Lipschutz Ulcers in an Adolescent After Sars-CoV-2 Infection.

This case report describes a 15-year-old female who presented with acute onset of painful genital ulcers. She denied being sexually active and tested positive for severe acute respiratory coronavirus 2 five days prior. Associated symptoms on days 1 to 3 included fatigue, nausea, headaches, and fever. Lipschutz ulcers (LUs), also known as aphthous ulcers, acute genital ulcers, and acquired genital ulcerations; are an uncommon, self-limiting, nonsexually transmitted condition characterized by the rapid onset of painful, necrotic ulcerations of the vulva or lower vagina. The pathogenesis of LUs is unclear, and the diagnosis is one of exclusion.

Case Report: Effects of Sars-CoV-2 on Marfan syndrome with resulting acute aortic dissection.

Marfan syndrome is one of the most common inherited connective tissue disorders that affects the heart, eyes, blood vessels, and bones. It occurs in approximately 1-2 per 10,000 individuals annually. Many patients with Marfan syndrome eventually develop aortic wall abnormalities, often resulting in aortic dilatation, which increases the risk of acute aortic dissection. Recent studies involving SARS-CoV-2 propose that individuals with connective tissue disorders such as Marfan syndrome can have additional associated conditions that could impose a higher risk for morbidity and mortality from SARS-CoV-2. The purpose of this article is to discuss the interrelationship between Marfan Syndrome, Acute Type A Aortic Dissection in a patient with Sars-CoV-2 infection. Pertinent review of these conditions, diagnostic findings, treatment, and the patient's clinical course will be discussed. There is minimal research focused on the connection between this novel virus, Marfan Syndrome, and compounding risk for aortic dissection.

Coexistence of vasculogenic erectile dysfunction and peripheral artery disease.

Erectile dysfunction (ED) is the most common sexual problem experienced by men. The incidence increases with age and causes significant negative impacts on self-esteem, intimate relationships, mental health, and may be a powerful prognostic indicator for underlying vascular disease. The purpose of this clinical column is to provide an overview of the pathophysiology, evaluation, and management of vasculogenic ED in a patient with peripheral artery disease. There is very little research focused on the coexistence of these two disease conditions.

Results of a Naloxone Screening Quality-Improvement Project in an Academic Emergency Department.

BACKGROUND: The Emergency Department (ED) is a medical setting increasingly utilized by opioid users. In January 2016, our health system initiated a take-home naloxone education and distribution program. From July to August 2016, screening was performed in the ED to identify patients for take-home naloxone. OBJECTIVE: To evaluate the outcomes of routine screening for take-home naloxone in the ED setting and to determine key screening questions. Secondary analysis of Electronic Health Records for discrete elements that could help identify individuals for naloxone. METHODS: This is a single-center, retrospective cohort study conducted at two EDs within an academic health system. A screening tool was verbally administered to a convenience sample of ED patients as part of a pilot project to identify patients for overdose education and naloxone. Patient charts were reviewed retrospectively for pre-determined historical elements, medications prescribed, and substance use history. Descriptive and comparative analysis using Fisher two-tailed tests were performed with regard to historical elements, naloxone recommendation and prescription. RESULTS: A total of 182 patients were included. Following screening, 58 (31.9%) were identified as candidates for take-home naloxone. Of those, 36 (62.1%) accepted naloxone recommendation and 19 (32.8%) were prescribed naloxone. Individuals not prescribed naloxone despite recommendation either declined naloxone 22 (37.9%) or were not prescribed naloxone 17 (29.3%). Subanalysis of questions with binary yes/no answers (N = 171) demonstrated significant prediction of both naloxone recommendation (ROC = 0.944) and prescription (ROC = 0.897). CONCLUSIONS: Routine screening for take-home naloxone can help identify patients at-risk for opioid overdose and increase naloxone access in the ED.

Implementing an overdose education and naloxone distribution program in a health system.

OBJECTIVE: To design and implement a health system-wide program increasing provision of take-home naloxone in patients at risk for opioid overdose, with the downstream aim of reducing fatalities. The program includes health care professional education and guidelines, development, and dissemination of patient education materials, electronic health record changes to promote naloxone prescriptions, and availability of naloxone in pharmacies. SETTING: Academic health system, San Diego, California. PRACTICE DESCRIPTION: University of California, San Diego Health (UCSDH), offers both inpatient and outpatient primary care and specialty services with 563 beds spanning 2 hospitals and 6 pharmacies. UCSDH is part of the University of California health system, and it serves as the county's safety net hospital. PRACTICE INNOVATION: In January 2016, a multisite academic health system initiated a system-wide overdose education and naloxone distribution program to prevent opioid overdose and opioid overdose-related deaths. An interdisciplinary, interdepartmental team came together to develop and implement the program. To strengthen institutional support, naloxone prescribing guidelines were developed and approved for the health system. Education on naloxone for physicians, pharmacists, and nurses was provided through departmental trainings, bulletins, and e-mail notifications. Alerts in the electronic health record and preset naloxone orders facilitated co-prescribing of naloxone with opioid prescriptions. EVALUATION: Electronic health record reports captured naloxone prescriptions ordered. Summary reports on the electronic health record measured naloxone reminder alerts and response rates. RESULTS: Since the start of the program, the health system has trained 252 physicians, pharmacists, and nurses in overdose education and take-home naloxone. There has been an increase in the number of prescriptions for naloxone from a baseline of 4.5 per month to an average of 46 per month during the 3 months following full implementation of the program including implementation of electronic health record alerts. CONCLUSION: Initiating and implementing an overdose education and naloxone distribution program is feasible in an academic health system.

