Search results
Found 30013 matches for
The effect of Cardiac Resynchronization Therapy (CRT) on functional capacity based on Cardiopulmonary Exercise Testing (CPET): a systematic review and meta-analysis
Abstract Aims Cardiac resynchronisation therapy (CRT) has a class 1a indication for patients with heart failure due to reduced ejection fraction (HFrEF) who also have conduction delay. Post-CRT management pathways are uncommon. Cardiopulmonary exercise testing (CPET) provides objective functional assessments and may serve as a valuable tool in assessing CRT response and guide device optimisation. This systematic review and meta-analysis aimed to assess the effect of CRT on key CPET parameters and identify patients who may benefit from further intervention. Methods A systematic search of MEDLINE, EMBASE, and Cochrane Central (May 2024) identified randomised controlled trials, non-randomised trials, and cohort studies evaluating changes in CPET post-CRT. Primary outcome was peak VO₂, with anaerobic threshold and ventilatory efficiency as secondary outcomes. Results were reported as standardised mean differences (SMD) and effect sizes using Cohen’s d. Results Fourteen studies (12 cohort studies and 2 RCTs) involving 858 patients were included. CRT was associated with significant improvements in peak VO₂ (SMD = 0.62, 95% CI 0.19–1.05, p < 0.001), anaerobic threshold (SMD = 0.70, 95% CI 0.03–1.36, p = 0.04), and ventilatory efficiency (SMD = -0.45, 95% CI -0.68 to -0.21, p < 0.001). Considerable heterogeneity was noted, likely reflecting differences in exercise protocols, patient characteristics, and device programming. Conclusions CRT improves exercise capacity and ventilatory efficiency, reinforcing its physiological benefits beyond cardiac remodelling. CPET may support personalised post-CRT care, including optimisation of device programming, medications, and rehabilitation. Worsening CPET parameters may help identify patients progressing to advanced heart failure, allowing for timely care planning.
Unmasking Oligosecretory multiple myeloma: a case report highlighting diagnostic pitfalls.
Oligosecretory multiple myeloma (OSMM) is a rare subtype of plasma cell dyscrasia that poses significant diagnostic challenges due to the absence of a clear monoclonal (M) spike on serum protein electrophoresis. We report the case of a 64-year-old woman with a history of ovarian tumor who presented with progressive fatigue, weight loss, bone pain, anaemia, hypercalcemia, and renal dysfunction. Despite the absence of a definitive M-spike, further immunochemical testing revealed discrete IgG-kappa bands on immunofixation, skeletal x-rays showed extensive osteolytic lesions. A bone marrow biopsy confirmed a diagnosis of OSMM. This case highlights the importance of considering oligosecretory variants in patients with clinical and radiological features suggestive of myeloma, even when routine tests appear normal, and illustrates how comprehensive evaluation with immunofixation and bone marrow examination can prevent diagnostic delays and allow timely initiation of treatment in these diagnostically challenging cases.
A23 Embedding Escalation Pathways: Critical Care Outreach in Simulation-Based NIV Training for Resident Doctors – A Quasi-Experimental Study
Introduction: Early and appropriate use of Non-Invasive Ventilation (NIV) reduces patient mortality [1]. Simulation-based multidisciplinary education enhances realism, teamwork, and clinical preparedness in acute care settings [2]. Embedding Critical Care Outreach (CCOT) teams into simulation training mirrors real-world escalation pathways and strengthens clinical decision-making. However, resident doctors often report low confidence and high anxiety when managing NIV, primarily due to limited formal training - a pattern seen in the UK [2]. Addressing this gap is essential to optimise acute patient care. We collaborated with CCOT and peer-led teaching initiatives to deliver simulation-based sessions focused on recognising suitable patients, setting up, and initiating NIV [3]. We aimed to evaluate the benefits of interdisciplinary, CCOT-integrated simulation in developing skills for managing respiratory failure. Methods: A quasi-experimental pre- and post-test study involved 16 participants, including foundation doctors, internal medicine trainees, and specialty registrars. All doctors attending the sessions were eligible to participate. The intervention comprised a simulation-based workshop delivered with CCOT, using