BACKGROUND:Maxillofacial trauma represents a significant challenge in emergency medicine,requiring both diagnostic accuracy and prompt intervention while balancing immediate life-saving interventions with preservation...BACKGROUND:Maxillofacial trauma represents a significant challenge in emergency medicine,requiring both diagnostic accuracy and prompt intervention while balancing immediate life-saving interventions with preservation of function and aesthetics.The complex anatomy of this region,with its proximity to critical structures,demands a thorough understanding of assessment and management principles.This narrative review aims to provide evidence-based guidelines for emergency physicians managing maxillofacial trauma,with particular emphasis on early recognition of critical injuries,airway management strategies,and special population considerations.METHODS:A narrative review was conducted via a comprehensive literature search of the PubMed and Scopus databases,which focused on maxillofacial trauma management in emergency settings.Articles were selected based on relevance to clinical practice,methodological quality,and current management guidelines.The review synthesized evidence from multiple study types,including original research,systematic reviews,and clinical practice guidelines,to provide practical guidance for emergency physicians.RESULTS:Initial assessment following Advanced Trauma Life Support(ATLS)principles is crucial,with airway management being a primary concern due to the risk of dynamic obstruction.Critical time-sensitive emergencies include orbital compartment syndrome,trapdoor fractures(in pediatric patients),and facial nerve injuries.Computed tomography(CT)imaging remains the gold standard for diagnosis.Special considerations are required for pediatric patients,who present unique anatomical challenges and injury patterns,and for elderly patients,who often have complex medical comorbidities and increased complication risks.Management strategies range from conservative treatment to urgent surgical intervention,with decisions based on the injury pattern and associated complications.CONCLUSION:Emergency physicians must maintain a structured yet fl exible approach to maxillofacial trauma,focusing on early recognition of critical injuries,appropriate airway management,and timely specialist consultation.Understanding injury patterns and their potential complications allows for eff ective risk stratifi cation and treatment planning,ultimately improving patient outcomes.展开更多
BACKGROUND Gastric antral vascular ectasia(GAVE)accounts for up to 4%of nonvariceal upper gastrointestinal bleeding.Argon plasma coagulation and radiofrequency ablation have been primary treatment modalities for patie...BACKGROUND Gastric antral vascular ectasia(GAVE)accounts for up to 4%of nonvariceal upper gastrointestinal bleeding.Argon plasma coagulation and radiofrequency ablation have been primary treatment modalities for patients with linear and punctate subtypes,with a newer trend of utilization of endoscopic band ligation(EBL).This study evaluates the outcomes of patients undergoing treatment for nodular GAVE.We hypothesize that patients treated initially with EBL will achieve higher rates of clinical remission with fewer endoscopic treatments and a shorter treatment interval.AIM To investigate the effects of EBL as an initial treatment therapy on outcomes associated with nodular GAVE.METHODS A total of 37 patients at a tertiary medical center with nodular GAVE were included in this retrospective study.The study population was divided between those treated initially with EBL(initial EBL)and initial endoscopic thermal therapy.Pretreatment and post-treatment hemoglobin values,the model for end-stage liver disease scores,hospitalization rates,and other outcomes.Additionally,endoscopic treatment modality type and frequency were recorded,including radiofrequency ablation,argon plasma coagulation,and EBL.Continuous variables were compared using a t-test,while categorical variables were compared using Fisher’s exact.RESULTS Linear regression analysis displayed a positive relationship between the time interval from initial therapeutic esophagogastroduodenoscopy to first EBL treatment and overall treatment interval(t=7.39,P<0.001),as well as between the number of endoscopic treatments(t=8.09,P<0.001).Hemoglobin levels increased in both the initial EBL group(8.7 vs 11.4,P<0.001)and the initial endoscopic thermal therapy group(8.6 vs 10.4,P=0.042).Clinical remission rates were higher in the initial EBL group(90%vs 69%P=0.041),with a non-significant trend of higher endoscopic remission rates(57.1%vs 37.5%,P=0.270).CONCLUSION The observed trend favoring EBL,combined with its association with improved clinical remission and reduced treatment burden,supports its consideration as a preferred initial treatment approach.展开更多
BACKGROUND There is increasing incidence of alcohol-associated liver disease in females.Despite this recent increased incidence,there is a paucity of research on the clinical course and outcomes of alcohol-associated ...BACKGROUND There is increasing incidence of alcohol-associated liver disease in females.Despite this recent increased incidence,there is a paucity of research on the clinical course and outcomes of alcohol-associated hepatitis(AH)in females compared to males.AIM To assess if there may be sex differences in severity,outcomes,and healthcare utilization for patients hospitalized for AH.METHODS This study used ICD-9-CM and ICD-10-CM codes to retrospectively identify inpatient encounters for AH at the University of Kentucky from 2012-2021 and obtained data on patient demographics and clinical outcomes.Encounters were cohorted by patient sex and differences in patient demographics and clinical outcomes were assessed.Multivariate logistic regression models were constructed to assess risk of mortality,sepsis,and mechanical ventilation during the encounter.RESULTS Of 1386 subjects,511(36.9%)were female and 875(63.1%)were male.Both sexes had similar baseline characteristics of race/ethnicity,discriminant function score,model of end-stage liver disease score,and length of hospital stay.However,the incidence of urinary tract infection,sepsis,and norepinephrine administration was significantly higher for females.Males had a significantly higher incidence of esophageal variceal bleed.On multivariate logistic regression analysis,females had higher odds of encounter sepsis(OR 1.41;95%CI:1.064-1.869)and mechanical ventilation(OR 1.352;95%CI:1.006-1.816).Odds of encounter mortality were significantly increased in encounters with sepsis(OR 2.309;95%CI:1.419-3.757)and mechanical ventilation(OR 9.301;95%CI:5.724-15.114).CONCLUSION This study shows sex-based differences in AH outcomes at the University of Kentucky.Future studies are warranted to assess whether tailoring treatments will improve clinical outcomes in females with AH.展开更多
