The Clot Thickens: COVID-19-Related ST-Elevation Myocardial Infarction in the Setting of Recent Boosters.

The coronavirus disease of 2019 (COVID-19) has an array of pathological effects that continue to be discovered. Vaccines against COVID-19 have quickly emerged as our main tool. However, the thrombotic risk of both the virus and the vaccine is yet to be established, let alone together. In this case report, we present a case involving a recently diagnosed COVID-19 patient who developed an ST-elevated myocardial infarction (STEMI) after receiving his booster shot. Our aim is to highlight the standard of treatment outcomes in COVID-19-associated clots, familiarize ourselves with the complexity of the clot burden in a COVID-19-associated STEMI, and illustrate the potential role of the cumulative pro-thrombotic effects of a recent COVID-19 booster with a concomitant symptomatic COVID-19 infection.

Adoption of Opioid-Sparing and Non-Opioid Regimens After Breast Surgery in a Large, Integrated Health Care Delivery System.

BACKGROUND: Postoperative prescriptions have contributed to the opioid epidemic. In response, a large, integrated health care delivery system implemented initiatives to reduce outpatient opioid prescriptions. We evaluated the impact of these interventions on opioid-prescribing practices after breast surgery. METHODS: We examined postoperative prescribing practices before and after the 2016-2018 intervention period. Primary endpoints were the use of non-opioid regimens (NORs) and morphine milligram equivalents (MMEs) prescribed for postoperative pain management, while secondary endpoints were emergency department (ED) visits and readmissions within 7 days of surgery. RESULTS: In a survey of breast surgeons, 23% reported using NORs in 2017 versus 79% in 2019 (p < 0.001). Comparing 1917 breast operations from 2016 with 2166 operations from 2019, NORs increased from 9% in 2016 to 39% in 2019 (p < 0.001). Average discharge MMEs per operation decreased from 190 in 2016 to 106 in 2019 (p < 0.001). NOR failure (defined as an additional opioid prescription within 2 weeks of surgery) was < 1%. Significantly fewer postoperative ED visits occurred in the NOR group (1.9% NOR vs. 3.4% opioid regimen [OR]; p < 0.001). The 7-day readmission rates for NOR and OR patients were similar (0.49% NOR vs. 0.32% OR; p = 0.45). CONCLUSION: Between 2016 and 2019, breast surgeons in a large, integrated health care delivery system adopted NORs for nearly 40% of breast operations, and prescribed significantly fewer MMEs, with no increases in ED visits or readmissions for NOR patients. This suggests that initiatives to decrease opioid prescribing were successful and that a NOR for pain management after breast surgery is feasible.

The Patient Selection Criteria for Veno-arterial Extracorporeal Mechanical Oxygenation.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) plays a crucial role in the management of patients with refractory cardiac and pulmonary dysfunction by providing temporary mechanical hemodynamic and respiratory support. However, the paucity of guidelines on indications for administering it and the failure to timely initiate VA-ECMO often result in a high in-hospital mortality rate and poor six-month outcomes after VA-ECMO deployment. Due to ethical issues, randomized controlled studies with VA-ECMO have not been conducted so that no recommended evidence-based guidelines exist for VA-ECMO patient-selection criteria. Therefore, the indication for administering the device depends solely on expert opinion after reviewing the literature. We conducted a review of the current literature to better understand and classify the need for proper patient selection, including proven indications for VA-ECMO.

Case of Irreducible Ileocecal Intussusception Due to Leiomyoma of the Colon.

Intussusception is defined as the telescoping of the proximal segment of the bowel into the distal segment. In most clinical cases, pediatric intussusception is much more common than adult intussusception. Pediatric intussusception is often due to viral or bacterial infections, which lead to the inflammation of lymphoid tissue in the intestine. Adult intussusception is typically secondary to tumors and idiopathic causes. Malignant tumors tend to affect the colon, while benign tumors affect the small intestine. Lipomas are the leading cause of benign tumors which cause intussusception. Conversely, adenocarcinomas are the leading cause of malignant tumors that cause intussusception.  Our case focuses on a young adult who developed intussusception secondary to a leiomyoma present near the ileocecal junction of the intestine. The treatment of intussusception caused by tumors is either surgical reduction or excision of the involved tissue. If excised, the specimens are sent to the pathology department for confirmation of the potential cause. If leiomyomas are suspected, staining is used to differentiate them from gastrointestinal stromal tumors (GISTs). These stromal tumors are unusual causes of intussusception, which require further research to determine their disease course and age at presentation.

