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INTRODUCTION: Leadless pacemakers (LPM) have established themselves as the important therapeutic modality in management of selected patients with symptomatic bradycardia. To determine real-world utilization and in-hospital outcomes of LPM implantation since its approval by the Food and Drug Administration in 2016. METHODS: For this retrospective cohort study, data were extracted from the National Inpatient Sample database from the years 2016-2020. The outcomes analyzed in our study included implantation trends of LPM over study years, mortality, major complications (defined as pericardial effusion requiring intervention, any vascular complication, or acute kidney injury), length of stay, and cost of hospitalization. Implantation trends of LPM were assessed using linear regression. Using years 2016-2017 as a reference, adjusted outcomes of mortality, major complications, prolonged length of stay (defined as >6 days), and increased hospitalization cost (defined as median cost >34 098$) were analyzed for subsequent years using a multivariable logistic regression model. RESULTS: There was a gradual increased trend of LPM implantation over our study years (3230 devices in years 2016-2017 to 11 815 devices in year 2020, p for trend <.01). The adjusted mortality improved significantly after LPM implantation in subsequent years compared to the reference years 2016-2017 (aOR for the year 2018: 0.61, 95% CI: 0.51-0.73; aOR for the year 2019: 0.49, 95% CI: 0.41-0.59; and aOR for the year 2020: 0.52, 95% CI: 0.44-0.62). No differences in adjusted rates of major complications were demonstrated over the subsequent years. The adjusted cost of hospitalization was higher for the years 2019 (aOR: 1.33, 95% CI: 1.22-1.46) and 2020 (aOR: 1.69, 95% CI: 1.55-1.84). CONCLUSION: The contemporary US practice has shown significantly increased implantation rates of LPM since its approval with reduced rates of inpatient mortality.
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Estimulación Cardíaca Artificial , Bases de Datos Factuales , Costos de Hospital , Tiempo de Internación , Marcapaso Artificial , Humanos , Marcapaso Artificial/tendencias , Marcapaso Artificial/economía , Estados Unidos , Estudios Retrospectivos , Masculino , Femenino , Anciano , Resultado del Tratamiento , Costos de Hospital/tendencias , Factores de Tiempo , Persona de Mediana Edad , Estimulación Cardíaca Artificial/tendencias , Estimulación Cardíaca Artificial/economía , Estimulación Cardíaca Artificial/mortalidad , Estimulación Cardíaca Artificial/efectos adversos , Tiempo de Internación/tendencias , Factores de Riesgo , Anciano de 80 o más Años , Bradicardia/terapia , Bradicardia/mortalidad , Bradicardia/diagnóstico , Frecuencia Cardíaca , Mortalidad Hospitalaria/tendencias , Diseño de Equipo/tendenciasRESUMEN
INTRODUCTION: Surgical management of Crohn's disease (CD) is common. Postoperative complications include anastomotic stricturing (AS). The natural history and risk factors for AS have not been elucidated. METHODS: A retrospective cohort study of patients with CD who underwent ileocolonic resection (ICR) with ≥1 postoperative ileocolonoscopy between 2009 and 2020. Postoperative ileocolonoscopies with corresponding cross-sectional imaging were evaluated for evidence of AS without neoterminal ileal extension. Severity of AS and endoscopic intervention at time of detection were collected. Primary outcome was development of AS. Secondary outcome was time to AS detection. RESULTS: A total of 602 adult patients with CD underwent ICR with postoperative ileocolonoscopy. Of these, 426 had primary anastomosis, and 136 had temporary diversion at time of ICR. Anastomotic configuration consisted of 308 side-to-side, 148 end-to-side, and 136 end-to-end. One hundred ten (18.3%) patients developed AS with median time of 3.2 years to AS detection. AS severity at time of detection was associated with need for repeat surgical resection for AS. On multivariable Cox proportional hazard regression, anastomotic configuration and temporary diversion were not associated with risk of or time to AS. Preoperative stricturing disease was associated with decreased time to AS (adjusted hazard ratio 1.8; P = 0.049). Endoscopic ileal recurrence before AS was not associated with subsequent AS detection. DISCUSSION: AS is a relatively common postoperative CD complication. Patients with previous stricturing disease behavior are at increased risk of AS. Anastomotic configuration, temporary diversion, and ileal CD recurrence do not increase risk of AS. Early detection and intervention for AS may help prevent progression to repeat ICR.
