IgG4-related disease (IgG4-RD) is a rare illness with inflammatory and fibrotic changes in affected organs such as pancreas, thyroid, salivary or lacrimal glands, and retroperitoneal space; rarely other organs may be involved. IgG4-related breast disease (IgG4-BD) is very rare and generally presents as a lump or mastitis. IgG4-BD as a presenting feature of IgG4-RD is extremely rare. Hence, this paper reviews the known (n=48) IgG-BD cases reported in the literature to date. The majority of cases were diagnosed on routine mammography or during assessment for other clinically significant features. The absence of a lump border, and especially the absence of calcifications on ultrasonography, mammography, or computed tomography, is typical for IgG4-BD. Characteristic IgG4-BD pathological findings were dense lymphoplasmacytic infiltration with stromal fibrosis, and more than 10% IgG4+ plasma cells/high-power field (HPF); the mean percentage of IgG4+/IgG+ plasma cells was 54.2%, and only one-third of the patients had all “classical” signs of IgG4-BD including storiform fibrosis and obliterative phlebitis. Most of the cases had a benign course and responded to surgical excision with or without steroid therapy.
Objectives: To assess the impact of different types of anemia and of concomitant non-cardiovascular chronic illnesses on outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and baseline anemia admitted to the Intensive Cardiac Care Unit.
Methods: Based on the mean corpuscular volume, anemia was stratified into: microcytic (<80 fL), normocytic (≥80, <96 fL), and macrocytic (≥96 fL). Data on concomitant chronic non-cardiovascular illnesses including malignancies were carefully collected. Endpoints included in-hospital bleeding as well as all-cause mortality at long-term follow-up.
Results: Of 1,390 patients with STEMI, 294 patients had baseline anemia (21.2%), in whom normocytic, microcytic, and macrocytic anemia was present in 77.2%, 17.0%, and 5.8% patients, respectively. In-hospital bleeding occurred in 25 (8.5%) of the study population without significant differences between the three groups. At a mean follow-up of 5.5±3.5 years, 104 patients (35.4%) had died. Mortality was the highest in patients with macrocytic anemia, followed by patients with normocytic anemia and microcytic anemia (58.8%, 37.0%, and 20.0%, respectively; P=0.009). Chronic non-cardiovascular condition was identified as an independent predictor of both in-hospital bleeding (odds ratio=2.57, P=0.01) and long-term mortality (hazard ratio [HR] 1.54, P=0.019). Performance of coronary angiography within index hospitalization was associated with lower long-term mortality (HR 0.38, P=0.001). Mean corpuscular volume did not predict either in-hospital bleeding or mortality.
Conclusions: Chronic non-cardiovascular illnesses are highly prevalent among patients with STEMI and baseline anemia, and are strongly associated with higher in-hospital bleeding and long-term mortality. Type of anemia is not related to prognosis post-STEMI.
Coronary artery stenting is the treatment of choice for patients requiring coronary angioplasty. We describe the major advancements with this technology. There have been significant developments in the design of stents and adjunctive medical therapies. Newer-generation drug-eluting stents (DES) have almost negligible restenosis rates and, when combined with proper anti-platelet treatment and optimal deployment, a low risk of stent thrombosis. The introduction of newer-generation DES with thinner stent struts, novel durable or biodegradable polymer coatings, and new antiproliferative agents has further improved the safety profile of early-generation DES. In parallel the effectiveness has been kept, with a significant reduction in the risk of target lesion revascularization compared with the early-generation DES. However, to date, the development of completely bioresorbable vascular scaffolds has failed to achieve further clinical benefits and has been associated with increased thrombosis. Newer-generation DES—including both durable polymer as well as biodegradable polymer—have become the standard of care in all patient and lesion subsets, with excellent long-term results.
Cardiopulmonary resuscitation (CPR) is a first-line therapy for sudden cardiac arrest, while extracorporeal membrane oxygenation (ECMO) has traditionally been used as a means of countering circulatory failure. However, new advances dictate that CPR and ECMO could be complementary for support after cardiac arrest. This review details the emerging science, technology, and clinical application that are enabling the new paradigm of these iconic circulatory support modalities in the setting of cardiac arrest.
