Background:
As we navigate the post-COVID era, it is essential to confront the health challenges that arose from our changed lifestyles. The World Health Organization (WHO) predicts that by 2025, one out of five adults globally will be obese. Researchers have identified a connection between obesity and mild cognitive impairment. Cognitive impairment is a major public health issue with rising costs for governments and communities. This study aims to evaluate the impact of obesity on cognitive function 

Methods:
A systematic review was undertaken, following the PRISMA 2020 guidelines. Initially, 1250 potentially eligible studies were discovered, out of which 12 duplicates were removed. A thorough assessment of titles and abstracts, 35 full-text articles carefully reviewed, and ultimately, 21 eligible studies incorporated. The search encompassed databases such as PubMed, ScienceDirect, and Google Scholar, focusing on the most recent 20-year period. Articles involving animal models were omitted, and only those freely available in the English Language were examined for inclusion.

Results: 
Based on the literature reviewed, obesity is significantly associated with an increased risk of cognitive impairment in younger and middle-aged individuals but not in older age. Older people with obesity may have a reduced risk of incident dementia. Studies show that obese individuals aged ≥65 years had lower risk ratios for incident dementia compared to normal-weight individuals (0.83 and 0.88, respectively). Another study indicates lower cognitive function in obese school children compared to healthy ones. 

Conclusion:
Obesity is a complex, multifactorial, but preventable disease. Evidence indicates that obesity is associated with cognitive impairment, increasing the risk of dementia later in life. Pathophysiological mechanisms, such as neural integrity reduction and inflammation, contribute to cognitive decline. Addressing obesity through public health interventions may help prevent cognitive impairment. More research is needed to understand the association fully, especially regarding body weight and dementia risk in older age. The lack of a universally accepted cognitive test approach hinders early detection of mild cognitive impairment.


Investigating Obesity-Related Cognitive Decline

**Scoring is only possible in the semifinals hall**

**Abstract:**



Heartbreak Hill: A Case Of Multivessel Disease Unmasked After A Bike Marathon

Hepatitis C virus (HCV) has a predisposition to spread via lymphatic route to extrahepatic sites. One common site is the heart. About 17–37% of HCV-infected individuals experience cardiac problems like cardiomyopathies, myocarditis, atherosclerosis, CVA's (stroke and ischemic heart disease), and coronary and peripheral artery disease. There are various mechanisms through which HCV can cause cardiomyopathies, however, in rare instances, the resultant dilated cardiomyopathy follows a transient course. Patients with early initiation of antiviral treatment and achievement of sustained virologic response(SVR) are seen to have reduced risk and better prognosis for HCV-related cardiovascular abnormalities. We report a case of a 65-year-old male with a history of congestive heart failure, atrial fibrillation, and a chronic HCV infection who presented to the hospital with worsening shortness of breath, lower leg swelling, and a six-month history of progressive dyspnea on exertion and fatigue. Initial echocardiography revealed severe left ventricular dysfunction with an EF of 25%. Cardiac magnetic resonance imaging (MRI) confirmed the presence of cardiomyopathy but did not reveal any evidence of myocardial infarction or ischemia. After managing the patients with appropriate antiviral therapy (sofosbuvir and ledipasvir) and adequate treatment for heart failure, we noticed a significant clinical improvement in the patient's heart failure symptoms and a 20% rise in his ejection fraction. Then we review the present literature about transient dilated cardiomyopathy in patients with chronic HCV infection, as well as describe our experience in diagnosis and management of this unusual complication.

Hepatitis C virus (HCV) has a lymphotropic nature, leading to its spread to extrahepatic sites, including the heart. Cardiac problems, such as cardiomyopathies, myocarditis, atherosclerosis, stroke, ischemic heart disease, and coronary/peripheral artery disease, occur in approximately 17-37% of HCV-infected individuals. HCV can contribute to cardiomyopathies through various mechanisms. However, in rare cases, resulting dilated cardiomyopathy may follow a transient course. Early initiation of antiviral treatment and achieving sustained virologic response (SVR) has been associated with reduced risk and improved prognosis for HCV-related cardiovascular abnormalities.

