Caribbean Medical University

Myasthenia gravis (MG) is a heterogeneous autoimmune neuromuscular disorder with distinct serological subtypes, including antibodies against acetylcholine receptors (AChRs), MuSK, and LRP4. Despite increasing recognition of these subtypes, clinical practice still lacks a standardized, subtype-specific approach to diagnosis, characterization, and management. Current treatment strategies are often applied uniformly, without fully accounting for differences in disease phenotype, prognosis, and therapeutic response among antibody-defined groups. This review provides a comprehensive overview of adult MG, focusing on the various autoantibody subtypes and their implications for pathogenesis, clinical features, diagnosis, and management. We highlight how combining serological findings with clinical subtyping can inform a more personalized approach to therapy and better align treatment decisions with disease biology. By emphasizing the clinical relevance of serological classification, this review aims to bridge the gap between immunopathological understanding and individualized patient care in MG.

INTRODUCTION:Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI) are standard treatments for Multivessel Coronary Artery Disease (MVD). Their long-term comparative effectiveness remains debated. METHOD:A systematic review and meta-analysis of randomized and observational studies was conducted, including patients with MVD followed for ≥5 years. Data were pooled using randomor fixed-effects models, depending on the level of heterogeneity. RESULTS:Thirteen studies met the inclusion criteria. CABG was associated with reduced all-cause mortality (RR 0.82, 95% CI 0.72-0.91) and fewer repeat revascularizations (RR 1.98, 95% CI 1.74-2.26) compared with PCI. Stroke risk was slightly higher after CABG. DISCUSSION:Findings suggest CABG provides superior survival and event reduction in long-term follow-up, particularly in higher-risk subgroups. However, the modestly increased stroke risk highlights the need for individualized decision-making, taking into account patient comorbidities, anatomy, and surgical suitability. CONCLUSION:CABG offers long-term survival and durability advantages over PCI in MVD, while PCI remains suitable for patients with lower-risk anatomy or when surgery is contraindicated.

Abstract Introduction/Rationale Acute myocardial infarction (AMI) remains a leading cause of in-hospital mortality. Obstructive sleep apnea (OSA) has increasingly been recognized as a modifiable contributor to adverse cardiovascular outcomes. Patients with AMI and OSA may experience worse clinical outcomes; however, evidence regarding factors associated with in-hospital mortality in this population remains limited. Identifying these factors may enhance risk assessment and management strategies. Methods A retrospective cross-sectional analysis of the National Inpatient Sample (NIS) from 2018 to 2021 was conducted. Adult hospitalizations (≥ 18 years) with primary diagnosis of acute myocardial infarction (ICD-10 I21.0-I21.4, I21.9) and a concurrent diagnosis of obstructive sleep apnea (G47.33) were included. The primary outcome was in-hospital mortality; secondary outcomes included length of hospital stay. Demographics and clinical comorbidities were analyzed as potential predictors of the outcome. Associations between categorical variables and mortality were evaluated using the Chi-square test, with statistical significance set at p < 0.05. Statistical analyses were performed using IBM SPSS Statistics version v25.0. Results A total of 20,771 patients with acute myocardial infarction and obstructive sleep apnea were included, with a mean age of 67 years; 66.3% of the patients were male. The in-hospital mortality rate was 5.2%. Mortality was significantly higher among patients aged ≥60 years (p < 0.001). Race showed a mild association with higher mortality in Caucasian patients (p = 0.03). Comorbid conditions, including chronic kidney disease (p < 0.001), congestive heart failure (p < 0.001), diabetes mellitus (p = 0.032), chronic obstructive pulmonary disease (p = 0.004), and coagulopathy (p = 0.018), were significantly associated with mortality. No significant associations were observed for hypertension, obesity, dyslipidemia, alcohol use, or tobacco use. Discussion Our findings indicate that cardiorenal and pulmonary comorbidities increase the risk of in-hospital mortality in patients with AMI and OSA. These conditions may compromise hemodynamic stability and respiratory function, worsening the ischemic injury and recovery time, leading to longer hospitalizations and poorer outcomes. Conclusion Patients with AMI and OSA present elevated in-hospital mortality, especially when cardiorenal or pulmonary comorbidities coexist. Early identification and targeted management are crucial for reducing mortality and improving patient outcomes. This abstract is funded by: None

BACKGROUND:Heart failure with reduced ejection fraction (HFrEF) remains associated with high rates of hospitalization and early readmission, with approximately 20-25% of patients readmitted within 30 days. Sacubitril/valsartan is a key component of guideline-directed medical therapy, but the optimal timing of initiation during hospitalization versus after discharge remains uncertain. OBJECTIVE:This study aimed to evaluate whether initiation of sacubitril/valsartan during hospitalization is associated with improved short-term outcomes compared with delayed outpatient initiation. METHODS:This retrospective cohort study used the MIMIC-IV database. Adult patients hospitalized with HFrEF who received sacubitril/valsartan were included. Patients were classified into in-hospital initiation and delayed outpatient initiation groups based on medication timing. The primary outcome was 30-day hospital readmission, and the secondary outcome was in-hospital mortality. Multivariable logistic regression was used to assess associations after adjustment for age, sex, race, and the Charlson Comorbidity Index. RESULTS:A total of 4,156 hospitalizations were included. There was no significant association between timing of sacubitril/valsartan initiation and 30-day readmission (aOR=0.91; 95% CI: 0.50-1.67; p=0.764). Higher comorbidity burden was associated with increased readmission risk (aOR=1.04; 95% CI: 1.00-1.07; p=0.035). No significant difference in in-hospital mortality was observed between groups. CONCLUSION:Timing of sacubitril/valsartan initiation was not associated with short-term outcomes. Comprehensive management strategies beyond the timing of therapy may be important for improving outcomes in this population.

Osteomyelitis is a devastating bone infection that occurs in individuals usually with significant comorbidities. This disease may lead to further major medical problems if not diagnosed and treated promptly. This case involves a 51-year-old male with multiple comorbidities, which led to the diagnosis of suspected chronic osteomyelitis. Laboratory work showed leukocytosis, decreased kidney function, anemia of unknown origin, and physical examination showing multiple skin ulcers. CT imaging supported the diagnosis of suspected chronic osteomyelitis. Due to the limited standard diagnostic testing modalities for osteomyelitis, significant clinical judgment had to be used and applied to treat osteomyelitis in this case. These diagnostic limitations included the absence of MRI evaluation, bone biopsy and subsequent histopathologic examination, as well as wound culture data. The antimicrobial drug use was influenced by the patient's underlying chronic kidney disease, which influenced treatment with cefepime and doxycycline rather than vancomycin. This case highlights the complexity of diagnosing and treating medically complex patients, with limited definitive diagnostic modalities, such as bone histopathology, wound cultures, and imaging, thus relying on clinical decision-making to formulate treatment options.