HCA healthcare journal of medicine最新文献

Background: A nondominant right coronary artery supplies a small portion of the myocardium. Albeit rare, an acute occlusion of a nondominant right coronary artery is believed to be inconsequential with minimal clinical relevance.

Case presentation: We present a case of a middle-aged man who presented with chest pain and an electrocardiogram demonstrating anterior ST-segment elevation. An emergent coronary angiogram revealed acute thrombotic occlusion of the proximal nondominant right coronary artery with no significant obstructive atherosclerotic disease in the dominant left coronary circulation. Balloon angioplasty of the occluded vessel followed by implantation of a drug-eluting stent resulted in the resolution of the chest pain and ST-segment elevation.

Conclusion: While electrocardiographic ST-segment elevations in the anterior precordial leads are highly suggestive of a left anterior descending artery occlusion, herein, we present a rare case of an acute anterior ST-segment elevation myocardial infarction secondary to a nondominant right coronary artery occlusion.

Introduction: Most reports of intrauterine or endometrial gas have been reported in the setting of underlying gynecologic malignancy or infection. The significance of this case report is to give a presentation of a patient presenting with intrauterine gas who subsequently was identified as having neither an infectious nor malignant cause for such a finding.

Case presentation: The patient is a 56-year-old postmenopausal woman who presented with "hip pain" and was found to have incidental intrauterine gas on a pelvic computed tomography. She underwent in-office and outpatient hysteroscopies with resection of a submucosal fibroid. Her final pathology was returned as benign, and ultimately no apparent cause for her intrauterine gas was found.

Conclusion: Our case report differs in that our patient was found to have no fistulous abnormalities, was not postpartum or post procedure, and had no evidence of malignancy on permanent pathology. Our primary goal was to evaluate all potential causes for such finding and provide a differential diagnosis that is not commonly presented in current literature reviews. This case report adds to the literature by providing an alternative presentation for incidental intrauterine air that is not commonly reported.

Background: Uterine fibroids have been found to increase the risk for venous thromboembolism. There have been other case reports linking large uterine fibroids, pulmonary embolisms, and deep vein thrombosis (DVT) together due to compression of blood vessels and increased venous stasis. This case report will discuss a case of a large fibroid uterus compressing the inferior vena cava causing a patient with few risk factors to have recurrent DVTs and pulmonary embolisms.

Case presentation: The patient was a 35-year-old woman who presented with repeated unprovoked thrombosis episodes. The patient had a full workup after the first episode of DVT and was started on anticoagulation; however, the patient stopped taking her anticoagulation medication due to cost and presented to the emergency room 4 months later with a right lower extremity DVT and bilateral pulmonary embolisms.

Conclusion: There are many common causes that can explain recurrent thrombotic events in patients; however, it is important to also consider gynecological causes as a differential diagnosis when a patient presents with recurrent unexplained thrombotic events. Uterine fibroids that are large enough can compress large vessels and cause venous stasis in a relatively healthy person. Treating uterine fibroids can decrease the risk of another thrombotic event and can ultimately keep the patient off anticoagulation.

Background: Internal medicine (IM) residents receive significant cardiology training, and previous surveys have evaluated IM resident competency on obstetric (OB)-related subjects. However, there is minimal literature on self-reported competence of cardiac-specific complications in OB patients. Our study assessed self-reported comfort and competency regarding cardiovascular complications in OB patients with medical residents across several specialties.

Methods: We surveyed 207 residents across 3 specialties and 3 teaching hospitals on 10 questions regarding their self-reported confidence in managing cardiovascular complications in OB patients, including practice setting, specific cardiac issues, and stages of labor. We received 42 responses. Results were obtained using Google Sheets and analyzed with Microsoft Excel.

Results: Internal medicine residents reported being less confident in managing cardiac complications in OB patients compared to family medicine (FM) and obstetrics and gynecology (OBGYN) residents across all categories. PGY3 IM residents rated themselves on par with FM/OB residents in the ICU setting. The presence of OB services in the hospital did not affect IM resident self-assessment.

