In-hospital outcomes of septal myectomy vs. alcohol septal ablation for hypertrophic cardiomyopathy with outflow tract obstruction: An update and insights from the national inpatient sample from 2011 to 2019

Septal Myectomy (SM) and Alcohol Septal Ablation (ASA) improve symptoms in patients with Hypertrophic Cardiomyopathy with outflow tract obstruction (oHCM). However, outcomes data in this population is predominantly from specialized centers. The National Inpatient Database was queried from 2011 to 2019 for relevant international classification of diseases (ICD)-9 and -10 diagnostic and procedural codes. We compared baseline characteristics and in-hospital outcomes of patients with oHCM who underwent SM vs ASA. A p-value  < 0.001 was considered statistically significant. We identified 15,119 patients with oHCM who underwent septal reduction therapies, of whom 57.4% underwent SM, and 42.6% underwent ASA. Patients who underwent SM had higher all-cause mortality (OR: 1.8 (1.3-2.5)), post-procedure ischemic stroke (OR: 2.3 (1.7-3.2)), acute kidney injury (OR: 1.4 (1.2-1.7)), vascular complications (OR: 3.6 (2.3-5.3)), ventricular septal defect (OR: 4.4 (3.2-6.1)), cardiogenic shock (OR: 1.7 (1.3-2.3)), sepsis (OR: 3.2 (1.9-5.4)), and left bundle branch block (OR: 3.5 (3-4)), compared to ASA. Patients who underwent ASA had higher post-procedure complete heart block (OR: 1.3 (1.1-1.4)), right bundle branch block (OR: 6.3 (5-7.7)), ventricular tachycardia (OR: 2.2 (1.9-2.6)), supraventricular tachycardia (OR: 1.6 (1.4-2)), and more commonly required pacemaker insertion (OR: 1.4 (1.3-1.7)) (p < 0.001 for all) compared to SM. This nationwide analysis evidenced that patients undergoing SM had higher in-hospital mortality and periprocedural complications than ASA; however, those undergoing ASA had more post-procedure conduction abnormalities and pacemaker implantation. The implications of these findings warrant further investigation regarding patient selection strategies for these therapies.

US trends of in-hospital morbidity and mortality for acute myocardial infarctions complicated by cardiogenic shock

BACKGROUND

There is limited real-world data highlighting recent temporal in-hospital morbidity and mortality trends for cases of acute myocardial infarction complicated by cardiogenic shock. The role of mechanical circulatory support within this patient population remains unclear.

METHODS

The US National Inpatient Sample database was sampled from 2011 to 2018 identifying 206,396 hospitalizations with a primary admission diagnosis of ST- or Non-ST elevation myocardial infarction complicated by cardiogenic shock. The primary outcomes included trends of all-cause in-hospital mortality, mechanical circulatory support use, and sex-specific trends for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) over the study period.

RESULTS

The annual number of AMI-CS hospitalizations increased from 22,851 in 2011 to 30,015 in 2018 and in-hospital mortality trends remained similar (42.9 % to 43.7 %, ptrend < 0.001). The proportion of patients receiving any temporary MCS device decreased (46.4 % to 44.4 %). The use of intra-aortic balloon pump (IABP) decreased (44.9 % to 32.9 %) and the use of any other non-IABP MCS device increased (2.5 % to 15.6 %), ptrend<0.001. Sex-specific mortality indicate female in-hospital mortality remained similar (50.3 % to 51 %, ptrend<0.001), but higher than male in-hospital mortality, which increased non-significantly (38.8 % to 40.2 %, ptrend = 0.372).

CONCLUSIONS

From 2011 to 2018, hospitalizations for AMI-CS patients have increased in number. However, there has been no recent appreciable change in AMI-CS mortality despite a changing treatment landscape with decreasing use of IABPs and increasing use of non-IABP MCS devices. Further research is necessary to examine the appropriate use of MCS devices within this population.

Bempedoic Acid: Lipid Lowering for Cardiovascular Disease Prevention

The management of low-density lipoprotein cholesterol (LDL-C) levels is a central strategy for the prevention of atherosclerotic cardiovascular disease. Current United States (2018 American Heart Association/American College of Cardiology/Multisociety) and European (2019 European Society of Cardiology/European Atherosclerosis Society) guidelines endorse statin therapy as the first-line therapy for pharmacologic LDL-C lowering. However, in clinical practice up to 30% of patients report partial or complete intolerance to statin therapy. While the nocebo effect with statins is well described, perceived statin intolerance prevents many patients from achieving LDL-C thresholds associated with clinical benefit. Bempedoic acid is a novel, oral, non-statin lipid-l owering therapy that works by inhibiting adenosine triphosphate-citrate lyase, an enzymatic reaction upstream of 3-hydroxy-3-methylglutaryl coenzyme A reductase in the hepatic cholesterol synthesis pathway. Bempedoic acid confers reduction in LDL-C of ~18% on background statin therapy,~21% in patients with statin intolerance, and ~38% when given in fixed-dose combination with ezetimibe. The CLEAR Outcomes trial, which enrolled high-risk primary and secondary prevention patients with reported statin intolerance and LDL-C levels ≥100 mg/dL, showed that bempedoic acid compared with placebo reduced 4-component major adverse cardiovascular events (MACE) by 13% (hazard ratio 0.87, 95% confidence interval 0.79-0.96). Bempedoic acid also reduced 3-component MACE by 15%, myocardial infarction by 23% and coronary revascularization by 19%. The benefit was even greater in the primary prevention cohort (hazard ratio 0.70, 95% confidence interval 0.55-0.89) for 4-component MACE. Bempedoic acid was associated with increases in uric acid levels and cholelithiasis, but numerically fewer events of myalgia and new-onset diabetes. These findings confirm that bempedoic acid is an effective approach to reduce cardiovascular outcomes in high-risk patients with statin intolerance who require further reduction in LDL-C.

