Capital Health

Introduction: Diuretics are an essential component of decompensated heart failure management. Yet, some patients develop diuretic resistance. Defined as inadequate response to escalating dosage of diuretics. Management includes increasing diuretic dosage, combination diuretic therapy and ultrafiltration. A less recognized approach is Hyperdiuresis, where loop diuretics are combined with hypertonic saline to enhance natriuresis and overcome diuretic resistance. We present a case of diuretic resistant heart failure responding to Hyperdiuresis. Description: A 76-year-old male with a history of congestive heart failure presented with respiratory failure secondary to pneumonia and pulmonary congestion requiring intubation. Chest Xray showed pulmonary infiltrates and congestion. Despite completing antibiotics and receiving Bumex 2mg IV twice daily for congestion, patient failed weaning trials due to tachypnea and continued need for pressure support. Chest X-ray and CT showed persistent pulmonary congestion, BNP was 30,000 and urine output was ~1L with an intake of 2.7L. Bumex dose was increased to 2 mg three times daily, and metolazone 5 mg was added. Urine output improved to 2L. However, pulmonary congestion persisted. Considering serum sodium of 148 and Creatinine Clearance of 60 mL/min2, decision was made to pursue Hyperdiuresis. Patient received 40 mg IV Lasix and 150 ml of 3% saline. Urine output increased to 5L over 24 hours. Patient was then resumed on Bumex 2 mg IV twice daily with an output of 3 liters. Patient was liberated from mechanical ventilation 2 days after Hyperdiuresis. Discussion: Diuretic resistance poses a challenge in heart failure management. When increasing dosages of diuretics or combination therapy fail, interventions as ultrafiltration are often considered. Proposed pathophysiology of diuretic resistance includes renal hypoperfusion, neurohormonal activation and decreased sodium delivery to the distal nephron. The mechanism of Hyperdiuresis includes complementary effects on sodium reabsorption and renal blood flow, with hypertonic saline causing intravascular volume expansion, increasing sodium and chloride delivery to macula dense, inhibiting RAAS system and Lasix increasing renal blood flow, sodium and chloride delivery to macula dense, achieving both diuresis and natriuresis.

Background: Septicemia often results in cardiovascular collapse and cardiac arrest (ICD-10 I46); however, national mortality trends within this population are not yet thoroughly analyzed. Hypothesis: We postulated that the age-adjusted mortality rates (AAMR) for cardiac arrest in adults aged 25 years and older with septicemia have significantly altered from 1999 to 2024 and that disparities are present based on demographic and geographic factors . Methods: CDC WONDER multiple cause-of-death data (1999–2024) were analyzed for U.S. decedents aged ≥25 years with both ICD-10 A41 and I46 codes. Total deaths and proportions by place of death (medical facility, home, nursing home, hospice, other) were tabulated. Annual AAMRs per 100,000 population were calculated. Joinpoint regression estimated average annual percent change (AAPC) in AAMR. Analyses were stratified by sex, race/ethnicity, U.S. Census region, and urban versus rural residence. Results: A total of 669,989 fatalities were recorded among adults aged ≥25 years due to septicemia and cardiac arrest (330,729 men; 339,260 women). The overall AAMR remained stable from 1999 to 2018, increased sharply from 2018 to 2021 (AAPC +7.2%, p < 0.001), and subsequently declined from 2021 to 2024 (AAPC –8.4%, p < 0.001). Men consistently exhibited higher rates than women, peaking at 17.2 per 100,000 compared to 12.4. When analyzed by race and ethnicity, non-Hispanic Black adults had the highest AAMR at 21.8, followed by Hispanic at 17.0. Hispanic adults experienced the steepest increase from 2018 to 2021 (AAPC +10.8%, p < 0.05) as well as the most significant decline thereafter (AAPC –11.0%, p < 0.05). Regionally, the Northeast exhibited the highest average AAMR at 16.3, whereas the Midwest reported the lowest average AAMR of 5.7. Urban areas surpassed rural areas in mortality rates (2020: 13.5 vs. 11.9). State AAMRs varied significantly, ranging from 27.7 in Nevada to 2.0 in Minnesota/Wisconsin. Most deaths occurred in medical facilities (90.2%), followed by nursing homes (5.4%). Conclusions: Cardiac arrest mortality in adults with septicemia was flat until 2018, surged during 2018–2021, then declined through 2024. Persistent disparities by sex, race/ethnicity, region, and urbanization highlight the need for targeted clinical and public health interventions to prevent and manage sepsis-related cardiac arrest during infectious disease surges.

