Treatment of Type 2 Diabetes Mellitus in Advanced Chronic Kidney Disease for the Primary Care Physician.

Diabetes mellitus (DM) is a common cause of chronic kidney disease (CKD), leading to the need for renal replacement therapy (RRT). RRT includes hemodialysis (HD), peritoneal dialysis (PD), kidney transplantation (KT), and medical management. As CKD advances, the management of DM may change as medication clearance, effectiveness, and side effects can be altered due to decreasing renal clearance. Medications like metformin that were safe to use early in CKD may build up toxic levels of metabolites in advanced CKD. Other medications, like sodium-glucose co-transporter 2 inhibitors, which work by excreting glucose in the urine, may not be able to work effectively in advanced CKD due to fewer working nephrons. Insulin breakdown may take longer, and both formulation and dosing may need to be changed to avoid hypoglycemia. While DM control contributes to CKD progression, effective DM control continues to be important even after patients have been placed on RRT. Patients on RRT are frequently taken care of by a team of providers, including the primary care physician, both in and outside the hospital. Non-nephrologists who are involved with the care of a patient treated with RRT need to be adept at managing DM in this population. This paper aims to outline the management of type 2 DM in advanced CKD.

Gastroesophageal Junction Adenocarcinoma With Skeletal Muscle Metastases: A Case Report and Literature Review.

Esophageal and gastroesophageal junction (GEJ) malignancies are aggressive, and survival is poor once metastasis occurs. The most common sites of metastatic involvement include the liver, lymph nodes, lung, peritoneum, adrenal glands, bone, and brain, while skeletal muscle (SM) involvement is rare. We report a case of a 68-year-old female who presented with intractable emesis for one month and was found to have a primary GEJ adenocarcinoma measuring up to 6.7 cm. Endoscopic biopsy revealed poorly differentiated GEJ adenocarcinoma with positive AE1/AE3 immunostains. Positron emission tomography/computed tomography and magnetic resonance imaging revealed metastases to the omentum and left lower extremity SMs, including the proximal adductor longus, adductor magnus, and gluteus minimus. This study reviews the literature on SM metastasis in esophageal and GEJ cancer, GEJ cancer classification, incidence, treatment, and prognosis.

Towards Optimal Cardiovascular Health: A Comprehensive Review of Preventive Strategies.

Heart disease remains a prominent global health concern, with cardiovascular disease (CVD) standing as a leading cause of death worldwide. Preventing heart disease not only decreases the risk of premature death but also mitigates complications like heart attacks, strokes, and arrhythmias, thereby enhancing overall health and quality of life. The economic burden of heart disease treatment highlights the importance of implementing preventive measures, such as lifestyle changes and early interventions, which can alleviate healthcare costs. These strategies, targeting risk factors like hypertension (HTN), diabetes mellitus (DM), dyslipidemia, and obesity, not only prevent heart disease but also reduce the risk of other health issues. Herein, this review covers various preventive measures, including dietary interventions, exercise, controlling HTN, DM, cholesterol, and weight, smoking cessation, and pharmacological interventions. By critically analyzing the guidelines and leveraging robust data alongside variations in recommendations, this review aims to elucidate effective primary prevention strategies for CVD.

Echocardiographic Evaluation of Cardiac Masses.

PURPOSE OF REVIEW: Cardiac masses encompass a broad range of etiologies and are often initially revealed by echocardiography. The differential may change depending on the location of the mass and patients' medical history or presentation. It is important for clinicians to be aware of subtle visual characteristics on echocardiography in order to correctly diagnose the pathology. METHODS: Patients who underwent transthoracic echocardiography and were found to have one or more cardiac masses between January 1, 2020, and May 15, 2023, were reviewed. Their demographic data, clinical presentation, medical history, imaging, and follow-up information were collected from hospital electronic medical records, de-identified, and used to complete this review paper. A detailed review of cardiac masses divided by cardiac chamber accompanied by real-world echocardiographic images from patients in a large inner city public hospital. We hope that this systematic review of cardiac masses with real-world echocardiographic images will help clinicians note subtle echocardiographic characteristics to aid in the diagnosis and treatment of cardiac masses.

