Atypical presentation of an epiphrenic esophageal diverticulum 20 years post fundoplication: a case report and review.

Esophageal diverticulum is a rare condition characterized by the herniation of the esophageal mucosa outside the esophageal wall. Here, we explore the prevalence of ED and its associated esophageal dysmotility. We also shed light on the potential impact of previous surgical interventions, such as Nissen's fundoplication, on the development of ED. This manuscript presents the case of a 72-year-old woman with a history of Nissen's fundoplication surgery who experienced worsening symptoms of dysphagia, heartburn and postprandial cough. Despite exhibiting a normal motility pattern, upper endoscopy revealed a large epiphrenic esophageal diverticulum. The patient underwent successful surgical resection with myotomy, resulting in the resolution of symptoms with no complications. This case highlights the rarity of symptomatic ED and the need to recognize it while choosing the optimal treatment modality.

Toll-like Receptor 4 Differentially Modulates Cardiac Function in Response to Chronic Exposure to High-Fat Diet and Pressure Overload.

BACKGROUND/AIM: The impact of myocardial stressors such as high-fat diet (HFD) and pressure overload has been extensively studied. Toll-like receptor 4 (TLR4) deficiency has been suggested to have a protective role in response to these stressors, although some conflicting data exist. Furthermore, there is limited information about the role of TLR4 on cardiac remodeling in response to long-term exposure to stressors. This study aims to investigate the effects of TLR4 deficiency on cardiac histology and physiology in response to chronic stressors. METHODS: TLR4-deficient (TLR4-/-) and wild-type (WT) mice were subjected to either HFD or a normal diet (ND) for 28 weeks. Another group underwent abdominal aortic constriction (AAC) or a sham procedure and was monitored for 12 weeks. Inflammatory markers, histology, and echocardiography were used to assess the effects of these interventions. RESULTS: TLR4-/- mice exhibited reduced cardiac hypertrophy and fibrosis after long-term HFD exposure compared to ND without affecting cardiac function. On the other hand, TLR4 deficiency worsened cardiac function in response to AAC, leading to decreased ejection fraction (EF%) and increased end-systolic volume (ESV). CONCLUSIONS: TLR4 deficiency provided protection against HFD-induced myocardial inflammation but impaired hemodynamic cardiac function under pressure overload conditions. These findings highlight the crucial role of TLR4 and its downstream signaling pathway in maintaining cardiac output during physiologic cardiac hypertrophy in response to pressure overload.

Pharmaco-endoscopic therapy for weight regain post-gastric bypass: a case report.

About 1 in every 4 patients who undergo bariatric surgery regains significant amount of weight some time along their journey, posing it as a serious problem that needs to be addressed in a pandemic of obesity. Lifestyle modification, anti-obesity medications, and bariatric endoscopy are multiple therapeutic options that can be used to support any weight loss attempt. A 53-year-old woman with morbid obesity who responded adequately to gastric-bypass regained significant weight 8 years later. We initially approached her post-operative weight regain in a behavioral, pharmacologic non-invasive manner; however, she failed to appropriately respond to several anti-obesity medications. Upper endoscopy revealed a dilated gastric pouch and gastro-jejunal anastomosis (GJA) that was reduced using argon plasma coagulation (APC), but also with a modest response. We then added liraglutide to her APC endo-therapy sessions and subsequentially patient started losing significantly more weight. For selective post-bariatric surgery weight re-gainers, endoscopic and pharmaco-therapy combined may be needed for more effective results.

Emphysematous pancreatitis with pulmonary embolism: A case report.

