HCA healthcare journal of medicine最新文献

Description In this review, we critically evaluate the Food and Drug Administration's modified risk tobacco product (MRTP) status granted to a smokeless tobacco product (March 2023), Copenhagen Classic Snuff (CCS). This new status necessitates an assessment of the product CCS use and its public health impacts. We assess the impact of CCS as it relates to the reduction of lung cancer risk and the potential increased risk for nasopharyngeal cancer, chronic rhinitis, nicotine dependence, and other health hazards. Concerns persist regarding nicotine's harm and public misperception due to risk reclassification, and caution should be maintained to discourage novel snuff users. Advocating prudent interpretation of MRTP status and comprehensive post-market surveillance is necessary for critical assessment by health care professionals and consumers.

Background: Obesity is a chronic medical condition with a rising prevalence in the United States. A wide range of morbidity and mortality is associated with obesity, with coronary artery disease being among the most common. Ischemic heart disease continues to be the primary cause of death in the United States. Taken together, interventions to minimize the detrimental effects of obesity on patients at risk of heart disease will not only benefit the patient, but the health care system as well.

Methods: In this retrospective study, we used the HCA Healthcare enterprise data warehouse to identify all adult patients who were admitted for acute coronary syndrome (ACS) and were currently or previously treated for obesity with either semaglutide or bariatric surgery. Descriptive and regression analysis were performed to examine our primary and secondary outcomes of interest.

Results: Of 10 316 total patients who met inclusion criteria, 6920 (67.1%) were in the semaglutide group and 3396 (32.9%) were in the bariatric surgery group. The semaglutide cohort was on average older, more frequently men, nonwhite race, and less frequently smokers compared with the bariatric surgery group. Results of regression analysis showed the semaglutide group was associated with lower odds of in-hospital mortality (AOR, 0.61; 95% CI, 0.41-0.92) and higher odds of acute heart failure (AOR, 3.45; 95% CI, 2.2-5.4) compared to bariatric surgery. Furthermore, negative binomial regression showed a 1.5 shorter duration of hospital stay for the semaglutide cohort following inpatient admission for ACS compared with the bariatric group. The semaglutide cohort was linked with higher odds of achieving revascularization via percutaneous coronary intervention (AOR, 1.19; 95% CI, 1.04-1.35) compared with the bariatric surgery group. Lastly, the semaglutide group was associated with higher odds of acute heart failure (3.45; 2.19-5.44) compared with the bariatric surgery group.

Conclusion: Semaglutide use was associated with lower in-hospital mortality and shorter duration of hospital stay but higher odds of acute heart failure compared with patients who had prior bariatric surgery. Semaglutide use was associated with higher odds of acquiring revascularization. Lastly, semaglutide may be an effective alternative to prevent major adverse events in obese patients at risk of ischemic heart disease.

Introduction: Cerebral venous thrombosis (CVT) is notoriously misdiagnosed as more benign etiologies during the initial examination owing to its relative rarity, its wide variety of presenting symptoms and onset and progression patterns, and its frequent requirement for less commonly utilized imaging techniques in its diagnosis. Accordingly, most cases are identified only after repeated evaluations for symptom persistence or progression, or in cases involving prothrombotic states linked to the disease, such as pregnancy, puerperium, genetic or acquired thrombophilia, and infection.

Case presentation: We present the case of a 29-year-old woman with a history of obesity and oral contraceptive use who was found to have an extensive cerebral venous thrombosis that required 4 emergency department visits and hospital admission with neurology consultation before the diagnosis was made.

Conclusion: It is important for the clinician to identify the risk factors and presenting symptoms associated with CVT to facilitate timely treatment and decrease the risk of long-term complications, which are associated with significant morbidity and mortality. The aim of this case report is to bring increased awareness to this disease process for these reasons.

Introduction: Abdominal compartment syndrome (ACS) is associated with significant mortality. Multiple studies have evaluated the prevalence of ACS at individual institutions and/or for short durations. No study has looked at the change of prevalence over an extended time or included nonresearch institutions. This study aims to evaluate the trend in the prevalence of ACS over time within the state of Florida.

Methods: This is a population-based retrospective study using deidentified data from the Florida's Agency of Healthcare Database between 2006 and 2021. A total of 16 217 617 patients were evaluated within the intensive care unit (ICU), with 4002 developing ACS. The primary outcome was the development of ACS. Secondary outcomes were mortality, ICU days, number of surgeries, hospital days, and complication rates.

Results: Patients with ACS were typically younger (>64 yrs, 34.9% vs 55.3%, P < .0001), male (65.3% vs 51.2%, P < .0001), and more frequently diagnosed with shock compared to the overall ICU population. Patients with ACS were more likely to be self-pay (6.3% vs 5.5%, P = .02) and non-White. The reported prevalence of ACS increased from 53 per million (2006) to 402 per million (2021). Mortality for ACS ranged from 39.4% to 55.4% but remained unchanged during the study period. Hospital length of stay for ACS trended down from 29.8 days to 22.4 days during the study period, while it remained unchanged for all ICU patients (6.82 to 7.54 days).

Conclusion: The prevalence of ACS has increased over the years within the state of Florida. Mortality and complication rates have remained relatively unchanged. Hospital length of stay has decreased during that same time period.

