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      Oligoarticular Hemarthroses and Osteomyelitis Complicating Pasteurella Meningitis in an Infant

      case-report

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          Abstract

          A 5-month-old previously healthy female presented with a one-week history of fever and increased fussiness. Her presentation revealed an ill-appearing infant with an exam and cerebrospinal fluid (CSF) studies concerning bacterial meningitis; CSF cultures grew Pasteurella multocida. Additionally, brain magnetic resonance imaging (MRI) demonstrated cervical osteomyelitis. Despite multiple days of antibiotic therapy, she remained febrile with continued pain; MRI showed oligoarticular effusions, and aspiration of these joints yielded bloody aspirates. Evaluations for coagulopathy and immune complex-mediated arthropathy were negative. The patient improved following appropriate antibiotic therapy and spontaneous resolution of hemarthroses, and was discharged to a short-term rehabilitation hospital. P. multocida is a small, encapsulated coccobacillus that is part of the commensal oral flora of animals. It most commonly causes skin infections in humans, yet is a rare cause of meningitis in the pediatric population, especially in children <1 year of age. Transmission due to P. multocida is most commonly due to direct contact with animals. To our knowledge, this is the first case of oligoarticular hemarthroses and cervical osteomyelitis complicating P multocida meningitis. This case highlights the physician’s potential for cognitive bias and premature anchoring, and the resulting implications in delivering excellent patient care.

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          Most cited references17

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          Critical Thinking in Critical Care: Five Strategies to Improve Teaching and Learning in the Intensive Care Unit.

          Critical thinking, the capacity to be deliberate about thinking, is increasingly the focus of undergraduate medical education, but is not commonly addressed in graduate medical education. Without critical thinking, physicians, particularly residents, are prone to cognitive errors, which can lead to diagnostic errors, especially in a high stakes environment such as the intensive care unit. Although challenging, critical thinking skills can be taught. Currently there is a paucity of data to support an educational gold standard for teaching critical thinking, but we believe that five strategies, routed in cognitive theory and our personal teaching experiences, provide an effective framework to teach critical thinking in the intensive care unit. The 5 strategies are: 1) Make the thinking process explicit by helping learners understand that the brain utilizes two cognitive processes; Type 1, an intuitive pattern-recognizing process and Type 2 an analytic process. 2) Discuss cognitive biases, such as premature closure, and teach residents to minimize biases by expressing uncertainty and keeping differentials broad. 3) Model and teach inductive reasoning by utilizing concept and mechanism maps and explicitly teach how this reasoning differs from the more commonly used, hypothetico-deductive reasoning. 4) Use questions to stimulate critical thinking. "How" or "why" questions can be used to coach trainees and to uncover their thought processes. 5) Assess and provide feedback on learner's critical thinking. We believe that these five strategies provide practical approaches for teaching critical thinking in the intensive care unit.
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            Exploring the biological basis of haemophilic joint disease: experimental studies.

            Haemophilia has been recognized as the most severe among the inherited disorders of blood coagulation since the beginning of the first millennium. Joint damage is the hallmark of the disease. Despite its frequency and severity, the pathobiology of blood-induced joint disease remains obscure. Although bleeding into the joint is the ultimate provocation, the stimulus within the blood inciting the process and the mechanisms by which bleeding into a joint results in synovial inflammation (synovitis) and cartilage and bone destruction (arthropathy) is unknown. Clues from careful observation of patient material, supplemented with data from animal models of joint disease provide some clues as to the pathogenesis of the process. Among the questions that remain to be answered are the following: (i) What underlies the phenotypic variability in bleeding patterns of patients with severe disease and the development of arthropathy in some but not all patients with joint bleeding? (ii) What is the molecular basis underlying the variability? (iii) Are there strategies that can be developed to counter the deleterious effects of joint bleeding and prevent blood-induced joint disease? Understanding the key elements, genetic and/or environmental, that are necessary for the development of synovitis and arthropathy may lead to rational design of therapy for the targeted prevention and treatment of blood-induced joint disease. © 2011 Blackwell Publishing Ltd.
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              Arthritis in disease due to Neisseria meningitidis.

              U Schaad (2015)
              Three clinical types of arthritis in meningococcal disease are presented; their classification is based on a review of the literature from 1887 and on experience with pediatric patients treated in Dallas, Texas. The most common type is arthritis complicating acute meningococcal disease; it occurred in 1,180 of the patients reviewed or approximately 5% of children and 11% of adults with meningococcal disease. Septic or allergic pathogenesis was documented in fewer than 5% of these, 1,180 patients. However, the search for an immunologic basis, conducted in a small number of patients, produced results suggesting that immune complexes are involved in many patients with sterile effusions. Large joints, especially the knee, were involved in 95% of the cases, and almost half the patients had polyarthritis. Chronic meningococcemia, an infrequently reported clinical entity, was accompanied more often by arthralgia than arthritis. Primary meningococcal arthritis, which is a rare form of acute septic arthritis, affected large joints almost exclusively and was polyarthritic in about one-third of cases. The management was the same for all types of meningococcal arthritis and consisted primarily of specific antimeningococcal chemotherapy. Evacuation of pus is recommended, since this treatment may be expected to shorten the relatively long symptomatic course. The prognosis for patients with meningococcal arthritis is excellent, and joint residua are rare.
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                Author and article information

                Journal
                Children (Basel)
                Children (Basel)
                children
                Children
                MDPI
                2227-9067
                16 October 2017
                October 2017
                : 4
                : 10
                : 87
                Affiliations
                [1 ]Department of Pediatrics, University of Louisville, Louisville, KY 40292, USA; jjfarg02@ 123456louisville.edu (J.F.); vastat01@ 123456louisville.edu (V.A.S.)
                [2 ]Department of Pediatric Cardiology, University of Pittsburgh, Pittsburgh, PA 15260, USA; Allison.black@ 123456chp.edu
                Author notes
                [* ]Correspondence: cnness01@ 123456louisville.edu ; Tel.: +1-(502)-629-8828; Fax: +1-(502)-629-6783
                Author information
                https://orcid.org/0000-0001-7119-1658
                Article
                children-04-00087
                10.3390/children4100087
                5664017
                29035302
                8107db44-b560-4705-83a6-d776f40d2631
                © 2017 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 17 August 2017
                : 10 October 2017
                Categories
                Case Report

                pasteurella multocida,meningitis,hemarthrosis,osteomyelitis

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