Characteristics and in-hospital outcomes of female patients presenting with ST-segment-elevation myocardial infarction without standard modifiable cardiovascular risk factors.

BACKGROUND: Standard Modifiable Cardiovascular Risk Factors (SMuRF) such as hypertension, diabetes mellitus, hyperlipidemia, and smoking have long been established in the etiology of atherosclerotic disease. We evaluate in-hospital outcomes of female STEMI patients without these risk factors. METHODS: The National Inpatient Sample databases (2016 to 2021) were queried to identify STEMI admissions as a principal diagnosis using ICD 10 codes. Patients with a history of coronary artery disease, myocardial infarction, coronary bypass graft, percutaneous coronary intervention, takotsubo cardiomyopathy, cocaine abuse, and spontaneous coronary dissection and males were excluded from our study population. A final study population aged >18 years was divided into cohorts of SMuRF and SMuRF-less based on the presence of ≥1 risk factor. Multivariate logistic regression model adjusting for baseline characteristics and comorbidities. The primary outcome was in-hospital mortality. The secondary outcomes are STEMI-related complications and the use of mechanical circulatory support devices. RESULTS: 200,980 patients were identified. 187,776 (93.4 %) patients were identified as having ≥1 SMuRF, and 13,205 (6.6 %) patients were SMuRF-less. Compared to SMuRF patients, SMuRF-less patients are more likely to be white (75.6 % vs. 73.1 %, p < 0.01) and older median age (69 years [IQR: 58-78] vs 67 years [IQR: 57-81], p < 0.01). In comparing co-morbidities, SMuRF-less patients were less likely to have heart failure (28.0 % vs. 23.4 %, p < 0.01), atrial fibrillation/flutter (16.1 % vs. 14.6 %, p = 0.03), chronic pulmonary disease (18.9 % vs. 9.5 %, p < 0.01), obesity (20.7 % vs. 9.2 %, p < 0.01) and aortic disease (1.1 % vs. 0.6 %, p < 0.01). They were however more likely to have dementia (6.9 % vs. 5.7 %, p < 0.01). In evaluating outcomes, SMuRF-less patients had higher in-hospital mortality (aOR 3.2 [95 % CI, 2.9-3.6]; p < 0.01), acute heart failure (aOR 1.6 [95 % CI, 1.4-1.8]; p < 0.01), acute kidney injury (aOR 1.8 [95 % CI, 1.7-2.1]; p < 0.01), and Intra-aortic balloon pump (aOR 1.7 [95 % CI, 1.5-1.9]; p < 0.01). Predictors of higher mortality in SMuRF-less patients include chronic liver disease (OR 6.8, CI 2.4-19.4, p < 0.01), and Hispanic race (OR 1.62, CI 1.1-2.5, p < 0.01). We also found that SMuRF-less patients were less likely to undergo coronary angiography (aOR 0.5 [95 % CI, 0.4-0.5]; p < 0.01) and percutaneous coronary intervention (aOR 0.7 [95 % CI, 0.6-0.8]; p < 0.01). CONCLUSION: Female SMuRF-less patients presenting with STEMI have worse in-hospital outcomes when compared to patients with ≥1SMuRF.

An Unlikely Case of Blastomycosis in an Elderly Female: A Diagnostic Challenge in a Non-endemic Region.

Blastomyces dermatitidis is a fungus typically found in the soil of endemic regions such as the Midwest, concentrating in areas like Ohio, Mississippi, and the Great Lakes area. The systemic infection caused by inhaling Blastomyces dermatitidis is known as blastomycosis. The frequency of blastomycosis in non-endemic regions is increasing for a variety of speculated reasons, such as higher rates of immunosuppressed individuals and possible climate. Due to clinician unfamiliarity, misdiagnosis of blastomycosis is common, which potentiates worsening systemic infections. This study shows the clinical course of a patient with blastomycosis in a non-endemic region, highlighting the need for education for clinicians in non-endemic areas. A 72-year-old female with a history of chronic obstructive pulmonary disease (COPD), coronary artery disease, a 47-year smoking history, and hypertension presented for outpatient management of COPD. CT three months prior to presentation showed nodular opacities in the lungs. A bronchoscopy was performed and revealed negative findings for malignancy or infection; the patient developed worsening symptoms leading to hospitalization. Subsequent testing revealed Blastomyces dermatitidis. She was promptly treated with a six to 12-month course of itraconazole with close follow-up. The study highlights the need not to rule out causes of infection based on location. Blastomycosis can resemble community-acquired pneumonia. Making the correct diagnosis is paramount, as delays can result in morbidity. Fungal cultures may be the gold standard, but due to the long culture time, there need to be other diagnostic tests like urine antigen testing. This study highlights the need to increase awareness of clinicians who experience blastomycosis patients in a non-endemic region.

