The most common symptom of cocaine abuse is chest pain. Cocaine induced chest pain (CICP) shares patho-physiological pathways with the acute coronary syndromes (ACS). A key event is the increase of activity of the adrenergic system. Beta blockers (BBs), a cornerstone in the treatment of ACS, are felt to be contraindicated in the patient with CICP due to a potential of an "unopposed alpha adrenergic effect (UAE)".Identify signs of UAE and in-hospital complications in patients who received BB while having cocaine induced chest pain.We performed a retrospective review of 378 patients admitted to a medical unit because of CICP. Twenty six of these were given a BB at the time of admission while having CICP. We compared these patients to a control group paired by age, sex, race and history of hypertension who did not received a BB while having CICP. Blood pressure, heart rate, length of stay and in-hospital cardiovascular complications were compared.No statistically significant differences were found between the two groups except for a longer length of stay in the case group. This was felt to be due to unrelated causes.This study does not support the presence of an UAE in patients with continuing CICP and treated early with BB. There were no in-hospital cardiovascular complications in the group of patients who had an early dose of BB while having CICP.BB appeared safe when given early on admission to patients with CICP.
The elderly have a higher incidence of ischemic stroke along with higher mortality and morbidity compared to their younger counterparts. However, though studies have included people >85 or 90 years of age, there haven't been reports of many individuals above 100 years of age. Among the oldest old, the oldest age studied for alteplase administration is possibly 101 years. We present a case of a 105-year-old woman with a medical history of a cerebrovascular accident in 2018 for which she received thrombolytic therapy with residual slurred speech and mild dysphagia. She was brought in from her nursing facility for worsening of slurred speech and right facial droop that began two hours before presentation to the emergency department. She was found to have aphasia, left-sided gaze preference, and upper motor neuron dysfunction of her right arm associated with drift. Her National Institutes of Health Stroke Scale (NIHSS) score at presentation was 17. An urgent CT scan of the head was performed that did not show any evidence of acute bleeding. CT angiogram of brain and neck was unremarkable with no evidence of high-grade stenosis, aneurysm, occlusion, or dissection. With the negative CT findings, the patient received thrombolytic therapy with alteplase. She was monitored in the intensive care unit for 24 hours after alteplase administration with neurological checks every one hour. The repeated CT head after 24 hours was negative for any hemorrhage. She was discharged after two days of hospital admission and her NIHSS score on the day of discharge was 4. Our patient was 105 years old, which is arguably one of the oldest ages to receive alteplase. Her NIHSS score improved considerably and she did not suffer from hemorrhagic complications.
In Internal Medicine, POCUS is gaining significant favorability. An increasing number of clinicians are interested in being trained for POCUS. The newer portable ultrasounds are small and can be transported easily during rounds. Their design is now for a more intuitive use. Training of Internists now involves assessing patients utilizing POCUS technology in residency. Here at Danbury Hospital, we have formal POCUS training. Attending internists are now attempting to incorporate POCUS training as a part of continuing medical education. POCUS in the hospitalist or general practitioner world has not been completely defined. Generally, the patient seen in the medical ward is not ill as the patients seen in intensive care units (ICU), Emergency Department (ED), and other high acute-care settings. However, from time to time, internists need to treat high acuity patients on the medical floors before transferring them to a higher level of care or when they are required to cover an open ICU or Progressive Care Unit (step-down unit). The role of POCUS while managing stable patients may differ significantly compared to the role in more acute patients. A well-defined spectrum for the use of POCUS does not currently exist. However, there are efforts in this regard.
POCUS is an emerging and exciting diagnostic modality in the medical ward. We believe that the pandemic has given it a new meaning for the hospitalist and general practitioner, and we expect that its use and significance will only grow in the few years ahead.
Gastric cancer is the 12th leading cause of cancer-related deaths in the United States and commonly metastasizes to the bones. However, the presentation of gastric cancer as bony metastases without preceding gastrointestinal symptoms is rare which has been infrequently reported in the literature. Moreover, leptomeningeal carcinomatosis is an unusual complication of gastric cancer accounting for less than 1 percent of these patients. We present a unique case of a middle aged male who presented to the emergency department with worsening backache which started one month priorly. The only abnormal laboratory test was an elevated alkaline phosphatase of 154 IU/L. The imaging of his spine showed osteolytic lesions which on biopsy revealed signet ring cells. A small 2 cm ulcerated mass was found on esophagogastroduodenoscopy at the gastric cardia which on biopsy revealed signet ring gastric carcinoma. The patient received chemotherapy with capecitabine and oxaliplatin as well as radiation and showed a good response initially. A few months later, he presented with persistent worsening headaches and on brain imaging was found to have leptomeningeal carcinomatosis. Ten months after the diagnosis of gastric carcinoma, he passed away.
No abstract available. (Published: 25 April 2016) Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6 : 30660 - http://dx.doi.org/10.3402/jchimp.v6.30660
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