The Smye method has been proposed to estimate the equilibrated post-dialysis BUN based on an additional intradialytic sample obtained approximately one hour into dialysis. However, the effects of access recirculation (AR) and cardiopulmonary recirculation (CPR) on the Smye computation and the corresponding details of how blood is sampled have not been studied. We examined the accuracy of two variations of the Smye technique. In one method, the intradialytic and postdialysis blood samples were obtained at full blood flow. In the other, the samples were obtained after two minutes of slow flow, to obviate the effects of both AR and CPR. Seventeen patients undergoing high efficiency dialysis and three- to four-hour treatment times were studied, in whom substantial AR was excluded based on two-minute slow flow urea rebound measurements during and just after dialysis. In this group equilibrated Kt/V (eKt/V) values computed using the Smye-derived equilibrated postBUN estimates (full flow samples, 1.22 +/- 0.058 SEM, slow flow samples, 1.23 +/- 0.064) were similar to eKt/V calculated from the 30-minute postdialysis BUN specimen (1.23 +/- 0.049, P = NS). In eight other patients with severe AR (mean 35% +/- 4.5), the accuracy of the full flow Smye estimates was poor when the degree of AR was not constant throughout the dialysis session. Accuracy of the slow flow Smye estimates of eKt/V was unaffected by the presence of severe AR. One advantage of using the full flow Smye method, however, was that a large delta Kt/V value ( < -0.40) was highly suggestive of severe AR.(ABSTRACT TRUNCATED AT 250 WORDS)

A 45-year-old male patient with Tourette syndrome presented to the emergency department with worsening neck pain and stiffness of 1-week duration. Associated symptoms included headache, hoarse voice, trismus and odynophagia. The patient was haemodynamically stable without fevers or leucocytosis. He exhibited cervical spinal and paraspinal tenderness with very limited range of motion. Erythrocyte sedimentation rate and C reactive protein were elevated, and blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Lumbar puncture was unremarkable. CT and MRI of the neck showed calcification of the longus colli, fluid and capsular distention of C1–C2 joints, enhancement of the joint capsule and retropharyngeal oedema suggestive of septic arthritis. Fluid was aspirated from C1 to C2 joint by interventional radiology and showed calcium pyrophosphate crystals and heavy MRSA colonisation, consistent with both pseudogout and septic arthritis of the cervical vertebrae. The patient was started on a 6-week course of daptomycin and showed gradual improvements in neck pain and mobility.

Patient: Male, 83Final Diagnosis: IgG4-related aortitis and pericarditisSymptoms: L hip painMedication: —Clinical Procedure: —Specialty: General and Internal MedicineObjective:Unusual clinical courseBackground:IgG4-related disease (IgG4-RD) is a systemic inflammatory condition with a myriad of presentations related to the pattern of organ involvement. Diagnostic workup for IgG4-RD requires a high index of suspicion, and further workup often includes the results of serological testing for elevated levels of IgG4. Correlation of presentation, past medical history, and histopathologic analysis are required to make a diagnosis.Case Report:In this case, incidental discovery of non-infectious aortitis and pulmonary mass lesions were the specific signs that led to the consideration of IgG4-RD. It was only after careful consideration of the patient’s past medical history and examination of previously stored surgical specimens (pericardial tissue) that a conclusive, retrospective diagnosis of IgG4-related disease was reached.Conclusions:This case demonstrates that the natural history of IgG4-related disease can be indolent and variable in presentation. Appropriate diagnosis requires consideration of all manifestations of the disease, sometimes with surveillance over several years.

Patient: Male, 25-year-old Final Diagnosis: Autism spectrum disorder • celiac disease Symptoms: Behavioral disturbance • diarrhea • weigh loss Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology • General and Internal Medicine Objective: Rare co-existance of disease or pathology Background: Celiac disease is very common, with some estimates placing the prevalence at approximately 1: 300 worldwide. Typified by autoimmune degradation of the duodenal brush border due to reactivity with dietary gluten, causing malabsorption, it classically presents with both gastrointestinal and extra-intestinal symptoms. Gastrointestinal symptoms commonly include diarrhea, constipation, foul steatorrhea, flatulence, and bloating. With increased awareness and availability of testing, it is rare that a patient would present with celiac crisis, which is a syndrome of profuse diarrhea and severe metabolic/nutritional disturbances. In children, interestingly, celiac disease can present primarily as behavioral disturbance, such as increased aggression or anxiety, with milder or absent gastrointestinal symptoms. Case Report: A 25-year-old man with a history of schizophrenia and autism spectrum disorder presented for behavioral disturbance after breaking into a neighbor’s house to eat food. He also reported several months of diarrhea and fecal incontinence and was noted to have severe malnutrition on exam, despite dramatic food intake. Tissue transglutaminase IgA antibody (TTG) and gliadin IgA were highly suggestive of celiac disease, which was confirmed by biopsy. He was started on a lactose-free and gluten-free diet, and required a short course of total parenteral nutrition (TPN) for nutritional resuscitation. He improved rapidly with this intervention, and returned to nutritional and behavioral baseline. Conclusions: We report a unique case in which an adult with psychiatric comorbidities presented with predominantly behavioral disturbances, a more common presentation in children with the disorder. These patients may present in an atypical fashion, and the clinician should have a high index of suspicion.

Background Diagnostic errors contribute to the morbidity and mortality of patients. We created and utilized a novel diagnostic tool (Diagnostic Reboot) and assessed its practical efficacy in the inpatient setting for improving diagnostic outcomes. Design This was a prospective sequential controlled study that involved University Hospitalist Adult Teaching Service (UHATS) teams. Senior residents were instructed to use the Diagnostic Reboot (DxR) tool whenever a patient aged 19-99 years was identified who had an uncertain diagnosis 24 hours into their admission. Results Participating residents identified a total of 32 patients as meeting the criteria of uncertain diagnosis after at least 24 hours of hospitalization during the six months of the study period. Of these, seven were during the intervention (DxR) period. The leading diagnosis was excluded in 3/7 (43%) patients in the DxR period and 13/25 (52%) in the control period. A new leading diagnosis was made in 6/7 (86%) cases in the DxR period and in 13/25 (52%) people in the control period. A new diagnostic plan was made in 100% of the patients in the DxR group and in 80% of patients in the control group. A new consultation was requested in 4/7 (57%) patients in the DxR group and in 9/25 (36%) patients in the control group. The Residents spent an average of 20 minutes on the DxR tool. Conclusions This study demonstrated that the use of DxR may help to improve analytical thinking in residents. It may also play a role in improving outcomes in medically challenging cases, but the use of the tool during the study period was not sufficient to draw concrete conclusions. The primary barrier to the use of such a diagnostic aid was identified as time pressure on a busy hospitalist service.