Light-Chain (AL) Cardiac Amyloidosis Presenting as Heart Failure With Reduced Ejection Fraction.

Systemic amyloidosis is caused by the extracellular deposition of misfolded proteins in various organs and usually leads to organ dysfunction. The two common subtypes include light-chain amyloidosis and transthyretin amyloidosis. Deposition of these proteins in the heart can lead to infiltrative and restrictive cardiomyopathy, commonly manifesting as heart failure with preserved ejection fraction. However, systolic heart failure with reduced ejection fraction is mainly seen in the advanced stages of the disease. Here, we present the case of a 53-year-old female who presented with new-onset heart failure with reduced ejection fraction with no prior symptoms or diagnosis of amyloidosis and diastolic dysfunction.

A Rare Case of a 54-year-old Male with Vocal Cord Paralysis Secondary to Left Atrial Enlargement.

Ortner's syndrome, a rare condition characterized by hoarseness due to left recurrent laryngeal nerve palsy caused by cardiovascular structural compression, is typically associated with an enlarged left atrium secondary to conditions like mitral stenosis. However, recent studies propose additional causes, including compression between the dilated pulmonary artery and the aorta. We present a case of a 54-year-old male with Ortner's syndrome secondary to severe mitral regurgitation and pulmonary hypertension. Our patient presented with a one-month history of progressive dyspnea and hoarseness. Diagnostic imaging revealed cardiac enlargement, left vocal cord paralysis, and severe mitral valve pathology. A transesophageal echocardiogram revealed mitral valve prolapse and severe flail motion of the anterior leaflet. Further assessments through catheterizations confirmed severely elevated right ventricular systolic pressures and pulmonary hypertension. Attempts at mitral valve replacement were hindered by persistently elevated pulmonary pressures, necessitating transfer for specialized care. Our case highlights the broad differentials for hoarseness, emphasizing rare cardiovascular origins such as Ortner's syndrome, involving compression of the left recurrent laryngeal nerve. Early identification is essential, often necessitating comprehensive head and neck examination and radiological studies. While management depends on nerve injury duration, a timely intervention targeting the underlying cardiovascular pathology, including appropriate medical therapy and surgical approaches, can potentially alleviate or reverse nerve damage. Furthermore, our case underscores the significance of initiating guideline-directed medical therapy early in chronic cardiovascular conditions to mitigate cardiac remodeling and prevent complications like left recurrent laryngeal nerve palsy. Timely identification and targeted management of underlying cardiovascular etiologies are crucial in preventing Ortner's syndrome.

Benign Pneumoperitoneum Following Mitral Valve Replacement.

The pneumoperitoneum refers to the presence of free air inside the abdominal cavity. This finding is usually a sequela of a gastrointestinal tract perforation. Still, in rare instances, it can present after cardiac surgery due to the proximity of the peritoneal cavity and pericardium, allowing air to enter the peritoneal cavity. Our patient was a 63-year-old female who initially presented for revision of the mitral valve replacement. A chest X-ray on postoperative day 13 revealed a 6.6 cm lucency under the right diaphragm suggestive of pneumoperitoneum. She was discharged after serial chest X-rays revealed a decrease in the size of the pneumoperitoneum. Twelve days later, our patient was readmitted, as another chest X-ray revealed that the size of the pneumoperitoneum was again increasing. An endoscopy was performed, but it did not reveal any lesions or etiology that would lead to a leak from the gastrointestinal tract. Finally, due to the benign nature of the pneumoperitoneum and the decrease in its size over the following days, we opted for conservative management, and she was discharged again. This case emphasizes the rare occurrence of benign pneumoperitoneum post-mitral valve surgery. While surgery may not always be required for asymptomatic cases, careful vigilance post-cardiac surgery remains crucial to detect potential abdominal complications promptly.

Proceed with Caution: Social Acceptability of Forestry Practices in Puerto Rico among Members of Local Environmental Organizations, Academia and Professional Associations.

