The Southwest Journal of Medicine

The association between hospital teaching status and in-hospital outcomes among patients with type 2 myocardial infarction in the United States

2026-04-18T08:15:16+00:00

Background: Type 2 myocardial infarction (T2MI) is characterized by an imbalance between myocardial oxygen supply and demand in the absence of acute coronary obstruction. The current lack of clear diagnostic and management guidelines for T2MI could lead to disparities in management and outcomes across different hospital settings.
Methods: We performed a retrospective analysis using the National Inpatient Sample from 2017 to 2022, identifying adult hospitalizations with T2MI. Hospitals were categorized as rural, urban non-teaching, or urban teaching. The primary outcome was in-hospital mortality. Survey-weighted logistic regression was used to identify predictors of mortality.
Results: Among all hospitalizations for T2MI, 8.3% occurred in rural hospitals, 16.3% in urban non-teaching hospitals, and 75.4% in urban teaching hospitals. Patients at urban teaching hospitals were slightly younger but had higher rates of comorbidities. In-hospital mortality was significantly greater in urban teaching hospitals (10.5% vs. 9.3% and 8.8% in urban non-teaching and rural hospitals, respectively). After adjustment, urban teaching hospital status remained an independent predictor of mortality.
Conclusion: Patients with T2MI treated at urban teaching hospitals were associated with increased mortality, length of stay, and total hospital charges. Teaching hospital status was also found to be an independent risk factor for in-hospital mortality.

Ventricular arrhythmias in type 2 myocardial infarction: Incidence and in-hospital outcomes: A national inpatient analysis (2017–2022)

2026-04-18T08:15:24+00:00

Background: Ventricular arrhythmias, including ventricular tachycardia and ventricular fibrillation, are well-known contributors to adverse outcomes in type 1 myocardial infarction, but their significance in type 2 myocardial infarction remains underexplored.

Objective: We aim to investigate the incidence of ventricular arrhythmias and their association with clinical outcomes among patients with type 2 myocardial infarction.

Methods: This retrospective cohort study utilized the National Inpatient Sample (2017–2022) and included adults hospitalized for type 2 myocardial infarction. Ventricular arrhythmias were identified using ICD-10-CM codes. Multivariable models were adjusted for patients’ demographics and comorbidities and employed to identify predictive factors for in-hospital mortality, length of stay, and total hospital charges.

Results: A total of 2,016,430 patients were included, and 5.89% developed ventricular arrhythmias. Patients with ventricular arrhythmias were younger (69.5 vs. 70.6 years, p<0.01), less female (33.4% vs. 47.9%, p<0.01), and more frequently African American (20.1% vs 17.0%, p<0.01). Ventricular arrhythmias were associated with significantly increased in-hospital mortality (19.3% vs. 9.2%, p<0.01), prolonged hospital length of stay (7 vs 5 days), and higher total hospital charges ($99,437 vs. $60,297 p<0.01). Adjusted multivariate models demonstrated ventricular arrhythmias as an independent predictor for in-hospital mortality (aOR 2.39, 95% CI 2.31-2.48), longer length of stay (β 2.83 days, 95% CI 2.66–3.00), and higher total hospital charges (cost ratio 1.60, 95% CI 1.57–1.63).

Conclusion: The incidence of ventricular arrhythmias is notable among hospitalized patients with type 2 myocardial infarction is associated with significantly worse clinical and economic outcomes.

Oral anticoagulant therapy for stroke prevention in patients with atrial fibrillation: a narrative review

2026-04-18T08:15:54+00:00

Background: The use of direct oral anticoagulants (DOACs) for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) has gradually increased since they were introduced in 2011. Today, more patients are treated with DOACs than with warfarin. As a result, the overall number of NVAF patients receiving oral anticoagulants has risen. However, it’s not clear whether this increase has led to a lower rate of stroke.

Main body: This review examines clinical studies from various regions around the world that have investigated the relationship between increased anticoagulant use and the incidence of stroke and systemic embolism. Across the studies reviewed, a higher use of oral anticoagulants in the community was linked to a drop in ischemic stroke rates in patients with NVAF.

Conclusion: These cumulative findings suggest a negative correlation between increased oral anticoagulant use and the rate of ischemic strokes.

