Nano-remediation technologies for the sustainable mitigation of persistent organic pollutants.

The absence of novel and efficient methods for the elimination of persistent organic pollutants (POPs) from the environment is a serious concern in the society. The pollutants release into the atmosphere by means of industrialization and urbanization is a massive global hazard. Although, the eco-toxicity associated with nanotechnology is still being debated, nano-remediation is a potentially developing tool for dealing with contamination of the environment, particularly POPs. Nano-remediation is a novel strategy to the safe and long-term removal of POPs. This detailed review article presents an important perspective on latest innovations and future views of nano-remediation methods used for environmental decontamination, like nano-photocatalysis and nanosensing. Different kinds of nanomaterials including nanoscale zero-valent iron (nZVI), carbon nanotubes (CNTs), magnetic and metallic nanoparticles, silica (SiO2) nanoparticles, graphene oxide, covalent organic frameworks (COFs), and metal organic frameworks (MOFs) have been summarized for the mitigation of POPs. Furthermore, the long-term viability of nano-remediation strategies for dealing with legacy contamination was considered, with a particular emphasis on environmental and health implications. The assessment goes on to discuss the environmental consequences of nanotechnology and offers consensual recommendations on how to employ nanotechnology for a greater present and a more prosperous future.

Association Between COVID-19 Diagnosis and In-Hospital Mortality in Patients Hospitalized With ST-Segment Elevation Myocardial Infarction.

IMPORTANCE: There has been limited research on patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19. OBJECTIVE: To compare characteristics, treatment, and outcomes of patients with STEMI with vs without COVID-19 infection. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of consecutive adult patients admitted between January 2019 and December 2020 (end of follow-up in January 2021) with out-of-hospital or in-hospital STEMI at 509 US centers in the Vizient Clinical Database (N = 80 449). EXPOSURES: Active COVID-19 infection present during the same encounter. MAIN OUTCOMES AND MEASURES: The primary outcome was in-hospital mortality. Patients were propensity matched on the likelihood of COVID-19 diagnosis. In the main analysis, patients with COVID-19 were compared with those without COVID-19 during the previous calendar year. RESULTS: The out-of-hospital STEMI group included 76 434 patients (551 with COVID-19 vs 2755 without COVID-19 after matching) from 370 centers (64.1% aged 51-74 years; 70.3% men). The in-hospital STEMI group included 4015 patients (252 with COVID-19 vs 756 without COVID-19 after matching) from 353 centers (58.3% aged 51-74 years; 60.7% men). In patients with out-of-hospital STEMI, there was no significant difference in the likelihood of undergoing primary percutaneous coronary intervention by COVID-19 status; patients with in-hospital STEMI and COVID-19 were significantly less likely to undergo invasive diagnostic or therapeutic coronary procedures than those without COVID-19. Among patients with out-of-hospital STEMI and COVID-19 vs out-of-hospital STEMI without COVID-19, the rates of in-hospital mortality were 15.2% vs 11.2% (absolute difference, 4.1% [95% CI, 1.1%-7.0%]; P = .007). Among patients with in-hospital STEMI and COVID-19 vs in-hospital STEMI without COVID-19, the rates of in-hospital mortality were 78.5% vs 46.1% (absolute difference, 32.4% [95% CI, 29.0%-35.9%]; P < .001). CONCLUSIONS AND RELEVANCE: Among patients with out-of-hospital or in-hospital STEMI, a concomitant diagnosis of COVID-19 was significantly associated with higher rates of in-hospital mortality compared with patients without a diagnosis of COVID-19 from the past year. Further research is required to understand the potential mechanisms underlying this association.

Physical and Psychological Outcomes of Patients Undergoing Traditional Cardiac Rehabilitation and Intensive Cardiac Rehabilitation.

