Geographical and socioeconomic disparities in post-transcatheter aortic valve replacement pacemaker placement

INTRODUCTION

Pacemaker (PPM) implantation is indicated for conduction abnormalities which can develop post-transcatheter aortic valve replacement (TAVR). However, whether post-TAVR PPM risk is associated with the geographical location of the hospital and socioeconomic status of the patient is not well established. Our goal was to explore geographical and socioeconomic disparities in post-TAVR PPM implantation.

METHODS

A retrospective cohort analysis was conducted using the National Inpatient Sample 2016-2020 with respective ICD-10 codes for TAVR and PPM implantation. A weighted multivariate logistic regression model was used to analyze prognostic outcomes.

RESULTS

The number of patients hospitalized for undergoing TAVR was 296,740, out of which 28,265 patients had PPM implantation (prevalence 9.5 %). Patients' demographics including sex, ethnicity, household income, and insurance were not associated with risk of post-TAVR PPM except age (OR 1.01, CI 1.07-12.5, p < 0.001). Compared to rural hospitals, urban non-teaching hospitals were associated with a higher risk of post-TAVR PPM (OR 2.09, 1.3-3.43, p = 0.003). Compared to New England hospitals (ME, NH, VT, MA, RI, CT), middle Atlantic hospitals (NY, NJ, PA) were associated with highest post-TAVR PPM risk (OR 1.54, CI 1.2-1.98, p < 0.001), followed by Pacific (AK, WA, OR, CA, HI), mountain (ID, MT, WY, NV, UT, CO, AZ, NM) and east north central US.

CONCLUSION

Patients' demographics including sex, ethnicity, household income, and insurance were not associated with the risk of post-TAVR PPM except for age. Compared to New England hospitals, Middle Atlantic hospitals were associated with the highest post-TAVR PPM risk followed by Pacific, Mountain, and East North Central US. Prospective studies with data on TAVR wait times, expertise of the interventional staff, and post-TAVR management and discharge planning are required to further explore the observed regional distribution of TAVR outcomes.

Outcomes of Clostridioides difficile infection in acute heart failure hospitalizations: insights from the National Inpatient Database

BACKGROUND

Heart failure (HF) patients are at a greater risk for nosocomial infections due to their higher prevalence of comorbidities, readmission rates, and prolonged hospital stays. Clostridioides difficile infection (CDI) remains a common nosocomial infection in hospitalized patients.

AIM

To identify patients with a diagnosis of acute HF and stratified based on the presence of CDI, using the National Inpatient Sample (NIS) database from 2016 to 2020.

METHODS

Adjusted odds ratios (aOR) of in-hospital outcomes were calculated, and a propensity-matched analysis was performed.

FINDINGS

Of 536,595 acute HF hospitalizations in this timeframe, 3030 were also diagnosed with CDI (0.56%). Patients with acute HF and CDI had significantly higher in-hospital mortality (adjusted odds ratio: (aOR): 1.91), cardiac arrest (aOR: 1.66), and use of mechanical circulatory support (MCS) (aOR 2.42). In propensity-matched analysis, in-hospital mortality (13.71 vs 8.44%; P=0.005), septic shock (7.54 vs 3.33%; P=0.002), and use of MCS (7.19 vs 3.68%; P=0.009) were significantly higher in HF patients with CDI than without. Coexisting neurological disease (aOR: 3.74) and liver disease (aOR: 2.97) showed the strongest association as independent predictors of mortality. HF patients with CDI had longer hospital stays (14.45 ± 19.40 vs 5.44 ± 7.10 days; P<0.0001) and higher inflation-adjusted total hospital costs ($186,225 ± 376,485 vs $60,740 ± 153,992; P<0.001) compared to those without CDI.

CONCLUSION

The occurrence of concomitant CDI in patients admitted with acute HF exacerbation is associated with worse in-hospital outcomes and deaths as well as longer hospitalizations and greater financial cost.

