HCA healthcare journal of medicine最新文献

Background: With the advent of catheter guided interventions, practitioners have added another tool alongside chemical lysis and surgical removal to reduce the clot burden of patients with large emboli and thrombi. Due to comorbid conditions, many patients are poor candidates for surgical or chemical clot treatment but may present optimally for catheter-based thromboembolectomy. In this case, we highlight the benefits of mechanical thrombectomy with transesophageal echocardiographic guidance to reduce the clot burden of a patient who would otherwise be considered a poor candidate for surgical or chemical treatment.

Case presentation: This case follows a 78-year-old man with a past medical history significant for persistent atrial fibrillation, type 2 diabetes, hypertension, hyperlipidemia, coronary artery disease, cardiomyopathy status post biventricular implantable cardioverter-defibrillator, left atrial appendage exclusion device, and a recent deep vein thrombosis. The patient was taking apixaban and was found to have a large, mobile, right atrial thrombus on a transthoracic echocardiograpic evaluation for a routine sepsis workup. The patient underwent an emergency thrombectomy due to the high risk of thrombus embolization. Due to the large size of the thrombus and complexity of the case, an intra-operative inferior vena cava filter was placed to prevent shower embolization of the thrombus during evacuation. Under guidance from the transesophageal echocardiography, the thrombus was successfully removed using a mechanical thrombectomy device.

Conclusion: In an aging population with significant cardiac or hematological comorbidities, some patients who develop right atrial thrombi may be considered poor candidates for an open thrombectomy or chemical thrombolysis. With the development of catheter based mechanical thrombectomy interventions, patients with relative contraindications to traditional methods may benefit from newer technology, especially if the technique allows for accurate visualization of the thrombus via transesophageal echocardiography.

Background: Temporary field hospitals play a crucial role in providing medical care to individuals who experience illnesses and injuries during mass gathering events. Handheld point-of-care ultrasound (POCUS) devices offer an affordable and portable adjunct for emergency care. We present multiple patients from a field hospital during a marathon event in which handheld POCUS devices changed clinical management.

Case presentation: A 75-year-old man who had fallen was able to be discharged after a lung exam confirmed no rib fractures or pneumothorax. A hypotensive and hypoglycemic 21-year-old man had an echocardiogram confirming volume depletion. He received treatment, and a repeat exam demonstrated improvement, which facilitated discharge. Finally, an ultrasound-guided intravenous catheter was placed in a 27-year-old woman with difficult vascular access.

Conclusion: Point-of-care ultrasound facilitated the triage and evaluation of conditions such as fractures, pneumothorax, altered mental status, chest pain, and dehydration in a field hospital. The portability, availability, and affordability of handheld POCUS devices allowed for quick and convenient access to real-time imaging of marathon runners and event spectators. By leveraging these advantages, field hospitals can enhance their capability to deliver efficient and comprehensive medical care to patients during mass gathering events.

Introduction: Management of patients with rare anaphylaxis to COVID-19 vaccines creates a challenge. Desensitization to medications and vaccines has proven to be effective in managing anaphylactic reactions in selected individuals with a high benefit-to-risk ratio. A previous report described the successful administration of the Moderna modified messenger RNA (MmRNA) COVID-19 vaccine via a graded dose protocol to a patient with previous anaphylaxis to the MmRNA vaccine. Our report describes successful desensitization to the MmRNA vaccine followed by administration of the full dose MmRNA vaccine.

Case presentation: A patient with a history of chronic allergies and anaphylaxis due to insect sting venom reported anaphylaxis after her first dose of the MmRNA vaccine, for which she was premedicated. She was subsequently clinically diagnosed with anaphylaxis to skin testing of the MmRNA vaccine-meeting Brighton's criteria for level 1 certainty of diagnosis-and underwent a desensitization protocol to the vaccine. After the desensitization protocol, the patient was administered the full second dose of the MmRNA vaccine via intramuscular injection, without systemic allergic reactions, and with elicitation of an immunological response.

Conclusion: This severely allergic patient developed 2 separate anaphylactic reactions to the MmRNA vaccine despite being treated with omalizumab. The patient was then desensitized to the MmRNA vaccine and was subsequently administered the full second dose of MmRNA vaccine via intramuscular injection without systemic allergic reactions and with elicitation of an immunological response. Our patient's case illustrates the ability to desensitize patients who desire administration of the MmRNA vaccine, but are unlikely to prevent anaphylaxis with premedication.

Background: Right heart (RH) strain in the setting of pulmonary embolisms can significantly increase the risk of mortality. Thus, screening for risk of complications in these patients is crucial. The goal of our study was to assess the strength of specific diagnostic findings of RH strain for predicting adverse outcomes including mortality, hospital length of stay, and the requirement of advanced interventions.

