A meta-analysis of left ventricular dysfunction in ankylosing spondylitis.

Ankylosing spondylitis (AS) is a chronic inflammatory arthritis affecting the spine, presenting a considerable morbidity risk. Although evidence consistently indicates an elevated risk of ischemic heart disease among AS patients, debates persist regarding the likelihood of these patients developing left ventricular dysfunction (LVD). Our investigation aimed to determine whether individuals with AS face a greater risk of LVD compared to the general population. To accomplish this, we identified studies exploring LVD in AS patients across five major databases and Google Scholar. Initially, 431 studies were identified, of which 30 met the inclusion criteria, collectively involving 2933 participants. Results show that AS patients had: (1) poorer Ejection Fraction (EF) [mean difference (MD): -0.92% (95% CI: -1.25 to -0.59)], (2) impaired Early (E) and Late (atrial-A) ventricular filling velocity (E/A) ratio [MD: -0.10 m/s (95% CI: -0.13 to -0.08)], (3) prolonged deceleration time (DT) [MD: 12.30 ms (95% CI: 9.23-15.36)] and, (4) a longer mean isovolumetric relaxation time (IVRT) [MD: 8.14 ms (95% CI: 6.58-9.70)] compared to controls. Though AS patients show increased risks of both systolic and diastolic LVD, we found no significant differences were observed in systolic blood pressure [MD: 0.32 mmHg (95% Confidence Interval (CI): -2.09 to 2.73)] or diastolic blood pressure [MD: 0.30 mmHg (95% CI: -0.40 to 1.01)] compared to the general population. This study reinforces AS patients' susceptibility to LVD without a notable difference in HTN risk.

Iatrogenic Pituitary Shutdown: A Rare Adverse Event of Programmed Cell Death-Ligand 1 Inhibitor.

Immune checkpoint inhibitors (ICIs) are one of the novel treatment strategies for malignancies, and their wide use has led to the emergence of immune-related adverse events (irAEs). Most of them have been reported in patients taking cytotoxic T lymphocyte-associated protein 4 inhibitors and are rarely reported among those taking programmed cell death-ligand protein 1 inhibitors. Here is a 74-year-old man who underwent treatment with atezolizumab for 33 weeks for hepatocellular carcinoma before presenting with chronic symptoms and laboratory results consistent with central adrenal insufficiency. Brain imaging did not show a possible culprit. He was incidentally found to have low thyrotropin (TSH) and low thyroxine prior to his presentation and began replacement with no further workup prior. We advocate keeping a low threshold for the diagnosis of adrenal insufficiency among patients taking ICIs and monitoring their pituitary hormones on a regular basis. Also, it is crucial to rule out pituitary hormonal deficiency among patients with central hypothyroidism prior to initiating replacement.

Life's essential eight as targets for cardiometabolic risk reduction among non-Hispanic black adults: A primary care approach.

Cardiovascular diseases remain the leading cause of death in the United States. Several studies have shown racial disparities in the cardiovascular outcomes. When compared to their Non-Hispanic White (NHW) counterparts, non-Hispanic Black (NHB) individuals have higher prevalence of cardiovascular risk factors and thus, increased mortality from atherosclerotic cardiovascular diseases. This is evidenced by lower scoring in the indices of the American Heart Association's Life Essential 8 among NHB individuals. NHB individuals score lower in blood pressure, blood lipids, nicotine exposure, sleep, physical activity level, glycemic control, weight, and diet when compared to NHW individuals. Measures to improve these indices at the primary care level may potentially hold the key in mitigating the health care disparities in cardiovascular health experienced by NHB individuals.

Caregivers' Self-Rated General Health, Physical and Mental Health Status, Disease Morbidity and Association with Uncontrolled Asthma in Children.

