Outcomes in patients with COVID-19 and new onset heart blocks: Insight from the National Inpatient Sample database.

BACKGROUND: Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in a worldwide health crisis since it first appeared. Numerous studies demonstrated the virus's predilection to cardiomyocytes; however, the effects that COVID-19 has on the cardiac conduction system still need to be fully understood. AIM: To analyze the impact that COVID-19 has on the odds of major cardiovascular complications in patients with new onset heart blocks or bundle branch blocks (BBB). METHODS: The 2020 National Inpatient Sample (NIS) database was used to identify patients admitted for COVID-19 pneumonia with and without high-degree atrioventricular blocks (HDAVB) and right or left BBB utilizing ICD-10 codes. The patients with pre-existing pacemakers, suggestive of a prior diagnosis of HDAVB or BBB, were excluded from the study. The primary outcome was inpatient mortality. Secondary outcomes included total hospital charges (THC), the length of hospital stay (LOS), and other major cardiac outcomes detailed in the Results section. Univariate and multivariate regression analyses were used to adjust for confounders with Stata version 17. RESULTS: A total of 1058815 COVID-19 hospitalizations were identified within the 2020 NIS database, of which 3210 (0.4%) and 17365 (1.6%) patients were newly diagnosed with HDAVB and BBB, respectively. We observed a significantly higher odds of in-hospital mortality, cardiac arrest, cardiogenic shock, sepsis, arrythmias, and acute kidney injury in the COVID-19 and HDAVB group. There was no statistically significant difference in the odds of cerebral infarction or pulmonary embolism. Encounters with COVID-19 pneumonia and newly diagnosed BBB had a higher odds of arrythmias, acute kidney injury, sepsis, need for mechanical ventilation, and cardiogenic shock than those without BBB. However, unlike HDAVB, COVID-19 pneumonia and BBB had no significant impact on mortality compared to patients without BBB. CONCLUSION: In conclusion, there is a significantly higher odds of inpatient mortality, cardiac arrest, cardiogenic shock, sepsis, acute kidney injury, supraventricular tachycardia, ventricular tachycardia, THC, and LOS in patients with COVID-19 pneumonia and HDAVB as compared to patients without HDAVB. Likewise, patients with COVID-19 pneumonia in the BBB group similarly have a higher odds of supraventricular tachycardia, atrial fibrillation, atrial flutter, ventricular tachycardia, acute kidney injury, sepsis, need for mechanical ventilation, and cardiogenic shock as compared to those without BBB. Therefore, it is essential for healthcare providers to be aware of the possible worse predicted outcomes that patients with new-onset HDAVB or BBB may experience following SARS-CoV-2 infection.

Impact of Hospital Readmissions Reduction Program Policy on 30-Day and 90-Day Readmissions in Patients With Acute Myocardial Infarction: A 10-Year Trend From the National Readmissions Database.

Hospital readmissions following acute myocardial infarction (AMI) pose a significant economic burden on health care utilization. The hospital readmission reduction program (HRRP) enacted in 2012 focused on reducing readmissions by penalizing Centers for Medicare & Medicaid Services (CMS) Medicare hospitals. We aim to assess the trend of readmissions after AMI hospitalization between 2010 and 2019 and assess the impact of HRRP. The National Readmission Database was queried to identify AMI hospitalizations between 2010 and 2019. In the primary analysis, trends of 30-day and 90-day all-cause and AMI specific readmissions were assessed from 2010 to 2019. In the secondary analysis, trend of readmission means length of stay and mean adjusted total cost were calculated. There were a total of 592,015 30-day readmissions and 787,008 90-day readmissions after an index hospitalization for AMI between 2010 and 2019. The rates of 30-day and 90-day all-cause readmissions decreased significantly from 12.8% to 11.6%, (P = 0.0001) and 20.6 to 18.8, (P = 0.0001) respectively in the decade under study. With regards to HRRP policy intervals, the pre-HRRP period from 2010 to 2012 showed a downward trend in all-cause readmission (12.8% to 11.6%) and similarly a downward trend was also seen in the post HRRP period (2013-2015:11.0%-8.2%, 2016-2019-12.3-11.7%). Secondary analysis showed a trend towards increase in mean length of stay (4.54-4.96 days, P = 0.0001) and adjusted total cost ($13,449-$16,938) in 30-day all-cause readmission for AMI in the decade under review. In our National Readmission Database-based analysis of patients readmitted to hospitals within 30-days and 90-days after AMI, the rate of all-cause readmissions down trended from 2010 to 2019.

Readmission and In-Hospital Outcomes After Transcatheter Aortic Valve Replacement in Patients With Dementia.

