A Case Report of Subacute Infective Endocarditis Presenting With Extreme Weight Loss, Aortic Regurgitation, and Splenic Infarct.

We present an insightful case of a middle-aged male who presented to the emergency department (ED) with complaints of excessive weight loss, accompanied by shortness of breath and vomiting. Consequently, this case explores many facets of the pathophysiology of infective endocarditis (IE), including but not limited to the most heavily implicated microorganisms, symptoms, predispositions, and disease outcomes. IE is a pathology of variable presentation with uniquely extensive diagnostic criteria, making it a fascinating topic of medical discussion.

Contrast-Induced Encephalopathy and the Blood-Brain Barrier.

BACKGROUND: Contrast-induced encephalopathy (CIE) is an adverse event associated with diagnostic and therapeutic endovascular procedures. Decades of animal and human research support a mechanistic role for pathological blood-brain barrier dysfunction (BBBd). Here, we describe an institutional case series and review the literature supporting a mechanistic role for BBBd in CIE. METHODS: A literature review was conducted by searching MEDLINE, Web of Science, Embase, CINAHL and Cochrane databases from inception to January 31, 2022. We searched our institutional neurovascular database for cases of CIE following endovascular treatment of cerebrovascular disease during a 6-month period. Informed consent was obtained in all cases. RESULTS: Review of the literature revealed risk factors for BBBd and CIE, including microvascular disease, pathological neuroinflammation, severe procedural hypertension, iodinated contrast load and altered cerebral blood flow dynamics. In our institutional series, 6 of 52 (11.5%) of patients undergoing therapeutic neuroendovascular procedures developed CIE during the study period. Four patients were treated for ischemic stroke and two patients for recurrent cerebral aneurysms. Mechanical stenting or thrombectomy were utilized in all cases. CONCLUSION: In this institutional case series and literature review of animal and human data, we identified numerous shared risk factors for CIE and BBBd, including microvascular disease, increased procedure length, large contrast volumes, severe intraoperative hypertension and use of mechanical devices that may induce iatrogenic endothelial injury.

Coil migration through two flow-diverting stents.

We report a case of a patient who initially presented with a subarachnoid haemorrhage secondary to a ruptured supraclinoid internal carotid artery (ICA) blister aneurysm. The patient was treated successfully with a flow diverter stent (FD) and coiling; however, a large aneurysm recurrence via a feeding posterior communicating artery (PCOM) was noted on the 1-year follow-up angiogram. During the retreatment, a second FD in the ICA resulted in insufficient aneurysm stasis. Therefore, the decision was made to coil sacrifice the PCOM via posterior circulation access. During the first coil deployment, the distal coil end migrated through the mesh of two overlapping FD into the middle cerebral artery. This complication was a previously unrecognised possibility given the composition of the FD. This case report aims to discuss this process as a potential complication during neurointerventional procedures using these devices.

Phytochemicals for the prevention and treatment of pancreatic cancer: Current progress and future prospects.

Pancreatic cancer is the third leading cause of cancer-related deaths in the United States, owing to its aggressive nature and suboptimal treatment options, emphasizing the need for novel therapeutic approaches. Emerging studies have exhibited promising results regarding the therapeutic utility of plant-derived compounds (phytochemicals) in pancreatic cancer. The purpose of this review is to evaluate the potential of phytochemicals in the treatment and prevention of pancreatic cancer. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was applied to collect articles for this review. Scholarly databases, including PubMed, Scopus and ScienceDirect, were queried for relevant studies using the following keywords: phytochemicals, phenolics, terpenoids, alkaloids, sulfur-containing compounds, in vitro, in vivo, clinical studies, pancreatic cancer, tumour, treatment and prevention. Aggregate results pooled from qualified studies indicate phytochemicals can inhibit pancreatic cancer cell growth or decrease tumour size and volume in animal models. These effects have been attributed to various mechanisms, such as increasing proapoptotic factors, decreasing antiapoptotic factors, or inducing cell death and cell cycle arrest. Notable signalling pathways modulated by phytochemicals include the rat sarcoma/mitogen activated protein kinase, wingless-related integration site/ß-catenin and phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin signal transduction pathways. Clinically, phytochemicals have been found to increase survival while being well-tolerated and safe, though research is scarce. While these promising results have produced great interest in this field, further in-depth studies are required to characterize the anticancer activities of phytochemicals before they can be utilized to prevent or treat pancreatic cancer in clinical practice.

