Colchicine for Patients With Coronary Artery Disease: A Systematic Review and Meta-analysis.

ABSTRACT: Several randomized controlled trials have studied the role of colchicine, a potent anti-inflammatory drug, to prevent adverse cardiovascular events in patients with coronary artery disease (CAD). In this meta-analysis, we aimed to determine the role of colchicine in patients with CAD in clinical outcomes and mortality. We searched PubMed, PubMed Central, Scopus, and Embase for randomized controlled trials/experimental studies evaluating the role of colchicine in patients with CAD. After assessing the eligibility for inclusion, risk-of-bias assessment, and data extraction from the included studies, a narrative synthesis was conducted. Of 17 studies included for the qualitative analysis, 11 studies reported that inflammatory markers such as C-reactive protein and cytokines were reduced in the colchicine group, suggesting an anti-inflammatory role of colchicine in CAD. Quantitative analysis with pooling of data from 9 studies using a fixed-effect model showed 28% lower odds of acute myocardial infarction [odds ratio (OR) 0.72, 95% CI 0.59-0.86; n = 11,712], 52% lower occurrence of stroke (OR 0.48, 95% CI 0.30-0.76), and 37% reduction in odds of coronary revascularization procedure in the colchicine group (OR 0.63, 95% CI 0.52-0.76; n= 11,258). However, the odds of gastrointestinal adverse events were 50% higher in the colchicine group (OR 1.50, 95% CI 1.01-2.23; n = 12,214). In conclusion, colchicine is associated with a lower risk of acute myocardial infarction, stroke, and coronary revascularization. However, there is some increased risk of gastrointestinal adverse events with the use of colchicine.

Striving toward safe abortion services in Nepal: A review of barriers and facilitators.

Background and Aims: Despite the decriminalization of abortion in Nepal in 2002, unsafe abortion is still a significant contributor to maternal morbidity and mortality. Nepal has witnessed a significant drop in abortion-related severe complications and maternal deaths owing to the legalization of abortion laws, lowered financial costs, and wider accessibility of safe abortion services (SAS). However, various factors such as sociocultural beliefs, financial constraints, geographical difficulties, and stigma act as barriers to the liberal accessibility of SAS. This review aimed to determine key barriers obstructing women's access to lawful, safe abortion care and identify facilitators that have improved access to and quality of abortion services. Methods: A systematic search strategy utilizing the databases PubMed, CINAHL, Scopus, and Embase was used to include studies on the accessibility and safety of abortion services in Nepal. Data were extracted from included studies through close reading. Barriers and facilitators were then categorized into various themes and analyzed. Results: Of 223 studies, 112 were duplicates, 73 did not meet the inclusion criteria, and 18 did not align with the research question; thus, 20 studies were included in the review. Various barriers to SAS in Nepal were categorized as economic, geographic, societal, legal/policy, socio-cultural, health systems, and other factors. Facilitators improving access were categorized as economic/geographic/societal, legal/policy, socio-cultural, and health systems factors. The patterns and trends of barriers and facilitators were analyzed, grouping them under legal/policy, socio-cultural, geographic/accessibility, and health systems factors. Conclusion: The review identifies financial constraints, unfavorable geography, lack of infrastructure, and social stigmatization as major barriers to SAS. Economics and geography, legalization, improved access, reduced cost and active involvement of auxiliary nurse-midwives and community health volunteers are key facilitators.

Atraumatic Splenic Rupture as an Unusual Presentation of Hairy Cell Leukemia: A Case Report.

Hairy cell leukemia (HCL) represents a rare B-cell malignancy with 2% of all leukemias and should be differentiated from HCL-like conditions, including HCL-variant (HCL-V) and splenic diffuse red pulp lymphoma (SDRPL). HCL gets its name from the short, thin projections that look like hair on its cells. It is associated with a specific immunophenotypic profile, cytopenia, and splenomegaly. Spontaneous splenic rupture can be a symptom of hematological malignancy such as HCL and is a life-threatening acute emergency. Here, we present a case of a 37-year-old man who presented to the hospital with signs of acute peritonitis and acute anemia and was found to have atraumatic splenic rupture secondary to splenomegaly. He underwent emergent angiography, where the bleeding splenic vessel was identified, and the patient was successfully treated with embolization. Immunophenotypic profile revealed that B-cells were positive for CD11c, CD103, CD25, and CD5, for which he received five days of cladribine and achieved complete clinical remission.

