Safety of Transcatheter Aortic Valve Replacement in Patients with Aortic Aneurysm: A Propensity-Matched Analysis

Introduction

There is a paucity of data regarding the outcomes of transcatheter aortic valve replacement (TAVR) among patients with thoracic or abdominal aortic aneurysms (AA). Using the Nationwide Inpatient Sample (NIS) database, we explored the safety of TAVR among patients with a diagnosis of AA.

Methods

We queried the National Inpatient Sample database (2012–2017) for hospitalized patients undergoing TAVR, using ICD-9 and ICD-10 codes for endovascular TAVR. Reports show that > 95% of endovascular TAVR in the US is via transfemoral access, so our population are mostly patients undergoing transfemoral TAVR. Using propensity score matching, we compared the trends and outcomes of TAVR procedures among patients with versus without AA.

Results

From a total sample of 29,517 individuals who had TAVR procedures between January 2012 and December 2017, 910 had a diagnosis of AA. In 774 matched-pair analysis, all-cause in-hospital mortality was similar in patients with and without AA OR 0.63 [(95% CI 0.28–1.43), p = 0.20]. The median length of stay was higher in patients with AA: 4 days (IQR 2.0–7.0) versus 3 days (IQR 2.0–6.0) p = 0.01. Risk of AKI [OR 1.01 (0.73–1.39), p = 0.87], heart block requiring pacemaker placement [OR 1.17 (0.81–1.69), p = 0.40], aortic dissection [OR 2.38 (0.41–13.75), p = 0.25], acute limb ischemia [OR 0.46 (0.18–1.16), p = 0.09], vascular complications [OR 0.80 (0.34–1.89), p = 0.53], post-op bleeding [OR 1.12 (0.81–1.57), p = 0.42], blood transfusion [OR 1.20 (0.84–1.70), p = 0.26], and stroke [OR 0.58 (0.24–1.39), p = 0.25] were similar in those with and without AA.

Conclusions

Data from a large nationwide database demonstrated that patients with AA undergoing TAVR are associated with similar in-hospital outcomes compared with patients without AA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40119-022-00258-6.

Outcomes in patients with severe COVID-19 disease treated with tocilizumab: a case-controlled study

BACKGROUND

COVID-19 is an ongoing threat to society. Patients who develop the most severe forms of the disease have high mortality. The interleukin-6 inhibitor tocilizumab has the potential to improve outcomes in these patients by preventing the development of cytokine release storm.

AIMS

To evaluate the outcomes of patients with severe COVID-19 disease treated with the interleukin-6 inhibitor tocilizumab.

METHODS

We conducted a retrospective, case-control, single-center study in patients with severe to critical COVID-19 disease treated with tocilizumab. Disease severity was defined based on the amount of oxygen supplementation required. The primary endpoint was the overall mortality. Secondary endpoints were mortality in non-intubated patients and mortality in intubated patients.

RESULTS

A total of 193 patients were included in the study. Ninety-six patients received tocilizumab, while 97 served as the control group. The mean age was 60 years. Patients over 65 years represented 43% of the population. More patients in the tocilizumab group reported fever, cough and shortness of breath (83%, 80% and 96% vs. 73%, 69% and 71%, respectively). There was a non-statistically significant lower mortality in the treatment group (52% vs. 62.1%, P = 0.09). When excluding intubated patients, there was statistically significant lower mortality in patients treated with tocilizumab (6% vs. 27%, P = 0.024). Bacteremia was more common in the control group (24% vs. 13%, P = 0.43), while fungemia was similar for both (3% vs. 4%, P = 0.72).

CONCLUSION

Our study showed a non-statistically significant lower mortality in patients with severe to critical COVID-19 disease who received tocilizumab. When intubated patients were excluded, the use of tocilizumab was associated with lower mortality.

