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Shekhar S, Kansara T, Morozowich ST, Mohananey D, Agrawal A, Narasimhan S, Nelson JA, Ramakrishna H. Renal Outcomes Following Transcatheter Mitral Valve Repair - Analysis of COAPT Trial Data. J Cardiothorac Vasc Anesth 2023; 37:2119-2124. [PMID: 37210324 DOI: 10.1053/j.jvca.2023.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/22/2023]
Abstract
The prevalence of valvular heart disease in the United States has been estimated at 4.2-to-5.6 million, with mitral regurgitation (MR) being the most common lesion. Significant MR is associated with heart failure (HF) and death if left untreated. When HF is present, renal dysfunction (RD) is common and is associated with worse outcomes (ie, it is a marker of HF disease progression). Additionally, a complex interplay exists in patients with HF who also have MR, as this combination further impairs renal function, and the presence of RD further worsens prognosis and often limits guideline-directed management and therapy (GDMT). This has important implications in secondary MR because GDMT is the standard of care. However, with the development of minimally invasive transcatheter mitral valve repair, mitral transcatheter edge-to-edge repair (TEER) has become a new treatment option for secondary MR that is now incorporated into current guidelines published in 2020 that listed mitral TEER as a class 2a recommendation (moderate recommendation with benefit >> risk) as an addition to GDMT in a subset of patients with left ventricular ejection fraction <50%. The Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial, which demonstrated favorable outcomes in secondary MR by adding mitral TEER to GDMT versus GDMT alone, was the evidence base for these guidelines. Considering these guidelines and the understanding that concomitant RD often limits GDMT in secondary MR, there is emerging research studying the renal outcomes from the COAPT trial. This review analyzes this evidence, which could further influence current decision-making and future guidelines.
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Affiliation(s)
- Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tikal Kansara
- Department of Hospital Medicine, Cleveland Clinic Union Hospital, Cleveland, Ohio
| | - Steven T Morozowich
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Divyanshu Mohananey
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ankit Agrawal
- Department of Cardiovascular Medicine, Heart, and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - James A Nelson
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.
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Abushouk A, Kansara T, Abdelfattah O, Badwan O, Hariri E, Chaudhury P, Kapadia SR. The Dicrotic Notch: Mechanisms, Characteristics, and Clinical Correlations. Curr Cardiol Rep 2023; 25:807-816. [PMID: 37493873 DOI: 10.1007/s11886-023-01901-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE OF REVIEW The dicrotic notch (DN) has long been considered a marker of arterial stiffness and compliance. Herein, we explored the recent developments in vascular medicine research in an attempt to assess the DN utility in clinical cardiovascular medicine. RECENT FINDINGS Since its discovery, several studies have attempted to measure the changes in different parameters of the DN in physiological and pathological states. Despite the significance of their findings, the clinical role of the DN remained limited. This may have been related to the difficulty of measuring the DN via indwelling arterial catheters in the past. However, over the past two decades, several non-invasive methods have been developed, which may re-ignite interest in DN research. The DN may have broader applications in clinical cardiovascular medicine. Further research is needed to establish the accuracy of DN non-invasive measurement methods and compare its prognostic value to other circulatory parameters.
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Affiliation(s)
- Abdelrahman Abushouk
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tikal Kansara
- Department of Hospital Medicine, Union Hospital, Cleveland Clinic Foundation, Dover, OH, USA
| | - Omar Abdelfattah
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Essa Hariri
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
- Division of Cardiovascular Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Pulkit Chaudhury
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA.
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Akinlonu AA, Alonso A, Mene-Afejuku TO, Lopez P, Kansara T, Ola O, Mushiyev S, Pekler G. The Impact of Cocaine Use and the Obesity Paradox in Patients With Heart Failure With Reduced Ejection Fraction Due to Non-ischemic Cardiomyopathy. Cureus 2023; 15:e40298. [PMID: 37448382 PMCID: PMC10337646 DOI: 10.7759/cureus.40298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/15/2023] Open
Abstract
Background Obesity and illicit drugs are independent risk factors for developing heart failure (HF). However, recent studies have suggested that patients who already have HF and are obese have better clinical outcomes. We aim to study the effect of cocaine use on this obesity paradox phenomenon as it pertains to HF readmissions. Methodology In a retrospective chart analysis, we reviewed patients with a diagnosis of HF with reduced ejection fraction (HFrEF) admitted to Metropolitan Hospital in New York. We studied the association between body mass index (BMI) categories, namely, non-obese (<30 kg/m2) and obese (≥30 kg/m2), cocaine use, and the primary outcome (time to readmission for HF within 30 days after discharge). The interaction between cocaine and obesity status and its association with the primary outcome was also assessed. Results A total of 261 patients were identified. Non-obese status and cocaine use were associated with an increased hazard of readmission in 30 days (hazard ratio (HR) = 2.28, p = 0.049 and HR = 3.12, p = 0.004, respectively). Furthermore, cocaine users who were non-obese were over six times more likely to be re-admitted in 30 days compared to non-cocaine users who were obese (HR = 6.45, p = 0.0002). Conclusions Non-obese status and continued use of cocaine have a negative additive effect in impacting HF readmissions.
