Journal of Community Hospital Internal Medicine Perspectives最新文献

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a growing global health concern which is driven by the increasing prevalence of diabetes and obesity. MAFLD is characterized by excessive fat accumulation in the liver, which encompasses a range of conditions, from simple hepatic steatosis to more severe forms. This condition is associated with various complications, including chronic kidney disease (CKD), Cardiovascular Disease (CVD), liver cirrhosis, and even malignancy. Recent research has highlighted a potential connection between gut dysbiosis and MAFLD, particularly in relation to CKD. This has underscored the significance of the gut-liver-kidney axis in understanding MAFLD's pathogenesis. Inflammation triggered by MAFLD increases the risk of CVD through multiple mechanisms linked to metabolic dysfunction. These mechanisms include heightened oxidative stress, systemic and hepatic insulin resistance, low-grade inflammation, and endothelial dysfunction. Hepatic steatosis and metabolic dysfunction are major diagnostic criteria for MAFLD, often coexisting with other liver ailments. This prospective review emphasizes the intricate associations between MAFLD, cardiovascular complications, renal issues, and hepatic diseases. Understanding the underlying pathophysiological pathways is crucial in comprehending the increased risk of CKD, CVD, and other hepatic complications in individuals with MAFLD.

Purpose: This study evaluated the predictive value of SCAI shock staging for mortality in patients with sepsis and septic shock admitted to the medical ICU.

Materials and methods: This is a single-center historical cohort study. We analyzed data for adults (≥18-year-old) admitted to the medical ICU at Mayo Clinic St. Mary's campus with sepsis between June 1, 2018, and December 31, 2021. Sepsis was identified using the Sepsis-III criteria. Patients were stratified based on SCAI shock staging. Our primary outcome was all-cause 30-day mortality.

Results: We identified 3079 eligible adult patients with sepsis or septic shock. The distribution of SCAI shock stages A through E was 9%, 12%, 25%, 49%, and 5%, respectively. The overall 30-day mortality was 24%. There was progression in all outcomes including ICU, hospital and 30-day mortality across SCAI shock stages. However, only SCAI shock stages D and E, had statistically significant adjusted HRs of 1.6 and 3, respectively. When compared to SOFA score, SCAI shock staging performed similarly in predicting ICU mortality with no statistically significant difference in AUCs, p-value of 0.07.

Conclusions: Our results support the use of SCAI shock staging in critically ill medical patients with sepsis and septic shock for risk stratification. We propose that the SCAI shock staging may be used as a universal system for grading the severity of shock in critically ill patients regardless of etiology.

Carbon black is the general term for a powdery commercial form of carbon. It can cause adverse health effects after inhalation, ingestion, or dermal contact. Exposure to carbon black particles can have adverse effects on the respiratory system; this exposure usually occurs when people inhale contaminated air in the workplace. Here we report a patient with massive carbon black exposure at work who continues to have productive cough with black material in sputum for over a year after this one-time exposure. This patient worked as a repair man and welder at a carbon black manufacturing facility. He had an intense exposure to carbon black for 4-10 min when equipment in the plant malfunctioned. He developed immediate respiratory symptoms, and these have persisted for at least 1.5 years post exposure with a chronic productive cough with black particles. Cytological analysis of his sputum revealed carbon laden macrophages. A high-resolution computed tomography scan documented patchy alveolar infiltrates at the lung bases with septal thickening. His symptoms have partially improved with empiric treatment with a long-acting beta agonist and inhaled corticosteroids. This case demonstrates that a single one-time exposure to a dense fog of carbon black can result in particle deposition in the lung that persists for prolonged periods of time.

Background: Spontaneous splenic rupture (SSR) is a known complication of hematologic malignancy. Rare cases have been reported in which patients presented with SSR prior to diagnosis of chronic myeloid leukemia (CML). We present a case of atraumatic SSR due to CML presenting as persistent abdominal pain.

Case presentation: A 42-year-old man presented with persistent left upper quadrant pain radiating to the lower quadrants ongoing for many months. He additionally had many other systemic symptoms including weight loss, night sweats, dark tarry stools, and progressive fatigue. Initial laboratory tests showed an anemia and a leukocytosis of 170 K/mm3 which uptrended to 230 K/mm³. CT abdomen showed spontaneous splenic rupture without major hemodynamic compromise and was treated conservatively. Peripheral smear was indicative of a chronic leukemia, and BCR-ABL testing was positive, leading to the diagnosis of CML - a rare cause of SSR.

Discussion: We present a case of SSR as the inciting factor for a work-up revealing hematologic abnormalities and later CML. While splenic rupture has been shown to be present in patients with lymphoma and AML, it is an uncommon presenting symptom of CML and has only been documented in case reports. We urge clinicians to keep splenic rupture on the differential for persistent abdominal pain, as well as a thorough hematological workup for malignancy if hematologic lab abnormalities exist.

Creutzfeldt-Jakob Disease (CJD) is an exceedingly rare condition with an incidence of one case per million people worldwide. It is diagnosed with symptoms of rapid neurological decline, positive CSF biomarkers, and diagnostic findings on MRI and EEG. There is no known effective therapy for CJD and prompt diagnosis is required to prepare for the expected disease prognosis and goals of care discussions.