PURPOSE: Both traditional cardiac rehabilitation (TCR) and intensive cardiac rehabilitation (ICR) have proven benefits for patients with cardiovascular disease. The aim of this study was to compare ICR versus TCR on cardiac rehabilitation (CR) outcomes in patients with cardiovascular disease. METHODS: In a retrospective cohort study of 970 patients (n = 251, ICR; n = 719, TCR) who were referred for CR between January 2018 and December 2019, 693 (71.4%) patients completed it. The TCR sessions were 90 min (60-min exercise) three times/wk for 12 wk, while ICR sessions were 4 hr (60-min exercise) two times/wk for 9 wk. Primary endpoints were change in cardiorespiratory fitness (CRF) (by difference in exercise prescription metabolic equivalents [METs] between the last session and the average of the second and third sessions), anxiety (Generalized Anxiety Disorder-7) scores, percent depression (Patient Health Questionnaire-9 or Center for Epidemiologic Studies Depression Scale) scores, and health status (36-item Short Form Health Survey physical and mental composite scores). Linear regression adjusted for imbalanced baseline characteristics (age, race, and diagnosis of angina). RESULTS: Of the 693 patients who completed CR (ICR = 204/251 [81%] vs TCR = 489/719 [68%], P < .01), mean age was 66 yr and 31% were female. Patients in TCR had a higher improvement in CRF (CR session METs: ICR +1.5 ± 1.2 vs TCR +1.9 ± 1.5, P < .01) but no difference in health status scores. Conversely, patients in ICR had more reduction in anxiety scores (-2 ± 4 vs -1 ± 3, P < .01) and percent reduction in depression scores (-8.3 ± 13.7% vs -5.0 ± 11.7%, P < .01) than patients in TCR. CONCLUSIONS: Patients in TCR had higher improvement in CRF while patients in ICR had higher improvement in anxiety and depression scores.

Comparison of telecardiac rehabilitation with centre-based cardiac rehabilitation and usual care: a protocol for systematic review including a meta-analysis.

INTRODUCTION: Cardiac diseases are the leading causes of morbidity and mortality. Cardiac rehabilitation is proven to be beneficial in reducing morbidity, mortality and rehospitalisation rates. Recently, more emphasis is given to home-based telemonitored cardiac rehabilitation due to the recent pandemic of SARS-CoV-2. We plan to perform this systematic review and meta-analysis to compare the differences in functional capacity (FC) (measured in peak oxygen uptake (PVO2)) and health-related quality of life (hr-QoL) between telecardiac rehabilitation and both centre-based cardiac rehabilitation (CBCR) and usual care (UC) separately. It will showcase the feasibility of using telemonitored cardiac rehabilitation as an alternative to CBCR considering the ease of performance, safety and limiting unnecessary contact. METHODS AND ANALYSIS: This systematic review and meta-analysis protocol was structured according to the published Preferred Reporting Items for Systematic Review and Meta-analysis-Protocol guidelines. We will devise a search strategy to use online databases to search for the randomised controlled trials (RCTs). Inclusion criteria will include adult population (18 years or older) suffering from at least one cardiac disease referred for cardiac rehabilitation comparing telecardiac rehabilitation with both CBCR and UC. Exclusion criteria will be RCTs in non-English language, hybrid studies, cross-over trials, observational studies and case series. The outcome of interest will be FC measured in PVO2 and hr-QoL. The articles will be reviewed by two independent reviewers and a third reviewer will be available to adjudicate any conflicts. The bias in the selected studies will be assessed using Cochrane risk-of-bias tool for randomised trials. The overall bias of the studies will be assessed. The selected articles will be reviewed and the data will be collected on Microsoft Excel spreadsheet for analysis. These data will include number of subjects in the intervention arm and the comparator arm (which will either be CBCR or UC), measures of FC and hr-QoL and SD. Subgroup analysis and sensitivity analysis will be considered based on heterogeneity among the study effect estimates and the number of available studies for each outcome. Results of the pooled estimates will be reported as standardised mean difference (and 95% CI) with fixed-effect model, if heterogeneity is not significant (I2 <50%). Otherwise, random-effects model will be used for I2 >50%. The data of the subjects who completed the rehabilitation programme of the study period will be used to calculate the effect estimates (per-protocol effect). Publication bias in the meta-analysis will be assessed using Egger's test and funnel plot. The strength of body of evidence of the outcomes will be assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. Data analysis will be performed using Stata SE V.15.0 (College Station, Texas, USA). ETHICS AND DISSEMINATION: There will be no direct involvement of the patient or the public in the conception, design, data collection, and analysis of this systematic review and meta-analysis. Results of this systematic review and meta-analysis will be disseminated via journal articles. PROSPERO REGISTRATION NUMBER: CRD42021245461.

Cardiovascular Outcomes of Patients Referred to Home Based Cardiac Rehabilitation.

