The Southwest Journal of Medicine

Heavy metal exposure and women’s endocrine–metabolic disorders: An integrative review of PCOS, thyroid dysfunction, metabolic syndrome, and type 2 diabetes

Taslima Zaman — 2026-10-20

Cadmium (Cd), lead (Pb), mercury (Hg), and arsenic (As) are persistent environmental contaminants that can accumulate in human tissues and exert long-term biological effects. Although the acute toxicity of these metals is well established, increasing attention has focused on the effects of chronic, low-level exposure in the general population. These metals may disrupt endocrine and metabolic regulation through mechanisms including oxidative stress, mitochondrial dysfunction, immune activation, and interference with hormonal signaling pathways.

These mechanisms are relevant to endocrine and metabolic disorders affecting women, including polycystic ovary syndrome (PCOS), thyroid dysfunction, metabolic syndrome, and type 2 diabetes mellitus (T2DM). Hormonal transitions across the female life course may also influence responses to environmental exposures and disease expression.

This narrative review synthesizes epidemiological and mechanistic evidence published primarily between 2016 and 2024 and evaluates the relationships between exposure to Cd, Pb, Hg, and As and endocrine and metabolic disorders in women. Arsenic demonstrates the most consistent association with insulin resistance and T2DM. Cadmium has been associated with ovarian dysfunction, oxidative imbalance, and PCOS-related endocrine abnormalities. Lead and cadmium have also been linked to alterations in thyroid hormone levels, thyroid antibodies, and hypothyroid status. Findings regarding mercury remain less consistent.

Overall, current evidence supports a biologically plausible association between heavy metal exposure and the risk of endocrine and metabolic disorders in women. However, most available studies are observational. Longitudinal studies, standardized exposure assessments, and women-centered study designs are needed to clarify causal relationships and inform prevention strategies.

Keywords: Heavy metals, environmental exposure, polycystic ovary syndrome, thyroid dysfunction, metabolic syndrome, type 2 diabetes mellitus, women’s health

Cardiopulmonary Home Exercise Program

Dolores Buscemi — 2026-10-20

Exercise provides significant benefits for individuals with cardiopulmonary disease. The traditional standard of care involves referring patients to specialized centers that offer cardiac or pulmonary rehabilitation programs. This approach is recommended internationally and is endorsed by the World Health Organization. However, use of these programs remains suboptimal. Multiple studies indicate that home-based exercise programs can also be highly beneficial for patients, with a very low incidence of adverse events. In this review, we outline a structured home exercise program for individuals with cardiopulmonary disease, incorporating exercises tailored to varying functional levels. In addition, we review key safety considerations and strategies for exercise recovery management. This program may serve as a valuable resource for both clinicians and patients.

Outcomes of hospitalizations for heart failure with reduced ejection fraction complicated by cardiac arrest, stratified by pre-existing implantable cardioverter-defibrillator status

Nithila Sivakumar — 2026-10-20

Background: Hospitalizations for heart failure with reduced ejection fraction complicated by cardiac arrest represent a high-risk population, and the role of a pre-existing implantable cardioverter-defibrillator in these patients remains unclear.

Methods: We conducted a retrospective observational study using the National Inpatient Sample from 2016 through 2022. Adult hospitalizations (age 18 years or older) with heart failure with reduced ejection fraction and cardiac arrest were identified using diagnosis codes. Pre-existing defibrillator status was defined by a code indicating a device present before admission. Outcomes were compared by device status using survey-weighted methods, and a multivariable logistic regression model evaluated the independent association between device status and in-hospital mortality, adjusting for demographics, comorbidities, and clinical severity.

Results: Among 11,945 weighted hospitalizations, 545 (4.6%) had a documented pre-existing defibrillator. Crude in-hospital mortality was higher among hospitalizations with a device than those without (21.1% vs 9.7%, P<0.01). After adjustment, device status was not independently associated with in-hospital mortality (adjusted odds ratio 1.34, 95% confidence interval 0.63 to 2.84). Do-not-resuscitate status (adjusted odds ratio 15.56) and cardiogenic shock (adjusted odds ratio 1.47) were strongly associated with higher mortality.

Conclusions: In this national sample, pre-existing defibrillators were uncommon. Although crude mortality was higher among patients with a device, device status was not independently associated with in-hospital mortality after adjustment, suggesting outcomes were driven primarily by baseline risk and clinical severity. Studies incorporating arrest rhythm, timing, and device interrogation are needed to clarify mechanisms and optimize post-arrest management.

