Successful Percutaneous Coronary Intervention in a Patient With Absent Right Coronary Artery Ostium: A Case Report and Literature Review.

Coronary artery anomalies present unique interventional challenges, particularly when associated with significant coronary artery disease. This case report contributes to the limited literature on congenital coronary artery anomalies, emphasizing the need for tailored approaches to optimize patient care. We present a case of a 70-year-old male with refractory angina and a rare congenital coronary anomaly characterized by the absence of the right coronary artery ostium, necessitating reliance on the left coronary system for myocardial perfusion. Cardiac catheterization revealed mid-left anterior descending artery stenosis, prompting percutaneous coronary intervention. Despite the anatomical complexities encountered, the procedure was successfully performed. This case underscores the importance of meticulous diagnostic evaluation, advanced imaging techniques, and a multidisciplinary approach to managing patients with rare coronary anomalies. This report also emphasizes the unique diagnostic and therapeutic considerations by providing a comprehensive literature review and identifying areas for further research to advance treatment strategies and improve outcomes.

Type 2 diabetes and health-related quality of life among older Medicare beneficiaries: The mediating role of sleep.

OBJECTIVE: To examine mediating effects of sleep quality and duration on the association between T2D and QoL among Medicare beneficiaries 65+. METHODS: Data from the Medicare Health Outcome Survey (2015-2020) were used. The outcome was QoL (physical and mental health component-summary scores [PCS and MCS]) measured by the Veterans-Rand-12. The main predictor was diagnosed T2D. Mediators were sleep duration and sleep quality. The effect modifier was race/ethnicity. Structural Equation Modeling was used to estimate moderated-mediating effects of sleep quality and duration across race/ethnicity. RESULTS: Of the 746,400 Medicare beneficiaries, 26.7% had T2D, and mean age was 76 years (SD ± 6.9). Mean PCS score was 40 (SD ± 12.2), and mean MCS score was 54.0 (SD ± 10.2). Associations of T2D with PCS and MCS were negative and significant. For all racial/ethnic groups, those with T2D reported lower PCS. For White, Black, Asian, and Hispanic beneficiaries only, those with T2D reported lower MCS. The negative impact of T2D on PCS and MCS was mediated through sleep quality, especially very bad sleep quality. CONCLUSION: Improving sleep may lead to improvement in QoL in elderly adults with T2D.

Ensuring fidelity: key elements to consider in disseminating a diabetes telemanagement program for underserved Hispanic/Latinos living with type 2 diabetes.

Background: The Hispanic/Latino population has greater risk (estimated >50%) of developing type 2 diabetes (T2D) and developing it at a younger age. The American Diabetes Association estimates costs of diagnosed diabetes in 2017 was $327 billion; with medical costs 2.3x higher than patients without diabetes. The purpose of this manuscript is to describe the methodology utilized in a randomized controlled trial aimed at evaluating the efficacy of a diabetes telemanagement (DTM) program for Hispanic/Latino patients with T2D. The intent is to provide information for future investigators to ensure that this study can be accurately replicated. Methods: This study was a randomized controlled trial with 240 participants. Eligible patients (Hispanic/Latino, aged 18+, living with T2D) were randomized to Comprehensive Outpatient Management (COM) or DTM. DTM was comprised of usual care, including routine clinic visits every three months, as well as: Biometrics (a tablet, blood glucose meter, blood pressure monitor, and scale); Weekly Video Visits (facilitated in the patient's preferred language); and Educational Videos (including culturally congruent diabetes self-management education and quizzes). COM consisted of usual care including routine clinic visits every three months. For this study, COM patients received a glucometer, glucose test strips, and lancets. Establishing a therapeutic nurse-patient relationship was a fundamental component of our study for both groups. First contact (post-enrollment) centered on ensuring that patients and caregivers understood the program, building trust and rapport, creating a non-judgmental environment, determining language preference, and establishing scheduling availability (including evenings and weekends). DTM were provided with a tablet which allowed for self-paced education through videos and weekly video visits. The research team and Community Advisory Board identified appropriate educational video content, which was incorporated in diabetes educational topics. Video visits allowed us to assess patient involvement, motivation, and nonverbal communication. Communicating in Spanish, and awareness of diverse Hispanic/Latino backgrounds was critical, as using relevant and commonly-used terms can increase adherence and improve outcomes. Shared decision-making was encouraged to make realistic health care choices. Conclusion: Key elements discussed above provide a framework for future dissemination of an evidence-based DTM intervention to meet the needs of underserved Hispanic/Latino people living with T2D.