BACKGROUND: Home Based Cardiac Rehabilitation (HBCR) has been considered a reasonable alternative to Center-based Cardiac Rehabilitation (CBCR) in patients with established cardiovascular disease, especially in the midst of COVID-19 pandemic. However, the long-term cardiovascular outcomes of patients referred to HBCR remains unknown. OBJECTIVES: To compare outcomes of patients who were referred and attended HBCR vs patients referred but did not attend HBCR (Non-HBCR). METHODS: We performed a retrospective study of 269 patients referred to HBCR at Providence Veterans Affairs Medical Center (PVAMC). From November 2017 to March 2020, 427 patients were eligible and referred for Cardiac Rehabilitation (CR) at PVAMC. Of total patients, 158 patients were referred to CBCR and 269 patients to HBCR based on patient and/or clinician preference. The analysis of outcomes was focused on HBCR patients. We compared outcomes of patients who were referred and attended HBCR vs patients referred but did not attend HBCR (Non-HBCR) from 3 to 12 months of the referral date. HBCR consisted of face-to-face entry exam with exercise prescription, weekly phone calls for education and exercise monitoring, with adjustments where applicable, for 12-weeks and an exit exam. Primary outcome was composite of all-cause mortality and hospitalizations. Secondary outcomes were all-cause hospitalization, all-cause mortality and cardiovascular hospitalizations, separately. We used cox proportional methods to calculate hazard ratios (HR) and 95% CI. We adjusted for imbalanced characteristics at baseline: smoking, left ventricular ejection fraction and CABG status. RESULTS: A total of 269 patients (mean age: 72, 98% Male) were referred to HBCR, however, only 157 (58%) patients attended HBCR. The primary outcome occurred in 30 patients (19.1%) in the HBCR group and 30 patients (30%) in the Non-HBCR group (adjusted HR=0.56, CI 0.33-0.95, P=.03). All-cause mortality occurred in 6.4% of patients in the HBCR group and 13% patients in the Non-HBCR group 3 to 12 months after HBCR referral (adjusted HR=0.43, CI 0.18-1.0, P= .05). There was no difference in cardiovascular hospitalizations (HBCR: 5.7% vs Non-HBCR: 10%, adjusted HR 0.57, CI 0.22-1.4, P= .23) or all cause hospitalizations at 3 to 12 months between the groups (HBCR: 12.7% vs Non-HBCR: 21%, adjusted HR 0.53, CI 0.28-1.01, P= .05). CONCLUSION: Completion of HBCR among referred patients was associated with a lower risk of the combined all-cause mortality and all-cause hospitalizations up to 12 months. Based on the outcomes, HBCR is a reasonable option that can improve access to CR for patients who are not candidates of or cannot attend CBCR. Randomized-controlled studies are needed to confirm these findings.

SARS-COV-2/COVID-19: scenario, epidemiology, adaptive mutations, and environmental factors.

The coronavirus pandemic of 2019 has already exerted an enormous impact. For over a year, the worldwide pandemic has ravaged the whole globe, with approximately 250 million verified human infection cases and a mortality rate surpassing 4 million. While the genetic makeup of the related pathogen (SARS-CoV-2) was identified, many unknown facets remain a mystery, comprising the virus's origin and evolutionary trend. There were many rumors that SARS-CoV-2 was human-borne and its evolution was predicted many years ago, but scientific investigation proved them wrong and concluded that bats might be the origin of SARS-CoV-2 and pangolins act as intermediary species to transmit the virus from bats to humans. Airborne droplets were found to be the leading cause of human-to-human transmission of this virus, but later studies showed that contaminated surfaces and other environmental factors are also involved in its transmission. The evolution of different SARS-CoV-2 variants worsens the condition and has become a challenge to overcome this pandemic. The emergence of COVID-19 is still a mystery, and scientists are unable to explain the exact origin of SARS-CoV-2. This review sheds light on the possible origin of SARS-CoV-2, its transmission, and the key factors that worsen the situation.

Circulating S-Glutathionylated cMyBP-C as a Biomarker for Cardiac Diastolic Dysfunction.