Outcomes of percutaneous coronary intervention (PCI) among patients with connective tissue disease: Propensity match analysis

BACKGROUND

Inflammation is the hallmark of coronary artery disease (CAD) and CTD. There are reports of increased prevalence of CAD among patients with CTD such as Rheumatoid Arthritis. However, there is a paucity of data regarding the outcomes of PCI among patients with CTD.

METHODS

Using the National Inpatient Database, patients that underwent PCI between 2007 and 2015 were identified using ICD-9-CM codes. Propensity match analysis with 1: 3 matching of patients with and without CTD was performed. Outcomes were acute kidney injury (AKI), access site complication (ASC), ventricular fibrillation (VF), cardiogenic shock (CS), Stroke, In-hospital mortality and hospital length of stay (LOS) compared between both groups.

RESULT

We identified 17,422 patients with CTD and matched with 52, 266 patients without CTD. Patients were predominantly female (63.1%) and white (77.2%), with a mean age of 63 ± 12.1 years. AKI (8.3% vs. 6.6%, p < 0.001), ASC (3.2% vs. 2.7%, p = 0.01) and hospital stay (4.2 ± 4.8 vs. 3.8 ± 5.2, p < 0.001) were higher among patients with CTD. There was no statistically significant difference in rates of VF, CS, stroke, and In-hospital mortality among the two groups. However, in subgroup analysis, rates of VF were lower among patients with Systemic Lupus Erythematosus (SLE) (1.5% vs. 2.2%, p = 0.006).

CONCLUSIONS

Patients with CTD undergoing PCI have a higher rate of AKI, Access site complications, and prolonged hospital stay.

Cannabis use is associated with reduced prevalence of progressive stages of alcoholic liver disease

BACKGROUND

Abusive alcohol use has well-established health risks including causing liver disease (ALD) characterized by alcoholic steatosis (AS), steatohepatitis (AH), fibrosis, cirrhosis (AC) and hepatocellular carcinoma (HCC). Strikingly, a significant number of individuals who abuse alcohol also use Cannabis, which has seen increased legalization globally. While cannabis has demonstrated anti-inflammatory properties, its combined use with alcohol and the development of liver disease remain unclear.

AIM

The aim of this study was to determine the effects of cannabis use on the incidence of liver disease in individuals who abuse alcohol.

METHODS

We analysed the 2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (NIS) discharge records of patients 18 years and older, who had a past or current history of abusive alcohol use (n = 319 514). Using the International Classification of Disease, Ninth Edition codes, we studied the four distinct phases of progressive ALD with respect to three cannabis exposure groups: non-cannabis users (90.39%), non-dependent cannabis users (8.26%) and dependent cannabis users (1.36%). We accounted for the complex survey sampling methodology and estimated the adjusted odds ratio (AOR) for developing AS, AH, AC and HCC with respect to cannabis use (SAS 9.4).

RESULTS

Our study revealed that among alcohol users, individuals who additionally use cannabis (dependent and non-dependent cannabis use) showed significantly lower odds of developing AS, AH, AC and HCC (AOR: 0.55 [0.48-0.64], 0.57 [0.53-0.61], 0.45 [0.43-0.48] and 0.62 [0.51-0.76]). Furthermore, dependent users had significantly lower odds than non-dependent users for developing liver disease.

CONCLUSIONS

Our findings suggest that cannabis use is associated with a reduced incidence of liver disease in alcoholics.