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Affiliation(s)
- Adedoyin A Akinlonu
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, USA
- Department of Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Alvaro Alonso
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, USA
| | - Tuoyo O Mene-Afejuku
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, USA
- Department of Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Persio Lopez
- Department of Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Tikal Kansara
- Department of Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Olatunde Ola
- Hospital Medicine, Mayo Clinic Health System, La Crosse, USA
| | - Savi Mushiyev
- Department of Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Gerald Pekler
- Department of Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
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Abushouk AI, Spilias N, Isogai T, Kansara T, Agrawal A, Hariri E, Abdelfattah O, Krishnaswamy A, Reed GW, Puri R, Yun J, Kapadia S. Three-Year Outcomes of Balloon-Expandable Transcatheter Aortic Valve Implantation According to Annular Size. Am J Cardiol 2023; 194:9-16. [PMID: 36921423 DOI: 10.1016/j.amjcard.2023.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 03/18/2023]
Abstract
Data on the association between annular size and transcatheter aortic valve implantation (TAVI) outcomes beyond 1 year are limited. The present study assessed the association between the aortic annulus size and TAVI clinical and hemodynamic outcomes at 3 years of follow-up. Patients were classified according to the aortic annulus size as having small, intermediate, and large annuli (size <400, 400 to 574, and ≥575 mm2, respectively). The co-primary endpoints were all-cause mortality and heart failure hospitalization. Further, the changes in hemodynamic outcomes over the follow-up period (median 37, interquartile range: 26 to 45 months) were assessed. The present analysis included 850 patients, with 182 patients (21.4%), 538 patients (63.3%), and 130 patients (15.3%) in the small, intermediate, and large-sized aortic annulus groups, respectively. The groups had comparable age and pre-TAVI pressure gradients; however, patients with small annuli had higher Society of Thoracic Surgeons risk scores. Adjusted Cox regression analysis showed that compared to patients with intermediate-sized annuli, patients with small and large annuli had similar all-cause mortality (hazard ratio [HR] = 1.11, 95% confidence interval [CI] 0.72 to 1.69 and HR = 0.74, 95% CI 0.48 to 1.16, respectively) and heart failure hospitalization rates (HR = 0.96, 95% CI 0.55 to 1.69 and HR = 1.26, 95% CI 0.73 to 2.17, respectively). However, patients with small annuli had consistently higher mean and peak pressure gradients and a higher risk of patient-prosthesis mismatch. The risks of moderate-to-severe regurgitation and structural valve deterioration were similar between the three groups. In conclusion, although patients with small annuli had higher transvalvular gradients, there was no significant association between the aortic annulus size and TAVI clinical outcomes at 3 years of follow-up. Future studies should compare the performance of transcatheter valve types in patients with different aortic annulus sizes.
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Affiliation(s)
- Abdelrahman I Abushouk
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nikolaos Spilias
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Tikal Kansara
- Department of Internal Medicine, Cleveland Clinic Union Hospital, Dover, Ohio
| | - Ankit Agrawal
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Essa Hariri
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Omar Abdelfattah
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Grant W Reed
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - James Yun
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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Abushouk A, Spilias N, Isogai T, Kansara T, Agrawal A, Hariri E, Abdelfattah O, Krishnaswamy A, Puri R, Yun J, Kapadia SR. MID-TERM OUTCOMES OF TRANSCATHETER AORTIC VALVE IMPLANTATION IN PATIENTS WITH SMALL AORTIC ANNULI. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01303-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Kodra A, Kansara T, Wang D, Basman C, Pirelli L, Patel N, Scheinerman SJ, Kliger C. COMPARISON OF OUTCOMES BETWEEN CONCOMITANT SURGERY OF THE AORTIC AND MITRAL VALVES VERSUS TRANSCATHETER AORTIC AND MITRAL INTERVENTIONS WITHIN ONE YEAR. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01301-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Krouss M, Israilov S, Alaiev D, Seferi A, Kansara T, Brandeis G, Saladini-Aponte C, Wat M, Talledo J, Tsega S, Chandra K, Zaurova M, Manchego PA, Najafi N, Cho HJ. Tell-a provider about tele: Reducing overuse of telemetry across 10 hospitals in a safety net system. J Hosp Med 2023; 18:147-153. [PMID: 36567609 DOI: 10.1002/jhm.13030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Telemetry is often a scarce resource at hospitals and is important for arrhythmia and myocardial ischemia detection. Overuse of telemetry monitoring leads to alarm fatigue resulting in failure to respond to arrhythmias, patient harm, and possible unnecessary testing. METHODS This quality improvement initiative was implemented across NYC Health and Hospitals, an 11-hospital urban safety net system. The electronic health record intervention involved the addition of a mandatory indication in the telemetry order and a best practice advisory (BPA) that would fire after the recommended time period for reassessment had passed. RESULTS The average telemetry hours per patient encounter went from 60.1 preintervention to 48.4 postintervention, a 19.5% reduction (p < .001). When stratified by the 11 hospitals, decreases ranged from 9% to 30%. The BPA had a 53% accept rate and fired 52,682 times, with 27,938 "discontinue telemetry" orders placed. The true accept rate was 50.4%, as there was a 2.6% 24-h reorder rate. There was variation based on clinician specialty and clinician type (attending, fellow, resident, physician associate, nurse practitioner). CONCLUSION We successfully reduced telemetry monitoring across a multisite safety net system using solely an electronic health record (EHR) intervention. This expands on previous telemetry monitoring reduction initiatives using EHR interventions at single academic sites. Further study is needed to investigate variation across clinician type, specialty, and post-acute sites.
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Affiliation(s)
- Mona Krouss
- Department of Quality and Safety, NYC Health + Hospitals, New York, New York, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sigal Israilov
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel Alaiev
- Department of Quality and Safety, NYC Health + Hospitals, New York, New York, USA
| | - Arta Seferi
- Department of Quality and Safety, NYC Health + Hospitals, New York, New York, USA
| | - Tikal Kansara
- Department of Medicine, Cleveland Clinic, Dover, Ohio, USA
| | - Gary Brandeis
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Monica Wat
- Department of Medicine, NYC Health + Hospitals/Kings County, Brooklyn, New York, USA
| | - Joseph Talledo
- Department of Quality and Safety, NYC Health + Hospitals, New York, New York, USA
| | - Surafel Tsega
- Department of Medicine, NYC Health + Hospitals/Kings County, Brooklyn, New York, USA
| | - Komal Chandra
- Department of Quality and Safety, NYC Health + Hospitals, New York, New York, USA
| | - Milana Zaurova
- Department of Quality and Safety, NYC Health + Hospitals, New York, New York, USA
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter A Manchego
- Department of Quality and Safety, NYC Health + Hospitals, New York, New York, USA
- Department of Pediatrics, NYC Health + Hospitals/Kings County, Brooklyn, New York, USA
| | - Nader Najafi
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Hyung J Cho
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Basman C, Ong C, Kansara T, Kassam Z, Wutawunashe C, Conroy J, Kodra A, Trost B, Mehla P, Pirelli L, Scheinerman J, Singh VP, Kliger CA. Utility of Multidetector Computed Tomographic Angiography as an Alternative to Transesophageal Echocardiogram for Preoperative Transcatheter Mitral Valve Repair Planning. J Cardiovasc Imaging 2023; 31:18-23. [PMID: 36693340 PMCID: PMC9880348 DOI: 10.4250/jcvi.2022.0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/03/2022] [Accepted: 07/12/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Three-dimensional (3D) transesophageal echocardiogram (TEE) is the gold standard for the diagnosis of degenerative mitral regurgitation (dMR) and preoperative planning for transcatheter mitral valve repair (TMVr). TEE is an invasive modality requiring anesthesia and esophageal intubation. The severe acute respiratory syndrome coronavirus 2 pandemic has limited the number of elective invasive procedures. Multi-detector computed tomographic angiography (MDCT) provides high-resolution images and 3D reconstructions to assess complex mitral anatomy. We hypothesized that MDCT would reveal similar information to TEE relevant to TMVr, thus deferring the need for a preoperative TEE in certain situations like during a pandemic. METHODS We retrospectively analyzed data on patients who underwent or were evaluated for TMVr for dMR with preoperative MDCT and TEE between 2017 and 2019. Two TEE and 2 MDCT readers, blinded to patient outcome, analyzed: leaflet pathology (flail, degenerative, mixed), leaflet location, mitral valve area (MVA), flail width/gap, anterior-posterior (AP) and commissural diameters, posterior leaflet length, leaflet thickness, presence of mitral valve cleft and degree of mitral annular calcification (MAC). RESULTS A total of 22 (out of 87) patients had preoperative MDCT. MDCT correctly identified the leaflet pathology in 77% (17/22), flail leaflet in 91% (10/11), MAC degree in 91% (10/11) and the dysfunctional leaflet location in 95% (21/22) of patients. There were no differences in the measurements for MVA, flail width, commissural or AP diameter, posterior leaflet length, and leaflet thickness. MDCT overestimated the measurements of flail gap. CONCLUSIONS For preoperative TMVr planning, MDCT provided similar measurements to TEE in our study.