HEPATITIS C VIRUS AND CARDIAC HEALTH: IDENTIFYING DILATED CARDIOMYOPATHY, TREATMENT AND CLINICAL OUTCOMES

Introduction

Atrial fibrillation is the most common arrhythmia in the world. Deglutition-induced tachyarrhythmias are rare, composing only 0.6% of the cases. These arrythmias occur during swallowing due to esophageal stimulation, likely involving vasovagal and adrenergic reflexes. Diagnosis relies on a documented history, Holter monitoring and echocardiograms. Lifestyle changes, medications including beta-blockers and antiarrhythmics, and radiofrequency catheter ablation are have shown to be viable treatment options. 

Case Presentation
A 58-year-old Caucasian woman presented at the emergency department with frequent palpitations. Her medical history included esophageal strictures with recent esophageal dilation, chronic immunosuppression post-kidney transplant, hypertension, hyperlipidemia, and hypothyroidism.

Prior to symptoms, patient underwent an esophageal dilation at an outside hospital. Following the procedure, she experienced short-lived, episodes of palpitations upon swallowing. At presentation, patient had an unremarkable physical examination. Labs showed a normal thyroid-stimulating hormone level, mild hyperbilirubinemia, and mild leukocytosis. The electrocardiogram showed normal sinus rhythm with minimal ST segment abnormalities and normal QTc. A Holter monitor was placed to further investigate the palpitations, The results showed sinus rhythm and mild sinus bradycardia with episodes suggestive of atypical atrial fibrillation. It was consistently noted these episodes were triggered by swallowing, leading to a diagnosis of deglutition-induced atrial fibrillation. The patient was prescribed metoprolol 25mg twice daily. The rate-controlling agent was switched from metoprolol to propafenone 225mg twice daily due to failure to eliminate the palpitations. Ultimately due to side effects of dizziness from the propafenone, the regiment was changed to flecainide 75mg twice daily. In subsequent follow-ups, the patient noted complete resolution of her symptoms.

Discussion
Swallowing-induced supraventricular tachycardias, like deglutition-induced atrial fibrillation, are exceptionally rare, representing less than 1% of reported atrial fibrillation cases with under 100 documented instances. The mechanisms underlying these tachycardias remain uncertain, with leading hypotheses suggesting mechanical left atrial stimulation after esophageal distention or activation of the vagus nerve due to increased intra-esophageal pressure. While first line treatment options involve beta-blockers, they have shown limited effectiveness, resolving symptoms in only about 18% of cases. Propafenone has shown promise, terminating supraventricular tachyarrhythmias in approximately 83% of cases, including deglutition-induced atrial fibrillation. Other antiarrhythmic medications like digoxin, flecainide, and procainamide have shown success in some cases. Radiofrequency ablation is a permanent therapeutic option with nearly 100% success rate for cases where pharmacological treatments are insufficient. Due to the rarity of deglutition-induced atrial fibrillation, extensive research is necessary to understand its mechanisms fully and optimize treatment strategies.

An Exceedingly Rare Case of Deglutition-Induced Atrial Fibrillation

Anomalous origin of the left main coronary artery (LMCA) from the right sinus of Valsalva (RSV) is a rare congenital anomaly that can cause myocardial ischemia, ventricular arrhythmia, and sudden cardiac death. We report a case of a 74-year-old male with a history of hyperlipidemia and hypertension who presented with NSTEMI (Non-ST elevation myocardial infarction). On Coronary angiogram patient was found to have LMCA originating from RSV (Image attached) and a 90% stenosis of left anterior descending (LAD) artery. Patient subsequently underwent computed tomography angiography (CTA) to assess the course of the LMCA which was found to be intramyocardial with no compression. Echocardiogram reported reduced ejection fraction (EF) of 40% and wall motion abnormalities in anterior wall. Patient had a successful staged PCI. Patient on follow-up reported no symptoms and EF improved to 50%. Anomalous origin of the LMCA from the RSV is a rare but potentially life-threatening congenital anomaly Further research is needed to determine the optimal treatment for this anomaly and to improve the long-term outcomes of affected individuals.