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Enfermedad de Crohn , Adulto , Humanos , Enfermedad de Crohn/cirugía , Enfermedad de Crohn/complicaciones , Ileostomía/efectos adversos , Colon/cirugía , Constricción Patológica/etiología , Constricción Patológica/cirugía , Estudios Retrospectivos , Recurrencia Local de Neoplasia/complicaciones , Íleon/cirugía , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Complicaciones Posoperatorias/etiología , RecurrenciaRESUMEN
INTRODUCTION: Data on the outcomes following transcatheter aortic valve replacement (TAVR) in patients with a bundle branch block (BBB) remains limited. METHODS: We studied the outcomes of TAVR patients with a BBB from the National Inpatient Sample (NIS) database between 2011 and 2018 using ICD-9-CM and ICD-10-CM codes. RESULTS: Between 2011 and 2018, 194,237 patients underwent TAVR, where 1.7% (n = 3,232) had a right BBB (RBBB) and 13.7% (n = 26,689) had a left BBB (LBBB). Patients with a RBBB and LBBB had a higher rate of new permanent pacemaker (PPM) implantation (31.5% - RBBB, 15.7% LBBB vs. 10.2% - no BBB). RBBB was associated with a significantly longer median length of stay (5 days) and total hospitalization cost ($53,669) compared with LBBB (3 days and $47,552) and no BBB (3 days and $47,171). Trend analysis revealed lower rates of PPM implantation and reduced lengths of stay and costs across all comparison groups. CONCLUSION: In conclusion, patients undergoing TAVR with a BBB are associated with higher new rates of PPM implantation. RBBB is the strongest independent predictor for new PPM implantation following TAVR. Rates of new PPM implantation in TAVR patients with and without a BBB have improved over time including reductions in length of stay and hospital costs. Further study is needed to reduce the risks of PPM implantation in TAVR patients.
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Estenosis de la Válvula Aórtica , Marcapaso Artificial , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/etiología , Estenosis de la Válvula Aórtica/cirugía , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/etiología , Bloqueo de Rama/terapia , Hospitales , Humanos , Pacientes Internos , Factores de Riesgo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del TratamientoRESUMEN
Aortic dissections and aneurysms (ADA) are associated with significant morbidity and mortality, and location of death for these patients is important in determining impact on end of life care. We analyzed the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research database. Black and Hispanic backgrounds had decreased odds of dying at home from ADA. Married or educated individuals tended to die at home at a higher rate than unmarried individuals. Overall, we have shown place of death in individuals with ADA is different among individuals of different demographics.
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Aneurisma de la Aorta , Disección Aórtica , Cuidados Paliativos al Final de la Vida , Cuidado Terminal , HumanosRESUMEN
OBJECTIVE: To evaluate contemporary national trends of morbidity, mortality, and healthcare utilization in patients with mitral regurgitation (MR) and co-existing chronic liver disease (CLD) undergoing transcatheter mitral valve repair (TMVR). METHODS: The National Inpatient Sample (NIS) was used to assess trends in patients undergoing TMVR between January 2012 and December 2017. Propensity match analysis was done to compare it to subjects without underlying CLD. Logistic regression analysis was used to identify predictors of in-hospital mortality. RESULTS: Of 15,270 patients undergoing TMVR, 569 (3.7%) had coexisting CLD. Patients with CLD had a higher proportion of males (61.3 vs 52.6%; p < .01), congestive heart failure (6.9 vs 1.0%; p < .01), renal failure (42.2 vs 36.7%; p < .01), and peripheral vascular disease (19.3 vs 12.5%; p < .01). After propensity matching subjects with CLD had significantly higher hospital mortality (19.8 vs 4.6%; p < .01), acute kidney injury (46.1 vs 37.8%; p < .01), cardiogenic shock (25.4 vs 12.1%; p < .01), mechanical ventilation (26.3 vs 14.0; p < .01), pneumothorax (6.6 vs <2%.; p < .01), length of stay (5 vs 9 days), and average cost of hospitalization (209,573 vs 250,587 $; p < .01). Over the years, in-hospital mortality in patients receiving TMVR has improved in both patients with (from 33.3 in 2013 to 22.2% in 2017) and without CLD (from 2.7 in 2011 to 1.6% in 2017). CONCLUSION: Patients with MR undergoing TMVR, with coexisting CLD bear substantially higher comorbidities, complication rates, and inpatient mortality compared with those without CLD. A favorable temporal trend of in-hospital mortality among these subjects is noteworthy.
