Catheter ablation versus medical therapy in atrial fibrillation: an umbrella review of meta-analyses of randomized clinical trials.

This umbrella review synthesizes data from 17 meta-analyses investigating the comparative outcomes of catheter ablation (CA) and medical treatment (MT) for atrial fibrillation (AF). Outcomes assessed were mortality, risk of hospitalization, AF recurrence, cardiovascular events, pulmonary vein stenosis, major bleeding, and changes in left ventricular ejection fraction (LVEF) and MLHFQ score. The findings indicate that CA significantly reduces overall mortality and cardiovascular hospitalization with high strength of evidence. The risk of AF recurrence was notably lower with CA, with moderate strength of evidence. Two associations reported an increased risk of pulmonary vein stenosis and major bleeding with CA, supported by high strength of evidence. Improved LVEF and a positive change in MLHFQ were also associated with CA. Among patients with AF and heart failure, CA appears superior to MT for reducing mortality, improving LVEF, and reducing cardiovascular rehospitalizations. In nonspecific populations, CA reduced mortality and improved LVEF but had higher complication rates. Our findings suggest that CA might offer significant benefits in managing AF, particularly in patients with heart failure. However, the risk of complications, including pulmonary vein stenosis and major bleeding, is notable. Further research in understudied populations may help refine these conclusions.

A case report of lung metastasis in a cervical cancer presenting as a consolidation.

Cervical cancer is a preventable cancer in the United States. We discuss a case of a 43-year-old woman who presented with signs and symptoms of Cerebrovascular accident (CVA) as well as shortness of breath and chest tightness. Upon investigation, it was concluded that she had developed multiple brain infarcts, pulmonary embolism, and deep venous thrombosis in both lower extremities. However, after her pulmonary symptoms worsened, further investigations revealed an uncommon occurrence of infiltrative lung metastasis. This finding was particularly surprising as she had recently been diagnosed with squamous cell carcinoma of the cervix. It is important to note that patients who have not undergone regular cervical cancer screening can remain without symptoms until the disease has reached an advanced stage, as is the case with this patient. Various screening methods, such as Pap smear cytology, human papillomavirus (HPV) DNA testing, and visual inspection tests, are available to detect and prevent cervical cancer.

Life before Death in India: A Narrative Review.

Palliative care is an ever-increasing need in India, with its large population and rising burden of chronic illness. India ranks 67th out of 80 countries in the quality of death index, which measures the availability and quality of palliative care. Community-led projects in Kerala have proven successful in improving palliative care access with modest resources and volunteer involvement. In India, the number of hospice facilities is increasing; however, <1% of the Indian population has access to palliative care. Financial and human resources limitations in the health-care system, poverty and high health-care expenditure, the lack of awareness among the public about end-of-life care, hesitance to seek care due to social stigma, strict laws regarding opiates that hinder adequate pain relief and the apparent conflict between traditional social values and western values regarding death are the major obstacles to improving palliative care. Significant efforts focused on public awareness of end-of-life care and locally-tailored programmes with family and community involvement are necessary to address this issue and integrate palliative care into the primary care system. Furthermore, we discuss the effects of the COVID-19 pandemic that has been managed effectively by palliative care involvement.

A Rare Case of Right-Sided Aortic Arch With Mirror-Image Branching and Congenital Absence of the Left Pulmonary Artery.

Both the right-sided aortic arch with mirror-image branching (RAMI) and the congenital absence of the left pulmonary artery are sporadic congenital defects. Both diseases are typically diagnosed in childhood, but occasionally asymptomatic cases may be incidentally detected through imaging in adulthood. We reported a 43-year-old female patient with a RAMI and congenital absence of the left pulmonary artery who was relatively asymptomatic until adulthood.

An Adult Female Presenting With "Scrofula-Tubercular Lymphadenitis" a Rare Encounter: A Case Report.

Cervical lymphadenitis is the most common extra-pulmonary manifestation of tuberculosis (TB). Usually, presenting with a neck mass with minimal systemic symptoms is a diagnostic challenge for physicians. Diagnosis is made by combining clinical features, microscopic and radiological imaging, and fine-needle aspiration biopsy. A biopsy is the simplest and most cost-effective means of diagnosis. We are reporting a case of a female presenting with a neck mass without systemic symptoms who were found to have lymph node TB along with active lung disease. She was treated with a nine-month course of the direct observation treatment regimen.

Rare Angina: A Case Report of Ludwig's Angina.