Acute Coronary Syndrome (ACS) and Anomalous Left Main Coronary Artery: A Case Report

A Case of Dual Left Anterior Descending Coronary Artery Supply with a Myocardial Bridge

Objective: To determine the effect of video and direct laryngoscopy on first-pass success rates for out-of-hospital orotracheal intubation.
Methods: MEDLINE, Embase, and Cochrane databases were searched from inception to January 2023. Out-of-hospital studies comparing video and direct laryngoscopy on either first-pass or overall intubation success were included. A random effects meta-analysis was performed with a primary outcome of first-pass success stratified by clinician type and laryngoscope blade geometry. The secondary outcomes were overall intubation success stratified by clinician type, and intubation time. All hypotheses and subgroup analyses were determined a priori.
Results: Twenty-five studies involving 35,489 intubations met inclusion criteria. Substantial heterogeneity (>75%) precluded reporting point estimates for nearly all analyses. For our primary outcome, video laryngoscopy was associated with improved first-pass success in 3/5 physician studies, 4/6 critical care paramedic/registered nurse studies, and 7/10 paramedic studies. Video laryngoscope devices with Macintosh blade geometry were associated with improved first-pass success in 7/10 studies, while devices with hyperangulated geometry were associated with improved first-pass success in 3/7 studies. Overall intubation success was greater with video laryngoscopy in 2/6 studies in the physician subgroup and 9/10 studies in the paramedic subgroup. Video laryngoscopy was not associated with overall intubation success among critical care paramedics/nurses (OR = 1.89, 0.96 to 3.72, I2 = 34%). Lastly, 4/5 studies found video laryngoscopy to be associated with longer intubation times.
Conclusions: We found substantial heterogeneity among out-of-hospital studies comparing video laryngoscopy to direct laryngoscopy on first-pass success, overall success, or intubation time. This heterogeneity was not explained with stratification by study design, clinician type, video laryngoscope blade geometry, or leave-one-out meta-analysis. A majority of studies showed that video laryngoscopy was associated with improved first pass success in all subgroups, but only for paramedics and not physicians when looking at overall success. This improvement was more common in studies that used Macintosh blades than those that used hyperangulated blades. Future research should explore the heterogeneity identified in our analysis with an emphasis on differences in training, clinical milieu, and specific video laryngoscope devices.


Out-of-Hospital Video Laryngoscopy: Should We Be Convinced?
A Systematic Review & Meta-Analysis

Introduction:

Mycotic aneurysms are a rare complication of Infective Endocarditis (IE). They can be the result of septic emboli from the heart occluding the vasa vasorum of the vessel or the vessel lumen leading to vascular wall infection. Though mycotic aneurysms can develop anywhere, they are most commonly seen in the intracranial arteries, followed by visceral, then upper and lower extremities arteries at the arterial bifurcations. In a review of 922 of definite IE, symptomatic mycotic aneurysms were observed in 2 percent of cases. Of these, 66% were intracranial (especially involving MCA), as in our patient. CT Angiogram (CTA) is the most useful imaging to diagnose infected aneurysms.

Case Presentation:

We present the case of a 45-year-old African American male who presented with encephalopathy and left hemiparesis and was found to have a right inferior MCA infarct, along with evidence of lucency in the right posterior insula, posterior frontal lobe, and anterior parietal lobe. On Transthoracic Echo (TTE), was found to have friable vegetation on the Mitral, Aortic, and Tricuspid Valves; also, was found to have an infection of the aorto-mitral curtain. On CTA chest and CTA head/neck, was also found to have Aortic root abscess, Aortic to Right Ventricle fistula, diffuse pulmonary opacities, and 2 mycotic saccular aneurysms on right M2 MCA measuring 6 x 5 mm and 4 x 4 mm. Given that the patient grew Enterococcus Faecalis in his blood cultures, management was treatment with Rocephin and Ampicillin for which E-faecalis was susceptible to. Neurology and Cardiothoracic (CT) surgery were also consulted. Hospitalization was further complicated by ruptured mycotic aneurysms resulting in Subarachnoid and Subdural Hematomas. Given the friability of the valves and brain bleed, he was deemed not a surgical candidate and ultimately decided on palliative measures given his poor prognosis.

