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Infective endocarditis caused by Pseudomonas aeruginosa in patients without a history of intravenous drug abuse and endovascular procedures is rare. We present a middle-aged man with fever, chills, night sweats and dyspnoea for 2weeks. Physical examination and blood cultures were drawn, and the patient was empirically started on antibiotics. Unfortunately, the patient experienced progressive clinical deterioration requiring endotracheal intubation and vasopressor support. Transthoracic echocardiogram followed by transesophageal echocardiogram was performed that showed bicuspid aortic valve, severe aortic regurgitation, membranous ventricular septal defect, vegetations on aortic and tricuspid valves, dilated aortic root, and a fistula between the aorta and right atrium. The patient underwent emergent aortic valve and aortic root replacement along with tricuspid commissuroplasty and ventricular septal defect (VSD) closure. Later, intraoperative tissue cultures grew P. aeruginosa, and antipseudomonal antibiotic coverage was added. This case highlights that P. aeruginosa endocarditis can occur without risk factors and can lead to fatal cardiovascular complications. [ABSTRACT FROM AUTHOR]

Background: Patients with prediabetes are at increased risk of coronary artery disease (CAD). However, the association between prediabetes and adverse clinical outcomes following percutaneous coronary intervention (PCI) is inconsistent, in contrast to outcomes in patients with diabetes mellitus (DM). Thus, this meta-analysis evaluated the impact of dysglycaemia on PCI outcomes. Methods: The PubMed, Embase, Cochrane, and ClinicalTrials. gov databases were systematically reviewed from inception of databases until June 2022. In 17 studies, outcomes of PCI in patients with prediabetes were compared with patients who were normoglycaemic, and patients with DM. The primary outcome was all-cause mortality at the longest follow-up. Results: Included were 12 prospective and five retrospective studies, with 11,868, 14,894 and 13,536 patients undergoing PCI in the prediabetes, normoglycaemic and DM groups, respectively. Normoglycaemic patients had a statistically lower risk of all- cause mortality, (risk ratio [RR] 0.66, 95% confidence interval [CI] 0.52-0.84), myocardial infarction (MI; RR 0.76, 95% CI 0.61-0.95) and cardiac mortality (RR 0.58, 95% CI 0.39-0.87) compared with prediabetic patients undergoing PCI at the longest follow- up. Patients with prediabetes had a lower risk of all- cause mortality (RR=0.72 [95% CI 0.53-0.97]) and cardiac mortality (RR =0.47 [95% CI 0.23-0.93]) compared with patients with DM who underwent PCI. Conclusion: Among patients who underwent PCI for CAD, the risk of all- cause and cardiac mortality, major adverse cardiovascular events and MI in prediabetic patients was higher compared with normoglycaemic patients but lower compared with patients with DM. [ABSTRACT FROM AUTHOR]

The academic half-day (AHD) curriculum is an alternative to the noon conference (NC) approach. To date, there is little literature evaluating the transition from NC to AHD in internal medicine residency programs. We investigated the effectiveness of AHD by comparing in-training exam (ITE) and American Board of Internal Medicine (ABIM) certifying exam scores of residents before and after implementation of AHD. In 2019, we transitioned to the AHD curriculum. Averages of three consecutive years of NC (2016–2018) and AHD (2019–2021) were used for statistical testing to determine ITE and ABIM score changes. The class of 2018 experienced both approaches. Cohen's d effect sizes were calculated to assess the magnitude of change in ITE and ABIM scores between NC (2016–2018) and AHD (2019–2021) cohorts. Residents' performance significantly improved (P < 0.05) on ABIM scores (513.80 ± 48.34) on average from 2019 to 2021 compared to ABIM scores (452.42 ± 49.72) on average from 2016 to 2018 with a large effect size of 1.27. Similarly, a significant (P = 0.005) improvement in ITE scores was observed from 2019 to 2021 with implementation of AHD compared to preceding NC scores (2016–2018) with a moderate effect size of 0.52. Participating residents in AHD sessions had higher ITE and ABIM scores compared to those in hourly NC didactic sessions with significantly improved resident attendance and overall satisfaction. [ABSTRACT FROM AUTHOR]

