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Rumpel - Leede phenomenon (RLP) was described as early 1909 by Theodore Rumpel and by Stockbridge Leede in 1911 in patients suffering from scarlet fever. Acute development of petechial rashes distal to the application of blood flow occlusive devices such as a blood pressure cuff or tight wrapped bandage, is a typical finding in this phenomenon. Multiple isolated cases of RLP associated with coronary angiogram have been reported. In this report, we present a case of a 53-year-old male who developed RLP after percutaneous intervention of the proximal-mid left anterior descending artery after application of a sphygmomanometer cuff to contain a right forearm hematoma and application of a trans-radial band. We here discuss the etiopathogenesis and management of RLP that develops post coronary angiogram.

Coronavirus Disease-19 (COVID-19) is a pandemic caused by severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). COVID-19 is known to cause a wide variety of cardiovascular manifestations, including myocarditis, pericarditis, myocardial infarction, stroke, thrombus, pulmonary embolism and acute ventricular failure In this paper, we explore cases of infective endocarditis (IE) that occurred in patients who were concurrently (not sure if they were concurrently infected but if so, makes the sentence smoother and easier to understand) infected with COVID-19 and discuss its association in contributing to factors that can ultimately lead to the development of infective endocarditis. Some of these factors that contribute to IE in COVID-19 include severe inflammatory response, endothelial damage and dysfunction and immunosuppression caused by medications that are used to treat COVID-19. In this systematic review, 12 papers detailing 15 pertinent cases of IE following an infection with COVID-19 were identified. Data from these cases were tabulated and analyzed. The ages of the patients ranged from 20-70 years, with 73% of the patients developing IE of native heart valves and the remaining 27% developing IE of mechanical and bioprosthetic valves. The three most common organism implicated were Enterococcus faecalis (28.57%), Methicillin Resistant Staphylococcus aureus (MRSA) (14.28%), and Methicillin Sensitive Staphylococcus aureus (MSSA) (14.28%). Medical management of these cases involved antibiotic therapy and was reported in 80% of the cases, while only one patient (6.67%) underwent surgical valve replacement. The mortality rate of the patients in this review was quite high at 38%, and other major complications included cardioembolic stroke (20%) and septic embolization to the extremities (6.67%). COVID-19 infection results in a severe inflammatory response caused by a variety of mechanisms. This severe degree of widespread inflammation may result in damage to the endocardium, thus creating an environment to which microorganisms can adhere to and colonize. Additionally, the immunosuppressive medications used in a COVID-19 infection can result in an increased risk of developing infections that have the potential to spread to the endocardium via a hematogenous route. Physicians should be aware of occurrences of IE in COVID-19, as delay in diagnosis and management may cause significant morbidity and mortality.

Ventricular septal rupture (VSR) is a rare complication of myocardial infarction (MI), open heart surgery, and cardiac-based procedures, such as septal myectomy and valve replacement. VSR is associated with high mortality rates and the reported 30-day survival rate is less than 10% without any interventional therapy. Hence, prompt diagnosis and aggressive medical treatment with appropriate surgical intervention are necessary to improve survival. Immediate surgical intervention which is the standard treatment of VSR has a mortality rate of 19-60%. Due to persistent high mortality rate and challenging management of VSR, alternatives to surgical repair has been proposed; transcatheter approach as a new alternative method has been used for the closure of post-surgery residual defects or as a bridge to surgery and in some cases as a definitive therapy instead of surgical repair. Amplatzer Occluder® (AO), a type of transcatheter closure devices, is an approved method of repairing congenital atrial septal defects and it is being used as an alternative method of treatment in VSR. In this systemic review, we assessed the cases of VSR who underwent septal repair by using AO. The study shows that the total mortality rate of percutaneous VSR repair with AO is 20% which is comparable to 19-60% rate of death in patients who undergo surgery. While early intervention is necessary to prevent biventricular dysfunction, immediate surgical intervention on soft and friable tissue surrounding the infarction increases the risk of residual shunt and reoperation. However, this study reveals that the mortality rate of primary percutaneous VSR closure within 7 days of VSR detection was 37 % which is significantly lower than 60% in surgical repair in the same period. In conclusion, given that the prevalence of residual leak in both interventions are similar and close to 20%, percutaneous VSR closure with AO device could be superior to the surgical repair as a primary intervention in unstable or high-risk surgical patients.

