Challenges and Insights: Severe Acute Right Ventricular Dysfunction in Pulmonary Hypertension.

Pulmonary hypertension (PH) is rarely a cause of syncope. We highlight an unusual presentation of pulmonary hypertension where management was a veritable challenge. We present a case report of a 35-year-old female with a history of stage 2 hypertension, polycystic ovarian syndrome, and obesity who presented to the hospital with a six-month history of progressive shortness of breath, lower extremity swelling, and recurrent syncope. Further evaluation with transthoracic echocardiography showed features consistent with severe pulmonary hypertension. This untreated severe pulmonary hypertension culminated in cardiogenic shock due to right ventricular (RV) failure. Successful care in this patient population entails preventing the acute downward spiral of decompensated right ventricular failure.

A Rare Differential of Epistaxis.

Glomus tympanicum is a type of glomus tumor that affects the middle ear, located at the auricular branch of the vagus nerve. Glomus tumors, in general, are rare, slow-growing tumors and may not require surgery in some patients. It can be challenging to manage due to its hypervascularity, location, and advanced stage of diagnosis. Although glomus tympanicum commonly presents with pulsatile tinnitus and conductive hearing loss, it presented in our patient with large-volume hemoptysis and epistaxis, requiring urgent diagnostic and therapeutic interventions. We highlight the unique presentation of a 48-year-old female with sudden onset large-volume hemoptysis and epistaxis, leading to the discovery of a hypervascular glomus tympanicum in the right middle ear, identified via MRI. On arrival, her vitals were within normal limits, and a physical examination was pertinent for the obvious ongoing bleeding from her mouth. The examination revealed increased respiratory effort and bilateral crackles. Laboratory values were pertinent for hemoglobin of 11.8 g/dl. Ear examination revealed a large, vascular-appearing mass filling the right ear. An MRI of the face and neck showed an avidly enhancing 3.7 cm x 1.8 cm x 1.2 cm mass within the right middle ear and mastoid cavity, extending into the external auditory canal and through the eustachian tube into the nasopharynx. The mass was inseparable from the lateral border of the internal auditory canal in the petrous canal. Due to concern for glomus tympanicum, the patient underwent urgent embolization and subsequent tumor resection. Considering our patient initially presented large-volume hemoptysis, there was concern for alveolar hemorrhage. However, as she had no increased oxygen requirement, there was suspicion of massive epistaxis mistaken for hemoptysis. Due to large volume epistaxis, she underwent urgent embolization as resection could have been challenging due to increased vascularity. It is important to remember that massive epistaxis may not present with blood in the anterior nares, thereby delaying diagnosis and management. Furthermore, probing such tumors should be avoided as it may lead to life-threatening bleeding.

The Masquerading Myocarditis: A Case of Late Recurrence of Acute Myocarditis Presenting as "Peripartum Cardiomyopathy".

Myocarditis is a potentially fatal medical condition with varied etiologies. Peripartum cardiomyopathy (PPCM) refers to systolic dysfunction occurring toward the end of pregnancy or in the months following delivery; it is a diagnosis of exclusion. We present a patient with chest pain, bipedal edema, markedly elevated troponins, electrocardiogram (EKG) findings that were concerning for myocardial infarction, and a significantly reduced left ventricular ejection fraction (LVEF) on the echocardiogram. The patient's presentation in the postpartum period closely resembled peripartum cardiomyopathy and presented a peculiar diagnostic challenge to our team. The right diagnosis was possible with cardiac magnetic resonance imaging, which revealed late gadolinium enhancement. Additionally, the patient had positive Coxsackie B5 and Epstein Bar virus serologies. While the clinical course of the disease is often benign, it could rapidly deteriorate, so early recognition and diagnosis are important to ensure patients receive adequate therapeutic support.

The impact of comorbidities and sociodemographic predictors on pneumococcal vaccination coverage in adults with coronary heart disease.

Aim: Coronary heart disease (CHD) increases the risk of adverse outcomes from invasive pneumococcal disease. Methods: Using the 2020 and 2021 data from the national health interview survey, we identified adults with CHD. Chi-square analysis and logistic regression were used to examine factors that influence vaccination status. Results: There were 2675 participants aged 41 and above with CHD. Participants were predominantly white people (82.5%) and males (60.1%). The odds of receiving the pneumococcal vaccine increased with stepwise increase in comorbidities from 1 to 2 and from 2 to 3. Among individuals with ≥2 comorbidities, black people were less likely to be vaccinated compared with white people. Conclusion: Pneumococcal vaccine uptake among adults with CHD is determined by cumulative comorbidities and ethnicity.

Masquerading bundle branch block: an often missed electrophysiological event.

Masquerading bundle branch block is an easily overlooked pattern on the ECG that indicates severe disease of the atrioventricular nodal conduction pathway. It is often caused by coronary artery disease, infiltrative diseases of the heart and idiopathic degeneration of the atrioventricular nodal conduction pathways. The diagnosis is easily missed as it needs a detailed interpretation of the ECG in addition to the clinical presentation of the patient. The presence of this specific bundle branch block pattern on the ECG indicates severe degeneration of the conduction system requiring intervention. Given its rarity, this clinical entity risks misdiagnosis and inappropriate management. This case highlights two diagnostic challenges for clinicians: the rarely described masquerading bundle branch block and the art of clinically differentiating between epilepsy and convulsive syncope.

