Background: Cancer is a major public health concern in the United States, especially among minority populations. Area-level social determinants of health (SDOH) influence cancer outcomes, but the impact of the Minority Health Social Vulnerability Index (MHSVI) on cancer incidence at the county level is less understood. Methods: We analyzed ecological data from the Agency for Health Care Research and Quality for 3,232 counties in 2019. Exposures included MHSVI themes: socioeconomic, household composition, minority status/language, housing/transportation, healthcare infrastructure/access, and medical vulnerability (continuous). Overall MHSVI was categorized into low (.01/.25), moderate (.26/.74), and high (.75/1) percentiles. The outcome was the total number of cancer cases (continuous). Covariates included US regions and rural-urban regions. Unadjusted and adjusted negative binomial regressions with population weighting were performed using STATA/MPv.17; P values <= 0.05 were considered statistically significant. Results: A total of 3,232 counties were analyzed, with an average of 2,817.9 (SD:7,733.5) cancer cases, ranging from 16 to 201,547. All variables were significantly associated with cancer cases in unadjusted analyses. Adjusted analysis showed increased cancer incidence in moderate (IRR:0.94, 95%CI:0.92-0.96, P<0.001) and high (IRR:0.86, 95%CI:0.84-0.88, P<0.001) MHSVI areas compared to low MHSVI areas. Regional differences were observed, with increased cancer incidence in the Northeast (IRR:1.18, 95%CI:1.15-1.22, P<0.001), South (IRR:1.03, 95% CI:1.01-1.05, P<0.001), and West (IRR:0.92, 95%CI:0.90-0.94, P<0.001) compared to the Midwest. Rural areas had a slight increase in cancer incidence compared to urban areas (IRR:1.03, 95%CI:1.01-1.04, P<0.001). Conclusions: Our study highlights the significant association between MHSVI and cancer incidence at the county level. Regional and rural-urban differences were evident, emphasizing the need for targeted interventions addressing SDOH to reduce cancer disparities.

Abstract Disclosure: T. Akcan: None. S. Sharma: None. J. Liu: None. A. Jayarangaiah: None. M. Gilani: None. A. Surendran: None. N. Imamudeen: None. R. Gabor: None. R.D. Pathak: None. Diabetes is becoming increasingly prevalent, and appropriate insulin therapy during the post-discharge period is essential to improve glycemic control and reduce readmissions. Despite extensive research on insulin use during hospitalization, little is known about insulin dosing at discharge and patient factors that affect post-discharge needs. Therefore, this retrospective study aimed to evaluate the adequacy of insulin dosing at hospital discharge for diabetic patients and identify patient characteristics impacting post-discharge insulin requirements. Using a retrospective study design, we identified 350 patients meeting the inclusion criteria. The results showed that 19.1% of patients required a decrease in insulin total daily dose (TDD) at follow-up, 50.9% experienced no change, and 30.0% necessitated an increase. Factors found to impact insulin dose adjustments post-discharge include BMI, CKD, discharge TDD, and HbA1c levels. The multivariate analysis revealed that CKD was associated with a decrease in insulin TDD at follow-up (95% CI: -9.65- -0.47, p=0.031). Additionally, insulin TDD at discharge was negatively associated with follow-up dose, with a 0.37 unit decrease (95% CI: -0.44- -0.30, p<0.001) in insulin TDD for each additional unit prescribed. Finally, there was a marginal significance observed in the discharge regimen. Patients on a premixed regimen had a decrease in insulin TDD at follow-up compared to those on a basal-bolus regimen (95% CI: -21.85- 0.27, p=0.057). Our study findings suggest the need for improved estimation of insulin doses at discharge and emphasize the importance of short-term follow-up for insulin titration post-discharge. Patient factors such as body weight, kidney disease, insulin dose at discharge, and HbA1c levels influence these changes. These findings have significant implications for optimizing patient outcomes and reducing hospital readmissions, underscoring the importance of carefully evaluating these factors when tailoring individualized insulin regimens. Presentation: Friday, June 16, 2023

