HEART and TIMI Scores Predict Severe Coronary Atherosclerosis in Patients With End-Stage Renal Disease.

Objectives History, EKG, age, risk factors, and troponin (HEART) and thrombolysis in myocardial infarction (TIMI) risk calculators have been validated to predict the risk of subsequent acute coronary syndromes and in some studies, severe coronary atherosclerosis in patients with a concerning clinical history. Their performance in patients with end-stage renal disease (ESRD), a population with a high pretest probability for the condition, is unknown. We aimed to determine whether HEART and TIMI scores can predict severe coronary atherosclerosis in patients with end-stage renal disease (ESRD). Methods A single-center retrospective cohort of admitted patients aged 18 years or older with ESRD on dialysis who underwent coronary angiography during admission (November 2010 to December 2017) was retrospectively reviewed. The outcome of coronary angiography was compared with the calculated HEART and TIMI scores at the time of presentation. Receiver operating characteristics and logistic regression models were used to determine optimal score cutoffs, score usefulness, and associations between outcomes, scores, and patient characteristics. Results Among 231 patient encounters, the mean HEART and TIMI scores were 6±2 and 3±1 points, respectively. Patients with diabetes mellitus, those 65 years old and older, and those reported to have angina pectoris were more likely to show severe coronary artery disease (CAD) lesions. Optimal score cutoffs for determining severe coronary lesions were between six and seven (area under the curve (AUC)=0.754, confidence interval (CI): 0.682-0.826) and between three and four (AUC=0.716, CI: 0.640-0.792) for the HEART and TIMI scores, respectively. Conclusion Similar to the general population, HEART and TIMI scores can predict severe coronary atherosclerosis in the complex ESRD population.

In persons at risk for poor vaccination response or COVID-19 exposure, tixagevimab + cilgavimab reduced COVID-19.

SOURCE CITATION: Levin MJ, Ustianowski A, De Wit S, et al. Intramuscular AZD7442 (tixagevimab-cilgavimab) for prevention of Covid-19. N Engl J Med. 2022;386:2188-200. 35443106.

A Case of Neuroparacoccidioidomycosis in Houston, Texas.

Paracoccidioidomycosis is a systemic fungal disease caused by the dimorphic Paracoccidioides species endemic to South America. Infection classically presents with pulmonary, mucosal, or reticuloendothelial involvement, though other organs can be involved. Central nervous system involvement is rare, and almost universally reported within the endemic area for the fungus. We present a 60-year-old Brazilian male who complained of occipital headache, ataxia, dysmetria, and dysarthria for two months, diagnosed with neuroparacoccidioidomycosis in Houston, Texas. The patient had a cerebellar mass and a left pulmonary spiculated apical mass suspicious for a lung metastatic malignancy and a preliminary histological report consistent with invasive cryptococcosis. The patient's work and travel history were paramount in achieving the final diagnosis.

Influenza Vaccination for the Prevention of Cardiovascular Disease in the Americas: Consensus document of the Inter-American Society of Cardiology and the Word Heart Federation.

Background: Cardiovascular mortality is decreasing but remains the leading cause of death world-wide. Respiratory infections such as influenza significantly contribute to morbidity and mortality in patients with cardiovascular disease. Despite of proven benefits, influenza vaccination is not fully implemented, especially in Latin America. Objective: The aim was to develop a regional consensus with recommendations regarding influenza vaccination and cardiovascular disease. Methods: A multidisciplinary team composed by experts in the management and prevention of cardiovascular disease from the Americas, convened by the Inter-American Society of Cardiology (IASC) and the World Heart Federation (WHF), participated in the process and the formulation of statements. The modified RAND/UCLA methodology was used. This document was supported by a grant from the WHF. Results: An extensive literature search was divided into seven questions, and a total of 23 conclusions and 29 recommendations were achieved. There was no disagreement among experts in the conclusions or recommendations. Conclusions: There is a strong correlation between influenza and cardiovascular events. Influenza vaccination is not only safe and a proven strategy to reduce cardiovascular events, but it is also cost saving. We found several barriers for its global implementation and potential strategies to overcome them.

