Thrombus Tango: Hypercoagulable State With a Right Atrial Mass and Superimposed Persistent Bacteremia.

Bacillus cereus is an uncommon nosocomial bacteria, typically dismissed as a contaminant. This case is a unique scenario in which B. cereus bacteremia persisted despite appropriate treatment. Further investigation revealed the presence of a right atrial thrombus believed to harbor a biofilm responsible for the sustained bacteremia. Clearance of the thrombus using the AngioVac system (AngioDynamics, Inc., Latham, NY) led to the resolution of blood cultures, and subsequently, the patient was discharged with a six-week course of intravenous (IV) antibiotics.

Navigating the Groove: A Unique Case of Groove Pancreatitis.

Groove pancreatitis (GP) is an uncommon form of chronic pancreatitis (CP) that affects the area between the duodenum, the head of the pancreas, and the common bile duct (CBD), which is known as the pancreaticoduodenal groove. Our case is based on a 68-year-old male with a past medical history of alcohol use disorder and a 50-pack-year smoking history who presented with nausea, vomiting, and poor oral intake. Computed tomography (CT) of the abdomen and pelvis showed gastric outlet obstruction due to a 6.0 cm mass in the pancreatic groove and the second portion of the duodenum, with dilation of the pancreatic, intrahepatic, and extrahepatic biliary ducts. In order to rule out malignancy and evaluate the acute symptoms, the patient underwent an open pancreaticoduodenectomy (PD). Pathologic findings and negative tumor markers confirmed GP. This case highlights a rare form of CP that symptomatically and radiographically mimics malignancy, but is benign.

Study protocol for a type III hybrid effectiveness-implementation trial to evaluate scaling interoperable clinical decision support for patient-centered chronic pain management in primary care.

BACKGROUND: The US continues to face public health crises related to both chronic pain and opioid overdoses. Thirty percent of Americans suffer from chronic noncancer pain at an estimated yearly cost of over $600 billion. Most patients with chronic pain turn to primary care clinicians who must choose from myriad treatment options based on relative risks and benefits, patient history, available resources, symptoms, and goals. Recently, with attention to opioid-related risks, prescribing has declined. However, clinical experts have countered with concerns that some patients for whom opioid-related benefits outweigh risks may be inappropriately discontinued from opioids. Unfortunately, primary care clinicians lack usable tools to help them partner with their patients in choosing pain treatment options that best balance risks and benefits in the context of patient history, resources, symptoms, and goals. Thus, primary care clinicians and patients would benefit from patient-centered clinical decision support (CDS) for this shared decision-making process. METHODS: The objective of this 3-year project is to study the adaptation and implementation of an existing interoperable CDS tool for pain treatment shared decision making, with tailored implementation support, in new clinical settings in the OneFlorida Clinical Research Consortium. Our central hypothesis is that tailored implementation support will increase CDS adoption and shared decision making. We further hypothesize that increases in shared decision making will lead to improved patient outcomes, specifically pain and physical function. The CDS implementation will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. The evaluation will be organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. We will adapt and tailor PainManager, an open source interoperable CDS tool, for implementation in primary care clinics affiliated with the OneFlorida Clinical Research Consortium. We will evaluate the effect of tailored implementation support on PainManager's adoption for pain treatment shared decision making. This evaluation will establish the feasibility and obtain preliminary data in preparation for a multi-site pragmatic trial targeting the effectiveness of PainManager and tailored implementation support on shared decision making and patient-reported pain and physical function. DISCUSSION: This research will generate evidence on strategies for implementing interoperable CDS in new clinical settings across different types of electronic health records (EHRs). The study will also inform tailored implementation strategies to be further tested in a subsequent hybrid effectiveness-implementation trial. Together, these efforts will lead to important new technology and evidence that patients, clinicians, and health systems can use to improve care for millions of Americans who suffer from pain and other chronic conditions. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05256394 , Registered 25 February 2022.

Elevated Serum Pancreatic Enzymes in a Patient With Acute Epigastric Pain and End-Stage Renal Disease.