Impact of Heart Failure on COVID-19 Patients: An Insight from Nationwide Inpatient Sample

BACKGROUND

Patients with COVID-19 have been reported to experience adverse cardiovascular outcomes, such as myocarditis, acute myocardial infarction, and heart failure. Among these complications, heart failure (HF) has emerged as the most common critical complication during exacerbations of COVID-19, potentially leading to increased mortality rates and poorer clinical outcomes. We aimed to investigate the in-hospital outcomes of COVID-19 patients with HF.

METHODS

We analyzed the Nationwide Inpatient Sample (NIS) dataset to select COVID-19 patients aged over 18 years who were hospitalized between January 1, 2020, and December 31, 2020, using ICD-10. Based on the presence of acute HF, the patients were divided into two cohorts. The clinical outcomes and complications were assessed at index admissions using STATA v.17."

RESULTS

1,666,960 COVID-19 patients were hospitalized in 2020, of which 156,755 (9.4 %) had associated HF. COVID-19 patients with HF had a mean age of (72.38 ± 13.50) years compared to (62.3 ± 17.67) years for patients without HF. The HF patients had a higher prevalence of hypertension, hyperlipidemia, type 2 diabetes, smoking, and preexisting cardiovascular disease. Additionally, after adjusting for baseline demographics and comorbidities, COVID-19 patients with HF had higher rates of in-hospital mortality (23.86% vs. 17.63%, p<0.001), acute MI (18.83% vs. 10.91%, p<0.001), acute stroke (0.78% vs. 0.58%, p=0.004), cardiogenic shock (2.56% vs. 0.69%, p<0.001), and sudden cardiac arrest (5.54% vs. 3.41%, p<0.001) compared to those without HF.

CONCLUSION

COVID-19 patients admitted with acute HF had worse clinical outcomes, such as higher mortality, myocardial infarction, cardiogenic shock, cardiac arrest, and a higher length of stay and healthcare than patients without HF.

Contemporary National Trends of Mechanical Circulatory Support Among Myocarditis Hospitalizations Before the Pandemic: A National In-patient Database (2005-2019) Study

According to the Global Burden of Disease Project, the morbidity and mortality of myocarditis continue to be a significant worldwide burden. On October 1, 2015, hospital administrative data started using the International Classification of Diseases (ICD)-10 codes instead of the ICD-9. To our knowledge, nationwide trends of myocarditis have not been studied after this update. The NIS database from 2005-2019 was analyzed using ICD-9 and 10 codes. Our search yielded 141,369 hospitalizations due to myocarditis, with 40.9% females. There were 6627 (4.68%) patients who required mechanical circulatory support (MCS) using left ventricular assisted devices (LVAD), intra-aortic balloon pump (IABP), or extracorporeal membrane oxygenation (ECMO). The use of LVAD and ECMO increased significantly during the study period (p-trend 0.003 and <0.001, respectively), whereas the use of IABP decreased during the same period (p-trend 0.025). Our study demonstrated an overall increase in the use of MCS overall in myocarditis, with increasing utilization of more advanced MCS in the forms of LVAD and ECMO.

Cardiovascular Outcomes and Readmissions of Atrial Fibrillation Among Patent Foramen Ovale Occluder Device Recipients: A Propensity Matched National Readmission Study

Patent foramen ovale (PFO) occluder devices are increasingly utilized in minimally invasive procedures used to treat cryptogenic stroke. Data on the impact of Atrial Fibrillation (AF) among PFO occluder device recipients are limited. The Nationwide Readmissions Database was queried between 2016 and 2019 to identify PFO patients with and without AF. The 2 groups were compared using propensity score matching (PSM) and multivariate regression models. The outcomes included in-hospital mortality, acute kidney injury (AKI), Mechanical circulatory support use (MCS), Cardiogenic shock (CS), acute ischemic stroke, bleeding, and other cardiovascular outcomes. Statistical analysis was performed using STATA v. 17. Out of 6508 Weighted hospitalizations for PFO occluder device procedure over the study period, 877 (13.4%) had AF compared to 5631 (86.6%) who did not. On adjusted analysis, PFO with AF group had higher rates of MCS (PSM, 4.5% vs 2.2 %, P value = 0.011) and SCA (PSM, 7.6% vs 4.6 %, P value = 0.015) compared to PFO with no AF. There was no statistically significant difference in the rate of in-hospital mortality (PSM, 5.4% vs 6.4 %, P value = 0.39), CS (PSM, 8.3% vs 5.9 %, P value = 0.075), AKI (PSM, 32.4% vs 32.3 %, P value = 0.96), bleeding (PSM, 2.08% vs 1.3%, P value = 0.235) or the readmission rates among both cohorts. Additionally, AF was associated with higher hospital length of stay (9.5 ± 13.2 vs 8.2 ± 24.3 days, P-value = 0.012) and total cost ($66,513 ± $80,922 vs $52,013±$125,136, 0.025, P-value = 0.025) compared to PFO without AF. AF among PFO occluder device recipients is associated with increased adverse outcomes, including MCS use and SCA, with no difference in mortality and readmission rates among both cohorts. Long-term follow-up needs further studies.

