Racial disparities in women with ST elevation myocardial infarction: A National Inpatient Sample review of baseline characteristics, co-morbidities, and outcomes in women with STEMI.

BACKGROUND: A third of the patients admitted with Acute coronary syndrome (ACS) have ST-elevation myocardial infarction (STEMI). Previous studies showed that females with STEMI have higher mortality than men. HYPOTHESIS: There exist significant disparities in outcomes among women of different races presenting with STEMI. METHODS: National inpatient sample (NIS) data was obtained from January 2016 to December 2018 for the hospitalization of female patients with STEMI. We compared outcomes, using an extensive multivariate regression analysis amongst women from different races. Our primary outcome was in-hospital mortality. Secondary outcomes were revascularization use, procedure complications, and healthcare utilization. RESULTS: Of 202 223 female patients with STEMI; 11.3% were African American, 7.4% Hispanic, 2.4% Asian, and 4.3% another race. In-hospital mortality was higher in non-Caucasian groups. African American (adjusted odds ratio [aOR] 1.2; 95% confidence interval [CI]: 1.07-1.30; p < .01) and another race (aOR 1.37; 95% CI: 1.15-1.63; p < .01) had higher odds of mortality when compared with white women. African American (aOR 0.69; 95% CI: 0.62-0.72; p < .01), Hispanics (aOR 0.81; 95% CI: 0.74-0.88; p < .01), and Asian (aOR 0.79; 95% CI: 0.69-0.90; p < .01) had lower odds of percutaneous intervention (PCI) when compared with whites. African Americans had fewer odds of Coronary Artery Bypass Graft (CABG) and use of Mechanical Circulatory Support (MCS) during the index admission. Non-Caucasians had more comorbidities, complications, and healthcare utilization costs. CONCLUSION: There are significant racial disparities in clinical outcomes and revascularization in female patients with STEMI. African American women have a higher likelihood of mortality among the different races. Females from minority groups are also less likely to undergo PCI.

Streptococcus sanguinis Endocarditis of Bicuspid Aortic Valve Presenting as Septic Arthritis of Lumbar Facet Joint.

Septic arthritis of the facet joint (SAFJ) is an uncommon etiology of low back pain that usually affects the elderly population and immunocompromised patients but is rare in immunocompetent and young patients. When such a clinical presentation occurs, it is imperative to diagnose the source of the infection. We report a case of septic arthritis of the left third and fourth lumbar vertebrae facet joint due to Streptococcus sanguinis in a young immunocompetent adult, and the source of infection was found to be subacute infective endocarditis of a bicuspid aortic valve which was undiagnosed till now. A 49-year-old male presented with new-onset palpitations, dyspnea with exertion, low back pain, night sweats, and chills. A physical exam was significant for spinal tenderness on palpation of the lumbar spine around the L3-L5 level. Blood cultures were positive for Streptococcus sanguinis, and an MRI of the lumbar spine showed left-sided L3-L4 septic arthritis with epidural abscess and posterior paravertebral cellulitis/myositis. Transesophageal echocardiography led to the diagnosis of a bicuspid aortic valve and moderate aortic insufficiency, but it was a cardiac computed tomography that showed a sub-aortic valve abscess leading to the diagnosis of infective endocarditis. He was treated with a six-week course of intravenous antibiotics with complete resolution of symptoms, followed by aortic valve replacement with a mechanical valve. This case report focuses on the importance of diagnosing occult sources in clinically atypical infections, especially when hematogenous seeding is suspected.

A Case Report and Literature Review of New-Onset Myasthenia Gravis After COVID-19 Infection.

Myasthenia gravis (MG) is an autoimmune disorder affecting the neuromuscular junction caused by a B-cell-mediated, T-cell-dependent immunologic attack at the end plate of the postsynaptic membrane. Attack on muscle acetylcholine receptors (AChR) of the postsynaptic membrane due to the AChR, muscle-specific tyrosine kinase, or lipoprotein receptor-related peptide 4 antibodies lead to symptoms of painless, fluctuating weakness of muscle groups and often begins with ocular signs and symptoms. Coronavirus disease 2019 (COVID-19) is an acute respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus closely related to SARS-CoV. Serious neurologic complications are infrequent and diverse with reported cases of stroke, encephalitis/meningitis, Guillain-Barré syndrome, acute disseminated encephalomyelitis, ataxia, and unspecified limb weakness. MG is a rarely reported sequela of COVID-19 infection. To date, there are 15 reported cases of post-COVID-19 MG. In this article, we present a case of post-COVID-19 MG and a concise review of other reported cases. An 83-year-old Caucasian male with a medical history of atrial fibrillation status post-ablation and non-ischemic cardiomyopathy was initially admitted for COVID-19 pneumonia. He was treated with remdesivir, convalescent plasma, and supplemental oxygen therapy but did not require invasive mechanical intubation. One month after discharge, he started experiencing fatigue with muscle weakness and progressive dyspnea. He progressed to develop dysphonia, especially at the end of the day. After extensive workup, he was diagnosed with MG with a positive antibody against the AChR. The chronological events of developing slowly worsening muscular weakness after recovering from COVID-19 infection and positive AChR antibody led to the diagnosis of post-COVID-19 new-onset MG. Post-COVID-19 fatigue, long-term use of steroids, and intensive care unit-related physical deconditioning can be confounders in the clinical presentation of post-COVID-19 new-onset MG. Careful history-taking and meticulous assessment of chronological events are needed to diagnose this rare entity.