real NIV equipment. Participants assessed a simulated patient using case-based vignettes, set up and initiated NIV pressure settings, and reassessed therapy effectiveness. CCOT actively guided escalation protocols, clinical decision-making, and team communication throughout the scenarios, providing real-time feedback. Data were collected before the programme and two weeks after the simulation. An 8-point Likert scale assessed self-rated confidence, and the Six-Item State Anxiety Scale (SAS) measured anxiety. Ethical approval was not required as the project was part of service improvement. Results: Among participants, 91.7% had not received previous formal NIV training. Baseline confidence averaged 2.7/5, improving to 4.2/5 post-simulation, Table 1. Anxiety scores decreased from 16/24 to 11.7/24. Overall, confidence increased by 56% and anxiety reduced by 27%, exceeding initial targets. Notably, 93.8% of participants reported that CCOT input benefited their learning experience, describing it as pivotal for understanding effective escalation processes, multidisciplinary communication, and the practical application of NIV management. Discussion: Embedding Critical Care Outreach into simulation-based education significantly improved resident doctor confidence and reduced anxiety in managing NIV. Positive feedback regarding CCOT involvement highlights the value of incorporating real-world multidisciplinary escalation pathways into training. Adopting this model could enhance national NIV training standards, strengthen acute care teamwork, and improve patient safety. Limitations include the small sample size and short follow-up period; however, immediate educational impacts were significant. Integration into local postgraduate teaching is planned to sustain and expand the benefits observed. Ethics Statement: As the submitting author, I can confirm that all relevant ethical standards of research and dissemination have been met. Additionally, I can confirm that the necessary ethical approval has been obtained, where applicable. References 1. Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet. 2000 Jun 3;355(9219):1931–5. doi: 10.1016/S0140-6736(00)02323-0. 2. Hare A, Simonds A. Simulation-based education for non-invasive ventilation. Breathe (Sheff). 2013 Dec;9(5):366–74. https://breathe.ersjournals.com/content/9/5/366 3. Moerer O, Harnisch LO, Herrmann P et al. Patient-ventilator interaction during noninvasive ventilation in simulated COPD. Respiratory Care. 2016;61(1):15–22. doi: 10.4187/respcare.04141. Supporting Documents – Table 1-A23
Transthyretin-Related Cardiac Amyloidosis: A Case of Delayed Diagnosis in the Comorbid Patient and Literature Review.
We report the case of an 82-year-old male with a history of bronchiectasis, asthma, and atrial fibrillation, who presented with progressive exertional dyspnoea, peripheral oedema, and recurrent heart failure exacerbations. Initial management targeted presumed pulmonary decompensation. Elevated natriuretic peptides, echocardiographic evidence of concentric left ventricular hypertrophy with preserved ejection fraction, and progressive conduction abnormalities prompted further evaluation. A 99mTc-DPD scintigraphy scan revealed Perugini grade 3 myocardial uptake consistent with wild-type transthyretin (ATTRwt) cardiac amyloidosis. Serum and urine studies excluded light-chain amyloidosis. Despite the presence of classical 'red flag' features, including atrial fibrillation, carpal tunnel syndrome, and unexplained left ventricular hypertrophy, diagnosis was significantly delayed by approximately 18 months, from initial symptom onset to definitive diagnosis, during which recurrent hospitalisations and progressive functional decline occurred. Earlier features were overlooked due to the attribution of symptoms to coexistent pulmonary disease and chronic kidney dysfunction. This case highlights the diagnostic challenges posed by ATTRwt, particularly in multimorbid older adults. Overlapping features with respiratory and renal pathology, as well as age-associated cardiovascular changes, obscure the clinical picture. Awareness of hallmark extracardiac features, systematic use of cardiac imaging, and prompt nuclear scintigraphy are essential for timely diagnosis. Early identification may enable consideration of disease-modifying therapy and improved symptom management.
Transient Bilateral Atrial Thrombi in a Patient With Multiple Sclerosis and Massive Pulmonary Embolism: A Case Report and Review of the Literature.
