Invasive hemodynamic characteristics in patients with mitral annular calcification related mitral stenosis and chest radiation.

Quantification of invasive hemodynamics and mitral annular calcification-related mitral stenosis remains underexplored in patients exposed to chest radiation. We sought to explore invasive hemodynamic parameters via transseptal catheterization in patients with and without chest radiation who had a diagnosis of mitral annular calcification-related mitral stenosis. After excluding patients with more than moderate mitral regurgitation, we found that there was no difference in mitral valve area on hemodynamic testing in patients with and without radiation with an elevated baseline transmitral gradient on transthoracic echocardiography in the setting of mitral annular calcification-related mitral stenosis. There was a higher transmitral gradient and left atrial pressure in patients with prior radiation consistent with left atrial noncompliance, suggesting that treatment mitral valve stenosis may not relieve symptoms in this cohort of patients.

A Historic Cohort Analysis of Radiographic and Serologic Findings in Patients With Scleroderma and Interstitial Lung Disease.

BACKGROUND/OBJECTIVE: Few studies have investigated associations between rheumatologic serology patterns and different interstitial lung disease (ILD) patterns. METHODS: We present novel findings of a historic cohort study (n = 454) with data collected from 2011 to 2021 within our hospital system. In this institutional review board-approved study, data regarding rheumatologic serologies and ILD patterns were noted based on chart review in patients with scleroderma. The Kruskal-Wallis rank sum and χ2 tests were used for statistical analysis. RESULTS: Results showed a statistically significant association between anti-U1 snRNP with lymphoid interstitial pneumonia, which has not been previously described. CONCLUSIONS: We demonstrated novel serologic associations with ILD patterns, which have important clinical implications. More robust and high-powered studies are needed to elucidate the role of serologic testing and their association with ILD phenotypes.

Nonatheromatous Coronary Kink Causing Angiographic Obstruction: A Rare Structural Anomaly.

Ischemic symptoms may be explained by a multitude of coronary pathologies, including coronary artery tortuosity, atherosclerosis, fibromuscular dysplasia, vasculitis, coronary vasospasm, or microvascular disease. We present an unusual case of coronary kinking in a patient presenting with exertional jaw pain in the absence of atherosclerotic risk factors. Multimodality imaging, coronary imaging, and coronary physiology helped establish the diagnosis and guide management.

Trigeminal Amyloidoma in a Patient With Cardiac Amyloidosis.

Trigeminal amyloidoma is a rare clinical phenomenon with scarce reports in the medical literature. This report presents a case of biopsy-proven trigeminal amyloidoma in a patient with cardiac amyloidosis. This case report sheds light on the differential diagnoses that may resemble trigeminal amyloidoma and strategies for workup and treatment.

Impact of Professional Society Guideline Publications in Medicine Subspecialties From 2012 to 2022: Implications for Clinical Care and Health Policy.

Clinical guidelines have become an integral part of clinical care. We assessed professional society-based clinical guidelines from 2012 to 2022 to elucidate the trends in numbers of documents, recommendations, and classes of recommendations. Our results found that 40% of the guidelines do not follow all recommendations made by the Institute of Medicine for trustworthy documents. There has been a significant increase in documents in cardiology, gastroenterology, and hematology/oncology. In addition, of more than 20,000 recommendations, there was significant variability in recommendations made by different professional societies within a specialty. In documents from 11 of the 14 professional societies, more than 50% of the recommendations are supported with the lowest levels of evidence. In cardiology, in addition to the guideline documents, 140 nonguideline documents provide 1812 recommendations using the guideline verbiage, and 74% of the recommendations are supported by the lowest level of evidence. These data have important implications for health care because guidelines and guideline-like documents can be used for health policy issues such as assessment of quality of care, medical liability, education, and payment.

A Rare Case of Cardiac Tamponade in a Patient With Anti-RNA Polymerase III Scleroderma.