'Tiger woman sign' hypercalcaemia: a diagnostic challenge.

Hypercalcaemia is a common electrolyte abnormality with 90% of cases due to either primary hyperparathyroidism or malignancy. Other causes of hypercalcaemia often require careful consideration. We describe an approach to the assessment of hypercalcaemia, particularly where preliminary tests are inconclusive.This approach is illustrated by a case which posed a diagnostic challenge: a patient with significant hypercalcaemia due to acute atypical isolated sarcoid myositis. This case highlights an under-recognised clinical syndrome with distinct biochemical and radiological findings.

Lymphangioleiomyomatosis Presenting as Recurrent Pneumothorax.

Lymphangioleiomyomatosis (LAM) is a disorder that causes cystic disease in the lungs. This condition is associated with renal angiomyolipomas and commonly occurs in individuals with tuberous sclerosis. Despite its frequent association with tuberous sclerosis, LAM is a rare condition and is often underdiagnosed. An identification of the array of signs for LAM is necessary to start the patient on appropriate long-term guideline-directed medical therapy. A 24-year-old female patient with a past medical history of tuberous sclerosis, gestational hypertension, stable renal angiomyolipoma, and recent pneumothorax presented to our emergency department complaining of four weeks of productive cough. On presentation, she was found to have stable vital signs, and on examination, she had absent breath sounds in the right basilar and anterior mid-lung field compared to the left. Subsequent imaging confirmed a recurrence of pneumothorax from her visit three months prior to her current presentation as well as progressive cystic lung disease and an unchanged angiomyolipoma, suggestive of LAM. We present this article with the hope of raising the index of suspicion for LAM in the setting of the particular signs and symptoms and to encourage prompt stabilization of the patient and initiation of guideline-directed medical therapy and strict follow-up to provide the greatest possible improvement in the patient's quality of life.

Spontaneous Necrotizing Fasciitis.

Necrotizing soft tissue infections typically begin with direct inoculation of bacteria into the subcutaneous tissues. Here, we present a case with no such exposure, but with severe necrotizing fasciitis. We present a middle-aged man presented to the emergency department for a presumed allergic reaction after having initially sought care twice at an urgent care facility. The patient had swelling, but no tenderness of his right lateral chest and flank. Subsequent imaging showed extensive fluid in the fascial planes of the right chest wall requiring surgical debridement. Necrotizing fasciitis that is not treated with surgical debridement carries a mortality rate approaching 100%. This case highlights a potential atypical presentation as well as highlights the fact that the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score lacks sensitivity to rule out a necrotizing soft tissue infection, requiring surgical debridement for diagnosis.

Living bridges using aerial roots of ficus elastica - an interdisciplinary perspective.

Here we report on a pilot study of the Living Root Bridges (LRBs) in the Indian State Meghalaya, which are grown with aerial roots of Ficus elastica, a facultative hemiepiphyte developing abundant aerial roots. Locals use these aerial roots to build living bridges, which strengthen themselves over time due to adaptive secondary growth and their capacity to form a mechanically stable structure via inosculations. An extensive inventory of LRBs in Meghalaya including data of location, altitude, approximate age and bridge length was performed in field studies. Root morphology was characterised by measurements of cross-sectional area and shape-related parameters and analysed in relation to the orientation of the roots. LRBs are found to occur mainly in the mountainous limestone rainforests where F. elastica may be native or traditionally cultivated. They cover an altitude range of 57-1211 m a.m.s.l. and display a length of 2 to 52.7 m. Some bridges are several hundreds of years old. Horizontally and vertically trained roots differ significantly in shape and cross-sectional area when approximately even-aged roots are compared. The results are discussed from an interdisciplinary perspective, considering the adaptive traits in the natural life cycle of F. elastica and possible applications in living architecture (Baubotanik).

Apical Hypertrophic Cardiomyopathy: A Concerning Electrocardiogram in the Emergency Department.

