A previously healthy 37-year-old man presented with a 10-month history of intractable back pain. On examination, there was tenderness to palpation along lower thoracic and lumbar spine. Complete blood count showed mild anaemia but was otherwise unremarkable. Imaging studies revealed compression deformities with multiple osteolytic lesions involving multiple levels of the thoracic and lumbar spine. Bone marrow aspiration and biopsy were performed and demonstrated blast cells involving 80% of the bone marrow cellularity. Findings on flow cytometry were consistent with B-lymphoblastic leukaemia. He was subsequently started on hyper-CVAD (fractionated cyclophosphamide, vincristine, Adriamycin and dexamethasone) induction chemotherapy.

BackgroundRecent systematic review and meta-analysis showed that the prevalence of cognitive impairment was significantly increased in patients with heart failure (HF) when compared to the general population. However, the effect of cognitive impairment on cardiovascular outcome in this population is still unclear. We performed a systematic review and meta-analysis to assess whether cognitive impairment associated with worse outcome in patients with HF.MethodsWe comprehensively searched the databases of MEDLINE and EMBASE from inception to October 2018. Included studies were published cohort (prospective or retrospective) or randomized control trials that evaluate the effect of cognitive impairment mortality in HF patients. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled hazard ratios (HR) and 95% confidence intervals (CI).ResultsEight studies were included in the analysis involving 3318 participants (951 participants had cognitive impairment). In a random-effects model, our analysis demonstrated that cognitive impairment significantly increased the risk of mortality in HF patients (pooled HR = 1.64, 95% CI = 1.42–1.88, I2 = 0.0%, p < 0.001).ConclusionOur systematic review and meta-analysis showed that the presence of cognitive impairment is strongly associated with an increased mortality risk in the HF population. Further research is needed to explore the pathophysiology of this association.

Coronary artery calcification is increasingly prevalent in our patient population. It significantly limits the procedural success of percutaneous coronary intervention and is associated with a higher risk of adverse cardiovascular events both in the short-term and long-term. There are several modalities for modifying calcified plaque, such as balloon angioplasty (including specialty balloons), coronary atheroablative therapy (rotational, orbital, and laser atherectomy), and intravascular lithotripsy. We discuss each modality’s relative advantages and disadvantages and the data supporting their use. This review also highlights the importance of intravascular imaging to characterize coronary calcification and presents an algorithm to tailor the calcium modification therapy based on specific coronary lesion characteristics.

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