Retrospective Study of Psychiatric Hospitalizations in a West Texas Mental Health Treatment Facility during the COVID-19 Pandemic.

OBJECTIVES: The association between the coronavirus disease (COVID-19) pandemic and adverse mental health outcomes has been well documented; however, little is known about its impact in rural areas of the United States. This study aims to characterize and compare inpatient psychiatric admissions in West Texas before and during the initial months of the COVID-19 pandemic. METHODS: A retrospective study was conducted using the electronic health records of 1392 inpatient psychiatric admissions from period A (March 13, 2019-July 3, 2019) to period B (March 13, 2020-July 3, 2020). RESULTS: During period B, there was a significant increase in the length of stay (P < 0.01) compared with period A. The pandemic was associated with an increased history of psychiatric medication use (P < 0.01), substance use (P ≤ 0.01), and suicide risk at the time of admission (P < 0.01). Significant differences were found in employment status (P < 0.01), living situation (P < 0.01), and ethnicity (P = 0.03). CONCLUSIONS: Rural communities in West Texas experienced a decrease in psychiatric hospitalizations during the beginning of the COVID-19 pandemic, followed by an increase as lockdown restrictions began to lift; this warrants further investigation into healthcare service utilization during the pandemic.

Role of skin autofluorescence in managing renal and cardiac diseases in outpatient dermatology.

INTRODUCTION: The accumulation of tissue-advanced glycation end products in skin results from complex and consecutive reactions and can be measured by skin autofluorescence (SAF) reader devices. This overview discusses studies evaluating the utilization of SAF in screening renal and cardiac disease. MATERIALS AND METHODS: Literature search was performed using Google Scholar, PubMed, Springer, Ovid, and ScienceDirect. RESULTS: SAF was an independent predictor of progression of chronic kidney disease (CKD) and was elevated in subjects on hemodialysis and peritoneal dialysis. Furthermore, SAF was significantly associated with cardiovascular events, cardiovascular mortality, and all-cause mortality in CKD patients. Other studies revealed a correlation between SAF and arterial stiffness, vascular damage, and subclinical atherosclerosis. A vegetarian diet was associated with lower SAF levels, whereas malnutrition was correlated with higher levels and increased mortality. CONCLUSIONS: SAF measurement may be useful in managing renal and cardiac disease. Future studies are needed to clarify the specific role of SAF in the management of CKD and its noninvasive office utilization to identify comorbidities in inflammatory diseases, such as psoriasis.

The Abl/Abi signaling links WAVE regulatory complex to Cbl E3 ubiquitin ligase and is essential for breast cancer cell metastasis.

The family of Abelson interactor (Abi) proteins is a component of WAVE regulatory complex (WRC) and a downstream target of Abelson (Abl) tyrosine kinase. The fact that Abi proteins also interact with diverse membrane proteins and intracellular signaling molecules places these proteins at a central position in the network that controls cytoskeletal functions and cancer cell metastasis. Here, we identified a motif in Abi proteins that conforms to consensus sequences found in a cohort of receptor and non-receptor tyrosine kinases that bind to Cbl-tyrosine kinase binding domain. The phosphorylation of tyrosine 213 in this motif is essential for Abi degradation. Double knockout of c-Cbl and Cbl B in Bcr-Abl-transformed leukemic cells abolishes Abi1, Abi2, and WAVE2 degradation. Moreover, knockout of Abi1 reduces Src family kinase Lyn activation in Bcr-Abl-positive leukemic cells and promotes EGF-induced EGF receptor downregulation in breast cancer cells. Importantly, Abi1 depletion impeded breast cancer cell invasion in vitro and metastasis in mouse xenografts. Together, these studies uncover a novel mechanism by which the WRC and receptor/non-receptor tyrosine kinases are regulated and identify Abi1 as a potential therapeutic target for metastatic breast cancer.

Comparison of patient satisfaction with diode laser treatment of female hirsutism: low fluence or high fluence?

The optimal fluence for treating hirsutism with the diode laser has not been elucidated. The aim of this study is to evaluate and compare the satisfaction and side effects of patients who have been treated with two diode laser therapy techniques: high-fluence and low-fluence. In this cross-sectional study, the medical records of 182 patients referred to Yazd Laser center were collected. Various side effects of laser therapy were assessed, and the satisfaction rate of the patients was evaluated at three points: after the first session, at the end of the treatment course, and six months after the end of the treatment. The satisfaction level after the first session of the laser treatment was higher with the low-fluence technique (P-value<0.001). The satisfaction level at the end of treatment was the same in the two groups (P-value = 0.394). However, six months after the treatment, satisfaction level was significantly higher with the low-fluence technique (P-value = 0.005). The rate of complications, such as burn and pain, was higher in the high-fluence group, while the number of treatment sessions was lower with the high-fluence technique. The low-fluence method of laser therapy has fewer complications associated with greater patient satisfaction.

Hold the Chemo! Leukostasis, a Presentation of Brown Recluse Spider Bite: A Case Report.