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Implantación de Prótesis de Válvulas Cardíacas , Hepatopatías , Insuficiencia de la Válvula Mitral , Cateterismo Cardíaco/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Pacientes Internos , Hepatopatías/diagnóstico , Masculino , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVE: Even in high-risk trials pertaining to transcatheter aortic valve replacement (TAVR), patients with end-stage liver disease (ESLD) have been under-represented. We sought to study this population group from a large national United States population database. METHODS: We used National Inpatient Sample (NIS) database from January 2005 to August 2015. Patients with ESLD were extracted using Goldberg's algorithm. Propensity match analysis was done for comparative analysis between surgical aortic valve replacement (SAVR) and TAVR groups. Logistic regression analysis was used for predictors of in-hospital mortality. RESULTS: Out of 309,959 ESLD patients, 1,375 underwent aortic valve replacement and 1,199 patients were included in our study. Mean age was 66.1 (SD, 9.1) years. In matched data, the in-hospital mortality was 5.5% in TAVR group when compared to 19.4% in SAVR group. Ventilator use (16.1 vs. 27.2%, p < .01), tracheostomy (<4 vs. 7.2%, p < .01), and vasopressin use (0 vs. 7.4%, p < .01) were utilized less in TAVR group as compared to SAVR group. The proportion of TAVR has increased from almost zero in 2011 to 51.3% in 2015. Mean cost for hospital stay has increased in SAVR group (from 254,427$ in 2005 to 321,791$ in 2015, p < .01). Similarly, a large decrease in length of stay has been observed for TAVR group (14.5 days in 2011 to 5.4 days in 2015, p < .01). TAVR (odds ratios [OR]: 0.42, 95% confidence interval [CI]: 0.20-0.87, p = .02) was associated with lower in-hospital mortality. CONCLUSION: TAVR was associated with lower in-hospital mortality, morbidity, and resource utilization in high-risk ESLD patients.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Enfermedad Hepática en Estado Terminal , Implantación de Prótesis de Válvulas Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Bases de Datos Factuales , Enfermedad Hepática en Estado Terminal/diagnóstico , Enfermedad Hepática en Estado Terminal/mortalidad , Femenino , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria , Humanos , Pacientes Internos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Diseño de Prótesis , Recuperación de la Función , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del Tratamiento , Estados UnidosRESUMEN
The aim of present study was to enhance topical permeation of clotrimazole gel preparation by using various permeability enhancers such as coconut oil, pistachio oil and sodium lauryl sulphate (SLS). Clotrimazole gel preparations were prepared and optimized by using three factor, five level central composite design. A second-order polynomial equation was generated in order to estimate the effect of independent variables i.e. coconut oil (X1), pistachio oil (X2) and sodium lauryl sulphate (X3) at various dependent variables i.e. flux (Y1), lag time (Y2), diffusion coefficient (Y3), permeability coefficient (Y4), and input rate (Y5) of clotrimazole gel formulations. Ex vivo skin permeation study was performed through rat skin by using modified Franz diffusion cell system. Optimized formulation F8 exhibited highest flux 2.17 µg/cm2/min, permeability coefficient 0.0019 cm/min and input rate 1.543 µg/cm2/min, along with moderate lag time 77.27 min and diffusion coefficient 0.063 cm2/min, which is further supported by anti-fungal activity that exhibited more prominent zone of inhibition against Candida albicans, Aspergillus niger and Mucor. Thus, it can be concluded that permeation of clotrimazole gel was enhanced by various combination of coconut oil, pistachio oil and sodium lauryl sulphate but optimized formulation F8 containing 0.4 ml pistachio oil, 0.8 ml coconut oil and 0.04 g of SLS exhibited more pronounced and promising effect through rat skin.