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Affiliation(s)
- Craig Basman
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Caroline Ong
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Tikal Kansara
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Zain Kassam
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Caleb Wutawunashe
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Jennifer Conroy
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Arber Kodra
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Biana Trost
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Priti Mehla
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Luigi Pirelli
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Jacob Scheinerman
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Varinder P Singh
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Chad A Kliger
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
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Abushouk A, Agrawal A, Hariri E, Dykun I, Kansara T, Saad A, Abdelfattah O, Badwan O, Jaggi C, Farwati M, Harb SC, Puri R, Reed GW, Krishnaswamy A, Yun J, Kapadia S. Association between haematological parameters and outcomes following transcatheter aortic valve implantation at mid-term follow-up. Open Heart 2022; 9:openhrt-2022-002108. [PMID: 36600647 PMCID: PMC9748985 DOI: 10.1136/openhrt-2022-002108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patients undergoing transcatheter aortic valve implantation (TAVI) often have multiple comorbidities, such as anaemia and chronic inflammatory disorders. We sought to investigate the association between preoperative and postoperative haematological parameters and clinical outcomes in TAVI patients at mid-term follow-up. METHODS In the present study, consecutive patients (N=908) who underwent TAVI at the Cleveland Clinic between 2017 and 2019 with available complete blood counts were studied. Data were collected on preoperative and postoperative anaemia and elevations in neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). Survival analysis was used to study the association of haematologic parameters with all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). RESULTS We found that preoperative anaemia and elevated NLR were significantly associated with a higher risk of all-cause mortality (aHR=1.6 (95% CI: 1.1 to 2.0) and 1.4 (95% CI: 1.1 to 1.6), respectively) and MACCE (aHR=1.9 (95% CI: 1.3 to 2.8) and 1.6 (95% CI: 1.1 to 2.4), respectively). While an elevated preoperative PLR was not associated with increased mortality risk, it had a significant association with MACCE risk (aHR: 1.6 (95% CI: 1.1 to 2.4)). Further, postoperative anaemia, elevated NLR and PLR were associated with increased risks of all-cause mortality and MACCE. CONCLUSION Pathological alterations in haematological parameters were associated with higher risks of post-TAVI mortality and MACCE at mid-term follow-up. Our findings advocate for further incorporating haematological parameters in the preoperative evaluation of TAVI candidates.
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Affiliation(s)
- Abdelrahman Abushouk
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ankit Agrawal
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Essa Hariri
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Iryna Dykun
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tikal Kansara
- Department of Internal Medicine, Cleveland Clinic Union Hospital, Dover, Ohio, USA
| | - Anas Saad
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Omar Abdelfattah
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Connor Jaggi
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Medhat Farwati
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Serge C Harb
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Grant W Reed
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - James Yun
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Abstract
Periodontitis, a chronic, inflammatory disease, induces systemic inflammation and contributes to the development of neurodegenerative diseases. The precise etiology of the most common neurodegenerative disorders, such as sporadic Alzheimer's, Parkinson's diseases and multiple sclerosis (AD, PD, and MS, respectively), remains to be revealed. Chronic neuroinflammation is a well-recognized component of these disorders, and evidence suggests that systemic inflammation is a possible stimulus for neuroinflammation development. Systemic inflammation can lead to deleterious consequences on the brain if the inflammation is sufficiently severe or if the brain shows vulnerabilities due to genetic predisposition, aging, or neurodegenerative diseases. It has been proposed that periodontal disease can initiate or contribute to the AD pathogenesis through multiple pathways, including key periodontal pathogens. Dysbiotic oral bacteria can release bacterial products into the bloodstream and eventually cross the brain-blood barrier; these bacteria can also cause alterations to gut microbiota that enhance inflammation and potentially affect brain function via the gut-brain axis. The trigeminal nerve has been suggested as another route for connecting oral bacterial products to the brain. PD and MS are often preceded by gastrointestinal symptoms or aberrant gut microbiome composition, and alterations in the enteric nervous system accompany the disease. Clinical evidence has suggested that patients with periodontitis are at a higher risk of developing PD and MS. This nexus among the brain, periodontal disease, and systemic inflammation heralds new ways in which microglial cells, the main innate immune cells, and astrocytes, the crucial regulators of innate and adaptive immune responses in the brain, contribute to brain pathology. Currently, the lack of understanding of the pathogenesis of neurodegeneration is hindering treatment development. However, we may prevent this pathogenesis by tackling one of its possible contributors (periodontitis) for systemic inflammation through simple preventive oral hygiene measures.
