VA Southern Nevada Healthcare System

Abstract Background ST-elevation myocardial infarction (STEMI) remains a major cause of mortality in resource-limited countries. Initiation of appropriate therapy and timely reperfusion are often delayed due to a lack of ECG interpretation expertise, limited specialist availability, and geographic barriers, leading to a five-fold increase in mortality. Additional challenges include the absence of an organized STEMI care system, financial constraints, and fragmented referral pathways. Cardiovascular diseases impose a significant economic burden, with costs in low- and middle-income countries (LMICs) projected to reach $3.76 trillion by 2025. Digital health solutions, particularly telemedicine-driven ECG interpretation and triage systems, offer a promising approach to reducing diagnostic delays and optimizing referral strategies. However, their success depends on real-time specialist involvement to ensure adherence to guideline-directed care. Using a Triage-Treat-Transfer (T3) approach, the system could enable early STEMI and high-risk Acute Coronary Syndrome (ACS) recognition through rapid ECG interpretation, point-of-care ultrasound, and troponin assays. Purpose This study evaluated the feasibility of a digital platform in improving STEMI and high-risk ACS management by reducing referral delays and enhancing adherence to guideline-directed medical therapy. Methods The platform was deployed across community clinics and mobile heart camps, enabling real-time expert consultation for suspected STEMI cases. Local physicians transmitted ECGs securely for automated STEMI detection and cardiologist validation. Patients were triaged based on clinical risk and ECG findings, guiding decisions on urgent reperfusion therapy, a pharmaco-invasive strategy when percutaneous coronary intervention (PCI) was unavailable, or high-risk monitoring. High-risk patients were prioritized for transfer to PCI-capable centers. Results The digital platform significantly enhanced STEMI and high-risk ACS care delivery, streamlining diagnosis and treatment. A total of 211 patients were evaluated for suspected ACS, with 51 confirmed cases, all received guideline-directed therapy. Of the 12 transferred, 8 underwent PCI, 1 required coronary artery bypass surgery, and 3 continued on optimal medical therapy post-angiography. Interim results show improved STEMI recognition, structured triage, and faster intervention, reducing unnecessary admissions and transfers. Conclusions A digital platform–enhanced acute cardiac care model, with real-time cardiologist guidance, structured triage, and expedited transfers, is a scalable and cost-effective strategy for improving STEMI and high-risk ACS outcomes in resource-limited settings. By integrating real-time ECG interpretation and expert decision support, this model may optimize early reperfusion, reduce mortality, and lower healthcare costs. Future trials and broader network integration could enhance its impact.

Abstract Intro: The differential for a nodule should be broad and extensive. Differentials often include malignancy, benign disease, infectious causes, immune-mediated diseases, congenital, and more. A rare, but often overlooked possibility is vascular disorders. We present a case of a pulmonary artery aneurysm (PAA) that was referred for tissue sampling. Case Report: We present a 64-year-old male who was referred to pulmonary clinic for consideration of biopsy for a 2.1cm nodule. The nodule was incidentally found on computed tomography (CT) chest while undergoing work up for cough (Figure 1a & 1b). The radiologist reported the nodule as a 2.1cm cystic lesion in the right middle lobe with a differential to include bronchogenic cyst, infectious cause, benign, or malignant neoplasm. Upon further review of the initial CT Chest, we noted that the nodule had smooth margins and what appeared to be a feeding vessel. Thus, raising suspicion for arterial-venous malformation or PAA. CT angiography chest was performed, revealing diffuse bright enhancement of the nodule with contrast and a sizable feeding artery supplying the nodule (Figure 1c & 1d). Subsequently, cardiothoracic surgery was consulted along with our interventional radiology team to discuss further treatment options for our patient. Discussion: Pulmonary artery aneurysms are relatively rare with prevalence rates reported to be between 1 in 15,000 to 1 in 100,000. A true aneurysm includes dilation of all three layers of the artery, including the tunica intima, tunica media, and tunica adventitia. Congenital diseases such as Ehlers-Danlos, Marfan's, or heart defects are often associated with PAA. Acquired conditions associated with PAA include infectious causes, vasculitis, pulmonary artery hypertension, trauma, and iatrogenic causes. Diagnosis of PAA is typically made with computed tomography angiography, but catheter-directed angiography is considered the gold-standard for confirmation. Additionally, endovascular treatments can be performed at the same time. Treatment options for PAA include either surgical resection versus endovascular therapy options such as coil embolization, vascular plugs, or stent placement. Conclusion: This case highlights the importance of thorough investigation and consideration of other differentials prior to jumping to biopsy. As simple as it would be to just biopsy every nodule that we are referred, this could have led to significant bleeding and complications if we had not further investigated our patient's nodule. We hope that this case helps emphasize the importance of carefully reviewing imaging and thoroughly considering the differential for each nodule prior to taking action.

Aortic atheroma (AA) is defined by the development of atherosclerotic plaques within the aorta wall and is associated with unfavorable cardiovascular outcomes such as cryptogenic stroke, systemic embolism, and other major adverse cardiac events (MACE). The clinical significance of AA is discussed in this review along with its relationship to cardiovascular outcomes. The purpose of this review article is to present a thorough summary of the current state of knowledge on AA, including its pathogenesis, classifications and grading systems, clinical implications, methods for diagnosis and imaging, therapeutic modalities and treatments, and lastly pertinent complications. There are various methods of AA classification or grading, which entail scoring extent of disease via plaque thickness, severity of atherosclerosis, or by the presence of mobile components or ulcerations. The implications of AA as a systemic atherosclerotic process on the development of coronary artery disease and MACE include, but are not limited to, vascular diseases such as strokes or peripheral arterial disease. The diagnostic approaches include multiple invasive and noninvasive imaging modalities. The treatment strategies range from prevention to medical therapy to invasive surgical interventions. The present evaluation highlights the significance of sustained investigation and advancement in the domain of aortic atherosclerosis to augment precision in diagnosis and effectiveness of treatment.