Pulmonary embolism (PE) can present with complex and atypical features that challenge diagnosis and management, particularly when coexisting with intracardiac thrombi and neurological symptoms. We report a case of a 67-year-old woman with multiple sclerosis (MS) who presented with bilateral PE, bi-atrial thrombi, and a subsequent embolic stroke. Despite initial imaging suggesting a possible atrial septal defect (ASD) as the route for paradoxical embolism, both transthoracic echocardiography and cardiac magnetic resonance imaging failed to confirm any intracardiac shunt. The case underscores the diagnostic difficulties in differentiating between stroke and MS relapse, as well as limitations of imaging modalities in transient thrombotic or shunt-related phenomena. The patient was managed with therapeutic anticoagulation, which resulted in thrombus resolution and clinical improvement. This case highlights the need for high clinical suspicion and multidisciplinary evaluation in patients with overlapping cardiovascular and neurological presentations, especially in the setting of chronic inflammatory diseases such as MS.
Evaluación de programas médicos: impacto en la práctica clínica y la toma de decisiones
Los sistemas de educación médica deben garantizar que los médicos egresados de sus escuelas estén capacitados para proveer atención segura, efectiva y de calidad a los pacientes. En educación médica, la evaluación permite conocer si dichos programas están formando un recurso acorde al diseño del programa. En Latinoamérica son pocas las universidades que realizan evaluaciones curriculares o que están acreditadas. Por tanto, se llevó a cabo una revisión narrativa de la literatura sobre los diferentes métodos de evaluación de programas de medicina comúnmente utilizados con el fin de ofrecer una guía de cómo se puede llevar a cabo este proceso.
Post-resuscitation Critical Illness Dysphagia: A Case Report.
Critical illness dysphagia (CID) is a common complication affecting patients following prolonged intensive care unit (ICU) admissions, particularly those who undergo endotracheal intubation and mechanical ventilation. CID is associated with increased morbidity, including aspiration pneumonia, prolonged hospitalisation, and the need for enteral nutrition. The aetiology is multifactorial, involving oropharyngeal trauma, neuromuscular weakness, neurological insult, and disuse atrophy. We report the case of a male patient in his sixties admitted with fluid overload who subsequently experienced a pulseless electrical activity (PEA) cardiac arrest, requiring ICU admission, mechanical ventilation, and inotropic support. His ICU course was complicated by staphylococcal bacteraemia and multi-organ dysfunction. Following extubation, he developed severe dysphagia. Structural and neurological causes were excluded through laryngoscopy, MRI of the brain, and autoimmune screening. Serial swallowing assessments, including fibreoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallow study (VFSS), confirmed profound pharyngeal dysphagia with silent aspiration. He required prolonged nasogastric feeding. Multidisciplinary care involving gastroenterology, neurology, endocrinology, speech and language therapy (SALT), and dietetics guided a structured rehabilitation programme. Despite initial deterioration, the patient showed gradual improvement with ongoing therapy, eventually progressing to a safe oral intake on a modified International Dysphagia Diet Standardisation Initiative (IDDSI) level 2-3 diet. He was discharged home with outpatient SALT and nutrition support. This case highlights the multifaceted nature of CID and the crucial role of early identification, multidisciplinary coordination, and structured dysphagia rehabilitation in enhancing functional outcomes. Instrumental assessments such as FEES and VFSS are key to guiding clinical decisions. With appropriate intervention, patients with CID can achieve meaningful recovery of swallowing function and avoid long-term enteral feeding.
Sudden Collapse in a Child Revealing a Malignant Coronary Anomaly: A Case of Congenital Anomaly of Left Coronary Artery Origin.
Chest pain in children can be a common presentation with causes including idiopathic, musculoskeletal and respiratory conditions, but is rarely cardiac in origin. However, in rare cases, it may indicate life-threatening conditions such as anomalous origin of coronary arteries. Among these, anomalous origin of the left coronary artery from the right sinus (ALCRSV) with an intramural and inter-arterial course is particularly concerning due to its association with myocardial ischemia and sudden cardiac death. We present the case of a previously healthy seven-year-old girl who experienced an episode of chest pain and syncope, initially misattributed to heat syncope. On her second presentation, she was acutely unwell with signs of central cyanosis and ischemic changes on ECG. Further investigation with echocardiography revealed a suspected coronary anomaly. She was transferred to a specialist centre where a diagnosis of the left main coronary artery arising from the right sinus of Valsalva was confirmed. The patient underwent successful surgical correction, including coronary unroofing and reimplantation, and was started on spironolactone and aspirin. Her recovery was uneventful, and she was discharged with a scheduled follow-up. ALCRSV is a rare but serious congenital coronary anomaly that can present with exertional chest pain and syncope in children. Diagnosis is often challenging due to nonspecific symptoms and inconclusive initial investigations. However, timely recognition and surgical intervention can prevent fatal outcomes. This case emphasises the importance of maintaining a high index of suspicion for coronary anomalies in paediatric patients presenting with exertional syncope or ischemic ECG changes, even in the absence of prior cardiac history.
