Internal Medicine Commons^™

Kounis Syndrome – Anaphylaxis-Induced Acute Coronary Syndrome, Austin T. Thacker Do, Brachman Herzig Oms, Brendan Robinson Do, Ahad Anjum Do

Advances in Clinical Medical Research and Healthcare Delivery

Kounis syndrome is an underdiagnosed condition in which anaphylaxis triggers vasospastic acute coronary syndrome, either with or without underlying coronary artery disease. The prevalence of this syndrome among hospitalized patients for allergic/hypersensitivity/anaphylactic reactions in the United States is 1.1%, with a 7% rate of all-cause inpatient mortality. This article presents an anaphylaxis-induced acute coronary syndrome case in a patient with underlying coronary artery disease. The pathophysiological mechanism of anaphylactic-induced acute coronary syndrome involves the inflammatory mediators of type I hypersensitivity reactions.

Role Of Soluble Urokinase Type Plasminogen Activator Receptor (Supar) In Predicting Mortality, Readmission, Length Of Stay And Discharge In Emergency Patients: A Systematic Review And Meta Analysis, Syeda Tayyaba Rehan, Hassan Ul Hussain, Eman Ali, Kanwal Ashok Kumar, Shehroze Tabassum, Muhammad Hasanain, Asim Shaikh, Gibran Ali, Zohaib Yousaf, Muhammad Sohaib Asghar

Section of Internal Medicine

Background: Soluble urokinase plasminogen activator receptor (suPAR) is an inflammatory biomarker that is used to predict mortality, readmission, early discharge, and LOS, thus, serves as a useful tool for ED physicians. Our study aims to analyze the efficacy of suPAR in predicting these prognostic markers in ED.
Methods: We performed a comprehensive search on 6 databases from the inception to 30th November 2022, to select the following eligibility criteria; a) observation or triage trial studies investigating the role of suPAR levels in predicting: 30 day and 90-day mortality, 30-day readmission, early discharge (within 24hr), and LOS in patients coming to …

Comparing Stroke Symptom Recognition And Intervention Times In The Rio Grande Valley, Joshua M. Ninan, Kelsey Baker

Research Symposium

This is a retrospective study that aims to evaluate the duration from onset of stroke-like symptoms to presentation to medical facilities for aid in the Rio Grande Valley. The main goal of the study is to understand the extent of pre-hospital delays with regards to the treatment of stroke in the RGV.

Pseudo-Wellens Syndrome: A Rare Entity Associated With Cocaine Use, Mohamed Salah Mohamed, Syed Hamza Waheed, Amir Mahmoud, Anas Hashem, Bipul Baibhav, Abdullah M. Firoze Ahmed

Advances in Clinical Medical Research and Healthcare Delivery

Wellens syndrome usually indicates critical left anterior descending artery (LAD) occlusion. Pseudo-Wellens syndrome consists of criteria of Wellens syndrome in the absence of critical LAD occlusion. We report a case of Pseudo-Wellens syndrome related to cocaine use. A 52-year-old male with a medical history of hypertension and diabetes, presented with acute retrosternal chest pain of 3 days duration. Physical examination was unremarkable. EKG on presentation showed deep T-wave inversions in leads V2 to V5. Highly sensitive troponin was elevated. The patient admitted to using cocaine daily for the past two months. Due to concerns for Wellens syndrome, the patient had …

Case Report: The Challenge Of Balancing Stewardship And Advocacy, Samuel Thalathoti, Kishan Patel, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 62-year-old female who presented with chief complaint of generalized weakness and was ultimately diagnosed with hypereosinophilia. This chief complaint is challenging for many EM physicians, and the differential diagnosis of generalized weakness is vast. Etiologies of generalized weakness in the adult population ranges from infection, dehydration, cardiovascular disease, to neurologic compromise. It is crucial for the Emergency Physician to put emphasis on proper history collection, detailed physical exam, and appropriate ancillary testing. In this case report we showcase the significance of the optimal evaluation of life-threatening disorders that presents as generalized weakness, as well …

Brash Syndrome Case Report And Brief Review, Kelly Schuitema

Rowan-Virtua Research Day

BRASH syndrome is an acronym that stands for bradycardia, renal failure, AV node blocker, shock and hyperkalemia. The syndrome is precipitated by synergism from AV nodal blocking agents and hyperkalemia. The combination of the AV nodal blockade and renal failure leads to a cycle of severe bradycardia and hyperkalemia. We will discuss a case of BRASH syndrome with a 68 year old female who presented with generalized weakness and was found to be hypotensive, bradycardia, in acute renal failure with hyperkalemia likely related to metoprolol and amlodipine use.

