Unraveling the Complexity: Ehrlichiosis-Induced Septic Shock and Acute Respiratory Distress Syndrome.

Human monocytic ehrlichiosis typically presents with nonspecific cold-like symptoms and a history of recent tick exposure, often responding well to early treatment. Here, we present the case of a 67-year-old immunocompetent male who initially presented with fevers, chills, dysuria, and hematuria, leading to admission to the intensive care unit with septic shock and acute respiratory distress syndrome (ARDS), which was later attributed to Ehrlichia chaffeensis infection. Prompt treatment with doxycycline resulted in a full clinical recovery. This case highlights the rare occurrence of severe ehrlichiosis and provides insights into its effective management based on updated literature.

Temporal trends in outcomes following inpatient transcatheter aortic valve replacement.

INTRODUCTION: Despite the growing adoption of transcatheter aortic valve replacement (TAVR), there remains a lack of clinical data evaluating procedural safety and discharge practices. AIMS: This study aims to investigate if there have been improvements in postoperative clinical outcomes following TAVR. METHODS: In this large-scale, retrospective cohort study, patients who underwent TAVR as an inpatient were identified from 2016 to 2020 using the National Readmissions Database. The primary outcome was temporal trends in the rates of discharge to home. Secondary endpoints assessed annual discharge survival rates, 30-day readmissions, length of stay, and periprocedural cardiac arrest rates. RESULTS: Over the 5-year study period, a total of 31,621 inpatient TAVR procedures were identified. Of these, 79.2 % of patients were successfully discharged home with home disposition increasing year-over-year from 74.5 % in 2016 to 85.9 % in 2020 (Odds ratio: 2.01; 95 % CI 1.62-2.48, p < 0.001). The mean annual discharge survival rate was 97.7 % which did not change significantly over the 5-year study period (p = 0.551). From 2016 to 2020, 30-day readmissions decreased from 14.0 % to 10.3 %, respectively (p = 0.028). Perioperative cardiac arrest occurred in 1.8 % (n = 579) of cases with rates remaining unchanged during the study (p = 0.674). CONCLUSION: Most TAVR patients are successfully discharged alive and home, with decreasing 30-day readmissions observed over recent years. This data suggests potential improvements in preoperative planning, procedural safety, and postoperative care. Despite perioperative cardiac arrest being associated with high mortality, it remains a relatively rare complication of TAVR.

Paradoxical Excitation Following Intravenous Lorazepam Administration for Alcohol Withdrawal - A Case Presentation and Literature Review.

Benzodiazepines are commonly used medications which are clinically useful towards the treatment of alcohol withdrawal, seizures, anxiety disorders, among other indications. Benzodiazepine use is also known to cause the rare phenomenon of paradoxical excitation whose mechanism has many postulated theories. We report this rare presentation of paradoxical excitation with the use of lorazepam in a 50-year-old male being treated for alcohol withdrawal. We also review the underlying pathophysiology, pharmacology, and current literature as it relates to this excitation. An inability to recognize this adverse effect and to appropriately withhold the agent may adversely affect a patient's course of treatment in the inpatient setting.

Site-Specific Survival of Extra Nodal Diffuse Large B-Cell Lymphoma and Comparison With Gastrointestinal Diffuse Large B-Cell Lymphoma.

Background: Diffuse large B-cell lymphoma (DLBCL) constitutes 30% of all non-Hodgkin's lymphomas. It can present as a nodal disease or as an extra nodal disease. Based on the site of origin, extra nodal DLBCL (EN-DLBCL) may have a distinct clinical outcome. Apart from the site of origin, factors including demographics, stage, and presence of any other primary malignancy also affect the outcome. The purpose of our study was to characterize prognostically distinct groups based on the site of presentation of EN-DLBCL. Methods: We used 18 registries in Surveillance, Epidemiology, and End Results database to identify the patients with EN-DLBCL for 2000 - 2015 with last follow-up till December 31, 2018. A total of 30,290 EN-DLBCL patients were selected and categorized based on 13 broad sites grouping. Demographic variables were summarized. We did overall survival analysis with univariate and multivariate Cox-proportional hazard modeling. Short-term survival trend was calculated as well. Results: The percentage of EN-DLBCL of all DLBCLs is 34.48%. EN-DLBCL was comparatively seen more in males (54.94%) and non-Hispanic whites (71.52%). In terms of clinical characteristics, patients with EN-DLBCL were mostly diagnosed at age ≥ 60 years (66.11%), early stage (69.33%), and presentation as first primary cancer (81.89%). A higher risk of mortality was seen in non-Hispanic black (hazard ratio (HR) 1.36), with late age of onset (HR 2.69), late stage at presentation (HR 1.42), and with history of other malignancy (HR 1.29). Compared to the intestinal tract, the risk of overall mortality was higher in individuals with involvement of nervous system (HR 1.85), pancreas and hepatobiliary system (HR 1.22), and respiratory system (HR 1.18) and the best outcomes were seen in heart and mediastinal site (HR 0.58) of DLBCL. Conclusion: Based upon our population-based study, we conclude that primary site of presentation of EN-DLBCL is an important prognostic factor with significant difference in survival based on histological and epidemiological characteristics.

