Uncontrolled Acromegaly Resulting in the Need for Left Ventricular Assist Device as Bridge to Heart Transplant.

Acromegaly is a rare pituitary condition stemming from hypersecretion of growth hormone (GH). Classic presentation involves enlarged hands, feet, and coarse facial features. However, late-onset cardiac manifestations develop in the absence of disease control. Of the various cardiac complications, heart failure is the rarest (3%-4% of cases). Here we present a case of acromegaly diagnosed after the patient exhibited symptoms of heart failure, with eventual placement of a left ventricular assist device (LVAD) as a bridge to orthotopic heart transplant. The 37-year-old patient originally presented with exercise intolerance and "heavy heartbeats" but was found to be in acute decompensated heart failure, with an ejection fraction (EF) of 15%. The acromegaly diagnosis was confirmed with labs, and he began treatment with lanreotide 120 mg weekly along with 0.5 mg cabergoline twice weekly. EF improved up to 30%. Soon after, he was lost to follow-up during the COVID-19 pandemic and returned with worsening EF. An LVAD was placed to support recovery while the patient awaited heart transplant. While LVADs are a common measure of cardiac support for ischemic cardiomyopathy, they can also be successful options in the setting of GH-driven cardiomegaly.

Wooden Chest Syndrome: A Case Report of Fentanyl-Induced Chest Wall Rigidity.

Wooden chest syndrome (WCS) describes a finding of fentanyl-induced skeletal muscle rigidity causing ventilatory failure. Known primarily to anesthesiology, pulmonary, and critical care fields, WCS is a rare complication that may affect patients of all ages if exposed to intravenous fentanyl, characterized by a patient's inability to properly ventilate. Given the rise of synthetic opioid deaths across the United States in the past decade, an understanding of all of fentanyl's effects on the body is necessary. In this article, we present a case of WCS in a patient with acute respiratory distress syndrome in a 61-year-old female.

Severe acute respiratory syndrome coronavirus 2-induced acute aortic occlusion: a case report.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 infection can lead to a constellation of viral and immune symptoms called coronavirus disease 2019. Emerging literature increasingly supports the premise that severe acute respiratory syndrome coronavirus 2 promotes a prothrombotic milieu. However, to date there have been no reports of acute aortic occlusion, itself a rare phenomenon. We report a case of fatal acute aortic occlusion in a patient with coronavirus disease 2019. CASE REPORT: A 59-year-old Caucasian male with past medical history of peripheral vascular disease presented to the emergency department for evaluation of shortness of breath, fevers, and dry cough. His symptoms started 5-7 days prior to the emergency department visit, and he received antibiotics in the outpatient setting without any effect. He was found to be febrile, tachypneic, and hypoxemic. He was placed on supplemental oxygen via a non-rebreather mask. Chest X-ray showed multifocal opacifications. Intravenous antibiotics for possible pneumonia were initiated. Hydroxychloroquine was initiated to cover possible coronavirus disease 2019 pneumonia. During the hospitalization, the patient became progressively hypoxemic, for which he was placed on bilevel positive airway pressure. D-dimer, ferritin, lactate dehydrogenase, and C-reactive protein were all elevated. Severe acute respiratory syndrome coronavirus 2 reverse transcription polymerase chain reaction was positive. On day 3, the patient was upgraded to the intensive care unit. Soon after he was intubated, he developed a mottled appearance of skin, which extended from his bilateral feet up to the level of the subumbilical plane. Bedside ultrasound revealed an absence of flow from the mid-aorta to both common iliac arteries. The patient was evaluated emergently by vascular surgery. After a discussion with the family, it was decided to proceed with comfort-directed care, and the patient died later that day. DISCUSSION: Viral infections have been identified as a source of prothrombotic states due to direct injury of vascular tissue and inflammatory cascades. Severe acute respiratory syndrome coronavirus 2 appears to follow a similar pattern, with numerous institutions identifying elevated levels of thrombotic complications. We believe that healthcare providers should be aware of both venous and arterial thrombotic complications associated with coronavirus disease 2019, including possible fatal outcome.

Evaluating the Readability of Online Patient Education Materials Related to Orthopedic Oncology.

The internet is increasingly used to access patient education materials. The average American reading level has been found to be that of a 7th- to 8th-grade student, prompting the National Institutes of Health (NIH) and the American Medical Association (AMA) to advise that patient education materials be written between the 4th- to 6th-grade reading level. The purpose of this study was to evaluate the reading level of current patient education materials for the most common musculoskeletal oncological tumors. A Google search was performed with all location filters off to account for geographic variability for patient education materials related to 28 orthopedic primary or secondary tumors. All patient education articles from the first 10 website hits for each tumor type were analyzed. Patient education materials from these websites were evaluated using 8 validated readability scales. Patient resources were found to be written at an average grade level nearly double the NIH and AMA recommendation. Patient education materials for soft tissue chondromas were written at the highest level (14.8±1.9), whereas education materials for chordomas (10.1±1.0) most closely approached national recommendations, despite still being written at a readability level nearly 4 grade levels higher than has been recommended. The Flesch Reading Ease assessment provided a mean score of 46.5±7.7, corresponding with a "difficult to read" result. Current patient education materials regarding oncological musculoskeletal-related patient education materials are written significantly above the recommended reading level. Further modification of these resources is warranted to ensure adequate comprehension and informed decision making in the clinical setting. [Orthopedics. 2021;44(1):38-42.].

