Crozer-Keystone Health System

This letter, signed by over 50 academic chairs of emergency medicine, urges the ACGME to reconsider a proposed mandate requiring all emergency medicine residency programs to adopt a four-year training model. The authors argue that current three-year programs are supported by data demonstrating equivalent educational and clinical outcomes compared to four-year formats. They criticize the flawed survey methodology underpinning the proposal, note the loss of milestone-based training flexibility, and highlight the lack of added scholarly or clinical value in the fourth year. The letter also outlines negative consequences for fellowship participation, workforce development, trainee debt, and diversity. The signatories advocate for maintaining the current flexible training model to preserve excellence, equity, and innovation in emergency medicine education.

IntroductionTracheal schwannoma is a rare benign neurogenic tumor originating from Schwann cells of the peripheral nerve sheath and accounts for less than 0.2% of all primary tracheal tumors. It commonly presents with nonspecific respiratory symptoms such as wheezing, dyspnea, or cough, often mimicking more common conditions like asthma. Syncope, a clinical manifestation not previously reported, is a rare presentation of tracheal schwannoma.Case presentationThe authors report a case of a middle-aged man with unexplained syncope, accompanied by a history of chronic cough and shortness of breath. Contrast-enhanced computed tomography (CT) identified a tracheal mass as the underlying cause of his symptoms. Histopathological analysis confirmed the diagnosis of tracheal schwannoma. The patient underwent tracheal resection and reconstruction, resulting in complete tumor removal, with no recurrence observed during follow-up.DiscussionTracheal schwannomas are rare benign tumors, typically presenting with nonspecific respiratory symptoms. This case describes an unusual presentation of syncope, likely due to airway obstruction and vagal compression. The diagnosis was confirmed by CT and histopathology, with surgical resection achieving complete tumor removal and symptom resolution. This highlights the importance of considering rare airway tumors in patients with syncope and respiratory symptoms, underscoring the need for timely diagnosis and intervention.ConclusionTo the best of our knowledge, this is the first reported case of tracheal schwannoma presenting with syncope. It highlights the importance of considering rare airway tumors in patients with unexplained syncope and chronic respiratory symptoms and reinforces the value of timely imaging and surgical intervention for optimal outcomes.

Dercum’s disease, alternatively known as adiposis dolorosa, is a rare condition characterized by multiple lipomas causing palpable skin defects associated with pain and tenderness. The prevalence and etiology of this disease remain unknown despite its debilitating impact on affected individuals. Current literature describes individuals with Dercum’s disease to be predominantly older, obese females. This report details a unique case involving a 29-year-old male who, between 2022 and 2024, underwent surgical excision of over 80 lipomas on five separate occasions. Prior to surgery, the nodules were assessed in an outpatient setting to determine their location, confirm skin changes, and evaluate their debilitating effects on the patient’s quality of life, thereby justifying the surgical approach. Histology proved all the lesions to be benign lipomas. Subsequent to the initial lipoma excisions, new lesions recurred on the torso and extremities. Differential diagnoses were considered such as neurofibromatosis, multiple familial lipomatosis, Madelung disease, Bannayan-Zonana syndrome, and Cowden syndrome were ruled out by family history, location of lesions, and histology. Although Dercum’s disease has been recognized since the late 1800s, advances in understanding and treating the condition have been limited. This case aims to shed light on the experience of a young patient with multiple recrudescent lipomas necessitating surgery.

ABSTRACT Introduction Diabetic nephropathy is a significant concern for patients with cardiovascular disease. Dapagliflozin, an SGLT2 inhibitor, has emerged as a promising therapeutic approach to managing diabetic nephropathy and reducing cardiovascular risk. Areas covered This review encompasses the research and literature search methodology, including clinical trials and real-world evidence, assessing the safety profile of Dapagliflozin in patients with diabetic nephropathy and cardiovascular risk. Expert opinion Dapagliflozin, an SGLT2 inhibitor, has redefined patient-centric care by simultaneously improving glycemic control, cardiovascular health, and renal outcomes in individuals with type 2 diabetes, cardiovascular disease, and nephropathy.