Myocardial Bridging of Mid-left Anterior Descending Artery (LAD) Presenting As Transient Left Bundle Branch Block During Nuclear Stress Test.

Transient left bundle branch block occurring during a nuclear stress test in the setting of myocardial bridging is a relatively rare finding. We report a case of a 75-year-old male who presented with typical stable angina. Serial troponins were negative, and the electrocardiogram revealed normal sinus rhythm with left ventricular hypertrophy and T-wave inversions in the lateral leads. The nuclear stress test was non-ischemic but showed a transient left bundle branch block associated with chest pain and shortness of breath that occurred right after the administration of regadenoson. Coronary angiography revealed non-obstructive coronary artery disease and a mid-LAD myocardial bridge.

The Role of Triglycerides in Atherosclerosis: Recent Pathophysiologic Insights and Therapeutic Implications.

Triglycerides have long been recognized as a cardiovascular disease risk factor. However, their precise role in atherosclerosis and potential utility as a therapeutic target remains debated topics. This review aims to shed light on these aspects by exploring the complex relationship between triglycerides and atherosclerosis from pathophysiological and pharmacological perspectives. Triglycerides, primarily carried by chylomicrons and very low-density lipoproteins, play an essential role in energy storage and utilization. Dysregulation of triglyceride homeostasis and triglyceride- rich lipoproteins metabolism often leads to hypertriglyceridemia and subsequently increases atherosclerosis risk. Triglyceride-rich lipoproteins remnants interact with arterial wall endothelial cells, get retained in the subendothelial space, and elicit inflammatory responses, thereby accelerating atherogenesis. Despite the clear association between high triglyceride levels and increased cardiovascular disease risk, intervention trials targeting triglyceride reduction have produced mixed results. We discuss a range of triglyceride-lowering agents, from fibrates to omega-3 fatty acids, with a focus on their mechanism of action, efficacy, and major clinical trial outcomes. Notably, the role of newer agents, such as angiopoietin-like protein 3 and apolipoprotein C3 inhibitors, is also explored. We highlight the challenges and controversies, including the ongoing debate on the causal role of triglyceride in atherosclerosis and the discordant outcomes of recent clinical trials. The potential confounding effects of associated risk factors, such as elevated apolipoprotein B, insulin resistance, and metabolic syndrome, are considered. In conclusion, this review underscores the importance of a nuanced approach to understanding the role of triglycerides in atherosclerosis and their potential as a therapeutic target. Further research is needed to unravel the complex interplay between triglycerides, triglyceride-rich lipoproteins, and associated factors in atherosclerosis pathogenesis and refine triglyceride-targeted therapeutic strategies.

A Rare Case of Metastatic Ampullary Adenocarcinoma Following the Whipple Procedure.

Ampullary carcinoma is an extremely rare type of gastrointestinal cancer that originates at the ampulla of Vater, distal to the junction between the pancreatic duct and the common bile duct (CBD). There are three subtypes depending on the histological findings: pancreatobiliary, intestinal, and mixed subtype. Symptoms can mimic other pathologies related to biliary obstruction, such as jaundice, diarrhea, steatorrhea, and weight loss. In this report, we present a case of a 40-year-old male who presented with painless jaundice and dizziness. Magnetic resonance cholangiopancreatography (MRCP) showed choledocholithiasis and CBD dilatation. Endoscopic ultrasound showed a 24 x 14 mm ampulla mass. Subsequently, he underwent the Whipple procedure that revealed an intestinal-type periampullary adenocarcinoma characterized as stage III (T3bN2M0), with lymphovascular and perineural invasion. He was lost to follow-up but was later found to have metastatic pancreatic adenocarcinoma to the lung and liver. In this report, we also discuss the clinical presentation, pathogenesis, and current evidence-based therapeutic options in the management of this tumor, highlighting the importance of treatment choice depending on the tumor type.