Outcomes of Acute Myocardial Infarction in Female Patients With Type 1 Diabetes Mellitus

There is a paucity of data on acute myocardial infarction (AMI) outcomes for female patients with type 1 diabetes (T1DM) compared with men. The National Inpatient Sample Database was queried from 2011 to 2019 for relevant International Classification of Diseases, Ninth and Tenth Revision procedural and diagnostic codes. Hospitalizations with an admitting diagnosis of non-ST-elevation myocardial infarction or ST-elevation myocardial infarction were compared between male and female patients with T1DM. A multivariate logistic regression adjusting for baseline characteristics and primary diagnosis was performed. A p <0.001 was considered significant. A total of 50,020 hospitalizations for AMI in patients with T1DM were identified, of which 23,980 (47.9%) were women. The baseline characteristics are listed in Table 1. Women experienced similar rates of all-cause and inhospital mortality (5.0% vs 4.7%, p = 0.082). However, after adjusting for baseline characteristics and primary diagnosis, women had higher odds of mortality (adjusted odds ratio [aOR] 1.26, 95% confidence interval [CI] 1.15 to 1.38). Women were less likely to undergo cardiac catheterization (65.7% vs 68.2%; aOR 0.90, 95% CI 0.86 to 0.94) and coronary artery bypass grafting (5.6% vs 6.9%; aOR 0.76, 95% CI 0.70 to 0.82, p <0.001 for both). There was no difference in the use of percutaneous coronary intervention (41.0% vs 41.9%; aOR 1.01, 95% CI 0.97 to 1.05, p = 0.042). The female gender is not protective against AMI in patients with T1DM. Women with T1DM, on average, experience AMI at the same age as men, are less likely to undergo surgical revascularization, and have higher odds of mortality.

Cirrhosis: Primary care approaches to screening, immunization, and lifestyle modifications

For patients with decompensated cirrhosis, health maintenance is critical to improve survival rates and prevent adverse outcomes. We review the primary care management of cirrhosis and its complications, such as esophageal varices, hepatocellular carcinoma, and chemical or medication exposures. We also highlight specific immunizations and lifestyle modifications to prevent decompensation, and we summarize current screening guidelines.

Impact of Chronic Heart Failure on Acute Pulmonary Embolism in-Hospital Outcomes (From a Contemporary Study)

There is a paucity of evidence on the impact of chronic heart failure (HF) on acute pulmonary embolism (PE) hospitalization outcomes. The aim of this study was to evaluate the in-hospital outcomes of patients with chronic HF and acute PE. A total of 1,391,145 hospitalizations with acute PE from the National Inpatient Sample Database from 2011 to 2019 were included. The database was queried for relevant International Classification of Diseases, Ninth and Tenth Revisions procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes for patients with acute PE were compared in patients with and without a history of chronic HF. Multivariate logistic regression analyses were performed, adjusting for age, race, gender, and statistically significant co-morbidities between cohorts. A p value <0.001 was considered significant. Overall, the mean age was 65.2±16 years; 50.9% of patients were women, and 230,875 patients (16.6%) had chronic HF. The patients in the chronic HF cohort were predominantly older (mean age 69.0 vs 61.4 years) and male (49.9% vs 48.3%). In the multivariate model, chronic HF was associated with increased all-cause mortality (odds ratio [OR] 1.6, 95% confidence interval [CI], 1.57 to 1.63, 10.4% vs 5.7%), acute respiratory distress (OR 1.7, 95% CI 1.70 to 1.74, 39.5% vs 22.1%), cardiac arrest (OR 1.4, 95% CI 1.40 to 1.49, 3.9% vs 2.2%), and cardiogenic shock (OR 3.0, 95% CI 2.85 to 3.06, 4.2% vs 1.2%). All p values were <0.001. In conclusion, patients with PE and chronicHF are associated with increased in-hospital complications compared with patients with PE and without chronic HF. Prospective studies are needed to evaluate optimal management strategies in this population at high risk.

Trends in the Use and Complications of Cardiac Resynchronization Therapy Device Implantation in Chronic Kidney Disease Patients

Large-scale multi-hospital data on cardiac resynchronization therapy (CRT) device implantation in patients with chronic kidney disease (CKD) are currently lacking. The purpose of this study was to examine the incidence of CRT device implantation in patients hospitalized with CKD and the impact of CRT device implantation on hospital complications and outcomes. We analyzed the Nationwide Inpatient Sample from 2008-2014 to identify yearly trends in CRT device implantation during CKD hospitalizations. We compared CRT biventricular pacemakers (CRT-Ps) and CRT defibrillators (CRT-Ds). We also obtained rates of comorbidities and complications associated with CRT device implantations. From 2008-2014, the proportion of hospitalized patients with a concurrent diagnosis of CKD receiving CRT-P devices consistently went up from 2008 to 2014 (from 12.3% to 23.8%, P < .0001) compared to the number of hospitalized patients with a concurrent diagnosis of CKD receiving CRT-D devices, which showed a consistent downward trend (from 87.7% to 76.2%, P < .0001). During CKD hospitalizations, most CRT device implantations were performed in patients aged 65-84 years (68.6%) and in men (74.3%). The most common complication of CRT device implantation during hospitalizations involving CKD was hemorrhage or hematoma (2.7%). Patients hospitalized with CKD who developed any complication associated with CRT device implantation had 3.35-fold increased odds of mortality compared to those without complications (odds ratio, 3.35; 95% confidence interval, 2.18-5.16; P < .0001). In summary, this study shows that CRT-P implantations became more common in CKD patients, while the rate of CRT-D implantations decreased over time. Hemorrhage or hematoma was the most common complication (2.7%), and the mortality risk was increased by 3.35 times in patients who developed periprocedural complications.

