Impact of Palliative Care on Interhospital Transfers to the Intensive Care Unit.

Community hospitals will often transfer their most complex, critically ill patients to intensive care units (ICUs) of tertiary care centers for specialized, comprehensive care. This population of patients has high rates of morbidity and mortality. Palliative care involvement in critically ill patients has been demonstrated to reduce over-utilization of resources and hospital length of stays. We hypothesized that transfers from community hospitals had low rates of palliative care involvement and high utilization of ICU resources. In this single-center retrospective cohort study, 848 patients transferred from local community hospitals to the medical ICU (MICU) and cardiac care unit (CCU) at a tertiary care center between 2016-2018 were analyzed for patient disposition, length of stay, hospitalization cost, and time to palliative care consultation. Of the 848 patients, 484 (57.1%) expired, with 117 (13.8%) having expired within 48 hours of transfer. Palliative care consult was placed for 201 (23.7%) patients. Patients with palliative care consult were statistically more likely to be referred to hospice (p<0.001). Over two-thirds of palliative care consults were placed later than 5 days after transfer. Time to palliative care consult was positively correlated with length of hospitalization among MICU patients (r=0.79) and CCU patients (r=0.90). Time to palliative consult was also positively correlated with hospitalization cost among MICU patients (r=0.75) and CCU patients (r=0.86). These results indicate early palliative care consultation in this population may result in timely goals of care discussions and optimization of resources.

Association of Reduced Hospitalizations and Mortality Rates Among COVID-19-Vaccinated Patients With Heart Failure.

BACKGROUND: Patients with heart failure (HF) are at high risk for adverse outcomes when they have COVID-19. Reports of COVID-19 vaccine-related cardiac complications may contribute to vaccine hesitancy in patients with HF. METHODS: To analyze the impact of COVID-19 vaccine status on clinical outcomes in patients with HF, we conducted a retrospective cohort study of the association of COVID-19 vaccination status with hospitalizations, intensive care unit admission and mortality after adjustment for covariates. Inverse probability treatment-weighted models were used to adjust for potential confounding. RESULTS: Of 7094 patients with HF, 645 (9.1%) were partially vaccinated, 2200 (31.0%) were fully vaccinated, 1053 were vaccine-boosted (14.8%), and 3196 remained unvaccinated (45.1%) by January 2022. The mean age was 73.3 ± 14.5 years, and 48% were female. Lower mortality rates were observed in patients who were vaccine-boosted, followed by those who were fully vaccinated; they experienced lower mortality rates (HR 0.33; CI 0.23, 0.48) and 0.36 (CI 0.30, 0.43), respectively, compared to unvaccinated individuals (P< 0.001) over the mean follow-up time of 276.5 ± 104.9 days, whereas no difference was observed between those who were unvaccinated or only partially vaccinated. CONCLUSION: COVID-19 vaccination was associated with significant reduction in all-cause hospitalization rates and mortality rates, lending further evidence to support the importance of vaccination implementation in the high-risk population of patients living with HF.

Recent temporal trends in hospital costs for non-surgical patients receiving implantable cardioverter defibrillators.

PURPOSE: Many studies have analyzed the cost-effectiveness of implantable cardioverter defibrillators (ICDs), but hospital costs have not been as thoroughly reported. This study reviewed the associated hospital costs for non-surgical patients who received ICDs from 2015 to 2019. METHODS: We performed a retrospective single-center analysis of patients who received an ICD between 2015 and 2019. ICD cost was analyzed with respect to time using linear regression t-test analysis. RESULTS: For 304 patients, we trended cost of the devices over time. 168 (55.2%) cases were single-chamber devices, 53 (17.4%) were dual-chamber, 59 (19.4%) were cardiac resynchronization therapy-defibrillators (CRT-D), and 24 (7.9%) were subcutaneous devices. The cost of all ICDs decreased by -$1.82/day (p<0.001), R2 = 0.056. By type, cost of single-chamber devices decreased by -$2.56/day (p<0.001), R2 = 0.47, dual-chamber ICD by -$3.50/day (p<0.001), R2 = 0.51, CRT-D by -$4.07/day (p<0.001), R2 = 0.47, and subcutaneous by -$3.33/day (p<0.001), R2 = 0.83. CONCLUSION: This is the first detailed analysis of ICD costs that we are aware of. The cost of all ICDs decreased modestly and became much greater when categorized by type. Overall hospital cost associated with ICD implantation did not show a significant trend, but total supply cost showed a significant decrease over time.

Safety and effects of SGLT-2 inhibitor use among LVAD patients with type 2 diabetes mellitus.