Gabapentin-Induced Myoclonus in a Patient With Chronic Kidney Disease.

Gabapentin contains a cyclohexyl group and is a form of gamma-aminobutyric acid (GABA). Despite its name, gabapentin does not affect the inhibitory neurotransmitter GABA or its receptors. Instead, it acts as a ligand, binding strongly to the α2δ (Ca) channel subunit and interfering with its regulatory function and the release of excitatory neurotransmitters. Gabapentin is approved by the FDA for treating seizure disorders and neuropathic pain, except for trigeminal neuralgia. However, it is frequently used off-label to treat other pain conditions and psychological disorders, such as anxiety. Unlike other drugs, gabapentin is not metabolized in the liver and is solely excreted by the kidneys. Therefore, it is crucial to adjust the dosage in patients with renal insufficiency to avoid severe adverse effects. In this case report, we present a patient with chronic renal impairment who experienced devastating myoclonic jerky movements shortly after increasing his gabapentin dose.

Spontaneous Pneumothorax in a Young Female With Lymphangioleiomyomatosis.

Lymphangioleiomyomatosis (LAM) is a rare disorder of abnormal proliferation of smooth muscle-like cells which results in the formation of thin-walled cysts and progressive lung destruction. It commonly presents with progressive dyspnea that is often associated with a history of pneumothorax or chylothorax particularly among females of reproductive age. In this report, we present a case of hydropneumothorax as the initial presentation of LAM in a 33-year-old woman, a rather rare presentation. We also discuss the pathogenetic mechanisms, the diagnosis, and treatment strategies using mTOR inhibitors like sirolimus.

Sarcoidosis Versus Lymphoma: A Clinical Diagnostic Dilemma in a Patient With Extensive Lymphadenopathy.

Sarcoidosis is a granulomatous disease involving multiple organ systems. In its classic form, sarcoidosis is associated with non-caseating granuloma. Several differential diagnostic entities exist for sarcoidosis, including tuberculosis (TB), as well as lymphomas. In this report, we present a case of sarcoidosis in a 55-year-old male with diffuse lymphadenopathy and hepatosplenic involvement, highlighting the differential diagnostic point for this disease.

Hyperhomocysteinemia and Accelerated Aging: The Pathogenic Role of Increased Homocysteine in Atherosclerosis, Osteoporosis, and Neurodegeneration.

Cardiovascular diseases and osteoporosis, seemingly unrelated disorders that occur with advanced age, share major pathogenetic mechanisms contributing to accelerated atherosclerosis and bone loss. Hyperhomocysteinemia (hHcy) is among these mechanisms that can cause both vascular and bone disease. In its more severe form, hHcy can present early in life as homocystinuria, an inborn error of metabolic pathways of the sulfur-containing amino acid methionine. In its milder forms, hHcy may go undiagnosed and untreated into adulthood. As such, hHcy may serve as a potential therapeutic target for cardiovascular disease, osteoporosis, thrombophilia, and neurodegeneration, collectively representing accelerated aging. Multiple trials to lower cardiovascular risk and improve bone density with homocysteine-lowering agents, yet none has proven to be clinically meaningful. To understand this unmet clinical need, this review will provide mechanistic insight into the pathogenesis of vascular and bone disease in hHcy, using homocystinuria as a model for accelerated atherosclerosis and bone density loss, a model for accelerated aging.

A Rare Case of Central Retinal Artery Occlusion in the Setting of Patent Foramen Ovale.

