Incidental chronic LV thrombus; a dreaded complication of anterior MI

Background: Left ventricular thrombus may develop after acute myocardial infarction and occurs most often with a large STEMI. The use of reperfusion therapy and fibrinolytics has dramatically reduced the incidence. Epidemiologic data suggest the incidence of LV thrombus is as high as 25% in patients with anterior MI. Risk of embolization has been reported up to 15% in patients without anticoagulation. Case presentation: 70 y/o man with history of coronary artery disease with remote LAD stent placed over 17 years ago presents to the office as a new patient for evaluation of exertional shortness of breath and chest pain. Upon review of patient’s history an echocardiogram and nuclear stress test where ordered. 2D echocardiogram showed impaired systolic dysfunction with EF of 35%, hypokinetic left anterior wall, and akinesis of apical anterior wall. A 2 x 3 cm regular with echodense borders left apical thrombus was identified with no protrusion nor mobility. Stress test showed nonreversible apical ischemia. Left heart catheterization was performed showing patent LAD stent with only mild CAD present. Due to chronicity without complications and echocardiographic characteristics along with patient discussion the decision was made not to initiate anticoagulation at this point. Conclusion: LV thrombus is a complication of anterior and apical MI that increases the risk for MACE and stroke. Guidelines recommend oral anticoagulation of at least 3 months upon diagnosis but there is no clear recommendation for chronic stable cases. Echocardiographic characteristics can help guide the decision for anticoagulation initiation until further protocols are developed

Osteomyelitis in Diabetic Foot Ulcer: a common dreaded complication of DM

Background: Group B ß-hemolytic streptococci is a rare offending agent in osteomyelitis with strong affinity for the diabetic foot. A high index of clinical suspicion, alongside radiological studies, should guide prompt diagnosis and treatment to avoid unfavorable complications. Case Presentation: A 42-year-old obese gentleman with history of hyperlipidemia, hypertension, peripheral artery disease, depression with alcohol abuse, and recently diagnosed type 2 diabetes mellitus and peripheral neuropathy presented to the emergency department with worsening left foot pain for 2 weeks with a nonhealing necrotic ulcer. Upon presentation, he was in no acute distress with insignificant initial labs except for blood glucose of 269 and HBA1c of 10.6. X-ray showed no obvious bone abnormalities with potential subcutaneous emphysema. Empiric treatment with IV Zosyn was initiated. MRI showed cortical changes of 5th metatarsal head compatible with early signs of osteomyelitis. Wound cultures of the necrotic ulcer consecutively grew predominantly group B streptococcus agalactiae. Podiatry was consulted and subsequently performed debridement with partial amputation of the left 5th foot digit. Discussion: Prompt diagnosis and empiric antibiotic treatment are imperative in the effective management of osteomyelitis, especially in patients with significant comorbidities. Osteomyelitis caused by group B ßhemolytic streptococci should be considered in any diabetic patient with foot lesions, even in the absence of systemic signs and symptoms, such as fever and bacteremia. Additionally, all patients diagnosed with type 2 Diabetes should be counseled in the prevention and care of foot lesions

Mediastinal mass presenting as an ST-elevation MI

Background: MINOCA is defined as a clinical syndrome in which there is myocardial ischemia in the setting of normal coronary arteries. Different causes include coronary spasms, SCAD, or external compression, e.g., by a mediastinal mass. CT or MRI would show presence of the mass, deferring any need for coronary angiography. Case: The patient is a 57-year-old lady with a past medical history of hypertension who presented to the ED complaining of shortness of breath associated with chest pain. Upon evaluation her vitals were BP 126/76, HR 94, RR 18, O2 98% on room air. Physical exam was unremarkable. Troponin peaked at 0.62. Chest x-ray showed no acute findings. EKG showed ST-elevation MI in leads V1-V3. She was immediately taken to the catheterization lab and was found to have normal coronary arteries without any evidence of coronary artery disease. CT angiography was done to rule out pulmonary embolism which showed an anterior mediastinal mass with invasion to the anterior cardiac wall consistent with malignancy. Interventional radiology was consulted, and she underwent CT guided biopsy of the mass. The patient remained stable with no further symptomatology and was discharged home. Biopsy results showed mass consistent with diffuse large B-cell lymphoma, activated B-cell type, with an exceedingly high proliferative fraction. She was started on chemotherapy regimen. Discussion: Primary mediastinal B-cell lymphomas are aggressive entities that can expand around the mediastinum and compromise the heart. Due to its cardiac invasion patients can present with an ACS picture. Coronary angiography would show no abnormalities. Aggressive chemotherapy regimen is pertinent in these patients due to the risk of myocardial rupture. Our case highlights the importance of viewing STEMI as a clinical syndrome with different etiologies and not just an EKG finding

Improving Internal Medicine Residents’ self perceived confidence, knowledge and procedural skill performing Pap smears

Background: Cervical cancer is the second most common cancer in women worldwide; early detection plays a key role in reducing morbidity and mortality. In Texas’ counties lining the border, cervical cancer death rate is 30% higher than the rest of the state. Methods: A total of 20 Internal medicine residents from the UTRGV - DHR were randomized to an intervention and control groups. Before the intervention, residents had not received any formal training skills on Pap smear technique during their residency. The educational intervention consisted of an eleven-minute video on Thin prep specimen collection and a single-day hands-on training skills Pap smear workshop using a life-size gynecological manikin. An electronic survey was sent one month later to the study participants. The post-survey consisted of a 5-point Likert scale with closed ended questions about perceived confidence and knowledge on cervical cancer screening. Results: A total of 20 unique survey responses were recorded (overall response rate 39%). Results didn’t show statistically significant difference between the intervention group (n=10) and the control group (n=10) regarding self-perceived confidence to perform a Pap smear, knowledge about the indications and proper technique and steps to perform a pap smear. Conclusion: Our interventions were not enough to increase self-perceived confidence, knowledge and procedural skills when performing pap smears. We strongly believe that additional interventions that help overcome the main limitations perceived by the IM residents will be able to increase cervical cancer screening

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status

Guidelines for the use and interpretation of assays for monitoring autophagy (4th edition)

In 2008, we published the first set of guidelines for standardizing research in autophagy. Since then, this topic has received increasing attention, and many scientists have entered the field. Our knowledge base and relevant new technologies have also been expanding. Thus, it is important to formulate on a regular basis updated guidelines for monitoring autophagy in different organisms. Despite numerous reviews, there continues to be confusion regarding acceptable methods to evaluate autophagy, especially in multicellular eukaryotes. Here, we present a set of guidelines for investigators to select and interpret methods to examine autophagy and related processes, and for reviewers to provide realistic and reasonable critiques of reports that are focused on these processes. These guidelines are not meant to be a dogmatic set of rules, because the appropriateness of any assay largely depends on the question being asked and the system being used. Moreover, no individual assay is perfect for every situation, calling for the use of multiple techniques to properly monitor autophagy in each experimental setting. Finally, several core components of the autophagy machinery have been implicated in distinct autophagic processes (canonical and noncanonical autophagy), implying that genetic approaches to block autophagy should rely on targeting two or more autophagy-related genes that ideally participate in distinct steps of the pathway. Along similar lines, because multiple proteins involved in autophagy also regulate other cellular pathways including apoptosis, not all of them can be used as a specific marker for bona fide autophagic responses. Here, we critically discuss current methods of assessing autophagy and the information they can, or cannot, provide. Our ultimate goal is to encourage intellectual and technical innovation in the field