Heroin-Induced Leukoencephalopathy Leading to Locked-In Syndrome: A Case Report.

Heroin-induced leukoencephalopathy (HLE) is a rare neurological sequela of heroin use. Heroin can be consumed through different routes such as inhalation, intravenous injection, and snorting. HLE cases have been reported via each route. However, heroin vapor inhalation has a higher rate of HLE and is also known as "chasing the dragon syndrome." We present a 65-year-old male who came unresponsive after heroin intoxication. During the hospital stay, he developed locked-in syndrome secondary to brain damage by HLE sequelae.

A Rare Case of Right-Sided Aortic Arch With Mirror-Image Branching and Congenital Absence of the Left Pulmonary Artery.

Both the right-sided aortic arch with mirror-image branching (RAMI) and the congenital absence of the left pulmonary artery are sporadic congenital defects. Both diseases are typically diagnosed in childhood, but occasionally asymptomatic cases may be incidentally detected through imaging in adulthood. We reported a 43-year-old female patient with a RAMI and congenital absence of the left pulmonary artery who was relatively asymptomatic until adulthood.

Posterior Reversible Encephalopathy Syndrome in a Male With Polysubstance Abuse: A Case Report.

Posterior reversible encephalopathy syndrome (PRES) is a neurologic disorder with multiple etiologies. The signs and symptoms of PRES are non-specific, making the differential diagnosis broad. Although PRES is suspected clinically, a diagnosis requires characteristic findings on imaging. In patients with undiagnosed PRES, the coexistence of substance abuse can divert the care provider from pursuing imaging studies, leading to a missed diagnosis. We describe the case of a 51-year-old male who presented with altered mental status and was diagnosed with PRES despite having a positive urine drug screen.

Streptococcus agalactiae as a Primary Cause of Infective Endocarditis With Septic Emboli in an Undiagnosed Rheumatic Mitral Stenosis Patient: An Encounter in a US-Based Safety-Net Hospital.

Splenic infarct is a rare sequel of Streptococcus agalactiae infective endocarditis (IE). We report a case of a 43-year-old woman with multiple comorbidities diagnosed with a splenic infarct secondary to group B Streptococcus IE. The development of a splenic hematoma complicated the hospital course. This case highlights the less common etiology of IE and the potential complications.

Acute Portal Vein Thrombosis as an Initial Presentation of Protein C Deficiency: A Case Report.

Protein C (PC) is an essential vitamin K-dependent protein that regulates thrombosis and hemostasis in the body. A mutation in the PROC gene on chromosome 2q14.3 results in PC deficiency. The clinical presentation of PC deficiency can vary, ranging from a single vein thrombosis to disseminated intravascular coagulation, purpura fulminans, or even life-threatening complications such as sepsis. Here, we present a case of a 37-year-old female who was found to have acute portal vein thrombosis as an initial presentation of PC deficiency. She presented to the hospital with acute onset of abdominal pain associated with nausea, blood-streaked emesis, and bloody bowel movement.

Severe Neurocysticercosis in an Immunocompetent Male Without Travel to an Endemic Region: A Case Report.

Neurocysticercosis is a neglected parasitic cause of seizures in the United States. It can have a wide array of presentations depending on the location and number of cysticercoids. The severity of symptoms varies with the location of the lesion in the brain and to the extent of the number of neurocysticercoids and host immune response. In the severe form of neurocysticercosis, it can present as an acute encephalitic picture. We present a case of severe neurocysticercosis in a patient without any significant travel history. Neurocysticercosis in nonendemic areas can be diagnostically challenging, given the lack of travel history as in our patient. Neurocysticercosis should be kept as a differential in all cases of seizures without prior history of seizure episodes.

Pontine Infarct Resulting in Millard-Gubler Syndrome: A Case Report.