Acute pancreatitis is one of the most common diagnoses for patients admitted to the hospital with acute abdominal pain and nausea and vomiting. often elevated amylase and lipase support the diagnosis. This case illustrates the importance of recognizing the elevated laboratory findings seen in patients with end-stage renal disease, especially those laboratory findings that aid in making clinical decisions and/or establishing the diagnoses. We present a case of a patient misdiagnosed with recurrent acute pancreatitis due to his recurrent episodes of nausea, vomiting, abdominal pain, and persistently elevated pancreatic enzymes in the setting of end-stage renal disease. It is important for clinicians to recognize that these enzymes are renally eliminated and thus will be elevated as a result of the renal disease, which would limit the use of pancreatic enzymes to establish the diagnosis of acute pancreatitis.

Musculoskeletal Ultrasound Diagnosis of Symptomatic Hoffa's Fat Pad Ganglion Cyst Successfully Managed Nonoperatively: A Case Report.

Ganglion cysts (GCs) can arise from a variety of different areas, but those arising from Hoffa's fat pad in the knee are relatively rare. A number of different types of cysts are also found in the knee, including meniscus cysts, proximal tibiofibular cysts, and cruciate ligament ganglion cysts. In this case report, a 54-year-old female presented with left knee pain and swelling for eight weeks. In-office musculoskeletal ultrasound (US) was used to diagnose a Hoffa's fat pad ganglion cyst and aid in targeted steroid injection. The patient was followed up 21 weeks after the injection. She was pain-free, and US findings showed the cyst had significantly decreased in size. This case shows how musculoskeletal ultrasound, a relatively inexpensive diagnostic modality, can be used to accurately diagnose the cause of knee pain, guide an in-office procedure for the treatment of Hoffa's fat pad ganglion cyst, and aid in monitoring.

Purpura Fulminans in a Patient With Septic Shock due to Escherichia coli Bacteremia With Emphysematous Pyelitis.

Purpura fulminans (PF) is a rapidly fatal disorder predominantly encountered in patients with an acquired deficiency of physiologic anticoagulants due to severe sepsis and septic shock with disseminated intravascular coagulation (DIC). This consumptive process eventually leads to widespread thrombosis, hemorrhagic necrosis, and gangrene. Rapid identification followed by aggressive management of the underlying etiology with a multidisciplinary team is critical to prevent long-term organ dysfunction, disability from amputation, and death. While bleeding is a common finding in DIC, anticoagulation must be considered if PF is present. We report a case of Escherichia coli--associated emphysematous pyelitis leading to bacteremia, septic shock, and PF with small- and medium-sized vessel thrombosis and acral ischemia.

Gout in Pregnancy: A Rare Phenomenon.

Gout is a rare phenomenon in reproductive age women due to the uricosuric effects of estrogen. Furthermore, gout in pregnancy has been reported in only a scant number of case reports. We present the case of a 21-year-old gravida-4 para-3 female at four-weeks gestation presenting with acute polyarticular gout, complicated by Haemophilus influenzae sepsis and hyperemesis gravidarum. The gout flare was likely precipitated by primary H. influenzae bacteremia, which was successfully treated with intravenous antibiotics. The treatment of gout in pregnancy is challenging because of the limited number of guidelines. We demonstrate successful management of an acute gout flare in pregnancy with colchicine and steroid injection of the affected joint. Unfortunately, the patient suffered a miscarriage, but the link between gout flare and spontaneous abortion is tenuous.

Black cohosh for the management of menopausal symptoms : a systematic review of clinical trials.