Cystocerebral Syndrome: An Updated Review and a New Proposed Mechanism for an Often Forgotten Cause of Delirium.

Cystocerebral syndrome is an often forgotten cause of delirium in elderly males, which is quite easily treated. We reviewed the current body of literature documenting cystocerebral syndrome and proposed a new mechanism of action explaining why all patients identified thus far have been male. Data was obtained from articles describing cases of cystocerebral syndrome, urinary retention, and confusion in addition to delirium via a PubMed database search. We reviewed all articles describing cases of cystocerebral syndrome via the PubMed database using the Medical Subject Headings (MeSH) keywords of "cystocerebral syndrome," urinary retention and confusion," and "delirium and urinary retention or cystocerebral syndrome," and identified eight cases of cystocerebral syndrome including the original publication by Blackburn and Dunn. We found that all patients reported in the literature were males older than 70 years and often with concomitant benign prostatic hypertrophy (BPH) who presented with acute episodes of delirium that rapidly responded to bladder decompression. The authors seek to update the medical community regarding this uncommon phenomenon of delirium in elderly male patients. We also propose that the lack of female patients in the literature is reflective of their decreased intraurethral flow resistance as is currently being described in other avenues of research in the field of urodynamics.

Efficacy of antibacterial envelope in prevention of cardiovascular implantable electronic device infections in high-risk patients: A systematic review and meta-analysis.

BACKGROUND: Limited evidence is available to determine the efficacy of an antibacterial enveloped (AE) cardiovascular implantable electronic device (CIED). OBJECTIVE: To assess if the use of antibacterial enveloped devices in high-risk patients are associated with lower chances of major CIED infections and mortality compared to non-enveloped devices. METHODS: A comprehensive literature search on multiple databases was performed. The relative odds ratio (OR) of major CIED infection and mortality was calculated using a random-effect model. RESULTS: A total of six studies consisting of 11,897 patients, were included; 5844 with an AE-CIED and 6053 with conventional CIED. In the pooled cohort, patients with AE-CIED had a 66% lower odds of major CIED infection (OR 0.34, 0.13, 0.86, CI 95%, p = 0.02) compared to CIED. Propensity matched analysis showed a 71% lower odds of major infection in the AE-CIED group (OR 0.29, 95% CI 0.10-0.82, p = 0.02). Stratified analysis based on the type of study (retrospective vs. prospective) and duration of follow up (6 months vs. greater than six months) also showed numerically lower infection odds in the AE-CIED. Similarly, the relative odds of mortality were lower in patients with AE-CIED (OR 0.55, 95% CI 0.16-1.91, p = 0.34) compared to CIED patients; however, this difference was statistically non-significant. CONCLUSION: In high-risk patients, AE-CIED might offer lower odds of CIED infections. It has numerically lower (45%) but statistically non-significant odds of mortality if used in conjunction with the standard infection prevention protocol. More large scale studies and long-term follow-ups are required to validate our findings.

A Rare Case of Bleeding Epiphrenic Esophageal Diverticulum From Arteriovenous Malformations.

Epiphrenic esophageal diverticula (EED) is a rare condition that usually presents with dysphagia in patients with a known motility disorder. In this article, we present a unique case of EED presenting with hemoptysis with clinical workup negative for any pulmonary pathology. Esophagogastroduodenoscopy revealed arteriovenous malformations within the EED successfully managed with argon plasma coagulation (APC), leading to a resolution of the patient's symptoms.

Mobile health applications for atrial fibrillation: A readability and quality assessment.

BACKGROUND: Mobile health applications may improve patient education and self-care for a complex condition such as atrial fibrillation (AF). Little is known about the accessibility of mobile health applications ("apps") and their readability. We evaluated the readability and quality of available apps for AF. METHODS: We searched the Apple and Google Play app stores with the terms "atrial fibrillation" and "afib." We downloaded English-language apps (up to n = 100 for each term) and categorized them by name, App store, cost, content, uploading agency (heath care associated [HCA] versus non-HCA), target audience (health care professional [HCP] versus non-HCP), scientific validity (i.e., citation of peer-reviewed or validated medical information), and user ratings. We analyzed the text of apps intended for a non-HCP target audience for readability with 10 established measures. RESULTS: Of the 206 downloaded apps, 50.5% were excluded as unrelated to AF, inaccessible, or non-English language. The majority of apps contained information about AF (63.2% Apple, 52.2% Google Play) and AF detection (52.6% Apple, 56.5% Google Play). A minority of non-HCP apps contained scientifically validated content (Apple, 15.8%; Google Play, 13.0%; P = NS). App mean readability was grade 12.1 ±â€¯2.6. CONCLUSIONS: Most AF apps lacked scientific validation and were written at excessively high reading-grade levels. Our results suggest caution with mobile health apps, particularly for users with limited health literacy. There is potential opportunity for a multi-disciplinary effort by regulatory agencies, healthcare organizations, and app stores to improve relevance, scientific validity, and readability of AF apps for patients with this complex and morbid disease.