Complex decision making in a patient with lung cancer with incidentally found fast-growing atrial mass.

Atrial myxomas are typically found in the left atrium and are the most common among overall rare cardiac tumors. Herein, we describe the clinical course of a 72-year-old female with non-small cell lung adenocarcinoma found to have an atrial mass during an imaging for evaluation for lung cancer progression. Differentiating between distinct types of masses can pose a challenge to the treatment team especially in the setting of exiting malignancy. This case demonstrates the complex decision making involved in the diagnosis, and timing of intervention to remove atrial mass in patients with frailty and a fast-growing cardiac mass.

Tricuspid mass-curious case of Li-Fraumeni syndrome: A case report.

BACKGROUND: Li-Fraumeni syndrome (LFS) is a rare autosomal dominant cancer-predisposing syndrome, which can manifest as a polymorphic spectrum of malignancies. LFS is associated with an early onset in life, with the majority of cases occurring prior to the age of 46. Notwithstanding the infrequency of primary cardiac tumors, it behooves clinicians to remain vigilant in considering the differential diagnosis of such tumors in LFS patients who present with a cardiac mass. This is due to the markedly elevated risk for malignancy in this particular population, far surpassing that of the general populace. CASE SUMMARY: Herein, we present a case of a 30-year-old female with LFS who was found to have a tricuspid valve leaflet mass. CONCLUSION: This case exemplifies valuable learning points in the diagnostic approach for this exceptionally rare patient population.

Late-stage diagnosis of carcinoid heart disease due to lack of access to health care.

Carcinoid syndrome (CS) is a unique constellation of symptoms caused by release of vasoactive substances from neuroendocrine tumors (Pandit et al., StatPearls, 2022). Neuroendocrine tumors are rare with an annual incidence of 2 in 100,000 people (Ram et al., 46:21-27, 2019). Up to 50% of patients with these tumors will develop carcinoid syndrome, which is characterized by symptoms caused by elevated levels of serotonin and most commonly include fatigue, flushing, wheezing, and non-specific gastrointestinal symptoms such as diarrhea and malabsorption (Pandit et al., StatPearls, 2022) (Fox et.al., 90:1224-1228, 2004). Over time, patients with carcinoid syndrome can develop carcinoid heart disease (CHD). CHD refers to the cardiac complications that occur when the vasoactive substances, such as serotonin, tachykinins, and prostaglandins, secreted from the carcinoid tumors. These complications most commonly include valvular abnormalities, but can also present as coronary artery damage, arrhythmias or direct myocardial injury (Ram et al., 46:21-27, 2019). While CHD is not typically an initial feature of carcinoid syndrome, it does eventually occur in up to 70% of patients with carcinoid tumors (Ram et al., 46:21-27, 2019) (Jin et.al., 146:65-73, 2021) (Macfie et.al., 224:665-669, 2022). CHD is associated with significant morbidity and mortality due to the risk of progressive heart failure (Bober et.al., 14:1179546820968101, 2020). In this case, we describe a 35-year-old Hispanic woman in South Texas with undiagnosed carcinoid syndrome for over 10 years that eventually progressed to severe CHD. In this patient's case, we emphasize how lack of access to healthcare resulted in delay of diagnosis, appropriate treatment, and worsened prognosis in this young patient.

Development of cardiac risk prediction model in patients with HER-2 positive breast cancer on trastuzumab therapy.

BACKGROUND: 25% of all breast cancer patients have HER-2 overexpression. Breast Cancer patients with HER-2 overexpression are typically treated with HER-2 inhibitors such as Trastuzumab. Trastuzumab is known to cause a decrease in left ventricular ejection fraction. The aim of this study is to create a cardiac risk prediction tool among women with Her-2 positive breast cancer to predict cardiotoxicity. METHOD: Using a split sample design, we created a risk prediction tool using patient level data from electronic medical records. The study included women 18 years of age and older diagnosed with HER-2 positive breast cancer who received Trastuzumab. Outcome measure was defined as a drop in LVEF by more than 10% to less than 53% at any time in the 1-year study period. Logistic regression was used to test predictors. RESULTS: The cumulative incidence of cardiac dysfunction in our study was 9.4%. The sensitivity and specificity of the model are 46% and 84%, respectively. Given a cumulative incidence of cardiotoxicity of 9%, the negative predictive value of the test was 94%. This suggests that in a low-risk population, the interval of screening for cardiotoxicity may be performed less frequently. CONCLUSION: Cardiac risk prediction tool can be used to identify Her-2 positive breast cancer patients at risk of developing cardiac dysfunction. Also, test characteristics in addition to disease prevalence may inform a rational strategy in performing cardiac ultrasound in Her-2 breast cancer patients. We have developed a cardiac risk prediction model with high NPV in a low-risk population which has an appealing cost-effectiveness profile.

Correction to: Spontaneous Coronary Artery Dissection in a Young Man.

[This corrects the article DOI: 10.14740/jmc3490.].

