• Acute Pancreatitis Due to Clipping of the Ampulla With Over-The-Scope Clip as a Complication of Bleeding Duodenal Ulcer Treatment

      Sehmbey, Gurbir; Srinivasan, Indu; Chuang, Keng-Yu; Univ Arizona, Internal Med, Coll Med Phoenix (CUREUS INC, 2020-07-02)
      Over-the-scope clips (OTSC) (Ovesco, Tubingen, Germany) are commonly used for closure of bowel perforations, fistulas and to achieve hemostasis. This device is attached to the endoscope and delivers a variety of clips, based on diameter and depth, that works through tissue approximation. Complications including local inflammation, ulcers, or obstruction can occur. When the clip is misplaced or OTSC-associated complications occur, OTSC removal may be indicated. We present a case of a patient who presented to our hospital with upper gastrointestinal (GI) bleeding. OTSC was used to achieve hemostasis, however, the clip was misplaced over the ampulla of Vater. remOVE system (Ovesco, Tubingen, Germany) was used to remove the misplaced clip.
    • An Aggressive Case of Mucormycosis

      Tran, Donovan; Schmit, Berndt; Univ Arizona, Coll Med Tucson, Diagnost Radiol; Univ Arizona, Coll Med Tucson, Radiol (CUREUS INC, 2020-08)
      Mucormycosis is an aggressive fungal disease that can occur in individuals with certain predisposing factors, such as diabetes mellitus and pharmacologic immunosuppression. An astounding aspect of this disease is the speed at which it can spread to surrounding structures once it begins to germinate inside the human body. This case involves a 24-year-old male patient who presented to the emergency room complaining of a headache after a dental procedure who developed fulminant rhinocerebral mucormycosis within days. The objective of this report is to shed light on how fast this disease spreads, discuss current management of rhinocerebral mucormycosis, and illustrate the subtle, but critical radiographic findings to raise clinical awareness for this life-threatening disease.
    • A Backwards Approach to Bariatric Surgery: The Perioperative Approach Used in a Woman with Situs Inversus Totalis Undergoing a Laparoscopic Sleeve Gastrectomy

      Villalvazo, Yadira; Jensen, Candice M; Univ Arizona, Coll Med (CUREUS INC, 2018-10-18)
      Situs inversus totalis is a rare congenital condition where organs are mirrored across the sagittal plane of the body. In the absence of associated comorbidities, most people have normal health and lifespan. Challenges with mirrored image anatomy arise when needing an operative procedure involving the intraabdominal organs. There are few reported cases in the literature of laparoscopic surgery in patients with situs inversus, with even fewer in the field of bariatric surgery. Obesity and obesity-related comorbidities continue to increase in our society, and bariatric surgery is a treatment option for weight loss. We report the perioperative approach used in a 59-year-old obese woman with confirmed situs inversus totalis undergoing laparoscopic sleeve gastrectomy.
    • Cholangiocarcinoma in a Resected Biliary Cyst: Importance of Follow-up

      Malik, Mustafa N; Saleem, Tabinda; Aslam, Shehroz; Riaz, Rida; Yousaf, Muhammad Abdullah; Univ Arizona, Internal Med (CUREUS INC, 2019-04-24)
      Biliary cysts are rare cystic dilatations of the biliary tree. Biliary cysts are positively associated with several significant complications, amongst them, cholangiocarcinoma befalls the most dreadful one. The elevated incidence is 20-30% in the unresected cyst and 0.7% in resected cysts. Magnetic resonance imaging (MRI) scan, magnetic resonance cholangiopancreatography (MRCP) or a contrast-enhanced computed tomography (CECT) is applied for the initial diagnostic study but the ultimate diagnosis ordinarily requires the tissue biopsy. Currently, the sole curative option involves the complete surgical resection of the lesion, with standard chemotherapy and active radiation applied as an alternative for the unresectable tumors. Despite the curative surgery the percentage of eternal recurrence of the tumor indefinitely persists, and effective post-surgical surveillance is reasonably demanded. We report a case of 29-year-old female with local recurrence of cholangiocarcinoma in a previously resected biliary cyst type I. The curative resection of the choledochal cyst only minimizes the considerable risk of the possible development of future cholangiocarcinoma but it does not completely prevent it. The appropriate follow-up for potential patients who have been typically treated for a biliary cyst is unclear. The lethal course of cholangiocarcinoma is believed due to its slow asymptomatic growing phase. Therefore, to adequately screen for malignancy, periodic imaging along with annual liver tests represents a reasonable approach to prevent the possible development of this appalling complication.
    • Ciprofloxacin-induced Stevens-Johnson Syndrome with Grapefruit Juice Consumption: A Case Report