Background: Patients with diabetes mellitus (DM) have a high prevalence of coronary chronic total occlusions (CTOs). We conducted a systematic review and meta-analysis to characterize outcomes after CTO percutaneous coronary intervention (PCI) in patients without or with DM.Methods: PubMed, EMBASE, Cochrane, and Google Scholar were queried for studies comparing non-DM vs. DM patients undergoing attempted CTO PCI. The primary outcome was all-cause mortality at longest follow-up (at least 6 months). Secondary outcomes were major adverse cardiovascular events (MACE) which is a composite endpoint including myocardial infarction, cardiac or all-cause mortality and any revascularization in patients after CTO PCI, target vessel revascularization (TVR), myocardial infarction (MI), Japanese chronic total occlusion (J-CTO) score and prevalence of multivessel (MV) CTO disease. We used a random effects model to calculate odds ratios (ORs) and 95% confidence intervals (CIs).Results: Sixteen studies, including 2 randomized control trials and 14 observational studies, met inclusion criteria. At longest follow-up, all-cause mortality (OR 0.54 [95% CI 0.37-0.80], p < 0.0001) and MACE (OR 0.82 [95% CI 0.72-0.93], p < 0.00001) were significantly lower in non-DM CTO patients. MV CTO disease was less prevalent in patients without DM (OR 0.80 [95% CI 0.69-0.93], p = 0.004). However, there were no differences in MI, TVR and J-CTO score.Conclusions: Non-diabetics undergoing CTO PCI have lower all-cause mortality and MACE than diabetics. Future research may determine if DM control improves diabetics' CTO PCI outcomes. [ABSTRACT FROM AUTHOR]

Background: Acquired thrombocytopenia (aTP) is associated with a high frequency of bleeding and ischemic complications in patients undergoing percutaneous coronary intervention (PCI). Herein, we report a meta-analysis evaluating the adverse effects of aTP on cardiovascular outcomes and mortality post-PCI.Methods: A literature search was performed using PubMed, Embase, Cochrane and, clinicaltrials.gov from the inception of these databases through October 2019. Patients were divided into two groups: 1) No Thrombocytopenia (nTP) and 2) Acquired Thrombocytopenia (aTP) after PCI. Primary endpoints were in-hospital, 30-day and all-cause mortality rates at the longest follow-up. The main summary estimate was random effects Risk ratio (RR) with 95% confidence intervals (CIs).Results: Seven studies involving 57,247 participants were included. There was significantly increased in-hospital all-cause mortality (HR 10.73 [6.82-16.88]), MACE (HR 2.96 [2.24-3.94]), major bleeding (HR 4.78 [3.54-6.47]), and target vessel revascularization (TVR) (HR 7.53 [2.8-20.2]), in the aTP group compared to the nTP group. Similarly, aTP group had a statistically significant increased incidence of 30-day all-cause mortality (HR 6.08), MACE (HR 2.77), post-PCI MI (HR 1.98), TVR (HR 5.2), and major bleeding (HR 12.73). Outcomes at longest follow-up showed increased incidence of all-cause mortality (HR 3.98 [1.53-10.33]) and MACE (HR 1.24 [0.99-1.54]) in aTP group, while there was no significant difference for post-PCI MI (HR 0.94 [0.37-2.39]) and TVR (HR 0.96 [0.69-1.32]) between both groups.Conclusions: Acquired Thrombocytopenia after PCI is associated with increased morbidity, mortality, adverse bleeding events and the need for in-hospital and 30-day TVR. [ABSTRACT FROM AUTHOR]