Predictive factors for success of awake proning in hypoxemic respiratory failure secondary to COVID-19: A retrospective cohort study.

BACKGROUND: Awake prone positioning has been recommended as an adjunctive measure in spontaneously breathing patients with hypoxemic respiratory failure during the COVID-19 pandemic. It remains uncertain as to how long this should be implemented, what variables to follow and who would be the ideal candidates for this adjunctive therapy. METHODS: A retrospective chart review of patients admitted from April to August 2020 within our institution with multifocal pneumonia and hypoxemic respiratory failure secondary to COVID-19 who underwent awake-proning for at least 3 hours was conducted. RESULTS: Improvement in respiratory parameters including ROX (SpO2/Fio2/ Respiratory Rate) indices and inflammatory markers within 4 days of institution of awake proning predicted a higher chance for success of this strategy in preventing need for mechanical ventilation. Moreover, benefits of awake proning were limited to patients with mild to moderate ARDS. CONCLUSIONS: Awake prone positioning can be safely performed with improvement in oxygenation. However, its institution may be beneficial only in patients with mild to moderate ARDS and requires careful evaluation of respiratory parameters and serum inflammatory markers to avoid a delay in endotracheal intubation and consequent increase in mortality rates.

The emerging spectrum of cardiopulmonary pathology of the coronavirus disease 2019 (COVID-19): Report of 3 autopsies from Houston, Texas, and review of autopsy findings from other United States cities.

This paper collates the pathological findings from initial published autopsy reports on 23 patients with coronavirus disease 2019 (COVID-19) from 5 centers in the United States of America, including 3 cases from Houston, Texas. Findings confirm that COVID-19 is a systemic disease with major involvement of the lungs and heart. Acute COVID-19 pneumonia has features of a distinctive acute interstitial pneumonia with a diffuse alveolar damage component, coupled with microvascular involvement with intra- and extravascular fibrin deposition and intravascular trapping of neutrophils, and, frequently, with formation of microthombi in arterioles. Major pulmonary thromboemboli with pulmonary infarcts and/or hemorrhage occurred in 5 of the 23 patients. Two of the Houston cases had interstitial pneumonia with diffuse alveolar damage pattern. One of the Houston cases had multiple bilateral segmental pulmonary thromboemboli with infarcts and hemorrhages coupled with, in nonhemorrhagic areas, a distinctive interstitial lymphocytic pneumonitis with intra-alveolar fibrin deposits and no hyaline membranes, possibly representing a transition form to acute fibrinous and organizing pneumonia. Multifocal acute injury of cardiac myocytes was frequently observed. Lymphocytic myocarditis was reported in 1 case. In addition to major pulmonary pathology, the 3 Houston cases had evidence of lymphocytic pericarditis, multifocal acute injury of cardiomyocytes without inflammatory cellular infiltrates, depletion of splenic white pulp, focal hepatocellular degeneration and rare glomerular capillary thrombosis. Each had evidence of chronic cardiac disease: hypertensive left ventricular hypertrophy (420 g heart), dilated cardiomyopathy (1070 g heart), and hypertrophic cardiomyopathy (670 g heart). All 3 subjects were obese (BMIs of 33.8, 51.65, and 35.2 Kg/m2). Overall, the autopsy findings support the concept that the pathogenesis of severe COVID-19 disease involves direct viral-induced injury of multiple organs, including heart and lungs, coupled with the consequences of a procoagulant state with coagulopathy.

Drug deprescription-withdrawal risk, prevention, and treatment.

In most cases, a sudden interruption of most medications has no major consequences. There are well-recognized therapies that, when withheld, can either lead to the reappearance of the symptoms they were controlling or to signs or symptoms of withdrawal. In this article, we present a table including medications that when interrupted can produce withdrawal syndromes, the signs and symptoms of the withdrawal syndrome, the time to onset and resolution of the syndrome, information regarding alternative delivery options for the drug/s when the oral route is not possible, as well as prevention and therapy.

Disseminated tuberculosis and gastric mucormycosis coinfection.