Background: Vertebral artery dissection (VAD) is a common cause of stroke within the younger patient population. It is usually associated with headache or neck pain, as well as signs and symptoms of a posterior circulation stroke, such as vertigo, dysarthria, and ataxia. However, there are very scarce reports of patients with this pathology presenting with focal neurologic deficits, which are more indicative of a cerebral stroke.

Case presentation: This case involves a 46-year-old woman who presented to the emergency department (ED) with complaints of right-sided headache and neck pain, which had been ongoing for 1 week, with newly developed right upper and lower extremity weakness and numbness 2.5 hours prior to arrival. There was a questionable finding of a VAD on the initial computed tomography angiography (CTA). Tenecteplase (TNK) was administered, and the patient's symptoms improved rapidly. Follow-up magnetic resonance imaging showed no evidence of cerebral infarction but did confirm the VAD. The patient was eventually discharged on antiplatelet therapy.

Conclusion: Vertebral artery dissection is an important diagnosis to consider in a patient presenting to the ED with neck pain and associated neurologic deficits. However, the patient's deficits in this scenario were more consistent with cerebral ischemia, and with a questionable CTA finding of dissection, the patient was treated with TNK. Currently, no official guidelines exist to recommend treatment of VAD with thrombolytics, as no randomized controlled trial has been done to show this is an effective and safe treatment. This case highlights a unique presentation of a VAD and adds to the growing support of using thrombolytics to treat VAD.

Description We are all passengers in this life, with unique trails and destinations but many common intersections along the way. I have always been fascinated by the multidimensional nature of the hospital-a place of hope, love, pain, mourning, reflection all at once, not only for patients, but also for friends, family, and employees. At times, journeys become so layered and intertwined that the lines between these different roles are blurred, seemingly dissolving the classical hierarchy we rely on to differentiate physicians, residents, nurses, patients etc. At the end of the day, we are all people persevering and growing the best we can, and this work attempts to express that shared experience.

Description We meet for friendship, laughter, and spending time together. Each person paints a 6 × 6 inch tile, some more competent than others. Each person comfortably shares their painting without judgment, and we are proud of what our bond produces. The output keeps us going with a refreshing breath of life. You see, we also work together every day in health care.

Background: The pathophysiology of idiopathic multicentric Castleman disease (iMCD) is poorly understood compared to the other subtypes of MCD, which has contributed to limited treatment options and poor prognosis for iMCD patients. The pathogenesis of iMCD is thought to be mediated in part by dysregulation of interleukin (IL)-6.

Case presentation: We present a case report of a 39-year-old Caucasian man with siltuximab-refractory iMCD. He presented with severe lower extremity lymphedema and wounds. His disease progressed through standard-of-care siltuximab. Due to his severe disease-related morbidity, he contracted recurrent infections, often complicated by sepsis. Ultimately, he required a left lower extremity amputation.

Conclusion: The first-line and only United States Food and Drug Administration-approved therapy for iMCD is siltuximab, an anti-IL6 agent. However, it is clear that the pathogenesis of iMCD is more complex than strictly an IL-6-driven disease as siltuximab only showed a 34% durable response rate in clinical trials. Cytokine and proteomic profiling have shown normal IL-6 levels in many patients with iMCD. Further efforts to understand the mechanisms and etiology of iMCD are needed, particularly for siltuximab-refractory patients.

Introduction: The Care Alert Program (CAP) is designed to help navigate encounters with patients who are high utilizers of Emergency Department (ED) resources. The CAP intends to address the needs of this challenging patient population by designing individualized care plans that are approved by a multidisciplinary committee. The patient populations that frequently use ED resources often have chronic medical conditions, a poor understanding of their conditions, unrealistic expectations regarding treatment, a lack of outpatient resources, and present with multiple complaints when using ED resources.

Methods: The CAP was adopted by our facility in the spring of 2020. The present study is an expanded version of a previously published pilot project conducted in 2020-2021, in which we demonstrated a decrease in both ED visits and admission rates.

Results: In this expanded study, we reviewed 46 CAP cases and determined the mean percentage of patient ED visits decreased by 42.3% in this patient population. Average hospital admission rates decreased by 50.4% during the initial 8 months after enrollment into the CAP.

Conclusion: Implementing the CAP is an effective way reduce hospital admission rate and average ED visits amongst high utilizers.

Background: Migraine affects about 1 billion people worldwide and is associated with a significant negative impact on personal and occupational functioning. Migraine accompanied by aura is seen in about 15% of migraineurs. Visual aura is the most common type of aura. Much less common though are auras that involve higher mental function, such as confusional state. The confusional state may manifest with a wide variety of cortical dysfunction, such as speech impairment, increased alertness, agitation, and amnesia, often lasting longer than a typical migraine aura.

Case presentation: The authors present the unique case of a 29-year-old patient with episodic and transient bizarre behavioral symptoms in the context of migraine headaches.

Conclusion: Our patient's presentation is suggestive of acute confusional migraine, which poses several diagnostic complexities and illustrates the difficulties with symptomatology that might have a medical/organic component versus a psychiatric one. The literature on this topic is lacking, and further research into this condition is warranted to optimize comprehensive patient care.