The Birth of Miles Henry DeVries.

In this birth story, a second-time mother relates her experience of birthing her son at home after her daughter was born via cesarean surgery. Support from the International Cesarean Awareness Network, as well as a home birth midwife specializing in vaginal birth after cesarean (VBAC), made the dream of a vaginal birth a reality for this mom. This story highlights the importance of having a supportive care provider and laboring in a safe and comfortable environment when pursuing a VBAC.

The ABCs of CMV.

Most infants exposed to cytomegalovirus (CMV) in utero will not be symptomatic; however, infants born with symptomatic CMV will have more severe consequences and poorer prognosis than will asymptomatic infants. The timing of infection during pregnancy largely affects the expected outcomes and consequences to the fetus. It is possible for a fetus to acquire congenital CMV infection from a nonprimary infection, although this accounts for a small number of cases. The presence of microcephaly, intrauterine growth restriction, petechiae, encephalitis, hepatosplenomegaly, and deafness are some of the physical characteristics of a congenital CMV infection. Treatment options remain limited at this time, so no routine screening has been recommended. The need for a vaccine or preventative treatment has been identified as a priority in the United States.

Real-time detection and alerting for acute ST-segment elevation myocardial ischemia using an implantable, high-fidelity, intracardiac electrogram monitoring system with long-range telemetry in an ambulatory porcine model.

OBJECTIVES: The purpose of this study was to evaluate feasibility of using real-time, high-fidelity, intracardiac electrogram monitoring from a permanently implantable ischemia detection system (IIDS), with long-range telemetry capability to detect ST-segment shifts associated with acute or subacute coronary occlusion in a porcine model. BACKGROUND: Early identification of coronary occlusion with ST-segment elevation could profoundly accelerate the timing of revascularization and improve clinical outcomes. METHODS: This paper reports the first investigation using real-time, high-fidelity, intracardiac electrogram monitoring from a permanently IIDS, with long-range telemetry capability. This IIDS was tested in an ambulatory porcine model, with acute coronary occlusion precipitated by stent thrombosis. Two overlapping copper stents were implanted in the left anterior descending (n = 3), the circumflex (n = 3), or the right coronary artery (n = 2) of juvenile farm pigs. Monitoring was carried using telemetry from the IIDS. RESULTS: All stented pigs had acute ST-segment elevation event(s) triggering the alerting thresholds of the IIDS. All triggered events were confirmed to be caused by thrombosis of the copper stent(s), and well correlated to infarct age and location. Four of the 8 pigs died from ventricular fibrillation, recorded by the IIDS at a mean time of 70 +/- 121 h after ST-segment alert. The sensitivity and specificity of alerting for ST-segment shift, associated with thrombotic coronary occlusion, were 100% and 100%, respectively. CONCLUSIONS: This study demonstrates the ability of an implantable ischemia detection system to detect ST-segment elevation from coronary occlusion in a porcine model of ST-segment elevation myocardial infarction. ST-segment elevation was sufficient to trigger alerting thresholds in all 3 epicardial coronary distributions. Such a system, with real-time alerting capability, could advance the time frame of reperfusion therapy and potentially prevent, rather than interrupt, acute myocardial infarction in patients with coronary artery disease.

Role of the "dogbone" effect of balloon-expandable stents: quantitative coronary analysis of DUET and NIR stent implantation introducing a novel indexing system.

UNLABELLED: Stent design and deployment characteristics of balloon-expandable stents may play an important role in determining both early and late outcomes of stenting. The purpose of this study was to compare the percent residual stenosis (RS) of two new-generation stent delivery systems, DUET and NIR, in patients with CAD. From September 1998 1999, a total of 100 consecutive patients with CAD receiving either a DUET (18 or 23 mm length; n = 50) or NIR stent (16 or 25 mm length; n = 50) using a 3.0 or 3.5 mm stent delivery system were compared by quantitative coronary analysis. The ability of each balloon delivery system to fully expand the stent was assessed using a new scoring index entitled the stent delivery balloon expansion ratio (SDBR; %). A high SDBR correlates with the angiographic appearance of a "dogbone" that is sometimes seen during stent deployment. A stent "scalloping" score was developed to quantitatively assess the cobblestone appearance observed angiographically with plaque protrusion after stent implantation. Mean deployment pressures were 14 +/- 2 atm (DUET) and 13 +/- 2 atm (NIR) (p=NS). Extent of elastic recoil was similar (6 +/- 5% for DUET vs. 6 +/- 4% for NIR; (p=NS). "Scalloping" was more pronounced in the DUET stent (score, 0.66 +/- 0.6 for DUET vs. 0.24 +/- 0.4 for NIR; p < 0.001). SDBR and RS were higher with DUET than with NIR stent implantation (SDBR, 15 +/- 5% vs. 12 +/- 5%; RS, 14 +/- 5% vs. 11 +/- 6%; p < 0.01). Multivariate analysis showed that SDBR and stent recoil, but not "scalloping", were associated with increased RS after stent implantation (r = 0.45 and p < 0.001 for "dogbone" effect; r = 0.39 and p < 0.001 for stent recoil). CONCLUSION: The second-generation DUET and NIR stents and their respective delivery systems show angiographically different acute performance characteristics. Insufficient deployment of stents visualized by the "dogbone" effect plays a role in the extent of RS after stenting. The introduced angiographic indexes require further validation.