Search

Cardiorenal syndrome (CRS) continues to be an area of concern due to the changing understanding of identification, pathophysiology and optimal management. Originally thought that diuretics were always the answer, recent literature has shed lights on the five major CRS subphenotypes, and while conceptual in their classifications, different strategies may be utilized to manage each type. The effect of CRS in pregnant women is largely under discussed and underappreciated as its own entity. Trials involving possible management, specifically utilizing serelaxin, a recombinant form of relaxin, have shown promising results but more data are needed to begin implementing it on a large scale.

BRASH syndrome is a newly coined diagnosis consisting of the clinical pentad of bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia. It is a rare syndrome with just under 50 reported cases. This case report and literature review present a case of BRASH syndrome, refractory to pharmaceutical measures, and subsequent literature review to assess treatment decisions and overall outcomes. The consensus from the literature supports the use of advanced interventions in most cases, including transcutaneous or transvenous pacing, hemodialysis, and adrenergic support. The early recognition and initiation of treatment in this patient demographic are paramount to reducing possible multi-system organ damage and mortality. This case report and literature review aim to improve patient outcomes and help further elucidate a protocol for treating BRASH syndrome.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a predominantly autosomal dominant genetic condition in which fibrous and fatty tissue infiltrate and replace healthy myocardial tissue. This uncommon yet debilitating condition can cause ventricular arrhythmias, cardiac failure, and sudden cardiac death. Management focuses primarily on prevention of syndrome sequelae in order to prevent morbidity and mortality. Genetic testing and screening in affected families, although utilized clinically, has not yet been incorporated in guidelines due to lack of larger studies and data. We aim herein to identify causative gene mutations, present advancements in diagnosis and management, and describe the role of genetic screening and counseling in patients with ARVC. With the advancement of genetic testing and therapy, diseases such as ARVC may become more accurately diagnosed and more effectively managed, ultimately significantly reducing morbidity and mortality.

Primary cardiac tumors are an incredibly rare finding. Cardiac myxomas are the most primary cardiac tumors that often occur within the left atrium. When left untreated, they pose a high risk of causing hemodynamic collapse by obstruction or can embolize and result in thromboembolic stroke. The presentation of cardiac myxoma varies greatly and can be associated with significant morbidity and mortality when undiagnosed. A careful physical examination and high degree of suspicion is crucial in early diagnosis and intervention. Our team presents a 46-year-old female patient with no significant past medical history that presented to the emergency department with a neurological deficit that was concerning for a transient ischemic attack. Initial laboratory workup and electrocardiogram was suggestive for pulmonary embolism; however, upon evaluation with imaging, the patient was found to have a 1.6 × 3.4 cm mass fixed to the mitral leaflet that was then confirmed on transthoracic echocardiography. Our patient was found to have non-obstructive coronary artery disease on cardiac catheterization and ultimately underwent successful mass resection by cardiothoracic surgery.

Acute myocardial infarction is a condition that classically presents with chest pain and corresponding biomarkers and changes on electrocardiogram. Although most causes of acute coronary syndrome are due to acute plaque rupture resulting in coronary thrombosis, an increasingly prevalent condition known as spontaneous coronary artery dissection (SCAD) is becoming more commonly diagnosed. SCAD is characterized by a tear in the tunica media resulting in an intramural hematoma. Depending on the size of the hematoma, progressive extension can ultimately lead to coronary occlusion. Our team presents a 52-year-old female patient that presented with substernal chest pain and positive cardiac enzymes. Urgent coronary catheterization revealed bilateral SCAD involving the left anterior descending and posterior descending arteries in a right coronary dominant circuit. Our patient was treated with medical therapy alone and was safely discharged to home after close monitoring in the coronary care unit. Our team hopes to contribute to a growing body of evidence that bilateral SCAD can occur and can be successfully treated without percutaneous coronary intervention.

