Transcatheter Aortic Valve Replacement Complicated by Aorto-Right Ventricular Fistula Repaired Via Valve-in-Valve Replacement.

A 59-year-old man with a history of severe aortic stenosis with transcatheter aortic valve replacement (TAVR) presented with worsening heart failure. Echocardiography showed a fistula between the aorta and the right ventricle with mild to moderate paravalvular regurgitation. He underwent a valve-in-valve TAVR with symptomatic improvement and decreased flow through the fistula.

Not Just an Accident: A Case of Insulinoma.

Insulinomas are a rare cause of recurrent hypoglycemia in non-diabetic patients. Diagnosis requires hypoglycemia (plasma glucose <50 mg/dL), neuroglycopenic symptoms, and prompt relief of symptoms following the administration of glucose, known as Whipple's triad. The gold standard diagnostic tests are measuring insulin, C-peptide, and glucose during a 72-hour fast. In the preoperative period and in patients with unresectable or metastatic tumors, medical management with diazoxide and octreotide can be considered for recurrent hypoglycemia. We present a case of insulinoma in a 37-year-old woman who initially presented after a seizure-related motor vehicle accident. Upon admission, her initial glucose level was 32 mg/dL, indicating a likely hypoglycemic seizure. During her hospitalization, she had recurrent episodes of fasting and postprandial hypoglycemia, ranging from 32-70 mg/dL. She exhibited the characteristics of Whipple's triad when values dropped below 50 mg/dL. These episodes necessitated continuous infusions of 10% dextrose. Tests for insulin autoantibodies, sulfonylurea screens, and thyroid function yielded unremarkable results. A 72-hour fasting test was initiated to investigate potential endogenous causes of excessive insulin production. Laboratory results from a venous glucose level of 46 mg/dL indicated a notable rise in C peptide and insulin levels, alongside beta hydroxybutyrate suppression, all of which fulfilled the diagnostic criteria for insulinoma. An abdominal magnetic resonance imaging (MRI) unveiled a 1.3 cm mass in the pancreatic tail. This case emphasizes the importance of employing a focused approach when evaluating non-diabetic individuals displaying hypoglycemia with positive Whipple's triad. This targeted method not only enables early detection of this rare condition but also assists in eliminating other common causes of recurrent hypoglycemia in non-diabetic individuals. Moreover, in addition to this diagnosis being rare, it is important to note that patients with insulinomas typically do not exhibit a glucose level low enough to induce seizures during their initial presentation.

A Fatal Case of Lisinopril-Induced Acute Necrotizing Pancreatitis.

Angiotensin-converting enzyme inhibitors (ACE-I), such as lisinopril, are used as first-line therapy in the treatment of hypertension, heart failure with reduced ejection fraction, and proteinuric chronic kidney disease due to their beneficial effects on reducing morbidity and mortality. Commonly cited adverse effects of lisinopril include hyperkalemia, acute kidney injury, and angioedema, and while uncommon, there have been reports of lisinopril-induced necrotizing pancreatitis in the literature. The true incidence of drug-induced pancreatitis is unknown since establishing a causal relationship between medication's adverse effects and disease occurrence is difficult; however, there are validated tools such as the Adverse Drug Reaction Probability Scale that can aid in determining causality. Here, we present a case of a 63-year-old man with a history of hypertension who was being treated with lisinopril for eight months and developed a fatal case of lisinopril-induced severe necrotizing pancreatitis.

Hand Hygiene and Hospital-Acquired Infections During COVID-19 Increased Vigilance: One Hospital's Experience.