Skeletonized versus Pedicled harvesting of internal mammary artery: A systematic review and Meta-analysis

There are two recognized internal mammary artery (IMA) harvesting techniques during coronary artery bypass grafting (CABG): pedicled and skeletonized. This systematic review and meta-analysis sought to compare the clinical outcomes of the two harvesting techniques. A comprehensive electronic literature search of PubMed, Scopus, and Embase was conducted from inception till June 2023. Thirty-one studies with a total of 13005 patients met our inclusion criteria. The results from the included studies were presented as weighted mean difference (WMD) with its relevant standard deviation (SD) for continuous variables, while Odds Ratio (OR) was used for dichotomous variables. A 95% confidence interval (CI) was used, and the results were pooled using a random effects model. The skeletonized IMA demonstrated a significantly reduced risk of sternal wound infection (SWI) compared to the pedicled IMA (OR = 0.45 [95% CI, 0.32-0.66]; p = 0.0001). The conduit length used was significantly longer in the skeletonized IMA (WMD -2.48, 95% CI, [-3.75, -1.20], P = 0.0001) and a significantly higher postoperative flow rate was observed while using skeletonization compared to the pedicled harvesting (WMD -13.11, 95% CI, [-22.52, -3.70], P = 0.006). However, no significant difference was seen in mortality between the two techniques (OR = 1.19 [95% CI, 1.00-1.41]; p = 0.05). Pedicled harvesting demonstrated significantly reduced incidents of MI (OR = 1.38 [95% CI, 1.13-1.69]; p = 0.002), while significant results in graft patency were observed favoring pedicled harvesting over skeletonization (OR = 0.63 [95% CI, 0.40-0.98]; p = 0.04).

Short-Term Outcomes of Cardiac Arrhythmias Among COVID-19 Patients: A Propensity Matched National Study

The risk of arrhythmia is high in patients with COVID-19. The current literature is limited in understanding the clinical impact of arrhythmias and the extent of healthcare utilization in COVID-19 patients. The Nationwide In-patient Sample Database (NIS) from 2019 to 2020 was queried to identify COVID-19 patients who developed arrhythmias vs those without. Multivariate regression for adjusted odds ratios (aOR) and propensity score matching (PSM) were done to compare outcomes among both cohorts. A total of 1,664,240 patients (weighted) were hospitalized with COVID-19 infection, 380,915 (22.89%) of whom were diagnosed with an arrhythmia. After propensity matching COVID-19 with arrhythmias had higher rates of in-hospital mortality (22.4% vs 13.5%, P < 0.001), acute kidney injury (PSM 39.4% vs 35.7%, P < 0.001), acute heart failure (AHF) (18.2% vs 12.6%, P < 0.001), acute stroke (0.76% vs 0.57%, P < 0.001), cardiogenic shock (1.38% vs 0.5%, P < 0.001), cardiac arrest (5.26% vs 2.3%, P < 0.001) acute myocardial infarction (AMI) (12.8% vs 7.8%, P < 0.001), intracerebral hemorrhage (0.63% vs 0.45%, P < 0.001), major bleeding (2.6% vs 1.8%, P < 0.001) and endotracheal intubation (17.04% vs 10.17% < 0.001) compared to arrhythmias without COVID-19. This cohort also had lower odds of receiving interventions such as cardiac pacing (aOR 0.15 95% Cl 0.13-0.189 P < 0.001), cardioversion (aOR 0.43 95% CI 0.40-0.46, P < 0.001), and defibrillator (aOR 0.087 95% Cl 0.061-0.124, P < 0.001) compared to arrhythmia patients without COVID-19. Cardiac arrhythmias associated with COVID-19 resulted in longer length of hospital stay and higher total costs of hospitalizations. Arrhythmias associated with COVID-19 had worse clinical outcomes with an increased rate of in-hospital mortality, longer length of hospital stay, and higher total cost. These patients also had lower odds of receiving interventions during the index hospitalization.

