Sinus of Valsalva Aneurysm: An Atypical Etiology of Recurrent Syncope.

The sinus of Valsalva presents the initial segment of the aorta from where the coronary vessels arise. Sinus of Valsalva aneurysms (SOVAs) present as progressive dilatation of the aortic sinus. SOVA arises both from the congenital and acquired weakness of the elastic lamina of the aortic media. Though most of the SOVAs are asymptomatic and diagnosed on screening for other pathologies, patients can present with symptoms of arrhythmia, aortic insufficiency, aorto-cardiac fistulas, and, in a few cases, with rupture. We describe a patient who presented with recurrent syncope and was found to have a 6 cm dilated SOVA with an ectatic ascending aorta. Further assessment revealed a left anterior fascicular block, aortic regurgitation, and mitral regurgitation. On further assessment, no other cause of syncope was found. There was no family history of aneurysm or sudden cardiac death. The patient was eventually discharged with outpatient follow-up with cardiothoracic surgery. In patients presenting with asymptomatic SOVA, a dilatation with a maximum diameter of 6.0 cm requires stringent monitoring and should be considered for surgery.

Candida lusitaniae, an Emerging Opportunistic Pathogen in Immunocompetent Populations: A Case Report.

Candida lusitaniae is an emerging opportunistic pathogen in immunocompromised hosts and hospitalized patients. However, the incidence is low in immunocompetent hosts. Because of their characteristic similarities, C. lusitaniae may be confused with other fungal species, such as Candida tropicalis, Candida parapsilosis, and even Saccharomyces cerevisiae. Recently reported cases of serious infections caused by C. lusitaniae have proven detrimental, and some cases reported amphotericin resistance. Here, we present a case report of empyema caused by C. lusitaniae in an immunocompetent patient who was admitted to the intensive care unit and intubated for acute hypoxic respiratory failure. This case demonstrates the importance of recognizing this organism and initiating early treatment for the prevention of fatal complications.

Heart Block and Sinus Pause Following Abdominal Surgery: A Case Requiring Temporary Pacemaker Insertion.

This case report presents the clinical course of a 70-year-old female with a history of hypertension who developed sinus pauses following abdominal surgery, ultimately requiring the placement of a pacemaker. The patient initially presented with altered mental status preceded by abdominal pain, which progressed to confusion and obtundation. Examination revealed signs of toxicity, tachycardia, tachypnea, and a distended abdomen with absent bowel sounds. A computed tomography (CT) scan of the abdomen indicated closed-loop small bowel obstruction with free air and ascites. The patient underwent exploratory laparotomy, revealing purulent fluid and a necrotic, perforated appendix, leading to appendectomy and peritoneal irrigation. Subsequent surgeries addressed the coagulative necrosis of the omentum and wound closure. During the recovery period, the patient exhibited bradycardia with sinus pauses, including episodes of complete heart block. Cardiology consultation attributed this to increased parasympathetic tone following surgery and recommended the placement of a temporary transvenous pacemaker. As the patient's condition improved, the sinus pacing function progressively returned, leading to the removal of the pacemaker. This case underscores the potential development of sinus pauses after abdominal surgery and highlights the importance of prompt recognition, appropriate management, and collaboration between surgical and cardiology teams to ensure patient recovery.

Malignant Airway Obstruction and Endobronchial Stent Placement: A Systematic Review on the Efficacy and Safety.

The systematic review aims to evaluate the efficacy and safety of endobronchial stent placement for malignant airway obstruction.  A comprehensive search was conducted across multiple databases to identify relevant studies. Cohort studies, randomized controlled trials, and case-control studies examining the outcomes of endobronchial stent placement in patients with malignant airway obstruction were included. Data on pre-treatment evaluation, such as pulmonary function testing, dyspnea severity scoring systems, arterial blood gas parameters, imaging, and degree of obstruction, were also collected. Primary outcomes of interest included post-procedure stenosis, pulmonary function testing evaluation, blood gas parameters, and survival outcomes. Secondary outcomes encompassed improvements in clinical status, dyspnea grade, and procedure-related complications. A total of 27 studies met the inclusion criteria and were included in the systematic review. The included studies demonstrated promising outcomes of endobronchial stent placement in managing malignant airway obstruction. Post-procedure airway diameters, pulmonary function testing, and blood gas parameters improved significantly. Survival outcomes varied among studies. Furthermore, endobronchial stent placement was associated with improvements in clinical status and dyspnea grade. Procedure-related complications ranged from pain, hemoptysis and mucus plugging to stent obstruction, migration and pneumothorax.  This systematic review suggests that endobronchial stent placement is an effective and safe intervention for managing malignant airway obstruction. It offers significant improvements in post-procedure stenosis, pulmonary function testing, blood gas parameters, and clinical outcomes. However, further studies with larger sample sizes and standardized reporting are warranted to better evaluate the long-term efficacy and safety of endobronchial stent placement for malignant airway obstruction.

Malignant Airway Obstruction and the Use of Nd:YAG Laser: A Systematic Review on Its Efficacy and Safety.