A Rare Case of Congestive Heart Failure due to Isolated Aortic Valve Disease in a Middle-Aged Man Secondary to Rheumatic Fever.

Rheumatic heart disease (RHD) is commonly seen in people from developing and low-income countries. More cases are being recorded in developed countries due to migration and globalization. RHD develops in people with a history of rheumatic fever; it is an autoimmune response to group A streptococcal infection due to similarities at the molecular level. Congestive heart failure, arrhythmia, atrial fibrillation, stroke, and infective endocarditis are a few of the many complications associated with RHD. Here we present a case of a 48-year-old male with a past medical history of rheumatic fever at the age of 12 years, who presented to the emergency room (ER) complaining of bilateral ankle swelling, dyspnea on exertion, and palpitations. The patient was tachycardic with a heart rate of 146 beats per minute and tachypneic with a respiratory rate of 22 breaths per minute. On physical exam, there was a harsh systolic and diastolic murmur at the right upper sternal border. A 12-lead electrocardiogram (EKG) revealed atrial flutter with a variable block. Chest X-ray revealed an enlarged cardiac silhouette with a pro-brain natriuretic peptide (proBNP) of 2,772 pg/mL (normal ≤ 125 pg/mL). The patient was stabilized with metoprolol and furosemide and was admitted to the hospital for further investigation. Transthoracic echocardiogram showed left ventricular ejection fraction (LVEF) of 50-55% with severe concentric hypertrophy of the left ventricle with a severely dilated left atrium. Increased thickness of the aortic valve with severe stenosis and a peak gradient of 139 mm Hg and a mean gradient of 82 mm Hg was noted. The valve area was measured to be 0.8 cm2. Transesophageal echocardiogram showed a tri-leaflet aortic valve with commissural fusion of valve cusps with severe leaflet thickening consistent with rheumatic valve disease. The patient underwent tissue aortic valve replacement with a bioprosthetic valve. The pathology report showed extensive fibrosis and calcification of the aortic valve. The patient came in for a follow-up visit 6 months later and expressed feeling better and more active.

A Case of Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome) in a Nonsurgical Patient with Plasma Cell Leukemia.

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction (ACPO), is a rare, nonobstructive dilation of the colon of unclear etiology. We present the case of a patient who presented with Ogilvie's syndrome and significant hypokalemia due to colonic loss despite repletion. This case report demonstrates the difficulty in diagnosis, treatment, and outcome.

A review of big data and medical research.

Universally, the volume of data has increased, with the collection rate doubling every 40 months, since the 1980s. "Big data" is a term that was introduced in the 1990s to include data sets too large to be used with common software. Medicine is a major field predicted to increase the use of big data in 2025. Big data in medicine may be used by commercial, academic, government, and public sectors. It includes biologic, biometric, and electronic health data. Examples of biologic data include biobanks; biometric data may have individual wellness data from devices; electronic health data include the medical record; and other data demographics and images. Big data has also contributed to the changes in the research methodology. Changes in the clinical research paradigm has been fueled by large-scale biological data harvesting (biobanks), which is developed, analyzed, and managed by cheaper computing technology (big data), supported by greater flexibility in study design (real-world data) and the relationships between industry, government regulators, and academics. Cultural changes along with easy access to information via the Internet facilitate ease of participation by more people. Current needs demand quick answers which may be supplied by big data, biobanks, and changes in flexibility in study design. Big data can reveal health patterns, and promises to provide solutions that have previously been out of society's grasp; however, the murkiness of international laws, questions of data ownership, public ignorance, and privacy and security concerns are slowing down the progress that could otherwise be achieved by the use of big data. The goal of this descriptive review is to create awareness of the ramifications for big data and to encourage readers that this trend is positive and will likely lead to better clinical solutions, but, caution must be exercised to reduce harm.

What Do We Know about Opioids and the Kidney?

Evidence suggests a link between opioid use and kidney disease. This review summarizes the known renal manifestations of opioid use including its role in acute and chronic kidney injury. Both the direct and indirect effects of the drug, and the context which leads to the development of renal failure, are explored. While commonly used safely for pain control and anesthesia in those with kidney disease, the concerns with respect to side effects and toxicity of opioids are addressed. This is especially relevant with the worldwide increase in the use of opioids for medical and recreational use.