Background cMyBP-C (Cardiac myosin binding protein-C) regulates cardiac contraction and relaxation. Previously, we demonstrated that elevated myocardial S-glutathionylation of cMyBP-C correlates with diastolic dysfunction (DD) in animal models. In this study, we tested whether circulating S-glutathionylated cMyBP-C would be a biomarker for DD. Methods and Results Humans, African Green monkeys, and mice had DD determined by echocardiography. Blood samples were acquired and analyzed for S-glutathionylated cMyBP-C by immunoprecipitation. Circulating S-glutathionylated cMyBP-C in human participants with DD (n=24) was elevated (1.46±0.13-fold, P=0.014) when compared with the non-DD controls (n=13). Similarly, circulating S-glutathionylated cMyBP-C was upregulated by 2.13±0.47-fold (P=0.047) in DD monkeys (n=6), and by 1.49 (1.22-2.06)-fold (P=0.031) in DD mice (n=5) compared with the respective non-DD controls. Circulating S-glutathionylated cMyBP-C was positively correlated with DD in humans. Conclusions Circulating S-glutathionylated cMyBP-C was elevated in humans, monkeys, and mice with DD. S-glutathionylated cMyBP-C may represent a novel biomarker for the presence of DD.

Endovascular Intravascular Lithotripsy in the Treatment of Calcific Common Femoral Artery Disease: A Case Series With an 18-Month Follow-Up.

BACKGROUND: Intravascular lithotripsy (IVL) is a novel endovascular treatment for calcified common femoral artery disease (CFA). Data on midterm effectiveness for clinically driven target lesions revascularization (CD-TLR) is lacking. This study investigated CD-TLR during 18-month follow-up in patients requiring IVL for CFA disease treatment. METHODS: In a single-center retrospective cohort study, electronic medical record of patients undergoing IVL for CFA disease from January 2018 to March 2020 were reviewed. Primary outcome was CD-TLR estimated by Kaplan-Meier method during 18-month follow-up. Univariate logistic regression was used to compare differences in CD-TLR by the type of adjunct therapy used. RESULTS: Among 54 CFA lesions in 50 patients, mean age (SD) was 75(8) years, gender and race were predominantly male (74%, n = 37) and white (94%, n = 47), respectively. Rutherford class III claudication was most common (70%, n = 35) with mean ABI of 0.66 (0.26) and mean angiographic stenosis of 77% (13%). Adjunct use of drug-coated balloon (DCB) angioplasty was 83% (n = 45) and atherectomy was 39% (n = 21). Residual angiographic stenosis was <30% in all cases. Complications included dissection requiring stent placement (2%, n = 1). After 18-months, 18% (n = 9) died unrelated to procedural complications and 6% (n = 3) were lost to follow-up. 18-month cumulative freedom from CD-TLR was 80.6% (95% CI: 69.1%, 92%). Univariate logistic regression did not reveal a statistically significant difference in CD-TLR with type of adjunct therapy used (p > 0.05). CONCLUSION: IVL with adjunct use of DCB and/or atherectomy is safe and effective in treatment of calcified CFA disease. Randomized studies are required to confirm these findings.

Preadmission Statin Treatment and Outcome in Patients Hospitalized With COVID-19.

Preadmission statin therapy is associated with improved outcome in patients hospitalized with COVID-19. Whether inhibition of inflammation and myocardial injury are in part responsible for this observation has not been studied. The aim of the present study was to relate preadmission statin usage to markers of inflammation, myocardial injury, and clinical outcome among patients with established atherosclerosis who were admitted with COVID-19. Adult patients with a diagnosis of coronary artery disease, peripheral artery disease, and/or atherosclerotic cerebrovascular disease who were hospitalized with COVID-19 between March 1, 2020 and December 31, 2020 were included. Statin use was related to the primary composite clinical outcome, death, intensive care unit admission, or thrombotic complications in sequential multivariable logistic regression models. Of 3,584 adult patients who were hospitalized with COVID-19, 1,360 patients met study inclusion criteria (mean age 73.8 years, 45% women, 68% White). Baseline troponin and C-reactive protein were lower in patients on statins before admission. In an unadjusted model, preadmission statin usage was associated with a significant reduction in the primary composite outcome (42.2% vs 53.7%, odds ratio 0.63 [95% confidence interval 0.50 to 0.80], p <0.001). This association remained significant after age, gender, ethnicity, other patient clinical characteristics, and cardiovascular medications were added to the model but became null when troponin and C-reactive protein were also included (odds ratio 0.83 [95% confidence interval 0.63 to 1.09] p = 0.18). In conclusion, among patients with established cardiovascular disease who were hospitalized with COVID-19, preadmission statin therapy was associated with improved in-hospital outcome, an association that was negated once inflammation and myocardial injury were considered.

