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Key Clinical Message It is important to maintain a vigilant approach towards incidental, rare findings like coronary artery aneurysms (CAAs) presenting with arrhythmia, particularly in patients with a history of myocardial infarction and cardiovascular risk factors. Diagnosis needs thorough evaluation. Tailoring management strategies to individual patient characteristics is crucial for optimizing outcomes.

We describe a rare case of a   ( ) infection causing mitral valve endocarditis and bacterial meningitis in a previously healthy young adult male in his 20s who presented with altered mentation. Though our patient did not endorse any respiratory issues, we suspected the paranasal sinuses to have been the cryptic primary source of disseminated infection into the respiratory system and meninges due to incidental mucosal thickening being found on imaging. Blood and cerebrospinal fluid analyses and cultures revealed the proliferation of   serotype 23B, despite our patient having previously received appropriate pneumococcal vaccinations in his childhood without delinquency. Ultimately, surgical replacement of the mitral valve, as well as a course of ceftriaxone, was indicated for this patient, in which full resolution of symptoms was achieved upon discharge.

With increased life expectancy and aging of the population, aortic stenosis is now one of the most common valvular heart diseases. Early recognition and management of aortic stenosis are of paramount importance because untreated symptomatic severe disease is universally fatal. The advent of transcather aortic valve replacement technologies provides exciting avenues of care to patients with this disease in whom traditional surgical procedures could not be performed or were associated with high risk. This review for clinicians offers an overview of aortic stenosis and updated information on the current status of various treatment strategies. An electronic literature search of PubMed, MEDLINE, EMBASE, and Scopus was performed from conception July 1, 2016, through November 30, 2017, using the terms aortic stenosis, aortic valve replacement, transcatheter aortic valve replacement (TAVR), transcatheter aortic valve insertion (TAVI), surgical aortic valve replacement, aortic stenosis flow-gradient patterns, low-flow aortic valve stenosis, natural history, stress testing, pathophysiology, bicuspid aortic valve, and congenital aortic valve disease.

Background Although anxiety has been proposed to be a potentially modifiable risk factor for suicide, research examining the relationship between anxiety and suicidal behaviors has demonstrated mixed results. Therefore, we aimed at testing the hypothesis that anxiety disorders are associated with suicidal behaviors and evaluate the magnitude and quality of supporting evidence. Methods A systematic literature search of multiple databases was conducted from database inception through August 2011. Two investigators independently reviewed and determined the eligibility and quality of the studies based upon a priori established inclusion criteria. The outcomes of interest were suicidal ideations, suicide attempts, completed suicides, and a composite outcome of any suicidal behaviors. We pooled odds ratios from the included studies using random effects models. Results Forty‐two observational studies were included. The studies had variable methodological quality due to inconsistent adjustment of confounders. Compared to those without anxiety, patients with anxiety were more likely to have suicidal ideations (OR = 2.89, 95% CI: 2.09, 4.00), attempted suicides (OR = 2.47, 95% CI: 1.96, 3.10), completed suicides (OR = 3.34, 95% CI: 2.13, 5.25), or have any suicidal behaviors (OR = 2.85, 95% CI: 2.35, 3.46). The increase in the risk of suicide was demonstrated for each subtype of anxiety except obsessive‐compulsive disorder (OCD). The quality of this evidence is considered low to moderate due to heterogeneity and methodological limitations. Conclusions This systematic review and meta‐analysis provides evidence that the rates of suicides are higher in patients with any type of anxiety disorders excluding OCD.

Background Identifying patients with increased risk of suicidal behaviors is a constant challenge and concern for clinicians caring for patients with psychiatric conditions. We conducted a systematic review to assess the association between suicidal behaviors and sleep disturbances in psychiatric patients. Methods A systematic literature search of Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid PsycInfo, Ovid Cochrane Database of Systematic Reviews, Ovid Cochrane Central Register of Controlled Trials, and Scopus was conducted using earliest inclusive dates to 28 June 2013. Eligible studies were comparative observational studies that reported sleep disturbances in psychiatric patients and the outcome of interest (any type of suicidal behaviors). Pairs of reviewers extracted descriptive data, study quality, and outcomes. Odds ratios (OR) and 95% confidence intervals (CI) were pooled across studies using the random-effects model. Newcastle-Ottawa scale was used to critically appraise study quality. Results Nineteen studies met the inclusion criteria. Compared to those without sleep disturbances, patients with psychiatric diagnoses and co-morbid sleep disturbances were significantly more likely to report suicidal behaviors (OR = 1.99, 95% CI 1.72, 2.30, P <0.001). The association was also demonstrated across several psychiatric conditions including depression (OR = 3.05, 95% CI 2.07, 4.48, P <0.001), post-traumatic stress disorder (PTSD) (OR = 2.56, 95% CI 1.91, 3.43, P <0.001), panic disorder (OR = 3.22, 95% CI 1.09, 9.45, P  = 0.03), and schizophrenia (OR = 12.66, 95% CI 1.40, 114.44, P  = 0.02). In subgroup analysis based on the type of sleep disorder, we also found suicidal behavior to be significantly associated with the presence of insomnia, parasomnias, and sleep-related breathing disorders, but not hypersomnias. Conclusions This systematic review and meta-analysis suggests that in patients with psychiatric diagnoses, sleep disturbances are associated with the increased risk of suicidal behaviors.