Background: Hospital-acquired infections are associated with increased morbidity, mortality, costs and length of stay. Prior studies have linked increased hand hygiene compliance with reduced hospital-acquired infection rate. With the increased vigilance for personal and institutional hygiene practices during the COVID-19 pandemic, we hypothesized increased hand hygiene compliance and, as a result, decrease in hospital-acquired infections in our hospital. Methods: Hand hygiene compliance data was provided by the hospital's Quality Department. We queried and empirically analyzed local hospital-acquired infection data obtained from our Quality Department and the National Healthcare Safety Network. We compared local hand hygiene compliance rates before and after the implementation of increased infection prevention and control measures in March 2020 and correlated various hospital-acquired infection rates with hand hygiene compliance. Results: Our results showed a statistically significant and sustained increase in compliance with hand hygiene at our hospital after implementation of hospital-wide infection control measures. We demonstrated a downward trend in all hospital-acquired infections, which was not statistically significant. A strong statistically significant negative correlation was found between hand hygiene compliance and the rate of Clostridium difficile hospital-acquired infection. Conclusion: Hand hygiene adherence has increased since the beginning of COVID-19 pandemic in our hospital, and a noticeable, although not statistically significant, downward trend in most of the analyzed hospital-acquired infections was identified. A significant limitation to our study was small sample size. Future studies are warranted to further analyze the impact of increased hygiene practice on the incidence of hospital-acquired infections.

Marijuana-associated ST-elevation myocardial infarction: is this a benign drug.

Marijuana is the most commonly used psychoactive drug in the USA. A 35-year-old man with a medical history of marijuana abuse is admitted to the hospital due to crushing substernal chest pain. ECG shows evolving ST-segment elevation with a rise in cardiac enzymes, consistent with ST-elevation myocardial infarction. A urine toxicology screen is positive for cannabis and negative for cocaine and other stimulant drugs. An emergent cardiac catheterisation reveals no evidence of coronary artery disease or thrombosis. A diagnosis of coronary vasospasm is strongly considered, and the patient is started on calcium channel blocker, with a resolution of symptoms and ECG changes. Marijuana-induced coronary spasm causing myocardial infarction has rarely been reported. Marijuana is becoming a social norm in adolescents and there remains a misconception that it is harmless and even beneficial. Increasing drug abuse remains a public health concern, necessitating population education by physicians for safer healthcare practices.

Spontaneous Pneumomediastinum as a Consequence of Severe Vomiting in Diabetic Ketoacidosis.

Spontaneous pneumomediastinum (SPM) is a rare entity with a reported incidence of approximately 1:7,000 to 1:100,000 of hospital admissions. It has been described as a complication of various conditions related to increased intrathoracic pressure, like recurrent vomiting, post-partum state, vigorous coughing or sneezing, and others. We present a 25-year-old man who came in with intractable vomiting, secondary to diabetic ketoacidosis (DKA), and was found to have pneumomediastinum on chest imaging. The patient was treated conservatively, eventually recovering and being discharged after several days. SPM is rarely seen as a complication of DKA. Diagnosis and management may present a challenge. Usually, the condition is benign and treated conservatively. We report this case to increase awareness among physicians of possible pneumomediastinum in a young male presenting with DKA and dyspnea and to emphasize the benign course of this condition.

Acquired Acrodermatitis Enteropathica: A Case Study.

We present a case of severe acquired acrodermatitis enteropathica in a vegan adult female with multiple underlying comorbidities. Acquired acrodermatitis enteropathica or zinc-deficiency dermatitis is the most common diagnosis than many practitioners realize with up to 10% of the patients in developed nations with the risk of zinc deficiency. The condition can be difficult to diagnose due to many similarly-presenting conditions. Furthermore, comorbid conditions in the patients can serve as confounders to the diagnosis. The symptoms are often extremely distressing for the patients, though the treatment is simple and clinical improvement occurs rapidly with appropriate care. We recommend a high index of suspicion to practitioners as well as a low-threshold for initiating treatment in the patients with any clinical symptoms of the condition.

Uric Acid as a Marker of Kidney Disease: Review of the Current Literature.

Uric acid has been implicated in the pathophysiology of renal disease; however renal clearance makes a causal relationship difficult to prove. We examine the current literature to support a potential role of uric acid in the development of kidney disease and to determine the potential to use uric acid as a marker for future renal decline. After review, we conclude that uric acid is definitively linked to the development of chronic kidney disease and can be a poor prognostic factor for the development of acute renal failure, as well. However, further human research is needed before predictive models utilizing uric acid can be developed and used in the clinical setting.