HCA healthcare journal of medicine最新文献

Background: The adaptive immune system consists of T and B lymphocytes, with some B lymphocytes further differentiating into plasma cells that secrete antibodies and make up the humoral immune system. Extramedullary plasmacytoma, mucosa-associated lymphoid tissue (MALT) lymphoma, and plasmablastic lymphoma are all plasma cell-rich lymphoid neoplasms that rarely present in the female genital tract. To date, few case reports of these malignancies arising within the uterine cervix exist.

Case presentation: This case report describes a 52-year-old perimenopausal woman who presented to her primary obstetrician-gynecologist for an annual exam with the complaint of light spotting following an endometrial ablation that occurred several years prior. During the pelvic exam, we discovered and subsequently biopsied an endocervical polyp. The pathological examination of this polyp demonstrated atypical plasma cells and lymphocytes, indicating a leading diagnosis of extramedullary plasmacytoma. The results of further workup, which included a complete blood count, comprehensive metabolic panel, bone marrow biopsy, and a whole-body PET-CT scan, all came back negative for systemic disease. A surgical resection, including a total hysterectomy and bilateral salpingectomy, was performed. Bilateral ovarian conservation was performed due to this patient's perimenopausal status as well as the positive cardiovascular, cognitive, and bone benefits. A secondary pathology review of the endocervical polyp broadened the differential diagnosis to include MALT and plasmablastic lymphoma.

Conclusion: Extramedullary plasmacytomas, MALT lymphomas, and plasmablastic lymphomas carry a risk of progression to multiple myeloma and systemic disease, requiring close surveillance. A total hysterectomy is the most definitive treatment for confined neoplasms. Removing the bilateral ovaries in premenopausal or perimenopausal women places the patient in surgical menopause, which is vastly detrimental to the overall health of the patient. Therefore, thoughtful consideration regarding the benefits and risks of a bilateral oophorectomy versus ovarian conservation is imperative. Additionally, plasma cell-rich lymphomas are not estrogen-driven cancers like other gynecologic cancers, which support ovarian conservation.

Background: Creutzfeldt-Jakob disease (CJD) is a rapidly progressive neurodegenerative condition that is not easily diagnosed and has no curative treatments available, essentially requiring palliative measures, including tube feeding. Nonetheless, data shows that the endoscope used for percutaneous endoscopic gastrostomy (PEG) tube insertion can be a vector for CJD transmission.

Case presentation: We discuss the case of an elderly patient diagnosed with CJD, requiring tube feeding. Multiple specialists were consulted, and they were unable to reach an agreement on the best approach. Eventually, the hospital ethics committee intervened, and the family agreed to comfort measures only. This case report sheds light on the ethical challenges surrounding the use of endoscopically assisted PEG tube placement for patients with confirmed or suspected CJD.

Conclusion: Ethical consideration for patients with dementia, especially with CJD, includes evaluating harm and benefit, considering legal and societal responsibilities, respecting autonomy, and managing transmission risks. Based on our findings, we encourage interdisciplinary collaboration when navigating complex medical decision-making for patients with human prion diseases and advanced dementia.

Background: Prior studies have shown an increase in mortality in trauma patients after 55 years of age. However, it is less certain which pre-existing comorbidities (PECs) are associated with poorer outcomes. The purpose of this study was to identify the risk factors associated with poor outcomes and death in patients 55 years old and older admitted for trauma.

Methods: Trauma patients (age ≥ 55) were studied retrospectively from the local trauma registry at HCA Florida Kendall Hospital, a level 1 trauma center (2020-22). We collected the subject's age, gender, PECs, and outcome data. Then we performed multiple logistic regression to assess which PECs were associated with in-hospital mortality, acute kidney injury (AKI), ventilator-associated pneumonia (VAP), and unplanned intensive care unit (ICU) admission.

Results: We identified 5168 trauma patients 55 years old and older, of which 54.9% were female. Chronic renal failure (CRF) increased the odds of in-hospital mortality (adjusted odds ratio [aOR] = 2.30, P < .001), unplanned ICU admission (aOR = 1.73, P = .033), and AKI (aOR = 2.97, P < .001). Congestive heart failure (CHF) increased the odds of in-hospital mortality (aOR = 1.75, P < .001), unplanned ICU admission (aOR = 2.64, P < .001), and VAP (aOR = 2.42, P = .047). Cirrhosis increased the odds of in-hospital mortality (aOR = 3.78, P = .007), unplanned ICU admission (aOR = 3.11, P = .007), and AKI (aOR = 3.78, P = .007).

