The Poisoned Heart: A Case of Takotsubo Cardiomyopathy Induced by Carbon Monoxide Poisoning.

BACKGROUND: Carbon monoxide is a common environmental toxin, and some patients present with features of cardiac injury in addition to the noxious effects of carbon monoxide poisoning. A very small fraction of those have a transient left ventricular apical ballooning syndrome or Takotsubo cardiomyopathy, both terms are used to define a syndrome that affects the systolic function of the heart. It usually presents with elevated troponin levels with or without electrocardiographic changes. Cardiac angiograms generally illustrate coronary arteries without significant obstruction. CASE REPORT: Here we report the curious case of a 37-year-old Hispanic man brought in for carbon monoxide poisoning, but found to have significantly elevated troponin levels. Echocardiogram demonstrated decreased ejection fraction of 35%. Left heart catheterization 2 days after admission revealed patent coronary arteries, improved ejection fraction to 45%, and wall motion abnormalities plus apical ballooning compatible with Takotsubo cardiomyopathy. The case is unusual because our patient differs from the classically defined elderly, postmenopausal female demographic, and did not experience an emotional crisis that could have provoked this series of events. It is also noteworthy for the fact that the only identifiable trigger was exposure to carbon monoxide. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Carbon monoxide poisoning is a common occurrence resulting in a multitude of annual emergency department visits. Given the known toxic effects of carbon monoxide poisoning on the heart, prompt cardiac workup is important to prevent overlooking a major, although rare, manifestation of carbon monoxide exposure.

Disparities in Cardiac Rehabilitation Among Individuals from Racial and Ethnic Groups and Rural Communities-A Systematic Review.

PURPOSE: Despite the well-described benefits of cardiac rehabilitation (CR) on long-term health outcomes, CR is a resource that is underutilized by a significant proportion of patients that suffer from cardiovascular diseases. The main purpose of this study was to examine disparities in CR referral and participation rates among individuals from rural communities and racial and ethnic minority groups with coronary heart disease (CHD) when compared to the general population. METHODS: A systematic search of standard databases including MedlLine, PubMed, and Cochrane databases was conducted using keywords that included cardiac rehabilitation, women, race and ethnicity, disparities, and rural populations. Twenty-eight clinical studies from 1990 to 2017 were selected and included 478,955 patients with CHD. RESULTS: The majority of available clinical studies showed significantly lower CR referral and participation rates among individuals from rural communities, women, and racial and ethnic groups when compared to the general population. Similar to geographic region, socioeconomic status (SES) appears to directly impact the use of CR programs. Patients of lower SES have significantly lower CR referral and participation rates than patients of higher SES. CONCLUSIONS: Data presented underscores the need for systematic referrals using electronic health records for patients with CHD in order to increase overall CR referral and participation rates of minority populations and other vulnerable groups. Educational programs that target healthcare provider biases towards racial and ethnic groups may help attenuate observed disparities. Alternative modalities such as home-based and internet-based CR programs may also help improve CR participation rates among vulnerable populations.

Cadaveric Temporal Bone Dissection: Is It Obsolete Today?

Introduction: Traditionally, surgical training in otology, is imparted by dissecting harvested human cadaveric temporal bones. However, maintenance of a cadaveric temporal bone laboratory is expensive and carries risk of exposure to infection. In recent times, other modalities of training are gaining ground and are likely to eventually replace cadaveric temporal bone dissection altogether. Objectives: Other alternative methods of training are emerging. New technology like simulation and virtual reality as high-fidelity, safer alternatives, are making rapid strides as teaching tools. Other options are the use of animal temporal bones as teaching tools. The advantages of these are compared. Data Synthesis None of these modalities can replicate the innumerable anatomical variations which are a characteristic feature of the human temporal bone. A novice surgeon not only needs exposure to surgical anatomy and it's variations but also needs to develop hand-eye coordination skills to gain expertise. Conclusion:  Deliberate practice on human cadaveric temporal bones only, will confer both mastery in anatomy and surgical technique. The human cadaveric temporal bone is ideal simulator for training in otology...

Cadaveric temporal bone dissection: is it obsolete today?

Introduction Traditionally, surgical training in otology, is imparted by dissecting harvested human cadaveric temporal bones. However, maintenance of a cadaveric temporal bone laboratory is expensive and carries risk of exposure to infection. In recent times, other modalities of training are gaining ground and are likely to eventually replace cadaveric temporal bone dissection altogether. Objectives Other alternative methods of training are emerging. New technology like simulation and virtual reality as high-fidelity, safer alternatives, are making rapid strides as teaching tools. Other options are the use of animal temporal bones as teaching tools. The advantages of these are compared. Data Synthesis None of these modalities can replicate the innumerable anatomical variations which are a characteristic feature of the human temporal bone. A novice surgeon not only needs exposure to surgical anatomy and it's variations but also needs to develop hand-eye coordination skills to gain expertise. Conclusion Deliberate practice on human cadaveric temporal bones only, will confer both mastery in anatomy and surgical technique. The human cadaveric temporal bone is ideal simulator for training in otology.