Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis.

Background: The long-term cardiovascular risk of isolated elevated office blood pressure (BP) is unclear. Purpose: To summarize the risk for cardiovascular events and all-cause mortality associated with untreated white coat hypertension (WCH) and treated white coat effect (WCE). Data Sources: PubMed and EMBASE, without language restriction, from inception to December 2018. Study Selection: Observational studies with at least 3 years of follow-up evaluating the cardiovascular risk of WCH or WCE compared with normotension. Data Extraction: 2 investigators independently extracted study data and assessed study quality. Data Synthesis: 27 studies were included, comprising 25 786 participants with untreated WCH or treated WCE and 38 487 with normal BP followed for a mean of 3 to 19 years. Compared with normotension, untreated WCH was associated with an increased risk for cardiovascular events (hazard ratio [HR], 1.36 [95% CI, 1.03 to 2.00]), all-cause mortality (HR, 1.33 [CI, 1.07 to 1.67]), and cardiovascular mortality (HR, 2.09 [CI, 1.23 to 4.48]); the risk for WCH was attenuated in studies that included stroke in the definition of cardiovascular events (HR, 1.26 [CI, 1.00 to 1.54]). No significant association was found between treated WCE and cardiovascular events (HR, 1.12 [CI, 0.91 to 1.39]), all-cause mortality (HR, 1.11 [CI, 0.89 to 1.46]), or cardiovascular mortality (HR, 1.04 [CI, 0.65 to 1.66]). The findings persisted across several sensitivity analyses. Limitation: Paucity of studies evaluating isolated cardiac outcomes or reporting participant race/ethnicity. Conclusion: Untreated WCH, but not treated WCE, is associated with an increased risk for cardiovascular events and all-cause mortality. Out-of-office BP monitoring is critical in the diagnosis and management of hypertension. Primary Funding Source: National Institutes of Health.

USMLE Step 2 CK Scores and Radiology Residency Applications: Does it Affect Diversity in Selection of Trainees?

RATIONALE AND OBJECTIVES: As residency programs in diagnostic radiology aspire to broaden trainee diversity, reliance on certain criteria may affect the selection of candidates from underrepresented groups. With the conversion of reporting of the United States Medical Licensing Examination (USMLE) Step 1 scores to pass/fail, programs may rely more on numerical USMLE Step 2 Clinical Knowledge (CK) scores. The purpose of our investigation is to assess the effects of Step 2 CK scores on the selection of underrepresented minority (URM) and female candidates. MATERIALS AND METHODS: Applications from United States senior allopathic medical students to a radiology residency program from the 2021-2023 National Residency Matching Program cycles were analyzed. Subjects were classified as male or female and URM or non-URM by self-identification. Step 2 CK scores were compared and the use of cutoff scores was examined for disparate effects. RESULTS: 1017 subjects fulfilled the entry criteria. There were 721 males and 296 females, with 164 URM and 853 non-URM candidates. Comparing males to females, there was no significant difference in the mean score (p = 0.21) and no disparate effects of cutoff scores. There was a significant difference between the mean score of URM versus non-URM candidates of eight points (p < 0.00011). The use of cutoffs showed a disparate effect on URM candidates with a cutoff score of 250 (average score for 2022 matched applicants) excluding 71% of URM candidates while excluding only 46% of non-URM candidates. CONCLUSION: Reliance on USMLE Step 2 CK scores to screen applications for radiology residency can disadvantage URM candidates. Females are not adversely affected.

Does Objective Scoring of Applications for Radiology Residency Affect Diversity?

RATIONALE AND OBJECTIVES: It is important to recognize if reliance on certain factors in applications affects selection of trainees from under-represented groups. Our purpose is to determine if objective scoring of radiology residency applications based on quantifiable data regarding academic performance, United States Medical Licensing Examination (USMLE) scores and research productivity affects selection of female and under-represented minority (URM) candidates. MATERIALS AND METHODS: We reviewed 502 applications from three successive match cycles from United States allopathic medical students. Each application was scored for academic performance, USMLE results and research productivity determining an overall score. The scores of males were compared to females and URM were compared to non-URM candidates. USMLE cutoff scores were evaluated for disparate effects. RESULTS: There were 348 male, 154 female, 73 URM and 429 non-URM candidates. For male versus female applicants, there was no significant difference in mean academic performance, USMLE Step 2 Clinical Knowledge and research productivity scores. Males had higher mean USMLE Step 1 (p = 0.005) and overall candidate scores (p = 0.02). Between URM and non-URM candidates there was no significant difference in academic performance. Non-URM applicants had higher mean USMLE Step 1 (p = 0.008), USMLE Step 2 (p = 0.002), research productivity (p = 0.001) and overall scores (p = 0.02). Use of USMLE cutoff scores demonstrated disparate effects on female and URM candidates. CONCLUSION: Objective scoring of applications and use of USMLE cutoff scores can disadvantage candidates from underrepresented groups. Screening filters can affect the diversity of candidate pools for radiology residency.

