Metropolitan Hospital Center

We present a case of acute fatty liver of pregnancy (AFLP) with significant coagulopathy despite no bleeding symptoms, which was managed with spinal anesthesia without adverse events. This phenomenon may not be attributable to coincidence alone. Upon reviewing the literature, standard coagulation tests fail to account for the simultaneous reduction in pro- and anticoagulant factors, leading to a misleading impression of coagulopathy and often overestimating the risk of bleeding. Thus, it is advised that coagulopathy tests associated with liver disease should not be used solely to dictate anesthesia decisions; a thorough history obtained from the patient, family, or medical records may be more informative than abnormal coagulation tests.

In 2017, the Icahn School of Medicine at Mount Sinai (ISMMS) conducted a survey in Jarabacoa, Dominican Republic that revealed a high rate of mental health disorders. To address the shortage of mental health services, ISMMS collaborated with the Instituto Terapéutico y Psicológico para la Familia (INTEP) to provide training sessions to local primary care providers (PCPs) and psychologists in psychopharmacotherapy and cognitive behavioral therapy, respectively. The aim of this study was to evaluate the impact of the training on providers' confidence about and attitudes towards providing mental health care.Trainees were administered a survey pre, immediate post, and three-months following training sessions to assess their comfort in diagnosing and treating psychiatric conditions. Post-training interviews were conducted to assess the impact of the training.A total of 78 PCPs participated in the initial training session. Chi-squared and Fisher Exact analyses conducted on PCPs' responses to individual survey items revealed significant increases in the proportion of respondents agreeing to feeling comfortable managing targeted psychiatric conditions after training as compared to before training. Interviews with 28 PCPs supported these results. Five of the 12 trained psychologists were interviewed and endorsed success in integrating the training into their practice, noting improved patient outcomes.Both PCPs and psychologists described an enhanced sense of confidence in managing patients with mental health disorders after training, emphasizing the positive impact that psychiatric training initiatives in primary care settings have in promoting sustainable mental healthcare systems in low-resource settings.

We present the case of a 72-year-old man with idiopathic pulmonary fibrosis (IPF) who presented with stiffness and pelvic girdle pain and was initially treated for polymyalgia rheumatica (PMR). Despite transient improvement on steroids, persistent symptoms and atypical MRI findings led to muscle and renal biopsies, revealing necrotizing vasculitis and pauci-immune glomerulonephritis. Positive myeloperoxidase and perinuclear antineutrophil cytoplasmic antibody titers confirmed the diagnosis of antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The patient's course was complicated by diffuse alveolar hemorrhage requiring intubation, which improved with pulse steroids and cyclophosphamide. The patient stabilized on methotrexate and methylprednisolone. This case highlights the complexity of diagnosing AAV, especially with overlapping PMR-like symptoms and underlying interstitial lung disease.

Transcatheter aortic valve replacement is a key intervention for high-risk patients with severe aortic stenosis. Myval, a newer transcatheter heart valve (THV), shows promise, but a comprehensive comparison with other THVs is lacking. This study evaluates the safety and efficacy of Myval compared with contemporary THVs. A systematic review and meta-analysis of six studies involving 2335 patients was performed. Primary outcomes included all-cause mortality, cardiovascular mortality, new permanent pacemaker implantation (PPI), device success, early safety, acute kidney injury, stroke, vascular complications, and valve regurgitation. Myval was associated with significantly lower rates of new PPI (RR, 0.62; 95% CI 0.45-0.86; P = .004), higher rates of device success (RR, 1.08; 95% CI 1.01-1.16; P = .02), and early safety (RR, 1.15;95% CI 1.05-1.27;P = .003) compared with contemporary THVs. No significant differences were observed in all-cause mortality, cardiovascular mortality, acute kidney injury, stroke, vascular complications, and valve regurgitation. Myval may offer better short-term outcomes in terms of new PPI, device success, and early safety compared with contemporary THVs. Larger, prospective studies with longer follow-ups are needed to confirm these findings.

Abstract Rationale: The impact of bronchiectasis on the severity of COVID-19 infection has been contradictory, with some studies reporting that bronchiectasis is a risk factor for severe COVID-19 infection, whereas others have found no relationship between bronchiectasis and the severity of COVID-19 infection. This National Inpatient Sample (NIS) study aimed to determine the impact of bronchiectasis on the severity of COVID-19 infection. Methods: We identified patients hospitalized with COVID-19 infection and a history of bronchiectasis from the 2020-2021 NIS database. STATA/MP 17.0 software was used for statistical analysis. Multivariate logistic regression analysis was performed. Results: There were 818,011 patients hospitalized with COVID-19 infection and 31,439 patients hospitalized with a history of bronchiectasis. The patients with COVID-19 infection were stratified based on their bronchiectasis status. There were 815,213 COVID-19 patients without bronchiectasis and 2,798 COVID-19 patients with bronchiectasis. The mean age was 61.6 years in patients with COVID-19 infection without bronchiectasis compared to 69.7 years for those with bronchiectasis. Caucasians constituted the largest ethnic group, and patients with Medicaid insurance constituted the largest insurance group in both categories. Patients in the lowest income quartile constituted the largest group among the COVID-19 patients without bronchiectasis compared to the second highest income quartile for those with bronchiectasis. The length of hospital stay among COVID-19 patients without bronchiectasis was 8.2 days; for those with bronchiectasis, it was 16.7 days, with a P value of <0.001. The mortality rate was 13.0 % among COVID-19 patients without bronchiectasis; for those with bronchiectasis, it was 21.5 %, with a P value of <0.001. The unadjusted odds ratio (OR) of mortality in COVID-19 patients with bronchiectasis was 1.82. The adjusted OR of mortality, after adjustment for age, sex, race, Charlson comorbid index, national income quartile, and insurance, was 1.37 with a P-value of <0.001, indicating that the mortality rate among COVID-19 patients with bronchiectasis was significantly higher than those without bronchiectasis. The unadjusted OR of invasive ventilation in COVID-19 patients with bronchiectasis was 2.12, and the adjusted OR was 1.89, with a P-value of <0.001, indicating that the need for invasive ventilation among COVID-19 patients with bronchiectasis was significantly higher than those without bronchiectasis. Conclusion: Our analysis of the NIS database suggests that bronchiectasis was a major risk factor for severe COVID-19 infection. Patients with COVID-19 infection with bronchiectasis had longer lengths of stay, higher need for invasive ventilation, and higher mortality rate than those without bronchiectasis.