Conclusion: Internal medicine residents demonstrated low self-assessment scores regarding confidence managing cardiac conditions in OB patients. There may be opportunities to introduce specific OB-related teaching material to increase confidence.

Background: Physician burnout, particularly among female graduate medical education (GME) trainees, is a growing concern that affects physician wellness and patient safety. Professional coaching has shown promise in improving physician wellness. The Better Together Physician Coaching program (BT) is a web-based, group-coaching program, piloted using female GME trainees, aimed at improving key indicators of well-being, including burnout and impostor syndrome. In this qualitative study, we aimed to understand the challenges faced by female physician trainees shared in the pilot of the BT coaching intervention.

Methods: A total of 101 female physician trainees participated in the BT pilot. A sample of 41 of the 80 group coaching calls and all 21 written coaching requests were included in this study. A qualitative content analysis was conducted of 132 coaching instances, using a team-based, deductive and inductive, rapid domain analysis strategy.

Results: Deductive analysis of 132 coaching instances confirmed burnout, impostor syndrome, self-compassion, and moral injury as key areas for which female physician trainees sought coaching. Inductive analysis also identified additional areas for which trainees sought coaching, including career uncertainty, feedback navigation, and relationship stress.

Conclusion: The preliminary findings highlight the importance of addressing these specific challenges and tailoring coaching interventions to meet the needs of female physician trainees.

Description The title of the image is inspired by a famous old song by the British rock band The Police. The song featured Sting's evocative lyrics and captures a profound sense of isolation and longing. The song tells the story of a castaway who sends out a distress signal, only to discover that he is not alone in his feelings of loneliness. Through its haunting melody and rhythmic pulse, the track conveys themes of connection and the human experience, illustrating how, despite physical separation, people share similar struggles and emotions. The metaphor of the bottle serves as a poignant reminder of our desire to reach out and find understanding in a vast and often indifferent world. Interestingly the image was taken in a street festival in India from a pandal decoration. Psychologically, the concept taps into deep-seated human desires for connection and understanding. A message in a bottle represents hope and the possibility of connecting others, spread across vast distances. Such notion can evoke feelings of belonging and purpose, counteracting feelings of isolation. Furthermore, the randomness of finding a message adds an element of serendipity, reinforcing the idea that connections can happen in unexpected ways.

Background: Sevoflurane and other inhaled anesthetics are gradually entering provider awareness as rescue therapies for patients in refractory status asthmaticus. This paper documents a case report and a literature review involving the use of sevoflurane to treat status asthmaticus.

Case presentation: A 27-year-old man presented to the emergency room in acute hypoxic respiratory failure due to status asthmaticus, refractory to multiple therapies and requiring intubation. He was successfully extubated following sevoflurane administration in the operating room, and his care was complicated by transient hypotension. A multidisciplinary effort was critical in ensuring successful and timely therapy.

Methods: We performed a literature review using the search terms "sevoflurane," "status asthmaticus," "acute asthma," and "asthma" in PubMed and Google Scholar. Our search returned a total of 1825 results, of which 1772 covered other topics and 53 discussed the use of sevoflurane for treatment of status asthmaticus. Eighteen articles were duplicates, and 2 were not available in English translation. Two additional sources were found by following citations within texts.

Results: We found 22 articles describing the use of sevoflurane to treat status asthmaticus, covering 30 total patient cases. All cases described resolution of status asthmaticus following sevoflurane administration. In 2 cases, sevoflurane was administered via mask to awake patients. Hypotension was a noted complication in 1 case.

Conclusion: Although not yet considered standard of care, sevoflurane has been extensively documented as a successful treatment for refractory status asthmaticus in multiple case reports. Administration of this therapy often requires multidisciplinary coordination. Hypotension is one noted adverse effect. However, further study is needed to investigate best practices and possible complications.

Background: COVID-19 infection, particularly with the Delta variant, has been associated with a heightened risk of thromboembolic events due to a profound hypercoagulable state. While venous thrombosis is more commonly reported, arterial thrombosis-including acute limb ischemia-has emerged as a serious complication with significant morbidity and mortality.