Background: Emphysematous pancreatitis is a severe systemic inflammatory process with reports of pulmonary embolism in the setting of acute pancreatitis rarely described. Case presentation: A 61-year-old woman presented with severe abdominal pain of 1 day duration. She was found to have acute interstitial pancreatitis. During her hospitalization, the patient developed worsening abdominal pain associated with increasing oxygen demands, requiring supplemental oxygen through nasal cannula. Workup showed pulmonary embolism in the posterior segmental branch of the left lower lobar artery and development of emphysematous pancreatitis was noted on imaging. The patient was started on intravenous antibiotics and therapeutic anticoagulation; her condition improved and was discharged home. Conclusion: Patients with severe acute pancreatitis may be at risk for pulmonary embolism due to immobilization and other inflammatory mechanisms. Mitigating individualized risk factors and anticoagulation use as prophylaxis should be considered in patients with pancreatitis to prevent embolism. Early detection by clinicians is critical to reduce misdiagnosis and mortality rates.

Application of Platelet-Rich Fibrin as Regeneration Assistant in Immediate Auototransplantation of Third Molar with Unformed Roots: Case Report and Review of Literature.

BACKGROUND: Autogenous Tooth Transplantation (ATT) is the surgical movement of a maturely or immaturely formed tooth from its original site to another extraction site or a surgically prepared socket in the same individual. The most important factor in the healing process after autotransplantation is the presence of intact and viable periodontal ligament cells, which have the ability to differentiate into osteoblasts and able to induce bone production. ATT can successfully replace removable dentures as a restoration option in a growing patient, while implants can be placed only after skeletal maturity is attained. Case Presentation. In this case, we presented an immediate ATT of the third molar with unformed roots to the extraction socket of the first molar with evidence of continued root formation after 2 years of follow-up. CONCLUSION: Platelet-Rich Fibrin (PRF) can induce sustainable and accelerated healing, and it can also induce the regeneration process of the periodontal tissues and pulpal formation. This process plays a key role in future root development and success rate.

Non-proliferative diabetic retinopathy symptoms detection and classification using neural network.

Diabetic retinopathy (DR) causes blindness in the working age for people with diabetes in most countries. The increasing number of people with diabetes worldwide suggests that DR will continue to be major contributors to vision loss. Early detection of retinopathy progress in individuals with diabetes is critical for preventing visual loss. Non-proliferative DR (NPDR) is an early stage of DR. Moreover, NPDR can be classified into mild, moderate and severe. This paper proposes a novel morphology-based algorithm for detecting retinal lesions and classifying each case. First, the proposed algorithm detects the three DR lesions, namely haemorrhages, microaneurysms and exudates. Second, we defined and extracted a set of features from detected lesions. The set of selected feature emulates what physicians looked for in classifying NPDR case. Finally, we designed an artificial neural network (ANN) classifier with three layers to classify NPDR to normal, mild, moderate and severe. Bayesian regularisation and resilient backpropagation algorithms are used to train ANN. The accuracy for the proposed classifiers based on Bayesian regularisation and resilient backpropagation algorithms are 96.6 and 89.9, respectively. The obtained results are compared with results of the recent published classifier. Our proposed classifier outperforms the best in terms of sensitivity and specificity.

A Phase 2a dose-escalation study of the safety, tolerability, pharmacokinetics and haemodynamic effects of BMS-986231 in hospitalized patients with heart failure with reduced ejection fraction.