Ludwig's angina is the rapidly progressive cellulitis of the soft tissue of the neck and the floor of the mouth. Airway compromise is a frequent and potentially fatal sequela of Ludwig's angina. Here we present a case of a 54-year-old African American male who presented with fever associated with painful swelling of the mouth and anterior neck. He was febrile and hypoxic on presentation. Imaging showed extensive involvement of the neck and mediastinum to the level of the clavicles. The diagnosis of Ludwig's angina of periodontal origin was made, and intubation was performed for airway protection. Management was done by surgical debridement along with a course of broad-spectrum antibiotics. The patient's condition improved, and he was discharged on oral antibiotics with a referral to a dentist. Our case demonstrates that early diagnosis, airway management, treatment with broad-spectrum antibiotics, and surgical intervention are vital for the successful management of severe cases of Ludwig's angina.

POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Protein, and Skin Changes): A Case Report of a Rare Paraneoplastic Syndrome.

POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes) syndrome is a multisystem disorder. Peripheral neuropathy and monoclonal plasma cell disorder are the most common manifestations of POEMS. Although osteosclerotic or mixed sclerotic-lytic lesions are typical, osteolytic lesions are rarely encountered. We present a case of a 39-year-old male with a history of multiple endocrine disorders who presented with paresthesia, edema, and hyperpigmentation and was eventually diagnosed with POEMS syndrome. Patients with unexplained neuropathy should be evaluated for POEMS syndrome, especially when it is associated with other findings like endocrinopathy, organomegaly, skin changes, or edema.

Aspergillosis: An Unwanted Tenant of Lung Cavity in an Immunocompromised Host.

Immunocompromised status predisposes an individual to infection from bacteria, fungi, and viruses that are otherwise uncommon. The presence of carcinoma and the use of chemotherapy weakens one's immune system and leads to opportunistic infections of many kinds. Aspergilloma is a fungal ball that grows inside a primary cavitary lesion within the pulmonary parenchyma. Generally, immunocompromised individuals have severe and invasive infections from Aspergillus. Here, we present a case report of a female with breast carcinoma undergoing chemotherapy who previously had a lung abscess with Klebsiella. During her subsequent presentation, she was detected to have aspergilloma along with multi-drug-resistant organisms in the lung abscess along with metastasis of breast carcinoma and lung squamous cell carcinoma encapsulating the fungal ball.

Rupture of Both Left-Sided Valves Following Endocarditis Causing One Trouble After Another: A Case Report.

Despite the advances in managing left-sided infective endocarditis, complications are still not uncommon. Both aortic and mitral insufficiency can occur from infective endocarditis. In addition, valvular insufficiency due to rupture of valves presents acutely with cardiac decompensation and requires early surgical intervention. Here, we report a case of a 38-year-old intravenous drug user male with Group A Streptococcus-associated left-sided native valve infective endocarditis who presented with acute heart failure three months after his treatment of infective endocarditis. Infective endocarditis complications can lead to severe valve damage, causing acute heart failure, and may require immediate surgical intervention.

Colchicine for Patients With Coronary Artery Disease: A Systematic Review and Meta-analysis.

ABSTRACT: Several randomized controlled trials have studied the role of colchicine, a potent anti-inflammatory drug, to prevent adverse cardiovascular events in patients with coronary artery disease (CAD). In this meta-analysis, we aimed to determine the role of colchicine in patients with CAD in clinical outcomes and mortality. We searched PubMed, PubMed Central, Scopus, and Embase for randomized controlled trials/experimental studies evaluating the role of colchicine in patients with CAD. After assessing the eligibility for inclusion, risk-of-bias assessment, and data extraction from the included studies, a narrative synthesis was conducted. Of 17 studies included for the qualitative analysis, 11 studies reported that inflammatory markers such as C-reactive protein and cytokines were reduced in the colchicine group, suggesting an anti-inflammatory role of colchicine in CAD. Quantitative analysis with pooling of data from 9 studies using a fixed-effect model showed 28% lower odds of acute myocardial infarction [odds ratio (OR) 0.72, 95% CI 0.59-0.86; n = 11,712], 52% lower occurrence of stroke (OR 0.48, 95% CI 0.30-0.76), and 37% reduction in odds of coronary revascularization procedure in the colchicine group (OR 0.63, 95% CI 0.52-0.76; n= 11,258). However, the odds of gastrointestinal adverse events were 50% higher in the colchicine group (OR 1.50, 95% CI 1.01-2.23; n = 12,214). In conclusion, colchicine is associated with a lower risk of acute myocardial infarction, stroke, and coronary revascularization. However, there is some increased risk of gastrointestinal adverse events with the use of colchicine.

