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.

Collagen-Specific HSP47+ Myofibroblasts and CD163+ Macrophages Identify Profibrotic Phenotypes in Deceased Hearts With SARS-CoV-2 Infections

Background Cardiac fibrosis complicates SARS-CoV-2 infections and has been linked to arrhythmic complications in survivors. Accordingly, we sought evidence of increased HSP47 (heat shock protein 47), a stress-inducible chaperone protein that regulates biosynthesis and secretion of procollagen in heart tissue, with the goal of elucidating molecular mechanisms underlying cardiac fibrosis in subjects with this viral infection. Methods and Results Using human autopsy tissue, immunofluorescence, and immunohistochemistry, we quantified Hsp47⁺ cells and collagen α 1(l) in hearts from people with SARS-CoV-2 infections. Because macrophages are also linked to inflammation, we measured CD163⁺ cells in the same tissues. We observed irregular groups of spindle-shaped HSP47⁺ and CD163⁺ cells as well as increased collagen α 1(I) deposition, each proximate to one another in "hot spots" of ≈40% of hearts after SARS-CoV-2 infection (HSP47⁺ P<0.05 versus nonfibrotics and P<0.001 versus controls). Because HSP47⁺ cells are consistent with myofibroblasts, subjects with hot spots are termed "profibrotic." The remaining 60% of subjects dying with COVID-19 without hot spots are referred to as "nonfibrotic." No control subject exhibited hot spots. Conclusions Colocalization of myofibroblasts, M2(CD163⁺) macrophages, and collagen α 1(l) may be the first evidence of a COVID-19-related "profibrotic phenotype" in human hearts in situ. The potential public health and diagnostic implications of these observations require follow-up to further define mechanisms of viral-mediated cardiac fibrosis.

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.

A Triad of Pericarditis, Pericardial Effusion, and Pleural Effusion as the Predominant Presentation of Rheumatoid Arthritis - A Case Report

We describe a case of a 67-year-old African American man who presented to the emergency department with a sharp, pleuritic chest pain and shortness of breath. After several admissions and extensive workup, he ultimately was diagnosed with a persistent pleural effusion, pericardial effusion, and secondary constrictive pericarditis due to rheumatoid arthritis. By highlighting immunological disorders such as rheumatoid arthritis in the differential diagnosis, in the setting of a refractory pericardial effusion and serositis, this case report addresses key aspects of the presentation both in the emergency and inpatient settings, reviews the criteria for a rheumatoid arthritis diagnosis, and emphasizes areas of importance in predominantly cardiopulmonary extra-articular manifestations of a typically musculoskeletal disease.

Comparing outcomes of diabetic ketoacidosis hospitalisations in patients with diastolic heart failure: A retrospective propensity matched analysis of the nationwide inpatient sample

INTRODUCTION

Diabetic ketoacidosis (DKA) is a known complication of patients with diabetes mellitus. The aim of this study was to compare the outcomes of patients admitted with a diagnosis of DKA with, and without, diastolic heart failure (DHF).

METHODS

This was a population-based, retrospective, observational study using data from the National Inpatient Sample database for the years 2016 and 2017. The primary outcome was in-hospital mortality. Secondary outcomes were rates of sepsis, non-ST elevation myocardial infarctions (NSTEMI), acute kidney failure, acute respiratory failure (ARF), deep vein thrombosis, pulmonary embolism, mean length of hospital stay (LOS) and total hospital charges (THC).

RESULTS

There was no statistically significant difference for the adjusted odds for in-hospital mortality between patients with and without DHF (adjusted odds ratio [aOR]: 0.55, 95% confidence interval [CI] 0.28-1.08, p = 0.081). Patients with DKA and DHF had increased odds of developing an NSTEMI (aOR: 1.31, 95% CI: 1.01-1.70, p = 0.045) or ARF (aOR: 1.82, 95% CI: 1.38-2.40, p < 0.001) during the same admission compared to patients without DHF. Patients with DKA and DHF also had an increased mean THC (6500 CI: 1900-11,200, p = 0.0006) in US dollars and increased LOS (0.7, 95% CI: 0.2-1.3, p = 0.011) in days when compared to patients without DHF.

CONCLUSIONS

Patients with DKA showed no statistically significant difference in mortality if they did or did not have a secondary diagnosis of DHF within the same admission.

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.