      Cravens, Matthew G; Sherman, Nathan; Sawaya, Jennifer; Univ Arizona, Coll Med, Emergency Med; Univ Arizona, Coll Med, Internal Med; Univ Arizona, Coll Med, Dermatol (CUREUS INC, 2019-01-04)
      We describe the case of a 49-year-old, otherwise healthy, Hispanic male who underwent an uncomplicated vasectomy and was treated prophylactically with a one-week course of ciprofloxacin. Two days after completing the antibiotic course, he developed a pruritic, blistering rash that covered 90% of his body surface area. Punch biopsy of the skin lesions confirmed the diagnosis of Stevens-Johnson syndrome (SJS). Upon further questioning, it was revealed that the patient had consumed approximately 32 ounces of grapefruit juice each of the seven days following his vasectomy. We hypothesized that the cytochrome P450 inhibitory effect of grapefruit juice had dramatically elevated systemic levels of ciprofloxacin, increasing the risk of developing SJS. Literature review revealed that ciprofloxacin is metabolized primarily by CYP1A2 with partial CYP3A4 metabolism, while grapefruit juice is strictly an enterocyte CYP3A4 inhibitor. To the authors' knowledge, consumption of grapefruit juice has never been demonstrated to increase systemic levels of ciprofloxacin or of other fluoroquinolones. We conclude that either this is the first reported case of a grapefruit juice-ciprofloxacin interaction causing SJS, or that this is simply ciprofloxacin-induced SJS. Importantly, ciprofloxacin is not recommended by the American Urological Association for a routine vasectomy without risk factors for infection. We remind clinicians that inappropriately prescribed antibiotic prophylaxis for routine procedures can cause serious morbidity, including SJS, and should only be prescribed when indicated.
    • Cirrhosis, Operative Trauma, Transfusion, and Mortality: A Multicenter Retrospective Observational Study

      Isbell, Claire; Cohn, Stephen M; Inaba, Kenji; O'Keeffe, Terence; De Moya, Marc; Demissie, Seleshi; Ghneim, Mira; Davis, Matthew L; Univ Arizona, Med Ctr, Surg (CUREUS INC, 2018-08-02)
      Background: In trauma patients with cirrhosis who require laparotomy, little data exists to establish clinical predictors of the outcome. We sought to determine the prognosticators of mortality in this population. Methods: We performed a 10-year review at four, busy Level I trauma centers of patients with cirrhosis identified during trauma laparotomy. We compared vital signs, laboratory values, and transfusion requirements for those who survived versus those who died. A linear regression was then conducted to determine the variables associated with death in this population. Results: A total of 66 patients were included and 47% (31/66) died. The model for end-stage liver disease (MELD) score was low (7.8 in Lived, 10.2 in Died). Packed red blood cell (PRBC) transfusion at six hours was greater in those who died; those receiving > 6 units of PRBCs at 6 hours had an increased likelihood of death (odds ratio OR 5.8 (95% CI 1.9, 17.4)). All patients receiving >= 17 units of PRBCs died. We found an association between lower preoperative platelets (PLTs), higher preoperative international normalized ratio (INR) and partial thromboplastin time (PTT), lower preoperative pH (presence of profound acidemia), increased intraoperative crystalloid use, and increased intraoperative blood product administration to be associated with death (p < 0.05). Conclusions: Cirrhotic trauma patients requiring laparotomy should be considered to have a high chance of mortality if they receive six or more PRBCs, are acidotic (pH <= 7.25) at the time of hospital arrival, or have coagulopathy at the time of admission (INR > 1.2, PTT > 40).
    • Clinical Efficacy and Safety Profile of Prucalopride in Chronic Idiopathic Constipation