Millard-Gubler syndrome is a crossed brainstem syndrome involving the facial nerve, abducens nerve, and the pyramidal tracts, typically resulting in ipsilateral facial weakness and contralateral hemiparesis. Here we report the case of a 76-year-old female with no pertinent past medical history who presented to the emergency department with acute left-sided facial droop and right upper extremity sensory loss. A pontine infarction was identified on imaging and she was managed medically with complete recovery. Pontine infarction can result in Millard-Gubler syndrome and present with facial weakness and subtle contralateral limb symptoms.

Prevalence of exposure to needle stick and sharp-related injury and status of hepatitis B vaccination among healthcare workers: A cross-sectional study.

Background and Aims: Hepatitis B is a leading cause of chronic liver disease and subsequent liver transplantation. This is a vaccine-preventable illness. Health workers continue to be at risk for blood-borne pathogens due to occupational exposures. The overall goals of our study were to determine the prevalence of exposure to needle sticks and sharp-related injuries (NSSI) and hepatitis B vaccination status among healthcare workers (HCWs) of Nepalgunj Medical College Teaching Hospital (NGMCTH), Kohalpur, Banke, Nepal. Methods: A descriptive cross-sectional study was conducted among HCWs at the NGMCTH following ethics approval by the NGMCTH Ethics Review Committee. A pretested structured questionnaire was used to compile the data. Data was collected from September 15, 2021 to September 14, 2022. Collected data entered in Microsoft Excel and analyzed using statistical package for social sciences version 22. Analyzed data were presented using simple descriptive statistics with appropriate figures and tables. Results: A total of 304 among 506 HCWs (60.1%) participated in the survey were exposed to Needle sticks. Nine of whom (3.7%) were injured substantially (more than 10 times). Among nursing students, 21.3% had experience with NSSI. 71.7% of HCWs had received at least one dose of the hepatitis B vaccine, of whom 61.9% (44.5% of total HCWs) had received three doses. Conclusions: This study demonstrated that more than two-quarters of HCWs were exposed to NSSI. Despite being at risk, vaccination status was still low, and less than half only received three complete doses. Precaution should be taken when working with instrumentation and procedures. Hepatitis B immunization programs for HCWs should be delivered at no cost with 100% coverage and protection. Raising awareness about hepatitis B infection and immunization remains crucial to primary prevention.

Spontaneous Coronary Artery Dissection in Young Patients: A Case Series and Review of Current Management Algorithm.

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized non-atherosclerotic cause of acute coronary syndrome. Common risk factors for SCAD are coronary atherosclerosis, female gender, peripartum period, systemic inflammatory conditions, and connective tissue disorders. It manifests as myocardial ischemia and infarction, arrhythmia, and sudden cardiac death. We present a case series of two young men and one young female with SCAD who had chest pain and were diagnosed with SCAD-associated ST-elevation myocardial infarction. Its diagnosis requires a high degree of clinical suspicion and its management is guided by the patient's clinical condition and the characteristics of the lesions.

Anomalous Origin of the Left Coronary Artery From the Right Coronary Cusp: A Case Report.

Anomalous origin of the left main coronary trunk from the right coronary sinus is a rare condition and is associated with a significantly increased risk of cardiac events, including sudden cardiac death, and it may pose difficulties in their management using revascularization strategies. We present a case of a 68-year-old man with worsening chest pain. Initial evaluation revealed ST elevation of the inferior wall leads and elevated troponins. He was diagnosed with ST-elevation myocardial infarction (STEMI) and sent for emergency cardiac catheterization. Coronary angiography showed 50% stenosis of the mid-right coronary artery (RCA) that extended as a total occlusion to the distal RCA and an unexpected anomalous origin of the left main coronary artery (LMCA). Our patient's LMCA originated from the right cusp sharing a single ostium with the RCA. Multiple attempts of revascularization with percutaneous coronary intervention (PCI), using multiple wires, catheters, and different-sized balloons, were unsuccessful due to complex anatomy. Our patient was managed with medical therapy and discharged home with close cardiology follow-up.

