Valley Hospital Medical Center

Hypertension remains a leading cause of cardiovascular morbidity and mortality. Although effective antihypertensive therapies are available, sustained blood pressure control remains suboptimal due to inconsistent medication use. Most adherence research is quantitative and offers limited understanding of how individuals interpret lifelong treatment within daily life, particularly in culturally grounded contexts. To explore the lived experiences of Filipino adults taking antihypertensive medication. A qualitative study grounded in Heideggerian interpretive phenomenology was conducted. Ten Filipino adults diagnosed with hypertension were purposively recruited from outpatient clinics in Manila, Philippines. In-depth semi-structured interviews were transcribed verbatim and analyzed using the six-step IPA framework. Analysis revealed six interconnected themes describing how participants interpreted and sustained medication use: (1) Diagnosis as Disruption; (2) Medication as Protection and Responsibility; (3) The Paradox of the Silent Illness; (4) Everyday Barriers to Sustained Treatment; (5) Constructing Routine and Adaptive Self-Management; and (6) Family as Anchor within Cultural Contexts. These themes reflected emotional adjustment, symptom-driven adherence, financial and work-related barriers, adaptive coping strategies, and strong family-centered motivation. Medication-taking was experienced as an ongoing negotiation shaped by bodily cues, daily demands, and relational obligations. Conclusion: Antihypertensive medication use is shaped by relational, cultural, and socioeconomic contexts, underscoring the need for family-inclusive and culturally responsive hypertension care.

Abstract Introduction Partial anomalous pulmonary venous return (PAPVR) is a rare congenital condition that is often underrecognized. It involves abnormal blood flow returning to the right atrium, either directly through abnormal vascular connections or indirectly via a sinus venosus defect or mispositioned septum primum. Here, we present a case of an incidentally discovered partial anomalous pulmonary venous connection. Case report A 90-year-old man with a history of vascular dementia, multiple strokes causing dysphagia and left-hemiparalysis, severe systolic heart failure (ejection fraction <20%), and atrial fibrillation was admitted due to feeding tube misplacement. During hospitalization, he developed acute hypoxic respiratory failure with septic shock from aspiration pneumonia, necessitating a transfer to the medical intensive care unit (MICU). A central venous catheter (CVC) was placed in the left internal jugular vein under ultrasound guidance, with venous wire placement confirmed pre-dilation. The procedure had no complications, and a post-procedure chest X-ray showed the CVC did not cross the midline. Additional methods, including confirmation of venous appearance of blood, assessment of pulsatility, monitoring the central venous pressure waveform, and obtaining a central venous gas, were used to verify venous placement. However, due to suspected malposition, the left CVC was not used, and a new one was placed in the right jugular vein. Vascular surgery was consulted and recommended no intervention, as the line appeared to be correctly positioned in the venous system. A chest CT was advised but the family opted for comfort measures. A previous head and neck CT, which included the chest, revealed the abnormal pulmonary venous connection. Discussion Our case involved PAPVR with an unusual connection where the left pulmonary vein was connected to the left brachiocephalic vein (Image A-F, Image 1). Diagnosing PAPVR as the cause of a malpositioned CVC is challenging using current bedside diagnostic tools. Specialized testing, such as CT scans, MRI, or cardiac catheterization, is often required, but these tests may be difficult to obtain promptly in unstable patients like ours. Thus, a conservative approach is recommended when a malpositioned CVC is suspected, despite other confirmatory testing of venous placement. Given limited safety data, it's advisable to use a different access point in future similar cases. Conclusion Proceduralists should consider PAPVR as a possible cause of catheter misposition. Consulting radiology to review or select appropriate imaging is beneficial. Once venous placement is confirmed, a conservative approach includes placing a new CVC and removing the mispositioned one.

