TRICUSPID VALVE DISEASE AND RIGHT VENTRICULAR DYSFUNCTION AFTER RIGHT VENTRICULAR TRANSVENOUS LEAD PLACEMENT IN PATIENTS WITH TRICUSPID VALVE PROSTHESIS

Background: First time transvenous right ventricular (RV) lead implant after tricuspid valve (TV) repair or bioprosthetic replacement is common. We evaluated outcomes in TV regurgitation (TR) and RV function in this population. Methods: We conducted single-center retrospective study on patients with TV repair or replacement from 2000 to 2020 followed by first-time transvenous RV lead implant. Primary outcomes were change in TR severity (defined as defined as none/trivial, mild, moderate, moderate-severe, or severe) and RV function (normal, mild, moderate, or severe). Baseline and follow-up echocardiogram (ECHO) data was reviewed, as well as time to death. Results: 52 patients were identified (29 female, 47 had hypertension, 41 had atrial fibrillation, 49 had TV repair, 3 had replacement). Median time from surgery to implant was 1.7 months and to last ECHO was 39.7 months. In TV repair, baseline TR was none/trivial in 15 (30.6%) and mild in 21 (42.8%) patients. RV function was normal in 33 (67.3%) patients. 58% had worsened TR (mean 0.9 levels) (Figure). No TR change was seen in TV replacement. Mean worsening RV function was by 0.9 levels. There was statistically significant correlation with RV pacing and RV dysfunction (Spearman correlation coefficient 0.37, p = 0.017), but not with change in TR (p = 0.36). 22 patients died at median follow-up (48.9 months). Conclusion: Presence of an RV lead after TV repair correlated with worsening TR. Higher RV pacing level correlated with RV dysfunction but not TR severity

Knowledge, attitude and practice of hepatitis (B) among healthcare workers in relation to their vaccination status in Khartoum, Sudan, 2015: a cross-sectional study

Background: Hepatitis B is a serious chronic infection of the liver and caused by hepatitis B virus. It is an endemic disease in Sudan. Healthcare workers are occupationally more prone to acquire the disease. Evaluation of their knowledge, attitude and practice and their vaccination status, are very important in the control of the disease. The aim of this study was to assess the knowledge, attitude, and practiceof healthcare workers towards hepatitis B and their vaccination status. Materials and Methods: In total, 372 healthcare workers were enrolled in the study, which was conducted at 10 public hospitals in Khartoum state during July-August 2015. After taking written informed consent from the Khartoum State Research Department, self-administrated questionnaires were distributed to the healthcareworkers. The KAP score was the sum of the three categories, which is 32 points, and the mean was then obtained. Results: The study revealed that the respondents’ mean scores of knowledge, attitude, and practice (KAP) were 18.4, 2.14 and 2.49, respectively. The study also showed that doctors have the highest KAP score in comparison with other occupations. Doctors are the least occupational category that uses gloves when dealing with patient’s blood. The KAP score was found higher among vaccinated healthcare workers 27.4% in comparison to unvaccinated ones, That yield to a significant the association between KAP score and vac-cination status (p-value0.007).Conclusions: This study concluded that, there is a positive association between the level of vaccination among Health care workers and their Knowledge, attitude and practice of hepatitis B virus. Further studies would be recommended on larger population

Tutors, The Valuable Resource to Enhance Medical Students’ Motivation.

Background: Students’ academic performance is largely affected by their motivation. Moreover, health professions’ education needs motivated students who are keen to tolerate the burden of clinical work along with the academic excellence to graduate competently. This study assessed the effect of tutors on students’ motivation. Method: A cross-sectional, institution-based study of the first-year medical students at University of Khartoum, Sudan was conducted. A self-administered questionnaire was used comprising a modified Motivated Strategies for Learning Questionnaire (MSLQ) with students’ evaluation of their tutors after semester one community medicine course. A total of 237 out of 324 students responded. Pearson productmoment correlation coefficient was used to test the relationship between motivation and evaluation. Hierarchical multiple regression model tested the ability of evaluation factors to predict motivation score. Results: There was a significant association between tutor’s characteristics regarding creativity in conducting the sessions, igniting discussion, and adequacy of knowledge about the course contents and the motivation score (p-value = 0.001). There was a strong, positive correlation between the perceived evaluation score and perceived motivation score (r = 0.505, n = 206, p < 0.0005). After controlling age, gender, paternal educational levels, and scores of Sudanese certificate upon entry, R squared change = 0.28, F change (9.181) = 8.416, p <0.001. In the final model, the content of the course was statistically significant, standardized Beta = 0.285, indicating that content uniquely explains 5.7% of the variance in total perceived motivation score. Conclusion: The evaluation score explained 28% of the variance in student motivation. Students’ motivation issignificantly associated with tutor’s teaching skills concerning knowledge, creativity, students’ involvement, and attractiveness in conducting the tutorials. Improving course content can enhance students’ motivation toward community medicine

