Endoscopic Rhizotomy for Facetogenic Back Pain: A Review of the History, Financial Considerations, Patient Selection Criteria, and Clinical Outcomes.

BACKGROUND: Chronic back pain (CBP) is a condition that places a considerable burden on society, with several million people affected in the United States alone. Treatment options to address this problem and relieve CBP are constantly evolving, and one of the most promising treatment modalities for CBP that is refractory to conservative treatment options is endoscopic rhizotomy (ER). METHODS: A thorough search of the PubMed (MEDLINE) database was conducted to assess the full progression of ER from its earliest uses to present day in a historical narrative review of ER, with treatment of facetogenic pain as a model pathology. RESULTS: ER allows for direct visualization and ablation of sensory branches of the dorsal ramus to provide pain relief in up to 80% of patients faced with refractory CBP. This technique has been built upon since the early 20th century, and the novel endoscopic approach continues to gain popularity among physicians. Benefits of ER include superior postoperative median pain-free duration compared with traditional percutaneous radiofrequency ablation, as well as direct visualization of regional anatomy. Patient selection criteria for the procedure and a modest list of contraindications allow the use of ER as a viable treatment option for a significant population of patients suffering from CBP. Potential barriers to ER include high cost of the procedure, longer intraoperative time, and expensive proprietary equipment. CONCLUSIONS: ER is an effective treatment for refractory CBP with notable advantages. As the technology and popularity of this procedure progress, improvements in the cost, training, and intraoperative time may make it a favorable alternative to the current standard of care.

Impact of pre-existing vascular disease on clinical outcomes.

AIMS: Little is known about the outcomes and processes of care of patients with non-ST-segment myocardial infarction (NSTEMI) who present with 'polyvascular' disease. METHODS AND RESULTS: We analysed 287 279 NSTEMI patients using the Myocardial Ischaemia National Audit Project registry. Clinical characteristics and outcomes were analysed according to history of affected vascular bed-coronary artery disease (CAD), cerebrovascular disease (CeVD), and peripheral vascular disease (PVD)-with comparison to a historically disease-free control group, comprising 167 947 patients (59%). After adjusting for demographics and management, polyvascular disease was associated with increased likelihood of major adverse cardiovascular events (MACEs) [CAD odds ratio (OR): 1.06; 95% confidence interval (CI): 1.01-1.12; P = 0.02] (CeVD OR: 1.19; 95% CI: 1.12-1.27; P < 0.001) (PVD OR: 1.22; 95% CI: 1.13-1.33; P < 0.001) and in-hospital mortality (CeVD OR: 1.24; 95% CI: 1.16-1.32; P < 0.001) (PVD OR: 1.33; 95% CI: 1.21-1.46; P < 0.001). Patients without vascular disease were less frequently discharged on statins (PVD 88%, CeVD 86%, CAD 90%, and control 78%), and those with moderate [ejection fraction (EF) 30-49%] or severe left ventricular systolic dysfunction (EF < 30%) were less frequently discharged on angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) (CAD 82%, CeVD 77%, PVD 77%, and control 74%). Patients with polyvascular disease were less likely to be discharged on dual antiplatelet therapy (DAPT) (PVD 78%, CeVD 77%, CAD 80%, and control 87%). CONCLUSION: Polyvascular disease patients had a higher incidence of in-hospital mortality and MACEs. Patients with no history of vascular disease were less likely to receive statins or ACE inhibitors/ARBs, but more likely to receive DAPT.

Outcomes of patients hospitalized for acute pulmonary embolism by obstructive sleep apnea status.