Impact of profession and wards on moral distress in a community hospital.

BACKGROUND: Recently, a singular survey titled "Measure of Moral Distress-Healthcare Professionals," which addresses shortcomings of previous instruments, has been validated. AIM: To determine how moral distress affects nurses and physicians differently across the various wards of a community hospital. PARTICIPANT AND RESEARCH CONTEXT: We distributed a self-administered, validated survey titled "Measure of Moral Distress-Healthcare Professionals" to all nurses and physicians in the medical/surgical ward, telemetry ward, intensive care units, and emergency rooms of a community hospital. FINDINGS: A total of 101 surveys were included in the study. The mean Measure of Moral Distress-Healthcare Professionals score for all respondents was 143.0 (standard deviation = 79.8). The mean Measure of Moral Distress-Healthcare Professionals score was 1.75 greater for nurses than for physicians (92.5 vs 161.5, p < .001), and nurses were 2.52 times more likely to consider leaving their position due to moral distress (68% vs 27%). The mean Measure of Moral Distress-Healthcare Professionals score for moral distress was least prevalent in the medical/surgical ward (92.5, SD = 38.2) and highest in the telemetry ward (197.7, SD = 83.6). The intensive care unit ward had a mean Measure of Moral Distress-Healthcare Professionals score mildly greater than the emergency room. ETHICAL CONSIDERATIONS: No participant identifying information or information connecting a survey response to an individual was collected. This study was approved by the Raritan Bay Medical Center's Institutional Review Board. DISCUSSION: This study provides insight into the level of moral distress in the community hospital setting. Telemetry nurses experience significantly more than nurses in other wards. Telemetry nurses typically manage patients sicker than medical/surgical wards, however do not have the resources of the critical care units. This scenario presents challenges for telemetry nurses and may explain their elevated moral distress. CONCLUSION: In community hospitals, telemetry nurses experience a considerably greater amount of moral distress compared to their colleagues in other wards. As measured by the Measure of Moral Distress-Healthcare Professionals questionnaire, moral distress continues to be higher among nurses compared to physicians.

Outcomes of Renal Function in Cardiogenic Shock Patients With or Without Mechanical Circulatory Support.

BACKGROUND: The objective of the study was to compare the renal outcomes in patients presenting with all-cause cardiogenic shock who were supported by either Impella devices (Abiomed, Danvers, MA), intra-aortic balloon pump (IABP), or vasopressors alone. Outcomes of cardiogenic shock remain poor even with the advancement of early revascularization and circulatory supportive care. Percutaneous mechanical circulatory support (MCS) device has emerged as an effective strategy in protecting end organ function especially renal function during high risk percutaneous coronary intervention (PCI) and in patients with cardiogenic shock. Currently, comparative data amongst various MCS modalities and their association with improvement of renal function in cardiogenic shock patients have not been well characterized. METHODS: Data from New Jersey Cardiac Catheterization Data registry of cardiogenic shock patients from a single tertiary care institution that underwent cardiac catheterization and the modality used to treat were obtained, either with Impella devices, IABP, or treatment with vasopressors alone. Retrospective chart review was conducted to assess the incidence of acute kidney injury (AKI) on patients with cardiogenic shock prior to and after cardiac catheterization and renal function was evaluated over the course of 96 h after cardiac catheterization. Statistical analysis was performed to ascertain significant difference in creatinine and estimated glomerular filtration rate (eGFR) in patients who received Impella devices, IABP, or were treated with vasopressors alone. RESULTS: A total of 61 all-cause cardiogenic shock patients met the inclusion and exclusion criteria and were included in the study with 19 receiving IABPs, 15 receiving Impella devices, and 27 treated with vasopressors alone. Baseline characteristics among these three groups did not show any statistically significant difference. A total of 29 cardiogenic shock patients had experienced AKI prior to cardiac catheterization in which those receiving Impella devices showed statistically significant decrease in creatinine and increase in eGFR at 72 and 96 h (P < 0.05) compared to baseline. Within the same cohort, Impella group showed statistically significant lower creatinine at 96 h when compared to IABP. Patients that experienced AKI after cardiac catheterization did not show any statistically significant changes in renal function regardless of modality used. CONCLUSION: The results of our study suggest that Impella devices improve renal function in all-cause cardiogenic shock patients who experience AKI prior to undergoing cardiac catheterization.