Superficial Venous Disease-An Updated Review.

BACKGROUND: This review article provides an updated review of a relatively common pathology with various manifestations. Superficial venous diseases (SVDs) are a broad spectrum of venous vascular disease that predominantly affects the body's lower extremities. The most serious manifestation of this disease includes varicose veins, chronic venous insufficiency, stasis dermatitis, venous ulcers, superficial venous thrombosis, reticular veins, and spider telangiectasias. METHODS: The anatomy, pathophysiology, and risk factors of SVD were discussed during this review. The risk factors for developing SVD were related to race, age, sex, lifestyle, and certain genetic conditions as well as comorbid deep vein thrombosis. Various classification systems were listed, focusing on the most common one-the revised Clinical-Etiology-Anatomy-Pathophysiology classification. The clinical features including history and physical examination findings elicited in SVD were outlined. RESULTS: Imaging modalities utilized in SVD were highlighted. Duplex ultrasound is the first line in evaluating SVD but magnetic resonance imaging and computed tomography venography, plethysmography, and conventional venography are feasible options in the event of an ambiguous venous duplex ultrasound study. Treatment options highlighted in this review ranged from conservative treatment with compression stockings, which could be primary or adjunctive to pharmacologic topical and systemic agents such as azelaic acid, diuretics, plant extracts, medical foods, nonsteroidal anti-inflammatory drugs, anticoagulants and skin substitutes for different stages of SVD. Interventional treatment modalities include thermal ablative techniques like radiofrequency ablationss, endovenous laser ablation, endovenous steam ablation, and endovenous microwave ablation as well as nonthermal strategies such as the Varithena (polidocanol microfoam) sclerotherapy, VenaSeal (cyanoacrylate) ablation, and Endovenous mechanochemical ablation. Surgical treatments are also available and include debridement, vein ligation, stripping, and skin grafting. CONCLUSIONS: SVDs are prevalent and have varied manifestations predominantly in the lower extremities. Several studies highlight the growing clinical and financial burden of these diseases. This review provides an update on the pathophysiology, classification, clinical features, and imaging findings as well as the conservative, pharmacological, and interventional treatment options indicated for different SVD pathologies. It aims to expedite the timely deployment of therapies geared toward reducing the significant morbidity associated with SVD especially varicose veins, venous ulcers, and venous insufficiency, to improve the quality of life of these patients and prevent complications.

Prenatal Choline Supplementation during High-Fat Feeding Improves Long-Term Blood Glucose Control in Male Mouse Offspring.

Maternal obesity increases the risk of metabolic dysregulation in rodent offspring, especially when offspring are exposed to a high-fat (HF), obesogenic diet later in life. We previously demonstrated that maternal choline supplementation (MCS) in HF-fed mouse dams during gestation prevents fetal overgrowth and excess adiposity. In this study, we examined the long-term metabolic influence of MCS. C57BL/6J mice were fed a HF diet with or without choline supplementation prior to and during gestation. After weaning, their pups were exposed to either a HF or control diet for 6 weeks before measurements. Prenatal and post-weaning dietary treatments led to sexually dimorphic responses. In male offspring, while post-weaning HF led to impaired fasting glucose and worse glucose tolerance (p < 0.05), MCS in HF dams (HFCS) attenuated these changes. HFCS (versus maternal normal fat control) appeared to improve metabolic functioning of visceral adipose tissue during post-weaning HF feeding, preventing the elevation in leptin and increasing (p < 0.05) mRNA expression of insulin receptor substrate 1 (Irs1) that promotes peripheral insulin signaling in male offspring. In contrast, MCS had minimal effects on metabolic outcomes of female offspring. In conclusion, MCS during HF feeding in mice improves long-term blood glucose homeostasis in male offspring when they are faced with a postnatal obesogenic environment.