Efficacy of subcutaneous interferon-beta in COVID-19: a meta-analysis and systematic review.

Type 1 interferons, especially interferon-beta, has been reported to be effective in COVID-19 patients in multiple randomized controlled trials. The aim of our meta-analysis and systematic review is to assess efficacy of subcutaneous IFN-beta in regards to mortality and discharge rate. Prospective, retrospective and randomized controlled trials were included. Primary outcomes measured were 28-day mortality and discharge rate. Secondary outcomes measured were mean hospital stay and post-intervention intubation rate. A thorough literature search was conducted in Medline, PubMed, Ovid journals, Google Scholar, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews from 1 April 2020 to 28 February 2021. Relative risk was calculated using both the Mantel-Haenszel method (fixed-effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test, based upon inverse variance weights. 7 studies were included in the meta-analysis and systematic review. The IFN-beta group did not improve the 28-day mortality (RR = 1.276; 95% CI: 1.106-1.472, p = 0.001) or the discharge rate (RR = 0.906; 95% CI = 0.85-0.95, p = < 0.001). The mean hospital stay was 11.95± 2.5 days in the interferon-beta group and 11.43 ± 3.74 days in the traditional treatment group. Likewise, interferon-beta did not add any advantage to post-intervention intubation rate (RR = 0.92; 95% CI = 0.7841-1.0816, p = 0.3154). Our findings revealed that use of subcutaneous interferon-beta is futile in COVID-19.

Pericardial Angiosarcoma: A Diagnostic Challenge.

Cardiac angiosarcomas are the most common malignant primary cardiac tumors accounting for 31% of all primary cardiac tumors. However, primary pericardial angiosarcomas are extremely rare and are associated with high mortality. A 41-year-old male with a past medical history of end-stage renal disease (ESRD) on hemodialysis, follicular thyroid carcinoma, hypertension, and asthma presented with recurrent pericardial effusions. Previously, different imaging modalities had shown small hemodynamically stable pericardial effusions with pericardial thickening. His pericardial effusion was attributed to his ESRD until this presentation. However, during the current admission, chest X-ray showed cardiomegaly with lobulated left heart border. Computed tomography (CT) and transthoracic echocardiogram showed an increased posterior complex pericardial effusion when compared to previous imaging. A pericardial window was created and the space was evacuated. Pericardial fluid cytology reported rare atypical cells, which were indeterminate for malignancy. Histopathology from the pericardial biopsy revealed fibrous tissue with cellular proliferation, consistent with an angiosarcoma. A positron emission tomography revealed findings of angiosarcoma (hypermetabolic pericardial soft tissue nodularity and complex pericardial fluid) limited only to the pericardium. Unfortunately, the angiosarcoma was deemed unresectable, and the patient underwent one cycle of chemotherapy with paclitaxel. The patient's hospital course was further complicated by myelosuppression from chemotherapy and disseminated intravascular coagulation. Therefore, no further chemotherapy was pursued. A repeat echocardiogram showed constriction of both ventricles with loculated pericardial effusion. The patient eventually transitioned to comfort care and passed away. Through this case report, we would like to highlight that multiple confounders can be present when considering the etiology of persistent pericardial effusions. We suggest contemplating alternate diagnosis, such as malignancy, and initiate aggressive work-up especially in young individuals with recurrent, unexplained pericarditis.

Abdominal pain - a common presentation with unusual diagnosis: a case report.

Acute abdominal pain is a frequent cause for evaluation in the clinic and emergency room. A number of causes of abdominal pain are diagnosed easily based on the history, physical exam, and some laboratory findings. However, unusual conditions may pose a challenge and require invasive procedures for diagnosis. Rare anomalies such as mobile caecum may present as either typical or atypical acute appendicitis. Endometriosis and pinworm infections can also present as acute appendicitis but are uncommon presentations. To increase the awareness of these uncommon causes of appendicitis, we present a 32 year old female who was previously diagnosed with irritable bowel syndrome later found to have all of the above mentioned rare conditions contributing to abdominal pain. She presented to the emergency room with a one day history of acute right lower quadrant abdominal pain along with nausea and non-bilious vomiting. Physical exam revealed right lower quadrant tenderness to palpation. A computerised tomography of the abdomen and pelvis demonstrated a mobile cecum in the left abdomen. She subsequently underwent a diagnostic laparotomy with cecopexy and appendectomy. Pathology of the appendix showed findings suggestive of endometriosis and intraluminal enterobius vermicularis. She was treated with two doses of pyrantel pamoate for the parasitic infection, and subsequently had resolution of her symptoms.

Transient Systolic Anterior Motion of the Anterior Mitral Valve Leaflet in a Critical Care Patient with a Structurally Normal Heart.

Systolic anterior motion (SAM) is defined as the displacement of the anterior mitral leaflet towards the left ventricular outflow tract, which results in left ventricular outflow tract obstruction (LVOTO). The SAM of the anterior mitral leaflet is a well-established phenomenon in hypertrophic obstructive cardiomyopathy (HOCM), but its occurrence in a structurally healthy heart is uncommon. We present a critical care patient with presumed septic shock whose blood pressure was previously controlled by fluid resuscitation and vasopressors. He developed a new cardiac murmur along with hypotension despite being on vasopressors. The echocardiographic assessment revealed no structural heart disease or valvular vegetations but a hyperdynamic left ventricle with significant SAM of the anterior mitral leaflet, resulting in mitral regurgitation (MR). The murmur and hypovolemia resolved after aggressive fluid resuscitation and by decreasing the vasopressor dose.