Cardiogenic shock due to acute severe ischemic mitral regurgitation.

The reduction in patients presenting with ST-elevation myocardial infarction (STEMI) during the COVID19 crisis could have resulted from fears about developing COVID-19 infection in hospital. Patients who delay presenting with STEMI are more likely to develop mechanical complications, including acute ischemic mitral regurgitation (MR). We present a 69-year-old women with an inferior STEMI and cardiogenic shock due to acute ischemic MR who delayed presenting to hospital due to the fear of COVID-19. Early identification of this mechanical complication using transthoracic echocardiography in the Emergency Department enabled the team to target her optimisation. Ultimately these patients require urgent surgery to repair the mitral valve and revascularize the myocardium but they are often too unwell to undergo surgery and even when it is feasible the outcomes are poor.

Association between troponin level and medium-term mortality in 20 000 hospital patients.

INTRODUCTION: Cardiac troponin (cTn) concentrations above the manufacturer recommended upper limit of normal (ULN) are frequently seen in hospital patients without a clinical presentation consistent with type 1 myocardial infarction, and the significance of this is uncertain. The aim of this study was to assess the relationship between medium-term mortality and cTn concentration in a large consecutive hospital population, regardless of whether there was a clinical indication for performing the test. METHOD: This prospective observational study included 20 000 consecutive in-hospital and outpatient patients who had a blood test for any reason at a large teaching hospital, and in whom a hs-cTnI assay was measured, regardless of the original clinical indication. Mortality was obtained via NHS Digital. RESULTS: A total of 20 000 patients were included in the analysis and 18 282 of these (91.4%) did not have a clinical indication for cardiac troponin I (cTnI) testing. Overall, 2825 (14.1%) patients died at a median of 809 days. The mortality was significantly higher if the cTnI concentration was above the ULN (45.3% vs 12.3% p<0.001 log rank). Multivariable Cox analysis demonstrated that the log10 cTnI concentration was independently associated with mortality (HR 1.76 (95% CI 1.65 to 1.88)). Landmark analysis, excluding deaths within 30 days, showed the relationship between cTnI concentration and mortality persisted. CONCLUSION: In a large, unselected hospital population, in 91.4% of whom there was no clinical indication for testing, cTnI concentration was independently associated with medium-term cardiovascular and non-cardiovascular mortality in the statistical model tested.

Relation of High-Sensitivity Troponin to 1 Year Mortality in 20,000 Consecutive Hospital Patients Undergoing a Blood Test for Any Reason.

This was an observational study of the 1-year outcomes of the 20,000 patients included in the original CHARIOT study. The aim of the study was to assess the association between high sensitivity troponin I (hs-cTnI) concentration and 1 year mortality in this cohort. The original CHARIOT study included a consecutive cohort of in- and out-patients undergoing blood tests for any reason. Hs-cTnI concentrations were measured regardless of whether the clinician requested them. These results were nested and not revealed to the team unless requested for clinical reasons. One year mortality data was obtained from NHS Digital as originally planned. Overall, 1782 (8.9%) patients had died at 1 year. Multivariable Cox regression analysis showed that a hs-cTnI concentration above the upper limit of normal was independently associated with the hazard of mortality (HR 2.23; 95% confidence intervals 1.97 to 2.52). Furthermore, the log (10) hs-cTnI concentration was independently associated with the hazard of 1 year mortality (HR 1.77; 95% confidence intervals 1.64 to 1.91). In conclusion, in a large, unselected hospital population of both in- and out-patients, in 18,282 (91.4%) of whom there was no clinical indication for testing, hs-cTnI concentration was associated with 1 year mortality.

Paediatric endoscopy performed by adult-service gastroenterologists.

BACKGROUND: Children often travel from district hospitals to teaching centres for endoscopic procedures by paediatric gastroenterologists. A 10-year district hospital experience of 'adult-service' gastroenterologists endoscoping children is reported with the aim of quantifying the workload, indications, sedation/anaesthesia practices, findings and safety of paediatric endoscopy performed by adult-service gastroenterologists. METHODS: Data on endoscopic procedures in patients younger than 16 years of age between 1997 and 2006 were obtained from hospital case-notes and computerized endoscopy/histology databases and were analysed. RESULTS: A total of 174 procedures (118 gastroscopies, 41 colonoscopies and 15 flexible sigmoidoscopies) were performed in 162 children. The median (interquartile range) age was 11.5 (5-14) years. Sixty-nine percent of patients were referred by paediatricians and 31% by general practitioners /other adult specialties. Children referred as outpatients waited a total of 50 (23.5-95) days from referral to procedure. Inpatient children waited 3 (1-4) days for their procedure. General anaesthesia was used in 89% (63 of 71) endoscopic procedures in children aged below 11 years and 100% of 47 procedures in children aged below 6 years. In contrast, 96% (99 of 103) procedures in children aged 11 years or older were done in the endoscopy unit with intravenous or no sedation. Organic disease was identified from 90 (52%) procedures. The most common diagnoses were coeliac disease (41), inflammatory bowel disease (26), gastro-oesophageal reflux (six) and foreign body removal (seven). No endoscopic complications occurred. CONCLUSION: General gastroenterologists supported by paediatricians can provide endoscopic services for children safely and promptly in their local hospital. This is appropriate for the management of common gastrointestinal problems affecting children.