Mobile Mammography Services and Underserved Women.

Breast cancer, the second most common cause of cancer in women, affects people across different ages, ethnicities, and incomes. However, while all women have some risk of breast cancer, studies have found that some populations are more vulnerable to poor breast cancer outcomes. Specifically, women with lower socioeconomic status and of Black and Hispanic ethnicity have been found to have more advanced stages of cancer upon diagnosis. These findings correlate with studies that have found decreased use of screening mammography services in these underserved populations. To alleviate these healthcare disparities, mobile mammography units are well positioned to provide convenient screening services to enable earlier detection of breast cancer. Mobile mammography services have been operating since the 1970s, and, in the current pandemic, they may be extremely helpful. The COVID-19 pandemic has significantly disrupted necessary screening services, and reinstatement and implementation of accessible mobile screenings may help to alleviate the impact of missed screenings. This review discusses the history and benefits of mobile mammography, especially for underserved women.

Obstructive jaundice, a rare presentation of lung cancer: A case report.

Lung cancer metastases to the pancreas are rare but potentially life-threatening. Oftentimes, the presence of symptoms is indicative of extensive disease burden. This report describes a case of primary lung adenocarcinoma metastasizing to the head of the pancreas presenting as obstructive jaundice. The patient was a 61-year-old female veteran who presented with a chronic dyspnea, weight loss, and 3-weeks of nausea and vomiting found to have jaundice, elevated alkaline phosphatase levels, hyperbilirubinemia, and transaminitis. Imaging of her chest revealed large pulmonary parenchymal nodules throughout both lungs with a large left lower lobe mass and consolidation. Abdominal imaging showed a large heterogeneous mass in the pancreatic head, a grossly dilated common bile duct, and enlarged retroperitoneal lymph nodes contiguous with the mass. Pancreatic head biopsies revealed metastatic cancer cells from her lung adenocarcinoma which was confirmed via cytology and the presence of thyroid transcription factor - 1 and cytokeritin-7 expression and the absence of tumor protein 63 staining. Lung adenocarcinomas commonly metastasize to the bones, liver, and central nervous system but very rarely to the pancreas. There have been only a few reported cases of pancreatic tumors that manifested clinically as a result of primary lung cancer metastases however, even though uncommon, hematogenous spread of cancerous tissue should be considered on the differential as a cause for obstructive jaundice in the setting of lung adenocarcinoma.

Clostridial Mycotic Aneurysm Leading to Emphysematous Aortitis.

Mycotic aneurysms account for less than 5% of all aneurysms of the aorta, with most cases linked to infection with either Staphylococcus or Salmonella species. Emphysematous aortitis is a rare consequence of mycotic aneurysms and is associated with high morbidity and mortality. It typically occurs from infection superimposed on already damaged endothelium, which is commonly seen in conditions such as atherosclerosis. This report discusses the presentation and relevant imaging findings of a unique case of emphysematous aortitis from Clostridial infection of the thoracic aorta. The patient was a 66-year-old male with a past medical history of end-stage renal disease, arteriovenous fistula for dialysis, hypertension, and diabetes, who presented with tachycardia and tachypnea. Computed tomography of the chest showed inflammatory changes of the thoracic aorta with gas bubbles along the aortic wall, and post-mortem aortic tissue cultures were positive for Clostridium innocuum. Although emphysematous aortitis is rare, the radiographic findings are strikingly characteristic and should prompt immediate and aggressive management.

Barotrauma Linked to Coronavirus Disease 2019 Infection in Younger Patients: A Case Series.

Patients infected with coronavirus disease 2019 (COVID-19) on invasive mechanical ventilation were found to have high rates of barotrauma. Herein, we present five patients admitted to the intensive care unit between March and April 2020, who developed barotrauma as a complication of COVID-19 pneumonia. This series includes four males and one female with a mean age of 54 years, most without significant chronic comorbidities or former tobacco use. All were intubated for hypoxic respiratory failure due to the COVID-19 infection. The diagnosis of barotrauma was confirmed via radiography showing the presence of pneumothorax, pneumomediastinum, or subcutaneous emphysema on radiographic imaging. At the time, they were evaluated for convalescent plasma infusion, remdesivir, and interleukin-6 inhibitor. Each of the five patient's hospital courses were documented. The average number of days between intubation and subsequent barotrauma was 6.8 days with the mean length of hospital stay being 49 days. Three of the five patients passed away due to complications related to COVID-19. Due to the unknown nature of the virus, our findings add to the growing evidence that those infected, even without significant comorbidities, are at high risk for pulmonary complications and in-hospital mortality.