Relation of Cannabis Use and Atrial Fibrillation Among Patients Hospitalized for Heart Failure

Left ventricular dysfunction triggers the activation of the sympathetic nervous system, providing inotropic support to the failing heart and concomitantly increasing the risk of atrial fibrillation (AF). The cardiovascular effects of cannabis have been characterized as biphasic on the autonomic nervous system with an increased sympathetic effect at low doses and an inhibitory sympathetic activity at higher doses. It is unknown if the autonomic effect of cannabis impacts the occurrence of AF in patients with heart failure (HF). We used data from the Healthcare Cost and Utilization Project-National Inpatient Sample for patients admitted with a diagnosis of HF in 2014. The outcome variable was the diagnosis of AF, with the main exposure being cannabis use. We identified a cannabis user group and a 1:1 propensity-matched non-cannabis user group, each having 3,548 patients. We then estimated the odds of AF diagnosis in cannabis users. An estimated 3,950,392 patients were admitted with a diagnosis of HF in the United States in 2014. Among these, there were 17,755 (0.45%) cannabis users. In the matched cohort, cannabis users were less likely to have AF (19.08% vs 21.39%; AOR 0.87 [0.77 to 0.98]). In conclusion, cannabis users have lower odds of AF when compared with nonusers, which was not explained by co-morbid conditions, age, insurance type, and socioeconomic status.

Seasonal variation in hospitalization outcomes in patients admitted for heart failure in the United States

BACKGROUND

There is lack of evidence of the impact of varying season on heart failure (HF) hospitalization outcomes in the U.S.

HYPOTHESIS

HF hospitalization outcomes exhibit significant seasonal variation in the U.S.

METHODS

Using data from the National Inpatient Sample (2011-2013), seasonal variation was classified based on meteorological classification of Northern Hemisphere-Spring, Summer, Fall, & Winter-and analysis was conducted via multivariable-adjusted mixed-effect model.

RESULTS

An estimated 2.8 million adults were hospitalized for HF in the U.S. from 2011 to 2013. Of all hospitalizations, admissions were highest in Winter (27%), followed by Spring (26%), Fall (24%), and Summer (23%). The overall mortality rate was 3.1%. Compared with Spring, there was significantly lower mortality in Summer (odds ratio [OR]: 0.95, 95% CI: 0.91-0.99) and Fall (OR: 0.94, 95% CI: 0.89-0.98), but the highest mortality was in Winter (OR: 1.06, 95% CI: 1.02-1.11). In addition, mean length of stay and median cost of hospitalization were highest in Winter (5.3 days, USD7459, respectively) and lowest in Summer (5.1 days, USD7181, respectively). However, age and sex differences existed (e.g. seasonal variation in inpatient mortality was only significant for patients age ≥65 years, and, compared with the Spring season, males had higher risk of inpatient mortality in Winter (OR: 1.10, 95% CI: 1.04-1.17) and females had lower risk of inpatient mortality in Summer (OR: 0.94, 95% CI: 0.88-1.00) and Fall (OR: 0.92, 95% CI: 0.87-0.98).

CONCLUSIONS

Among HF patients in the U.S., hospitalization outcomes were worse in Winter but better in Summer.

Regional Variation in Mortality, Length of Stay, Cost, and Discharge Disposition Among Patients Admitted for Heart Failure in the United States

The objective of the study was to provide contemporary evidence on regional variation in hospitalization outcomes in patients with heart failure (HF) in the United States. Using the National Inpatient Sample, we compared hospitalization outcomes among primary HF admissions (2013 to 2014) among the 4 Census regions of the United States. Overall, an estimated 1.9 million HF hospitalizations occurred in the United States over the study period. Mortality rate was 3%, the mean length of stay was 5.3 days, the median cost of hospitalization was US$7,248, and the rate of routine home discharge was 51%. There was a significant regional variation for all end points (p <0.001); for example, compared with other regions of the country, the risk-adjusted rate of in-hospital mortality was highest in the Northeast (3.2%) and lowest in the Midwest (2.7%); and within each region, these mortalities were higher in the rural locations (range: 3.0% to 3.8%) than in the urban locations (range: 2.7% to 3.1%). In addition, the Northeast region had the longest length of stay (mean: 5.9 days) and the lowest risk-adjusted rate of routine home discharge (42%). However, the cost of hospitalization was highest in the West (median: US$8,898) and lowest in the South (US$6,366). A similar pattern of variation was found in subgroup analysis except that the risk-adjusted rate of in-hospital mortality was highest in the West among patients <65 years (1.7% vs 1.2% [lowest] in the Midwest), male gender (3.2% vs 2.8% in the Midwest), and rural location (3.8% vs 3% in the Midwest). In conclusion, HF hospitalization outcomes tend to be worse in the Northeast compared with other regions of the country. In addition, the in-hospital mortality rate was higher in rural locations than in urban locations.

