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Severe Anemia From Vitamin B12 Deficiency Presenting With a Craving for Bleach Powder: An Odd Case of Pica
No full textPica, the ingestion of nonnutritive substances, represents a complex and poorly understood phenomenon. Although it is inherently a psychiatric condition, it has an intricate relationship with other psychiatric, physiological, and pathological states, suggesting a highly multifactorial etiology. Recognizing and addressing pica in acute settings is crucial, as it poses significant health risks for patients, including the potential of toxic ingestion. Our presentation highlights the case of a 36-year-old woman with a complex psychiatric history who presented to the emergency department (ED) with severe symptomatic anemia. Her anemia was found to be macrocytic and a result of autoimmune-induced vitamin B12 deficiency. Further inquiry uncovered that, prior to admission, the patient exhibited a craving for smelling bleach powder that progressed to mouthing the toxic substance for more than a month. This is the first report of a case of bleach craving in a patient with vitamin B12 deficiency absent coexisting iron-deficiency. This unique presentation underscores the importance of psychiatric consultations as a part of comprehensive clinical assessments in emergency medical settings. We also suggest that pica presentations may be nuanced and thus it is critical to understand the biopsychosocial factors driving this behavior and target interventions in the appropriate medical domains
Early Recognition and Management of Arrhythmogenic Right Ventricular Cardiomyopathy in a Young Athlete: A Case Report Highlighting the Role of Multimodal Diagnosis and Preventive Implantable Cardioverter Defibrillator (ICD) Therapy
No full textArrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is a rare inherited cardiomyopathy marked by fibrofatty replacement of right ventricular (RV) myocardium, leading to electrical instability and increased risk for ventricular arrhythmias and sudden cardiac death (SCD). ARVC is typically inherited in an autosomal dominant pattern and often involves mutations in desmosomal proteins such as plakophilin-2 (PKP2). Clinical presentation can vary from asymptomatic to life-threatening arrhythmias, particularly among young athletes. This case emphasizes the importance of early detection and intervention in patients with ARVC. A 21-year-old previously healthy male presented with recurrent exertional syncope. Initial ECG demonstrated sinus rhythm with T-wave inversions in leads V1-V3. Coronary CT angiography and resting echocardiography were normal. However, the stress electrocardiogram revealed frequent premature ventricular complexes (PVCs) with a left bundle branch block morphology. Ambulatory event monitoring detected over 500 monomorphic PVCs in a 24-hour period. Cardiac MRI demonstrated mildly reduced RVEF (39%) with regional dyskinesia, meeting major diagnostic criteria per the 2010 Task Force Criteria for ARVC. Genetic testing confirmed a heterozygous pathogenic mutation (c.1689-1G\u3eC) in the PKP2 gene. The patient was started on beta-blockers and underwent implantation of a single-chamber implantable cardioverter defibrillator (ICD) due to elevated arrhythmic risk. Post-implantation, the ICD successfully terminated three episodes of ventricular tachycardia, highlighting its life-saving role. This case underscores the necessity for a high index of suspicion when evaluating young patients with unexplained syncope or arrhythmias. Diagnosis of ARVC requires integration of clinical, electrocardiographic, imaging, and genetic data. Early diagnosis and prompt management, including activity modification, pharmacologic therapy, and ICD implantation, are critical to mitigating the risk of SCD. Genetic testing and vigilant follow-up remain essential components in the care of ARVC patients
Early U.S. Commercial Experience With a Novel Transcatheter Edge-to-Edge Repair System: Insights From Real-World Data
No full textBACKGROUND: The PASCAL Precision transcatheter valve repair system provides a new option for treating prohibitive surgical risk patients with significant, symptomatic degenerative mitral regurgitation (DMR).
OBJECTIVES: The authors report early U.S. commercial experience with the PASCAL Precision system.
METHODS: Patients with DMR treated with the PASCAL Precision system in the United States were analyzed from the STS/ACC TVT Registry. Procedural, clinical, echocardiographic, functional, and quality-of-life outcomes to 30 days were assessed. All outcomes, including echocardiographic assessments, were site-assessed.