Preadmission Oral Anticoagulation for Atrial Fibrillation/Flutter and Death or Thrombotic Events During COVID-19 Admission.

Atrial fibrillation/flutter (AF) and COVID-19 are associated with an elevated risk of arterial and venous thrombosis. Whether preadmission oral anticoagulation (OAC) for AF reduces the incidence of in-hospital death or thrombotic events among patients with COVID-19 is unknown. We identified 630 patients with pre-existing AF and a hospitalization diagnosis of COVID-19 and stratified them according to preadmission OAC use. Multivariable logistic regression was employed to relate preadmission OAC to composite in-hospital mortality or thrombotic events. Unadjusted composite in-hospital mortality or thrombotic complications occurred less often in those on than not on preadmission OAC (27.1% vs 46.8%, p <0.001). After adjustment, the incidence of composite in-hospital all-cause mortality or thrombotic complications remained lower with preadmission OAC (odds ratio 0.37, confidence interval 0.25 to 0.53, p <0.0001). Secondary outcomes including all-cause mortality (16.3% vs 24.9%, p = 0.007), intensive care unit admission (14.7% vs 29.0%, p <0.001), intubation (6.4% vs 18.6%, p <0.001), and noninvasive ventilation (18.6% vs 27.5%, p = 0.007) occurred less frequently, and length of stay was shorter (6 vs 7 days, p <0.001) in patients on than those not on preadmission OAC. A higher CHA2DS2-VASc score was associated with an increased risk of thrombotic events. In conclusion, among patients with baseline AF who were hospitalized with COVID-19, those on preadmission OAC had lower rates of death, arterial and venous thrombotic events, and less severe COVID-19.

Cardiac rehabilitation in women; comparison of enrollment, adherence and outcomes between heart failure and coronary artery disease.

BACKGROUND: There is paucity of data on cardiac rehabilitation (CR) enrollment and outcomes in women with heart failure (HF). METHODS: In this retrospective analysis, we compared enrollment, adherence and outcomes between women with HF versus coronary artery disease (CAD)-related indications referred to a university-affiliated CR program from June 2014-July 2018. A multivariate regression analysis was performed to adjust for imbalanced variables at baseline and baseline value of each outcome to compare change in outcomes between HF and CAD groups RESULTS: A total of 538 women (HF=63 vs CAD=475) were included in the study. At baseline, women with HF were younger, had lower attendance to CR intake and worse perceived health, higher AACVPR risk category and lower exercise capacity but had similar enrollment, weight and dieatry habits when compared to women with CAD. Adjusted analyses showed that almost all cardiac rehabilitation outcomes except for positive affect (anxiety, depression symptoms, negative affect, dietary habits, perceived physical and mental health summary scores, exercise duration and capacity) improved significantly from baseline and in a similar fashion in both groups. Weight loss was significantly greater for women with CAD versus those with HF (CAD: Δ -1.12 ± 2.23 kg versus HF: Δ -0.66 ± 2.78 kg, p = 0.03). CONCLUSION: Despite a lower attendance to CR intake, lower perceived physical health and higher baseline AACVPR risk in women with HF, they have similar CR enrollment, adherence and completion rates compared to women with CAD. Both groups showed significant but similar improvements from baseline in almost all cardiac rehabilitation outcomes. These findings should alert cardiology providers to help overcome obstacles for women with HF to attend CR intake.

Eosinophilic Myocarditis in a Patient With Sickle Cell Disease.

A 23-year-old man with sickle cell disease treated with splenectomy and allogenic stem cell transplantation presented with recurrent chest pain, elevated cardiac enzymes, and unremarkable electrocardiography. His work-up revealed eosinophilia, raising concern for eosinophilic myocarditis. Cardiac magnetic resonance imaging showed patchy late gadolinium enhancement of the left ventricular free wall, suggestive of myocarditis. He was treated with high-dose intravenous steroids followed by oral prednisone, with improvement in his symptoms and eosinophilia and a decrease in cardiac enhancement on follow-up imaging. (Level of Difficulty: Intermediate.).

Cardiac Resynchronization and Circulating Markers of Sarcoplasmic Reticulum Calcium Handling and Sudden Death Risk.