Tuberculosis and mucormycosis coinfection has rarely been reported in the medical literature. We present a case of gastrointestinal (GI) mucormycosis in a diabetic patient with disseminated tuberculosis. Early diagnosis, addressing the risk factors for mucormycosis, surgical debridement, and timely antifungal treatment are the mainstay of care.

Tuberculous cellulitis in an immunocompetent patient.

Mycobacterial skin infections are rare, with a wide spectrum of clinical features in immunocompromised individuals. Overall, they represent <2% of all forms of extrapulmonary tuberculosis. Tuberculous cellulitis is considered a skin manifestation of miliary tuberculosis. We present a case of tuberculous cellulitis in an immunocompetent patient.

Actinomycosis of the breast and lungs.

Actinomycosis is a chronic, progressive, and often relapsing granulomatous infection that characteristically crosses tissue planes and forms abscesses and sinus tracts. We report a unique case of a woman with actinomycosis presenting with a breast abscess, a sinus tract spontaneously exiting the sternum, and miliary lung lesions.

Juvenile xanthogranuloma: A herald to the diagnosis of Erdheim-Chester disease in an adult with acute leukemia.

A 21-year-old man with B-cell acute lymphoblastic leukemia developed an eruption of multiple flesh-colored nodules and persistent fevers. A lesional biopsy showed diffuse dermal infiltrates of histiocytes, foam cells, and Touton giant cells consistent with juvenile xanthogranulomatosis. Upon further investigation, the patient's constellation of findings fit criteria for Erdheim-Chester disease.

Prognostic value of serum lipase levels in patients with small bowel obstruction.

Elevated serum pancreatic enzymes have been described among patients with small bowel obstruction (SBO) initially misdiagnosed as having pancreatitis. We studied whether serum lipase elevation carries prognostic value in patients with SBO. Patients with SBO and at least one serum lipase level measured were included. Demographic, laboratory, and imaging information, as well as need for surgery or intensive care unit and mortality, were evaluated. Of 344 patients, 38 (11%) had elevated serum lipase levels. Patients with radiographic diagnosis of pancreatitis were excluded. Patients with elevated lipase had significantly higher levels of creatinine and lactic acid levels, length of stay, need for intensive care monitoring, and death than patients with normal lipase levels. The need for surgical intervention was not significantly different between the two groups. Logistic regression analysis showed elevated serum lipase and serum creatinine >1.5 mg/dL as predictors for mortality. We conclude that, in SBO, elevated serum lipase is a risk factor for higher serum creatinine and lactate, use of intensive care unit, and mortality. The strength of this association justifies studying it prospectively.

Follow-up Blood Cultures in Gram-Negative Bacteremia: Are They Needed?

BACKGROUND: Bloodstream infections remain a major cause of morbidity and mortality. Gram-negative bacilli (GNB) bacteremia is typically transient and usually resolves rapidly after the initiation of appropriate antibiotic therapy and source control. The optimal duration of treatment and utility of follow-up blood cultures (FUBC) have not been studied in detail. Currently, the management of gram-negative bacteremia is determined by clinical judgment. To investigate the value of repeat blood cultures, we analyzed 500 episodes of bacteremia to determine frequency of FUBC and identify risk factors for persistent bacteremia. METHODS: Of 500 episodes of bacteremia, we retrospectively analyzed 383 (77%) that had at least 1 FUBC. We sought information regarding presumed source of bacteremia, antibiotic status at the time of FUBC, antibiotic susceptibility, presence of fever, comorbidities (intravenous central lines, urinary catheters, diabetes mellitus, AIDS, end-stage renal disease, and cirrhosis), need for intensive care, and mortality. RESULTS: Antibiotic use did not affect the rate of positivity of FUBC, unless bacteria were not sensitive to empiric antibiotic. Fever on the day of FUBC was associated with higher rates of positive FUBC for gram-positive cocci (GPC) but not GNB. Mortality and care in the intensive care unit were not associated with positive FUBC. Seventeen FUBC and 5 FUBC were drawn for GNB and GPC to yield 1 positive result. CONCLUSIONS: FUBC added little value in the management of GNB bacteremia. Unrestrained use of blood cultures has serious implications for patients including increased healthcare costs, longer hospital stays, unnecessary consultations, and inappropriate use of antibiotics.