A Case Report of Acute Transient Encephalopathy Following a Trans-esophageal Echocardiography.

Methemoglobinemia is caused due to an increase in methemoglobin in the blood, impairing oxygen transfer to tissues. Acquired methemoglobinemia is caused by various drugs like local anesthetics, antibiotics, nitrates, nitrites, and food additives. We present a case of a 73-year-old male who presented with cyanosis, altered mental status, and hypoxia following transesophageal echocardiography. Arterial blood gas analysis revealed methemoglobinemia. He had been given topical lidocaine and benzocaine spray before the procedure. He improved after the administration of methylene blue. The case highlights the importance of considering methemoglobinemia in patients presenting with cyanosis, altered mental status, and hypoxia after endoscopic procedures.

Concealed Malignancy as a Rare Cause of Refractory Lactic Acidosis: A Fatal Case.

Lactic acidosis is a state in which there is a buildup of lactate in the body to form an excessively low pH in the blood. Elevated lactate levels are often thought to be indicative of relative tissue hypoxia or type A lactic acidosis. Shock, severe anemia, and thromboembolic events can all cause elevated lactate due to tissue hypoperfusion. Malignancy can also lead to an elevation in lactate, a phenomenon described as type B lactic acidosis. Here, we report a case of a 66-year-old male with elevated lactate level, which was refractory to medical treatment. Despite adequate management, including continuous renal replacement therapy, the lactate continued to rise, and consequently, the patient died due to cardiac arrest. Type B lactic acidosis must be considered in patients with elevated lactate levels without hypotension as it has a high mortality rate.

Superior Sagittal Sinus Thrombosis in a Young, Immunocompetent HIV Patient: A Rare Case.

Cerebral venous thrombosis is a rare form of stroke that can present with various clinical features. In addition, it can present with nonspecific neurological features, and initial computed tomography (CT) cannot rule it out even if negative. Human immunodeficiency virus (HIV) infection is a hypercoagulable state; however, it is not much discussed. Here, we present a case of a 24-year-old immunocompetent female who presented with acute meningeal symptoms. She was managed as a case of an opportunistic central nervous system infection at initial presentation, which did not resolve her symptoms completely. Later, however, cerebral thrombosis was diagnosed, and she improved symptomatically on anticoagulants.

Long-Term Favorable Outcome With Nivolumab in a Case of Advanced Non-Small Cell Lung Cancer: A Case Report.

Non-small cell lung cancer (NSCLC) constitutes around 85% of lung cancer cases. Advanced non-small cell lung cancer has a poor prognosis. Immunotherapy plays a pivotal role in managing advanced non-small cell lung cancer not positive for driver mutations. Nivolumab is a monoclonal antibody against programmed death-ligand 1 (PDL1). It is approved as a second-line treatment for patients with advanced non-small cell lung cancer who progress on or after chemotherapy. We present a case of a 71-year-old female with advanced non-small cell lung cancer without any driver mutations diagnosed four years ago. Her disease progressed while on conventional chemotherapy, and she was started on nivolumab three and a half years ago. Her lung nodules resolved, she did not show signs of progression, and her performance status improved while on nivolumab. This case report highlights the current role of nivolumab in the management of NSCLC. Patients whose condition worsens while on conventional chemotherapy can respond very well to modern targeted immunotherapy.

HIV Encephalopathy Mimicking Acute Demyelinating Processes.

Human immunodeficiency virus (HIV) encephalopathy lies in the severe spectrum of HIV-associated neurological disorder (HAND) and ranges from asymptomatic condition to minor neurological features to severe dementia. Cerebrospinal fluid (CSF) analysis helps to rule out the presence of other opportunistic infections. Neuroimaging helps establish the diagnosis. We report a case of a 39-year-old African American female who presented with signs and symptoms suggestive of acute multiple sclerosis (MS) flares in the setting of advanced acute immunodeficiency syndrome (AIDS) encephalopathy. She presented with bilateral lower extremity muscle weakness and pain with apparent cognitive decline. Notable laboratory findings included leukopenia with normal neutrophils and positive serology for HIV-1. The MRI showed mild post-contrast enhancement suggestive of demyelinating disease, favoring MS over progressive multifocal leukoencephalopathy (PML). Cerebrospinal fluid analysis was significant for positive oligoclonal bands and negative serology. She was started on antiretroviral therapy (ART) for AIDS while holding steroids due to the possibility of worsening AIDS. After treatment for HIV, she showed immunologic and functional status improvement. HIV encephalopathy must be diagnosed by ruling out other similar presenting neurological illnesses for tactful patient management.