BACKGROUND:BRASH syndrome(Bradycardia,Renal failure,AV nodal blockade,Shock,and Hyperkalemia)is a recently described clinical entity characterized by synergistic interaction between AV nodal blocking medications and h...BACKGROUND:BRASH syndrome(Bradycardia,Renal failure,AV nodal blockade,Shock,and Hyperkalemia)is a recently described clinical entity characterized by synergistic interaction between AV nodal blocking medications and hyperkalemia.Despite increasing recognition,its clinical characteristics,risk factors,and outcomes remain poorly defined.The rationale of this review is to provide clinicians an upto-date overview of the most commonly encountered risk factors,triggers,clinical pictures,usual lab values,complications and outcomes,via the systemic analysis of currently published cases.METHODS:A systematic review was conducted using MEDLINE,Web of Science,and Cochrane Library databases through December 2024.Case reports,case series,and conference abstracts involving adult patients with BRASH syndrome were included.Data extraction focused on demographics,clinical presentations,laboratory findings,management strategies,and outcomes.RESULTS:Analysis included 131 patients from 111 published cases.Mean age was(71±13)years,with female predominance(58.1%).Hypertension(77.0%),chronic kidney disease(48.4%),and diabetes mellitus(46.7%)were the most common comorbidities.Beta-blockers were the predominant medication(76.5%).Most common presenting symptoms were syncope(17.9%),generalized weakness(16.2%),and altered mental status(11.9%).Mean potassium level was 6.6 mEq/L,with more than half of cases presenting with non-severe hyperkalemia(<6.5 mEq/L).Management often required multimodal therapy,with 50.8% of patients requiring vasopressors and 31.6% requiring hemodialysis.CONCLUSION:This systematic review provides the most comprehensive analysis of BRASH syndrome to date,demonstrating that while potentially serious,outcomes are generally favorable with appropriate recognition and management.The syndrome can develop even with modest hyperkalemia,particularly in elderly patients with multiple comorbidities.Early recognition and systematic management addressing all components of the syndrome appear crucial for optimal outcomes.展开更多
BACKGROUND Liver imaging and transient elastography(TE)are both tools used to assess liver fibrosis and steatosis among people with hepatitis C virus(HCV)infection.However,the diagnostic accuracy of conventional imagi...BACKGROUND Liver imaging and transient elastography(TE)are both tools used to assess liver fibrosis and steatosis among people with hepatitis C virus(HCV)infection.However,the diagnostic accuracy of conventional imaging in detecting fibrosis and steatosis in this patient population remains unclear.AIM To investigate the correlation between steatosis and fibrosis and abnormal findings on liver imaging in patients with HCV.METHODS We conducted a retrospective cross-sectional analysis of patients with HCV at Grady Liver Clinic who had TE exams between 2018-2019.We analyzed the correlation of controlled attenuation parameter and liver stiffness measurement on TE and abnormal findings on liver imaging.Liver imaging findings(hepatic steatosis,increased echogenicity,cirrhosis,and chronic liver disease)were further evaluated for their diagnostic performance in detecting fibrosis(≥F2,≥F3,≥F4)and steatosis(≥S1,≥S2,≥S3).RESULTS Of 959 HCV patients who underwent TE,651 had liver imaging.Higher controlled attenuation parameter scores were observed in patients with abnormal liver findings(P=0.0050),hepatic steatosis(P<0.0001),and increased echogenicity(P<0.0001).Higher liver stiffness measurement values were also noted in those with abnormal liver(P<0.0001)and increased echogenicity(P=0.0026).Steatosis severity correlated with hepatic steatosis(r=0.195,P<0.001)and increased echogenicity(r=0.209,P<0.001).For fibrosis detection,abnormal liver imaging had moderate sensitivity(81.7%)and specificity(70.4%)for cirrhosis(≥F4),while cirrhosis on imaging had high specificity(99.2%)but low sensitivity(18.3%).Increased echogenicity showed high specificity(92.8%)but low sensitivity(20.9%)for steatosis detection.CONCLUSION Liver imaging detects advanced fibrosis and steatosis but lacks early-stage sensitivity.Integrating TE with imaging may improve evaluation in patients with HCV.展开更多
BACKGROUND Giant cell tumor of bone(GCTB)is a rare,locally aggressive neoplasm that should be treated surgically,whenever possible.This treatment approach may be linked with greater morbidity besides functional impair...BACKGROUND Giant cell tumor of bone(GCTB)is a rare,locally aggressive neoplasm that should be treated surgically,whenever possible.This treatment approach may be linked with greater morbidity besides functional impairment.Denosumab is a human monoclonal antibody.Its administration inhibits bone resorption and has become part of the therapeutic armamentarium against GCTB,as it allows local control with a view to downstaging for a more conservative surgical procedure.However,there is no consensus in the literature regarding the optimal denosumab regimen for GCTB.Therefore,a wide discussion of denosumab regimen is necessary.AIM To assess the effectiveness of various therapy protocols employing denosumab in individuals with GCTB.METHODS A broad and systematic literature search was carried out using the PRISMA guidelines.We analyzed studies that reported skeletally mature patients with GCTB regardless of sex or ethnicity treated with denosumab.Articles with fewer than five patients and in languages except Spanish,Portuguese and English were excluded.Statistical analysis with proportion meta-analysis was performed due to the dichotomous nature of the data.RESULTS 1005 articles were screened,of which 26 articles met the inclusion criteria and were selected,totaling 1742 patients,51.8%women and 48.2%men,with an average of 35 years of age.Treatment with denosumab was associated with high rates of clinical benefit(CB)and imaging response(IR),without changing local recurrence rates when compared to patients treated without denosumab,regardless of the therapeutic regimen adopted and the number of doses applied.The adverse events(AE)presented were mostly mild,with the exception of a malignant transformation to osteosarcoma.CONCLUSION Treatment of GCTB with denosumab is effective,showing high rates of CB and IR.The AE that occurred were mostly mild.We found no differences between the articles considering the researched outcomes regardless of the therapeutic regimen adopted.展开更多
Hepatocellular carcinoma(HCC) makes up 75%-85% of all primary liver cancers and is the fourth most common cause of cancer related death worldwide. Chronic liver disease is the most significant risk factor for HCC with...Hepatocellular carcinoma(HCC) makes up 75%-85% of all primary liver cancers and is the fourth most common cause of cancer related death worldwide. Chronic liver disease is the most significant risk factor for HCC with 80%-90% of new cases occurring in the background of cirrhosis. Studies have shown that early diagnosis of HCC through surveillance programs improve prognosis and availability of curative therapies. All patients with cirrhosis and high-risk hepatitis B patients are at risk for HCC and should undergo surveillance. The recommended surveillance modality is abdominal ultrasound(US) given that it is cost effective and noninvasive with good sensitivity. However, US is limited in obese patients and those with non-alcoholic fatty liver disease(NAFLD). With the current obesity epidemic and rise in the prevalence of NAFLD, abdominal computed tomography or magnetic resonance imaging may be indicated as the primary screening modality in these patients. The addition of alpha-fetoprotein to a surveillance regimen is thought to improve the sensitivity of HCC detection.Further investigation of serum biomarkers is needed. Semiannual screening is the suggested surveillance interval. Surveillance for HCC is underutilized and low adherence disproportionately affects certain demographics such as nonCaucasian race and low socioeconomic status.展开更多
Primary sclerosing cholangitis(PSC) is a rare cholestatic liver disease characterized by progressive fibroinflammatory destruction of the intra-and/or extrahepatic biliary ducts. While its features and disease course ...Primary sclerosing cholangitis(PSC) is a rare cholestatic liver disease characterized by progressive fibroinflammatory destruction of the intra-and/or extrahepatic biliary ducts. While its features and disease course can be variable,most patients with PSC have concurrent inflammatory bowel disease and will eventually develop liver cirrhosis and end-stage liver disease, with liver transplantation representing the only potentially curative option. Importantly,PSC is associated with a significantly increased risk of malignancy compared to the general population, mainly cholangiocarcinoma, gallbladder carcinoma,hepatocellular carcinoma, and colorectal cancer, with nearly 50% of deaths in patients with PSC being due to cancer. Therefore, robust surveillance strategies are needed, though uncertainty remains regarding how to best do so. In this review, we discuss the epidemiology, prevention, and surveillance of cancers in patients with PSC. Where evidence is limited, we present pragmatic approaches based on currently available data and expert opinion.展开更多
