Amanda Frugoli

Background Every American was affected by the COVID-19 pandemic. The novelty and virulence spurred the rapid evolution of treatment strategies. While large multicenter studies established key mortality risk factors and treatment efficacy, community hospital experiences are underrepresented. Methods This retrospective study examines clinical characteristics, mortality predictors, and outcome trends among 1,949 adults hospitalized with COVID-19 at a Southern California community hospital from January 31, 2020, through May 11, 2023. Results Overall mortality was 7.6%, and the mean length of stay was 9.2 days. Older age was independently associated with increased mortality, with the odds of death nearly doubling for every decade of life (adjusted odds ratio (aOR) 1.98, 95% CI 1.65-2.39, P < 0.001). Univariable laboratory predictors of inpatient mortality, and log transformation of D-dimer, demonstrated that D-dimer was the best predictor of inpatient mortality. Septic shock was associated with a twofold increase in mortality (aOR 2.26, 95% CI 1.11-4.63, P = 0.025). Respiratory failure requiring a mechanical ventilator is a marker for disease severity and was the strongest predictor of mortality in this cohort. Mechanical ventilation was associated with a 10-fold increase in the odds of death (aOR 10.07, 95% CI 6.18-16.38, P < 0.001). Multivariable analysis comparing mortality and pharmaceutical treatments identified that receipt of systemic corticosteroids was associated with higher odds of in-hospital mortality (aOR 6.70; 95% CI 4.00-11.22; P < 0.001). Receipt of tocilizumab was also associated with higher mortality (aOR 3.87; 95% CI 2.06-7.26; P < 0.001). Time-lapse analysis of the interval between admission and mortality demonstrated a 23% reduction in the odds of death per successive year (aOR 0.77 per year, 95% CI 0.62-0.96, P = 0.018). Conclusion Mortality decreased nearly one-fourth each year. D-dimer was the best laboratory predictor of death. Older age, septic shock, and ventilator need were associated with increased risk of inpatient mortality. Receipt of systemic steroids and tocilizumab was associated with higher mortality. These are not causal treatment effects, as medication receipt at that time was related to disease severity. These community hospital findings complement larger studies and reinforce the importance of early risk stratification and evidence-based treatments.

Primary thyroid lymphomas (PTL) are a unique malignancy that arises from within the thyroid gland and is not typically considered in the differential diagnosis of thyroid cancers. PTL is strongly associated with underlying autoimmune thyroiditis; despite this association, there are no screening guidelines. Management of PTL involves chemotherapy, contrasting with the surgical and radioactive iodine therapies employed in differentiated thyroid cancers.

Endometrial stromal sarcoma is a rare malignancy that can be difficult to diagnose due to its nonspecific presentation. Unfortunately, the presenting symptoms of abnormal uterine bleeding (AUB), anemia, and pelvic pain overlap with symptoms of benign uterine fibroids, which can delay diagnosis. Additionally, initial evaluations with imaging or even a negative endometrial biopsy may provide false reassurance. Due to novelty, mimicry of benign uterine processes, and high false-negative endometrial biopsy rates, this malignancy is often diagnosed at advanced stages. In this case vignette, we describe a case of metastatic high-grade endometrial stromal sarcoma (HG-ESS) presenting with menorrhagia, pulmonary embolism, and recurrent pneumothoraces in a 42-year-old G1P1 woman.