Acute atrial fibrillation in type 2 myocardial infarction: A national analysis of incidence and in-hospital outcomes

Ben Thiravetyan — 2026-10-20

Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia linked to worse outcomes. However, data on AF in type 2 myocardial infarction (T2MI), characterized by oxygen supply-demand mismatch without coronary occlusion, are limited.

Objective: To evaluate the incidence of acute AF in patients hospitalized with T2MI and its association with in-hospital outcomes.

Methods: We conducted a retrospective cohort study using the National Inpatient Sample from 2017 to 2022. Adult patients hospitalized with T2MI were included, excluding those with chronic AF. The primary outcome was the incidence of acute AF. Secondary outcomes were in-hospital mortality, cardiogenic shock, acute kidney injury (AKI), and bleeding. Survey-weighted analyses and multivariable logistic regression were used to calculate adjusted odds ratios.

Results: Among patients with T2MI, acute AF occurred in 31.3%. Patients with AF were older and had more comorbidities. In-hospital mortality, cardiogenic shock, and AKI were higher in the AF group compared to non-AF group. After adjustment, acute AF was independently associated with in-hospital mortality (aOR 1.17, 95% CI: 1.14–1.20) and cardiogenic shock (aOR 1.46, 95% CI: 1.40–1.51).

Conclusions: Acute AF is common in T2MI hospitalizations and is associated with mortality and cardiogenic shock.

Timing of initial post-discharge walk-in bridge clinic visit and outpatient linkage to care in opioid use disorder

Nico Carswell — 2026-10-20

Introduction: Opioid use disorder (OUD) bridge clinics are used as temporary post-discharge “bridges” for OUD treatment after a hospital or emergency department (ED) discharge while patients wait to obtain a regular outpatient provider. The objective of this study was to assess whether earlier initial follow up after discharge in a walk-in based OUD bridge clinic is associated with increased outpatient OUD treatment linkage. Methods: This was a retrospective cohort study of patients (N=165, 66% male) referred to a single walk-in, urgent care center-based OUD bridge clinic within a county safety-net hospital system after hospital or ED discharge. A modified Poisson regression model with a log link and robust standard errors was used to estimate adjusted risk ratios and 95% confidence intervals. Results: There was no significant association between the amount of time until a patient’s first OUD bridge clinic visit after being referred at discharge from the hospital or ED and eventual outpatient treatment linkage (unadjusted RR 1.00; 95% CI: 0.99, 1.01; p=0.84). Discussion: Our study contrasts with previous studies showing that earlier appointments after discharge improve linkage to care in patients with OUD. This may suggest that the walk-in structure of our bridge clinic may attenuate the negative impact of delays to follow-up care by allowing patients to present according to readiness and availability.

Role of Iron in Collagen-expressing Proangiogenic Macrophages in Diabetic Nephropathy

Chhanda Bose — 2026-10-20

Diabetic nephropathy is the leading cause of end-stage renal disease (ESRD) worldwide. The number of patients requiring hemodialysis for diabetes-related kidney disease has increased dramatically over the past two decades. Diabetes mellitus remains the leading cause of end-stage kidney disease (ESKD) in the United States, accounting for approximately 40% of patients requiring renal replacement therapy. Therefore, it is important to identify novel interventions to halt the progression of diabetic nephropathy.

Inflammatory mechanisms, including macrophage (MΦ) recruitment into the glomerulus and tubulointerstitial region, play an important role in diabetic nephropathy. In diabetic kidneys, macrophage development and accumulation depend on angiotensin II. Iron accumulation occurs in diabetic nephropathy. Iron dysregulation and heme oxygenase-1 (HO-1), an inducible regulator of heme and iron metabolism, have anti-inflammatory effect, so we need to assess their pro-fibrotic role and oxidative stress; they may promote macrophage profibrotic responses. These macrophages also play a central role in recycling iron from senescent erythrocytes. They can contain substantial intracellular and extracellular pools of catalytic iron, which promote free radical formation and oxidative stress.