SGLT-2 inhibitors have been shown to confer reduced risk of adverse cardiovascular events in patients with heart failure, and have also been studied preliminarily among heart transplant patients, with overall positive findings. Use of SGLT-2 inhibitors among patients with durable mechanical circulatory support has not been studied. Here we present our results from a combined retrospective cohort of LVAD patients on SGLT-2 inhibitors at two major academic centers, which showed a good safety profile but prompted questions for further investigation. We advocate for further research into the safety and impact of SGLT-2 inhibitors among LVAD patients.

Comorbidity Burden and Adverse Outcomes After Transcatheter Aortic Valve Replacement.

Background Transcatheter aortic valve replacement (TAVR) has become the preferred treatment for symptomatic patients with aortic stenosis and elevated procedural risk. Many deaths following TAVR are because of noncardiac causes and comorbid disease burden may be a major determinant of postprocedure outcomes. The prevalence of comorbid conditions and associations with outcomes after TAVR has not been studied. Methods and Results This was a retrospective single-center study of patients treated with TAVR from January 2015 to October 2018. The association between 21 chronic conditions and short- and medium-term outcomes was assessed. A total of 341 patients underwent TAVR and had 1-year follow-up. The mean age was 81.4 (SD 8.0) years with a mean Society of Thoracic Surgeons predicted risk of mortality score of 6.7% (SD 4.8). Two hundred twenty (65%) patients had ≥4 chronic conditions present at the time of TAVR. There was modest correlation between Society of Thoracic Surgeons predicted risk of mortality and comorbid disease burden (r=0.32, P<0.001). After adjusting for Society of Thoracic Surgeons predicted risk of mortality, age, and vascular access, each additional comorbid condition was associated with increased rates of 30-day rehospitalizations (odds ratio, 1.21; 95% CI, 1.02-1.44), a composite of 30-day rehospitalization and 30-day mortality (odds ratio, 1.20; 95% CI, 1.02-1.42), and 1-year mortality (odds ratio, 1.29; 95% CI, 1.05-1.59). Conclusions Comorbid disease burden is associated with worse clinical outcomes in high-risk patients treated with TAVR. The risks associated with comorbid disease burden are not adequately captured by standard risk assessment. A systematic assessment of comorbid conditions may improve risk stratification efforts.

Electric cigarette-related lung injury and cardiovascular insult.

The cardiovascular effects of electronic cigarette use are unknown. Here we present a case describing a young, previously healthy patient without prior cardiopulmonary comorbidities who developed severe, acute cardiac dysfunction in the setting of e-cigarette use, in addition to the more commonly encountered respiratory symptoms. While pulmonary manifestations are characteristic of e-cigarette or vaping product use-associated lung injury (EVALI), the acute and reversible cardiomyopathy seen here has not been previously described in association with either EVALI or e-cigarette use.

Sarcoidosis-associated hypercalcemia potentiating calcific uremic arteriolopathy in a patient with a left ventricular assist device.

Calcific uremic arteriolopathy is a rare, life-threatening syndrome of vascular calcification characterized by occlusion of microvessels that results in extremely painful skin necrosis. We present a case of sarcoidosis-associated hypercalcemia potentiating calcific uremic arteriolopathy in a patient with a left ventricular assist device. The patient's calcific uremic arteriolopathy was successfully treated with sodium thiosulfate. Clinicians should be vigilant in diagnosing calcific uremic arteriolopathy early since it is especially life-threatening in patients with multiple risk factors.

Noninvasive Assessment of Right Ventricular Function in Patients with Pulmonary Arterial Hypertension and Left Ventricular Assist Device.

PURPOSE OF REVIEW: Right ventricular (RV) failure in patients with pulmonary arterial hypertension (PAH) and left ventricular assist device (LVAD) is associated with increased hospitalizations, worsening functional class, and poor survival. Accurate RV function assessment is essential in diagnosing RV failure, guiding therapies, and determining prognosis. Noninvasive imaging techniques provide fast and reliable quantification of RV morphology and function. RECENT FINDINGS: We review echocardiography, nuclear medicine, and cardiac magnetic resonance imaging (MRI) uses for RV function assessment in patients with PAH and LVAD. We identify current knowledge gaps in utilizing noninvasive tests to assess RV function. Echocardiography is most widely used to quantify RV function in patients with PAH and LVAD, followed by cardiac MRI for RV morphology and function measurement in PAH patients. The first-pass radionuclide angiography with radiolabeled RBC is the gold standard for calculating RV function. Gated blood pool SPECT can be an alternative as it separates the cardiac chambers well and provides accurate assessment of the RV function with high reproducibility, which is particularly useful for monitoring treatment. More research is needed to compare and validate these modalities in evaluating RV function.

A Case of Bartonella Quintana Culture-Negative Endocarditis.