Cardiac resynchronization therapy (CRT) can improve heart function and decrease arrhythmic events. We tested whether CRT altered circulating markers of calcium handling and sudden death risk. Circulating cardiac sodium channel messenger RNA (mRNA) splicing variants indicate arrhythmic risk, and a reduction in sarco/endoplasmic reticulum calcium adenosine triphosphatase 2a (SERCA2a) is thought to diminish contractility in heart failure. CRT was associated with a decreased proportion of circulating, nonfunctional sodium channels and improved SERCA2a mRNA expression. Patients without CRT did not have improvement in the biomarkers. These changes might explain the lower arrhythmic risk and improved contractility associated with CRT.

Role of sodium glucose co-transporter 2 inhibitors in patients with heart failure: an elusive mechanism.

Heart failure (HF) is a major cause of morbidity and mortality worldwide, and the burden of HF continues to rise. There has been an interest in sodium-glucose co-transporter-2 (SGLT2) inhibitors for their role in reducing HF hospitalizations in pivotal trials. Since these agents were approved by the Food and Drug Administration for the management of diabetes mellitus, multiple small trials and analyses have tried to explain the underlying beneficial mechanisms in HF . In this review, we discuss different mechanisms by which SGLT2 inhibitors play hemodynamic, metabolic, and cellular roles in different HF phenotypes. We also address issues pertaining to the safety of these relatively newer agents.KEY MESSAGESSGLT2 inhibitors are associated with a reduction in HF hospitalizations in both diabetics and non-diabetics.The beneficial role of SGLT2 inhibitors in reducing HF hospitalization is observed among participants with established cardiovascular disease/HF and at-risk population.SGLT2 inhibitors pose an important role in renal protection, another mechanism by which these medications can be helpful in HF patients.

Efficacy of adding activity of daily living simulation training to traditional pulmonary rehabilitation on dyspnea and health-related quality-of-life.

INTRODUCTION: Exercise modalities offered as part of traditional pulmonary rehabilitation (PR) do not always translate to successful performance of Activities of Daily Living (ADL) and may hinder gains in patient's sense of well-being. Data is lacking on the efficacy of incorporation of ADL-focused training in PR. The aim of this study was to determine the impact of incorporation of ADL simulation and energy-conservation training in PR as part of a quality-initiative on health-related-quality-of-life (HRQOL), dyspnea, fatigue, and six-minute-walk-test among PR patients. METHODS: Retrospective study where medical records of consecutive patients with chronic respiratory diseases who completed PR from 2016 to 2018 were reviewed. ADL-focused energy-conservation training was added to traditional PR in September 2017 by replacing three monthly sessions of traditional PR with energy-conservation training as a quality-improvement-initiative. The change from baseline on HRQOL measured by COPD assessment test (CAT), six-minute-walk-test, MMRC dyspnea score and CRQ-dyspnea and CRQ-fatigue questionnaires, were compared between patients who received traditional PR versus energy-conservation PR. Within and between group differences were calculated via repeated-measures ANOVA. RESULTS: The baseline characteristics of 91 patients who participated in traditional PR versus energy-conservation PR (n = 85) were similar (mean age = 68.6±10.4 years, 49% men). While improvement from baseline was similar and significant for both groups for MMRC, CRQ-dyspnea and CRQ-fatigue scores, and six-minute walk test, patients who participated in energy-conservation PR had significantly higher improvement in HRQOL CAT scores (p = 0.01) than those who completed traditional PR. CONCLUSION: Tailoring patient's training programs to include energy-conservation training exercises specific to ADL in PR improved HRQOL over traditional PR in patients with chronic respiratory diseases despite no significant change in functional status. Future randomized-controlled trials will be needed to confirm these initial findings.

Endovascular Revascularization of Superficial Femoral Artery Stent Occlusion by Combined Retrograde Access With Catheter-Directed Thrombolysis and Pharmaco-Mechanical Thrombectomy.

We report a case of a patient with history of peripheral arterial disease who presented to the hospital with critical limb ischemia. We performed endovascular revascularization of stent thrombosis in superficial femoral artery (SFA), by retrograde pedal access with wire exteriorization. This case highlights the utility of retrograde pedal access in failed antegrade approach of culprit lesion in SFA and the effectiveness of multimodal endovascular thrombectomy to restore blood flow in patients who are otherwise not suitable for surgical interventions.

Pulmonary Hypertension Post Liver-Kidney Transplant.