This study examined the association between caregivers' self-rated general health, poor physical/mental health days, disease morbidity and asthma control in children from the United States with current asthma. The data analyzed for this study were obtained from 7522 children aged 0-17 years who participated in the 2012-2014, 2015-2017, 2018, and 2019 cycles of the Behavioral Risk Factor Surveillance System Asthma Call-back Survey (ACBS). We employed univariate analysis to describe the study population and weighted binary logistic regression to examine the association of predictors with asthma control. Approximately 50% of the children had uncontrolled asthma. The results show that caregivers who reported fair general health had a 61% higher likelihood of reporting uncontrolled asthma in their children compared to those who reported good/very good/excellent health (adjusted odds ratio [aOR] = 1.61; 95% confidence interval [CI], 1.14-2.26). Poor caregiver general health did not reach statistical significance in predicting uncontrolled asthma (aOR = 1.05, 95% CI, 0.62-1.75). Furthermore, having 1 to 14 poor physical/mental health days ([aOR] = 1.70; 95% CI, 1.28-2.227) and ≥15 poor physical/mental health days (aOR = 1.82, 95% CI, 1.31-2.53) was predictive of uncontrolled asthma in children. Additionally, endorsing one reported disease (aOR = 1.49, 95% CI, 1.15-1.93) and ≥2 diseases (aOR = 1.38, 95% CI, 1.08-1.78) was associated with uncontrolled child asthma. These findings underscore the association between caregivers' self-reported general health, poor mental/physical health days, disease morbidity and uncontrolled asthma among children from the U.S. with asthma. Pediatricians and child health practitioners should recall the importance of this relationship. To facilitate the identification of caregivers at risk and provide more comprehensive and effective care for children with asthma, healthcare practitioners should utilize every child asthma care encounter to inquire about the overall health of caregivers.

Dehiscent Prosthetic Aortic Valve and Aortic Root Pseudoaneurysm Complicated by Left Main Coronary Artery Compression.

Prosthetic aortic valve dehiscence is an uncommon complication of prosthetic valve endocarditis that may occur in patients who have undergone aortic valve replacement (AVR). The concurrent presence of aortic root pseudoaneurysm may further complicate the clinical presentation through the external compression of coronary arteries. Thus, patients may present with clinical features of coronary ischemia. Echocardiogram and coronary angiography are useful in establishing diagnosis. Treatment involves a multidisciplinary approach involving cardiologists, infectious disease specialists, and cardiothoracic surgeons. The authors of this study discuss a 51-year-old male who presented with anginal chest pain and was found to have a new left bundle branch block, elevated troponins, and left main coronary artery compression complicating aortic root aneurysm. He ended up requiring a re-do AVR, repair of the pseudoaneurysm, and coronary artery bypass graft.

A Novel Case of Acquired Isolated Left Ventricular Non-compaction in a Primigravida: Revisiting the Diagnostic Criteria of Left Ventricular Non-compaction.

Left ventricular non-compaction (LVNC) is rare cardiomyopathy characterized by the presence of a two-layered myocardium with prominent trabeculations. It has high rates of mortality and morbidity. Clinical presentation could vary from asymptomatic patients to developing ventricular arrhythmias, thromboembolism, heart failure, and even sudden cardiac death. We present a 23-year-old primigravida with a childhood history of dilated cardiomyopathy secondary to post-viral myocarditis presenting at 32 weeks gestation with dyspnea on exertion. Initial 2-D echocardiogram revealed a mildly dilated left ventricle with apical trabeculation and a 2-layer distinction between compacted and noncompacted myocardium indicating non-compaction of the left ventricle. This case presents a peculiar confluence of cardiac genetics, normal physiology, and infection. We describe a rare form of acquired LVNC that transformed from another type of cardiomyopathy to LVNC during pregnancy drawing attention to the causality pathways of LVNC.

A Busted Sac: A Case of Spontaneous Bladder Rupture Secondary to Acute Urinary Retention in a Healthy Middle-Aged Male.

Spontaneous bladder rupture is a relatively rare medical emergency that can be easily misdiagnosed. Although spontaneous bladder rupture is more common in those with previously diagnosed bladder conditions, this phenomenon may also occur in patients with an otherwise insignificant past medical history. Early diagnosis and treatment are critical to avoid fatal complications. Here, we present a 49-year-old male with insignificant past medical history who was diagnosed with spontaneous bladder rupture after the attempted placement of a Foley catheter.

ST-Segment Elevation Myocardial Infarction on the Line: Inadvertent Arterial Infusion of Vasopressors Causing Acute Myocardial Infarction.