Patent foramen ovale (PFO) is a congenital heart anomaly with persistent non-closure of the atrial septum that generally closes six to 12 months after birth in the majority of adults. While remaining asymptomatic in the majority of cases, PFO could lead to paradoxical embolism and cryptogenic strokes in most symptomatic cases. The incidence of small arterial occlusion due to paradoxical emboli is quite uncommon. In this report, we present a case of a 51-year-old man who presented with acute left-sided painless visual loss due to central retinal artery occlusion (CRAO). Stroke work-up and hypercoagulability evaluations were negative. The patient was found to have PFO with the initial presentation as CRAO, a rather rare presentation in the setting of PFO. In this report also, we discuss the clinical presentation, pathogenesis, and the current evidence-based therapeutic options in the management of PFO in adults, highlighting the importance of considering this diagnostic entity in the setting of acute visual loss, as with our case presentation.

Association of marijuana, tobacco and alcohol use with estimated glomerular filtration rate in women living with HIV and women without HIV.

OBJECTIVE: Marijuana, tobacco and alcohol use are prevalent among people with HIV and may adversely affect kidney function in this population. We determined the association of use of these substances with estimated glomerular filtration rate (eGFR) among women with HIV (WWH) and women without HIV. DESIGN: We undertook a repeated measures study of 1043 WWH and 469 women without HIV within the United States Women's Interagency HIV Study, a multicenter, prospective cohort of HIV-seropositive and HIV-seronegative women. METHODS: We quantified substance exposures using semi-annual questionnaires. Using pooled eGFR data from 2009 to 2019, we used linear regression models with multivariable generalized estimating equations to ascertain associations between current and cumulative substance use exposures with eGFR, adjusting for sociodemographics, chronic kidney disease risk factors and HIV-related factors. RESULTS: Marijuana use of 1-14 days/month versus 0 days/month was associated with 3.34 ml/min per 1.73 m 2 [95% confidence interval (CI) -6.63, -0.06] lower eGFR and marijuana use of >0.02-1.6 marijuana-years versus 0-0.2 marijuana-years was associated with 3.61 ml/min per 1.73 m 2 (95% CI -5.97, -1.24) lower eGFR. Tobacco use was not independently associated with eGFR. Alcohol use of seven or more drinks/week versus no drinks/week was associated with 5.41 ml/min per 1.73 m 2 (95% CI 2.34, 8.48) higher eGFR and alcohol use of >0.7-4.27 drink-years and >4.27 drink-years versus 0-0.7 drink-years were associated with 2.85 ml/min per 1.73 m 2 (95% CI 0.55, 5.15) and 2.26 ml/min per 1.73 m 2 (95% CI 0.33, 4.20) higher eGFR, respectively. CONCLUSION: Among a large cohort of WWH and women without HIV, marijuana use was associated with a lower eGFR while alcohol use was associated with a higher eGFR.

A Novel Finding of Increased ß-Aminoisobutyric Acid Levels in Classic Homocystinuria With Homocysteine-Lowering Treatment.

Hyperhomocysteinemia is an independent risk factor for cardiovascular disease. Although commonly seen as a milder elevation of homocysteine levels in adult patients, on rare occasions, the internist may face extremely elevated homocysteine levels (>100 µmol/L). In such rare cases, the search for a monogenic disease is warranted. In this report, we present a patient with classical homocystinuria, where the diagnosis was delayed due to various factors. The patient experienced a constellation of symptoms over an extended period, including visual problems, recurrent thrombosis, and neurodevelopmental delay. Delayed diagnosis of genetic diseases is problematic, as patients may grow from pediatric care to adult internal medicine, where knowledge and exposure to such a rare genetic disorder are limited. A diagnosis was finally confirmed with amino acid profiling, revealing extremely elevated homocysteine levels, which were reduced with sequential treatment modalities, including folate, vitamin B12, vitamin B6, methionine restriction, and betaine. We also present derangements in other amino acids, namely, methionine, taurine, serine, and urea cycle products. With treatment, a progressive increase in body weight is noticed. Furthermore, we present a novel finding of increased levels of ß-aminoisobutyric acid with homocysteine-lowering treatment. ß-aminisobutyric acid is a myokine that potentiates some of the metabolic benefits of exercising muscle such as improved insulin resistance and browning of white adipose tissue.

Kaposi Sarcoma: A Rare Presentation of Elephantiasis Nostras Verrucosa.