Fusobacterium Necrophorum bacteremia involving multi-organ systems

A 62-year-old African American man with a history of avascular necrosis (AVN) of the right hip joint presented with severe right hip pain, dyspnea, fever, tachycardia, and hypertension. Computed tomography (CT) scan showed bilateral airspace opacities with a mild tree-in-bud nodularity in the left lower lobe. Ultrasonography of the lower extremities revealed a deep venous thrombus (DVT) in the right deep veins. Blood cultures grew Fusobacterium necrophorum. CT and magnetic resonance imaging showed right hip joint destruction and septic arthritis. The patient had a complicated hospital course leading to total hip arthroplasty with antibiotic-impregnated cementing.

Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

Limited data comparing prasugrel and ticagrelor in acute coronary syndrome are available. Online databases, including MEDLINE and Cochrane Central, were queried to compare these drugs. The primary outcomes of this meta-analysis are myocardial infarction (MI), all-cause mortality, cardiovascular mortality, noncardiovascular mortality, stent thrombosis, and stroke. The secondary outcome is major bleeding. A total of 9 studies, including 94,590 patients (prasugrel group = 32,759; ticagrelor group = 61,831), were included in this meta-analysis. The overall mean age was 62.73 years, whereas the mean age for the ticagrelor and prasugrel groups was 63.80 and 61.65 years, respectively. Prasugrel is equally effective as compared with ticagrelor in preventing MI. There was no difference between the 2 groups regarding all-cause mortality, stent thrombosis, stroke, or major bleeding. In patients with acute coronary syndrome, prasugrel is equally effective when compared with ticagrelor in preventing MI.

Effect of Furosemide Versus Torsemide on Hospitalizations and Mortality in Patients With Heart Failure: A Meta-Analysis of Randomized Controlled Trials

Loop diuretics are essential in the treatment of patients with heart failure (HF) who develop congestion. Furosemide is the most commonly used diuretic; however, some randomized controlled trials (RCTs) have shown varying results associated with torsemide and furosemide in terms of hospitalizations and mortality. We performed an updated meta-analysis of currently available RCTs comparing furosemide and torsemide to see if there is any difference in clinical outcomes in patients treated with these loop diuretics. PubMed, MEDLINE, Cochrane, and Embase databases were searched for RCTs comparing the outcomes in patients with HF treated with furosemide versus torsemide. The primary end points included all-cause mortality, all-cause hospitalizations, cardiovascular-related hospitalizations, and HF-related hospitalizations. A random-effects meta-analysis was performed to estimate the risk ratio (RR) with a 95% confidence interval (CI). A total of 10 RCTs with 4,127 patients (2,088 in the furosemide group and 2,039 in the torsemide group) were included in this analysis. A total of 56% of the patients were men and the mean age was 68 years. No significant difference was noted in all-cause mortality between the furosemide and torsemide groups (RR 1.02, 95% CI 0.91 to 1.15, p = 0.70); however, patients treated with furosemide compared with torsemide had higher risks of cardiovascular hospitalizations (RR 1.36, 95% CI 1.13 to 1.65, p = 0.001), HF-related hospitalizations (RR 1.65, 95% CI 1.21 to 2.24, p = 0.001), and all-cause hospitalizations (RR 1.06, 95% CI 1.01 to 1.11, p = 0.02). In conclusion, patients with HF treated with torsemide have a reduced risk of hospitalizations compared with those treated with furosemide, without any difference in mortality. These data indicate that torsemide may be a better choice to treat patients with HF.

