Journal of Community Hospital Internal Medicine Perspectives最新文献

Background: To investigate the etiology of pleural effusion, a variety of examinations are performed, including invasive ones: Thoracentesis is an invasive procedure to remove fluid or air from the pleural cavity for diagnostic or therapeutic purposes. Until now, there are no blood markers that can help us diagnose the type of pleural effusion without the need for pleural puncture or drainage.

Aims: The aim of this study was to investigate the relationship and the utility of the new inflammatory markers taken from complete blood count (CBC) to differentiate between the various types of pleural effusion before the invasive procedure decision.

Material and methods: This is an observational retrospective study. Data was collected from medical records of patients aged 18-90 admitted in Ziv Medical Center, Safed, Israel that were diagnosed with pleural effusion from 2013 to 2019. Of those patients, of whom inflammatory markers from blood counts and thoracentesis results were obtained, the outcomes were compared with the diagnosis type of pleural effusion.

Results: This study involved 391 patients, 256 suffered from exudate type effusion, their median age was 72 years, while 135 suffered from transudate effusion, their median age was 80 years. Those with exudate effusion had higher levels of CRP, platelets, neutrophils, and lymphocytes in blood, whereas those with transudate effusion had higher levels of MPV and RDW in blood. Other blood markers such as NLR and PLR were not statistically significant, but were also higher in the blood of patients with exudate effusion.

Conclusion: An evaluation of simple and inexpensive measurements of blood count such as platelets, neutrophils, lymphocytes, MPV, RDW may provide insight into the etiology of pleural effusion.

This meta-analysis assesses the recent Food and Drug Administration (FDA)-approved antifungal, rezafungin, for treating candidemia and invasive candidiasis-both are significant health concerns with limited treatment options. Two randomized controlled trials comparing rezafungin to caspofungin were meta-analyzed, revealing no significant differences in global cure rates and 30-day all-cause mortality. While rezafungin's unique attributes, like a novel mechanism and once-weekly dosing, may enhance patient adherence, concerns arise about its clinical relevance given the substantial investment. The study emphasizes the need for ongoing research, post-marketing surveillance, and real-world data to determine rezafungin's true value in managing these life-threatening fungal infections. Despite FDA approval, further investigation is warranted for a comprehensive understanding of rezafungin's efficacy and safety.

Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN) is a rare hematologic cancer, accounting for less than 1% of acute leukemias in the U.S. Diagnosis involves detecting markers like CD123, CD4, CD56, TCL1, and TCF4. Treatment typically involved acute leukemia therapies, but Tagraxofusp, a targeted therapy, was recently approved. Despite advancements, prognosis remains grim, with a median survival of around 1 year. Atraumatic splenic rupture (ASR) is a rare complication of this condition, with only five cases reported from 1994 to 2018. Here we present a case of BPDCN complicated by ASR. This case emphasizes the challenges of diagnosing and treating BPDCN, noting its rarity and absence of standard therapy. Tagraxofusp has shown promising results but presents safety concerns like capillary leak syndrome, particularly in elderly patients with comorbidities.

Acquired hemophilia A (AHA) is a bleeding disorder that occurs from aberrant production of autoantibodies that target factor VIII. The underlying cause of AHA is unclear but can present postpartum. Very few cases have reported instances of AHA coexisting with other hematological disorders, such as sickle cell trait (SCT). Although rare and no direct correlation between the two, critical situations involving intractable bleeding can intensify the severity of these disorders. A 31-year-old pregnant female with a medical history significant for SCT presented to the hospital for a C-section. Shortly after the procedure she experienced intractable bleeding from multiple sites. Initial lab work yielded an isolated increase in activated partial thromboplastin time (aPTT). Further investigation showed abnormal mixing studies, reduced factor VIII activity and the presence of factor VIII antibodies. The patient was diagnosed with postpartum AHA (PAH) and treated with activated Factor VII and prednisone. PAH is an uncommon bleeding disorder that commonly occurs one to four months postpartum and presents as excessive bleeding elevated aPTT, abnormal mixing studies, and reduced factor VIII levels with abnormally high inhibitor levels. Despite an unknown identifiable etiology, treatment hinges upon establishing hemostasis and eradicating the aberrant generated factor VIII inhibitors. The association of AHA and other hematological disorders is not yet elucidated.

Adenoma detection rate (ADR) is a key quality metric in screening colonoscopies. An adenoma detection rate of greater than 30% reduces the incidence of colorectal carcinoma (CRC). Furthermore, studies have demonstrated an inverse relationship between ADR and the incidence of CRC. Computer aided detection (CAD) can improve ADR, but these studies have largely been in major medical centers. In this retrospective single center observational study, screening colonoscopies in average-risk patients were compared among 5 experienced endoscopists in the year before and the year after implementation of the CAD (GI Genius). Training for GI Genius was completed in December 2021 and the technology was implemented the beginning of January 2022. We evaluated the adenoma detection rate (ADR) for 1838 screening colonoscopies in 2021 (before CAD incorporation) and 2629 screening colonoscopies in 2022 (after CAD incorporation) to assess efficacy of AI-assisted colonoscopy. Our study demonstrates that the incorporation of CAD technology in a group of experienced endoscopists in a community setting significantly improved ADR. The ADR of the entire group increased significantly (p < 0.05) following the implementation of CAD technology. The improvement in ADR was attributed to an increased detection of small (<6 mm) polyps. The clinical significance of improved detection of small polyps is uncertain, and further investigation should be done on the economical benefit of incorporating an AI model in the community setting.