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is a right ventricular disease caused by desmosomal gene mutations leading to fibro-fatty replacement of the myocardium causing ventricular arrhythmias such as ventricular tachycardia (VT). A 59-year-old female presented with new onset VT manifesting as shortness of breath and chest discomfort. Diagnostic workup revealed right ventricular dilation/dysfunction on echocardiogram, VT with left bundle branch block (LBBB) and diffuse T wave inversions (TWIs) on EKG. She was discharged with a diagnosis of ARVC. Later, she developed VT storm, treated with epi-endocardial ablation for complete resolution of recurrent VT. Our case demonstrates the rare presentation of ARVC as ventricular storm and the various management strategies such as anti-arrhythmics, automated implantable cardioverter-defibrillator (AICD) and ablation procedures.

Objectives: To determine the effect of actively training the crura of diaphragm which is a part of lower esophageal sphincter using abdominal breathing exercises to treat gastroesophageal reflux disease.

Methodology: With a randomized controlled study design, a total of 22 (11 in each group) clinically diagnosed patients of GERD presenting to the gastroenterology outpatient department at Holy Family Hospital in Pakistan were assessed using GERD related "quality of life index (QoLI)" questionnaire and their on-demand proton pump inhibitors (PPI) usage. Single blinding technique will be used. Patients ages 18-60 years with GERD were included. However, those with hiatal hernia > 2 cm, previous surgeries on LES and those with who could not undergo the breathing exercise training were excluded. The data was collected via interviews. The intervention group was trained to do a 5-min breathing exercise and advised to perform it 5 times a day for 4 continuous weeks. On demand PPI usage was self-recorded. The control group was also trained to perform a breathing exercise that had no effect on LES and was asked to self-record on demand PPI usage. After 4 weeks the data was collected from both groups and compared quality-of-life index and PPI usage. Data was retrieved and analyzed using SPSS version 22. Descriptive analysis was used for describing the study variables. Paired t-test was used for in group comparison before and after intervention and independent t test was used for between group comparison, p value of <0.05 was taken as significant. Mean PPI usage of the two groups was also compared.

Results: An improved QoLI and reduced PPI usage was seen in the intervention group as compared to control group. Paired t test confirmed a statistically significant difference, but the independent t test did not. Linear regression test showed that F (1,20) = 32.822, p = 0.000. Adjusted R value is 0.603. y = 13.182x +2.812. The beta value is 0.789 and p value is 0.000.

Conclusion: The study concludes that abdominal breathing exercises can improve the GERD symptoms as assessed by QoLI score and on demand PPI usage. It advocates for an alternative treatment option for GERD patients that is more efficacious as compared to no breathing exercises and has less potential side effect as compared to continuous PPI use, enabling us to lead our way towards revolution in medicine providing more effective and less invasive treatment options to facilitate our patients.

Lactobacillus rhamnosus is a gram-positive bacterium commonly found in dairy products and used as a probiotic due to its resistance to acid and bile. While generally considered safe, rare cases of L. rhamnosus bacteremia and endocarditis have been reported, primarily in individuals with significant risk factors. This report discusses an elderly male with a history of cardiovascular diseases, diabetes, and asthma, who developed L. rhamnosus bacteremia and endocarditis after consuming large quantities of Greek yogurt. The patient initially presented with fatigue, myalgias, and fever, and was treated empirically with cefepime and vancomycin. On that occasion, blood cultures recovered L. rhamnosus which was treated with a short course of oral antibiotics. Despite initial improvement, the patient was re-hospitalized with a transient cerebral ischemic attack. Subsequent investigations again revealed L. rhamnosus in blood cultures raising suspicion for subacute bacterial endocarditis. Antibiotic therapy with ampicillin resulted in the clearance of bacteremia; unfortunately, the patient experienced a non-ST elevation myocardial infarction leading to cardiac arrest and death. This case highlights the potential pathogenicity of L. rhamnosus in susceptible individuals and underscores the need for caution in consuming probiotic products among those with severe or multiple comorbidities.

Marginal zone lymphoma has seldom been described in relation to adalimumab used for treatment of hidradenitis suppurativa. Although studies have shown an increased risk of lymphoma with adalimumab, most of these studies were done in patients with underlying inflammatory bowel disease or rheumatoid arthritis where the disease itself presents as a confounder for lymphoma. Our case described adds to the role of chronic anti-TNF alpha therapy as a possible etiology of lymphoma.

Introduction: Cobalamin deficiency (CD) due to pernicious anemia (PA) leads to hyperhomocystinemia, a risk factor for thrombosis. However, the clinical presentations and outcomes of hyperhomocystinemia-associated thrombosis (HAT) are not fully understood.

Methods: We undertook a literature search using PUBMED, SCOPUS and WEB OF SCIENCE databases for the terms "pernicious anemia AND thrombosis", "pernicious anemia AND embolism", "pernicious anemia AND thromboembolism", "autoimmune gastritis AND thrombosis", "autoimmune gastritis AND embolism", "autoimmune gastritis AND thromboembolism" through January 2024 and reviewed the published literature. Our aim was to illustrate the clinical features of PA-related HAT.

Results: Of 20 patients, the median age was 54.5 years (60 % males). 35 % of patients were elderly. The median serum homocysteine level was 67.75 umol/L. 35 % of patients developed thromboses at multiple locations while 20 % had thromboses at unusual sites. 45 % of patients had co-existing neuropsychiatric symptoms. 80 % of patients were positive for anti-IF (anti-intrinsic factor) antibodies. All patients received cobalamin replacement and the median duration of antithrombotic therapy was 6.5 months for reported cases. None developed recurrent thromboembolism.

Conclusion: This rare condition is associated with high incidence of thromboses at unusual sites, multiple-site thromboses, co-existing neuropsychiatric symptoms, high positivity rate for anti-IF antibodies and low recurrent thrombosis rate.