Keywords: Direct oral anticoagulants, non-valvular atrial fibrillation, ischemic stroke

Critical measles in children

2026-04-18T08:14:47+00:00

Measles is a highly contagious viral illness that remains a major vaccine-preventable cause of severe pediatric illness. It has re-emerged in the United States through recent outbreaks in under-immunized communities. Although most cases are self-limited, a significant portion of children develop critical illness requiring pediatric intensive care. Complications, including severe pneumonia, pediatric acute respiratory distress syndrome, acute encephalitis, shock, and secondary bacterial infection, are among the top reasons for PICU admission. Severe measles reflects both direct viral injury and immune dysregulation, which can increase susceptibility to superinfection and multiorgan dysfunction. Diagnosis relies on recognition of characteristic clinical features in the appropriate epidemiologic setting and is confirmed by reverse transcription polymerase chain reaction and serologic testing. Management is primarily supportive and heavily relies on early recognition of respiratory, neurologic, and hemodynamic compromise. It includes escalating respiratory support and lung-protective ventilation when indicated; vitamin A supplementation; nutritional support; and careful evaluation for complications and bacterial superinfection. Strict isolation and outbreak preparedness remain essential to prevent nosocomial transmission. This review summarizes the epidemiology, pathophysiology, diagnosis, complications, and pediatric critical care management of severe measles in children.

A cross-sectional, national survey on current practices and patterns in telenephrology among nephrologists

2026-04-18T08:14:54+00:00

Introduction: Telenephrology is an emerging but underreported area of practice. This study evaluated nephrologists’ confidence in diagnosing and managing a range of kidney conditions using telenephrology.

Methods: A cross-sectional online survey was conducted between September 2024 and January 2025 among practicing nephrologists in India. The questionnaire included 11 general and 110 condition-specific items. Respondents rated their confidence across clinical scenarios using a Likert scale. A response of moderate, high, or very high (≥60% confidence) was defined as “confident.”

Results: A total of 136 nephrologists from India participated. Of these, 73 (53.7%) used synchronous methods, with half conducting video consultations. The most frequently cited limitations were incomplete clinical examination (115; 84.6%) and medico-legal risks (89; 65.4%). Overall, 11 (44%) of 25 kidney conditions in the naïve diagnostic setting surpassed the confidence threshold. In contrast, only 2 (8%) of 25 conditions in naïve management reached this benchmark, primarily urinary tract infections and early-stage CKD (≤G3a). In chronic dialysis care, confidence was higher for hemodialysis-related complications but notably lower for peritoneal dialysis issues. Follow-up care in general nephrology (97; 71.3%) and kidney transplant recipients (103; 75.7%) exceeded the threshold in several scenarios. Counseling-related tasks reflected the lowest confidence (43; 31.6%). Factors such as pediatric exposure, academic affiliation, years of experience, sector of work, and workload did not significantly affect confidence levels.

Conclusion: This India-focused survey highlights promising confidence in telenephrology for diagnosis and follow-up but underscores the need for targeted improvements in management and counseling applications.

In AI we trust? A promised panacea in the consult culture of modern medicine

2026-04-18T08:16:25+00:00

Cancer incidence and rural surveillance challenges in West Texas

2026-04-18T08:15:39+00:00

Purpose: This study aimed to report cancer incidence across West Texas, with a focus on differences in urban and rural counties.

Methods: Aggregate population data was obtained from the Texas Cancer Registry and the United States Census to describe cancer incidence and population size for 107 counties across West Texas. Five-year cancer incidence reports were used to calculate annual mean cancer incidence to retain as much data as possible from low population rural counties.

Findings: An average of 13,500 new cancer diagnoses were reported across West Texas annually from 2018–2022. Over two-thirds of these new cases occurred among residents in the nine urban counties in the region, leaving about 4,150 new cases across the geographically large and sparsely populated 98 rural counties of West Texas.

Conclusions: West Texas cancer incidence aligns proportionally with the state of Texas when accounting for population size. However, a substantial challenge remains for rural cancer epidemiology for identifying meaningful patterns when annual absolute incidence numbers are too small for statistical analysis.

