Cardioembolic Stroke Secondary to Massive Stress-Induced Apical Thrombosis: A Clinical Conundrum Relating to Anticoagulation Initiation.

Takotsubo cardiomyopathy or stress cardiomyopathy is a condition characterized by acute and transient left ventricular systolic dysfunction in the absence of coronary heart disease, occurring after an acute emotional or physical stressful event. Cardiac dysfunction in these patients is suspected to be secondary to catecholamine induced cardiac myocyte injury via cyclic AMP-mediated calcium overload or due to endothelial dysfunction. Even though left ventricular dysfunction in takotsubo cardiomyopathy is transient, it can lead to acute complications. Left ventricular thrombus formation is a widely reported complication and has an incidence of around 5-14% in Takotsubo cardiomyopathy patients and can lead to thromboembolic events like stroke. We report a case of takotsubo cardiomyopathy with an apical LV thrombus, complicated by a large cardioembolic stroke. This case constitutes a clinical conundrum, as LV thrombus would warrant prompt initiation of anticoagulation, while the severe ischemic stroke would be a contraindication for immediate anticoagulation.

Predictors of Escalation to Intensive Care Unit Level of Care Among Admissions for Alcohol Withdrawal.

According to the 2019 National Survey on Drug Use and Health, 14.5 million people ages 12 and older had alcohol abuse disorder. Alcohol withdrawal syndrome (AWS) can be defined as a collection of physical symptoms experienced due to abrupt cessation of alcohol after long-term dependence. In instances where regular inpatient management fails to control AWS symptoms, patients are shifted to intensive care units (ICUs) for closer monitoring and prevention of life-threatening complications like withdrawal seizures and delirium tremens (DTs), labeled as severe alcohol withdrawal syndrome (SAWS). Although this represents a significant healthcare burden, minimal studies have been conducted to determine objective predictors. In this study, we aim to determine the effect of patient demographics, socio-economic status, biochemical parameters, and clinical factors on the need for escalation to ICU level of care among admissions for AWS. Our study showed that factors such as a history of DTs or alcohol-related seizures, the initial protocol of management, degree of reported alcohol usage, activation of rapid response teams, mean corpuscular value, alcohol level on admission, highest Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) scored during the hospital stay, and the total amount of sedatives used were significantly associated with escalation to ICU level of care. Clinicians must use these objective parameters to identify high-risk patients and intervene early. We encourage further studies to establish a scoring algorithm incorporating biochemical parameters to tailor management algorithms that might better suit high-risk patients.

Trazodone Overdose Manifesting as Hypotension and QT Prolongation.

Trazodone is a medication used to treat major depressive disorder (MDD). It is in the serotonin-antagonist-and-reuptake-inhibitor class of medications with anti-cholinergic effects. Trazodone is known for its sedative effects and is hence often prescribed in those with MDD with concurrent insomnia. While few, there have been reports of patients overdosing on trazodone and developing QTc prolongation leading to fatal arrhythmias such as torsades des pointes and variable atrioventricular blocks. We present a case of a 45-year-old female with a past medical history of MDD and anxiety, who presented with dizziness, transient ataxia, and urinary incontinence following ingestion of five 100 mg trazodone tablets. Although her vitals were initially stable on admission, her EKG was concerning for QTc prolongation of 502 ms. A few hours later, she started developing hypotension and progressive QTc prolongation, with a peak of 586 ms. Given the high risk of decompensation, the patient was admitted to the ICU for further care where she received adequate supportive management in the form of fluid resuscitation, electrolyte repletion, serial EKGs every hour, and telemetry monitoring for arrhythmias, with eventual improvement in her clinical condition. Trazodone poisoning, while rare, can be fatal and hence requires close monitoring to prevent complications. Clinicians must be aware of these possible adverse outcomes when managing trazodone toxicity.

A practical approach to pseudoexudative pleural effusions.

Light's criteria falsely label a significant number of effusions as exudates. Such exudative effusions with transudative etiologies are referred to as "pseduoexudates". In this review, we discuss a practical approach to correctly classify an effusion that may be a pseudoexudate. A PubMed search yielded 1996 manuscripts between 1990 and 2022. Abstracts were screened and 29 relevant studies were included in this review article. Common etiologies for pseudoexudates include diuretic therapy, traumatic pleural taps, and coronary artery bypass grafting. Here, we explore alternative diagnostic criteria. Concordant exudates (CE), defined as effusions where proteins in pleural fluid/serum (PF/SPr) > 0.5 and pleural fluid LDH level of >160 IU/L (>2/3 upper limit of normal) confer higher predictive value to the Light's criteria. Serum-pleural effusion albumin gradient (SPAG) > 1.2 g/dL and serum-pleural effusion protein gradient (SPPG) > 3.1 g/dL together yielded a sensitivity of 100% in heart failure and a sensitivity of 99% in hepatic hydrothorax whe n identifying pseudoexudates (Bielsa et al., 2012) [5]. Pleural fluid N-Terminal Pro Brain Natriuretic Peptide (NTPBNP) offered a specificity and sensitivity of 99% in identifying pseudoexudates when using a cut-off of >1714 pg/mL (Han et al., 2008) [24]. However, its utility remains questionable. Additionally, we also looked at pleural fluid cholesterol and imaging modalities such as ultrasound and CT scan to measure pleural thickness and nodularity. Finally, the diagnostic algorithm we suggest involves using SPAG >1.2 g/dL and SPPG >3.1 g/dL in effusions classified as exudates when there is a strong clinical suspicion for pseudoexudates.