Effect of Hospital Ownership on Outcomes of Heart Failure Hospitalization

This study aimed to evaluate the impact of hospital ownership on heart failure (HF) hospitalization outcomes in the United States using data from the National Inpatient Sample of the Agency for Healthcare Research and Quality. Hospital ownership was classified into three, namely, nonfederal government, not-for-profit, and for-profit hospitals. Participants were adults hospitalized with a primary diagnosis of HF (2013 to 2014). End points included inpatient mortality, length-of-stay, cost and charge of hospitalization, and disposition at discharge. Of the estimated 1.9 million HF hospitalizations in the United States between 2013 and 2014, 73% were in not-for-profit hospitals, 15% were in for-profit hospitals, and 12% were in nonfederal government hospitals. Overall, mortality rate was 3%, mean length of stay was 5.3 days, median cost of hospitalization was USD 7,248, and median charge was USD 25,229, and among those who survived to hospital discharge, 51% had routine home discharge. There was no significant difference in inpatient mortality between hospital ownership among male patients, but there was a significant difference for female patients. Compared with government hospitals, mortality in female patients was lower in not-for-profit (odds ratio: 0.85 [95% confidence interval: 0.77 to 0.94]) and for-profit hospitals (odds ratio: 0.77 [0.68 to 0.87]). In addition, mean length of stay was highest in not-for-profit hospitals (5.4 days) and lowest in for-profit hospitals (5 days). Although cost of hospitalization was highest in not-for-profit hospitals (USD 7462) and lowest in for-profit hospitals (USD 6,290), total charge billed was highest in for-profit hospitals (USD 35,576) and lowest in government hospitals (USD 19,652). The average charge-to-cost ratio was 3:1 for government hospitals, 3.5:1 for not-for-profit hospitals, and 5.9:1 for for-profit hospitals. In conclusion, there exist significant disparities in HF hospitalization outcomes between hospital ownerships. Outcomes were generally better in for-profit hospitals than other tiers of hospital and, notably, there was a significant difference in inpatient mortality for female patients (but not for male patients).

Abstract 209: Association Between Cannabis Use and TakoTsubo Cardiomyopathy (TTC): Analysis from the NIS 2012 - 2014

Background and Objective: Marijuana use causes catecholamine surge with consequent tachycardia and elevation of both systolic and diastolic blood pressure. It is unclear if the catecholamine surge associated is sufficient to cause left ventricular wall apical ballooning (TakoTsubo Cardiomyopathy (TTC)). Given the similarity in the pathophysiology of TTC and mechanism of action of cannabis, we sought to investigate if there is any association.

Methods: We obtained data from the HCUP-NIS of all patients older than 45 years hospitalized between 2012 - 2014. Our main outcome was diagnosis of TTC, and main exposure variables was cannabis use both identified using the ICD-9 codes. Using the SURVEYLOGISTICS procedure, we performed logistic regressions to estimate the odds of TTC diagnosis and in-hospital mortality among cannabis users adjusting for demographics, comorbidities, and other recreational drugs.