Keywords: Cancer incidence, rural health, West Texas, population health

COVID-19 precipitated sarcopenia in a patient with COPD and initially preserved functional status

2026-04-18T08:16:09+00:00

Case Presentation: We report a case of a 67-year-old male with COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) grade B, who developed significant sarcopenia following a mild COVID-19 infection. Prior to infection, the patient had preserved functional capacity, with a 6-minute walk distance (6MWD) of 420 meters. During the acute phase, he experienced mild respiratory symptoms managed entirely on an outpatient basis. Three weeks post-infection, he exhibited marked proximal muscle weakness, reduced handgrip strength (21 kg), slow gait speed (0.9 m/s), and decreased 6MWD (290 m). Laboratory evaluation revealed elevated creatine phosphokinase (CPK 420 U/L) and lactate dehydrogenase (LDH 280 U/L), persistent mild lymphopenia, and low-grade systemic inflammation. Serum 25-hydroxyvitamin D, albumine and calcium levels were within normal ranges. Immunological work-up for inflammatory myopathy, including antinuclear antibodies (ANA) and anti–Jo-1 (anti–histidyl-tRNA synthetase) antibodies, was negative. A structured rehabilitation program, including respiratory therapy, postural exercises, low-intensity resistance training, and optimized protein intake (1.2-1.5 g/kg/day), was initiated.

Outcome: Over 12 months, the patient demonstrated progressive recovery of muscle strength, functional capacity, and normalization of most laboratory parameters, with residual mild proximal weakness.

Conclusion: This case underscores that COVID-19 can precipitate or unmask sarcopenia even after mild respiratory illness in COPD patients with previously preserved functional status. Systematic muscle assessment and early rehabilitation, including nutritional optimization, are essential to preserve functional independence in this vulnerable population.

Methamphetamine-associated severe coronary artery ectasia presenting as ST-elevation myocardial infarction in young adult

2026-04-18T08:16:01+00:00

While cocaine has been reported as a risk factor for coronary artery ectasia (CAE), the effects of other stimulants, such as methamphetamine, on CAE is inadequately described. We present a case of a mid-40s man with a history of hypertension, hyperlipidemia, and methamphetamine abuse who presented with acute-onset chest pain. His electrocardiogram indicated an inferior wall ST-elevation myocardial infarction (STEMI). Coronary angiography revealed diffuse and severe CAE with complete thrombotic occlusion of distal RCA and large thrombus burden in mid-RCA segment. Percutaneous coronary intervention was performed in the distal RCA. However, residual thrombus persisted in the mid-RCA segment. He was later discharged on dual antiplatelet therapy with a plan to initiate anticoagulation in the outpatient setting due to right groin hematoma. Prior studies regarding CAE and methamphetamine are still limited. In addition to his atherosclerotic risk factors, methamphetamine may have also contributed to the development of CAE.

Keywords: Coronary artery ectasia; Methamphetamine; Myocardial infarction

Red herrings and rocky mountains: a case of unsuspected rocky mountain spotted fever in a critically ill patient

2026-04-18T08:15:31+00:00

Rocky Mountain Spotted Fever is a tick-borne illness caused by Rickettsia rickettsii that can rapidly progress to irreversible fatal outcomes, especially with delayed treatment. Diagnosis of this disease can be difficult given its initial non-specific presentation that can easily be mistaken for other community-acquired illnesses or non-infectious etiology. This case was also confounded by a red herring associated with the limitation of unknown diagnostic tests. Here we report a 62-year-old male who presented for three days of altered mentation, fever, and significantly elevated blood alcohol level (0.372 WT/VOL). Relevant findings on initial ED evaluation include leukocytosis (11.5 K/uL), lactic acidosis (3.2 mmol/L), AKI (Cr 3.04 mg/dL, from baseline 0.8 mg/dL), transaminitis (AST 145 U/L, ALT 57 U/L). Patient was admitted to intensive critical care, started on phenobarbital taper for alcohol withdrawal, and concomitantly treated with vancomycin and cefepime for broad sepsis coverage. An initial tick-borne infection panel resulted on hospital day (HD) 1 and was negative, and an atypical infection was believed to be ruled out. Over the next three days, the patient rapidly deteriorated into acute respiratory failure requiring rapid sequence intubation, acute renal failure started on renal replacement therapy, septic shock, thrombocytopenia, and acute deep vein thrombosis. Patient was finally started on doxycycline on hospital day 3 after an unidentified rickettsial panel yielded high titer immunoglobulin M and G for RMSF. Patient fortunately improved with extended doxycycline treatment and was able to be discharged, though now with persistent peripheral neuropathy, ataxia, and short-term memory deficits. This case serves as a reminder of the high mortality outcome for delayed RMSF treatment. In addition, while clinicians strive to maintain broad differential, it is just as important to develop a structured approach to ensure accurate interpretation of clinical data and familiarity with the limitations of various diagnostic tests.

