Postinfarction Ventricular Septal Ruptures During the COVID-19 Pandemic: Two Case Series.

This case series highlights the occurrence of hemodynamically significant ventricular septal defects (VSDs) in two patients presenting with ST-elevation myocardial infarction (STEMI) during the COVID-19 pandemic. This paper aims to emphasize the delayed presentation of cardiac emergencies, such as STEMI, due to concerns about contracting COVID-19. This delay has led to an increased risk of rare complications, including VSD, associated with STEMI. The first case involves a 92-year-old male with a history of hypertension, hyperlipidemia, chronic kidney disease, and coronary artery disease. He presented with acute chest pain, and diagnostic tests revealed ST elevations and a VSD. Despite intervention efforts, including hemodynamic support, the patient's condition deteriorated, and he passed away due to advanced age and high surgical risk. The second case involves a 62-year-old female with a medical history of diabetes, hypertension, and hyperlipidemia. She presented with left-sided chest pain, and an angiogram revealed a mid-right coronary artery stenosis and a thrombus. During the procedure, the patient experienced hypotension, requiring hemodynamic support. Subsequent evaluations identified a large VSD with right ventricular dysfunction. The patient underwent a series of interventions, including a ventricular assist device and VSD closure, but experienced multi-organ failure and ultimately passed away. VSDs following acute myocardial infarction (MI) are rare but life-threatening complications. Early revascularization is crucial in preventing the development of VSDs. These cases demonstrate the importance of prompt diagnosis and intervention, as delayed presentation increases the risk of mechanical complications. Surgical closure remains the definitive treatment for postinfarction VSDs.

Radial Arteriovenous Fistula After a Left Heart Catheterization: Two Case Reports.

The distal transradial artery (TRA) approach has been increasing in popularity over recent years due to its favorable ergonomics and potential for fewer vascular complications. Other advantages include lower bleeding risk, early ambulation, lower procedural costs, and same-day discharge, resulting in additional cost savings. We discuss two cases of patients who underwent left heart catheterizations through the radial artery access site and afterwards experienced fistula formation. Our case series brings to light a rare occurrence of arteriovenous fistulas (AVFs) following cardiac catheterization via the transradial artery site, thus enhancing our knowledge of the risk associated with this access site. The pathophysiology of AV fistula remains the same regardless of transfemoral or transradial artery use. During the procedure, needle diversion into the venous tributary results in an unrecognized combined artery and vein puncture, which usually seals spontaneously. However, if the communication persists, an AV fistula may occur. The majority of patients who suffer from an iatrogenic AVF as a result of TRA do not develop clinical signs of hemodynamic significance. There are various therapeutic strategies, which include surgical repair, placement of a covered stent, ultrasound-guided compression of the AV fistula, and conservative management. Both of our patients were evaluated by vascular surgery; one of the patients found the constant pulsation and bruit burdensome and underwent surgical repair.

Prevalence of sexual harassment and its relationship with family birth order among female undergraduates: New findings from institutional-based cross-sectional study in the south east, Nigeria.

Family is the microcosm of a larger society that provides care that shapes the behavior of children. However, the different levels of attention children receive from their parents may affect their behaviour and self-esteem, which can lead to them being more vulnerable to sexual harassment. An institutional-based cross-sectional survey was conducted from March - August 2021, to assess the relationship between family birth order and prevalence of sexual harassment. The multistage sampling procedure was used to draw 1070 participants. The data was analyzed using percentages, mean, and multivariate logistic regression statistics. The multivariate logistic regression was used to estimate adjusted odds ratios (AOR) along with 95% confidence intervals (CIs). The level of significance was set at P < 0.05. The findings revealed prevalence (73.6%) of sexual harassment, and the two forms such as verbal ( = 2.63) and non-verbal sexual harassment ( = 2.56) were high. The multivariate logistic regression odds ratios adjusted shows that the middle born were approximately 2 folds (AOR = 1.62; CI = 1.14 - 2.30; P = 0.008 0.05) more likely to predict sexual harassment. The study recommended amongst others that parents in South Eastern Nigeria should refrain from given special attention to a particular child as this may predispose the unfavoured child to sexual harassment.

Prevalence of sexual harassment and its relationship with family birth order among female undergraduates: New findings from institutional-based cross-sectional study in the south east, Nigeria

Family is the microcosm of a larger society that provides care that shapes the behavior of children. However, the different levels of attention children receive from their parents may affect their behaviour and self-esteem, which can lead to them being more vulnerable to sexual harassment. An institutional-based cross-sectional survey was conducted from March ­ August 2021, to assess the relationship between family birth order and prevalence of sexual harassment. The multistage sampling procedure was used to draw 1070 participants. The data was analyzed using percentages, mean, and multivariate logistic regression statistics. The multivariate logistic regression was used to estimate adjusted odds ratios (AOR) along with 95% confidence intervals (CIs). The level of significance was set at P < 0.05. The findings revealed prevalence (73.6%) of sexual harassment, and the two forms such as verbal (x= 2.63) and non-verbal sexual harassment (x= 2.56) were high. The multivariate logistic regression odds ratios adjusted shows that the middle born were approximately 2 folds (AOR = 1.62; CI = 1.14 ­ 2.30; P = 0.008 0.05) more likely to predict sexual harassment. The study recommended amongst others that parents in South Eastern Nigeria should refrain from given special attention to a particular child as this may predispose the unfavoured child to sexual harassment

Cardiac Biventricular Metastasis From Renal Cell Carcinoma.