Background Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly.It is related to unfavorable outcomes in various cardiovascular conditions.We conducted a systematic review and meta...Background Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly.It is related to unfavorable outcomes in various cardiovascular conditions.We conducted a systematic review and meta-analysis of the association of frailty with all-cause mortality and bleeding after acute myocardial infarction(AMI)in the elderly.Methods We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2019.The studies that reported mortality and bleeding in AMI patients who were evaluated and classified by frailty status were included.Data from each study were combined using the random-effects,generic inverse variance method of Der Simonian and Laird to calculate hazard ratio(HR),and 95%confidence interval(CI).Results Twenty-one studies from 2011 to 2019 were included in this meta-analysis involving 143,301 subjects(mean age 75.33-year-old,60.0%male).Frailty status was evaluated using different methods such as Fried Frailty Index.Frailty was statistically associated with increased early mortality in nine studies(pooled HR=2.07,95%CI:1.67-2.56,P<0.001,I^2=41.2%)and late mortality in 11 studies(pooled HR=2.30,95%CI:1.70-3.11,P<0.001,I^2=65.8%).Moreover,frailty was also statistically associated with higher bleeding in 7 studies(pooled HR=1.34,95%CI:1.12-1.59,P<0.001,I^2=4.7%).Conclusion Frailty is strongly and independently associated with bleeding,early and late mortality in elderly with AMI.Frailty assessment should be considered as an additional risk factor and used to guide toward personalized treatment strategies.展开更多
Inflammatory fibroid polyp(IFP) is a rare,idiopathic pseudotumorous lesion of the gastrointestinal tract.While mostly reported as solitary gastric lesions,multiple cases of small bowel IFPs are also reported.It is a d...Inflammatory fibroid polyp(IFP) is a rare,idiopathic pseudotumorous lesion of the gastrointestinal tract.While mostly reported as solitary gastric lesions,multiple cases of small bowel IFPs are also reported.It is a documented cause of intussusception in adults.In the case reports of ileal inflammatory fibroid polyps with intussusception,an emergent presentation with small bowel obstruction has been most often described.Here we depict a case of ileal inflammatory fibroid polyp presenting with chronic intermittent ileocolic intussusception,anemia and weight loss with an endoscopic appearance mimicking necrotic cecal carcinoma.展开更多
BACKGROUND Gastrointestinal cancer(GICA)is associated with a higher incidence of venous thromboembolism(VTE)compared to other solid tumors,moreover,recurrent VTE and major bleeding(MB)complications during anticoagulat...BACKGROUND Gastrointestinal cancer(GICA)is associated with a higher incidence of venous thromboembolism(VTE)compared to other solid tumors,moreover,recurrent VTE and major bleeding(MB)complications during anticoagulation treatment have an associated increase rate.GICA-VTE remains a challenging clinical scenario with MB concerns for utilization of direct oral anticoagulants(DOAC),especially with active cancer therapies.AIM To evaluate patient risk factors,effectiveness(VTE)and safety(MB)of DOACs and low molecular weight heparin(LMWH)in patients with active GICA-VTE.METHODS A retrospective chart review of patients receiving DOACs and LMWH with GICA and symptomatic or incidental VTE treated at comprehensive cancer center from November 2013 to February 2017 was performed.Inclusion criteria included active GI cancer diagnosed at any stage or treatment+/-6 mo of VTE diagnosis,whom were prescribed 6 mo or more of DOACs or LMWH.The Chi-squared test was used for overall and the Fisher exact test for pairwise comparisons of the proportions of patients experiencing recurrent VTE and MB events.Odds ratios were used to compare the relative odds of the occurrence of the outcome given exposure to the risk factor.RESULTS A total of 144 patients were prescribed anticoagulation,in which 106 fulfilled inclusion criteria apixaban(27.3%),rivaroxaban(34.9%)and enoxaparin(37.7%),and 38 were excluded.Patients median age was 66.5 years at GICA diagnosis and 67 years at CAVTE event,with 62%males,80%Caucasian,70%stage IV,pancreatic cancer(40.5%),30%Khorana Score(≥3 points),and 43.5%on active chemotherapy.Sixty-four percent of patients completed anticoagulation therapy(range 1 to 43 mo).Recurrent VTE at 6 mo was noted in 7.5%(n=3),6.8%(n=2)and 2.7%(n=1)of patients on enoxaparin,apixaban and rivaroxaban,respectively(all P=NS).MB at 6 mo were 5%(n=2)for enoxaparin,6.8%(n=2)for apixaban and 21.6%(n=8)for rivaroxaban(overall P=0.048;vs LMWH P=0.0423;all other P=NS).Significant predictors of a primary or secondary outcome for all anticoagulation therapies included:Active systemic treatment(OR=5.1,95%CI:1.3-19.3),high Khorana Score[≥3 points](OR=5.5,95%CI:1.7-17.1),active smoker(OR=6.7,95%CI:2.1-21.0),pancreatic cancer(OR=6.8,95%CI:1.9-23.2),and stage IV disease(OR=9.9,95%CI:1.2-79.1).CONCLUSION Rivaroxaban compared to apixaban and enoxaparin had a significantly higher risk of MB on GICA-VTE patients with equivocal efficacy.展开更多
Myocarditis is a disease process that every emergency physician fears missing.Its severity can be mild to life-threatening,and many cases are likely undetected because they are subclinical with nonspecifi c signs.[1]S...Myocarditis is a disease process that every emergency physician fears missing.Its severity can be mild to life-threatening,and many cases are likely undetected because they are subclinical with nonspecifi c signs.[1]Subtle cardiac signs may be overshadowed by systemic symptoms of the underlying infectious process.Fever,myalgias,lethargy,symptoms commonly associated with viral syndrome,can mask the life-threatening myocarditis that may be present.In fact,in the United States Myocarditis Treatment Trial,almost 90%of patients reported symptoms consistent with a viral prodrome.[2]Ammirati et al[3]reported that 27%of patients with myocarditis had either reduced left ventricular ejection fraction,ventricular arrhythmias,or low cardiac output.Here,we present a case report,in which handheld point-of-care ultrasound was utilized at the bedside to aid in the critical diagnosis of myocarditis.With the additional information provided through this imaging modality,this patient was able to be transferred to the appropriate tertiary care facility in an expeditious manner and receive possible defi nitive treatment.展开更多