Abstract Background Congenital diaphragmatic hernia (CDH) is a life-threatening neonatal condition, and concurrent severe pulmonary arterial hypertension (PAH) is its leading cause of death. Objective To explore the perioperative efficacy of treprostinil in neonates with CDH and severe PAH. Methods This was a single-center retrospective observational study. Clinical data of 67 neonates with CDH and severe PAH were collected. All neonates received immediate endotracheal intubation, high-frequency oscillatory ventilation (HFOV), inhaled nitric oxide (iNO), and continuous intravenous treprostinil after birth. PAH severity was evaluated via preductal-postductal oxygen saturation (SiO₂) difference and echocardiographic parameters. Results Among the 67 neonates (40 males, 27 females; 49 left-sided CDH, 18 right-sided CDH), 24 hours after treprostinil treatment: peak tricuspid regurgitation velocity (TRV), tricuspid regurgitation pressure (TVP), preductal-postductal SiO₂ difference (△SiO₂), patent ductus arteriosus (PDA) diameter, and patent foramen ovale (PFO) diameter all decreased significantly (all p < 0.001), with reduced right-to-left shunting. Fifty neonates survived surgery, and their key indicators (△SiO₂, PDA, PFO, TRV, TVP) showed a downward trend within 2 weeks postoperatively. Seven neonates died within 4 days postoperatively due to refractory severe PAH and multiple organ dysfunction. Conclusion Early treprostinil combined with HFOV + iNO effectively reduces pulmonary artery pressure, improves right-to-left shunting, creates favorable conditions for CDH repair and postoperative recovery, and is well-tolerated in neonates with CDH and severe PAH.

BackgroundSevere anoxic brain injury after cardiac arrest can produce a clinical picture suggestive of brain death (BD). However, when ancillary testing, such as radionuclide cerebral perfusion scans (RCPS), shows preserved cerebral perfusion, the diagnosis of brain death cannot be confirmed, complicating end-of-life decision-making.Case summaryWe present a case of a post-cardiac arrest patient with profound neurological injury and absent brainstem reflexes. Although the clinical findings resembled brain death, two RCPS showed preserved cerebral perfusion, ruling out a formal brain death diagnosis. As a result, withdrawal of life-sustaining therapies was not permitted under existing protocols, despite a poor prognosis.

Tumor necrosis factor (TNF) inhibitors have significantly improved outcomes for patients with rheumatoid arthritis (RA). However, these biologic agents can lead to rare but serious adverse events, including drug-induced vasculitis. We report a rare case of anti-TNF-induced medium-vessel vasculitis in a 33-year-old female with seronegative RA and a complex medical history. After inadequate responses and adverse effects from previous treatment, the patient was switched to anti-TNF certolizumab pegol. Shortly after initiation, she developed painful, erythematous, and pruritic rashes on her hands and arms. A skin biopsy confirmed medium-vessel vasculitis. The condition improved following the discontinuation of certolizumab and initiation of immunosuppressive therapy with corticosteroids. This case underscores the importance of vigilance for dermatologic adverse effects in patients receiving TNF inhibitors. Vasculitis should be considered as a differential diagnosis when new skin lesions appear during biologic therapy, and management should be initiated accordingly.

