HCA healthcare journal of medicine最新文献

Background: Atrial flutter is a common arrhythmia, and catheter ablation offers a potentially curative intervention. However, there is a continued desire to enhance the procedure's efficiency and safety to optimize patient outcomes. Recently, local impedance (LI) has garnered attention as a novel approach to optimizing ablation procedures. The parameters of LI change when associated with durable ablation lesions for cavo-tricuspid isthmus (CTI) which remains poorly defined. This study aims to address this gap through analysis of gathered data.

Methods: We conducted a retrospective data analysis of 121 consecutive patients who underwent local impedance-guided catheter ablation of the CTI for typical atrial flutter. The durability of the ablated lesions was assessed using high-resolution activation and voltage mapping to detect conduction gaps. The maximum LI drop was calculated for each ablation point. Each point was assessed by 3-dimensional electroanatomic mapping with binary categorization denoting either durable/successful ablation lesion or non-durable/unsuccessful ablation lesion. In addition, subjective evaluation of catheter-tissue contact was assessed by a single proceduralist using intracardiac echocardiography (ICE) and was then stratified as high-level contact, intermediate-level contact, and low-level contact. A total of 1814 ablation points were analyzed.

Results: The mean maximum drop in LI was significantly different (P < .0001) between the -16.38 ohms (95% confidence interval [CI], -17.54 to -15.23) for unsuccessful lesions and -20.79 ohms (95% CI, -21.20 to -20.38) for successful lesions. Among patients with at least 1 unsuccessful lesion, the maximum drop in LI was -16.38 for those that were unsuccessful in comparison to -19.81 for successful lesions (95% CI [-20.56, -19.06], P < .0001). The mean maximum drop in LI was progressively smaller moving from the high-level contact group (-25.93 ± 9.35), to the intermediate-level contact group (-19.04 ± 7.64), and again for the low-level contact group (-13.84 ± 6.93).

Conclusion: Our results give insight into the relationship between maximal local impedance change and the achievement of a durable block along the CTI.

Background: Hughes-Stovin Syndrome (HSS) is a rare vasculitis characterized by pulmonary artery aneurysms (PAAs) and peripheral venous thrombosis. Anticoagulation, the standard treatment for venous thrombosis, is often contraindicated in HSS due to the risk of fatal pulmonary hemorrhage, especially since mortality rates of patients with a history of hemoptysis are reported at 50%-100% from PAA ruptures, yet treatment guidelines are limited due to the condition's rarity with fewer than 90 reported cases globally. This report highlights the complex management decisions required.

Case presentation: A 24-year-old man with a 3-month history of PAAs, left lower extremity deep vein thrombosis (DVT), and hemoptysis presented with worsening right lower extremity DVT after discontinuing apixaban due to the hemoptysis. He was initially evaluated for chest pain potentially signaling myocardial infarction, which was ruled out. Imaging confirmed extensive new bilateral lower extremity DVTs and a chronic infrarenal inferior vena cava (IVC) occlusion with collateralization. Importantly, the PAAs remained stable without imaging signs suggesting impending rupture. HSS was diagnosed based on the constellation of PAAs, recurrent DVT, and the patient's history of hemoptysis.

Conclusion: Despite the inherent risks associated with anticoagulation in HSS, the decision was made to resume apixaban due to the patient's significant thrombotic burden and stable PAAs, alongside continued immunosuppression and close monitoring. This case underscores the necessity of individualized treatment in HSS, balancing thrombotic versus hemorrhagic risk in the absence of definitive guidelines. Further research is crucial to establish evidence-based strategies for managing anticoagulation in this complex patient population.

Description Within the United States (US), colorectal cancer (CRC) remains the fourth most common malignancy and is responsible for over 50 000 deaths annually, second only to lung cancer in cancer mortality. Despite increased public awareness and increasing screening rates, the US remains far below the 80% screening mark set by the National Colorectal Cancer Roundtable at 59%. The addition of non-invasive blood-based tests for CRC screening could potentially increase screening rates and lower CRC deaths. I performed a PubMed search using the search term "blood-based colorectal cancer screening." I was particularly interested in articles that looked at Shield, which is the first and (currently) only blood-based DNA test that is approved by the US Food and Drug Administration (FDA) to screen for CRC. The FDA approval for Shield was based on 1 large cohort trial (ECLIPSE), the results of which were published in Gastroenterology in March 2024. This brief synopsis will detail the major parts of that study and layout the potential benefits, risks, and cost analysis of implementing this test into routine practice.