Case Report: Anaphylactic Reaction To Magnesium Sulfate, Nicholas Coan, Kelly Schiers, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 65-year-old female who prior to being discharged from the hospital developed an anaphylactic reaction after receiving an intravenous magnesium sulfate infusion. After extensive literature review, there are few documented hypersensitivity reactions documented. This case report is to highlight a known human response, anaphylaxis, but in response to the repletion of an essential electrolyte to human life, magnesium.

Case Report And Brief Review: A Puzzling Case Of Leg And Ankle Swelling, Michael Morris, James Espinosa, Alan Lucerna, Robin Lahr, James Lee

Rowan-Virtua Research Day

Here we present the case of a medical student in his twenties who had experienced episodes of heat edema that had been previously evaluated at other EDs and thought to be possible DVT. An awareness of heat edema as a minor heat-related illness is important in order to avoid unnecessary testing and in order to help prevent future episodes

Focused Pocus: Cardiopulmonary Curriculum For Internal Medicine Residents, Daniel Tran, Krunalkumar Patel, Shivani Dalal, Umang Patel, Troy Randle

Rowan-Virtua Research Day

Problem Statement: Point-of-care ultrasound (POCUS) is currently not a required core competency in internal medicine (IM) residency despite its inherent benefits, and many hospitalists are not equipped to confidently acquire nor interpret basic ultrasound images.

Background: POCUS is used at the bedside by physicians to answer directed clinical questions to help guide patient management. During the COVID-19 pandemic, the use of ultrasound for quick, accurate diagnosis of life-threatening pathology has been instrumental in early detection of acute cardiopulmonary failure, monitoring treatment response, and minimizing nosocomial spread. We aimed to determine interest in learning POCUS, confidence level, self-rated proficiency, and perceived …

Mixed Beri’S: High Output Heart Failure From Severe Anemia And Thiamine Deficiency, Rohan Umrani, Hiral Amin, Ashley Pinckney, Charles Yang, Daniel Tran

Rowan-Virtua Research Day

Background: Severe anemia and thiamine deficiency can independently result in high output heart failure (HOHF) through different mechanisms. Data on the threshold and timeframe at which these etiologies may precipitate HOHF is unclear.

Case: A 63-year-old male with alcohol use disorder consuming 18 drinks/week presented with progressive shortness of breath and lower extremity edema for a few months. Physical exam revealed tachycardia, anasarca, jugular venous distension, Lancisi’s sign, and a midsystolic murmur. Echocardiogram demonstrated EF of 30-35%, dilated left ventricle, and cardiac index of 4.2L/min/m2.

Decision-Making: Heart failure can independently precipitate anemia while severe alcoholism can induce myelosuppression and promote …

Accidental Extravasation Of Mitomycin C Into The Subcutaneous Tissue, Johnathon Chung, Brooke Walterscheid, Jose Lopez-Vera, Hytham Rashid, Mike K. Liang

HCA Healthcare Journal of Medicine

Introduction

Mitomycin C (MMC) is a common chemotherapeutic agent used to treat a variety of solid tumors. Cutaneous adverse events are rare, but MMC is a known vesicant reported to cause tissue necrosis and sloughing, erythema, and ulceration if incorrectly infused into the subcutaneous tissue. Definitive treatment of extravasation injuries due to MMC depends on the severity of the cutaneous manifestation, which includes stopping the infusion, removing the catheter, or possible debridement.

Case Presentation

We present the case of a 70-year-old female with extensive soft-tissue injury secondary to extravasation of MMC that required hospital admission and surgical intervention to remove …

Exploring Hapi Incidence In Patients Admitted Through The Ed: A Quality Improvement Initiative, Alexa L. Tietgens

DNP Scholarly Projects

Each year in the U.S., pressure injuries, or PIs, are responsible for more than 60,000 patient deaths and billions of dollars’ worth of treatment costs. Research shows that roughly 95% of all PIs are preventable by following evidence-based practice guidelines which include early identification of patients at risk, frequent skin assessments, and implementation of prevention strategies. However, the ED environment creates unique risks for PI development due to the routine use of hard surfaces (i.e., stretchers, backboards, exam tables) and frequent hospital overcrowding. Although nurses play a pivotal role in PI prevention, frequent staffing shortages, high patient acuity levels, and …

