Atorvastatin versus Placebo in ICU Patients with COVID-19: Ninety-day Results of the INSPIRATION-S Trial

BACKGROUNDS

In the INSPIRATION-S trial, atorvastatin versus placebo was associated with a non-significant 16% reduction in 30-day composite of venous/arterial thrombosis or death in ICU patients with COVID-19. Thrombo-inflammatory response in COVID-19 may last beyond the first 30 days.

METHODS

This article reports the effects of atorvastatin 20 mg daily versus placebo on 90-day clinical and functional outcomes from INSPIRATION-S, a double-blind multicenter randomized trial of adult ICU patients with COVID-19. The main outcome for this pre-specified study was a composite of adjudicated venous/arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO), or all-cause mortality. Functional status was assessed with Post-COVID-19 Functional Scale (PCFS).

RESULTS

In the primary analysis, 587 patients were included (age: 57 (Q1, Q3: 45, 68) years; 44% women). By 90-day follow-up, the main outcome occurred in 96 (33.1%) patients assigned to atorvastatin and 113 (38.0%) assigned to placebo (hazard ratio, HR: 0.80, 95% confidence interval, CI: 0.60-1.05, P=0.11). Atorvastatin in patients who presented within 7 days of symptom onset was associated with reduced 90-day hazard for the main outcome (HR: 0.60, 95% CI: 0.42-0.86, Pinteraction=0.02). Atorvastatin use was associated with improved 90-day functional status, although the upper bound CI crossed 1.0 (ORordinal, 0.64, 95% CI: 0.41 to 1.01, P=0.05).

CONCLUSIONS

Atorvastatin 20 mg compared with placebo did not significantly reduce the 90-day composite of death, treatment with ECMO, or venous/arterial thrombosis. However, the point estimates do not exclude a potential clinically meaningful treatment effect, especially among patients who presented within 7 days of symptom onset. (NCT04486508).

Donor heart selection: Evidence-based guidelines for providers

The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.

COVID-19 and Vaccine-Induced Thrombosis

Coronavirus disease 2019 (COVID-19), a highly contagious infectious disease, has had a catastrophic effect on the world's demographics resulting in more than 2.9 million deaths worldwide till January 2021. It can lead to systemic multi-organ complications; in particular, venous and arterial thromboembolism risk is significantly increased. Venous thromboembolism (VTE) occurs in 22.7% of patients with COVID-19 in the ICU and 8% in non-ICU hospitalized patients. Studies evaluating thromboprophylaxis strategies in patients with COVID-19 are needed to improve the prevention of VTE. VTE is the most commonly reported thrombotic complication, with higher incidence rates among critically ill patients. Several vaccines have been licensed and are currently used to combat the COVID-19 pandemic. Also, several cases of vaccine-induced thrombosis have been reported. Vaccination remains the most critical measure to curb the COVID-19 pandemic. There is a broad consensus that the benefits of vaccination greatly outweigh the potential risks of rare vaccine side effects, such as vaccine-induced immune thrombotic thrombocytopenia (VITT). Therefore, the importance of vaccination should be emphasized. This statement aims to focus on VITT.

Hemoptysis Resolution with Rituximab in Behçet's Disease: A Case Report

Behçet's disease (BD) is a multisystem, progressive, and inflammatory disorder of unknown etiology. Vasculitis is believed to underlie various clinical manifestations of BD and is known to be one of the main causes of death due to BD, in cases of large vessel involvement. The current study is done in order to examine the effects of rituximab on the patient's debilitating clinical manifestations, as a result of not responding to the standard treatment regimens. The present case is a 28-year-old female patient with BD associated vasculitis. She was referred to the respiratory referral center, chiefly complaining of intermittent episodes of massive hemoptysis. She had also recurrent oral and genital ulcers, and difficulty in walking, despite considering the common treatment approaches for BD. Our patient received two courses of rituximab in combination with intravenous methylprednisolone. Over six months follow-up period from the date of treatment initiation with rituximab, symptoms of BD such as recurrent hemoptysis and aphthous ulcers were reduced in both frequency and severity. Lower limb weakness and difficulty in walking were improved as well. To summarize, rituximab appears to be an effective alternative for treatment-resistant vasculitis in BD patients.

N-Chromosome Royal Jelly, Propolis and Bee Pollen Supplementation Improve the Clinical Conditions of COVID-19 Patients: A Randomized Controlled Trial

Royal jelly, propolis, and bee pollen are used for different purposes all around the world according to their anti-inflammatory, antioxidant, and antimicrobial activities. Given that Coronavirus 2019 (COVID-19) is a viral condition accompanied by a dysregulated inflammatory response in the body, we intend to evaluate the effects of natural supplementations on the disease course. A randomized, open-label, controlled trial was conducted among 50 definitive cases of COVID-19. These patients were randomly assigned into control and intervention groups. Royal Jelly, propolis, and bee pollen were prescribed to patients in the intervention group (n = 24) in addition to conventional treatment; while the control group only received the standard treatment (n = 26). At the end of the study, functional class improved in both groups, but this change was more pronounced in the intervention group (p < 0.05). Moreover, total symptoms duration and the time to return to work were significantly reduced in the intervention group (p < 0.05). Although royal jelly, propolis, and bee pollen are not definitive treatments in COVID-19 patients, they can be used as an adjuvant treatment to limit disease symptoms and virus propagation.

Correlation of Echocardiographic and Right Heart Catheterization Estimations of Pulmonary Artery Systolic Pressure

Background

Pulmonary artery pressure (PAP) is one of the most important and valuable markers in cardiovascular disease, measured by right heart catheterization (RHC) as the gold standard diagnostic modality. However, due to several limitations, such as invasiveness, lack of repeatability, and high health costs, echocardiographic estimation of PAP has been used to substitute RHC for diagnosis and monitoring of this disease. This study aimed to evaluate the correlation of echocardiographic and RHC estimations of systolic PAP.

Materials and Methods

In this study, patients, who were referred to Masih Daneshvari Hospital in Tehran, Iran, evaluated by RHC and echocardiography, were selected. The median PAP (mPAP) and systolic PAP (sPAP) for each modality, time interval between the two modalities, sex, and age were extracted from the patients' records. The RHC mPAP data was used for categorization of patients as pulmonary hypertension, while the sPAP data of two modalities was used to assess correlations and define a cut-off point by the ROC analysis. Data analysis was performed using SPSS version 24, and the level of statistical significance was less than 0.05.

Results

Seventy-six patients, including 31 males (40.8%) and 45 females (59.2%) with the mean age of 45±14 years, were evaluated in this study. The mean sPAP was 71.98±30.22 mmHg when measured by RHC and 69.75±26.03 mmHg when measured by echocardiography (correlation coefficient=0.805; P<0.001). Agreement between the two measurements was 97%, and the accuracy of echocardiography was 43%. By considering 40 mmHg as the cutoff point, the sensitivity and specificity of echocardiography were estimated at 89.2% and 42.8%, respectively. Based on the ROC analysis, the highest sensitivity (86.7%) and specificity (87.5%) were achieved with an estimated sPAP of 57.5 mmHg.

Conclusion

Echocardiography showed a good correlation and agreement with RHC in estimating sPAP; therefore, it is appropriate for screening of patients because of high sensitivity. However, for diagnosis confirmation, monitoring, and follow-up of pulmonary hypertension via echocardiography, high specificity is needed, which can be achieved by considering sPAP of 57.5 mmHg as the cutoff value for pulmonary hypertension.