Management of Resistant Hypertension Based on Recommendations from Different Guidelines and the Systolic Blood Pressure Intervention Trial.

The long-term management of patients with resistant hypertension has been made even more difficult by a "moving target" goal blood pressure (BP). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines defined resistant hypertension as the failure to achieve goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic. The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) guidelines laid out more lenient target BP goals, without addressing the definition of resistant hypertension directly. The present scenario is a state of confusion, with providers selectively adopting recommendations from different guidelines. The Systolic Blood Pressure Intervention Trial (SPRINT) trial contributed to the confusion with further evidence supporting the strict control of hypertension. In addition, the failure of another trial on renal denervation in the US has essentially put an end to six long years of experimentation with catheter ablation in patients with resistant hypertension. Other therapies are still experimental. Adding a new dimension of medical management, spironolactone has made a comeback in resistant hypertension, with reports of better responsiveness when added to existing anti-hypertensive therapy. The present review discusses the current state and management options for patients with resistant hypertension considering the new evidence. Newer advances in pharmacological and device therapy are also discussed to improve understanding and quality in the management of resistant hypertension.

Global Initiative for Chronic Obstructive Lung Disease: The Changes Made.

Chronic obstructive pulmonary disease or COPD is one of the conditions that physicians frequently see in both the hospital and outpatient setting. In order to improve diagnostic and treatment outcomes, the Global Strategy for the Diagnosis, Management and Prevention of COPD, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was created in 2001. Every year, a new report is generated based on an analysis of published studies which attempts to improve the way physicians handle COPD. GOLD reports are considered to be essential evidence-based reference tools for the implementation of effective management plans, and represent the current best practices for the care of patients with COPD. The 2017 report greatly revised the guidelines and added a few components that changed the system of COPD diagnosis and treatment. This review article addresses those changes, explains the current guidelines, and draws attention to areas that still require improvement.

The Association of Obstructive Sleep Apnea and Hypertension.

Obstructive sleep apnea (OSA) is a condition characterized by recurrent episodes of partial or complete upper airway obstruction during sleep. Hypertension (HTN) is defined by the presence of a chronic elevation of systemic arterial pressure above a certain threshold value (≥140 mm Hg systolic or ≥90 mm Hg diastolic). On the surface, OSA and HTN appear very different from one another. Despite this, they share several common risk factors including obesity, male gender, and advancing age. In 2003, the Seventh Joint National Committee (JNC VII) recognized OSA as a secondary cause of HTN. As physicians, our goal is to understand the OSA-HTN association better through academic study regarding its epidemiology, its pathophysiology, and its treatment.

Venovenous Extracorporeal Membrane Oxygenation Therapy in Adults.

Extracorporeal membrane oxygenation (ECMO) therapy is used as supportive therapy for patients with respiratory failure, cardiac failure, and cardiopulmonary failure. Venovenous extracorporeal membrane oxygenation (VV-ECMO) is one subtype used for respiratory failure as a supportive treatment for critically ill patients. The principle behind it is that the membrane lung (oxygenator) is placed sequentially with the normal lungs rather than in parallel like with cardiopulmonary bypass, therefore, the lungs do not have to work as hard to oxygenate the blood. Then using a drainage cannula, blood is drained from the right atrium (RA) and after going through the membrane lung, the newly oxygenated blood is returned back to the RA. Because of this, there is enough systemic oxygen delivery to manage metabolism and preserve the airway even at lower tidal volume ventilation settings. With ventilator settings placed at lower tidal volume, there is less risk of barotrauma. This is a review article discussing VV-ECMO therapy with adult patients. It will also go into detail regarding its indications, contraindications, configurations, patient assessment, vascular access, and complications.