AIM To evaluate the safety and efficacy of ledipasvir/sofosbuvir on hepatitis C eradication in patients with hepatitis C virus(HCV)/human immunodeficiency virus(HIV) co-infection in an urban HIV clinic.METHODS A retro...AIM To evaluate the safety and efficacy of ledipasvir/sofosbuvir on hepatitis C eradication in patients with hepatitis C virus(HCV)/human immunodeficiency virus(HIV) co-infection in an urban HIV clinic.METHODS A retrospective cohort study of 40 subjects co-infected with HIV-1 and HCV treated with the fixed-dose combination of ledipasvir and sofosbuvir for 12 wk from 2014 to 2016.All patients included were receiving antiretroviral therapy(ART) with HIV RNA values of 100 copies/m L or fewer regardless of baseline HCV RNA level.The primary end point was a sustained virologic response of HCV at 12 wk(SVR12) after the end of therapy.RESULTS Of the 40 patients enrolled,55% were black,22.5% had been previously treated for HCV,and 25% hadcirrhosis.The patients were on a wide range of ART.Overall,39 patients(97.5%) had a SVR 12 after the end of therapy,including rates of 97.1% in patients with HCV genotype 1 a and 100% in those with HCV genotype 1 b.One patient with HCV genotype 3 a was included and achieved SVR12.Rates of SVR12 were similar regardless of previous treatment or the presence of compensated cirrhosis.Only 1 patient experienced relapse at week 12 following treatment and deep sequencing didn't reveal any resistance associated mutation in the NS5A or NS5B region.Interestingly,7(17.5%) patients who were adherent to ART experienced HIV viral breakthrough which resolved after continuing the same ART regimen.Two(5%) patients experienced HIV-1 virologic rebound due to noncompliance with HIV therapy,which resolved after resuming the same ART regimen.No severe adverse events were observed and no patient discontinued treatment because of adverse events.The most common adverse events included headache(12.5%),fatigue(10%),and diarrhea(2.5%).CONCLUSION This retrospective study demonstrated the high rates of SVR12 of ledipasvir/sofosbuvir on HCV eradication in patients co-infected with HCV and HIV,regardless of HCV baseline levels,HCV treatment history or cirrhosis condition.The oral combination of ledipasvir/sofosbuvir represents a safe and well tolerated HCV treatment option that does not require modification for many of the common HIV ART.Occasional HIV virologic rebound occurred but later resolved without the need to change ART.展开更多
BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction(STEMI)improves outcomes. System delay is that between first medical contact and reperfusion therapy,comprising prehospital and hospital comp...BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction(STEMI)improves outcomes. System delay is that between first medical contact and reperfusion therapy,comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore.METHODS: A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services(EMS),ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique.RESULTS: Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5minutes(interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes(IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes(IQR=1.30, 22.13); between arrival-at- and departurefrom-patient-location was 13.12 minutes(IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes(IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulancedispatch and arrival-at-patient-location was shorter(5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter(10.78 vs.14.37 minutes, P<0.01).CONCLUSION: Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.展开更多
Cardiovascular diseases(CVDs)remain the leading cause of death in the world and in most developed countries.Patients with type 2 diabetes mellitus(T2DM)suffer from both microvascular and macrovascular diseases and the...Cardiovascular diseases(CVDs)remain the leading cause of death in the world and in most developed countries.Patients with type 2 diabetes mellitus(T2DM)suffer from both microvascular and macrovascular diseases and therefore have higher rates of morbidity and mortality compared to those without T2DM.If current trends continue,the Center for Disease Control and Prevention estimates that 1 in 3 Americans will have T2DM by year 2050.As a consequence of the controversy surrounding rosiglitazone and the increasing prevalence of diabetes and CVDs,in 2008 the Food and Drug Administration(FDA)established new expectations for the evaluation of new antidiabetic agents,advising for pre and,in some cases,post-marketing data on major cardiovascular events.As a direct consequence,there has been a paradigm shift in new antidiabetic agents that has given birth to the recently published American Diabetes Association/European Association for the Study of Diabetes consensus statement recommending sodium-glucose cotransporter-2 inhibitors(SGLT2i)and glucagon like peptide-1 receptor agonists(GLP-1RA)in patients with T2DM and established CVD.As a result of over a decade of randomized placebo controlled cardiovascular outcome trials,the aforementioned drugs have received FDA approval for risk reduction of cardiovascular(CV)events in patients with T2DM and established CV disease.SGLT2i have been shown to have a stronger benefit in patients with congestiveheart failure and diabetic kidney disease when compared to their GLP-1RA counterparts.These benefits are not withstanding additional considerations such as cost and the multiple FDA Black Box warnings.This topic is currently an emerging research area and this mini-review paper examines the role of these two novel classes of drugs in patients with T2DM with both confirmed,and at risk for,CVD.展开更多
Prolongation of the QT interval is associated with adverse cardiac events specifically Torsades de pointes(TdP).There are multiple mediations that have a known,possible,or conditional risk for prolonged QT interval,bu...Prolongation of the QT interval is associated with adverse cardiac events specifically Torsades de pointes(TdP).There are multiple mediations that have a known,possible,or conditional risk for prolonged QT interval,but general practitioners’knowledge of these medications is unknown.We conducted a survey to assess internal medicine(IM)providers’knowledge of risk factors and medications associated with prolonged QT as well as provider experience and comfort when treating patients with prolonged QT.A 17-question,anonymous survey was constructed in 2019 and distributed to IM providers and residents at a tertiary care center.Questions included demographic information,6 Likert-scale questions gauging provider experience with prolonged QT,and 10 multiple choice clinical vignettes to assess clinical knowledge.Data was analyzed descriptively.Knowledge was assessed via clinical vignettes and compared by level of training.Forty-one responses were received out of a total of 87 possible respondents(47.1%response rate).About 70%of respondents see patients with acquired prolonged QT once monthly or more.95%rarely see congenital prolonged QT.When presented with QTc drug issues,73%of providers seldom or sometimes consulted pharmacy,but about half used online resources.The average correct score on the clinical vignettes was 5.59/10,with the highest scores seen in attending physicians in their first five years of practice(6.96/10).Our survey suggests that IM providers commonly encounter QT prolonging drugs.Educational efforts to improve knowledge of drug and patient risk factors for TdP may be needed.展开更多
<strong>Aim:</strong> To evaluate the efficacy and safety of intraluminal lithotripsy with a pneumatic lithotripter (EMS, Switzerland) and laser Holmium YAG in retrograde rigid ureteroscopy for proximal an...<strong>Aim:</strong> To evaluate the efficacy and safety of intraluminal lithotripsy with a pneumatic lithotripter (EMS, Switzerland) and laser Holmium YAG in retrograde rigid ureteroscopy for proximal and distal ureteric calculi. <strong>Materials and Methods:</strong> This was a retrospective study carried out from January 2015 to December 2019 including 175 patients with ureteric calculi who presented with ureteric colic at a mini-invasive surgical urological center in Douala, Cameroon. All the patients underwent retrograde ureteroscopy with a 7F rigid ureteroscope, and fragmentation was done with either a pneumatic lithotripter or a laser holmium YAG. Six patients who had urinary tract infection benefited from double J stent placement before retrograde ureteroscopy. The study variables included age, clinical symptoms, size and location of the stone, the type of lithotripsy, operating time, and the results of lithotripsy. <strong>Results:</strong> We included a total of 175 patients with a mean age of 40.95 ± 12.50 years. Seventy-six (43.43%) of our participants were females and all patients had at least one calculus confirmed by a CT scan. Stone sizes ranged from 5 - 26 mm (median of 12 mm). Fifteen (8.57%) stones were located in the upper ureter (pyeloureteric junction), 64 in the middle ureter, 20 in the iliac ureter, 43 in the pelvic ureter, and 33 at the vesico-ureteric orifice. The success rate was 100% for stones located in the iliac ureter, pelvic ureter and the ureteric orifice. For those in the middle and upper ureter, the success rate was 92.18% and 60%, respectively. <strong>Conclusion:</strong> Rigid ureteroscopy is an excellent treatment modality for ureteral calculi, especially those located at the distal part of the ureter. The procedure is associated with a shorter operation time and a shorter post-operative hospitalization period, in addition to its safety and effectiveness compared to open surgery.展开更多
