It was my first time on call, and I was to cover the emergency room from 4 pm until 8 am the next morning. The early part of my shift was uneventful, and I successfully cleared the minor cases of malaria, colds, and catarrhs. My great fear had long been of being accosted by a patient and not knowing what to do, so that night I retired to bed with hopes and prayers for a sweet sleep, dreaming of nothing related to medicine.
My ordeal started at about 11 pm. The …
Background: Cannabidiol (CBD)-a component of cannabis with no psychoactive or cognitive effect has been proven in animal models to have a vasodilatory, anti-oxidant and anti-inflammatory effect on the blood vessels. However, it is unclear if cannabis users - while being exposed to its CBD constituents - benefit from its vasodilatory and anti-inflammatory effect in the prevention of acute myocardial infarction (MI). Objective: To investigate if there is a difference in the odds of MI among cannabis users when compared to nonusers. Methods: We used data from the Nationwide Inpatient Sample on patients ages 45 years and older admitted between 2012 - 2014. The main study outcome was clinical diagnosis of MI, and the main exposure variable was cannabis use identified using ICD-9 codes. Cannabis use was categorized into non-use, non-dependent, and dependent use. Multivariable logistic regression models were used to estimate the odds of MI and In-hospital mortality in relation to cannabis use adjusting for demographics, comorbidities, and use of other recreational drugs. Results: Of the 7, 995,162 hospitalized patients who were > 45 years, 532,112 (6.7%) had a diagnosis of MI, 56,836 (0.7%) were non-dependent cannabis user and 5,417 (0.1%) were dependent cannabis users. We observed a significant inverse association between cannabis use and MI (non-dependent OR: 0.86, 95% CI: 0.83-0.90; dependent OR 0.26, 95% CI: 0.21-0.31). After adjusting for confounding variables, the association was attenuated for non-dependent cannabis users (OR: 1.03, 95% CI: 0.99-1.06]). However, among dependent cannabis users, there was 66% decreased odds of MI when compared to nonusers. Also, cannabis use was associated with 32% decreased odds of in-hospital mortality among patients with MI when compared to nonuse. Conclusions: Using the largest national data, our study showed cannabis use was not a risk factor for MI and alternatively may point to a protective benefit in the diagnosis of MI and in-hospital mortality. Future prospective studies may aid in further exploring this association to maximize the therapeutic advantage of the cannabinoid system in MI prevention.
Background: In light of rising healthcare costs and evidence of inefficient use of medical resources, there is growing interest in reducing healthcare waste by clinicians. Unwarranted lab tests may lead to further tests, prolonged hospital stays, unnecessary referrals and procedures, patient discomfort, and iatrogenic anemia, resulting in significant economic and clinical effects. Blood tests are essential in guiding medical decisions, but they are also associated with significant financial and clinical costs. We designed a quality improvement study that attempted to decrease inappropriate ordering of laboratory tests while maintaining quality of care in a large residency program. Methods: An algorithm outlining indications for complete blood count (CBC), coagulation profile (PT/INR) and basic metabolic profile (BMP) was created by the study team. Data from 1,312 patients over a 3-month period in the pre-intervention phase and 1,255 patients during the selected intervention phase were analyzed. The primary endpoint was mortality rate and secondary endpoints were length of stay and laboratory costs. Results: There were significant decreases in the number of PT/INR orders (20.6%), followed by BMP orders (12.4%), and CBC orders (9.3%). The mortality rate was 5.3% for the pre-intervention phase and 5.8% for the selected intervention phase, with a difference of 0.5% (P = 0.44). Conclusion: Our approach leads to a decrease in costs, preventing unnecessary downstream testing, and improving patient experience. It also brought a mental discipline while ordering blood tests amongst residents. J Clin Med Res. 2017;9(12):965-969 doi: https://doi.org/10.14740/jocmr3210w
Neurologic manifestations in systemic lupus erythematosus (SLE) ranges broadly from more common manifestations such as headaches, mood disorders, cognitive dysfunction, cerebrovascular disease to rarer ones including Guillan Barre syndrome, myasthenia gravis and autonomic dysfunction.
We present a case of a 39 year old Hispanic female with newly diagnosed SLE who presents with childlike behaviour. She had serologic evidence of lupus activity and all infectious etiology was ruled out. She had a protracted course but symptoms were eventually controlled with intravenous steroids, cyclophosphamide, rituximab and intravenous immunoglobulin.
This case is reported because regression has not previously been documented as one of the possible manifestations of neuropsychiatric SLE.
Tuberculosis is one of the top 10 causes of death worldwide according to the World Health Organization. Central nervous system involvement is usually the least common presentation of tuberculosis occurring in about 1% of all cases but yet can have very devastating outcomes. Lupus nephritis is one of the most common complications of systemic lupus erythematosus with up to two thirds of patients presenting with some degree of renal dysfunction. The mainstay of treatment is glucocorticoids; however, to sustain remission, steroid sparing agents such as cyclophosphamide, azathioprine and mycophenolate mofetil are used. Such patients, in addition to their baseline dysfunctional immune system, have a heightened risk of infections due to these drugs. In this article, we present a young woman who had recently been started on mycophenolate mofetil for control of class V lupus nephritis who presented with headaches, sinus pressure, and fevers. She had a protracted course of hospitalization as she failed to improve clinically and to respond to conventional therapy for acute bacterial sinusitis and meningitis. She was empirically started on antitubercular therapy 9 days after hospitalization. The diagnosis was not confirmed until day 18, the day results of cerebrospinal fluid acid-fast bacillus culture was reported. This case is reported to highlight the challenges in diagnosing Mycobacterium tuberculosis infection in an immunocompromised state and to demonstrate that its presentation can mimic numerous other conditions. Clinicians must maintain a high index of suspicion of Mycobacterium tuberculosis infection in such patients who present with nonspecific or unexplainable symptoms.