Ingestion of food grade hydrogen peroxide with resultant gastrointestinal and neurologic symptoms treated with hyperbaric oxygen therapy: case report and review with emphasis on the therapeutic value of HBO2 in vascular gas embolism.

A 52-year-old male accidentally ingested approximately 100 mL of 35% hydrogen peroxide (H2O2), resulting in the sudden onset of gastrointestinal and neurologic symptoms. Non-contrast abdominal CT revealed extensive portal venous gas and gastric pneumatosis. The patient was treated with hyperbaric oxygen therapy which resulted in complete resolution of symptoms. The case highlights the therapeutic value of hyperbaric oxygen therapy in the treatment of vascular gas embolism and mitigation of concentrated H2O2 ingestion toxicity.

Gastrointestinal Bleeding as a Complication in Continuous Flow Ventricular Assist Devices: A Systematic Review With Meta-Analysis.

BACKGROUND: The use of ventricular assist devices (VADs) has become predominant in this era of medicine. It is commonly used as a bridge to transplant, recovery and as a destination therapy for patients with severe heart failure, who are not responsive to maximum optimal management or ineligible for transplant. However, several complications are known to occur with the use of these devices. In this research, we will compare gastrointestinal bleeding in patients who used centrifugal flow versus axial flow VADs. We hope that the result of this meta-analysis and the review presented provide adequate information to future researchers, physicians and other healthcare professionals who are interested in this topic. METHODS: Published articles evaluated for inclusion were obtained from MEDLINE (PubMed), Cochrane, EBSCO, clinicaltrials.gov, and international clinical trials registry. This research was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Procured articles were reviewed by two independent reviewers. Only randomized control trials and observational studies were used. Quality assessment was done with Cochrane Collaboration's tool (RoB.2 with visualization through robviz) and Newcastle-Ottawa Scale (NOS). Data analysis was carried out with the use of R data analysis tool (version 4.0.0; release date: April 24th, 2020). RESULTS: At the end of this meta-analysis, the occurrence of gastrointestinal bleeding was not significantly different between both groups; with odds ratio (OR): 0.81; 95% confidence interval (CI): 0.65 - 1.00; P value = 0.05. Between-study variance (Tau-squared) was zero (0), standard error (SE) = 0.06. The degree of heterogeneity measured with I-squared statistic was 0% (minimal). Egger's regression test was not statistically significant, P = 0.93. Symmetry of distribution was observed on the funnel plot. Trim and fill analysis showed no missing studies on the left; SE = 1.68. CONCLUSIONS: The result obtained from this research indicates that the occurrence of gastrointestinal bleeding is not significantly different in both groups of patients, irrespective of the type of continuous flow VAD used. Although, the study sample used in this meta-analysis was limited.

Spontaneous Coronary Artery Dissection in a Young Man.

Spontaneous coronary artery dissection (SCAD) is an idiosyncratic phenomenon by which a spontaneous separation of the intimal and medial layer in the coronary artery occurs with intramural hemorrhage in the absence of trauma. This intramural hematoma, in turn, leads to compression and occlusion of the arterial lumen. Unlike traumatic dissection of coronary arteries, more than half of SCAD heals spontaneously over time. SCAD is known to occur predominantly in women under the age of 50, particularly during pregnancy or peripartum period. Herein, we present a case of a 32-year-old man with an SCAD on the left anterior descending coronary artery. The discordance between clinical presentation and angiographic finding posed a unique challenge in therapeutic decision making. This case reminds clinicians that SCAD should be kept in mind as a differential diagnosis even for young men presenting with acute chest pain.

Primary care providers' awareness, knowledge, and practice with regard to cardiovascular risk in patients with rheumatoid arthritis : PCPs' awareness, knowledge, and practice with regard to CV risks in patients with RA.

Rheumatoid arthritis (RA) is a systemic auto-inflammatory disease associated with increased cardiovascular risk. Early identification and aggressive cardiovascular risk factor modification are critical for improvement in morbidity and mortality in patients with RA. This study is a cross-sectional survey with the purpose of evaluating primary care providers' awareness, practice patterns, and satisfaction with continuing medical education on cardiovascular risk in patients with RA. Our study showed that 71% of clinicians felt that the CME on RA patient management regarding CV risk factors is inadequate. Only 37% of providers reported feeling well prepared to manage CV risk for RA patients. Only 15% of participants were actively initiating a discussion regarding CV risk with RA patients. A better understanding of the educational needs and practice patterns of primary care providers may warrant the development of strategies for cardiovascular risk management in patients with RA.

Myocardial damage on SPECT imaging among patients treated with radiotherapy for left-sided breast cancer: Systematic review with meta-analysis and narrative synthesis.

