HCA healthcare journal of medicine最新文献

Introduction: Bortezomib is a reversible proteasome inhibitor that is a first-line chemotherapeutic agent for multiple myeloma. Bortezomib can be administered intravenously or subcutaneously with similar efficacy. Subcutaneous administration has fewer side effects. Many cutaneous reactions have been associated with bortezomib treatment. These include morbilliform exanthems, erythematous nodules and papules, leukocytoclastic vasculitis, Sweet syndrome, and rarely Stevens-Johnson Syndrome.

Case presentation: This paper reports the occurrence of serpentine supravenous hyperpigmentation (SSH) after subcutaneous administration of bortezomib. SSH is a rare, characteristic cutaneous reaction that has been reported following intravenous administration of chemotherapeutic agents. Intravenous administration of bortezomib rarely results in documented cases of SSH. Subcutaneous injections of chemotherapeutic agents, including bortezomib, have not produced SSH.

Conclusion: This case is unique since subcutaneous administration of chemotherapeutic agents has never been reported to cause SSH. Additionally, bortezomib has not been reported as a common causative agent of this reaction.

Background: Testicular seminoma is the most common malignant tumor of the testis. It occurs at a rate of 5 per 100 000 men, primarily between the ages of 15 to 34. While seminomas typically occur in the testis, other primary sites include the mediastinum, the retroperitoneum, or other extra-gonadal sites. Due to the curable nature of the malignancy (5-year survival rate > 95%), detection at early stages of the disease is key. This case presentation explores the delayed diagnosis and treatments of an atypical presentation of disseminated seminoma.

Case presentation: We present the unusual case of a 56-year-old male who had abdominal pain secondary to a 3.6 × 3.3 × 3.8 cm aortocaval mass. After 3 unsuccessful endoscopic/percutaneous biopsies, the patient consented to an open surgical biopsy that revealed disseminated seminoma abutting the inferior vena cava. The patient subsequently underwent a right radical/inguinal orchiectomy and started on 3 cycles of bleomycin, etoposide, and cisplatin. A positron emission tomography/computed tomography (PET/CT) scan at a 6-month follow-up appointment after treatment showed near complete resolution of the initial aortocaval mass and the interval improvement of accompanying lymphadenopathy. Previously elevated β-human chorionic gonadotropin and lactate dehydrogenase tumor markers are within normal limits to date.

Conclusion: Retroperitoneal masses range from primary neoplasms to solid organ neoplasms to metastatic disease. The challenge with these masses is accurate and prompt diagnosis. Treatment varies for each retroperitoneal mass. A painless lump in the testicle is the most common sign of testicular cancer. Symptoms related to the site of the metastases (ie, back/flank pain) can sometimes occur, making early diagnosis exceedingly challenging. Radical orchiectomy is the mainstay of treatment for seminomatous testicular tumors. Management following surgery is dependent upon staging. Surveillance following treatment requires frequent office visits as well as abdomen/pelvis CT scans and/or serum tumor markers.

Background: Veillonella is an anaerobic gram-negative coccus found as a commensal organism in the oral, respiratory, gastrointestinal, and genitourinary tract of humans. Rarely, it can cause serious infections by the production of lipopolysaccharide, an endotoxin. Although most Veillonella infections occur in immunocompromised individuals, we herein describe cases of Veillonella discitis, a rare presentation of Veillonella, in immunocompetent patients.

Case presentation: The first presented case was encountered in a patient admitted at our facility. All patient data were obtained from the hospital's electronic medical record system. Thereafter, a literature search and subsequent review was done on PubMed with the MEDLINE database, using the term "Veillonella discitis," to obtain other reported cases of discitis caused by Veillonella.We found a total of 9 cases of Veillonella discitis in immunocompetent patients, apart from our patient. It was most frequently found in those aged 60 to 70 years, with no particular association with patient sex. Chronic backache was the most reported presenting symptom, the lumbar spine being the most commonly affected area, with a high number of cases occurring in the presence of an inciting event. Ceftriaxone, amoxicillin, and clavulanic acid were the most commonly used drugs, with an average duration of therapy of 6 weeks.

Conclusion: The objective of our study was to highlight the importance of recognizing Veillonella as a potential cause of discitis. We aim to educate medical professionals regarding the presentation of Veillonella discitis, the demographic groups affected, predisposing factors, and the treatment options available.

Background: Ventral hernias are a common but heterogeneous disease. Communication among key stakeholders (eg, patients, clinicians, administrators, payers, and researchers) can be augmented by a widely utilized classification system. The European Hernia Society (EHS) developed an expert-opinion-based hernia classification system organized by hernia type (primary versus incisional) and size. We sought to assess what components of the EHS ventral hernia classification system were correlated to real-world clinical outcomes.

Methods: This was a multicenter cohort study. All hospitals contributing to the database were affiliated with 1 of 6 academic institutions. All adult patients who underwent ventral hernia repair over a 4-year period were included. The primary endpoint was adverse events defined as any major (deep or organ space) surgical site infection (SSI), abdominal reoperation, or hernia recurrence. Utilizing a multivariable Cox regression, factors associated with adverse events were identified. Accuracy was assessed using Harrell's C concordance statistic.