Polymorphic Ventricular Tachycardia (PMVT) in a Patient With Troponin-Negative Chest Pain: A Case Report and Literature Review.
Polymorphic ventricular tachycardia (PMVT) is a potentially life-threatening arrhythmia, typically associated with acute myocardial ischemia or inherited channelopathies. We present a case of PMVT in the context of critical coronary artery disease (CAD) but without biomarker-evident myocardial injury, such as troponin elevation. We present a case of a 61-year-old man with critical left anterior descending (LAD) artery stenosis who developed symptomatic PMVT. This case highlights the paradox of negative troponin values despite severe coronary pathology and a life-threatening arrhythmia. Despite initial normal troponin levels, the patient's recurrent chest pain and arrhythmias were ultimately attributed to critical LAD stenosis, which was successfully treated with percutaneous coronary intervention (PCI). This case emphasizes the importance of considering high-risk coronary disease, particularly in patients with exertional symptoms and arrhythmias, even when initial biomarkers may be reassuring. It underscores the importance of considering ischemia even when troponin levels are normal, particularly in patients with unstable angina. The case illustrates the limitations of relying solely on troponin for risk stratification in acute coronary presentations and supports the need for comprehensive clinical and electrocardiographic evaluation.
Faculty Training to Enhance Medical Education: Evaluating Laboratory Instructors at the National Autonomous University of Honduras (UNAH).
Background Medical education is essential for training competent healthcare professionals capable of addressing evolving patient needs. Faculty development plays a crucial role in improving teaching quality and supporting competency-based education (CBE), particularly in Honduras, where reforms aim to modernize medical curricula. Despite a long history of medical training, formal, standardized faculty development programs remain limited, with many instructors relying on informal, unstandardized training. This study evaluates the impact of a structured faculty development program designed to strengthen teaching competencies and integrate CBE into medical education. Objectives This study aimed to identify gaps in faculty knowledge regarding self-directed learning (SDL), formative assessment (FA), reflective practice (RP), and problem-based learning (PBL); assess instructors' interest in these methodologies; and evaluate competency improvements following a voluntary faculty development course. Methods A descriptive, cross-sectional study was conducted at two campuses of the National Autonomous University of Honduras (UNAH)-Ciudad Universitaria and Valle de Sula-with 219 active laboratory instructors. A voluntary learning needs assessment survey was completed by 141 instructors (64%) to evaluate baseline knowledge, perceived proficiency, and interest in SDL, FA, RP, and PBL. Based on the results, 107 instructors (49%) enrolled in a 10-week faculty development course and 45 instructors (20%) completed it. PBL was selected as the primary methodology due to its effectiveness in fostering critical thinking and alignment with UNAH's educational reforms. The course included interactive sessions, competency-based assessments, and structured feedback. The primary outcome was the ability to design, facilitate, and assess a PBL session, evaluated using a standardized competency-based framework. Descriptive statistics were used to measure learning gains. Results The survey (N=141) revealed that 93% of instructors lacked formal pedagogical training, despite 83.8% having over two years of teaching experience. Institutional barriers - such as limited budget or development opportunities - contributed to this gap. Instructors rated their knowledge of SDL and FA as "good," while RP was "average," though interest in all methodologies was high. Post-training, participants demonstrated mastery of 91% of assessed competencies, with 70% struggling with PBL assessment tools. Inferential analysis using a Chi-square Test for Independence showed a significant association between training participation and competency achievement (χ² = 425.73, df = 75, p = 1.81 × 10⁻⁵⁰, Cramér's V = 0.27). A majority (66.7%) rated the course a perfect 10/10, and 91.1% reported an improved understanding of educational methodologies. Conclusions This study underscores the urgent need for structured faculty development in Honduras. Implementing competency-based training earlier through policy changes, mandatory certification, and continuous professional development could enhance teaching quality, improve student engagement, and modernize medical education. Future research should include follow-up assessments to measure long-term retention, apply further inferential analysis, and explore challenges across specific competencies while addressing potential biases such as social desirability.