Investigation of two general venous thromboembolism risk-stratification models in predicting venous thromboembolic events in TB patients

BACKGROUND

Tuberculosis (TB) remains an infectious disease with a high prevalence worldwide and represents a major public health concern. It is known that TB causes a hyper-coagulable state due to its infective nature. Thus, patients are prone to higher incidence rates of venous thromboembolism (VTE) in comparison with the general population. Although there are many risk assessment models (RAMs) that estimate the risk of VTE incidence in the general population, none have been proven to show significant prognostic value in early and accurate VTE prediction among TB patients. This study aims to investigate the accuracy of general RAMs in prediction of VTE incidence in the population of TB-positive patients.

METHODS

The following survey is a retrospective study among patients afflicted with TB, in whom VTE had occurred either during or at the onset of admission. A total number of 865 smear-positive TB cases were recorded in hospital in a 7-year timespan, among which a total sum of 37 patients (67.6% males, age: 56.19 ± 20 years) experienced at least one episode of thromboembolic incidence. We nominated Padua and Geneva RAMs and calculated the scores with regard to their inpatient hospital records.

RESULTS

Of 865 adult hospitalized smear-positive TB patients, 37 patients happened to develop VTE in the course of infection, after excluding the unacceptable data. The incidence of VTE was calculated at 4.27%. Of all VTEs, 73% turned out to be deep venous thromboembolism (DVT), 18.9% were pulmonary thromboembolism (PTE), and 8.1% of patients developed both DVT and PTE during the course of disease. Among all cases, 32.4% revealed Geneva score equivalent or >3. It conveys the meaning that these patients were at greater risk for VTE development and were indicated to receive prophylactic medication. Similarly, Padua model was capable of predicting 29.7% cases scoring >4, which is alarming for elevated VTE probability. 21.6% of TB patients, who had developed VTE during the course of their disease eventually passed away.

CONCLUSION

Our statistics show minimal positive predictive value for Padua and Geneva RAMs, which are seemingly in sharp contrast with the excellent validation of these models verified by numerous surveys in general population. This fact could be attributable to failing to consider TB, or in general chronic infections, as independent indicators of VTE incidence. These findings indicate the need for revising the presenting RAMs or establishing a separate RAM for VTE prediction in TB patients, resembling the VTE risk assessment model for cancer patients.

Comparison of Scores for Child-Pugh Criteria and Standard and Modified Models for End-Stage Liver Disease to Assess Cardiac Hepatopathy in Heart Transplant Recipients

OBJECTIVES

Congestive hepatopathy as a result of advanced heart failure correlates with poor outcomes. Thus, risk-scoring systems have been established to assess the risks for cardiac surgery and hearttransplant, although these systems were originally designed to measure mortality risk in patients with end-stage liver disease. We compared the scores for the Child-Pugh criteria andstandardandmodifiedModels for End-Stage LiverDisease to evaluate the effect of preoperative liver dysfunction on postoperative outcomes inpatients with heart failure who underwent heart transplant.

MATERIALS AND METHODS

Data of 60 consecutive patients who underwent orthotopic heart transplant were analyzed from a historical cohort study from January 1, 2015, to December 31, 2018. We calculated the scores for Child-Pugh criteria and the standard and modified Models for End-Stage Liver Disease.

RESULTS

Of the 60 total patients, 48 were male patients, with a median age of 43 years (range, 13-69 years). Twenty patients died before the end of the study. The causes of death were cardiac, liver, and renal diseases. The mortality risk increased 25% (interquartile range, 0.05-0.51) for the patients with 1 point higher score compared with the patients with 1 point lower score based on a modified Model for End-Stage Liver Disease (P = .01).

CONCLUSIONS

Preoperative liver dysfunction has a significant effect on patient survival. The modified Modelfor End-Stage LiverDisease scoring system could be an effective predictor of perioperative risk stratification for patients with congestive hepatopathy who are undergoing cardiac transplant.

Coronavirus disease 2019 outcomes in heart transplant recipients: a single-center case series

Background

With the rapidly expanding pandemic of severe acute respiratory syndrome coronavirus-2, a chronic immunosuppressed state in solid organ transplant recipients is a concern. We reported coronavirus disease 2019 in heart transplant recipients and described the patients’ course from diagnosis to either hospital admission or improvement in symptoms.

Case presentation

This study retrospectively identified 13 white (Iranian) heart transplant patients with coronavirus disease 2019 between December 2019 and October 2020. The mean age of patients was 43.7 years (19–65 years); seven (70%) were men. Laboratory and treatment data were collected for those admitted or managed as outpatients. Outcomes were also recorded for all patients. This report demonstrates a range of symptoms, clinical severity, and disease course in heart transplant recipients with coronavirus disease 2019, including ten hospitalized patients and three patients, managed entirely in the outpatient setting. One patient passed away, and none of them experienced an episode of clinically overt rejection.

Conclusions

We would like to emphasize the importance of being alert in these patients to consider testing in a broad range of clinical presentations and gathering more data for better management.

Angioembolization in massive hemoptysis for a patient with acute coronary syndrome and history of hydatid cyst

Cystic echinococcosis (CE) or hydatid disease is a zoonosis caused by ingestion of the eggs of the tapeworm Echinococcus granulosus. Larger cysts can cause symptoms by compressing surrounding tissues. Large cysts can also rupture and cause sudden onset of cough, fever, hypersensitivity reactions, and massive hemoptysis. We report a case of hydatid cyst, which caused massive hemoptysis after an urgent percutaneous coronary intervention and was successfully controlled with bronchial artery embolization. <Learning objective: In patients with hydatid cyst, even old lesions, there is a possibility of bleeding and massive hemoptysis after anticoagulation treatment. Bronchial artery embolization is a safe and effective therapy in these situations, when the patient is not a good surgical candidate and the bleeding is life-threatening.>.

Effect of Intermediate-Dose vs Standard-Dose Prophylactic Anticoagulation on Thrombotic Events, Extracorporeal Membrane Oxygenation Treatment, or Mortality Among Patients With COVID-19 Admitted to the Intensive Care Unit: The INSPIRATION Randomized Clinical Trial

IMPORTANCE

Thrombotic events are commonly reported in critically ill patients with COVID-19. Limited data exist to guide the intensity of antithrombotic prophylaxis.

OBJECTIVE

To evaluate the effects of intermediate-dose vs standard-dose prophylactic anticoagulation among patients with COVID-19 admitted to the intensive care unit (ICU).

DESIGN, SETTING, AND PARTICIPANTS

Multicenter randomized trial with a 2 × 2 factorial design performed in 10 academic centers in Iran comparing intermediate-dose vs standard-dose prophylactic anticoagulation (first hypothesis) and statin therapy vs matching placebo (second hypothesis; not reported in this article) among adult patients admitted to the ICU with COVID-19. Patients were recruited between July 29, 2020, and November 19, 2020. The final follow-up date for the 30-day primary outcome was December 19, 2020.

INTERVENTIONS

Intermediate-dose (enoxaparin, 1 mg/kg daily) (n = 276) vs standard prophylactic anticoagulation (enoxaparin, 40 mg daily) (n = 286), with modification according to body weight and creatinine clearance. The assigned treatments were planned to be continued until completion of 30-day follow-up.

MAIN OUTCOMES AND MEASURES

The primary efficacy outcome was a composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days, assessed in randomized patients who met the eligibility criteria and received at least 1 dose of the assigned treatment. Prespecified safety outcomes included major bleeding according to the Bleeding Academic Research Consortium (type 3 or 5 definition), powered for noninferiority (a noninferiority margin of 1.8 based on odds ratio), and severe thrombocytopenia (platelet count <20 ×103/µL). All outcomes were blindly adjudicated.