Direct oral anticoagulants (DOAC) versus vitamin K antagonist in left ventricular thrombus: An updated meta-analysis.

Background and Aims: Current clinical guidelines for treating left ventricular thrombus (LVT) are limited by inadequate evidence to inform the comparative efficacy of oral anticoagulants. In this meta-analysis, we aimed to compare the efficacy and safety of direct oral anticoagulants (DOAC) to vitamin K antagonists (VKA) in patients with LVT. Methods: Four standard databases were searched for relevant literature comparing the efficacy and safety between DOAC and VKA for LVT treatment, published before August 19, 2023. Both the randomized controlled trials and observational studies were included in the analysis. The outcomes of interest were the resolution of LVT, all-cause mortality, stroke, systemic embolism, and bleeding. Data from the selected studies were extracted and analyzed using RevMan 5.4 using odds ratio. Results: Among 3959 studies from the database search and bibliography review, 33 were included in the analysis. LVT resolution was observed in 72.59% in the DOAC group versus 67.49% in the VKA group (odds ratio [OR]: 1.28, confidence interval [CI]: 1.07-1.53). Mortality was lower in the DOAC group (11.71% vs. 18.56%) (OR: 0.60, CI: 0.36-1.00; borderline statistical significance). Likewise, bleeding events (9.60% vs. 13.19%) (OR: 0.65, CI: 0.52-0.81) and stroke (7.54% vs. 11.04%) (OR: 0.71, CI: 0.53-0.96) were also significantly lower in the DOAC group. Conclusion: DOAC use for LVT showed better thrombus resolution and reduced risk of bleeding and stroke compared to VKA. Likewise, DOAC use was associated with lower mortality with borderline statistical significance.

Differences in treatment and outcomes among patients with ST-segment elevation myocardial infarction with and without standard modifiable risk factors: a systematic review and meta-analysis.

There are limited data available on outcomes and pathophysiology behind ST-segment elevation myocardial infarction (STEMI) in populations without standard modifiable risk factors (SMuRFs). The authors carried out this meta-analysis to understand the differences in treatment and outcomes of STEMI patients with and without SMuRFs. Methods: A systematic database search was performed for relevant studies. Studies reporting desired outcomes among STEMI patients with and without SMuRFs were selected based on predefined criteria in the study protocol (PROSPERO: CRD42022341389). Two reviewers independently screened titles and abstracts using Covidence. Full texts of the selected studies were independently reviewed to confirm eligibility. Data were extracted from all eligible studies via a full-text review of the primary article for qualitative and quantitative analysis. In-hospital mortality following the first episode of STEMI was the primary outcome, with major adverse cardiovascular events (MACE), repeat myocardial infarction (MI), cardiogenic shock, heart failure, and stroke as secondary outcomes of interest. Odds ratio (OR) with a 95% CI was used to estimate the effect. Results: A total of 2135 studies were identified from database search, six studies with 521 150 patients with the first STEMI episode were included in the analysis. The authors found higher in-hospital mortality (OR: 1.43; CI: 1.40-1.47) and cardiogenic shock (OR: 1.59; 95% CI: 1.55-1.63) in the SMuRF-less group with no differences in MACE, recurrent MI, major bleeding, heart failure, and stroke. There were lower prescriptions of statin (OR: 0.62; CI: 0.42-0.91) and Angiotensin converting enzyme inhibitor /Angiotensin II receptor blocker (OR: 0.49; CI: 0.28-0.87) at discharge in SMuRF-less patients. There was no difference in procedures like coronary artery bypass graft, percutaneous coronary intervention, and thrombolysis. Conclusion: In the SMuRF-less STEMI patients, higher in-hospital mortality and treatment discrepancies were noted at discharge.

A Case of Advanced Non-Small-Cell Lung Cancer With Response to Alectinib and Favorable Quality of Life.