      Tameez Ud Din, Asim; Khan, Ameer H; Bajwa, Hamza; Maqsood, Muhammad Haisum; Malik, Mustafa N; Univ Arizona, Internal Med (CUREUS INC, 2019-04-04)
      Chronic idiopathic constipation (CIC) can be defined as bowel movements that are difficult to pass, are not occurring frequently, or have incomplete evacuation during defecation. A high-fiber diet and laxatives are the commonly used treatments, but in many cases, they do not produce satisfactory results. The first line of treatment is osmotic laxatives. If there is no improvement, the second line is guanylate cyclase-C (GCC) agonists like linaclotide or prokinetic agents such as prucalopride. On December 14, 2018, the United States Food and Drug Administration (US FDA) approved prucalopride for treating chronic idiopathic constipation. Prucalopride is a prokinetic agent which works at the 5-hydroxytryptamine receptor 4 (5-HT4) as an agonist with greater receptor selectivity. Patients on prucalopride reported improved symptoms, quality of life and satisfaction. The most frequent adverse events were headaches and problems related to the gastrointestinal tract. Caution should be taken when using prucalopride in patients with impaired liver and renal function. In Canada, prucalopride has been approved for treatment of female patients with chronic idiopathic constipation who have failed therapy with at least two laxatives from different classes over a six-month period.
    • Definitive Chemoradiation With Dose Escalation for Locally Advanced Gastric Cancer: Case Studies

      Anthony, Michelle; Goyal, Uma; Univ Arizona, Coll Med, Radiat Oncol; Univ Arizona, Radiat Oncol, Canc Ctr (CUREUS INC, 2020-10-19)
      Gastric cancer is a prevalent cancer with a predilection for Asian ethnicity and male patients. In early and locally advanced gastric cancer, without significant comorbidities, surgery is a part of the treatment management of this cancer. However, with concurrent comorbidities, surgery may not be recommended and alternative treatment options such as palliative chemotherapy and/or radiation and definitive chemoradiation can be considered to reduce morbidity. We present three cases of gastric cancer where definitive chemoradiation with dose escalation was utilized due to underlying comorbidities and poor performance status. The treatment was generally well tolerated by patients and resulted in substantial reduction in gastric mass size in two patients with median overall survival of 10 months.
    • Development of a Medical Student Cardiopulmonary Resuscitation Elective to Promote Education and Community Outreach

      Panchal, Ashish; Keim, Samuel; Ewy, Gordon; Kern, Karl; Hughes, Kate E; Beskind, Daniel; Univ Arizona, Emergency Med (CUREUS INC, 2019-04-20)
      Introduction: One of the barriers to improving cardiac arrest survival is the low rate of cardiopulmonary resuscitation (CPR) provision. Identifying this as a public health issue, many medical students often assist in training the community in CPR. However, these experiences are often short and are not associated with structured resuscitation education, limiting the student's and the community's learning. In this assessment, we identified a need and developed a curriculum, including defined goals and objectives, for an undergraduate medical education (UME) elective in CPR. Methods: At an academic university environment with a strong UME program, we developed a longitudinal UME elective in CPR. The curriculum is a four-year longitudinal experience, which satisfies two weeks of their fourth year of medical school. The curriculum includes structured training over the four-year period in the fundamentals of resuscitation science (through didactics, journal club, and hands-on skills training), in addition to structured community CPR teaching. The elective concludes with a final hands-on summative appraisal. Data concerning medical student program enrollment, CPR training events conducted, venues of events, and the number of individuals trained were collected over a five-year period. Results: The CPR elective was developed with clear goals and objectives based on identified needs. Over the five-year period, 186 medical students completed the CPR longitudinal elective, accounting for 8.4% of the total medical student population. Students completed curriculum requirements and satisfied both didactic and hands-on training with all students passing the final summative appraisal. Over the five-year period, students trained 8,694 people in bystander CPR. The summative evaluation had a 100% pass rate. Conclusion: Implementation of a longitudinal CPR elective improved resuscitation science education for medical students and fostered increased community CPR training. This describes one local effort to improve resuscitation science education and training for medical students. Further work will need to be done to evaluate the impact of UME resuscitation curricula on medical student career choice and resuscitation outcomes.
    • Disease Milestones through Bibliometric Analysis of the Top 100 Cited Articles in Multiple Myeloma