A case of allopurinol-induced dress syndrome

Case Presentation: We present the case of a 57-year-old male with gouty arthritis who presented with a diffuse body rash. The rash initially began as red spots on his face, which then became confluent and developed into diffuse erythema. Within a day, the rash spread to the rest of his body. He also reported associated fever and chills. He presented to the emergency room a few days after developing symptoms. He was believed to have had a reaction to the allopurinol, which he had started 4 weeks prior, and was instructed to stop it. He was discharged home with a 5-day course of diphenhydramine and prednisone. He did experience improvement in symptoms with some clearing of the rash and reduced pruritis. 2 days after completing the 5-day course, he awoke with lip and throat swelling, hoarseness of his voice, as well as worsening of his rash. He then returned to the emergency room. He was noted to have supraclavicular lymphadenopathy, as well as facial and hand swelling. His labs demonstrated eosinophilia (11%) and transaminitis (ALT 375, AST 86). He was admitted to the general medical floor. The diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS) due to allopurinol was suspected. He was reinitiated on steroids, with improvement in swelling and desquamation of rash. Transaminases and eosinophils downtrended. He was prescribed a 4-week prednisone taper, and discharged with close follow-up. He continued to improve with gradual resolution of rash several weeks later. Discussion: DRESS is a rare drug-related hypersensitivity reaction. Presentation generally involves skin eruption, eosinophilia and/or atypical lymphocytosis, lymphadenopathy, and organ involvement (liver, lung or kidney). It is characterized by a latency period of about 2-8 weeks between initial drug exposure and development of the syndrome. Frequent relapses may occur despite discontinuation of the offending drug, and herpesvirus reactivation may occur. Commonly implicated drugs include antiepileptics, olanzapine, sulfa drugs and allopurinol. Diagnosis is based on clinical features and laboratory findings. Treatment generally involves cessation of the offending drug. Milder cases without evidence of renal or pulmonary involvement, and with transaminases \u3c3 times the upper limit of normal can be treated with topical steroids. Those with more severe liver injury, interstitial nephritis or interstitial pneumonia may be treated with an 8-12 week taper of systemic steroids until clinical improvement and resolution of laboratory abnormalities. Severe hepatocellular injury may occasionally progress to fulminant liver failure requiring transplantation. Conclusions: DRESS syndrome is a systemic drug reaction that can potentially be life-threatening. It is important to recognize the disorder particularly in the setting of use of the commonly implicated drugs. Steroid therapy may successfully alleviate symptoms and organ damage

A case of pancreatic ascites.

Learning Objective #1: Identify the etiology of pancreatic ascites Learning Objective #2: Manage pancreatic ascites CASE: We present a case of a 50 year-old female with a history of alcoholic cirrhosis and recurrent pancreatitis who presented to the emergency room with worsening abdominal distention for two months. Her labs were significant for elevated liver function tests, amylase and lipase. On exam, her abdomen was noted to be distended with a positive fluid wave. She underwent a paracentesis with fluid studies demonstrating SAAG \u3c 1.1 and 4136 IU/L of amylase, consistent with an etiology of pancreatic ascites. She underwent an ERCP, which demonstrated no frank pancreatic duct leak. Given her high ascitic amylase, however, there was persistent concern for a leak and a pancreatic duct stent was placed. She continued to have worsening bilirubin, INR and creatinine but given her recent alcohol use she was deemed not to be a transplant candidate. The decision was made to enroll her into hospice, where she expired shortly after. IMPACT: This case demonstrates the importance of considering alternative etiologies of ascites in cirrhotic patients and obtaining a comprehensive work-up of new onset ascites as thei may change management. DISCUSSION: Pancreatic ascites is the accumulation of large amounts of pancreatic fluid in the peritoneal cavity. It is most commonly found in patients with chronic alcoholic pancreatitis. The exact prevalence is not yet known, but is estimated to be ~3.5% in patients with chronic pancreatitis. It can be caused by one of various mechanisms including ductal leak, pancreatic fistula and pseudocyst rupture. An elevated amylase, usually greater than 1000 IU/L, in ascitic fluid is diagnostic. Conservative management with somatostatin ana-logues, TPN and large-volume paracentesis is complicated by high failure rates. Alternatively, endoscopic treatment with pancreatic stent placement has demonstrated excellent therapeutic efficacy in patients with pancreatic ascites and is therefore considered first line therapy. Despite being the least common complication of pancreatitis, pancreatic ascites carries considerable morbidity and mortality

