Relationship Between Obesity and Youth Athletes' Physical Activity and Exercise-Related Cardiac Symptoms.

Background: While studies have identified the negative cardiovascular effects of obesity, the effects of obesity on youth athletes are less studied. This study investigates the associations between obesity in youth athletes and exercise activity and exertional cardiac symptoms. Methods: The HeartBytes National Youth Database produced by Simon's Heart, a nonprofit that organizes adolescents' sports pre-participation examinations (PPEs), was used. This database contains demographic data, exercise-related symptoms, and electrocardiogram data obtained during PPEs. BMI was converted to percentiles, with obesity defined as BMI ≥95th percentile. Outcomes were evaluated using a chi-squared test with odds ratios (ORs) and 95% confidence intervals (CIs). Results: Of 7363 patients, there were 634 individuals with obesity. Youth athletes within normal weight ranges (5th-85th percentile) had higher exercise rates than those with underweight, overweight, or obesity (p < 0.001 for each). Athletes with obesity had higher odds of exertional symptoms overall (OR: 1.63 [CI: 1.36-1.96]; p < 0.001). However, for athletes who exercised >10 hours a week, there was no association between obesity and exertional symptoms. Athletes with obesity had higher odds of elevated blood pressure (OR: 5.35 [CI: 2.00-14.30]; p < 0.001) and hypercholesterolemia (OR: 3.84 [CI: 2.51-5.86]; p < 0.001). Conclusions: In this dataset, obesity in youth athletes is associated with decreased physical activity and increased exertional symptoms in general. Obesity is not associated with exertional symptoms in athletes who participated in higher weekly physical activity. Further studies are needed to elucidate the cause-effect relationship of these findings.

Relationship Between Caffeine Consumption and Young Athletes' Comorbidities, Exercise-Related Symptoms, and Baseline Electrocardiogram.

BACKGROUND: Caffeine consumption causes diverse physiologic effects that can affect athletes both positively and negatively. There is a lack of research investigating the long-term effects of caffeine intake on exercise and on overall cardiovascular health in young athletes. HYPOTHESIS: Certain characteristics such as age, body mass index (BMI), race, and medical diagnoses are associated with increased caffeine use, and there is a relationship between caffeine consumption and symptoms during exercise and cardiovascular abnormalities in young athletes. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 4. METHODS: This study utilized the HeartBytes National Youth Cardiac Registry to collect data related to demographics, caffeine use, and physical examination and electrocardiogram (ECG) findings of 7425 12- to 20-year-olds (60.6% male, 39.4% female) who attended a Simon's Heart cardiac screening event between 2014 and 2021. Univariable and multivariable logistic regression models were used for analysis. RESULTS: Persons who consumed caffeine were more likely to have attention deficit hyperactivity disorder (ADHD) (adjusted odds ratio [aOR], 1.43; CI, 1.15-1.76]; P < 0.01) and more likely to have a BMI ≥30 kg/m2 (aOR, 1.69; CI, 1.27-2.25]; P < 0.01) compared with nondrinkers. After controlling for age, gender, race, and BMI, there were no significant differences in symptoms during exercise (aOR, 1.27; CI, 0.97-1.66; P = 0.08) or abnormal ECG findings (OR, 0.93; CI, 0.66-1.31; P = 0.70) between those who consume caffeine and those who do not. CONCLUSION: Caffeine consumption was associated with increased BMI and increased likelihood of having ADHD; however, caffeine use overall was not associated with increased risk of symptoms during exercise or ECG abnormalities. CLINICAL RELEVANCE: Whereas caffeine consumption overall did not increase risk of exercise-related symptoms, soda drinkers were at higher risk for symptoms during exercise, and coffee drinkers were at higher risk of syncope with exercise. Prospective studies with longitudinal follow-up and more specific outcomes data is the next step in qualifying the impact of caffeine on young athletes.