AIMS: This study was designed to evaluate the safety, tolerability and haemodynamic effects of BMS-986231, a novel second-generation nitroxyl donor with potential inotropic, lusitropic and vasodilatory effects in patients hospitalized with decompensated heart failure and reduced ejection fraction (HFrEF). METHODS AND RESULTS: Forty-six patients hospitalized with decompensated HFrEF were enrolled into four sequential dose-escalation cohorts in this double-blind, randomized, placebo-controlled Phase 2a study. Patients with baseline pulmonary capillary wedge pressure (PCWP) of ≥20 mmHg and a cardiac index of ≤2.5 L/min/m2 received one 6-h i.v. infusion of BMS-986231 (at 3, 5, 7 or 12 µg/kg/min) or placebo. BMS-986231 produced rapid and sustained reductions in PCWP, as well as consistent reductions in time-averaged pulmonary arterial systolic pressure, pulmonary arterial diastolic pressure and right atrial pressure. BMS-986231 increased non-invasively measured time-averaged stroke volume index, cardiac index and cardiac power index values, and decreased total peripheral vascular resistance. There was no evidence of increased heart rate, drug-related arrhythmia or symptomatic hypotension with BMS-986231. Analyses of adverse events throughout the 30-day follow-up did not identify any toxicities specific to BMS-986231, with the potential exception of infrequent mild-to-moderate headaches during infusion. There were no treatment-related serious adverse events. CONCLUSIONS: BMS-986231 demonstrated a favourable safety and haemodynamic profile in patients hospitalized with advanced heart failure. Based on preclinical data and these study's findings, it is possible that the haemodynamic benefits may be mediated by inotropic and/or lusitropic as well as vasodilatory effects. The therapeutic potential of BMS-986231 should be further assessed in patients with heart failure.

Outcomes of Middle Eastern Patients Undergoing Percutaneous Coronary Intervention: The Primary Analysis of the First Jordanian PCI Registry.

AIM: This is a prospective multicenter registry designed to evaluate the incidence of adverse cardiovascular events in Middle Eastern patients undergoing percutaneous coronary interventions (PCI). The registry was also designed to determine the predictors of poor outcomes in such patients. METHODS AND RESULTS: We enrolled 2426 consecutive patients who underwent PCI at 12 tertiary care centers in Jordan between January 2013 and February 2014. A case report form was used to record data prospectively at hospital admission, discharge, and 12 months of follow-up. Mean age was 56 ± 11 years, females comprised 21% of the study patients, 62% had hypertension, 53% were diabetics, and 57% were cigarette smokers. Most patients (77%) underwent PCI for acute coronary syndrome. In-hospital and 1-year mortality rates were 0.78% and 1.94%, respectively. Definite or probable stent thrombosis occurred in 9 patients (0.37%) during hospitalization and in 47 (1.94%) at 1 year. Rates of target vessel repeat PCI and coronary artery bypass graft surgery at 1 year were 3.4% and 0.6%, respectively. The multivariate analysis revealed that cardiogenic shock, congestive heart failure, ST-segment deviation, diabetes, and major bleeding were significantly associated with higher risk of 1-year mortality. CONCLUSIONS: In this first large Jordanian registry of Middle Eastern patients undergoing PCI, patients treated were relatively young age population with low in-hospital and 1-year adverse cardiovascular events. Certain clinical features were associated with worse outcomes and may warrant aggressive therapeutic strategies.

Incidence and prognosis of stent thrombosis following percutaneous coronary intervention in Middle Eastern patients: The First Jordanian Percutaneous Coronary Intervention Registry (JoPCR1).