Brown recluse spiders, also known as Loxosceles reclusa, are endemic to the Southwest and Central Midwestern United States. A bite from this spider can cause a range of clinical manifestations, anywhere from a painless papular lesion to life-threatening reactions. We report a possible spider bite presenting as leukostasis initially suspected to be acute leukemia. A 22-year-old female patient presented to the emergency department with confusion and right upper arm pain, redness, and swelling after a suspected spider bite. Initial labs showed WBC count of 103.5x10e3/µL, hemoglobin of 3.3 g/dL, positive Direct Coombs' test, creatinine of 1.8 mg/dL, transaminitis, and lactic acid of 20 mmol/L. Acute leukemia with leukostasis was suspected. She was started emergently on hydroxyurea in conjunction with prophylaxis for tumor lysis syndrome. However, peripheral smear showed left-shifted granulocytosis with lymphocytosis, monocytosis, and no blast cells or evidence of myelodysplasia. Bone marrow aspirate showed mildly hypercellular marrow with myeloid hyperplasia and no myelodysplasia. Flow cytometry analysis confirmed a left-shifted myeloid maturation pattern with 0.3% myeloblasts. BCR-ABL1 and JAK2 testing was negative. Hence, she had no evidence of leukemia but rather had leukostasis from a spider bite. Hydroxyurea was stopped and follow-up labs normalized. Sphingomyelinase D in the brown recluse spider venom is unique to Loxosceles and Sicarius and may be responsible for the unique clinical presentation of loxoscelism. The presentation of hyperleukocytosis complicated by shock with an unclear history poses a diagnostic challenge. In diagnostic uncertainty, consider delaying chemotherapy until a diagnosis can be confirmed to avoid potential harm.

Case in Point: Correction of Dialysis-Induced Metabolic Alkalosis.

Normal saline solution infusion with concurrent removal by ultrafiltration successfully corrected pretreatment metabolic alkalosis when other measures were inadequate for a patient on dialysis.

Bullous Pemphigoid Mimicking Cellulitis.

Bullous pemphigoid (BP) is the most prevalent autoimmune blistering skin disease in the Western world affecting mainly the elderly population. The diagnosis is based on clinical assessment along with specific immunopathologic findings on skin biopsy. Risk factors include genetic factors, environmental exposures, and several infections including hepatitis B, hepatitis C, Helicobacter pylori, Toxoplasma gondi, and cytomegalovirus. A variety of drugs have been associated with BP including but not limited to dipeptidyl peptidase-4 inhibitors, loop diuretics, spironolactone, and neuroleptics. Associated neurologic disorders (dementia, Parkinson's disease, bipolar disorder, previous stroke history, and multiple sclerosis) have also been described. Common clinical presentation consists of extremely pruritic inflammatory plaques that resemble eczematous dermatitis or urticaria, followed by formation of tense bullae with subsequent erosions. Typical distribution involves the trunk and extremities. Mucosa is typically spared affecting only 10% to 30% of patients. Several unusual clinical presentations of BP have been described such as nonbullous forms with erythematous excoriated papules, plaques, and nodules. Other reported findings include urticarial lesions, prurigo-like nodules, multiple small vesicles resembling dermatitis herpetiformis or pompholyx, vegetating and purulent lesions localized in intertriginous areas, and even exfoliative erythroderma. Recognition and management of such cases can present a diagnostic challenge to clinicians. In this article, we describe another variant which to our knowledge is the first case to present with a cellulitis-like presentation in a patient with a known history of BP.

Erythema Multiforme-Like Presentation in an Asymptomatic COVID-19 Patient.

In clinical practice, there are a lot of variations in disease manifestations. Diseases are constantly evolving, and one negative test cannot completely rule out a disease. Erythema multiforme (EM) is a common mucocutaneous disease that can be linked to a lot of etiologies, with the most common being herpes simplex virus (HSV) types 1 and 2, Mycoplasma pneumoniae, and the use of various drugs. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new virus, and traditionally it is not the first differential for EM eruptions. We report the case of a 52-year-old female patient with a history of multiple drug use, pneumonia-like symptoms, an initial negative viral panel for SARS-CoV-2, followed by a positive polymerase chain reaction (PCR) test, asymptomatic coronavirus disease 2019 (COVID-19) clinical course, and break-out of typical targetoid lesions of EM. Throughout her hospital stay, the patient maintained her oxygenation levels and improved clinically with steroids and symptomatic treatment. She regained her health and was counseled to quit smoking, alcohol, and opioid usage at the time of discharge from the hospital, and a regular follow-up with her primary care practitioner (PCP) was advised.

First Reported Case of Candida dubliniensis Endocarditis Related to Implantable Cardioverter-Defibrillator.

