density. Taking extra vitamin D, however, does not appear to change the risk."
},
{
"id": "pubmed23n0644_7970",
"title": "Strategies for treatment to prevent fragility fractures in postmenopausal women.",
"score": 0.014254192409532214,
"content": "The objective of treatment of osteoporosis is to decrease the risk of fractures in patients at high risk for a first or subsequent fracture. The efficacy of treatment will depend on the efficiency and level of implementation of clinical case finding to select patients at risk, the results of additional investigations, the efficacy, tolerance and safety of medical intervention and the adherence to treatment during follow-up. Each of these steps is critical in treatment in daily practice. Failure to consider one or another step can result in suboptimal fracture prevention or overtreatment. The aim of case finding is to identify patients for treatment, who have disease characteristics of patients in whom fracture prevention has been demonstrated in randomised controlled trials (RCTs). These include patients with a low-trauma hip or vertebral fracture, with a low bone mineral density (BMD) or with a high risk of fracture based on the presence of clinical risk factors (CRFs) for osteoporosis and fractures such as included in the FRAX case-finding algorithm, with or without BMD. Case finding starts clinically, with systematic or opportunistic doctor- and/or patient-driven evaluation for the presence of CRFs, but its implementation is low. Further investigations aim to assess the risk of fracture(s) and to have baseline measurements for the subsequent monitoring of treatment, to exclude diseases that mimic osteoporosis, to identify the cause of osteoporosis and contributory factors and to select the most appropriate treatment. Medical intervention consists of providing information about osteoporosis to the patient, lifestyle advice, optimalisation of calcium intake and vitamin D status, fall prevention to reduce fall risk, correction of reversible contributors to secondary osteoporosis and a wide array of drugs for prevention of a first or subsequent vertebral, hip and non-vertebral, non-hip fracture. Drug treatment is based on manipulation of bone remodelling by inhibiting bone resorption (bisphosphonates, selective oestrogen-receptor modulator (SERMs), calcitonin), stimulating bone formation (parathyroid hormone) or mixed effects (strontium ranelate). Follow-up allows to check tolerance and safety, to optimise adherence and to decide about adequacy of response, duration and switching of therapy."
},
{
"id": "pubmed23n0044_15714",
"title": "Vitamin D3 and calcium to prevent hip fractures in elderly women.",
"score": 0.013963118108719726,
"content": "Hypovitaminosis D and a low calcium intake contribute to increased parathyroid function in elderly persons. Calcium and vitamin D supplements reduce this secondary hyperparathyroidism, but whether such supplements reduce the risk of hip fractures among elderly people is not known. We studied the effects of supplementation with vitamin D3 (cholecalciferol) and calcium on the frequency of hip fractures and other nonvertebral fractures, identified radiologically, in 3270 healthy ambulatory women (mean [+/- SD] age, 84 +/- 6 years). Each day for 18 months, 1634 women received tricalcium phosphate (containing 1.2 g of elemental calcium) and 20 micrograms (800 IU) of vitamin D3, and 1636 women received a double placebo. We measured serial serum parathyroid hormone and 25-hydroxyvitamin D (25(OH)D) concentrations in 142 women and determined the femoral bone mineral density at base line and after 18 months in 56 women. Among the women who completed the 18-month study, the number of hip fractures was 43 percent lower (P = 0.043) and the total number of nonvertebral fractures was 32 percent lower (P = 0.015) among the women treated with vitamin D3 and calcium than among those who received placebo. The results of analyses according to active treatment and according to intention to treat were similar. In the vitamin D3-calcium group, the mean serum parathyroid hormone concentration had decreased by 44 percent from the base-line value at 18 months (P < 0.001) and the serum 25(OH)D concentration had increased by 162 percent over the base-line value (P < 0.001). The bone density of the proximal femur increased 2.7 percent in the vitamin D3-calcium group and decreased 4.6 percent in the placebo group (P < 0.001). Supplementation with vitamin D3 and calcium reduces the risk of hip fractures and other nonvertebral fractures among elderly women."
