Estimated glomerular filtration rate and the risk of stroke in individuals with diabetes mellitus and atrial fibrillation insight from a large contemporary population study.

BACKGROUND: Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Impaired renal function (IRF) increases the risk of stroke as well, but this finding is not consistent among all studies. Our aim was to assess the incidence rates and risk of ischemic stroke and mortality by baseline Estimated Glomerular Filtration Rate (eGFR) levels Among individuals with AF and DM. METHODS: A prospective, historical cohort study using the Clalit Health Services electronic medical records database. Among patients with AF and DM, we compared three groups according to eGFR levels: eGFR ≥ 60, between 30 and 60, and ≤ 30 (mL/min/1.73m2). RESULTS: A total of 17,567 cases were included in the final analysis; of them, 11,013 (62.7%) had eGFR ≥ 60, 4930 (28%) had eGFR between 30 and 60, and 1624 (9.24%) with eGFR ≤ 30. The incidence of stroke per 100 person-years in the three study groups was: 1.88, 2.69, and 3.34, respectively (p < 0.001). IRF was associated with increased risk of stroke in univariate analysis, but not after multivariate adjustment (Adjusted Hazard Ratio (AHR) 0.96 {95%CI; 0.74-1.25} for eGFR 30-60 and 0.96 {95%CI; 0.60-1.55} for eGFR ≤ 30). Mortality per 100 person-years was 10.78, 21.49, and 41.55, respectively (p < 0.001). IRF was associated with increased mortality risk in univariate analysis, as well as in multivariate analysis (AHR 1.08 {95%CI; 0.98-1.18} for eGFR 30-60, and 1.59 {95%CI; 1.37-1.85} for eGFR ≤ 30. CONCLUSION: In patients with NVAF and DM, IRF was not associated with an increased risk of stroke, but severe IRF (eGFR ≤ 30) was associated with increased mortality risk.

Clinical Outcomes of Patients with COVID-19 Infection and Cardiac Implantable Electronic Devices.

BACKGROUND: Existing cardiac disease contributes to poor outcome in patients with coronavirus disease 2019 (COVID-19). Little information exists regarding COVID-19 infection in patients with a cardiac implantable electronic device (CIED). OBJECTIVES: To assess the association between CIEDs and severity of COVID-19 infection. METHODS: We performed a retrospective analysis including 13,000 patients > 18 years old with COVID-19 infection between January and December 2020. Patients with COVID-19 who had a permanent pacemaker or defibrillator were matched 1:4 based on age and sex followed by univariate and multivariate analyses. Baseline characteristics and clinical outcomes were assessed. RESULTS: Forty patients with CIED and 160 patients without CIED were included in the current analysis. Mean age was 72.6 ± 13 years, and approximately 50% were females. Majority of the patients in the study arm had a pacemaker (63%), whereas only 15 patients (37%) had a defibrillator. Patients with COVID-19 and CIED presented more often with atrial fibrillation, coronary artery disease, heart failure, hypertension, diabetes, and chronic kidney disease. They were more likely to be hospitalized in the intensive care unit (ICU) and required more ventilatory support (35% vs. 18.3%). Thirty-day mortality (22.5% vs. 13.8%) and 1-year mortality (25% vs. 15%) were higher among patients with COVID-19 and CIED. CONCLUSIONS: Patients with COVID-19 and CIED had a significantly higher prevalence of co-morbidities that were associated with increased mortality. Although, CIED by itself was not found as an independent risk factor for morbidity and mortality, it may serve as a warning for severe illness with COVID-19.

[THE ASSOCIATION BETWEEN OBESITY AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)].