Ablation Versus Antiarrhythmic Drugs as First-Line Therapy for Treatment-Naive Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Evidence on the relative safety and efficacy of atrial fibrillation catheter ablation and antiarrhythmic drugs (AADs) as the first-line therapy for patients with treatment-naive atrial fibrillation (AF) remains disputed. Digital databases were queried to identify relevant randomized controlled trials. The incidence of recurrent AF, major adverse cardiovascular events, and its components (all-cause death, nonfatal stroke, and bleeding) were compared using the DerSimonian and Laird method under the random-effects model to calculate pooled unadjusted risk ratio (RR) with 95% confidence intervals (CIs). A total of 6 randomized controlled trials consisting of 1,120 patients (574 ablation and 549 AADs) were included in the final analysis. Over a median follow-up of 1 year, the risk of any AF recurrence (RR 0.54, 95% CI 0.39 to 0.75) was significantly lower in patients receiving ablation than in patients receiving AADs. However, there was similar risk of major adverse cardiovascular events (RR 2.65, 95% CI 0.61 to 11.46), trial-defined composite end point of adverse events (RR 0.71, 95% CI 0.28 to 1.80), stroke (RR 2.42, 95% CI 0.22 to 26.51), all-cause mortality (RR 1.98, 95% CI 0.28 to 13.90), and procedure/medication failure (RR 2.65, 95% CI 0.61 to 11.46) with both therapies. In conclusion, in patients presenting with treatment-naive AF, ablation as a first-line therapy lowers the risk of AF recurrence with no associated increase in major adverse events, stroke, and mortality compared with AADs.

Outcomes of Intravascular Imaging in Orbital Atherectomy; Insight From the National Readmissions Database.

The impact of intravascular imaging guidance [intravascular ultrasound (IVUS)/optical coherence tomography (OCT)] on clinical outcomes in patients undergoing orbital atherectomy (OA) and percutaneous intervention (PCI) are not well characterized. The Nationwide Readmissions Database (NRD) from 2015 to 2019 was used to select all cases of OA. The adjusted odds ratios (aOR) of in-hospital, 30-day, and 180-day hospitalization outcomes between patients who underwent PCI with OA vs without intravascular imaging were calculated using a propensity-matched analysis. A total of 15,681 patients undergoing PCI after OA (12,649 with no-imaging, 3032 with imaging) were identified. Due to a significant difference in the baseline characteristics, a matched sample of 3008 in the no-imaging group and 3032 in the imaging group was selected. On adjusted analysis, the odds of all-cause in-hospital mortality (aOR 0.68, 95% CI 0.54-0.86) were significantly lower in patients undergoing IVUS/OCT guided OA and PCI compared with those having PCI without imaging. There was no difference in the rate of in-hospital stroke (aOR 0.86, 95% CI 0.51-1.45) and major bleeding (aOR 0.87, 95% CI 0.65-1.16) between the two groups. There was no significant difference in the 30- and 180-day odds of readmission, major bleeding, coronary dissection, pericardial effusion, and AKI between the two groups. IVUS and OCT use during PCI with OA for patients with calcified coronary artery disease appear to be associated with reduced in-hospital mortality at index admission. Prospective trials are necessary to determine the long-term benefits of imaging with PCI.

Early Transcatheter or Surgical Aortic Valve Replacement Versus Conservative Management in Asymptomatic Patients With Severe Aortic Stenosis: A Systematic Review and Meta-analysis.

The merits of conservative management vs early intervention in patients with asymptomatic severe aortic stenosis remains unknown. Digital databases (MEDLINE, Google Scholar, and Embase) were searched for all relevant studies from inception through September 2022. Studies comparing conservative management with early intervention were compared using a random-effects model to calculate risk ratios (RRs) with 95% confidence interval (CI). A total of 12 studies comprising 3624 asymptomatic aortic stenosis patients (1747 receiving surgery, and 1877 receiving conservative treatment) were included in the analysis. The average follow-up time was 4.45 (IQR 3.5-5) years. Early intervention was associated with a significantly reduced risk of cardiac (RR 0.42, 95% CI 0.25-0.72; P = 0.001; I2 = 54%), non-cardiac (RR 0.46, 95% CI 0.32-0.68; P < 0.0001; I2 = 0%), all-cause mortality (RR 0.40, 95% CI 0.32-0.51; P < 0.00001; I2 = 58%), heart failure hospitalization (RR 0.21, 95% CI 0.13-0.36; P < 0.00001; I2 = 0%), sudden cardiac death (RR 0.29, 95% CI 0.12-0.66; P = 0.004, I2 = 24%), and MACE (RR 0.46, 95% CI; 0.28-0.75; P = 0.002; I2 = 68%), compared with conservative management. There was no significant difference in the 30-day mortality (RR 0.63, 95% CI 0.19-2.04; P = 0.44; I2 = 28%), myocardial infarction (RR 0.44, 95% CI 0.19-1.06; P = 0.07, I2=0%), and 90-day mortality (RR 0.68, 95% CI 0.20-2.37; P = 0.55; I2 = 61%) between the 2 groups. This meta-analysis shows statistically significant reductions in the risk for all-cause mortality, cardiac specific mortality, non-cardiac mortality, heart failure hospitalization, MACE, and sudden cardiac death among asymptomatic aortic stenosis patients who underwent early intervention as opposed to conservative management.