Inferior ST-segment myocardial infarction (STEMI) is often due to acute occlusion of the right coronary artery (RCA) or left circumflex artery (LCx). Anatomically, distal occlusion of a dominant left anterior descending artery (LAD) wrapping around the apex supplying posterior descending artery (PDA) can also lead to inferior wall MI. The occurrence of inferior MI with LAD occlusion is underappreciated. We are presenting a case of proximal LAD occlusion leading to inferior wall MI in the presence of non-occlusive right coronary artery (RCA). Physicians should keep in mind the possibility of inferior myocardial infarction with LAD occlusion and interventional cardiologists should perform a complete angiogram to identify the faulty lesion in inferior STEMI before deciding on a RCA or LCx as the culprit artery. Isolated IWMI (inferior wall myocardial infarction) from proximal occlusion of the wrapped around LAD as noted in our patient is a rare occurrence.

Background. The diagnosis of infective endocarditis is difficult, especially when it involves atypical organisms. Therefore, our study identified risk factors of infective endocarditis caused by rare pathogen, Gemella spp. Methods. A systematic review was conducted to investigate characteristics of endocarditis patients infected with Gemella spp. using the search term “Gemella” and “endocarditis.” Case reports were gathered by searching Medline/Pubmed, Google Scholar, CINAHL, Cochrane CENTRAL, and Web of Science databases. 83 articles were selected for review. Results. 5 species of Gemella were identified. Typical patient affected were male between 31 and 45 years of age. On admission, patients had fever, tachycardia, and normal blood pressure. Common clinical manifestation other than fever included fatigue and weakness, chills and sweating, and nausea, vomiting, diarrhea, and weight changes. 1 in 4 reported a history of congenital heart disease, and a recent oral infection. 1 in 2 patients underwent surgical procedure. Laboratory tests revealed anemia, leukocytosis, and elevated erythrocyte sedimentation in all age groups, as well as elevated C-reactive protein in adult and geriatric populations only. Mitral and aortic valves were most commonly infected by Gemella spp.. The most common Gemella spp.-susceptible antibiotics were penicillin, vancomycin, cephalosporin, macrolide, and aminoglycosides. However, antibiotic resistance was observed against penicillin, aminoglycoside, and fluoroquinolone. Antibiotic therapy of at least 6 weeks resulted in superior clinical improvements than durations under 6 weeks. Finally, 1 in 2 patients underwent valve replacement or repair, with common complications affecting the cardiovascular, neurological, and renal systems. Finally, death occurred in 1 in 8 patients, half of which occurred post-surgical procedure, and the majority occurring equal to or greater than 1 week from admission. Conclusion. Our systematic review highlights the importance of considering rare pathogens, particularly in the presence of predisposing risk factors.

Infective endocarditis (IE) is a serious medical condition with a high morbidity and mortality rate. Staphylococcus aureus is the most common etiologic organism in IE. While echocardiography plays an important role in diagnosis and management of IE, the electrocardiogram (ECG) is helpful in determination of disease progression as well as in prognostication. We present a case of a 72-year-old man who was diagnosed with IE following methicillin resistant Staphylococcus aureus (MRSA) bacteremia. The course of hospitalization was complicated with multiple septic-embolic strokes and aortic root abscess. Serial ECG revealed PR prolongation and new onset left bundle branch block (LBBB) before the patient became terminal. Our case highlights the utility of serial ECGs monitoring in the patients with IE that may reveal subtle ECG findings, such as PR prolongation and LBBB. These findings which might serve as a clue of the presence of peri-annular extension of IE, help in prognostication and aid in the therapeutic decision-making such as early surgical intervention in these high-risk patients with poor prognosis. In this report, we also present the pathophysiologic mechanisms underlining the ECG changes in patients with aortic valve endocarditis.

Swimming-induced pulmonary edema (SIPE), also called immersion pulmonary edema (IPE), is a medical condition seen in various water-based activities such as scuba diving, swimming, aqua jogging, triathlete competition and snorkeling. It occurs when transcapillary filtration of low protein fluid collects in the lungs, in the absence of water aspiration during an aquatic activity, causing acute dyspnea, cough and/or hemoptysis. The hallmark of this entity is the complete resolution of symptoms within 48 hours. SIPE in snorkeling is an under-reported and understudied subject. The true prevalence of SIPE is unknown with an estimated range from 1.8–60% among combat swimmers trainee and 1.4% in triathletes. Recent developments have been done in elucidating the pathophysiology of SIPE with regards to pulmonary capillary pressure so that the predisposing factors and potential causes can be targeted. SIPE can be a potentially life-threatening condition, which needs to be recognized by the swimmers, divers, supervising physicians in order to diagnose and manage it promptly. We report a rare case of SIPE in snorkeling which presented with acute respiratory symptoms and managed with supportive measures in the hospital.