},
{
"id": "pubmed23n0913_22460",
"title": "Pharmacological treatment of osteoporosis in the oldest old.",
"score": 0.013877207737594618,
"content": "The incidence of osteoporotic fractures increases with age. Consequently, the global prevalence of osteoporotic fractures will increase with the aging of the population. In old age, osteoporosis is associated with a substantial burden in terms of morbidity and mortality. Nevertheless, osteoporosis in old age continues to be underdiagnosed and undertreated. This may, at least partly, be explained by the fact that evidence of the antifracture efficacy of osteoporosis treatments comes mainly from randomized controlled trials in postmenopausal women with a mean age of 70-75 years. However, in the last years, subgroup analyses of these landmark trials have been published investigating the efficacy and safety of osteoporosis treatment in the very elderly. Based on this evidence, this narrative review discusses the pharmacological management of osteoporosis in the oldest old (≥80 years). Because of the high prevalence of calcium and/or vitamin D deficiency in old age, these supplements are essential in the management of osteoporosis in the elderly people. Adding antiresorptive or anabolic treatments or combinations, thereof, reduces the risk of vertebral fractures even more, at least in the elderly with documented osteoporosis. The reduction of hip fracture risk by antiresorptive treatments is less convincing, which may be explained by insufficient statistical power in some subanalyses and/or a higher impact of nonskeletal risk factors in the occurrence of hip fractures. Compared with younger individuals, a larger absolute risk reduction is observed in the elderly because of the higher baseline fracture risk. Therefore, the elderly will benefit more of treatment. In addition, current osteoporosis therapies also appear to be safe in the elderly. Although more research is required to further clarify the effect of osteoporosis drugs in the elderly, especially with respect to hip fractures, there is currently sufficient evidence to initiate appropriate treatment in the elderly with osteoporosis and osteoporotic fractures."
},
{
"id": "wiki20220301en286_22362",
"title": "Canadian health claims for food",
"score": 0.013797313797313799,
"content": "Research supporting the claim There is a significant body of evidence which establishes that high calcium intakes augment bone gain during growth, retards age-related bone loss, and reduces osteoporotic fracture risk. A meta-analysis study in 2007 assessed whether calcium supplementation can reduce osteoporotic fractures. The meta-analysis included all the randomized trials in which calcium, or calcium in combination with vitamin D, was used to prevent fracture and osteoporotic bone loss."
},
{
"id": "pubmed23n0540_22200",
"title": "Addressing the musculoskeletal components of fracture risk with calcium and vitamin D: a review of the evidence.",
"score": 0.013624338624338624,
"content": "Osteoporotic fractures are an extremely common and serious health problem in the elderly. This article presents the rationale for calcium and vitamin D supplementation in the prevention and treatment of osteoporotic fractures and reviews the literature evidence on the efficacy of this strategy. Two musculoskeletal risk factors are implicated in osteoporotic fractures in the elderly: the loss of bone mass due to secondary hyperparathyroidism and the increased propensity to falls. Calcium and vitamin D reverse secondary hyperparathyroidism with resultant beneficial effects on bone mineral density (BMD). Additionally, calcium and vitamin D supplementation significantly improves body sway and lower extremity strength, reducing the risk of falls. The effects of combined calcium and vitamin D on parathyroid function and BMD provide a strong rationale for the use of this therapy in the prevention and treatment of osteoporosis and osteoporotic fractures. There is general agreement that, in patients with documented osteoporosis, calcium and vitamin D supplementation should be an integral component of the management strategy, along with antiresorptive or anabolic treatment. Frail elderly individuals constitute another major target population for calcium and vitamin D because evidence from randomized studies in institutionalized elderly subjects demonstrates that these supplements reduce osteoporotic fracture risk, particularly in the presence of dietary deficiencies. However, the results of trials in community-dwelling subjects have been equivocal. Within the primary-care setting, further research is required to establish appropriate target subgroups for calcium and vitamin D supplementation; overall, the data are consistent with a benefit individuals with insufficient calcium and/or vitamin D, although patients with documented osteoporosis will derive further benefit in terms of fracture prevention from the addition of an antiresorptive agent."
},
{
"id": "wiki20220301en159_33147",
"title": "Senile osteoporosis",
"score": 0.013558201058201057,
"content": "Calcium and vitamin D3 intake from diet or supplementation are crucial in the ethiopathogenesis of this disease; therefore, the effective treatments should consist of non pharmacological methods (such as a modified diet with more calcium 1000–1500 mg/day and vitamin D3 intake of 600-800 IU/day, exercising, smoking cessation, and alcohol restriction), fall prevention, and individually chosen pharmacological intervention (antiresorptive agent like bisphosphonate or estrogen replacement therapy in women). Given bone fracture (hip, vertebrae, and colles) is a devastating complication of osteoporosis, vitamin D3 combined with calcium are used as primary prevention, along with alendronate, residronate, strontium and zoledronic acid which have proven efficacy in primary and secondary hip fracture prevention. The Institute of Medicine recommends a daily allowance of 800 IU of Vitamin D for people 70 and over, to get to a level of serum 25-hydroxyvitamin D (25OHD) of at least 20 ng/ml (50"
},
{
"id": "wiki20220301en509_6723",
"title": "Calcium supplement",
"score": 0.013408636852620254,
"content": "Health effects Bone health In healthy people, calcium supplementation is not necessary for maintaining bone mineral density, and carries risks that outweigh any benefits. Calcium intake is not significantly associated with hip fracture risk in either men or women. The U.S. Preventive Service Task Force recommends against a daily supplement of calcium or vitamin D. Although a slight increase in bone mineral density occurred in healthy children from calcium supplementation, using additional dietary calcium is not justified, according to a 2006 review. Cardiovascular impact There is good evidence that 1,000 mg to 1,500 mg of daily calcium supplementation can effect a modest reduction in blood pressure in adults who do not have a blood pressure condition."