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Affiliation(s)
- X. Li
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY, USA
- Department of Urology, New York University Grossman School of Medicine, New York, NY, USA
- Perlmutter Cancer Institute, New York University Langone Medical Center, New York, NY, USA
| | - M. Kiprowska
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY, USA
| | - T. Kansara
- Cleveland Clinic- Union hospital, Dover, OH, USA
| | - P. Kansara
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY, USA
| | - P. Li
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY, USA
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Kesharani P, Kansara P, Kansara T, Kini A, Bhat R, Shetty P, Penugonda B. Is Periodontitis a Risk Factor for Lung Cancer? A Meta-Analysis and Detailed Review of Mechanisms of Association. Contemp Clin Dent 2022; 13:297-306. [PMID: 36686995 PMCID: PMC9855255 DOI: 10.4103/ccd.ccd_117_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/05/2022] [Accepted: 08/23/2022] [Indexed: 11/27/2022] Open
Abstract
Background Numerous studies have explored the correlation of periodontal disease (PD) with the risk of lung cancers, but the findings were inconsistent. Therefore, we did a meta-analysis to ascertain the correlation of PD with the risk of incident lung cancer. Methods The authors searched relevant studies in databases (PubMed, Web of Science, Scopus, Embase, and MEDLINE) till November 2020. We registered the study at the International database of Prospectively Registered Systemic Reviews under the CRD42020198119. The summary relative risk (RR) along with a 95% confidence interval (CI) was calculated using fixed-effects models. Results Twelve studies were included in the qualitative synthesis. The pooled analysis revealed that PD was significantly associated with an increased risk of lung cancer (RR 1.71; 95%CI 1.61-1.81; P < 0.01). Subgroup analysis was performed based on gender distribution, geographic location, and type of studies. Conclusion From this current evidence, PD is a potential risk factor for the development of lung cancer. The risk for incidence of lung cancer is surged twice in the patients with PD, even though age and smoking are controlled in the studies.
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Affiliation(s)
- Pooja Kesharani
- College of Dental Sciences & Research Centre, Ahmedabad, India
| | | | | | - Arjun Kini
- New York University College of Dentistry, New York, USA
| | - Raksha Bhat
- Nitte (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences(ABSMIDS), Department of Conservative Dentistry and Endodontics, Mangaluru, Karnataka, India
| | - Preethesh Shetty
- Nitte (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences(ABSMIDS), Department of Conservative Dentistry and Endodontics, Mangaluru, Karnataka, India
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Shekhar S, Ajay A, Isogai T, Kaw R, Saad A, Agrawal A, Lak H, Kansara T, Mentias A, Krishnaswamy A, Svensson L, Kapadia SR. Utilization and outcomes of aortic valve replacements (from the United States readmissions database). Am Heart J Plus 2022; 19:100184. [PMID: 38558864 PMCID: PMC10978345 DOI: 10.1016/j.ahjo.2022.100184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 04/04/2024]
Abstract
Study objective Assess the utilization of aortic valve replacements (AVR). Design Retrospective analysis of the Nationwide Readmissions Database (2016-2018). Setting Nationwide. Participants Heart failure patients with concomitant aortic stenosis (CHF + AS cohort) or aortic stenosis with aortic regurgitation (CHF + AS+AR cohort). Interventions Transcatheter aortic valve implantation (TAVI), surgical aortic valve replacement (SAVR), no-AVR. Main outcome measures Utilization of treatment interventions. Results In the CHF + AS cohort, TAVI, SAVR and no-AVR were done in 9.3 %, 10.8 % and 79.9 % of patients respectively. Similarly, majority of CHF + AS+AR patients were managed with no-AVR (53.2 %). Of patients managed with no-AVR in the first six months of each year, only 7.9 % of CHF + AS and 11.8 % of CHF + AS+AR patients underwent AVR in the subsequent six months of the year. No-AVR patients had worse short-term outcomes in comparison to AVR recipients. Conclusion More studies are needed to understand the timing, indications and utilization of AVR in this population.
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Affiliation(s)
- Shashank Shekhar
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Abhishek Ajay
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Roop Kaw
- Department of Hospital Medicine and Outcomes Research, Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Anas Saad
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Ankit Agrawal
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Hassan Lak
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Tikal Kansara
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Amgad Mentias
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Lars Svensson
- Department of Thoracic & Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Majmundar M, Kansara T, Park H, Ibarra G, Marta Lenik J, Shah P, Kumar A, Doshi R, Zala H, Chaudhari S, Kalra A. Absolute lymphocyte count as a predictor of mortality and readmission in heart failure hospitalization. Int J Cardiol Heart Vasc 2022; 39:100981. [PMID: 35281758 PMCID: PMC8904225 DOI: 10.1016/j.ijcha.2022.100981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 12/15/2022]
Abstract
Lymphopenia (<1500/mm3) was associated with 82% higher mortality in heart failure patients irrespective of ejection fraction. Lymphopenia was a good predictor of all-cause readmission in heart failure patients with reduced ejection fraction. Due to cost-effectiveness, easy availability, and ability to predict outcomes in the short-term and medium-term, lymphopenia can be a valuable tool in the mortality, readmission prediction model of heart failure.
Background There is renewed interest in pursuing frugal and readily available laboratory markers to predict mortality and readmission in heart failure. We aim to determine the relationship between absolute lymphocyte count (ALC) and clinical outcomes in patients with heart failure hospitalization. Methods This was a retrospective cohort study of patients with heart failure. Patients were divided into two groups based on ALC, less than or equal to 1500 cells/mm3 and > 1500 cells/ mm3. The primary outcome was all-cause mortality. We did subgroup analysis based on ejection fraction and studied the association between ALC categories and clinical outcomes. Both ALC groups are matched by propensity score, outcomes were analyzed by Cox regression, and estimates are presented in hazard ratios (HR) and 95% confidence intervals (CI). Results We included 1029 patients in the pre-matched cohort and 766 patients in the propensity-score matched cohort. The median age was 64 years (IQR, 54–75), and 60.78% were male. In the matched cohort, ALC less than or equal to 1500 cells/mm3 had a higher risk of mortality compared with ALC > 1500 cells/mm3 (HR 1.51, 95% CI: 1.17–1.95; P = 0.002). These results were reproducible in subgroups of heart failure. When ALC was divided into four groups based on their levels, the lowest group of ALC had the highest risk of mortality. Conclusions In patients with heart failure and both subgroups, ALC less than or equal to 1500 cells/mm3 had a higher risk of mortality. Patients in lower groups of the ALC categories had a higher risk of mortality.
