A Case of "Anaphylaxis" to NovoSeven in a Hemophiliac Patient.

Anaphylaxis is a life-threatening emergency that may be confused with other less serious conditions. The onset of true anaphylaxis typically occurs within minutes following exposure to an offending agent, and it can variably include dyspnea/wheezing, hemodynamic compromise, rash, hives/pruritus, swelling, or gastrointestinal symptoms. The absence of an expected association between exposure(s) and classic symptoms should lead to the consideration of alternative diagnoses. Here, we describe the course of a patient with hemophilia B who developed stridor and wheezing after exposure to the recombinant factor VII, NovoSeven, and tranexamic acid (TXA) for the management of hematomas. Due to a reported prior history of anaphylaxis to multiple factor replacements, the patient's initial management included NovoSeven with steroid/antihistamine prophylaxes and close monitoring with epinephrine at the bedside. Despite the administration of prophylaxis, the patient developed significant stridor, was treated with epinephrine and nebulizers and additional steroids, and was transferred to the intensive care unit. There, a pattern of NovoSeven administration followed variably by wheezing and stridor continued for two days until the patient's respiratory condition was predictable and stable. The patient's subsequent clinical course following transfer to the general medical ward was not consistent with anaphylaxis. This case highlights the importance of evaluating for mimickers of anaphylaxis, especially where only select symptoms such as stridor and wheezing are present without other serious signs of anaphylaxis such as hypoxemia, hypotension, or significant tachycardia.

Gastrointestinal haemorrhage in extracorporeal membrane oxygenation: insights from the national inpatient sample.

Introduction: Extracorporeal membrane oxygenation (ECMO) is associated with gastrointestinal haemorrhage (GIH), which may result from coagulopathy, systemic inflammation, reduced gastric perfusion, and arteriovenous malformation from non-pulsatile blood flow. Data are limited regarding the burden of this complication in the United States. Material and methods: We analysed the National Inpatient Sample (NIS) database for the years 2007 to 2011 to identify hospitalisations in which an ECMO procedure was performed. Hospitalizations complicated by GIH in this cohort were then identified by relevant codes. Results: Between 2007 and 2011, ECMO hospitalisations increased from 1869 to 3799 (p < 0.01). The proportion of hospitalisations complicated by GIH increased from 2.12% in 2007 to 7.46% in 2011 (p < 0.01). Gastrointestinal haemorrhage was more common in men (56.7%) and in Caucasians (57.4%). Common comorbidities in this population were renal failure (71%), anaemia (55%), and hypertension (26%). All-cause inpatient mortality showed a numerical but nonsignificant increase from 56.7% to 61.9% (p = 0.49). The average cost of care per hospitalisation with GIH associated with ECMO use increased from $132,420 in 2007 to $215,673 in 2011 (p < 0.01). Conclusions: Gastrointestinal haemorrhage during ECMO hospitalisations occurred in small but significantly increasing proportions. The inpatient mortality rate and costs associated with GIH were substantial and increased significantly during the study period.

Impact of chronic obstructive pulmonary disease on heart failure hospitalizations after an acute myocardial infarction.

Introduction: The presence of chronic obstructive pulmonary disease (COPD) can impact the management of acute myocardial infarction (AMI) and is associated with higher mortality. Few studies addressed COPD impact on heart failure hospitalisations (HFHs) in AMI survivors. Material and methods: Adult survivors of an AMI between January and June 2014 were identified from the US Nationwide Readmissions Database. The impact of COPD on HFH within 6 months, fatal HFH and the composite of in-hospital HF or 6-month HFH was studied. Results: Of 237,549 AMI survivors, patients with COPD (17.5%) were older, more likely female, had a higher prevalence of cardiac comorbidities and a lower coronary revascularization rate. In-hospital HF was more frequent in patients with COPD (47.0% vs. 25.4%; p < 0.001). HFH within 6 months occured in 12,934 (5.4%) patients, at a 114% higher rate in patients with COPD (9.4% vs. 4.6%, OR = 2.14, 95% CI : 2.01-2.29; p < 0.001), which was attenuated to a 39% higher adjusted risk (OR = 1.39, 95% CI: 1.30-1.49). Findings were consistent across subgroups of age, AMI type, and major HF risk factors. Mortality during a HFH (5.7% vs. 4.2%, p < 0.001) and the rate of the composite HF outcome (49.0% vs. 26.9%, p < 0.001) were significantly higher in patients with COPD. Conclusions: COPD was present in 1 of 6 AMI survivors and was associated with worse HF related outcomes. The increased HFH rate in COPD patients was consistent across several clinically relevant subgroups and these findings highlight the need for optimal in-hospital and post-discharge management of these higher-risk patients.