Social acceptability of forestry practices plays a key role in defining sustainable forestry policies and strategies. In this study an online survey was distributed among members of environmental, non-governmental, professional, and academic organizations to assess the acceptability of forestry practices in Puerto Rico among members of civic society interested in environmental management issues. Participants were asked about their perception of forest uses, their preference of tree harvesting technologies, methods that may apply in small scale wood production settings, and trust in organizations providing forest information. We also inquired about attitudes towards economic activity in forests and the impact of such activity on recreation and biodiversity. The results show that even though participants do not place a high priority on economic development through forestry activities, acceptance of forest management for wood harvesting will be possible by considering adherence to particular forestry technologies and methods to safeguard current recreation activities and biodiversity conservation. Social acceptability information would be worthwhile when seeking consensus among a broader group of local stakeholders. As a next step we suggest the creation of a council constituted by diverse forestry sector stakeholders that would engage in a strategic planning exercise to delineate a clear road map that can guide short and long-term sustainable forest management, including wood industry development.

Acute Pancreatitis-Induced Thrombosis of Celiac Artery: An Unusual Complication of Acute Pancreatitis.

Acute pancreatitis can lead to both local and systemic complications, including pseudocysts, biliary obstruction, duodenal obstruction, sepsis, necrosis, vascular complications, and multiorgan failure. Vascular complications following acute pancreatitis are associated with a high risk of morbidity and mortality due to their thrombotic and hemorrhagic effects. When thrombosis is present, it usually involves the splanchnic venous system, but it is rarely seen in the arterial system. Celiac artery thrombosis is rare with only a few cases reported in the literature. In this case, we present a 65-year-old Hispanic female who presented to the emergency department with abdominal pain and nausea, with computed tomography angiography (CTA) of the abdomen revealing acute pancreatitis with thrombosis of the celiac artery, which was managed with anticoagulation.

Acute Fulminant Cerebral Edema Caused by Influenza Type B in an 18-Year-Old Female: A Rare Case.

Most influenza B infections are self-limited, but in some instances, they can cause substantial morbidity and mortality due to complications. Acute fulminant cerebral edema (AFCE) is one of the rare complications. AFCE, a consequence of acute encephalitis, presents as acute onset of alteration in mental status, seizure, and/or headache followed by rapidly progressive encephalopathy, often leading to death. The exact pathophysiology of AFCE is unknown, but many pathomechanisms have been proposed. We present a case of an 18-year-old female in excellent physical condition who presented with respiratory insufficiency after being recently diagnosed with influenza B infection. Three days later, she developed acute encephalopathy, leading to brain death. To our knowledge, this rare case of AFCE developing following influenza B infection is the first reported case outside the pediatric population.

Ileocecal Mesentery Arteriovenous Malformation as a Rare Cause of Ectopic Variceal Bleeding in a 58-Year-Old Male With Cirrhosis.

Ectopic varices can be defined as dilated portosystemic venous collaterals that are located at a site other than the esophagus or stomach. These varices can be seen in patients with underlying portal hypertension, but bleeding from them is quite rare. The bleeding usually occurs in patients with a history of intra-abdominal surgery and adhesions. These varices are commonly found in the duodenum or rectum, but they can be present anywhere along the gastrointestinal tract. Currently, there are no well-established guidelines regarding the diagnosis and management of these variceal bleeds, and further investigations with randomized controlled or large-scale trials are required. Here, we report an unusual case of ectopic variceal bleeding from an ileal arteriovenous malformation (AVM), which presented as syncope associated with an acute abdomen in a patient with no prior history of intra-abdominal surgery.

Fulminant Hepatic Failure With Minimal Alcohol Consumption in a 25-Year-Old Female With Hereditary Hemochromatosis: A Rare Case.

Hereditary hemochromatosis (HH) is an inherited disorder in which organ damage and other clinical manifestations are commonly seen in patients with a homozygous mutation involving C282Y of the HFE gene, causing increased iron absorption in the intestine. The liver is the primary site of iron deposition, and excessive iron overload can eventually lead to hepatic cirrhosis. Patients who drink significant amounts of alcohol are more likely to develop cirrhosis, and in females, it is commonly seen after menopause. We describe a young female with hereditary hemochromatosis who developed fulminant hepatic failure with minimal alcohol consumption at age 25.

An Unusual Case of Nonbacterial Thrombotic Endocarditis Attributable to Malignancy.

Nonbacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a condition characterized by the deposition of thrombi and fibrin on normal or degenerated cardiac valves in the absence of microorganisms. We report a case of a 60-year-old male with nonbacterial thrombotic endocarditis found on transesophageal echocardiogram (TEE) after a normal TEE just one month prior. Our patient presented with abdominal pain associated with poor appetite and unintentional 20-pound weight loss for one month. Chest computed tomography revealed the presence of a mass-like opacification in the right lung middle lobe with moderate pericardial effusions. A biopsy of the mass confirmed malignancy consistent with lung primary adenocarcinoma. Subsequently, during hospitalization, the patient developed left lower extremity pain. Arterial ultrasound showed occlusion of the distal left popliteal artery for which he underwent thrombectomy of the left superficial femoral artery, balloon angioplasty of the left posterior tibial artery, and left popliteal artery. Repeat TEE during current hospitalization revealed a large 2 cm vegetation on the noncoronary cusp of the aortic valve. Studies for infective endocarditis were unremarkable. Subsequently, he was treated with aortic valve replacement and anticoagulation. After discharge, he returned with bilateral occipital infarcts four days later and expired.

Photochemical Relaxation Pathways in Dinitropyrene Isomer Pollutants.

Dinitropyrenes are polycyclic aromatic pollutants prevalent in the environment. While their transformations by sunlight in the environment have been documented, the effect that the nitro-group substitution pattern has on the relaxation pathways has not been extensively studied. In this contribution, the steady-state and femtosecond-to-microsecond excited-state dynamics of 1,3-dinitropyrene and 1,8-dinitropyrene isomers are investigated upon visible light excitation at 425 nm and compared with those recently reported for the 1,6-dinitropyrene isomer. The experimental results are complemented with ground- and excited-state density functional calculations. It is shown that excitation at 425 nm results in the ultrafast branching of the excited-state population in the S1 state to populate the triplet state in ca. 90% yield and to form a nitropyrenoxy radical in less than 10% yield. In addition, the position of the NO2 group does not affect significantly the excited-state relaxation mechanism, while it does influence the absorption and fluorescence spectra, the fluorescence, triplet, singlet oxygen, and photodegradation yields, as well as the relative yield of radical formation. Radical formation is implicated in the photodegradation of these pollutants, while in the presence of hydrogen donors, direct reactions from the triplet state are also observed.

The Photochemical Branching Ratio in 1,6-Dinitropyrene Depends on the Excitation Energy.

Nitropolycyclic aromatic hydrocarbons constitute one of the most disconcerting classes of pollutants. Photochemical degradation is thought to be a primary mode of their natural removal from the environment, but the microscopic mechanism leading to product formation as a function of excitation wavelength is poorly understood. In this Letter, it is revealed that excitation of 1,6-dinitropyrene with 425, 415, or 340 nm radiation leads to an increasing amount of radical production through photodissociation at the expense of triplet-state population-the two primary reaction pathways in this class of pollutants. Radical formation requires overcoming an energy barrier in the excited singlet manifold. This activation energy explains the large fraction of the initial singlet-state population that intersystem crosses to a doorway triplet state, instead of leading overwhelmingly to photodissociation. The unforeseen excitation wavelength dependence of this branching process is expected to regulate the photochemistry of 1,6-dinitropyrene and possibly of other nitroaromatic pollutants in the environment.

Assessment of Concentrations of Heavy Metals and Phthalates in Two Urban Rivers of the Northeast of Puerto Rico.

Urbanization adjacent to rivers has increased in recent years and is considered a source of environmental contamination. The resulting increase in number of urban rivers in highly populated areas, such as the Caribbean island of Puerto Rico, has led to the appearance of synthetic as well as naturally occurring chemicals not previously observed nor regularly monitored in freshwater habitats. Some of these chemicals, such as heavy metals and plasticizers, have been shown to affect endocrine, respiratory, and nervous system function in animals and humans, even at relatively low concentrations. The purpose of this study was to measure concentrations of such emergent contaminants on rivers of urbanized areas on the northeast of Puerto Rico, as one element in the assessment of the impact of urbanism on water quality in these communities. To accomplish this, we used Inductively Coupled Plasma and Gas Chromatography Mass Spectrometry to measure amounts of heavy metals and phthalates, respectively, in superficial water of three rivers of Puerto Rico: Mameyes (non-urban), Río Piedras (urban river without a dam), and La Plata (urban river with a dam). The urban rivers had significantly higher concentrations of heavy metals arsenic, barium, cadmium, manganese, and antimony, when compared with the reference non-urban river. Manganese was the only metal found in concentrations higher than limits established by the EPA for drinking water. Of eight phthalates amenable to measurement with the chosen protocol and instrumentation, only dibutyl phthalate was detected, only in the La Plata river, and at concentrations ranging from 3 to 8 parts-per-billion. These findings suggest that urbanism close to rivers of Puerto Rico is likely having an impact on water quality and thus further study to identify the potential sources, as well as the inclusion of these emergent contaminants on the list of chemicals regularly monitored by government agencies is justified.