},
{
"id": "wiki20220301en038_11967",
"title": "Women's Health Initiative",
"score": 0.013382754584471322,
"content": "CaD component findings Among the intervention cohort, a small but significant improvement in hip bone density was observed, although a significant reduction in hip fractures was not observed. However, subgroup analysis revealed a possible benefit to older women in terms of a reduced risk of hip fractures, attributable to calcium plus vitamin D supplementation. It was also found that the intervention did not have an effect on the incidence of colorectal cancer, possibly owing to the long latency associated with colorectal cancers. Calcium plus vitamin D was not found to affect the incidence of breast cancer. Finally, an increased risk of kidney stones was observed among those taking calcium plus vitamin D."
},
{
"id": "wiki20220301en396_2959",
"title": "Eldecalcitol",
"score": 0.013305860166235943,
"content": "The new analogs of vitamin D, such as eldecalcitol, are observed to have stronger effects in preventing bone loss, fractures, and falls in comparison to calcitriol. Eldecalcitol is even more effective than its counterpart alfacalcidol, another vitamin D analog. Studies have shown eldecalcitol is more effective than alfacalcidol in preventing vertebral and wrist fractures, and even falls, with osteoporotic patients with vitamin D insufficiencies. Eldecalcitol is also more effective at preventing fractures than vitamin D and calcium supplements. Eldecalcitol increases calcium absorption for vitamin D deficient patients, and therefore could be used for osteoporosis treatment for all age groups."
},
{
"id": "wiki20220301en004_137076",
"title": "Dietary supplement",
"score": 0.01323935257701201,
"content": "\"Adequate calcium as part of a healthful diet, along with physical activity, may reduce the risk of osteoporosis in later life.\" \"Adequate calcium and vitamin D throughout life, as part of a well-balanced diet, may reduce the risk of osteoporosis.\" \"Adequate calcium and vitamin D as part of a healthful diet, along with physical activity, may reduce the risk of osteoporosis in later life.\" In the same year, the European Food Safety Authority also approved a dietary supplement health claim for calcium and vitamin D and the reduction of the risk of osteoporotic fractures by reducing bone loss."
},
{
"id": "pubmed23n0269_7683",
"title": "Can we stop bone loss and prevent hip fractures in the elderly?",
"score": 0.013131648936170214,
"content": "The two main determinants of hip fractures are falls and bone loss leading to an intrinsic femoral fragility. Substantial femoral bone loss continues throughout old age, with a continuous and exponential increase in the risk of hip fracture; thus any reduction or arrest of this loss will induce an important reduction in the incidence of hip fracture. Preventive measures may be achieved during childhood by increasing peak bone mass with calcium and exercise, by using long-term estrogen replacement therapy after menopause, but also by using vitamin D and calcium supplements for late prevention in the elderly. Vitamin D insufficiency and a deficit in calcium intake are very common in the elderly living either in institutions or at home and the cumulative response to these deficits is a negative calcium balance which stimulates parathyroid hormone secretion. This senile secondary hyperparathyroidism is one of the determinants of femoral bone loss and can be reversed by calcium and vitamin D supplements. We have shown in a 3-year controlled prospective study that the daily use of supplements (1.2 g calcium and 800 IU vitamin D3) given in a large population of 3270 elderly ambulatory women living in nursing homes reduced the number of hip fractures by 23% (intention-to-treat analysis). In parallel, serum parathyroid hormone concentrations were reduced by 28% and low baseline serum 25-hydroxyvitamin D concentration returned to normal values. After 18 months of treatment the bone density of the total proximal femoral region had increased by 2.7% in the vitamin D3-calcium group and decreased by 4.6% in the placebo group (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)"
},
{
"id": "pubmed23n0364_20168",
"title": "Effect of calcium or 25OH vitamin D3 dietary supplementation on bone loss at the hip in men and women over the age of 60.",
"score": 0.012991339107261825,
"content": "Dietary supplements that prevent bone loss at the hip and that can be applied safely in the elderly are likely to reduce hip fractures. A daily dietary supplement of 750 mg calcium or 15 microg 25OH vitamin D3 on bone loss at the hip and other sites, bone turnover and calcium-regulating hormones were studied over 4 yr in elderly volunteers using a randomized, double-blind, placebo-controlled trial. Bone mineral density (BMD) was measured by dual x-ray absorptiometry and bone structure by radiographs. Calcium biochemistry and bone turnover markers were measured in blood and urine. The 316 women entering the trial had a mean age of 73.7 yr and the 122 men of 75.9 yr. Baseline median calcium intake was 546 mg/day, and median serum 25OH vitamin D3 was 59 nmol/L. On placebo, loss of BMD at total hip was 2% and femoral medulla expansion was 3% over 4 yr. Calcium reduced bone loss, secondary hyperparathyroidism, and bone turnover. 25OH vitamin D3 was intermediate between placebo and calcium. Fracture rates and drop-out rates were similar among groups, and there were no serious adverse events with either supplement. A calcium supplement of 750 mg/day prevents loss of BMD, reduces femoral medullary expansion, secondary hyperparathyroidism, and high bone turnover. A supplement of 15 microg/day 25OH vitamin D3 is less effective, and because its effects are seen only at low calcium intakes, suggests that its beneficial effect is to reverse calcium insufficiency."