Foreign body ingestion encompasses both foreign object ingestion(FOI) and esophageal food impaction(EFI) and represents a common and clinically significant scenario among patients of all ages. The immediate risk to th...Foreign body ingestion encompasses both foreign object ingestion(FOI) and esophageal food impaction(EFI) and represents a common and clinically significant scenario among patients of all ages. The immediate risk to the patient ranges from negligible to life-threatening, depending on the ingested substance,its location, patient fitness, and time to appropriate therapy. This article reviews the FOI and EFI literature and highlights important considerations and implications for pediatric and adult patients as well as their providers. Where published literature is insufficient to provide evidence-based guidance, expert opinion is included to supplement the content of this comprehensive review.展开更多
文摘BACKGROUND:Maxillofacial trauma represents a significant challenge in emergency medicine,requiring both diagnostic accuracy and prompt intervention while balancing immediate life-saving interventions with preservation of function and aesthetics.The complex anatomy of this region,with its proximity to critical structures,demands a thorough understanding of assessment and management principles.This narrative review aims to provide evidence-based guidelines for emergency physicians managing maxillofacial trauma,with particular emphasis on early recognition of critical injuries,airway management strategies,and special population considerations.METHODS:A narrative review was conducted via a comprehensive literature search of the PubMed and Scopus databases,which focused on maxillofacial trauma management in emergency settings.Articles were selected based on relevance to clinical practice,methodological quality,and current management guidelines.The review synthesized evidence from multiple study types,including original research,systematic reviews,and clinical practice guidelines,to provide practical guidance for emergency physicians.RESULTS:Initial assessment following Advanced Trauma Life Support(ATLS)principles is crucial,with airway management being a primary concern due to the risk of dynamic obstruction.Critical time-sensitive emergencies include orbital compartment syndrome,trapdoor fractures(in pediatric patients),and facial nerve injuries.Computed tomography(CT)imaging remains the gold standard for diagnosis.Special considerations are required for pediatric patients,who present unique anatomical challenges and injury patterns,and for elderly patients,who often have complex medical comorbidities and increased complication risks.Management strategies range from conservative treatment to urgent surgical intervention,with decisions based on the injury pattern and associated complications.CONCLUSION:Emergency physicians must maintain a structured yet fl exible approach to maxillofacial trauma,focusing on early recognition of critical injuries,appropriate airway management,and timely specialist consultation.Understanding injury patterns and their potential complications allows for eff ective risk stratifi cation and treatment planning,ultimately improving patient outcomes.
文摘BACKGROUND Gastric antral vascular ectasia(GAVE)accounts for up to 4%of nonvariceal upper gastrointestinal bleeding.Argon plasma coagulation and radiofrequency ablation have been primary treatment modalities for patients with linear and punctate subtypes,with a newer trend of utilization of endoscopic band ligation(EBL).This study evaluates the outcomes of patients undergoing treatment for nodular GAVE.We hypothesize that patients treated initially with EBL will achieve higher rates of clinical remission with fewer endoscopic treatments and a shorter treatment interval.AIM To investigate the effects of EBL as an initial treatment therapy on outcomes associated with nodular GAVE.METHODS A total of 37 patients at a tertiary medical center with nodular GAVE were included in this retrospective study.The study population was divided between those treated initially with EBL(initial EBL)and initial endoscopic thermal therapy.Pretreatment and post-treatment hemoglobin values,the model for end-stage liver disease scores,hospitalization rates,and other outcomes.Additionally,endoscopic treatment modality type and frequency were recorded,including radiofrequency ablation,argon plasma coagulation,and EBL.Continuous variables were compared using a t-test,while categorical variables were compared using Fisher’s exact.RESULTS Linear regression analysis displayed a positive relationship between the time interval from initial therapeutic esophagogastroduodenoscopy to first EBL treatment and overall treatment interval(t=7.39,P<0.001),as well as between the number of endoscopic treatments(t=8.09,P<0.001).Hemoglobin levels increased in both the initial EBL group(8.7 vs 11.4,P<0.001)and the initial endoscopic thermal therapy group(8.6 vs 10.4,P=0.042).Clinical remission rates were higher in the initial EBL group(90%vs 69%P=0.041),with a non-significant trend of higher endoscopic remission rates(57.1%vs 37.5%,P=0.270).CONCLUSION The observed trend favoring EBL,combined with its association with improved clinical remission and reduced treatment burden,supports its consideration as a preferred initial treatment approach.
文摘BACKGROUND There is increasing incidence of alcohol-associated liver disease in females.Despite this recent increased incidence,there is a paucity of research on the clinical course and outcomes of alcohol-associated hepatitis(AH)in females compared to males.AIM To assess if there may be sex differences in severity,outcomes,and healthcare utilization for patients hospitalized for AH.METHODS This study used ICD-9-CM and ICD-10-CM codes to retrospectively identify inpatient encounters for AH at the University of Kentucky from 2012-2021 and obtained data on patient demographics and clinical outcomes.Encounters were cohorted by patient sex and differences in patient demographics and clinical outcomes were assessed.Multivariate logistic regression models were constructed to assess risk of mortality,sepsis,and mechanical ventilation during the encounter.RESULTS Of 1386 subjects,511(36.9%)were female and 875(63.1%)were male.Both sexes had similar baseline characteristics of race/ethnicity,discriminant function score,model of end-stage liver disease score,and length of hospital stay.However,the incidence of urinary tract infection,sepsis,and norepinephrine administration was significantly higher for females.Males had a significantly higher incidence of esophageal variceal bleed.On multivariate logistic regression analysis,females had higher odds of encounter sepsis(OR 1.41;95%CI:1.064-1.869)and mechanical ventilation(OR 1.352;95%CI:1.006-1.816).Odds of encounter mortality were significantly increased in encounters with sepsis(OR 2.309;95%CI:1.419-3.757)and mechanical ventilation(OR 9.301;95%CI:5.724-15.114).CONCLUSION This study shows sex-based differences in AH outcomes at the University of Kentucky.Future studies are warranted to assess whether tailoring treatments will improve clinical outcomes in females with AH.