Trends and In-Hospital Outcomes of Patients With Baseline Right Bundle Branch Block Who Underwent Transcatheter Aortic Valve Implantation

This study aimed to explore contemporary in-hospital outcomes and trends of transcatheter aortic valve implantation (TAVI) outcomes in patients with baseline right bundle branch block (RBBB) using data collected from a nationwide sample. Using the National Inpatient Sample, we identified patients hospitalized for an index TAVI procedure from 2016 to 2019. Primary outcomes included in-hospital all-cause mortality, complete heart block, and permanent pacemaker (PPM) implantation. A total of 199,895 hospitalizations for TAVI were identified. RBBB was present in 10,495 cases (5.3%). Patients with RBBB were older (median age 81 vs 80 years, p <0.001) and less likely to be female (35% vs 47.4%, p <0.001). After adjusting for differences in baseline characteristics and elective versus nonelective admission, patients with RBBB had a higher incidence of complete heart block (adjusted odds ratio [aOR] 4.77, confidence interval [CI] 4.55 to 5.01, p <0.001) and PPM implantation (aOR 4.15, CI 3.95 to 4.35, p <0.001) and no difference in-hospital mortality rate (aOR 0.85, CI 0.69 to 1.05, p = 0.137). Between 2016 and 2019, there was a 3.5% and 2.9% decrease in in-hospital PPM implantation in patients with and without RBBB, respectively. In conclusion, from 2016 to 2019, the rate of in-hospital PPM implantation decreased during index TAVI hospitalization in both patients with and without RBBB. However, in those with baseline RBBB, complete heart block complication rates requiring PPM implantation remain relatively high. Further research and advances are needed to continue to reduce complication rates and the need for PPM implantation.

Temporary Mechanical Circulatory Support: Left, Right, and Biventricular Devices

Temporary mechanical circulatory support (MCS) encompasses a wide array of invasive devices, which provide short-term hemodynamic support for multiple clinical indications. Although initially developed for the management of cardiogenic shock, indications for MCS have expanded to include prophylactic insertion prior to high-risk percutaneous coronary intervention, treatment of acute circulatory failure following cardiac surgery, and bridging of end-stage heart failure patients to more definitive therapies, such as left ventricular assist devices and cardiac transplantation. A wide variety of devices are available to provide left ventricular, right ventricular, or biventricular support. The choice of a temporary MCS device requires consideration of the clinical scenario, patient characteristics, institution protocols, and provider familiarity and training. In this review, the most common forms of left, right, and biventricular temporary MCS are discussed, along with their indications, contraindications, complications, cannulations, hemodynamic effects, and available clinical data.

Endoscopic Retrograde Cholangiopancreatography (ERCP) in Patients With Liver Cirrhosis: Analysis of Trends and Outcomes From the National Inpatient Sample Database

GOALS

We aimed to assess outcomes of patients with liver cirrhosis who underwent therapeutic or diagnostic endoscopic retrograde cholangiopancreatography (ERCP) to determine whether these patients had different outcomes relative to patients without cirrhosis.

BACKGROUND

ERCP is an important procedure for treatment of biliary and pancreatic disease. However, ERCP is relatively technically difficult to perform when compared with procedures such as esophagogastroduodenoscopy or colonoscopy. Little is known about how ERCP use affects patients with liver cirrhosis.

STUDY

Using patient records from the National Inpatient Sample (NIS) database, we identified adult patients who underwent ERCP between 2009 and 2014 using International Classification of Disease, Ninth Revision coding and stratified data into 2 groups: patients with liver cirrhosis and those without liver cirrhosis. We compared baseline characteristics and multiple outcomes between groups and compared outcomes of diagnostic versus therapeutic ERCP in patients with cirrhosis. A multivariate regression model was used to estimate the association of cirrhosis with ERCP outcomes.

RESULTS

A total of 1,038,258 hospitalizations of patients who underwent ERCP between 2009 and 2014 were identified, of which 31,294 had cirrhosis and 994,681 did not have cirrhosis. Of the patients with cirrhosis, 21,835 (69.8%) received therapeutic ERCP and 9459 (30.2%) received diagnostic ERCP. Patients with cirrhosis had more ERCP-associated hemorrhages (2.5% vs. 1.2%; P <0.0001) compared with noncirrhosis patients but had lower incidence of perforations (0.1% vs. 0.2%; P <0.0001) and post-ERCP pancreatitis (8.6% vs. 7%; P <0.0001). Cholecystitis was the same between groups (2.3% vs. 2.3%; P <0.0001). In patients with cirrhosis, those who received therapeutic ERCP had higher post-ERCP pancreatitis (7.9% vs. 5.1%; P <0.0001) and ERCP-associated hemorrhage (2.7% vs. 2.1%; P <0.0001) but lower incidences of perforation and cholecystitis (0.1% vs. 0.3%; P <0.0001) and cholecystitis (1.9 vs. 3.1%; P <0.0001) compared with those who received diagnostic ERCP.

CONCLUSIONS

Use of therapeutic ERCP in patients with liver cirrhosis may lead to higher risk of complications such as pancreatitis and postprocedure hemorrhage, whereas diagnostic ERCP may increase the risk of pancreatitis and cholecystitis in patients with cirrhosis. Comorbidities in cirrhosis patients may increase the risk of post-ERCP complications and mortality; therefore, use of ERCP in cirrhosis patients should be carefully considered, and further studies on this patient population are needed.

The association of racial differences with in-hospital outcomes of patients admitted for sinus node dysfunction

Background

The impact of race and its related social determinants of health on cardiovascular disease outcomes has been well documented. However, limited data exist regarding the association of race with in-hospital outcomes in patients admitted for sinus node dysfunction (SND).

Objective

To evaluate whether racial disparities exist in outcomes for patients hospitalized with a primary diagnosis of SND.

Methods

The National Inpatient Sample was queried from 2011 to 2018 for relevant ICD-9 and ICD-10 diagnosis and procedure codes. Baseline characteristics and in-hospital outcomes in patients with a primary diagnosis of SND were compared among White and non-White patients. A multivariate logistic regression model was used to adjust for potential confounding factors and statistically significant comorbidities between both cohorts.