RESULTS

Among 600 randomized patients, 562 (93.7%) were included in the primary analysis (median [interquartile range] age, 62 [50-71] years; 237 [42.2%] women). The primary efficacy outcome occurred in 126 patients (45.7%) in the intermediate-dose group and 126 patients (44.1%) in the standard-dose prophylaxis group (absolute risk difference, 1.5% [95% CI, -6.6% to 9.8%]; odds ratio, 1.06 [95% CI, 0.76-1.48]; P = .70). Major bleeding occurred in 7 patients (2.5%) in the intermediate-dose group and 4 patients (1.4%) in the standard-dose prophylaxis group (risk difference, 1.1% [1-sided 97.5% CI, -∞ to 3.4%]; odds ratio, 1.83 [1-sided 97.5% CI, 0.00-5.93]), not meeting the noninferiority criteria (P for noninferiority >.99). Severe thrombocytopenia occurred only in patients assigned to the intermediate-dose group (6 vs 0 patients; risk difference, 2.2% [95% CI, 0.4%-3.8%]; P = .01).

CONCLUSIONS AND RELEVANCE

Among patients admitted to the ICU with COVID-19, intermediate-dose prophylactic anticoagulation, compared with standard-dose prophylactic anticoagulation, did not result in a significant difference in the primary outcome of a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days. These results do not support the routine empirical use of intermediate-dose prophylactic anticoagulation in unselected patients admitted to the ICU with COVID-19.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04486508.

Intermediate-Dose versus Standard-Dose Prophylactic Anticoagulation in Patients with COVID-19 Admitted to the Intensive Care Unit: 90-Day Results from the INSPIRATION Randomized Trial

BACKGROUND

 Thrombotic complications are considered among the main extrapulmonary manifestations of coronavirus disease 2019 (COVID-19). The optimal type and duration of prophylactic antithrombotic therapy in these patients remain unknown.

METHODS

 This article reports the final (90-day) results of the Intermediate versus Standard-dose Prophylactic anticoagulation In cRitically-ill pATIents with COVID-19: An opeN label randomized controlled trial (INSPIRATION) study. Patients with COVID-19 admitted to intensive care were randomized to intermediate-dose versus standard-dose prophylactic anticoagulation for 30 days, irrespective of hospital discharge status. The primary efficacy outcome was a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO), or all-cause death. The main safety outcome was major bleeding.

RESULTS

 Of 600 randomized patients, 562 entered the modified intention-to-treat analysis (median age [Q1, Q3]: 62 [50, 71] years; 237 [42.2%] women), of whom 336 (59.8%) survived to hospital discharge. The primary outcome occurred in 132 (47.8%) of patients assigned to intermediate dose and 130 (45.4%) patients assigned to standard-dose prophylactic anticoagulation (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 0.95-1.55, p = 0.11). Findings were similar for other efficacy outcomes, and in the landmark analysis from days 31 to 90 (HR: 1.59, 95% CI: 0.45-5.06). There were 7 (2.5%) major bleeding events in the intermediate-dose group (including 3 fatal events) and 4 (1.4%) major bleeding events in the standard-dose group (none fatal) (HR: 1.82, 95% CI: 0.53-6.24).

CONCLUSION

 Intermediate-dose compared with standard-dose prophylactic anticoagulation did not reduce a composite of death, treatment with ECMO, or venous or arterial thrombosis at 90-day follow-up.

Evaluation of cardiomyopathy diagnosis in heart transplant recipients: comparison of echocardiographic and pathologic classification

Background

Definite diagnosis of cardiomyopathy types can be challenging in end-stage disease process. New growing data have suggested that there is inconsistency between echocardiography and pathology in defining type of cardiomyopathy before and after heart transplantation. The aim of the present study was to compare the pre-heart transplant echocardiographic diagnosis of cardiomyopathy with the results of post-transplant pathologic diagnosis.

Results

In this retrospective cross-sectional clinicopathological study, 100 consecutive patients have undergone heart transplantation in Masih-Daneshvari hospital, Tehran, Iran, between 2010 and 2019. The mean age of patients was 40 ± 13 years and 79% of patients were male. The frequency of different types of cardiomyopathy was significantly different between two diagnostic tools (echocardiography versus pathology, P < 0.001). On the other hand, in 24 patients, the results of echocardiography as regard to the type of cardiomyopathy were inconsistent with pathologic findings.

Conclusion

Based on the findings of the present study, it could be concluded that there is a significant difference between echocardiographic and pathologic diagnosis of cardiomyopathy; therefore, it is necessary to use additional tools for definite diagnosis of cardiomyopathy like advanced cardiac imaging or even endomyocardial biopsy before heart transplantation to reach an appropriate treatment strategy.

Curable Syncope in Primary Pulmonary Hypertension with Novel Atrial Flow Regulator

Pulmonary artery hypertension (PAH) occurs when mean pulmonary artery pressure (PAP) is higher than 25 mmHg in rest or 30 mmHg during activity. Idiopathic pulmonary artery hypertension (IPAH) is defined as PAH without a definite reason. The IPAH is a rare disease with a high mortality rate if left untreated. To date, there has been no definite cure for this entity, and most treatments are for symptom relief or improvement in the quality of life. For many years, decompressing the right heart through a hole in the interatrial septum has been advised to alleviate some of their symptoms, specifically syncope. Atrial flow regulator (AFR) is a device to make an iatrogenic interatrial hole and finally a unidirectional shunt. It has been used for some PAH patients for symptom relief. Herein, we report a 36-year-old female case with diagnosed IPAH for 6 years. In the last 3 years, the case had frequent syncope with shortening intervals. The AFR was implanted for her without any complications. Then, within 6 months of follow-up, she had only one syncope episode. A significant change was observed in her 6-minute walk and PAP.

Bronchial Angioembolization for Management of Hemoptysis Due to Pulmonary Tuberculosis

BACKGROUND

The study aimed to evaluate the effectiveness and safety of BAE in TB patient with massive hemoptysis and evaluate the recurrence rate of hemoptysis after BAE.

MATERIALS AND METHODS

In this prospective study, 68 patients with moderate and severe hemoptysis due to active or old tuberculosis who underwent bronchial arteriography were included. CXR and CT scan were performed in all patients. Selective and nonselective bronchial artery angiography was performed in all patient and 62 patients underwent embolization.

RESULTS

Thirty-two patients (47.1%) had active TB and 36 patients (52.9%) had inactive TB (post-tuberculosis sequelae). Abnormality was detected in a single vessel in 30 (44.1%) patients, in two vessels in 23 (33.8%) and in more than two vessels in 13 (19.1%) patients. Embolization was performed in 62 patients and overall 95 abnormal arteries were embolized. Hemoptysis control rate was 82.3% at one month, 73.5% at three months, 69.1 % at 6 months, 63.2% at one year and 60.3% after two years.

CONCLUSION

No major complication occurred as a result of BAE procedures. BAE is a safe and effective method for the management of hemoptysis in patient with tuberculosis. Only 20.6% of the patients need to repeat BAE during 2 years of follow up.

Preemptive non-selective bronchial artery angioembolization to reduce recurrence rate of hemoptysis

Background

Massive hemoptysis which is presented in advanced lung diseases is a life-threatening condition. Bronchial artery embolization as a minimally invasive procedure is the treatment of choice either in first or recurrent hemoptysis. This study aimed to assess the early and late efficacy of bronchial angioembolization (BAE) without microcatheter.

Methods

In this prospective cohort study, all patients with hemoptysis who had undergone BAE from August 2018 to March 2019 were included. Angiographic patterns including bleeding sources, number of involved vessels, the underlying etiology, and recurrence rate were evaluated in a one-year follow up.

Results

153 patients were included with mean age of 55 ±16 years. 68% of them were male and 58% had life-threatening massive hemoptysis. Three distinct angiographic patterns were recognized. The culprit bleeding vessel was bronchial in 126 (92%), intercostal in 4 (3%), and both vessels in 7 (5%) of cases (p<0.05). One vessel involvement was seen in 56 patients; however it was observed in 69% of non-cystic fibrosis lobar bronchiectasis patients. In 1, 3 and 12 months follow up, recurrent hemoptysis was reported in 15 (11%), 4 (2.5%), and 24 (15.5%), respectively. In 52% of cases, no abnormal vessels were observed during aorta injection, but culprit bronchial or intercostal arteries were found in selective investigational angiography.