Results: Of the 7,805,400 hospitalized patients who were > 45 years, 10,160 (0.1%) had a diagnosis of TTC, 54,311 (0.7%) were nondependent cannabis user and 5,045 (0.1%) were dependent cannabis users. We observed a significant association between TTC and nondependent cannabis use (OR 1.35, 95% CI: 1.10-1.65), but the association was nonsignificant for dependent cannabis use. After adjusting for potential confounders such as age, race, gender, comorbidities, cocaine, amphetamine and alcohol, nondependent cannabis use was associated with a 2-fold increased odds of TTC (AOR 2.00, 95% CI: 1.61-2.40). However, the association remained nonsignificant for dependent cannabis users (AOR 0.70, 95% CI: 0.25-1.92). Also, among patients diagnosed with TTC, there was no significant difference in the odds of in-hospital mortality among cannabis users (dependent and nondependent) when compared to nonusers (AOR 1.04, 95% CI: 0.39 - 2.70).

Conclusion: In our study population, nondependent cannabis use was associated with significantly increased odds of TTC. However, among patients with TTC, in-hospital mortality rate was the same irrespective of cannabis exposure.

Abstract 444: Association Between Cannabis Use and Acute Myocardial Infarction

Background: Cannabidiol (CBD)-a component of cannabis with no psychoactive or cognitive effect has been proven in animal models to have a vasodilatory, anti-oxidant and anti-inflammatory effect on the blood vessels. However, it is unclear if cannabis users - while being exposed to its CBD constituents - benefit from its vasodilatory and anti-inflammatory effect in the prevention of acute myocardial infarction (MI).

Objective: To investigate if there is a difference in the odds of MI among cannabis users when compared to nonusers.

Methods: We used data from the Nationwide Inpatient Sample on patients ages 45 years and older admitted between 2012 - 2014. The main study outcome was clinical diagnosis of MI, and the main exposure variable was cannabis use identified using ICD-9 codes. Cannabis use was categorized into non-use, non-dependent, and dependent use. Multivariable logistic regression models were used to estimate the odds of MI and In-hospital mortality in relation to cannabis use adjusting for demographics, comorbidities, and use of other recreational drugs.

Results: Of the 7, 995,162 hospitalized patients who were > 45 years, 532,112 (6.7%) had a diagnosis of MI, 56,836 (0.7%) were non-dependent cannabis user and 5,417 (0.1%) were dependent cannabis users. We observed a significant inverse association between cannabis use and MI (non-dependent OR: 0.86, 95% CI: 0.83-0.90; dependent OR 0.26, 95% CI: 0.21-0.31). After adjusting for confounding variables, the association was attenuated for non-dependent cannabis users (OR: 1.03, 95% CI: 0.99-1.06]). However, among dependent cannabis users, there was 66% decreased odds of MI when compared to nonusers. Also, cannabis use was associated with 32% decreased odds of in-hospital mortality among patients with MI when compared to nonuse.

Conclusions: Using the largest national data, our study showed cannabis use was not a risk factor for MI and alternatively may point to a protective benefit in the diagnosis of MI and in-hospital mortality. Future prospective studies may aid in further exploring this association to maximize the therapeutic advantage of the cannabinoid system in MI prevention.

Abstract 491: Racial Disparities in the Trends of Acute Myocardial Infarction Outcomes Among Medicaid Patients, 2007-2011

Background: Although, in-hospital mortality from acute myocardial infarction (AMI) have declined in the United States recently, there is a gap in knowledge regarding racial differences in this trend. We sought to evaluate the effect of race on the trends in outcomes after Acute Myocardial Infarction among Medicaid patients in a nationwide cohort from 2007-2011

Methods: We extracted data from the Nationwide Inpatient Sample (NIS) for all hospitalizations between 2007 and 2011 for Medicaid patients aged 45 years or older with principal diagnosis of AMI using ICD-9-CM codes. Primary outcome of this study was all cause in-hospital mortality. We then stratified hospitalizations by racial groups; Whites, African Americans and Hispanics, and assessed the time trends of in-hospital mortality before and after multivariate analysis.

