Does Baseline Diuretics Use Affect Prognosis in Patients With COVID-19?

The rapid emergence of coronavirus disease 2019 (COVID-19) has become the biggest healthcare crisis of the last century, resulting in thousands of deaths worldwide. There have been studies that evaluated the role of angiotensin-converting enzyme (ACE) inhibitors (ACEi) and angiotensin receptor blockers (ARBs) in treating patients with COVID-19. However, the prior use of diuretics and their effect on mortality in this setting remains unknown. The aim of the study was to evaluate the effect of diuretics in patients admitted with COVID-19. The current study was conducted between March 15, 2020, and April 30, 2020, during the COVID-19 pandemic in three different hospitals in Northern New Jersey, USA. The primary outcome was survival or in-hospital mortality from COVID-19 from the day of admission. The secondary outcome was severe or non-severe illness from COVID-19. This retrospective study included a total of 313 patients with a median age of 61.3 ± 14.6 years. There was a total of 68 patients taking diuretics at home and 245 patients who were not taking diuretics. There was a total of 39 (57.35%) deaths in patients taking diuretics as compared to 93 (37.96%) deaths in patients not taking diuretics (p-value 0.0042). Also, 54 (79.41%) patients who took diuretics had severe COVID-19 illness as compared to 116 (47.35%) who did not take diuretics (p-value <.0001). However, after adjusting for the confounding factors, there was no difference in mortality or severity of illness in COVID-19 patients taking diuretics at the time of admission. In conclusion, there was no effect of the baseline use of diuretics in the prognosis of COVID-19.

Acute motor-sensory axonal polyneuropathy variant of Guillain-Barre syndrome complicating the recovery phase of coronavirus disease 2019 infection: a case report.

INTRODUCTION: The novel coronavirus, since its first identification in China, in December 2019, has shown remarkable heterogeneity in its clinical behavior. It has affected humans on every continent. Clinically, it has affected every organ system. The outcome has also been variable, with most of the older patients showing grave outcomes as compared with the younger individuals. Here we present a rare and severe variant of Guillain-Barre syndrome that complicated the disease in recovery phase. CASE PRESENTATION: A 60-year-old Afghan man, who had been recovering from symptoms related to novel coronavirus associated disease, presented with sudden onset of progressive muscle weakness and oxygen desaturation. Electrophysiological workup confirmed the diagnosis of Guillain-Barre syndrome, and early institution of intravenous immunoglobulin resulted in complete resolution. CONCLUSION: Guillain-Barre syndrome has recently been reported in many patients diagnosed with novel coronavirus associated disease. While clinical suspicion is mandatory to guide towards an effective diagnostic workup, early diagnosis of this complication and timely institution of therapeutic interventions are indispensable and lifesaving.

The utility of bedside echocardiography in critically ill COVID-19 patients: Early observational findings from three Northern New Jersey hospitals.

INTRODUCTION: Cardiovascular complications related to coronavirus disease 2019 (COVID-19) have led to the need for echocardiographic services during the pandemic. The present study aimed to identify the echocardiographic findings in hospitalized COVID-19 patients and their utility in disease management. METHODS: We included patients who were diagnosed with COVID-19 using polymerase chain reaction and those who underwent echocardiographic examination during their hospitalization. RESULTS: Altogether, 45 patients were evaluated. The mean age was 61.4 ± 12.2 years. Hypertension (n = 29, 64%) and diabetes mellitus (n = 25, 55%) were the most common comorbidities followed by congestive heart failure (n = 11, 24%), coronary artery disease (n = 9, 20%), and valvular heart disease (n = 3, 7%). Eight patients (18%) showed evidence of myocardial injury, as suggested by elevated troponin levels. Brain natriuretic peptide was elevated in 14 patients (36%), and 14 patients had left ventricular dysfunction in the form of reduced ejection fraction (31%). Right ventricular (RV) dilatation was observed in six patients, and five patients had reduced RV ejection fraction. RV pressure and volume overload were observed in three patients. RV thrombus was observed in one patient. Pulmonary pressure was elevated in 10 patients (24%). CONCLUSION: Two-dimensional echocardiography can be an important bedside tool for the assessment of cardiovascular abnormalities and hemodynamic status of COVID-19 patients.