Discussion:

This case presents a rare complication of disseminated infective endocarditis such as mycotic aneurysms. There is no true consensus in management, however, the current standard of treatment is antibiotic therapy with consideration of surgical debridement with or without revascularization. In one study of 26 patients studied retrospectively, 60% of them had ruptured aneurysms, though only 5 patients required clipping of aneurysm and 8 patients had intraparenchymal hemorrhage (1). In another case series of 25 patients with mycotic aneurysm, 10 patients had these due to IE, and 5 patients had early surgery but no case of emergent surgical procedure for decompression or aneurysmal repair were required in these patients (3). Therefore, a review of literature revealed rupture rate can vary from <2% to 72% (4).

Conclusion:

Our case demonstrates the importance of screening for vascular complications in the post-stroke workup for any patient who presents with a stroke in the setting of IE. Additionally given the wide variation of aneurysmal rupture, early antibiotic treatment remains the mainstay of management, though early surgical evaluation and debridement should be considered.

Severe case of disseminated infective endocarditis

Background
Type 2 diabetes mellitus (T2DM) may be a long-term sequela of Mycobacterium tuberculosis (M.tb) infection by mechanisms yet to be fully unraveled. Using the 2011-2012 NHANES, we evaluated (i) the association between latent tuberculosis infection (LTBI) and T2DM among adults (≥20 years old), and (ii) the extent to which this association is mediated by insulin resistance and β-cell failure.

Methods
T2DM was assessed by fasting plasma glucose and HbA1c; homoeostasis model assessment 2 (HOMA2) was used to estimate β-cell function (HOMA2-B) and insulin resistance (HOMA2-IR); while LTBI status was ascertained by interferon-γ release assay. Quintile and probit regression models were used to examine associations between LTBI and, respectively, HOMA2 indices, and prevalent T2DM. Mediation analyses using the counterfactual framework were then performed to quantify the contribution of each of β-cell dysfunction and insulin resistance to the association of LTBI with T2DM. Analyses were adjusted for sociodemographic, behavioral and clinical confounders.

Results
The analytic sample included 2,235 adults. Compared to TB uninfected individuals, those with LTBI were older [median (IQR): 60 (46, 69) vs. 44 (30, 61) years old], and more frequently male [58.5% vs. 48.9%]. LTBI was associated with increased insulin resistance [adjusted mean difference (AMD) (95% CI) in median: 0.08 (0.01, 0.22); p=0.048] but not β-cell function [AMD in median: -2.6 (-9.4, 4.3); p=0.46]. Similarly, T2DM was more prevalent among those with LTBI [adjusted prevalence (95% CI): 18.3 (13.1, 23.5)%] than peers without TB [11.2 (9.7, 12.9)%], corresponding to an adjusted absolute risk difference of 7.4 (2.3, 13.4)%. In mediation analyses, insulin resistance and β-cell function mediated 22.7 (12.2, 68.9)% and 2.7 (-1.4, 9.7)%, respectively, of the total effect of the association between LTBI and T2DM.

Conclusion
Definitive prospective studies examining incident T2DM following tuberculosis are warranted. Notwithstanding, our findings suggest infection with M.tb may be a novel risk factor for T2DM, likely driven by an increase in insulin resistance.

Insulin resistance, and not β-cell impairment, mediates association between latent tuberculosis infection and type II diabetes mellitus among US adults.

