Amyloid Light-Chain (AL) Amyloidosis of the Trachea Associated With an Indolent B-cell Neoplasm.

We report the case of a 66-year-old woman who was diagnosed with localized tracheal amyloid light-chain (AL) amyloidosis caused by an underlying B-cell neoplasm. The diagnosis was confirmed through subsequent bronchoscopy and biopsies; however, she experienced a challenging episode of hypoxic respiratory failure that required intervention. Repeat bronchoscopies showed persistent subglottic stenosis and tracheobronchomalacia, which led to tracheal debulking surgery and additional interventions. The patient's treatment began with rituximab, zanubrutinib, and dexamethasone with outpatient follow-up. The rarity of tracheobronchial amyloidosis and its connection to B-cell malignancies are highlighted, emphasizing the challenges in diagnosis and the importance of tailored treatment strategies. The patient's clinical course, characterized by atypical respiratory symptoms, delayed diagnosis, and an evolving treatment approach, underscores the complexities of managing such a rare and intricate case.

Autologous stem cell boost improves persistent immune effector cell associated hematotoxicity following BCMA directed chimeric antigen receptor T (CAR T) cell therapy in multiple myeloma.

Persistent Immune Effector Cell Associated Hematotoxicity (ICAHT) is a significant side effect of BCMA CAR T-Cell therapy in patients with relapsed multiple myeloma (MM). The use of stem cell boosts in ICAHT has been described, however studies have been limited by small patient numbers and short follow up. Herein, we report on our multi-institutional experience of ICAHT, defined by an absolute neutrophil count (ANC) of ≤ 1000, thrombocytopenia with a platelet count ≤ 50,000 or/and anemia as hemoglobin (hgb) ≤9 g/dL, in patients who received BCMA CAR T therapy, and the effects of subsequent stem cell boost on hematopoietic reconstitution and clinical outcome. In this study, ICAHT was observed in 60% (n = 61/101) of patients at D + 21, and risk factors for its development included history of a prior ASCT, higher number of prior lines of therapy, a decreased platelet count prior to lymphodepletion and history of ICANS. 28% of patients with ICAHT received a stem cell boost at a median of 116 days due to profound and prolonged cytopenias often requiring ongoing transfusion support. Stem cell boost significantly improved cytopenias at 3 and 6 months follow up without any adverse effects on PFS and OS, underscoring the safety of this procedure.

Necrotizing Enterocolitis in a Patient With Newly Diagnosed Multiple Myeloma and Hyperviscosity Syndrome: A Case Report.

Multiple myeloma (MM) is a clonal plasma cell proliferative disorder characterized by the abnormal increase of monoclonal paraprotein and can lead to specific end-organ damage. Necrotizing enterocolitis or bowel necrosis is a surgical emergency defined by cellular death because of reduced blood flow to the gastrointestinal tract. We report a case of a 75-year-old female who was diagnosed with hyperviscosity syndrome (HVS) and was sent to ED. Further workup showed that she had a new diagnosis of IgG kappa MM for which she was started on chemotherapy. Later, she developed respiratory distress and abdomen distention with less frequent bowel movements, and general surgery was consulted. CT scan of the abdomen and pelvis with contrast showed findings consistent with bowel ischemia vs infarction. The patient was immediately taken to the operating room, and exploratory laparotomy showed nonsurvivable bowel necrosis. She was transitioned to comfort care and passed away later. We aim to increase awareness among physicians to include HVS as one of the possible complications of MM and to detect it early to prevent morbidity and mortality.

Sixth Nerve Palsy From Multiple Myeloma in Central Nervous System: Case Series and Review of Current Literature.

We reported two cases of the central nervous system (CNS) multiple myeloma (MM) with unusual presentation of sixth nerve palsy. The first patient developed in the setting of newly diagnosed MM and the second patient in the relapsed refractory setting. One underwent surgery, and the other received radiation. Both patients received systemic chemotherapy and noted improvement. We also performed a comprehensive literature review of previously published cases of sixth nerve palsy from MM. This review highlights the importance of recognizing this presentation of CNS multiple myeloma to avoid delays in diagnosis and to get appropriate management in time.

Calciphylaxis in End-Stage Renal Disease: A Rare Condition With High Mortality.

