Acute myocardial infarction or Takotsubo syndrome in a patient with stunned myocardium due to myocardial bridging? A case report of diagnostic dilemma clarified after serial workup.

BACKGROUND: Myocardial bridging is a cardiac anomaly where a segment of epicardial coronary arteries runs through the myocardium and can rarely cause MI. Takotsubo syndrome is a stress-induced cardiomyopathy that can mimic MI. Catecholamine surge during stress can contribute to Takotsubo syndrome, but whether this surge can trigger an inconspicuous myocardial bridging to manifest symptomatically remains unclear, and alternately, whether a myocardial bridge might cause worsening of Takotsubo syndrome is also a matter that needs further research. CASE PRESENTATION: We report the case of a patient who initially presented with features of acute exacerbation of bronchiectasis and subsequently developed symptoms and ECG features suggestive of acute myocardial infarction. Echocardiography revealed features of takotsubo syndrome, and complete myocardial bridging was revealed via coronary angiography. The patient was managed conservatively with pharmacological treatment, and after a few days, echocardiographic features were reversed. As such, the diagnosis shifted toward Takotsubo syndrome with myocardial stunning due to co-existent myocardial bridging. CONCLUSION: We report a rare case of a patient with acute bronchiectasis exacerbation with features suggestive of acute myocardial infarction who had findings of Takotsubo syndrome and complete myocardial bridging. In the beginning, it was difficult to determine whether the symptoms arose due to acute MI resulting from myocardial bridging or were solely due to takotsubo syndrome because of stress from bronchiectasis. Although myocardial bridging is often overlooked as an etiology for acute MI, this case highlights the importance of expanding the differential diagnosis to myocardial bridging in the work-up for the cause of acute MI and how Takotsubo syndrome can mimic acute MI and pose a diagnostic challenge.

Pilot Training Program on Hands-Only CPR and Choking First Aid for Frontline Police Responders in Rural Nepal.

INTRODUCTION: Basic life support (BLS) is an emergency skill that includes performing appropriate cardiopulmonary resuscitation (CPR). Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality worldwide and is rising in Nepal. After an OHCA event, a bystander starting CPR quickly has been shown to increase the survival rate. While the Nepali police are generally the first responders to emergencies in rural parts, they are not trained in BLS. This program assesses a pilot training of hands-only CPR and choking first aid to the Nepal Police and Nepal Army participants in rural Nepal. METHODS: A community-based nonprofit organization, HAPSA-Nepal, coordinated with local government to pilot this program. The program included pre- and post-tests, lectures, videos, and small group hands-on exercises; facilitators included faculty emergency physicians, residents, and medical officers. Structured pre- andp post-test questionnaires, confidence surveys, and skills checklists were conducted. Descriptive analysis examined the respondent's characteristics, and paired t-test was used to compare pretest and post-test scores. RESULTS: A total of 126 participants received the training in this pilot phase. Prior to this training, 98.4% of the participants had not received any CPR training, and 100% of the participants had not received training on first aid for choking. The average pretest score was 4.4 with 95% CI ± 1.75, and the average post-test score was 8.06 with 95% CI ± 1.73 (out of a total of 11). All participants passed the skills assessment. CONCLUSIONS: Locally adapted BLS training programs that included hands-only CPR and choking first aid showed a significant knowledge gain and skills competence among the frontline participants.

Alcohol Use and the Risk of Colorectal Liver Metastasis: A Systematic Mapping Review.

The consumption of alcohol has long been associated with the development of liver disease as well as cancers including colorectal cancer (CRC). Leading healthcare concerns include the prevalent use of alcohol and the high burden of CRC mortality. Many CRC deaths are attributed to the development of colorectal liver metastasis (CRLM) as the liver is the foremost site of CRC spread. However, an association has not been defined for the role of alcohol intake and related liver injury with the development of CRLM. Here, a mapping review of recent research was undertaken to evaluate the relationship between alcohol consumption and the risk of CRLM. The literature search revealed 14 articles meeting the inclusion criteria that included patient database analyses and preclinical studies. Most of the human data analyses found alcohol use independently associates with worse CRC outcomes. The preclinical evaluations identified several pathways involved in the alcohol-mediated promotion of CRLM burden and CRC cell metastatic behavior. The limited number of studies identified exposes a significant need for more prospective analyses to define the role of alcohol intake and advanced CRC as well as the translation of preclinical research to fully characterize targetable mechanisms for the generation of new therapeutic options.