Pembrolizumab-Induced Diabetes Mellitus Presenting as Diabetic Ketoacidosis in a Patient With Metastatic Colonic Adenocarcinoma

Immunotherapy drugs are gaining popularity in the treatment of certain malignancies due to the success of these agents in recent clinical trials. Pembrolizumab is an immune checkpoint inhibitor that acts via binding to programmed cell death 1 (PD-1) receptors on T-cells, allowing for the constitutive activation of T-cells to fight malignant tumor cells. Immune checkpoint molecules such as PD-1 act to inhibit T-cell function, promoting tolerance to self-antigens. Inhibition of these molecules may lead to increased T-cell activation against cancer cells, but also against healthy tissue, leading to the side effects of these medications known as immune-related adverse events. In this article, we present the case of a 77-year-old female with a history of metastatic colonic adenocarcinoma presenting with new-onset diabetes mellitus and diabetic ketoacidosis in the setting of receiving pembrolizumab chemotherapy. Our patient was treated with hydration, insulin therapy, and management of her electrolytes, ultimately being discharged with the need for home insulin therapy to manage her new-onset diabetes. There are no current guidelines for the management or surveillance of patients receiving pembrolizumab chemotherapy, and further research should be done to determine which patients are at highest risk to developing this rare but potentially lethal side effect.

Management of Postural Orthostatic Tachycardia Syndrome in the Absence of Randomized Controlled Trials

Postural orthostatic tachycardia syndrome (POTS) is a clinical syndrome causing patients to experience light-headedness, palpitations, tremors, and breathlessness upon assuming an upright posture. Despite the absence of available long-term, multicenter, randomized controlled trial data, this literature review aims to concisely present the nonpharmacological and pharmacological interventions that have been used in the treatment of POTS reported to date by cross-sectional studies, cohort studies, and retrospective studies. We attempt to classify treatments as first-, second-, and third-line therapies based on our own experience and available data.

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.

ST-segment elevation during arrhythmia ablations-A review

Coronary injury presenting as ST segment elevation (STE) during ablation procedures for different arrhythmias is a rare and most feared complication. There have been multiple reports on STE during various ablation procedures in the recent past. Herein, we review various mechanisms, presentations, and management of STE observed during various ablations, including atrial fibrillation ablation cavotricuspid isthmus and ablation, supraventricular tachycardia ablations, coronary sinus ablation, and ventricular arrhythmia ablations.

Gastric Antral Vascular Ectasia: Trends of Hospitalizations, Biodemographic Characteristics, and Outcomes With Watermelon Stomach

Background

Gastric antral vascular ectasia (GAVE) syndrome is a rare but significant cause of acute or chronic gastrointestinal (GI) bleeding, particularly in the elderly. The primary objective of this study was to determine the biodemographic characteristics, adverse outcomes, and the impact of GAVE hospitalizations on the US healthcare system.

Methods

This retrospective database cross-sectional study used the National Inpatient Sample (NIS) from 2001 to 2011 to identify all adult hospitalizations with a primary discharge diagnosis of GAVE, with and without hemorrhage, using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Individuals less than 17 years of age were excluded from the study. The outcomes included biodemographic characteristics, comorbidity measures, and inpatient mortality and the burden of the disease on the US healthcare system in terms of healthcare cost and utilization.

Results

We noted an increase in the total hospitalizations for GAVE from 25,423 in 2001 to 44,787 in 2011. Furthermore, GAVE hospitalizations with hemorrhage rose from 19,168 in 2001 to 27,679 in 2011 while GAVE hospitalization without hemorrhage increased from 6,255 in 2001 to 17,108 in 2011. We also noted a female predominance, the proportional trend of which did not show significant difference from 2001 to 2011. For GAVE hospitalizations, the inpatient mortality decreased from 2.20% in 2001 to 1.73% in 2011. However, the cost of hospitalization increased from $11,590 in 2001 to $12,930 in 2011. After adjusting for possible confounders, we observed that the presence of hemorrhage in GAVE hospitalizations was associated with an increased risk of mortality (odds ratio (OR): 1.27; 95% confidence interval (CI): 1.1 - 1.46; P = 0.001).

Conclusions

For the study period, the total number of GAVE hospitalizations increased with an increase noted in the proportion of GAVE hospitalizations without bleeding, reflecting an improvement in diagnostic and therapeutic techniques. Although inpatient mortality for GAVE slightly decreased, we noted a significant increase in the cost of care likely secondary to increased use of advanced and expensive interventions.

