Esophageal Perforation Presenting Initially as Multiple Brain Abscesses Secondary to Streptococcus intermedius.

Brain abscess is a life-threatening infection that can occur secondary to contiguous or hematogenous spread. Several underlying conditions can lead to brain abscesses, such as dental infection, otitis media, sinusitis, and immunosuppression. Esophageal perforation leading to brain abscesses is extremely rare. We report a rare case of a 32-year-old man who presented to the emergency department with progressive headaches and upper-extremity weakness. Upon further evaluation, computed tomography (CT) revealed multiple brain abscesses secondary to Streptococcus intermedius infection. The patient eventually underwent esophagogastroduodenoscopy (EGD), which showed a perforation in the middle third of the esophagus. This case highlights the importance of considering esophageal perforation as a predisposing condition for brain abscesses.

Psychological Distress and the Risk of Adverse Cardiovascular Outcomes in Patients With Coronary Heart Disease.

BACKGROUND: Psychological distress is a recognized risk factor in patients with coronary heart disease (CHD), but its clinical significance is unclear. OBJECTIVES: The purpose of this study was to determine if an index of psychological distress is independently associated with adverse outcomes and significantly contributes to risk prediction. METHODS: Pooled analysis of 2 prospective cohort studies of patients with stable CHD (N = 891). A psychological distress score was constructed using measures of depression, anxiety, anger, perceived stress, and post-traumatic stress disorder, measured at baseline. The study endpoint included cardiovascular death or first or recurrent nonfatal myocardial infarction or hospitalization for heart failure at 5.9 years. RESULTS: In both cohorts, first and recurrent events occurred more often among those in the highest tertile of distress score than those in the lowest tertile. After combining the 2 cohorts, compared with the lowest tertile, the hazards ratio for having a distress score in the highest tertile was 2.27 (95% CI: 1.69-3.06), and for the middle tertile, it was 1.52 (95% CI: 1.10-2.08). Adjustment for demographics and clinical risk factors only slightly weakened the associations. When the distress score was added to a traditional clinical risk model, C-statistic, net reclassification index, and integrative discrimination index all significantly improved. CONCLUSIONS: Among patients with CHD, a composite measure of psychological distress was significantly associated with an increased risk of adverse events and significantly improved risk prediction.

Towards Quantifying Stress in Patients with a History of Myocardial Infarction: Validating ECG-Derived Patch Features.

Patients with prior myocardial infarction (MI) have an increased risk of experiencing a secondary event which is exacerbated by mental stress. Our team has developed a miniaturized patch with the capability to capture electrocardiogram (ECG), seismocardiogram (SCG) and photoplethysmogram (PPG) signals which may provide multimodal information to characterize stress responses within the post-MI population in ambulatory settings. As ECG-derived features have been shown to be informative in assessing the risk of MI, a critical first step is to ensure that the patch ECG features agree with gold-standard devices, such as the Biopac. However, this is yet to be done in this population. We, thus, performed a comparative analysis between ECG-derived features (heart rate (HR) and heart rate variability (HRV)) of the patch and Biopac in the context of stress. Our dataset contained post-MI and healthy control subjects who participated in a public speaking challenge. Regression analyses for patch and Biopac HR and HRV features (RMSSD, pNN50, SD1/SD2, and LF/HF) were all significant (p<0.001) and had strong positive correlations (r>0.9). Additionally, Bland-Altman analyses for most features showed tight limits of agreement: 0.999 bpm (HR), 11.341 ms (RMSSD), 0.07% (pNN50), 0.146 ratio difference (SD1/SD2), 0.750 ratio difference (LF/HF).Clinical relevance- This work demonstrates that ECG-derived features obtained from the patch and Biopac are in agreement, suggesting the clinical utility of the patch in deriving quantitative metrics of physiology during stress in post-MI patients. This has the potential to improve post-MI patients' outcomes, but needs to be further evaluated.

Exaggerated Peripheral and Systemic Vasoconstriction During Trauma Recall in Posttraumatic Stress Disorder: A Co-Twin Control Study.

BACKGROUND: Individuals with posttraumatic stress disorder (PTSD) face an increased risk of cardiovascular disease, but the mechanisms linking PTSD to cardiovascular disease remain incompletely understood. We used a co-twin control study design to test the hypothesis that individuals with PTSD exhibit augmented peripheral and systemic vasoconstriction during a personalized trauma recall task. METHODS: In 179 older male twins from the Vietnam Era Twin Registry, lifetime history of PTSD and current (last month) PTSD symptoms were assessed. Participants listened to neutral and personalized trauma scripts while peripheral vascular tone (Peripheral Arterial Tone ratio) and systemic vascular tone (e.g., total vascular conductance) were measured. Linear mixed-effect models were used to assess the within-pair relationship between PTSD and vascular tone indices. RESULTS: The mean age of participants was 68 years, and 19% had a history of PTSD. For the Peripheral Arterial Tone ratio analysis, 32 twins were discordant for a history of PTSD, and 46 were discordant for current PTSD symptoms. Compared with their brothers without PTSD, during trauma recall, participants with a history of PTSD had greater increases in peripheral (ß = -1.01, 95% CI [-1.72, -0.30]) and systemic (total vascular conductance: ß = -1.12, 95% CI [-1.97, -0.27]) vasoconstriction after adjusting for cardiovascular risk factors. Associations persisted after adjusting for antidepressant medication use and heart rate and blood pressure during the tasks. Analysis of current PTSD symptom severity showed consistent results. CONCLUSIONS: PTSD is associated with exaggerated peripheral and systemic vasoconstrictor responses to traumatic stress reminders, which may contribute to elevated risk of cardiovascular disease.

