Browsing by Author "Segovia, Alicia"
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Item Cardiac troponin elevation in a middle-aged female consistent with COVID myocarditis(2024-03-21) Segovia, Alicia; Gulley, Taylor; Bautista, TrisshaBackground: Coronavirus (SARS-CoV-2) is known to cause severe acute respiratory syndrome, but more recently, it has been linked to increased cardiac involvement. It has recently been suggested by evidence that increased troponin levels seen in patients with severe COVID-19 reliably identifies myocardial damage. However, few longitudinal observations on troponin levels in mild COVID-19 cases over time have been published. Given its recent discovery, our understanding of the long-term effects of Coronavirus infections on individuals remains incomplete. The Center for Disease Control has recently estimated an overall incidence of myocarditis secondary to COVID-19 infection to be at around 150 cases per 100000 individuals in the United States alone. Case Presentation: A 45 year-old caucasian female with past medical history of T2DM, HTN, HLD, CKD, PCOS, and past COVID-19 infection presented to the Emergency Department with recurrent chest pain associated with shortness of breath, left hand numbness, and diaphoresis while at rest. A month prior, this female was admitted for NSTEMI with cardiac catheterization showing normal coronary arteries, echo demonstrating EF of 50-55% without wall motion abnormalities, and CTA demonstrating no signs of PE. Patient had been compliant with all medications since discharge, states nitroglycerin helped with pain, and had not been taking aspirin due to scheduled hysterectomy. Initial troponin levels were 3.409 ng/mL (0.00-0.013), glucose level 107, and platelet count was 426. A focused cardiac ultrasound performed by the emergency physician demonstrated absence of pericardial effusion, normal LV function, mild LV dilation, absent RV dilation, and absence of pericardial tamponade. EKG showed no signs of acute ischemia and repeated EKG was normal. However, cardiology was consulted due to evidence of myocardial injury as indicated by elevated troponins. The patient received ASA, Plavix, and Lovenox in the ED and heparin was started as part of ACS protocol. Tylenol 650 mg Q6H PRN and Morphine 2mg Q30M PRN were added for pain. Troponin levels continued to trend upward to 7.115 over the course of 7 days. Normal studies and images led to the conclusion that this patient would benefit from a heart MRI and outpatient medical management. Conclusions: This case highlights the long-term impact of Coronavirus infections on cardiac health, as indicated by notable elevations in troponin levels. It also demonstrates the atypical presentation of elevated troponin levels in the absence of acute ischemic myocardial injury.Item The Effects of Low Dose Naltrexone in Children with Chronic Pain(2023) Olsen, Dana; Darvesh, Kamran; Segovia, Alicia; Hamby, Tyler; Campbell, Throy; Gandhi, Artee; Brooks, MeredithBackground: Naltrexone is an FDA-approved opioid antagonist. At one-tenth the usual dosage, it is thought to have antinociceptive effects mediated through microglial cell inactivation, which can be helpful for chronic pain states, such as fibromyalgia, in adults.[1,2] The percentage of youth that are affected from chronic pain conditions is estimated to be at 15-35%.[3] The present study is the first to examine the efficacy of low-dose naltrexone (LDN) in treating chronic pain in pediatric patients. Methods: A retrospective chart review was conducted on pediatric patients who were prescribed LDN between 2019 and 2022 for a chronic pain condition. At the start of LDN treatment and for each pain-clinic visit in the subsequent year, pain scores and functional disability inventory (FDI) scores were collected. Multilevel cumulative logit models and multilevel linear models were used to determine the effect of time of LDN on pain and FDI scores, respectively. Results: There were 168 patients who met inclusion criteria. As compared to visits without LDN, there was no statistically significant difference in pain scores for visits in which the patient had been on LDN for 0-2 months (p=0.88) or for ≥2 months (p=0.25). As compared to visits without LDN, FDI scores significantly decreased after taking LDN for ≥2 months (p< 0.001) but not for 0-2 months (p=0.12). Conclusion: Children who took LDN had a significant improvement in daily function as compared to before taking LDN. Citations: 1. Parkitny, L., & Younger, J. (2017). Reduced Pro-Inflammatory Cytokines after Eight Weeks of Low-Dose Naltrexone for Fibromyalgia. Biomedicines, 5(2), 16. https://doi.org/10.3390/biomedicines50200162. YOUNGER, J., NOOR, N., MCCUE, R., MACKEY, S. (2013). LOW-DOSE NALTREXONE FOR THE TREATMENT OF FIBROMYALGIA. ARTHRITIS AND RHEUMATISM. HTTPS://DOI.ORG/10.1002/ART.37734 3. KING, S., CHAMBERS, C. T., HUGUET, A., MACNEVIN, R. C., MCGRATH, P. J., PARKER, L., & MACDONALD, A. J. (2011). THE EPIDEMIOLOGY