Conclusion

BAE was successful in the control of hemoptysis and resulted in a low rate of recurrence in different types of lung diseases. This could be due to the embolization of all pathological arteries found during angiography which might have prevented recurrent bleeding.

Intermediate versus standard-dose prophylactic anticoagulation and statin therapy versus placebo in critically-ill patients with COVID-19: Rationale and design of the INSPIRATION/INSPIRATION-S studies

BACKGROUND

Microvascular and macrovascular thrombotic events are among the hallmarks of coronavirus disease 2019 (COVID-19). Furthermore, the exuberant immune response is considered an important driver of pulmonary and extrapulmonary manifestations of COVID-19. The optimal management strategy to prevent thrombosis in critically-ill patients with COVID-19 remains unknown.

METHODS

The Intermediate versus Standard-dose Prophylactic anticoagulation In cRitically-ill pATIents with COVID-19: An opeN label randomized controlled trial (INSPIRATION) and INSPIRATION-statin (INSPIRATION-S) studies test two independent hypotheses within a randomized controlled trial with 2 × 2 factorial design. Hospitalized critically-ill patients with reverse transcription polymerase chain reaction confirmed COVID-19 will be randomized to intermediate-dose versus standard dose prophylactic anticoagulation. The 600 patients undergoing this randomization will be screened and if meeting the eligibility criteria, will undergo an additional double-blind stratified randomization to atorvastatin 20 mg daily versus matching placebo. The primary endpoint, for both hypotheses will be tested for superiority and includes a composite of adjudicated acute arterial thrombosis, venous thromboembolism (VTE), use of extracorporeal membrane oxygenation, or all-cause death within 30 days from enrollment. Key secondary endpoints include all-cause mortality, adjudicated VTE, and ventilator-free days. Key safety endpoints include major bleeding according to the Bleeding Academic Research Consortium definition and severe thrombocytopenia (platelet count <20,000/fL) for the anticoagulation hypothesis. In a prespecified secondary analysis for non-inferiority, the study will test for the non-inferiority of intermediate intensity versus standard dose anticoagulation for major bleeding, considering a non-inferiority margin of 1.8 based on odds ratio. Key safety endpoints for the statin hypothesis include rise in liver enzymes >3 times upper normal limit and clinically-diagnosed myopathy. The primary analyses will be performed in the modified intention-to-treat population. Results will be tested in exploratory analyses across key subgroups and in the intention-to-treat and per-protocol cohorts.

CONCLUSIONS

INSPIRATION and INSPIRATON-S studies will help address clinically-relevant questions for antithrombotic therapy and thromboinflammatory therapy in critically-ill patients with COVID-19.

Spirometry, cardiopulmonary exercise testing and the six-minute walk test results in sarcoidosis patients

Background

The 6-minute walking test, cardiopulmonary exercise testing, and spirometry are useful tools for evaluation of respiratory impairment and functional capacity in patients with lung disease. Sarcoidosis is a multisystem granulomatous disease of unknown etiology.

Objectives

Since the pulmonary involvement can affect the quality of life in sarcoidosis patients, this study is aimed to evaluate the tests mentioned above in order to examine the functional capacity of sarcoidosis patients in different stages as well as the cause of exercise intolerance.

Methods

This cross-sectional study was carried out on 50 Iranian patients with sarcoidosis. Patients were classified into three groups based on the findings of the chest radiography as well as the pulmonary CT scan, reported by an expert radiologist. Pulmonary, cardiac, and activity function have been evaluated in the patients, using cardiopulmonary exercise testing, the 6-minutes walking test, and spirometry.

Results

In cardiopulmonary exercise testing, percent-predicted peak VO₂ (57.75±15.49, p=0.015) and percent-predicted O₂ pulse (70.54±17.37, p=0.013) were significantly lower in the third group, in comparison with the others. Also, VE/CO₂ (AT) (34.99±5.67, p=0.000) was significantly higher in the third group, in comparison with the other ones. Percent-predicted VO₂ showed a strong positive correlation with age (r=0.377, p=0.009), TSH (r= 0.404, p=0.007), and percent-predicted FVC (r=0.443, p=0.002). In addition, O₂ pulse had a positive correlation with BMI (r=0.324, p=0.026), percent-predicted FVC (r=0.557, p= 0.000), and percent-predicted FEV₁ (r=0.316, p=0.032).

Conclusions

According to this study, ventilatory limitation, pulmonary involvement, and deconditioning are the main causes of activity limitations in sarcoidosis patients.

Characteristics of software used in self-management of vitamin K antagonist therapy: A systematic review

INTRODUCTION AND GOAL

Currently, 1-2% of the population in developed countries are under treatment with oral anticoagulants. An appropriate strategy to deal with this increase in demand of treatment with oral anticoagulants and to manage the costs is the transfer of part or all of the responsibility for managing treatment to the patients. The use of information technology, particularly electronic health software, can be an appropriate method to improve the quality of self-management of treatment with these drugs. Therefore, this systematic review investigated studies that discuss the characteristics of electronic health software in self-management of oral anticoagulation therapy.

METHOD

A systematic review based on PRISMA protocol was conducted. In this study, articles were investigated that were in English. Articles existing in Cochrane, EMBASE and PubMed databases were searched up to 14 May 2017. Then, articles searched through Google Scholar were added to this study.

FINDINGS

The common characteristics used in most software included 'encryption in exchanging information', having an 'instruction module' and 'being Android-based'. In terms of functionality, 'communication between the patient and healthcare team' existed in most of the software.

CONCLUSION

The results of the study showed that the accuracy of administration of the dose of the drug using computer to reach a target international normalized ratio level was not less than those administered with experienced medical staff. In addition, the results indicated that important characteristics of the software include encryption in exchanging information, instruction module and Android-based instruction module. The most important characteristic was the interaction between the patient and the healthcare team.

Outcomes and Complications of Bronchial Angioembolization in Patients with Massive Hemoptysis

BACKGROUND

Massive hemoptysis is a potentially life threatening medical condition and one major problem for both patients and physicians. Choosing the appropriate treatment for the patients is crucial in order to decrease the complications and increase the success rate. Hence, in this study the outcomes and complications of bronchial angioembolization (BAE) were determined in patients with massive hemoptysis.

MATERIALS AND METHODS

In this prospective cohort, 189 consecutive patients with moderate and severe hemoptysis who had referred to two large cardiovascular centers were enrolled. The Chest X Ray, CT Scan, Fiberoptic Bronchoscopy, Selective and Nonselective Bronchial Angiography were performed in patients. The outcomes with 20-month follow-up were compared.

RESULTS

The immediate success rate was 97.3%. In 79.7% there were no complications. Temporary chest pain, subintimal dissection, temporary dysphagia, and pancreatitis were seen in 12.3, 2.4, 5.1, and 0.5%, respectively, without any major complication. The in-hospital mortality rate was 1.1% and mortality during 20-month follow-up was 9.6%, and recurrence rate was 28.3% on total.

CONCLUSION

Our case series showed that BAE is a safe and effective method in treating patients with hemoptysis. Compared to surgery, the procedure is faster and less invasive and might be used both as first line or bridging therapy. Importantly, no major complications have been detected.

The Relationship between Electrocardiographic Changes and Prognostic Factors in Severely Symptomatic Pulmonary Hypertension

BACKGROUND

The prognostic role of the electrocardiogram (ECG) in PH is not fully known. We aimed to evaluate ECG abnormalities in severe PH, the association of ECG patterns with known prognostic factors and to determine whether ECG abnormalities were associated with decreased survival in patients with severe PH.