The natural forces of the lunar cycle and seasonal solstice variation on the water surfaces have been studied extensively but not on patients with fluid problems such as heart failure (HF). This retrospective review investigates these temporal effects on admission rates of patients with heart failure and length of stay. In this study, we try to answer the following questions: Do moon cycles (full moon vs new moon) significantly affect the number of patients admitted? and Do moon cycles significantly affect the patient’s hospital length of stay (LOS?). All patients with HF exacerbation admission between January 1, 2016 to December 31, 2019, were filtered according to admission date based on the lunar calendar. Patients admitted on the day of, the day before, and the day after a new and full moon were included. Question 1, Poisson regression models were employed. The overdispersion obtained from the AER package was 1.63. All analyses were performed using R (R Core Team). A total of 758 patients were admitted during lunar cycles, 50.1% (N = 380) were admitted during the new moon and 49.4% (N = 378) during the full moon. The mean age is 78.4 (SD 7.2), the mean BMI is 28.8 (SD 6.7), and the mean LOS is 5.6 (SD 3.4) with no significant differences in patients admitted during both of the moon cycles. The seasons variable showed statistically significant coefficients, with the summer season (S2) having the highest impact (coefficient 0.85, P = .001). Some interaction between Moon-Cycle, summer season, and BMI influenced patient admissions during lunar cycles (coefficient = 0.49 P ≤ .001). This study showed that the moon cycle may impact patients with HF during the summer season only. Prospective studies are needed on a national level to investigate further the impact of the moon cycle on HF patients. This will help improve patient outcomes and pathogenesis, and there is excellent potential for reducing medical costs.

The incidence of insulin -induced amyloidosis distant from an injection site is unknown. Due to its rare nature, only a few case reports have been reported, with even fewer describing amyloidoma as distant from the insulin injection site. We present a case of a 52 -year -old male with a left arm mass that was determined to be cutaneous amyloidosis and successfully treated with total excision of the mass. Histopathological examination with Congo red stain demonstrated classic characteristics of amyloidosis. We present this case report to increase awareness of this relatively rare occurrence.

Atrial fibrillation is the most common cardiac arrhythmia. Cardiac ablation is indicated for patients refractory to medical management. During the ablation process, a transseptal puncture is utilized to access and isolate the pulmonary veins, which results in a temporary iatrogenic atrial septal defect (iASD). Generation of an iASD is considered unavoidable and is a generally accepted risk due to high rates of spontaneous closure. Studies have shown that persisting iASD may occur in 5%-20% of patients for up to nine to 12 months after undergoing radiofrequency ablation and that spontaneous rates of closure are high in patients with normal intracardiac pressures. Patients with preexisting elevated right intracardiac pressures from pulmonary hypertension or other right-sided cardiac pathology are at an increased risk of complications from iASD. These increased pressures can lead to clinically significant hypoxemia from right-to-left shunting following a transseptal puncture. Intervention with closure is considered in high-risk settings such as right atrial or ventricular enlargement, right-to-left shunting with hypoxemia, and intraseptal defect greater than 8 mm. This case vignette describes a 67-year-old female who developed clinically significant right-to-left shunting intraoperatively from iASD with ongoing hypoxemia for several months but with spontaneous closure. We highlight this case as it demonstrates spontaneous closure in a high-risk iASD. We also provide a review of the literature on iASD after cardiac ablations.

Giant cell arteritis (GCA) is a relatively rare, auto-immune vasculitis, more common in women over age 50. It is important to recognize and treat the disease early to prevent late complications of permanent vision loss. Inflammation-associated weakening of vessel walls involved by GCA may also represent a potential etiology for intracranial aneurysm development. In this report, we describe an atypical presentation of GCA confirmed with temporal artery biopsy with associated manifestations including intracranial right posterior communicating artery aneurysm and extracranial right internal carotid aneurysm. Our patient in a 78-year-old female who presented with progressively worsening headaches that began 10 days prior to admission. These were described as global, non-pulsatile, and located over her occiput. She reported associated jaw soreness while chewing or claudication. Her erythrocyte sedimentation rate (ESR) was elevated at 74 mm/hr. Magnetic resonance angiogram showed a right posterior communicating artery aneurysm measuring 5 mm and a right cervical carotid lengthwise dissecting aneurysm measuring 12 mm. Left temporal artery biopsy confirmed the diagnosis of GCA. High-dose steroid therapy was initiated and was continued for treatment of GCA with resolution of symptoms at her one month follow-up. This case highlights a rare instance of cervical internal carotid aneurysm and intracranial aneurysm associated with GCA, emphasizing the systemic nature of this vasculitis.