},
{
"id": "pubmed23n0913_22610",
"title": "The use of cholecalciferol in patients with hip fracture.",
"score": 0.012763750947309641,
"content": "Major osteoporotic fractures are steadily increasing due to population aging. Programs of secondary prevention against refracture are essential to decrease morbidity and mortality and the cost for individuals and the society. Vitamin D supplementation and optimization of calcium intake are of a pivotal importance to start specific osteoporosis treatment and for its safety and efficacy. Cholecalciferol is the most widely employed drug for vitamin D supplementation. Aim of this study was to assess the trends in the use of vitamin D supplements containing cholecalciferol in the population of hip fracture patients older than 65 years, resident in the region of Tuscany (Italy) in the years 2011-2015 and to describe vitamin D status in a subgroup of this individuals directly referred to a bone clinic for further evaluation after hip osteoporotic fracture. Data were retrieved from the electronic anonymous regional administrative database administered by the Region of Tuscany (Italy) in the years 2011-2015 within the T.A.R.Ge.T. project (Trattamento Appropriato delle Rifratture Geriatriche in Toscana, i.e., \"Appropriate treatment of geriatric refractures in Tuscany\"), a program endorsed by the region itself. Data pertaining to cholecalciferol prescriptions and hospital discharge codes were retrieved and appropriately crossed to get data on the use of cholecalciferol supplements in patients before and after a hip fracture. A retrospective analysis was carried out in a subgroup of subjects (n 254) appropriately referred to the local fracture liaison service after the major osteoporotic fracture and vitamin D status in terms of serum 25(OH) vitamin D levels was assessed. The majority of subjects experiencing a hip fracture (98.2% and 88.3% in 2011 and 2015, respectively) did not receive vitamin D supplements at the time of the fracture event. Although a trend in increase in prescriptions for cholecalciferol supplements could be observed in the years of the study, the percentage of treated individuals remained low even after the fracture, since only 30-35% of subjects receives cholecalciferol supplements at one year after the fracture. Cholecalciferol remained the most prescribed drug in this population, while a substantial decrease of cholecalciferol in association with calcium salts was observed. The use of high doses of cholecalciferol has decreased in this population, while diminished the use of the drops has been accompanied by an increase in prescriptions of single monthly dose supplements. The correction of vitamin D inadequacy is preliminary to any treatment for osteoporosis and together with calcium may reduce fracture risk by itself. The prescription of vitamin D supplements is low in patients before and after a hip fracture in a Mediterranean region and despite the overall increase in vitamin use and abuse in the general population. Proper educational programs and active fracture liaison services are needed in order to bridge this gap."
},
{
"id": "pubmed23n1145_11485",
"title": "What is the impact of daily oral supplementation of vitamin D3 (cholecalciferol) plus calcium on the incidence of hip fracture in older people? A systematic review and meta-analysis.",
"score": 0.01256885142878267,
"content": "Hip fractures have a huge impact in reducing the quality of life and increasing mortality. This review aims to assess the impact of daily oral supplementation of vitamin D3 plus calcium on the incidence of hip fracture in people over 65 years. PRISMA guidelines were followed and RCTs that evaluated the effectiveness of daily oral supplementation of vitamin D3 plus calcium in preventing hip fracture in adults over 65 years were included in the study. The databases such as Cochrane Library, Embase, Medline, PubMed, CINAHL, Web of Science and Scopus were searched from October 2019- January 2020.The Cochrane risk of bias tool was used to check the quality of the included studies. A meta-analysis with fixed effect model using Review Manager (Revman 5.3) was used to analyse the data. The meta-analysis of seven RCTs on vitamin D3 plus calcium supplementation and hip fracture (n = 12,620) identified odds ratio (OR) of 0.75; 95% Confidence interval (CI): 0.64, 0.87; p = .0003. Daily oral supplementation of 800 IU of Vitamin D3 plus 1200 mg of calcium was found more effective (n = 5676 participants; OR = 0.69; 95% CI: 0.58, 0.82; p < .0001) than daily oral supplementation of 800 IU of Vitamin D3 plus 1000 mg of calcium (n = 6555,OR = 1.08; 95% CI: 0.74, 1.56; p = .70) in reducing hip fracture. A meta-analysis of the seven RCTs to identify the incidence of non-vertebral fracture gave the OR of 0.80; 95% CI: 0.72, 0.89; p < .0001. A meta-analysis of three RCTs on femoral neck bone mineral density (BMD) (n = 483) gave a mean difference of 1.21; 95% CI: -0.79, 3.20; p = .24. Daily oral supplementation 800 IU of vitamin D3 plus 1200 mg of calcium reduces hip fracture and non-vertebral fracture in older people. Administering vitamin D3 and calcium supplements had no effect in increasing the femoral neck BMD. Even though it is evident from the review that optimal daily intake of vitamin D3 plus calcium supplementation help in the prevention of fracture, it is only one essential element in fracture prevention. Also, people who are on dietary supplements should be compliant with same for better result. Efforts to prevent bone loss and osteoporosis should begin from an early age. It includes maintaining a healthy lifestyle, optimal intake of calcium and vitamin D3, proper nutrition, adequate exposure to sunlight, exercise etc. Proper education on healthy lifestyle, avoiding risk factors like smoking, caffeine, alcohol and awareness of bone health should continue throughout life with emphasis during menopause when increased bone loss is expected."