Background:Left ventricular dysfunction and cardiomyopathy are well documented adverse effects associated with chemotherapy agents. Limited information exists regarding the impact of chemotherapeutic agents on the integrity and function of the right ventricle (RV). Objectives:The current metanalysis compared pre- chemotherapy versus post- chemotherapy RV parameters measured on 2D echocardiography in patients receiving anthracycline and/or trastuzumab across all breast cancer patients. Methods:A systematic search across PubMed, EMBASE and Cochrane databases were performed from inception of the databases until November 2021 for relevant studies. We used the inverse variance method with a random effect model and DerSimonian and Laird method of Tau2 generation to calculate mean difference [MD] with 95% confidence interval [CI]. The analysis was carried out using RevMan Version 5.3 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). Results:Fifteen studies, constituting total of 644 patients, met the inclusion criteria, with most studies having a follow up period of less than 12 months from initiation of chemotherapy. Anthracycline and/or Trastuzumab chemotherapy resulted in a statistically significant reduction in right ventricular ejection fraction (RVEF) at follow-up [MD: 2.70, 95% CI: 0.27 to 5.13, P-value- 0.03, I2- 71%, χ2 P-value < 0.05]. Treatment with Anthracycline and/or Trastuzumab chemotherapy resulted in a significant reduction in RV fractional area change (RVFAC) at follow-up [MD: 3.74, 95% CI: 1.33 to 6.15, P-value < 0.01, I2- 68%, χ2 P-value < 0.05]. RV free wall longitudinal strain (RVFWLS) was lower at baseline, while LVEF was significantly reduced at follow-up [MD: -1.00, 95% CI: -1.86 to -0.15, P-value < 0.05, I2- 0%, χ2 P-value-0.40], [MD: 4.04, 95% CI: 2.08 to 6.01, P-value < 0.01, I2- 91%, χ2 P-value < 0.05], respectively. However, treatment with Anthracycline and/or Trastuzumab chemotherapy had no statistically significant effect on Tricuspid annular plane systolic excursion (TAPSE) at follow-up [MD: 0.53, 95% CI: -0.11 to 1.17, P-value-0.11, I2- 98%, χ2 P-value < 0.05]. Conclusions:Chemotherapy with anthracyclines and trastuzumab negatively affects right ventricular function leading to decline in RVEF, RVFAC, RVFWLS and LVEF.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China in December 2019. Since then, the disease has spread globally, leading to the ongoing pandemic. It can cause severe respiratory illness; however, many cases of pericarditis have also been reported. This systematic review aims to recognize the clinical features of pericarditis and myopericarditis in COVID-19 patients.Google Scholar, Medline/PubMed, CINAHL, Cochrane Central, and Web of Science databases were searched for studies reporting "Coronavirus" or "COVID" and "Peri-myocarditis," "heart," or "retrospective." Case reports and retrospective studies published from May 2020 to February 2021 were reviewed.In total, 33 studies on pericarditis, myopericarditis, and pericardial infusion were included in this review. COVID-19 pericarditis affected adult patients at any age. The incidence is more common in males, with a male-to-female ratio of 2:1. Chest pain (60%), fever (51%), and shortness of breath (51%) were the most reported symptoms, followed by cough (39%), fatigue (15%), myalgia (12%), and diarrhea (12%). Laboratory tests revealed leukocytosis with neutrophil predominance, elevated D-dimer, erythrocyte rate, and C -reactive protein. Cardiac markers including troponin-1, troponin-T, and brain natriuretic peptide were elevated in most cases. Radiographic imaging of the chest were mostly normal, and only 31% of chest X-rays showed cardiomegaly and or bilateral infiltration. Electrocardiography (ECG) demonstrated normal sinus rhythm with around 59% ST elevation and rarely PR depression or T wave inversion, while the predominant echocardiographic feature was pericardial effusion. Management with colchicine was favored in most cases, followed by non-steroidal anti-inflammatory drugs (NSAIDs), and interventional therapy was only needed when patient developed cardiac tamponade. The majority of the reviewed studies reported either recovery or no continued clinical deterioration.The prevalence of COVID-19-related cardiac diseases is high, and pericarditis is a known extrapulmonary manifestation. However, pericardial effusion and cardiac tamponade are less prevalent and may require urgent intervention to prevent mortality. Pericarditis should be considered in patients with chest pain, ST elevation on ECG, a normal coronary angiogram, and COVID-19. We emphasize the importance of clinical examination, ECG, and echocardiogram for decision-making, and NSAIDs, colchicine, and corticosteroids are considered to be safe in the treatment of pericarditis/myopericarditis associated with COVID-19.