Background
The bi-directional relationship between depression and prescription opioids is well-established. Evidence shows that adults with depression and non-cancer pain are more likely to remain on opioids and are at risk for opioid use disorder. In contrast, less is known about persistent opioid use and change in anxiety. Among chronic pain patients, opioid users are at higher risk for developing anxiety symptoms compared to those receiving other forms of pain management. However, it is unknown if continued use leads to worsening anxiety when compared to quitting. This study aims to determine if persistent opioid use is a risk factor for developing or worsening generalized anxiety disorder (GAD).

Methods
This prospective cohort study involved non-cancer pain patients (n=361) 18-70 years old starting a period of 30 to 90-day opioid use. Patients from Saint Louis University’s medical practice and the Henry Ford Health System self-administered web surveys or participated in telephone interviews. Difference in difference (D.I.D) analysis determined if change in opioid use was associated with change in GAD-7 scores. Outcome measures included mean GAD-7 score, change in GAD-7 score between baseline and 6 months, and threshold change from a GAD-7 score<10 before and after adjusting for age, race, gender, depression, PTSD, anhedonia, substance use disorder, smoking, and alcohol use.

Results
At baseline, those who persistently used opioids had significantly higher GAD scores [6.4 (±5.9)] compared to those who quit [4.7 (±5.3)]. However, there was no significant difference in GAD score at 6 months between persistent users [5.3 (±5.5)] and quitters [5.2 (±5.8)]. The crude D-I-D analysis revealed no differences in GAD score change from baseline to 6 months between the groups (D.I.D = -1.58; 95% CI: -3.38, -0.23). An adjusted analysis revealed similarly insignificant results (D.I.D = -1.16; 95% CI: -2.94,0.62). Furthermore, among patients with negative GAD (score<10) at baseline, there was no significant difference in risk of GAD (score>=10) at 6 months, whether they persisted or not [crude RR = 1.10; 95% CI: 0.55,2.20); adjusted RR = 1.01 95% CI: 0.53,1.93)].

Conclusion
Patients who persisted vs. quit opioid use at 6 months did not differ in association with worsening or new-onset GAD. However, the results reveal a trend for persistent opioid users to have lower 6-month GAD scores. Additional analysis with a larger sample is needed to determine the characteristics of patients who persist yet experience a decrease in GAD symptoms compared to those who experience constant or worsening GAD.

Persistent Opioid Use and the Development of Generalized Anxiety Disorder

Background:
The spectrum of vascular access-site complications following cardiac catheterization can vary widely in severity ranging from simple to complex that can contribute to significant morbidity with a high economic burden and healthcare costs.

Aim:
The aim of the case presentation was to describe post-discharge delayed complication (acute limb ischemia) of cardiac catheterization due to noncalcified plaque.

Case Presentation:
A 58-year-old male with a history of coronary artery disease, diabetes mellitus, and hyperlipidemia underwent cardiac catheterization status-post angioplasty to the right coronary artery via right-femoral artery access. The patient was discharged home post-procedure, however, 8 hours later, he developed a sudden-onset cold foot, and worsening numbness, and tingling sensation in his right extremity that prompted him to present to the ER. Physical examination was notable for cold skin in his right leg with diminished dorsalis pedis and popliteal pulses, and a mild loss of “touch sensation” below the level of the knee. The patient was staged “IIa” on the Rutherford Acute Limb Ischemia score. Vitals and labs were within normal limits. CT Angiogram revealed focal high-grade stenosis in the right common femoral artery at the site of a recent arterial puncture from cardiac catheterization. This was likely secondary to nonocclusive, noncalcified plaque that has been disrupted from recent instrumentation. A Heparin drip was initiated and the patient underwent emergent revascularization with a diagnostic angiogram and balloon angioplasty of the right common femoral artery with the placement of a 27mm stent. A completion angiogram showed the resolution of the high-grade stenosis with good flow through the profound and superficial femoral artery. 

Discussion:
The risk of access-site complications following cardiac catheterization, although quite low, is increased with the femoral artery with an incidence estimated to be as high as 17%. Bleeding and hematoma are often reported, however, thrombosis is infrequent with mechanisms involving atherosclerotic plaque rupture or subintimal dissection of the plaque with secondary thrombosis. When the severity of limb ischemia is threatening, immediate anticoagulation followed by surgical revascularization is the most appropriate intervention. Thrombosis at the access site of cardiac catheterization can cause critical limb ischemia, particularly with the femoral artery, thus highlighting the need for careful post-operative follow-up. 


