Anomalous Bronchial Artery Origin - Canary in the Coal Mine - For Diagnosing Chronic Thromboembolic Pulmonary Hypertension.

Anomalous bronchial artery origins may have clinical implications beyond their anatomical curiosity. In this case, identification of such an anomaly led to the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH). A 49-year-old male with a history of recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE) on anticoagulation presented with chest pain and shortness of breath. Laboratory analysis was remarkable for a troponin peak of 14.74 ng/ml, a brain natriuretic peptide level of 602 pg/ml and a D-dimer level of 0.62 µg/ml. Electrocardiogram showed non-specific ST elevation in the anterolateral and inferior leads. Computed tomography angiography (CTA) of the chest was positive for PE involving the right lower lobe pulmonary arterial tree. Echocardiogram showed reduced left ventricular function (ejection fraction 38%) and akinesis of the antero-apical and infero-apical segments. Cardiac catheterization revealed non-obstructive coronary arteries, and an anomalous origin of a right bronchial artery from the right coronary artery. The right bronchial hypertrophied as it supplied collateral flow to the occluded right pulmonary artery. This anomaly and the patient's history of multiple DVT/PEs while on therapeutic levels of warfarin with near normal D-dimer levels raised suspicion for a false positive PE. Pulmonary angiogram revealed chronic occlusion in branches of the right pulmonary artery, mean pulmonary artery pressure of 36 mmHg and no acute thrombus. Ventilation-perfusion scan confirmed the diagnosis of CTEPH. The patient underwent successful pulmonary thromboendarterectomy and subsequently had normalization of mean pulmonary artery pressure. This case underscores the importance of a comprehensive diagnostic approach, and consideration of alternative explanations for imaging findings, that unveiled the diagnosis of a complex and life-threatening condition such as CTEPH. LEARNING POINTS: This case underscores the diagnostic significance of identifying anomalous bronchial artery origin which played a crucial role in the diagnosis of the underlying chronic thromboembolic pulmonary hypertension (CTEPH).It is important to understand the limitations of computed tomography angiography (CTA) chest for diagnosis of CTEPH.

Pericardial Mesothelioma Presenting as Constrictive Pericarditis.

This case report presents a 60-year-old gentleman with a significant smoking history and possible asbestos exposure who was referred to the emergency department for atrial fibrillation with a rapid ventricular rate and symptoms of heart failure. Labs showed normal brain natriuretic peptide and troponin I. His echocardiography finding suggested constrictive pericarditis with an ejection fraction of 60%. A computed tomography scan was concerning for a pericardial mass. Left and right heart catheterization hinted more toward constrictive physiology; however, some findings were concerning for restrictive physiology. Hence, cardiac magnetic resonance imaging was done, which established the diagnosis of constrictive pericarditis. Pericardiectomy was planned with a maze procedure for atrial fibrillation. However, a malignant neoplasm was seen on a frozen biopsy. Hence, surgery was limited to partial pericardiectomy, as the patient had advanced infiltrative neoplasm that had resulted in constrictive pericarditis. The final pathology report confirmed the diagnosis of malignant pericardial mesothelioma mixed type. Malignancy is usually diagnosed in an advanced stage, like in our case, due to nonspecific initial presentation. A literature review suggests that there is a lack of established consensus on treatment. The response to therapy also seems to be poor and results only in palliation of symptoms, with a median survival of six months from diagnosis despite optimum medical management.

Brugada Syndrome: When Strict Treatment of Febrile Episodes Really Matters.

We present a case of Brugada syndrome (BrS) diagnosed in a 32-year-old male during a febrile episode. This syndrome has characteristic ECG findings and predisposes patients to ventricular tachyarrhythmias and sudden cardiac death. We would like to highlight the necessity of aggressively treating febrile episodes in patients with BrS. The degree of risk for malignant arrhythmias in asymptomatic patients diagnosed with BrS is not clear. However, the potential for malignant arrhythmia is still there and increases in the setting of febrile episodes.

Atrial fibrillation post central retinal artery occlusion: Role of implantable loop recorders.

OBJECTIVE: This study evaluated the risk of subclinical atrial fibrillation (AF) in patients with central retinal artery occlusion (CRAO) compared to those with cryptogenic stroke using implantable loop recorders (ILR). METHODS: We conducted a retrospective analysis of 273 consecutive patients who had ILRs inserted at our institution for either cryptogenic stroke (n = 227) or CRAO (n = 46). Our primary endpoint was a time to event analysis for the new diagnosis of AF by ILR. Univariable and multivariable Cox proportional hazard models were used to determine the predictors of time-to-AF. RESULTS: A total of 64 patients were found to have newly diagnosed AF by remote monitoring of the ILR. AF was detected in 57 of 227 (25%) cryptogenic stroke patients by the end of a maximum 5.1 years follow-up and in seven of 46 (15%) CRAO patients by the end of a maximum 3.6 years follow-up (P = .215, log-rank test). The Kaplan-Meier estimates for freedom from AF was 59.4% for CRAO and 66.6% for cryptogenic stroke (P = NS, log-rank test). Baseline variables predicting AF included older patients, higher CHADS2 VASC score, longer PR interval on initial EKG evaluation, and mitral annular calcification on transthoracic echocardiogram. CONCLUSIONS: Patients with CRAO are at risk for subclinical AF, similar to those with cryptogenic stroke. Long-term monitoring to detect AF may lead to changes in pharmacotherapy to reduce the risk for subsequent stroke.