BACKGROUND Culture-negative Bartonella quintana endocarditis is challenging to diagnose and is associated with high mortality rates. Diagnostic confirmation of Bartonella quintana infection requires specialized assays, as identifying Bartonella henselae endocarditis by serology can be difficult due to the high rate of serological cross-reactivity. This is a case report of culture-negative Bartonella quintana endocarditis that was diagnosed with epidemiologic data, histology, and nucleic acid amplification testing. CASE REPORT A 28-year-old man with a history of homelessness was admitted to hospital with worsening productive cough, weight loss, and abdominal pain. A transthoracic echocardiogram (TTE) showed pulmonary valve vegetation and several aortic valve vegetations. His hospital course was complicated by cardiogenic shock and septic shock requiring transfer to a tertiary care medical intensive care unit. Although blood cultures remained negative for bacterial infection, serology testing was positive for Bartonella henselae and Bartonella quintana IgM and IgG. Nucleic acid amplification testing for 16S ribosomal RNA (rRNA) using valve tissue was diagnostic for Bartonella quintana. CONCLUSIONS This case of culture-negative Bartonella quintana endocarditis demonstrates the use of diagnostic nucleic acid amplification methods to confirm the diagnosis.

Successful Management of Cryptococcal Meningitis and Bone Marrow Infiltration in a Young HIV/AIDS Patient: A Case Report and Review of the Literature.

Bone marrow cryptococcosis has been rarely reported in the literature, and there are no established treatment guidelines specific to this AIDS-related complication. The recommended treatment for AIDS-related invasive fungal treatments include amphotericin B and flucytosine which are associated with an array of complications making optimal treatment recommendations difficult. This case presentation represents an example of a patient with newly diagnosed AIDS and bone marrow cryptococcosis, which was successfully managed with an antifungal regimen adjusted to her comorbidities.

Head-neck taper corrosion following total hip arthroplasty with Stryker Meridian stem.

BACKGROUND: Taper corrosion at the modular junctions of total hip arthroplasty (THA) femoral stems are known to cause locally destructive adverse local tissue reaction (ALTR). However, the implants at risk remain to be fully elucidated. CASE REVIEW: We report the case of a 76-year-old woman with hip pain, abductor weakness, and sciatic nerve symptoms 2 years following metal-on-polyethylene THA. Serum cobalt levels were elevated, while chromium levels were normal. Magnetic resonance imaging demonstrated ALTR. The patient's symptoms resolved following head and liner exchange with ceramic head and titanium sleeve. LITERATURE REVIEW: Previous studies have reported ALTR secondary to head-neck taper corrosion in cobalt chrome alloy and titanium alloy stems used in metal-on-polyethylene (MoP) THA. The stems described above span 4 manufacturers with varying taper geometries. To our knowledge, this is the first report of ALTR due to head-neck taper corrosion in a Stryker Meridian titanium-molybdenum-zirconium-iron (TMZF) alloy stem. CLINICAL RELEVANCE: Close surveillance for ALTR may be considered in patients with this prosthesis. Further investigation of the TMZF alloy and V40 taper geometry of this stem may guide future implant design.

Prevalence and location of bone bruises associated with anterior cruciate ligament injury and implications for mechanism of injury: a systematic review.

BACKGROUND: Bone bruising is commonly observed on magnetic resonance imaging (MRI) after non-contact anterior cruciate ligament (ACL) injury. OBJECTIVES: The primary objective of this study was to determine if the location and prevalence of tibial and femoral bone bruises after ACL injury can be explained by specific injury mechanism(s). The secondary objective was to determine whether the bone-bruise literature supports sex-specific injury mechanism(s). We hypothesized that most studies would report bone bruising in the lateral femoral condyle (LFC) and on the posterior lateral tibial plateau (LTP). METHODS: MEDLINE, PubMed, and SCOPUS were searched for studies that reported bone bruise prevalence and location in ACL-injured subjects. Sex differences in bone-bruise patterns were assessed. Time from injury to imaging was assessed to account for confounding effects on bone-bruise size and location. RESULTS: Thirty-eight studies met the inclusion/exclusion criteria. Anterior-posterior location of bone bruises within the tibiofemoral compartment was assessed in 11 studies. Only five of these studies reported bone-bruise locations on both the tibia and the femur. The most common bone-bruise combination in all five studies was on the LFC and the posterior LTP. Sex differences were only assessed in three studies, and only one reported significantly greater prevalence of LTP bruising in females. CONCLUSION: Bone-bruise patterns in the current literature support a valgus-driven ACL injury mechanism; however, more studies should report the specific locations of tibial and femoral bone bruises. There is insufficient evidence in the literature to determine whether there are sex-specific bone-bruise patterns in ACL-injured subjects.