We investigated the role of iron in collagen-secreting macrophages under hyperglycemic conditions. Human peripheral blood mononuclear cells (PBMCs) were cultured with normal (5 mM) or high (25 mM) glucose (GLUC) for 2–8 days in the presence of angiotensin II (Ang II). Ang II (0.1 or 1.0 μM) was added for 24 hours to 4 days. We assessed macrophage phenotype, procollagen-1 (PC-1), ferroportin (FPN), heme oxygenase-1 (HO-1), and angiogenic markers using immunofluorescence, Western blotting, and flow cytometry. Catalytic iron levels were measured, and the effect of iron chelation was evaluated using deferiprone (DFP; 25 μM). We examined human kidney tissue for CD163 and procollagen-1 expression. Our results showed that high glucose increased the number of CD163+ and CD68+ macrophages expressing procollagen-1. Ang II further enhanced these responses. Hyperglycemia and Ang II increased catalytic iron levels (P < 0.0001) and altered HO-1 and FPN expression, consistent with activation of iron- and oxidative stress-related pathways. Collagen-expressing macrophages displayed an angiogenic phenotype, with increased lectin and acetylated low-density lipoprotein (LDL) expression. Deferiprone significantly reduced macrophage adhesion, PC-1 expression, and angiogenic markers. In human kidney tissue, CD163+ macrophages and procollagen-1+ cells were detected in the interstitium and sclerotic glomeruli, with procollagen-1+ cells predominantly localized to the interstitium.

Hyperglycemia and Ang II promote iron accumulation and the development of collagen-secreting, fibrotic, and proangiogenic macrophages. These cells may play an important pathophysiological role in the progression of diabetic nephropathy. The association with FPN and HO-1 suggests that iron recycling pathways may be involved in this response. Iron chelation attenuated these macrophage phenotypes, supporting the iron–FPN–HO-1 axis as a potential therapeutic target in diabetic nephropathy.

Our findings identify catalytic iron accumulation as a potential driver of a collagen-secreting, proangiogenic macrophage phenotype induced by the combined dysmetabolic and renin–angiotensin stress associated with diabetes.

Keywords: Angiogenic markers, Angiotensin II, Catalytic iron, diabetic nephropathy, Deferiprone, iron chelation, Glucose, pro-collagen and profibrotic positive macrophages, peripheral blood mononuclear cells

Predicting the failure on noninvasive ventilation in hypoxemic patients by updated HACOR score

Karthik K Shetty — 2026-10-20

Background: Acute hypoxemic respiratory failure is a major cause of morbidity and mortality requiring ventilatory support. Non-invasive ventilation (NIV) is an alternative to invasive ventilation, and the HACOR score is widely used to predict NIV failure. The updated HACOR score incorporates additional baseline variables such as ARDS, septic shock, immunosuppression, organ failure, and SOFA score. Evidence on its predictive utility remains limited.

Methods: This prospective observational study included adult ICU patients initiated on NIV for hypoxemic respiratory failure. Baseline data included age, sex, indication for NIV, comorbidities, SOFA score, and presence of COVID-19, septic shock, and ARDS. NIV failure prediction was assessed using original and updated HACOR scores at baseline, 1–2 hours, 12 hours, and 24 hours. Diagnostic performance was compared using AUC

Results: A total of 63 patients were included. The AUC for original vs updated HACOR scores was 0.522 vs 0.404 (baseline), 0.899 vs 0.404 (1–2 hours), 0.862 vs 0.957 (12 hours), and 0.485 vs 0.500 (24 hours). Differences were statistically significant at 1–2 hours and 12 hours (p = 0.0001), but not at baseline or 24 hours.

Conclusion: The updated HACOR score, which is determined based on six baseline variables and the five original scale items, has significantly improved predictive power for NIV failure compared to the original HACOR score at certain timeframes. This suggests time-dependent utility of both scores in predicting NIV failure.

Pulmonary nocardiosis in West Texas: A case series and literature review

Camila Padovese — 2026-10-20

Pulmonary nocardiosis is a rare, potentially fatal infection that predominantly affects immunocompromised hosts but is increasingly recognized in patients with chronic lung disease or corticosteroid exposure. Its nonspecific radiographic features often mimic tuberculosis, fungal infection, or malignancy, delaying diagnosis. We present three cases illustrating this diagnostic challenge. A woman with lupus nephritis developed empyema refractory to fibrinolytics and thoracotomy, with cultures eventually growing Nocardia pneumoniae. A man with interstitial lung disease on high-dose steroids presented with a cavitary lesion mimicking mycobacterial disease, later confirmed as nocardiosis on sputum culture. A woman with lupus and post-COVID lung disease developed bilateral cavitary consolidations radiographically suggestive of fungal infection, with negative fungal and viral workup; sputum culture grew Nocardia cyriacigeorgica. All three improved with species-tailored, prolonged antimicrobial therapy. Nocardiosis should remain on the differential for cavitary lung disease unresponsive to standard antibiotics, particularly in immunocompromised or steroid-exposed patients.

Keywords: Pulmonary nocardiosis, Immunocompromised host, Cavitary lung disease, Chronic lung disease, Empyema, Trimethoprim-sulfamethoxazole.