Alcapa of adult hood.

Learning Objective #1: Diagnosis of congenital heart disease in adults. Learning Objective #2: Anomalous origin of the left coronary artery from the pulmonary artery usually manifests and causes death in infancy, however, with significant collateral blood supply to the left coronary artery patients may survive into adulthood. CASE: This is a case of a 33 year old male who presented to the emergency room with chest pain that started shortly after having an altercation with his boss at work. He described it as a squeezing left sided chest pain radiating to the left arm. On presentation the patient had stable vital signs, physical exam was unremarkable. Electrocardiogram revealed new T wave inversions in leads I and aVL, and the patient had a troponin elevation up to 0.9 (normal \u3c 0.04). The patient was diagnosed with a non-ST elevation myocardial infarction (NSTEMI) and admitted for coronary angiography. Coronary angiography revealed a large caliber ectatic right coronary artery filling many arteriovenous fistulae flowing into the left coronary system which in turn appeared to drain into the pulmonary artery. No coronary artery disease was seen. The patient then underwent computed tomography angiogram which confirmed a left coronary artery arising form the main pulmonary artery posteriorly at the superior aspect of the pulmonary valve. Follow up echocardiogram revealed an ejection fraction 40% with anterior, anteroseptal and anterolateral wall hypokinesis as well as mitral valve regurgitation. The patient was referred to cardiothoracic surgery, and a few days later underwent tunneling from the main pulmonary artery-left coronary artery origin to the aorta using a pericardial patch. The patient did well after surgery and was discharged a few days later with minimal symptoms. IMPACT: This case shows us that we need to consider congenital heart disease even when adults present with common cardiac syndromes. Most patients presenting with NSTEMI in adulthood are as a result of coronary artery disease, however in this vignette that was not the case. This also shows the rising diagnostic importance of imaging modalities such as CTand MR in cardiac patients, especially younger patients. DISCUSSION: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) occurs in 0.25%-0.5% of all congenital heart diseases. 85% of patients present with heart failure symptoms within the first 1-2 months of life due to myocardial ischemia. Up to 90% of patients with ALCAPA die within the first year of life. A small subset of patients develop good collateral circulation and may live into childhood or adulthood. Despite this, blood supply to the left ventricle is insufficient and myocardial ischemia usually leads to mitral valve regurgitation, ischemic cardiomyopathy and sudden cardiac death. Diagnosis is usually confirmed by imaging modalities such as CTor MRI. Treatment is surgical correction consisting of reimplantation of the coronary artery to the aorta or tunneling of the coronary artery to the aorta

Iatrogenic cardiomyopathy in patients with manifest right supero-paraseptal accessory pathways

INTRODUCTION: We describe 2 patients with right supero-paraseptal accessory pathway (SPAP) who developed left ventricular dysfunction associated with increased degree of ventricular pre-excitation and frequent orthodromic reciprocating tachycardia (ORT) due to worsening AV node conduction. METHODS AND RESULTS: Case 1: 48-year-old female with a history of normally functioning mechanical mitral valve, CABG, and ventricular pre-excitation that worsened after her open heart surgery. She presented with frequent palpitations with documented supraventricular tachycardia (SVT) and found to have a new left ventricular dysfunction with decrease in left ventricular ejection fraction (LVEF) from 55% to 46% with dyssynchrony. Electrophysiological study confirmed a right SPAP and ORT. The pathway was successfully ablated from the antegrade approach after careful mapping. After ablation and six month follow up echocardiogram showed improvement of EF to 54% and the LV dyssynchrony resolved. Case 2: 51-year-old male with a history of frequent SVT with recent unsuccessful ablations that resulted in worsening ventricular pre-excitation, more frequent SVT and new left ventricular dysfunction (LVEF from 60% to 40%). He was started on amiodarone which resulted in significant sinus bradycardia, intermittent ventricular pre-excitation and first degree AV block with significant increase in ORT events. His Electrophysiology study confirmed SPAP which was successfully ablated from the antegrade approach after careful mapping. After one month, follow-up echocardiogram showed an improved ejection fraction to 60%. CONCLUSION: Left ventricular dysfunction due to dyssynchrony and symptomatic frequent ORT of right SPAP can develop in the setting of new iatrogenic diminished AV node conduction. Successful ablation will result in LV function recovery to baseline. This article is protected by copyright. All rights reserved