      Latif, Azka; Kapoor, Vikas; Sipra, Qurat Ul Ain Riaz; Malik, Saad Ullah; Bilal, Jawad; bin Riaz, Irbaz; Anwer, Faiz; Univ Arizona, Hematol & Oncol; Univ Arizona, Dept Internal Med; Univ Arizona, Med; et al. (CUREUS INC, 2018-04-05)
      Multiple myeloma (MM) accounts for 1.6% of all cancers and 5%-10% of all hematologic malignancies in the United States (US). Despite marked progress in disease management, it remains incurable with high rates of relapse. We conducted a bibliographic analysis on the Web of Science (WOS) from July 25, 2017 and July 29, 2017. Among the top 100 most-cited articles (1901-2012), the most cited article received 2404 citations and least cited article received 336 citations. Forty-four of 100 articles were published in journals with impact factors greater than 20. We observed that over the years, the focus of research has shifted from diagnosis, staging, and pathogenesis to better treatment outcomes. A subgroup analysis of the top 100 cited articles published in the last five years (2012-2017) demonstrated that several landmark studies, which will likely change the landscape of treating multiple myeloma, were not included in the top 100 list. Interestingly, most of these articles were focused on novel therapeutic agents. This bibliographic analysis provides a list of the 100 top-cited articles in multiple myeloma along with the captivating comprehension of the history and development in various aspects of disease processes. The landscape of this disease is rapidly evolving, and bibliometric studies such as the one presented provide a valuable tool that can highlight the important transitions in the field.
    • Double Vision: Isolated Third Cranial Nerve Palsy After Cardiac Catheterization

      Jilani, Mohammad H; Iqbal, Hameed; Huda, Syed; Khan, Ali Younas; Charlamb, Larry; Univ Arizona, Hematol & Oncol (CUREUS INC, 2020-07-15)
      Neurological complications after cardiac catheterization are rare. We report an unusual case of isolated third cranial nerve palsy in a 72-year-old male patient whose past medical history was significant for diabetes mellitus and coronary artery disease (CAD). He presented for elective cardiac catheterization for stable angina, which revealed multivessel CAD and no intervention was done. Two hours after the procedure, the patient suddenly started complaining of newonset double vision in his left eye. Ophthalmologic exam revealed ptosis of the left eye lid, sluggish pupillary reflex and impaired adduction of the left eye along with exotropia of the left eye on primary gaze, all findings consistent with the left third nerve palsy. Rest of the neurological exam and neuroimaging (CT angiogram of head and MRI brain) were normal. Embolic phenomenon has been described as a possible mechanism in such patients leading to small vessel ischemic disease and cerebral microinfarction. Neuro-ophthalmologic complications after cardiac catheterization are rare but devastating for the patients. These should be recognized promptly, and patients should undergo neuroimaging to evaluate for any identifiable causes. These patients should be treated with aspirin and statin therapy and evaluated by ophthalmology for correction with prism lenses if symptoms persist.
    • Factors Associated with Functional Decline in Elderly Female Breast Cancer Patients in Appalachia

      Singh, Raj; Ansinelli, Hayden; Katz, Heather; Jafri, Hassaan; Gress, Todd; Tirona, Maria T; Univ Arizona, Dept Radiat Oncol (CUREUS INC, 2018-05-12)
      Background Functional status has been previously shown in the elderly cancer population to predict both mortality as well as treatment tolerance. The goal of this study was to determine if there are certain subsets of the elderly breast cancer population that are at higher risk of experiencing functional decline following treatment. Methods Patient charts from the Edwards Comprehensive Cancer Center in Huntington, West Virginia, from January 2006 - January 2016 were reviewed. Relevant inclusion criteria included patients of 65 years of age and older with a new diagnosis of Stage 0-III breast cancer. Functional decline was defined as an increase of at least one point in Eastern Cooperative Oncology Group (ECOG) scores within one year of diagnosis. ECOG performance status was subjectively determined by the physician. Fisher's exact test and Pearson's Chi-squared test were initially utilized to assess potential factors associated with functional decline such as pretreatment ECOG score, age at diagnosis, stage, hormone receptor status, type of surgery received, whether radiation therapy, chemotherapy, or hormonal therapy was received, medical comorbidities, body mass index (BMI), complaints of weakness at diagnosis, and ambulatory status. Factors that were found to be significant were further assessed via multivariate logistic regressions. Results Three-hundred and fourteen patients were identified as meeting inclusion criteria. At one-year follow-up, 45 patients (14.3% of the cohort) had documented functional decline. On initial analysis, factors associated with functional decline included Stage III disease (p=0.002) and complaints of weakness at diagnosis (p=0.004). Following multivariate analysis, Stage III disease (p = 0.02), complaints of weakness at diagnosis (p = 0.04), and bilateral mastectomy (p = 0.03) were significantly associated with functional decline. Conclusion Patients who were diagnosed with Stage III breast cancer, had complaints of weakness at time of diagnosis, or had bilateral mastectomies were more likely to have a decline in functional status at one-year follow-up. Awareness of factors associated with functional decline in the elderly Appalachian population with Stage 0-III breast cancer will be useful during discussions regarding patient expectations, treatment, and goals of care. Elderly breast cancer patients for whom bilateral prophylactic mastectomies are not indicated may be better served by lumpectomy alone (based on patient age, hormone receptor status, and tumor size), lumpectomy followed by radiation therapy, or unilateral mastectomy to maximize the likelihood of functional preservation following treatment.
    • Fascia Iliaca Block Successfully Prolonged With Dexmedetomidine and Dexamethasone for Pain Control in a Patient Undergoing Total Hip Arthroplasty

