Trends, Predictors and Outcomes of Ischemic Stroke Among Patients Hospitalized with Takotsubo Cardiomyopathy.

OBJECTIVES: This study assessed the temporal trends in the incidence of ischemic stroke among patients hospitalized with takotsubo cardiomyopathy (TCM) stratified by the subtypes of ischemic stroke (cardioembolic versus thrombotic). Predictors of each stroke subtype, the association with atrial fibrillation (AF), the occurrence of ventricular fibrillation/ventricular tachycardia (VF/VT), cardiogenic shock (CS), in-hospital mortality, length of stay (LOS), and total healthcare cost were also assessed. BACKGROUND: Ischemic stroke in TCM is thought to be primarily cardioembolic from left ventricular mural thromboembolism. Limited data are available on the incidence of thrombotic ischemic stroke in TCM. MATERIALS AND METHODS: We identified 27,970 patients hospitalized with the primary diagnosis of TCM from the 2008 to 2017 National Inpatient Sample, of which 751 (3%) developed ischemic stroke. Of those with ischemic stroke, 571 (76%) had thrombotic stroke while 180 (24%) had cardioembolic stroke. Cochrane armitage test was used to assess the incidence of thrombotic and cardioembolic strokes and multivariate regression was used to identify risk factors associated with each stroke subtype. We compared the incidence of AF, VF/VT, CS, LOS, in-hospital mortality and total cost between hospitalized patients with TCM alone to those with cardioembolic and thrombotic strokes. RESULTS: From 2008 - 2017, the incidence of thrombotic stroke (4.7%-9.5% (p< 0.0001) increased while it was unchanged for cardioembolic stroke (0.5%-0.7% P=0.5). In the multivariate regression, peripheral artery disease, prior history of stroke, and hyperlipidemia were significantly associated with thrombotic stroke, while CS, AF, and Asian race (compared to White race) were associated with cardioembolic stroke. Both cardioembolic and thrombotic strokes were associated with higher odds of IHM, AF, CS, longer LOS and increased cost. Trends in in-hospital mortality and the utilization of thrombolysis, cerebral angiography, and mechanical thrombectomy among patients with TCM and ischemic stroke were unchanged from 2008 to 2017. CONCLUSION: Among patients with TCM and ischemic stroke, thrombotic stroke was more common compared to cardioembolic stroke. Ischemic stroke was associated with poorer outcomes, including higher in-hospital mortality and increased healthcare resource utilization in TCM.

The association between health care coverage and prevalence of cardiovascular diseases and diabetes over a 10-year period.

Persons without health care coverage have poorer health outcomes. We investigated the association between health care coverage and trends in the prevalence of cardiovascular disease (CVD) and diabetes pre- and post-Affordable Care Act (ACA) periods. Using data from 3,824,678 surveyed adults in the Behavioral Risk Factor Surveillance System survey from 2007 - 2016, we calculated the yearly prevalence of CVD and diabetes. Using logistic regression, we investigated the association between health care coverage and CVD and diabetes, controlling for sociodemographic factors (age, sex, race, marital status, education and income). The mean age of participants was 55.3 ± 18.9 years. Health care coverage increased from 88.6% in 2007 to 93% in 2016. The prevalence of CVD and diabetes increased from pre- to post-ACA periods. After adjustment, in pre-ACA period, the odds ratio (OR) for the association between health care coverage and CVD and diabetes was 1.32 (95% CI:1.30-1.34) and 1.44 (95% CI:1.41-1.46), respectively; in the post-ACA period, the OR was 1.26 (95% CI:1.22-1.30) and 1.48 (95% CI:1.44-1.52), respectively. We found a significant association between health care coverage and trends in the prevalence of CVD and diabetes in the pre- and post-ACA periods.

Intensive care unit hospitalizations and outcomes in patients with severe COVID-19 during summer and fall surges in Georgia.

BACKGROUND: There is limited data on the difference in the clinical characteristics and outcomes of patients with severe coronavirus disease 2019 (COVID-19) infection in the summer compared to the fall surge. AIM: To compare the sociodemographic, clinical characteristics, and outcomes among mechanically ventilated patients with severe COVID-19 infection admitted to the intensive care unit (ICU) during the summer and fall surges in the year 2020. METHODS: We included patients admitted to the ICU and treated with invasive mechanical ventilation for COVID-19 associated respiratory failure between April 1 and December 31, 2020. Patients were categorized into summer surge for ICU admissions between June 15, 2020, and August 15, 2020, and fall surge between October 15, 2020, and December 31, 2020. We compared patients' characteristics and outcomes using descriptive and inferential statistics. RESULTS: A total of 220 patients were admitted to the Grady Memorial Hospital ICU and mechanically ventilated for COVID-19 associated hypoxemic respiratory failure during the period considered (125 during the summer surge and 95 during the fall surge). More women were admitted in the fall compared to summer (41.1% vs 36.8%, difference, 4.3%; 95%CI: 1.2, 7.5). Patients admitted in the fall had fewer comorbidities (chronic obstructive pulmonary disease, stroke, diabetes mellitus, obstructive sleep apnea and body mass index ≥ 35 kg/m2). Overall, patients in the fall had a lower ICU mortality rate (27.4% vs 38.4%, difference, -11.0; 95%CI: -6.4, -18.2), shorter length of stay on the mechanical ventilator (7 d vs 11 d, difference, 4 d; 95%CI: 2.1, 6.6) and shorter ICU length of stay (9 d vs 14 d, difference, 5 d; 95%CI: 2.7, 9.4). CONCLUSION: Patients admitted with severe COVID-19 infection requiring mechanical ventilation had better outcomes in the fall than summer. This difference observed is likely attributable to a better understanding of the condition and advances in treatment strategies.

Multiple jejunal perforation secondary to intestinal tuberculosis infection: a case report.

Abdominal tuberculosis (TB) may affect any part of the gastrointestinal tract resulting in significant morbidity and mortality. There is an increase in the incidence of abdominal TB favored by the emergence of multi-drug resistant Mycobacterium tuberculosis and immunosuppression especially from HIV co-infection. Our case is that of a 31 year old HIV-positive woman, adherent to antiretroviral therapy, who presented with a 2 month history of progressive abdominal distention, drenching night sweat and fatigue, but without fever. She was admitted on a presumptive diagnosis of peritoneal TB, and suddenly developed signs and symptoms of an acute abdomen. Laboratory investigations showed a CD4+ count of 155 cells/µL, white blood cell count of 15,700 cells/mm3 and haemoglobin of 8.0g/dl. An emergency laparotomy revealed small bowel caseous necrosis with multiple jejunal perforations. Ziehl-Nelsen staining of operative specimen was positive for acid fast bacilli. Given her immunodeficiency status, clinical signs and symptoms, CD4 cell count > 50 cells/µL, and intestinal sample showing caseous necrosis and perforations, a final diagnosis of intestinal TB was made. In conclusion, abdominal tuberculosis may mimic a number of intra-abdominal pathologies; thus should always be considered as a differential diagnosis in patients presenting with acute abdomen in TB-endemic areas especially in an HIV-positive individual.