Unraveling the culprit behind the exercise-induced recurrent rhabdomyolysis in a young adult

2026-04-18T08:15:46+00:00

Background: Recurrent rhabdomyolysis induced by exercise or physical exertion in a healthy young individual is uncommon and necessitates further investigations of an underlying disorder. Metabolic myopathy is one of the rare causes of recurrent rhabdomyolysis in adolescents and adults. Clinical parameters are normal in between the episodes in which patients remain asymptomatic. The acylcarnitine profiles provide a significant clue to diagnosis.

Case: We present a case of a young adult female who presented with recurrent exercise-induced rhabdomyolysis. The appropriate diagnosis was established two years after the onset of the first episode of her seemingly uneventful rhabdomyolysis. Her signs and symptoms including her acylcarnitine profile were similar to a long-chain fatty acid oxidation disorder (LC-FAOD). However, genetic analysis showed a missense mutation of RYR1 that has never been reported before. After fatty diet restriction, she has not reported rhabdomyolysis since.

Conclusion: Due to the unpredictable nature of symptomatology, the diagnosis and management of metabolic myopathy should be approached carefully. An inconclusive acylcarnitine profile must be confirmed with genetic analysis.

Early onset of nivolumab-induced central adrenal insufficiency in gastric adenocarcinoma

2026-04-18T08:16:17+00:00

Secondary adrenal insufficiency (AI) due to nivolumab, an immune checkpoint inhibitor, is a common occurrence. The mechanism underlying this phenomenon was believed to be the destruction of endocrine cells triggered by immune activation from the medication. A woman in her 60s developed symptoms of adrenal insufficiency (AI) complicating her sepsis a few days after her first administration of nivolumab for gastric adenocarcinoma treatment. Low morning cortisol, low ACTH and the ACTH stimulation test confirmed the diagnosis of AI. An MRI of the pituitary was normal. It is believed that by the time symptoms develop, a significant portion of the cells may have already been destroyed irreversibly. Life-long hormonal therapy is indicated based on the underlying endocrine disorder. Gastric adenocarcinoma is a serious neoplastic disease. Nivolumab should be continued if necessary for oncologic reasons, with concurrent treatment for adrenal insufficiency as indicated.

Keywords: Nivolumab, Immune checkpoint inhibitor, Central adrenal insufficiency, Secondary adrenal insufficiency, Gastric cancer

From angina to atypical infection: a rare case of pseudomonas oryzihabitans bloodstream infection after percutaneous coronary intervention

2026-04-18T08:16:32+00:00

Pseudomonas oryzihabitans is an infrequent, yellow-pigmented non-fermenting gram-negative bacillus most often linked to device-related infections. We report a rare case of a 73-year-old male with diabetes mellitus, chronic kidney disease and recent non-ST-elevation myocardial infarction (NSTEMI) who underwent three-vessel percutaneous coronary intervention. A left internal jugular central venous catheter was inserted for peri-procedural management. Seventy-two hours later he developed fever (38.3 °C) without localizing signs. Paired peripheral and catheter blood cultures flagged positive after 48 hours. Gram stain showed slender gram-negative rods and empirical antibiotic therapy with piperacillin–tazobactam was started. Subculture yielded non-lactose-fermenting; oxidase-positive colonies identified as Pseudomonas oryzihabitans. Antimicrobial susceptibility testing demonstrated sensitivity only to minocycline; piperacillin/tazobactam and carbapenems were intermediate; amikacin and meropenem resistant. A diagnosis of central-line-associated bloodstream infection (CLABSI) was made and the catheter was removed in accordance with Infectious Diseases Society of America (IDSA) guidelines and intravenous minocycline initiated. The patient became afebrile within 48 hours and completed five days of therapy with full recovery, being discharged on day eight. This case underscores the need to recognize rare non-fermenters as potential CLABSI pathogens in cardiology units, highlights their distinct antimicrobial profile and reinforces guideline-based catheter removal coupled with targeted therapy for optimal outcomes.

