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.

Effect of the COVID-19 pandemic on the epidemiological trends and outcomes of gastrointestinal bleeding: a nationwide study.

The COVID-19 pandemic altered healthcare delivery in the United States. This study examined the effect of the COVID-19 pandemic on the epidemiological trends and outcomes of gastrointestinal bleeding. We compared the admission rate, in-hospital mortality rate, and mean length of hospital stay between 2019 and 2020 to estimate the pandemic effect. The study highlighted disparities in outcomes of gastrointestinal bleeding hospitalizations stratified by sex and race. We noted a 9.5% reduction in the total number of hospitalizations in 2020. We also observed a 13% increase in overall mortality during the pandemic (P < 0.001). There was a 15.8% increase in mortality among men (P = 0.007), compared to a 4.7% increase among women (P = 0.059). There was a significant increase in mortality among Whites in 2020 compared to Black and Hispanic populations. On multivariable logistic regression, admission during the COVID-19 pandemic was associated with increased length of stay when adjusted for age, sex, and race. Despite the direct COVID-19-related morbidity and mortality, the so-called indirect effect of the pandemic cannot be overlooked. For the remainder of the pandemic and future health emergencies, it is critical to balance mitigation of the spread of the contagion with clear public health messages to not neglect other life-threatening emergencies.

Rates, Reasons, and Independent Predictors of Readmissions in Portal Venous Thrombosis Hospitalizations in the USA.

Background: Portal vein thrombosis (PVT), generally considered rare, is becoming increasingly recognized with advanced imaging. Limited data exist regarding readmissions in PVT and its burden on the overall healthcare cost. This study aimed to outline the burden of PVT readmissions and identify the modifiable predictors of readmissions. Methods: The National Readmission Database (NRD) was used to identify PVT admissions from 2016 to 2019. Using the patient demographic and hospital-specific variables within the NRD, we grouped patient encounters into two cohorts, 30- and 90-day readmission cohorts. We assessed comorbidities using the validated Elixhauser comorbidity index. We obtained inpatient mortality rates, mean length of hospital stay (LOS), total hospital cost (THC), and causes of readmissions in both 30- and 90-day readmission cohorts. Using a multivariate Cox regression analysis, we identified the independent predictors of 30-day readmissions. Results: We identified 17,971 unique index hospitalizations, of which 2,971 (16.5%) were readmitted within 30 days. The top five causes of readmissions in both 30-day and 90-day readmission cohorts were PVT, sepsis, hepatocellular cancer, liver failure, and alcoholic liver cirrhosis. The following independent predictors of 30-day readmission were identified: discharge against medical advice (AMA) (adjusted hazard ratio (aHR) 1.86; P = 0.002); renal failure (aHR 1.44, P = 0.014), metastatic cancer (aHR 1.31, P = 0.016), fluid and electrolyte disorders (aHR 1.20, P = 0.004), diabetes mellitus (aHR 1.31, P = 0.001) and alcohol abuse (aHR 1.31, P ≤ 0.001). Conclusion: The readmission rate identified in this study was higher than the national average and targeted interventions addressing these factors may help reduce the overall health care costs.

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.

Hypothermia versus normothermia after out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The current guidelines recommend targeted temperature management (TTM) as part of the post-resuscitation care for comatose patients following out-of-hospital cardiac arrest. These recommendations are based on the weak evidence of benefit seen in the early clinical trials. Recent large multicentered trials have failed to show a meaningful clinical benefit of hypothermia, unlike the earlier studies. Thus, to fully appraise the available data, we sought to perform this systematic review and meta-analysis of randomized controlled trials. METHODS: We searched four databases for randomized controlled trials comparing therapeutic hypothermia (32-34 °C) with normothermia (≥36 °C with control of fever) in adult patients resuscitated after out-of-hospital cardiac arrest. Independent reviewers did the title and abstract screening, full-text screening, and extraction. The primary outcome was mortality six months after cardiac arrest, and secondary outcomes were neurological outcomes and adverse effects. RELEVANCE FOR PATIENTS: Six randomized controlled trials were included in this review. There was no significant difference between the hypothermia and normothermia groups in mortality till 6 months follow up after out-of-hospital cardiac arrest (OR 0.88, 95% CI 0.67-1.16; n = 3243; I2 = 51%), or favorable neurological outcome (OR 1.31, 95% CI 0.93-1.84; n = 3091; I2 = 68%). Rates of arrhythmias were notably higher in the hypothermia group than the normothermia group (OR 1.43, 95% CI 1.20-1.71; n = 3029; I2 = 4%). However, odds for development of pneumonia showed no significant differences across two groups (OR 1.13, 95% CI 0.98-1.31; n = 3056; I2 = 22%). Therefore, targeted hypothermia with a target temperature of 32-34 °C does not provide mortality benefit or better neurological outcome in patients resuscitated after the out-of-hospital cardiac arrest when compared with normothermia.

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.

Pulmonary barotrauma in COVID-19: A systematic review and meta-analysis.

BACKGROUND: An ever-increasing number of studies have reported an increased incidence of spontaneous pulmonary barotrauma such as pneumothorax, pneumomediastinum, and subcutaneous emphysema in patients with COVID-19. We conducted this systematic review and meta-analysis to assess the value and significance of the available data. METHODS: A thorough systematic search was conducted to identify studies of barotrauma in hospitalized patients with COVID-19. Data analysis of case reports was done using a statistical package for the social sciences (SPSS) version 22, and meta-analysis was performed using CMA-3. RESULTS: We identified a total of 4488 studies after thorough database searching.118 case reports and series, and 15 observational studies were included in the qualitative analysis. Fifteen studies were included in the quantitative analysis. The observational studies reported barotrauma in 4.2% (2.4-7.3%) among hospitalized patients; 15.6% (11-21.8%) among critically ill patients; and 18.4% (13-25.3%) in patients receiving invasive mechanical ventilation, showing a linear relationship of barotrauma with the severity of the disease. In addition, barotrauma was associated with a longer length of hospital stay, more extended ICU stay, and higher in-hospital mortality. Also, a slightly higher odds of barotrauma was seen in COVID-19 ARDS compared with non-COVID-19 ARDS. CONCLUSION: COVID-19 pneumonia is associated with a higher incidence of barotrauma. It presents unique challenges for invasive and non-invasive ventilation management. Further studies are required to unravel the underlying pathophysiology and develop safer management strategies.

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.

A Narrative Review of Existing Options for COVID-19-Specific Treatments.

The new coronavirus disease 2019 (COVID-19) was declared a global pandemic in early 2020. The ongoing COVID-19 pandemic has affected morbidity and mortality tremendously. Even though multiple drugs are being used throughout the world since the advent of COVID-19, only limited treatment options are available for COVID-19. Therefore, drugs targeting various pathologic aspects of the disease are being explored. Multiple studies have been published to demonstrate their clinical efficacy until now. Based on the current evidence to date, we summarized the mechanism, roles, and side effects of all existing treatment options to target this potentially fatal virus.

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.