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Affiliation(s)
- Monil Majmundar
- Department of Cardiology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Tikal Kansara
- Department of Internal Medicine, Cleveland Clinic Union Hospital, OH, USA
| | - Hansang Park
- Department of Internal Medicine, New York Medical College/Metropolitan Hospital, NY, USA
| | - Gabriel Ibarra
- Department of Internal Medicine, New York Medical College/Metropolitan Hospital, NY, USA
| | - Joanna Marta Lenik
- Department of Internal Medicine, New York Medical College/Metropolitan Hospital, NY, USA
| | - Palak Shah
- Department of Internal Medicine, New York Medical College/Metropolitan Hospital, NY, USA
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Rajkumar Doshi
- Department of Cardiology, St. Joseph's Medical Center, NJ, USA
| | - Harshvardhan Zala
- Department of Clinical Research, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Shobhana Chaudhari
- Department of Internal Medicine, New York Medical College/Metropolitan Hospital, NY, USA
| | - Ankur Kalra
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, IN, USA
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Majmundar M, Kansara T, Kumar A, Park H, Shah P, Doshi R, Zala H, Amin H, Chaudhari S, Kalra A. Right Ventricular Systolic Pressure – Non-invasive Bedside Predictor of Mortality and Readmission in Heart Failure with Reduced and Preserved Ejection Fraction Hospitalization. Indian Heart J 2022; 74:314-321. [PMID: 35346663 PMCID: PMC9453053 DOI: 10.1016/j.ihj.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/07/2021] [Accepted: 03/11/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To study the prognostic role of right ventricular systolic pressure (RVSP) in patients with heart failure (HF). Background Although RVSP is a readily available echocardiographic parameter, it is often underused. Its prognostic role in patients with heart failure is not well established compared with pulmonary artery pressure measured by right heart catheterization. Methods This single-center retrospective cohort study included patients with acute heart failure hospitalization admitted to the hospital from January 2005 to December 2018. The primary predictor was right ventricular systolic pressure (RVSP) obtained from bedside transthoracic echocardiography at admission. We divided RVSP into two groups, RVSP <40 mm Hg (reference group) and RVSP ≥40 mm Hg. Primary outcome was all-cause mortality. Secondary outcomes were all-cause readmission and cardiac readmission. We conducted propensity-score matching and applied cox-proportional hazard model to compute hazard ratio (HR) with 95% confidence interval (CI). Results Out of 972 HF patients, 534 patients had RVSP <40 mm Hg and 438 patients had RVSP ≥40 mm Hg. Patients with RVSP ≥40 mm Hg compared with RVSP <40 mm Hg were associated with higher rates of death [HR: 1.60, 95% CI: 1.22–2.09, P-value = 0.001], all-cause readmissions [HR: 1.37, 95% CI: 1.09–1.73, P-value = 0.008] and cardiac readmissions [HR: 1.41, 95% CI: 1.07–1.85, P-value = 0.014]. Conclusion Higher RVSP (≥40 mm Hg) in HF patients was associated with higher rates of death, all-cause readmissions, and cardiac readmissions. RVSP can be considered as a prognostic marker for mortality and readmission.
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Affiliation(s)
- Monil Majmundar
- Department of Cardiology, Maimonides Medical Center, Brooklyn, NY, USA; Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA
| | - Tikal Kansara
- Department of Internal Medicine, New York Medical College/Metropolitan Hospital, NY, USA
| | - Ashish Kumar
- Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA; Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Hansang Park
- Department of Internal Medicine, New York Medical College/Metropolitan Hospital, NY, USA
| | - Palak Shah
- Department of Internal Medicine, New York Medical College/Metropolitan Hospital, NY, USA
| | - Rajkumar Doshi
- Department of Cardiology, St. Joseph's Medical Center, Paterson, NJ, USA
| | - Harshvardhan Zala
- Department of Clinical Research, Icahn School of Medicine, Mount Sinai Hospital, NYC, NY, USA
| | - Hossam Amin
- Department of Internal Medicine, New York Medical College/Metropolitan Hospital, NY, USA
| | - Shobhana Chaudhari
- Department of Internal Medicine, New York Medical College/Metropolitan Hospital, NY, USA
| | - Ankur Kalra
- Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
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15
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Kansara T, Gandhi H, Majmundar M, Kumar A, Patel JA, Kokkirala A, Moskovits N, Mushiyev S, Basman C. Tolvaptan add-on therapy and its effects on efficacy parameters and outcomes in patients hospitalized with heart failure. Indian Heart J 2021; 74:40-44. [PMID: 34919966 PMCID: PMC8891010 DOI: 10.1016/j.ihj.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Even with the adequate use of diuretics and vasodilators, volume overload and congestion are the major causes of morbidity and mortality in patients hospitalized with acute heart failure (HF). We aim to evaluate the additive effect of tolvaptan on efficacy parameters as well as outcomes in hospitalized patients with HF. Methods We searched PubMed, EMBASE, Cochrane library, and Web of Science databases for randomized controlled trials that studied the effects of tolvaptan versus placebo in hospitalized patients with HF. Studies were included if they had any of the following endpoints: mortality, re-hospitalization, and in-hospital parameters like dyspnea relief, change in weight, sodium, and creatinine. Results The meta-analysis analyzed data from 14 studies involving 5945 patients. The follow up duration ranged from 30 days to 2 years. Between tolvaptan and placebo groups, there was no difference in mortality and rehospitalization. HF patients had a better dyspnea relief score (Likert score) in tolvaptan group and mean reduction in weight in the first 48 h (short-term). However, at 7 days (medium-term) the mean difference in weight was not significant. Serum sodium increased significantly in tolvaptan group. There was no difference in creatinine among the two groups. Conclusions Our meta-analysis shows that tolvaptan helps in short-term symptomatic dyspnea relief and weight reduction, but there are no long term benefits including reduction in mortality and rehospitalization.
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Affiliation(s)
- Tikal Kansara
- Department of Internal Medicine, Cleveland Clinic - Union Hospital, Dover, OH, USA.
| | - Haresh Gandhi
- Department of Internal Medicine, Manmouth Medical Center, Long Branch, NJ, USA
| | - Monil Majmundar
- Department of Cardiology, Maimonides Hospital, New York, NY, USA
| | - Ashish Kumar
- Department of Internal Medicine, Akron General Hospital, Akron, OH, USA
| | - Jignesh A Patel
- Department of Cardiology, St. Joseph's Medical Center, Stockton, CA, USA
| | - Aravind Kokkirala
- Department of Cardiology, Brown University - VA Medical Center, RI, USA
| | | | - Savi Mushiyev
- Division of Cardiology, New York Medical College - Metropolitan Hospital Center, New York, NY, USA
| | - Craig Basman
- Department of Cardiology, Lenox Hill Hospital, New York, NY, USA
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16
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Abstract
Hyperkalemia is a potentially life-threatening condition that can lead to sudden cardiac death. We report a case of transient left bundle branch block (LBBB) pattern on an electrocardiogram (EKG) secondary to hyperkalemia in a patient with a history of end-stage renal disease. A 48-year-old female presented to the emergency department (ED) with chief complaints of weakness and shortness of breath after a missed hemodialysis session. A 12-lead EKG in the ED showed the LBBB pattern with left axis deviation, prolonged PR interval, and peaked T-waves in the precordial leads. The initial serum potassium level was 8.5 mEq/L. EKG changes resolved after correcting the serum potassium level.