Coronavirus Disease-19 (COVID-19) is a worldwide pandemic and it has created many difficulties in providing medical care due to the various multi-organ disease manifestations caused by the virus. In this paper we explore cases of stent thrombosis which occurred in patients who were infected with COVID-19 and discuss its role in potentiating this complication through the variety of mechanisms in which it creates a prothrombotic state. Stent thrombosis is described as the thrombotic occlusion of a coronary stent. The incidence of this complication has decreased considerably (from 16% to 0.7%) since the advent of antiplatelet therapy and drug eluting stents. In this systematic review, 8 papers were found which detailed 11 patients who were infected with COVID-19 and suffered a stent thrombosis. Data from these cases were tabulated and analyzed. The ages of the patient’s ranged from 49-81 years and quite interestingly the time between the time of stent placement and occurrence of stent thrombosis had great variation between patients, with some occurring within minutes of stent placement and others occurring in a stent that was placed many years ago. 91% of the patients had ST-segment elevation myocardial infarction (STEMI) for presentation of stent thrombosis and 9% had a non-ST segment myocardial infarction (NSTEMI) on presentation. Therapy mainly involved antiplatelet therapy and Percutaneous Coronary Angioplasty with new stent placement. Despite this mortality rate among the cases present was quite high at 45%, with some patients dying as a result of COVID-19 related complications. Through various literature reviews, we have found that COVID-19 contributes in creating a prothrombotic state through various inflammatory mediated mechanisms. This prothrombotic state is a major risk factor towards stent thrombosis and we recommend that physicians be aware of this potentially fatal complication in COVID-19 patients.

Löffler endocarditis is an uncommon, but known complication of hypereosinophilic syndrome (HES). It is a relatively rare entity, and remains poorly understood. To this point in time, the compendium of knowledge about this disease consists of various case reports, prospective studies and review articles. We aim to present a scoping study about this disease. Our goals are to identify the characteristic features found in case reports to identify characteristic features found in patients with Löffler endocarditis as a result of hypereosinophilic syndrome. An analysis of the 26 case reports showed a mean age of 41.6 years with a standard deviation of 17.1 years. Dyspnea was the most common presenting complaint (64%) followed by fatigue (23%), cough (19%), fever (19%), orthopnea/paroxysmal nocturnal dyspnea (19%), stroke related symptoms (15%), chest pain (15%) and lower extremity edema (15%). The most common cardiac structure affected was the mitral valve (65%), followed by the tricuspid valve (42%), left ventricle (23%), with 35% of cases having involvement of two valves. The most common therapeutic modality was immunosuppression (85%), followed by anticoagulation (73%) and mitral valve replacement (23%). Death was reported in 19% of the cases. Löffler's endocarditis continues to be associated with high morbidity and mortality. Further research must aim to develop guidelines for management of this uncommon manifestation of hypereosinophilic syndrome.

Rumpel - Leede phenomenon (RLP) was described as early 1909 by Theodore Rumpel and by Stockbridge Leede in 1911 in patients suffering from scarlet fever. Acute development of petechial rashes distal to the application of blood flow occlusive devices such as a blood pressure cuff or tight wrapped bandage, is a typical finding in this phenomenon. Multiple isolated cases of RLP associated with coronary angiogram have been reported. In this report, we present a case of a 53-year-old male who developed RLP after percutaneous intervention of the proximal-mid left anterior descending artery after application of a sphygmomanometer cuff to contain a right forearm hematoma and application of a trans-radial band. We here discuss the etiopathogenesis and management of RLP that develops post coronary angiogram.