Coronavirus disease-19 (COVID-19) is a pandemic infectious disease caused by a novel coronavirus. Infection can result in a wide range of clinical outcomes, from an asymptomatic condition to severe bilateral pneumonia and life-threatening conditions. Diagnosis is based on the combination of a history of exposure, clinical presentation, and real-time polymerase chain reaction (RT-PCR) assays. In endemic areas, imaging tests including computed tomography (CT), chest X-ray (CXR), and ultrasound (US) have been included in the diagnostic workup. Multiple and peripheral areas of parenchymal injury is the hallmark of COVID-19 lung infection, seen as ground-glass opacification and consolidation on CT, as hazy opacities on CXR, and as multiple B-lines and subpleural consolidations on US. Of these modalities, CT has the best sensitivity and specificity, while CXR has moderate sensitivity and unknown specificity. Both CT and CXR involve ionizing radiation, increase the risk of cross-infection, and require a long sterilization time. Ultrasound is the only modality used by clinicians. Early reports have shown promising results, comparable to CT. With high availability, the lowest risk of cross-infection, and a rapid sterilization process, US may potentially become the primary imaging tool for COVID-19 pulmonary injury. Lung US training programs are needed to provide clinicians with the ability to better implement this technique.
Diarrhea, an illness of both the developed and developing world, involves the burdensome characteristics of frequent bowel movements, loose stools, and abdominal discomfort. Diarrhea is a long-standing challenge in palliative care and can have a myriad of causes, making symptomatic treatment pertinent when illness evaluation is ongoing, when there is no definitive treatment approach, or when effective treatment cannot be attained. Symptomatic therapy is a common approach in palliative care settings. Bismuth is a suitable agent for symptomatic therapy and can be effectively employed for management of chronic diarrhea. The objective of this narrative review is to examine the role of bismuth in management of diarrheal symptoms. To explore this, PubMed (including Medline) and Embase were used to search the existing literature on bismuth and diarrhea published from 1980 to 2019. It was found that bismuth has potential utility for diarrheal relief in multiple settings, including microscopic colitis, traveler’s diarrhea, gastrointestinal infection, cancer, and chemotherapy. It also has great potential for use in palliative care patients, due to its minimal side effects. Overall, the antisecretory, anti-inflammatory, and antibacterial properties of bismuth make it a suitable therapy for symptomatic treatment of diarrhea. The limited range of adverse side effects makes it an appealing option for patients with numerous comorbidities. Healthcare providers can explore bismuth as an adjunct therapy for diarrhea management in an array of conditions, especially in the palliative care setting.
Introduction: Hydroxychloroquine (HCQ) emerged early in the course of the coronavirus disease 2019 (COVID-19) pandemic as a possible drug with potential therapeutic and prophylactic benefits. It was quickly adopted in China, Europe, and the USA. We systematically reviewed the existing clinical evidence of HCQ use for the prevention and treatment of COVID-19.
Methods: We screened for clinical studies describing HCQ administration to treat or prevent COVID-19 in PubMed. We included randomized controlled trials (RCTs), non-randomized comparative cohorts, and case series studies that had all undergone peer review.
Results: A total of 623 studies were screened; 17 studies evaluating HCQ treatment were included. A total of 13 were observational studies, and 4 were RCTs. In terms of effect on mortality rates, observational studies provided conflicting results. As a whole, RCTs, including one large British RCT that has not yet been published, showed no significant effect of HCQ on mortality rates, clinical cure, and virologic response. The use of HCQ as a post-exposure prophylactic agent was found to be ineffective in one RCT.
Conclusion: There is no evidence supporting HCQ for prophylaxis or treatment of COVID-19. Many observational trials were methodologically flawed. Scientific efforts have been disappointingly fragmented, and well-conducted trials have only recently been completed, more than 7 months and 600,000 deaths into the pandemic.
