The Plumber Versus Electrician Dilemma: To Bypass or to Defibrillate?

We present a unique case of an 80-year-old male who presented to our emergency department following cardiac defibrillation when he was found to be in polymorphic ventricular tachycardia (VT) after a syncopal event while at cardiac rehabilitation. He had known coronary artery disease and had a four-vessel coronary artery bypass graft (CABG) 20 years prior to presentation. He underwent left heart catheterization (LHC) two months prior to the syncopal event for worsening shortness of breath and the decision at that time was to proceed with medical management and intervene with redo-CABG if shortness of breath did not improve or progressively worsened. While admitted under our care after the polymorphic VT event, we faced the dilemma of whether to proceed with redo-CABG first since cardiac ischemia is a common cause of polymorphic VT or whether to insert an implantable cardioverter-defibrillator (ICD) before proceeding with redo-CABG. We present the current literature that addresses ICD implantation for secondary prevention and our approach to this complicated case.

Bicuspid Aortic Valve Endocarditis Caused by Streptococcus sanguinis: A Case Report.

Antibiotic prophylaxis prior to dental work in bicuspid aortic valve (BAV) patients is currently a matter of debate. The American Dental Association does not require those with native BAV to receive antibiotic prophylaxis prior to dental work as BAV is considered an "intermediate" risk for infective endocarditis (IE). We present the case of a 63-year-old male, with a medical history of BAV, who acquired Streptococcus sanguinis IE after a routine dental cleaning four months prior to initial onset of symptoms. He exhibited new-onset and severe aortic regurgitation at presentation, requiring urgent aortic valve replacement to restore valve function. BAV patients are at high risk of IE, emphasizing the need for prophylactic antibiotics in dental cleaning as well as invasive dental procedures in those with BAV.

Incidental Finding of Thoracic Aortic Dissection in a Patient Post-Coronary Artery Bypass Graft Surgery.

Thoracic aortic dissection (TAD) is an uncommon but potentially fatal complication of coronary artery bypass graft (CABG). Most patients present to the emergency room with severe chest pain, shortness of breath, or after a syncopal episode. Asymptomatic patients pose a challenge to diagnosis. The authors present a case of an 82-year-old male, who was found to have an incidental finding of a 5-cm ascending aortic aneurysm with an intimal dissection flap four months after CABG. Extensive workup on possible risk factors such as underlying aortic diseases, genetic conditions, and hypertensive crisis proved noncontributory. Aggressive blood pressure control was achieved, and the patient was observed in the intensive care unit before discharge with follow-up. The purpose of this case report is to alert clinicians of TAD after CABG and highlight the importance of developing a protocol for follow-up and monitoring of patients who have undergone CABG, as complications can be asymptomatic. Early and accurate diagnosis of TAD as a complication of CABG is essential to improving survival rates.

Principles of Surgery in Head and Neck Cutaneous Melanoma.

Surgical management of head and neck melanoma starts from the primary biopsy of the cutaneous site by a narrow excision with a 1 to 3 mm margins. The margin should include the whole breadth and sufficient depth of the lesion. The key is not to transect the lesion. With the advent of molecular testing, gene expression profiling, and immunotherapies, the surgical management of advanced melanoma has changed. Sentinel lymph node biopsy is an essential armamentarium for T2a and higher staging/greater than 1 mm thick and advance stage disease. Molecular pathogenesis and cancer immunology are recognized in the recent treatment protocols along with surgery in advanced stages of melanoma.

Modified Papanicolaou staining for oral swab samples stored long term.

Pathologists collect swab samples for Papanicolaou (Pap) staining to diagnose various diseases including cancer and HIV. Time constraints and limited resources, may preclude staining a sample immediately. To re-confirm results, samples must be frozen for later analysis. We present a method for Pap staining cells that have been stored long term. An effective method for Pap staining of frozen cells should enable flexibility for processing samples.

Impact of Social Determinants of Health on the Emerging COVID-19 Pandemic in the United States.

A novel coronavirus (2019-nCoV) caused a global pandemic in the months following the first four cases reported in Wuhan, China, on December 29, 2019. The elderly, immunocompromised, and those with preexisting conditions-such as asthma, cardiovascular disease (CVD), hypertension, chronic kidney disease (CKD), or obesity-experience higher risk of becoming severely ill if infected with the virus. Systemic social inequality and discrepancies in socioeconomic status (SES) contribute to higher incidence of asthma, CVD, hypertension, CKD, and obesity in segments of the general population. Such preexisting conditions bring heightened risk of complications for individuals who contract the coronavirus disease (COVID-19) from the virus (2019-nCoV)-also known as "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2). In order to help vulnerable groups during times of a health emergency, focus must be placed at the root of the problem. Studying the social determinants of health (SDOH), and how they impact disadvantaged populations during times of crisis, will help governments to better manage health emergencies so that every individual has equal opportunity to staying healthy. This review summarizes the impact of social determinants of health (SDOH) during the COVID-19 pandemic.