MATERIALS AND METHODS

Fifty-two patients with severe PH were included. Clinical assessment included basic demographics, complete physical examination, determination of WHO FC, measurement of N-terminal pro-BNP, 12-lead electrocardiography, transthoracic echocardiography, right heart catheterization (RHC) and six minute walk test (6MWT).

RESULTS

Heart rate was correlated with NT-proBNP (r=0.54; p-value: 0.0001) and was higher in patients with severe RV dysfunction (93±12 vs. 83±4 bpm in moderate RV dysfunction). P-pulmonale was present in 51.9% of the patients and was significantly associated with severe RV dysfunction. qR in V1 (48.1%) was significantly associated with 6MWT and severe RV dysfunction. Overall, 10 patients died. Based on Kaplan-Meier results, median survival time was 38 months and estimated survival at 1 year, 3 years, and 5 years was 88%, 80% and 71 % respectively. In Cox regression analysis WHO FC, 6MWT, pericardial effusion, NT-pro BNP, heart rate, ST depression in V1 to V3, and presence of qR in V1 were predictors of mortality. After controlling for covariates, only NT-proBNP was independently associated with decreased survival.

CONCLUSION

ECG changes including P-pulmonale, qR pattern in V1, and heart rate indicative of right ventricular dysfunction are associated with prognostic factors in severe PH and may be a useful tool in the follow-up.

Development of a Catheterization and Percutaneous Coronary Intervention Registry with a Data Management Approach: A Systematic Review

Coronary catheterization is the gold standard for diagnosis and treatment of cardiovascular conditions. The development of a catheterization and percutaneous coronary intervention (CathPCI) registry considering key steps of data management has a pivotal role in coronary catheterization because it could help improve CathPCI approaches, develop equipment and devices, and minimize complications of the CathPCI procedure. Data management comprises data gathering, data processing, and information distribution. Data gathering involves the collection of data elements, including demographics, episode of care, history and relevant risk factors, visits to the catheterization laboratory, diagnosis of cardiac catheterization, estimation of the coronary arterial anatomy, percutaneous coronary intervention procedures, lesions, devices, outcomes, and discharge. Data processing is performed with respect to the number of procedures performed in different circumstances, the outcomes of the performed procedures, improvement in the healthcare approach, development of devices and equipment, and the quality of the performed procedures. Information distribution involves the sharing of information and making information accessible to researchers and clinicians, relevant health care managers, and manufacturers of medical devices and equipment. This study reviewed relevant English-language publications regarding cardiac catheterization registries, data collection, data processing, and information distribution, regardless of the date of publication.

Traumatic Transection of Descending Thoracic Aorta Presenting as Pseudo- Coarctation

Background: Thoracic Aortic Injury (TAI) due to penetrating or blunt chest trauma is a critical life-threatening aortic injury. Its diagnosis and treatment always is challenging. An 18-year-old male was admitted due to blunt chest trauma after a high-impact road traffic collision. According to presenting dyspnea, an emergency chest-x-ray revealed left hemothorax for which chest tube was inserted. Hemodynamic monitoring demonstrated uncontrolled hypertension with systolic blood pressure of 200-220 mmHg despite multiple anti-hypertensive drugs. Trans-Thoracic Echocardiography (TTE) revealed abnormal Doppler flow pattern in proximal descending thoracic aorta suggestive for probable coarctation of aorta. Chest CT scan revealed pseudoaneurysm of the descending thoracic aorta just below the isthmus. Due to uncontrolled hypertension, persistent hemothorax and probable aortic pseudoaneurysm presenting as aortic luminal narrowing, surgical resection of the aneurysm was planned. The postoperative course was uneventful and blood pressure normalized without any drugs. Patient is normotensive after 8 years follow up.

Investigating β-adrenergic-induced cardiac hypertrophy through computational approach: classical and non-classical pathways

The chronic stimulation of β-adrenergic receptors plays a crucial role in cardiac hypertrophy and its progression to heart failure. In β-adrenergic signaling, in addition to the well-established classical pathway, Gs/AC/cAMP/PKA, activation of non-classical pathways such as Gi/PI3K/Akt/GSK3β and Gi/Ras/Raf/MEK/ERK contribute in cardiac hypertrophy. The signaling network of β-adrenergic-induced hypertrophy is very complex and not fully understood. So, we use a computational approach to investigate the dynamic response and contribution of β-adrenergic mediators in cardiac hypertrophy. The proposed computational model provides insights into the effects of β-adrenergic classical and non-classical pathways on the activity of hypertrophic transcription factors CREB and GATA4. The results illustrate that the model captures the dynamics of the main signaling mediators and reproduces the experimental observations well. The results also show that despite the low portion of β2 receptors out of total cardiac β-adrenergic receptors, their contribution in the activation of hypertrophic mediators and regulation of β-adrenergic-induced hypertrophy is noticeable and variations in β1/β2 receptors ratio greatly affect the ISO-induced hypertrophic response. The model results illustrate that GSK3β deactivation after β-adrenergic receptor stimulation has a major influence on CREB and GATA4 activation and consequent cardiac hypertrophy. Also, it is found through sensitivity analysis that PKB (Akt) activation has both pro-hypertrophic and anti-hypertrophic effects in β-adrenergic signaling.

Caspofungin as Salvage Therapy for Pneumocystis Pneumonia in a Heart Transplant Recipient

Pneumocystis pneumonia (PCP) is a common opportunistic infection in immunocompromised patients. In general, clinical response to therapy with cotrimoxazole is excellent. However, therapy may be limited by side effects or treatment failure. We present a case of PCP in a 35-year-old male patient with history of heart transplantation and renal failure who was admitted with a 10-day history of fever, nonproductive cough and elevated level of creatinine with a diagnosis of PCP confirmed by chest radiography and in bronchoalveolar lavage specimens. He was treated with trimethoprim-sulphamethoxazole (SMZ/TMP) and primaquine but treatment was completed with reduced dosage of cotrimoxazole, primaquine and with the addition of caspofungin. This therapy was effective and without any adverse effects in a patient with elevated level of creatinine.

Impact of Thrombus Sidedness on Presentation and Outcomes of Patients with Proximal Lower Extremity Deep Vein Thrombosis

Small studies have suggested differences in demographics and outcomes between left- and right-sided deep vein thrombosis (DVT), and also unilateral versus bilateral DVT. We investigated the clinical presentation and outcomes of patients with DVT based on thrombus sidedness. The authors used the data from the Registro Informatizado Enfermedad TromboEmbólica (RIETE) database (2001-2016) to identify patients with symptomatic proximal lower-extremity DVT. Main outcomes included cumulative 90-day symptomatic pulmonary embolism (PE) and 1-year mortality. Overall, 30,445 patients were included. The majority of DVTs occurred in the left leg (16,421 left-sided, 12,643 right-sided, and 1,390 bilateral; p < 0.001 for chi-squared test comparing all three groups). Comorbidities were relatively similar in those with left-sided and right-sided DVT. Compared with those with left-sided DVT, patients with right-sided DVT had higher relative frequency of PE (26% versus 23%, p < 0.001) and 1-year mortality (odds ratio [OR]: 1.08; 95% confidence interval [CI]: 1.00-1.18). This difference in mortality did not persist after multivariable adjustment (OR: 1.01; 95% CI: 0.93-1.1). Patients with bilateral DVT had a greater burden of comorbidities such as heart failure, and recent surgery compared with those with unilateral DVT (p < 0.001), and higher relative frequency of PE (48%), and 1-year mortality (24.1%). Worse outcomes in patients with bilateral DVT were attenuated but persisted after multivariable adjustment for demographics and risk factors (OR: 1.64; 95% CI: 1.43-1.87). Patients with bilateral DVT had worse outcomes during and after discontinuation of anticoagulation. There is a left-sided preponderance for proximal lower-extremity DVT. Compared with those with left-sided DVT, patients with right-sided DVT have slightly higher rates of PE. Bilateral DVT is associated with markedly worse short-term and 1-year outcomes.