      Noor, Nazir A; Urits, Ivan; Viswanath, Omar; Kaye, Alan D; Eskander, Jonathan; Univ Arizona, Coll Med, Anesthesiol (CUREUS INC, 2020-10-11)
      Regional anesthesia has found many advocates as enhanced recovery after surgery continues to become a more popular option for procedures such as total hip arthroplasty. Among the many benefits is the better pain control with a reduction or complete elimination of the need for opioids for perioperative pain management. With aims to improve the multi-modal approach to pain management, we present a case demonstrating further improvements in the regional anesthetic technique with the addition of a dexamethasone and dexmedetomidine adjuvant to the local anesthetic injectate. Our case is that of a 65-year-old woman with a history of hypertension, hyperlipidemia, and right hip osteoarthritis undergoing a right total hip arthroplasty who received a preoperative ultrasound-guided fascia iliaca block with the adjuvants dexamethasone and dexmedetomidine added to the injectate. The surgery was uneventful. She did not require any postoperative opioid or non-opioid analgesics, denying any pain for the first three postoperative days.
    • Gallbladder Perforation Secondary to Enteric Fever: An Interesting Case of Acute Abdomen

      Malik, Mustafa N; Mahmood, Tayyab; Tameez Ud Din, Asim; Aslam, Shehroz; Imtiaz, Maria; Univ Arizona, Internal Med (CUREUS INC, 2019-04-22)
      Enteric fever is a common infectious disease, especially in countries with poor sanitation and in the tropics. It is caused mainly by Salmonella typhi and accounts for nearly 27 million cases worldwide and 200,000 deaths annually. Enteric fever involves the reticuloendothelial system such as bone marrow, spleen, and liver. As it mostly involves the Peyer's patches of the terminal ileum, enteric perforation occurs commonly. However, gallbladder perforation can also occur, though not very often. Ultrasound as well as computerized tomography (CT) abdomen and pelvis lack specificity for detecting gallbladder perforations in enteric fever. Diagnosis is usually confirmed intraoperatively when the gallbladder is visualized and perforation is seen. Gallbladder perforation is usually seen in acute cholecystitis when the gallbladder becomes necrotic and gangrenous. In acalculous cholecystitis, perforation is rare. Enteric fever is one of the rarest causes of acalculous cholecystitis, leading to perforation. Here, we present the case of a 20-year-old man who presented with fever for 10 days along with loose stools, vomiting, and acute abdomen. Labs showed leukopenia, positive Typhidot test but X-ray erect abdomen and ultrasound abdomen and pelvis were nonspecific. Only after resuscitation and exploration of the abdomen was it found that the gallbladder had multiple perforations. The patient was improved after eight days of postoperative intravenous antibiotics. This is a unique and rare presentation of such a common infectious disease.
    • Gastric Cardia Adenocarcinoma with Metastasis to the Scalp: A Case Report