Central Pontine Myelinolysis Secondary to Hyperglycemia in a Young Patient.

Central pontine myelinolysis (CPM) is a neurological disorder typically caused by rapid correction of severe chronic hyponatremia. Conditions causing a hyperosmolar state can also cause CPM, but it is rarely seen in diabetes. Here we describe a case of a 34-year-old female with longstanding uncontrolled diabetes mellitus who presented with bilateral upper and lower limb weakness and dysphagia. Examination showed decreased muscle strength, and laboratory investigations showed high HbA1c, high blood glucose, increased serum osmolality, and normal sodium. A diagnosis of CPM was made after MRI showed restricted diffusion in the bilateral pons and CT showed pontine hypodensities. The patient was started on insulin therapy, and she showed clinical improvement with improving blood glucose levels. After five days of hospital stay, she was discharged home with appointments to neurology and endocrinology clinics. This case shows that CPM is a potential complication of uncontrolled diabetes mellitus in the presence of normal serum sodium. Timely treatment of hyperglycemia can lead to improvement of symptoms, but it is a potentially fatal condition. Thus, a diagnosis of CPM should be considered in diabetic patients who present with neurological symptoms and hyperglycemia.

Palliative Care and Chronic Obstructive Pulmonary Disease (COPD) Readmissions: A Narrative Review.

Despite all the advances in the treatment and management of chronic obstructive pulmonary disease (COPD), COPD readmissions remain a major challenge nationwide. Increasing evidence suggests that palliative care involvement with a holistic approach towards end-of-life care can significantly improve outcomes related to the quality of life and survival for late-stage cancers and chronic progressive illnesses like COPD, chronic heart failure, and end-stage renal disease. Some studies have attempted to evaluate an association between the involvement of palliative care and readmission reduction, the effect of which remains elusive, especially with regards to COPD readmissions. This review examined the existing literature to analyze the relationship between palliative care involvement for COPD patients and its effect on COPD readmissions.

Scedosporium apiospermum Pneumonia in an Immunocompetent Host.

Invasive fungal infections are being increasingly identified recently. Scedosporium is a significant cause of non-Aspergillus mold infection. It can cause disseminated disease in an immunocompromised host and localized pulmonary infection in immunocompetent ones, especially in those with preformed lung cavities. We present a case of scedosporiosis in an elderly female with bronchiectasis who presented with refractory pulmonary symptoms and infiltrates. The case emphasizes the need to keep the fungal infection in the differential diagnosis of refractory infiltrates in immunocompetent individuals without preformed cavities if they have bronchiectasis. Voriconazole monotherapy can be used as the first-line in proven cases of scedosporiosis.

Successful Treatment of Respiratory Syncytial Virus Infection in an Immunocompromised Patient With Ribavirin.

Respiratory syncytial virus (RSV) is a frequent cause of respiratory tract infections in children. Still, it can also cause seasonal outbreaks affecting persons of all ages, especially those with comorbidities or immunocompromised states. Ribavirin is one of the two approved therapies for the treatment of RSV respiratory tract infections. Unfortunately, its aerosolized formulation has been approved only in children, and the oral formulation is not frequently used to treat the infection. However, ribavirin has demonstrated morbidity and mortality benefit in immunocompromised patients. A 70-year-old female had started chemotherapy for a diagnosis of B-cell acute lymphoblastic leukemia (B-ALL). She developed an upper respiratory tract infection (URTI) along with positive RSV status. We started her on oral ribavirin therapy, which had to be stopped after five days of treatment due to an acute hemolytic reaction. She was re-initiated on oral ribavirin after cessation of medication for seven days and showed improvement. Therefore, ribavirin can be used in immunocompromised patients with RSV infection under proper supervision.

Outlet Ventricular Septal Defect in an Elderly Male.

Ventricular septal defect (VSD) is the most common congenital cardiac anomaly in children and the second most common congenital cardiac anomaly in adults. The hemodynamic compromise associated with VSD is due to the shunt formation created by the abnormal communication between the right and left ventricles. While 85%-90% of small VSDs close spontaneously during the first year of life, some do not close spontaneously. If spontaneous closure does not occur during childhood, a VSD may persist into adulthood and may first be recognized after the development of a complication. We present a case of outlet VSD with secondary aortic insufficiency due to the prolapse of the aortic valve leaflet, especially in the right coronary cusp (RCC) sparing the left coronary cusp. RCC prolapse is an important finding in outlet VSD as the prolapse has the potential to cause permanent aortic insufficiency and closure is indicated regardless of the size of VSD.