Abstract Lung cancer is the leading cause of cancer-related death globally, with adenocarcinoma being the most common type in the United States, particularly among women and non-smokers. Symptoms include cough, dyspnea, weight loss, and hemoptysis, but early-stage cancers may be asymptomatic and found incidentally on imaging. Diagnosis requires a biopsy, followed by staging for treatment planning. While tobacco use is the primary risk factor, exposure to wood smoke (WS) also significantly increases risk, especially in developing regions. A 42-year-old female from Mexico presented to the hospital for persistent shortness of breath. She was previously treated for pneumonia but continued to experience dyspnea along with cough, fevers, chills, night sweats, and body aches. Initial labs were notable for leukocytosis and elevated d-dimer 1.60 mcg/mL. Chest x-ray showed diffuse interstitial opacities throughout the right lung. Subsequent CTA chest revealed a 5.6 x 2.7 cm mass-like right upper lobe consolidation, bilateral pulmonary nodules, ground glass opacities, and a moderate right-sided pleural effusion. Due to risk factors, infectious etiologies, including tuberculosis, were ruled out. Fluid studies from ultrasound-guided thoracentesis were consistent with exudative effusion. Ultimately, she had an endobronchial ultrasound with transbronchial biopsies and bronchoscopy with forceps biopsy. Pathology reports from the biopsies confirmed metastatic adenocarcinoma of lung primary with immunohistochemical stains positive for CK7 and TTF1. The results were discussed with the patient and referred to oncology for further treatment. This case highlights wood-burning stove exposure as a primary risk factor for lung cancer in a non-smoking patient with extensive exposure to WS from her childhood in Mexico and her work in a restaurant kitchen. In Mexico, up to 30% of lung cancer patients report WS exposure. While less common in the United States, WS remains a significant source of particulate matter due to wood stoves and increasing wildfires. WS contains carcinogenic chemicals and particles that can cause respiratory diseases like COPD and cancer. Long-term exposure can trigger inflammation and increase lung cancer risk. The International Agency for Research on Cancer classifies indoor emissions from biomass combustion as probably carcinogenic to humans (Group 2A), while coal is classified as outright carcinogenic (Group 1). Although WS is not officially labeled as a carcinogen, its exposure should be considered in patients diagnosed with lung cancer, particularly given occupational risks and the rise in environmental exposure due to climate change. Recognizing WS as a significant risk factor could enhance cancer risk assessment, diagnosis, and treatment.

Peripheral artery disease exerts a substantial toll on public health in the United States, straining healthcare resources. In challenging cases, the axillofemoral bypass graft had emerged as a cornerstone in managing this condition. Unforeseen events, such as trauma, can lead to a presentation mimicking stroke and thus exacerbating the complexity of the diagnostic process. Herein, we present the case of a 64-year-old male with complex peripheral artery disease who developed a pseudoaneurysm mimicking stroke symptoms following a traumatic incident post axillofemoral bypass graft surgery. This case underscores the critical importance of employing diverse diagnostic modalities to navigate the complex differential diagnosis of stroke-like symptoms in patients post-surgery.

In Reply: We thank Dr. Horgan and colleagues for their interest in our Narrative Review in the April 2024 issue.1 It is important to emphasize that the soluble fms-like tyrosine kinase 1/placental growth factor (sFlt-1) assay should be used along with other laboratory tests and clinical assessments and should not be used in isolation to make clinical decisions. We stand by our algorithm, which was evidence-based and developed in conjunction with society guidelines, peer-reviewed trials, and the U.S. Food and Drug Administration label. As with all new tests, the value of the sFlt-1 assay needs to be determined for each community. For those health care professionals who find our algorithm useful, they are welcome to incorporate it into their practices. Others may elect not to use our approach, and we encourage them to develop a protocol for sFlt-1/PlGF testing in their population. It is important that all health care professionals, regardless of their approach, evaluate implementation of the sFlt-1/PlGF test over time to be certain that patient outcomes are favorable. Adjustments should be made as necessary if new information arises.