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hesis that other aspects beyond physical and hemodynamic ones might impact the daily physical activity of patients with pulmonary arterial hypertension.Pulmonary embolism (PE) is a major cause of cardiovascular morbidity and mortality. Obstructive sleep apnea (OSA) is increasingly recognized in the aging population, especially with the rising obesity epidemic. The impact of OSA on inpatient mortality in PE is not well understood. We used the Nationwide Inpatient Sample databases from 2005 to 2016 to identify 755,532 acute PE patients (age≥18 years). Among these, 61,050 (8.1%) were OSA+. Temporal trends in length of stay, inpatient mortality, and its association with OSA in PE patients were analyzed. The proportion of PE patients who were OSA+ increased from 2005 to 2016. OSA+ PE patients were younger and predominantly men. Despite a higher prevalence of traditional risk factors for inpatient mortality in OSA+ patients, OSA was associated with a lower risk of mortality in PE patients (odds ratio, 95% confidence interval; p unadjusted 0.56, 0.53-0.58; p less then 0.0001 and adjusted 0.55, 0.52-0.58; p less then 0.0001). Overall mortality and length of stay in PE patients decreased over time. Relative to OSA- patients, there was a slight increase in mortality among OSA+ PE patients over time, although the length of stay remained unchanged between the two groups. In conclusion, OSA+ PE patients had a lower inpatient mortality compared to OSA- patients despite a higher prevalence of traditional mortality risk factors. Secondary pulmonary hypertension related to OSA with preconditioning of the right ventricle to elevated afterload may potentially explain the protective effect of OSA on mortality in PE. However, mechanistic studies need to further elucidate the links behind this association.
Treatment with clozapine requires regular blood monitoring in order to minimise the risk of agranulocytosis. The demands on patients and clinicians associated with monitoring may be reduced by using point-of-care, as opposed to lab-based assessments. We assessed the utility of a device that can measure white blood cell (WBC) and neutrophil counts by capillary fingerstick blood.
The performance of a small, portable device (HemoCue® WBC DIFF System) was compared with that of a widely used laboratory analyser (ADVIA® 2120i) for measuring WBC and neutrophil counts. Patients with schizophrenia who were being treated with clozapine (
= 201) provided a fingerstick capillary sample and a venous sample for the respective assays.
WBC counts and neutrophil counts from venous blood as determined by ADVIA 2120i, ranged from 3.0 × 10
/l to 19.5 × 10
/l, and 1.2 × 10
/l to 15.9 × 10
/l, respectively. There was a strong correlation between the results from venous and the capillary sample methods (WBC
= 0.89, nmonitoring blood counts in patients on clozapine, although confirmatory standard venous testing is recommended for test results falling below accepted thresholds.
Results from the capillary blood HemoCue WBC DIFF analyser compared well with the venous blood ADVIA 2120i analyser for determining WBC and neutrophil counts. PFKFB inhibitor There was a slight overall bias, with the capillary method reporting lower values for both measures. Fingerstick point-of-care analysis is suitable for monitoring blood counts in patients on clozapine, although confirmatory standard venous testing is recommended for test results falling below accepted thresholds.Our case report illustrates effective implementation of conservative measures without the need for more invasive procedures, which can be required in refractory cases. Our patient was a 42-year-old female who fell from a horse and presented with a 1-week history of dyspnoea. Investigations revealed her to have a large right chylothorax, which was treated conservatively with chest drainage and octreotide. The patient remained in hospital for a total of 3 days prior to being discharged home without further complications. Blunt traumatic chylothorax should be considered as part of the differential diagnosis in patients who present with ongoing dyspnoea or chest discomfort within a 2-week preceding history of blunt trauma. Radiological imaging should be mandatory and the absence of posterior thoracic fractures does not exclude the diagnosis. Conservative management with pleural drainage, medium-chain triglyceride diet and octreotide yielded excellent results in our case.Extradural atlantoaxial cysts are typically related to C1-2 degeneration. Intradural cysts may cause secondary syringobulbia depending on the size and cerebrospinal fluid flow obstruction. However, medullary syrinxes have not been previously described with extradural cysts. Treatment of symptomatic lesions involves surgical resection, often via a far-lateral approach, with consideration of fusion if C1-2 instability is present. We present a case of an extradural C1-2 cyst with intradural extension causing syringobulbia. Effective surgical resection was accomplished via a far-lateral, partial transcondylar approach without fusion. It is important to recognize that cysts of extradural origin may exhibit intradural extension and compress critical neurovascular structures.We present a case of lung adenocarcinoma metastasizing to the right clear cell renal cell carcinoma diagnosed by computed tomography (CT)-guided renal biopsy and immunohistochemistry. A 72-year-old male patient had right lower abdominal pain for 3 days, followed by right loin pain for 10 days. On CT scan, renal cell cancer was suspected with multiple metastases. Renal cell cancer with metastatic lung adenocarcinoma was diagnosed on CT-guided renal biopsy with positive immunohistochemical markers. The patient, unfortunately, expired after few days of diagnosis. Tumor-to-tumor metastasis is an unusual disease, and its tumors are aggressive. A definite diagnosis of tumor-to-tumor metastasis is a clinical challenge. Immunohistochemistry helped us in the diagnosis without the primary lesion biopsy.Penetrating thoracoabdominal