Relevance of Procalcitonin Levels as a Marker of Severity and Predictor of Mortality, Initiation and Duration of Antibiotics in Patients Admitted with Acute Pancreatitis: A Retrospective Cohort Study.

Introduction: Procalcitonin levels have been studied to predict the benefit of adding antibiotics in a patient with acute pancreatitis. Through this study, we are searching for any possible correlation between serum procalcitonin levels and the severity of acute pancreatitis (included acute on chronic cases) to determine whether procalcitonin levels can predict a benefit from antibiotic therapy in acute pancreatitis. Methods: This is a retrospective cohort study involving patients with acute pancreatitis and acute on chronic pancreatitis. We included all hospitalized patients admitted to Kern Medical from January 2020 to October 2022 with a diagnosis of acute pancreatitis in a consecutive manner. The primary outcome studied was mortality related to the pancreatitis episode. Logistic regression was used to control numerous confounders. Results: Based on univariate analysis of procalcitonin, we found starting antibiotics on the day of admission statistically significant. We also found the median differences in mortality to be mildly significant (difference = 0.79, p = 0.0640) based on procalcitonin values. In a multivariate analysis of ln(procalcitonin), we found lipase (p = 0.0249), duration of antibiotics (p = 0.0009), multi-organ failure (p = 0.0045) to be statistically significant, and lactate being mildly significant in the multivariate model (p = 0.0643). Conclusion: The procalcitonin level can predict the initiation of antibiotics, duration of antibiotics, multi-organ failure, and mortality in patients with acute pancreatitis.

Spurious Presentation of Pulmonary Kaposi Sarcoma as Unresolved Pneumonia Led to Fatal Outcome.

Acquired immunodeficiency syndrome (AIDS)-associated Kaposi sarcoma (KS) is an angioproliferative neoplasia caused by infection with human herpesvirus 8 (HHV-8). It typically presents with mucocutaneous involvement, but it can be disseminated. Initial presentation with primarily pulmonary KS is rare. We present a case of a 32-year-old male with untreated human immunodeficiency virus (HIV) diagnosed 1 year before presentation who developed progressively worsening cough and shortness of breath for 6 months. He was hospitalized twice and treated for unresolved pneumonia in an outside hospital. The patient concomitantly developed purplish nodules on his face, then the upper trunk, back, chest, and thighs bilaterally that gradually increased in size and number. Histopathology findings from skin lesions were consistent for KS. Bronchoscopy found multiple erythematous plaques throughout the tracheobronchial tree with telangiectasias and inflammation suggestive of pulmonary KS. His imaging findings and positive serum HHV-8 polymerase chain reaction (PCR) were consistent with disseminated KS. He started antiretroviral therapy (ART) to treat his HIV infection, followed by liposomal doxorubicin chemotherapy. But both ART and chemotherapy were interrupted due to adherence and insurance issues. The patient was readmitted with acute respiratory failure requiring mechanical ventilation with multiple vasopressors that led to the patient's demise. The late recognition of KS diagnosis and delayed treatment can lead to worse outcomes.

A Unique Case of Pseudomonas aeruginosa-Associated Diarrhea in a Long-Term Hospitalized Adult Patient.

A 53-year-old Caucasian man with a history of alcohol use disorder, hypertension, and hypothyroidism presented with a myxedema coma requiring intubation. He had a complicated hospital course with ventilator-associated pneumonia with MRSA, sepsis with candida, and abdominal compartment syndrome requiring decompressive laparotomy. The patient slowly recovered during 43 days of hospitalization. During the intensive care unit (ICU) stay, a flexi-seal rectal tube was placed due to fecal incontinence. After being moved to a regular medicine unit, he started having loose watery stools with leukocytosis and neutrophilia. Clostridium difficile (C. diff.) colitis was suspected, and he was placed on oral vancomycin empirically. His stool test for C. diff. came back negative, and his rectal tube was subsequently removed. Imaging did not show any abscess, perforated viscus, or fistula formations. His stool culture grew a heavy colony of Pseudomonas aeruginosa (P. aeruginosa). Vancomycin was stopped, and he was started on oral ciprofloxacin 750 mg twice a day with complete resolution of his diarrhea and leukocytosis.

LECT-2 amyloidosis: what do we know?