A case of isolated acquired factor VIII inhibitor.

LEARNING OBJECTIVE #1: Diagnose and manage the presence of factor VIII inhibitor. CASE: We present the case of a 76-year-old lady with a history of breast cancer post mastectomy who was transferred to our Intensive Care Unit (ICU) for acute blood loss anemia. The patient had initially presented 3 weeks prior to an outside hospital (OSH) after a fall with a hemoglobin of 4.7 g/dL (from 11.7 g/dL), PTT at 73, creatinine at 3.8 mg/dL, and BUN at 55 mg/dL. CT demonstrated a large intramuscular hematoma anterior to the right femur and a retroperitoneal hematoma. She was given several units of blood, and hemoglobin remained stable. Femoral dialysis catheter placement was then attempted due to worsening renal function with resultant profuse bleeding. Given her persistent bleeding of unknown etiology, she was transferred for escalation of care. On arrival to the ICU, the patient required suturing of the femoral site. Workup of her elevated PPT was initiated. Monoclonal protein evaluation, cardiolipin antibodies, beta 2 glycoprotein were all within normal limits. ANA was mildly positive. Her Factor VIII levels were \u3c1% with elevated inhibitor level. Mixing study was consistent with presence of an inhibitor. She was believed to have acquired factor VIII inhibitor. CT was done to rule out an associated malignancy and was negative. She was given 4 days of high dose decadron, followed by daily cyclophosphamide and prednisone, as well as intermittent doses of Novoseven (factor VII), Obizur (factor VIII), and later Feiba (longer acting factor VII). She did not require further doses as her hemoglobin remained stable with resolution of bleeding. She was discharged on low dose oral prednisone maintenance therapy. IMPACT: Our case highlights the importance of consideration of other etiologies for coagulopathy, especially in patients with no known coagulopathic disorders. Though factor VIII inhibitor is uncommon, it could be an aqcuired disorder in adults with otherwise unexplained elevation in PTT. DISCUSSION: Acquired Factor VIII inhibitor is a rare disorder that may present with severe bleeding episodes that may be life-threatening, with mortality rates up to 22%. The most commonly associated illnesses reported in the literature include autoimmune disorders and malignancy/pre-malignant states. Diagnosis is made both clinically and based on laboratory evaluation; an isolated prolonged PTT (normal PT and platelets), and a mixing study consistent with the presence of an inhibitor, in the absence of heparin contamination and lupus anticoagulant. Factor VIII activity should be measured, and the strength of inhibitor quantified. Acute bleeding episodes with low-titer inhibitors can be treated using human factor VIII concentrates, whereas factor VIII bypassing agents (prothrombin complex concentrates or recombinant activated factor VII) are effective in the presence of high-titer inhibitors. The first-line treatment for the eradication of factor VIII autoantibodies is a combination of steroids and cyclophosphamide

A case of isolated acquired factor VIII inhibitor.