Fecal pollution source characterization in the surface waters of recharge and contributing zones of a karst aquifer using general and host-associated fecal genetic markers.

Fecal pollution of surface waters in the karst-dominated Edwards aquifer is a serious concern as contaminated waters can rapidly transmit to groundwaters, which are used for domestic purposes. Although microbial source tracking (MST) detects sources of fecal pollution, integrating data related to environmental processes (precipitation) and land management practices (septic tanks) with MST can provide better understanding of fecal contamination fluxes to implement effective mitigation strategies. Here, we investigated fecal sources and their spatial origins at recharge and contributing zones of the Edwards aquifer and identified their relationship with nutrients in different environmental/land-use conditions. During March 2019 to March 2020, water samples (n = 295) were collected biweekly from 11 sampling sites across four creeks and analyzed for six physico-chemical parameters and ten fecal indicator bacteria (FIB) and MST-based qPCR assays targeting general (E. coli, Enterococcus, and universal Bacteroidales), human (BacHum and HF183), ruminant (Rum2Bac), cattle (BacCow), canine (BacCan), and avian (Chicken/Duck-Bac and GFD) fecal markers. Among physico-chemical parameters, nitrate-N (NO3-N) concentrations at several sites were higher than estimated national background concentrations for streams. General fecal markers were detected in the majority of water samples, and among host-associated MST markers, GFD, BacCow, and Rum2Bac were more frequently detected than BacCan, BacHum, and HF183, indicating avian and ruminant fecal contamination is a major concern. Cluster analysis results indicated that sampling sites clustered based on precipitation and septic tank density showed significant correlation (p < 0.05) between nutrients and FIB/MST markers, indicating these factors are influencing the spatial and temporal variations of fecal sources. Overall, results emphasize that integration of environmental/land-use data with MST is crucial for a better understanding of nutrient loading and fecal contamination.

Trends in PCSK9 Inhibitor Prescriptions before and after the Price Reduction in Patients with Atherosclerotic Cardiovascular Disease.

BACKGROUND: Proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors reduce low-density lipoprotein (LDL) cholesterol and cardiovascular event rates, yet due to their high price remain underutilized and difficult to prescribe in clinical practice. In March 2018, their price was significantly reduced. We evaluated whether the price reduction would improve prescribing patterns of PCSK9 inhibitors in eligible patients with atherosclerotic cardiovascular disease (ASCVD). METHODS: We identified the number of eligible ASCVD patients and those prescribed a PCSK9 inhibitor for each year between July 2015 and December 2019. Patient demographics and clinical characteristics for those prescribed a PCSK9 inhibitor were extracted from their electronic health record. RESULTS: In total 1059 patients of eligible patients received a new prescription for a PCSK9 inhibitor. From 2015 to 2019, the rate of new prescriptions among eligible patients increased from 0.5 to 3.3% (p < 0.001) and continuation rates increased from 18 to 60% (p < 0.001). Following the price reduction, patients who were prescribed a PCSK9 inhibitor were younger and more likely to be female, but less likely to have Medicare insurance. CONCLUSIONS: Despite the reduction in the cost of PCSK9 inhibitors, most eligible patients are not prescribed one. The reduction in cost has improved adherence, primarily in patients with commercial insurance. Older patients and those on Medicare still face significant barriers in accessing a PCSK9 inhibitor. Further reductions in the price of the PCSK9 inhibitors are needed as is further study of the barriers that exist in prescribing one.

Usefulness of Mobile Electrocardiographic Devices to Reduce Urgent Healthcare Visits.