文摘BACKGROUND:BRASH syndrome(Bradycardia,Renal failure,AV nodal blockade,Shock,and Hyperkalemia)is a recently described clinical entity characterized by synergistic interaction between AV nodal blocking medications and hyperkalemia.Despite increasing recognition,its clinical characteristics,risk factors,and outcomes remain poorly defined.The rationale of this review is to provide clinicians an upto-date overview of the most commonly encountered risk factors,triggers,clinical pictures,usual lab values,complications and outcomes,via the systemic analysis of currently published cases.METHODS:A systematic review was conducted using MEDLINE,Web of Science,and Cochrane Library databases through December 2024.Case reports,case series,and conference abstracts involving adult patients with BRASH syndrome were included.Data extraction focused on demographics,clinical presentations,laboratory findings,management strategies,and outcomes.RESULTS:Analysis included 131 patients from 111 published cases.Mean age was(71±13)years,with female predominance(58.1%).Hypertension(77.0%),chronic kidney disease(48.4%),and diabetes mellitus(46.7%)were the most common comorbidities.Beta-blockers were the predominant medication(76.5%).Most common presenting symptoms were syncope(17.9%),generalized weakness(16.2%),and altered mental status(11.9%).Mean potassium level was 6.6 mEq/L,with more than half of cases presenting with non-severe hyperkalemia(<6.5 mEq/L).Management often required multimodal therapy,with 50.8% of patients requiring vasopressors and 31.6% requiring hemodialysis.CONCLUSION:This systematic review provides the most comprehensive analysis of BRASH syndrome to date,demonstrating that while potentially serious,outcomes are generally favorable with appropriate recognition and management.The syndrome can develop even with modest hyperkalemia,particularly in elderly patients with multiple comorbidities.Early recognition and systematic management addressing all components of the syndrome appear crucial for optimal outcomes.
文摘BACKGROUND Liver imaging and transient elastography(TE)are both tools used to assess liver fibrosis and steatosis among people with hepatitis C virus(HCV)infection.However,the diagnostic accuracy of conventional imaging in detecting fibrosis and steatosis in this patient population remains unclear.AIM To investigate the correlation between steatosis and fibrosis and abnormal findings on liver imaging in patients with HCV.METHODS We conducted a retrospective cross-sectional analysis of patients with HCV at Grady Liver Clinic who had TE exams between 2018-2019.We analyzed the correlation of controlled attenuation parameter and liver stiffness measurement on TE and abnormal findings on liver imaging.Liver imaging findings(hepatic steatosis,increased echogenicity,cirrhosis,and chronic liver disease)were further evaluated for their diagnostic performance in detecting fibrosis(≥F2,≥F3,≥F4)and steatosis(≥S1,≥S2,≥S3).RESULTS Of 959 HCV patients who underwent TE,651 had liver imaging.Higher controlled attenuation parameter scores were observed in patients with abnormal liver findings(P=0.0050),hepatic steatosis(P<0.0001),and increased echogenicity(P<0.0001).Higher liver stiffness measurement values were also noted in those with abnormal liver(P<0.0001)and increased echogenicity(P=0.0026).Steatosis severity correlated with hepatic steatosis(r=0.195,P<0.001)and increased echogenicity(r=0.209,P<0.001).For fibrosis detection,abnormal liver imaging had moderate sensitivity(81.7%)and specificity(70.4%)for cirrhosis(≥F4),while cirrhosis on imaging had high specificity(99.2%)but low sensitivity(18.3%).Increased echogenicity showed high specificity(92.8%)but low sensitivity(20.9%)for steatosis detection.CONCLUSION Liver imaging detects advanced fibrosis and steatosis but lacks early-stage sensitivity.Integrating TE with imaging may improve evaluation in patients with HCV.
文摘BACKGROUND Giant cell tumor of bone(GCTB)is a rare,locally aggressive neoplasm that should be treated surgically,whenever possible.This treatment approach may be linked with greater morbidity besides functional impairment.Denosumab is a human monoclonal antibody.Its administration inhibits bone resorption and has become part of the therapeutic armamentarium against GCTB,as it allows local control with a view to downstaging for a more conservative surgical procedure.However,there is no consensus in the literature regarding the optimal denosumab regimen for GCTB.Therefore,a wide discussion of denosumab regimen is necessary.AIM To assess the effectiveness of various therapy protocols employing denosumab in individuals with GCTB.METHODS A broad and systematic literature search was carried out using the PRISMA guidelines.We analyzed studies that reported skeletally mature patients with GCTB regardless of sex or ethnicity treated with denosumab.Articles with fewer than five patients and in languages except Spanish,Portuguese and English were excluded.Statistical analysis with proportion meta-analysis was performed due to the dichotomous nature of the data.RESULTS 1005 articles were screened,of which 26 articles met the inclusion criteria and were selected,totaling 1742 patients,51.8%women and 48.2%men,with an average of 35 years of age.Treatment with denosumab was associated with high rates of clinical benefit(CB)and imaging response(IR),without changing local recurrence rates when compared to patients treated without denosumab,regardless of the therapeutic regimen adopted and the number of doses applied.The adverse events(AE)presented were mostly mild,with the exception of a malignant transformation to osteosarcoma.CONCLUSION Treatment of GCTB with denosumab is effective,showing high rates of CB and IR.The AE that occurred were mostly mild.We found no differences between the articles considering the researched outcomes regardless of the therapeutic regimen adopted.
文摘Hepatocellular carcinoma(HCC) makes up 75%-85% of all primary liver cancers and is the fourth most common cause of cancer related death worldwide. Chronic liver disease is the most significant risk factor for HCC with 80%-90% of new cases occurring in the background of cirrhosis. Studies have shown that early diagnosis of HCC through surveillance programs improve prognosis and availability of curative therapies. All patients with cirrhosis and high-risk hepatitis B patients are at risk for HCC and should undergo surveillance. The recommended surveillance modality is abdominal ultrasound(US) given that it is cost effective and noninvasive with good sensitivity. However, US is limited in obese patients and those with non-alcoholic fatty liver disease(NAFLD). With the current obesity epidemic and rise in the prevalence of NAFLD, abdominal computed tomography or magnetic resonance imaging may be indicated as the primary screening modality in these patients. The addition of alpha-fetoprotein to a surveillance regimen is thought to improve the sensitivity of HCC detection.Further investigation of serum biomarkers is needed. Semiannual screening is the suggested surveillance interval. Surveillance for HCC is underutilized and low adherence disproportionately affects certain demographics such as nonCaucasian race and low socioeconomic status.