Introduction: While the association between gout and cardiovascular disease (CVD) has been extensively studied, scarce data is available for the Black population. We aimed to assess, in a predominantly Black urban population with gout, the prevalence of traditional CVD risk factors, CV outcomes, and the strength of the association between gout and CVD after adjusting for CVD risk factors. Hypothesis: Black patients with gout have higher CVD rates compared to a matched cohort without gout. Methods: Cross-sectional analysis of data obtained from the EMR of gout patients followed at our primary care clinics. Patients were identified by ICD codes and compared to age, sex and race matched non- gout cohort. Descriptive data was obtained, and logistic regression used to assess the strength of association between gout and CVD, before and after adjustment for CVD risk factors including obesity, DM, HTN, dyslipidemia and smoking. Results: There were 471 patients with gout with a mean age of 63.7 ± 0.5 years (mean ±SEM); 89% were Black, 63% were men, mean BMI was 31.3 ± 0.4 Kg/m 2 . HTN, DM and dyslipidemia were present in 89%, 46% and 52% respectively.Compared to controls, patients with gout had significantly higher rates of angina, arrythmia, CAD/stents, MI, CABG, CVA, and PVD. The odds ratio (OR) for CVD = 4.5 (3.3-6.2) (95% CI), p Conclusion: Gout in a predominantly Black population confers three times the CVD risk and overall mortality compared to a race, age and sex-matched cohort.This risk appears greater compared to previously published data in whites (OR 1.25-1.55) (Choi HK et al Circulation 2007;116:894-900). Further research is needed to confirm our findings and to develop interventions to reduce morbidity and mortality among these vulnerable patients.

