Real-world abdominal aorta aneurysm screening patterns among patients with new or worsening of symptomatic peripheral artery disease.

BACKGROUND: Patients with peripheral artery disease (PAD) have an increased risk of abdominal aortic aneurysms (AAA), but it remains unclear whether practitioners are screening patients for AAA as part of routine PAD management. METHODS: The Patient-centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease (PORTRAIT) Registry is an international prospective registry of patients with new or worsening PAD symptoms presenting to 16 specialty centers in the United States, Netherlands, and Australia, from June 2011 to December 2015. Patients were stratified by AAA screening or AAA positivity. An adjusted median odds ratio was calculated for AAA screening rates across sites. RESULTS: Of the 1275 patients in the study, 871 (68%) were screened for AAA, with 53 (6.1%) having AAA. AAA screening rates did not differ significantly by country (p = 0.36), but there was a large variation across sites for documentation of AAA screening with an adjusted median odds ratio 12.0 (95% CI 4.7-93.1), with AAA screening rates ranging from 7% to 100% across vascular specialty centers. CONCLUSIONS: Among patients with PAD in a multicenter registry, over two-thirds were screened for AAA, with 6% having documented aneurysms. A large variation was seen across clinical sites, suggesting efforts are needed to increase awareness for guideline implementation and establish new benefit-risk evidence inclusive of high-risk populations such as patients with PAD.

Temporal Trends for Patients Hospitalized With Atrial Fibrillation in the United States: An Analysis From the National Inpatient Sample (NIS) Database 2011-2018.

BACKGROUND: Atrial fibrillation (AF) has historically been a growing burden on the global public health system. Previously, literature on the trends associated with AF-related hospitalizations has been published. However, there seems to be a gap in up-to-date information, notably within the last decade. PURPOSE: This study aims to investigate the trends, outcomes, and factors associated with AF hospitalization and the continued impact of AF on the United States health system. METHODS: Patient data were collected from the years 2011 to 2018 from the National Inpatient Sample (NIS) database using the International Classification of Diseases (ICD)-9 and ICD-10 codes. We selected patients hospitalized with a diagnosis of AF. Descriptive statistics, statistical analysis, and Mann-Whitney U testing were employed to compare continuous dichotomous variables. After respective adjustments, multivariate hierarchical logistic regression was used to establish mortality rates, length of stay (LOS), and hospital charges. RESULTS: The study included 509,305 patients hospitalized with a primary diagnosis of unspecified AF. The mean age of patients hospitalized with AF was 71 years. AF hospitalizations were slightly higher in women as compared to men (51.7% vs. 48.2%). The predominant race involved was Caucasians at 77.9% followed by African Americans and Hispanics at 7.4% and 5.4%, respectively. The three most frequent coexisting conditions noted were hypertension (69.9%), diabetes mellitus (24.3%), and chronic obstructive pulmonary disease (16.4%). Medicare/Medicaid was the primary payer associated with the majority of AF hospitalizations at 72.6%. Overall in-hospital mortality associated with AF hospitalizations was 0.96%. Comorbid conditions conferring the highest mortality risks included coagulopathies (644%) and cerebral vascular accidents (597%). Mean LOS was found to be 3.35 days. Hospitalization charges increased year-over-year and correlated with an increase in the national burden of cost for these patients of $3.6 billion. CONCLUSIONS: Our study investigates the national trends surrounding AF hospitalizations. Overall in-hospital mortality rates appear to be stable as compared to prior years and past literature. Comorbid conditions conferring significantly higher mortality rates included coagulopathies, cerebral vascular accidents, acute kidney injury, and end-stage renal disease. Additionally, suboptimal insurance status was also associated with increased mortality risk. The cost of hospitalization in AF patients has increased steadily, conferring a $3.6 billion burden on the US healthcare system.

A Rare Case of Severe Manifestation of COVID-19 Infection Presenting as Immune-Related Thrombotic Thrombocytopenic Purpura With Multiorgan Involvement Treated With Plasmapheresis, Steroids, Rituximab, and Caplacizumab.

Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) caused by decreased activity of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13). Platelet-rich thrombi in small vessels lead to fragmentation of RBCs causing microangiopathic hemolytic anemia (MAHA). Therapeutic plasma exchange is life-saving and is the mainstay of the treatment of TTP. Higher dose IV steroids along with rituximab are used as an adjunct to plasma exchange. Our case report describes a 26-year-old healthy male who presented with new onset seizures and encephalopathy. Blood work demonstrated anemia, severe thrombocytopenia, elevated lactate dehydrogenase, decreased haptoglobin, and elevated creatinine, and peripheral blood smear showed marked schistocytosis indicating MAHA. Plasma exchange and high-dose steroids were started on a presumptive diagnosis of TTP. ADAMTS13 activity was undetectable and ADAMTS13 inhibitor levels were elevated. Rituximab and caplacizumab were then added. Symptoms of encephalopathy improved by day five and platelet counts started improving by day nine. After several days of plasma exchange, he showed a "clinical response" with several weeks of active treatment. The association between coronavirus disease 2019 (COVID-19) infection and the severity of TTP with multiorgan failure is not well understood yet. Although we describe a successful multimodal approach to the management of TTP, which we believe is secondary to COVID-19 infection, further research is warranted to analyze and understand the pathophysiology by which COVID-19 infection causes TTP. It would help in establishing standardized therapy in the future.

Evidence-Based Mechanical Ventilatory Strategies in ARDS.

Acute respiratory distress syndrome (ARDS) remains one of the leading causes of morbidity and mortality in critically ill patients despite advancements in the field. Mechanical ventilatory strategies are a vital component of ARDS management to prevent secondary lung injury and improve patient outcomes. Multiple strategies including utilization of low tidal volumes, targeting low plateau pressures to minimize barotrauma, using low FiO2 (fraction of inspired oxygen) to prevent injury related to oxygen free radicals, optimization of positive end expiratory pressure (PEEP) to maintain or improve lung recruitment, and utilization of prone ventilation have been shown to decrease morbidity and mortality. The role of other mechanical ventilatory strategies like non-invasive ventilation, recruitment maneuvers, esophageal pressure monitoring, determination of optimal PEEP, and appropriate patient selection for extracorporeal support is not clear. In this article, we review evidence-based mechanical ventilatory strategies and ventilatory adjuncts for ARDS.

Central Vein Thrombosis in Pulmonary Neuroendocrine Neoplasm: A Novel Presentation.

Internal jugular vein (IJV) thrombosis is a rare finding and is usually associated with central venous catheterization, neck infections, or local trauma. Neuroendocrine tumors (NETs) rarely predispose to central vein thrombosis. The usual presentation of pulmonary NET depends on tumor location and is usually non-specific. It ranges from asymptomatic to cough, hemoptysis, dyspnea, etc. Here we present the case of a 52-year-old male with right-sided neck swelling. Ultrasound imaging of the neck revealed right IJV and right subclavian vein thrombosis. Further imaging with computed tomography (CT) scan of the chest showed mediastinal mass. Histopathology findings were consistent with NET of pulmonary origin. Patient was started immediately on anti-coagulation and radiology oncology was consulted for tumor-specific treatment. This case highlights an association of central vein thrombosis with underlying mediastinal and lung malignancies.