文摘Primary sclerosing cholangitis(PSC) is a rare cholestatic liver disease characterized by progressive fibroinflammatory destruction of the intra-and/or extrahepatic biliary ducts. While its features and disease course can be variable,most patients with PSC have concurrent inflammatory bowel disease and will eventually develop liver cirrhosis and end-stage liver disease, with liver transplantation representing the only potentially curative option. Importantly,PSC is associated with a significantly increased risk of malignancy compared to the general population, mainly cholangiocarcinoma, gallbladder carcinoma,hepatocellular carcinoma, and colorectal cancer, with nearly 50% of deaths in patients with PSC being due to cancer. Therefore, robust surveillance strategies are needed, though uncertainty remains regarding how to best do so. In this review, we discuss the epidemiology, prevention, and surveillance of cancers in patients with PSC. Where evidence is limited, we present pragmatic approaches based on currently available data and expert opinion.
文摘Background Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly.It is related to unfavorable outcomes in various cardiovascular conditions.We conducted a systematic review and meta-analysis of the association of frailty with all-cause mortality and bleeding after acute myocardial infarction(AMI)in the elderly.Methods We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2019.The studies that reported mortality and bleeding in AMI patients who were evaluated and classified by frailty status were included.Data from each study were combined using the random-effects,generic inverse variance method of Der Simonian and Laird to calculate hazard ratio(HR),and 95%confidence interval(CI).Results Twenty-one studies from 2011 to 2019 were included in this meta-analysis involving 143,301 subjects(mean age 75.33-year-old,60.0%male).Frailty status was evaluated using different methods such as Fried Frailty Index.Frailty was statistically associated with increased early mortality in nine studies(pooled HR=2.07,95%CI:1.67-2.56,P<0.001,I^2=41.2%)and late mortality in 11 studies(pooled HR=2.30,95%CI:1.70-3.11,P<0.001,I^2=65.8%).Moreover,frailty was also statistically associated with higher bleeding in 7 studies(pooled HR=1.34,95%CI:1.12-1.59,P<0.001,I^2=4.7%).Conclusion Frailty is strongly and independently associated with bleeding,early and late mortality in elderly with AMI.Frailty assessment should be considered as an additional risk factor and used to guide toward personalized treatment strategies.
文摘Inflammatory fibroid polyp(IFP) is a rare,idiopathic pseudotumorous lesion of the gastrointestinal tract.While mostly reported as solitary gastric lesions,multiple cases of small bowel IFPs are also reported.It is a documented cause of intussusception in adults.In the case reports of ileal inflammatory fibroid polyps with intussusception,an emergent presentation with small bowel obstruction has been most often described.Here we depict a case of ileal inflammatory fibroid polyp presenting with chronic intermittent ileocolic intussusception,anemia and weight loss with an endoscopic appearance mimicking necrotic cecal carcinoma.
基金The University of Arizona Hematology and Medical Oncology Fellowship program
文摘BACKGROUND Gastrointestinal cancer(GICA)is associated with a higher incidence of venous thromboembolism(VTE)compared to other solid tumors,moreover,recurrent VTE and major bleeding(MB)complications during anticoagulation treatment have an associated increase rate.GICA-VTE remains a challenging clinical scenario with MB concerns for utilization of direct oral anticoagulants(DOAC),especially with active cancer therapies.AIM To evaluate patient risk factors,effectiveness(VTE)and safety(MB)of DOACs and low molecular weight heparin(LMWH)in patients with active GICA-VTE.METHODS A retrospective chart review of patients receiving DOACs and LMWH with GICA and symptomatic or incidental VTE treated at comprehensive cancer center from November 2013 to February 2017 was performed.Inclusion criteria included active GI cancer diagnosed at any stage or treatment+/-6 mo of VTE diagnosis,whom were prescribed 6 mo or more of DOACs or LMWH.The Chi-squared test was used for overall and the Fisher exact test for pairwise comparisons of the proportions of patients experiencing recurrent VTE and MB events.Odds ratios were used to compare the relative odds of the occurrence of the outcome given exposure to the risk factor.RESULTS A total of 144 patients were prescribed anticoagulation,in which 106 fulfilled inclusion criteria apixaban(27.3%),rivaroxaban(34.9%)and enoxaparin(37.7%),and 38 were excluded.Patients median age was 66.5 years at GICA diagnosis and 67 years at CAVTE event,with 62%males,80%Caucasian,70%stage IV,pancreatic cancer(40.5%),30%Khorana Score(≥3 points),and 43.5%on active chemotherapy.Sixty-four percent of patients completed anticoagulation therapy(range 1 to 43 mo).Recurrent VTE at 6 mo was noted in 7.5%(n=3),6.8%(n=2)and 2.7%(n=1)of patients on enoxaparin,apixaban and rivaroxaban,respectively(all P=NS).MB at 6 mo were 5%(n=2)for enoxaparin,6.8%(n=2)for apixaban and 21.6%(n=8)for rivaroxaban(overall P=0.048;vs LMWH P=0.0423;all other P=NS).Significant predictors of a primary or secondary outcome for all anticoagulation therapies included:Active systemic treatment(OR=5.1,95%CI:1.3-19.3),high Khorana Score[≥3 points](OR=5.5,95%CI:1.7-17.1),active smoker(OR=6.7,95%CI:2.1-21.0),pancreatic cancer(OR=6.8,95%CI:1.9-23.2),and stage IV disease(OR=9.9,95%CI:1.2-79.1).CONCLUSION Rivaroxaban compared to apixaban and enoxaparin had a significantly higher risk of MB on GICA-VTE patients with equivocal efficacy.
文摘Myocarditis is a disease process that every emergency physician fears missing.Its severity can be mild to life-threatening,and many cases are likely undetected because they are subclinical with nonspecifi c signs.[1]Subtle cardiac signs may be overshadowed by systemic symptoms of the underlying infectious process.Fever,myalgias,lethargy,symptoms commonly associated with viral syndrome,can mask the life-threatening myocarditis that may be present.In fact,in the United States Myocarditis Treatment Trial,almost 90%of patients reported symptoms consistent with a viral prodrome.[2]Ammirati et al[3]reported that 27%of patients with myocarditis had either reduced left ventricular ejection fraction,ventricular arrhythmias,or low cardiac output.Here,we present a case report,in which handheld point-of-care ultrasound was utilized at the bedside to aid in the critical diagnosis of myocarditis.With the additional information provided through this imaging modality,this patient was able to be transferred to the appropriate tertiary care facility in an expeditious manner and receive possible defi nitive treatment.