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Affiliation(s)
- Abida Naz
- Internal Medicine, New York Medical College, NYC Health + Hospitals/Metropolitan, New York, USA
| | - Tikal Kansara
- Internal Medicine, New York Medical College, NYC Health + Hospitals/Metropolitan, New York, USA
| | - Marco Ruiz Santillan
- Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Mohammad Saeed
- Internal Medicine, New York Medical College, NYC Health + Hospitals/Metropolitan, New York, USA
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Abstract
Diagnosing intestinal tuberculosis (TB) with uncommon clinical manifestations is often challenging. Here, we report a case of an alcoholic patient who presented with vague symptoms and was later diagnosed with intestinal TB. This patient experienced multiorgan failure causing hemodynamic instability requiring ionotropic support; acute hypoxic respiratory failure managed with non-invasive positive pressure ventilation, hepatic failure, transudative peritoneal effusion, and transudative pleural effusion. These conditions clouded our judgment to pursue colonoscopy for a definite diagnosis and delayed the anti-tuberculosis treatment. When intestinal tuberculosis TB is suspected, the differential diagnosis must be established with other gastrointestinal involving diseases, including mycobacterium avium complex (MAC) and Crohn's disease (CD). MAC can show overlapping features with intestinal TB or coexist with it; Acid-fast stain and tissue culture are the key tests to differentiate these two. In the presence of diagnostic uncertainty between intestinal TB and CD, a therapeutic trial with anti-tuberculous therapy may be warranted.
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Affiliation(s)
- Hansang Park
- Internal Medicine, New York City Health and Hospitals Corporation (NYC HHC) Metropolitan, New York, USA
| | - Tikal Kansara
- Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Ana M Victoria
- Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Noella Boma
- Internal Medicine, Metropolitan Hospital, New York, USA
| | - Jungrak Hong
- Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
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18
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Kansara T, Majmundar MM, Lenik J, Vista M, Chaudhari S. Infective Endocarditis and Intravenous Drug Users: Never Was and Never Will Be Taken Lightly. Cureus 2021; 13:e12812. [PMID: 33628679 PMCID: PMC7894215 DOI: 10.7759/cureus.12812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Infective endocarditis (IE) is the infection of the endocardial surface (innermost layer - valves, chordae tendineae, and papillary muscles) of the heart. It usually refers to infection of one or more of the heart valves which may be native or prosthetic. The definition also includes infection on indwelling cardiac devices. Over time, the etiology, as well as causes of IE, have evolved and doubled in numbers because of a greater number of patients with indwelling cardiac devices and central lines. Some characteristic features have remained the same, including intravenous drug users (IVDU) and right-sided IE, fever, or peripheral signs of IE. However, there are instances where the clinical presentation is unique. Here we describe an unusual case of an IVDU patient developing acute decompensated heart failure following acute aortic regurgitation (AR) from IE without fever and right-sided heart or tricuspid valve involvement.
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Affiliation(s)
- Tikal Kansara
- Internal Medicine, Metropolitan Hospital Center, New York Medical College, New York, USA
| | - Monil M Majmundar
- Internal Medicine, Metropolitan Hospital Center, New York Medical College, New York, USA
| | - Joanna Lenik
- Internal Medicine, Metropolitan Hospital Center, New York Medical College, New York, USA
| | - Manuel Vista
- Internal Medicine, Metropolitan Hospital Center, New York Medical College, New York, USA
| | - Shobhana Chaudhari
- Internal Medicine, Metropolitan Hospital Center, New York Medical College, New York, USA
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Kansara T, Majmundar M, Basman C, Visco F. Problems with interpreting troponins in chronic kidney disease patients for ruling out acute coronary syndrome. Am J Emerg Med 2020; 41:14-15. [PMID: 33378716 DOI: 10.1016/j.ajem.2020.12.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/16/2020] [Accepted: 12/16/2020] [Indexed: 11/17/2022] Open
Abstract
Chest pain is one of the most common reasons for emergency department visits worldwide, and troponins play a central role in diagnosing acute coronary syndrome (ACS) in these patients. Hence, the tests for these molecules are imperative in triage for ACS. Presently, multiple high-sensitivity troponin tests are available, including those for troponin T and I. However, in the presence of physiological and pathological alterations such as chronic kidney disease (CKD) and muscle dysfunction, these tests lose their sensitivity and specificity, especially if not interpreted in the right clinical background. Further, no guidelines exist for interpreting the results in patients with CKD. We identified studies that compared the relative efficacy, sensitivity, and specificity of tests for troponin T and I in patients with CKD to understand the practical problems in the clinical interpretation of these results in the specific setting of CKD and highlight the measures to be taken into consideration.
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Affiliation(s)
- Tikal Kansara
- Department of Internal Medicine, New York Medical College - Metropolitan Hospital Center, New York, NY 10029, United States of America.
| | - Monil Majmundar
- Department of Internal Medicine, New York Medical College - Metropolitan Hospital Center, New York, NY 10029, United States of America
| | - Craig Basman
- Department of Cardiology, Lenox Hill Hospital, New York, NY 10029, United States of America
| | - Ferdinand Visco
- Department of Cardiology, New York Medical College - Metropolitan Hospital Center, New York, NY 10029, United States of America
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Kansara T, Kumar A, Majmundar M, Basman C. Mitral regurgitation following PASCAL mitral valve repair system: A single arm meta-analysis. Indian Heart J 2020; 73:129-131. [PMID: 33714399 PMCID: PMC7961240 DOI: 10.1016/j.ihj.2020.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/03/2020] [Indexed: 12/20/2022] Open
Abstract
Major consequences of untreated severe mitral regurgitation (MR) includes heart failure, ventricular remodeling and pulmonary hypertension leading to significant morbidity and mortality. MitraClip is the most widely used device for treatment of severe MR. To overcome some of the shortcomings of MitraClip, novel devices like PASCAL mitral valve repair system are developed. We performed a single arm meta-analysis for patients with severe mitral regurgitation (MR) undergoing PASCAL mitral valve repair system. The results showed that 93.8% patients had reduction in MR grade, with an average operative time of 88 min and an average increase of 86.33 m in 6-min walk test.