Pulmonary embolism (PE) is a major cause of cardiovascular morbidity and mortality. Obstructive sleep apnea (OSA) is increasingly recognized in the aging population, especially with the rising obesity epidemic. The impact of OSA on inpatient mortality in PE is not well understood. We used the Nationwide Inpatient Sample databases from 2005 to 2016 to identify 755,532 acute PE patients (age≥18 years). Among these, 61,050 (8.1%) were OSA+. Temporal trends in length of stay, inpatient mortality, and its association with OSA in PE patients were analyzed. The proportion of PE patients who were OSA+ increased from 2005 to 2016. OSA+ PE patients were younger and predominantly men. Despite a higher prevalence of traditional risk factors for inpatient mortality in OSA+ patients, OSA was associated with a lower risk of mortality in PE patients (odds ratio, 95% confidence interval; p: unadjusted 0.56, 0.53-0.58; p < 0.0001 and adjusted 0.55, 0.52-0.58; p < 0.0001). Overall mortality and length of stay in PE patients decreased over time. Relative to OSA- patients, there was a slight increase in mortality among OSA+ PE patients over time, although the length of stay remained unchanged between the two groups. In conclusion, OSA+ PE patients had a lower inpatient mortality compared to OSA- patients despite a higher prevalence of traditional mortality risk factors. Secondary pulmonary hypertension related to OSA with preconditioning of the right ventricle to elevated afterload may potentially explain the protective effect of OSA on mortality in PE. However, mechanistic studies need to further elucidate the links behind this association.

Racial Disparities in Management and Outcomes of Out-of-Hospital Cardiac Arrest Complicating Myocardial Infarction: A National Study From England and Wales.

BACKGROUND: Studies of racial disparities in care of patients admitted with an out-of-hospital cardiac arrest (OHCA) in the setting of acute myocardial infarction (AMI) have shown inconsistent results. Whether these differences in care exist in the universal healthcare system in United Kingdom is unknown. METHODS: Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. All patients were stratified based on ethnicity into a Black, Asian, or minority ethnicity (BAME) group vs a White group. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy. RESULTS: From 14,287 patients admitted with AMI complicated by OHCA, BAME patients constituted a minority of patients (1185 [8.3%]), compared with a White group (13,102 [91.7%]). BAME patients were younger (median age [interquartile range]) for BAME group, 58 [50-70] years; for White group, 65 [55-74] years). Cardiogenic shock (BAME group, 33%; White group, 20.7%; P < 0.001) and severe left ventricular impairment (BAME group, 21%; White group, 16.5%; P < 0.003) were more frequent among BAME patients. BAME patients were more likely to be seen by a cardiologist (BAME group, 95.9%; White group, 92.5%; P < 0.001) and were more likely to receive coronary angiography than the White group (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-1.88). The BAME group had significantly higher in-hospital mortality (OR 1.26, 95% CI 1.04-1.52) and re-infarction (OR 1.52, 95% CI 1.06-2.18) than the White group. CONCLUSIONS: BAME patients were more likely to be seen by a cardiologist and receive coronary angiography than White patients. Despite this difference, the in-hospital mortality of BAME patients, particularly in the Asian population, was significantly higher.

INTRODUCTION: Les études sur les inégalités raciales en matière de soins aux patients admis en raison d'un arrêt cardiaque hors de l'hôpital (ACHO) dans le cadre d'un infarctus aigu du myocarde (IAM) ont montré des résultats contradictoires. On ignore si ces différences en matière de soins existent dans le système de soins de santé universel de l'Angleterre. MÉTHODES: Les patients admis en raison d'un diagnostic d'IAM et d'ACHO entre 2010 et 2017 du Myocardial Ischaemia National Audit Project (MINAP) ont fait l'objet de l'étude. Nous avons réparti tous les patients selon l'origine ethnique dans le groupe BAME (de l'anglais Black, Asian and minority ethnic, c.-à-d. Noirs, Asiatiques ou d'une minorité ethnique) vs le groupe des Blancs. Nous avons utilisé les modèles multivariés de régression logistique pour évaluer les prédicteurs des résultats cliniques et la stratégie de traitement. RÉSULTATS: Parmi les 14 287 patients admis en raison d'un IAM compliqué par l'ACHO, les patients du BAME constituaient une minorité de patients (1 185 [8,3 %]) par rapport au groupe des Blancs (13 102 [91,7 %]). Les patients du groupe BAME étaient plus jeunes (âge médian [écart interquartile]), 58 [50-70] ans que le groupe des Blancs, 65 [55-74] ans). Le choc cardiogénique (groupe BAME, 33 %; groupe des Blancs, 20,7 %; P < 0,001) et l'insuffisance ventriculaire gauche grave (groupe BAME, 21 %; groupe des Blancs, 16,5 %; P < 0,003) étaient plus fréquents au sein des patients du BAME. Il était plus probable que les patients du BAME soient vus par un cardiologue (groupe du BAME, 95,9 %; groupe des Blancs, 92,5 %; P < 0,001) et qu'ils passent une angiographie coronarienne que le groupe des Blancs (ratio d'incidence approché [RIA] 1,5, intervalle de confiance [IC] à 95 % 1,2-1,88). Le groupe BAME avait une mortalité intrahospitalière (RIA 1,26, IC à 95 % 1,04-1,52) et une récidive d'infarctus (RIA 1,52, IC à 95 % 1,06-2,18) plus élevées que le groupe des Blancs. CONCLUSIONS: Il était plus probable que les patients du BAME soient vus par un cardiologue et qu'ils passent une angiographie coronarienne que les patients blancs. Malgré cette différence, la mortalité intrahospitalière des patients du BAME, particulièrement de la population asiatique, était significativement plus élevée.