Introduction: Wilson's disease is a rare autosomal recessive disorder, affecting approximately 1 in 30 000 individuals and is characterized by abnormal copper accumulation in the body, primarily affecting the liver and brain. Psychiatric manifestations as a first presentation, particularly psychosis, are less commonly recognized resulting in failure to begin treatment early in the course of the disease. This case report highlights a patient that presented to the hospital with psychosis, who was later diagnosed with Wilson's disease. This case underscores the importance of considering organic causes in first-episode psychosis.

Case presentation: An 18-year-old man with a history of autism spectrum disorder and epilepsy presented to the emergency room with symptoms of a panic attack. During his evaluation, he expressed suicidal ideation and was placed under a 72-hour involuntary hold, then transferred to an inpatient psychiatric unit. His symptoms had worsened during quarantine for military boot camp, and included auditory and visual hallucinations, severe panic attacks, and depression.The patient had a history of being bullied, a past suicide attempt, and significant psychosocial stressors, including a recent breakup. He also had a family history of schizophrenia. On admission, psychiatric rating scales revealed an overall illness score in the markedly ill range and a depression scale, which was scored as moderately severe. Initial laboratory tests for potential organic causes of first-episode psychosis showed abnormal copper and ceruloplasmin levels, prompting further investigation into Wilson's disease.During hospitalization, he was initially treated with aripiprazole, which was changed to quetiapine due to side effects. His hallucinations and suicidal ideations significantly improved with quetiapine. Outpatient evaluations, including a liver biopsy, confirmed the diagnosis of Wilson's disease. His symptoms were managed with chelation therapy, exercise, and dietary modifications, leading to improved psychiatric and physical health.

Conclusion: This case underscores the importance of considering organic etiologies in psychiatric presentations, particularly in young individuals. A multidisciplinary approach, involving thorough medical and psychiatric evaluations, was crucial in making the diagnosis of Wilson's disease and providing appropriate management. This case highlights the need for comprehensive diagnostic evaluations and integrated care to optimize outcomes for patients with complex psychiatric and medical conditions.

Background: Hepatic encephalopathy is a common cause of altered mental status for patients with decompensated cirrhosis. Their conditions typically improve with high-dose laxatives; if not optimally treated, can develop neurologic sequelae like cerebral edema and herniation. In severe cases, despite normal systemic oxygenation, hyperammonemia may result in mixed restricted diffusion patterns that partially resemble those seen in hypoxic-anoxic brain injury.

Case presentation: A 61-year-old woman with cirrhosis secondary to metabolic dysfunction-associated steatotic liver disease, scleroderma, and rheumatoid arthritis presented to the emergency room with altered mental status. She was admitted to the intensive care unit (ICU) and was intubated due to hepatic encephalopathy and acute blood loss anemia found to be esophagitis on esophagogastroduodenoscopy. After being downgraded to medical care, the patient was altered again and had an ammonia level of 450 μmol/L. The patient was minimally alert after an aggressive bowel regimen, had ammonia levels within normal limits on day 2 of ICU readmission, and was successfully extubated, which prompted further workup for her neurological status. A negative initial head computed tomography, and a subsequent magnetic resonance imaging (MRI) a few days later showed signs of restricted diffusion reported to be consistent with hypoxic-anoxic brain injury, which did not correlate with her hemodynamically stable vital signs throughout the hospital admission. These findings were reported as potentially related to metabolic abnormalities on repeat MRI which were not present at the time of the initial MRI.

Conclusion: This case demonstrates a rare instance of neurologic and radiologic sequelae for a reported ammonia level of 450 μmol/L. Additionally, the rapidly down-trending ammonia levels with a standard bowel regimen and rectal tube suggest that the initial ammonia level may not have been as elevated. Neurologic imaging plays a key role in cirrhotic patients when metabolic correction fails to restore normal consciousness despite sometimes mixed and/or nonspecific restricted diffusion patterns.