Mycobacterium avium Complex-Related Pulmonary Parenchyma Destruction: A Case Report.
Non-tuberculous mycobacteria, particularly Mycobacterium avium complex (MAC), have become significant causes of pulmonary infections, especially in immunocompromised individuals. MAC lung disease presents a diagnostic challenge due to its clinical overlap with other pulmonary conditions, including Mycobacterium tuberculosis infections. The need for microbiological confirmation and radiological evaluation complicates early diagnosis. New molecular diagnostic methods, such as PCR, have improved detection but are not universally accessible. Treatment for MAC lung disease typically involves a multidrug regimen including macrolides, rifamycins, and ethambutol. However, the disease often proves resistant to standard therapies, and treatment failure is common due to drug resistance, delayed diagnosis, and poor adherence. Recent research has highlighted the need for personalized treatment strategies and alternative therapies, such as intravenous antibiotics and host-directed treatments, to improve outcomes. The prognosis for MAC lung disease remains poor, especially in patients with preexisting lung conditions like bronchiectasis or rheumatoid arthritis, who are at increased risk of disseminated infection. This case report and review underscore the importance of early recognition and intervention, highlighting the role of a multidisciplinary approach in managing complex infections. Additionally, it emphasizes the need for continued research to identify more effective treatment options and improve patient outcomes in this growing patient population.
Navigating Misplaced Leads: A Case of Left Ventricle (LV) Lead Placement via a Patent Foramen Ovale (PFO) in a Dual-Chamber Permanent Pacemaker (PPM).
Pacemaker lead misplacement is a rare but clinically significant complication of pacemaker implantation. We present the case of a male patient in his 80s with a permanent pacemaker (PPM) who was found to have an inadvertently misplaced right ventricular (RV) lead coursing through a patent foramen ovale (PFO) into the left ventricle (LV). The patient presented with progressive dyspnoea and was found to have moderate mitral regurgitation related to lead interference with valve closure. Imaging modalities confirmed the lead's anomalous position. A multidisciplinary discussion concluded that conservative management with anticoagulation was the safest approach. This case highlights the importance of multimodal imaging in identifying lead misplacement and the clinical implications of inadvertent LV pacing. Furthermore, it underscores the importance of routine post-implantation assessment to detect lead displacement, which can often occur without symptoms. Early identification through systematic evaluation is essential to prevent complications and ensure optimal device function.
Prosthetic Valve Endocarditis and Aortic Root Abscess: A Case of High-Risk Infection.
Aortic root abscess is a severe complication of infective endocarditis (IE), particularly in patients with prosthetic valves, nearly doubling mortality risk. Due to the potential for rupture and systemic spread, urgent surgical intervention is recommended. We present the case of a 77-year-old man with a recent aortic valve replacement and a history of discitis who presented with non-specific symptoms, complete heart block, and persistent Staphylococcus epidermidis bacteremia. Multimodal imaging, including positron emission tomography (PET) and CT coronary angiography, confirmed an aortic root abscess. Following the IE multidisciplinary team (MDT) recommendations, the patient underwent successful aortic valve and root repair. Post-operatively, he required a pacemaker and dual antibiotic therapy for eight weeks, with no further infection detected. This case highlights the diagnostic challenges of prosthetic valve endocarditis, the critical role of multimodal imaging in detecting complications, and the necessity of early surgical intervention. The development of a heart block underscores the impact of aortic root abscess on conduction pathways. MDT management was essential in optimising patient outcomes.
Wolff Parkinson White en emergencia: reporte de caso
El síndrome de Wolff-Parkinson-White (WPW) es un trastorno pre-excitatorio caracterizado por una vía accesoria entre aurículas y ventrículos, que puede generar arritmias graves, incluso muerte súbita. A menudo es asintomático y se detecta incidentalmente mediante un electrocardiograma (ECG). Este caso describe a un paciente masculino de 39 años con antecedentes de arritmias, manejado inicialmente con bisoprolol. Tras presentar episodios recurrentes de palpitaciones y disnea, se confirmó el diagnóstico de WPW con ECG y Holter, identificando una vía accesoria lateral derecha. El manejo incluyó tratamiento expectante y seguimiento en espera de ablación. La ablación con catéter es el tratamiento de primera línea en pacientes sintomáticos o con alto riesgo, con pronóstico favorable si se realiza a tiempo.