Results: Of the 2385 patients who underwent repair of ventral hernias (primary n = 810, 34.0% and incisional n = 1575, 66%), with a median follow-up of 11.1 months, 27.5% suffered adverse events including major SSIs (5.7%), hernia recurrences (12.1%), and abdominal reoperations (9.7%). In the overall cohort and the primary ventral hernia subgroup, all hernia-specific variables were associated with adverse events. American Society of Anesthesiologist score, low albumin, and prior SSI were associated with adverse events in the overall cohort and primary ventral hernia subgroup while surgical approach was associated with adverse events in the overall cohort and incisional ventral hernia subgroup. On multivariable Cox regression analyses, incisional ventral hernia and larger hernia width were independently associated with adverse events.

Conclusion: Hernia size and type (primary versus incisional) from the EHS ventral hernia classification system were associated with clinical outcomes. Additional factors, including patient and operative factors, also impact outcomes. Our model allows key stakeholders to communicate more clearly regarding the challenges and outcomes of various patients with diverse ventral hernias.

Background: Rising nosocomial Clostridioides difficile infections pose high risks, especially for immunocompromised leukemia patients, necessitating targeted research to enhance patient care and outcomes.The objective of this study was to investigate the impact of nosocomial Clostridioides difficile infections (CDI) on patients hospitalized with acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML).

Methods: Our study was a retrospective analysis of adult patients hospitalized with a primary diagnosis of ALL or AML, using the Nationwide Inpatient Sample (NIS) database for 2020. Primary outcomes included the incidence of nosocomial CDI and all-cause inpatient mortality. Secondary outcomes included hospital length of stay, resource utilization, and morbidity. Statistical analyses were conducted with STATA (address). Fisher's exact test was utilized to compare proportions, while the Student's t test was employed for continuous variables. Multivariate logistic and linear regression analyses were used to adjust for confounding variables.

Results: We found in 21 135 ALL and 58 560 AML adult patients that the CDI incidences were 2.77% and 3.0%, respectively. ALL and AML patients with CDI had adjusted mortality odds ratios of 3.02 (P = .003) and 1.51 (P = .02). Hospital length of stay was extended by mean differences of 10.16 days (ALL) and 8.33 days (AML) for those with CDI compared to those without it. In addition, patients with CDI displayed a significantly higher incidence of acute kidney injury, sepsis, vasopressor use, and intensive care unit admissions.

Conclusion: This study highlights the significant impact of CDI infections on health outcomes for leukemia patients, emphasizing the need for robust infection control measures, early detection, and aggressive management of CDI to improve patient outcomes and minimize healthcare costs.

Introduction: As illicit drug manufacturers find new ways to market their products and increase their profit margins, multiple contaminants have found their way into the illicit drug supply. The newest addition, xylazine, also known as "tranq," has spread through the city of Philadelphia and has recently been gaining ground across the United States, including in the state of Florida.

Case presentation: This case describes a 37-year-old male with a significant past psychiatric history of severe polysubstance intravenous (IV) use, including fentanyl and methamphetamine. He was comorbid with other mental and physical conditions and presented to the emergency department with acute psychosis and worsening multi-digit ulcerations. The patient reported that the ulcerations started and progressed since he began injecting fentanyl cut with tranq. The patient was hospitalized for over 30 days due to his complex psychiatric illness as well as complications related to his ulcerations. Over the course of the hospitalization, the ulcerations began to heal, which was likely due to stopping IV drug use and receiving IV antibiotics in a restricted setting.

Conclusion: Continued use of IV drugs that are contaminated with xylazine or other dangerous additives can lead to increased morbidity and mortality. Suspicion of xylazine contamination should be prompt in patients with a history of IV drug use, skin ulcerations, and suspected opiate overdose that is unresponsive to naloxone. Further research on and awareness of the presence of xylazine in illicit drug supplies across the country is crucial to the prevention and early detection of xylazine-related complications.

Description One of my favorite themes in medicine is the concept of identity. Medicine is layered. It is continually saving lives, expanding in capabilities, and recruiting new students. But how does it shape us, and where does one draw the line between self and profession? Physicians are classically a symbol of hope and healing. But medicine is challenging physically, emotionally, and spiritually. Add on top of that the daily burdens of our personal lives, and the responsibility can become quite heavy, making it difficult to walk with a smile every day. There is a time to stand behind a "curtain", for some longer than others, and patients and perhaps even peers may never see the full person behind it. This poem is about those individuals who must carry this duality.

Background: The United States Food and Drug Administration approved 6 atypical antipsychotics for pediatric treatment of schizophrenia. However, little has been published on the effectiveness of these medications in the acute treatment setting of adolescents with psychosis. Since the clinical uncertainty and poor prognosis proceeding the early onset of schizophrenia has a significant impact on a child's development, there is a critical need for evidence-based data on this population. The aim of our study was to investigate the effect of various antipsychotics on young patients admitted to the inpatient ward presenting with acute psychosis.