Background: The novel coronavirus disease-2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) has been a major cause of morbidity and mortality around the world Thirteen million cases have been diagnosed with approximately 570,000 deaths worldwide COVID-19 is associated with ischemia, myocarditis and eventual resulting arrhythmia Cases may present as acute thrombotic occlusion, stress cardiomyopathy, or coronary spasm Hydroxychloroquine (HCQ) was temporarily approved by FDA for COVID-19 treatment In this study, we planned to characterize the risk and degree of QTc prolongation in largely African-American population in central Brooklyn, who were hospitalized with COVID-19 infection in association with inpatient administration of HCQ and azithromycin One of the major adverse drug effects of HCQ and chloroquine is the potential prolongation of corrected QT interval (QTc) Methods: In our retrospective study, we included patients, both males and females, 18 years of age and older who were admitted at SUNY Downstate Medical Center, Brooklyn, New York, for COVID-19 infection and were treated with hydroxychloroquine Native baseline RR, QRS, and QT intervals were measured before administering the first dose of hydroxychloroquine and within 24 h of administration The RR interval was measured as a distance between the peak of the R-wave and the peak of the previous R-wave in the same lead in milliseconds and converted to a heart rate by equation, 60,000/RR For correction of the QT, we used common formulas: QTc = QT/√RR [Bazett formula], QTc = QT/∛RR [Fridericia formula], QTc = QT + 0 154 (1-RR) [Framingham formula], QTc = QT + 1 75 (heart rate-60) [Hodges formula] QTc interval prolongation was defined based on the following rules: Male Rules: 1) Baseline 450 ms;2) >15% increase over baseline post HCQ;and 3) baseline >450 ms and 500 ms;Female Rules: 1) Baseline 470 ms;2) >15% increase over baseline post HCQ;and 3) baseline >470 ms and 500 ms Statistics: Means were compared using independent sample t-tests;paired sample t-tests and proportions were compared using Chi square analysis QT correction formulas were compared using 1-way ANOVA and post hoc analysis was done with Tukey correction Binary univariate and multivariate regression were performed to determine risk factor predictors for QTc prolongation Results: We screened 444 consecutive patients with COVID-19 who were admitted to our hospital between March 10 and April 15, 2020, a total of 247 were excluded from this study because they met the exclusion criteria Thus, 197 patients were included in the analysis The mean baseline QTc interval calculated using the Bazett, Hodges, Frederica, Framingham methods were 451 0 ± 34 3, 425 1 ± 28 9, 417 2 ± 34 0, and 413 9 ± 31 ms, respectively Of the 4 correction methods, 35 5% of all patients met the criteria for prolongation using the Bazett method Of all patients included in the study 125 (63 5%) were male and 72 (36 5%) were female Subjects were predominantly African American ancestry, 179 (90 9%) The mean age of all patients was 66 1 ± 13 3 years The most common comorbidities were hypertension (74 6%), diabetes (55 3%), and hyperlipidemia (37 5%) Of all study participants, 91 7% received concomitant azithromycin;31% of patients were on home beta-blocker therapy, while 27 9% were on home calcium-channel blockers Of baseline electrocardiograms, 87 8% were sinus rhythm Total number of patients meeting prolongation criteria was less using the Hodges, Frederica, and Framingham methods Mean QTc values in both genders are presented in (Tables 1, 2, 3, and 4) All 4 methods showed statistically significant increases in QTc Bazett had the relatively largest difference between pre- and post-therapy QT interval with a mean difference of 14 48 ms The increase was present in both men and women The mean difference across sexes was largest using the Bazett method 16 43, bu this was not statistically significant Univariate analysis across all methods found that the concomitant use of azithromycin was not a significant predictor in QT prolongation across the Bazett, Hodges, Frederica, and Framingham methods However, the presence of coronary artery disease was a statistically significant predictor for QT prolongation The presence of congestive heart failure was also a predictor using the Hodges and Framingham methods (Table 5, 6, 7, and 8) (Figure 1) [Formula presented] ANOVA analysis across all subjects showed a significant difference between the four methods There were significant differences between Bazett and 3 methods The largest difference was between Bazett and Framingham, by 37 12 s There was also a smaller difference between the Hodge and Framingham methods The significant difference between the Bazzett method and the others also persisted across both men and women The difference between Hodges and Bazzett was only significant in men (Table 9, 10, and 11) QT prolongation irrespective of the method used for correction did not predict mortality [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented] Conclusion: It was notable that the longest QTc prolongation seen in this study was only 14 48 ms, using the Bazett formula With other formulas, this prolongation was significantly smaller and so was the proportion of patients meeting QTc prolongation criteria Not surprisingly, the Bazett formula again overestimated extend of QT prolongation We can only speculate that the differences are perhaps related to the fact that our population was nearly exclusively African American Common channels variation has been well documented to be a factor in QT prolongation, including drug-inducted QT prolongation In the African-American ethnic subgroup, Ser1103Tyr-SCN5A is seen in approximately 8 % of population and can certainly explain our data Furthermore, frequency of CAD and CHF was slightly higher than reported in other studies and both entities were associated with QT prolongation on our population Reassuringly, the presence of QT prolongation was not found to be a predictor of mortality in our cohort Categories Other: COVID-19 Lectures

Accurate detection of lymph node involvement on pre-operative imaging in patients diagnosed with renal cell carcinoma (RCC) is critical for determination of disease stage, one of the most significant prognostic factors in RCC. The presence of lymph node involvement in RCC doubles a patient's risk of distant metastasis and significantly reduces their 5-year survival. Currently, lymph node involvement in patients with RCC is evaluated with numerous modalities, with rapid advancements occurring across these modalities. The purpose of this study was to evaluate the advantages and disadvantages of each modality and utilize sensitivities and specificities to determine the highest performing modalities for accurate lymph node involvement in renal cancer. A comprehensive computer-based literature search of full-length original research English language studies of human subjects with biopsy-proven RCC was performed to evaluate publications on the diagnostic performance of color Doppler sonography (CDS), magnetic resonance imaging (MRI), lymphotrophic nanoparticle enhanced MRI (LNMRI), multidetector-row computed tomography (MDCT), F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET), and PET/CT for evaluation of lymph node status in kidney cancers in articles that were published prior to May 2018. Limited studies were available for evaluating CDS performance for determination of lymph node involvement in renal cancer. While CT is the most common modality for nodal staging, due to its availability and relatively low expense, it did not demonstrate the highest performance of the modalities examined for determination of lymph node status in patients with RCC. Of the modalities examined, MRI demonstrated the highest sensitivity (92-95.7%) for detection of lymph node involvement in RCC. Studies of lymph node involvement in RCC using both MRI and CT indicated that using the current diameter criteria (greater than 1 cm) for determination of positive lymph nodes should be re-evaluated as micro-metastases are frequently overlooked. Studies evaluating lymph node involvement with FDG-PET had the highest specificity (100%), indicating FDG-PET is the preferred modality for confirming lymph node involvement and extent of involvement. However, due to the low sensitivity of FDG-PET, clinicians should be skeptical of negative reports of lymph node involvement in RCC patients. Further studies examining determination of lymph node involvement in renal cancer across modalities are greatly needed, current literature suggests utilizing a combination of MRI and FDG-PET may offer the highest accuracy.