Calciphylaxis is a rare but life-threatening condition, seen in patients with end-stage renal disease (ESRD) on renal replacement therapy. Its pathogenesis is not completely known, but microvascular calcification and thrombosis are considered the likely processes. It is characterized by significant morbidity due to severe pain and nonhealing wounds with frequent hospitalizations. Sepsis is the most common cause of mortality with more than 50% of patients dying within the first year after diagnosis. Optimal management requires a multidisciplinary approach. We describe a case of a 66-year-old female with ESRD on hemodialysis (HD) who presented with severe progressive calciphylaxis wounds on both lower extremities and died within two months after diagnosis. She had multiple admissions in the past for cellulitis when she presented with swelling in the legs and chronic wounds. Our goal is to increase awareness among physicians to include calciphylaxis in their differential diagnosis when treating ESRD patients with significant risk factors to detect it early and prevent morbidity and mortality.

Cerebral Venous Thrombosis Presenting as a Subacute Headache in a Young Man With Undiagnosed Factor V Leiden Mutation.

Cerebral venous sinus thrombosis (CVT) is a rare but potentially life-threatening condition that presents with non-specific symptoms. This condition is more common in women and can be associated with local infection and hypercoagulable conditions, including protein C and S deficiency, factor V Leiden mutation, anti-thrombin III deficiency, thrombophilia, vasculitis, and malignancy. We report the case of a 24-year-old man who presented with a left temporal headache and right upper and lower extremity paresthesia. He also experienced impaired vision (altered spatial sensation), dental pain, bruxism, nausea, and vomiting. Magnetic resonance imaging and magnetic resonance venography of the brain revealed widespread thrombosis of the cerebral sinuses as well as left superior cerebral cortical veins bilaterally. No evidence of venous infarct was found. Subsequent hematologic evaluation showed the presence of heterozygous factor V Leiden mutation. Testing of family members subsequently revealed the presence of this same mutation in his mother and all three siblings, although there was no family history of stroke, hypercoagulability, or atypical headaches. The patient was started on low-molecular-weight heparin and later transitioned to apixaban. Progression of his headache and visual abnormalities led to the discovery of increased intracranial pressure as demonstrated by papilledema and characteristic findings on computed tomography scan. He was treated with acetazolamide with improvement of his symptoms. CVT is uncommon and can be a diagnostic challenge due to its atypical presentation. Clinicians should consider this diagnosis in patients with a subacute onset of atypical headache, especially when accompanied by seizures, focal neurological deficits, or altered consciousness.

New Delhi Metallo-beta-lactamase-producing Enterobacter Cloacae - A Rare Multidrug Resistance Strain in a Caucasian Woman.

New Delhi metallo-beta-lactamase (NDM-1) is a novel metallo-beta-lactamase (MBL) gene carried by some Enterobacteriaceae that induces resistance to most of the antibiotics. First described in a Swedish patient hospitalized in India with an infection due to Klebsiella pneumoniae. NDM-1 makes bacteria resistant to a broad range of beta-lactam antibiotics. These include the antibiotics of the carbapenem family, which are a mainstay for the treatment of antibiotic-resistant bacterial infections. Most of these carbapenem resistant Enterobacteriaceae (CRE) are increasingly recognized in hospital settings and post-acute care settings like long-term acute care settings. Percentage of CRE infections is increasing in the United States of America, and invasive infections with CRE carry high mortality rates and limited treatment options. We here present a rare case of elderly Caucasian woman with CRE cellulitis of both legs with no travel history.

Marijuana use and acute myocardial infarction: A systematic review of published cases in the literature.

BACKGROUND AND OBJECTIVE: Marijuana use has gained popularity following legalization in the US. Marijuana can affect the heart through various mechanisms. This study aims to conduct a systematic review of published case reports of individuals with acute myocardial infarction (AMI) following marijuana use. METHODS: We conducted a systematic review of literature, including case reports, case series, and the letter to the editor on MEDLINE. Forty-six studies were included, with a total number of 62 patients with AMI and marijuana use. RESULTS: The mean age was 27.7 (±10.3) years with male predominance. About 3.7 g marijuana was used for an average of 9.7 years by the patients. From the cases reporting the onset of AMI symptoms, the average time was within 5 h after last marijuana use. The angiographic findings were normal in 36.8% of cases. In 42.1% of individuals, the left anterior descending coronary artery was occluded, making it the most common artery involved, followed by the right coronary artery (10.5%). Most cases were managed medically, followed by thrombectomy and stent placement, and percutaneous transluminal coronary angioplasty (PTCA). Complications included cardio-embolic stroke, and seven deaths were reported. CONCLUSION: It is important to consider episodic marijuana use as a significant risk factor of AMI, particularly in individuals with no cardiac risk factors, as delay in management can result in fatal outcomes including increased risk of mortality.

The Effectiveness of Selective Serotonin Reuptake Inhibitors for Treatment of Obsessive-Compulsive Disorder in Adolescents and Children: A Systematic Review and Meta-Analysis.