Mobile electrocardiogram (mECG) devices are being used increasingly, supplying recordings to providers and providing automatic rhythm interpretation. Given the intermittent nature of certain cardiac arrhythmias, mECGs allow instant access to a recording device. In the current COVID-19 pandemic, efforts to limit in-person patient interactions and avoid overwhelming emergency and inpatient services would add value. Our goal was to evaluate whether a mECG device would reduce healthcare utilization overall, particularly those of urgent nature. We identified a cohort of KardiaMobile (AliveCor, USA) mECG users and compared their healthcare utilization 1 year prior to obtaining the device and 1 year after. One hundred and twenty-eight patients were studied (mean age 64, 47% female). Mean duration of follow-up pre-intervention was 9.8 months. One hundred and twenty-three of 128 individuals completed post-intervention follow-up. Patients were less likely to have cardiac monitors ordered (30 vs 6; p <0.01), outpatient office visits (525 vs 382; p <0.01), cardiac-specific ED visits (51 vs 30; p <0.01), arrhythmia related ED visits (45 vs 20; p <0.01), and unplanned arrhythmia admissions (34 vs 11; p <0.01) in the year after obtaining a KardiaMobile device compared to the year prior to obtaining the device. Mobile technology is available for heart rhythm monitoring and can give feedback to the user. This study showed a reduction of in-person, healthcare utilization with mECG device use. In conclusion, this strategy would be expected to decrease the risk of exposure to patients and providers and would avoid overwhelming emergency and inpatient services.

Flecainide-Induced Atrial Flutter With 1:1 Conduction Complicated by Ventricular Fibrillation After Electrical Cardioversion.

Flecainide, a widely prescribed class IC agent used to treat atrial arrhythmias, can in rare cases cause 1:1 atrial flutter with rapid conduction. We describe the case of a 59-year-old man who was on a maintenance regimen of flecainide for refractory atrial fibrillation. When 1:1 atrial flutter with rapid conduction developed, emergency medical technicians attempted synchronized cardioversion, which caused ventricular fibrillation necessitating defibrillation. The patient ultimately underwent radiofrequency ablation and cryoablation to resolve his symptomatic atrial flutter. We discuss the atrial proarrhythmic effects of flecainide and how to mitigate complications in high-risk patients.

Atypical Reactivation of Varicella Zoster Virus Associated with Pancreatitis in a Heart Transplant Patient.

BACKGROUND Acute pancreatitis is rare following solid organ transplantation but is associated with high mortality. It has been most commonly reported following renal transplant but can occur with other solid organ transplantations. CASE REPORT A 46-year-old male who had an orthotopic heart transplant 6 months ago presented with a 3-week history of abdominal pain. The patient described it as intermittent, sharp, and stabbing, originating in the periumbilical area and radiating to the back. His lipase was elevated at 232 U/L. Given that the patient's symptoms and lipase were elevated to greater than three times the upper limit of normal, he patient was diagnosed with acute pancreatitis. The patient also mentioned a diffuse itchy rash that started a few days prior to admission. Dermatology was consulted, and given the man's clinical presentation, there was concern for atypical reactivation of varicella zoster virus (VZV). VZV polymerase chain reaction of the vesicles returned positive. The patient was started on acyclovir and his symptoms improved. CONCLUSIONS This is the first reported case of VZV-associated pancreatitis in a heart transplant patient. Our patient presented with acute pancreatitis and was treated supportively. However, he did not receive antiviral treatment until his rash was discovered. Timely treatment of VZV resulted in resolution of both the rash and pancreatitis. Timely diagnosis of pancreatitis and VZV is important to prevent development of multiorgan failure and death.

Determining the primary sources of fecal pollution using microbial source tracking assays combined with land-use information in the Edwards Aquifer.

