Rhode Island medical journal (2013)最新文献

Over 800,000 acute myocardial infarction (AMI) events occur annually in the United States. Increased emphasis on primary prevention strategies has decreased the incidence of AMI.1,2 Treatment of AMI includes reperfusion of the culprit coronary arteries, and expeditious intervention has led to a decrease in the rate of post-AMI complications.3 However, these complications still occur in approximately 0.3% of patients presenting with AMI; this is estimated to be about 2,400 patients annually.4,5 Myocardial tissue necrosis secondary to AMI can lead to several different mechanical complications, including papillary muscle rupture, ventricular septal rupture (VSR), and free-wall rupture.2,3,6 These complications usually occur within the first seven days after an AMI.2,3 Mortality from one of these MCs is over 42%, with women and patients older than 75 years of age having an even higher mortality rate.5 This makes prevention, recognition, and prompt treatment critically important. Here we present a case report of a patient with post-AMI VSR.

Food protein-induced enterocolitis syndrome (FPIES) is a less common etiology of vomiting in an infant and can be challenging to diagnose. The absence of confirmatory laboratory testing or clear clinical criteria and signs/symptoms that overlap with other entities can lead to instances of misdiagnosis. We present a case of an exclusively breastfed infant who presented with emesis and dehydration. The infant was initially diagnosed with and treated for sepsis but was eventually diagnosed with FPIES. We discuss challenges in making a diagnosis of FPIES and potential factors that can distinguish it from sepsis.

Objective: To review the primary care provider's (PCP's) role in the management of obese patients who may be candidates for metabolic and bariatric surgery, including early identification and referral, preoperative preparation, risk assessment, and long-term postoperative care. He we synthesize current guidelines and evidence to equip PCPs with practical strategies for management of metabolic and bariatric surgery patients.

Metabolic and bariatric surgery is increasingly utilized as a treatment for obesity worldwide. Despite significant weight loss, weight regain can occur long-term with bariatric surgery, with factors related to weight regain including the presence of comorbid psychiatric conditions. Psychiatric comorbidity in bariatric surgery candidates is common; although these comorbidities sometimes improve in the short-term, they may worsen in the long-term or new problems may emerge post-surgically. Many patients may continue to take psychotropic medications after surgery to maintain behavioral health, yet some medications are associated with weight gain or may pose certain risks due to changes in pharmacokinetics following surgery. The research on psychiatric comorbidity in bariatric surgery patients is presented, along with a review of psychotropic medications that may pose risks of weight gain post-surgically. Clinical recommendations are provided based on existing evidence with respect to managing psychiatric comorbidity in patients in ways that can optimize behavioral health outcomes while also ensuring positive outcomes with bariatric surgery.

Chromoblastomycosis (CBM) is a subcutaneous fungal infection caused by one of several dematiaceae molds with melanotic pigmentation in the cell walls. CBM is characterized by various clinical and dermatological features, leading to common misdiagnosis as several other infectious and noninfectious diseases. Histopathologically, in addition to the pathognomonic muriform cells or "copper pennies," the causative agents of subcutaneous and systemic mycosis lead to a granulomatous reaction due to the influx of mononuclear phagocytic cells and a suppurative infiltrate of neutrophils. Treatment of CBM can be challenging as no standard treatment has been established. This case highlights a rare presentation of subcutaneous chromoblastomycosis caused by Rhinocladiella species in the United States with satisfactory management. It emphasizes the role of occupational and exposure history, keeping a high index of suspicion in cases of verrucous nodules or plaques with new satellite lesions on extremities, and recognizing this entity's distinct dermatopathology characteristics.

A Hispanic male in his 20s presented to the hospital with altered mental status and severe hypercalcemia. During his hospitalization, he developed clinical deterioration requiring intubation and ICU transfer. Initial work-up revealed low PTH and PTHrP levels, along with elevated vitamin D 25-OH and 1,25-OH levels. He developed progressive acute kidney injury, and a kidney biopsy later confirmed macrophage activation syndrome (MAS) in a background of type III lupus nephritis. His hypercalcemia resolved following pulse methylprednisolone therapy. Once clinically improved, the patient reported recent use of vitamin D supplementation. After excluding other causes of non-PTH-dependent hypercalcemia with elevated 1,25-OH vitamin D, MAS was determined to be the driver of increased 1-alpha hydroxylase activity, exacerbated by exogenous vitamin D. This is the first reported case of severe hypercalcemia due to MAS from lupus nephritis, compounded by vitamin D supplementation.

Background: Latin American immigrants experience disparities in health care access and quality. Many underutilize emergency medical care, but some may overuse emergency departments as safety nets.

Methods: This qualitative study used semi-structured interviews to understand Latin American immigrant experiences with emergency medical care. Thematic analysis and grounded theory were used to uncover recurring concepts.

Results: The 15 Spanish-speaking Latin American participants generally understood that emergency medical care was for life-threatening conditions. Friends and family were major sources of information about accessing healthcare. Barriers to emergency medical care included high cost, long wait times, and lack of knowledge about the healthcare system. Some participants increased emergency medical care utilization once in the United States because of increased quality of care, while others decreased utilization because of high costs.

Conclusions: Latin American immigrants face many barriers to emergency medical care. Avenues of reform include expanding free clinics and employing social networks to spread information about the healthcare system.

Primary Effusion Lymphoma (PEL) is a rare subtype of large B-cell lymphoma characterized by malignant effusions in body cavities, typically without solid masses. Commonly affected areas include pleural, pericardial, and peritoneal spaces. However, PEL can present as Extracavitary Primary Effusion Lymphoma (EC-PEL) with solid tumor masses in different organs. We encountered a unique case of EC-PEL in an HIV-infected patient presenting concomitant with a squamous cell carcinoma as a penile mass. This case highlights the diverse presentations of PEL and the importance of considering lymphomatous involvement in uncommon sites, particularly in immunocompromised individuals. To our knowledge, this is the first EC-PEL case presenting as a penile mass, in association with an invasive squamous cell carcinoma.

Objective: To assess how the overturn of Roe v. Wade affected decisions of Maternal-Fetal Medicine (MFM) fellowship applicants.

Methods: This is a cross-sectional survey distributed to MFM fellowship applicants in the 2024 Match appointment cycle. The dual primary outcome was whether the overturn of Roe v. Wade affected the number and geographic distribution of MFM programs to which the applicants planned to apply and applicants' desire to receive dilation and evacuation (D&E) training during fellowship.

Results: A total of 167 individuals applied to MFM fellowships in the 2024 Match appointment cycle. Thirty-seven applicants (22%) responded to our survey. Most identified as women (84%) and White (73%). While most participants planned to apply to the same number of programs (65%), 68% of participants planned to apply to fewer programs in abortion-restrictive states. Most participants (89%) were interested in receiving D&E training during fellowship.

Conclusion: These findings highlight the need for further assessment of how abortion restrictions impact MFM fellowship application, training, and practice.

Intentional foreign body ingestion is often seen in individuals with psychiatric disorders, particularly mood and personality disorders. This case illustrates the substantial healthcare resources involved in managing foreign body ingestion, which may require multiple endoscopic procedures and intensive care monitoring. Endoscopic removal, while minimally invasive, carries risks such as perforation and bleeding, particularly in the upper gastrointestinal tract. Surgical intervention in psychiatric patients can inadvertently reinforce maladaptive behaviors, complicating management strategies. Therefore, a collaborative approach between psychiatry and gastroenterology is essential to address both the medical and psychological aspects of care.