Possible predictive factors for recovery of left ventricular systolic function in Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) is a transient systolic dysfunction of the left ventricle which is usually seen in elderly women, often following a physical or emotional stressful event. Little is known about the prognostic factors affecting the recovery of systolic function. Thirty-six patients diagnosed with TTC from January 2006 to January 2017 at our hospital were included. Median time to recovery of ejection fraction (EF) was calculated to be 25 days. Early recovery of ejection fraction was defined as less than or equal to 25 days (group 1) and late recovery was defined as more than 25 days (group 2). Demographic and clinical factors were compared between the groups. Fifty percent patients had early recovery of EF with a mean time to recovery of 7.11 days and 50% had late recovery of ejection fraction with a mean time to recovery of 58.38 days. Younger age at presentation was associated with early recovery of systolic function (58.83 ± 2.7 years vs. 67.33 ± 2.7 years, p = 0 .032). Presence of an identifiable triggering event was associated with early recovery (83% in group 1 vs. 50% in group 2, p = 0.034). Generalized anxiety disorder was seen more commonly in the group with early recovery (78% in group 1 vs. 45% in group 2, p = 0.040). In conclusion, younger age, generalized anxiety disorder and presence of triggering event were seen more commonly in patients with early recovery of left ventricular systolic function in Takotsubo cardiomyopathy.

Pneumomediastinum and Mediastinal Hematoma Secondary to Right Brachiocephalic Vein Thrombectomy Mimicking STEMI

A 50-year-old male with a history of hemodialysis dependent chronic kidney disease presented to our emergency department with acute midsternal crushing chest pain. Patient was diagnosed with acute anterolateral wall Myocardial Infraction due to the presence of corresponding ST segment elevations in EKG and underwent emergent cardiac catheterization which revealed normal patent coronaries without any disease. He continued to have chest pain for which CT of the chest was done which revealed pneumomediastinum with mediastinal hematoma, due to the recent attempted thrombectomy for thrombus in his right brachiocephalic vein.

Respiratory papillomas

Papillomas are known to occur in the lower respiratory tract. They are however, rare compared to their occurrence in the upper respiratory tract. These are generally exophytic tumors in the more proximal upper airways however cases with more distal location with an inverted growth pattern have also been described in the literature. These can be solitary or multiple and multifocality associated with multiple papillomas in the upper respiratory/aerodigestive tract. The four major types of respiratory papillomas are (1) Recurrent respiratory papillomas, (2) solitary squamous papillomas, (3) solitary glandular papillomas, (4) mixed papillomas. We review the incidence, etiopathology, diagnosis, and possible treatment modalities and algorithms for these respiratory papillomas.

Richter's transformation presenting as splenic rupture after 6 years of complete remission of chronic lymphocytic leukaemia

Richter's transformation is a rare clinical condition occurring in about 5-10% of patients with chronic lymphocytic leukaemia (CLL). Patients usually present with lymphadenopathy, hepatosplenomegaly and elevated serum lactate dehydrogenase levels. These patients have a very poor prognosis with a median survival of about 10 months. We present a patient, with a history of CLL in complete remission, who presented with splenic rupture requiring splenectomy. She was eventually diagnosed with diffuse large B-cell lymphoma with Richter's transformation.

Abstract 37: Measure of Appropriateness in the Placement of Intravenacaval Filters Among Guidelines From Major Medical Societies

Objective: With healthcare focusing towards quality based healthcare it has created significant interest among physicians in measuring and defining appropriateness in the treatment of medical conditions. We compared the indications for which the Intravenacaval (IVC) filter was placed in our hospital with the current guidelines by three of the major medical societies the American Heart Association (AHA), American College of Chest Physicians (ACCP) and Society for Interventional Radiology (SIR) to compare the measure of appropriateness in the placement of IVC filters among the guidelines

Methods: We conducted a retrospective review of all charts with the ICD 9 code for placement of IVC filter from January, 2010 to January, 2015. Each patient chart was reviewed for patient demographics, complications and indications which were compared with the guidelines as defined by AHA, ACCP and SIR

Results: During the 5 years, 592 patients underwent the procedure which included 233 men and 359 women who had a mean age of 67.2 +/- 17.4. 75.8% filters were inserted by vascular surgery and 24.2% filters were inserted by interventional radiology. 1.8% of the patients had some form of complication either during insertion or retrieval. On comparing the indications, we found that 35.5%(AHA), 30.9%(ACCP), 35.5%(SIR) were appropriate. While 4.4%(AHA), 4.4%(ACCP), 47.4%(SIR) were relatively appropriate and 60.1%(AHA), 64.7%(ACCP), 17.1%(SIR) were not appropriate. Commonly used indications not defined clearly included prophylaxis for bariatric surgery (14.4%) and high risk for fall (11%). Statistical analysis with the Chi-square test showed there was no statistical difference between AHA and ACCP (p =0.243), while statistical difference was present between AHA and SIR (p <0.001) and ACCP and SIR (p < 0.001)