Effect of Insulin Pump Use on Diabetic Ketoacidosis in Type 1 Diabetes Mellitus: A Matched Cohort Study.

BACKGROUND: Diabetic ketoacidosis (DKA) is a well-known complication of diabetes mellitus with a significantly high mortality if not immediately and properly treated. Therefore, strategies for prevention of DKA are ever so important when managing diabetes mellitus, especially in the non-compliant patient population. Previously studies have suggested insulin pump use to carry an increased risk of DKA compared to insulin injections, while European studies suggest the opposite. We aimed to perform a retrospective cohort study to determine the risk of DKA in insulin pump versus injection in the United States. METHODS: We utilized the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) 2017 database, which represents a 20% sample of all payer hospitalizations in the United States. These hospitalizations were systematically selected by the Agency for Healthcare Resources and Quality (AHRQ) and we included all type 1 diabetes mellitus patients over the age of 18 who were on insulin, either pump or injections, in our study. RESULTS: We found a total of 58,260 admissions for patients with type 1 DM. Of these, 7850 had insulin pump, 30,672 used insulin injection, and 19,738 had no prior insulin use. We found that insulin pump use, compared to injections, failed to predict a lower incidence of DKA in hospitalized patients. CONCLUSION: Although several studies from European countries have found a reduction of DKA risk with insulin pump use, in this study we found no clear significant difference in a United States-based study. While this may be possible due to different legislating and regulation organizations, further studies are warranted to further evaluate the benefit of either insulin dispensing modality.

Hyperammonemic Encephalopathy: A Unique Presentation of Multiple Myeloma.

Multiple myeloma is a malignancy of plasma cells which are commonly found in the bone marrow. Known for causing a wide range of symptoms and affecting various organ systems, multiple myeloma is a rare malignancy with the entire pathophysiological process yet to be elucidated. We present a case of a 51-year-old male with a history of previously treated multiple myeloma in remission, initially presenting with chest pain with an unremarkable work-up. His hospital course was complicated by hyperammonemia causing encephalopathy requiring mechanical ventilation. After an extensive work-up to find an underlying cause, he was diagnosed with relapsing multiple myeloma. Due to a prolonged and complicated hospital course, the family pursued comfort measures and the patient passed away peacefully. Multiple myeloma induced hyperammonemic encephalopathy is a rare phenomenon carrying a high morbidity and mortality rate. Being still poorly understood, this manifestation of an already lethal diagnosis should be considered as a differential diagnosis of hyperammonemia. While early and aggressive treatment has shown some benefit and improved patient outcomes, further studies and understanding is needed to help diminish the mortality associated with hyperammonemic encephalopathy due to multiple myeloma.

Why Do Patients Leave against Medical Advice? Reasons, Consequences, Prevention, and Interventions.

BACKGROUND: A patient decides to leave the hospital against medical advice. Is this an erratic eccentric behavior of the patient, or a gap in the quality of care provided by the hospital? With a significant and increasing prevalence of up to 1-2% of all hospital admissions, leaving against medical advice affects both the patient and the healthcare provider. We hereby explore this persistent problem in the healthcare system. We searched Medline and PubMed within the last 10 years, using the keywords "discharge against medical advice," "DAMA," "leave against medical advice," and "AMA." We retrospectively reviewed 49 articles in our project. Ishikawa fishbone root cause analysis (RCA) was employed to explore reasons for leaving against medical advice (AMA). This report presents the results of the RCA and highlights the consequences of discharge against medical advice (DAMA). In addition, the article explores preventive strategies, as well as interventions to ameliorate leaving AMA.

Symptomatic pericardial effusion in the setting of asymptomatic COVID-19 infection: A case report.