Case presentation: We report the case of a 53-year-old man with severe COVID-19 pneumonia who developed recurrent acute limb ischemia secondary to an aortic mural thrombus. Despite therapeutic anticoagulation and multiple surgical interventions-including thrombectomy, angioplasty, and stenting-the patient experienced repeated episodes of arterial thrombosis. His clinical course was further complicated by pneumothorax and hemothorax, ultimately resulting in cardiopulmonary arrest and death.

Conclusion: This case highlights the aggressive and resistant nature of arterial thrombosis in the setting of severe COVID-19. Recurrent arterial thrombosis in severe COVID-19 underscores the need for early recognition and aggressive anticoagulation strategies. Further research is warranted to establish protocols for thromboembolic prevention in this high-risk population.

Background: Immune checkpoint inhibitors, such as nivolumab, have become integral in treating metastatic malignancies by enhancing immune responses against tumors. However, they are associated with immune-related adverse events (irAEs), including cutaneous reactions. We report a case of persistent lichenoid dermatitis during therapy and eruptive keratoacanthomas (KAs) following the cessation of nivolumab.

Case presentation: A 77-year-old Caucasian man presented with a subcutaneous melanoma on the left lateral chest, treated with excision followed by adjuvant nivolumab. Seven weeks into therapy, he developed pruritic erythematous macules, forming patches on his forearms, later spreading to his trunk. Biopsy confirmed lichenoid dermatitis. Treatment with triamcinolone cream 0.1% provided limited relief. Despite completing nivolumab therapy, the rash persisted. Oral prednisone 10 mg daily for 14 days yielded temporary improvement. Nineteen weeks post-therapy, he developed tender nodules on his left lower extremity, diagnosed as KAs via biopsy. Further KAs emerged and were treated and resolved with intralesional 5-fluorouracil. Forty weeks post-therapy, the lichenoid dermatitis remained stable with topical and intermittent oral steroids. The patient opted against additional treatments, such as UV-B therapy, preferring to await spontaneous resolution.

Conclusion: This case underscores the need for vigilance in identifying and managing dermatologic irAEs associated with programmed cell death protein 1 inhibitors. Persistent lichenoid dermatitis and eruptive KAs present unique challenges, requiring tailored therapeutic strategies. Further research is essential to optimize management of these adverse events and improve patient outcomes.

Background: Vaccinations for COVID-19 have played a pivotal role in controlling the global pandemic, with most adverse events being mild and transient. However, rare post-vaccination autoimmune responses have been reported. The understanding of long-term rheumatologic sequelae, particularly autoimmune polyarthritis following COVID-19 vaccination, remains limited.

Case presentation: We report the case of a 41-year-old previously healthy man who developed progressive polyarthritis and systemic symptoms following the Johnson & Johnson COVID-19 vaccine. The initial symptoms of joint swelling and arthralgia appeared within a week of the first vaccine dose, subsiding temporarily with medication. After receiving a booster dose, the patient experienced worsening polyarthritis affecting multiple joints including knees, elbows, wrists, shoulders, and neck, along with low-grade fever, fatigue, and functional decline. Despite outpatient anti-inflammatory therapy, symptoms persisted and worsened over the next six months, prompting hospitalization. Workup revealed elevated inflammatory markers (ESR 77 mm/hr, CRP 193.2 mg/L), synovial fluid consistent with inflammatory arthritis, and infectious serologies. Imaging showed joint effusions and calcified pulmonary granulomas. He was diagnosed with vaccine-induced reactive arthritis. Treatment with intravenous corticosteroids led to partial symptom relief, and he was discharged on oral steroids and initiated on methotrexate for long-term management.

Conclusion: Clinicians should maintain a high index of suspicion for autoimmune phenomena such as reactive polyarthritis following COVID-19 vaccination, especially in patients with new-onset joint symptoms. Early recognition and referral to rheumatology may improve outcomes. Further studies are needed to clarify the pathophysiology, risk factors, and long-term prognosis of such vaccine-associated autoimmune conditions.