Introduction: Since the approval of transcatheter aortic valve replacement (TAVR), nonagenarian group patients are being increasingly considered for TAVR. Therefore, we compared the clinical outcomes of surgical aortic valve replacement (SAVR) vs TAVR in nonagenarians with severe aortic stenosis. Methods: A literature search was performed using MEDLINE, Embase, Web of Science, Cochrane, and Clinicaltrials.gov for studies reporting the comparative outcomes of TAVR versus SAVR in nonagenarians. The primary endpoint was short-term mortality. Secondary endpoints were post-operative incidences of stroke or transient ischemic attack (TIA), vascular complications, acute kidney injury (AKI), transfusion requirement, and length of hospital stay. Results: Four retrospective studies qualified for inclusion with a total of 8,389 patients (TAVR = 3,112, SAVR = 5,277). Short-term mortality was similar between the two groups [RR = 0.91 (95% CI: 0.76–1.10), p = 0.318]. The average length of hospital stay was shorter by 3 days in the TAVR group (p = 0.037). TAVR was associated with a significantly lower risk of AKI [RR = 0.72 (95% CI: 0.62–0.83), p < 0.001] and a lower risk of transfusion [RR = 0.71 (95% CI: 0.62–0.81), p < 0.001]. There was no difference in risk of stroke/TIA[RR = 1.01 (95% CI: 0.70–1.45), p = 0.957]. The risk of vascular complications was significantly higher in the TAVR group [RR = 3.39 (95% CI: 2.65–4.333), p < 0.001]. Conclusion: In this high-risk population, TAVR compared to SAVR has similar short-term mortality benefit but has lower risks of perioperative complications and a higher number of patients being discharged to home. [ABSTRACT FROM AUTHOR]

Obstructive sleep apnea (OSA) is an established risk factor for poor cardiovascular outcomes and coronary artery disease, but its influence on the development of peripheral artery disease (PAD) is not well established. The aim of our study was to understand the mutual prevalence of OSA and PAD and any reported statistical association between the two conditions. PubMed, Ovid Embase, Web of Science, Cochrane library and clinicaltrials.gov databases were systematically searched up to 29 November 2018. A total of 844 articles were identified and 744 articles were screened for relevance. Eleven prospective cohorts qualified for inclusion with N = 63,642 (M = 28,062, F = 35,494). All studies evaluated OSA severity primarily with apnea–hypopnea index (AHI) values. The overall prevalence of PAD was 20.5% (N = 13,068). Except for two studies, all studies reported an increased prevalence of OSA in patients with PAD. OSA severity was not found to have an association with poor ankle brachial index values or increasing daytime sleepiness as measured by Epworth sleepiness scale. Further prospective clinical trials are required to further delineate this finding. [ABSTRACT FROM AUTHOR]

Atrial Fibrillation (AFib) is the most common cardiac arrhythmia, occurring in ≈1% of the general population. An increased risk of malignancy among patients with AFib would be of substantial public health importance, given the high prevalence and associated economic burden of both disorders. To evaluate the relationship between atrial fibrillation (AFib) and cancer. We conducted an extensive database search on PubMed, Google Scholar, ScienceDirect, and SEER Database from their inception to September 2019 for any study that evaluated the association between AFib and cancer. In the first 3 months of AFib diagnosis, Ostenfeld et al. reported an absolute cancer risk of 2.5% with a standardized incidence ratio of 7.02 and 3.53 for metastatic and localized cancer, respectively. Likewise, Saliba et al. detected an increase in the odds of cancer diagnosis in first 90 days after AF diagnosis with OR of 1.85. Moreover, in another study new-onset breast and colorectal cancer was especially associated with AF in the first 90 days after diagnosis with HR of 3.4 but not thereafter (HR 1.0). Similarly, Conen et al. reported high relative risk of cancer with HR of 3.54 in the first 3 months after new-onset AFib. However, beyond the initial 90 day period, the risk of cancer in AFib is only slightly increased. Based on our review, there appears to be an increase in risk of subsequent diagnosis of cancer in patients with AF, likely owing to the shared risk factors between the two conditions. While the results of this study raise interesting questions for future search, they are not currently strong enough to justify initiating cancer screening for an occult cancer in a patient with AF. Regardless, measures to target modification of these shared risk factors remains an important consideration. [ABSTRACT FROM AUTHOR]