Acute limb ischemia due to iatrogenic plaque rupture in the common femoral artery at the site of cardiac catheterization - A Case Report

Obstructive sleep apnea (OSA) affects millions of U.S. Veterans and is linked to severe illnesses such as stroke and heart failure. However, understanding how OSA interacts with common comorbidities and the additive risk of OSA in developing severe illnesses is lacking. Large language models (LLMs) are promising tools for clinical natural language processing (NLP). These models are pre-trained on vast amounts of text data and learn to generate coherent and contextually appropriate text by predicting tokens in a sequence. This study explores the quality of LLM embeddings in clustering disease phenotypes related to OSA and its comorbidities such as atrial fibrillation, coronary artery disease, heart failure, hypertension, stroke, and type 2 diabetes mellitus. By identifying sub-cohorts of patients with similar diagnoses, procedures, medications, and adherence to continuous positive airway pressure (CPAP) treatment, we aim to score LLM embeddings by how well pre-trained LLMs discriminate OSA-related phenotypes. Document-level embeddings for discharge reports in the MIMIC-IV database were computed using NERSC's Perlmutter supercomputer. Twelve clinical LLMs of different sizes and pre-training schemes were evaluated including BioBART, BioBERT, BioGPT, BioMegatron, Gatortron, and RadBERT. To visualize the LLMs embedding, UMAP was used to enable plotting of embedded documents in 2D. Each set was clustered using K-Means with increasing values for K, and the purity of the clusters was measured using the Shannon entropy of cluster assignments. Finally, we test the performance of quantized document-level data for supervised phenotype classification.
Qualitatively, we examined the LLM embeddings along UMAP plots and reviewed K-Means cluster assignment by reading sampled text. Gatrotron_medium, BioGPT_large, and BioBERT_base were the best models at separating OSA from its comorbidities. Quantitatively, the clusters were measured on their Shannon entropy factor in which the lower value correlated to greater purity of clusters and vice versa. Gatortron_medium, Gatortron_base, and BioBART_base consistently scored with low entropy across comorbidities. The developed method selected the Gatortron_medium LLM as the best pre-trained model for OSA-related phenotypes both qualitatively and quantitatively. The method also has potential for assessing bias in LLMs by measuring how embeddings group patients according to social determinants of health such as gender and race. In the context of the Department of Veterans Affairs (VA) healthcare, there is a need for early OSA detection and prevention. Leveraging LLMs for feature discovery and risk factor identification, this research can provide valuable insights for allocating CPAP treatment effectively by grouping patients with similar health histories and OSA outcomes.

Underline digital video library

Investigating Obesity-Related Cognitive Decline

Heartbreak Hill: A Case Of Multivessel Disease Unmasked After A Bike Marathon

HEPATITIS C VIRUS AND CARDIAC HEALTH: IDENTIFYING DILATED CARDIOMYOPATHY, TREATMENT AND CLINICAL OUTCOMES

An Exceedingly Rare Case of Deglutition-Induced Atrial Fibrillation

Acute Coronary Syndrome (ACS) and Anomalous Left Main Coronary Artery: A Case Report

A Case of Dual Left Anterior Descending Coronary Artery Supply with a Myocardial Bridge

Out-of-Hospital Video Laryngoscopy: Should We Be Convinced? A Systematic Review & Meta-Analysis

Severe case of disseminated infective endocarditis

Insulin resistance, and not β-cell impairment, mediates association between latent tuberculosis infection and type II diabetes mellitus among US adults.

Persistent Opioid Use and the Development of Generalized Anxiety Disorder

Acute limb ischemia due to iatrogenic plaque rupture in the common femoral artery at the site of cardiac catheterization - A Case Report

Utilizing Large Language Models for DiseasePhenotyping in Obstructive Sleep Apnea

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