Conclusion: This study demonstrates that there are significant differences between the guidelines from major medical societies for the placement of IVC filter which leads to compelling discrepancies amongst physicians in their decision for the placement of IVC filters

Atrial Fibrillation Due to Over The Counter Stimulant Drugs in A Young Adult

The usage of over the counter stimulant drugs and energy drinks is increasing on a day to day basis for various purposes including work, sports and leisure among individuals in all age groups. Multiple formulations are available in the market including pills, liquid capsules and drinks in various flavours. Many of them contain excessively high doses of caffeine along with a variety of stimulant compounds that have multiple effects in different parts of the human body. The consumption of such high amounts of caffeine itself has shown to have caused cardiac arrhythmias in healthy individuals and when it is mixed with a number of stimulant compounds can be associated with a number of adverse effects in the human body. However, the awareness of such life threatening complications associated with these energy drinks does not exist among people who consume it on a day to day basis. We report a case of 25-year-old Caucasian male with no significant past medical history for cardiac diseases, no risk factors for atrial fibrillation, non smoker, occasional alcohol drinker who presents with new onset atrial fibrillation with rapid ventricular response due to the consumption of over the counter stimulant energy capsule which had high doses of caffeine.

Atrial Fibrillation Due to Over The Counter Stimulant Drugs in A Young Adult

The usage of over the counter stimulant drugs and energy drinks is increasing on a day to day basis for various purposes including work, sports and leisure among individuals in all age groups. Multiple formulations are available in the market including pills, liquid capsules and drinks in various flavours. Many of them contain excessively high doses of caffeine along with a variety of stimulant compounds that have multiple effects in different parts of the human body. The consumption of such high amounts of caffeine itself has shown to have caused cardiac arrhythmias in healthy individuals and when it is mixed with a number of stimulant compounds can be associated with a number of adverse effects in the human body. However, the awareness of such life threatening complications associated with these energy drinks does not exist among people who consume it on a day to day basis. We report a case of 25-year-old Caucasian male with no significant past medical history for cardiac diseases, no risk factors for atrial fibrillation, non smoker, occasional alcohol drinker who presents with new onset atrial fibrillation with rapid ventricular response due to the consumption of over the counter stimulant energy capsule which had high doses of caffeine.

Role of transplantation in the treatment of benign solid tumors of the liver: a review of the United Network of Organ Sharing data set

IMPORTANCE

The role of orthotopic liver transplantation for the treatment of benign solid liver tumors (BSLT) is not well defined.

OBJECTIVE

To analyze outcomes in the United Network of Organ Sharing data set of patients with a diagnosis of BSLT who underwent transplantation.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis of the United Network of Organ Sharing data set was performed for all (N = 87,280) patients who underwent transplantation for BSLT in the United States from October 1, 1988, through January 31, 2013.

MAIN OUTCOMES AND MEASURES

Demographics, clinicopathological characteristics, distribution of the procedures by region and state, and overall survival rates.

RESULTS

During the study period, 147 liver transplants (0.17%) were to treat BSLT. Sixty-two patients (42.2%) had adenomas, 29 (19.7%) had focal nodular hyperplasia, 25 (17.0%) had hemangiomas, 11 (7.5%) had hepatic epithelioid hemangioendotheliomas, and 20 (13.6%) were classified as having unknown benign tumors. The overall 1-, 3-, and 5-year survival rates were 90.9%, 85.2%, and 81.8%, respectively. Using multivariable analysis, we found that age was the only independent factor associated with patient survival. The overall 5-year survival rate for patients older than 50 years was 88% compared with 91% in younger individuals (95% CI, 148-384; P = .005). Region 3 (Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, and Puerto Rico) contributed the maximum number (33 [22.4%]) of these transplants.

CONCLUSIONS AND RELEVANCE

Although liver transplantation cannot be considered a first-line treatment, it is a valid therapeutic option in selected patients who are not amenable to resection. Only 0.17% of the transplants in the United States are performed for this indication, with satisfying long-term results. Age was an independent predictor of patient survival. Further studies are needed to better understand the role of liver transplantation in the treatment of BSLT.

Role of surgery and transplantation in the treatment of hepatic metastases from neuroendocrine tumor

Neuroendocrine tumors (NET) are a heterogeneous group of cancers, with indolent behavior. The most common primary origin is the gastro-intestinal tract but can also appear in the lungs, kidneys, adrenals, ovaries and other organs. In general, NET is usually discovered in the metastatic phase (40%-80%). The liver is the most common organ involved when metastases occur (40%-93%), followed by bone (12%-20%) and lung (8%-10%).A number of different therapeutic options are available for the treatment of hepatic metastases including surgical resection, transplantation, ablation, trans-arterial chemoembolization, chemotherapy and somatostatin analogues. Recently, molecular targeted therapies have been used, usually in combination with other treatment options, to improve outcomes in patients with metastases. This article emphasizes on the role of surgery in the treatment of liver metastases from NET.