Results

We identified 655,139 persons admitted with a primary diagnosis of SND, 520,926 (79.5%) of whom were White. Non-White patients had significantly higher all-cause mortality, length of stay, and total hospital cost. There were lower odds of pacemaker insertion (adjusted odds ratio [aOR] 1.13 [95% confidence interval (CI) 1.11–1.15]), temporary transvenous pacing (aOR 1.15 [95% CI 1.11–1.22]), and cardioversion (aOR 1.50 [95% CI 1.42–1.58]) in non-White patients. A subgroup analysis was performed and non-Hispanic Black race was predictive of a decreased odds of pacemaker insertion, cardioversion/defibrillation, and temporary transvenous pacing.

Conclusion

Significant differences of in-hospital outcomes exist between White and non-White patients with SND. These findings appeared to be primarily driven by disparities in non-Hispanic Black patients. Increased recognition and focused efforts to mitigate these disparities will improve the care of underrepresented populations treated for SND.

Hospitalizations and inpatient mortality for hyperosmolar hyperglycemic state over a decade

OBJECTIVES

This study aimed to describe rates and trends in hospitalizations, inpatient mortality, total hospital charges, and mean lengths of stay among adult patients hospitalized for hyperosmolar hyperglycemic state (HHS).

METHODS

The study included NIS databases 2008, 2010, 2012, 2014, 2016, and 2018. These databases were searched for hospitalizations with a principal discharge diagnosis of HHS in patients with T2DM using ICD codes (25020, 25022, and E110). Patients less than 18 years, elective hospitalizations, HHS in patients with T1DM or secondary diabetes mellitus were excluded. We used multivariable regression analysis to obtain trends in mortality, length of stay (LOS), and total hospital charges (THC).

RESULTS

Between 2008 and 2018, there was a trend towards increasing hospitalizations for T2DM with HHS (p trend < 0.001). The mean age over the period ranged from 56.9 to 59.1 years old. Men made up the majority of hospitalizations. Over the decade, there was a steady rise in the proportion of Whites and Hispanics with HHS, and Medicare was the most prevalent insurer overall. Inpatient mortality for HHS decreased from 1.44% in 2008 to 0.77% in 2018 (p trend 0.007). There was also a statistically significant decrease in both LOS and THC over the studied period.

CONCLUSIONS

Trends in HHS showed increased hospitalizations, LOS, and THC over the decade in the study period, but inpatient mortality declined.

Radiation Proctitis and Management Strategies

Radiotherapy (RT) is a treatment modality that uses high-energy rays or radioactive agents to generate ionizing radiation against rapidly dividing cells. The main objective of using radiation in cancer therapy is to impair or halt the division of the tumor cells. Over the past few decades, advancements in technology, the introduction of newer methods of RT, and a better understanding of the pathophysiology of cancers have enabled physicians to deliver doses of radiation that match the exact dimensions of the tumor for greater efficacy, with minimal exposure of the surrounding tissues. However, RT has numerous complications, the most common being radiation proctitis (RP). It is characterized by damage to the rectal epithelium by secondary ionizing radiation. Based on the onset of signs and symptoms, post-radiotherapy RP can be classified as acute or chronic, each with varying levels of severity and complication rates. The treatment options available for RP are limited, with most of the data on treatment available from case reports or small studies. Here, we describe the types of RT used in modern-day medicine and radiation-mediated tissue injury. We have primarily focused on the classification, epidemiology, pathogenesis, clinical features, treatment strategies, complications, and prognosis of RP.

Transbronchial Needle Aspiration Cytology and Purulent Pericarditis

Endobronchial ultrasound with transbronchial needle aspiration (TBNA) is commonly performed for the evaluation of mediastinal lymphadenopathy. Purulent pericarditis is a rare, yet potentially fatal complication of TBNA. It commonly presents with nonspecific symptoms such as chest pain, shortness of breath, palpitations, or vague abdominal discomfort. Additionally, more severe symptoms such as cardiac tamponade and even death have been reported. In this article, we present the case of a 58-year-old male who developed purulent pericardial effusion with tamponade thought to be caused by TBNA cytology. This case raises an important question regarding the current guidelines for prophylactic antibiotic treatment for patients at high risk of developing purulent pericarditis as a complication of TBNA.

Predictors of outcomes in hospitalized patients undergoing pacemaker insertion: Analysis from the national inpatient database (2016-2017)

BACKGROUND

Pacemaker implantation in the U.S. is rising due to an aging population. The aim of this analysis was to identify risk factors associated with increased mortality and complications in hospitalized patients requiring pacemaker implantation.

METHODS

We performed a retrospective analysis using the National Inpatient Sample database, identifying hospitalized patients who underwent pacemaker implantation using International Classification of Disease, Tenth Revision, Clinical Modification codes. Independent predictors of inpatient mortality were identified using multivariate logistic regression analysis.

RESULTS

There were 242,980 hospitalizations with pacemaker implantation during 2016 and 2017. The most frequently encountered indications for hospitalizations involving pacemaker insertion included sick sinus syndrome (SSS) (27.60%), complete atrioventricular (AV) block (21.57%), and second-degree AV block (7.83%). Chronic liver disease was associated with the highest adjusted odds of inpatient mortality (aOR = 5.76, 95% CI: 4.46 to 7.44, p < .001). Comorbid anemia had the highest statistically significant adjusted odds ratio (aOR) for predictors of post-procedural cardiac complications (aOR = 3.17, 95% CI: 2.81 to 3.58, p < .001). Mortality in hospitalized patients needing pacemaker implantation was 1.05%. About 3.36% of hospitalizations developed post procedural circulatory complications (PPCC), 2.45% developed sepsis, and 1.84% developed mechanical complications of cardiac electronic devices.

CONCLUSIONS

We identified several predictors of inpatient mortality in hospitalized patients undergoing pacemaker implantation, including chronic liver disease, protein-calorie malnutrition, chronic heart failure, anemia, and history of malignancy. Anemia, chronic liver disease, and congestive heart failure were independent predictors of adverse outcomes in such patients.

