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Transgender individuals are increasingly seeking the care of physicians to physically transition to their self-identified gender identity. Gender-affirming hormone therapy (GAHT) has significant endocrine effects which may have cardiovascular consequences, and cardiovascular disease in transgender individuals is a growing area of study. The effects of GAHT on cardiac mechanics have yet to be characterized, but there is existing literature regarding changes to cardiac mechanics in similar altered hormonal states. We reviewed this literature, with a focus on echocardiographic findings. We found variable results between studies of different methodologies. These include findings that supraphysiological levels of testosterone may impair cardiac mechanics, whereas estrogen-containing hormonal replacement therapy may improve diastolic echocardiographic parameters. In summary, there are alterations to echocardiographic parameters in altered endocrine states related to exogenous testosterone and estrogen, in a manner that is likely dose-dependent. Encouragingly, the studies we reviewed did not suggest that hormonal changes within physiologic ranges would detrimentally affect echocardiographic parameters of systolic and diastolic function. Future research into the cardiovascular effects of long-term GAHT is warranted to safely guide the longitudinal treatment of transgender individuals., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Endurance athletes are at higher risk for developing atrial fibrillation as compared to the general population. The exact mechanism to explain this observation is incompletely understood. Our study aimed to determine whether degree of left atrial fibrosis detected by late gadolinium-enhancement magnetic resonance imaging (LGE-MRI) differed between Masters athletes and non-athlete controls., Methods: We recruited 20 endurance healthy Masters athletes and 20 healthy control subjects who underwent cardiac MRI. Healthy controls were recruited during screening colonoscopies and Masters athletes were recruited through word of mouth and at competitions. The two groups were age and gender matched. None of the participants were known to have an arrhythmia. Fibrosis, as measured by late gadolinium-enhancement, was measured in each participant by blinded readers. The degree of left atrial fibrosis was compared between the two groups. All participants were recruited from the Salt Lake City region and scanned at the University of Utah healthcare complex., Results: Left ventricular function was normal in all study participants. Left atrial volumes were significantly larger in the athletes (74.2 ml ± 14.4) as compared to the healthy control subjects (60.8 mL ± 21.4) (P = .02). Mean left atrial fibrosis score, reported as a percentage of the LA, was 15.5% ± 5.9 in the athlete cohort compared to 9.6% ± 4.9 in the controls (P = .002)., Conclusions: To our knowledge this is the first study that describes, characterizes and specifically quantifies fibrotic changes within the left atrium of highly trained endurance athletes. Increased atrial fibrosis seen in this population may be an early indicator for endurance athletes at risk of developing atrial arrhythmias., Competing Interests: Declaration of competing interest There are no pertinent relationships with industry., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Fever of unknown origin (FUO) is a well-known pediatric presentation. The primary studies determining the causes of prolonged fever in children were performed 4 decades ago, before major advances in laboratory and diagnostic testing. Given that the distribution of diagnosed causes of adult FUO has changed in recent decades, we hypothesized that the etiology of FUO in children has concordantly changed and also may be impacted by a definition that includes a shorter required duration of fever., Methods: A single-center, retrospective review of patients 6 months to 18 years of age admitted to the North Carolina Children's Hospital from January 1, 2002, to December 21, 2012, with an International Classification of Diseases, Ninth Revision diagnosis of fever, a documented fever duration >7 days before admission, and a previous physician evaluation of each patient's illness., Results: A total of 1164 patients were identified, and of these, 102 met our inclusion criteria for FUO. Etiologic categories included "infectious" (42 out of 102 patients), "autoimmune" (28 out of 102 patients), "oncologic" (18 out of 102 patients), and "other" or "unknown" (14 out of 102 patients). Several clinical factors were statistically and significantly different between etiologic categories, including fever length, laboratory values, imaging performed, length of stay, and hospital costs., Conclusions: Unlike adult studies, the categorical distribution of diagnoses for pediatric FUO has marginally shifted compared to previously reported pediatric studies. Patients hospitalized with FUO undergo prolonged hospital stays and have high hospital costs. Additional study is needed to improve the recognition, treatment, and expense of diagnosis of prolonged fever in children., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Background: Patient-reported outcomes (PROs) quantify, from patients' perspectives, their symptoms, function, and quality of life. Our aim was to determine the feasibility of integrating PRO capture into routine clinical practice at a large heart failure (HF) clinic., Methods: We examined the practicality of PRO completion at the time of clinic visit, the time required to complete the selected instruments, the completion rate, and the feasibility of immediate PRO scoring and integration of the results into the electronic health record (EHR). We deployed a computer program to capture PROs (Kansas City Cardiomyopathy Questionnaire, Patient-Reported Outcomes Measurement Information System) on a portable computer platform at the time of a clinic visit. An automated algorithm identified patients scheduled for appointments at the HF clinic at registration, provided a portable tablet computer with which to complete the appropriate PRO instruments and then scored and immediately integrated the results in the patient's EHR., Results: In a 12-month period, 862 unique patients completed 1,320 PRO assessments. The mean age of this cohort was 60.1 ± 16.3 years and 66% were male. The average time for PRO assessment was 6.7 minutes and the completion rate among eligible patients was 58%, with 91% of started assessments completed in full., Conclusions: These preliminary data support the feasibility of serial PRO assessment with real-time integration into the EHR in a large outpatient population of patients with HF. We identified critical steps that should enhance adoption of this approach by clinicians and render PRO results meaningful and actionable in routine clinical care., (Published by Elsevier Inc.)