Diagnosing Allergic Bronchopulmonary Aspergillosis: A Review.

Dr. Hinson and his colleagues first described allergic bronchopulmonary aspergillosis (ABPA) in 1952. Later in 1977, Rosenberg proposed a diagnostic criteria for ABPA that even today remains widely acknowledged. Despite these steps taken, there still isn't a standardized diagnostic criteria set for ABPA although many have been proposed by various physicians over the years. ABPA is a condition caused by hypersensitivity to Aspergillus fumigatus antigens. It is seen most commonly in patients with either asthma or cystic fibrosis. In susceptible hosts, repeated inhalation of Aspergillus spores can cause an allergic response. Although a standardized diagnostic criteria is re-quired, there is no single test that establishes the diagnosis oth-er than a demonstration of central bronchiectasis (CB) with nor-mal tapering bronchi, a feature that is still considered pathognomonic of ABPA. Because of lack of standardized diagnostic criteria and screening, even today ABPA is under diagnosed and often times treatment for it is delayed. This can lead to complications in patients like pulmonary fibrosis, bronchiectasis with chronic sputum production, and increasingly severe persistent asthma with loss of lung function. For this alone, it becomes imperative that the diagnostic criteria guidelines need to be reviewed and standardized preferably with the help of larger research studies. In the following review article, we address the epidemiology, pathophysiology, and the current cumulative view regarding the diagnosis of ABPA.

Cardiac Ultrasound in the Intensive Care Unit: A Review.

Transthoracic echocardiography (TTE) is an incredibly valuable tool in today's emergency rooms and intensive care units (ICUs). It has the ability to provide a complete evaluation of the structure and function of the heart, the valves, stroke volume, ejection fraction, and much more. Previous academic studies have also determined that point-of-care TTE done by non-cardiologist physicians can also provide higher accuracy in patient assessment and management, with potential prognostic impact by assessing the severity of cardiac dysfunction and response to treatment. The aim of this review article is to examine further these point-of-care evaluations, what they entail, their benefits, and where further research would better our own understanding.

Central Line Catheters and Associated Complications: A Review.

The use of a central line or central venous catheterization was brought to attention in 1929 when Dr. Werner Forssmann self-inserted a ureteric catheter through his cubital vein and into the right side of his heart. Since that time the central line technique has developed further and has become essential for the treatment of decompensating patients. Central lines are widely used for anything from rapid fluid resuscitation, to drug administration, to parenteral nutrition, and even for administering hemodialysis. Central lines come in different sizes, types, and sites of administration. Sometimes their use can be associated with complications as well. The following review article addresses these parameters of central lines and goes into detail regarding their complications.

Treating Allergic Bronchopulmonary Aspergillosis: A Review.

Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder that results from a hypersensitivity reaction to the fungi Aspergillus fumigatus (Af). It presents with pulmonary infiltrates and bronchiectasis. Past research studies on ABPA have led to the conclusion that it is both underdiagnosed and much more prevalent than previously assumed. The underdiagnosing of ABPA is due to a lack of consensus regarding diagnosis and treatment. Complications that result from delay in treatment for ABPA are pulmonary fibrosis, bronchiectasis with chronic sputum production, and severe persistent asthma with loss of lung function. Because of this, it becomes imperative that ABPA treatment guidelines are reviewed and more thoroughly evaluated regarding their efficacy. The following article addresses the epidemiology, the pathophysiology, and the treatment of ABPA. The treatment is studied in detail regarding the types of medications used and their proven clinical impact on patients according to past research studies. The aim of this article is to address the current need for larger clinical trials in order to learn more and establish more formal treatment protocols for ABPA.

The Underlying Stroke Etiology: A Comparison of Two Classifications in a Rural Setup.