RATIONALE: Infection with the severe acute respiratory coronavirus disease 2019 (COVID-19) has been shown to cause multi-organ involvement including cardiopulmonary serosal layers infection and inflammation. As a result, pericarditis and pericardial effusion may occur with or without COVID-19 related respiratory signs. Due to limitations in sensitivity and specificity of current COVID-19 diagnostic studies, cases that trigger high clinical intuition, even with negative serologic and polymerase chain reaction testing results, may necessitate further diagnostic workup to discover the underlying etiology. PATIENT CONCERNS: Here we present a rare case of pericardial effusion in the setting of asymptomatic COVID-19 infection manifesting with the chief complaint of chest pain. DIAGNOSIS: While undergoing diagnostic workup, the patients first 2 sets of COVID 19 reverse transcription-polymerase chain reaction (RT-PCR) were negative while a latter RT-PCR test, as well as serology, were positive, leading to the diagnosis of COVID-19 reinfection or subacute presentation of viral infection with pericardial effusion. Echocardiogram depicted large circumferential pericardial effusion with mildly thickened pericardium. INTERVENTIONS: The patient underwent pericardial window placement followed by ibuprofen administration and discharged from the hospital. OUTCOMES: During the follow-up visit patient had no symptoms and echocardiogram demonstrated complete resolution of the effusion. LESSONS: Due to the possible establishment of pericardial effusions and consecutively tamponade even without any COVID-19 related clinical presentation, it is crucial for clinicians to trust their intuition, conduct the appropriate diagnostic tests, find the underlying diagnosis and prevent the devastating consequences.

Spontaneous Recurrent Pneumoperitoneum due to Opioid-Induced Constipation: A Case Report.

Long-term treatment with or addiction to methadone and other opiates can lead to serious complications such as opioid-induced constipation (OIC). Here we report a case where a long-term opioid user presents in the ER in respiratory distress. Radiographic findings concerning pneumoperitoneum and cooperation with specialists lead to a diagnosis of stercoral colitis with possible micro-perforations. Through fecal disimpaction and counseling on chronic opioid use, the patient initially improved, but consecutively had a fatal outcome.

Mechanism and Effect of Beta-Blockers on Pancreatic Adenocarcinoma: A Literature Review.

Pancreatic adenocarcinoma has a poor 5-year survival rate despite many advancements in pharmacotherapies. Studies have suggested the involvement of ß-adrenergic pathway in the progression of pancreatic adenocarcinoma. Animal experiments and retrospective trials have reported the use of beta-blockers as potential chemo-preventative agents. This review aims to discuss ß-adrenergic physiology as it relates to the progression of pancreatic adenocarcinoma and review outcomes on the use of beta-blockers for its treatment.

Unilateral Purple Urine Bag Syndrome in an Elderly Man with Nephrostomy.

Purple urine bag syndrome, or PUBS, is a manifestation of a complicated urinary tract infection. Organisms such as Escherichia coli (E. coli) and Enterococcus can reside in urinary catheters and exhibit the purple color detected in this phenomenon. Risk factors described for this syndrome include the use of plastic urinary catheterization, the malfunctioning of the catheter, and long-term institutionalization. This disorder could be the earliest presentation of a urinary catheter flaw and requires immediate intervention and revision. In our case, a male resident of nursing home presented with urosepsis and appropriate antibiotics were initiated. Computed tomography (CT) urogram was done and showed left kidney hydronephrosis and bilateral staghorn calculi. To address the source of infection, a nephroureteral drain was placed in both kidneys. A few days after the initiation of treatment and urological intervention, urine on the left side became purple. The urologist re-evaluated the nephroureteral drainage tubes and replaced them. The purple color in the urine resolved later. In our case, PUBS was the earliest sign of urinary drainage malfunctioning and required early intervention and treatment.

A Rare Case of Monophasic Synovial Sarcoma of Thoracic Vertebra.

Synovial sarcoma of spine is an extremely rare malignancy with poor prognosis. It is often metastatic at the time of presentation. Its relative rarity and histological resemblance to other tumors make it diagnostically challenging, requiring the need of immunohistochemistry and cytogenetics for definite diagnosis. Surgery is the mainstay of therapy with adjunct chemotherapy, although survival rates are very low.

Primary Small Intestinal Angiosarcoma: Epidemiology, Diagnosis and Treatment.