The Decimating Army: Hemophagocytic Lymphohistiocytosis as the Initial Presentation of Adult-Onset Still's Disease.

Hemophagocytic lymphohistiocytosis (HLH) is a rare and often missed presentation in the hospital setting. It is a hyperinflammatory syndrome of immune activation and dysregulation characterized by fever, cytopenias, elevated serum ferritin levels, and hepatosplenomegaly. It has a multifactorial etiology occurring primarily secondary to infection, malignancy, immune checkpoint inhibitors, or autoimmune disease. HLH that occurs in autoimmune diseases such as adult-onset Still's disease and systemic lupus erythematosus is referred to as macrophage activation syndrome. However, it may rarely be a primary disorder from a genetic defect. The pathophysiology of HLH is poorly understood and often results in multiorgan dysfunction. We present an older adult male patient with several hospital stays due to his symptoms, who presented with lethargy, low-grade fever, cough, dyspnea, and recurrent pleural effusions. He had bicytopenia, elevated ferritin, and hypertriglyceridemia. The diagnosis of HLH may be delayed, especially in older adult patients with an insidious course, and requires a high index of suspicion.

The Thyroid Forecast: A Case of a Thyroid Storm Diagnosed Under Unforeseen Circumstances.

Hyperthyroidism and thyrotoxicosis are common conditions in clinical practice. Untreated, they are associated with several co-morbidities. One of these conditions, and arguably the most lethal, is the thyroid storm. Our case presentation is one of a young female who had previously been diagnosed with thyroid illness but was lost to follow-up, subsequently given a clean bill of health, and emerged with what would eventually be diagnosed as a thyroid storm. While the thyroid storm may pose some diagnostic challenges, it has come a long way in securing diagnostic tools. What remains is a tool for physicians and patients to stratify patients by their risk of developing a storm in the outpatient setting.

The Effectiveness of Intraosseous Basivertebral Nerve Ablation in the Treatment of Nonradiating Vertebrogenic Pain: A Systematic Review.

Intraosseous basivertebral nerve ablation has shown sustained efficacy in treating chronic axial low back pain (LBP) in patients with type 1 or 2 Modic changes. This systematic review aims to determine the efficacy of intraosseous basivertebral nerve radiofrequency ablation in treating nonradiating axial chronic LBP compared to standard therapy, sham, or without contrast. The population of interest is individuals greater than or equal to 18 years old with chronic nonradiating vertebrogenic pain. The key outcome was the percentage of patients with greater than or equal to 50% pain reduction, greater than or equal to 10-point improvement in function and disability measured by the Oswestry Disability Index (ODI), greater than or equal to two-point pain reduction in the visual analog scale (VAS) or numerical pain rating scale, and a decrease in opioid utilization by 10 morphine milligram equivalents. Three databases, PubMed, MEDLINE, and Google Scholar, were used to retrieve the studies for the review. Two independent reviewers assessed the studies for inclusion using the validated tools for quality appraisal. There were 286 articles in total; however, only 11 publications with extensive data on 413 participants matched the inclusion criteria and were used for this review. At three months, a majority of the participants reported greater than or equal to 10-point improvement in the ODI, a measure of functional and disability improvement on a 10-point scale, and greater than or equal to two-point improvement in the VAS. A good number of patients in the basivertebral nerve ablation (BVNA) arm reported complete pain resolution demonstrating therapy success and the superiority of BVNA over sham and standard treatment.  Basivertebral nerve radiofrequency ablation, among other criteria, is a safe and minimally invasive therapy that significantly lowers pain and impairment in individuals with vertebrogenic pain with distinct Modic type 1 and 2 changes at lumbar vertebra three-sacral vertebra one (L3-S1) vertebral levels. Proper patient selection and exact procedural methods are essential to the success of basivertebral nerve neurotomy. The findings of the existing investigations require confirmation by nonindustry-funded, large-scale, high-quality trials using generalizable study participants.

A Deceptively Unremarkable Standstill: A Case Report of a Rare Cardiac Electrophysiologic Event.

Ventricular standstill is a rare cardiac event associated with a high mortality. It is considered a ventricular fibrillation equivalent. The longer the duration, the poorer the prognosis. It is therefore unusual for an individual to have recurrent episodes of standstill and survive, without morbidity and rapid mortality. Here, we report the unique case of a 67-year-old male, previously diagnosed with heart disease, requiring intervention, who lived with recurrent syncopal episodes for a decade. Though such occurrences have previously been documented, we seek to stress the importance of using clinical tools in assessing what could easily have been passed off as orthostatic in origin.

The Impact of Dietary Fat on Breast Cancer Incidence and Survival: A Systematic Review.