Amyloidosis is a rare group of diseases characterized by abnormal folding of proteins and extracellular deposition of insoluble fibrils. It can be localized to one organ system or can have systemic involvement. The kidney is the most common organ to be involved in systemic amyloidosis often leading to renal failure and the nephrotic syndrome. The two most common types of renal amyloidosis are immunoglobulin light chain-derived amyloidosis (AL) and reactive amyloidosis (AA). A novel form of amyloidosis (ALECT2) derived from leukocyte chemotactic factor 2 (LECT-2) and primarily involving the kidneys was first described by Benson et al in 2008. The liver was subsequently identified as the second most common organ involved in ALECT2 amyloidosis. LECT-2 is a unique protein that can form amyloid deposits even in its unmutated form. Patients with ALECT2 present with minimal proteinuria in contrast to other forms of amyloidosis especially AL and AA. They may present with slightly elevated serum creatinine. Nephrotic syndrome and hematuria are rare. ALECT2 can be found in association with other types of amyloidosis as well as malignancies or autoimmune diseases. ALECT2 may be confused with amyloidosis associated with light and heavy chain monoclonal gammopathy if the immunofluorescence is positive with anti-light chain and anti-AA sera. The other organs involved are the duodenum, adrenal gland, spleen, prostate, gall bladder, pancreas, small bowel, parathyroid gland, heart, and pulmonary alveolar septa, but consistently uninvolved organs included brain and fibroadipose tissue. A renal biopsy along with characteristic features found on immunohistochemistry and mass spectrometry is diagnostic of ALECT2. ALECT2 should be suspected when all markers for AL and AA are negative. Proper diagnosis of ALECT2 can determine need for supportive care versus more aggressive interventions.

Echocardiographic Findings in Heart Failure Patients With Methamphetamine Use: A Case-Control Study.

Background Methamphetamine use is associated with cardiovascular disease and significant morbidity and mortality. There is only one previous study performed on echocardiographic parameters in patients with methamphetamine cardiomyopathy. Methods We performed a retrospective review of medical records in a county hospital in Southern California with a high population of methamphetamine users. We reviewed medical records and echocardiogram findings in patients seen in our institution from November 2019 to November 2020 who had cardiomyopathy with and without methamphetamine use. We excluded patients who either left the hospital or expired before appropriate assessment. We divided our patient population into a case group (methamphetamine users) and a control group (non-methamphetamine users) to study and compare their echocardiographic parameters. Results Case group included a total of 254 patients and control group included 268 patients. Majority of the patient population were males - 178 (70%) and 180 (67%) in the case and control group respectively. Age was found to be statistically significant with the younger population in the case group (p = 0.0000). Our analysis revealed statistically significant difference in methamphetamine users compared to non-users in regards to left ventricle ejection fraction (33.65% ± 18.02 vs. 41.55% ± 15.61, p=0.0000), left ventricle mass index (122.49 grams/m2 ± 40.66 vs. 108.62 grams/m2 ± 32.82, p=0.0000), left ventricle end diastolic volume index (85.91 mL/m2 ± 37.40 vs. 72.44 mL/m2 ± 25.44; p=0.0000) and marginally significant right ventricle systolic pressure (42.29mmHg ± 17.53 vs. 39.59mmHg ± 15.61; p=0.0540) Conclusion Our results indicated that methamphetamine users had echocardiogram findings with decreased ejection fraction and increased left ventricular mass index, end-diastolic volume index, and right ventricular systolic pressure consistent with worse dilated cardiomyopathy comparison to non-users.

Prognostic Significance of Diastolic Dysfunction With Multiple Comorbidities in Heart Failure Patients.

Background Heart failure poses a significant burden on health care and economy. In recent years, diastolic dysfunction has been increasingly recognized as a significant predictor of readmission in heart failure patients. Objectives We aimed to identify factors predicting readmission in patients with clinical heart failure at 30 days and six months. Methods A retrospective chart review was performed at a single urban medical center, including 208 patients in our final analysis. Results A higher Charlson comorbidity index (CCI) and moderate anemia (hemoglobin [Hb] < 10 g/dL) were significant predictors of readmission at both 30 days and six months. In addition, advanced chronic kidney disease (CKD) stage (4 or 5) and follow-up in a cardiology clinic were significant predictors at six months. During multivariate analysis, worsening diastolic dysfunction (grade 3 or 4) (OR: 2.09; 95% CI: 1.03 to 4.23), higher CCI (OR: 1.18; 95% CI: 1.03-1.36), and Hb < 10 g/dL (OR: 3.42; 95% CI: 1.44-8.13) were independent predictors of readmission at 30 days. Higher CCI (OR: 1.37; 95% CI: 1.19-1.58) and CKD stage 4 or 5 (OR: 3.05; 95% CI: 1.40-6.62) were independent predictors of readmission at six months. Conclusions Worse diastolic dysfunction (grade 3 or 4) was a significant predictor of all-cause readmission at 30 days post-discharge in heart failure patients. Higher CCI precisely predicted readmission as an independent variable at 30 days and six months. Anemia (Hb < 10 g/dL) and CKD stage 4 or 5 were significant predictors of readmission at 30-days and six months, respectively.