Type I Kounis syndrome variant: A case report and literature review.

Kounis syndrome defined as the occurrence of acute coronary syndrome in the setting of allergic reaction due to mast cells activation and inflammatory mediators release that induces coronary vasospasm, plaque erosion, or even stent thrombosis. A 25-year-old postpartum female with asthma and recurrent episodes of chest pain was admitted with ST-segment elevation myocardial infarction in the setting of coronary artery spasms. The patient was started on calcium channel blockers and nitrite-based medication with no improvement. She was noted to have eosinophilia and initiation of corticosteroid-based regimen lead to resolution of chest pain episodes and normalization of eosinophilia. Kounis syndrome should be considered in young patients with chest pain. Coronary vasodilators are considered as the first-line of treatment. The use of corticosteroids has been described in the literature in severe or refractory cases.

The role of wall shear stress in the assessment of right ventricle hydraulic workload.

Pulmonary hypertension (PH) is a devastating disease affecting approximately 15-50 people per million, with a higher incidence in women. PH mortality is mostly attributed to right ventricle (RV) failure, which results from RV hypotrophy due to an overburdened hydraulic workload. The objective of this study is to correlate wall shear stress (WSS) with hemodynamic metrics that are generally accepted as clinical indicators of RV workload and are well correlated with disease outcome. Retrospective right heart catheterization data for 20 PH patients were analyzed to derive pulmonary vascular resistance (PVR), arterial compliance (C), and an index of wave reflections (Γ). Patient-specific contrast-enhanced computed tomography chest images were used to reconstruct the individual pulmonary arterial trees up to the seventh generation. Computational fluid dynamics analyses simulating blood flow at peak systole were conducted for each vascular model to calculate WSS distributions on the endothelial surface of the pulmonary arteries. WSS was found to be decreased proportionally with elevated PVR and reduced C. Spatially averaged WSS (SAWSS) was positively correlated with PVR (R (2) = 0.66), C (R (2) = 0.73), and Γ (R (2) = 0.5) and also showed promising preliminary correlations with RV geometric characteristics. Evaluating WSS at random cross sections in the proximal vasculature (main, right, and left pulmonary arteries), the type of data that can be acquired from phase-contrast magnetic resonance imaging, did not reveal the same correlations. In conclusion, we found that WSS has the potential to be a viable and clinically useful noninvasive metric of PH disease progression and RV health. Future work should be focused on evaluating whether SAWSS has prognostic value in the management of PH and whether it can be used as a rapid reactivity assessment tool, which would aid in selection of appropriate therapies.

Patient-specific computational modeling of blood flow in the pulmonary arterial circulation.