Medically Supervised Low-Energy Total Diet Replacement Before Staged Arthroplasty in Severe Obesity and Type 2 Diabetes: A Case Report

Yazmine Huizar — 2026-10-20

Low-energy total diet replacement (TDR), when paired with medical monitoring, may support preoperative metabolic optimization in selected patients with severe obesity and type 2 diabetes (T2D). We report a case of a 57-year-old woman with severe obesity, T2D, chronic prednisone exposure, obstructive sleep apnea, hypertension, and limited mobility who entered a medically supervised TDR program to improve candidacy for staged arthroplasty. Baseline weight was 312 lb (141.5 kg), body mass index was 57.1 kg/m², and hemoglobin A1c was 7.6%. The intensive phase prescribed approximately 960 kcal/day using formula-based meal replacement products, with weekly clinical visits, medication reconciliation, laboratory surveillance, electrocardiographic monitoring per clinic protocol, behavioral support, and perioperative diet planning coordinated with the orthopedic team. Weight decreased to 222 lb (100.7 kg), representing 28.8% total body weight loss. Hemoglobin A1c decreased to 5.0%, lisinopril and potassium chloride were discontinued at week five, and metformin was discontinued at 11 months. Hemoglobin A1c remained below 6.5% for at least three months after cessation of glucose-lowering therapy, meeting consensus criteria for T2D remission. The patient underwent staged left hip and right knee arthroplasty with uncomplicated wound healing and no documented postoperative infection. This case illustrates a medically supervised interdisciplinary pathway for high-risk arthroplasty candidates, while emphasizing that single-patient findings cannot establish causality or determine whether the intervention reduced perioperative risk.

Delayed adult-onset recurrent symptomatic pleural effusion secondary to ventriculopleural shunt

Liz Thaliath — 2026-10-20

Extracranial shunts alleviate symptoms in patients with hydrocephalus by diverting cerebrospinal fluid (CSF) to an extravascular compartment. The most common procedure is ventriculoperitoneal shunting (VPS). However, certain patients with multiple shunt revisions, morbid obesity, or a history of abdominal surgeries may not be suitable VPS candidates; ventriculopleural shunting (VPLS) may be considered as an alternative route for CSF diversion when the peritoneal cavity is unsuitable. Pleural effusions, shunt obstruction, pneumothorax, and empyema can complicate the course of these shunts, though they are infrequent. Most reports of pleural effusions have been in young adults and children, particularly within three years of placement. We report the case of a 36-year-old female who presented with recurrent symptomatic pleural effusion. The onset of symptoms was more than 25 years since insertion of VPLS. Initially managed with multiple therapeutic thoracentesis. Eventually patient underwent revision of shunt to VPS leading to resolution of symptoms.

Challenging diagnosis of pulmonary scedosporiosis in an immunocompetent elderly woman

Iqra Jabeen Mazhar — 2026-10-20

We report a rare case of pulmonary Scedosporium infection in a 64-year-old immunocompetent woman who presented with exertional dyspnoea and intermittent wheezing. Imaging revealed a right lower lobe infiltrate with a Positron Emission Tomography (PET) scan showing hypermetabolic activity, raising concern for malignancy. CT-guided biopsy showed noncaseating granulomas that suggested a broad list of differentials. Eventually, bronchoalveolar lavage cultures identified Scedosporium species. The patient was managed with antifungal therapy. This case highlights the diagnostic challenges of fungal infections in immunocompetent individuals and the importance of considering opportunistic pathogens even in the absence of classical risk factors.

Acetazolamide for selected cases of sleep apnea-related hypercapnia

Constantine Manthous — 2026-10-20

Acetazolamide is a diuretic used in treatment and prophylaxis of mountain sickness. But its mechanism of action may offer utility in selected cases of sleep-apnea-related hypercapnia. We report three case examples where carefully monitored use of acetazolamide was safe and expedited reversal of hypercapnia.

Incidental peripheral reticulation in a high-frequency recreational diver

Taylor Britton — 2026-10-20

Pulmonary barotrauma is a recognized complication of scuba diving, but the long-term pulmonary effects of repetitive subclinical pressure-related injury remain poorly understood. We report a 60-year-old male never-smoker with extensive recreational diving exposure (150–175 dives annually) who was referred for evaluation of incidentally discovered pulmonary nodules and peripheral reticulation on computed tomography (CT). The patient remained asymptomatic with preserved exercise tolerance and an unremarkable pulmonary examination. CT imaging demonstrated mild bilateral peripheral reticulation with subpleural predominance and stable pulmonary nodules without honeycombing, traction bronchiectasis, pleural effusion, or pneumothorax. Although causality cannot be established, chronic repetitive micro-barotrauma represents a biologically plausible mechanism. This case highlights the need for further investigation into the long-term pulmonary consequences of frequent scuba diving exposure.