Methods: A single-center, retrospective cohort study of 81 patients diagnosed with acute pulmonary embolism with RH strain on computed tomography pulmonary angiogram (CTPA) from September 12, 2019, to August 30, 2023. Data were collected on patient computed tomography findings, transthoracic echocardiogram (TTE) findings, electrocardiogram findings, troponin I, and B-type natriuretic peptide values. Adverse outcomes were recorded including 30-day mortality, increased hospital length of stay, and utilization of advanced therapy (systemic fibrinolysis, catheter-directed therapy, or pulmonary embolectomy). Stepwise regression analysis was performed to model predictors of adverse outcomes in RH strain patients.

Results: Right ventricle (RV) dilation on TTE was significantly associated with 30-day mortality (P = .005). Tricuspid annular plane systolic excursion (TAPSE) of less than 16 mm on TTE was significantly associated with the use of advanced therapy (P = .001). An increased length of hospital stay was significantly associated with right ventricular dilation on TTE (P < .001), renal insufficiency (P = .012), and surgery within 90 days (P = .003). A finding of McConnell's sign on TTE (P = .044) was significantly associated with a higher pulmonary embolism severity index.

Conclusion: Advanced interventions should strongly be considered in patients with a CTPA diagnosis of RH strain who have TTE findings of RV dysfunction including RV dilation, TAPSE less than 16 mm, and McConnell's sign due to the high risk of mortality and morbidity.

Background: Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment. They pose challenges, particularly in the form of immune-related adverse events (irAEs). Although cases of gastrointestinal irAEs have been well-documented, acute esophageal necrosis (AEN) characterized by a circumferential blackening and fragility of the esophagus, weeks after immunotherapy discontinuation, has not been reported.

Case presentation: A 75-year-old diabetic male who was recently diagnosed with high-grade papillary urothelial cancer with liver and retroperitoneal metastases and had undergone radical cystectomy with ileal conduit urinary diversion, presented to the hospital for sepsis secondary to a urinary tract infection. While in the hospital, he experienced hematemesis, with an acute drop in hemoglobin from 10.6 to 5.3 g/L and a rise in serum lactate from 1.5 to 3.6 mmol/L. An esophagogastroduodenoscopy (EGD) revealed diffuse circumferential eschar, exudate, and inflammation. He was diagnosed with acute esophageal necrosis (AEN), which was found to be secondary to his pembrolizumab use.

Conclusion: Immune-related adverse events will remain a challenge in patients receiving ICI therapy. AEN is a rare life-threatening irAE associated with ICIs. Further research is warranted to clarify the exact mechanism of injury, optimal treatment strategies, and possible preventative measures.

Background: Diabetes is a well-known risk factor for the severity of illness in patients with SARS-CoV-2 infection (COVID-19). However, there is less published data on illness severity differences between patients with type 1 (T1D) and type 2 (T2D) diabetes mellitus.

Methods: We performed a retrospective review of records of patients with COVID-19 (March 2020 - November 2020) extracted from a large, private hospital system database. Of the 76 467 patients with COVID-19, 54 007 (70.6%) did not have a diabetes diagnosis (NON), 22 084 (28.9%) had T2D, and 376 (0.49%) had T1D. We further subgrouped diabetic patients into groups with A1C above 7% (T2D7 and T1D7) or above 8% (T2D8 and T1D8). Logistic regression analysis was used to determine the association between selected predictor variables and our primary outcome variables of ventilator, intensive care unit (ICU) admission, mortality, and length of stay.

Results: Patients with T2D were substantially older (62.9 years) than NON (48.8) or T1D (43.2). The proportion of Black, White, and other race patients was similar, with a somewhat higher proportion of Black patients having T1D. Patients with T1D and T2D had significantly higher odds of requiring a ventilator, being admitted to ICU, and had a higher mortality rate than NON. As an example, T1D had 5.68 higher odds and T2D 1.82 higher odds of ICU admission compared to NON. T2D patients with A1C above 7% or 8% were roughly 2 times more likely to require a ventilator, were less likely to be admitted to the ICU, and had a roughly 3-day longer length of stay than T1D patients with A1C above 7% or 8%.

Conclusion: Both T1D and T2D were independent predictors of illness severity for SARS-CoV-2 patients, leading to higher odds of requiring ventilation, ICU admission, mortality, and hospital stay duration. Our older patient group with T2D had somewhat worse outcomes and longer hospital stays than T1D.

Background: Aspiration of dental instruments is a rare event that carries potentially serious complications when it occurs, especially in older patients, where protective reflexes are diminished. Clinical management may be difficult because of the risk of granulation tissue and different retrieval strategies according to the object's characteristics. In this report, we describe the case of an 84-year-old man who aspirated a dental bur during a routine dental procedure, necessitating immediate intervention. Timely and precise management was essential to avert severe complications.