Introduction This study compares the Trial of Org 10172 in Acute Stroke Treatment (TOAST) and the atherothrombosis, small vessel disease, cardiac pathology, other causes, and dissection (ASCOD) classification performed in a rural hospital setup. Stroke is the second leading cause of death after ischemic heart disease with over 9.5 million new cases of ischemic stroke in 2016. Stroke is a complex disease with numerous contributing factors. India needs a standardized stroke classification system, as without one it becomes difficult to collect data on stroke patients, perform follow-ups, and provide appropriate secondary prevention. A standardized stroke classification system would also help in building a nationwide database in order to note epidemiological trends of ischemic stroke. This would also create greater awareness regarding stroke in rural parts of India where healthcare is difficult to access.  Aims and objectives Our aim was to review all admitted stroke patients' data and classify their etiology and mechanism based on the TOAST and ASCOD classification systems. The ASCOD classification has yet to be utilized in the Indian population. The two classifications are then compared in order to gain a better insight into which classification is a better fit for the Indian population. Both are based on the etiology of ischemic stroke but the ASCOD classification differs because it gives suitable secondary prevention measures based on the diseases linked to stroke. ASCOD also gives a proper indication of the patient's present causative factor (similar to TOAST) and other factors that can possibly lead to further recurrences. This is different from TOAST, which denotes only a single cause for stroke and eliminates the possibility of other involved contributing factors. Materials and methods All patients involved in the study were admitted to a rural Indian hospital from January 2014 to July 2016. All the relevant clinical details of each patient were then retrieved from the hospital's electronic medical record system for the study. We then classified all the patients based on the TOAST and ASCOD classification criteria. Results Using the ASCOD classification, we found that 179 (86%) patients out of 209 had either atherothrombosis or small vessel disease. The ASCOD classification also showed substantial evidence that the determined stroke mechanism/etiology is interconnected to multiple causal factors in over 50% of patients. In contrast, the TOAST classification had identified a larger number of ischemic stroke patients as having an etiology of other and undetermined causes as compared to the ASCOD classification. Conclusion The ASCOD classification is better to use in patients and helps decide the secondary prevention appropriately.

Applied Uses of Extracorporeal Membrane Oxygenation Therapy.

Extracorporeal membrane oxygenation (ECMO) therapy has been around since the 1970s and has completely changed how critical care physicians view supportive therapy for certain patients. ECMO therapy is a supportive therapy provided by a mechanical extracorporeal circuit that is able to directly oxygenate and remove carbon dioxide from the blood. By performing this, ECMO can provide cardiac, respiratory, or combined cardiopulmonary supportive therapy in cases of failure. ECMO therapy also places less emphasis on invasive mechanical ventilation, which prevents barotrauma and gives rest to the lungs. Therefore, they are used for several different conditions. This review article focuses on the definition, principles, types, and practical applications of ECMO therapy.

Acute Hemiballismus as the Presenting Feature of Parietal Lobe Infarction.

It is widely believed that hemiballismus and chorea are suggestive of a basal ganglia subthalamic nucleus lesion; however, this not a rule. We report the case of a 63-year-old male with complaints of slurred speech, increased movement of the left half of his body, and headache. He had diabetes, hypertension, and a past medical history of stroke with residual weakness over the right side of his body. The patient developed the sudden onset of irregular, large amplitude, increased involuntary movements of his left upper and lower limbs with a flinging pattern. His blood sugar and serum osmolality were normal. His magnetic resonance imaging (MRI) showed an acute right parietal lobe infarction. Patients can experience hemiballismus with lesions other than the subthalamic nucleus in the basal ganglia. This is contrary to the classic belief that hemiballismus is associated with, and only with, lesions in the subthalamic nucleus. This manuscript describes a case of hemiballismus occurring in a patient secondary to a parietal lobe infarction.

The Association Between Obstructive Sleep Apnea and Arrhythmias.

Obstructive sleep apnea (OSA) is caused by intermittent episodes of partial or complete closure of the upper airway, leading to apneic episodes while the patient is asleep. Atrial fibrillation (AF) leads to more than 750,000 hospitalizations per year and accounts for an estimated 130,000 deaths each year. The death rate from AF as the primary or a contributing cause of death has been rising for more than two decades. The material reviewed in this paper focuses on the association between OSA and arrhythmias. It goes into the details of the epidemiology, pathophysiology, and types of arrhythmias and the therapies seen in association with OSA.