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease, with major respiratory and systemic expressions. Obesity is defined as a BMI>30 kg/ m2 and its prevalence has doubled in recent decades. The possible relationship of obesity to COPD, and its influence on respiratory pathophysiology, is considered a mystery. Studies show obesity to be a survival advantage among COPD patients, unlike in the general population, in which obesity correlates to decreased life expectancy. This study aims to assess the differences between obese and non-obese COPD patients. The main clinical aspect assessed is the number of COPDexacerbation related hospital admissions. METHODS: We conducted a retrospective cohort study of 323 COPD patients (95 obese, 228 non-obese), who had been followed from 2003-2010 by the Pulmonology Institute at the Soroka Medical Center. We collected demographics, medical history, BMI, lung function tests, information about hospital admissions and mortality. RESULTS: Non-obese COPD patients are 1.6 times more likely to be hospitalized due to COPD exacerbation. Additionally, women are 1.8 times more likely to be hospitalized due to COPD exacerbation. The FEV1 and FEV1/FVC ratios, which were measured latest during the study period, were higher among obese COPD patients. There was no significant difference in mortality. CONCLUSIONS: Obesity and male gender act as protective factors against COPD exacerbations requiring hospitalization. Lung function test values are higher among obese patients. Despite this, obesity has no influence on COPD patient survival. Subsequent studies are required, in order to define nutrition recommendations and target weights for COPD patients.

[THE UTILITY OF BRONCHOSCOPY IN INTENSIVE CARE UNIT PATIENTS WITH VENTILATOR ASSOCIATED PNEUMONIA].

BACKGROUND: Ventilator associated pneumonia (VAPI is a common complication leading to lengthier hospitalizations and higher mortality. Prompt adequate initial antibiotic coverage is the crucial issue affecting survival. Currently, there is no gold standard diagnostic test. No conclusive data regarding the benefit of bronchoscopy exists in the literature reviewed. AIM: This study aims to evaluate the change of prognosis for patients who developed VAP, following a positive culture from bronchoalveolar lavage (BAL). DESIGN: This is a retrospective cohort study. SETTING: General intensive care unit in a tertiary university healthcare center. PARTICIPANTS: All patients who were admitted to Surgical ICU and developed VAP and who then underwent diagnostic bronchoscopy with BAL between the period 01/02/2007 - 31/02/2011. MEASUREMENTS AND RESULTS: A total of 66 patients who were admitted to the ICU, developed VAP and underwent bronchoscopy while ventilated; 30 patients were excluded. The positive BAL culture group was compared to the negative BAL culture group; there was no difference between demographic and clinical characteristics, mortality rates (for 30 days) or therapy change between the two groups. No complications were reported regarding the bronchoscopy procedure. CONCLUSIONS: Our findings demonstrate that performing y a diagnostic bronchoscopy with BAL does not improve the prognosis of patients with VAP. Furthermore, expanded prospective studies will be needed to conclude regarding its benefit in diagnosis and subsequent rectifying of therapy.

Compound Heterozygosity for Late-Onset Cardiomyopathy-Causative ALPK3 Coding Variant and Novel Intronic Variant Cause Infantile Hypertrophic Cardiomyopathy.

Hypertrophic and dilated cardiomyopathy (HCM, DCM) are leading causes of cardiovascular morbidity and mortality in children. The pseudokinase alpha-protein kinase 3 (ALPK3) plays an essential role in sarcomere organization and cardiomyocyte differentiation. ALPK3 coding mutations are causative of recessively inherited pediatric-onset DCM and HCM with variable expression of facial dysmorphism and skeletal abnormalities and implicated in dominantly inherited adult-onset cardiomyopathy. We now report two variants in ALPK3-a coding variant and a novel intronic variant affecting splicing. We demonstrate that compound heterozygosity for both variants is highly suggestive to be causative of infantile-onset HCM with webbed neck, and heterozygosity for the coding variant presents with adult-onset HCM. Our data validate partial penetrance of heterozygous loss-of-function ALPK3 mutations in late-onset hypertrophic cardiomyopathy and expand the genotypic spectrum of autosomal recessive ALPK3-related cardiac disease with Noonan-like features.

Development of saliva-based cardiac troponin I point-of-care test using alpha-amylase depletion: a feasibility study.