Case presentation: During a routine dental procedure, an 84-year-old man aspirated a bud-shaped cross-cut carbide dental bur. Despite initial stability, within an hour he developed a cough and hemoptysis. A chest X-ray confirmed the presence of the foreign body in the right mainstem bronchus. After administering intravenous methylprednisolone, bronchoscopy was conducted using a flexible scope and laryngeal mask airway. Initial attempts at retrieval with forceps were unsuccessful, but the subsequent use of a foreign body "grabber" led to successful and intact removal of the bur. The patient recovered swiftly post-procedure and was discharged within a few hours.

Conclusion: Swift bronchoscopic intervention is vital in managing aspirated dental instruments, especially in older patients. This case highlights the significance of preventive measures in clinical dentistry, using rubber dams and throat packs along with clear emergency protocols. The importance of timely identification and management is also equally emphasized. Furthermore, the administration of corticosteroids played a crucial role in this case by mitigating inflammation and preventing granulation tissue formation, and facilitating successful retrieval. Incorporating the use of corticosteroids for the management of aspirated dental instruments has the potential for better outcomes and fewer complications, particularly when used in older patients with weakened airway defense mechanisms.

Description Narrative medicine, specifically the 55-word story, provides clinicians an opportunity to reflect on experiences they encounter and garner significant meaning from them. These 2 stories discuss difficult situations I have experienced in my practice of medicine. "Reasonable Suspicion" is an internal reflection on the weight of the complex decisions providers are often faced with (mandatory reporting, etc) and are not emphasized enough in health care. Doing the right thing in a clinical situation is taught. How doing the right thing can make a provider feel is not. "There's an Art to This" discusses grief. How do you grieve a patient? How do you help a colleague grieve their patient? These are questions providers often wrestle with. These are questions I struggled to answer during my time covering craniofacial trauma.

Background: Acetabular cup migration is a rare complication of hip replacement surgery. If the acetabular socket of the ilium is weak, the prosthesis can erode or pass through it. There have been multiple reports of acetabular cup prosthesis migration to the colon, creating a coloarticular fistula between the hip joint and the cecum, sigmoid colon, or rectum. We report a rare presentation of a complete intracolonic migration of a prosthetic acetabular cup without creating a fistula.

Case presentation: A 53-year-old female patient with a remote history of a total right hip replacement presented with abdominal pain and rectal bleeding. Computed tomography imaging revealed that the acetabular cup prosthesis was inside the colon. The patient underwent a colonoscopy as well as exploratory abdominal surgery, and the object was retrieved. The patient recovered without complications from the surgery. The acetabular cup migrated into the colon without formation of a residual fistula or any notable complications involving the hip joint despite the loss of the acetabular component.

Conclusion: The mechanism is unknown for how the acetabular prosthesis was able to pass from the hip joint into the colon, without a fistula, bowel perforation, or significant hip injury. At the time of writing, this case appears to be the first to document a complete intracolonic migration of a hip prosthesis.

Background: Over the last 2 decades, there has been a cultural shift in the graduate medical education (GME) space, focusing on an important facet: physician burnout. Burnout is defined as a combination of emotional exhaustion, depersonalization, and a lack of personal accomplishment. With increasing awareness of physician burnout, various wellness initiatives have begun to be implemented throughout training programs, and their results have been measured for effectiveness in reducing burnout rates. Due to the increasing rates of burnout emerging throughout GME programs, an initiative to evaluate our internal medicine (IM) residency on this matter was discussed with all residents at forums and yielded several areas where improvement could help reduce burnout. This project aimed to measure the burnout rates among our IM resident physicians using the Maslach Burnout Inventory (MBI) self-assessment tool after implementing new wellness initiatives in the GME program.

Methods: We sought to actively address the physician burnout phenomenon using a multi-factorial approach that involved several stakeholders and focused on aspects our IM residents outlined during held forums, which included education, financial, physical, mental, and social wellness. Once areas of improvement were identified, steps to improve each field were implemented. The MBI Survey 1 was the primary assessment tool used to measure the rates of burnout after interventions. Survey data were collected, and burnout rates were averaged across postgraduate year (PGY) 1, 2, and 3 residents.

Results: Depersonalization was significantly reduced (P = .0224) for PGY1 residents following intervention. Emotional exhaustion (P = .0014) and depersonalization (P = .0345) were significantly lower for PGY3 residents following interventions. There were no significant changes for PGY2 residents.

Conclusion: Based on preliminary data showing improved outcomes following interventions in various aspects, we aim to grow our wellness initiative using data to guide our efforts to reduce burnout and improve the overall well-being of our residents.