Prophylactic Fibrinogen Decreases Postoperative Bleeding but Not Acute Kidney Injury in Patients Undergoing Heart Transplantation

The present study is the premier clinical attempt to scrutinize the practicability of prophylactic fibrinogen infusion in patients undergoing heart transplantation (HT). A total of 67 consecutive patients who had undergone HT between January 2012 and December 2014 were assessed. After exclusion of some patients, 23 patients were given preoperative 2 g fibrinogen concentrate over a period of 15 minutes after the termination of cardiopulmonary bypass pump and complete reversal of heparin, and 30 patients were not given. Some laboratories were measured before general anesthesia and at 6 and 24 hours after surgery. In addition, major adverse events were also evaluated during hospitalization. The mean age of the patients was 39.5 ± 11.4 years, with a predominance of male sex (77.4%). All laboratories at baseline were comparable between groups. The length of hospital stay was longer in the control group compared to the fibrinogen group (20 [16-22] vs 16 [12-19] days; P = .005). There was a trend for patients in the fibrinogen group to have more acute kidney injury (AKI) after surgery (10% vs 30.4%) and less reoperation for bleeding (20% vs 8.7%). The amount of postoperative bleeding was significantly higher in the control group compared to the fibrinogen group (P < .001). The number of packed red blood cell transfused during 24 hours after surgery was significantly lower in the fibrinogen group (P < .001). The transfusion of fibrinogen in patients undergoing HT may be associated with reductions in postoperative bleeding, the number of packed red blood cells, and hospital length of stay; however, it may enhance postoperative AKI.

Relationship between Serum Uric Acid Levels and the Severity of Pulmonary Hypertension

BACKGROUND

Right heart catheterization is the gold standard test for diagnosis and clinical assessment of the patients with pulmonary hypertension (PH). In recent years, the usefulness of cheaper and non-invasive tests in the follow-up of PH patients is being studied. The aim of the present study was to evaluate the relationship between serum uric acid level and severity of pulmonary hypertension in PH patients.

MATERIALS AND METHODS

In a cross-sectional study, serum uric acid was measured in 110 patients with PH (63 women; mean age [±SD] was 52.83±17.88 years). Pulmonary arterial pressure and severity of right ventricular dysfunction were assessed using RHC and echocardiography, respectively.

RESULTS

Serum uric acid was higher in PH patients with severe RV dysfunction, compared to mild and moderate dysfunction (7.8mg/dl [IQR: 5.8-9.2] in severe dysfunction, versus 4.7 mg/dl [3.87-5.82] in mild dysfunction and 5 mg/dl [3.5-6.95] in moderate dysfunction. Serum uric acid was significantly correlated with pulmonary artery systolic pressure (r=0.51, P<0.001). Serum uric acid level also had a significant positive correlation with the World Health Organization functional class of the patients (r=0.49, P<0.001). Serum uric acid level greater than 5.7 mg/dl was found to be the most sensitive and specific points for predicting severe RV dysfunction in PH patients (sensitivity 76.6%, specificity 71.4%; AUC=0.79, P<0.001) .

CONCLUSION

Serum uric acid is correlated with the severity of symptoms and RV dysfunction in patients with pulmonary hypertension. Further studies are recommended with larger sample size in this regard.

Estimated Prevalence of Venous Thromboembolism in Iran: Prophylaxis Still an Unmet Challenge

BACKGROUND

Inappropriate thromboprophylaxis is a serious problem in Iran. Venous thromboembolism (VTE) is one of the most important causes of morbidity in patients in surgical and obstetrics departments and intensive care units (ICUs). It is a leading preventable cause of mortality among in-patients. This study was designed to determine the prevalence of VTE and its epidemiology in an Iranian population for the first time.

MATERIALS AND METHODS

There is no national registry system for keeping VTE records in Iran. To statistically calculate the annual prevalence of VTE, we used the prevalence of VTE in presence of each VTE predisposing condition and the annual prevalence of each VTE predisposing condition in Iran.

RESULTS

The average annual number of total adult patients with predisposing conditions of deep vein thrombosis (DVT) in Iran was 5,288,272 people. The mean annual prevalence of DVT in Iran was between 686,928 and 2,089,738 cases. The mean annual prevalence rate of DVT among the hospitalized Iranian adult patients with the risk of DVT was approximately between 129.90 and 395.16 cases per 1000 patients.

CONCLUSION

The mean annual prevalence of DVT among the hospitalized Iranian adult patients not receiving prophylaxis is high. We also found that appropriate prophylaxis was provided for less than half the patients in need.

Effect of pulmonary hypertension on outcome of pulmonary tuberculosis

Background

This study performed at the National Research Institute of Tuberculosis and Lung Disease, Tehran, Iran, aimed to evaluate the effect of concomitant pulmonary hypertension on the outcome of pulmonary tuberculosis.

Methods

New cases of pulmonary tuberculosis were recruited for the study. Pulmonary hypertension was defined as systolic pulmonary arterial pressure ≥35 mm Hg estimated by transthoracic Doppler echocardiography. We assessed the relationship between pulmonary hypertension and mortality during the six-month treatment of tuberculosis.

Results

Of 777 new cases of pulmonary tuberculosis, 74 (9.5%) had systolic pulmonary arterial pressure ≥35 mm Hg. Ten of them (13.5%) died during treatment compared to 5% of cases with pulmonary arterial pressure less than 35 mm Hg (p = 0.007). Logistic regression analysis showed that pulmonary hypertension and drug abuse remained independently associated with mortality (OR = 3.1; 95% CI: 1.44–6.75 and OR = 4.4; 95% CI: 2.35–8.17, respectively).

Conclusion

A significant association was found between mortality and presence of pulmonary hypertension and drug abuse among new cases of pulmonary tuberculosis.

Late relapse of multiple myeloma presenting as a right atrial mass

Intracardiac involvement is a rare presentation of relapsed multiple myeloma. We present a case of lobulated mass in the wall of the right atrium, with extension to the inferior vena cava and obliteration and encasement of the interatrial septum in a 57-year-old man, a known case of multiple myeloma, with progressive exertional dyspnea and anasarca.

Comparison of three risk assessment methods for venous thromboembolism prophylaxis

Venous thromboembolism (VTE) is a major problem for hospitalized patients. Nevertheless, adherence to VTE prophylaxis guidelines is suboptimal, partly because of physicians' neglect due to excessive workload. Simplified risk assessment methods (RAMs) facilitate timely risk stratification and thromboprophylaxis. However, the accuracy of such RAMs has not been extensively studied. Using the prospectively collected data from hospitalized patients of Masih-Daneshvari Hospital, we tested the accuracy of the Goldhaber RAM and the Harinath and St. John RAM for VTE prophylaxis, compared with the eighth edition of the American College of Chest Physicians (ACCP) recommendations. We evaluated 1091 patients. With reference to the ACCP recommendations, both RAMs had high specificities for detection of patients at risk of VTE (97.33 and 99.11%, respectively); however, we found significant interdepartment differences. The Goldhaber RAM had superior accuracy in medical oncology patients (P = 0.03), whereas the Harinath and St. John method was superior among surgical patients (P < 0.001). Overall accuracies of Goldhaber RAM for appropriate VTE risk assessment and for proper detection of at-risk patients were close to 60%. Corresponding figures were close to 70% for the Harinath and St. John method. Simplified VTE prophylaxis RAMs are valuable, especially for transmitting electronic alerts and for timely risk assessment and thromboprophylaxis. Both of the studied RAMs had high specificities and positive-predictive values, minimizing the risk of overprophylaxis. Improving the sensitivity of such RAMs can help for timely risk assessment for a greater array of real-world patients.