Conclusion: Our analysis showed an association between certain comorbidities and poor outcomes in geriatric trauma patients 55 years old and older; namely, CRF, CHF, and cirrhosis were linked to increased in-hospital mortality, unplanned ICU admission, and the development of complications. Identifying these risk factors can aid in developing protocols to improve monitoring and complication-reduction strategies.

Description Idiopathic pulmonary fibrosis (IPF) is a progressive disease characterized by gradual destruction and replacement of pulmonary parenchyma with fibrous tissue, which occurs in conjunction with chronic inflammation. It is often considered a prototypical interstitial lung disease and is both the most prevalent and perhaps the most dangerous in that family. Although the disease is uncommon in the general population, its prevalence increases with age and is typically diagnosed around the age of 65. This does not preclude the development of IPF in younger individuals, and the mean survival is 2 to 5 years post-diagnosis regardless of age. Contemporary studies have provided insight into how altered pulmonary parenchyma results in increased susceptibility to opportunistic infections. It has also been demonstrated that pulmonary insults that cause inflammation, such as pneumonia, may accelerate the progression of IPF. Eosinophilic pneumonias are a collection of pulmonary diseases in which eosinophil-mediated inflammation results in respiratory compromise. Early recognition and appropriate intervention are imperative to minimize the risk of residual pulmonary function deficits, a risk that is increased in individuals with separate pulmonary risk factors. While prompt diagnosis and pharmacologic interventions are associated with improved outcomes, patients with IPF remain at risk of deterioration to the point of requiring lung transplantation. Early screening for those at risk continues to be a topic of interest. Despite the prevalence of IPF, its pathogenesis remains poorly understood and few management options are available. In this article, we document a unique case of previously undiagnosed IPF in a young individual that acutely worsened in the setting of acute eosinophilic pneumonia and the involvement of an opportunistic organism, Aspergillus niger. The case section will serve as a transition into a discussion of each of the major pathologic factors at play, supported by a review of recent literature.

Background: Geographical cohorting in hospital settings represents a significant shift from traditional patient rounding practices and aims to enhance the efficiency of health care delivery. This model assigns hospitalists to a particular inpatient unit, where most of their patients are located. While this model has several benefits, including streamlining health care procedures, optimizing resource allocation, and fostering better provider communication, its implementation is not without its challenges.

Methods: Our methodology for researching geographical cohorting involved a comprehensive literature review of peer-reviewed studies, surveys, and retrospective analyses. We utilized academic databases, such as PubMed, JSTOR, and Google Scholar, to identify relevant articles. Keywords used in the search included "geographic cohorting," "geographic rounding," "hospitalist," "patient outcomes," "provider satisfaction," and "hospital-acquired infections."

Conclusion: Geographical rounding has been associated with a reduction in the incidence of hospital-acquired infections and other adverse outcomes, suggesting its potential to create a safer patient care environment. However, problems such as increased interruptions, indirect care time, and the possibility of diminished interpersonal communication highlight the intricacy involved in successfully implementing such a model. The adoption of geographical cohorting is further complicated by operational problems, such as the necessity for major operational expenditure and patient flow management. Notwithstanding these difficulties, research has shown mixed results regarding geographic cohorting, with some studies suggesting potential advantages, such as enhanced interdisciplinary collaboration and a decline in provider burnout. However, its impact on patient outcomes, like in-patient stay and satisfaction, is inconsistent.

Background: Parkinson's disease is a primary neurological dysfunction syndrome in which the body's natural production of dopamine is reduced. Therapeutic intervention for this disease primarily includes medications that increase the body's natural production of dopamine. These medications can have side effects, requiring constant titration based on the patient's symptoms.

Case presentation: We report a case study of a 75-year-old man diagnosed with Parkinson's disease who had a profound acute exacerbation of psychological symptoms following modifications to his dopaminergic treatment regimen. Initially, the patient was prescribed carbidopa/levodopa, rasagiline, and carbidopa/levodopa/entacapone. However, the treatment plan was adjusted due to the worsening of symptoms. The dose of carbidopa/levodopa was reduced, and rasagiline and Stalevo were stopped. Although the patient initially saw a temporary improvement, the patient later had hallucinations, delusions, agitation, dyskinesias, and akathisia. The laboratory testing and CT scan results showed no significant abnormalities.

Conclusion: This case highlights the importance of accurate dosage and vigilant supervision of Parkinson's disease medications' "wearing off" phenomenon. The patient's varying reaction to changes in medication and the subsequent appearance of psychiatric symptoms highlights the need for an individualized approach to managing Parkinson's disease. Collectively, these symptoms suggest that clinicians should consider the possibility of non-linear connections between dopaminergic therapy and symptom control. To effectively address the intricate relationship between motor symptoms and psychiatric manifestations, it is imperative to implement a multidisciplinary team approach in future management. This approach would involve closely monitoring and adapting treatment strategies.