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Acrilatos , Clotrimazol/síntesis química , Administración Tópica , Animales , Clotrimazol/administración & dosificación , Clotrimazol/farmacocinética , Aceite de Coco/farmacología , Composición de Medicamentos/métodos , Geles , Técnicas In Vitro , Pistacia/química , Aceites de Plantas/farmacología , Ratas , Absorción Cutánea , Dodecil Sulfato de Sodio/farmacologíaRESUMEN
Introduction Data regarding clinical outcomes after transcatheter aortic valve replacement (TAVR) vs surgical aortic valve replacement (SAVR) in patients with sarcoidosis is lacking. This study aims to clarify the clinical outcomes of TAVR vs SAVR in patients with sarcoidosis. Methods Data was collected from the National Inpatient Sample database from 2016-2019 using validated ICD-10-CM codes for sarcoidosis, TAVR, and SAVR. Patients were divided into two cohorts: those who underwent TAVR and those who underwent SAVR. Statistical analysis was performed using Pearson's chi-squared test to determine clinical outcomes of TAVR vs SAVR in patients with sarcoidosis. Results The prevalence of sarcoidosis was 0.23% among total study patients (n=142,420,378). After exclusions, the prevalence of TAVR was 650 (49%) and SAVR was 675 (51%) in patients with sarcoidosis. Patients who underwent TAVR were on average older (74 vs 65 years old, p=0.001), and more likely to be female (57 vs 40%, p<0.001) compared to patients who underwent SAVR. The TAVR cohort had higher rates of congestive heart failure (CHF) (77.7 vs 42.2%, p=0.001), chronic kidney disease (CKD) (42.3 vs 24.4% p=0.001), anemia (5.4 vs 2.2%, p=0.004), percutaneous coronary intervention (PCI) (1.5 vs 0%, p=0.004), and hypothyroidism (31.5 vs 16.3%, p=0.001) compared to the SAVR cohort. Inpatient mortality post-procedure was higher in the SAVR cohort compared to the TAVR cohort (15 vs 0, p=0.001). Regarding post-procedure complications, respiratory complications were more common in the SAVR cohort (4.4 vs 0%, p=0.001), while TAVR was associated with a higher incidence of permanent pacemaker (PPM) insertion (2.15 vs 0.8%, p=0.001). There was no statistical difference in the development of acute kidney injury (AKI) (0.8 vs 1.5%, p=0.33), AKI requiring hemodialysis (0 vs. 0.7%, p=0.08), or stroke (0.8 vs 0.7, p=1) post-procedure between the two cohorts. Conclusion This study found that in the sarcoidosis population, TAVR was associated with reduced mortality, shorter hospital length of stay, and lower hospitalization costs in comparison to SAVR.
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Carmustine is an intravenous alkylating agent that inhibits DNA synthesis and protein synthesis by forming cross-links in DNA and RNA and ultimately causing cell death. We report a rare case of Takotsubo cardiomyopathy that is thought to be related to carmustine, where the patient presented with chest pain, and ST depression within 12 hours of carmustine therapy. Workup, including echocardiography, showed global hypokinesis of the left ventricle with regional variations; mid and apical anterior septum and apex were akinetic with left ventricular ejection fraction (EF) of 30%. Cardiac catheterization showed nonobstructive coronary artery disease. The patient was treated with a beta-blocker, angiotensin receptor-neprilysin inhibitor (ARNi), and aldosterone receptor antagonists. Two days later, he had a repeat echocardiogram that showed improved EF. After stem cell infusion, his course was complicated with atrial fibrillation with rapid ventricular response and septic shock. Unfortunately, he suffered a cardiac arrest and expired. Carmustine-related cardiomyopathy seems to be very rare, and, to our knowledge, this is the first case report.
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BACKGROUND: Bovine milk is a significant substitute for human breast milk and holds great importance in infant nutrition and health. Apart from essential nutrients, bovine milk also contains bioactive compounds, including a microbiota derived from milk itself rather than external sources of contamination. AIM OF REVIEW: Recognizing the profound impact of bovine milk microorganisms on future generations, our review focuses on exploring their composition, origins, functions, and applications. KEY SCIENTIFIC CONCEPTS OF REVIEW: Some of the primary microorganisms found in bovine milk are also present in human milk. These microorganisms are likely transferred to the mammary gland through two pathways: the entero-mammary pathway and the rumen-mammary pathway. We also elucidated potential mechanisms by which milk microbiota contribute to infant intestinal development. The mechanisms include the enhancing of the intestinal microecological niche, promoting the maturation of immune system, strengthening the intestinal epithelial barrier function, and interacting with milk components (e.g., oligosaccharides) via cross-feeding effect. However, given the limited understanding of bovine milk microbiota, further studies are necessary to validate hypotheses regarding their origins and to explore their functions and potential applications in early intestinal development.
