Delayed Closure of Ventricular Septal Defect with Prolonged Mechanical Support.

Introduction: Ventricular septal defect (VSD) is a severe complication following acute myocardial infarction (MI) resulting from mechanical disruption of the interventricular septum due to extensive myocardial necrosis. Despite advances in management, the mortality rate approaches 50%. We report a case of a 58-year-old male with VSD following MI who was successfully treated with a delayed surgical approach after haemodynamic support using Impella. Case description: A 58-year-old man with type 2 diabetes mellitus and hypertension presented with three days of chest pain. Testing revealed late presenting acute anterior ischaemic infarction and left-to-right shunt in the apical ventricular septum. Urgent cardiac catheterisation showed near-total occlusion of the left anterior descending artery. An Impella CP® was placed before angioplasty with a drug-eluting stent to optimise haemodynamics. After a multidisciplinary discussion, the Impella CP® was upgraded to Impella 5.5®, and surgery was delayed allowing for scar formation. The patient remained in the intensive care unit, where he underwent physical therapy, showing improvements in exercise tolerance by the time of surgery. He underwent a left ventriculotomy with a successful repair via an endocardial patch 28 days after initial presentation. Post-operative recovery was uneventful, with the patient discharged five days later, reporting no physical limitations one month post-discharge. Conclusion: The successful management of VSD post-MI relies on interdisciplinary collaboration, careful timing of surgical intervention and the strategic use of mechanical support devices such as the Impella. This case highlights the potential for favourable outcomes when tailored treatment approaches are employed. LEARNING POINTS: Given the rarity of ventricular septal defects (VSD) post-myocardial infarction (MI), maintaining a high index of suspicion, particularly in patients with anterior infarcts and other high-risk features, is imperative for ensuring early recognition and management of this life-threatening complication.Surgical repair is the treatment of choice for VSD post-MI, offering improved survival rates, particularly when intervention is delayed to allow for myocardial scarring.Mechanical circulatory support devices, such as the Impella, can play a crucial role in bridging patients to surgical repair by providing temporary haemodynamic stabilisation. However, timing is vital, and early initiation of mechanical support can prevent the progression of cardiogenic shock and multi-organ failure.

Gastroduodenal artery aneurysm - an extremely rare but insidious cause of abdominal pain: a case report.

An arterial aneurysm is a localized weakening of the artery wall that results in pathological dilatation. All intra-abdominal artery aneurysms are labeled as visceral artery aneurysms (VAA), apart from the aorto-iliac artery aneurysms. VAA´s are rare, gastroduodenal artery aneurysms (GDAA), constituting 1.5% of visceral artery aneurysms. A woman in her early 80s´ presented with chronic epigastric pain, weight loss, and nausea. Conservative management was unsuccessful. Imaging revealed a GDAA, prompting endovascular coil embolization. Subsequent evaluation confirmed Polyarteritis Nodosa (PAN), treated with rituximab. The report underscores the diagnostic challenges, emphasizing the need for a multidisciplinary approach using imaging and angiography. GDAA's potential life-threatening rupture necessitates prompt intervention, as illustrated in this case. The rare association with PAN, although infrequent, underscores the importance of considering underlying etiologies in multiple visceral aneurysms. Early diagnosis and intervention are pivotal for this uncommon yet potentially lethal condition.

Trends in rheumatoid arthritis associated cardiovascular mortality in the United States from 1999 to 2020.

INTRODUCTION: Rheumatoid Arthritis (RA) is a risk enhancing factor for cardiovascular diseases (CVD). However, data regarding the magnitude and trends of RA associated CVD-related mortality in the United States (U.S) remains scarce. METHODS: A retrospective analysis was conducted using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) dataset. We extracted age-adjusted mortality rates (AAMR) per 100,000 persons and calculated the annual percentage change (APC) through Joinpoint regression. The outcomes were stratified to discern temporal, sex-based, racial, and geographic patterns in RA-associated CVD mortality. RESULTS: Between 1999 and 2020, 128,058 deaths related to CVD in RA patients aged 25 and above were recorded. The AAMR decreased from 3.50 in 1999 to 2.79 in 2020. However, sex disparities persisted, with females consistently experiencing a higher AAMR (3.35) compared to males (1.74). Non-Hispanic (NH) American Indian/Alaska Native had the highest AAMR (4.44) followed by NH White (2.83), NH Black or African American (2.47) and Hispanic or Latino (2.13), while NH Asian/Pacific Islander had the lowest AAMR (1.28). Geographically, the Midwestern region had the highest AAMR (3.12), while the Northeast had the lowest (2.19) with micropolitan (3.47) and nonmetropolitan (3.37) areas exhibiting higher AAMRs compared to large metropolitans (2.28). Notably, states with the highest AAMRs included North Dakota, South Dakota, Vermont, Minnesota and Wyoming. CONCLUSION: Recent trends reveal an upward incline in RA-associated CVD-related mortality with profound disparities related to sex, race, geography and regions. Redressing these disparities necessitates the implementation of targeted population level interventions.