BACKGROUND/PURPOSE: The prevalence of dementia and aortic stenosis (AS) increases with each decade of age. Transcatheter aortic valve replacement (TAVR) is a definitive treatment for AS, but there are scarce data on morbidity, mortality, and readmission risk after TAVR in patients with dementia. METHODS/MATERIALS: We identified all admissions for TAVR in patients with AS in the National Readmissions Database in 2017-2018 and stratified them according to the presence or absence of a secondary diagnosis of dementia. Inpatient outcomes were compared using logistic regression. Cox proportional-hazards models were used to compare 30-, 60-, and 90-day readmissions. RESULTS: A total of 48,923 index hospitalizations for TAVR were identified, of which 2192 (4.5 %) had a secondary diagnosis of dementia. Presence of dementia was associated with higher odds of delirium, pacemaker placement, acute kidney injury, and fall in hospital. The hazard of 30-day readmission was not significantly different between patients with and without dementia, but patients with dementia experienced a higher hazard of 60-day readmission (HR 1.15, 95 % CI 1.03-1.26, p = 0.011) in the unadjusted model and higher hazard of 90-day readmission in both unadjusted (HR 1.18, 95 % CI 1.08-1.30, p < 0.001) and adjusted models (aHR 1.14, 95 % CI 1.04-1.25, p = 0.004). CONCLUSIONS: Patients with dementia who undergo TAVR are at higher risk of in-hospital adverse outcomes and 60- and 90-day readmissions compared with patients without dementia. These estimates should be integrated into shared decision-making discussions with patients and families.

Impact of end-stage renal disease on in-hospital outcomes of hypertensive emergency from the National Inpatient Sample, 2016 to 2018.

The prevalence and incidence of end-stage renal disease (ESRD) has been increasing. However, data on inpatient outcomes of hypertensive emergencies in patients with ESRD are lacking. We performed a retrospective study using the largest inpatient database in the United States. Hospitalizations for hypertensive emergency between 2016 and 2018 were identified from the National Inpatient Sample. Propensity score matching was performed between those with and without ESRD. The primary outcome was in-hospital mortality, and secondary outcomes included end-organ complications of hypertensive emergency. Multivariable logistic regression was used to identify potential risk factors of in-hospital mortality. Of 105,565 hospitalizations for hypertensive emergency, 15% occurred in patients with ESRD. Hospitalizations for hypertensive emergency in patients with ESRD were associated with higher odds of cardiac arrest (odds ratio [OR] 4.52, 95% confidence interval [CI] 1.53-13.3, P = 0.01) and acute pulmonary edema (OR 2.80, 95% CI 2.15-3.65, P < 0.01) and a longer hospital stay (mean difference 1.15 days, 95% CI 0.88-1.43, P < 0.01). Age ≥65 years, obesity, atrial fibrillation, and malnutrition were associated with higher odds of in-hospital mortality. Our findings demonstrate the excess morbidities in patients with ESRD admitted for hypertensive emergency.

Crystalline Nephropathy With High-Dose Methotrexate in a Patient With Primary CNS Lymphoma: A Case Report.

Methotrexate (MTX) is a folate antimetabolite used in the treatment of several malignancies and rheumatologic diseases. It is metabolized in the liver and excreted via the kidneys. Several adverse effects of MTX have been noted, including bone marrow suppression, mucositis, and hepatic and renal dysfunction. Close monitoring of drug levels, concurrent leucovorin administration, and urinary alkalization with aggressive hydration are some steps taken to prevent these unfavorable outcomes. We describe a case of a patient with primary CNS lymphoma undergoing chemotherapy with high-dose methotrexate (HD-MTX) who developed methotrexate-induced crystalline nephropathy despite preventative measures. Birefringent needle-shaped crystals were demonstrated under polarized light in the urine sample in the setting of acute kidney injury (AKI). The slow decay curve of MTX causing renal and hepatic dysfunction was an indication to start glucarpidase, and a subsequent rapid decline in MTX levels with improvement in AKI was observed. Methotrexate-induced crystalline nephropathy results from damage to the renal tubules, which in most cases is reversible. Patients with a slow decline in MTX levels may be candidates for treatment with glucarpidase, a recombinant form of carboxypeptidase G2, to allow for rapid MTX breakdown and clearance. Hemodialysis is another available treatment option for patients who develop these adverse effects.

Laparoscopic Removal of a 40-cm Paratubal Cyst in a Morbidly Obese Patient.

Paratubal cysts (PTCs) are remnants of the paramesonephric or the mesonephric ducts that are present during embryogenesis. They are mostly benign; however, malignancy has been described. The incidence of PTCs is estimated to be 5%-20% of all adnexal masses. They can present in any age group but most commonly the third or fourth decades. Huge PTCs exceeding 10-15 cm in diameter are considered rare and challenging, as only a few cases have been reported that describe complete laparoscopic excision. A simple asymptomatic PTC can be managed expectantly; however, surgery is mandatory if the cyst is huge, complicated, or causes severe symptoms. In this article, we describe a laparoscopic removal of a 40-cm PTC in a 32-year- old woman, as the largest PTC in literature that was removed by laparoscopy.