Secondary cardiac tumors are much more common than primary tumors. Cardiac metastases from renal cell carcinoma (RCC) are rare and can present many years after the patient has been disease-free. We report the case of a 64-year-old man who had been treated for recurrent metastatic RCC. He presented with shortness of breath, and TEE (transthoracic echocardiography) revealed new biventricular hypertrophy and small-to-moderate circumferential pericardial effusion. Cardiac magnetic resonance demonstrated multiple lesions in both the ventricular walls, highly suspicious for metastasis. A tissue biopsy was obtained, which was inconclusive due to the small sample size. The patient's disease progressively worsened, and, subsequently, he died from cardiac and respiratory failure secondary to the underlying advanced metastatic disease. Cardiac metastasis from RCC is rare and has a wide range of presentations. Metastatic RCC tends to be resistant to chemotherapy and radiotherapy. Systemic therapy (immunotherapy, molecularly targeted agents) and surgery may have a role in these patients depending on the extent of disease and sites of involvement.

A Twisting Tale of Infective Endocarditis.

We present a case of a unique complication of enterococcus endocarditis in an elderly man with a cardiac pacemaker who presented with low-grade fever and cough. He had no history of IV drug use. Blood cultures were positive for Enterococcus faecalis, Both trans-thoracic echo and trans-esophageal echo showed vegetation on the aortic valve. He was discharged on adequate antibiotic coverage but later presented again with near syncope. On cardiac monitoring, he was found to have episodes of torsades. Unlike heart failure or peri-valvular abscess, torsades is a rare complication of endocarditis. We aim to present a case report of a rare complication of infective endocarditis (IE) which if not identified timely, can lead to lethal outcomes. Unfortunately, our patient did not survive, but we learnt that though rare, we should always anticipate rhythm problems such as torsades as complications of endocarditis and should promptly treat with magnesium and antiarrhythmic drugs such as lidocaine if needed.

A case report of atrial myxoma presenting with systemic embolization and myocardial infarction.

BACKGROUND: Cardiac myxomas are the most common benign primary tumour of the heart. Clinical presentation is variable and ranges from constitutional symptoms to clinical features due to intracardiac obstruction, such as mitral stenosis, coronary embolization, or systemic embolization. Surgical resection is the only effective treatment to prevent its debilitating and catastrophic complication. CASE SUMMARY: A 61-year-old woman presented with an-hour history of bilateral leg pain, numbness, lightheadedness, dyspnoea, and diaphoresis. Physical exam was remarkable for pale and cold lower extremities. Arterial pulse was not palpable in the right femoral, popliteal, and posterior tibial and dorsalis pedis arteries bilaterally. Electrocardiogram demonstrated normal sinus rhythm with T-wave inversion in lead I, V2, V3, and V4. Laboratory investigations were remarkable for leucocytosis and elevated troponin. Computed tomography angiogram showed emboli with acute infarcts involving the spleen and kidneys, acute embolic occlusion of right external and internal iliac arteries, and left distal common femoral artery. She underwent emergent bilateral cut-down and femoral artery thrombectomies. Transthoracic echocardiogram demonstrated wall motion abnormalities. Computed tomography angiography of the chest revealed an atrial mass and transoesophageal echocardiography was obtained which confirmed an atrial myxoma. Coronary angiography demonstrated no significant coronary artery disease, raising the possibility of myxoma embolization to the coronary arteries as the cause of her troponin elevation and wall motion abnormality. Subsequently she underwent successful resection of the atrial myxoma. DISCUSSION: The majority of cardiac myxomas are sporadic and arise from the left atrium as an isolated lesion in middle-aged women. Echocardiography is the diagnostic procedure of choice. The long-term survival after surgical resection is excellent and recurrence is rare.

Renal cholesterol crystal embolism in the setting of warfarin use.

A 73-year-old man presented for evaluation of weakness and black tarry stools that occurred 1 day prior to admission. His medical history is significant for diabetes mellitus, stage 3 chronic kidney disease and deep vein thrombosis on warfarin. He was admitted to the hospital and was found to have acute kidney injury and gastrointestinal bleeding due to a supratherapeutic International Normalized Ratio. His hospital course was complicated by persistent decline in his renal function. He was given intravenous fluid resuscitation, fresh frozen plasma and packed red blood cells for his acute blood loss anaemia. Urinalysis was consistent with acute tubular necrosis. Given the persistent rise in creatinine, a kidney biopsy was obtained, and was significant for mild inflammatory changes, without evidence of vasculitis or allergic interstitial nephritis. Histopathological examination with tissue fixation revealed cholesterol embolisation. Given that he had no recent endovascular procedure or instrumentation, this atheroembolic event was attributed to his warfarin use.