The Edwards Aquifer serves as a primary source of drinking water to more than 2 million people in south-central Texas, and as a karst aquifer, is vulnerable to human and animal fecal contamination which poses a serious risk to human and environmental health. A one-year study (Jan 2018 - Feb 2019) was conducted to determine the primary sources of fecal pollution along the Balcones and Leon Creek within the Edwards Aquifer recharge and contributing zones using general (E. coli, enterococci, and universal Bacteriodales) and host-associated (human-, dog-, cow- and chicken/duck-associated Bacteriodales) microbial source tracking (MST) assays. Additionally, sites were classified based on surrounding land use as a potential source predictor and marker levels were correlated with rain events and water quality parameters. Levels for the three general indicators were highest and exhibited similar trends across the sampling sites, suggesting that the sole use of these markers is not sufficient for specific fecal source identification. Among the host-associated markers, highest concentrations were observed for the dog marker (BacCan) in the Leon Creek area and the cow marker (BacCow) in the Balcones Creek area. Additionally, Chicken/Duck-Bac, BacCan and BacCow all exhibited higher concentrations during the spring season and the end of fall/early winter. Relatively lower concentrations were observed for the human-associated markers (HF183 and BacHum), however, levels were higher in the Leon Creek area and highest following rainfall events. Additionally, relatively higher levels in HF183 and BacHum were observed at sites having greater human population and septic tank density and may be attributed to leaks or breaks in these infrastructures. This study is the first to examine and compare fecal contamination at rural and urban areas in the recharge and contributing zones of the Edwards Aquifer using a molecular MST approach targeting Bacteroidales 16S rRNA gene-based assays. The Bacteroidales marker assays, when combined with land use and weather information, can allow for a better understanding of the sources and fluxes of fecal contamination, which can help devise effective mitigation measures to protect water quality.

Anti-coagulant and anti-platelet therapy in the COVID-19 patient: a best practices quality initiative across a large health system.

The coronavirus disease 2019 (COVID-19) pandemic due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has challenged health-care systems and physicians worldwide to attempt to provide the best care to their patients with an evolving understanding of this unique pathogen. This disease and its worldwide impact have sparked tremendous interest in the epidemiology, pathogenesis, and clinical consequences of COVID-19. This accumulating body of evidence has centered around case series and often empiric therapies as controlled trials are just getting underway. What is clear is that patients appear to be at higher risk for thrombotic disease states including acute coronary syndrome (ACS), venous thromboembolism (VTE) such as deep vein thrombosis (DVT) or pulmonary embolism (PE), or stroke. Patients with underlying cardiovascular disease are also at higher risk for morbidity and mortality if infected. These patients are commonly treated with anticoagulation and/or antiplatelet medications and less commonly thrombolysis during hospitalization, potentially with great benefit but the management of these medications can be difficult in potentially critically ill patients. In an effort to align practice patterns across a large health system (Jefferson Health 2,622 staffed inpatient beds and 319 intensive care unit (ICU) beds across 14 facilities), a task force was assembled to address the utilization of anti-thrombotic and anti-platelet therapy in COVID-19 positive or suspected patients. The task force incorporated experts in Cardiology, Vascular Medicine, Hematology, Vascular Surgery, Pharmacy, and Vascular Neurology. Current guidelines, consensus documents, and policy documents from specialty organizations were used to formulate health system recommendations. OBJECTIVE: Our goal is to provide guidance to the utilization of antithrombotic and antiplatelet therapies in patients with known or suspected COVID-19.

Physician adherence to 'Seattle' and 'International' ECG criteria in adolescent athletes: An analysis of compliance by specialty, experience, and practice environment.

BACKGROUND: Screening electrocardiography (ECG) for athletes is both controversial and rapidly evolving. While identifying an abnormal ECG could detect a serious cardiovascular disease, falsely interpreting a benign ECG pattern as abnormal can lead to unnecessary testing, cost, and anxiety. Though recent refinements of athlete screening ECG criteria have significantly improved its accuracy, in clinical practice physician adherence to these criteria may vary. METHODS: We analyzed physician adherence to contemporary athlete ECG criteria in a large, national athlete screening registry. 1577 consecutive screening ECGs were independently re- interpreted to assess for physician adherence to Seattle Criteria or International Criteria, respective to the criteria in place when the screening was performed. We further determined the most common ECG interpretations that deviated from these criteria, and analyzed physician characteristics for independent predictors of adherence to published ECG criteria. RESULTS: Though overall adherence to contemporary criteria was high, 60.4% of ECGs interpreted as abnormal did not meet athlete ECG criteria for pathology when independently re- read. The most common ECG patterns misinterpreted as abnormal were isolated left ventricular hypertrophy (LVH) and non-pathologic T-wave inversions (TWI). Multivariate regression identified three independent predictors of adherence to athlete ECG criteria: participating in a screening overseen by the organization's medical leadership, electrophysiology specialists and adult cardiologists. CONCLUSION: This study highlights the need for quality control measures and continued clinician education in a controversial and rapidly evolving field. Clinician education for athlete screening ECG criteria should emphasize the recent changes in how TWI and LVH voltage criteria should be interpreted in this patient population.