A 36-year-old male presented to the ED with acute chronic hyponatremia found on routine weekly lab work with one-week history of generalized weakness, confusion, nausea/vomiting, and diarrhea. The patient has nonischemic cardiomyopathy of unknown etiology diagnosed in his teens with an AICD device placed 8 years ago and receiving milrinone infusion 3 years ago via peripherally inserted central catheter (PICC) line. Two sets of blood cultures grew Candida dubliniensis. The patient was started on micafungin and the PICC line was removed and replaced with a central line. A transthoracic echocardiogram (TEE) showed findings consistent with AICD lead involvement. The patient was continued on treatment for fungal infective endocarditis and transferred to another hospital where he had successful AICD lead extraction. Blood cultures upon transfer back to our facility were positive for methicillin-sensitive Staphylococcus aureus (MSSA). This bacteremia was thought to be secondary to right-sided internal jugular (IJ) central line and resolved with line removal and initiation of intravenous (IV) cefazolin. The patient was discharged on IV cefazolin and IV micafungin. He had a LifeVest® until completion of his antibiotic course and a new AICD was placed.

Leclercia adecarboxylata Cholecystitis with Septic Shock in Immunocompetent Patient.

L. adecarboxylata is a Gram-negative rod previously named Escherichia adecarboxylata, isolated as normal flora in the gut of animals including human stool. Most reported cases refer to immunocompromised patients with polymicrobial infections and water environments. Here we present a case of 51-year-old immunocompetent female presented with nausea, vomiting, malaise, and subjective fever for few days. On examination, she was drowsy but arousable and oriented to person, place, time, and situation. Her abdomen was tender globally and more tender in the epigastric area. Vitals showed a temperature of 37°C, pulse of 110 beats/min, blood pressure of 75/50 mmHg, and oxygen saturation of 91% on room air. An HIV panel and hepatitis panel were negative. Liver and gallbladder ultrasound was performed, revealing multiple nonmobile stones with shadowing noted within the gallbladder sac, a thickened gallbladder wall, and a moderate amount of pericholecystic fluid. Broad spectrum antibiotics, crystalloid fluids, and vasopressors were initiated. A few hours after admission she developed respiratory failure for which she underwent endotracheal intubation. An ultrasound guided gallbladder drain was performed. Culture of the biliary fluid yielded pure growth of pan-sensitive L. adecarboxylata; antibiotics were narrowed accordingly. The patient was on the maximum doses of vasopressin, norepinephrine, and epinephrine with a blood pressure of 75/45 and a mean arterial pressure of 51. She passed away on the fourth day of admission.

Bilateral Chylothorax as a Unique Presentation of Pancreaticobiliary or Upper Gastrointestinal Cancer.

Chylothorax presents as exudate with lymphocytic predominance and high triglyceride-low LDH levels, usually due to a traumatic disruption of the thoracic duct, possibly iatrogenic. Other causes include malignancy, sarcoidosis, goiter, AIDS, or tuberculosis. Here we present a case of a 66-year-old male who came in with cough and shortness of breath for few weeks. A week earlier, at an ED visit, he was diagnosed with pneumonia based on CT angiogram of the chest without contrast that showed bilateral pleural effusion and bilateral pulmonary infiltrates. The CT-guided placement of bilateral chest tube drained 1160 cc of creamy yellow fluid on the right and 1200 cc of creamy yellow fluid on the left. CT chest/abdomen/pelvis showed bilateral ground-glass opacities within the lungs and possible bony metastasis. A whole-body bone scan showed multiple bony metastatic lesions throughout the skeleton. IR guided bone biopsy suggested upper GI or pancreaticobiliary cancer. Venous ultrasound with Doppler of left upper extremity showed findings suggestive of a nonocclusive DVT of proximal/mid left subclavian vein which is difficult to compress. Eventually, malignancy-related DVT of the left subclavian/brachiocephalic vein was identified as the possible etiology for the bilateral chylothorax.

Risks of PEG tube placement in patients with cirrhosis-associated ascites.

This study examined the safety of placing percutaneous endoscopic gastrostomy (PEG) tube in people with liver cirrhosis. The target population was further subdivided into people with ascites (case group) and people without ascites (control). We compare the morbidity and the mortality difference of PEG placement in cirrhotic patients with ascites vs cirrhotic patients without ascites. We then examined multiple factors including sex, race, chronic illness including hypertension, congestive heart failure, and others and their influence on the inpatient mortality of all cirrhotic patients who had PEG placement. A total of 38,175 inpatient PEG tube placements were identified. Only 583 patients out of 38,175 had a history of cirrhosis. One hundred seven had ascites and the rest did not. Mean age of the patients was 61.14 years. Patient demography included (65.2%) male and the rest were female, 359 were white (64.4%), 90 black (14.8%), 84 Hispanic (13.7%), 23 Asians (3.3%), 7 Native Americans (0.4%), and 20 others (3.5%). Complications from PEG procedure in cirrhosis with ascites vs non-ascites included bleeding of 4 (0.8%) vs 2 (1.9%) (P=0.35), surgical site infection 2 (0.4%) vs 1 (0.9%) (P=0.51), and urinary tract infection 105 (22.1%) vs 34 (23.8%) (P=0.34), respectively. There was no colonic injury in either group. The total inpatient mortality was 75 out of the 583. Fifty-six (11.8%) were in the ascites group and 19 (17.8%) in the non-ascites group (P=0.097). Factors including ascites, postsurgical bleeding, and surgical site infection did not have influence on the inpatient mortality and there were no statistical differences between the two groups.