Central venous catheters (CVCs), regarded as lines of life, are helpful in hemodynamic monitoring and delivering medications to patients. However, there are several complications that can result from the placement of CVCs. This includes accidental arterial puncture, which has a temporal association with hemorrhage, hematoma, and stroke. Infusion of vasopressors through such a mispositioned arterial CVC further increases the risk of these complications with potential end-organ ischemia. Here, we discuss the case of a 76-year-old woman who developed a myocardial infarction, heart failure, and subarachnoid hemorrhage following the arterial infusion of vasopressors through a malpositioned CVC.

Endovascular Venous Interventions - A State-of-the-Art Review.

Venous vascular diseases are an important clinical entity estimated to affect several million people worldwide. Deep vein thrombosis (DVT) is a common venous disease with a population variable prevalence of 122 to 160 persons per 100,000 per year, whereas pulmonary embolism (PE) affects up to 60 to 70 per 100 000 and carries much higher mortality. Chronic venous diseases, which cause symptoms like leg swelling, heaviness, pain, and discomfort, are most prevalent in the elderly and significantly impact their quality of life. Some estimate that chronic vascular diseases account for up to 2% of healthcare budgets in Western countries. Treating venous vascular disease includes using systemic anticoagulation and interventional therapies in some patient subsets. In this comprehensive review, we discuss endovascular treatment modalities in the management of venous vascular diseases.

An Unusual Presentation of Left Ventricular Non-compaction Cardiomyopathy in a Female Patient With Sudden Cardiac Arrest: A Case Report.

Left ventricular non-compaction (LVNC), a kind of cardiomyopathy, is characterized by excessive and prominent trabeculations in the mature left ventricle (LV). LVNC has been defined as the heart's developmental failure to fully form the compact myocardium during the latter stages of cardiac development. Clinical features vary from asymptomatic to symptomatic individuals with gradual loss of heart function, heart failure, thromboembolic events, arrhythmias, and sudden cardiac death are all possible outcomes. We describe a case of a 39-year-old Caucasian female who presented with a sudden cardiac arrest that was later attributed to LVNC. To the best of our knowledge, only a few occurrences are found in the literature where female patients with LVNC were presented with sudden cardiac arrest.

Negative Stress Test Is Not Always Negative: Revisiting the Clinical Implications of Balanced Ischemia.

Myocardial perfusion imaging with technetium (99mTc) sestamibi often aids in the diagnosis of coronary artery disease. This diagnostic tool is highly important in dictating future clinical decision-making and determining whether patients may benefit from revascularization. However, it is not completely sensitive and may be unreliable in diagnosing coronary artery disease in patients with balanced perfusion deficits. Here, we present the case of a 45-year-old male with severe coronary artery disease and false-negative myocardial perfusion imaging.

The Slower, the Better: Wide Complex Tachycardia Triggered by Flecainide in an Elderly Female.

Class IC antiarrhythmics are generally considered a safe means of treating many common arrhythmias such as atrial fibrillation (a-fib), atrial flutter (a-flutter), and paroxysmal supraventricular tachycardia (PSVT). Essentially, flecainide works by binding and blocking sodium channels more effectively at higher heart rates. However, this class of drugs is known to exhibit use dependence which could predispose patients to the development of malignant arrhythmias during episodes of tachycardia. In this case, we present a patient who was being treated with flecainide for a-fib who ultimately developed a wide complex tachycardia after her metoprolol was held.

A Rare Metastatic Primary Rectal Melanoma in a Geriatric Male.

Primary rectal melanoma (PRM) is an uncommon malignancy whose etiology remains unknown. Most patients present with rectal bleeding. Distant metastasis is commonly seen in the lung and liver. The incidence rates for locoregional lymph node metastases on initial presentation are almost 60%. Histology and immunochemistry are useful and are the gold standard for diagnosis. The prognosis is very poor due to the late presentation of patients. Optimum surgical treatment remains controversial. Abdominoperineal resection was considered traditionally but over time, has been found to have no survival benefit. Current literature and studies, therefore, recommend wide local excision. The beneficial effects of chemotherapy versus radiotherapy use are still debatable. Herein, we discuss a case of a 72-year-old Caucasian male with rectal bleeding found to have metastasized PRM.

The Tale of a Bleeding Tree: A Rare Case of Peripancreatic Variceal Hemorrhage Causing Hemosuccus Pancreaticus.