Anatomical dissection is almost ubiquitous in modern medical education, masking a complex history of its practice. Dissection with the express purpose of understanding human anatomy began more than two millennia ago with Herophilus, but was soon after disavowed in the third century BCE. Historical evidence suggests that this position was based on common beliefs that the body must remain whole after death in order to access the afterlife. Anatomical dissection did not resume for almost 1500 years, and in the interim anatomical knowledge was dominated by (often flawed) reports generated through the comparative dissection of animals. When a growing recognition of the utility of anatomical knowledge in clinical medicine ushered human dissection back into vogue, it recommenced in a limited setting almost exclusively allowing for dissection of the bodies of convicted criminals. Ultimately, the ethical problems that this fostered, as well as the increasing demand from medical education for greater volumes of human dissection, shaped new considerations of the body after death. Presently, body bequeathal programs are a popular way in which individuals offer their bodies to medical education after death, suggesting that the once widespread views of dissection as punishment have largely dissipated.
The world, as a global village, is currently taking part in a real-time public health, medical, socio-cultural, and economic experiment on how best to combat the COVID-19 pandemic. Extraordinary times demand extraordinary measures. Depending on the time from the outbreak, strategies have ranged from minimal intervention to mitigation by quarantine for high-risk groups (elderly with chronic illnesses) to containment and lockdown. Adherence to such restrictions have depended on the individual and national psyche and culture. One can understand and forgive governments for being over-cautious, but not for being ill-prepared. It seems that Singapore after SARS (2003) and South Korea after MERS (2015) learnt from their experiences and have fared relatively well with minimal disruption to daily routines. Coping with the challenge of COVID-19 is an urgent global task. We use the Sociotype ecological framework to analyze different coping responses at three levels: Context (government and leadership, social context, health services, and media); Relationships; and the Individual. We describe the many negative outcomes (e.g. mortality [obviously], unemployment, economic damage, food insecurity, threat to democracy, claustrophobia) and the positive ones (e.g. new, remote teaching, working, and medical routines; social bonding and solidarity; redefining existential values and priorities) of this surreal situation, which is still evolving. We highlight the importance of humor in stress reduction. Regular and reliable communication to the public has to be improved, acknowledging incomplete data, and learning to deal with fake news, misinformation, and conspiracy theories. Excess mortality is the preferred statistic to follow and compare outcomes. When the health risks are over, the economic recovery responses will vary according to the financial state of countries. If world order is to be reshaped, then a massive economic aid plan should be launched by the rich countries—akin to the Marshall plan after the Second World War. It should be led preferably by the USA and China. The results of the tradeoffs between health and economic lockdowns will only become apparent in the months to come. The experiences and lessons learned from this emergency should be used as a rehearsal for the next epi-/pandemic, which will surely take place in the foreseeable future.
During the coronavirus disease 2019 (COVID-19) pandemic, the increasing fear of leaving home and entering hospitals, together with guidelines to the public from Israel’s Ministry of Health recommending the use of telemedicine rather than physical visits to the doctor, led to delayed diagnoses of non-COVID-19-related medical conditions. This research letter presents a cluster of severe medical conditions that were delayed in diagnosis due to postponed presentation to healthcare facilities during the COVID-19 pandemic. Ewing sarcoma, severe hemolytic anemia, endocarditis requiring surgery, and septic hip requiring surgery are some examples of cases we encountered with delayed diagnoses. This led to the appearance of a rather low burden of disease in the pediatric population during the pandemic, and pediatric hospitals and clinics experienced a very low volume of activity. Given the low burden of COVID-19 in children, and the well-defined separation between infected and non-infected areas within the hospitals, we should consider improving the guidelines and messages conveyed to the public regarding the importance of prompt medical assessment for other medical conditions, even during a pandemic, along with reassurance of the safety of entering medical facilities given the strict isolation procedures being observed. Conclusion: Medical associations should reconsider the messages being sent to the public during future outbreaks, and encourage medical assessment.