Background: An rSr' pattern in leads V1-V2 can be observed when ECG leads are placed in the 2nd intercostal space. Recently, three criteria analyzing the ST segment and r' width to identify true Brugada pattern ECGs have been described., Objectives: To assess the feasibility and reliability of using high precordial lead ECGs in conjunction with three new criteria for identifying true Brugada pattern ECGs., Methods: ECGs of 491 college athletes and 181 non-athletes were performed with standard and high-lead ECGs. ECGs were then analyzed using the newly proposed criteria., Results: Zero patients had a Brugada type 1 or 2 pattern at baseline; 76 patients demonstrated an rSr' pattern in leads V1-V2 on the high-lead ECG. Two of the 76 (3%) met criteria suggesting a true Brugada ECG., Conclusion: New ECG criteria based on the r' wave accurately identify rSr' patterns in V1-V2 from potential Brugada type 2 patterns in patients with purposely placed high precordial leads., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Importance: Rapidly detecting dangerous arrhythmias in a symptomatic athlete continues to be an elusive goal. The use of handheld smartphone electrocardiogram (ECG) monitors could represent a helpful tool connecting the athletic trainer to the cardiologist., Observations: Six college athletes presented to their athletic trainers complaining of palpitations during exercise. A single lead ECG was performed using the AliveCor Heart Monitor and sent wirelessly to the Team Cardiologist who confirmed an absence of dangerous arrhythmia., Conclusions and Relevance: AliveCor monitoring has the potential to enhance evaluation of symptomatic athletes by allowing trainers and team physicians to make diagnosis in real-time and facilitate faster return to play., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Atrial fibrillation is associated with a risk of stroke, primarily from embolization of clots that form in the left atrial appendage. This structure has been targeted to reduce stroke risk in patients who have contraindications to oral anticoagulation. This article appraises the current literature describing surgical and percutaneous isolation of the left atrial appendage., (Copyright © 2015 Cleveland Clinic.)

Importance: Left ventricular noncompaction (LVNC) is a rare cause of progressive cardiomyopathy thought to result from incomplete myocardial development. It has been associated with an increased risk of sudden death, especially in those with a depressed left ventricular ejection fraction. Thus, the current recommendation for patients with this diagnosis is restriction from participation in competitive sports., Observations: An asymptomatic 18-year-old African American collegiate football player had a murmur on his preparticipation physical examination. Subsequent cardiology workup revealed hypertrabeculation vs LVNC. Second and third opinions were sought from national experts in the field: one gave the diagnosis of LVNC and recommended restriction; the other gave the diagnosis of hypertrabeculation. After a family meeting including the player, mother, team physician, and consulting cardiologist, the player was permitted to participate in football., Conclusions and Relevance: Distinguishing between pathologic LVNC and physiologic hypertrabeculation is a diagnostic challenge and is becoming increasingly commonplace with enhanced echocardiography and magnetic resonance imaging modalities. Given the limited data on such patients, careful workup and discussion between patient and providers is required.

Reactivation of latent varicella zoster virus is one infectious complication associated with the extensive immunosuppression necessary for hematopoietic stem cell transplant. Most cases are limited to skin and mortality is low. Isolated visceral zoster is rare, presenting with ileus/abdominal pain, hepatitis, and/or hyponatremia. We present 2 cases of visceral varicella zoster virus in adolescents with chronic graft-versus-host disease after hematopoietic stem cell transplant. Both presented with elevated liver enzymes, severe abdominal pain, and hyponatremia but lacked cutaneous involvement. Both received high-dose acyclovir and showed improvement, but eventually expired from hepatic failure. The diagnosis of visceral zoster can be difficult especially without cutaneous manifestations. Vigilance is necessary in patients with chronic graft-versus-host disease, abdominal pain, and/or hepatitis and antiviral therapy should be initiated promptly.