A patient with single coronary artery, bicuspid aortic valve and sinus of Valsalva aneurysm.

BACKGROUND: We report a rare case of a patient who presented with chest pain and was found to have a constellation of rare cardiac anomalies. CASE PRESENTATION: A 67-year-old patient with no past medical history presented with chest pain. He had mild troponin elevation, but no ischemic changes on ECG. He underwent a CT coronary angiogram for further evaluation. He was found to have a type 0 bicuspid aortic valve, large left sinus of Valsalva aneurysm and type R-III single coronary artery. These findings were confirmed with transesophageal echocardiogram and coronary angiogram. He underwent a successful repair of his aortic root aneurysm with a synthetic patch. CONCLUSIONS: The combination of type R-III single coronary artery, bicuspid aortic valve, and left sinus of Valsalva aneurysm congenital anomalies in one individual is extremely rare and marks our case unique. Given the size of his Sinus of Valsalva aneurysm, the patient underwent surgical repair of his aneurysm and was asymptomatic when seen in follow-up.

Facilitators and barriers to colorectal cancer screening in an outpatient setting.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related deaths in the United States. Still, 1 in 3 adults aged 50 years to 75 years have not been screened for CRC. Early detection and management of precancerous or malignant lesions has been shown to improve overall mortality. AIM: To determine the most significant facilitators and barriers to CRC screening in an outpatient clinic in rural North Carolina. The results of this study can then be used for quality improvement to increase the rate of patients ages 50 to 75 who are up to date on CRC screening. METHODS: This retrospective study examined 2428 patients aged 50 years to 75 years in an outpatient clinic. Patients were up to date on CRC screening if they had fecal occult blood test or fecal immunochemical test in the past one year, Cologuard in the past three years, flexible sigmoidoscopy/virtual colonoscopy in the past five years, or colonoscopy in the past ten years. Data on patient socioeconomic status, comorbid conditions, and other determinants of health compliance were included as covariates. RESULTS: Age [odds ratio (OR) = 1.058; P = 0.017], no-show rate percent (OR= 0.962; P < 0.05), patient history of obstructive sleep apnea (OR = 1.875; P = 0.025), compliance with flu vaccinations (OR = 1.673; P < 0.05), compliance with screening mammograms (OR = 2.130; P < 0.05), and compliance with screening pap smears (OR = 2.708; P < 0.05) were important factors in determining whether a patient will receive CRC screening. Race, gender, insurance or employment status, use of blood thinners, family history of CRC, or other comorbid conditions including diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and end-stage renal disease were not found to have a statistically significant effect on patient adherence to CRC screening. CONCLUSION: Patient age, history of sleep apnea, and compliance with other health maintenance tests were significant facilitators to CRC screening, while no-show rate percent was a significant barrier in our patient population. This study will be of benefit to physicians in addressing and improving the CRC screening rates in our community.

Should Baseline Hemoglobin A1c or Dose of SGLT-2i Guide Treatment With SGLT-2i Versus DPP-4i in People With Type 2 Diabetes? A Meta-Analysis and Systematic Review.

Our aim was to explore whether the baseline hemoglobin A1c or the dose of sodium glucose cotransporter-2 inhibitor (SGLT-2i) chosen better predicted the efficacy of SGLT-2i versus dipeptidyl peptidase-4 inhibitor (DPP-4i) in type 2 diabetes. We searched for randomized trials that compared SGLT-2i with DPP-4i in type 2 diabetes and reported a change in hemoglobin A1c over time. We created 2 separate analyses (one based on baseline hemoglobin A1c and the other according to US Food and Drug Administration [FDA]-approved SGLT-2i dose). Thirteen trials were included. In the analysis according to baseline hemoglobin A1c , there was a significantly greater reduction in hemoglobin A1c when baseline hemoglobin A1c was ≥8.5%, favoring SGLT-2i over DPP-4i but not when baseline hemoglobin A1c was <8.5% (mean difference [95%CI], -0.36% [-0.53% to -0.18%] and 0.04% [-0.09% to 0.17%], respectively). On restricting the analysis to trials stratifying hemoglobin A1c to <8.0% or ≥8.0%, results did not change. In the analysis based on FDA-approved SGLT-2i doses, higher SGLT-2i doses caused a significantly greater hemoglobin A1c reduction at ≤26 and ≥52 weeks compared with the highest DPP-4i doses (mean difference [95%CI], -0.11% [-0.18% to -0.04%] and -0.24% [-0.34% to -0.15%], respectively). Lower SGLT-2i doses caused a significantly greater hemoglobin A1c reduction at ≥52 weeks but not at ≤26 weeks compared with the highest DPP-4i doses (mean difference [95%CI], -0.12% [-0.23% to -0.02%] and 0.01% [-0.05% to 0.07%], respectively). In people with type 2 diabetes and a baseline hemoglobin A1c ≥ 8.0%, SGLT-2i produced significantly greater reductions in hemoglobin A1c compared with DPP-4i and may be preferred. SGLT-2i dose titration to a higher FDA-approved dose is recommended in suitable patients.