injury is a common presentation in the trauma resuscitation room with the possibility of a myriad of injuries which may involve thoracic and abdominal viscera. Management is usually operative however non-operative management is a possibility especially following knife stab injuries when compared with gunshot injuries. Clinical presentation will depend on the injured organ, extent of injury and time from injury to presentation. Unusual presentation of delayed haematemesis is a possibility with injury to the stomach, however, due to its rarity, a high index of suspicion with emergency surgery will help to mitigate the fatal consequences that may follow. This type of presentation is not documented in the available on-line literature which portends the importance of this paper. This case highlights the possibility of this clinical presentation and importance of early management to improve patient outcome.Abdominal wall endometriosis has an incidence of 0.3-1% of extrapelvic disease. Α 48-year-old female appeared in the emergency department with cellulitis in a lower midline incision. She had an endometrioma of the anterior abdominal wall removed 2 years ago. After 5 months, she underwent an open repair of an incisional hernia with a propylene mesh, which was unfortunately infected and removed 1 month later. Finally, in July 2019, she had her incisional hernia repaired with a biological mesh. Imaging modalities revealed a large mass below the umbilicus. Mass was punctured under ultrasound guidance. Cytology reported the recurrence of endometriosis. Pain and abdominal mass associating with menses were the two most typical symptoms. Wide local excision of the mass with at least 1 cm negative margins is the preferred treatment. Surgeons should maintain a high suspicion of the disease in reproductive women with circular pain, palpable abdominal mass and history of uterine-relating surgery.This study investigates outcomes of surgical management of pediatric patients with nasal dermoids with prior infection. A retrospective review at Nationwide Children's Hospital, a large free-standing pediatric hospital in the Midwestern USA, was performed. Patients were identified by the Current Procedural Terminology codes 30124 (simple excision of dermoid cyst) and 30125 (complex excision of nasal dermoid cyst) from 2011 to 2016. Demographic, imaging data, surgical findings, microbiological data and recurrence rates were collected for these patients. Descriptive statistical investigation was performed. In total, 14 patients were identified, 4 of the 14 patients (28.5%) had recurrent infection and required additional surgery. Three of seven patients required incision and drainage prior to definitive excision. One of seven patients in the infected group had recurrence. Prior infection does not increase the recurrence rate and almost half of the patients required I&D prior to definitive management.Juvenile xanthogranuloma is a proliferative cutaneous manifestation encountered in the paediatric population. Adult cases are uncommon, but have been reported. Lesions are prevalent in the head and neck region, but rarely observed in the external auditory canal. We present the case of a 39-year-old female with a rapidly progressing obstructive soft tissue lesion of the external auditory canal. Surgical excision diagnosed the lesion as a rarely observed otological manifestation of juvenile xanthogranuloma. Surgical excision was curative with no locoregional recurrence. Otolaryngologists should consider juvenile xanthogranuloma as a differential for atypical soft tissue cutaneous lesions of the head and neck, including in divergent populations.
Along with the increasing use of immune checkpoint inhibitors comes a surge in immune-related toxicity. Here, we review the currently available data regarding neurological immune adverse events, and more specifically aseptic meningitis and encephalitis, and present treatment and diagnostic recommendations. Furthermore, we present five cases of immunotherapy-induced aseptic meningitis and encephalitis treated at our institution.
Neurological immune-related adverse events, including aseptic meningitis and encephalitis, secondary to checkpoint inhibitors are a rare but complex and clinically relevant entity, comprising a wide range of diseases, most often presenting with symptoms with a wide range of differential diagnoses. Our case-series highlights the challenges of such entities and the importance of properly identifying and managing aseptic meningitis and encephalitis.
Checkpoint inhibitor-induced meningoencephalitis warrants prompt investigations and treatment. Properly diagnosing aseptic meningitis, mprising a wide range of diseases, most often presenting with aspecific symptoms. In this paper, we discuss a single institution case-series of patients with autoimmune aseptic meningitis and encephalitis, and we perform a narrative literature review on this subject. We conclude with our treatment recommendations based on available evidence.
Although landmark clinical trials have demonstrated an increased risk for genitourinary infection (GUI) after initiation of sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapy that led to an FDA label warning, real world findings have been inconsistent and evidence specifically in older adults is lacking. The objective of the study was to examine the incidence of GUI in patients aged 65 years or older initiated on SGLT2i compared with glucagon-like peptide-1 receptor agonist (GLP1-RA) therapy at a large academic health system.
A retrospective population-based cohort study was conducted using electronic health records of patients aged 65 years and older with a diagnosis of type 2 diabetes mellitus. Patients newly initiated on SGLT2i or GLP1-RA therapy with estimated glomerular filtration rate (eGFR) ⩾30 mL/min per 1.73 m² and active within the health system for at least 1 year prior to initiation were included. We compared the incidence of inpatient, emergency room, or outpatient diagnosis of GUI (bacterial and mycotic) within 6 months of SGLT2i or GLP1-RA initiation.