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BACKGROUND: Mycotoxins, the secondary fungal metabolites, are unavoidable contaminants of human and animal food and feeds. The objectives of this study were to evaluate the effect of concurrent feeding of ochratoxin A (OTA) and aflatoxin B(1) (AFB(1) ) to breeder hens, upon their deposition in different tissues and eggs. RESULTS: Residues of OTA and AFB(1) in (ng g(-1) ) were significantly higher in liver followed by kidneys and breast muscles by 22.54 ± 1.48, 4.22 ± 0.93 and 0.56 ± 0.06 for OTA (group fed OTA at 5 mg kg(-1) diet) and 1.44 ± 0.21, 0.25 ± 0.01 and 0.03 ± 0.01 for AFB(1) (group fed AFB(1) at 5 mg kg(-1) diet), respectively. Residues of OTA and AFB(1) in eggs appeared at days 3 and 5 of toxin feeding and disappeared at days 5 and 6 of withdrawal of mycotoxins contaminated feed, respectively. The residues of OTA and AFB(1) were significantly lower in the tissues of hens fed these toxins concurrently compared with the groups fed OTA and AFB(1) independently. CONCLUSIONS: Residues of OTA and AFB(1) appeared in the tissues and eggs of laying hens kept on OTA- and AFB(1) -contaminated diets. Concurrent feeding of OTA and AFB(1) to hens significantly decreased the concentration of OTA and AFB(1) residues in the tissues and eggs.
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Aflatoxina B1/metabolismo , Alimentación Animal , Pollos/metabolismo , Dieta , Huevos/análisis , Contaminación de Alimentos , Ocratoxinas/metabolismo , Aflatoxina B1/administración & dosificación , Animales , Mama/metabolismo , Femenino , Humanos , Riñón/metabolismo , Hígado/metabolismo , Ocratoxinas/administración & dosificaciónRESUMEN
Transcatheter aortic valve replacement (TAVR) is a new, rapidly evolving technology used in severe cases of aortic stenosis. Some TAVR procedures have failed to deliver the prosthetic valve due to challenges. In these cases, it is difficult to pass a bulky prosthesis through a narrowed and calcified aortic valve. Special techniques may be needed in these challenging cases. In our case, the extreme calcification and the horizontal aorta caused the delivery system to hang up on the aortic valve. We used a buddy balloon from the contralateral femoral artery to assist in crossing the native aortic valve.
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[This corrects the article DOI: 10.3389/fgene.2022.922019.].
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Myocarditis was identified as a rare but serious adverse event that can occur after mRNA-based coronavirus disease 2019 (COVID-19) vaccination, particularly in young males. During the COVID-19 pandemic, we report a case of a young obese male without multiple comorbidities who presented with abdominal pain and was found to have severe myocarditis/cardiomyopathy, which was likely due to mRNA-based COVID-19 vaccination. The patient had left ventricular assist device (LVAD) implantation during hospitalization. Myocarditis/cardiomyopathy may be a rare complication of the mRNA-based COVID vaccine; however, one should maintain a high index of suspicion that these vaccines may cause irreversible cardiomyopathy if the patient had prior COVID-19 infection.