Alternative medicine preparations represent a significant industry worldwide. Black cohosh (Cimicifuga racemosa), a buttercup plant grown in North America, is one such popular preparation for the treatment of menopausal symptoms. Because the proportion of women experiencing climacteric symptoms is high, black cohosh merits further study as to its efficacy and safety. Convincing evidence for its efficacy in this setting remains to be demonstrated. The purpose of this systematic review was to assess the current literature on the benefits of black cohosh for women experiencing climacteric symptoms. To this end, a PubMed search was conducted on 1 November 2007 using the search terms 'black cohosh' AND 'menopause'. The search was limited to randomized controlled trials in the English language involving adults. Several additional reviews dealing with alternative therapies for menopause were included to capture additional older and non-English language literature. Ultimately, 16 studies eligible for review were identified. Many of the studies had conflicting results. Methodological flaws included lack of uniformity of the drug preparation used, variable outcome measures and lack of a placebo group. The benefits of black cohosh in the management of climacteric symptoms remain to be proven. Case studies suggest an additional unexplored area of adverse events that also needs to be addressed.

Mediastinal pancreatic pseudocyst--a case report and review of the literature.

Pancreatic pseudocyst, a common complication of acute or chronic pancreatitis, in rare instances may also extend to the mediastinum. A case of 67-year-old woman presenting with a triad of chest pain, dysphagia, and dyspnea is presented. The patient had an episode of acute alcoholic pancreatitis 1 year before presentation. Chest radiography on admission showed a retrocardiac opacity. Two-dimensional echocardiography revealed an echolucent mass compressing the left atrium. A subsequent upper gastrointestinal series for her dysphagia showed extrinsic compression of the distal esophagus. Finally a definitive diagnosis was made with computed tomography (scan), which revealed a 19 x 12 cm pseudocyst extending from the body of pancreas into the thorax and compressing the esophagus and the cardiac chambers. A mediastinal pseudocyst can cause symptoms due to compression or invasion of surrounding structures. The fluid collection may enlarge slowly and hence the symptoms can be delayed as in our patient. The pseudocyst was successfully treated using endoscopic ultrasound-guided transesophageal drainage. Approximately 50 cases of mediastinal extension of the pancreatic pseudocyst in the world literature are reported. At this time, this is only the second time that successful drainage of a mediastinal pseudocyst using a transesophageal approach under endoscopic ultrasound guidance has been reported. The literature was reviewed for clinical presentation, complications, and available treatment options for mediastinal pancreatic pseudocysts.

Characteristics of patients prescribed angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or the combination at an urban medical center.

BACKGROUND: The realization that angiotensin-converting enzyme (ACE) inhibitors do not provide complete blockade of angiotensin II synthesis has resulted in an increased use of combinations of ACE inhibitors and angiotensin receptor blockers (ARBs). This study examines the characteristics of patients in whom this combination was prescribed. METHODS: Seventy-two patients diagnosed with primary hypertension and receiving an ACE inhibitor, an ARB, or their combinations were included. A retrospective review using outcome variables of mean arterial pressure (MAP), and changes between pretreatment MAP and post-treatment MAP were compared between groups. Statistical analysis was performed with SPSS statistical software. Analysis of variance (ANOVA) with Tukey's post hoc analysis was performed on continuous variables. Chi-square analysis was performed on categorical variables. Multivariate linear regression was performed to determine the best predictors of post-treatment MAP. RESULTS: There were no significant differences between the groups in pre- or post-treatment MAP. Patients on combination therapy with an ACE and ARB agent tended to be on more antihypertensive medications and tended to be diabetic. CONCLUSION: All treatment groups had similar blood pressure control and changes in MAP regardless of treatment. These findings suggest that combination ARB and ACE inhibitor therapy is a strategy being used for diabetics with difficult-to-control hypertension, although we cannot determine from our study whether this is primarily for blood pressure control or for renal protection. Whether combining an ACE inhibitor and ARB for blood pressure control alone is supported by the literature may be debatable. Further studies should evaluate the efficacy of such intervention to control hypertension. KEY POINTS: 1. Antihypertensive therapies using ACE inhibitors with ARBs are gaining popularity. 2. This retrospective chart review was completed to examine the characteristics of patients on monotherapy and of patients on combination therapy with ACE inhibitors and ARB agents. 3. This study suggests a tendency toward combined ARB and ACE inhibitor therapy in patients with diabetes who are on multiple antihypertensive medications.