Return of the old guard: a case of tetanus in an unvaccinated patient.

A 78-year-old woman with no known medical history presented with severe neck pain that began 4 days prior to admission located in the paraspinal cervical region radiating to the shoulders, legs and back. She had associated stiffness of her neck and progression of pain to her jaw and throat with progression to generalised body spasms with lower extremity stiffness and weakness that limited her ability to walk. She quickly developed dysphagia and odynophagia with subsequent generalised spasms and profound hypoxic respiratory failure requiring nasotracheal intubation. The presumptive diagnosis of tetanus was made and she was given tetanus toxoid immune globulin and Tdap vaccine. She was managed in the intensive care unit and after a week of admission, required a tracheostomy and gastrostomy tube placement. She required a prolonged hospitalisation stay of 21 days before being transferred to a long-term vent facility.

Left ventricular apical hypertrophy in a transplanted heart: a case report.

BACKGROUND: Left ventricular apical hypertrophic cardiomyopathy is a rare presentation of hypertrophic cardiomyopathy associated with thickening of the apical segment of the left ventricle. It was initially described in Japan in 1976 and is characterized by electrocardiogram findings showing giant T wave inversions in the precordial leads as well as a spade shaped appearance of the apical cavity on imaging (Abugroun et al., Cardiol Res 8:265-268, 2017). In this case, we present a patient with a heart transplant with a stable post-transplant course who was found to have apical hypertrophic cardiomyopathy. There have been a few cases of apical hypertrophy in a transplanted heart documented in the literature. Making this case even more unique is that this presentation is evident 17 years after heart transplantation. CASE PRESENTATION: Fifty-four year-old male with a history of orthotropic heart transplant in 2001 on immunosuppressive therapy presented with palpitations and associated lightheadedness. He had a blood pressure of 184/89 mmHg on arrival but otherwise had stable vital signs and physical examination. Cardiac biomarkers revealed a CK of 59 U/L and a troponin of 0.11NG/ML(normal < 0.04NG/ML). B type natriuretic peptide was 371 PG/ML(normal 0-100PG/ML). Routine laboratory studies demonstrated normal sodium, magnesium, serum creatinine, and a potassium of 3.3 mmol/L(normal 3.5-5.1 mmol/L). His hemoglobin and hematocrit were normal. His EKG showed sinus rhythm with old T wave inversions in the anterior and lateral leads. Echocardiogram revealed a left ventricular ejection fraction of 55-65%, left posterior wall of 1.3 cm and interventricular septal wall 1.2 cm, thickened trabeculated apex, with severely dilated left atrium. He had a stress test that showed mild inferior wall thinning and a cardiac MRI performed to further evaluate apical hypertrophy revealed prominent apical hypertrophy of the left ventricle with near obliteration of the apical cavity. He had no events on cardiac monitoring and was discharged with close followup with the transplant team. CONCLUSION: While there are many etiologies of ApHCM, it has not been well described in transplanted patients who are on chronic immunosuppressive therapy. It is unclear if these groups of patients are at an increased risk of developing this condition. The literature suggests that ApHCM is associated with a being prognosis but there is new data suggesting increased mortality in a subset of patients with this condition.

The Discontinuation of Antibiotics in Patients with Chronic Obstructive Pulmonary Disease Exacerbation and a Positive Respiratory Viral Assay: A Single-center Retrospective Analysis.

Background The use of antibiotics in chronic obstructive pulmonary disorder (COPD) exacerbations attributed to viral infections is observed in this study. The aim of this analysis is to describe the rate of discontinuation of antibiotics in patients who have an acute exacerbation of COPD (AECOPD) caused by viral infections, in turn encouraging the use of the respiratory viral panel in an effort to improve antibiotic stewardship at our facility. Methods A retrospective chart review was performed. A total of 92 patients were analyzed who had a positive respiratory viral polymerase chain reaction (PCR) (RVP) admitted for COPD exacerbations, of which 20 patients had a bacterial co-infection by a sputum analysis. Patients with a positive infiltrate on chest X-ray (CXR) were excluded. The rate of discontinuation of antibiotics, excluding azithromycin and doxycycline, in patients with a positive RVP with and without a bacterial co-infection were analyzed. Results Of these 92 patients, we found that a bacterial co-infection was detected by sputum culture in 20 patients. The average number of days until discontinuation for patients with no bacterial coinfection was 1.67 days while for those with a bacterial co-infection was 3.20 days. The difference in the number of days was statistically significant (p<0.001). Conclusion In conclusion, patients with an identified viral etiology of COPD exacerbations had antibiotics discontinued significantly sooner than those patients with bacterial coinfections.