},
{
"id": "pubmed23n0480_21551",
"title": "A randomised, controlled comparison of different calcium and vitamin D supplementation regimens in elderly women after hip fracture: The Nottingham Neck of Femur (NONOF) Study.",
"score": 0.012470469772665659,
"content": "survivors of hip fracture are at 5- to 10-fold risk of a second hip fracture. There is little consensus about secondary prevention. Many are given calcium and vitamin D, but the evidence supporting this is circumstantial. to compare the effects of different calcium and vitamin D supplementation regimens on bone biochemical markers, bone mineral density and rate of falls in elderly women post-hip fracture. randomised controlled trial. orthogeriatric rehabilitation ward. 150 previously independent elderly women, recruited following surgery for hip fracture, were assigned to receive a single injection of 300,000 units of vitamin D(2), injected vitamin D(2) plus 1 g/day oral calcium, 800 units/day oral vitamin D(3) plus 1 g/day calcium, or no treatment. Follow-up was one year, with measurement of 25-hydroxyvitamin D, parathyroid hormone, bone mineral density, and falls. mean 25-hydroxyvitamin D increased and mean parathyroid hormone was suppressed in all the actively treated groups, more so in the group receiving combined oral vitamin D and calcium. Twenty per cent of participants injected with vitamin D were deficient in 25-hydroxyvitamin D a year later. Bone mineral density showed small but statistically significant differences of up to 4.6% between actively treated groups and placebo. Relative risk of falling in the groups supplemented with vitamin D was 0.48 (95% CI 0.26-0.90) compared with controls. Vitamin D supplementation, either orally or with injected vitamin D, suppresses parathyroid hormone, increases bone mineral density and reduces falls. Effects may be more marked with calcium co-supplementation. The 300,000 units of injected vitamin D may not last a whole year."
},
{
"id": "wiki20220301en028_33474",
"title": "Bone fracture",
"score": 0.012408012408012408,
"content": "Other A Cochrane review of low-intensity pulsed ultrasound to speed healing in newly broken bones found insufficient evidence to justify routine use. Other reviews have found tentative evidence of benefit. It may be an alternative to surgery for established nonunions. Vitamin D supplements combined with additional calcium marginally reduces the risk of hip fractures and other types of fracture in older adults; however, vitamin D supplementation alone did not reduce the risk of fractures. Children"
},
{
"id": "pubmed23n0617_17583",
"title": "Calcium and vitamin d in the prevention and treatment of osteoporosis.",
"score": 0.01227106227106227,
"content": "An increasing prevalence of calcium and/or vitamin D deficiency in the general population (especially, but not only, in elderly subjects) has been emphasized in recent epidemiologic studies. These deficiencies could be responsible for accelerated bone loss mediated by secondary hyperpara-thyroidism and increased bone turnover and could explain the dramatic increase of the incidence of osteoporotic fractures with age. High calcium intake in prepubertal girls seems to be associated with higher peak bone mass in late adolescence. Calcium supplementation could slow bone turnover and bone loss in particular subsets of patients, including calcium-deficient postmenopausal women and elderly patients. A specific antif-racture effect of calcium supplementation in postmenopausal osteoporotic patients has not been established, but a calcium-plus-low-dose-vitamin D3 supplementation has been suggested to decrease the peripheral fracture incidence (especially hip fracture) in elderly institutionalized women. After a critical review of these data, some practical recommendations are suggested."