Objective To investigate the clinical characteristics of older adults undergoing inpatient rehabilitation after hip fractures and to find factors associated with discharge location. Design Cross-sectional analysis. Setting Inpatient rehabilitation units in the United States. Participants ≥65 years old patients with hip fractures. Intervention Inpatient rehabilitation with ≥1 hour of physical and occupational therapy per weekday. Main measures Home versus nonhome discharges. Results 79% of 7439 (n = 5,908) patients were discharged to home after a median stay of 14 days, while 13% (n = 990) were discharged to skilled nursing facilities. 6% (n = 423) were transferred to acute care during rehabilitation stay. Functional mobility levels for bed-to-chair transfer and sit-to-stand at admission were significantly lower in patients discharged to facilities than in patients discharged to home. Older age (OR 0.97 per 1 year, CI 0.96–0.98); comorbidities of dementia (OR 0.68, CI 0.56–0.83) and cerebrovascular disease (OR 0.53, CI 0.36–0.78); and the use of opioid analgesics (OR 0.71, CI 0.56–0.91), antipsychotics (OR 0.73, CI 0.58–0.92), and anticonvulsants (OR 0.81, CI 0.67–0.96), and lower initial functional levels in bed-to-chair transfers (OR 0.08, CI 0.05–0.12) for dependent level; OR 0.16, CI 0.10–0.25 for level requiring maximal assistance; OR 0.38, CI 0.24–0.60 for level requiring partial, moderate assistance), were associated with a decreased likelihood of discharge to home after inpatient rehabilitation. Conclusion Older adults with dementia, cerebrovascular disorders, and lower bed-to-chair transfer mobility levels at admission after hip fractures may benefit from additional targeted rehabilitation to improve the chances of a successful community discharge.

Acute retinal necrosis is a rare, sight-threatening condition typically found in immunocompromised patients and is most commonly caused by varicella zoster virus. Due to the poor prognosis and rapid progression of the disease course, prompt antiviral management is paramount. A case report of acute retinal necrosis in a patient with herpes virus infection following a cervical epidural corticosteroid injection. Extensive laboratory work and frequent follow-ups are necessary for management. This case report outlines the clinical signs of acute retinal necrosis and discusses the appropriate referrals and treatment needed to improve prognosis. A 63-year-old man presented to our eye clinic with symptoms of pain and light sensitivity. Examination revealed anterior uveitis, vitritis, optic disc edema, macular edema, vasculitis, and retinitis of the left eye. The serum antibody test results showed abnormal ranges for varicella zoster virus and herpes simplex virus type 1, and the patient was diagnosed with acute retinal necrosis. Treatment prescribed by a retina specialist included oral valacyclovir and later oral prednisolone, for which the patient responded well before developing the common complication of retinal detachment. The progressive nature of acute retinal necrosis is usually debilitating to vision, even when managed properly. Because prognosis is often poor, it is important to make proper diagnoses combined with a complete review of the patient's medical history and immune status to prevent further vision loss.

Though overall death from opioid overdose are increasing in the United States, the death rate in some states and population groups is stabilizing or even decreasing. Several states have enacted a Naloxone Accessibility Laws to increase naloxone availability as an opioid antidote. The extent to which these laws permit layperson distribution and possession varies. The aim of this study is to investigate differences in provisions of Naloxone Accessibility Laws by states mainly in the Northeast and West regions, and the impact of naloxone availability on the rates of drug overdose deaths.This cross-sectional study was based on the National Vital Statistics System multiple cause-of-death mortality files. The average changes in drug overdose death rates between 2013 and 2017 in relevant states of the Northeast and West regions were compared according to availability of naloxone to laypersons.Seven states in the Northeast region and 10 states in the Western region allowed layperson distribution of naloxone. Layperson possession of naloxone was allowed in 3 states each in the Northeast and the Western regions. The average drug overdose death rates increased in many states in the both regions regardless of legalization of layperson naloxone distribution. The average death rates of 3 states that legalized layperson possession in the West region decreased (-0.33 per 100,000 person); however, in states in the West region that did not allow layperson possession and states in the Northeast region regardless of layperson possession increased between 2013 and 2017.The provision to legalize layperson possession of naloxone was associated with decreased average opioid overdose death rates in 3 states of the West region.

Background Data on the role of minocycline intravenous (IV) in the treatment of serious gram-negative infections under real-world conditions are sparse. This study sought to provide evidence of real-world practices, including outcomes and safety. Methods A multicenter observational study was conducted of 71 consecutive adult inpatients enrolled at 6 geographically diverse US hospitals between May 2015 and February 2018 who were treated with minocycline IV for gram-negative infections for at least 48 hours as monotherapy or combination therapy. Results Infections included pneumonia (51%) and bacteremia (25%). The most prevalent gram-negative pathogens included Stenotrophomonas maltophilia (52%), Acinetobacter baumannii (30%), and Burkholderia complex (10%). In vitro susceptibility to minocycline was 100% for S. maltophilia. Clinical plus microbiologic response was observed in 80% of evaluable patients. Treatment of 29 evaluable patient infections due to S. maltophilia resulted in a clinical response rate of 79% and a microbiologic response rate of 72%. All patients with bacteremia due to S. maltophilia responded to minocycline IV. There were 17 (24%) in-hospital deaths of which 8 responded to minocycline. Minocycline was well tolerated. Conclusions Minocycline demonstrated that high in vitro susceptibility against problematic gram-negative pathogens and administered as an IV formulation was associated with good clinical and microbiologic outcomes alone or in combination in a seriously ill patient population.