Acute myocardial infarction and antiphospholipid antibody syndrome: a systematic review.

BACKGROUND: Antiphospholipid antibody syndrome (APS) is a disorder associated with both arterial and venous thromboembolic disease, including acute myocardial infarction (AMI). Given that management with anticoagulants is critical and differs from usual AMI care, identification of key discriminators of patients with AMI with APS is important. METHODS: We performed an English-language systematic review of the literature of cases and case series of patients with AMI and APS from inception until 20 March 2016, collecting demographics, investigations, and outcomes. RESULTS: Forty cases of AMI because of APS were identified from 27 articles. Patients were younger than typical AMI patients (41.10±13.61 years) and 45% were women. STelevation myocardial infarction was the presentation in 45% (18/40) of cases. The average platelet count was 130 000±138 912 c/mm in the 10 cases reporting it and partial thromboplastin time was elevated in all four reporting it. Coronary arteries were described as normal or with acute thrombosis in 75%. Three died during hospitalization and six had recurrence of myocardial infarction within 3 months after admission. CONCLUSION: APS should be considered in young patients with AMI, especially if previous unprovoked thromboses, lower platelet counts, high partial thromboplastin times, and normal coronary arteries or coronary thromboses are identified.

Aerococcus urinae, a rare cause of infective endocarditis.

We present the case of an elderly male who was initially seen in our hospital for a urinary tract infection that was treated with oral ciprofloxacin. He was admitted 2 weeks later with altered mental status and fever, and was found to have bacteraemia with Aerococcus urinae Owing to altered mental status a brain MRI was performed which showed evidence of embolic stroke. Following this, a transesophageal echocardiogram showed severe mitral regurgitation and a vegetation >1 cm involving the mitral valve with associated destruction of posterior valve leaflets. The patient was started on antibiotics intravenous penicillin G and intravenous gentamicin for a total duration of 6 weeks. He underwent mitral valve replacement on day 4 of hospitalisation. The postoperative course was complicated by ventilator-dependent respiratory failure, requiring tracheostomy and eventual transfer to a skilled nursing facility. Unfortunately, he died after 2 weeks of stay at the facility.

Use of Varenicline in Smokeless Tobacco Cessation: A Systematic Review and Meta-Analysis.

OBJECTIVE: Conduct a systematic review and meta-analysis on the effectiveness and safety of varenicline in smokeless tobacco (SLT) cessation. METHODS: PubMed, EMBASE, clinicaltrials.gov, and the Cochrane Registry were searched up to February 1, 2014, for randomized clinical trials (RCTs) comparing varenicline to placebo. Random effects Mantel-Haenszel summary relative risks (RRs), risk difference (RD), and 95% CIs were used for analysis and reporting of outcomes. Primary and secondary outcomes were the 7-day point prevalence of SLT abstinence at the end of 12 and 26 weeks, respectively. Adverse events reported include nausea, sleep disturbance, and mood disorders. RESULTS: Three published RCTs involving 744 SLT users with a mean age of 39.7 years, of which greater than 88% were males, were randomized to varenicline (n = 370) and placebo (n = 374). Subjects in the varenicline arm had a significantly higher 7-day point prevalence of SLT abstinence at 12 weeks (48% vs. 33%; RR = 1.45, 95% CI = 1.22-1.72, p < .0001, I2 = 0%; RD = 13%, 95% CI = 4%-23%, p = .008) but not at 26 weeks (49% vs. 39%; RR = 1.38, 95% CI = 0.93-2.03, p = .11, I2 = 51%). There were no statistically significant differences in the incidences of adverse events between the 2 arms but interpretation is limited by high heterogeneity. CONCLUSION: This pooled analysis suggests that varenicline is effective in achieving a 7-day point prevalence of SLT abstinence at 12 weeks but showed that this effect was not sustained at 26 weeks.

Improving antibiotic adherence in treatment of acute upper respiratory infections: a quality improvement process.