Cannabinoid hyperemesis syndrome from delta-8 tetrahydrocannabinol after discontinuing regular cannabis use

2026-04-18T08:15:09+00:00

Cannabis is the most frequently used illicit substance in the United States and its use has only continued to grow as more states legalize or decriminalize its use and an ever-expanding array of cannabinoid products have continued to enter the market. Excessive cannabis use is associated with multiple neuropsychiatric and medical effects. One notable effect of excessive cannabis use is cannabinoid hyperemesis syndrome (CHS), a syndrome of cyclic nausea, vomiting and abdominal pain following prolonged cannabis use. While most existing literature associates CHS with excessive cannabis use, the role of other cannabinoid-related products in the development of CHS is less established. To date, there is only one published case report of CHS developing in a patient exclusively using delta-8 tetrahydrocannabinol (THC). We present the case of a 35-year-old female who was admitted to our hospital for suicidal ideations. During admission, she exhibited classic signs and symptoms of CHS in the setting of a long multiyear history of daily cannabis use. However, she reported that she had discontinued smoking cannabis about 5 months ago after being told about CHS and had been exclusively using delta-8 THC daily with the assumption that this cannabinoid product would not cause the same effect. This case adds to the growing body of evidence to support delta-8 THC being associated with the development of CHS, thus highlighting the importance of educating patients with CHS on complete abstinence from all forms of cannabinoid products including delta-8 THC.

Falsely elevated immunologic markers with erythema nodosum and arrythmias in the setting of Q Fever

2026-04-18T08:15:01+00:00

This work describes a case of a young adult male who presented with a fever of unknown origin of several weeks’ duration and a painful, palpable rash. Initial workup suggested a viral or immunologic cause of his symptoms, as both rheumatoid factor and CMV antibodies (IgM and IgG) were positive. Repeat testing one week later was negative for CMV antibodies, and send-off testing eventually confirmed a diagnosis of Q fever. Biopsy of a skin lesion showed panniculitis consistent with erythema nodosum, an exceedingly rare manifestation of Q fever. The patient also experienced cardiac arrythmias during his hospital stay, although no structural heart disease was noted on imaging. The severity and duration of this patient’s symptoms were unusual for Q fever, particularly as they presented in an otherwise healthy young male. His positive rheumatoid factor and CMV antibodies were likely a result of immunologic activation in response to the Q fever infection. Falsely elevated immunologic markers may delay the diagnosis and treatment of Q fever—especially when combined with signs such as erythema nodosum that are more commonly associated with other immunologic or infectious etiologies. As a result, this case serves as an important reminder to consider immunologic overlap when test results are inconsistent and when the patient may have experienced direct or indirect animal exposure.

Key Words

Q Fever, Coxiella burnetii, erythema nodosum, myocarditis, endocarditis, immunologic overlap, immunologic arousal, immunologic activation

Hemorrhagic cardiac tamponade presenting as isolated exertional dyspnea in an otherwise healthy individual: A diagnostic challenge

2026-04-18T08:16:48+00:00

Abstract

Background: Pericardial effusion presents with a wide clinical spectrum, ranging from incidental findings to life-threatening cardiac tamponade. Hemorrhagic pericardial effusions (HPE) are most associated with malignancy, autoimmune conditions, and tuberculosis; however, idiopathic cases are rarely reported and can pose diagnostic challenges.

Case Summary: We report the case of a 57-year-old female presenting with progressive dyspnea, orthopnea, and dry cough. Echocardiography revealed a large pericardial effusion with tamponade physiology, prompting urgent pericardiocentesis with drainage of 800 mL of hemorrhagic fluid. Extensive infectious, malignant, and autoimmune workup was unrevealing, and pericardial biopsy showed no evidence of malignancy or infection. The patient was managed empirically for pericarditis with NSAIDs and colchicine. At a two-month follow-up, she demonstrated clinical and echocardiographic improvement without evidence of constrictive physiology.

Conclusion: Idiopathic hemorrhagic cardiac tamponade, although rare, must be considered when common etiologies are excluded. Timely recognition and intervention are critical to patient survival. Comprehensive evaluation and long-term follow-up remain essential to guide management and monitor for recurrence.

Keywords: Pericardial tamponade, hemorrhagic pericardial effusion.

Key Clinical message

Pericardial tamponade may present subtly without Beck’s triad. In hemorrhagic effusion, infection, autoimmune diseases, and malignancy should be ruled out. If the workup is negative, we suggest empirical treatment for acute pericarditis.

Massive non-bacterial vegetation of aortic valve visualized by transesophageal echocardiogram in Libman-Sacks endocarditis

2026-04-18T08:16:40+00:00