Increased inpatient mortality in patients hospitalized for atrial fibrillation and atrial flutter with concomitant amyloidosis: Insight from National Inpatient Sample (NIS) 2016-2017

Purpose

Using National Inpatient Database (NIS), comparison of clinical outcomes for patients primarily admitted for atrial fibrillation/flutter with and without a secondary diagnosis of amyloidosis was done. Inpatient mortality was the primary outcome and hospital length of stay (LOS), mean total hospital charges, odds of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block, cardiogenic shock and cardiac arrest were secondary outcomes.

Methods

NIS database of 2016, 2017 was used for only adult hospitalizations with atrial fibrillation/flutter as principal diagnosis with and without amyloidosis as secondary diagnosis using ICD-10 codes. Multivariate logistic with linear regression analysis was used to adjust for confounders.

Results

932,054 hospitalizations were for adult patients with a principal discharge diagnosis of atrial fibrillation/flutter. 830 (0.09%) of these hospitalizations had amyloidosis.

Atrial fibrillation/flutter hospitalizations with co-existing amyloidosis have higher inpatient mortality (4.22% vs 0.88%, AOR: 3.92, 95% CI 1.81–8.51, p = 0.001) and likelihood of having a secondary discharge diagnosis of cardiac arrest (2.40% vs 0.51%, AOR: 4.80, 95% CI 1.89–12.20, p = 0.001) compared to those without amyloidosis.

Conclusions

Hospitalizations of atrial fibrillation/flutter with co-existing amyloidosis have higher inpatient mortality and odds of having a secondary discharge diagnosis of cardiac arrest compared to those without amyloidosis. However, LOS, total hospital charges, likelihood of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block and cardiogenic shock were similar between both groups.

Hyperkalemia: Major but still understudied complication among heart transplant recipients

Hyperkalemia is a recognized and potentially life-threatening complication of heart transplantation. In the complex biosystem created by transplantation, recipients are susceptible to multiple mechanisms for hyperkalemia which are discussed in detail in this manuscript. Hyperkalemia in heart transplantation could occur pre-transplant, during the transplant period, or post-transplant. Pre-transplant causes of hyperkalemia include hypothermia, donor heart preservation solutions, conventional cardioplegia, normokalemic cardioplegia, continuous warm reperfusion technique, and ex-vivo heart perfusion. Intra-transplant causes of hyperkalemia include anesthetic medications used during the procedure, heparinization, blood transfusions, and a low output state. Finally, post-transplant causes of hyperkalemia include hemostasis and drug-induced hyperkalemia. Hyperkalemia has been studied in kidney and liver transplant recipients, but there is limited data on the incidence, causes, management, and prevention in heart transplant recipients. Hyperkalemia is associated with an increased risk of hospital mortality and readmission in these patients. This review describes the current literature pertaining to the causes, pathophysiology, and treatment of hyperkalemia in patients undergoing heart transplantation and focuses primarily on post-heart transplantation.

Systemic adverse effects and toxicities associated with immunotherapy: A review

Immunotherapy is rapidly evolving secondary to the advent of newer immunotherapeutic agents and increasing approval of the current agents by the United States Food and Drug Administration to treat a wide spectrum of cancers. Immunotherapeutic agents have gained immense popularity due to their tumor-specific action. Immunotherapy is slowly transforming into a separate therapeutic entity, and the fifth pillar of management for cancers alongside surgery, radiotherapy, chemotherapy, and targeted therapy. However, like any therapeutic entity it has its own adverse effects. With the increasing use of immuno-therapeutic agents, it is vital for physicians to acquaint themselves with these adverse effects. The aim of this review is to investigate the common systemic adverse effects and toxicities associated with the use of different classes of immunotherapeutic agents. We provide an overview of potential adverse effects and toxicities associated with different classes of immunotherapeutic agents organized by organ systems, as well as an extensive discussion of the current recommendations for treatment and clinical trial data. As we continue to see increasing usage of these agents in clinical practice, it is vital for physicians to familiarize themselves with these effects.

Association of non-alcoholic fatty liver disease with gallstone disease in the United States hospitalized patient population

BACKGROUND

Gallstones and cholecystectomy have been proposed as risk factors for non-alcoholic fatty liver disease (NAFLD). The reason for this may be that both gallstones, as well as NAFLD share several risk factors with regards to their development. Currently, there is a lack of sufficient evidence showing an association between these clinical conditions.

AIM

To determine whether there is a meaningful association between gallstones and cholecystectomy with NAFLD.

METHODS

We queried the National Inpatient Sample database from the years 2016 and 2017 using International Classification of Diseases, 10th revision, Clinical Modification diagnosis codes to identify hospitalizations with a diagnosis of gallstone disease (GSD) (includes calculus of gallbladder without cholecystitis without obstruction and acquired absence of gallbladder) as well as NAFLD (includes simple fatty liver and non-alcoholic steatohepatitis). Odds ratios (ORs) measuring the association between GSD (includes gallstones and cholecystectomy) and NAFLD were calculated using logistic regression after adjusting for confounding variables.

RESULTS

Out of 14294784 hospitalizations in 2016-2017, 159259 were found to have NAFLD. The prevalence of NAFLD was 3.3% in patients with GSD and 1% in those without. NAFLD was prevalent in 64.3% of women with GSD as compared to 35.7% of men with GSD. After controlling for various confounders associated with NAFLD and GSD, multivariate-adjusted analysis showed that there was an association between NAFLD with gallstones [OR = 6.32; 95% confidence interval (CI): 6.15-6.48] as well as cholecystectomy (OR = 1.97; 95%CI: 1.93-2.01). The association between NAFLD and gallstones was stronger in men (OR = 6.67; 95%CI: 6.42-6.93) than women (OR = 6.05; 95%CI: 5.83-6.27). The association between NAFLD and cholecystectomy was stronger in women (OR = 2.01; 95%CI: 1.96-2.06) than men (OR = 1.85; 95%CI: 1.79-1.92). P value was less than 0.001 for all comparisons.