INTRODUCTION: Approximately 25 million people in the United States visit their primary care physician each year for acute respiratory infections (ARI). They are a common cause of unnecessary prescription of antibiotics; despite well-validated national treatment guidelines, around 73% of adults with ARI are prescribed antibiotics in the United States. Inappropriate use of antibiotics has profound implications. METHODS: Our aim was to increase adherence to antibiotic guidelines for treatment of ARI in an internal medicine outpatient practice. We used a package of active and passive interventions to improve physician awareness of treatment guidelines; these included short sessions of didactic teaching, antibiotic guidelines posters in patient examination rooms and staff areas, clinical decision support (CDS) tools integrated into the electronic medical record system, guideline adherence report cards for providers, and reiteration of CDS tool use and guideline adherence at monthly group meetings. Process measures were the rate of use of CDS tools for the management of ARI and patient callbacks within 72 h for the same issue. Outcome measures were compliance with antibiotic prescribing guidelines. RESULTS: Our low-cost interventions led to a significant improvement in ARI treatment guideline adherence. There was improvement in compliance with treatment guidelines for sinusitis (90.90% vs. 57.58%, p<0.001), pharyngitis (64.28% vs. 25.00%, p=0.003), upper respiratory infection (96.18% vs. 73.68%, p=0.008), and the aggregated measure of ARI (91.25% vs. 78.6%, p<0.001). Rate of CDS tool usage was 40.5% with a 72-h callback rate of 0.05%. CONCLUSION: Simple, low-cost interventions can improve appropriate antibiotic use for ARI and change the prescribing habits of providers in an outpatient setting. Provider and patient education is a vital component of antibiotic stewardship. Simple interventions for common outpatient conditions can have a positive impact on patient outcomes and reduce unnecessary healthcare costs.

Mixed adenocarcinoma and neuroendocrine prostate cancer: a case report.

BACKGROUND: Neuroendocrine prostate cancer is rare but lethal. It is one of the most common extra pulmonary manifestations of small cell cancer. CASE PRESENTATION: Here we present a case report of a 53-year-old male who presents with a mixed adenocarcinoma and neuroendocrine prostate tumor on a background of previously normal prostate-specific antigen (PSA). His initial symptoms prior to diagnosis included decreased urine output and acute kidney injury (AKI). CONCLUSION: Neuroendocrine tumor does not elevate the PSA level and hence is often a late finding with a poor prognosis. Special staining on histopathogy is required to reveal this diagnosis.

Stress-only Tc-99m myocardial perfusion imaging in an emergency department chest pain unit.

BACKGROUND: Stress-only myocardial perfusion imaging (MPI) saves time by eliminating rest imaging, which is important for emergency department (ED) throughput but has not been studied in an ED population. STUDY OBJECTIVE: To determine the prognosis of a normal stress-only MPI study compared to a normal rest-stress MPI and establish its effectiveness in an ED setting. METHODS: All patients evaluated in the ED over 6.5 years who underwent a stress-only technetium-99m gated MPI were compared to those who had a rest-stress study. All-cause mortality was determined using the Social Security Death Index. Survival was analyzed in patients with normal and abnormal MPI results. RESULTS: A total of 4145 studies (2340 stress-only, 1805 rest-stress) were performed. Patients' average age was 57.9 years, 38.5% were male, and most had an intermediate or low pretest risk of coronary artery disease (87.7%). Average follow-up was 35.9 ± 20.9 months. In patients with normal perfusion, at 1 year of follow-up there were 11 deaths in the stress-only group (0.5% 1-year mortality), and 13 deaths in the rest-stress cohort (1.1% 1-year mortality). At the end of follow-up, the stress-only group had a lower all-cause mortality (p < 0.0001) and similar risk adjusted all-cause mortality (p = 0.10) than the rest-stress cohort. Patients with abnormal perfusion demonstrated the expected differential prognosis based on total perfusion deficits in both groups. CONCLUSIONS: A normal stress-only MPI study has a benign 1-year prognosis similar to a rest-stress study when performed in the ED. The ability to triage patients more rapidly and reduce radiation exposure represents an attractive alternative for low-risk patients.

Nonlinear viscoelasticity in rabbit medial collateral ligament.

The goal of this study was to characterize the viscoelastic behavior of the rabbit medial collateral ligament (MCL) at multiple levels of strain (between 0% and approximately 5%) and their corresponding stresses (between 0 and approximately 55 MPa) for stress relaxation and creep, respectively. We hypothesized that in the rabbit MCL the rate of stress relaxation would be strain dependent and the rate of creep would be stress dependent. Thirty MCLs from 15 rabbits were tested ex vivo for this study. Results show that within the physiologically relevant region of ligament behavior, the rate of stress relaxation is strain dependent in the rabbit MCL, with the rate of relaxation decreasing with increasing tissue strain. The rate of creep is stress dependent in the rabbit MCL, with the rate of creep decreasing with increasing stress. These results support our hypothesis, with the greatest nonlinearities in a physiologically relevant region of loading. As such, these nonlinearities should be considered when quantifying ligament viscoelastic behavior with a rabbit model.