INTRODUCTION: Cardiac troponin (cTn) is the biomarker of choice for detection of myocardial injury. There is a great need for simple point-of-care (POC) troponin testing among patients with chest pain, mainly in the prehospital setting. The purpose of this study was to evaluate the presence of cardiac troponin I (cTnI) in saliva of patients with myocardial injury using alpha-amylase depletion technique. METHODS: Saliva samples were collected from 40 patients with myocardial injury who were tested positive for conventional high-sensitivity cardiac troponin T (cTnT) blood tests, and from 66 healthy volunteers. Saliva samples were treated for the removal of salivary alpha-amylase. Treated and untreated samples were tested with blood cTnI Rapid Diagnostic Test. Salivary cTnI levels were compared to blood cTnT levels. RESULTS: Thirty-six of 40 patients with positive blood cTnT had positive salivary samples for cTnI following alpha-amylase depletion treatment (90.00% sensitivity). Moreover, three of the four negative saliva samples were obtained from patients with relatively low blood cTnT levels of 100 ng/L or less (96.88% sensitivity for 100 ng/L and above). The negative predictive value was 93.65% and rose up to 98.33% considering the 100 ng/L cutoff. Positive predictive values were 83.72% and 81.58%, respectively. Among 66 healthy volunteers and 7 samples yielded positive results (89.39% specificity). CONCLUSION: In this preliminary work, the presence of cTnI in saliva was demonstrated for the first time to be feasibly identified by a POC oriented assay. The specific salivary alpha-amylase depletion technique was shown to be crucial for the suggested assay.

Aspirin with Low-Dose Ticagrelor or with Low-Dose Rivaroxaban for Secondary Prevention: A Cost per Outcome Analysis.

INTRODUCTION: Secondary prevention of cardiovascular events among patients with diagnosed cardiovascular disease and high ischemic risk poses a significant challenge in clinical practice. The combinations of aspirin with low-dose (LD) ticagrelor or LD rivaroxaban have shown superiority in preventing major adverse cardiovascular events (MACE) compared with aspirin treatment alone. The comparative value for money of these two regimens remains unexplored. METHODS: We analyzed each regimen's annual cost needed to treat (CNT) by multiplying the annualized number needed to treat (aNNT) by the annual cost of each drug. The aNNTs were based on outcome data from PEGASUS TIMI-54 and COMPASS trials. Scenario analyses were performed to overcome variances in terms of population risk. Costs were calculated as 75% of US National Average Drug Acquisition Cost (NADAC), extracted in January 2022. The primary outcome was defined as CNT to prevent one MACE across the two regimens. Secondary value analysis was performed for myocardial infarction (MI), stroke, and cardiovascular death as separate outcomes. RESULTS: The aNNTs to prevent MACE with LD ticagrelor and with LD rivaroxaban were 229 [95% confidence interval (CI) 141-734] and 147 (95% CI 104-252), respectively. At an annual cost of US$3726 versus US$4533, the corresponding CNTs were US$853,254 (95% CI 525,366-2,734,884) with LD ticagrelor and US$666,351 (95% CI 471,432-1,142,316) with LD rivaroxaban. CONCLUSION: Combining aspirin with LD rivaroxaban provides better value for money than with LD ticagrelor for secondary prevention of MACE.

When the brain slows the heart-herpes encephalitis and sinus arrest: a case report.

BACKGROUND: Herpes simplex virus (HSV) encephalitis is a known cause of cognitive deterioration, neurological disturbances, and seizures though are rarely associated with sinus node dysfunction. CASE SUMMARY: We present a 54-year-old man admitted to the hospital with a 10-day history of fever, confusion, and fatigue, 1 week following a transient loss of consciousness. An initial workup suggested HSV encephalitis and the patient was started on intravenous Acyclovir. Due to his episode of syncope, a 24 h Holter electrocardiogram monitoring was performed. The Holter documented multiple episodes of sinus arrest, with a second episode of syncope noticed by the hospital staff concurrent with the last documented sinus arrest. Following antiviral treatment and resolution of the encephalitis we noticed complete resolution of sinus node dysfunction. We subsequently avoided permanent pacemaker implantation. DISCUSSION: Our case of proven HSV encephalitis complicated by sinus node arrest and syncope with complete resolution following antiviral treatment suggests no indication for permanent pacemaker implantation. This approach is consistent with data from previously reported cases.