ST-elevation and complete heart block: a rare presentation of pulmonary embolism

Chanyanuch Nakapakorn — 2026-10-20

Pulmonary embolism can present with non-specific symptoms that overlap with acute coronary syndrome, such as chest pain, shortness of breath, and palpitations. Common electrocardiogram findings include sinus tachycardia and right bundle branch block; ST-segment elevations and complete heart block are extremely rare. We report a case of a 77-year-old man who initially presented with electrocardiogram findings of transient complete heart block and ST-segment elevation, which raised concern for acute coronary syndrome. Left heart catheterization was performed and did not reveal significant obstructive disease. Computed tomography pulmonary angiography with saddle pulmonary embolism suggested that thromboembolic disease was the main cause of the electrocardiogram changes. Clinicians should maintain a high index of suspicion for pulmonary embolism in patients presenting with abnormal electrocardiogram results and any underlying risk factors so as not to miss a life-threatening diagnosis.

Shilajit-associated orgasmic thunderclap headache: A probable case of reversible cerebral vasoconstriction syndrome managed with nerve blocks

Deb Kumar Mojumder — 2026-10-20

A 46‑year‑old man with no prior headache history developed explosive orgasmic headaches six days after starting the Ayurvedic supplement Shilajit. The pain was of instantaneous maximal intensity (10/10), interrupted ejaculation, and later recurred with mild Valsalva‑like exertion. Neuroimaging (CT, CTA, MRI) was negative for hemorrhage or vasoconstriction. Lumbar puncture excluded subarachnoid hemorrhage. Due to low‑normal blood pressure (110/70 mmHg), calcium channel blockers were not used. He underwent a transnasal sphenopalatine ganglion block combined with bilateral greater occipital, lesser occipital, and supraorbital nerve blocks. His headache resolved immediately, and he resumed sexual activity without recurrence within 48 hours. This is the first report linking Shilajit to a probable reversible cerebral vasoconstriction syndrome (RCVS)-like presentation. Combined autonomic and sensory nerve blocks provided rapid headache control when standard vasodilators were contraindicated.

Scedosporium apiospermum infection in a non-healing diabetic foot ulcer patient: First report from Pakistan

Moiz Khan — 2026-10-20

Diabetic foot ulcers (DFUs) are a common and challenging complication of diabetes mellitus, often resulting from neuropathy, vascular insufficiency, trauma, and infection. Fungal infections, though less commonly recognized than bacterial infections, can contribute to non-healing ulcers. Scedosporium apiospermum, an emerging opportunistic fungal pathogen, is a rare cause of skin and soft tissue infections, especially in DFUs. To the best of our knowledge, this report presents the first documented case of a DFU caused by S. apiospermum from Pakistan. A 65-year-old male with a 20-year history of diabetes mellitus, hypertension, and ischemic heart disease presented with two non-healing ulcers on his left leg. Examination and lab testing revealed generalized body edema and ulcers with purulent discharge. Pus and tissue samples from the shin ulcer were cultured on Sabouraud's dextrose agar, leading to the identification of S. apiospermum based on macroscopic and microscopic features. The patient was treated with oral voriconazole, along with wound care and regular dressing changes and scheduled for follow up. This case emphasizes the importance of considering rare fungal pathogens such as S. apiospermum in the differential diagnosis of non-healing DFUs, especially in patients with multiple comorbidities. Mycological evaluation should be performed in diabetic patients with chronic non-healing ulcers, particularly when antibacterial therapy fails. Accurate identification of the fungal pathogen is crucial for appropriate antifungal therapy, as S. apiospermum exhibits resistance to many conventional antifungal agents. A multidisciplinary approach, including glycemic control, wound care, and targeted antifungal therapy, is essential for successful management.

Lipomatous hypertrophy of the interatrial septum: An unexpected finding complicating a routine CABG

Kiriti Vattikonda — 2026-10-20

Lipomatous hypertrophy of the interatrial septum (LHIS) is a benign cardiac non-neoplastic mass. In the vast majority of cases, LHIS is an incidental finding found on cardiac imaging requiring no specific therapy. However, due to its size and location, LHIS can complicate cardiac surgery or structural heart interventional procedures.

Keywords: Lipomatous hypertrophy, interatrial septum, coronary artery bypass, cardiac mass, cardiac surgery

Silently we went round and round...

Connie Nugent — 2026-10-20

Randomized clinical trial data analysis

Shengping Yang — 2026-10-20