Hemosuccus pancreaticus (HP) is a rare cause of upper gastrointestinal bleeding. It was described by Lawal and Farrel in 1931. This disorder has also been referred to as pseudohemobilia or wirsungorrhagia, caused by bleeding into the pancreatic duct. The rarity of this condition can pose a diagnostic challenge. HP is life-threatening and requires immediate attention. The commonly used treatment modality is coil embolization. Surgery is considered in the case of failed embolization or uncontrolled bleeding. Described below, is a case of a 72-year-old female with a history of chronic pancreatitis who presented with anemia secondary to bleeding peripancreatic varices.

The Jailed Sinoatrial Node: An Interesting Case of Cardiogenic Shock Secondary to Sinus Arrest Following Percutaneous Intervention.

Complete occlusion of the sinoatrial node artery can be a complication of percutaneous intervention (PCI) to the right coronary artery (RCA). When this happens, dysfunction of the sinus node may follow resulting in sinus arrest. When this occurs, it is usually transient and as such, is typically not accompanied by hemodynamic instability. Permanent sinus arrest and shock state may, however, occur on rare occasions. The presence of junctional rhythms on the electrocardiogram (ECG) may predict the occurrence of these permanent arrhythmias and cardiogenic shock. In this case report, we present a 78-year-old woman who developed cardiogenic shock secondary to sinus arrest following PCI to RCA. Her ECG showed junctional rhythm, and she went on to require permanent ventricular pacing. This illustrates a known but rare complication of PCI to RCA.

The Unmasking Effect: Propofol-Induced Brugada Pattern in a Critically Ill Patient.

Brugada syndrome is a known cause of dysrhythmias and sudden cardiac death. It is linked to mutations in myocardial sodium channel leading to hyperexcitable cardiac myocytes. The use of this sedative has been linked to the development of inducible Brugada via blockade of sodium currents in cardiac myocytes. Although propofol is usually avoided in patients with known Brugada syndrome, some patients might have undiagnosed Brugada syndrome and thus are at risk for complications. We present a case of propofol induced Brugada in a critically ill patient.

Crescendo Angina Secondary to Congenital Absence of the Left Circumflex Coronary Artery: A Case Report.

Congenital coronary artery abnormalities (CAAs) are very rare in the general population. Among these congenital anomalies, left circumflex artery (LCx) anomaly is the most common. Although many are asymptomatic, a small percentage of patients with this anomaly present with angina-like symptoms. Usually, a majority of these cases are found incidentally during coronary angiography. We present a 71-year-old male with crescendo angina with a positive chemical stress test. Coronary angiography showed an absent LCx and a superdominant right coronary artery (RCA). Although congenital LCx absence is a benign finding, the coexistence of this abnormality with significant atherosclerotic disease in the coronary artery can lead to significant morbidity and mortality in this population. Understanding the embryological and morphological significance of these anomalies is important in adequately diagnosing and managing these patients.

Diagnosed by Reversibility: Unmasking Propofol-Related Infusion Syndrome in a Critically-Ill Elderly Male.

Propofol-related infusion syndrome (PRIS) is an uncommon complication resulting from prolonged propofol use. Common clinical presentations include metabolic acidosis, cardiac arrhythmias, and renal complications. The mortality rate is high if it is not recognized in time. There is no antidote to propofol. Initial treatment involves discontinuing ongoing propofol use and providing supportive measures. The reversal of clinical and laboratory features upon discontinuation of propofol provides a basis for retrospective diagnosis or PRIS. In severe cases, ultrafiltration may be utilized.

Left Internal Mammary Artery-to-Pulmonary Vein Fistula: A Rare Cause of Unstable Angina.

The incidence of acquired left internal mammary artery-to-pulmonary vein fistulas has been increasing in the last few decades. This has been attributed to the increase in coronary artery bypass surgery (CABG). The most commonly reported symptoms are angina and dyspnea. The timing of the presentation varies widely from a few months to several years after CABG. Medical management is the treatment of choice and usually controls the symptoms in most patients. Percutaneous intervention is, however, indicated when medical therapy fails. In this case report, a 72-year-old man with a history of CABG presented with progressively worsening chest pain and dyspnea. Troponin was negative and the electrocardiogram showed no acute ischemic changes. He was found to have left internal mammary artery-to-pulmonary vein fistula on coronary angiogram. His symptoms improved upon intensifications of his guideline-directed therapy for coronary artery disease. This represents an unusual cause of unstable angina.