CONCLUSION

NAFLD is more prevalent in women with GSD than men. The association between NAFLD and cholecystectomy/gallstones indicates that they may be risk factors for NAFLD.

Marijuana: A systems-based primer of adverse effects associated with use and an overview of its therapeutic utility

Marijuana use is on the rise in the United States. By the end of 2019, 33 states have legalized marijuana use and marijuana byproduct use for medical purposes. However, marijuana use does not come without side effects. This manuscript reviews the increasing usage of marijuana and the different forms (natural and synthetic) that patients may use when presenting to clinicians. It also addresses the biochemical and behavioral changes observed with marijuana use, including the location and changes associated with cannabinoid receptors (abbreviated CB1 and CB2). These two topics lead into an extensive review of the side effects of marijuana use. This manuscript discusses gastrointestinal side-effects, such as Cannabinoid Hyperemesis Syndrome, pancreatitis, and hepatotoxicity. It also briefly reviews cardiovascular, neurologic, and pulmonary side effects. This article provides an overview of therapeutic effects of marijuana including the antiemetic effect, its medical utility as an appetite stimulant, and usefulness in cancer patients post-chemotherapy. A thorough social history pertaining to marijuana use is an important consideration for clinicians in patients presenting with a variety of symptoms, including those effecting the gastrointestinal, cardiovascular, pulmonary, or neurologic systems.

Intermittent fasting: is there a role in the treatment of diabetes? A review of the literature and guide for primary care physicians

Background

Type 2 Diabetes is a metabolic disorder characterized by hyperglycemia that causes numerous complications with significant long-term morbidity and mortality. The disorder is primarily due to insulin resistance particularly in liver, skeletal muscle, and adipose tissue. In this review, we detail the hormonal mechanisms leading to the development of diabetes and discuss whether intermittent fasting should be considered as an alternative, non-medicinal treatment option for patients with this disorder.

Methods

We searched PubMed, Ovid MEDLINE, and Google Scholar databases for review articles, clinical trials, and case series related to type 2 diabetes, insulin resistance, and intermittent fasting. Articles were carefully reviewed and included based on relevance to our topic. We excluded abstracts and any non-English articles.

Results

The majority of the available research demonstrates that intermittent fasting is effective at reducing body weight, decreasing fasting glucose, decreasing fasting insulin, reducing insulin resistance, decreasing levels of leptin, and increasing levels of adiponectin. Some studies found that patients were able to reverse their need for insulin therapy during therapeutic intermittent fasting protocols with supervision by their physician.

Conclusion

Current evidence suggests that intermittent fasting is an effective non-medicinal treatment option for type 2 diabetes. More research is needed to delineate the effects of intermittent fasting from weight loss. Physicians should consider educating themselves regarding the benefits of intermittent fasting. Diabetic patients should consult their physician prior to beginning an intermittent fasting regimen in order to allow for appropriate oversight and titration of the patients medication regimen during periods of fasting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40842-020-00116-1.

Emerging therapeutics in the management of COVID-19

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019, COVID-19) pandemic has placed a tremendous burden on healthcare systems globally. Therapeutics for treatment of the virus are extremely inconsistent due to the lack of time evaluating drug efficacy in clinical trials. Currently, there is a deficiency of published literature that comprehensively discusses all therapeutics being considered for the treatment of COVID-19. A review of the literature was performed for articles related to therapeutics and clinical trials in the context of the current COVID-19 pandemic. We used PubMed, Google Scholar, and Clinicaltrials.gov to search for articles relative to the topic of interest. We used the following keywords: "COVID-19", "therapeutics", "clinical trials", "treatment", "FDA", "ICU", "mortality", and "management". In addition, searches through the references of retrieved articles was also performed. In this paper, we have elaborated on the therapeutic strategies that have been hypothesized or trialed to-date, the mechanism of action of each therapeutic, the clinical trials finished or in-process that support the use of each therapeutic, and the adverse effects associated with each therapeutic. Currently, there is no treatment that has been proven to provide significant benefit in reducing morbidity and mortality. There are many clinical trials for numerous different therapeutic agents currently underway. By looking back and measuring successful strategies from previous pandemics in addition to carrying out ongoing research, we provide ourselves with the greatest opportunity to find treatments that are beneficial.

Histoplasmosis and inflammatory bowel disease: A case report

BACKGROUND

Infection with Histoplasma capsulatum can lead to a disseminated disease involving the gastrointestinal tract presenting as diffuse abdominal pain and inflammatory diarrhea which may mimic inflammatory bowel disease (IBD).

CASE SUMMARY

In the current report, we discuss the case of a 41-year old male who presented to the emergency department with complaints of high-grade intermittent fevers and severe abdominal pain with associated diarrhea and hematochezia. Laboratory results demonstrated transaminitis and elevated erythrocyte sedimentation rate, C-reactive protein and ferritin levels. The patient’s presentation was thought to be an exacerbation of his underlying IBD, but further investigations revealed a positive Histoplasma antigen in the urine. The patient was offered a colonoscopy and biopsy to confirm the diagnosis; however, he refused. He was treated with itraconazole and showed significant improvement of his symptoms, thereby confirming the diagnosis of gastrointestinal histoplasmosis.

CONCLUSION

Here within, we provide a review of IBD, evaluation of chronic diarrhea, and gastrointestinal histoplasmosis.