Impact of Obesity on In-Hospital Morbidity and Mortality Among Patients Admitted for Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD).

Background Obesity has been considered to be a risk factor for increased morbidity and mortality among patients with cardiopulmonary diseases. The burden of chronic obstructive pulmonary disease (COPD) and obesity is very high in the United States. We aimed to use the National Inpatient Sample (NIS) to evaluate the impact of obesity on the outcomes of patients hospitalized with COPD exacerbation. Materials & Methods This is a retrospective cohort study from the NIS database involving adult patients hospitalized for COPD exacerbation in the year 2019 obtained using the international classification of diseases, 10th revision coding system (ICD-10). Obese and morbidly obese subgroups were identified. Statistical analyses were done using the Stata software, and regression analysis was performed to calculate odds ratios. Adjusted odds ratios (aOR) were calculated after adjusting for potential confounders. Results Among patients hospitalized for COPD exacerbations, mortality rates were lower among obese and morbidly obese patients; aOR 0.72 [0.65, 0.80] and aOR 0.88 [0.77-0.99], respectively. Obese and morbidly obese were more likely to require non-invasive ventilation aOR 1.63 [1.55, 1.7] and aOR 1.93 [1.85-2.05], respectively, and were more likely to require mechanical ventilation aOR 1.25 [1.19, 1.31], and aOR 1.53 [1.44-1.62], respectively. The tracheostomy rate was 1.17%, 0.83%, and 0.38% among patients with morbid obesity, obesity, and nonobese patients, respectively. Obese (aOR 1.11 [1.07-1.14]) and morbidly obese patients (aOR 1.21 [1.16-1.26]) had higher odds of being discharged on home oxygen and to a skilled nursing facility (SNF), aOR 1.32[1.27-1.38] and aOR 1.37 [1.3-1.43], respectively. Average hospital charges and length of hospitalization were significantly higher for morbidly obese and obese patients as compared to non-obese patients (p < 0.01). Conclusions Among admissions for COPD exacerbation, the rates of non-invasive ventilation, mechanical ventilation, tracheostomy, discharge with supplemental oxygen, length of hospitalization, hospitalization charges, and discharge to an SNF were higher among obese patients representing a higher morbidity and healthcare utilization in this group. This, however, did not translate into increased mortality among obese patients admitted with COPD exacerbations, and further randomized controlled trials are required to confirm our findings.

Klebsiella invasive syndrome: a challenging diagnosis.

Klebsiella invasive syndrome is a rare condition that typically presents as a liver abscess with metastatic infection, with mortality rates as high as 14% potentially due to diagnostic delay by clinicians. Here, we present a case of a woman in her 60s, who presented with symptoms and signs consistent with meningitis, imaging findings suggestive of possible leptomeningeal carcinomatosis a long with areas of lung consolidation and abdominal nodules and lymphadenopathy, presumably metastatic malignancy. We diagnosed Klebsiella invasive syndrome and treated it conservatively with medical management, including a long course of intravenous antibiotic therapy and supportive care. This is an infrequently encountered clinical entity with potentially fatal consequences, and we hope to add to the existing literature on the subject and drive home the point that it should be considered in the differential diagnoses in the appropriate clinical scenario.

Prevalence and Correlates of Excessive Smartphone Use among Medical Students: A Cross-sectional Study.

BACKGROUND: Increasing smartphone use has led to the introduction of smartphone addiction as a behavioral addiction with detrimental effects on health. This phenomenon has not been widely studied in the Indian context. This study assessed the rate of smartphone addiction in a sample of medical students, with a focus on its correlation with sleep quality and stress levels. METHODS: A cross-sectional study was conducted between November 2016 and January 2017 in 195 medical students. Their smartphone use, level of smartphone addiction, sleep quality, and perceived stress levels were measured using the Smartphone Addiction Scale-Short Version (SAS-SV), the Pittsburgh Sleep Quality Index (PSQI), and the Perceived Stress Scale (PSS-10), respectively. RESULTS: Of the 195 students, 90 (46.15%) had smartphone addiction as per the scale. A self-reported feeling of having smartphone addiction, use of the smartphone right before sleeping, PSS scores, and PSQI scores were found to be significantly associated with the SAS-SV scores. Significant positive correlations were observed between the SAS-SV and PSS-10 scores, and the SAS-SV and PSQI scores. CONCLUSIONS: There is a high magnitude of smartphone addiction in medical students of a college in Western Maharashtra. The significant association of this addiction with poorer sleep quality and higher perceived stress is a cause for concern. The high self-awareness among students about having smartphone addiction is promising. However, further studies are required to determine whether this self-awareness leads to treatment seeking. Further studies are required to explore our finding of the association of smartphone addiction with using the smartphone before sleeping.