Computational fluid dynamics (CFD) modeling of the pulmonary vasculature has the potential to reveal continuum metrics associated with the hemodynamic stress acting on the vascular endothelium. It is widely accepted that the endothelium responds to flow-induced stress by releasing vasoactive substances that can dilate and constrict blood vessels locally. The objectives of this study are to examine the extent of patient specificity required to obtain a significant association of CFD output metrics and clinical measures in models of the pulmonary arterial circulation, and to evaluate the potential correlation of wall shear stress (WSS) with established metrics indicative of right ventricular (RV) afterload in pulmonary hypertension (PH). Right Heart Catheterization (RHC) hemodynamic data and contrast-enhanced computed tomography (CT) imaging were retrospectively acquired for 10 PH patients and processed to simulate blood flow in the pulmonary arteries. While conducting CFD modeling of the reconstructed patient-specific vasculatures, we experimented with three different outflow boundary conditions to investigate the potential for using computationally derived spatially averaged wall shear stress (SAWSS) as a metric of RV afterload. SAWSS was correlated with both pulmonary vascular resistance (PVR) (R(2)=0.77, P<0.05) and arterial compliance (C) (R(2)=0.63, P<0.05), but the extent of the correlation was affected by the degree of patient specificity incorporated in the fluid flow boundary conditions. We found that decreasing the distal PVR alters the flow distribution and changes the local velocity profile in the distal vessels, thereby increasing the local WSS. Nevertheless, implementing generic outflow boundary conditions still resulted in statistically significant SAWSS correlations with respect to both metrics of RV afterload, suggesting that the CFD model could be executed without the need for complex outflow boundary conditions that require invasively obtained patient-specific data. A preliminary study investigating the relationship between outlet diameter and flow distribution in the pulmonary tree offers a potential computationally inexpensive alternative to pressure based outflow boundary conditions.

Prolonged duration of transbrachial intra-aortic balloon pump as bridge to heart transplantation.

We describe a case demonstrating the quality of life (QOL) benefit and safety of using a transbrachial approach for insertion of an intra-aortic balloon pump (IABP) in a patient awaiting cardiac transplantation. A 68-year-old man with ischaemic cardiomyopathy was admitted to our cardiac intensive care unit to await the availability of a suitable donor organ for orthotopic heart transplant. An IABP was needed for haemodynamic support due to cardiogenic shock. Since the patient did not want to be committed to lying supine in bed for multiple days, as would have been the case had the IABP been placed using the conventional femoral route, we inserted a 7.5 Fr 'sheathless' IABP via the transbrachial approach. The patient's haemodynamics improved and the device was left in place for 240 h without vascular compromise. He was subsequently successfully transplanted and is doing well on follow-up.

Acute myocardial infarction associated with dietary supplements containing 1,3-dimethylamylamine and Citrus aurantium.

We describe the case of a previously healthy 22-year-old man who presented with anginal chest pain and was diagnosed with a non-ST-elevation myocardial infarction. For 3 weeks, he had been ingesting the dietary supplements Jack3d® (principal ingredient, 1,3-dimethylamylamine) and Phenorex™ (principal ingredient, Citrus aurantium) daily, before undertaking physical activity. Coronary angiograms revealed a proximal left anterior descending coronary artery thrombus with distal embolization. A combined medical regimen led to resolution of the thrombus. Three months later, the patient was asymptomatic with no evidence of ischemia. The primary ingredients in the sympathomimetic supplements taken by our patient are controversial in the medical community and have been individually associated with adverse cardiac events. There are no safety data on their simultaneous use. We discuss other reports of adverse effects associated with these supplements and recommend that the relevant safety guidelines be revised.

An unusual etiology of infective endocarditis: Enterobacter cloacae.

Gram-negative microorganisms are rarely implicated in causing infective endocarditis (IE). Although the traditionally identified risk factor for Gram-negative endocarditis has been intravenous drug abuse, recent studies have revealed that healthcare contact and the presence of prosthetic cardiac devices are primary risk factors for IE secondary to non-HACEK Gram-negative bacteria. We present a case of Enterobacter endocarditis in a patient with no prior history of valvular heart disease, implanted endovascular device, or intravenous drug abuse. The patient was treated successfully with carbapenem monotherapy. We have reviewed 43 cases of Enterobacter endocarditis reported in the literature to date. Clinical summary and management of IE secondary to Enterobacter based on all the published cases is outlined.