Myroides odoratus is a relatively little-known pathogen despite its ubiquitous presence in the environment. It is an opportunistic gram-negative bacillus commonly found in soil and water. Infection by Myroides species is rare, but the spectrum of illness varies from skin and soft tissue infections, urinary tract infections, pneumonia, and, in severe cases, bacteremia and septic shock. Though infection with Myroides species is uncommon and typically limited to immunocompromised individuals, the wide range of antimicrobial resistance it exhibits makes treatment challenging. In this report, we present the case of a 76-year-old male with compensated cirrhosis who presented with cellulitis complicated by bacteremia secondary to M. odoratus and was managed successfully with levofloxacin.

Mixed Connective Tissue Disease (MCTD) is a complex disease that is a combination of several other clinical conditions, including systemic lupus erythematosus (SLE), systemic sclerosis (SSc), and polymyositis/dermatomyositis (PM/DM). What makes MCTD challenging is the fact that there are no current management guidelines. Instead, treatment is usually chosen based on organ involvement using SLE, SSc, and PM/DM guidelines. In this paper, we will discuss an unusual presentation of MCTD, the workup that led to the diagnosis, the immunological profile, and the management plan for this rare disease.

Objective: To assess the association between thyroid dysfunction and mortality among patients hospitalized with COVID-19. Design: This is a retrospective multi-center study, which examined all patients admitted with Covid-19 diagnoses, and thyroid function results in absence of known thyroid disease.

Results: 10,933 hospitalized COVID-19 positive patients were included in the study. These patients were without prior diagnosis or treatment of thyroid disease. Outcomes assessed were mortality, ICU admission, Ventilator use, length of stay, readmission and complications during hospital stay. Patients with low TSH and Low free T4 had odds of mortality of 10.07(95% CI [7.44-13.6]) compared to patients with Normal TSH and any free T4 levels. Patients with Low TSH and High free T4 also had odds of mortality of 1.38 (95% CI [1.19-1.59]) compared to patients with Normal TSH and Any free T4 level. Patients with Low TSH and Normal free T4 levels also had an Odds of mortality of 1.46 (95% CI [1.31-1.62]) compared to patients with Normal TSH and any free T4 level. Patients with Low TSH also had higher odds of ICU admission and Ventilator use when compared to patients with normal TSH.

Conclusions: This study shows that patients with low TSH, regardless of free T4 level, indicates poor prognosis for hospitalized patients with SARS-CoV-2 infection and offers further insights into possible prognostic value of TSH levels for severe COVID-19 outcomes.

Lyme disease is a very common infectious disease worldwide. The seventh cranial nerve palsy occurred in 9% of Lyme disease cases and the majority of them present as unilateral facial palsy. We present a rare case of bilateral facial palsy in Lyme disease due to Borrelia burgdorferi infection. A total of eleven cases of Lyme disease with bilateral facial palsy reported in literature were summarized and compared to our case. The diagnosis and management of Lyme disease with facial nerve palsy were also discussed in this article.

Background: Malignant Pleural Mesothelioma (MPM) is a primary pleural tumor with scarce prognostic data estimates given its rarity. This study aims to explore the epidemiologic and survival predictors amongst patients with MPM, extending from the largest and most recent study conducted between 1973 and 2009.

Methods: 3384 patients diagnosed with MPM between 2010 and 2017 were enrolled from the Surveillance, Epidemiology, and End Results (SEER) database. Demographics, clinical characteristics, overall mortality (OM), and cancer-specific mortality (CSM) estimates were analyzed. Multivariate Cox model was used to identify independent prognostic factors, where a hazard ratio (HR) greater than 1 denotes adverse prognostic factors.

Results: Our cohort revealed a male predominance (77.16%), with over 80% diagnosed after age 59, peaking between 60 and 79 years old (60.17%). Epithelioid mesothelioma (41.78%), non-Hispanic whites (78.13%), and diagnosis at distant stage (71.60%) were the most common subgroups in their respective categories. 365 patients (10.79%) lacked pleural effusion at diagnosis. In multivariate analyses, higher overall mortality (OM) was associated with male gender (HR = 1.24, 95% CI 1.14-1.37, p < 0.01), age >80 years (HR = 2.17, 95% CI 1.41-3.35, p < 0.01), fibrous mesothelioma (HR = 2.21, 95% CI 1.95-2.51, p < 0.01), and distant stage (HR = 1.55, 95% CI 1.34-1.81, p < 0.01). Higher cancer-specific mortality (CSM) was associated with male gender (HR = 1.25, 95% CI 1.13-1.38, p < 0.01), age >80 years (HR = 2.02, 95% CI 1.29-3.15, p < 0.01), fibrous mesothelioma (HR = 2.24, 95% CI 1.97-2.55, p < 0.01), and distant stage (HR = 1.59, 95% CI 1.36-1.87, p < 0.01). Lower OM and CSM was observed in patients who underwent any type of treatment. Nonmalignant pleural effusion, based on histology, was associated with higher CSM (HR = 1.22, 95% CI 1.05-1.4, p < 0.05).

Conclusion: Fibrous mesothelioma, older age, and distant disease were associated with increased mortality. All intervention strategies were associated with improved survival outcomes. Earlier diagnosis may improve outcomes, as available interventions are associated with lower mortality when feasible at diagnosis. The study paves the way for further prospective and retrospective studies to focus on the identification of patient subsets that may benefit from early mesothelioma screening.