Solid organ transplantation from COVID positive donors in the United States: Analysis of United Network for Organ Sharing database.

BACKGROUND: Significant uncertainties remain regarding the utilization of organs for solid organ transplantation (SOT) from donors with coronavirus disease 2019 (COVID-19). The aim of this study was to assess the trends in utilization of organs from donors with COVID-19 and their short-term outcomes. METHODS: Deceased donors between March 2020 and December 2021 with a positive COVID nucleic acid test from respiratory tract within 14 days of transplantation were analyzed using the de-identified United Network for Organ Sharing (UNOS) database. Donor and recipient characteristics of COVID-19 positive (COVID+) organs were compared to COVID-19 negative (COVID-) organs during this period. We analyzed the trends in the utilization of SOT from COVID+ donors across the United States, donor characteristics, and the quality of donor organ and recipient outcomes (length of hospitalization, rates of organ rejection, delayed graft function, 30-day graft/patient survival). RESULTS: During the study period, 193 COVID+ donors led to the transplantation of 281-kidneys, 106-livers, and 36-hearts in 414 adult recipients. COVID+ patients donated a median of two organs. These donors were younger and had a lower median Kidney Donor Profile Index (0.37 vs. 0.50, p < .001), lower median serum creatinine (0.8 vs. 1.0 mg/dl, p = .003), similar median serum total bilirubin (0.6 mg/dl, p = .46), and similar left ventricular ejection fraction (60%, p = .84) when compared to COVID- donors. Short-term outcomes, including 30-day graft/patient survival, were similar in both groups. CONCLUSIONS: Analysis of short-term outcomes from the UNOS database indicates that a positive COVID test in an otherwise medically suitable donor should not preclude consideration of non-lung solid organ transplantation.

Coronavirus Disease 2019 and Heart Transplantation: Single-Center Experience and Review of the Literature.

Coronavirus disease 2019 (COVID-19) was declared a global pandemic in March 2020, and since then it has had a significant impact on healthcare including on solid organ transplantation. Based on age, immunosuppression, and prevalence of chronic comorbidities, heart transplant recipients are at high risk of adverse outcomes associated with COVID-19. In our center, 31 heart transplant recipients were diagnosed with COVID-19 from March 2020 to September 2021. They required: hospitalization (39%), intensive care (10%), and mechanical ventilation (6%) with overall short-term mortality of 3%. Early outpatient use of anti-SARS CoV-2 monoclonal antibodies in our heart transplant recipients was associated with a reduction in the risk of hospitalization, need for intensive care, and death related to COVID-19. In prior multicenter studies, completed in different geographic areas and pandemic timeframes, diverse rates of hospitalization (38-91%), mechanical ventilation (4-38%), and death (16-33%) have been reported. Progression of disease and adverse outcomes were most significantly associated with severity of lymphopenia, chronic comorbid conditions like older age, chronic allograft vasculopathy, increased body mass index, as well as intensity of baseline immune suppression. In this article, we also review the current roles and limitations of vaccination, anti-viral agents, and anti-severe acute respiratory syndrome coronavirus 2 monoclonal antibodies in the management of heart transplant recipients. Our single-center experience, considered together with other studies indicates a trend toward improved outcomes among heart transplant patients with COVID-19.

The potential impact of mammographic breast arterial calcification on physician practices in a primary care setting.

Aim: This study sought to determine breast arterial calcification (BAC) prevalence in a primary care setting and its potential use in guiding further cardiovascular workup. Materials & methods: A radiologist reviewed 282 consecutive mammograms. Characteristics of BAC-positive and negative women were compared. Results: BAC prevalence was 34%. BAC-positive women were older (mean age: 60 vs 52, p < 0.001), had higher mean 10-year cardiac risk (11 vs 6%, p < 0.001), more hypertension (65 vs 40%, p < 0.001) and coronary artery disease (10 vs 2%, p = 0.0041), statin (50 vs 32%, p = 0.006) and aspirin use (28 vs 16%, p = 0.012). Thirty-seven percent (33/96) of BAC-positive women could potentially benefit from further cardiac testing. Conclusion: Mammography identifies BAC-positive women with low traditionally assessed cardiovascular risk who might benefit from further cardiovascular workup.

The Impact on Medical Students of the 9/11 Attacks on New York's World Trade Center.