Lung cancer is the leading cause of cancer death globally and in the United States. Non-small-cell lung cancer (NSCLC) accounts for approximately 85% of lung cancer cases. A progressive increase in morbidity and mortality is seen with advanced disease. Identifying specific driver mutations, such as anaplastic lymphoma kinase (ALK) mutations and directed therapy, has improved the quality of life and survival in ALK-positive NSCLC patients. Here, we present the case of a 37-year-old female who was diagnosed with stage IV NSCLC (adenocarcinoma) with a positive ALK mutation six years ago. Our case report highlights a rare ALK mutation NSCLC treated with targeted ALK inhibitor therapy. Despite having advanced-stage cancer, the treatment significantly impacted her survival with an improved quality of life.

An Adult Female Presenting With "Scrofula-Tubercular Lymphadenitis" a Rare Encounter: A Case Report.

Cervical lymphadenitis is the most common extra-pulmonary manifestation of tuberculosis (TB). Usually, presenting with a neck mass with minimal systemic symptoms is a diagnostic challenge for physicians. Diagnosis is made by combining clinical features, microscopic and radiological imaging, and fine-needle aspiration biopsy. A biopsy is the simplest and most cost-effective means of diagnosis. We are reporting a case of a female presenting with a neck mass without systemic symptoms who were found to have lymph node TB along with active lung disease. She was treated with a nine-month course of the direct observation treatment regimen.

POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Protein, and Skin Changes): A Case Report of a Rare Paraneoplastic Syndrome.

POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes) syndrome is a multisystem disorder. Peripheral neuropathy and monoclonal plasma cell disorder are the most common manifestations of POEMS. Although osteosclerotic or mixed sclerotic-lytic lesions are typical, osteolytic lesions are rarely encountered. We present a case of a 39-year-old male with a history of multiple endocrine disorders who presented with paresthesia, edema, and hyperpigmentation and was eventually diagnosed with POEMS syndrome. Patients with unexplained neuropathy should be evaluated for POEMS syndrome, especially when it is associated with other findings like endocrinopathy, organomegaly, skin changes, or edema.

Rare Angina: A Case Report of Ludwig's Angina.

Ludwig's angina is the rapidly progressive cellulitis of the soft tissue of the neck and the floor of the mouth. Airway compromise is a frequent and potentially fatal sequela of Ludwig's angina. Here we present a case of a 54-year-old African American male who presented with fever associated with painful swelling of the mouth and anterior neck. He was febrile and hypoxic on presentation. Imaging showed extensive involvement of the neck and mediastinum to the level of the clavicles. The diagnosis of Ludwig's angina of periodontal origin was made, and intubation was performed for airway protection. Management was done by surgical debridement along with a course of broad-spectrum antibiotics. The patient's condition improved, and he was discharged on oral antibiotics with a referral to a dentist. Our case demonstrates that early diagnosis, airway management, treatment with broad-spectrum antibiotics, and surgical intervention are vital for the successful management of severe cases of Ludwig's angina.

Team-Based Learning Among Health Care Professionals: A Systematic Review.

Introduced in the 1970s to meet the academic needs of a growing number of students with relatively stagnant faculty, team-based learning (TBL) has revolutionized the modern classroom structure. Contrary to the traditional didactic model where the teacher assumes the central role and students are passive listeners, TBL participants are actively involved in the learning process. Teachers act as facilitators while the TBL participants work in groups to solve problems through engagement with their peers. The objective of the article is to conduct a systematic review on team-based learning using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The studies were searched in databases like PubMed®, Scopus®, Embase®, and PubMed Central® using appropriate keywords. Two authors screened the papers, and a third author resolved the conflicts. This was followed by a bibliographic review based on the references of the selected study and bias assessment using the Joanna Briggs Institute (JBI) critical appraisal tool. The team-based learning model is increasingly being used by different institutions globally. TBL and traditional lecture-based teaching outcomes revealed that TBL participants performed better in academic, clinical, and communication domains. In addition, TBL enhanced learners' engagement, collaborative spirit, and satisfaction. Our study results are similar to the prior meta-analysis and systematic review. Nevertheless, this systematic review remains more comprehensive, up-to-date, and inclusive thus far. Team-based learning is a pragmatic and superior approach to learning among health care professionals. It has resulted in better academic, clinical, and communication outcomes. This finding spans all the medical and allied professions studied in this systematic review.