Zero-Contrast Left Atrial Appendage Occlusion Using a Hybrid Echocardiography-Fluoroscopy Technique Without Iodinated Contrast.

Contrast exposure during left atrial appendage occlusion may be harmful in those with chronic kidney disease or allergy. This single-center registry (n = 31) demonstrates the feasibility and safety of zero-contrast percutaneous left atrial appendage occlusion using echocardiography, fluoroscopy, and fusion imaging, with 100% procedural success and no device complications at 45 days.

A Rare Case of Renal Thrombotic Microangiopathy and Focal Segmental Glomerulosclerosis Secondary to Plasma Cell Leukemia.

Plasma cell dyscrasias are a subset of hematological malignancies involving the production of monoclonal immunoglobulins. This spectrum of disorders includes asymptomatic conditions such as monoclonal gammopathy of unknown significance as well as extremely aggressive malignancies such as plasma cell leukemia. Monoclonal gammopathies are occasionally associated with renal failure, which can occur via many pathophysiological processes. The most common of these is light chain cast nephropathy, but many rare renal complications exist, including thrombotic microangiopathy (TMA) and focal segmental glomerulosclerosis (FSGS). Here, we report a patient with new renal failure with features of TMA and FSGS on biopsy and found to be secondary to plasma cell leukemia.

Vulvar Pruritus in Postmenopausal Diabetic Women With Candidiasis Secondary to Sodium-Glucose Cotransporter Receptor-2 Inhibitors.

We present a case series of recurrent vulvovaginal candidiasis (RVVC) secondary to sodium-glucose cotransporter receptor-2 (SGLT2) inhibitor-induced glucosuria in postmenopausal women that resulted in extensive vulvar skin involvement. We describe 5 cases of RVVC presenting primarily with vulvar pruritus and external rash, in type 2 diabetic, postmenopausal women on SGLT2 inhibitor therapy. This work was exempt from institutional review board approval in compliance with the university guidelines for determining human subject research. All patients consented to the use of pictures for educational and research purposes. All patients developed RVVC, with vulvar cultures positive for Candida albicans and resolution of symptoms after treatment with oral fluconazole. All patients presented primarily with severe vulvar pruritus that developed after beginning treatment with SGLT2 inhibitors (range: 4 wk­16 mo). Given the intermittent nature of symptoms, variable degree of activity at presentation, lack of vaginal discharge, atypical population, and extensive skin involvement, RVVC was not considered initially. Three patients were misdiagnosed with lichen sclerosus and treated with topical steroids, which may have allowed for disease progression. Two patients were prescribed topical estrogen creams for presumed vaginal atrophy. One patient was misdiagnosed with improper vulvar hygiene and neuropathic itch. Because of these diagnostic missteps, 4 patients endured symptomatically for extended periods (range: 2­6 years) without adequate treatment. Four patients have discontinued their SGLT2 inhibitor, all with resolution of vulvar symptoms. Postmenopausal, diabetic women taking SGLT2 inhibitors presenting with vulvar pruritus and rash require early evaluation for RVVC to prevent misdiagnoses and need for diabetic medication alterations.

Novel systemic treatments in atopic dermatitis: Are there sex differences?

Atopic dermatitis (AD) is a common inflammatory skin disease with a significant global disease burden. Several mechanisms underlie AD, such as epidermal barrier dysfunction and immune dysregulation, which have led to innovative systemic treatment options. Other inflammatory disorders, as well as innate and adaptive immune responses, have noted sex differences, but our article highlights a paucity of data on the impact of sex, gender, and gender identity on the pathophysiology and systemic treatments of AD.

Improving Readiness and Reducing Costs: An Analysis of Factors That Influence Site Selection for Army Outpatient Surgical Services.

EXECUTIVE SUMMARY: The variable costs of providing surgical procedures for military beneficiaries are greater when care is rendered in the civilian purchased care network than when provided at a direct care military treatment facility (MTF). To reduce healthcare-related costs, retaining surgical services is a priority at MTFs across the U.S. Army Medical Command. This study is the first to identify factors significantly associated with outpatient surgical service site selection in the military health system (MHS). We analyzed 1,000,305 patient encounters in fiscal year 2014, of which 970,367 were direct care encounters and 29,938 were purchased care encounters. We used multiple binomial logistic regression to assess and compare the odds of site selection at a purchased care facility and an MTF. We found that an increase in provider administrative time (OR = 1.024, p < .001) and an increase in case complexity (OR = 1.334, p < .001) were associated with increased odds that an outpatient surgical service was provided in a purchased care setting. The increased odds that highly complex cases were seen in purchased care has the potential to affect the medical readiness of military providers and the efficacy of graduate medical education programs. Healthcare administrators can use the results of this study to develop and implement MTF level policies to enhance outpatient surgical service practices in the Army medical system. These efforts may reduce costs and increase military provider medical readiness.