Effect of COVID-19 Pandemic on PCI Outcomes: A Single-center Retrospective Race and Gender-based Study

African Americans (AAs) have a higher risk for postpercutaneous coronary intervention (PCI) ischemic events and worse Coronavirus Disease 2019 (COVID-19)-related events than non-AAs. Race and gender-related post-PCI events before and during the COVID-19 pandemic in a community hospital setup are unknown. Demographics and one-year adverse events in patients undergoing PCI immediately before (2018-2020) and during (2020-2021) pandemic were compared. About 291 and 292 non-AAs and 220 and 219 AAs who underwent PCI before and during the pandemic, respectively, were included. AAs were younger than non-AAs and had a higher prevalence of diabetes and acute coronary syndrome during the pandemic (P < 0.01 for all). Although total ischemic events were the same, cardiovascular death and myocardial infarction were higher during COVID-19 (P < 0.05) and were more prevalent among AAs. The highest ischemic events were observed in AA women during the pandemic compared to other gender and races. These data highlight the high intrinsic thrombogenicity phenotype in AA women.

Predictors and Outcomes of Extracorporeal Membrane Oxygenation in COVID-19 Patients With ARDS: A Propensity-Matched Analysis of National Inpatient Sample

Extracorporeal membrane oxygenation (ECMO) is a significant treatment modality for COVID-19 patients on ventilators. The current data is limited for understanding the indicators and outcomes of ECMO in COVID-19 patients with acute respiratory distress syndrome (ARDS). The National Inpatient Sample (NIS) database from 2020 was queried in this study. Among 1,666,960 patients admitted with COVID-19, 99,785 (5.98%) patients developed ARDS, and 60,114 (60.2%) were placed on mechanical ventilation. Of these mechanically ventilated COVID-ARDS patients, 2580 (4.3%) were placed on ECMO. Patients with ECMO intervention had higher adjusted odds (aOR) of blood loss anemia (aOR 9.1, 95% CI: 6.16-13.5, propensity score-matched (PSM) 42% vs 5.4%, P < 0.001), major bleeding (aOR 3.79, 95% CI: 2.5-5.6, PSM 19.9% vs 5.9%, P < 0.001) and acute liver injury (aOR 1.7, 95% CI: 1.14-2.6 PSM 14% vs 6%, P = 0.009) compared to patients without ECMO intervention. However, in-hospital mortality, acute kidney injury, transfusions, acute MI, and cardiac arrest were insignificant. On subgroup analysis, patients placed on veno-arterial ECMO had higher odds of cardiogenic shock (aOR 13.4, CI 3.95-46, P < 0.0001), cardiac arrest (aOR 3.5, CI 1.45-8.47, P = 0.0057), acute congestive heart failure (aOR 4.18, CI 1.05-16.5, P = 0.042) and lower odds of major bleeding (aOR 0.26, CI 0.07-0.92). However, there was no significant difference in mortality, intracranial hemorrhage, and acute MI. Further studies are needed before considering COVID-19 ARDS patients for placement on ECMO.

A Propensity-Matched National Analysis of Transcatheter Aortic Valve Implantation Outcome in Patients With Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding is often observed in severe aortic stenosis, which can be attributed to the presence of arteriovenous malformations and von Willebrand's factor deficiency. GI is one of the most common complications in patients who underwent transcatheter aortic valve implantation (TAVI). The outcome of the TAVI procedure with GI bleeding is unknown. We performed an International Classification of Diseases, Tenth Revision-based national cohort analysis using the national readmission database from 2016 to 2020. We compared cardiovascular outcomes, mortality, and readmission rates of patients with TAVI who developed GI bleeding compared with those who had no GI bleeding. A total of 320,353 hospitalizations with TAVI were identified from the year 2016 to 2020. Patients with TAVI with GI bleeding were 6,193.37 and without GI bleeding were 314,160. The median age of the patients with TAVI with GI or without GI bleeding was 80. GI bleed patients had statistically significantly higher readmission rates at 30, 90, and 180 days and they had higher odds of in-hospital mortality (adjusted odds ratio [aOR] = 6.35; 95% confidence interval [CI]: 5.37 to 7.52; p <0.0001), acute kidney injury (aOR = 5.22; 95% CI:4.75 to 5.74; p <0.0001), stroke (aOR = 2.83; 95% CI 2.05 to 3.91 p:0.0001, postprocedural bleeding (aOR: 1.76; 95% CI: 1.35 to 2.30; p:0.0001), cardiac tamponade (aOR = 2.54; 95% CI 1.86 to 3.49; p <0.0001), use of mechanical circulatory support (aOR: 5.33; 95% CI:4.13 to 6.86; p <0.0001), and heart failure (aOR:1.73; 95%CI: 1.54 to 1.94; p <0.0001). The total cost of hospitalization and length of stay was higher in the GI bleed group. Patients with TAVI with GI bleeding have worse clinical outcomes and higher in-hospital mortality and readmission rates compared with patients with no GI bleeding.