Synthesis of enantiopure 1,2-azido and 1,2-amino alcohols via regio- and stereoselective ring-opening of enantiopure epoxides by sodium azide in hot water.

A practical and convenient method for the efficient and regio- and stereoselective ring-opening of enantiopure monosubstituted epoxides by sodium azide under hydrolytic conditions is reported. The ring-opening of enantiopure styryl and pyridyl (S)-epoxides by N3- in hot water takes place preferentially at the internal position with complete inversion of configuration to produce (R)-2-azido ethanols with up to 99% enantio- and regioselectivity, while the (S)-adamantyl oxirane provides mainly the (S)-1-adamantyl-2-azido ethanol in excellent yield. In general, 1,2-amino ethanols were obtained in high yield and excellent enantiopurity by the reduction of the chiral 1,2-azido ethanols with PPh3 in water/THF, and then converted into the Boc or acetamide derivatives.

Photooxidation mechanism of levomepromazine in different solvents.

Unwanted photoinduced responses are well-known adverse effects of most promazine drugs, including levomepromazine (LPZ, Levoprome(®) or Nozinan(®)). This drug is indicated in psychiatry primarily for the treatment of schizophrenia and other schizoaffective disorders. Levomepromazine's particular sedative properties make it especially fit for use in psychiatric intensive care. Nevertheless, it is photolabile under UV-A and UV-B light in aerobic conditions resulting in the formation of its sulfoxide. The LPZ photochemistry in acetonitrile (MeCN) is completely different from that in methanol (MeOH) and phosphate buffer solutions (PBS, pH = 7.4). The major photoproduct in PBS and MeOH under aerobic conditions is levomepromazine sulfoxide (LPZSO), although the amount is considerably higher in the aqueous environment. The corresponding main photoproduct in MeCN could not be characterized. The destruction quantum yields of LPZ in PBS, MeOH and MeCN are 0.13, 0.02 and <10(-3), respectively. It is further demonstrated that LPZSO does not form by the reaction of singlet oxygen with ground-state LPZ. This oxidation product is actually produced by the reaction of the cation radical of LPZ (LPZ·(+)) with molecular oxygen. This cation radical in turn, is produced by an electron transfer process between the (3) LPZ* and ground-state molecular oxygen.

Solvent dependence of the photophysical properties of 2-chlorothioxanthone, the principal photoproduct of chlorprothixene.

2-chlorothioxanthone (CTX) is used as photoinitiator for the reticulation of synthetic resins and for the preparation of pharmaceuticals. It was previously determined that CTX is the primary photoproduct of z-chlorprothixene (CPTX) when irradiated at 313 nm and is formed in an autocatalyzed reaction through an energy-transfer mechanism (Piñero et al. [2009] Photochem. Photobiol., 85, 895-900). In this work, the photophysical properties of CTX were measured in acetonitrile/water solutions to determine if their magnitude can affect the side effects of CPTX. The results show that CTX has higher absorption coefficients in the visible region (400-420 nm) and higher triplet quantum yields than its parent compound. Similar to TX, both properties strongly depend on the solvent polarity/hydroxylicity. The quantum yield of the triplet intermediate is very close to the value of the phenothiazine triplets. The phenothiazines are the most phototoxic antidepressants. Therefore, given the appropriate microenvironment, the photosensitization side effects of CPTX can be intensified on the production of CTX.

A model for predicting daily peak visitation and implications for recreation management and water quality: evidence from two rivers in Puerto Rico.

Visitor use surveys and water quality data indicates that high visitor use levels of two rivers in Puerto Rico does not appear to adversely affect several water quality parameters. Optimum visitor use to maximize visitor defined satisfaction is a more constraining limit on visitor use than water quality. Our multiple regression analysis suggests that visitor use of about 150 visitors per day yields the highest level of visitor reported satisfaction, a level that does not appear to affect turbidity of the river. This high level of visitor use may be related to the gregarious nature of Puerto Ricans and their tolerance for crowding on this densely populated island. The daily peak visitation model indicates that regulating the number of parking spaces may be the most effective way to keep visitor use within the social carrying capacity.