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Affiliation(s)
- Tikal Kansara
- Department of Internal Medicine, New York Medical College - Metropolitan Hospital Center, New York, NY, USA.
| | - Ashish Kumar
- Department of Cardiovascular Research, Cleveland Clinic, Akron, OH, USA
| | - Monil Majmundar
- Department of Internal Medicine, New York Medical College - Metropolitan Hospital Center, New York, NY, USA
| | - Craig Basman
- Department of Cardiology, Lenox Hill Hospital, New York, NY, USA
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21
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Kapasi K, Kesharani P, Kansara P, Patil D, Kansara T, Sheth S. In vitro comparative evaluation of efficiency of XP-endo shaper, XP-endo finisher, and XP-endo finisher-R files in terms of residual root filling material, preservation of root dentin, and time during retreatment procedures in oval canals - A cone-beam computed tomography analysis. J Conserv Dent 2020; 23:145-151. [PMID: 33384486 PMCID: PMC7720764 DOI: 10.4103/jcd.jcd_257_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/07/2020] [Accepted: 08/04/2020] [Indexed: 11/15/2022] Open
Abstract
Background: In an oval-shaped canal, no single instrumentation systems were effective in absolute removing obturation. Aim: The aim of the study was to evaluate the performance of ProTaper Universal Retreatment (PTUR) system, XP-endo Shaper (XPS), XP-endo Finisher (XPF), and XP-endo Finisher-R (XPF-R) in removing root-canal filling material and preservation of sound dentin during retreatment procedure. Methodology: Root-canal preparation was performed on 60 mandibular premolars with oval-shaped canals using the ProTaper Gold file system. Preobturation scans were performed to measure canal volume of the canal and recorded. Obturation was performed and the samples were randomly assigned into four groups according to the retreatment protocol used (n = 15): H-file, PTUR files, PTUR followed by XPF file, and XPS supplemented with XPF-R file. After retreatment, the specimens were re-scanned and volumetric analysis of remaining root filling material, volume of the canal space were measured using EZ-3Di Software Version 5.0.0.2. All the data were subjected to one-way ANOVA and post hoc Tukey's test with a significance of 5%. Results: XPS + XPF-R showed promising results in the removal of obturating material and preservation of root dentin than any other group. The difference is statistically significant. Conclusion: XPS + XPF-R removed gutta-percha more significantly without sacrificing the sound dentin along with instrumentation.
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Affiliation(s)
- Khyati Kapasi
- Department of Conservative Dentistry and Endodontics, College of Dental Sciences and Research Center, Manipur, Ahmedabad, Gujarat, India
| | - Pooja Kesharani
- Department of Conservative Dentistry and Endodontics, College of Dental Sciences and Research Center, Manipur, Ahmedabad, Gujarat, India
| | - Payalben Kansara
- Department of Cariology and Comprehensive Dentistry, New York University College of Dentistry, New York, New York, USA
| | - Deepu Patil
- Department of Conservative Dentistry and Endodontics, AME's Dental College, Raichur, Karnataka, India
| | - Tikal Kansara
- Department of Medicine, New York Medical College - Metropolitan Hospital Center, New York, New York, USA
| | - Shirali Sheth
- Department of Oral and Maxillofacial Radiology, Dharamsingh Desai University, Nadiad, Gujarat, India
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22
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Abstract
A 95-year-old male with a medical history of focal epilepsy presented with transient ischemic attack (TIA)/pre-syncope like symptoms. He was on lacosamide (LCM) and levetiracetam. On evaluation, he was found to have left bundle branch block (LBBB), sinus pause of three seconds, and 1st degree atrioventricular (AV) block. After holding LCM, electrocardiogram changes were reversed to baseline (before commencing LCM). In conclusion, to the best of our knowledge, this is the first case of reversible LBBB along with sinoatrial (SA) node and AV node dysfunction in an elderly male on LCM therapy.
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Affiliation(s)
- Monil M Majmundar
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Tikal Kansara
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Palak Shah
- Department of Internal Medicine, Smt. B.K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Vadodara, IND
| | | | - Shobhana Chaudhari
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
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Majmundar MM, Azhar AZ, Kansara T, Shah P, Doshi RP, Mene-Afejuku T, Patel K, Patel H, Visco F, Pekler G. LEFT VENTRICULAR ASSIST DEVICE VERSUS INTRA AORTIC BALLOON PUMP IN HIGH-RISK PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: A META-ANALYSIS OF RANDOMIZED TRIALS. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31866-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Actinomyces turicensis (A. turicensis) are normal commensals of the oral, gut, vagina, and skin flora. Infection with these organisms is usually benign, and bacteremia is rare. Here, we describe a case of an otherwise healthy female patient presenting with renal calculi and life-threatening A. turicensis bacteremia. The patient did not have any risk factors for A. turicensis bacteremia. The patient developed multi-organ dysfunction syndrome and received a biodegradable right ureter stent. The patient improved with urosurgical intervention and appropriate antibiotic coverage.