},
{
"id": "pubmed23n0624_21250",
"title": "Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials.",
"score": 0.01226321741588917,
"content": "Antifracture efficacy with supplemental vitamin D has been questioned by recent trials. We performed a meta-analysis on the efficacy of oral supplemental vitamin D in preventing nonvertebral and hip fractures among older individuals (> or =65 years). We included 12 double-blind randomized controlled trials (RCTs) for nonvertebral fractures (n = 42 279) and 8 RCTs for hip fractures (n = 40 886) comparing oral vitamin D, with or without calcium, with calcium or placebo. To incorporate adherence to treatment, we multiplied the dose by the percentage of adherence to estimate the mean received dose (dose x adherence) for each trial. The pooled relative risk (RR) was 0.86 (95% confidence interval [CI], 0.77-0.96) for prevention of nonvertebral fractures and 0.91 (95% CI, 0.78-1.05) for the prevention of hip fractures, but with significant heterogeneity for both end points. Including all trials, antifracture efficacy increased significantly with a higher dose and higher achieved blood 25-hydroxyvitamin D levels for both end points. Consistently, pooling trials with a higher received dose of more than 400 IU/d resolved heterogeneity. For the higher dose, the pooled RR was 0.80 (95% CI, 0.72-0.89; n = 33 265 subjects from 9 trials) for nonvertebral fractures and 0.82 (95% CI, 0.69-0.97; n = 31 872 subjects from 5 trials) for hip fractures. The higher dose reduced nonvertebral fractures in community-dwelling individuals (-29%) and institutionalized older individuals (-15%), and its effect was independent of additional calcium supplementation. Nonvertebral fracture prevention with vitamin D is dose dependent, and a higher dose should reduce fractures by at least 20% for individuals aged 65 years or older."
},
{
"id": "pubmed23n1027_7405",
"title": "Real-world effectiveness of osteoporosis treatment in the oldest old.",
"score": 0.012191827085444105,
"content": "We studied effectiveness of osteoporosis treatment in women older than 80 years, who often are not included in clinical trials. Treatments were as effective on bone density and fractures as in younger women. To study real-world effectiveness of osteoporosis treatment on BMD and fractures in the oldest old women (≥ 80 years) compared with women (60-79 years) in the clinical setting using Swedish health register data. National registers and data from DXA machines were used to study effectiveness of all available osteoporosis treatments in women 60-79 and ≥ 80 years using three approaches: (1) Total Hip BMD change up to 8 years after treatment start; (2) fracture incidence where patients served as their own controls, comparing the first 3 months after treatment start with the subsequent 12 months; and (3) comparison of fracture incidence post-fracture in women ≥ 80 years treated with osteoporosis treatment or calcium/vitamin D. Analysis 1: Total Hip BMD increased by up to 6.7% and 7.7% in women 60-79 and ≥ 80 years old, respectively. The mean increase in BMD was 1.1%-units per year in both age groups. Analysis 2: Relative to the 3-month baseline, fracture incidence decreased during the subsequent 12 months of treatment. Incidence rate ratios were estimated at 0.65, 0.74, 0.29, and 0.81 for any, hip, vertebral, and non-hip-non-vertebral fracture, respectively. Analysis 3: A 24-month incidence of any fracture in women ≥ 80 years given post-fracture osteoporosis treatment was lower (HR = 0.78) than in women given calcium/vitamin D, but treatment allocation was not random, with lower mortality (HR = 0.51) in patients receiving OP treatment. Osteoporosis medication in women > 80 years in clinical practice likely works, and the magnitude of effect is similar to what was estimated in younger women. The choice between osteoporosis treatment and calcium/vitamin D after fracture in women ≥ 80 years is not random but appears associated with the patient's health status and presence of vertebral fractures, rather than the known risk profile of sustaining a fracture at a high age."
},
{
"id": "pubmed23n0532_1411",
"title": "Calcium, vitamin D and involutional osteoporosis.",
"score": 0.012187557015143222,
"content": "Previous studies suggest that combined calcium and vitamin D supplementation decreases the risk of fractures in older people, particularly those living in care homes, but trials of vitamin D alone in fracture prevention have generated inconsistent results. This review examines the physiological functions of calcium and vitamin D, and the contrasting views of what constitutes an adequate dietary calcium intake and vitamin D sufficiency in adults, and highlights the results of recent large studies of calcium and vitamin D supplementation. The RECORD study shows that calcium (1000 mg/day) and vitamin D (800 IU/day), either alone or in combination, are ineffective in the secondary prevention of osteoporotic fractures in older men and women living in the community. The Northern and Yorkshire Study also suggests that calcium (1000 mg/day) and vitamin D (800 IU/day) are of no benefit in the primary prevention of fractures in community-dwelling older women. Furthermore, the Wessex study demonstrated no reduction in fractures in older people living in the community treated with annual IM injections of vitamin D (300 000 IU). The latest studies highlight that vitamin D, either alone or in combination with calcium supplementation, is ineffective in the primary or secondary prevention of fractures in community-dwelling older people. In contrast, calcium and vitamin D supplementation prevents fractures in institutionalized elderly people, who commonly have vitamin D deficiency and secondary hyperparathyroidism."