Prevalence and Prognostic Implications of Amyloidosis in Valvular Heart Disease

There has been less emphasis on the prognostic impact of amyloidosis in patients with valvular heart disease (VHD). We aimed to determine the prevalence of amyloidosis in VHD and its clinical implications in terms of mortality. Patients hospitalized for VHD were identified using National Inpatient Sample 2016-2020 which were divided into 2 cohorts: with and without amyloidosis. Among 5,728,873 patients hospitalized with VHD, 11,715 patients had amyloidosis in which mitral valve disease has the highest prevalence (7.6%) followed by aortic (3.6%), and tricuspid valve disease (1%). Underlying amyloidosis is associated with higher mortality in VHD (OR 1.45, CI 1.2-1.7, P<0.001), mainly mitral valve disease (OR 1.44, CI 1.1-1.9, P<0.01). Patients with amyloidosis have higher adjusted mortality rates (5-6% vs 2.6%, P<0.01), longer mean length of stay (7.1 vs 5.7 days, P<0.001), but they have lower valvular intervention rates. In hospitalized VHD patients, underlying amyloidosis is associated with higher in-hospital mortality.

An update on novel therapies for treating patients with arterial thrombosis

INTRODUCTION

Antithrombotic therapy field is undergoing rapid and significant changes during the past decade. In addition to new therapeutic strategies with existing targets, investigators are exploring the potential use of new targets to address unmet needs to treat patients with arterial diseases.

AREAS COVERED

We aim to provide an update on and a comprehensive review of the antithrombic agents that are being explored in patients with arterial diseases. We discuss latest developments with respect to upstream antiplatelet agents, and collagen and thrombin pathway inhibitors. We searched PubMed databases for English language articles using keywords: antiplatelet agents, thrombin pathway inhibitors, collagen receptors, arterial disease.

EXPERT OPINION

Despite implementation of potent P2Y12 inhibitors, there are numerous unmet needs in the treatment of arterial diseases including ceiling effect of currently available antiplatelet agents along with and an elevated risk of bleeding. The latter observations encouraged investigators to explore new targets that can attenuate the generation of platelet-fibrin clot formation and subsequent ischemic event occurrences with minimal effect on bleeding. These targets include collagen receptors on platelets and thrombin generation including FXa, FXIa, and FXIIa. In addition, investigators are studying novel antiplatelet agents/strategies to facilitate upstream therapy in high-risk patients.

Superior Vena Cava Syndrome: An Umbrella Review

Superior vena cava syndrome (SVCS) is a medical emergency that encompasses an array of signs and symptoms due to obstruction of blood flow through the superior vena cava (SVC). It poses a significant healthcare burden due to its associated morbidity and mortality. Its impact on the healthcare system continues to grow due to the increasing incidence of the condition. This incidence trend has been attributed to the growing use of catheters, pacemakers, and defibrillators, although it is a rare complication of these devices. The most common cause of SVCS remains malignancies accounting for up to 60% of the cases. Understanding the pathophysiology of SVCS requires understanding the anatomy, the SVC drains blood from the right and left brachiocephalic veins, which drain the head and the upper extremities accounting for about one-third of the venous blood to the heart. The most common presenting symptoms of SVCS are swelling of the face and hand, chest pain, respiratory symptoms (dyspnea, stridor, cough, hoarseness, and dysphagia), and neurologic manifestations (headaches, confusion, or visual/auditory disturbances). Symptoms generally worsen in a supine position. Diagnosis typically requires imaging, and SVCS can be graded based on classification schemas depending on the severity of symptoms and the location, understanding, and degree of obstruction. Over the past decades, the management modalities of SVCS have evolved to meet the increasing burden of the condition. Here, we present an umbrella review providing an overall assessment of the available information on SVCS, including the various management options, their indications, and a comparison of the advantages and disadvantages of these modalities.

