Anxiety, Depression, and Pain: Considerations in the Treatment of Patients with Uncontrolled Hypertension.

PURPOSE OF REVIEW: The association between mental health, pain, and treatment-resistant hypertension is an important consideration for treating physicians. We review and discuss the connection between conditions of anxiety, depression, and chronic pain and their effect on uncontrolled hypertension. RECENT FINDINGS: There is significant co-occurrence of hypertension with anxiety, depression, and chronic pain which may lead to undertreatment of hypertension and undertreatment of the underlying mental health disorder. The association between mental health and hypertension is complex and is modulated by physiologic and environmental factors. Physicians treating patients with hypertension should be cognizant of the role anxiety, depression, and chronic pain play in treatment efficacy and compliance. Patients undergoing treatment should be screened for mental health disorders at treatment initiation and frequently thereafter to ensure optimal overall health and compliance.

Back pain: A puzzle in children.

Back pain in children is underdiagnosed and increases incidence in adolescence. A systematic approach can diagnose the most common causes: trauma, structural deformities, inflammatory diseases, infection and malignancy.

Teaching and Assessing Bedside Procedures: A Standardized Cross-Disciplinary Framework for Graduate Medical Education.

ABSTRACT: Performing bedside procedures requires knowledge, reasoning, physical adeptness, and self-confidence; however, no consensus on a specific, comprehensive strategy for bedside procedure training and implementation is available. Bedside procedure training and credentialing processes across large institutions may vary among departments and specialties, leading to variable standards, creating an environment that lacks consistent accountability, and making quality improvement difficult. In this Scholarly Perspective, the authors describe a standardized bedside procedure training and certification process for graduate medical education with a common, institution-wide educational framework for teaching and assessing the following 7 important bedside procedures: paracentesis; thoracentesis; central venous catheterization; arterial catheterization; bladder catheterization or Foley catheterization; lumbar puncture; and nasogastric, orogastric, and nasoenteric tube placement. The proposed framework is a 4-stage process that includes 1 preparatory learning stage with simulation practice for knowledge acquisition and 3 clinical stages to guide learners from low-risk to high-risk practice and from high to low supervision. The pilot rollout took place at Henry Ford Hospital from December 2020 to July 2021 for 165 residents in the emergency medicine and/or internal medicine residency programs. The program was fully implemented institution-wide in July 2021. Assessment strategies encompass critical action checklists to confirm procedural understanding and a global rating scale to measure performance quality. A major aim of the bedside procedure training and certification was to standardize assessments so that physician trainers from multiple specialties could train, assess, and supervise any participating trainee, regardless of discipline. The authors list considerations revealed from the pilot rollout regarding electronic tracking systems and several benefits and implementation challenges to establishing institution-wide standards. The proposed framework was assembled by a multidisciplinary physician task force and will assist other institutions in adopting best approaches for training physicians in performing these critically important and difficult-to-perform procedures.

Ocular manifestations of severe familial hypercholesterolemia.

Background: To study ocular manifestations of patients with severe familial hypercholesterolemia (FH). Methods: In this population-based case-control study, patients suffering from severe familial hypercholesterolemia from the Lebanese Familial Hypercholesterolemia Registry, along with age and gender-matched healthy controls were recruited. All participants underwent a comprehensive eye examination, and patients underwent fluorescein angiography as well. Logistic regression models were used to identify any association between patients with severe familial hypercholesterolemia and abnormal eye findings, while adjusting for hypertension and pack-year smoking. The main outcome measure of this study was the development of ocular vascular abnormalities. Results: 28 patients and 28 controls were recruited. Patients with severe familial hypercholesterolemia had significantly greater odds of developing corneal arcus and xanthelasmas than the control group (p < 0.001). Retinal vascular abnormalities (plaques) were exclusively and more significantly present in patients with familial hypercholesterolemia (18 %). Similarly, retinal arteriosclerosis was exclusively and significantly more prevalent in the familial hypercholesterolemia group (p < 0.001, adjusted odds ratio 6.8). Stratification by LDL levels and genotypes did not show any significant change in the prevalence of any ocular finding. Conclusion: In addition to the well-established increase in incidence of corneal arcus and xanthelasmas, severe familial hypercholesterolemia patients have more prevalent retinal vascular abnormalities that include vascular plaques and arteriosclerosis.

Acute coronary syndrome prediction in emergency care: A machine learning approach.

BACKGROUND AND OBJECTIVE: Clinical concern for acute coronary syndrome (ACS) is one of emergency medicine's most common patient encounters. This study aims to develop an ensemble learning-driven framework as a diagnostic support tool to prevent misdiagnosis. METHODS: We obtained extensive clinical electronic health data on patient encounters with clinical concerns for ACS from a large urban emergency department (ED) between January 2017 and August 2020. We applied an analytical framework equipped with many well-developed algorithms to improve the data quality by addressing missing values, dimensionality reduction, and data imbalance. We trained ensemble learning algorithms to classify patients with ACS or non-ACS etiologies of their symptoms. We used performance evaluation metrics such as accuracy, sensitivity, precision, F1-score, and the area under the receiver operating characteristic (AUROC) to measure the model's performance. RESULTS: The analysis included 31,228 patients, of whom 563 (1.8%) had ACS and 30,665 (98.2%) had alternative diagnoses. Eleven features, including systolic blood pressure, brain natriuretic peptide, chronic heart disease, coronary artery disease, creatinine, glucose, heart attack, heart rate, nephrotic syndrome, red cell distribution width, and troponin level, are reported as significantly contributing risk factors. The proposed framework successfully classifies these cohorts with sensitivity and AUROC as high as 86.3% and 93.3%. Our proposed model's accuracy, precision, specificity, Matthew's correlation coefficient, and F1-score were 85.7%, 86.3%, 93%, 80%, and 86.3%, respectively. CONCLUSION: Our proposed framework can identify early patients with ACS through further refinement and validation.