Phenomenon: Little is known about how participation in disaster relief impacts medical students. During the terror attacks of September 11, 2001, New York Medical College School of Medicine students witnessed the attacks and then became members of emergency treatment teams at St. Vincent's Hospital, the trauma center nearest to the World Trade Center. To date, only two reports describe how 9/11 influenced the lives of medical students. This study was designed to characterize the short- and long-term effects on NYMC students and to compare those effects between students assigned to St Vincent's Hospital and classmates assigned to rotations at facilities more remote from the attack site. We hypothesized that participation in direct relief efforts by students assigned to the St. Vincent's site might have long-lasting effects on their lives and these effects might vary when compared to classmates assigned elsewhere. Approach: This was a retrospective, survey-based, unmatched cohort study. Participants included all school of medicine graduates who were St. Vincent's rotators on 9/11 (N = 22) and classmates (N = 24) assigned to other sites who could be contacted and agreed to participate. Our primary measure was whether the 9/11 experience affected the participant's life, defined as an affirmative response to the item which asked whether the 9/11 experience affected the participant's "life thereafter, career choice, attitudes toward life or attitudes toward practice." Secondary measures included self-reported effects on career, life, attitudes, health, resilience, personal growth, personality features, and the temporal relationship between the attack and stress symptoms. Findings: Completed surveys were received from 16/22 (73%) St. Vincent's and 18/24 (75%) non-Saint Vincent's participants: 62% male, 82% had children, 74% identified as Caucasian/white and 76% employed full-time. Overall, slightly more than half (58%) of respondents reported an effect of 9/11 on their life, with a greater but non-significant proportion of St. Vincent's rotators reporting life impact (67% versus 50% for St. Vincent's versus other locations, respectively). High post-9/11 stress levels, current marriage, and ability to make and keep family and social relationships were associated with an effect on life which approached statistical significance. Participants reported positive or no post 9/11 effects on empathy and altruism (50%), resilience (47%), attitudes toward medical practice and career (32%), and charitable giving (24%), while positive, negative, or no effects were reported for attitude toward life, family and social relations, physical health, and conscientiousness. Mental health was the only domain in which all participants reported unchanged or negative effects. Two St. Vincent's rotators but no students assigned elsewhere believed they experienced 9/11-related post-traumatic stress disorder. Insights: Just over half of New York Medical College School of Medicine students rotating at St. Vincent's Hospital on 9/11 or elsewhere reported significant life-effects as a result of direct/indirect experiences related to the attack. Perceived stress may have been a more important driver of this life-change than other factors such as geographic proximity to the disaster site and/or direct participation in relief efforts. Further study of medical school interventions focused on stress reduction among students who participate in disaster relief is warranted.

Successful liver transplantation in a patient recovered from COVID-19.

Transplantation in potential candidates who have recently recovered from COVID-19 is a challenge with uncertainties regarding the diagnosis, multi-organ systemic involvement, prolonged viral shedding in immunocompromised patients, and optimal immunosuppression. A 42 year male with alcoholic hepatitis underwent a successful deceased donor liver transplantation 71 days after the initial diagnosis of COVID-19. At the time of transplant, he was SARS-CoV-2 PCR negative for 24 days and had a MELD score of 33. His post-operative course was complicated by acute rejection which responded to intense immune-suppression using T-cell depletion and steroids. He was discharged with normal end-organ function and no evidence of any active infection including COVID-19. Prospective organ transplant recipients who have recovered from COVID-19 can be considered for transplantation after careful pre-transplant evaluation, donor selection, and individualized risk-benefit analysis.

Characteristics and Outcomes of Patients 80 Years and Older Hospitalized With Coronavirus Disease 2019 (COVID-19).

Patients older than 65 years hospitalized with COVID-19 have higher rates of intensive care unit admission and death when compared with younger patients. Cardiovascular conditions associated with COVID-19 include myocardial injury, acute myocarditis, cardiac arrhythmias, cardiomyopathies, cardiogenic shock, thromboembolic disease, and cardiac arrest. Few studies have described the clinical course of those at the upper extreme of age. We characterize the clinical course and outcomes of 73 patients with 80 years of age or older hospitalized at an academic center between March 15 and May 13, 2020. These patients had multiple comorbidities and often presented with atypical clinical findings such as altered sensorium, generalized weakness and falls. Cardiovascular manifestations observed at the time of presentation included new arrhythmia in 7/73 (10%), stroke/intracranial hemorrhage in 5/73 (7%), and elevated troponin in 27/58 (47%). During hospitalization, 38% of all patients required intensive care, 13% developed a need for renal replacement therapy, and 32% required vasopressor support. All-cause mortality was 47% and was highest in patients who were ever in intensive care (71%), required mechanical ventilation (83%), or vasopressors (91%), or developed a need for renal replacement therapy (100%). Patients older than 80 years old with COVID-19 have multiple unique risk factors which can be associated with increased cardiovascular involvement and death.