Pulmonary Large Cell Neuroendocrine Carcinoma: A Rare Type of Non-Small Cell Lung Cancer.

Pulmonary large cell neuroendocrine carcinoma (LCNEC) is an uncommon type of non-small cell lung cancer (NSCLC) with an incidence of approximately 3% of all lung cancer diagnoses. The patient was a 60-year-old male with a 90-pack year smoking history who presented with dyspnea on exertion and productive cough for five weeks. Decreased breath sounds without respiratory distress and generalized cachexia were noted on the initial physical exam. Laboratory results were unremarkable except for chronic microcytic anemia. Computed tomography revealed extensive lymphadenopathy of the paratracheal, paraaortic, hilar, and nodes surrounding the left pulmonary arteries. Additionally, there were areas of necrosis in the left upper lobe, lingula, and left lower lobe with extensive pleural thickening extending to the abdomen and subcutaneous tissue of the anterior chest wall. Biopsy and staining showed disorganized tight cell clusters with irregular and prominent nuclei and numerous lymphocytes consistent with LCNEC. Immunohistochemistry was positive for neural cell adhesion molecule CD56 and synaptophysin, which was indicative of neuroendocrine origin. It was also positive for pan-cytokeratin antibody AE1 and AE3 and cytokeratin (CAM) 5.2, which arise from epithelial origin consistent with NSCLCs. Lastly, the patient's tissue was positive for thyroid transcription factor-1, which confirmed the tumor's primary lung origin. This combination of neuroendocrine and primary lung tumor markers, in conjunction with the histology, confirmed the patient's diagnosis of LCNEC.

Systematic Review of Negative Pressure Pulmonary Edema in Otolaryngology Procedures.

OBJECTIVE(S): Negative pressure pulmonary edema (NPPE) is a rare perioperative complication with a potentially fatal outcome. The aim of this study was to perform a systematic review of NPPE in adult otolaryngology procedures with the goal of identifying risk factors, clinical presentation, diagnosis, management and outcomes. METHODS: Systematic review performed using PubMed, Scopus, Web of Science, and Cochrane databases. RESULTS: Sixty-nine studies including data from 87 individual patients were included in this review. Fifty-six (68%) patients were male and the average patient age was 37 years old. Type 1 NPPE occurred in 63 (72%) cases, while type 2 NPPE accounted for 20 (23%) cases. The most common procedures leading to NPPE were septoplasty, rhinoplasty or sinus surgery (n = 22, 25%), directly laryngoscopy or bronchoscopy (n = 13, 15%), and tracheostomy or cricothyroidotomy (n = 11, 13%). The most employed treatment options included diuretics (n = 55, 63%) and mechanical ventilation (n = 54, 62%). Seventy-eight (90%) patients made a full recovery with an average time to NPPE resolution of 33 hours and an average length of hospitalization of 5.6 days. Five (6%) patients had a long-term morbidity and four (5%) patients died, with age and ICU stay increasing risk for death and long-term morbidity (OR 1.044 and 7.42, respectively, P < .05). CONCLUSION: Septoplasty, rhinoplasty and sinus surgery account for the majority of NPPE cases in adult otolaryngology procedures. Young, healthy patients are the most commonly involved with a slight male predominance. The vast majority of patients recover fully, however there is a significant risk for morbidity and mortality.

Glass table injuries: A silent public health problem.

BACKGROUND: Glass tables can break and cause traumatic injury. This public health issue is avoidable by adequate regulatory measures. We describe the burden and characteristics of these injuries using the National Electronic Injury Surveillance System (NEISS) database and data from a level 1 trauma center. METHODS: NEISS data was extracted from 2009 to 2015. Injuries were classified by type, severity, and involvement of faulty glass using predetermined criteria. A retrospective chart review of a level 1 trauma center data was performed. Epidemiologic and outcomes data are reported. RESULTS: 3241 cases were reviewed from NEISS. 56% of injuries were attributable to faulty tables. 15% were severe. A bimodal age distribution of age under 7 and early 20s was observed. Commonly injured areas were the upper extremity and forehead. 24 trauma center cases were reviewed. 21% presented with hemodynamic instability, 34% had major organ, body cavity or joint space injuries, and 58% required surgical intervention. 30-day mortality rate was 8%. More than 54% required inpatient care. CONCLUSION: Glass table injuries are common, estimated at over 2.5 million per year. Regulation of glass quality may prevent injury. SUMMARY: Glass table injuries are more common than may be recognized and represent a public health problem that can be mitigated through proper regulatory measures.