BACKGROUND: The incidence, risk factors, and outcome of stent thrombosis (ST) after percutaneous coronary intervention (PCI) in Middle Eastern patients are largely unknown. OBJECTIVE: To determine the incidence, risk factors and outcome in our population. DESIGN: Retrospective study of a prospective multicenter registry of consecutive patients who underwent PCI between January 2013 and February 2014 (JoPCR1). SETTING: 12 tertiary care centers in Amman and Irbid, Jordan. PATIENTS AND METHODS: We collected clinical baseline and follow-up data. MAIN OUTCOME MEASURES: Incidence of stent thrombosis. RESULTS: The mean (standard deviation) age of patients (n=2426) was 59.0 (10.1) years and 20.6% were women. Stents (n=3038) were drug eluting (89.6%), bare metal (9.4%) or bioabsorbable (1.0%). After 1 year, 47 patients (1.97%) had ST, including 44 (94%) definite and 3 (6%) probable ST. Patients who had ST presented with sudden death (n=6; 12.2%) or with a nonfatal event (n=43; 87.8%). Nonfatal events included non-ST-segment elevation acute coronary syndrome (26; 53%), acute ST segment elevation myocardial infarction (n=15; 31%) or heart failure (n=2; 4.1%). ST was associated with significantly higher one-month (22.0% vs. 0.7%) and one-year (12.3% vs. 0.73%) mortality rates compared with patients who did not have ST (P < .001). ST patients were younger (mean age 52.9 years vs. 58.4 years), had heart failure (64% vs. 18%), left ventricular ejection fraction (LVEF) < 45% (36% vs. 13%), ST-segment deviation (70% vs. 48%), and elevated cardiac biomarkers blood levels (62% vs. 40%). In the multivariate analysis, the only factor that was significantly associated with ST was the heart failure (OR=3.5, 95% confidence interval: 1.8, 6.6; P < .0001). CONCLUSIONS: The incidence of ST was not different from that in other regions and was associated with an increased one-year mortality. Younger age, heart failure, low LVEF, ST-segment deviation, and elevated blood levels of cardiac biomarkers were predictors of ST. LIMITATIONS: Possible selection bias, recall bias, and missing or incomplete information. The majority of patients were lost to follow up after the 6th month. The registry may not fully represent PCI practice and outcome in all areas in the country or region.

The significance of circulating endothelin-1 as a predictor of coronary artery disease status and clinical outcomes following coronary artery catheterization.

BACKGROUND/OBJECTIVES: Coronary artery disease (CAD) is responsible for significant morbidity and mortality. Inflammatory, pro-thrombotic and structural factors contribute to the etiology of CAD. This study sought to determine the relationship of plasma endothelin-1 (pET-1), a potent vasoconstrictor, mitogen and modulator of cardiac inflammation, to clinical characteristics and outcomes of CAD patients. METHODS: Blood samples were collected from 336 patients with underlying chest pain or recent myocardial infarction (MI), prior to coronary catheterization. pET-1 was correlated with clinical characteristics and outcomes following catheterization and at 30-day follow-up. RESULTS: pET-1 was higher in recent MI patients than in patients with CAD (coronary occlusion≥50%) or without CAD (<50%) (Mean±sem (pg/ml): 2.12±0.13, 1.51±0.10, 1.21±0.06; 95% confidence interval (1.85-2.38, 1.31-1.72, 1.07-1.32; respectively, P<.0001). Patients with ST elevation MI (STEMI) had higher pET-1 than non-STEMI (P=.008). pET-1 was associated with heart failure (HF) and low left ventricular ejection fraction (LVEF) and was highest in MI patients presented with acute HF. At 30-day follow up, pET-1 was not associated with the change in LVEF. In multivariate analysis, pET-1 was positively associated with age, smoking, HF, CAD status, and need for revascularization by coronary artery bypass surgery (CABG). pET-1 was negatively correlated with LVEF and preoperative statin use. CONCLUSIONS: pET-1 is associated with recent MI, HF, age, smoking, CABG, and low LVEF. Preoperative statin use was associated with lower pET-1. pET-1 may serve as a risk marker and a potential therapeutic target in CAD patients.

Level and significance of plasma myeloperoxidase and the neutrophil to lymphocyte ratio in patients with coronary artery disease.

