Acute rupture of a sinus of Valsalva aneurysm into the right atrium: a case report and a narrative review.

BACKGROUND: Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly which has potential for spontaneous rupture into other cardiac chambers or the pericardial space (depending on its location). A ruptured SVA has a very poor prognosis with high morbidity and mortality. The development of a shunt between the sinus of Valsalva and right-sided cardiac chambers results in a continuous murmur on examination. Our case report is a case of SVA rupture into the right atrium. CASE PRESENTATION: In this case report, we describe a 23-year-old patient with an acute onset of chest pain, shortness of breath, palpitations and dizziness starting 2 days prior to presentation to the emergency department. The patient was initially treated for presumed pulmonary embolism overnight while awaiting CTPA the next morning. However, further examination by the inpatient medical team demonstrated a continuous machinery cardiac murmur. Subsequent echocardiography demonstrated an acutely ruptured SVA with shunting to the right atrium. Emergency surgical repair resulted in an excellent outcome for the patient. CONCLUSION: A thorough clinical history and physical examination is the cornerstone of all medical encounters. An SVA could be asymptomatic until acute rupture. Echocardiography is the preferred initial diagnostic tool. Additional imaging techniques can be used to confirm the diagnosis. In cases of rupture, prognosis is poor and surgical repair is always required.

Treatment of poppy seed tea misuse with buprenorphine in a telehealth practice: a case series.

BACKGROUND: Poppy seed tea (PST) is a legally obtainable source of opiates made from the seeds of the opium poppy. Our large telehealth opioid use disorder (OUD) provider group has treated several patients with PST misuse. METHODS: We retrospectively identified patients with primary PST use disorder treated with buprenorphine in a telehealth-only practice with first visits between January 2021 and December 2022. Patients were identified by having the word "poppy" in their enrollment note, and then charts were reviewed to determine which patients had primary PST misuse. Demographics, buprenorphine doses, and retention in treatment were recorded. RESULTS: We identified 18 patients treated for PST use disorder. Fifteen (83.3%) identified as male, mean age was 40.4 (standard deviation 8.8) years, and patients resided in 10 different U.S. states. Median starting buprenorphine dose was 2 mg (interquartile range (IQR) 2-2.5 mg). Median stabilizing dose of buprenorphine was 16 mg daily (IQR 15-20.5 mg). As of June 2023, 5 patients (27.8%) were still in active treatment. Two patients (11.1%) had completed a planned, elective taper. Ten patients (55.6%) had unplanned discontinuation from treatment, and 3 patients (16.7%) discontinued for other reasons. CONCLUSIONS: To our knowledge, this is the largest case series describing PST misuse in the U.S., and the first to demonstrate its treatment in the telehealth setting. PST use disorder is treatable with buprenorphine with doses similar to treatment of other opioid use disorders. Clinicians who treat patients with OUD should be aware of PST use disorder and its treatment.

Clinical Outcomes for Hemiarthroplasty Versus Total Hip Arthroplasty in Patients With Femoral Neck Fracture Who Meet Published National Criteria for Total Hip Arthroplasty.

OBJECTIVES: To examine outcome for patients with hip fracture treated by a hemiarthroplasty (HA) but who actually met the United Kingdom, National Institute for Health and Care Excellence (NICE) criteria for receiving a total hip arthroplasty (THA). DESIGN: Match cohort study. SETTING: Level 1, Academic Trauma Centre (UK Major Trauma Centre). PATIENTS/PARTICIPANTS: Three hundred ninety-eight patients underwent either a HA or THA for a nonpathological displaced intracapsular fractured neck of the femur [OTA/AO 31 B3 (garden 3-4)], having met the NICE criteria for THA. INTERVENTION: HA versus THA. Two analyses were performed, the first comparing the outcome in a cohort of patients who either received a THA or HA but who all had met the NICE criteria to receive a THA (n = 398). The second analysis assessed the outcome of THA versus HA, in a matched cohort of patients who all met the NICE criteria for a THA (n = 44 matched pairs). All patients in the matched cohort were able to walk independently outdoors (WIOs) before injury. MAIN OUTCOME: Mobility and functional outcome, 1 year after surgery. RESULTS: Of the 398 patients who met the criteria for THA, only 78 (19.6%) patients actually received a THA. Within the matched cohort, significantly more THA patients (92.9%, 39/42) maintained the ability to WIOs at 1-year compared with patients with HA (56.4%, 22/39; P = 0.001). There was no difference in mortality, reoperation, or complication rates for our matched population at 1 year. CONCLUSIONS: Patients who meet the NICE criteria for THA and are able to WIOs preinjury are more likely to have a higher level of independent mobility and a better functional outcome at 1-year if they receive a THA, as opposed to receiving a HA. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A scoping review of high-fidelity bench models for teaching closed reduction of distal radial fractures.

This article was migrated. The article was marked as recommended. INTRODUCTION: Simulation training can be beneficial for developing clinical skills without risks to patients. This review considers the literature on simulation models used for teaching closed reduction (manipulation) procedures for distal radius (wrist) fractures, particularly high-fidelity models, and the evidence supporting the use of such models. METHODS: A scoping review of Medline and Embase was performed. RESULTS: Five articles described low-fidelity models, predominantly focussing on low costs and teaching basic principles. Three articles and two commentary pieces discussing high-fidelity models were identified. DISCUSSION: Attitudes towards a high-fidelity simulator were assessed by Egan et al. (2013), who found the majority of participants to be in favour of the model's use as a teaching tool, although participant selection may have been subject to bias. Mayne et al. (2016) subsequently used a high-fidelity model including radio-opaque markers and more objective measurements tools to assess orthopaedic trainees' closed reduction technique and adequacy of the achieved fracture position and casting. Seniority correlated with higher scores on objective structured assessment of technical skills (OSATS) and global rating scores (GRS) but not radiological measures of fracture position or cast quality, and over 90% of all participants achieved an adequate reduction. Seeley et al. (2017) used radiological measurements and time to task completion with another high-fidelity reduction model. The two most experienced participant groups could not be differentiated on any radiological measures of fracture reduction or on the time taken for reduction, although these groups were significantly better than the most junior participants. CONCLUSION: The discussed models appear helpful to teach inexperienced participants the basic principles and steps in a procedures but a plateau effect appears to limit the potential benefit to more experienced learners. The constraints of educators' time and financial costs may influence the usage of such models in this type of training.