BACKGROUND: Apical hypertrophic cardiomyopathy is a rare, complex phenotypic variant of the classically taught hypertrophic cardiomyopathy. It is highly variable in its pathophysiology as well as its clinical course, spanning the spectrum from a healthy asymptomatic lifestyle to sudden cardiac death and severe diastolic dysfunction. The hallmark electrocardiographic findings of unusually large T-wave inversions, in conjunction with the most common presenting symptom being chest pain, makes this disease entity concerning in the emergency department (ED) setting. CASE REPORT: A 61-year-old man with a history of hypertension presented to the ED with chest pain. His electrocardiogram exhibited a biphasic T wave in lead V2 with ST depressions in leads V3-V6 with deep symmetrical T-wave inversions in these leads as well. His troponin was negative and the patient was taken for cardiac catheterization. Catheterization revealed no coronary artery disease; however, it revealed a "spade like" filling pattern of the left ventricle, suggestive of an apical variant of hypertrophic cardiomyopathy. Subsequent cardiac magnetic resonance imaging confirmed the diagnosis of apical hypertrophic cardiomyopathy and the patient was started on a beta-blocker and discharged with cardiology follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Electrocardiographic interpretation is a critical skill of the emergency physician. Awareness of the syndrome and its specific electrocardiogram findings may help facilitate further testing that will aid in timely diagnosis and interventions.

A Stroke Mimic: Methotrexate-induced Neurotoxicity in the Emergency Department.

BACKGROUND: Acute lymphoblastic leukemia (ALL) is the most common form of childhood leukemia. The treatment of ALL involves multimodality therapy, and methotrexate (MTX) remains a mainstay of treatment. A complication of MTX therapy includes acute, subacute, and chronic neurotoxocity. Signs and symptoms may range from headaches, dizziness, and mood disorders to seizures and stroke-like symptoms. CASE REPORT: An 18-year-old woman with a history of ALL presented to the emergency department with acute onset of right-sided facial paralysis, right upper extremity flaccid paralysis, and right lower extremity weakness after receiving MTX therapy 3 days earlier. Diagnostic studies were unremarkable and the patient was treated with oral dextromethorphan for presumed MTX-induced neurotoxicity. The patient's symptoms began to improve within hours and she was discharged home within 48 hours with no neurologic deficits. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware of this complication of MTX therapy given the sensitivity in regards to time with respect to cerebral vascular accidents. An awareness of this complication in the setting of the appropriate history and physical examination can lead to an accurate diagnosis and intervention and the avoidance of administering thrombolytics.

Failed hip arthroscopy: causes and treatment options.

Indications for arthroscopic surgery of the hip have increased over the past several years, along with the number of procedures performed annually. In addition, the number of unsuccessful procedures and subsequent revision surgeries have also increased. Recent literature has defined several common causes for failed hip arthroscopy. Severe osteoarthritis and osteonecrosis are associated with poor outcomes. Findings during revision hip arthroscopy consistently demonstrate untreated femoroacetabular impingement, chondral defects, labral tears, and postoperative adhesions. The treating surgeon must be diligent in his or her indications for surgery, as well as in addressing all pathology at the initial surgery.

Does a general practitioner support unit reduce admissions following medical referrals from general practitioners?

BACKGROUND: Emergency medical admissions to UK hospitals have been increasing steadily over the past few decades and there are likely to be a proportion of these admissions that are avoidable. This evaluation aims to demonstrate whether a general practitioner support unit (GPSU) reduces general practitioner (GP) referred emergency medical admissions to an acute hospital. METHODS: The GPSU comprises a team of GPs based in the hospital with the purpose of providing alternatives to admission for medical referrals from community GPs. This is an observational study of patients referred and admitted to the Medical Admissions Unit (MAU) of an acute hospital over two six-month periods, in 2007 prior to and in 2008 after the introduction of the GPSU. RESULTS: The number of GP referrals to the MAU per day decreased by 1.55 (confidence interval -2.45 to -0.51) patients with the GPSU in place. The number admitted to the hospital per day from MAU decreased by a mean of 0.48 patients but with confidence intervals that included the null hypothesis (-1.39 to 0.44). In comparison, non-GP admissions that were not targeted by the GPSU increased by 3.99 per day (2.64 to 5.33). CONCLUSION: An acute GP led service run from within the hospital to provide support to community GPs led to a modest reduction in the number of GP admissions to the MAU, but did not reduce the number of GP admissions to the hospital wards.