Endobronchial malignancies with significant airway obstruction can lead to multiple complications including pneumonia, and atelectasis over a period of time. Various intraluminal treatments have proven their value in palliative treatment for advanced malignancies. Nd:YAG (neodymium-doped yttrium aluminum garnet; Nd:Y3Al5O12) laser has established its role as a major palliative intervention due to its minimal side effects and improvement in quality of life by relieving local symptoms. The systematic review was conducted with the goal of elucidating the patient characteristics, pre-treatment parameters, clinical outcomes, and possible complications resulting from the use of the Nd:YAG laser. A thorough literature search for relevant studies was conducted on PubMed, Embase, and Cochrane Library from the inception of the idea to November 24, 2022. Our study included all original studies including retrospective studies and prospective trials, but excluded case reports, case series with less than 10 patients, and studies with incomplete or irrelevant data. A total of 11 studies were included in the analysis. The primary outcomes focused on the evaluation of pulmonary functional tests, postprocedural stenosis, blood gas parameters after the procedure, and survival outcomes. Improvement in clinical status, improvement in objective scale for dyspnea, and complications were the secondary outcomes. Our study shows that Nd:YAG laser treatment is an effective form of palliative treatment to provide subjective and objective improvement in patients with advanced and inoperable endobronchial malignancies. Due to the heterogeneous study populations in the studies reviewed and the presence of many limitations, more studies are still warranted to reach a definitive conclusion.

Phenobarbital and Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis.

Alcohol withdrawal syndrome (AWS) is a complication frequently encountered among patients who are chronic alcohol abusers. It is considered to have a significant impact on the United States healthcare system. It not only has a toll on the healthcare spending but also contributes to significant morbidity and mortality. Benzodiazepines are considered first line in the treatment of AWS. Since patients with alcohol use disorder have downregulated gamma aminobutyric acid (GABA) receptors, this often leads to benzodiazepine resistance. Phenobarbital is also used in the management of alcohol withdrawal syndrome. Here we present a systematic review and meta-analysis of the efficacy and safety of the drug. We conducted an electronic database search for relevant studies published between the inception of the project and November 20, 2022, in three databases, including Medline/PubMed, Embase, and Cochrane Library. Our study included all original studies with prime focus on the baseline characteristics of patients admitted to the intensive care unit (ICU) for alcohol withdrawal syndrome and management/monitoring protocol implemented for its treatment. The primary outcomes that were the focus of our study consisted of changes in the length of hospital stay, length of ICU stay, and changes in scoring systems (for alcohol withdrawal assessment and monitoring) following the implementation of phenobarbital. The secondary outcomes included complications such as intubation and mortality. Based on our analysis, the mean difference in hospital stay was statistically significant at -2.6 (95% CI, -4.48, -0.72, P=0.007) for phenobarbital compared to the benzodiazepine group. We were unable to comment on the heterogeneity in our meta-analysis due to the standard deviation not being reported in one study. There was no statistically significant difference regarding the length of stay in the intensive care unit compared to the control/comparative arm, with a mean difference of -1.17 (95% CI, -1.17, 0.09, P=0.07), with considerable heterogeneity (I2=77%, P=0.002). Our meta-analysis also investigated the risk of intubation between the phenobarbital and the control/comparative group. There was statistically significant difference in the incidence of intubation, relative risk (RR) 0.52 (95% CI, 0.25, 1.08, P=0.08), with considerable heterogeneity (I2=80%, P=0.0001). Our study concludes that phenobarbital is an effective tool in the management of AWS in an ICU setting. However, various studies have reported contradictory results, and vital information appears to be lacking. Moreover, there is a lack of uniformity in terms of phenobarbital dosing. Drug administration should be adapted according to the severity of the symptoms. Further studies need to be conducted discussing the safety profile and adverse effects of the drug when it comes to the management of alcohol withdrawal syndrome.

Neuroendocrine Tumor Causing Carcinoid Syndrome in the Elderly.

Neuroendocrine tumors (NETs) causing carcinoid syndrome are very rare. Patients can have very general symptoms and tumors can be missed especially in the elderly where many symptoms may be attributed to the aging process. It is of the utmost importance to do a full workup on elderly patients even if the symptoms can be explained by aging alone.

A Case of Bronchopleural Fistula and Hydropneumothorax in a Patient With Necrotizing Pneumonia Complicated by Mycobacterium avium Complex.

A bronchopulmonary fistula is a pathological connection that develops between the bronchi and the pleural cavity as a result of etiologies including surgery, infection, blunt or penetrating trauma, radiation, chemotherapy, and chronic obstructive pulmonary disease sequela. Diagnosis and treatment are challenging for intensivists. We present a case report of bronchopulmonary fistula resulting in hydropneumothorax caused by necrotizing pneumonia and complicated by mycobacterium avium complex that resolved spontaneously. The aim of this case report is to discuss the presentation and treatment of bronchopleural fistulas.

A Case of Chronic Pulmonary Embolism Resulting in Pulmonary Hypertension and Decompensated Right Heart Failure.

Chronic thromboembolic pulmonary hypertension is a deadly condition that results from thrombus organization and formation of fibrous tissue in the large and/or middle-sized pulmonary artery; as a result, pulmonary vascular resistance increases resulting in pulmonary hypertension and right heart failure. Untreated chronic pulmonary embolism causes decompensated right heart failure. Early diagnosis and appropriate treatment are crucial for improving survival. Pulmonary endarterectomy (PEA) is the treatment of choice as it reduces pulmonary vascular resistance. For patients who are not a candidate for PEA, alternative treatment options improve quality of life.