Gastrointestinal amyloidosis: A focused review

Amyloidosis, a heterogenous group of disorders, is characterized by the extracellular deposition of autologous, insoluble, fibrillar misfolded proteins. These extracellular proteins deposit in tissues aggregated in ß-pleated sheets arranged in an antiparallel fashion and cause distortion to the tissue architecture and function. In the current literature, about 60 heterogeneous amyloidogenic proteins have been identified, out of which 27 have been associated with human disease. Classified as a rare disease, amyloidosis is known to have a wide range of possible etiologies and clinical manifestations. The exact incidence and prevalence of the disease is currently unknown. In both systemic and localized amyloidosis, there is infiltration of the abnormal proteins in the layers of the gastrointestinal (GI) tract or the liver parenchyma. The gold standard test for establishing a diagnosis is tissue biopsy followed by Congo Red staining and apple-green birefringence of the Congo Red-stained deposits under polarized light. However, not all patients may have a positive tissue confirmation of the disease. In these cases additional workup and referral to a gastroenterologist may be warranted. Along with symptomatic management, the treatment for GI amyloidosis consists of observation or localized surgical excision in patients with localized disease, and treatment of the underlying pathology in cases of systemic amyloidosis. In this review of the literature, we describe the subtypes of amyloidosis, with a primary focus on the epidemiology, pathogenesis, clinical features, diagnosis and treatment strategies available for GI amyloidosis.

Current immunotherapy in gastrointestinal malignancies A Review

Immunotherapy is an extremely important breakthrough and an exciting new modality of treatment for a wide spectrum of cancers. It is focused around developing agents to stimulate or suppress the immune system, in a specific manner, to fight off a wide spectrum of diseases, particularly cancers. Traditional therapies available for the treatment of cancers include surgical intervention, chemotherapy, radiation therapy or a combination of these, which tend to be very non-specific. However, immunotherapy shows a stark difference from conventional therapy, in fact, that it has a high level of specificity for the tumor-specific antigens. The recent success of cancer immunotherapies in clinical trials is slowly revolutionizing the landscape for cancer therapy. The US Food and Drug Administration has approved numerous agents, after clinical trials showed promising results, for the treatment of multiple cancers. The role of immunotherapy in gastrointestinal cancers has also been very promising, particularly in patients with advanced metastatic disease or malignancies refractory to initial treatment. In this review of literature, we detail and discuss the immunotherapy agents approved for the treatment of GI cancers and glance at the future of immunotherapy for patients with these cancers.

Utilization of extracorporeal membrane oxygenation during the COVID-19 pandemic

The ongoing outbreak of severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2, or coronavirus disease 2019 (COVID-19)] was declared a pandemic by the World Health Organization on March 11, 2020. Worldwide, more than 65 million people have been infected with this SARS-CoV-2 virus, and over 1.5 million people have died due to the viral illness. Although a tremendous amount of medical progress has been made since its inception, there continues to be ongoing research regarding the pathophysiology, treatments, and vaccines. While a vast majority of those infected develop only mild to moderate symptoms, about 5% of people have severe forms of infection resulting in respiratory failure, myocarditis, septic shock, or multi-organ failure. Despite maximal cardiopulmonary support and invasive mechanical ventilation, mortality remains high. Extracorporeal membrane oxygenation (ECMO) remains a valid treatment option when maximal conventional strategies fail. Utilization of ECMO in the pandemic is challenging from both resource allocation and ethical standpoints. This article reviews the rationale behind its use, current status of utilization, and future considerations for ECMO in critically ill COVID-19 patients.

Implantable cardiac devices in geriatric patients: a primer for primary and geriatric physicians

In the next 20 years, the percentage of people older than 65 years of age in the United States is expected to double. Heart disease is the leading cause of mortality in developed nations, including the United States. Due to the increased incidence of cardiac disease in elderly patients, the need for special treatment considerations, including cardiac devices, may be necessary to reduce morbidity and mortality in this patient population. The purpose of this review is to provide a primer of the common cardiac devices used in the management of cardiac disorders in the geriatric patient population. In order to do this, we have performed a literature review for articles related to cardiac devices published between 2000 and 2020, in addition to reviewing guidelines and recommendations from relevant professional societies. We provide readers with an overview of several cardiac devices including implantable loop recorders, pacemakers, cardiac resynchronization therapy, automated implantable cardiac defibrillators, watchman devices, and ventricular assist devices. Indications, contraindications, clinical trial data, and general considerations in the geriatric population were included. Due to the aging population and increased incidence of cardiac disease, clinicians should be aware of the indications and contraindications of cardiac device therapy in the management of various cardiac conditions that afflict the geriatric population.

In-hospital outcomes and prevalence of comorbidities in patients with ST-elevation myocardial infarction with and without infective endocarditis: insight from the National Inpatient Sample (2013-2014)

In patients with infective endocarditis (IE), ST-elevation myocardial infarction (STEMI) is an uncommon phenomenon. Due to limited data, we intend to evaluate the clinical outcomes in hospitalized patients with STEMI with and without underlying IE. Mortality and morbidity are exponentially worse in STEMI with concomitant IE when compared with without IE. Patients with primary diagnosis of STEMI with and without IE were identified by querying the Healthcare Cost and Utilization Project database of the National Inpatient Sample for the years 2013 and 2014 based on International Classification of Diseases, Ninth Revision codes. During 2013 and 2014, a total of 117,386 patients were admitted with the principle diagnosis of STEMI, out of whom 305 had comorbid IE. There was a significantly increased in-hospital mortality (27.5% vs 10.8%), length of stay (LOS) (14 days vs 5 days), acute kidney injury (AKI; 44.9% vs 18.7%), stroke (23.6% vs 3%), aortic valve replacement (9.5% vs 0.3%), mitral valve replacement (0.2%-5.2%), sepsis (50% vs 6%) and acute respiratory failure (36.7% vs 16.7%) in patients with STEMI with IE when compared with patients with STEMI and without comorbid IE. STEMI without IE had a higher number of angiographies (58.7% vs 25.9%) and percutaneous coronary interventions (50.7% vs 14.4%) during the hospital course when compared with STEMI with IE. In conclusions, hospitalized patients with STEMI with a concurrent diagnosis of IE are at higher risk of in-hospital mortality, increased LOS, AKI, stroke, valve replacements, and acute respiratory failure.