Holiday Heart Syndrome: A Literature Review.
Holiday Heart Syndrome (HHS) is a condition characterised by the development of atrial fibrillation (AF) and other tachyarrhythmias following episodes of binge drinking in individuals without pre-existing cardiac disease. As the binge drinking rate rises worldwide, it is increasingly important to understand the pathophysiology, epidemiology, and clinical significance of this syndrome. The objective of this literature review is to synthesise current evidence on the relationship between binge alcohol drinking and AF, exploring the underlying mechanisms and risk factors associated with HHS. A literature review was conducted using PubMed and Cochrane databases up to August 2024. Articles were selected based on predefined inclusion criteria, focusing on studies assessing the impact of acute alcohol intake on AF incidence. Studies evaluating chronic alcohol consumption, literature reviews, case series, and publications in languages other than English were excluded. A total of 11 studies met the inclusion criteria, comprising cohort and case-control studies. The findings consistently demonstrated a strong association between binge drinking and AF onset. Epidemiological evidence suggests that an increased incidence of new AF cases in individuals without structural heart disease can be attributed to alcohol consumption. Mechanistic insights identify several pathophysiological processes that contribute to the development of HHS, including autonomic dysregulation, ion channel modifications, and transient atrial structural changes. Acute alcohol consumption leads to increased sympathetic activity and reduced vagal tone, increasing heart rate variability and predisposing individuals to AF. Furthermore, alcohol has been shown to increase the activity of T-type calcium channels, which contributes to atrial ectopy and electrical instability. Structural alterations, such as reduced left atrial emptying fraction, have also been observed in binge drinkers, further supporting the link between alcohol and arrhythmogenesis. The evidence reviewed underscores the significant arrhythmogenic risk of binge drinking. While some studies suggest a J-shaped relationship between alcohol intake and AF risk, binge drinking consistently appears as a major trigger. However, variability in study populations and methodologies necessitates further research to establish safe consumption thresholds and interventions. Most studies relied on self-reported alcohol intake, with inconsistent screening methods, and physiological assessments included electrocardiogram monitoring and blood alcohol level measurements. This review highlights the significant role of binge drinking in the pathogenesis of HHS, stressing the need for targeted public health interventions and personalised patient counselling. Future research should prioritise longitudinal studies to improve risk assessment models and clarify the long-term cardiovascular impacts of alcohol-induced AF. Clinicians are encouraged to routinely screen for alcohol use, particularly in patients with a history of arrhythmias, to help prevent recurrent episodes and minimise associated complications.
When Psychiatry Meets Cardiology: A Case Report on the Challenges of Diagnosing and Managing Cardiovascular Disease in Patients With Severe Mental Illness.
Coronary artery aneurysms (CAA) are rare vascular abnormalities defined as focal dilations exceeding 1.5 times the diameter of an adjacent normal segment. Serious complications of CAAs include thrombosis, rupture, and myocardial infarction. Despite the risk of severe complications, patients with CAAs are often asymptomatic and diagnosed incidentally during imaging for unrelated conditions. The presence of a severe mental illness (SMI) poses additional challenges in dealing with patients with cardiovascular disease. We present the case of a 68-year-old woman who was admitted to the emergency department with hemoptysis, hypoxia, tachycardia, and hypertension in addition to being agitated and uncooperative. A computed tomography pulmonary angiography revealed several concerning findings, most notably an aneurysmal structure located inferior to the right pulmonary artery. Several challenges were faced in further investigating and managing the CAA discovery. These resulted from concerns surrounding the patient's ability to tolerate further investigations, the risk of poor compliance with medical management, and the limited capacity for invasive treatments. Following multi-disciplinary team discussions, conservative management was favored, and anticoagulation therapy was initiated. This case underscores the complexity of diagnosing and managing coronary artery aneurysms in patients with severe mental illness. The absence of standardized guidelines for CAAs further complicates management decisions, requiring a case-by-case approach. A holistic, patient-centered approach that integrates psychiatric, cardiovascular, and ethical considerations is essential in improving outcomes in this vulnerable population.