Coronary sinus thrombosis (CST) is a rare but life-threatening condition that involves clot formation within the vessel responsible for draining all of the venous blood from the myocardium itself. The coronary sinus is situated in the right atrium approximately half-way between the tricuspid value and the inferior vena cava. The coronary sinus is rarely cited in medical literature due to limited knowledge as well as rarity in clinical encounters. CST can be a rapidly progressive life-threatening emergency as the interruption of vascular drainage can result in pericardial effusions, tamponade and cardiogenic shock. A major clinical challenge in diagnosing and treating this condition is due to relative rarity as well as the non-specificity of presenting symptoms that are often associated with more commonly encountered cardiopulmonary diseases. CST is most commonly induced by endothelial damage, such as post intracardiac instrumentation with catheter guidewires, or any of the criteria outlined by Virchow’s triad. Our team described the finding of a thrombus 1.8 cm in diameter in a patient with underlying hepatobiliary cancer as well as underlying bacteremia from infected ascitic fluid. Though our patient remained hemodynamically stable without cardiopulmonary complications, we hope to spark a discussion within the medical community to increase awareness as well as to highlight the need for more research on this potentially life-threatening condition. J Med Cases. 2021;12(9):355-358 doi: https://doi.org/10.14740/jmc3726

Background: Over the past 2 years of the several strategies recommended to help fight COVID-19, nirmatrelvir/ritonavir is a novel drug shown in the EPIC-HR phase 2 to 3 clinical trial to lower COVID-19-related death or hospitalization at day 28 when compared with placebo. Objective: Our study’s aim was to explore the reported adverse events (AEs) associated with nirmatrelvir/ritonavir use for COVID-19. Method: We conducted a retrospective analysis using the FDA Adverse Event Reporting System (FAERS) database for AEs, listing nirmatrelvir/ritonavir as the primary drug between January and June 2022. The primary outcome was the incidence of reported AEs associated with nirmatrelvir/ritonavir. The OpenFDA database was queried using Python 3.10 to collect the AEs and Stata 17 was used to analyze the database. Adverse events were analyzed by associated medication, with “Covid-19” excluded. Results: A total of 8098 reports were identified between January and June 2022. Most reported complaints in the AE system were COVID-19 and disease recurrence. The most common symptomatic AEs were dysgeusia, diarrhea, cough, fatigue, and headache. Event rates significantly rose between April and May. Disease recurrence and dysgeusia were the most commonly reported complaints for the top 8 concomitant drugs identified. Cardiac arrest, tremor, akathisia, and death were reported in 1, 3, 67, and 5 cases, respectively. Conclusions and Relevance: This is the first retrospective study done on reported AEs associated with nirmatrelvir/ritonavir use for COVID-19. COVID-19 and disease recurrence were the most reported AEs. Further monitoring of the FAERS database is warranted to periodically reassess the safety profile of this medication.

Fetal hemoglobin (HbF) is a physiologic protein tetramer that is crucial for a developing fetus to survive in utero. Maternal hemoglobin has a relatively lower affinity for oxygen, and thus allows for an efficient transfer of oxygen from maternal to fetal blood. In addition to fulfilling a critical physiologic role, HbF is also known to alleviate symptoms of sickle-cell disease (SCD). The concentration of HbF depends on several factors. HbF is elevated in inherited conditions, such as hereditary persistence of HbF, hereditary spherocytosis, and thalassemia. The level of HbF is also increased in acquired states, such as pregnancy, aplastic anemia, thyrotoxicosis, hepatoma, myeloproliferative disorders, or hypoplastic myelodysplastic syndrome. It has been identified that some genetic loci have significant influence on HbF levels. The XmnI polymorphism, the HMIP locus, and the BCL11A gene are responsible for 45% of variations in HbF levels. Although SCD has been well described in the subpopulations of Africa, it is less common in the subpopulations of India. We describe a case of SCD, in which a patient with high HbF level presented at a very late age (27 years old). We presume the patient’s inherently elevated HbF levels were able to compensate for the hypoxic episodes associated with SCD. The onset of symptoms was delayed as a result of elevated HbF levels. Keywords: Acute chest syndrome, HbF, Hereditary hemoglobinopathies, Late presentation, Sickle cell