Diagnose and manage the presence of factor VIII inhibitor. CASE: We present the case of a 76-year-old lady with a history of breast cancer post mastectomy who was transferred to our Intensive Care Unit (ICU) for acute blood loss anemia. The patient had initially presented 3 weeks prior to an outside hospital (OSH) after a fall with a hemoglobin of 4.7 g/dL (from 11.7 g/dL), PTT at 73, creatinine at 3.8 mg/dL, and BUN at 55 mg/dL. CT demonstrated a large intramuscular hematoma anterior to the right femur and a retroperitoneal hematoma. She was given several units of blood, and hemoglobin remained stable. Femoral dialysis catheter placement was then attempted due to worsening renal function with resultant profuse bleeding. Given her persistent bleeding of unknown etiology, she was transferred for escalation of care. On arrival to the ICU, the patient required suturing of the femoral site. Workup of her elevated PPT was initiated. Monoclonal protein evaluation, cardiolipin antibodies, beta 2 glycoprotein were all within normal limits. ANA was mildly positive. Her Factor VIII levels were \u3c1% with elevated inhibitor level. Mixing study was consistent with presence of an inhibitor. She was believed to have acquired factor VIII inhibitor. CT was done to rule out an associated malignancy and was negative. She was given 4 days of high dose decadron, followed by daily cyclophosphamide and prednisone, as well as intermittent doses of Novoseven (factor VII), Obizur (factor VIII), and later Feiba (longer acting factor VII). She did not require further doses as her hemoglobin remained stable with resolution of bleeding. She was discharged on low dose oral prednisone maintenance therapy. IMPACT: Our case highlights the importance of consideration of other etiologies for coagulopathy, especially in patients with no known coagulopathic disorders. Though factor VIII inhibitor is uncommon, it could be an aqcuired disorder in adults with otherwise unexplained elevation in PTT. DISCUSSION: Acquired Factor VIII inhibitor is a rare disorder that may present with severe bleeding episodes that may be life-threatening, with mortality rates up to 22%. The most commonly associated illnesses reported in the literature include autoimmune disorders and malignancy/pre-malignant states. Diagnosis is made both clinically and based on laboratory evaluation; an isolated prolonged PTT (normal PT and platelets), and a mixing study consistent with the presence of an inhibitor, in the absence of heparin contamination and lupus anticoagulant. Factor VIII activity should be measured, and the strength of inhibitor quantified. Acute bleeding episodes with low-titer inhibitors can be treated using human factor VIII concentrates, whereas factor VIII bypassing agents (prothrombin complex concentrates or recombinant activated factor VII) are effective in the presence of high-titer inhibitors. The first-line treatment for the eradication of factor VIII autoantibodies is a combination of steroids and cyclophosphamide

Impact of mitral clip implantation on left atrial appendage velocity

Background: Previous studies have demonstrated the feasibility of mitral clip to improve safety and achieve similar clinical outcomes compared to surgical mitral valve repair in high risk surgical patients with severe mitralregurgitation. Transesophageal echocardiogram (TEE) plays an integral role in planning of a successful procedure. Leftatrial appendage (LAA) velocity serves as a marker of LAA function. However, there is no data about the impact ofmitral clip procedure on the LAA function and velocity. We sought to assess the impact of mitral clip procedure on pre and post-procedure LAA velocity as assessed by intra-procedural TEE. Methods: We evaluated a total of 29 patients with severe mitral regurgitation who were poor surgical candidates for mitral valve surgery and thus underwent mitral clip procedure between July 2015 to December 2016. Baseline demographics and intra-procedure TEE data was obtained and patients were followed for 30-days clinical outcomes. Mitral regurgitation (MR) severity was graded as (1=mild, 2=moderate, 3=moderate-severe, 4=severe). Results: Among the 29 patients, 70% were females and the mean age at the time ofprocedure was 78.5 years. The mean Society of Thoracic Surgeons mortality risk score was 8.3%. 18 (62%) patients had pre-existing atrial fibrillation or flutter with mean CHA2DS2-VASc score of 5.5. All patients had pre-existing grade 4 MR which was reduced to grade 1 in 20/29 and grade 2 in 5/29 patients after the procedure. There was a significant decrease in LAA velocity after the procedure (39.1± 17.8 cm/sec vs 27.11 ± 11.9 cm/sec, p = 0.001). In 4 patients, the post-procedure LAA velocity was higher compared to the pre-procedure LAA velocity and they had residual grade 3 MR which was eccentric in nature. There were a total of 2 non-cardiac related deaths at 30 days with no cases of post-procedure stroke. At 30-days, NYHA class improved from III/IV to I/II (p\u3c0.05). Conclusion: Mitral clipimplantation was associated with significant decrease in the post-procedure LAA velocity which may in turn serve as a marker of procedural success as demonstrated by more pronounced improvement in MR grade and improved NYHA class at 30-days follow-up. Larger studies with longer follow-up are needed to assess the long-term clinical impact ofchange in LAA velocity over time