Ventricular septal rupture (VSR) is a rare complication of myocardial infarction (MI), open heart surgery, and cardiac-based procedures, such as septal myectomy and valve replacement. VSR is associated with high mortality rates and the reported 30-day survival rate is less than 10% without any interventional therapy. Hence, prompt diagnosis and aggressive medical treatment with appropriate surgical intervention are necessary to improve survival. Immediate surgical intervention which is the standard treatment of VSR has a mortality rate of 19-60%. Due to persistent high mortality rate and challenging management of VSR, alternatives to surgical repair has been proposed; transcatheter approach as a new alternative method has been used for the closure of post-surgery residual defects or as a bridge to surgery and in some cases as a definitive therapy instead of surgical repair. Amplatzer Occluder® (AO), a type of transcatheter closure devices, is an approved method of repairing congenital atrial septal defects and it is being used as an alternative method of treatment in VSR. In this systemic review, we assessed the cases of VSR who underwent septal repair by using AO. The study shows that the total mortality rate of percutaneous VSR repair with AO is 20% which is comparable to 19-60% rate of death in patients who undergo surgery. While early intervention is necessary to prevent biventricular dysfunction, immediate surgical intervention on soft and friable tissue surrounding the infarction increases the risk of residual shunt and reoperation. However, this study reveals that the mortality rate of primary percutaneous VSR closure within 7 days of VSR detection was 37 % which is significantly lower than 60% in surgical repair in the same period. In conclusion, given that the prevalence of residual leak in both interventions are similar and close to 20%, percutaneous VSR closure with AO device could be superior to the surgical repair as a primary intervention in unstable or high-risk surgical patients.

Coronavirus Disease-19 (COVID-19) is a pandemic caused by severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). COVID-19 is known to cause a wide variety of cardiovascular manifestations, including myocarditis, pericarditis, myocardial infarction, stroke, thrombus, pulmonary embolism and acute ventricular failure In this paper, we explore cases of infective endocarditis (IE) that occurred in patients who were concurrently (not sure if they were concurrently infected but if so, makes the sentence smoother and easier to understand) infected with COVID-19 and discuss its association in contributing to factors that can ultimately lead to the development of infective endocarditis. Some of these factors that contribute to IE in COVID-19 include severe inflammatory response, endothelial damage and dysfunction and immunosuppression caused by medications that are used to treat COVID-19. In this systematic review, 12 papers detailing 15 pertinent cases of IE following an infection with COVID-19 were identified. Data from these cases were tabulated and analyzed. The ages of the patients ranged from 20-70 years, with 73% of the patients developing IE of native heart valves and the remaining 27% developing IE of mechanical and bioprosthetic valves. The three most common organism implicated were Enterococcus faecalis (28.57%), Methicillin Resistant Staphylococcus aureus (MRSA) (14.28%), and Methicillin Sensitive Staphylococcus aureus (MSSA) (14.28%). Medical management of these cases involved antibiotic therapy and was reported in 80% of the cases, while only one patient (6.67%) underwent surgical valve replacement. The mortality rate of the patients in this review was quite high at 38%, and other major complications included cardioembolic stroke (20%) and septic embolization to the extremities (6.67%). COVID-19 infection results in a severe inflammatory response caused by a variety of mechanisms. This severe degree of widespread inflammation may result in damage to the endocardium, thus creating an environment to which microorganisms can adhere to and colonize. Additionally, the immunosuppressive medications used in a COVID-19 infection can result in an increased risk of developing infections that have the potential to spread to the endocardium via a hematogenous route. Physicians should be aware of occurrences of IE in COVID-19, as delay in diagnosis and management may cause significant morbidity and mortality.

As per the 2013 guidelines of ACCF/AHA (American College of Cardiology Foundation/American Heart Association), ST Elevation (STE) in lead augmented vector right (aVR), along with ST depression in multiple leads, is associated with critical stenosis of left main coronary artery (LMCA), left anterior descending artery (LAD) or a triple vessel disease (TVD). Early identification of ST-Elevation Myocardial Infarction (STEMI) is important as timely reperfusion with intervention can save myocardium and improve survival. We present a case of a 70 years old female, with cardiovascular risk factors, who presented to the emergency department with chest pain decompensating with ventricular tachycardia. On cardioversion, she was found to have ST elevation in aVR with ST depression in V4-V6, I, II, and aVL. However subsequent echocardiogram and coronary angiogram showed normal coronary arteries and left ventricular function.