Acute pancreatitis is a common reason for hospitalization in the United States and can have a high degree of morbidity and mortality if not treated appropriately. Establishing the diagnosis and following guideline-directed medical therapy are both important. In the Western world, the most common causes include acute alcohol overuse, hypertriglyceridemia, gallstone pancreatitis, post-instrumentation including endoscopic cholangiopancreatography, and medication side effects. Our team describes the case of an 84-year-old male that was found to have acute pancreatitis secondary to repaglinide, a commonly used medication for the management of diabetes mellitus. The diagnosis was made based on the imaging findings, physical examination, and the corresponding laboratory markers. The patient was also found to have a blood-alcohol level at baseline and triglyceride levels within normal range. The patient’s symptoms resolved with the cessation of repaglinide administration. Our team hopes to make the medical community more aware of the potential association between repaglinide and the potentially rapidly debilitating disease.

Percutaneous coronary intervention (PCI) is one of the most frequently performed invasive therapeutic procedures and plays a key role in the long-term survival of patients with ischemic heart disease. Over 965,000 angioplasties are performed annually in the United States alone. While the technique and equipment have undergone significant revisions and improvement, the medical community will still benefit from more data and guidance on the optimal selection of mandatory peri-operation anticoagulation in specific, high-risk populations. Many of these procedures are performed on high-risk individuals who have an inherently higher risk of hemorrhage or thrombosis. Unfractionated heparin is the most popular choice in the general population, however, its use carries certain limitations. Here we will describe the use of an uncommonly used anticoagulant in a patient being actively treated for leukemia. We will also discuss the unique properties and benefits of the four most frequently used anticoagulants during a cardiac angioplasty. Our team describes the successful use of bivalirudin during an urgent PCI in a 71-year-old female with eight previous stents that was followed by an uncomplicated recovery period. Our experience contributes to a small, but growing, body of evidence that bivalirudin may be a safe choice to use in lieu of unfractionated heparin in patients with underlying oncological disease. Our patient had several comorbidities that significantly increased their risk of bleeding. We will also review the clinical trials that compared the four most commonly used anticoagulants during cardiac catheterization.

Novel coronavirus 2019 (COVID‐19) has been the focus of the medical community since its emergence in December 2019 and has already infected more than 100 million patients globally. Primarily described to cause a respiratory illness, COVID‐19 has been found to affect almost every organ system. Bradycardia is a newly recognized ramification of COVID‐19 that still has unknown prognostic value. Studies have shown an increase in the incidence of arrhythmias, cardiomyopathies, myocarditis, acute coronary syndromes, and coagulopathies in infected patients as well as an increased risk of mortality in patients with preexisting cardiovascular disease. While the pathogenesis of bradycardia in COVID‐19 may be multifactorial, clinicians should be aware of the mechanism by which COVID‐19 affects the cardiovascular system and the medication side effects which are used in the treatment algorithm of this deadly virus. There has yet to be a comprehensive review analyzing bradyarrhythmia and relative bradycardia in COVID‐19 infected patients. We aim to provide a literature review including the epidemiology, pathogenesis, and management of COVID‐19 induced bradyarrhythmia., Bradycardia is a newly recognized ramification of the COVID‐19 that still has unknown prognostic value. Studies have shown an increase in the incidence of arrhythmias, cardiomyopathies, myocarditis, acute coronary syndromes, and coagulopathies in infected patients as well as an increased risk of mortality in patients with preexisting cardiovascular disease. While the pathogenesis of bradycardia in COVID‐19 may be multifactorial, clinicians should be aware of the mechanism by which COVID‐19 affects the cardiovascular system and the medication side effects which are used in the treatment algorithm of this deadly virus.