Noninvasive Radioablation of Ventricular Tachycardia.

Ventricular tachycardia (VT) occurs most commonly in the presence of structural heart disease or myocardial scarring from prior infarction. It is associated with increased mortality, especially when it results in cardiac arrest outside of a hospital. When not due to reversible causes (such as acute ischemia/infarction), placement of an implantable cardioverter-defibrillator for prevention of future sudden death is indicated. The current standard of care for recurrent VT is medical management with antiarrhythmic agents followed by invasive catheter ablation for VT that persists despite appropriate medical therapy. Stereotactic arrhythmia radioablation (STAR) is a novel, noninvasive method of treating VT that has been shown to reduce VT burden for patients who are refractory to medical therapy and/or catheter ablation, or who are unable to tolerate catheter ablation. STAR is the term applied to the use of stereotactic body radiation therapy for the treatment of arrhythmogenic cardiac tissue and requires collaboration between an electrophysiologist and a radiation oncologist. The process involves identification of VT substrate through a combination of electroanatomic mapping and diagnostic imaging (computed tomography, magnetic resonance imaging, positron emission tomography) followed by carefully guided radiation therapy. In this article, we review currently available literature describing the utilization, efficacy, safety profile, and potential future applications of STAR for the management of VT.

Paralytic ileus in the United States: A cross-sectional study from the national inpatient sample.

INTRODUCTION: Paralytic ileus is a common clinical condition leading to significant morbidity and mortality. Most studies to date have focused on postoperative ileus, a common but not exclusive cause of the condition. There are limited epidemiological data regarding the incidence and impact of paralytic ileus and its relationship to other clinical conditions. In this cross-sectional study, we analyzed national inpatient hospitalization trends, demographic variation, cost of care, length of stay, and mortality for paralytic ileus hospitalizations as a whole. METHODS: The National Inpatient Sample database was used to identify all hospitalizations with the diagnosis of paralytic ileus (International Classification of Diseases, 9th Revision code 560.1) as primary or secondary diagnosis during the period from 2001 to 2011. Statistical analysis was performed using Cochran-Armitage trend test, Wilcoxon rank sum test, and Poisson regression. RESULTS: In 2001, there were 362,561 hospitalizations with the diagnosis of paralytic ileus as compared to 470,110 in 2011 (p < 0.0001). The age group 65-79 years was most commonly affected by paralytic ileus throughout the study period. In-hospital all-cause mortality decreased from 6.03% in 2001 to 5.10% in 2011 (p < 0.0001). However, the average cost of care per hospitalization increased from US$19,739 in 2001 to US$26,198 in 2011 (adjusted for inflation, p < 0.0001). CONCLUSION: There was a significant rise in the number of hospitalizations of paralytic ileus with increased cost of care and reduced all-cause mortality.

Dieulafoy's Lesion: Decade-Long Trends in Hospitalizations, Demographic Disparity, and Outcomes.

Background Dieulafoy's lesion is a relatively rare, but potentially life-threatening, condition where a tortuous arteriole, most commonly in the stomach, may bleed and lead to significant gastrointestinal hemorrhage. Limited epidemiological data exist on patient characteristics and the annual number of hospitalizations associated with such lesions. The aim of our study is to determine the inpatient burden of Dieulafoy's lesion. Methods We analyzed the National Inpatient Sample (NIS) database for all subjects with a discharge diagnosis of Dieulafoy's lesion of the stomach, duodenum, and colon using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 537.84 and 569.86 as the primary or secondary diagnosis during the period from 2002 to 2011. Statistical significance of variation in the number of hospital discharges and demographics during the study period was achieved using the Cochrane-Armitage trend test. Results In 2002, there were 1,071 admissions with a discharge diagnosis of Dieulafoy's lesion as compared to 7,414 in 2011 (p < 0.0001). Dieulafoy's lesion was found to be most common in the age group of 65-79 years (p < 0.0001). Overall, it was found to be more common in males as compared to females (p = 0.0261). The white race was most commonly affected amongst all the races. The average cost of care per hospitalization increased from $14,992 in 2002 to $25,594 in 2011 (p < 0.0001). Conclusion There has been a steady rise in the number of inpatient admissions with Dieulafoy's lesions. Advances in diagnostic techniques likely play a key role in the higher detection rates along with the possible involvement of other unknown factors. Men, in the age group of 65 to 79 years, and Whites were found to have significantly higher admission rates than all other groups, with a significant increase in the cost of care.