RESULTS: In 1,995 DMR patients, the median age was 81.6 years, and 57.0% were male. Median STS-PROM for mitral valve repair was 3.6%, and 69.4% were in NYHA functional class III/IV. Mixed etiology (DMR + other etiology) was present in 11.4%, and 66.9% had complex anatomy (annular/leaflet calcification, mitral valve area \u3c 4 cm(2), bileaflet flail/prolapse/tethering, or mitral stenosis). The device was successfully implanted in 97.7%. MR reduction was significant at 30 days with 94.2% achieving ≤ moderate MR and 72.6% ≤ mild MR (P \u3c 0.001 vs baseline). Patients experienced significant functional and quality-of-life improvements with a mean 21.0-point increase in Kansas City Cardiomyopathy Questionnaire score and 84.6% in NYHA functional class I/II (all P \u3c 0.001). Mitral valve reintervention and single-leaflet device attachment rates were 0.4% and 0.5%, respectively, and all-cause mortality, cardiovascular mortality, and heart failure readmission rates were 2.2%, 1.2%, and 2.6%, respectively, at 30 days.
CONCLUSIONS: Early U.S. STS/ACC TVT Registry commercial experience confirms the safety and effectiveness of the novel PASCAL Precision system in the treatment of a broad population of real-world DMR patients
Transcatheter tricuspid valve replacement using the LuX-Valve Plus system: 1-year compassionate use outcomes
No full textSingle-cell multiomics identifies Tcf1 and Lef1 as key initiators of early thymic progenitor fate
No full textBone marrow-derived multipotent hematopoietic progenitors seed the thymus and generate early thymic progenitors (ETPs). However, the factors governing ETP formation remain poorly defined. Using single-cell RNA sequencing (scRNA-seq) and single-cell assay for transposase-accessible chromatin with sequencing (scATAC-seq), we dissected the heterogeneity of transcriptomic and chromatin accessibility landscapes in murine ETPs. Whereas Tcf1(-) ETPs exhibited higher proliferative capacity, Tcf1(+) ETPs appeared to be immediate, more robust precursors to T lineage-specified early thymocytes. Prethymic ablation of Tcf1 and its homolog Lef1 severely impaired ETP formation in vivo. Whereas ablating Tcf1 alone had limited impact, loss of both Tcf1 and Lef1 impaired transcriptional activation of Notch1 and Notch pathway effector molecules, including Hes1 and Hhex, accompanied by aberrantly induced B cell and myeloid gene programs. Acute deletion of both factors compromised Notch pathway, glycolysis, and T cell gene programs in emergent ETPs ex vivo. Thus, Tcf1 and Lef1 act upstream of the Notch pathway, functioning as prethymic initiators of ETP fate and intrathymic gatekeepers of ETP identity and T lineage potential
Hyperpigmentation After Melanocyte-Keratinocyte Transplantation Procedure in a Patient With Stable Vitiligo
No full textCosmetic and functional outcomes of excisional surgical wounds healed by secondary intention: A systematic review
No full textBACKGROUND: Data regarding short-term and long-term cosmesis and functional outcomes of excisional surgical wounds healed by secondary intention healing (SIH) are limited.
OBJECTIVE: To conduct a systematic review and assess the cosmetic and functional acceptability of SIH for acute excisional surgical wounds.
METHODS: Full-text articles queried from PubMed and Embase databases between January 1964 and April 2024 with cosmetic outcome data of human subjects with acute surgical wounds healed by SIH were included. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed.
RESULTS: A total of 1655 surgical wounds, of which 1518 (91.7%) healed by SIH, from 35 studies, were included in this review. The most frequent indication for SIH was a defect resulting from excision of nonmelanoma skin cancer (keratinocyte carcinoma), which was identified in 1439 (86%) of patients. Common sites for SIH included the nose (23.3%), periocular region (15.46%), and forehead (13.5%). The majority of wounds on the forehead, medial canthus, lower eyelid, nasal ala, cheeks, lips, postauricular area, and feet resulted in good to excellent cosmetic results, whereas those on the scalp, nasal dorsum, nasal tip, nasal sidewall, and chin yielded less acceptable cosmetic results. Given the baseline variability in cosmesis of primarily closed wounds in some anatomic locations, however, these data suggest the need for future prospective studies.