PURPOSE: With advancements in radiation oncology techniques, the use of radiation therapy (RT) as a treatment modality for cancer has been steadily increasing. Incidental radiation exposure to surrounding tissue during breast cancer treatment has been known to cause myocardial damage, the extent of which can be detected with single-photon emission computed tomography (SPECT) perfusion studies. We undertook a systematic review and meta-analysis to investigate the impact of RT on myocardial perfusion. METHODS: A systematic review of the literature was conducted to identify 17 studies, of which 4 were included in this meta-analysis and 13 were included in the narrative synthesis. RESULTS: The incidence of post-radiation cardiac perfusion defects on SPECT was significantly higher in patients who received RT for left-sided breast cancer compared to those who had RT for right-sided breast cancer (OR=3.10, 95% CI 1.35-7.08, p=0.007). CONCLUSION: In patients who undergo RT for left-sided breast cancer, the incidence of post-radiation cardiac perfusion defects on SPECT is higher compared to patients who undergo RT for right-sided breast cancer.

Serum Uric Acid and Atrial Fibrillation: Meta-analysis.

Hyperuricemia has been recently speculated to be associated with the development of atrial fibrillation (AF). A meta-analysis of observational studies was conducted to explore the relationship between serum uric acid (SUA) and AF. We searched the MEDLINE, EMBASE, and CINAHL databases and performed extensive bibliography search to identify studies with mean SUA level for patients with and without AF. Key search terms were "atrial fibrillation" and "uric acid." Under the random-effects model, the pooled standardized difference in means between patients with and without AF was calculated. A total of 24 studies with 30,609 patients were included for quantitative analyzation of the difference in SUA levels between the patients with and without AF. The SUA level of patients with atrial AF was found to be significantly higher compared with those without AF (standardized difference in means = 0.66; 95% confidence interval, 0.43-0.88; P < 0.0001). The mean SUA level of patients with AF significantly is higher than those without AF.

Posttransplant Tacrolimus-Induced Diabetic Ketoacidosis: Review of the Literature.

Diabetic ketoacidosis (DKA) in patients receiving tacrolimus as part of their immunosuppressive regimen is a rarely reported adverse event. We report a patient with autosomal dominant polycystic kidney disease (ADPKD) and no known history of diabetes mellitus who presented with DKA, 3 months after kidney transplantation.

Pasteurella multocida pneumonia in an immunocompetent patient: Case report and systematic review of literature.

Pasteurella multocida infection is most commonly associated with the immunocompromised, mostly in the form of soft-tissue infection, although other sites of infection are still possible and have been reported in the immunocompetent. We report a case of an immunocompetent male with a history of exposure to carrier organisms without portal of entry who developed P. multocida pneumonia with bacteremia. We undertook a focused review of literature of previously reported cases of P. multocida pneumonia in patients with chronic obstructive pulmonary disease. This literature review supports the use of penicillins as the first line of treatment over macrolides. Considering the high mortality rates with P. multocida bacteremia, it is important for clinicians to maintain a high level of suspicion for this organism in any patient with a history of carrier species exposure.

Primary Small Intestinal Angiosarcoma: Epidemiology, Diagnosis and Treatment.

Angiosarcoma is an aggressive mesenchymal sarcoma of endothelial cell origin with high mortality. Its occurrence in the small intestine is exceedingly low. In addition to the rarity of small intestine angiosarcoma, the nonspecific early clinical symptoms obscure the suspicion of such tumors and thereby delay the diagnosis. In a hope to improve the knowledge of this rare but fatal neoplasm, we report one case of angiosarcoma of duodenum and jejunum in a 73-year-old man. Furthermore, we summarize and analyze the common clinical features, tumor markers, treatment, and survival of previous reported cases of this malignancy. Small bowel angiosarcoma occurs more often in men than women (1.6:1). The median age at diagnosis is 68.5 years. The overall median survival time is 150 days; the median survival time in female (300 days) is longer than that of male patients (120 days). Von Willebrand factor (vWF), CD31, CD34, vimentin, and Ulex europaeus agglutinin 1 appear to be the most useful markers for the diagnosis. The majority of the patients underwent surgical resection alone or surgery with subsequent chemotherapy. The patients treated with surgery plus chemotherapy survive longer than those underwent surgical resection only (median 420 days, n = 7 vs. 96.5 days, n = 26, respectively; P = 0.0275). Further studies of more cases are needed for a better understanding of this rare entity, as well as the development of effective strategies for prevention, early diagnosis, and treatment.

Cardiorespiratory Failure in Thyroid Storm: Case Report and Literature Review.

Thyroid storm is a potentially fatal manifestation of thyrotoxicosis. Cardiopulmonary failure is the most common cause of death in thyroid storm. Clinicians should keep in mind that thyroid storm complicated with cardiopulmonary failure can be the first presentation of thyrotoxicosis. As early intervention is associated with improved patient outcome, prompt diagnosis based on clinical grounds is of paramount importance in the management of thyrotoxicosis. A high index of suspicion and the ability of early recognition of impending thyroid storm depends on a thorough knowledge of both the typical and atypical clinical features of this illness. Herein, we report a case of thyroid storm presenting as cardiopulmonary failure in a 51-year-old woman with undiagnosed Grave's disease. Additionally, we review the pathophysiology of cardiopulmonary failure associated with thyrotoxicosis and various treatment modalities for thyroid storm.