Pancreatic splenosis demonstrated by contrast-enhanced sonography.

Pancreatic splenosis is a very rare condition whose features on contrast-enhanced ultrasound (CEUS) have not, to our knowledge, been previously reported. We present the imaging findings in a case of pancreatic splenosis, in which a confident diagnosis was achieved with the use of CEUS and confirmed by a labeled heat denatured red cell scan. Accumulation of ultrasound contrast microbubbles in splenic tissue can be readily visualized on late-phase CEUS and this technique has already been used to confirm the nature of intrapancreatic accessory spleens. This case shows that it can also confirm the diagnosis of splenosis.

Information warehouse - a comprehensive informatics platform for business, clinical, and research applications.

Since its inception in 1997, the IW (Information Warehouse) at the Ohio State University Medical Center (OSUMC) has gradually transformed itself from a single purpose business decision support system to a comprehensive informatics platform supporting basic, clinical, and translational research. The IW today is the combination of four integrated components: a clinical data repository containing over a million patients; a research data repository housing various research specific data; an application development platform for building business and research enabling applications; a business intelligence environment assisting in reporting in all function areas. The IW is structured and encoded using standard terminologies such as SNOMED-CT, ICD, and CPT. The IW is an important component of OSUMC's Clinical and Translational Science Award (CTSA) informatics program.

Use of synthesized data to support complex ad-hoc queries in an enterprise information warehouse: a diabetes use case.

The Ohio State University Medical Center (OSUMC) Information Warehouse (IW) is a comprehensive data warehousing facility incorporating operational, clinical, and biological data sets from multiple enterprise system. It is common for users of the IW to request complex ad-hoc queries that often require significant intervention by data analyst. In response to this challenge, we have designed a workflow that leverages synthesized data elements to support such queries in an more timely, efficient manner.

A comparative analysis of the dissemination of best practice measures for key populations.

In collaboration with the department of Quality and Operations Improvement, Clinical Applications and the Information Warehouse, we have leveraged available Information Warehouse data to build a Best Practice Compliance Measurement Dashboard. This tool combines information from our operating room charting system, our order entry system and coding information from the patient billing and management system to provide 'previous day', data on a patients current course of treatment.

Data delivery workflow in an academic information warehouse.

The Ohio State University Medical Center (OSUMC) Information Warehouse (IW) collects data from many systems throughout the OSUMC on load cycles ranging from real-time to on-demand. The data then is prepared for delivery to diversity of customers across the clinical, education, and research sectors of the OSUMC. Some of the data collected at the IW include patient management, billing and finance, procedures, medications, lab results, clinical reports, physician order entry, outcomes, demographics, and so on. This data is made available to the users of the IW in variety of formats and methods.

Using data mining tools to discover novel clinical laboratory test batteries.

Using statistical analysis and data mining tools, we examined possible associations among clinical laboratory orders placed at the Ohio State University Medical Center between January and October of 2006. Upon applying the Frequent Itemset data mining technique to this data set, the results indicated that, while the most frequently ordered battery of tests was not associated with others, some highly associated orders may be good candidates to comprise new test batteries.

Using an information warehouse to screen patients for clinical trials: a prototype.

Success of a clinical trial recruitment process for drug discovery and new treatments depends on screening and identifying eligible patients in a timely manner. This can be a complex and tedious process that in many instances requires a research nurse to manually track patients that may be eligible. At the Ohio State University Medical Center (OSUMC) we have developed a web-based functional prototype that uses the data stored in the Information Warehouse (IW) to screen patients that meet the eligibility criteria for clinical trials. Using this prototype, a researcher can apply a set of inclusion/exclusion criteria pertinent to a research protocol and instantly find patients that may qualify for the clinical trial without revealing their identity. A researcher has access to all detailed historical clinical information such as lab results, diagnosis codes, pathology reports and clinical notes.