文摘AIM To evaluate the safety and efficacy of ledipasvir/sofosbuvir on hepatitis C eradication in patients with hepatitis C virus(HCV)/human immunodeficiency virus(HIV) co-infection in an urban HIV clinic.METHODS A retrospective cohort study of 40 subjects co-infected with HIV-1 and HCV treated with the fixed-dose combination of ledipasvir and sofosbuvir for 12 wk from 2014 to 2016.All patients included were receiving antiretroviral therapy(ART) with HIV RNA values of 100 copies/m L or fewer regardless of baseline HCV RNA level.The primary end point was a sustained virologic response of HCV at 12 wk(SVR12) after the end of therapy.RESULTS Of the 40 patients enrolled,55% were black,22.5% had been previously treated for HCV,and 25% hadcirrhosis.The patients were on a wide range of ART.Overall,39 patients(97.5%) had a SVR 12 after the end of therapy,including rates of 97.1% in patients with HCV genotype 1 a and 100% in those with HCV genotype 1 b.One patient with HCV genotype 3 a was included and achieved SVR12.Rates of SVR12 were similar regardless of previous treatment or the presence of compensated cirrhosis.Only 1 patient experienced relapse at week 12 following treatment and deep sequencing didn't reveal any resistance associated mutation in the NS5A or NS5B region.Interestingly,7(17.5%) patients who were adherent to ART experienced HIV viral breakthrough which resolved after continuing the same ART regimen.Two(5%) patients experienced HIV-1 virologic rebound due to noncompliance with HIV therapy,which resolved after resuming the same ART regimen.No severe adverse events were observed and no patient discontinued treatment because of adverse events.The most common adverse events included headache(12.5%),fatigue(10%),and diarrhea(2.5%).CONCLUSION This retrospective study demonstrated the high rates of SVR12 of ledipasvir/sofosbuvir on HCV eradication in patients co-infected with HCV and HIV,regardless of HCV baseline levels,HCV treatment history or cirrhosis condition.The oral combination of ledipasvir/sofosbuvir represents a safe and well tolerated HCV treatment option that does not require modification for many of the common HIV ART.Occasional HIV virologic rebound occurred but later resolved without the need to change ART.
文摘BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction(STEMI)improves outcomes. System delay is that between first medical contact and reperfusion therapy,comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore.METHODS: A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services(EMS),ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique.RESULTS: Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5minutes(interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes(IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes(IQR=1.30, 22.13); between arrival-at- and departurefrom-patient-location was 13.12 minutes(IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes(IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulancedispatch and arrival-at-patient-location was shorter(5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter(10.78 vs.14.37 minutes, P<0.01).CONCLUSION: Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.
文摘Cardiovascular diseases(CVDs)remain the leading cause of death in the world and in most developed countries.Patients with type 2 diabetes mellitus(T2DM)suffer from both microvascular and macrovascular diseases and therefore have higher rates of morbidity and mortality compared to those without T2DM.If current trends continue,the Center for Disease Control and Prevention estimates that 1 in 3 Americans will have T2DM by year 2050.As a consequence of the controversy surrounding rosiglitazone and the increasing prevalence of diabetes and CVDs,in 2008 the Food and Drug Administration(FDA)established new expectations for the evaluation of new antidiabetic agents,advising for pre and,in some cases,post-marketing data on major cardiovascular events.As a direct consequence,there has been a paradigm shift in new antidiabetic agents that has given birth to the recently published American Diabetes Association/European Association for the Study of Diabetes consensus statement recommending sodium-glucose cotransporter-2 inhibitors(SGLT2i)and glucagon like peptide-1 receptor agonists(GLP-1RA)in patients with T2DM and established CVD.As a result of over a decade of randomized placebo controlled cardiovascular outcome trials,the aforementioned drugs have received FDA approval for risk reduction of cardiovascular(CV)events in patients with T2DM and established CV disease.SGLT2i have been shown to have a stronger benefit in patients with congestiveheart failure and diabetic kidney disease when compared to their GLP-1RA counterparts.These benefits are not withstanding additional considerations such as cost and the multiple FDA Black Box warnings.This topic is currently an emerging research area and this mini-review paper examines the role of these two novel classes of drugs in patients with T2DM with both confirmed,and at risk for,CVD.
文摘Prolongation of the QT interval is associated with adverse cardiac events specifically Torsades de pointes(TdP).There are multiple mediations that have a known,possible,or conditional risk for prolonged QT interval,but general practitioners’knowledge of these medications is unknown.We conducted a survey to assess internal medicine(IM)providers’knowledge of risk factors and medications associated with prolonged QT as well as provider experience and comfort when treating patients with prolonged QT.A 17-question,anonymous survey was constructed in 2019 and distributed to IM providers and residents at a tertiary care center.Questions included demographic information,6 Likert-scale questions gauging provider experience with prolonged QT,and 10 multiple choice clinical vignettes to assess clinical knowledge.Data was analyzed descriptively.Knowledge was assessed via clinical vignettes and compared by level of training.Forty-one responses were received out of a total of 87 possible respondents(47.1%response rate).About 70%of respondents see patients with acquired prolonged QT once monthly or more.95%rarely see congenital prolonged QT.When presented with QTc drug issues,73%of providers seldom or sometimes consulted pharmacy,but about half used online resources.The average correct score on the clinical vignettes was 5.59/10,with the highest scores seen in attending physicians in their first five years of practice(6.96/10).Our survey suggests that IM providers commonly encounter QT prolonging drugs.Educational efforts to improve knowledge of drug and patient risk factors for TdP may be needed.
文摘<strong>Aim:</strong> To evaluate the efficacy and safety of intraluminal lithotripsy with a pneumatic lithotripter (EMS, Switzerland) and laser Holmium YAG in retrograde rigid ureteroscopy for proximal and distal ureteric calculi. <strong>Materials and Methods:</strong> This was a retrospective study carried out from January 2015 to December 2019 including 175 patients with ureteric calculi who presented with ureteric colic at a mini-invasive surgical urological center in Douala, Cameroon. All the patients underwent retrograde ureteroscopy with a 7F rigid ureteroscope, and fragmentation was done with either a pneumatic lithotripter or a laser holmium YAG. Six patients who had urinary tract infection benefited from double J stent placement before retrograde ureteroscopy. The study variables included age, clinical symptoms, size and location of the stone, the type of lithotripsy, operating time, and the results of lithotripsy. <strong>Results:</strong> We included a total of 175 patients with a mean age of 40.95 ± 12.50 years. Seventy-six (43.43%) of our participants were females and all patients had at least one calculus confirmed by a CT scan. Stone sizes ranged from 5 - 26 mm (median of 12 mm). Fifteen (8.57%) stones were located in the upper ureter (pyeloureteric junction), 64 in the middle ureter, 20 in the iliac ureter, 43 in the pelvic ureter, and 33 at the vesico-ureteric orifice. The success rate was 100% for stones located in the iliac ureter, pelvic ureter and the ureteric orifice. For those in the middle and upper ureter, the success rate was 92.18% and 60%, respectively. <strong>Conclusion:</strong> Rigid ureteroscopy is an excellent treatment modality for ureteral calculi, especially those located at the distal part of the ureter. The procedure is associated with a shorter operation time and a shorter post-operative hospitalization period, in addition to its safety and effectiveness compared to open surgery.
文摘Foreign body ingestion encompasses both foreign object ingestion(FOI) and esophageal food impaction(EFI) and represents a common and clinically significant scenario among patients of all ages. The immediate risk to the patient ranges from negligible to life-threatening, depending on the ingested substance,its location, patient fitness, and time to appropriate therapy. This article reviews the FOI and EFI literature and highlights important considerations and implications for pediatric and adult patients as well as their providers. Where published literature is insufficient to provide evidence-based guidance, expert opinion is included to supplement the content of this comprehensive review.