Scleroderma is a chronic, progressive autoimmune disease that often presents with multiorgan involvement. Cardiac manifestations are common and include microvascular coronary artery disease, conduction abnormalities, autonomic insufficiency, and pericardial effusions. Although rare, pericardial effusions may progress and lead to cardiac tamponade. Patients diagnosed with scleroderma can be further prognosticated based on the presence of serologic scleroderma-specific antibodies. The anti-RNA polymerase III autoantibody (anti-RNAP3) is associated with an aggressive subtype of scleroderma. Looking at the current literature, no association has been reported between anti-RNAP3 and the development of cardiac tamponade in patients with underlying scleroderma. We discuss a unique case of a patient with scleroderma who was found to be anti-RNAP3 positive and signs of cardiac tamponade. This case illustrates the importance of an expeditious diagnosis and timely interventions to treat cardiac tamponade. Additionally, we share a rare but important association between anti-RNAP3 and the formation of tamponade physiology in scleroderma.

Cardio-Oncology for the Primary Care Provider.

Cardiovascular disease is a major cause of mortality among oncologic patients. As cancer therapies continue to evolve and advance, cancer survival rates have been increasing and so has the burden of cardiovascular disease within this population. For this reason, cardio-oncology plays an important role in promoting multidisciplinary care with the primary care provider, oncology, and cardiology. In this review, we discuss the roles of different providers, strategies to monitor patients receiving cardiotoxic therapies, and summarize cancer therapy class-specific toxicities. Continued collaboration among providers and ongoing research related to cardiotoxic cancer therapies will enable patients to receive maximal, evidence-based, comprehensive care.

Hereditary transthyretin amyloidosis presenting with spontaneous periorbital purpura: a case report.

Background: Amyloidosis is a systemic disorder of abnormal protein folding and deposition resulting in a range of symptoms including neuropathy, heart failure, renal disease, and dermatologic findings. The two most common types of amyloidosis that affect the heart are transthyretin (ATTR) amyloidosis and light chain (AL) amyloidosis, which vary in clinical presentation. Skin findings such as periorbital purpura are considered more specific for AL amyloidosis. However, there are rare cases of ATTR amyloidosis causing the same dermatologic findings. Case Summary: A 69-year-old female presented for evaluation of amyloidosis after cardiac imaging done at the time of a recent atrial fibrillation ablation showed signs of infiltrative disease. On examination, she had periorbital purpura which she reportedly had for years without receiving a diagnosis, as well as macroglossia with teeth indentation. These exam findings, in addition to her transthoracic echocardiogram showing apical sparing, are typically considered characteristic of AL amyloidosis. Subsequent workup revealed the presence of hereditary ATTR (hATTR) amyloidosis with a heterozygous pathogenic variant in the TTR gene producing the p.Thr80Ala mutation. Conclusion: Spontaneous periorbital purpura is thought to be pathognomonic for AL amyloidosis. However, we describe a case of hereditary ATTR amyloidosis with the Thr80Ala TTR genetic variant presenting initially with periorbital purpura, the first case documented in the literature to our knowledge.

Localized Delayed T-cell Mediated Hypersensitivity After mRNA SARS-CoV-2 Vaccination.

Since the emergency authorization of SARS-CoV-2 vaccines, the medical literature has been investigating the management of allergic reactions to the vaccines. Anaphylaxis has been reported among a minority of vaccinated individuals, and many trials monitoring the safety profile of the vaccines have identified cases of benign cutaneous reactions. Typical features of delayed benign cutaneous hypersensitivity reactions include localized erythema, pruritus, and rash. However, reports have described rare cases of rash and atopy at sites apart from the injection site following vaccine delivery. We will discuss a unique case of delayed benign cutaneous hypersensitivity presenting in the lower extremity after an upper-extremity administration of an mRNA SARS-CoV-2. Additionally, we describe management strategies to guide clinicians who encounter similar vaccine-induced hypersensitivity reactions.

Palpitations and Shortness of Breath-Just a "Bump in the Road" or Something More?

A previously healthy person in their 60s with progressive shortness of breath and fatigue for the past 6 months presented to the emergency department with palpitations and shortness of breath. What is your diagnosis?

A review of testosterone supplementation and cardiovascular risk.