Contemporary outcomes of long-term anticoagulation in COVID-19 patients: a regression matched sensitivity analysis of the national inpatient sample

BACKGROUND

The role of oral anticoagulation during the COVID-19 pandemic has been debated widely. We studied the clinical outcomes of COVID-19 hospitalizations in patients who were on long-term anticoagulation.

RESEARCH DESIGN AND METHODS

The Nationwide Inpatient Sample (NIS) database from 2020 was queried to identify COVID-19 patients with and without long-term anticoagulation. Multivariate regression analysis was used to calculate the adjusted odds ratio (aOR) of in-hospital outcomes.

RESULTS

Of 1,060,925 primary COVID-19 hospitalizations, 102,560 (9.6%) were on long-term anticoagulation. On adjusted analysis, COVID-19 patients on anticoagulation had significantly lower odds of in-hospital mortality (aOR 0.61, 95% CI 0.58-0.64, P < 0.001), acute myocardial infarction (aOR 0.72, 95% CI 0.63-0.83, P < 0.001), stroke (aOR 0.79, 95% CI 0.66-0.95, P < 0.013), ICU admissions, (aOR 0.53, 95% CI 0.49-0.57, P < 0.001) and higher odds of acute pulmonary embolism (aOR 1.47, 95% CI 1.34-1.61, P < 0.001), acute deep vein thrombosis (aOR 1.17, 95% CI 1.05-1.31, P = 0.005) compared to COVID-19 patients who were not on anticoagulation.

CONCLUSIONS

Compared to COVID-19 patients not on long-term anticoagulation, we observed lower in-hospital mortality, stroke and acute myocardial infarction in COVID-19 patients on long-term anticoagulation. Prospective studies are needed for optimal anticoagulation strategies in hospitalized patients.

Meta-Analysis Comparing Hypothermia Versus Normothermia in Patients After a Cardiac Arrest

The current American Heart Association 2022 guidelines recommend actively preventing fever by targeting a temperature ≤37.5°C for comatose patients after cardiac arrest. Contemporary randomized controlled trials (RCTs) show conflicting results regarding the benefit of targeted hypothermia (TH). We performed this updated meta-analysis of RCTs to evaluate the role of hypothermia in patients after a cardiac arrest. We searched Cochrane, MEDLINE, and EMBASE from inception to December 2022. Trials with patients randomly allocated for targeted temperature monitoring and reported neurologic and mortality outcomes were included. Statistical analysis was performed using Cochrane Review Manager using the random-effects model and calculated the pooled risk ratios of outcomes using the Mantel-Haenszel method. A total of 12 RCTs and 4,262 patients were included in the review. Compared with normothermia, the TH group had significantly improved neurologic outcomes (risk ratio 0.90, 95% confidence interval 0.83 to 0.98). However, no significant difference in mortality was observed (risk ratio 0.97, 95% confidence interval 0.90 to 1.06) between the groups. This meta-analysis supports the role of TH in patients after a cardiac arrest, especially secondary to improvement in neurologic outcomes.

Treatment Failure in Patient with Severe Mpox and Untreated HIV, Maryland, USA

A 33-year-old man in Baltimore, Maryland, USA, with untreated HIV infection had a 74-day course of mpox with multiorgan system involvement and unique clinical findings. In this clinical experience combining 3 novel therapeutic regimens, this patient died from severe mpox in the context of untreated HIV and advanced immunodeficiency.