Results: The overall mortality from AMI among Medicaid patients declined during the study period (8.80% in 2007 to 7.46% in 2011). In the adjusted models, compared to 2007, in-hospital mortality from AMI for Medicaid patients decreased across the 3 racial groups; Whites (aOR= 0.88, CI=0.70-0.99), African Americans (aOR=0.76, CI=0.57-1.01), Hispanics (aOR=0.87, CI=0.66-1.25). While the length of hospital stay declined significantly among African American and Hispanic with 2 days and 1.76 days decline respectively, the length of stay remained unchanged for Whites. There was non-significant increase in the incidence of stroke across the various racial groups; Whites (aOR= 1.23, CI=0.90 -1.69), African Americans (aOR=1.10, CI=0.73 -1.64), Hispanics (aOR=1.03, CI=0.68-1.55) when compared to 2007.

Conclusion: In this study, we found that in-hospital mortality from AMI among Medicaid patients have declined across the racial groups. However, while the length of stay following AMI declined for African Americans and Hispanics with Medicaid insurance, it has remained unchanged for Whites. Future studies are necessary to identify determinants of these significant racial disparities in outcomes for AMI.

Cannabis use is associated with reduced prevalence of non-alcoholic fatty liver disease: A cross-sectional study

Cannabis use is associated with reduced prevalence of obesity and diabetes mellitus (DM) in humans and mouse disease models. Obesity and DM are a well-established independent risk factor for non-alcoholic fatty liver disease (NAFLD), the most prevalent liver disease globally. The effects of cannabis use on NAFLD prevalence in humans remains ill-defined. Our objective is to determine the relationship between cannabis use and the prevalence of NAFLD in humans. We conducted a population-based case-control study of 5,950,391 patients using the 2014 Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Survey (NIS) discharge records of patients 18 years and older. After identifying patients with NAFLD (1% of all patients), we next identified three exposure groups: non-cannabis users (98.04%), non-dependent cannabis users (1.74%), and dependent cannabis users (0.22%). We adjusted for potential demographics and patient related confounders and used multivariate logistic regression (SAS 9.4) to determine the odds of developing NAFLD with respects to cannabis use. Our findings revealed that cannabis users (dependent and non-dependent) showed significantly lower NAFLD prevalence compared to non-users (AOR: 0.82[0.76-0.88]; p<0.0001). The prevalence of NAFLD was 15% lower in non-dependent users (AOR: 0.85[0.79-0.92]; p<0.0001) and 52% lower in dependent users (AOR: 0.49[0.36-0.65]; p<0.0001). Among cannabis users, dependent patients had 43% significantly lower prevalence of NAFLD compared to non-dependent patients (AOR: 0.57[0.42-0.77]; p<0.0001). Our observations suggest that cannabis use is associated with lower prevalence of NAFLD in patients. These novel findings suggest additional molecular mechanistic studies to explore the potential role of cannabis use in NAFLD development.

Abstract 100: Prevalence of Peripheral Vascular Disease Among Patients Using Cannabis, an Analysis of the 2014 National Inpatient Sample data

Background: Despite being illegal in most countries, cannabis is highly utilised by a growing number of individuals for recreational purposes worldwide. With its increasing legalisation in many states across the United States, the effects of cannabis on different body systems are expected to rise. Its association with peripheral vascular disease (PVD) remains ambiguous.

Objective: To examine if there is a difference in prevalence of PVD amongst patients who use cannabis when compared to non-users.

Methods: Using the 2014 National Inpatient Sample database (N=7,071,762), we identified patients with and without a diagnosis of PVD. We also identified patients using cannabis (nondependent and dependent users) and non-users. We performed the univariate and bivariate analysis. After we had composed the crude models, we adjusted for every known risk factor for PVD. These factors included age, gender, tobacco, hypercholesterolemia, coronary artery disease (CAD), cerebrovascular vessel disease (CVD), hypertension, diabetes, renal failure, alcohol, obesity, race, insurance type, average income at the location of residence, and family history of PVD/CVD/CAD.