Testosterone therapy is commonly utilized to treat hypogonadism. After diagnosis with morning serum testosterone level in patients with symptoms of hypogonadism, therapy has been shown to improve symptoms. Research focusing on cardiovascular risks associated with testosterone therapy has produced contradictory statements. We review trials that have investigated the impact of testosterone supplementation on heart failure, coronary artery disease, and myocardial ischemia.

A review of transthyretin cardiac amyloidosis.

Transthyretin cardiac amyloidosis is a progressive disease known to cause heart failure, conduction anomalies, and arrythmias. Due to poor outcomes and mortality from severe cardiomyopathy, prevalence and incident rates are often underreported. As global longevity is increasing and rates of amyloidosis are also increasing, there is a need to improve diagnostic and therapeutic interventions. Previously, symptom management and transplantation were the mainstay of treatment for heart failure symptoms, but studies using RNAi and siRNA technologies have shifted the paradigm of therapeutic strategy in amyloid cardiomyopathy management. Additionally, early detection and clinical monitoring with numerous imaging and non-imaging techniques are being increasingly investigated. Here, we review the epidemiology, pathophysiology, diagnosis, and management of transthyretin amyloid cardiomyopathy.

Bedside Healers: An approach to increase humanistic practices in the inpatient setting.

In light of the COVID-19 pandemic and resulting visitor restrictions, the inpatient setting has become isolative for many patients. We initiated a program, Bedside Healers, in which medical students rotating at Allegheny General Hospital in Pittsburgh, Pennsylvania dedicate time to bedside discussions with patients in the Complex Medical Care Unit in an effort to provide more individualized care to patients and enable them to feel connected with their physicians. After collecting their weekly entries detailing the patient experiences the students had, we found that this program was able to increase patient-centric humanistic practices and improved the overall patient care experience for patients and physicians alike. We encourage other inpatient settings to adopt similar initiatives especially during these unprecedented and isolating times.

Impact factor of major dermatology journals and the increasing influence of dermatology in the house of medicine.

BACKGROUND: Journal impact factor (JIF) is a bibliometric proxy of relative journal importance. Mean dermatology JIF has nearly doubled since 1997. The reasons behind the increase have not been previously explored. OBJECTIVE: To assess factors contributing to rising dermatology JIF. METHODS: This bibliometric study utilized publicly-available citation and JIF data from the Thomson-Reuters InCites Journal Citation Reports "Dermatology and Venereology" category, from 1997-2017. RESULTS: From 1997-2017, aggregate dermatology JIF increased by 70%, associated with a 64% increase in JIF numerator (total journal citations) and a 3% decrease in JIF denominator (total journal articles and reviews). In the four highest-JIF journals (JAAD, JAMA Dermatology/Archives of Dermatology, JID, and BJD), there was an increase in citations coming from non-dermatology specialty journals, including oncology, rheumatology, and multidisciplinary sciences. Journal impact factor was positively correlated with five JIF alternatives. Immediacy Index, a reflection of how fast dermatology journals are cited, increased four-fold (P<0.001). LIMITATIONS: Impact factor numerator/denominator data were not available before 1999. CONCLUSIONS: The nearly two-fold rise in dermatology JIF from 1997-2017 was associated with increased citations, an increasing proportion of which came from non-dermatology journals. This may reflect growing influence of dermatology research within both dermatology and other fields of medicine.

Sterility and cost of gloves during Mohs micrographic surgery: Sterile or peril?

In recent years, the focus in the field of health care has shifted toward cost-saving strategies without the sacrifice of patient safety and clinical outcomes. Therefore, we decided to look into the use of nonsterile gloves and sterile gloves during Mohs micrographic surgery. This practice varies widely between Mohs surgeons. However, studies have shown no differences in infection rates. Here, we review the pertinent studies and also combine the data to offer readers an overall financial analysis.

Preinjection aspiration for injectable fillers in aesthetic dermatology: Trust or bust?

In recent years, the utility of preinjection aspiration for injectable fillers as a safety checkpoint has been debated. It is a clinical technique that has become controversial in both the literature and at national aesthetic conferences. Many consensus papers and anecdotal reports have been divided on how helpful preinjection aspiration is in reducing adverse events and subsequently increasing patient safety. Here, we summarize the prominent studies in the literature and offer an evaluation and insights.