Breast cancer has become one of the most common cancers affecting women worldwide, and researchers have struggled to explore new avenues for managing it for decades. One of the ways was to analyze the diet and its importance concerning this disease. This review aims to study the effect dietary fat has on the risk of breast cancer incidence as well as its influence on the survival of breast cancer patients. The main population under consideration for this review is women older than the age of 18. A thorough and detailed search was conducted until July 21, 2022, using four databases: PubMed, ScienceDirect, Google Scholar, and The Cochrane Library. After screening, 22 articles were selected for inclusion in this review. Of the 22 articles, 12 were from PubMed, two from ScienceDirect, one from The Cochrane Library, and seven from Google Scholar. The risk of bias was assessed, and the required information was extracted from the articles. A systematic review of all the included articles found a significant correlation between dietary fat and an increased risk of breast cancer development and worsening the prognosis for patients already diagnosed with breast cancer. Although many overlapping factors may be responsible for this development, studies show a trend that suggests that this particular factor can be a contributor. Further studies need to be conducted to highlight the role of fat in the diet and the use of dietary modification to curb breast cancer rates.

A Systematic Review of Antibiotic Resistance Trends and Treatment Options for Hospital-Acquired Multidrug-Resistant Infections.

Antimicrobial resistance is a major public health challenge described by the World Health Organization as one of the top 10 public health challenges worldwide. Drug-resistant microbes contribute significantly to morbidity and mortality in the hospital, especially in the critical care unit. The primary etiology of increasing antibiotic resistance is inappropriate and excessive use of antibiotics. The alarming rise of drug-resistant microbes worldwide threatens to erode our ability to treat infections with our current armamentarium of antibiotics. Unfortunately, the pace of development of new antibiotics by the pharmaceutical industry has not kept up with rising resistance to expand our options to treat microbial infections. The costs of antibiotic resistance include death and disability, extended hospital stays due to prolonged sickness, need for expensive therapies, rising healthcare expenditure, reduced productivity from time out of the workforce, and rising penury. This review sums up the common mechanisms, trends, and treatment options for hospital-acquired multidrug-resistant microbes.

Efficacy of Anakinra in Pericarditis: A Systematic Review.

Inflammation of the pericardium is referred to as pericarditis, which can cause sharp chest pain and has a high chance of recurrence even after treatment. This review will explore anakinra, which is an interleukin-1 receptor antagonist, as a potential new treatment for pericarditis. The systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by searching PubMed and GoogleScholar from the years 2012 to 2022. After applying inclusion and exclusion criteria, thorough screening, and quality appraisal, a total of eleven studies were included in the review; eight case reports and three clinical trials. All studies showed that 100 mg/day of anakinra caused a remarkable improvement in patient outcomes. In addition, the pericarditis resolved quicker and had a lower chance of recurrence in comparison to conventional therapy.

Targeted Temperature Management After Cardiac Arrest: A Systematic Review.

Targeted temperature management (TTM) has been the cornerstone of post-cardiac arrest care, but even after therapy, neurological outcomes remain poor. We performed a systematic review to evaluate the influence of TTM in post-cardiac arrest treatment, its effect on the neurological outcome, survival, and the adverse events associated with it. We also aimed to examine any difference between the effect of therapy at various intensities and durations on the prognosis of the patient. A search of two databases was done to find relevant studies, followed by a thorough screening in which the inclusion and exclusion criteria were applied, and a quality appraisal of clinical trials was done. In this systematic review, six randomized clinical trials with a total of 3870 participants were examined. Of these, 2,767 participants were treated with targeted hypothermia to varying degrees (between 31 and 36 degrees Celsius), 931 participants were treated with targeted normothermia (36.5 to 37.5 degrees Celsius), and 172 participants were treated with only normothermia (without any active cooling or interventions). It was concluded that TTM at a lower temperature did not have any benefit regarding the neurological outcome and mortality over targeted normothermia but was superior to no temperature management. TTM was also found to have significantly more negative effects when the intensity or duration was increased.

A Suspected Case of COVID-19-Induced Immunosuppression.

While COVID-19 has gained popularity as a pandemic and as a cause of pulmonary-systemic disease, the condition continues to evolve our knowledge and understanding of immunology and medicine through its myriad clinical presentations. This article features a previously healthy 65-year-old female who presented with sudden features of cryptococcal meningitis, the progression of which raises questions as to what role the virus plays in the innate, adaptive, and overall host factors leading to immunosuppression.

A Case Reflecting the Impact of a Deferred Transesophageal Echocardiogram on a COVID-19 Disease Patient.

COVID-19 has been amongst us for over two years and has seen a strong response from the international health community regarding mobilization. There has also been the advancement of vaccine science-regulations surrounding the day-to-day decisions regarding patients who tested positive for the virus. Guidelines for treatment continue to vary. While this may benefit most patients, more objective metrics in deciding elective, urgent, and emergent procedures have been proposed. In this paper, a patient who tested positive for the virus was refused a procedure ( transesophageal echo ) based on COVID status, which may have contributed to a delay in treatment and detrimental outcomes.