Piloting a Coping Skills Group Intervention to Reduce Depression and Anxiety Symptoms in Patients Awaiting Kidney or Liver Transplant.

The authors evaluated the use of a coping skills group (CSG) therapy intervention to decrease depression and anxiety and increase healthy coping skills in a population of kidney and liver transplant candidates. The study, using a pre-posttest design, piloted a CSG with a convenience sample of 41 consenting participants on a waiting list or in workup for kidney or liver transplant. Two transplant social workers led five eight-week closed psychoeducational groups. Coping skills, depression symptoms, and anxiety symptoms were assessed preintervention, postintervention, and at follow-up one month later. Results suggest that the CSG group created significant changes in some coping areas, such as decreasing the use of denial and self-blame and increasing the use of acceptance, religion, and instrumental supports. In this study, instrumental supports are strategies such as seeking assistance, finding information, or asking for advice about what to do. The effects on instrumental supports did not sustain at the one-month follow-up. Anxiety and depression scores were significantly reduced, and these changes were sustained at one-month follow-up. This study supports the use of a group-based psychosocial intervention for the pretransplant population and will be most relevant to social workers practicing in the transplant field.

An evaluation of a multi-component adult weight management on referral intervention in a community setting.

BACKGROUND: National Institute for Health and Care Excellence (NICE) guidance on adult weight management recommends interventions are multi-component. We aimed to assess the implementation and health benefits of a primary care referral to an adult multi-component weight management intervention in a community setting. The intervention was offered through Primary care in National Health Service (NHS) South Gloucestershire, UK, from Oct 2008 to Nov 2010, in partnership with statutory, community and commercial providers. The scheme offered 12 weeks' community based concurrent support of dietary (Weight Watchers, WW), physical activity (Exercise on Prescription, EOP) and behavioural change (motivational interviewing) components to obese adults. Funding was available for 600 places. RESULTS: Five hundred and fifty nine participants engaged with the intervention, mean age 48 years, 88% female. Mean weight loss for all engagers was 3.7 kg (95 % confidence interval 3.4, 4.1). Participants completing the intervention achieved the largest weight reduction (mean loss 5.9 kg; 5.3, 6.6). Achievement of 5% weight loss was higher in completers (58%; 50, 65) compared to non-completers (19%; 12, 26) and people who only participated in one commercial component of the intervention (either WW or EOP; 19%; 13, 24). CONCLUSION: A multi-component weight management programme may be beneficial for weight loss, but a randomized controlled trial is needed to establish effectiveness and to evaluate cost.

The LDL receptor-related protein 1 (LRP1) regulates the PDGF signaling pathway by binding the protein phosphatase SHP-2 and modulating SHP-2- mediated PDGF signaling events.

BACKGROUND: The PDGF signaling pathway plays a major role in several biological systems, including vascular remodeling that occurs following percutaneous transluminal coronary angioplasty. Recent studies have shown that the LDL receptor-related protein 1 (LRP1) is a physiological regulator of the PDGF signaling pathway. The underlying mechanistic details of how this regulation occurs have yet to be resolved. Activation of the PDGF receptor ß (PDGFRß) leads to tyrosine phosphorylation of the LRP1 cytoplasmic domain within endosomes and generates an LRP1 molecule with increased affinity for adaptor proteins such as SHP-2 that are involved in signaling pathways. SHP-2 is a protein tyrosine phosphatase that positively regulates the PDGFRß pathway, and is required for PDGF-mediated chemotaxis. We investigated the possibility that LRP1 may regulate the PDGFRß signaling pathway by binding SHP-2 and competing with the PDGFRß for this molecule. METHODOLOGY/PRINCIPAL FINDINGS: To quantify the interaction between SHP-2 and phosphorylated forms of the LRP1 intracellular domain, we utilized an ELISA with purified recombinant proteins. These studies revealed high affinity binding of SHP-2 to phosphorylated forms of both LRP1 intracellular domain and the PDGFRß kinase domain. By employing the well characterized dynamin inhibitor, dynasore, we established that PDGF-induced SHP-2 phosphorylation primarily occurs within endosomal compartments, the same compartments in which LRP1 is tyrosine phosphorylated by activated PDGFRß. Immunofluorescence studies revealed colocalization of LRP1 and phospho-SHP-2 following PDGF stimulation of fibroblasts. To define the contribution of LRP1 to SHP-2-mediated PDGF chemotaxis, we employed fibroblasts expressing LRP1 and deficient in LRP1 and a specific SHP-2 inhibitor, NSC-87877. Our results reveal that LRP1 modulates SHP-2-mediated PDGF-mediated chemotaxis. CONCLUSIONS/SIGNIFICANCE: Our data demonstrate that phosphorylated forms of LRP1 and PDGFRß compete for SHP-2 binding, and that expression of LRP1 attenuates SHP-2-mediated PDGF signaling events.