A Pilot Study of Neurobiological Mechanisms of Stress and Cardiovascular Risk.

Objective: Coronary heart disease is a leading cause of death and disability. Although psychological stress has been identified as an important potential contributor, mechanisms by which stress increases risk of heart disease and mortality are not fully understood. The purpose of this study was to assess mechanisms by which stress acts through the brain and heart to confer increased CHD risk. Methods: Coronary Heart Disease patients (N=10) underwent cardiac imaging with [Tc-99m] sestamibi single photon emission tomography at rest and during a public speaking mental stress task. Patients returned for a second day and underwent positron emission tomography imaging of the brain, heart, bone marrow, aorta (indicating inflammation) and subcutaneous adipose tissue, after injection of [18F]2-fluoro-2-deoxyglucose for assessment of glucose uptake followed mental stress. Patients with (N=4) and without (N=6) mental stress-induced myocardial ischemia were compared for glucose uptake in brain, heart, adipose tissue and aorta with mental stress. Results: Patients with mental stress-induced ischemia showed a pattern of increased uptake in the heart, medial prefrontal cortex, and adipose tissue with stress. In the heart disease group as a whole, activity increase with stress in the medial prefrontal brain and amygdala correlated with stress-induced increases in spleen (r=0.69, p=0.038; and r=0.69, p=0.04 respectfully). Stress-induced frontal lobe increased uptake correlated with stress-induced aorta uptake (r=0.71, p=0.016). Activity in insula and medial prefrontal cortex was correlated with post-stress activity in bone marrow and adipose tissue. Activity in other brain areas not implicated in stress did not show similar correlations. Increases in medial prefrontal activity with stress correlated with increased cardiac glucose uptake with stress, suggestive of myocardial ischemia (r=0.85, p=0.004). Conclusions: These findings suggest a link between brain response to stress in key areas mediating emotion and peripheral organs involved in inflammation and hematopoietic activity, as well as myocardial ischemia, in Coronary Heart Disease patients.

Glomangiomyoma of the Stomach: Case Report.

Glomus tumor (glomus cell tumor) is a rare, often benign neoplasm, which is, in most cases, seen as a solitary bluish nodule involving the nail beds. Solid glomus tumor, glomangioma, and glomangiomyoma are the three main histopathological variants. In this case report, we present the rarest subtype of a glomus tumor, glomangiomyoma, in an atypical location: the stomach. A 45-year-old female from Syria presented to the clinic with severe dizziness and left epigastric abdominal pain accompanied by melena. We performed a thorough clinical study, laboratory workup, upper gastrointestinal endoscopy, endoscopic ultrasound, CT scan, as well as macroscopic and microscopic histologic examination of the surgical specimen, in addition to the immunohistochemical staining. Although rare, gastric glomangiomyoma was diagnosed and a 4.5 × 3 × 3 cm soft tissue mass was resected from the gastric antrum, and no clinical or endoscopic evidence of recurrence was observed for the follow-up duration of 4 years. Undiagnosed gastric lesions with unexplained symptoms should be further investigated and not be disregarded immediately. To the best of our knowledge, this is only the second report of an instance of gastric glomangiomyoma.

Sclerosing pneumocytoma in a 1-year-old girl presenting with massive hemoptysis: A case report.

INTRODUCTION AND IMPORTANCE: Sclerosing pneumocytoma (SP) is a rare benign neoplasm of the lung with peak age incidence in middle aged-women. Here we report, for the first time in the literature, a case of a 1-year-old girl with SP. CASE PRESENTATION: A 1-year-old girl was reported to emergency department for massive hemoptysis. After admission, the patient had a three-days episode of melena, with normal body temperature and generally stable condition. CLINICAL DISCUSSION: Fiberoptic bronchoscopy was normal. MSCT was done along with angiography and Three-Dimensional Reconstruction which revealed a well-circumscribed round mass with well-defined borders located near the vessels in the upper lobe of left lung. Anatomic lingula resection was performed. Hilar node was also resected. The histopathological examination confirmed the presence of SP. Fourteen months postoperatively, the patient was in a good health with no clinical or radiological evidence of recurrence. CONCLUSION: SP is a rare benign tumor which usually presents in middle aged-women asymptomatically or with nonspecific symptoms. We report this case to highlight that SP should be considered in cases of hemoptysis in young children.