Systematic Review of Literature Citing the ISCHEMIA Trial.

PURPOSE OF REVIEW: Optimal therapy for patients with chronic coronary artery disease (CCD) has long been a topic under investigation and a subject of debate. Seeking to clarify appropriate management, the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial compared medical management versus coronary angiography for patients with stable ischemic heart disease. Its reception in the medical community has been met with both acclaim and criticism. In light of such disparate views of this trial, a systematic review of the literature citing the ISCHEMIA trial was performed. RECENT FINDINGS: All articles citing the ISCHEMIA trial on PubMed as of July 21, 2023, were compiled and underwent qualitative analysis. A total of 430 articles were evaluated; 109 (25.3%) did not offer substantial commentary on ISCHEMIA and cite it as background evidence for further study. Of the commentary articles, the majority (224, 52.1%) gave balanced, honest appraisals of the ISCHEMIA trial. A total of 46 (10.7%) strongly praised the trial while another 39 (9.1%) were strongly critical of the results. Almost three-quarters of the literature citing the ISCHEMIA trial was commentary in nature, with roughly equal distribution across the spectrum of praise and criticism. Despite being one of the largest studies on CCD and coronary revascularization ever conducted, the impact of ISCHEMIA on the cardiology community appears to be mixed.

Epidural pain management in advanced gastric cancer with inoperable malignant bowel obstruction.

Presented is a case of a man in his 20s with gastric cancer with metastasis to a perineal nodule and the splenic flexure (previously resected due to acute bowel obstruction) who presented with prolonged, intermittent, inoperable bowel obstruction likely due to adhesions, exacerbated by functional ileus due to substantial opioid requirement. In an episode of obstruction during the described admission, the patient remained obstructed after more than 10 days of medical management. The patient suffered from intense abdominal distention and pain, necessitating hundreds of oral morphine equivalents daily. A ropivacaine thoracic epidural infusion was initiated, allowing decreased opioid use and relief of opioid-induced ileus contributing to his bowel obstruction. He subsequently had multiple formed bowel movements, which quickly decreased the patient's abdominal distention and immediate risk of perforation. This case explores epidurals as an underutilised approach to pain management in metastatic gastric malignancy and inoperable malignant bowel obstructions.

One year follow up for case series of myocarditis following mRNA vaccination against SARS-CoV-2.

In 2021, the first rounds of modified mRNA vaccines against SARS-CoV-2 were tested and deployed. The vaccines themselves had great efficacy against severe infection, with rare and minimal side effects. One adverse effect that was reported, however, was incidence of myocarditis seen amongst mostly young males after their second vaccination dose. The disease course was self-limited. This study group published a case series in August of 2021 of four cases of this phenomenon. This paper is a followup to the original case series, providing an updated literature review and expert recommendations concerning the safety and benefits of the vaccines.

Amyloid transthyretin cardiac amyloidosis with different manifestations, test findings and types.

Amyloid transthyretin amyloidosis usually presents with cardiac amyloidosis manifestations, most commonly with a heart failure syndrome. The history and physical examination offer clues of other cardiac and extracardiac manifestations. Taking a detailed history is essential in elucidating pertinent family and medical history that may increase suspicion for amyloidosis. Further, certain findings on electrocardiogram and imaging should raise suspicion and trigger further workup that can confirm the diagnosis, since treatment is evolving.

Assessment of Cardiovascular Risk for Noncardiac and Nonsurgical Activities.

Cardiovascular risk stratification is a frequent evaluation performed by health professionals. Not uncommonly, requests for risk stratification involve activities or procedures that fall outside of the scope of current evidence-based guidelines. Estimating risk and providing guidance for these requests can be challenging due to limited available evidence. This review focuses on some of these unique requests, each of which are real examples encountered in our practice. We offer guidance by synthesizing the available medical literature and formulating recommendations on topics such as the initiation of testosterone and erectile dysfunction therapy, SCUBA and skydiving, polygraphy, and electroconvulsive therapy.

TAVR in the tricuspid domain: valve-in-valve transcatheter tricuspid valve replacement for bioprosthetic valve degeneration.

We report a novel use of transcatheter aortic valve replacement (TAVR) for valve-in-valve tricuspid valve replacement. A man in his 50s with prohibitive risks for surgical intervention underwent this procedure to improve severe, symptomatic tricuspid stenosis. Though current literature is limited to case reports, the Valve-in-Valve International Database (VIVID) reports similar mortality rates between surgical and transcutaneous replacement. As a novel, off-label procedure, there is limited operator experience. Nonetheless, in non-operative or high-risk patients, similar outcomes are noted in between transcatheter tricuspid valve replacement and surgical replacement. This registry sets the framework for further studies with the possibility of observing outcomes as operator experience increases, while highlighting the feasibility of the procedure.

Myocarditis following mRNA vaccination against SARS-CoV-2, a case series.

INTRODUCTION: mRNA COVID-19 vaccines have emerged as a new form of vaccination that has proven to be highly safe and effective against COVID-19 vaccination. Rare adverse events including myocarditis have been reported in the literature. METHODS: Data were gathered from the electronic medical record of four patients personally treated by the authors. RESULTS: Four patients, ages 20 to 30, presented with myocarditis characterized by chest pain, elevations in troponin-I and C-reactive protein, and negative viral serologies two to four days following mRNA vaccine administration. One had a cardiac MRI showing delayed gadolinium enhancement in a subpericardial pattern. All experienced symptom resolution by the following day, and the two who have returned for follow-up had normal troponin-I and CRP values. DISCUSSION: Along with previously reported instances, these cases raise suspicion for a possible link between mRNA vaccines and myocarditis.