Methods: A retrospective analysis was performed to review the medical records of the patients with specified schizophrenia disorders who were admitted to the inpatient psychiatric unit for treatment with antipsychotics. We analyzed the efficiency of treatment by measuring 30-day readmissions (yes/no), number of readmissions in 30 days, and the length of stay in the inpatient ward. Negative binomial regression and binary logistic regression were used to count the discrete occurrences of an outcome and predict the likelihood of that outcome.

Results: We analyzed the medical records of 1117 patients who were assigned to groups based on whether they were treated with aripiprazole (31.9%), risperidone (26.0%), quetiapine (16.2%), and olanzapine (26.0%). Pairwise comparisons revealed receiving risperidone increased the log count of days by an incidence response ratio of 1.15 (1/0.87) compared to receiving aripiprazole (P < .05, 95% CI [0.76, 0.98]). Similarly, quetiapine increased the count of hospital days by a factor of 1.22 (1/0.82) (P < .01, 95% CI [0.70, 0.94]), as well as olanzapine by a factor of 1.23 (1/0.82) compared to receiving aripiprazole (P < .001, 95% CI [0.72, 0.93]). The number of admissions in 30 days was not significantly associated with medication groups (χ² = 3.93, P = .270) when controlling for other variables. The medication group was also not significantly associated with the likelihood of readmission (χ² = 5.594, P = .133) when controlling for other variables.

Conclusion: Aripiprazole was significantly associated with shortening the log count of days (χ² = 21.82, P < .0001) when compared to olanzapine and quetiapine. There was no statistical evidence to conclude a difference in readmission rates when comparing medication groups. To our knowledge, these results provide the largest cohort describing the efficacy of different antipsychotics for acute stabilization of psychosis in the inpatient setting.

Background: Hemophagocytic lymphohistiocytosis (HLH) is a non-neoplastic proliferation and macrophage activation that induces cytokine-mediated bone marrow suppression and features of intense phagocytosis in the bone marrow and liver, leading to multi-organ dysfunction and ultimate failure. The diagnosis of HLH in an intensive care setting is challenging, and it is associated with high morbidity and mortality. HLH-94 is the standard protocol for treatment, consisting of dexamethasone and chemotherapy like etoposide.

Case presentation: We present the case of a 73-year-old woman who had a prolonged hospitalization for vomiting, diarrhea, and dehydration. Her conditions were complicated by acute refractory pancytopenia on the 12th day of admission, leading to multi-organ failure, including anuric renal failure requiring renal replacement therapy and respiratory failure requiring intubation. After a thorough workup, she was diagnosed with HLH using HLH-2004 diagnostic criteria and confirmed by a bone marrow biopsy. She was started on supportive therapy and high-dose intravenous dexamethasone with an appropriate clinical response. Her pancytopenia improved, and she no longer required ventilator support for respiratory failure or dialysis for renal failure. Unfortunately, her hospital course was complicated by a sentinel event leading to her death.

Conclusion: This case emphasizes that early recognition and treatment initiation of HLH are crucial to prevent adverse outcomes and mortality. Treatment should be tailored based on the underlying HLH trigger, as chemotherapy-based treatment regimens may result in overtreatment and unnecessary toxicities. Further studies are needed to increase clinicians' awareness and management of secondary cases of HLH.

Background: Hemophagocytic lymphohistiocytosis (HLH) is an immunologic syndrome characterized by excessive inflammation and tissue injury due to uncontrolled activation of the phagocytic system. The underlying mechanism is a lack of downregulation of activated macrophages and lymphocytes by natural killer and T cells. Unfortunately, the diagnosis is often delayed or missed due to the rarity of the disease, decreased awareness, and clinical picture variability. Ehrlichiosis is becoming a more prevalent tick-borne illness in endemic regions and a relatively uncommon but increasingly considered cause of HLH.

Case presentation: We describe the cases of 2 patients diagnosed with secondary HLH as per the 2004 HLH criteria, with the trigger secondary to ehrlichiosis. Our first patient presented with a febrile illness and a remarkably elevated blood ferritin concentration. He ended up meeting HLH criteria despite having a negative bone marrow biopsy. Patient 1 had significant clinical improvement in vitals and had a down-trending ferritin with steroids, doxycycline, and intravenous immunoglobulin. The second patient presented with severe systemic involvement and hemodynamic instability. She was found to have HLH with a positive bone marrow biopsy and a positive Ehrlichia PCR. Patient 2 had significant improvement in her hemodynamic instability with the use of anakinra and doxycycline.

Conclusion: Raising awareness about HLH is imperative for early diagnosis and trigger-directed treatment, which can help in preventing the disease's severe complications. There are an increased number of reports of Ehrlichiosis progressing to HLH. Early identification and treatment with doxycycline, with the use of immunomodulatory treatment in severe cases, has shown favorable outcomes.