Inflammation plays a pivotal role in the etiology of coronary artery disease (CAD). Myeloperoxidase (MPO) is a potent inflammatory factor and a critical modulator of coronary inflammation and oxidative stress. The goal of this study was to determine the impact of the plasma MPO (pMPO) level and neutrophil/lymphocyte ratio on the clinical characteristics and outcomes of patients with CAD. Blood samples were collected from 210 patients with underlying chest pain or recent myocardial infarction (MI) prior to coronary angiography in order to measure pMPO levels. The pMPO levels and neutrophil/lymphocyte ratio were correlated with clinical characteristics and outcomes following catheterization. The pMPO level and neutrophil/lymphocyte ratio were higher in patients with recent MI than in patients with CAD (coronary occlusion ≥50%) or without CAD (coronary occlusion <50%). Patients with ST segment elevated MI (STEMI) had a higher neutrophil/lymphocyte ratio relative to patients with non-STEMI. The pMPO level was identified to correlate with the neutrophil/lymphocyte ratio and the need for coronary artery reperfusion by coronary artery bypass surgery or percutaneous coronary intervention. Patients who were taking aspirin had lower pMPO levels and neutrophil/lymphocyte ratio compared with those who were not taking aspirin. The plasma neutrophil/lymphocyte ratio was negatively associated with the left ventricular ejection fraction at baseline and the 30-day follow-up, whereas pMPO showed no correlation. Multivariate analysis indicated that the pMPO level was positively associated with MI, the neutrophil/lymphocyte ratio and coronary intervention. The preoperative use of aspirin was associated with a lower pMPO level and neutrophil/lymphocyte ratio. In conclusion, pMPO is positively associated with MI, the neutrophil/lymphocyte ratio and coronary intervention. The preoperative use of aspirin is associated with a lower pMPO level and neutrophil/lymphocyte ratio. pMPO may serve as a predictor of coronary intervention and as a potential therapeutic target for the reduction of inflammation in patients with CAD.

Sinus of valsalva aneurysm with fistula to the right atrium presented as acute heart failure in a young man.

PATIENT: Male, 23 FINAL DIAGNOSIS: Sinus of valsalva aneurysm (SVA) Symptoms: Chest pain • low O2 saturation • short of breath MEDICATION: - Clinical Procedure: - Specialty: Cardiology. OBJECTIVE: Rare disease. BACKGROUND: Sinus of valsalva aneurysm (SVA) is a rare cardiac anomaly. It may be congenital or acquired; a coexisting cardiac lesion might be present. Rupture of the aneurysm, where it usually occurs in the right atrium, can cause acute symptoms of heart failure. Echocardiography (particularly TEE) can provide all necessary diagnostic data for safe surgical treatment. Treatment of choice is surgery. CASE REPORT: A 23-year-old male, previously healthy, presented to the emergency room (ER) with shortness of breath for the last 10 hours after lifting a heavy object. The patient had central chest pain. His O2 sat was 88%. ECG showed ischemic changes. Diagnosis of AMI was made, but auscultation revealed a murmur followed by a TTE and TEE, which revealed a ruptured sinus of valsalva aneurysm. CONCLUSIONS: This case report highlights the superiority of TEE over TTE in diagnosis and in planning adequate surgical treatment for patients with ruptured SVA, as well as the importance of ultrasonographer experience in the diagnosis. The optimal management for a ruptured SVA is surgical repair, with an acceptably low operative risk and good long-term outcome.

An intelligent decision support system for quantitative assessment of gastric atrophy.

AIMS: To build an automated decision support system to assist pathologists in grading gastric atrophy according to the updated Sydney system. METHODS: A database of 143 biopsies was used to train and examine the proposed system. A panel of three experienced pathologists reached a consensus regarding the grading of the studied biopsies using the visual scale of the updated Sydney system. Digital imaging techniques were utilised to extract a set of discriminating morphological features that describe each atrophy grade sufficiently and uniquely. A probabilistic neural networks structure was used to build a grading system. To evaluate the performance of the proposed system, 66% of the biopsies (94 biopsy images) were used for training purposes and 34% (49 biopsy images) were used for testing and validation purposes. RESULTS: During the training phase, a 98.9% precision was achieved, whereas during testing, a precision of 95.9% was achieved. The overall precision achieved was 97.9%. CONCLUSIONS: A fully automated decision support system to grade gastric atrophy according to the updated Sydney system is proposed. The system utilises advanced image processing techniques and probabilistic neural networks in conducting the assessment. The proposed system eliminates inter- and intra-observer variations with high reproducibility.