Pericardial hydatid cyst in oblique sinus, obstructing all pulmonary veins: a rare presentation

Hydatid cyst of the heart is an uncommon presentation of hydatidosis. We present a case of pericardial hydatid cyst in pericardial oblique sinus with extension to posterior wall of left atrium (LA), occluding all pulmonary vein ostia in a 35 year-old female with progressive dyspnea and severe orthopnea.

First successful combined heart and kidney transplant in Iran: a case report

Combined heart and kidney transplant has become an accepted therapy for patients with coexisting heart and kidney failure. This method, compared with single-organ transplant, has a better outcome. Here, we report the first successful combined heart and kidney transplant in Iran. The patient was a 36-year-old man with end-stage renal disease owing to IgA nephropathy, admitted to Masih Daneshvari Hospital in Tehran, Iran for progressive dyspnea and chest pain. In-patient evaluations revealed cardiomyopathy leading to end-stage heart failure. Owing to concurrent heart and kidney end-stage diseases, combined cardiorenal transplant was done. Eight months after his transplant, routine follow-ups have not shown any signs of acute rejection. He is now New York Heart Association functional class I. Both cardiac and renal functions are within normal ranges. Good outcome during follow-up for this case justifies simultaneous heart plus kidney transplants as an alternate treatment for patients with advanced disease of both organs.

Chest physicians' knowledge of appropriate thromboprophylaxis: insights from the PROMOTE study

Venous thromboembolism (VTE) is a major cause of in-hospital mortality. Several international guidelines provide thromboprophylaxis recommendations; however, guidelines adherence is missing worldwide. We evaluated the chest physicians' knowledge regarding VTE prophylaxis, using a systematically developed questionnaire. The Prophylaxis-foR-venOus-throMbOembolism-assessmenT-questionnairE (PROMOTE) questionnaire was developed using an algorithm encompassing the most important VTE prophylaxis topics and included 13 clinical scenarios. Responses were evaluated with reference to the eighth edition of American College of Chest Physicians guidelines for VTE prevention to assess thromboprophylaxis appropriateness. The questionnaires were distributed during the fourth International Congress on Pulmonary Disease, Intensive Care and Tuberculosis. From the 88 received questionnaires (response rate: 39.8%), 82 were acceptable (62 men, 20 women). The most commonly cited VTE risk factors were immobility (79.2%), surgery (68.2%), and cancer (60.9%). The mean correct response ratio to the questions was 67% [95% confidence interval (CI) 64-70%] with highest appropriateness ratios amongst cardiologists (77.1 ± 5.8%) and lowest ratios among thoracic surgeons (59.2 ± 5%). Physicians' specialty had a significant effect on the overall appropriateness (P = 0.04) and most of appropriateness subcategories. Thoracic surgeons had the lowest rate of over-prophylaxis (P = 0.02). Years passed from graduation were inversely associated with overall appropriateness (P = 0.006). Physicians with academic engagements had a higher overall appropriateness (P = 0.04). We found a wide gap between the guideline recommendations and the responses. PROMOTE is the first systematically developed questionnaire that addresses chest physicians' thromboprophylaxis knowledge and could be useful to strategies to improve VTE prophylaxis. Because of the dissimilar prophylaxis pitfalls of different specialists, distinct educational programs seem necessary to improve their knowledge of proper VTE prophylaxis.

AssessMent of ProphylAxis for VenouS ThromboembolIsm in Hospitalized Patients

Background: Venous thromboembolism (VTE) accounts for several cases of in-hospital mortality (over 100 000 deaths annually in the West). Despite the existence of effective prophylaxis guidelines for at-risk patients, the guidelines adherence is missing. Methods: We evaluated the thromboprophylaxis reception and appropriateness based on the eighth edition of the American College of Chest Physicians (ACCP) guidelines on VTE prophylaxis, among hospitalized patients of a World Health Organization (WHO)-collaborating teaching hospital in a 3-month period. Results: From the 904 evaluated cases, 481 entered the study. Appropriate decision on whether to prophylaxe or not, was made in 305 (63.40%), however, complete appropriateness (considering correct regimen type, dosing, and duration) was seen only in 229 patients (47.60%). The ACCP risk for VTE was the strongest predictor of thromboprophylaxis prescription (odds ratio [OR]: 2.62, 95% confidence interval [CI]: 1.35-5.05). Conclusions: Our thromboprophylaxis results were comparable to that of Western countries. Improved thromboprophylaxis appropriateness, which requires improving the physicians' thromboprophylaxis awareness and knowledge, could reduce the rate of in-hospital VTE and translate into better patient care.

Dexter versus sinister deep vein thrombosis: which is the more sinister? Findings from the NRITLD DVT registry

Deep vein thrombosis (DVT) is a major health problem. Despite the wealth of studies on its epidemiology, few have described the thrombus sidedness and particularly the association of thrombus sidedness with clinical presentation and subsequent complications. This article reviews current knowledge regarding this topic and in light of recent data from a large prospective study. This is the first report from the prospective National Research Institute of Tuberculosis and Lung Disease DVT registry. Patients with ultrasound-confirmed symptomatic DVT were enrolled, and thrombus sidedness was investigated in each case. Computed tomography pulmonary angiography was used to diagnose coexisting pulmonary embolism (PE) in DVT patients with suggestive symptoms. Embolic burden score was calculated for those with PE. From the total of 100 patients, 45 had left-sided DVT, 41 had right-sided DVT, and 14 had bilateral DVT. Presenting symptoms and comorbidities were comparable, except for cancer, which was more common in those with right-sided involvement (either right-sided or bilateral DVT; P = 0.004). Compared with those with left-sided DVT, PE happened more frequently in right-sided DVT patients. Right-sided DVT patients also had a higher rate of massive PE ( P = 0.03) and a greater mean embolic burden (13.32 ± 1.63 versus 6.05 ± 1.06; P = 0.001). These findings support raised awareness for global reconsideration of the assumption of complete identicalness of right-sided and left-sided DVT. Although future studies are needed to better elucidate epidemiological and prognostic differences based on the thrombus sidedness, our preliminary findings suggest that the two are not completely identical and right-sided DVT might be more ominous.

Impact of calcification on diagnostic accuracy of 64-slice spiral computed tomography for detecting coronary artery disease: a single center experience

BACKGROUND

The main aim of our study was to investigate the influence of calcification on the accuracy of 64-slice computed tomography for identification of significant coronary artery disease.

METHODS

A contrast-enhanced 64-slice computed tomography was performed prior to invasive coronary angiography in 168 consecutive patients with suspected coronary artery disease. All coronary segments 1.5 mm or larger in diameter were evaluated for the presence or absence of significant coronary artery stenosis, defined as a diameter reduction of >50%. The patients were also ranked by total calcium score which was expressed in Agatston units and the impacts of calcification on diagnostic accuracy of 64-slice computed tomography were assessed. Results were compared with quantitative coronary angiography as the standard of reference.

RESULTS

The overall sensitivity, specificity, positive predictive value, and negative predictive value of 64-slice computed tomography for detection of significant stenosis were: by segments, 95%, 98%, 91%, and 99%, respectively; by patient, 98%, 97%, 96%, and 99%, respectively; and by artery, 94%, 93%, 91%, and 95%, respectively. In mild and moderate calcium scores (0-418 Agatston units), the sensitivity was 100%, specificity was 93%, positive predictive value was 97% and negative predictive value was 100%. Severe calcification (>419 Agatston units) reduced the sensitivity, specificity, positive, and negative predictive values of multi-slice computed tomography to 89%, 60%, 89%, and 60%, respectively.

CONCLUSION

Our study revealed that the 64-slice computed tomography is a highly accurate diagnostic modality for detecting hemodynamically significant coronary stenosis; however, severe calcification is considered as a shortcoming which limits the routine application of multi-slice computed tomography in daily practice.