Porto-pulmonary hypertension has been recently recognized in patients post-liver transplantation with or without pre-transplant hepatopulmonary syndrome. We present a unique case of pulmonary hypertension in a 65-year-old patient after simultaneous liver-kidney transplantation for cirrhosis secondary to chronic hepatitis C infection and alcohol use disorder and end-stage renal disease secondary to diabetic nephropathy. He presented to pulmonary hypertension clinic with progressive shortness of breath and elevated right-sided pulmonary pressures on echocardiogram. He did not have pre-transplant hepatopulmonary syndrome and his post-transplant liver and kidney functions were normal. His right heart catheterization showed normal capillary wedge pressure, elevated mean pulmonary artery pressure and high pulmonary vascular resistance with normal cardiac index. His symptoms and pulmonary pressures improved with ligation of AV fistula.

Efficacy and safety of adjunctive drug-coated balloon therapy in endovascular treatment of common femoral artery disease.

BACKGROUND: Surgical endarterectomy with or without patch angioplasty has been considered the gold standard for treatment of symptomatic common femoral artery (CFA) disease. Surgical risks include wound infection, hematoma and lymph leak in approximately 17% of patients. Endovascular therapy has less procedure-related morbidity and mortality. Endovascular approaches achieve patency rates of 60% to 90% at 1 and 2 years utilizing atherectomy and balloon angioplasty. CFA stenting has been limited due to concerns of stent kinking, thrombosis and restenosis. Combined directional atherectomy with drug-coated balloon to treat CFA disease in patients with Rutherford II/III patients has been studied recently. We sought to study the safety and outcomes of adjunct drug-coated balloon (DCB) therapy in symptomatic CFA disease patients, including critical limb ischemia (Rutherford IV), after achieving procedural success. OBJECTIVE: To evaluate the additive efficacy of drug coated balloon in treating CFA disease. METHODS: Using retrospective single center data, we analyzed the outcomes of patients who underwent CFA interventions. In this non-randomized study, all patients from December 2010 to December 2014 with CFA disease underwent atherectomy (orbital, plaque excision or both) with adjunctive scoring balloon angioplasty (Ath/PTA). After December 2014, patients treated with combination atherectomy and DCB, (Ath/DCB), underwent final drug delivery to the vessel wall with drug-coated balloon. Distal embolic protection devices were used in the majority of patients. Primary efficacy endpoint was 1-year primary patency and freedom from clinically driven target lesion revascularization (CD-TLR). Patency of vessels was assessed at 12-month interval using duplex ultrasound. RESULTS: Seventy de novo common femoral artery stenotic lesions were treated in both groups. Mean age was 69 in (Ath/PTA) group and 72 in Ath/DCB group. Patients in each group had similar risk factor profiles including diabetes mellitus, hypertension, smoking, coronary artery disease, myocardial infarction, prior coronary revascularization, congestive heart failure, cerebrovascular accidents and chronic kidney disease. The Ath/DCB group had more advanced disease presentation by Rutherford classification (intermittent claudication in 61% and critical limb ischemia in 39% versus intermittent claudication in 76% and chronic limb ischemia in 24%) when compared with the Ath/PTA group. Primary efficacy endpoint was met in 85% and 94% (p = 0.26) in the Ath/PTA and Ath/DCB groups respectively. All patients had run-off angiography at the end of procedure to ensure patency. CONCLUSION: Adjunctive drug-coated balloon therapy does not increase the primary patency rate when compared with atherectomy and scoring balloon angioplasty alone at 1-year in common femoral artery disease treatment.

A Review of the Pharmacological Management of Chronic Pain in Patients with Heart Failure.

Background: The incidence rates of heart failure (HF) and chronic pain increase with age. In the geriatric population, both disorders often coexist and pose a challenge to clinicians in treating them simultaneously. Methods: We conducted an online literature search for reports of the heart failure effects of pharmacological treatments for chronic pain. Results: Topical pain medications are favored agents because of their efficacy, tolerability, and favorable side-effect profile. Acetaminophen is a preferred oral medication for the treatment of pain in patients with HF. Due to deleterious effects including HF, the long-term use of oral nonsteroidal anti-inflammatory drugs and gabapentinoids are discouraged. Conclusion: Prescribers should thoroughly consider the risk-benefit ratio and individual patient-risk profile before instituting pharmacological treatment for chronic pain in patients with HF.