      Menghani, Sanjay V; Barbosa, Alexandra; Sagerman, Paul; Beal, Matthew W; Scott, Aaron; Univ Arizona, Coll Med, Dermatol; Univ Arizona, Coll Med, Internal Med; Univ Arizona, Ctr Canc, Oncol (CUREUS INC, 2020-01-27)
      Cutaneous metastasis is a rare manifestation of advanced gastrointestinal (GI) cancers. Gastric adenocarcinoma rarely presents with cutaneous metastasis, as cutaneous manifestations occur in less than 1% of upper GI tract malignancies. Here, we present the case of a patient with advanced gastric cardia adenocarcinoma with metastasis to the right occipital region of the scalp. Following shave biopsy, the immunohistochemistry (IHC) and molecular profile of the scalp lesion were analyzed, both of which confirmed metastasis and guided the treatment approach. The lesion demonstrated programmed death ligand-1 (PD-L1), an immune checkpoint protein, positivity by IHC, which led to the recommendation for treatment with immunotherapy as per the National Comprehensive Cancer Network (NCCN) guidelines. Clinicians should conduct dermatologic examinations in patients with a history of gastric cancer or who are currently undergoing chemotherapy for gastric cancer in order to monitor for disease progression or metastatic lesions. The aim of this report is to increase awareness of scalp metastasis as an indicator of advanced internal visceral carcinoma for earlier diagnosis and improved management of the condition.
    • Hypocalcemia and a Positive Metabolic Screen for Severe Combined Immunodeficiency in an 11-Day-Old Male With DiGeorge Syndrome

      Ford, Jessica; Pena, Jose M.; Rainey, Shane C.; Univ Arizona, Coll Med Phoenix, Child Hlth (CUREUS INC, 2020-09)
      22q11 deletion syndrome (22q11DS), also known as DiGeorge syndrome or velocardiofacial syndrome, is the most common human genetic microdeletion. Hypocalcemia secondary to hypoparathyroidism is a common finding in this condition and may present with seizures. We describe a case of an 11-day-old male presenting with hypocalcemic seizures and a positive newborn screen for severe combined immunodeficiency as the primary manifestations of 22q11 DS. Given the potential for wide phenotypic variability, clinicians should maintain a high index of suspicion for this syndrome, especially in the neonate presenting with hypocalcemia.
    • Ibuprofen Overuse Leading to Life-threatening Hypokalemia Associated with Renal Tubular Acidosis in Two Patients

      Thammineni, Nikhila; Kathi, Pradeep R; Sharma, Aditi; Jawed, Areeba; Univ Arizona, Internal Med Gastroenterol (CUREUS INC, 2019-12-17)
      Ibuprofen is a commonly used medication in the United States and is used both by prescription and over the counter, while hypokalemia is a life-threatening condition caused by various etiologies, one of which is the side effect of medications. Ibuprofen is well-known for its various nephrotoxic side effects, including hyperkalemia as a common electrolyte abnormality, however, renal tubular acidosis leading to hypokalemia with the use of ibuprofen has been reported rarely. We present here two cases of life-threatening hypokalemia due to over-thecounter use of large doses of ibuprofen and describe its management.
    • Impact of Storage Lesion on Post-transfusion Rise in Hemoglobin

      Sardar, Muhammad; Shaikh, Nasreen; Ansell, Jack; Jacob, Aasems; Yada, Srujana; Kelly, David B; Doraiswamy, Mohankumar; Khan, Wahab J; Anwer, Faiz; Eng, Margaret Hh; et al. (CUREUS INC, 2018-07-09)
      Background: The storage lesion is defined as the set of changes that occur in red blood cells (RBCs) during storage. Studies have shown that a prolonged storage period of RBCs is associated with increased destruction after transfusion. The aim of this study is to determine the impact of the storage lesion on the efficacy of RBC transfusions by comparing the mean rise in the hemoglobin of patients who received new vs old blood. Methods: We did a retrospective chart review of all patients who received a single unit of pure red blood cell (PRBC) transfusion in a three-month period. Patients with hemolytic anemia and active bleeding were excluded. The storage lesion was estimated by calculating the number of days to expiration on the day of transfusion. Median days to expiration was calculated to be 11 days. Patients were divided into two groups based on days to expiration. Group A included patients who received old blood (days to expiration: 0-11) and group B included patients who received new blood (days to expiration: 11-38). The mean rise in hemoglobin between the two groups was compared using the paired t-test. Results: The baseline characteristics of both groups were similar. There was no statistically significant difference in the mean rise in hemoglobin (1.01 vs 1.08- p-value 0.298), hematocrit (3.37 vs 3.61- p-value 0.249), and RBC count (0.42 vs 0.44- p-value 0.097) in the group that received old blood vs new blood, respectively. Conclusion: An RBC transfusion with a shorter storage period does not increase hemoglobin more than RBC with a longer storage period.
    • Infective Endocarditis Causing Acute Myocardial Infarction