FDG-PET Versus PSMA-PET: A Patient With Prostate Cancer

A 64-year old male presented to the hospital with a 1-week history of stools with bright red blood. Subsequent colonoscopy with a biopsy revealed a low-lying, moderately differentiated, rectal adenocarcinoma. A pelvic magnetic resonance imaging done afterwards showed a possible T3N1 rectal cancer with intact muscularis mucosa and a singular presacral lymph node enlargement. Furthermore, a suspicious peripheral prostatic enlargement and a possible left iliac crest sclerotic bone lesion were incidentally identified. ¹⁸F-FDG (fluorodeoxyglucose) PET (positron emission tomography) scan confirmed a primary FDG avid rectal tumor and a presacral lymph node; however, there was no prostate or iliac crest uptake. A serum prostate-specific antigen performed in the hospital returned with a value of 37 ng/mL, which prompted a prostate biopsy, eventually returning as positive for adenocarcinoma. Consequently, a ⁶⁸Ga-PSMA PET scan to rule out possible metastatic prostate disease revealed increased PSMA expression in the prostate only. After consultation with the radiologist and nuclear medicine physician who concluded the iliac crest lesion is likely not cancerous, the final diagnosis of T3N1 rectal cancer with simultaneous high-grade prostate adenocarcinoma was declared. This case highlights the low sensitivity of ¹⁸F-FDG PET scans for prostate cancer, the need for routine serum prostate-specific antigen screening, and the progression of ⁶⁸Ga-PSMA PET as a diagnostic tool for prostate cancer.

Monoclonal Gammopathy of Renal Significance-A Rare Renal Presentation: A Review of Cases Reported

Monoclonal gammopathy of undetermined significance is a precursor to multiple myeloma characterized by monoclonal gammopathy without evidence of end organ damage. Some patients with clonal plasma cell disorder that do not meet the requirements for multiple myeloma have been seen to develop pathologic renal disease due to direct effects from deposition of monoclonal protein, referred to as monoclonal gammopathy of renal significance. In this article, we present a rare renal manifestation of monoclonal gammopathy of renal significance as focal segmental glomerulosclerosis.

The 2020 ACC/AHA Guidelines for Management of Patients With Valvular Heart Disease: Highlights and Perioperative Implications

Valvular heart disease contributes to a large burden of morbidity and mortality in the United States. During the last decade there has been a paradigm shift in the management of valve disease, primarily driven by the emergence of novel transcatheter technologies. In this article, the latest update of the American College of Cardiology/American Heart Association valve heart disease guidelines is reviewed.

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.

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.

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.

The Effect of Atrial Fibrillation on Inpatient Outcomes of Patients with Acute Pancreatitis: A Two-year National Inpatient Sample Database Study

Limited published data exist regarding the association of atrial fibrillation (AF) and acute pancreatitis. To test our hypothesis that AF increases mortality and clinical outcomes in patients with acute pancreatitis, we conducted a cross-sectional data review of the National Inpatient Sample (NIS) database. The NIS database was reviewed for the collection of data on patient hospitalizations in 2016 and 2017. Patients diagnosed with acute pancreatitis with and without concomitant AF were included in the analysis. The International Classification of Diseases, 10th revision coding system was used for the variables of interest. The Stata software program (StataCorp LLC, College Station, TX, USA) was used to perform statistical analyses. The chi-squared test or analysis of variance was used to identify differences in demographic characteristics between the groups. The study population included two groups of patients: those with acute pancreatitis only (n = 542,440) and those with both acute pancreatitis and AF (n = 32,790). The group with acute pancreatitis and AF had a two- to threefold higher rate of mortality [adjusted odds ratio (OR): 2.59; 95% confidence interval (CI): 2.04-3.28] and increased length of stay (adjusted OR: 1.28; 95% CI: 1.08-1.48). Also, significantly higher odds of sepsis (adjusted OR: 2.49; 95% CI: 2.06-3.01), congestive heart failure (adjusted OR: 3.16; 95% CI: 2.87-3.49), acute coronary syndrome (adjusted OR: 1.61; 95% CI: 1.17-2.21), stroke (adjusted OR: 3.94; 95% CI: 1.42-10.93), and acute kidney injury (adjusted OR: 1.42; 95% CI: 1.30-1.55) were observed in patients with acute pancreatitis and AF relative to in patients with acute pancreatitis only. Our results suggest AF increases mortality in patients with acute pancreatitis and that patients with acute pancreatitis and AF are at greater risk of worse clinical outcomes.