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Introduction The purpose of our study is to determine in-hospital outcomes of acute myocardial infarction in patients with hematological malignancies and their subtypes. Method Patient data were obtained from the nationwide inpatient sample (NIS) database between the years 2009-2014. Patients with hematological cancer subtypes and acute MI (non-ST segment elevation myocardial infarction and ST-segment elevation myocardial infarction (NSTEMI/STEMI) were identified using validated international classification of diseases (ninth revision) and clinical modification (ICD-9-CM) codes. Statistical analysis using the chi-square test was performed to determine the hospital outcomes of acute MI in patients with hematological cancers and subtypes. Results The prevalence of acute myocardial infarction was 2.4% in patients with hematological neoplasms (N=3,027,800). Amongst the subtypes of blood cancers, the highest prevalence of acute MI was seen in lymphocytic leukemia (2.9%). The mortality of MI in patients with hematological malignancies was 16.8% vs 8.8% in patients with non-hematological malignancies, in-hospital costs were $25469 ± 36763 vs. $20534 ± 24767, and length of in-hospital stay was 8.3 ± 10 vs 6.3 ± 7.8 days. Amongst the hematological cancer subtypes, the highest mortality of acute MI was found in myeloid leukemia (23%) followed by multiple myeloma (MM) (17.9%), lymphocytic leukemia (15.9%), and lymphoma (14.4%). The length of stay and hospitalization cost was highest for myeloid leukemia, followed by MM, lymphocytic leukemia, and lymphoma. Conclusion This study showed that acute MI in patients with hematological malignancies has higher in-hospital mortality, length of stay, and cost. Amongst the blood neoplasm subtypes the highest mortality, length of hospital stay, and hospitalization cost were found in myeloid leukemia.
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PURPOSE OF REVIEW: The present review discusses current concepts of HIV-associated neurocognitive disorders (HAND) in the era of antiretroviral therapy (ART). As the HIV epidemic enters its fourth decade (the second decade of ART), research must address evolving factors in HAND pathogenesis. These include persistent systemic and central nervous system (CNS) inflammation, aging in the HIV-infected brain, HIV subtype (clade) distribution, concomitant use of drugs of abuse, and potential neurotoxicity of ART drugs. RECENT FINDINGS: Although the severest form of HAND, HIV-associated dementia (HAD), is now rare due to ART, the persistence of milder, functionally important HAND forms persist in up to half of HIV-infected individuals. HAND prevalence may be higher in areas of Africa where different HIV subtypes predominate, and ART regimens that are more effective in suppressing CNS HIV replication can improve neurological outcomes. HAND are correlated with persistent systemic and CNS inflammation, and enhanced neuronal injury due to stimulant abuse (cocaine and methamphetamine), aging, and possibly ART drugs themselves. SUMMARY: Prevention and treatment of HAND requires strategies aimed at suppressing CNS HIV replication and effects of systemic and CNS inflammation in aging and substance-abusing HIV populations. Use of improved CNS-penetrating ART must be accompanied by evaluation of potential ART neurotoxicity.
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Complejo SIDA Demencia/fisiopatología , Infecciones por VIH/fisiopatología , Complejo SIDA Demencia/tratamiento farmacológico , Complejo SIDA Demencia/etiología , Complejo SIDA Demencia/patología , Fármacos Anti-VIH/efectos adversos , Fármacos Anti-VIH/uso terapéutico , Sistema Nervioso Central/patología , Sistema Nervioso Central/virología , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/patología , VIH-1/inmunología , VIH-1/fisiología , Humanos , Inflamación/complicaciones , Trastornos Relacionados con Sustancias/complicaciones , Replicación ViralRESUMEN
Shock caused by an aortic root abscess is a rare phenomenon. Due to its rarity, it is commonly not diagnosed on time to have a favorable prognosis for the patient. Our case involves an 80-year-old male presenting with leukocytosis, lactic acidosis, and hypoglycemia. Initial studies were not fruitful in determining the cause of septic shock. However, an echocardiogram conducted to clarify the finding of a non-ST segment myocardial infraction led to the incidental finding of an aortic root abscess with retrograde flow, suggesting a perforated abscess without endocarditis. Though the patient expired on day seven, our case demonstrates the importance of echocardiography in diagnosing an aortic root abscess in cases with a sterile blood culture and uneventful initial lab investigations.