Boerhaave Syndrome Causing Bilateral Empyemas.

Boerhaave syndrome is a perforation of the esophagus caused by a sudden increase in intraluminal pressure. It is known to be associated with left-sided pleural effusion and mediastinitis, but rarely presents with bilateral effusion. Its association with the presence of a hiatal hernia is unclear. We present a patient with a hiatal hernia who developed bilateral empyemas because of Boerhaave syndrome and was treated with an endoscopically placed esophageal stent.

Clinical and electrophysiological characteristics of patients with paroxysmal intra-His block with narrow QRS complexes.

BACKGROUND: Atrioventricular (AV) block is usually due to infranodal disease and associated with a wide QRS complex; such patients often progress to complete AV block and pacemaker dependency. Uncommonly, infranodal AV block can occur within the His bundle with a narrow QRS complex. OBJECTIVES: The aims of this study were to define clinical/echocardiographic characteristics of patients with AV block within the His bundle and report progression to pacemaker dependency. METHODS: We retrospectively identified patients with narrow QRS complexes and documented intra-His delay or block at electrophysiology study (group A) or with electrocardiogram-documented Mobitz II AV block/paroxysmal AV block (group B). Clinical, electrophysiological, and echocardiographic variables at presentation and pacemaker parameters at the last follow-up visit were evaluated. RESULTS: Twenty-seven patients (19 women) were identified (mean age 64 ± 13 years; range, 38-85 years). Four patients who had <1 month of follow-up were excluded. There were 12 patients in group A and 11 in group B; 21 of 23 presented with syncope/presyncope. All patients received pacemakers: 8 single chamber and 15 dual chamber. After a median follow-up of 6.4 years, the median percentage of ventricular pacing was 1% (interquartile range 0%-4.66%). One patient developed true pacemaker dependency. Aortic and/or mitral annular calcification was present in 13 of 22 patients with available echocardiograms. CONCLUSION: Patients who present with syncope and narrow QRS complexes with intra-His delay or Mobitz II paroxysmal AV block with narrow QRS complexes rarely progress to pacemaker dependency and require infrequent pacing. This entity is more common in women, with a higher prevalence of aortic and/or mitral annular calcification. If confirmed by additional studies, single-chamber pacemaker may be sufficient.

Unsuspected pheochromocytoma incidentally found on chest CT.

A 51-year-old woman with history of migraine headaches and intermittent nausea, vomiting, palpitations, and diaphoresis presented to the emergency department with hypertensive emergency 1 month after starting a beta blocker for migraine prophylaxis. Contrast-enhanced computed tomography of the chest incidentally revealed a large abdominal mass in the area of the left adrenal gland. Iodine-123 metaiodobenzylguanidine scan imaging showed localized uptake into the left adrenal gland. Along with imaging results, laboratory testing confirmed the diagnosis of pheochromocytoma. The patient was treated with blood pressure control, specifically alpha blockade, and surgical excision of the mass. This case displays a typical clinical presentation of pheochromocytoma coupled with atypical radiographic size and appearance.

The Impact of a Transition of Care Program on Acute Myocardial Infarction Readmission Rates.

Hospital discharge is a high-risk time period, and acute myocardial infarction (AMI) patients often have early readmissions. The authors hypothesized that a multifaceted AMI care coordination program would reduce early hospital readmission rates. The outcomes of patients receiving care coordination (n = 304) were compared to patients receiving standard care (n = 192). Multivariable analyses of the outcomes were conducted by conditional logistic regression of propensity score matched sets. The primary outcome-hospital readmission within 30 days of discharge-occurred in 18% of standard care patients and 11.8% of care coordination patients. Patients receiving care coordination demonstrated a 48% reduction in odds of readmission within 30 days (odds ratio = 0.52; P = .04; 95% CI = 0.28-0.97). These results are the first to demonstrate that inclusion in an AMI-specific care coordination program is associated with a significantly lower risk of 30-day hospital readmission.