BACKGROUND: Identification of markers to aid in understanding the growth kinetics of Von Hippel–Lindau (VHL)-associated clear cell renal cell carcinoma (ccRCC) has the potential to allow individualization of patient care, thereby helping prevent unnecessary screening and optimizing intervention. PURPOSE: To determine whether the degree of restricted diffusion at baseline MRI holds predictive potential for the growth rate of VHL-associated ccRCC. MATERIALS AND METHODS: Patients with VHL disease who underwent surgical resection of tumors between November 2014 and October 2017 were analyzed retrospectively in this HIPAA-compliant study. The change in ccRCC volume between two time points and apparent diffusion coefficient (ADC) at baseline was calculated by using segmentations by two readers at nephrographic-phase CT and diffusion-weighted MRI, respectively. Intraclass correlation coefficient was used to assess agreement between readers. Repeated-measures correlation was used to investigate relationships between ADC (histogram parameters) and tumor size at baseline with growth rate and volume doubling time (VDT). Predictive performance of the ADC parameter with highest correlation and tumor size at baseline was reviewed to differentiate tumors based on their VDT (≤1 year or >1 year). RESULTS: Forty-six patients (mean age, 46 years ± 7 [standard deviation]; 25 women) with 100 ccRCCs were evaluated. Interreader agreement resulted in mean κ scores of 0.89, 0.82, and 0.93 for mean ADC, baseline tumor volume, and follow-up tumor volume, respectively. ADC percentiles correlated negatively with tumor growth rate but correlated positively with VDT. Lower ADC values demonstrated stronger correlations. The 25th percentile ADC had the strongest correlation with growth rate (ρ = −0.52, P < .001) and VDT (ρ = 0.60, P < .001) and enabled prediction of VDT (≤1 year or >1 year) with an area under the receiver operating characteristic curve of 0.86 (sensitivity, 67%; specificity, 89%) (P < .001). CONCLUSION: Apparent diffusion coefficient at baseline was negatively correlated with tumor growth rate. Diffusion-weighted MRI may be useful to identify clear cell renal cell carcinomas with higher growth rates. © RSNA, 2020 See also the editorial by Goh and Prezzi in this issue.

Peritoneal free fluid can indicate an underlying disease process; however detection of minimal peritoneal free fluid in healthy children is not uncommon. To assess the significance of incidental peritoneal free fluid within healthy children by MRI and its relation to physiological changes during puberty. This prospective study was performed on 32 healthy volunteers (20 boys) between the ages of 8 years and 13 years, with consecutive follow-ups every 8–10 months for an average of 3 years. Body mass index (BMI) z-score, pubertal status, C-reactive protein and sex hormone concentrations were assessed prior to MRI studies. We reviewed a total of 120 pelvic MRI studies (61 boys) and measured the quantity of peritoneal free fluid. For statistical analysis we used linear mixed-model accounting for within-patient correlations. The mean ± standard deviation volume of peritoneal free fluid was 4.7±5.7 mL in girls and 1.9±3.1 mL in boys, with a maximum volume of 25 mL and 17 mL, respectively. The prevalence of peritoneal free fluid was significantly higher in girls (91%) compared to boys (67%; P=0.0035). In 15% of the girls and 3% of the boys the fluid was greater than 10 mL. The mean volume of peritoneal free fluid in the fourth stage of puberty was higher and significantly different from the mean volume in the first stage of puberty (P=0.01). Among healthy pubescent children, the prevalence of peritoneal free fluid is significantly higher in girls. The volume of peritoneal free fluid can reach volumes greater than 10 mL during normal puberty, especially in the fourth stage, and can be assumed normal in the absence of active disease.