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Pneumocephalus is defined as the presence of air inside the cranial vault. Benign and tension pneumocephalus are different ends of the same disease spectrum. Tension pneumocephalus leads to the formation of a pressure gradient, requiring emergent surgical decompression to prevent herniation of the intracranial structures. In this report, we present a rare case of tension pneumocephalus with essentially benign radiological findings secondary to a ruptured cholesteatoma. The patient was a 64-year-old woman with a history of end-stage renal disease on hemodialysis and hypertension. She presented to the emergency department (ED) with acute-onset weakness and decreased mentation. Physical exam findings were consistent with a cerebrovascular accident (CVA). CT scan and CT angiogram (CTA) were unremarkable for ischemia or hemorrhage but showed signs of free intracranial air, consistent with the diagnosis of pneumocephalus. After the activation of the code stroke, neurosurgery and neurology were consulted. Worsening respiratory status led to a decision to proceed with emergent intubation, but it was held based on the family's decision to proceed with comfort measures. The patient's status declined further within minutes and she died. Afterward, the case was discussed with the radiologist, who interpreted the cause as a cholesteatoma that had eroded through the temporal bone.
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Infective endocarditis (IE) complicated by heart block can have adverse outcomes and usually requires immediate surgical and cardiac interventions. Data on outcomes and trends in patients with IE with concurrent heart block are lacking. Patients with a primary diagnosis of IE with or without heart block were identified by querying the Healthcare Cost and Utilization Project database, specifically the National Inpatient Sample for the years 2013 and 2014, based on International Classification of Diseases Clinical Modification Ninth Revision codes. During 2013 and 2014, a total of 18,733 patients were admitted with a primary diagnosis of IE, including 867 with concurrent heart blocks. Increased in-hospital mortality (13% vs 10.3%), length of stay (19 vs 14 days), and cost of care ($282,573 vs $223,559) were found for patients with IE complicated by heart block. Additionally, these patients were more likely to develop cardiogenic shock (8.9% vs 3.2%), acute kidney injury (40.1% vs 32.6%), and hematologic complications (19.3% vs 15.2%), and require placement of a pacemaker (30.6% vs 0.9%). IE and concurrent heart block resulted in increased requirement for aortic (25.7% vs 6.1%) and mitral (17.3% vs 4.2%) valvular replacements. Conclusion was made that IE with concurrent heart block worsens in-hospital mortality, length of stay, and cost for patients. Our analysis demonstrates an increase in cardiac procedures, specifically aortic and/or mitral valve replacements, and Implantable Cardiovascular Defibrillator/Cardiac Resynchronization Therapy/ Permanent Pacemaker (ICD/CRT/PPM) placement in IE with concurrent heart block. A close telemonitoring system and prompt interventions may represent a significant mitigation strategy to avoid the adverse outcomes observed in this study.
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Endocarditis , Bloqueo Cardíaco , Comorbilidad , Endocarditis/complicaciones , Endocarditis/epidemiología , Mortalidad Hospitalaria , Hospitales , Humanos , Pacientes Internos , Prevalencia , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Hiatal hernia results from the translocation of intra-abdominal contents from their usual position into the thorax. They can be categorized into type I-IV which implies varying gradations of herniation. The symptomatology can range from just chest pain in the less severe types to respiratory and hemodynamic compromise resulting from strangulation in the advanced hernias. Our patient was an 81-year-old female with a past medical history of gastroesophageal reflux disease (GERD), deep venous thrombosis (DVT), hypertension, hyperlipidemia, coronary artery disease (CAD), and cerebrovascular accident (CVA), who presented to the emergency department (ED) with the chief complaint of chest pain. Assessment of the vitals in the ED revealed a temperature of 37.2 °C, respiratory rate of 18 breaths/minute with an oxygen saturation of 100% on room air, heart rate of 95 beats/min, and blood pressure reading of 132/110 mmHg. Due to significant concern of a possible coronary pathology leading to chest pain, the patient was given 325 mg of aspirin and one tablet of sublingual nitroglycerin. Her electrocardiogram (EKG) was unremarkable but the chest X-ray revealed a large retrocardiac hernia. The finding was corroborated after a review of the computerized tomography (CT) scan performed at the outlying facility. She was treated with omeprazole, a gastroenterologist was consulted, and an esophagogastroduodenoscopy (EGD) performed which revealed significant erosions in the distal esophagus and gastric antrum. She was deemed a high-risk surgical candidate for any intervention and thus managed conservatively with proton pump inhibitor (PPI) therapy. The case highlights the pertinent facts about hiatal hernia. Although the diagnosis of chest pain with the aforementioned comorbidities could be skewed towards coronary pathology, keeping a wide differential is important so that the right diagnosis can be made in a timely fashion and complications avoided.