Although a low-grade vascular tumor, Kaposi sarcoma (KS) can have mucosal, and visceral involvement. Additionally, disfiguring disseminated lesions can be seen in patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). KS may cause lymphatic obstruction leading to chronic lymphedema that further contributes to progressive cutaneous hypertrophy and severe disfigurement in the form of non-filarial elephantiasis nostras verrucosa (ENV). This report highlights a case of a 33-year-old male with AIDS who presented in acute respiratory distress with bilateral lower extremity nodular lesions. We confirmed a diagnosis of KS with overlying ENV via a multi-disciplinary approach. Collaboratively, we optimized our patient and observed adequate treatment response and overall improvement in clinical status. Our report emphasizes the importance of a multi-disciplinary approach in recognizing a rare presentation of ENV. Recognition of the disease and understanding the extent of the disease are crucial in preventing irreversible disease progression and allowing for maximum response.

Low Bone Mass and Recurrent Fractures in Neurofibromatosis With Concomitant Hemoglobin SC Disease.

Bone disease and bone loss are common features in certain monogenic diseases such as RASopathies, including neurofibromatosis (NF). Similarly, bone complications are frequent in hemoglobinopathies, another group of Mendelian diseases. This paper reports a young patient with both NF and hemoglobin SC (HbSC) diseases who had multiple vertebral fractures with osteopenia. We also discuss the cellular and pathophysiological mechanisms underlying both diseases and the factors responsible for bone pain and low bone mass in NF and hemoglobinopathies such as HbSC. This case emphasizes the importance of careful evaluation and management of osteoporosis in patients with HbSC and NF1, as both are relatively common monogenic diseases in certain communities.

COVID-19 stressors for Hispanic/Latino patients living with type 2 diabetes: a qualitative study.

Background and aim: During the early stages of the COVID-19 pandemic, nationwide lockdowns caused disruption in the diets, physical activities, and lifestyles of patients with type 2 diabetes. Previous reports on the possible association between race/ethnicity, COVID-19, and mortality have shown that Hispanic/Latino patients with type 2 diabetes who are socioeconomically disadvantaged are disproportionately affected by this novel virus. The aim of this study was to explore stressors associated with changes in diabetes self-management behaviors. Our goal was to highlight the health disparities in these vulnerable racial/ethnic minority communities and underscore the need for effective interventions. Methods and participants: Participants were enrolled in part of a larger randomized controlled trial to compare diabetes telehealth management (DTM) with comprehensive outpatient management (COM) in terms of critical patient-centered outcomes among Hispanic/Latino patients with type 2 diabetes. We conducted a thematic analysis using patient notes collected from two research nurses between March 2020 and March 2021. Two authors read through the transcripts independently to identify overarching themes. Once the themes had been identified, both authors convened to compare themes and ensure that similar themes were identified within the transcripts. Any discrepancies were discussed by the larger study team until a consensus was reached. Results: Six themes emerged, each of which can be categorized as either a source or an outcome of stress. Sources of stress associated with the COVID-19 pandemic were (1) fear of contracting COVID-19, (2) disruptions from lockdowns, and (3) financial stressors (e.g., loss of income). Outcomes of COVID-19 stressors were (1) reduced diabetes management (e.g., reduced diabetes monitoring and physical activity), (2) suboptimal mental health outcomes (e.g., anxiety and depression), and (3) outcomes of financial stressors. Conclusion: The findings indicated that underserved Hispanic/Latino patients with type 2 diabetes encountered a number of stressors that led to the deterioration of diabetes self-management behaviors during the pandemic.

Autoimmune Encephalitis With Autoimmune Diabetes: A Case of Horror Autotoxicus.