Description The HCA Healthcare Journal of Medicine would like to thank those behind the scenes who make this publication possible. Our journal would not be possible without the assistance of our peer reviewers, authors, and board members.

Background: Biologic mesh is often used in complex hernia repair, but there has been limited clinical evidence to date to support this practice. The aim of this study was to compare clinical and patient-reported outcomes of biologic versus synthetic mesh for complex open ventral hernia repair (OVHR) at 3 years.

Methods: Patients from a single center, randomized, controlled, pilot trial comparing biologic versus synthetic mesh in complex OVHR were followed for 3 years. The primary outcome focused on major complications, namely mesh infections, hernia recurrences, reoperations, and deaths. Secondary outcomes included surgical site infections, surgical site occurrences, and patient-reported outcomes. Outcomes were assessed using frequentist generalized linear models.

Results: A total of 87 patients (44 biologic mesh, 43 synthetic mesh) were randomized, and 61 patients (70%; 28 biologic and 33 synthetic) completed 3-year follow-up. Baseline demographics were similar in both groups. No significant differences were seen in major complications (50% vs 30%, P = .123), mesh infection (14% vs 3%, P = .144), recurrence (39% vs 24%, P = .214), reoperation (14% vs 9%, P = .531), or mortality (4% vs 0%, P = .459) between the 2 arms. A single death occurred as a result of bacteremia in a patient with hepatocellular carcinoma. Similarly, no significant differences were seen in secondary or patient-reported outcomes. Both groups demonstrated clinically important improvements in quality of life and pain scores at 3 years.

Conclusion: This study failed to find benefits with biologic mesh as opposed to synthetic mesh in complex OVHR at 3 years when comparing both clinical and patient-reported outcomes.

Background: Ovarian or adnexal torsions occur when an ovary rotates around one of the supporting ligaments, often the infundibulopelvic (IP) ligament. This rotation can cause the blood flow to the ovary to be hindered, and this decrease in perfusion can often present as adnexal pain, nausea, and vomiting. A significant risk factor for developing an ovarian torsion is the presence of an ovarian mass, such as a cyst. The diagnosis of ovarian torsion is a medical emergency, but symptoms typically resolve with prompt surgical intervention. Hematomas occurring within or around the inguinal region have been reported to occur primarily after procedures such as ablations or inguinal hernia repairs. These hematomas commonly present post-operatively and are not typical features in the setting of adnexal torsion.

Case presentation: We report the case of a 36-year-old woman who presented with severe, acute-onset pelvic pain and prominent bruising on her left groin area following intercourse. A transvaginal ultrasound revealed the presence of a left ovarian cyst and lack of arterial blood flow to the left ovary, indicating the possibility of a left ovarian torsion. The patient underwent diagnostic laparoscopy with left oophorectomy. However, during the procedure an aberrant vessel was identified that branched from the left IP ligament, running through the inguinal canal, and terminated at the anterior abdominal wall. The vessel was ligated intraoperatively, and the patient ultimately recovered without complications. At the time of post-operative evaluation, the patient was without any recurring symptoms. This case report identifies an unusual presentation of symptoms mimicking ovarian torsion with accompanying ipsilateral subcutaneous inguinal hematoma secondary to aberrant pelvic vasculature.

Conclusion: Our patient had an unusual presentation of pelvic pain mimicking ovarian torsion with accompanying ipsilateral subcutaneous inguinal hematoma secondary to aberrant pelvic vasculature. According to our recent literature searches, there is no available clinical information regarding this combination presentation. The goal of this report is to provide insight into diagnosis and treatment for patients with this atypical presentation.

Introduction: Acute variceal bleeding from portal hypertension is one of the most serious complications with a mortality rate of 15% to 25%. Terlipressin is a vasopressor that controls variceal bleeding by lowering the portal pressure and reducing blood flow to the varices.

Case presentation: We report a case of a patient with acute variceal bleeding, treated endoscopically and with terlipressin, who developed severe hyponatremia and seizures requiring admission to intensive care. Clinical and biochemical improvements were noticeable upon the cessation of terlipressin, with an eventual discharge from the hospital.

Conclusion: Prompt management of acute variceal bleeding with both endoscopic and medical interventions is required. Regular biochemical monitoring is necessary while a patient is on terlipressin treatment. The duration of treatment with terlipressin should not be prolonged unnecessarily.