Description A 91-year-old man presented with 2 violaceous, ulcerated plaques on his left lower leg, which developed over a 4-month period following a fall. The patient reported the initial formation of a solitary lump, which gradually enlarged and began bleeding a few weeks before his clinic visit. A histological examination of 2 biopsy samples revealed a dermal proliferation of large, severely atypical lymphoid cells with mitotic figures. Immunohistochemistry showed positivity for CD20, Bcl2, Bcl6, and MUM1, with cytokeratin 20 (CK20) negativity and a high percentage (80%-90%) of C-MYC positivity, which was consistent with a primary cutaneous diffuse large B-cell lymphoma (PCDLBC-LT). Given the findings, the patient was referred to oncology for further management.

Introduction: Postoperative urinary retention following hernia repair is a common complication, with its incidence ranging from 2%-30%. Treatment typically consists of a 5-alpha-reductase inhibitor, like tamsulosin. The goal of this study was to identify whether pretreatment with tamsulosin 7 days prior to an elective hernia repair reduced the rate of postoperative urinary retention.

Methods: A single institution randomized controlled trial was conducted with 140 patients. Patients were randomly assigned to either a control or treatment group, with all patients completing a pre- and postoperative International Prostate Symptom Score (IPSS). The inclusion criteria were men with no history of tamsulosin usage and who were undergoing elective hernia repair. Urinary retention was measured postoperatively by either placement of a urinary catheter or a subjective inability to void.

Results: The incidence of urinary retention of patients included in the study was 17.5%. Postoperative urinary retention was noted in 10 of the 66 patients in the treatment arm and 12 of the 60 in the control arm. Statistical evaluation did not reveal a significant difference between the treatment and control groups (P = .492). Though our original intervention of alpha-blockade did not have an impact on postoperative urinary retention rates, we did discover a statistically significant difference in the preoperative IPSS between patients who had postoperative urinary retention and those who did not (P = .013).

Conclusion: Seven days of preoperative tamsulosin did not show a statistically significant reduction in postoperative urinary retention in men undergoing elective hernia operations. However, the subgroup analysis did reveal a statistically significant difference in the preoperative IPSS of patients who had postoperative urinary retention and those who did not, possibly indicating that the IPSS could be used as a predictive tool in the future.

Background: Staphylococcal scalded skin syndrome (SSSS) is a dermatologic emergency that most commonly affects young children, requiring prompt recognition and treatment to avoid severe symptoms and fatal sequelae. It is characterized by a desquamation of the skin caused by exotoxins produced by the Staphylococcus aureus species and may present differently in melanated skin.

Case presentation: Our case describes a 6-month-old Black infant girl who presented to the emergency department with SSSS that was unrecognized on 2 prior encounters. This delay in diagnosis and the misapplication of topical antibacterial agents and steroids may have contributed to the worsening of her symptoms when she presented for the third visit.

Conclusion: Emergency medicine providers should be aware of how SSSS presents in children with melanated skin to decrease misdiagnosis or delay in treatment.

Background: The thin, vascularized skin of the eyelids makes them prone to irritation and discoloration, potentially revealing underlying issues, such as subcutaneous deposits, and an abundance of pigments like carotenoids and lipofuscins. First described in 2008 by Assouly et al, orange palpebral spots (OPS) present as painless orange-yellow lesions on the upper eyelids, primarily affecting White women with Fitzpatrick skin types I to III. Despite various hypotheses, the exact cause of OPS remains elusive, with no established links to malignancy or systemic illnesses.

Case presentation: A 63-year-old woman, with a medical history including basal and squamous cell carcinoma, diabetes mellitus, hypertension, and hypercholesterolemia, was found to have asymptomatic orange-yellow patches on bilateral eyelids during a routine dermatological exam. There was no prior treatment for these lesions. A clinical diagnosis of OPS was made without obtaining biopsies.

Conclusion: Orange-yellow discoloration of the eyelids suggests lipid deposition in the dermis, leading to differentials including xanthelasma and carotenoderma. Biopsies of OPS show increased lipid deposition without xanthelasma's characteristic lipid-laden macrophages, also described as foamy histiocytes. Carotenoderma primarily affects sweat and sebum, leading to pigmentation in specific areas, like palms, soles, and nasolabial folds. Though the cause of OPS is unknown, factors like microscopic fat cells, increased pigments, and local trauma, are implicated. However, further research is needed to determine the etiology. Orange palpebral spots remain poorly recognized, with no established treatments, underscoring the need for accurate diagnosis to avoid unnecessary biopsies and provide reassurance to patients.

Description This letter to the editor addresses limitations to diagnosing thiamine deficiency for multisystem disorders and discusses the potential differential diagnoses that must be considered.