Results: In our total 7,071,762 sample, 98.27% (6,949,339) are non-users, 1.54% (108,910) are nondependent users and 0.19% (13,513) are dependent users. About 3.75% (264,920) of the patients had a diagnosis of PVD versus 96.25% (6,806,842) without a diagnosis of PVD. The odds of PVD is 20% less among nondependent users when compared to nonusers (AOR 0.80[0.76-0.85]). Furthermore, dependent users have a 55% reduced odds of developing PVD when compared to nonusers (AOR 0.45[0.35-0.57]) showing a dose-response relationship. The in-group comparison showed that dependent users were 44% less likely to have PVD when compared to non-dependent users (AOR: 0.56[0.44-0.72]). Overall, the odds of PVD remain significantly high among patients who uses tobacco (AOR 1.97 [1.95-1.99]), diabetes (AOR 1.54 [1.53-1.55]), hypercholesterolemia (AOR 1.46 [1.45-1.47]), family history of PVD/CVD/CAD (AOR 1.03 [1.01-1.05]), personal history of CAD (AOR 2.55 [2.53-2.57]).

Conclusions: Cannabis is an independent protective factor against PVD. Molecular biology evidence shows that cannabis contains various bioactive agents. Beta-caryophyllene (out of many) preferentially binds to CB-2 receptors on immune cells causing an anti-inflammatory response. We believe that more molecular studies targeting such receptors or isolating such anti-inflammatory compounds in cannabis might be useful in the treatment of vascular disease.

Abstract 065: Hospital Teaching Status and TAVR Outcomes in the United States - Analysis of the National Inpatient Sample (NIS)

Background: Evidence suggest that medical service offerings vary by hospital teaching status. However, little is known about how these translate to patient outcomes. We therefore sought to evaluate this gap in knowledge in patients undergoing TAVR

Methods: This study was conducted using the National Inpatient Sample (NIS) in the U.S (2011-2013). Teaching status was classified as teaching vs non-teaching and endpoints were clinical outcomes, length of stay and cost. Procedure-related complications were identified via ICD-9 coding and analysis was performed via mixed effect model

Results: An estimated 17,020 TAVR procedures were performed in the U.S between 2011 and 2013, out of which 87% were in teaching hospitals. Mean (SD) age was 80 (8) and 47% were females. There was no significant difference between hospital teaching status with regards to procedure-related in-patient mortality, myocardial infarction, or other cardiac, vascular, neurological, respiratory complications, post-op DVT/PE, or sepsis (Fig 1). However, compared to non-teaching hospitals, teaching hospitals tend to have higher risk of acute kidney injury (OR: 1.47 [95% CI, 1.08-1.99]) but lower risk of hemorrhage requiring transfusion (OR: 0.67 [95% CI, 0.50-0.91]). The mean length of stay was higher in teaching hospitals (8.3 days) compared to non-teaching hospitals (7.5 days) (fig 2A), but median cost of hospitalization was higher in non-teaching hospitals (USD 59702 vs 49708) (fig 2B)

Conclusion: We found that the risks of most TAVR-related complications (except for AKI and hemorrhage) are about the same in teaching compared to non-teaching hospitals. However, length of stay was higher in teaching hospitals while cost was higher in non-teaching hospitals

Hereditary angioedema (HAE): a cause for recurrent abdominal pain

A 44-year-old Hispanic woman presented to the emergency room with a 2-day history of sudden onset of severe cramping left lower quadrant abdominal pain associated with ∼20 episodes diarrhoea. Abdominal CT scan exhibited bowel wall oedema and acute extensive colitis. On the basis of the preliminary diagnosis of acute abdomen, the patient was admitted under the surgical team and treated for acute colitis. Since her family history was significant for hereditary angioedema (HAE), complement studies were performed which revealed low complement C4 levels and abnormally low values of C1q esterase inhibitor. Thus, the diagnosis of HAE type I was established. This case report summarises that the symptoms of HAE are often non-specific, hence making the underlying cause difficult to diagnose.