      Cohen, Seth; Ford, Lucie; Situ-LaCasse, Elaine; Tolby, Noah; Univ Arizona, Emergency Med (CUREUS INC, 2020-10-29)
      Endocarditis is a well-known disease, yet septic embolization resulting in myocardial infarction is much rarer and very infrequently diagnosed in the emergency department (ED). Point-of-Care-Ultrasound (POCUS) can be used to confirm clinical suspicion within minutes of patient presentation, thereby expediting patient care. We report the case of a 26-year-old female with known intravenous drug use who presented with altered mental status. Her clinical presentation prompted urgent evaluation in the ED with POCUS which showed a hyperdynamic functioning left ventricle, greater than 50% inferior vena cava collapse, and a large tricuspid valve vegetation. In light of the electrocardiogram (ECG) ST changes suggesting an acute myocardial infarction, the patient was emergently taken to the cardiac catheterization laboratory where coronary angiography revealed multiple coronary emboli. Primary diagnoses included endocarditis due to Staphylococcus, septic pulmonary embolism, and ST-elevated myocardial infarction (STEMI) due to embolic occlusion of the distal left anterior descending artery. Myocardial infarction caused by septic embolization from endocarditis is a rare condition; however, POCUS is a quick, non-invasive tool that can aid the emergency medicine (EM) physician in identifying this life-threatening pathology thereby expediting appropriate care for the patient.
    • Investigating the Impact of Gadolinium-Based Contrast Agents on the Corrected QT Interval

      Gress, Kyle L.; Gallo, Tyler; Urits, Ivan; Geng, Xue; Viswanath, Omar; Kaye, Alan D.; Woosley, Raymond L.; Univ Arizona, Div Clin Data Analyt, Coll Med; Univ Arizona, Med, Coll Med (CUREUS INC, 2020-08)
      Introduction The manufacturing labels for all currently marketed gadolinium-based MRI contrast agents describe adverse cardiac events reported during post-market use. The goal of this study was to determine prolongation of the rate-corrected QT interval occurs in the immediate setting after gadolinium-based MRI contrast agent injection. Methods This study enrolled adults scheduled to have a gadolinium-based MRI contrast agent injection as part of a diagnostic MRI. A single-lead electrocardiogram was recorded using the AliveCor Kardia (R) ECG (Mountain View, CA) device before and after injection. The rate-corrected QT interval was subsequently measured by two independent investigators. The QT interval was corrected for rate using the two most common formulas, originally cited by Bazett and Fridericia. These rate-corrected QT intervals from before and after gadolinium-based MRI contrast agent injection were compared using the Wilcoxon signed-rank test paired analysis. Results A total of 24 consenting adults had electrocardiogram that were free of motion artifact. The mean age of the final patient cohort was 59.4 years. There was an equal split of 12 men and 12 women. The mean pre-injection, rate-corrected QT interval, corrected using Bazett's formula, was 395 msec. The mean post-injection, rate-corrected QT interval, corrected using Bazett's formula, was 396 msec. The corrections using Fridericia's formula were 384 and 381 msec, respectively. There was no statistically significant change in Bazett-corrected QT interval (QTcB) when pre-injection and post-injection values were directly compared. Discussion The results of the present investigation support the conclusion that gadolinium-based MRI contrast agents do not commonly affect rate-corrected QT interval in routine clinical use. While the frequency of rate-corrected QT interval prolongation might be overstated, the severity of adverse events is definitively not. A role for concomitant rate-corrected QT interval-prolonging drugs or unidentified rare factors such as genetic predisposition cannot be ruled out. The limitations of this study include its relatively small size and the implementation of a single- lead electrocardiogram to measure rate-corrected QT interval. Conclusion The present investigation revealed that significant rate-corrected QT interval prolongation, while previously reported in as many as 55% of patients after gadolinium-based MRI contrast agent injection, is not a common occurrence in the routine clinical setting.