Septic arthritis is a debilitating, inflammatory condition of joints that can cause patients to experience significant pain and discomfort. An estimated 0.006% of people annually develop the condition; the absence of prompt diagnosis and treatment can lead to long-term joint dysfunction. Septic arthritis is usually caused by hematologic seeding of the joint space by bacteria, however, those who receive intra-joint injections and IV access are also at high risk for developing the condition. In this article, we present the case of a 58-year-old male with no immediately identifiable risk factors for septic arthritis, who was found to have a septic joint as a result of an invading perirectal abscess that was discovered in an imaging study.

Background: Atherosclerosis is an inflammatory disease that contributes significantly to cardiovascular mortality. Arterial stiffening due to calcification can coexist with or directly influence pathogenesis of atherosclerosis. We hypothesize that arteriosclerosis caused by genetically engineered calcification in mice redistributes shear stress on the endothelial cells, which in turn leads to further accelerated rate of plaque formation. Methods: All of the mice had an LDL receptor mutation and were fed pro-atherogenic diet (1.25% cholesterol). The case group overexpressed tissue-nonspecific alkaline phosphatase in endothelial cells (eTNAP). The luminal surfaces of descending thoracic aorta (TA) and suprarenal abdominal aorta (AA) were scanned using Sensofar S Neox optical confocal microscope at 1 μm vertical resolution. The surface topographies per sample, each measuring 500 x 700 microns, were analyzed for ISO 25178-2 areal roughness parameters using SensoMap. Parameters were compared by t test (n=5 eTNAP, n=6-7 control). Results: We observed a significant difference in the incidence as well as the morphology of the plaques in the eTNAP group compared to control mice. There was a 4.8 fold increase in the number of topological motifs in the thoracic aorta of the eTNAP vs. controls (p < 0.01). Similarly, the number of motifs was increase in the abdominal aorta of the eTNAP mice compared to controls (2.8 fold; p=0.06). The average area of the motifs was significantly larger in the controls compared to the eTNAP group in both segments of the aorta (p=0.06 TA; p < 0.05 AA). The maximum height of the lesions in the TA was not different between the groups (p=0.62), however increased by 74% in the abdominal aorta of the eTNAP compared to controls (p Conclusion: Arteriosclerosis increases surface roughness. In our model, the abdominal region had a high incidence of taller, irregular lesions whereas those in the thoracic aorta were flatter and more spaced. The high resolution scans will be further used to study the hemodynamic disturbances to the endothelial cells using flow dynamics simulations.

While the assembled 1D magnetic nanoparticle (NP) chains have demonstrated synergistic magnetic effects from the individual NPs, it is essential to prepare new 1D NP chains that can combine the magnetism with other important material properties for multifunctional applications. This paper reports the fabrication and multifunctional investigation of a new type of 1D NP chains that combine the magnetic properties with fluorescent properties, photothermal conversion ability, and drug carrier function. The building block NPs are composed of magnetic Fe(3)O(4) nanocrystals clustered in the core and fluorescent carbon dots embedded in the mesoporous carbon shell with hydroxyl/carboxyl groups anchored on their surface. These NPs can assemble under the induction of external magnetic field and form stable 1D NP chains of diameter ∼ 90 nm and length ∼ 3 μm via the hydrogen bonding and π-π stacking linkage of the carbon shell. The resulted 1D hybrid NP chains not only demonstrate much higher magnetic resonance imaging (MRI) contrasting ability than the dispersed building block NPs, but also enter into intracellular region and light up the B16F10 cells under a laser excitation with strong and stable fluorescence. While the mesoporous carbon shell provides high drug loading capacity, the embedded fluorescent carbon dots convert near-infrared (NIR) light to heat, and hence kill the tumor cells efficiently and enhance the drug release rate to further improve the therapeutic efficacy under NIR irradiation. Such designed 1D magnetic-fluorescent hybrid NP chains with enhanced MRI contrast, fluorescent imaging ability, and combined chemo-/photothermal therapeutic ability have great potential for various biomedical applications.