The extraordinary prothrombotic manifestations of Coronavirus Disease-2019 (COVID-19), caused by severe acute respiratory syndrome CoV (SARS-CoV-2) virus, presenting as venous and arterial thrombosis have been reported in the literature. The incidence of arterial thrombosis is reported to be 4% in critically ill COVID-19 patients.. Arterial thrombosis in the setting of COVID-19 has been reported to occur in a multitude of organs leading to ischemic strokes, ST-segment elevation myocardial infarction, aortic thrombus and acute limb ischemia. Diffuse endothelial activation, along with aberrant immuno-thrombotic mechanisms have been implicated in the widespread thrombosis occurring in COVID-19 patients. We performed a literature review of 55 reported cases to delineate the clinical characteristics, management patterns and outcomes of patients with COVID-19 who developed complications of acute limb thrombosis and ischemia. Our systematic review revealed that acute limb ischemia had a male predominance, with either hypertension or diabetes mellitus as the most common underlying cardiovascular risk factors. Aortic thrombus was reported in 23.6% of the cases. The majority of the cases involved thrombosis in more than one limb, indicative of a diffuse thrombotic state. The most common artery affected was the left popliteal artery. Upper limb thrombosis occurred in 40% of the cases. Most of the cases (74.5%) were managed with urgent revascularization interventions and anticoagulation. Negative outcomes, including amputations (14.9%) and death (26.5%) occurred at a higher rate in this population, despite the use of standard management.

Lacosamide (LCM) is a new antiepileptic drug used as an adjunctive treatment for partial seizures with and without secondary generalization. One of the modes of action is the enhancement of slow inactivation of voltage-gated sodium channels. Experimental studies and clinical trials suggest that LCM acts upon both neurons and the heart and may increase the risk of cardiac arrhythmias. A systematic review was conducted to investigate characteristics of arrhythmias related to the use of LCM for the treatment of seizures. The search terms "lacosamide", "arrhythmias", "AV block", "atrial fibrillations/flutter", "cardiac conductions defects", "ventricular tachycardia", "ventricular fibrillation were used. Case reports and retrospective studies were gathered by searching Medline/PubMed, Google Scholar, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases. Seventeen articles were selected for review. Ventricular tachycardia was the most reported LCM related arrhythmia (29.4%), followed by new-onset atrial fibrillation (17.6%), complete heart block (17.6%), Mobitz type 1 Atrio-ventricular block (11.8%), sinus pauses (11.8%), pulseless electrical activity (5.9%) and widening QRS complex (5.9%). Further research and clinical trials are needed to explore the etiopathogenesis and causative relationship between the use of LCM and arrhythmias.

Spontaneous coronary artery dissection (SCAD) is a cardiac emergency and an uncommon cause of acute coronary syndrome (ACS) with a higher predominance in younger women. It is a non-traumatic, non-atherosclerotic lesion found to be associated with pregnancy, inflammatory disorders, connective tissue diseases and substance abuse. Our patient was a young woman with a chronic marijuana smoking history who was found to have a NSTEMI. Initial angiogram showed triple vessel disease involving left anterior descending artery (LAD), left circumflex artery (LCX) and obtuse marginal artery (OM). A repeat angiogram notably showed spontaneous progression with dissection in all three vessels attributable to substance abuse. We present you this rare occurrence of triple vessel SCAD secondary to marijuana with a literature review and discussion.

Our systematic review highlights the importance of considering rare pathogens, particularly in the presence of predisposing risk factors.