Diagnosing autoimmune encephalitis relies on clinical, radiological, and serological studies. Several autoantibodies have been implicated and recognized, with dozens of potential targets identified in the past 20 years. Despite that progress, some patients with encephalitis present a diagnostic dilemma with a seronegative status. The presence of other autoimmune diseases in a patient with encephalitis should provide a clue to the autoimmune nature of a developing neurological syndrome (cognitive, psychiatric, behavioral, and catatonia). In this report, we describe the case of a young man with type 1 diabetes mellitus who was diagnosed with seronegative autoimmune encephalitis after presenting with catatonia. We describe the lengthy clinical course, the various therapeutic trials, and his clinical outcome and response to B-cell depleting agent. This study also discusses the potential pathophysiologic pathways, providing a rationale for the diagnostic workup and therapeutic options for autoimmune encephalopathy in this case presentation.

The Effects of Bariatric Surgery on Cardiovascular Outcomes and Cardiovascular Mortality: A Systematic Review and Meta-Analysis.

Obesity is a major public health problem that is associated with serious comorbidities and premature mortality. Cardiovascular disease (CVD) is the major cause of morbidity and mortality associated with obesity. Lifestyle modifications, pharmacological therapy, and weight reduction surgery are the major interventions to date available for obesity management. Bariatric surgery has been increasingly utilized as a therapeutic option for obesity. In this meta-analysis, we aim to assess the effects of bariatric surgery on CVD outcomes and cardiovascular mortality. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Embase, Cochrane Library, Google Scholar, and Web of Science were searched until 03/01/2022. Our search included three types of bariatric surgery: Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy, and gastric banding (GB). All were searched in conjunction with "coronary artery disease," "ischemic heart disease," "myocardial infarction," "cerebrovascular accident," "stroke," "atrial fibrillation," "heart failure," "arrhythmias," and "mortality." We included 49 studies meeting the study criteria. Bariatric surgery showed a beneficial effect on coronary artery disease (CAD) (hazard ratio (HR) of 0.68 {95% confidence interval (CI): 0.52-0.91}, p = 0.008), myocardial infarction (MI) (HR of 0.53 {95% CI: 0.44-0.64}, p < 0.01) heart failure (HF) (HR of 0.45 {95% CI: 0.37-0.55}, p < 0.01), cerebrovascular accident (CVA) (HR of 0.68 {95% CI: 0.59-0.78}, p < 0.01), and cardiovascular mortality (HR of 0.48 {95% CI: 0.40-0.57}, p < 0.01). The effect on atrial fibrillation (AF) did not reach statistical significance: HR of 0.81 (95% CI: 0.65-1.01), p = 0.07. Our study, that is, an updated meta-analysis, including the three types of procedure, confirms beneficial effects on the major CVD outcomes, including coronary artery disease, myocardial infarction, cerebrovascular accident, and heart failure, and on CVD mortality. This study provides updated insights into the long-term CV effects of bariatric surgery, an increasingly common intervention for obesity.

Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH) With Severe Hyponatremia As the Initial and Sole Presentation of COVID-19 Infection: A Case Report and Pathophysiologic Insights.

Hyponatremia is one of the common electrolyte imbalances among hospitalized patients with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) being a common etiology for hyponatremia. There are multiple pathophysiologic considerations in the differential diagnosis of the etiologic factor for SIADH, including infections such as pneumonia and meningitis, as well as coronavirus disease 2019 (COVID-19) infection. However, SIADH, as the sole initial presentation of the infection of COVID-19, is rarely reported. In this report, we present a case of SIADH as the initial and only presentation of a COVID-19 infection, highlighting the clinical course and treatment strategy while providing the putative pathophysiologic insights into this unusual and potentially serious complication of COVID-19 infection.

Artificial Hallucinations in ChatGPT: Implications in Scientific Writing.

While still in its infancy, ChatGPT (Generative Pretrained Transformer), introduced in November 2022, is bound to hugely impact many industries, including healthcare, medical education, biomedical research, and scientific writing. Implications of ChatGPT, that new chatbot introduced by OpenAI on academic writing, is largely unknown. In response to the Journal of Medical Science (Cureus) Turing Test - call for case reports written with the assistance of ChatGPT, we present two cases one of homocystinuria-associated osteoporosis, and the other is on late-onset Pompe disease (LOPD), a rare metabolic disorder. We tested ChatGPT to write about the pathogenesis of these conditions. We documented the positive, negative, and rather troubling aspects of our newly introduced chatbot's performance.