Background: Obsessive-compulsive disorder (OCD) is a common behavioral disorder among adolescents and children. The selective serotonin reuptake inhibitors (SSRIs) are the first pharmacological choice for this condition due to mild adverse effect profile. Objective: This systematic review was performed to evaluate the efficacy of SSRI for OCD in adolescents and children. Methods: Search terms were entered into PubMed, PsycINFO, Scopus, CINAHL, and Google Scholar. The included studies were randomized, placebo-controlled trials of SSRIs conducted in populations of children and adolescents younger than 18 years. Change from baseline Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), end-treatment CY-BOCS with respective SD, and response and remission rates were collected for continuous and dichotomous outcome assessment, respectively. Cochrane Rev Man software was used for meta-analyses, providing Forest plots where applicable. Results: SSRIs were superior to placebo with a small effect size. There was no additional benefit of combination treatment over cognitive behavioral therapy (CBT) alone, but CBT added substantial benefit to SSRI monotherapy. Fluoxetine and sertraline appear to be superior to fluvoxamine. Conclusion: The results of current systematic review and meta-analysis support the existing National Institute for Health and Care Excellence (NICE) guidelines for choosing CBT as first line of treatment and substituting it with SSRI, depending on patient preference. Adding CBT to current SSRI treatment is effective for non-responders and partial responders, but adding SSRI to ongoing CBT does not prove beneficial. The SSRIs have different effectiveness, and their relative efficacy remains to be investigated.

A national study for regional variation of inpatient ECT utilization from 4,411 hospitals across the United States.

BACKGROUND: We conducted a study to examine regional variation in the utilization of inpatient electroconvulsive therapy (ECT) across the United States, and its impact on length of hospital stay and cost. METHODS: Analysis of the Nationwide Inpatient Sample databases to compare patient and hospital characteristics, and regional variation of ECT administration across different regions of the United States. RESULTS: The study included 41,055 inpatients who had ECT from 4,411 hospitals. Electroconvulsive therapy use is significantly higher in the Midwest. A higher proportion of females (65.2%) than males received ECT across the United States. Medicaid beneficiaries were less likely to undergo ECT compared with patients with Medicare (52.2%) or private insurance (32%). Electroconvulsive therapy was used mainly for mood disorders (84.3%). There were marked reductions of inpatient costs ($25,298 to $38,244) and average hospital stay (16 days) when ECT was initiated within the first 5 days of admission compared with later during the hospitalization. CONCLUSIONS: There is a wide variability of utilization of ECT, depending on the region, type of hospital, and type of insurance carrier. The utilization of ECT services is reduced across the United States. Appropriate utilization of this effective treatment can greatly help patients who are not responding to standard therapeutics, reduce overall health care cost and length of stay, and, most importantly, alleviate suffering.

Use of Gabapentin in the Treatment of Substance Use and Psychiatric Disorders: A Systematic Review.

Objective: Gabapentin (GBP) is an anticonvulsant medication that is also used to treat restless legs syndrome (RLS) and posttherapeutic neuralgia. GBP is commonly prescribed off-label for psychiatric disorders despite the lack of strong evidence. However, there is growing evidence that GBP may be effective and clinically beneficial in both psychiatric disorders and substance use disorders. This review aimed to perform a systematic analysis of peer-reviewed published literature on the efficacy of GBP in the treatment of psychiatric disorders and substance use disorders. Methods: This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PubMed and Ovid MEDLINE literature databases were screened and filtered by using specific search terms and inclusion/exclusion criteria. The full texts of selected studies were subsequently retrieved and reviewed. The search terms generated 2,604 results from the databases. After excluding all duplicates, 1,088 citations were left. Thereafter, we applied inclusion and exclusion criteria; a total of 54 papers were retained for detailed review. Results: This literature review concludes that GBP appears to be effective in the treatment of various forms of anxiety disorders. It shows some effectiveness in bipolar disorder as an adjunctive therapeutic agent, while the evidence for monotherapy is inconclusive. In substance use disorders, GBP is effective for acute alcohol withdrawal syndrome (AWS) with mild to moderate severity; it reduces cravings, improves the rate of abstinence, and delays return to heavy drinking. GBP may have some therapeutic potential in the treatment of opioid addiction and cannabis dependence, but there is limited evidence to support its use. No significant benefit of GBP has been conclusively observed in the treatment of OCD, PTSD, depression, or cocaine and amphetamine abuse. Conclusion: GBP appears to be effective in some forms of anxiety disorders such as preoperative anxiety, anxiety in breast cancer survivors, and social phobia. GBP has shown to be safe and effective in the treatment of alcohol dependence. However, the literature suggests that GBP is effective as an adjunctive medication rather than a monotherapy. More clinical trials with larger patient populations are needed to support gabapentin's off-label use in psychiatric disorders and substance use disorders. It is worth noting that numerous clinical studies that are discussed in this review are open-label trials, which are inherently less rigorously analyzed. Therefore, more extensive investigations are required to examine not only the efficacy of GBP, but also its safety and tolerance.