Sudden cardiac death: epidemiology, pathogenesis and management

Sudden cardiac death (SCD) is an unexpected sudden death due to a heart condition, that occurs within one hour of symptoms onset. SCD is a leading cause of death in western countries, and is responsible for the majority of deaths from cardiovascular disease. Moreover, SCD accounts for mortality in approximately half of all coronary heart disease patients. Nevertheless, the recent advancements made in screening, prevention, treatment, and management of the underlying causes has decreased this number. In this article, we sought to review established and new modes of screening patients at risk for SCD, treatment and prevention of SCD, and the role of new technologies in the field. Further, we delineate the current epidemiologic trends and pathogenesis. In particular, we describe the advancement in molecular autopsy and genetic testing, the role of target temperature management, extracorporeal membrane oxygenation (ECMO), cardiopulmonary resuscitation (CPR), and transvenous and subcutaneous implantable cardioverter devices (ICDs).

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.

Coexisting Cirrhosis Worsens Inpatient Outcomes in Patients With Infective Endocarditis: A Cross-Sectional Analysis of the National Inpatient Sample 2013-2014

Introduction

Cirrhosis is known to be an important prognostic factor in determining morbidity and mortality in preoperative cardiac risk assessment for cardiac surgery. Data is limited on outcomes in patients with infective endocarditis (IE) and comorbid liver cirrhosis. The objective of our study is to evaluate the clinical outcomes in patients suffering from IE both with and without underlying liver cirrhosis as well as to determine rates of in-hospital mortality and factors that contribute to this outcome.

Hypothesis

Liver cirrhosis worsens clinical outcomes in patients with IE.

Materials and methods

Patients with a principal diagnosis of IE with and without liver cirrhosis were identified by querying the Healthcare Cost and Utilization (HCUP) database, specifically the National Inpatient Sample for the years 2013 and 2014 using International Classification of Diseases, Ninth Revision (ICD-9) codes.

Results

During 2013 and 2014, a total of 17,952 patients were admitted with a diagnosis of IE, out of whom 780 had concurrent liver cirrhosis. There was increased in-hospital mortality [15.6% vs 10.2%, aOR = 1.57 (1.27-1.93)], acute kidney injury [41.4% vs 32.6%, aOR = 1.45 (1.24-1.69)], and hematologic complications [32.1 vs 14.7%, aOR = 2.87 (2.44-3.37)] in patients with IE with liver cirrhosis when compared to patients with IE without liver cirrhosis. Patients having IE without liver cirrhosis underwent an increased number of interventions, i.e. aortic (7.2 vs 3.7%, aOR = 0.51 (0.34-0.76)) and mitral (4.9% vs 3.4%, aOR = 0.39 (0.23-0.69)) valvular replacements as compared to those with liver cirrhosis, which may explain the increased mortality seen in patients with liver cirrhosis.

Conclusion

Liver cirrhosis is an important prognostic risk factor for in-hospital mortality in patients with IE. The coagulopathic state in addition to increased rates of bleeding complications and renal dysfunction make these patients poor surgical candidates thus contributing to higher mortality. Further research into the individual risk factors contributing to the increased mortality rates in patients with IE and cirrhosis is required.

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.

Atezolizumab-Induced Bell's Palsy in a Patient With Small Cell Lung Cancer

Immune checkpoint inhibitors are rapidly becoming popular therapeutic options for patients suffering from a number of malignancies. Atezolizumab is a programmed cell death ligand-1 inhibitor, and binding to this ligand decreases the ability of tumor cells to evade the immune system, resulting in self-tolerance. While inhibition of these molecules leads to increased T-cell destruction of tumor cells, it also may lead to autoimmune destruction of healthy cells. Neurotoxicity is a rare complication of immune checkpoint inhibitor therapy, and facial palsy as a complication of atezolizumab therapy has only been reported in one additional study. We present the case of a 68-year-old female with a history of small cell carcinoma of the lung presenting with sudden-onset facial palsy and numbness of the distal extremities in the setting of receiving atezolizumab immunotherapy. Our patient was managed with temporary cessation of her immunotherapy, oral prednisone, and supportive measures. Within 4 weeks, the patient had complete resolution of her facial palsy and was able to resume immunotherapy without further complication. Clinicians should be aware of this rare adverse effect in order to enact early management including temporary cessation of therapy to prevent morbidity in patients undergoing immunotherapy.