Objective: To examine the effect of age on procedural and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) lesions. Methods: Literature search was conducted across PubMed, Google Scholar and Web of science, databases till March 2019. Results: Seven studies including 7671 patients with an overall follow-up period of 1.5 to 5 years were included in our review. A total of 6299/1372 patients were included in non-elderly and elderly groups, respectively, with mean age and 67%/61% male patients. CTO-PCI was similarly successful in younger and older patients (82.8%, n = 5070 vs. 78.1%, n = 1010). The incidence of short-term outcomes was low across the studies and comparable between the two groups (all-cause mortality: 0.4% younger vs. 0.85% elderly, cerebrovascular accidents: 0.3% vs. 0.4%, major adverse cardiovascular events (MACE): 1.53% vs. 3.72% and major bleeding: 0.57% vs. 2.18%). Long-term outcomes including all-cause mortality (8.89% vs. 29.5%), cardiac mortality (3.72% vs. 15%) and MACE (24.9% vs. 40%) occurred with a higher incidence in elderly patients. When results were segregated according to the success of CTO-PCI, reduced clinical events were noted with successful revascularization in either age group. Conclusion: Compared with the younger age group, CTO-PCI in elderly patients is safe and feasible with a comparable incidence of short-term outcomes. In either population, the incidence of long-term outcomes including survival remains a concern but when successful, CTO-PCI may be associated with improvement in terms of multiple patient-important clinical end-points. [ABSTRACT FROM AUTHOR]

Bronchogenic cysts are rare incidental findings, but they can have life-threatening complications. Herein, we report a case of a 44-year-old man who presented with complaints of left-sided chest pain, intermittent dyspnea, and pink-tinged sputum. Computed tomography angiography of the chest revealed a large cystic mediastinal mass in the subcarinal location. During his hospital stay, the patient became hypotensive with jugular venous distention and muffled heart sounds on auscultation. A stat echocardiogram depicted a large pericardial effusion with early diastolic collapse of the right ventricle. Pericardiocentesis was performed for cardiac tamponade, followed by thoracotomy with removal of bronchogenic cyst. Herein, we highlight the relation between bronchogenic cysts and cardiac tamponade and review the surgical treatment options. [ABSTRACT FROM AUTHOR]

The prevalence of different cancers after heart transplant (HT) is unclear due to small and conflicting prior studies. Herein, we report a systematic review and meta-analysis to highlight the prevalence and pattern of malignancies post-HT. We conducted an extensive literature search on PubMed, Scopus, Cochrane databases for prospective or retrospective studies reporting malignancies after HT. The proportions from each study were subjected to random effects model that yielded the pooled estimate with 95% confidence intervals (CI). Fifty-five studies comprising 60,684 HT recipients reported 7759 total cancers during a mean follow-up of 9.8 ± 5.9 years, with an overall incidence of 15.3% (95% CI = 12.7%-18.1%). Mean time from HT to cancer diagnosis was 5.1 ± 4 years. The most frequent cancers were gastrointestinal (7.6%), skin (5.7%), and hematologic/blood (2.5%). Meta-regression showed no association between incidence of cancer and mean age at HT (coeff: -0.008; P = 0.25), percentage of male recipients (coeff: -0.001; P = 0.81), donor age (coeff: -0.011; P = 0.44), 5-year (coeff: 0.003; P = 0.12) and 10-year (coeff: 0.02; P = 0.68) post-transplant survival. There is a substantial risk of malignancies in HT recipients, most marked for gastrointestinal, skin, and hematologic. Despite their occurrence, survival is not significantly impacted. [ABSTRACT FROM AUTHOR]

Despite the advancements in the management of heart failure, acute heart failure is one of the most common causes of mortality and morbidity. In light of the financial burden imposed by heart failure hospitalizations on the health care system, this area remains the focus of research, clinical advances, and policy changes aimed at improving the quality of care and outcomes. Despite practice guidelines, high-quality trial data, and consensus statements, barriers to therapy remain. The barriers related to physician, patient, economic, health care system, and logistical factors prevent widespread adoption of available therapeutics. In this review article, we outline guidelines directed therapies for heart failure, challenges associated with their implementation, and potential solutions to these challenges to help reduce mortality and improve clinical outcomes in this patient population. [ABSTRACT FROM AUTHOR]

Lemierre's syndrome is a rare disorder characterized by thrombophlebitis of the internal jugular vein and is caused by gram-negative anaerobes, primarily Fusobacterium necrophorum. We report a case of a 20-year-old man who developed chronic osteomyelitis of the femur and myonecrosis of thigh muscles secondary to this syndrome. The diagnosis was made based on clinical presentation and evidence of thrombosis in the internal jugular vein on ultrasound. The patient was initially treated with antibiotics, and anticoagulants were added later due to deep vein thrombosis in the lower limb. [ABSTRACT FROM AUTHOR]