Beta Blocker Therapy in Heart Failure Patients with Active Cocaine Use: A Systematic Review.

BACKGROUND: Cocaine use is associated with multiple cardiovascular complications including heart failure. The use of different types of beta blockers in heart failure patients with active cocaine use is still a matter of debate. In this review, our objective is to systematically review the available literature regarding the use of beta blockers in the treatment of heart failure patients with concurrent cocaine use. METHODS: PubMed, EMBASE, Web of Science, and Clinical Trials.gov were searched from inception to March 2019 using the Medical Subject Headings (MeSH) terms "cocaine", "heart failure", "beta blocker," and "cardiomyopathy". Only studies containing the outcomes of heart failure patients with active cocaine use who were treated with beta blockers were included. RESULTS: The search resulted in 2072 articles out of which 12 were finally included in the review. A total number of participants were 1994 with a median sample size of 111. Most of the studies were retrospective in nature with Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence from 3 to 5. The main primary outcomes included readmission rates, mortality, left ventricular ejection fraction (LVEF) improvement, New York Heart Association (NYHA) functional class, and major adverse cardiovascular events (MACEs). In the studies analyzed, beta blockers were found to have either a beneficial or a neutral effect on primary outcomes in heart failure patients with active cocaine use. CONCLUSION: The use of beta blocker therapy appears to be safe and beneficial in heart failure patients with active cocaine use, although the evidence is not robust. Furthermore, large-scale studies are required to confirm this finding.

Evaluation of Effects of Health Literacy, Numeracy Skills, and English Proficiency on Health Outcomes in the Population of People With Diabetes in East Harlem.

IN BRIEF In the management of diabetes, adequate health literacy is necessary to help patients monitor their caloric and carbohydrate intake and monitor their blood glucose to achieve adequate glycemic control. This cross-sectional study was conducted to assess the health literacy of patients with diabetes from East Harlem in New York City using the validated Newest Vital Sign screening tool and to investigate its association with microvascular complications of diabetes. Lower health literacy was found to be associated with higher microvascular complications in these patients with diabetes.

An Overall Glance of Evidence Supportive of One-Hour and Two-Hour Postload Plasma Glucose Levels as Predictors of Long-Term Cardiovascular Events.

This review summarizes the vast literature describing the long-term epidemiological studies with emphasis on postprandial glucose as a stronger predictor of cardiovascular complications as compared to fasting glucose and HbA1c. Many molecular studies also supported this fact by illustrating that postchallenge hyperglycemia is associated with elevated biomarkers of systemic inflammation in the plasma and thus increasing the chances of vascular damage. Large-scale studies have proved that vascular stiffness, brachial-ankle pulse-wave velocity, carotid intima thickness, and left ventricular hypertrophy have been associated with postprandial glucose as compared to fasting glucose or glycosylated hemoglobin.

Acne cosmetica revisited: a case-control study shows a dose-dependent inverse association between overall cosmetic use and post-adolescent acne.

BACKGROUND: Case-control studies to support the concept of acne cosmetica are lacking. OBJECTIVE: To examine the association of post-adolescent acne with the use of cosmetics and cosmetic procedures. METHODS: 910 post-adolescent patients with acne and an equal number of matched controls were studied for exposure to cosmetics and cosmetic procedures. A cumulative cosmetic exposure index was stratified into four quarters of increasing exposure. RESULTS: Comparison of different cumulative exposure categories with the lowest exposure category (multivariate analysis, logistic regression) showed that the odds ratios, which were always <1, progressively declined as cosmetic exposure increased [odds ratios (95% confidence intervals): 0.679 (0.501-0.922), 0.355 (0.258-0.487), 0.307 (0.217-0.433)]. However, some individual cosmetics had odds ratios >1. CONCLUSION: Overall cosmetic use was negatively associated with post-adolescent acne. The term 'acne cosmetica' is appropriate in the sense that some cosmetics may cause acne.

Insect bite reactions.