Epstein-Barr Virus Versus Novel Coronavirus-Induced Hemophagocytic Lymphohistocytosis: The Uncharted Waters

Hemophagocytic lymphohistocytosis (HLH) is a hyperinflammatory syndrome characterized by fever, hepatosplenomegaly, and pancytopenia. It may be associated with genetic mutations or viral/bacterial infections, most commonly Epstein-Barr virus (EBV) and cytomegalovirus. As for the novel coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), also known as COVID-19 (coronavirus disease-2019), the cytokine storm it triggers can theoretically lead to syndromes similar to HLH. In this article, we report a case of a 28-year-old female who presented with high-grade fevers, found to have both SARS-CoV-2 and EBV infections, and eventually began to show signs of early HLH. To our knowledge, this is the first case reported in literature that raises the possibility of SARS-CoV-2–related HLH development.

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.

Resistant Hypertension Secondary to Severe Renal Artery Stenosis With Negative Duplex Ultrasound: A Brief Review of Different Diagnostic Modalities

Renal artery stenosis is a cause of resistant hypertension, which can present with several features such as severe hypertension, deterioration of renal function (with or without associated angiotensin-converting inhibitor or angiotensin receptor blocker therapy), and flash pulmonary edema. When evaluating for the presence of renal artery stenosis, the most widely utilized imaging modalities are duplex ultrasonography and computed tomography angiography. In this article, we discuss the case of a 77-year-old female who presented with shortness of breath and mild pulmonary edema, secondary to hypertensive emergency. Later, she was diagnosed with renal artery stenosis and underwent stent placement in the left renal artery. Our case highlights the different diagnostic modalities and emphasizes that the most commonly used screening, which is duplex ultrasonography, was performed on our patient but gave a false-negative result, despite high-grade stenosis, which was later diagnosed on computed tomography angiography.

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.

Acute Recurrent Exacerbations of Mesenteric Panniculitis With Immunosuppressive Therapy: A Case Report and a Brief Review

Mesenteric panniculitis (MP) is a rare, benign, and idiopathic disorder characterized by chronic inflammation of the mesenteric adipose tissue of the small intestine. The exact etiology of MP is unknown and its associations with underlying malignancies continues to be poorly understood. In this case report, we describe a rare case of acute exacerbations of MP in a middle-age female with a known past medical history of non-Hodgkin’s lymphoma in remission and small bowel resection for a localized carcinoid tumor. The patient was diagnosed with MP 4 years ago and started on tamoxifen therapy with adequate control of her symptoms. Last year, she reported to the emergency department with multiple episodes of sudden-onset, severe, and localized right upper quadrant abdominal pain and nausea without vomiting. She was diagnosed with an acute exacerbation of MP and a decision was made to add 60 mg prednisone daily in addition to her tamoxifen regimen. She remained symptomatically stable for the next 6 months after the start of dual therapy with tamoxifen and prednisone. However, for the past 6 months, the patient reported to the emergency department on an average of 2 times/month with the same recurrent symptoms despite high compliance with tamoxifen and prednisone therapy. She was admitted for her pain management and her dose of prednisone was increased and she was subsequently discharged home with improvement of her symptoms. Her tamoxifen was switched to mycophenolate on her follow-up visit with gastrointestinal clinic, and her disease has remained stable for the past 2 months. Our case report discusses in-depth the literature on MP and its management. We also detail the steps in management of a rare case of recurrent acute exacerbations of MP despite the patient being on immunosuppressive therapy.

Optimal glucocorticoid dose and the effects on mortality, length of stay, and readmission rates in patients diagnosed with acute exacerbation of chronic obstructive pulmonary disease (AECOPD)

The burden of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is staggering on a national and global level. Yet, surprisingly, there is a profound lack of treatment standardization with glucocorticoids in the treatment of AECOPD. In this review, we bring attention to specific literature that use a cut-off of 60 mg prednisone equivalent per day when distinguishing between high-dose and low-dose glucocorticoid treatment. We hope this review encourages future research to begin incrementally lowering the cut-off dose of 60 mg to discover if mortality, length of hospital stays, and readmission rates change between high-dose and low-dose glucocorticoid treatment. The final hope would be to establish an optimal glucocorticoid dose to treat AECOPD and eliminate treatment ambiguity.