Since the onset of the global pandemic in early 2020, coronavirus disease 2019 (COVID-19) has posed a multitude of challenges to health care systems worldwide. In order to combat these challenges and devise appropriate therapeutic strategies, it becomes of paramount importance to elucidate the pathophysiology of this illness. Coronavirus disease 2019, caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), is characterized by a dysregulated immune system and hypercoagulability. COVID-associated coagulopathy (CAC) was recognized based on profound d -dimer elevations and evidence of microthrombi and macrothrombi, both in venous and arterial systems. The underlying mechanisms associated with CAC have been suggested, but not clearly defined. The model of immunothrombosis illustrates the elaborate crosstalk between the innate immune system and coagulation. The rendering of a procoagulant state in COVID-19 involves the interplay of many innate immune pathways. The SARS-CoV2 virus can directly infect immune and endothelial cells, leading to endothelial injury and dysregulation of the immune system. Activated leukocytes potentiate a procoagulant state via release of intravascular tissue factor, platelet activation, NETosis, and inhibition of anticoagulant mechanisms. Additional pathways of specific relevance in CAC include cytokine release and complement activation. All these mechanisms have recently been reported in COVID-19. Immunothrombosis provides a comprehensive perspective of the several synergistic pathways pertinent to the pathogenesis of CAC.

On electrocardiography (ECG), ventricular pacing appears as a spikes that precede induced QRS complexes. The induced complexes with a right ventricular lead have the morphology of a left bundle branch block (LBBB). We describe a case of malposition right ventricular (RV) lead in the coronary sinus diagnosed based on the changes noted in the ECG tracing. An 80-year-old man with a pacemaker implanted for high-grade AV block was found unresponsive. Six minutes of cardiopulmonary resuscitation resulted in return of spontaneous circulation. The ECG demonstrated a new paced right bundle branch block (RBBB) pattern. Chest radiography revealed a misplaced right ventricular (RV) lead in the coronary sinus which was confirmed by 2D-echocardiography. The patient's healthcare proxy (HCP) declined invasive interventions. The patient expired due multiorgan failure secondary to ventilator associated pneumonia. When an RBBB pattern is seen with RV pacing, patients must be evaluated for mispositioning of the RV lead navigation through an atrial septal defect (ASD) or perforation of the ventricular septum, aberrant retrograde conduction, pre-existing right bundle disease and the "pseudo-RBBB" pattern (seen with the ventricular lead placed in the RV apex/distal septum). A frontal axis of 0° to 90° and precordial transition by lead V3 differentiates RV septal pacing from all fonns of LV pacing, including lead placement in the coronary sinus. Our patient had precordial transition at V3.

Quadricuspid aortic valve (QAV) is a rare congenital valvular abnormality with less than 200 cases reported to date. The first QAV was reported in 1862 by Balington. Clinical manifestations of patients with a QAV depend on the functional status of the QAV and the associated cardiac disorders. Most QAV are asymptomatic and are incidentally found. Severe aortic regurgitation and/or stenosis can develop overtime, requiring aortic valve replacement or repair. Transesophageal echocardiography is the preferred modality to diagnose QAV. We present a case of QAV which was incidentally diagnosed in a 43-year-old woman who presented with gastroenteritis.

Cardiac free wall rupture (CFWR) is an uncommon complication of myocardial infarction, cardiac-based procedures, and blunt chest trauma. Cardiac tamponade and shock which occurs as a result of CFWR results in a high mortality rate. Despite the high mortality rate, there is a window of opportunity for intervention in selected patients with acute or subacute free wall rupture. Hence, prompt diagnosis and intervention are key to prevent cardiac tamponade and death. Even though emergency surgical repair is the standard treatment for the CWFR, the catheter-based procedure has provided an alternative treatment option, especially, in the high-risk surgical patients. For instance, Amplatzer occluder® (AO), a device which is used in repairing congenital septal swall defect, is being used as an alternative method of treatment in CFWR. In this systemic review, we assessed the 19 cases of CFWR occurring after invasive cardiac procedures who underwent repair with the utilization of AO®. The study shows that the successful rate of percutaneous closure of CFWR was 84.3% (16/19) with a mortality rate of 15.7% (3/19) in this cohort. Therefore, the in-hospital mortality rate of CFWR closure is comparable with the average in-house mortality rate of emergency surgical repair which is 14%. Furthermore, we found that AO® placement technique has a lower mortality rate compared to the other less-invasive methods such as percutaneous intrapericardial fibrin-glue injection which has a mortality rate of 25%. In conclusion, employing AO® in CFWR repair not only serves as the treatment of choice in the high-risk surgical candidates but could also be applied as an alternative method in the general population. However, further studies are required to assess the outcome and mortality rate of using A® in CFWR to provide us with a more consistent and accurate data.