Historical data review and source analysis of PCBs/Arochlors in the Lower Leon Creek Watershed.

PCBs have been banned since the late 1970s, but concentrations still exist in sediments and riverine fish and continue to exceed regulatory limits which can result in negative health effects. This study looks at historical records of PCB and Arochlor concentrations in surface water, sediments, and fish tissue for the Lower Leon Creek, Bexar County in Texas. Temporal analysis on the concentrations of PCBs and Arochlors was conducted for detection and exceedance of selected screening criteria. In addition, the half-lives of select PCB congeners were calculated for 2007-2012 data to ascertain differences in PCB concentrations with their hydrophobicity. Source analysis was conducted to determine the potential contributing sources of PCB contamination using source data (landfills, outfalls, etc.) and the PCB exceedance data. For sediment and fish tissue sampling results, historic data shows high concentrations of PCB/Arochlors over the course of several decades. The historical data is characterized as being widely variable for detections in Arochlors and concentrations between years, with a dramatic drop in concentrations detected starting in 2009. Overall, the sampling locations adjacent to and downstream from the former Kelly Air Force Base have the highest concentrations of PCB/Arochlors over the longest period of time. The results of this work will aid regulatory agencies in addressing impairment.

Right Ventricular Enlargement within Months of Arteriovenous Fistula Creation in 2 Hemodialysis Patients.

Surgically created arteriovenous fistulae (AVF) for hemodialysis can contribute to hemodynamic changes. We describe the cases of 2 male patients in whom new right ventricular enlargement developed after an AVF was created for hemodialysis. Patient 1 sustained high-output heart failure solely attributable to the AVF. After AVF banding and subsequent ligation, his heart failure and right ventricular enlargement resolved. In Patient 2, the AVF contributed to new-onset right ventricular enlargement, heart failure, and ascites. His severe pulmonary hypertension was caused by diastolic heart failure, diabetes mellitus, and obstructive sleep apnea. His right ventricular enlargement and heart failure symptoms did not improve after AVF ligation. We think that our report is the first to specifically correlate the echocardiographic finding of right ventricular enlargement with AVF sequelae. Clinicians who treat end-stage renal disease patients should be aware of this potential sequela of AVF creation, particularly in the upper arm. We recommend obtaining preoperative echocardiograms in all patients who will undergo upper-arm AVF creation, so that comparisons can be made postoperatively. Alternative consideration should be given to creating the AVF in the radial artery, because of less shunting and therefore less potential for right-sided heart failure and pulmonary hypertension. A multidisciplinary approach is optimal when selecting patients for AVF banding or ligation.

Characterization of limb differences in children with Cornelia de Lange Syndrome.

Cornelia de Lange syndrome (CdLS) is a well-described multisystem developmental disorder characterized by dysmorphic facial features, growth and behavioral deficits, and cardiac, gastrointestinal, and limb anomalies. The limb defects seen in CdLS can be mild, with small feet or hands only, or can be severe, with variable deficiency defects involving primarily the ulnar structures and ranging from mild hypoplasia of the fifth digit to complete absence of the forearm. Interestingly, the upper limbs are typically much more involved than the lower extremities that generally manifest with small feet and 2-3 syndactyly of the toes and shortened fourth metatarsal. The upper limbs often manifest asymmetric involvement. The limb findings in our cohort of 378 individuals with CdLS demonstrate a consistent pattern of laterality and symmetry involvement (with increased severity of right-sided limb in individuals with asymmetric limb defects) and a correlation of more significant limb defects with an increased risk of other structural anomalies, and more severe behavioral outcomes. Additionally, we found that individuals with mutations in NIPBL were most likely to have limb defects compared to mutations in other genes with nonsense, exonic deletion, and frameshift mutations being most prevalent in those with limb defects. Characterization of the limb differences in children with CdLS may provide a tool to assist in genetic counseling and determining prognosis. This paper will review the limb involvement in a large cohort of individuals with CdLS assessing the correlation with molecular etiologies, symmetry, additional structural birth defects, and cognitive outcomes. © 2016 Wiley Periodicals, Inc.