}
]
}
}
} |
4 | {"1":{"exist":false,"char_ranges":[],"word_ranges":[],"text":""},"2":{"exist":false,"char_ranges":[](...TRUNCATED) | Gram negative does NOT rule out infection. We mark four. | Gram negative does NOT rule out infection. We mark [HIDDEN]. | "A 41-year-old man comes to the Emergency Department for three days of swelling and pain in the righ(...TRUNCATED) | 396 | en | {"1":"Treatment with cloxacillin and ceftriaxone should be initiated pending the result of the fluid(...TRUNCATED) | 136 | TRAUMATOLOGY AND ORTHOPEDICS | 2,016 | {"clinical_case_options":{"MedCorp":{"RRF-2":[{"id":"pubmed23n0705_7704","title":"Approach to septic(...TRUNCATED) |
4 | {"1":{"exist":false,"char_ranges":[],"word_ranges":[],"text":""},"2":{"exist":false,"char_ranges":[](...TRUNCATED) | "When a severe flare does not respond to iv corticosteroid therapy at full doses (1mg/kg body weight(...TRUNCATED) | "When a severe flare does not respond to iv corticosteroid therapy at full doses (1mg/kg body weight(...TRUNCATED) | "A 37-year-old woman with extensive ulcerative colitis presents a severe flare-up for which treatmen(...TRUNCATED) | 253 | en | {"1":"Emergency subtotal colectomy and in a second time prostectomy and ileoanal reservoir.","2":"As(...TRUNCATED) | 86 | DIGESTIVE TRACT | 2,014 | {"clinical_case_options":{"MedCorp":{"RRF-2":[{"id":"pubmed23n0257_19331","title":"Cyclosporine for (...TRUNCATED) |
3 | {"1":{"exist":true,"char_ranges":[[499,585]],"word_ranges":[[84,100]],"text":"If we do 1 we take awa(...TRUNCATED) | "Something aortic. They give me a gradient, which without knowing the values seems somewhat high (55(...TRUNCATED) | "Something aortic. They give me a gradient, which without knowing the values seems somewhat high (55(...TRUNCATED) | "A 52-year-old patient who has been complaining of dyspnea on medium exertion for 6 months. He has n(...TRUNCATED) | 224 | en | {"1":"Diuretics and more frequent check-ups by a specialist.","2":"In case of increasing dyspnea on (...TRUNCATED) | 63 | CARDIOLOGY | 2,014 | {"clinical_case_options":{"MedCorp":{"RRF-2":[{"id":"pubmed23n0944_14334","title":"[Aortic stenosis (...TRUNCATED) |
2 | {"1":{"exist":false,"char_ranges":[],"word_ranges":[],"text":""},"2":{"exist":true,"char_ranges":[[0(...TRUNCATED) | "Patient on her 30th post-transplant day of hematopoietic precursor transplantation, in severe neutr(...TRUNCATED) | "Patient on her 30th post-transplant day of hematopoietic precursor transplantation, in severe neutr(...TRUNCATED) | "A 65-year-old woman who underwent hematopoietic precursor transplantation 30 days ago and has sever(...TRUNCATED) | 430 | en | {"1":"Septic embolisms.","2":"Invasive pulmonary aspergillosis.","3":"Pneumonia due to Staphylococcu(...TRUNCATED) | 115 | INFECTIOUS DISEASES AND MICROBIOLOGY | 2,018 | {"clinical_case_options":{"MedCorp":{"RRF-2":[{"id":"pubmed23n0610_2963","title":"Septic pulmonary e(...TRUNCATED) |
2 | {"1":{"exist":true,"char_ranges":[[585,684]],"word_ranges":[[78,93]],"text":"Adenopathy being very t(...TRUNCATED) | "The involvement of the preauricular node is the typical lymphadenopathy of conjunctival infectious (...TRUNCATED) | "The involvement of the preauricular node is the typical lymphadenopathy of conjunctival infectious (...TRUNCATED) | "A 36-year-old male consults for conjunctival hyperemia and foreign body sensation. Which of the fol(...TRUNCATED) | 588 | en | {"1":"Adenoviral conjunctivitis.","2":"Allergic conjunctivitis.","3":"Parinaud's oculoglandular synd(...TRUNCATED) | 63 | OPHTHALMOLOGY | 2,022 | {"clinical_case_options":{"MedCorp":{"RRF-2":[{"id":"pubmed23n0668_21993","title":"[Trachoma in pati(...TRUNCATED) |
3 | {"1":{"exist":true,"char_ranges":[[100,458]],"word_ranges":[[21,84]],"text":"The statement of 1 is c(...TRUNCATED) | "I think the correct answer is 3 answers 2,4 and 5 are clearly false. The doubt is between 1 and 2. (...TRUNCATED) | "I think [HIDDEN] answers [HIDDEN]. The doubt is [HIDDEN]. The statement of 1 is correct in cases of(...TRUNCATED) | "Ten days after performing a hemithyroidectomy on a patient with a 1.5 cm thyroid nodule you receive(...TRUNCATED) | 11 | en | {"1":"As there is no capsular invasion, no further surgery is necessary.","2":"Follicular pattern is(...TRUNCATED) | 74 | SURGERY | 2,011 | {"clinical_case_options":{"MedCorp":{"RRF-2":[{"id":"pubmed23n0306_4298","title":"Selective treatmen(...TRUNCATED) |
4 | {"1":{"exist":true,"char_ranges":[[177,205]],"word_ranges":[[26,31]],"text":"anti-Sm are specific to(...TRUNCATED) | "Another question about SLE antibodies. Clinical case of SLE with renal involvement, in which positi(...TRUNCATED) | "Another question about SLE antibodies. Clinical case of SLE with renal involvement, in which positi(...TRUNCATED) | "A 27-year-old black woman consults for the appearance of edema in the lower limbs, decreased diures(...TRUNCATED) | 535 | en | {"1":"The anti-Sm antibodies are not specific for this pathology.","2":"Anti-centromere antibodies a(...TRUNCATED) | 121 | RHEUMATOLOGY | 2,021 | {"clinical_case_options":{"MedCorp":{"RRF-2":[{"id":"pubmed23n0395_10395","title":"Clinical and labo(...TRUNCATED) |
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MexExpQA: Multilingual Benchmarking of Medical QA with reference gold explanations and Retrieval Augmented Generation (RAG)
We present a new multilingual parallel medical benchmark, MedExpQA, for the evaluation of LLMs on Medical Question Answering. This benchmark can be used for various NLP tasks including: Medical Question Answering or Explanation Generation.