Correlation between the Pulmonary Artery Pressure Measured in Echocardiography and Pulmonary Artery Diameter in the CT-Scan of Patients Suffering from Interstitial Lung Disease

BACKGROUND

Pulmonary hypertension (PH) is a significant cause of morbidity and mortality in patients suffering from pulmonary parenchymal diseases. Diagnosis of PH has always been a major clinical dilemma due to its non-specific clinical manifestations. However, diagnosing PH and determining its severity are essential for the prognosis and treatment planning in PH patients. This study aimed at evaluating the correlation between the pulmonary artery diameter (PAD) in the CT-scan and pulmonary artery pressure (PAP) in echocardiography of patients.

MATERIALS AND METHODS

PAD was evaluated in the CT-scan of 117 patients suffering from interstitial lung disease (ILD) and the correlation between PAD and PAP was studied. A receiver operating characteristic curve (ROC curve) which is indicative of the precision of the diagnostic test was drawn to find the cut off point for the MPAD representing PH. The area under the curve was also calculated in order to define the discriminative power of the test.

RESULTS

PAP higher than 25 mmHg was considered as PH. PAD over 29 mm reported in the CT-scan for the diagnosis of PH in ILD patients had sensitivity of 63% and specificity of 41.5%. No significant linear correlation was found between PAD and PAP (P-value = 0.17, r = 0.15). The area under the ROC curve was calculated to be 0.49 in the cutoff point of 29 mm for determining PH (CI 95% = 0.38-0.60, P = 0.89).

CONCLUSION

ROC curve showed a weak discriminative power. PAD had low sensitivity and specificity in the CT-scan for the diagnosis of PH. Therefore, we conclude that CT-scan alone is not helpful in finding PH cases and further examinations are required.

Incidence of fever and bacteriemia following flexible fiberoptic bronchoscopy: a prospective study

The latest American Heart Association (AHA) statement for preventing infectious endocarditis, has not recommended prophylactic antibiotic therapy prior to fiberoptic bronchoscopy (FB) except for patients with preexisting predisposing cardiac conditions. Our aim was to determine the incidence of bacteriemia and fever following FB in our experience and compare with those which have been mentioned in AHA guideline as well as other studies. Venous blood of 85 consecutive patients was evaluated for both aerobic and anaerobic cultures before (for detecting possible previous bacteriemia) and after FB. None of the patients were treated with antibiotics prior to the procedure. All the patients were examined during the first 24 hours after FB for detecting fever defined as temperature more than 38 °C. Positive hemocultures were noted in 7 (8.2 %) patients after FB examination. Coagulase negative Staphylococcus, coagulase positive Staphylococcus, beta haemolytic Streptococcus, Citrobacter freundii and Streptococcus viridans were found in 4, 1, 1 and 1 cultures of patients, respectively. By excluding 6 contaminated samples, the rate of bacteriemia reduced to 1 (1.1%) patient in whom the identical pathogen (Streptococcus viridans) was found both in bronchial lavage and venous blood culture. We also found fever in 9 (10.5 %) cases in the first 24 hours following the bronchoscopy. Our results were in consistent with AHA recommendations regarding prevention of infectious endocarditis as a practical gridline in patients who schedule for FB. Besides, transient fever following bronchoscopy is a common self-limited event which does not need medical intervention.

Sticker reminders improve thromboprophylaxis appropriateness in hospitalized patients

BACKGROUND

Venous thromboembolism (VTE) is a major health problem. Even though effective thromboprophylaxis measures exist to prevent VTE, close adherence to guidelines is missing. We assessed the effects of pasting VTE prophylaxis sticker reminders, on the appropriateness of thromboprophylaxis and prophylaxis underutilization.

METHODS

Thromboprophylaxis reception was sought prospectively in two time points before and two time points after pasting sticker reminders in hospitalized patients of Masih Daneshvari Medical Center, Tehran, Iran. Thromboprophylaxis reception appropriateness was evaluated by the eighth American College of Chest Physicians (ACCP) guidelines on antithrombotic and thrombolytic therapy. Co-morbidities and conditions considered to affect the risk of venous thromboembolism were also recorded.

RESULTS

Prophylaxis reception and appropriateness were studied in 298 patients before and 306 patients after the intervention. Based on the ACCP guidelines, overall thromboprophylaxis appropriateness was improved after the intervention (70.4% before, and 78.1% after the intervention, P=0.03). Prophylaxis underutilization, and prophylaxis initiation delay in those who needed thromboprophylaxis, were also reduced (P=0.03, and P=0.011 respectively). The intervention did not result in an increased rate of overprophylaxis (P=0.45).

CONCLUSION

Sticker reminders could be safely and effectively incorporated into strategies to improve VTE prophylaxis and prophylaxis appropriateness, particularly in healthcare settings where electronic alert systems are not available.

Bilateral diffuse pulmonary infiltration in a heart transplant recipient

Pulmonary complications are not infrequent after heart transplantation. Kaposi sarcoma is a vascular tumor that can involve the skin as well as visceral organs. We describe a case of visceral and cutaneous Kaposi sarcoma that presented with diffuse bilateral pulmonary infiltration and breathlessness 6 month after heart transplantation. Following modulation of the immunosuppressive regimen and addition of chemotherapy, the patient had an excellent response and has had an uneventful 1-year follow-up.

Assessment of patients after coronary artery bypass grafting using 64-slice computed tomography

The aim was to investigate the diagnostic accuracy of 64-slice computed tomography (CT) for the identification of obstructive disease in both bypass grafts and native coronary vessels in symptomatic patients with a history of coronary artery bypass grafting. Eighty-nine symptomatic patients (81 men; mean age 64 +/- 8 years) were prospectively studied 8 +/- 4.5 years after bypass surgery. A total of 287 grafts (89 arterial grafts, 198 venous grafts) and 1,183 segments in 356 native coronary arteries >1.5 mm in diameter were evaluated using 64-slice computed tomographic angiography for the detection of significant stenosis, defined as >or=50% decrease in diameter of artery. Results were compared with quantitative coronary angiography as the standard of reference. Sensitivity, specificity, and positive and negative predictive values of 64-slice CT for the detection of significant lesions in bypass grafts were 98%, 97%, 96%, and 99%, respectively. Segment-by-segment analysis of native coronary arteries and distal runoff vessels for the detection of significant obstructive disease yielded sensitivity of 93% with specificity of 88%. If analysis was restricted to nongrafted and distal runoff segments, sensitivity and specificity were 89% and 94%, respectively. The diagnostic accuracy of 64-slice CT was significantly lower for the evaluation of severely calcified segments. In conclusion, 64-slice CT was a valuable and noninvasive tool for accurate comprehensive assessment of bypass grafts and native coronary circulation. However, its usefulness was limited in the presence of heavy calcium deposits.

Screening for Deep Vein Thrombosis in Asymptomatic High-risk Patients: A Comparison between Digital Photoplethysmography and Venous Ultrasonography

Objective

To determine the role of digital photoplethysmography in screening asymptomatic patients who are susceptible for developing deep vein thrombosis.

Methods

Three hundred and thirty-seven limbs in 169 patients who were high risk for development of deep vein thrombosis were assessed by ultrasonography digital photoplethysmography and the results were compared.

Results

Thirteen limbs were found to have deep vein thrombosis as demonstrated by ultrasonography. All limbs with a venous refilling time greater than 12 seconds had a normal ultrasonography. Compared with ultrasonography and using refilling time less than 12 seconds as the cutoff point, digital photoplethysmography achieved a sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 73.8%, 13.3%, and 100% respectively, for detecting deep vein thrombosis in asymptomatic high-risk patients.

Conclusion

Digital photoplethysmography is a simple, noninvasive, and highly sensitive test for screening of deep vein thrombosis.