In-hospital outcomes and prevalence of comorbidities in patients with infective endocarditis with and without heart blocks: Insight from the National Inpatient Sample

Infective endocarditis (IE) complicated by heart block can have adverse outcomes and usually requires immediate surgical and cardiac interventions. Data on outcomes and trends in patients with IE with concurrent heart block are lacking. Patients with a primary diagnosis of IE with or without heart block were identified by querying the Healthcare Cost and Utilization Project database, specifically the National Inpatient Sample for the years 2013 and 2014, based on International Classification of Diseases Clinical Modification Ninth Revision codes. During 2013 and 2014, a total of 18,733 patients were admitted with a primary diagnosis of IE, including 867 with concurrent heart blocks. Increased in-hospital mortality (13% vs 10.3%), length of stay (19 vs 14 days), and cost of care ($282,573 vs $223,559) were found for patients with IE complicated by heart block. Additionally, these patients were more likely to develop cardiogenic shock (8.9% vs 3.2%), acute kidney injury (40.1% vs 32.6%), and hematologic complications (19.3% vs 15.2%), and require placement of a pacemaker (30.6% vs 0.9%). IE and concurrent heart block resulted in increased requirement for aortic (25.7% vs 6.1%) and mitral (17.3% vs 4.2%) valvular replacements. Conclusion was made that IE with concurrent heart block worsens in-hospital mortality, length of stay, and cost for patients. Our analysis demonstrates an increase in cardiac procedures, specifically aortic and/or mitral valve replacements, and Implantable Cardiovascular Defibrillator/Cardiac Resynchronization Therapy/ Permanent Pacemaker (ICD/CRT/PPM) placement in IE with concurrent heart block. A close telemonitoring system and prompt interventions may represent a significant mitigation strategy to avoid the adverse outcomes observed in this study.

Gastrointestinal implications in COVID-19

Believed to have originated from a local Huanan Seafood Wholesale Market in Wuhan, Hubei Province in China, the COVID-19 has had an unprecedented and catastrophic impact on humanity, with the WHO declaring it a global pandemic. Although the first case of COVID-19 was reported in December 2019, the primary source and intermediate host have not been confirmed, but human-to-human transmission has been universally accepted. The main mode of transmission of the virus is through respiratory droplets along with prominent respiratory system involvement. However, fecal-oral transmission due to the shedding of the virus in the gastrointestinal (GI) tract may continue for up to 10 weeks after respiratory clearance and is fast becoming important. SARS-CoV-2 shows a high affinity to ACE2 receptors, making sites of high ACE2 receptor expression, such as lungs, GI tract, brain, kidneys, heart, liver and immune system, a prime target for infection. Through this literature review, we aim to summarize the current knowledge of immunological pathways that contribute to the disease with a focus specifically on the GI tract involvement. We direct attention to the pathophysiological mechanism of involvement of the GI tract leading to symptomatic manifestations, track GI organ-specific viral loads to compare and contrast with other organ systems. We briefly detail specific treatment strategies from a GI disease standpoint and mention special considerations when there is involvement of the GI tract.

Telemedicine, the current COVID-19 pandemic and the future: a narrative review and perspectives moving forward in the USA

A narrative review was conducted to examine the current state of the utilisation of telemedicine amid the current COVID-19 pandemic and to evaluate the benefits of continuing telemedicine usage in the future. A literature review was performed for articles related to telemedicine. Databases including PubMed, Google Scholar, Cochrane Library and Ovid MEDLINE were searched. Three reviewers independently performed article selection based on relevance to our topic. We included all articles between 1990 and 2020 related to telemedicine using the following keywords: ‘telemedicine’, ‘telehealth’, ‘policy’, ‘COVID-19’, ‘regulation’, ‘rural’, ‘physical examination’, ‘future’. A total of 60 articles were identified, and through careful selection we narrowed the final number of articles to 42 based on relevance to our topic. Telemedicine has been rapidly evolving over the past several decades. Issues with regulation and reimbursement have prevented its full immersion into the healthcare system. During the current pandemic, Centers for Medicare and Medicaid services have expanded access to telemedicine services. The advantages of telemedicine moving forward include its cost-effectiveness, ability to extend access to specialty services and its potential to help mitigate the looming physician shortage. Disadvantages include lack of available technological resources in certain parts of the country, issues with security of patient data, and challenges in performing the traditional patient examination. It is critically important that changes are made to fully immerse telemedicine services into the healthcare landscape in order to be prepared for future pandemics as well as to reap the benefits of this service in the future.

COVID-19 and Acute Lupus Pneumonitis: Diagnostic and Treatment Dilemma

In this article, we present a case of a young female patient with previously diagnosed lupus pneumonitis, now with a flare and new superimposed COVID-19 infection that was treated with intravenous steroids. On computed tomography scans, she had extensive interstitial lung fibrosis in addition to a positive COVID-19 polymerase chain reaction test requiring 6 L of oxygen via nasal cannula on admission. After administration of methylprednisolone, the patient improved and was weaned off her oxygen requirements and was discharged home.

COVID-19 and Hypercoagulability: A Review

Thrombotic complications of the novel coronavirus (COVID-19) are a concerning aspect of the disease, due to the high incidence in critically ill patients and poor clinical outcomes. COVID-19 predisposes patients to a hypercoagulable state, however, the pathophysiology behind the thrombotic complications seen in this disease is not well understood. Several mechanisms have been proposed and the pathogenesis likely involves a host immune response contributing to vascular endothelial cell injury, inflammation, activation of the coagulation cascade via tissue factor expression, and shutdown of fibrinolysis. Treatments targeting these pathways may need to be considered to improve clinical outcomes and decrease overall mortality due to thrombotic complications. In this review, we will discuss the proposed pathophysiologic mechanisms for thrombotic complications in COVID-19, as well as treatment strategies for these complications based on the current literature available.