Background:Excess body weight in children is associated with multiple immediate and long-term medical comorbidities. We aimed to identify the degree of reduction in excess body weight associated with cardiometabolic changes (lipid panel, liver function tests, systolic blood pressure (SBP), diastolic blood pressure, glycosylated hemoglobin, and fasting blood glucose) in overweight and obese children.Methods:We conducted a comprehensive search of MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus through February 12, 2015. We included randomized controlled trials and cohort studies that evaluated interventions to treat pediatric obesity (medication, surgery, lifestyle, and community-based interventions) with ≥ a 6-month follow-up. We used a random effects meta-regression approach to assess the association between body mass index (BMI)/weight and cardiometabolic changes.Results:We included 42 studies (37 randomized controlled trials and five cohorts) enrolling 3807 children (mean age, 12.2 years; weight, 74.7 kg; and BMI, 31.7 kg/m2). Studies had overall moderate to low risk of bias. A 1-mm Hg decrease in SBP was significantly associated with a decrease of 0.16 kg/m2 (P = .04) in BMI. A 1-mg/dL increase in HDL was significantly associated with a 0.74-kg decrease in weight (P = .02). A 1-mg/dL decrease in triglycerides was significantly associated with a 0.1-kg decrease in weight (P = .03). The remaining associations were not statistically significant.Conclusions:Weight reduction in children is associated with significant changes in several cardiometabolic outcomes, particularly HDL, SBP, and triglycerides. The magnitude of improvement may help in setting expectations and may inform shared decision-making and counseling.

Cardiovascular disease (CVD) disproportionately affects older adults. It is expected that by 2030, one in five people in the United States will be older than 65 years. Individuals with CVD now live longer due, in part, to current prevention and treatment approaches. Addressing the needs of older individuals requires inclusion and assessment of frailty, multimorbidity, depression, quality of life, and cognition. Despite the conceptual relevance and prognostic importance of these factors, they are seldom formally evaluated in clinical practice. Further, although these constructs coexist with traditional cardiovascular risk factors, their exact prevalence and prognostic impact remain largely unknown. Development of the right decision tools, which include these variables, can facilitate patient-centered care for older adults. These gaps in knowledge hinder optimal care use and underscore the need to rigorously evaluate the optimal constructs for providing care to older adults. In this review, we describe available tools to examine the prognostic role of age-related factors in patients with CVD.

Abstract Aims We hypothesize that poor quality of life (QOL) is highly prevalent in frail older adults and is associated with worse prognosis. Methods and results Predismissal standardized tests for frailty and QOL were prospectively administered to patients included in two cohorts. In Cohort 1, 629 patients ≥65 years who underwent percutaneous coronary intervention (PCI) from 2005 to 2008, frailty (Fried criteria), and QOL [SF-36 and Seattle Angina Questionnaires (SAQ)] were ascertained. Cohort 2 included 921 patients ≥55 years who underwent cardiac catheterization (535 had PCI) from 2014 to 2018 and frailty was determined by Rockwood criteria and QOL by single-item, self-reported health questionnaire. In Cohort 1, 19% were frail and 20% patients in Cohort 2 were frail with a frailty index >0.30. The median SAQ for physical limitation (58.9 vs. 82.2, P < 0.001), physical (29.5 vs. 43.9, P < 0.001), and mental (49.2 vs. 57.4, P < 0.001) component scores of SF-36 in Cohort 1 were lower and self-rating of fair/poor health (56% vs 18%, P < 0.001) in Cohort 2 was significantly higher in frail patients. As compared to patients without frailty, frail patients were five times more likely (59% vs. 11%, P < 0.001) in Cohort 1 and seven times more likely (56% vs. 8%) in Cohort 2 to be classified with poor QOL. Age- and gender-adjusted 3-year all-cause death and death or myocardial infarction (MI) was significantly higher for patients undergoing PCI with frailty; [hazard ratio (95% confidence interval) death, 4.20 (2.63–6.68, P < 0.001) and death or MI hazard ratio (HR) 2.72 (1.91–3.87, P < 0.001)] and with poor QOL [HR death 2.47 (1.59–3.84, P < 0.001)] and death or MI 1.61 (1.16–2.24, P < 0.001). There was no significant interaction between frailty and QOL (P = 0.64) and only modest attenuation was observed when considered together indicating their independent prognostic influence. Conclusion In elderly patients undergoing cardiac catheterization or PCI, poor QOL is seen more frequently in frail patients. Both frailty and poor QOL had significant and independent association with long-term survival.

To determine whether the early trials in chronic medical conditions demonstrate an effect size that is larger than that in subsequent trials. We identified randomized controlled trials (RCTs) evaluating a drug or device in patients with chronic medical conditions through meta-analyses (MAs) published between January 1, 2007, and June 23, 2015, in the 10 general medical journals with highest impact factor. We estimated the prevalence of having the largest effect size or heterogeneity in the first 2 published trials. We evaluated the association of the exaggerated early effect with several a priori hypothesized explanatory variables. We included 70 MAs that had included a total of 930 trials (average of 13 [range, 5-48] RCTs per MA) with average follow-up of 24 (range, 1-168) months. The prevalence of the exaggerated early effect (ie, proportion of MAs with largest effect or heterogeneity in the first 2 trials) was 37%. These early trials had an effect size that was on average 2.67 times larger than the overall pooled effect size (ratio of relative effects, 2.67; 95% CI, 2.12-3.37). The presence of exaggerated effect was not significantly associated with trial size; number of events; length of follow-up; intervention duration; number of study sites; inpatient versus outpatient setting; funding source; stopping a trial early; adequacy of random sequence generation, allocation concealment, or blinding; loss to follow-up or the test for publication bias. Trials evaluating treatments of chronic medical conditions published early in the chain of evidence commonly demonstrate an exaggerated treatment effect compared with subsequent trials. At the present time, this phenomenon remains unpredictable. Considering the increasing morbidity and mortality of chronic medical conditions, decision makers should act on early evidence with caution.