SUMMARY: SIH may produce an acceptable cosmetic and functional outcome for selected defects and may be of clinical benefit in the appropriate setting. This must be weighed against the potentially improved cosmesis and more rapid healing seen with primarily closed defects
Beyond Sun Protection Factor: The Future of Personalized Photoprotection through Biomarkers, Artificial Intelligence, and Digital Twins
No full textOnce-daily oral icotrokinra versus placebo and once-daily oral deucravacitinib in participants with moderate-to-severe plaque psoriasis (ICONIC-ADVANCE 1 & 2): two phase 3, randomised, placebo-controlled and active-comparator-controlled trials
No full textBACKGROUND: Monoclonal antibodies targeting interleukin-23 and interleukin-12 are efficacious in treating plaque psoriasis but must be delivered via intravenous or subcutaneous injection. Here, we aimed to evaluate the efficacy and safety of icotrokinra (JNJ-77242113), a targeted oral peptide that selectively binds the interleukin-23 receptor, compared with both placebo and deucravacitinib in adults with moderate-to-severe plaque psoriasis.
METHODS: The phase 3, randomised, double-blind, placebo-controlled and active-comparator-controlled ICONIC-ADVANCE 1 and ICONIC-ADVANCE 2 trials, which are being done at 149 sites across 13 countries and 114 sites across 11 countries, respectively, randomly assigned (2:1:2 and 4:1:4, respectively) adults with moderate-to-severe plaque psoriasis diagnosed for at least 26 weeks (body-surface-area involvement ≤10%, Psoriasis Area and Severity Index [PASI] ≤12, and Investigator\u27s Global Assessment [IGA] ≤3) to once-daily oral icotrokinra 200 mg, placebo, or deucravacitinib 6 mg; participants randomly assigned to placebo or deucravacitinib transitioned to icotrokinra at week 16 or week 24, respectively. Coprimary endpoints were proportions of participants achieving IGA 0 or 1 (clear or almost clear skin) with at least a two-grade improvement and at least 90% improvement in PASI (PASI 90) at week 16 with icotrokinra versus placebo. These studies are registered with ClinicalTrials.gov, NCT06143878 (ADVANCE 1) and NCT06220604 (ADVANCE 2), and are ongoing.
FINDINGS: ICONIC-ADVANCE 1 enrolled participants from Jan 17, 2024, to May 24, 2024, and ICONIC-ADVANCE 2 enrolled participants from March 9, 2024, to June 13, 2024. Participants (ADVANCE 1: 774 of 988 patients screened; ADVANCE 2: 731 of 917 patients screened) were randomly assigned to icotrokinra (n=311 and 322), placebo (n=156 and 82), or deucravacitinib (n=307 and 327). All coprimary endpoints were met in both trials. Higher proportions of icotrokinra-treated versus placebo-treated participants achieved IGA 0 or 1 (ADVANCE 1: 213 [68%] of 311 vs 17 [11%] of 156, treatment difference 95% CI 58% [50-64]; ADVANCE 2: 227 [70%] of 322 vs seven [9%] of 82, 62% [53-69]; both p\u3c 0·0001) and PASI 90 (ADVANCE 1: 171 [55%] of 311 vs six [4%] of 156, treatment difference 95% CI 51% [44-57]; ADVANCE 2: 184 [57%] of 322 vs one [1%] of 82, 56% [48-62]; both p\u3c 0·0001) at week 16. Across studies, adverse event rates to week 16 were 303 (48%) of 632 and 136 (57%) of 237 with icotrokinra and placebo, respectively; the most common adverse events were nasopharyngitis (37 [6%] of 632 and 13 [5%] of 237) and upper respiratory tract infection (23 [4%] of 632 and eight [3%] of 237). To week 24, adverse event rates were lower than with icotrokinra (359 [57%] of 632) than deucravacitinib (411 [65%] of 634).
INTERPRETATION: Icotrokinra showed superior clinical response rates versus placebo and deucravacitinib in phase 3 moderate-to-severe plaque psoriasis trials, with similar adverse event rates to placebo. These findings suggest the potential of once-daily oral icotrokinra to provide robust efficacy and a favourable safety profile.
FUNDING: Johnson & Johnson