Western Reserve Hospital

We read with great interest the study “Intra-articular corticosteroid injections versus platelet-rich plasma as a treatment for cervical facetogenic pain: a randomized clinical trial”[1][1] and commend the authors for investigating innovative, non-steroid interventions for the treatment of

Abstract Background: Acute coronary syndrome (ACS) is a common, sometimes difficult to diagnose spectrum of diseases occurring after abrupt reduction in blood flow through a coronary artery. Given the diagnostic challenge, it is sensible for emergency physicians to have an approach to prognosticate patients with possible ACS. Multiple prediction models have been developed to help identify patients at increased risk of adverse outcomes. The HEART score is the first model to be derived, validated, and undergo clinical impact studies in emergency department (ED) patients with possible ACS. Methods/design: Pre-defined eligibility criteria are provided. Multiple strategies will be used to identify potentially relevant studies. Studies will be selected and data extracted using standardised forms based on the CHARMS checklist. Outcome measures will include prevalence, risk ratio, and absolute risk reduction for MACE within 6 weeks of ED evaluation, comparing HEART scores 0-3 versus 4-10. HEART score prognostic performance will be evaluated with the concordance (C) statistic (model discrimination), observed to expected events ratio (model calibration), and a decision curve analysis. Reporting biases and methodological, clinical, and statistical heterogeneity will be scrutinised. Results: Out of 100 patients: Mean age of the respondents was 47.4±12 years where 78% of them were male. 25% had smoking habit, 34% had history of Diabetes Mellitus, and 42% had history of HTN. Among the respondents 63 % was improved. 12 % respondents developed heart failure, 15% recurrent ischemic pain, 6% of recurrent MI, 2 % cardiogenic shock, and 2 % cases of death. HEART score as predictor was statistically significant (p<0.05), indicated to distinguish between major adverse cardiac events and no major cardiac events. Conclusion: Almost one third of respondents with high HEART score had heart failure and recurrent ischemic pain. There was statistically significant difference in incidence of major adverse cardiac events between high and low HEART score groups. The HEART score can be used to predict risk for major adverse cardiac events effectively in patients with suspected ACS. This can help us to determine needs for urgent treatment and hospitalization among the patients who present with suspected ACS.

Granulicatella adiacens, a nutritionally variant streptococcus, is part of the normal oral, gastrointestinal, and urogenital flora. It is associated with bacteremia, infectious endocarditis, and, rarely, bone and joint infections. G. adiacens infections also tend to have high mortality due to diagnostic challenges and antibiotic resistance. Few case reports have documented its role in abscess formation. Here, we report the first known case of G. adiacens causing a gallbladder abscess in a patient with gallbladder carcinoma (GBC), a rare but aggressive cancer. Enhanced awareness and improved diagnostic methods are needed to manage such infections and understand their underlying mechanisms, particularly in immunocompromised patients with malignancies.

Abstract Introduction Narcolepsy is typically diagnosed by symptoms and an abnormal multiple sleep latency test (MSLT). However, many factors can affect the results of the MSLT, leading to an overdiagnosis of narcolepsy. Report of case(s) A 37-year-old female was referred with prior diagnoses of narcolepsy, depression, post-traumatic stress disorder, polysubstance abuse, obstructive sleep apnea (OSA), and hypertension. The patient obtained the diagnosis of narcolepsy by polysomnography/MSLT through another facility and was prescribed amphetamine/dextroamphetamine. The overnight polysomnogram demonstrated: total sleep time 285 minutes, rapid-eye movement (REM) latency 223 minutes, overall apnea-hypopnea index (AHI) 6/h, and REM AHI 45/h. The next day MSLT demonstrated a mean sleep latency of 7 minutes and 2 sleep-onset REM periods on the second and fourth naps. A urine drug screen (UDS) was not obtained. She reported 4-6 hours of sleep/day at the time of her MSLT. She denied cataplexy, sleep paralysis, or sleep-related hallucinations. Conclusion This case is one of many seen at our tertiary referral center of patients presenting with a diagnosis of narcolepsy by MSLT, but the MSLT was performed in invalid conditions. Many medications, substances, insufficient sleep, inappropriate timing of testing, untreated OSA, and other medical conditions all have the potential to lead to an abnormal MSLT that would appear consistent with narcolepsy, but often these factors are not considered. Insufficient sleep at home or on the preceding polysomnogram can lead to an abnormal MSLT. Though our patient had a history of polysubstance abuse, a UDS was not obtained. The American Academy of Sleep Medicine enjoins a polysomnogram for a duration of a 7-hour minimum (with 6 hours of sleep) prior to conducting an MSLT. Our patient only slept for 4.75 hours in the overnight polysomnogram. Her polysomnogram also showed OSA. A combination of these factors likely contributed to the patient’s daytime sleepiness. Her insufficient sleep, OSA, and use of sedating medications/substances should have been addressed first before performing an MSLT. We strongly encourage providers to ensure the MSLT is done in valid conditions to prevent the misdiagnosis of narcolepsy and initiation of unnecessary treatment. Support (if any)