Although the design of MedExpQA is independent of any specific dataset, for the first version of the MedExpQA benchmark we leverage the commented MIR exams from the Antidote CasiMedicos dataset which includes gold reference explanations, which is currently available for 4 languages: English, French, Italian and Spanish.
| Antidote CasiMedicos splits | |
|---|---|
| train | 434 |
| validation | 63 |
| test | 125 |
- 📖 Paper:MedExpQA: Multilingual Benchmarking of Large Language Models for Medical Question Answering
- 💻 Github Repo (Data and Code): https://github.com/hitz-zentroa/MedExpQA
- 🌐 Project Website: https://univ-cotedazur.eu/antidote
- Funding: CHIST-ERA XAI 2019 call. Antidote (PCI2020-120717-2) funded by MCIN/AEI /10.13039/501100011033 and by European Union NextGenerationEU/PRTR
Example of Document in Antidote CasiMedicos Dataset
In this repository you can find the following data:
- casimedicos-raw: The textual content including Clinical Case (C), Question (Q), Possible Answers (P), and Explanation (E) as shown in the example above.
- casimedicos-exp: The manual annotations linking the explanations of the correct and incorrect possible answers.
- MedExpQA: benchmark for Medical QA based on gold reference explanations from casimedicos-exp and knowledge automatically extracted using RAG methods.
Data Explanation
The following attributes composed casimedicos-raw:
- id: unique doc identifier.
- year: year in which the exam was published by the Spanish Ministry of Health.
- question_id_specific: id given to the original exam published by the Spanish Ministry of Health.
- full_question: Clinical Case (C) and Question (Q) as illustrated in the example document above.
- full answer: Full commented explanation (E) as illustrated in the example document above.
- type: medical speciality.
- options: Possible Answers (P) as illustrated in the example document above.
- correct option: solution to the exam question.
Additionally, the following jsonl attribute was added to create casimedicos-exp:
- explanations: for each possible answer above, manual annotation states whether:
- the explanation for each possible answer exists in the full comment (E) and
- if present, then we provide character and token offsets plus the text corresponding to the explanation for each possible answer.
For MedExpQA benchmarking we have added the following elements in the data:
- rag
- clinical_case_options/MedCorp/RRF-2: 32 snippets extracted from the MedCorp corpus using the combination of clinical case and options as a query during the retrieval process. These 32 snippets are the resulting RRF combination of 32 separately retrieved snippets using BM25 and MedCPT.
MedExpQA Benchmark Overview
Prompt Example for LLMs
Benchmark Results (averaged per type of external knowledge for grounding)
LLMs evaluated: LLaMA, PMC-LLaMA, Mistral and BioMistral.
Citation
If you use MedExpQA then please cite the following paper:
@article{ALONSO2024102938,
title = {MedExpQA: Multilingual benchmarking of Large Language Models for Medical Question Answering},
journal = {Artificial Intelligence in Medicine},
pages = {102938},
year = {2024},
issn = {0933-3657},
doi = {https://doi.org/10.1016/j.artmed.2024.102938},
url = {https://www.sciencedirect.com/science/article/pii/S0933365724001805},
author = {Iñigo Alonso and Maite Oronoz and Rodrigo Agerri},
keywords = {Large Language Models, Medical Question Answering, Multilinguality, Retrieval Augmented Generation, Natural Language Processing},
}
Contact: Iñigo Alonso and Rodrigo Agerri HiTZ Center - Ixa, University of the Basque Country UPV/EHU
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