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Affiliation(s)
- Tikal Kansara
- Internal Medicine, New York Medical College-Metropolitan Hospital Center, New York City, USA
| | - Monil Majmundar
- Internal Medicine, New York Medical College-Metropolitan Hospital Center, New York City, USA
| | - Rajkumar Doshi
- Internal Medicine, University of Nevada, Reno School of Medicine, Reno, USA
| | - Kuldeep Ghosh
- Internal Medicine, New York Medical College-Metropolitan Hospital Center, New York City, USA
| | - Mohammad Saeed
- Internal Medicine, New York Medical College-Metropolitan Hospital Center, New York City, USA
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25
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Kansara T, Dumancas C, Neri F, Mene-Afejuku TO, Akinlonu A, Mushiyev S, Pekler G, Visco F. Rare Association of Takotsubo Cardiomyopathy with Right Bundle Branch Block in the Dual Setting of Asthma Exacerbation and Psychiatric Illness. Am J Case Rep 2020; 21:e920461. [PMID: 31959739 PMCID: PMC6998788 DOI: 10.12659/ajcr.920461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patient: Male, 58-year-old Final Diagnosis: Takotsubo cardiomyopathy Symptoms: Dyspena Medication:— Clinical Procedure: — Specialty: Cardiology
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Affiliation(s)
- Tikal Kansara
- Department of Internal Medicine, New York Medical College, NYC Health + Hospitals/Metropolitan, New York City, NY, USA
| | - Carissa Dumancas
- Department of Internal Medicine, New York Medical College, NYC Health + Hospitals/Metropolitan, New York City, NY, USA
| | - Feizi Neri
- Department of Internal Medicine, New York Medical College, NYC Health + Hospitals/Metropolitan, New York City, NY, USA
| | - Tuoyo O Mene-Afejuku
- Department of Internal Medicine, New York Medical College, NYC Health + Hospitals/Metropolitan, New York City, NY, USA
| | - Adedoyin Akinlonu
- Department of Internal Medicine, New York Medical College, NYC Health + Hospitals/Metropolitan, New York City, NY, USA
| | - Savi Mushiyev
- Department of Medicine, Division of Cardiology, New York Medical College, NYC Health + Hospitals/Metropolitan, New York City, NY, USA
| | - Gerald Pekler
- Department of Medicine, Division of Cardiology, New York Medical College, NYC Health + Hospitals/Metropolitan, New York City, NY, USA
| | - Ferdinand Visco
- Department of Medicine, Division of Cardiology, New York Medical College, NYC Health + Hospitals/Metropolitan, New York City, NY, USA
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26
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Abstract
Acute pulmonary embolism (PE) can be potentially fatal if not diagnosed and treated early. Mortality in untreated cases can be as high as 30%. Atypical presentation and submassive PE can be missed due to subtle clinical features. Computerized tomography pulmonary angiogram is expensive, exposes to radiation and carries the risk of contrast nephropathy or anaphylactic reactions. On the contrary, McConnell's sign, which is a highly specific sign of PE, can be demonstrated at the bedside with a transthoracic echocardiogram (TTE). Here we discuss two cases where bedside TTE demonstrating McConnell's sign helped in the diagnosis and treatment of PE.
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27
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Doshi R, Majmundar M, Kansara T, Desai R, Shah J, Kumar A, Patel K. Frequency of Cardiovascular Events and In-hospital Mortality With Opioid Overdose Hospitalizations. Am J Cardiol 2019; 124:1528-1533. [PMID: 31521260 DOI: 10.1016/j.amjcard.2019.07.068] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/26/2019] [Accepted: 07/30/2019] [Indexed: 01/12/2023]
Abstract
The United States is in the kernel of cataclysmic opioid misuse epidemic with over 33,000 deaths per year from both prescription and illegal opioids use. One of the most common pernicious effects of opioids is on the cardiovascular system. The purpose of this analysis was to determine the incidence of opioid overdose associated cardiovascular events and its impact on short-term outcomes. This was a retrospective, observational study which utilized data from the National Inpatient Sample from January 2005 to September 2015 using International Classifications of Disease, Ninth Revision, Clinical Modification diagnosis codes to identify patients with opioid overdose and associated cardiovascular outcomes. Cardiovascular events were mainly divided into the following 3 parts: Ischemic Events (ischemic stroke and myocardial infarction), acute heart failure, and arrhythmias. The primary outcome of this study was incidence of any cardiovascular event. This study analyzed a total of 430,459 patients hospitalized with opioid overdose, out of which 36,837 (8.6%) had at least 1 cardiovascular event. In all the opioid overdose hospitalizations, 13,979 (3.2%) developed ischemic events, 3,074 (0.7%) developed acute heart failure, and 22,444 (5.2%) developed arrhythmia. Opioid overdose patients with new-onset cardiovascular events had higher odds for in-hospital mortality (odds ratio 4.55; 95% confidence interval 4.11 to 5.04, p <0.001) as compared to patients without cardiovascular events in the multivariable-adjusted model. This study group also demonstrated longer length of stay and higher cost of hospitalization associated with opioid overdose and associated cardiovascular outcome. In conclusion, opioid overdose is associated with higher rates of cardiovascular events, particularly ischemic events and cardiac arrhythmias. These adverse events eventually lead to higher mortality rates and more resource utilization.
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Affiliation(s)
- Rajkumar Doshi
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, Nevada.
| | - Monil Majmundar
- Department of Internal Medicine, Metropolitan Hospital Center, New York Medical College, New York, New York
| | - Tikal Kansara
- Department of Internal Medicine, Metropolitan Hospital Center, New York Medical College, New York, New York
| | - Rupak Desai
- Division of Cardiology, Atlanta VA Medical Center, Decatur, Georgia
| | - Jay Shah
- Department of Internal Medicine, Mercy St Vincent Medical Center, Toledo, Ohio
| | - Ashish Kumar
- Department of Critical Care Medicine, St John's Medical College Hospital, Bangalore, India
| | - Krunalkumar Patel
- Department of Cardiology, North Shore University Hospital, Manhasset, New York
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28
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Kansara T, Pernia M, Kim Y, Saeed M. Rare Occurrence of Prosthetic Knee Septic Arthritis Due to Streptococcus viridans in the Background of a Dental Procedure. Cureus 2019; 11:e5980. [PMID: 31803562 PMCID: PMC6874422 DOI: 10.7759/cureus.5980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The American Academy of Oral Medicine, American Dental Association (ADA), in conjunction with the American Academy of Orthopedic Surgeons (AAOS) and the British Society for Antimicrobial Chemotherapy, advises against the universal use of antimicrobial prophylaxis prior to dental procedures for the prevention of prosthetic joint infection (PJI). Here, we discuss the case of a patient with PJI in the background of periodontal scaling, which was done a week prior to presentation to the hospital. The PJI occurred with Streptococcus (S.) viridans, a rare organism for PJI but a common oral commensal. As the number of prosthetic joint surgeries are increasing and more data become available, prophylactic antibiotics might be considered to prevent PJI, especially in high-risk patients.
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Affiliation(s)
- Tikal Kansara
- Internal Medicine, New York Medical College - Metropolitan Hospital Center, New York, USA
| | - Monica Pernia
- Internal Medicine, New York Medical College - Metropolitan Hospital Center, New York, USA
| | - Yoojin Kim
- Internal Medicine, New York Medical College - Metropolitan Hospital Center, New York, USA
| | - Mohammad Saeed
- Internal Medicine, New York Medical College - Metropolitan Hospital Center, New York, USA
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29
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Sheth T, Gandhi S, Maitra N, Singh S, Kansara T. Cancer cervix screening and treatment of precancer: population- vs. facility-based approach. Contraception 2012. [DOI: 10.1016/j.contraception.2012.04.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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