Background: Coffee is one of the most widely consumed beverages in the world, and contains caffeine in it. Previous pre clinical studies and meta analysis have shown conflicting results with majority supporting that coffee consumption was associated with lower risk of stroke. Objective: This study aims to investigate the association between coffee consumption and risk of stroke. Methods: We performed a systematic literature search on PubMed, EMBASE, and ClinicalTrials.gov for relevant studies from inspection until August 10th, 2024, without any language restrictions. Risk ratios (RR) and 95% confidence intervals (CI) were pooled using a random-effect model, and a p-value of <0.05 was considered statistically significant. Results: A total of 10 studies with 2,35,969 patients were included. The mean age of the patients was 55.6 years. Pooled analysis showed that people who consumed >4 cup of coffee/day were having higher odds of all stroke (RR, 1.33(95%CI: 1.05-1.67). However, there was no such association between low to moderate (1-3 cup) coffee consumption and stroke risk (RR, 1.24(95%CI: 0.94-1.64). Conclusion: High coffee consumption was associated with higher risk of stroke, however not with low to moderate coffee consumption. It can help individuals who are addicted to more coffee drinking/day to avoid stroke risk.

Carotid‐Cavernous fistulas (CC fistula) are aberrant connections between the carotid arterial system and the cavernous sinus (CS). The result is an abnormal arteriovenous shunt which can have a range of symptomatology based on involvement of neighboring neural and vascular structures within the CS. Clinically, patients can present with Dandy's triad of exophthalmos, bruit and chemosis, but often present insidiously with diplopia/visual disturbance, orbital pain or cranial nerve deficits. While cross‐sectional imaging bears high diagnostic value, cerebral angiography remains the gold‐standard for the characterization of CC fistulas. We describe a case of a Barrow Type‐D indirect CC fistula, treated endovascularly with transfacial venous approach and retrograde coil embolization of the right greater than left CS.

Fever of unknown origin (FUO) presents a diagnostic challenge, particularly in patients with human immunodeficiency virus (HIV) due to their immunocompromised state. We report a case of a 21-year-old male with HIV who presented with persistent fever and was found to have a positive proteinase-3 antibody, raising suspicion of granulomatosis with polyangiitis (GPA). The patient's symptoms, negative infectious workup, and elevated proteinase-3 levels prompted consideration of non-infectious etiologies. Despite the absence of renal involvement, corticosteroid therapy was initiated, leading to the resolution of fever. However, the false positive association of proteinase-3 in HIV patients introduces uncertainty regarding the definitive diagnosis of GPA. A tissue biopsy would have provided further clarity, but it was not performed in this case. Our workup aligns more closely with a diagnosis of GPA, considering the patient's response to treatment and the absence of clinical deterioration. This case highlights the complexity of diagnosing non-infectious causes of FUO in HIV-infected individuals. It emphasizes the need for a multidisciplinary approach involving infectious disease specialists and rheumatologists to ensure accurate diagnosis and appropriate management.

Coronary bifurcation lesions are frequent challenging findings during percutaneous coronary intervention (PCI). Contemporary evidence has explored the potential sex-specific differences in patients undergoing PCI. In the present meta-analysis, we compared clinical outcomes of patients undergoing bifurcation PCI between women and men. Using the random-effects method, we compared the clinical outcomes of patients with a coronary bifurcation lesion following PCI between women and men. The results were reported using relative risk (RR) and 95% confidence interval (CI). Baseline comorbidities and mean age were compared between the 2 studied groups. Four observational studies comprising 30,684 patients (8898 women and 21,786 men) were included in the meta-analysis. Women were significantly older than men with a relatively higher prevalence of baseline comorbidities. After using adjusted data from 2 out of 4 available studies, performing PCI for bifurcation lesions in women was not associated with an increased risk of mortality (RR 1.33, 95% CI, 0.78-2.29), myocardial infarction (RR 1.22, 95% CI, 0.41-3.61), target lesion revascularization (RR 1.06, 95% CI, 0.40-2.81), stent thrombosis (RR 0.99, 95% CI, 0.09-10.52), and stroke (RR 1.19, 95% CI, 0.64-2.22). Women were at higher risk of major bleeding compared to male counterparts (RR 2.23, 95% CI, 1.73-2.89). The present study showed no difference in the risk of adverse clinical outcomes except the risk of bleeding between genders with coronary bifurcation lesions. Future studies with adjustment of age and baseline comorbidities are needed to confirm these findings.