The MELD score assesses liver disease severity and guides liver allocation in the United States. This study aims to address the knowledge gap regarding potential disparities in the performance of MELD-Na and MELD 3.0 scores across races and ethnicities. A retrospective cohort study of Asian, White, African American, and Hispanic patients with cirrhosis from MIMIC-IV (Beth Israel Deaconess Medical Center) and Emory University databases. The performance of the MELD scores in predicting a composite outcome of death or liver transplant (LT) during the hospital stay or within 90days was analyzed using AUROC for discrimination, and calibration curves for calibration. A total of 4,306 patients with cirrhosis from MIMIC-IV and 5801 patients from Emory were included. Across both datasets, no significant differences were found in the discriminative ability of both scores to predict in-hospital death or LT across races and ethnicities (p > 0.05). A small group of Asian patients influenced score performance differences at 90days in MIMIC-IV. Calibration plots showed both scores tend to overpredict outcomes at higher values, particularly MELD-Na in MIMIC-IV among African Americans. Both scores demonstrated consistent discriminative ability across major ethnic/racial groups. Both scores predicted outcomes better in Emory, a high-volume LT center, than in MIMIC-IV, suggesting site-specific differences and the Emory cohort's closer resemblance to populations used for MELD derivation. These findings suggest disparities in cirrhosis care may relate to socioeconomic factors rather than score performance.

BackgroundThe New York City (NYC) Pregnant Workers Fairness Act (PWFA) went into effect in January 2014 to provide greater flexibility for pregnant workers’ accommodations, yet no studies to date have evaluated its effectiveness and utilization. We examined factors associated with pregnant workers’ PWFA awareness, understanding of PWFA, and receipt of accommodations in a lower socioeconomic status population in NYC.MethodsParticipants included 481 pregnant workers who attended prenatal visits at Mount Sinai Hospital Obstetrics and Gynecology Clinic in NYC in 2017. Detailed demographic and occupational data were collected via in-person interviews using a pregnancy and work survey. Information on participants’ PWFA awareness, knowledge of PWFA-eligible accommodations, and accommodations received was also obtained. Multivariable-adjusted logistic regressions were used to identify the factors influencing PWFA awareness, knowledge of PWFA-eligible accommodations, and accommodations received among six common examples.ResultsOnly 14% of participants had ever heard of NYC PWFA legislation. Lower educational level (≤ 12th grade) (Adjusted Odds Ratio [aOR] = 0.54, 95% Confidence Interval [CI] = 0.30–0.98) and being unsure of workplace maternity leave policy (aOR=0.39, 95% CI=0.18-0.87) were associated with lack of PWFA awareness. Regardless of PWFA awareness, no maternity leave policy (aOR = 0.15, 95% CI = 0.04–0.48 vs. paid policy) and being unsure of maternity leave policy (aOR = 0.19, 95% CI = 0.06–0.59 vs. paid policy) were associated with no knowledge of any PWFA-eligible accommodations. Regardless of their PWFA awareness, women working for ≤ 5 years (aOR=0.42, 95% CI=0.22-0.83), non-U.S. born (aOR=0.57, 95% CI=0.36-0.90), and high-risk pregnancy clinic patients (aOR=0.59, 95% CI=0.38-0.93) all had lower odds of receiving PWFA-eligible accommodations, such as adjustment to lighter duty, compared to their counterparts.ConclusionsLower educational level, lack of paid workplace maternity leave policy, shorter job tenure, and non-U.S. born were associated with decreased PWFA awareness and/or accommodations received. As more women continue to work during pregnancy, interventions promoting PWFA awareness and utilization are paramount for protecting the maternal and child health of these identified vulnerable groups, especially given that final regulations for a national PWFA recently went into effect across the United States in June 2024.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12889-025-23404-w.

In recent years, the population suffering from alopecia in China has been increasing, which severely affects the daily life and mental health of individuals, making it one of the diseases that cannot be ignored. The occurrence of alopecia is associated with various factors, including genetic predisposition, induction by other diseases or medications, and environmental influences. Current research on the specific etiology of alopecia is not comprehensive, which hinders the diagnosis and treatment of various types of alopecia and the inhibition of hair loss from its roots or progression. This article summarizes several types of alopecia with high incidence rates, such as androgenetic alopecia, alopecia areata, frontal fibrosing alopecia, and seborrheic dermatitis, aiming to elucidate the specific causes of different types of alopecia and to organize the relationships between various forms of alopecia. This work lays a solid foundation for the diagnosis and treatment of alopecia by considering potential common etiologies and proposing three biological indicators for triggering alopecia: hormones, microorganisms, and the "common pathway" – immune dysregulation.