Commotio Cordis: Indeed?

We discuss an unusual case of a patient who initially presented with apparent commotio cordis but returned several months later with spontaneous wide complex tachycardia. This case highlights the importance of investigation of survivors of commotio cordis, especially if atypical, to determine if there is underlying cardiac disease. (Level of Difficulty: Beginner.).

The Presence of Snoring as Well as its Intensity Is Underreported by Women.

STUDY OBJECTIVES: Women are underrepresented and thus sleep conditions are underdiagnosed at sleep clinics that evaluate sleep-disordered breathing. The most common sign of obstructive sleep apnea (OSA) is snoring; therefore, it is one of the main red flags for suspected OSA. The aim of this study is to determine whether self-reported snoring and snoring intensity by women and men correlates with snoring volume measured objectively during sleep laboratory study. METHODS: Consecutive patients who were referred to a polysomnography (PSG) study in a university hospital over a 2-year period had their snoring volume quantified by means of a calibrated digital sound survey meter. Participants were given a questionnaire in which they were asked to rate the severity of their snoring. The correlation between objective snoring intensity as measured during PSG and the self-reported snoring intensity was evaluated. RESULTS: A total of 1,913 patients were enrolled in the study. A positive correlation was found between objectively measured snoring intensity and the intensity listed by each participant in the questionnaire. Measurement of the volume of snoring revealed that women snored as loudly as men; however, 28% of the females (189/675) considered themselves to be nonsnorers compared to only 6.9% of men (P < .05). Furthermore, 36.5% of women (69/189) who reported themselves as nonsnorers turned out to have severe or very severe snoring intensity, whereas, in contrast, only 11.7% of men (10/85) of men had this discrepancy. These findings are in concordance with the finding that fewer women quantified their snoring as very severe or severe (38.4%), significantly less than men of whom 61.5% reported their snoring to be severe or very severe. CONCLUSIONS: In a population of individuals referred to a PSG study, although no difference in snoring intensity was found between sexes, women tend to underreport the fact that they snore and to underestimate the loudness of their snoring. Improved awareness of this discrepancy may increase women's access to sleep laboratories, and improve diagnostic rates of sleep apnea in females.

Snoring intensity and excessive daytime sleepiness in subjects without obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Snoring and excessive daytime sleepiness (EDS) are major obstructive sleep apnea (OSA) symptoms. Snorers with apnea/hypopnea index < 5 are designated "simple snorers" and do not meet OSA criteria. This study aimed to explore a possible association between snoring intensity and EDS defined as Epworth Sleepiness Scale (ESS) scores ≥ 11 in non-OSA subjects. STUDY DESIGN: Prospective cohort study. METHODS: From a total of 2,225 subjects who underwent polysomnography (PSG), 307 simple snorers qualified for the study and were assessed for snoring intensity and ESS score. The correlation between PSG-based snoring intensity measurements and ESS score was evaluated. A prediction model for EDS was derived using multivariate logistic regression. RESULTS: Subjects with EDS tended to be male and of heavier body habitus. Although both genders exhibited similar snoring intensities, men had higher ESS scores than women. A strong linear correlation was demonstrated between the maximal snoring intensity and the ESS score. Maximal snoring sound and male gender were shown to be predictors of EDS, with odds ratios of 1.93 (95% confidence interval [CI]:1.63-2.26, P < .001) and 3.70 (95% CI: 1.29-12.5, P = .01), respectively. CONCLUSIONS: In a population of non-OSA subjects referred to a PSG study, snoring intensity was associated with EDS in both men and women. A positive linear correlation was observed between snoring intensities and ESS scores. Additional studies are needed to further consolidate the evidence regarding the implications of simple snoring for public health. LEVEL OF EVIDENCE: 2b Laryngoscope, 126:1696-1701, 2016.