Interpreting a Delayed Workup of Idiopathic Inflammatory Myopathy.

Idiopathic inflammatory myopathies are a widely heterogeneous group of muscle diseases and encompass multiple clinicopathologic entities. Our case presentation describes a 70-year-old male who presented with progressively worsening dyspnea, along with worsening proximal muscle weakness in the bilateral lower extremities. Extensive clinical evaluation revealed a creatine kinase level of 105 IU/L, severe and chronic widespread myopathy seen on electromyography (EMG), and asymmetric but widespread muscle atrophy with fibro-fatty replacement seen on ultrasonography. Muscle biopsy specimen from the left deltoid was suboptimal but demonstrated characteristics that could be consistent with several clinicopathologic diagnoses, including sporadic inclusion body myositis (sIBM), immune-mediated necrotizing myositis (IMNM), antisynthetase syndrome (AS), and direct toxin-induced myopathy. Electron microscopy revealed tubulofilamentous inclusion associated with autophagic debris, finally rendering an accurate diagnosis. This case summary highlights the testing workflow required to diagnose a patient with an inflammatory myopathy and outlines the difficulty in establishing a diagnosis when the workup for an inflammatory myopathy is delayed and the muscle biopsy is suboptimal.

Integrating evidence-based medicine into resident education.

Evidence-based medicine (EBM) is the practice of applying scientific evidence to clinical decision-making, with a focus on addressing the individualized needs and values of patients. It requires not only a solid foundation of medical knowledge and the ability to gather a thorough patient history but also the skills to locate, interpret, and apply relevant principles from the medical literature. Given the rapid advancements in the field of medicine, understanding medical literature holds significant importance for residents during their education and future careers. It is particularly crucial for reducing medical waste, adhering to guidelines, and decreasing morbidity and mortality rates. This paper aims to underscore the significance of increasing residents' exposure to evidence-based approaches in clinical decision-making, propose time-efficient and effective methods to enhance their understanding of EBM, and promote the implementation of evidence-based practices within the inpatient setting.

Reducing unpleasant side effects of topical 5-Fluorouracil treatment for actinic keratosis: a randomized controlled trial.

Introduction: 5-Fluorouracil (5-FU) for prophylactic treatment of diffuse actinic keratosis results in an exuberant inflammatory reaction, contributing to patient noncompliance and dissatisfaction.Design: This 5-week split-faced, double-blind, randomized controlled trial involved 30 subjects with diffuse facial AK who received twice daily 5-FU treatment for 2 weeks. This was followed by pre-randomized twice daily use of one of three topical interventions on one half of the face. TEWL, pH, and hydration were assessed on each quadrant of the face at all visits. Additionally, photographs were subjectively graded by three blinded trained observers.Results: Thirty subjects were enrolled, and had an average 27.1 (SD 11.8, range: 13-62) palpable AKs at baseline. Average resolution of baseline AK count was 98.1% by week 4. Clobetasol propionate is best at decreasing TEWL (p = .034), while petrolatum jelly most significantly improves hydration (p = .019) and erythema (p = .014). Though controlled release skin barrier emulsion trended towards improvement in TEWL (p = .17) and hydration (p = .19), there was no significant decrease in erythema (p = .257). Patient free-text response identified erythema as the most bothersome symptom.Conclusions: Given the low cost, wide availability, and ability to significantly reduce erythema, petrolatum should be used for post-5-FU treatment for diffuse AK.

Revisiting Role of Vaccinations in Donors, Transplant Recipients, Immunocompromised Hosts, Travelers, and Household Contacts of Stem Cell Transplant Recipients.

Vaccination is an effective strategy to prevent infections in immunocompromised hematopoietic stem cell transplant recipients. Pretransplant vaccination of influenza, pneumococcus, Haemophilus influenza type b, diphtheria, tetanus, and hepatitis B, both in donors and transplant recipients, produces high antibody titers in patients compared with recipient vaccination only. Because transplant recipients are immunocompromised, live vaccines should be avoided with few exceptions. Transplant recipients should get inactive vaccinations when possible to prevent infection. This includes vaccination against influenza, pneumococcus, H. influenza type b, diphtheria, tetanus, pertussis, meningococcus, measles, mumps, rubella, polio, hepatitis A, human papillomavirus, and hepatitis B. Close contacts of transplant recipients can safely get vaccinations (inactive and few live vaccines) as per their need and schedule. Transplant recipients who wish to travel may need to get vaccinated against endemic diseases that are prevalent in such areas. There is paucity of data on the role of vaccinations for patients receiving novel immunotherapy such as bispecific antibodies and chimeric antigen receptor T cells despite data on prolonged B cell depletion and higher risk of opportunistic infections.

Marantic endocarditis: incidental infarcts leading to diagnosis of pancreatic cancer.

Non-bacterial thrombotic endocarditis (NBTE) is a well-described phenomenon associated with malignancies due to hypercoaguable state. In the setting of pancreatic cancer, NBTE is more commonly diagnosed postmortem. We describe a case of a man who was diagnosed with pancreatic carcinoma after incidental finding of NBTE. Imaging incidentally revealed multiple strokes, bilateral renal and splenic infarcts, while subsequent workup for cardioembolic source demonstrated a 1.1×0.7 cm mitral valve vegetation. As multiple blood cultures were sterile and patient lacked clinical signs of infection, an underlying malignancy was suspected. CT abdomen demonstrated a dilated pancreatic duct, MRI showed a 2.8×2.2 cm pancreatic head mass. Endoscopic biopsy of the mass revealed pancreatic adenocarcinoma. Other than NBTE, there were no other clinical or laboratory findings to clearly suggest pancreatic cancer. Thus, incidental discovery of this mitral valve vegetation led to the diagnosis of pancreatic malignancy.