Fulminant Clostridioides difficile Colitis With SARS-CoV-2 Infection

Clostridioides difficile (C. difficile)and coronavirus disease 2019 (COVID-19) infections can have overlapping symptoms. Recently, the association and outcomes of coinfection have been studied. We present the case of an 83-year-old lady with Parkinson's disease (PD) who was admitted with pneumonia secondary to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. She was treated with empiric antibiotics ampicillin-sulbactam and azithromycin, along with antiviral therapy remdesivir and baricitinib, and dexamethasone. The patient developed severe C. difficile infection with a leukemoid reaction. She was treated with intravenous metronidazole and oral vancomycin without any improvement. Before she could receive a fecal microbiota transplant, her infection progressed to fulminant colitis, and she required emergent surgery. The patient developed several complications post-surgery and succumbed to the severe illness. Our patient's multiple comorbidities and an underlying COVID-19 infection predisposed her to severe illness. This case emphasizes the long-standing discussion on antibiotic stewardship and encourages a debate on the role of immunosuppressant antiviral medications and underlying PD in predisposing patients to a severe C. difficile infection.

Duodenal Adenocarcinoma With Suspected Brain Metastasis

Duodenal adenocarcinoma (DA) is a rare tumor. We present the case of an 84-year-old lady who presented with episodic emesis with progressive dysphagia to solids and liquids. She also noted a significant weight loss of 31kg over four months. She was reported to have multiple brain masses three months before this admission. A computed tomography (CT) scan showed a heterogeneous mass (8cm) in the left retroperitoneum, inseparable from the duodenum. Additional peritoneal nodules and enlarged retroperitoneal lymph nodes were suspicious for metastases. Esophagogastroduodenoscopy revealed extrinsic compression of the stomach by the tumor. A large friable distal duodenal mass (fourth part) partially obstructed the lumen, which was biopsied. Pathology results demonstrated high-grade dysplasia but did not confirm malignancy. The patient's carcinoembryonic antigen (CEA) was elevated, but cancer antigens (CA)125 and CA19-9 were normal. A percutaneous biopsy of the mass revealed enteric-type adenocarcinoma. Immunohistochemistry showed that the tumor was positive for caudal-type homeobox (CDX)2, negative for special AT-rich sequence-binding protein (SATB)2, and patchy positive for cytokeratin (CK)7 and CK20 staining. The collective evidence suggested a duodenal primary. The patient opted for hospice and died in three days. We lack pathological evidence, but the patient's brain masses were suspicious of metastases. This would be one of the few reported cases of DA with possible brain metastases.

An Unusual Cause of Persistent Tachycardia: Atypical Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS) is a rare, life-threatening emergency caused more commonly by typical antipsychotics. However, unusual presentations of NMS are intermittently reported with the use of atypical antipsychotics. We present the case of a 42-year-old gentleman with schizoaffective and bipolar disorder who was admitted for change in mentation and lithium toxicity. His mentation did not improve despite being dialyzed and the resolution of lithium level to baseline. He developed persistent tachycardia and hyperthermia, initially attributed to Streptococcal infection. But despite appropriate antibiotic therapy, his clinical symptoms did not improve. An extensive workup for his neurological symptoms, including lumbar puncture, 5-hydroxy indole acetic acid urine test, and brain magnetic resonance imaging, was inconclusive of any underlying etiology. Given the suspicion of atypical NMS, bromocriptine 2.5 mg three times daily was initiated. This led to the gradual resolution of his symptoms and a return to his baseline mental status. Diagnosing atypical NMS can be challenging and must be differentiated from similar disorders. Lithium toxicity can predispose patients to develop NMS.

Atypical Whipple's disease

We report an unusual case of Whipple's disease diagnosed with help from the patient himself. The patient presented with rash resembling dermatitis herpetiformis, constipation, and intermittent diarrhea. A suspicion of celiac disease led to duodenal biopsy, which showed features of Whipple's disease on histology and electron microscopy.

Unicompartmental osteoarthritis of the knee: an innovative osteotomy

Thirty patients with unicompartmental osteoarthritis of the knee and genu varum deformity ranging from 2 degrees to 15 degrees were treated with high tibial osteotomy by using a medial open wedge, stabilized and distracted with our fixator. Pain relief and correction of deformity were achieved in all except two cases.