Angiosarcoma is an aggressive mesenchymal sarcoma of endothelial cell origin with high mortality. Its occurrence in the small intestine is exceedingly low. In addition to the rarity of small intestine angiosarcoma, the nonspecific early clinical symptoms obscure the suspicion of such tumors and thereby delay the diagnosis. In a hope to improve the knowledge of this rare but fatal neoplasm, we report one case of angiosarcoma of duodenum and jejunum in a 73-year-old man. Furthermore, we summarize and analyze the common clinical features, tumor markers, treatment, and survival of previous reported cases of this malignancy. Small bowel angiosarcoma occurs more often in men than women (1.6:1). The median age at diagnosis is 68.5 years. The overall median survival time is 150 days; the median survival time in female (300 days) is longer than that of male patients (120 days). Von Willebrand factor (vWF), CD31, CD34, vimentin, and Ulex europaeus agglutinin 1 appear to be the most useful markers for the diagnosis. The majority of the patients underwent surgical resection alone or surgery with subsequent chemotherapy. The patients treated with surgery plus chemotherapy survive longer than those underwent surgical resection only (median 420 days, n = 7 vs. 96.5 days, n = 26, respectively; P = 0.0275). Further studies of more cases are needed for a better understanding of this rare entity, as well as the development of effective strategies for prevention, early diagnosis, and treatment.

Cardiorespiratory Failure in Thyroid Storm: Case Report and Literature Review.

Thyroid storm is a potentially fatal manifestation of thyrotoxicosis. Cardiopulmonary failure is the most common cause of death in thyroid storm. Clinicians should keep in mind that thyroid storm complicated with cardiopulmonary failure can be the first presentation of thyrotoxicosis. As early intervention is associated with improved patient outcome, prompt diagnosis based on clinical grounds is of paramount importance in the management of thyrotoxicosis. A high index of suspicion and the ability of early recognition of impending thyroid storm depends on a thorough knowledge of both the typical and atypical clinical features of this illness. Herein, we report a case of thyroid storm presenting as cardiopulmonary failure in a 51-year-old woman with undiagnosed Grave's disease. Additionally, we review the pathophysiology of cardiopulmonary failure associated with thyrotoxicosis and various treatment modalities for thyroid storm.

A Rare Case of Pancreatic Tuberculosis.

Tuberculosis remains a major public health concern, although it has reportedly shown a decline in prevalence both in the United States and abroad in recent years. The focus on diagnosing and treating tuberculosis is on pulmonary tuberculosis. Meanwhile, pancreatic tuberculosis remains exceedingly rare, accounting for less than 5% (Gastroenterol Rep (Oxf), 2014;2:154-157) of all tuberculosis cases in the developing world. A literature review shows that the head is primarily affected in pancreatic tuberculosis (Gastroenterol Rep (Oxf), 2014;2:154-157).

A case of reversible drug-induced liver failure.

Acute fulminant liver failure and acute renal failure are devastating complications caused by many drugs. The use of N-acetylcysteine has been well established in acetaminophen toxicity, but it remains controversial in other cases. Dialysis is a very effective method of removing certain drugs from the system. With the invention of new street drugs such as "synthetic marijuana," it may be beneficial in patients whom the substances ingested are unknown. We report a case of a 42-year-old male who developed acute fulminant hepatic failure and acute renal failure, who was cured with dialysis, N-acetylcysteine, and other supportive measures.

Isolated Streptococcus intermedius pulmonary nodules.

Streptococcus intermedius, a member of the Streptococcal anginosus group of alpha-hemolytic streptococci, remains a notable infectious agent causing necrotizing pneumonia and abscesses. We report a case of a young male with pulmonary nodules found to have Streptococcus intermedius and no other underlying hepatic or dental history who was treated with ceftriaxone and avoided surgical intervention. A review of the literature reveals cases that are typically treated with a combined surgical and medical approach. These same cases often involve middle aged to elderly individuals who have a past history of tobacco use, alcoholic liver cirrhosis and/or poor dentition. This case stands out given the patient's atypical presentation.

A rare cause of acute abdomen: spontaneous dissection of the superior mesenteric artery.

Spontaneous superior mesenteric artery (SMA) dissection is a rare, but potentially fatal disease. Prompt diagnosis and treatment of SMA dissections result in a lower prevalence of intestinal infarction and mortality. In the current era, imaging techniques can promptly diagnose SMA dissection; however, no definitive guidelines have been established to treat this condition.