Effect Of Thromboprophylaxis On Clinical Outcomes After Covid-19 Hospitalization, Tracy Y Wang, Abdus S Wahed, Alison Morris, Lisa Baumann Kreuziger, John G Quigley, Gervasio A Lamas, Alexandra J Weissman, Jose Lopez-Sendon, M Margaret Knudson, Deborah M Siegal, Raj S Kasthuri, Andrew J Alexander, Lana Wahid, Bassel Atassi, Peter J Miller, Janice W Lawson, Bela Patel, Jerry A Krishnan, Nancy L Shapiro, Deborah E Martin, Andrei L Kindzelski, Eric S Leifer, Jungnam Joo, Lingyun Lyu, Annie Pennella, Brendan M Everett, Mark W Geraci, Kevin J Anstrom, Thomas L Ortel, Activ-4c Study Group

Journal Articles

BACKGROUND: Patients hospitalized with COVID-19 have an increased incidence of thromboembolism. The role of extended thromboprophylaxis after hospital discharge is unclear.

OBJECTIVE: To determine whether anticoagulation is superior to placebo in reducing death and thromboembolic complications among patients discharged after COVID-19 hospitalization.

DESIGN: Prospective, randomized, double-blind, placebo-controlled clinical trial. (ClinicalTrials.gov: NCT04650087).

SETTING: Done during 2021 to 2022 among 127 U.S. hospitals.

PARTICIPANTS: Adults aged 18 years or older hospitalized with COVID-19 for 48 hours or more and ready for discharge, excluding those with a requirement for, or contraindication to, anticoagulation.

INTERVENTION: 2.5 mg of apixaban versus placebo twice daily for …

Recurrent Cyanotic Spells In An Octogenarian, Chin Tong Kwok, Chun Kit Wong

Journal of the Hong Kong College of Cardiology

We report rare case of an octogenarian who, after years of diagnostic delay, was found to have a patent foramen ovale, and due to an ascending aortic aneurysm that anatomically facilitated right-to-left shunt, presenting with life-threatening cyanotic attacks. The characteristic orthodeoxia-platypnea syndrome and high alveolar arterial gradient hint to the diagnosis. She was eventually treated successfully with urgent percutaneous PFO closure. Routine ordering of a transthoracic echocardiogram, without agitated saline injection under provocation maneuvers, may not be sufficient to rule out shunts.

Modified Early Warning Scoring (Mews) Versus Epic Deterioration Index (Edi): Battle Royale For Which Has The Best Patient Outcomes In The Inpatient Setting, Dirk A. Church

DNP Projects

Abstract

Background: The increased workload bedside nurses face today requires new tools to assist with the identification of deteriorating patients during hospitalization. The Modified Early Warning Score (MEWS) tool has formed the background of early warning tools. Newer, more complex tools, like Epic’s Deterioration Index (EDI), have been developed to identify patient deterioration earlier. There is lack of evidence in the literature comparing different early warning tools, implementation, and patient outcomes.

Objective: The purpose of the study was to examine models for EWS notification for RRT and patient outcomes between the use of the MEWS and EDI in an adult, …

Ethnic And Racial Differences In Self-Reported Symptoms, Health Status, Activity Level, And Missed Work At 3 And 6 Months Following Sars-Cov-2 Infection., Kelli N O'Laughlin, Robin E Klabbers, Imtiaz Ebna Mannan, Nicole L Gentile, Rachel E Geyer, Zihan Zheng, Huihui Yu, Shu-Xia Li, Kwun C G Chan, Erica S Spatz, Ralph C Wang, Michelle L'Hommedieu, Robert A Weinstein, Ian D Plumb, Michael Gottlieb, Ryan M Huebinger, Melissa Hagen, Joann G Elmore, Mandy J Hill, Morgan Kelly, Samuel Mcdonald, Kristin L Rising, Robert M Rodriguez, Arjun Venkatesh, Ahamed H Idris, Michelle Santangelo, Katherine Koo, Sharon Saydah, Graham Nichol, Kari A Stephens

Journal Articles

INTRODUCTION: Data on ethnic and racial differences in symptoms and health-related impacts following SARS-CoV-2 infection are limited. We aimed to estimate the ethnic and racial differences in symptoms and health-related impacts 3 and 6 months after the first SARS-CoV-2 infection.

METHODS: Participants included adults with SARS-CoV-2 infection enrolled in a prospective multicenter US study between 12/11/2020 and 7/4/2022 as the primary cohort of interest, as well as a SARS-CoV-2-negative cohort to account for non-SARS-CoV-2-infection impacts, who completed enrollment and 3-month surveys (

RESULTS: Following SARS-CoV-2 infection, the majority of symptoms were similar over time between ethnic and racial groups. At …