OF CHRONIC PAIN IN CHILDREN AND ADOLESCENTS REVISITED: A SYSTEMATIC REVIEW. PAIN, 152(12), 2729–2738.Item Elevated Troponins in a Middle-Aged Male Presenting with Cough, Dyspnea, and Chest Pain(2024-03-21) Bautista, Trissha Belle; Gulley, Taylor Cemone; Segovia, AliciaBackground: Respiratory complications from SARS-CoV-2 infection are most commonly reported; however, adverse cardiac events such as acute coronary syndromes, thromboembolic syndromes, and myocarditis have been described. A study by the Centers for Disease Control estimates an overall incidence of COVID-related myocarditis to be at around 150 cases per 100000 individuals in the United States. Case Presentation: A 45-year-old male with a past medical history of exercise-induced asthma, obstructive sleep apnea, and gastroesophageal reflux disease was admitted to our hospital from the emergency department due to chest pain, shortness of breath on exertion, and cough. Patient reports having a cough that started three days prior to ED presentation. He managed his cough conservatively over the weekend, but his symptoms increased in severity and he developed a headache and chest pain radiating to his neck and jaw. Upon presentation to the ED, patient endorses the chest pain to be resolved. His vitals at the ED were temperature 97.8F, HR 97, RR 16, BP (MAP) 121/82 (95), O2 96% on room air. At the ED, his electrocardiogram showed ST depression in leads III and aVF, but no ST elevations to suggest STEMI. Initial workup shows unremarkable electrolytes, mild hyperglycemia with glucose 119 mg/dL, mild transaminase elevation with ALT 46 IU/L and AST 46 IU/L, and elevated troponin 0.308 ng/mL (normal: 0.00-0.013 ng/mL). Patient also tested positive for SARS-CoV-2 via rapid test. Serial troponins were monitored in the ED and rose to 0.910 ng/mL then 4.446 ng/mL before admission to inpatient floor. No radiographic evidence of acute pulmonary disease was identified. ACS protocol was initiated and patient received dual antiplatelet therapy, heparin, and metoprolol/lisinopril. Cardiology was consulted and an echocardiogram was performed which showed normal chamber sizes, normal left ventricular systolic function, and mild concentric left ventricular hypertrophy. Due to patient’s stable clinical presentation and echocardiogram results, the cardiologist recommended serial troponin measurements and felt that a stress test was not indicated. Troponins continued to trend upward to 16.7 ng/mL two days later. Conclusions: This case highlights the cardiac manifestations of COVID-19 in a patient with stable clinical presentation and markedly elevated troponin levels. The magnitude of troponin elevation in hospitalized patients with COVID-19 is typically associated with worse outcomes; however, this case illustrates the wide array of clinical cardiac presentation in patients with COVID-19-related myocardial injury.Item Single Agent Opioid vs Combination Agent Opioids in Postoperative Pain Control(2023) Aishat, Muhammad; Segovia, Alicia; Hamby, Tyler; Campbell, Throy; Brooks, Meredith; Gandhi, ArteeIntroduction: Treating post-surgery pain in pediatric populations often involves combination opiates, commonly hydrocodone and oxycodone. Unfortunately, this approach can lead to confusion for parents and concerns for overdose, as half of pediatric opioid prescriptions are considered high-risk. An opioid stewardship committee was established to oversee prescribing guidelines at Cook Children’s Medical Center (CCMC). This large-scale retrospective study examined whether educational interventions increased the likelihood of single-agent opioid prescriptions for post-surgery pain. This practice allows providers to more freely utilize NSAIDs and acetaminophen for postoperative pain. Methods: This was a retrospective single-center quality improvement (QI) project of all patients, who were prescribed opioids after surgery at CCMC in Fort Worth, TX between 3/1/2018 and 2/28/2022. Logistic regression was used to determine whether likelihood of single-agent (vs. combination) opioid prescriptions differed by intervention and department. Results: There were 5227 (38.30%) pre-intervention procedures and 8419 (61.70%) post-intervention procedures. Post-intervention procedures (vs. pre-intervention) were statistically significantly more likely to result in single-agent, rather than combination, opioid prescriptions (88.10% vs. 8.84%, OR=79.62, p<0.0001), and likelihood of single-agent opioid prescriptions significantly differed by department (p<0.0001). The proportion of single-agent opioids prescribed increased post-intervention in all 7 departments examined, and the proportion increased by 70% in the 3 departments with the most procedures: orthopedics, urology, and otolaryngology. Conclusion: Ongoing educational efforts by the Opioid Stewardship Committee have resulted in a sustained change in prescribing practices in multiple surgical departments from the use of combination to single-agent opioids.