Cognitive Behavioral Therapy versus Eye Movement Desensitization and Reprocessing in Patients with Post-traumatic Stress Disorder: Systematic Review and Meta-analysis of Randomized Clinical Trials.

Background Post-traumatic stress disorder (PTSD) is prevalent in children, adolescents and adults. It can occur alone or in comorbidity with other disorders. A broad range of psychotherapies such as cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) have been developed for the treatment of PTSD. Aim Through quantitative meta-analysis, we aimed to compare the efficacy of CBT and EMDR: (i) relieving the post-traumatic symptoms, and (ii) alleviating anxiety and depression, in patients with PTSD. Methods We systematically searched EMBASE, Medline and Cochrane central register of controlled trials (CENTRAL) for articles published between 1999 and December 2017. Randomized clinical trials (RCTs) that compare CBT and EMDR in PTSD patients were included for quantitative meta-analysis using RevMan Version 5. Results Fourteen studies out of 714 were finally eligible. Meta-analysis of 11 studies (n = 547) showed that EMDR is better than CBT in reducing post-traumatic symptoms [SDM (95% CI) = -0.43 (-0.73 - -0.12), p = 0.006]. However, meta-analysis of four studies (n = 186) at three-month follow-up revealed no statistically significant difference [SDM (95% CI) = -0.21 (-0.50 - 0.08), p = 0.15]. The EMDR was also better than CBT in reducing anxiety [SDM (95% CI) = -0.71 (-1.21 - -0.21), p = 0.005]. Unfortunately, there was no difference between CBT and EMDR in reducing depression [SDM (95% CI) = -0.21 (-0.44 - 0.02), p = 0.08]. Conclusion The results of this meta-analysis suggested that EMDR is better than CBT in reducing post-traumatic symptoms and anxiety. However, there was no difference reported in reducing depression. Large population randomized trials with longer follow-up are recommended to build conclusive evidence.

Efficacy and Safety of Varenicline for Smoking Cessation in Schizophrenia: A Meta-Analysis.

Objective: Smoking represents a major public health problem among patients with schizophrenia. To this end, some studies have investigated the efficacy of varenicline for facilitating smoking cessation in schizophrenia patients. The present review seeks to synthesize the results of these studies as well as document the reported side effects of using this medication. Methods: An electronic search was performed using five major databases: PubMed, Scopus, EMBASE, Web of Science, and Cochrane Library. Included in the current analysis were randomized clinical trials (RCTs) that have investigated the effect of varenicline in promoting smoking cessation in patients with schizophrenia. Risk of bias among included RCTs was assessed using the Cochrane Collaboration's quality assessment tool. Results: Among the 828 screened articles, only four RCTs, which involved 239 participants, were eligible for meta-analysis. In patients with schizophrenia, varenicline treatment when compared to placebo significantly reduced the number of cigarettes consumed per day [SMD (95% CI) = 0.89(0.57-1.22)] and expired carbon monoxide levels [SMD (95% CI) = 0.50 (0.06-0.94)] respectively. Conclusion: Despite a limited number of studies included in the meta-analysis, our results suggest that varenicline is an effective and safe drug to assist smoking cessation in patients with schizophrenia. Future large-scale well-designed RCTs are required to validate these findings.

Factors Related to Physician Burnout and Its Consequences: A Review.

Physician burnout is a universal dilemma that is seen in healthcare professionals, particularly physicians, and is characterized by emotional exhaustion, depersonalization, and a feeling of low personal accomplishment. In this review, we discuss the contributing factors leading to physician burnout and its consequences for the physician's health, patient outcomes, and the healthcare system. Physicians face daily challenges in providing care to their patients, and burnout may be from increased stress levels in overworked physicians. Additionally, the healthcare system mandates physicians to keep a meticulous record of their physician-patient encounters along with clerical responsibilities. Physicians are not well-trained in managing clerical duties, and this might shift their focus from solely caring for their patients. This can be addressed by the systematic application of evidence-based interventions, including but not limited to group interventions, mindfulness training, assertiveness training, facilitated discussion groups, and promoting a healthy work environment.