Insects are a class of living creatures within the arthropods. Insect bite reactions are commonly seen in clinical practice. The present review touches upon the medically important insects and their places in the classification, the sparse literature on the epidemiology of insect bites in India, and different variables influencing the susceptibility of an individual to insect bites. Clinical features of mosquito bites, hypersensitivity to mosquito bites Epstein-Barr virus NK (HMB-EBV-NK) disease, eruptive pseudoangiomatosis, Skeeter syndrome, papular pruritic eruption of HIV/AIDS, and clinical features produced by bed bugs, Mexican chicken bugs, assassin bugs, kissing bugs, fleas, black flies, Blandford flies, louse flies, tsetse flies, midges, and thrips are discussed. Brief account is presented of the immunogenic components of mosquito and bed bug saliva. Papular urticaria is discussed including its epidemiology, the 5 stages of skin reaction, the SCRATCH principle as an aid in diagnosis, and the recent evidence supporting participation of types I, III, and IV hypersensitivity reactions in its causation is summarized. Recent developments in the treatment of pediculosis capitis including spinosad 0.9% suspension, benzyl alcohol 5% lotion, dimethicone 4% lotion, isopropyl myristate 50% rinse, and other suffocants are discussed within the context of evidence derived from randomized controlled trials and key findings of a recent systematic review. We also touch upon a non-chemical treatment of head lice and the ineffectiveness of egg-loosening products. Knockdown resistance (kdr) as the genetic mechanism making the lice nerves insensitive to permethrin is discussed along with the surprising contrary clinical evidence from Europe about efficacy of permethrin in children with head lice carrying kdr-like gene. The review also presents a brief account of insects as vectors of diseases and ends with discussion of prevention of insect bites and some serious adverse effects of mosquito coil smoke.

Matched case-control study to examine association of psoriasis and migratory glossitis in India.

BACKGROUND: Psoriasis is a multifactorial disease. Genetic and environmental factors, which determine the disease epidemiology and clinical spectrum, are heterogeneous in different populations. A few case-control studies from other countries have shown an association between psoriasis and migratory glossitis (MG). The characteristics of the association (e.g. relationship with gender, severity of psoriasis, early- versus late-onset psoriasis, etc.) have not been clearly defined. AIM: To investigate the association of psoriasis and MG by conducting a matched case-control study in India. METHODS: The study was conducted on 600 patients with psoriasis and 800 age- and sex-matched controls. Patients were examined for oral lesions and psoriasis severity was assessed by overall severity index (OSI) and psoriasis area and severity index (PASI). We compared the proportions of patients and controls with oral lesions, proportions of male and female patients who had MG, psoriasis severity scores of patients with or without MG, and proportions of early- and late-onset psoriasis patients who had MG. RESULTS: Significantly, more patients had oral lesions than controls (P=0.0013). There was a strong association between psoriasis and MG (P<0.0001). MG and fissured tongue (FT) occurring in the same patient were also strongly associated with psoriasis (P=0.0003). There was a weak association of psoriasis with FT (P=0.0456). Significantly, higher proportion of male patients had MG compared to female patients (P=0.0246). Patients with MG had more severe psoriasis compared to those without the tongue lesions (P<0.0001). Similar proportions of patients with type 1 and type 2 psoriasis had MG (P=0.7268). CONCLUSIONS: The results suggest that MG is a rare manifestation of psoriasis which occurs more commonly in male patients and in those with severe disease, and that it occurs with equal frequency in early- and late-onset psoriasis. It will be interesting to follow those patients who have MG, but not psoriasis, to see whether they develop psoriasis phenotype in future.

Clinical utility of clocortolone pivalate for the treatment of corticosteroid-responsive skin disorders: a systematic review.

Clocortolone pivalate 0.1% cream is a class IV mid-strength topical glucocorticoid. After topical application the glucocorticoid achieves higher concentration in inflamed skin compared with normal skin. Furthermore, pharmacologic studies have shown that there is little systemic absorption of clocortolone pivalate and hence no adrenal suppression. Systematic review was performed to evaluate the efficacy and safety of the glucocorticoid. PubMed, the Cochrane Library, and individual websites of the top 20 dermatology journals were searched using a defined strategy. Following the selection criteria, eight clinical trials were selected, of which five were randomized controlled trials. The trials mainly included patients with atopic dermatitis and eczemas. Quality appraisal of randomized controlled trials was done using the Delphi list, which showed that the trials had weaknesses in several items. The results of the systematic review tend to show that clocortolone pivalate cream is generally effective with early onset of action and has a good safety profile in the treatment of these conditions. Further studies comparing this glucocorticoid with other glucocorticoids and treatments in steroid-responsive dermatoses are desirable.