Barriers in Opting for Emergency Medicine as a Career in Pakistan: A Cross-Sectional Survey Study.

BACKGROUND: Medical professionals' low level of apprehension and insights may result in the undervaluing of emergency medicine (EM) as a speciality to pursue in the future, which is a vital component in the everyday management of hundreds of patients. AIM: The aim of this study is to assess medical professionals' perception of the barriers in opting for EM as a career option in Pakistan. METHOD: This was an online survey study that examined doctors'/medical students' perception of hurdles in EM in Pakistan between November and December 2023. This study was conducted at Rawalpindi Medical University, Rawalpindi, Pakistan. Social media platforms were used to recruit the participants to carry out this survey. The questionnaire proforma comprised three sections: a demographic characteristics section (six questions), a perception section (11 questions), and the last section, where participants were asked to give their opinion to improve EM for a future speciality. RESULTS: An online Google survey form was used for the acquisition of data. Percentage and frequency distribution analysis was used. A total of 144 individuals (N = 144) participated in this study. Around 33.3% (N = 48) of the participants expressed that they had not considered a career in EM. Around 43% (N = 62) of them reported not having done a clinical placement in this speciality. A majority of the participants said that either they or their close friends/family members had faced a medical emergency. Leading barriers that proved a hindrance in pursuing this field were high levels of burnout, poor work-life balance, loss of patient follow-up, inability to work independently, more hostile environment, increased mortalities, and lack of exposure. Interestingly, family pressure had been reported by some participants as a limiting factor in pursuing EM. CONCLUSION: In Pakistan, many doctors and medical students are not willing to pursue their careers in EM. Nationwide educational seminars should be conducted to increase awareness and interest among doctors in this field. Moreover, more and more clinical placement opportunities should be made available for junior doctors in EM. In the future, further research should be carried out to identify effective educational interventions to increase doctors'/medical students' awareness in this field of medicine.

A 31-Year-Old Female With Postcoital Hemoptysis.

Hemoptysis is a common presenting symptom in the clinical setting. The most frequent causes of non-life-threatening hemoptysis, which usually originates from the pulmonary arterial circulation, include pulmonary pathologies such as infections, inflammatory airway diseases, and bronchial neoplasms. Hemoptysis occurring only after sexual intercourse, however, is a rare phenomenon. Most of the reported cases have resulted from an underlying cardiac pathology that is predisposed to acute cardiovascular decompensation, a sharp increase in pulmonary capillary pressures, and pulmonary capillary rupture during intercourse. We present the case of a 31-year-old African-American hypertensive female who presented with a six-month history of recurrent post-coital hemoptysis. Other strenuous physical activities did not result in similar episodes. Her workup ruled out the more common etiologies of hemoptysis. Computed tomography of the chest revealed bilateral centrilobular ground-glass opacities and transthoracic and transesophageal echocardiograms revealed moderate to severe mitral regurgitation with a normal left ventricular ejection fraction of 60-65%. After management with lisinopril, she reported no new episodes of post-coital hemoptysis, and a repeat chest CT showed complete resolution of the ground glass opacities bilaterally. This underscores the importance of performing a thorough cardiovascular workup in patients presenting with only post-coital hemoptysis.

A Rare Case of Isolated Male Epispadias.

Epispadias is a congenital malformation marked by the failure of the urethral bulb to tubularize dorsally. This results in a wide-open urethral plate dorsally. Epispadias is frequently associated with bladder exstrophy-epispadias complex.  We report the case of a five-year-old patient who presented in the outpatient department with isolated epispadias without any other associated abnormality. This report aims to document this rare case of isolated male epispadias with incontinence and the success of using the modified Cantwell-Ransley technique for its treatment.