Occipital arteriovenous malformations and migraine.

BACKGROUND: Headache has been reported to be the first clinical presentation in several patients with cerebral arteriovenous malformations (AVMs). Headache associated with AVMs often shows characteristics of migraine with and without aura. Angiographic characteristics of AVMs, such as their location, could determine the 'migraine-like' features of attacks. METHODS: We performed an observational study of the clinical and angiographic characteristics of a cohort of 40 consecutive patients with AVMs who had been admitted to our institute for endovascular embolization over a 4-year period. Headache was characterized according to ICHD-II criteria. The relationship between headaches and the angioarchitectural features of AVMs was also analysed. RESULTS: Migraine-like headache was the first clinical manifestation in 22.5% of patients. The location of the malformation was significantly associated with migraine-like presentation (p=0.03) and the occipital lobe was the predominant site. CONCLUSIONS: An occipital location may be linked with spreading depression, a pathogenic mechanism of migraine. Headache associated with arteriovenous malformations in the occipital lobe, although secondary in nature, could have clinical features similar to migraine.

Prehospital Tibial Intraosseous Drug Administration is Associated with Reduced Survival Following Out of Hospital Cardiac Arrest: A study for the CARES Surveillance Group.

BACKGROUND: Recent reports have questioned the efficacy of intraosseous (IO) drug administration for out-of-hospital cardiac arrest (OHCA) resuscitation. Our aim was to determine whether prehospital administration of resuscitative medications via the IO route was associated with lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge than peripheral intravenous (IV) infusion in the setting of OHCA. METHODS: We obtained data on all OHCA patients receiving prehospital IV or IO drug administration from the three most populous counties in Michigan over three years. Data was from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) database. The association between route of drug administration and outcomes was tested using a matched propensity score analysis. RESULTS: From a total of 10,626 OHCA patients, 6869 received parenteral drugs during their prehospital resuscitation (37.8% by IO) and were included in analysis. Unadjusted outcomes were lower in patients with IO vs. IV access: 18.3% vs. 23.8% for ROSC (p < 0.001), 3.2% vs. 7.6% for survival to hospital discharge (p < 0.001), and 2.0% vs. 5.8% for favorable neurological function (p < 0.001). After adjustment, IO route remained associated with lower odds of sustained ROSC (OR 0.72, 95% CI 0.63-0.81, p < 0.001), hospital survival (OR 0.48, 95% CI 0.37-0.62, p < 0.001), and favorable neurological outcomes (OR 0.42, 95% CI 0.30-0.57, p < 0.001). CONCLUSION: In this cohort of OHCA patients, the use of prehospital IO drug administration was associated with unfavorable clinical outcomes.

Situs Inversus: Inferior-Lateral ST-Elevation Myocardial Infarction on Right-Sided Electrocardiogram.

Dextrocardia is a rare anatomical anomaly in which the heart is located in the patient's right hemithorax with its apex directed to the right. Although it usually does not pose any serious health risks, patients with undiagnosed dextrocardia present a diagnostic challenge especially in those presenting with chest pain. Traditional left-sided electrocardiograms (ECG) inadequately capture the electrical activity of a heart positioned in the right hemithorax, which if unnoticed could delay or even miss an acute coronary syndrome diagnosis. Here, we present a case of a patient with dextrocardia presenting with chest pain and diagnosed with ST-elevation myocardial infarction using a right-sided ECG.

Therapeutic efficacy of different iron chelators in Egyptian children with Beta Thalassemia with iron overload.

BACKGROUNDS: Beta thalassemia is a hereditary blood disorder characterized by reduced or absent beta chains of hemoglobin resulting in imbalanced globin chain synthesis with early destruction of RBCs and anemia. Patients with thalassemia major become transfusion- dependent with subsequent iron overload. Effective iron chelation therapy remains the main target of management of thalassemia major. OBJECTIVES: 'The aim of this work was to compare the efficacy of different iron chelating agents' in the treatment of ' iron overload in children with beta thalassemia major'. PATIENTS AND METHODS: 'The current study was conducted on 120 children with beta thalassemia major with serum ferritin level of more than 1000 ng/ml who were divided into 4 groups': Group A: 30 patients were treated with 8 hours intravenous infusion of Desferrioxamine, '40 mg/kg/day, 6 days per week for 6 months'. Group B: 30 patients were treated with subcutaneous infusion of Desferrioxamine, 40 mg/kg/day, 6 days per week 8-12 hours per day at night using Desferal pump for 6 months. Group C: 30 patients were treated with oral Deferiprone 75 mg/kg/day in three divided doses daily for 6 months. Group D: 30 patients were treated with oral Deferasirox 30 mg/kg/day in single dose on empty stomach daily for 6 months. 'For all patients laboratory investigations were carried out including complete blood count (CBC), measurement of serum ferritin, serum iron, TIBC (total iron binding capacity), liver enzymes and kidney functions'. RESULTS: There were significant reductions in 'serum ferritin and serum iron' after treatment in all studied groups with the highest reduction in group A, group B, group D and group C but without statistically significant differences between the four studied groups before and after chelation therapy. 'There were no significant differences in' the mean values of the parameters of CBC, liver enzymes and kidney functions between the studied groups before and after chelation therapy. CONCLUSION: From this study we concluded that there was significant reduction in serum ferritin and serum iron after chelation therapy in studied groups with the highest reduction in group A (IV Desferrioxamine), group B (SC Desferrioxamine), group D (oral Deferasirox) and group C (oral Deferiprone) with no statistically significant differences between the studied groups of patients before and after 6 months of regular chelation.