COVID-19 Presenting as Acute Limb Ischaemia.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic that developed in late 2019 and early 2020 has caused thousands of deaths and has had an enormous impact on our health systems and economies. Coronavirus disease 2019 (COVID-19) complications include disseminated coagulation and thrombosis, but, to the best of our knowledge, the literature to date on these manifestations has been limited. Herein, we report an unusual presentation in a 43-year-old man with a medical history of diabetes and hypertension who presented with dyspnoea and acute pain in his right leg and was found to have acute limb ischaemia and diabetic ketoacidosis. Our case adds to the literature regarding arterial thrombosis in COVID-19. LEARNING POINTS: Arterial thrombosis in the form of acute limb ischaemia can occur in COVID-19.A high index of suspicion should be maintained for acute limb ischaemia, which is a vascular emergency.

Conquering the pneumococcal nemesis with oral antibiotics.

Introduction: Streptococcus pneumoniae endocarditis (SPE) occurs in <3% of all EI cases due to the evolution of penicillin and vaccination. However, immunocompromised and unvaccinated patients are still at grave risk. Case: A 58-year-old African American male who used alcohol and intravenous (IV) drugs presented with confusion, fever, and hemoptysis. He had coarse rhonchi with a grade 2/5 holosystolic apical murmur. CT chest showed diffuse bilateral infiltrates. Blood cultures were positive for pansensitive Streptococcus pneumoniae. Echocardiogram demonstrated large vegetations on the anterior and posterior leaflets of the mitral valve with flail leaflet and severe eccentric mitral regurgitation. Patient was started on IV ceftriaxone, but after 3 weeks of therapy, he wished to leave against medical advice. He was discharged on combination oral therapy with successful resolution of SPE on follow-up. Discussion: Invasive pneumococcus is highly virulent causing irreversible valvular destruction or death. IV beta-lactams are first-line treatment, but there are currently no guideline-recommended alternatives for oral therapy. Recent data suggest partial oral therapy may be noninferior to IV only therapy. Conclusion: Switching to oral combination antibiotics after at least 2 weeks of IV therapy is an acceptable alternative to treat SPE.

Value of neutrophil to lymphocyte ratio as a predictor of mortality in patients undergoing aortic valve replacement.

BACKGROUND: Neutrophil to lymphocyte ratio (NLR) has been studied as a measure of inflammation and as a prognosticating factor in various medical conditions including neoplastic, inflammatory and cardiovascular. The prognostic role of NLR in predicting mortality in patients with aortic stenosis undergoing surgical aortic valve replacement (AVR) has not been studied. The aim of our study is to explore the utility of NLR as a predictor of both, short and long-term mortality, in patients undergoing surgical AVR. METHODS: Consecutive patients with aortic stenosis admitted for AVR to our institution were evaluated for study inclusion. Of the 335 patients admitted from January 2007 to September 2011, 234 met study inclusion criteria. Patients were divided into two groups depending on their initial preoperative NLR level with a cutoff value of 3. Three-year vital status was accessed with electronic medical records and Social Security Death Index. Survival analysis, stratified by NLR, was used to evaluate the predictive value of preoperative NLR levels. RESULTS: Patients with NLR ≥3, when compared to those with NLR <3, had a significantly higher short-term (9.40% vs. 0, P=0.0006), 6-month (19.54% vs. 0.95%, P<0.0001), and 3-year mortality (27.35% vs. 3.78%, P<0.0001). After adjustment for baseline characteristics, co-morbidities, symptomatology, echocardiographic findings, and blood tests, NLR level remained a significant independent predictor of 3-year mortality; Hazard ratios (HRs) increased by a factor of 1.18 (1.05-1.33, P=0.0068) and patients with a NLR ≥3 had 4.77 fold increase in 3-year mortality (1.48-15.32, P=0.0090). CONCLUSIONS: NLR is an independent predictor of short-term and long-term mortality in patients with aortic stenosis undergoing AVR surgery, especially those with NLR ≥3. We strongly suggest the use of NLR as a tool to risk stratify patients with aortic stenosis undergoing AVR surgery.

Cardiac troponin and outcome in decompensated heart failure with preserved ejection fraction.

BACKGROUND: Cardiac troponin (cTn) has been established as an effective prognostic marker in acute heart failure (HF) with predominantly reduced ejection fraction. However, it's prognostic value in heart failure with preserved ejection fraction (HFpEF) is unclear. The aim of this study is to describe the prognostic role of troponin I in patients hospitalized for HFpEF decompensation. METHODS: We included 363 consecutive patients admitted for HFpEF decompensation that was not associated with acute coronary syndrome (ACS). Patients with troponin level elevation (troponin I level ≥0.04 ng/mL) were compared to patients with normal troponin level. The primary outcome was short-, intermediate-, and long-term all-cause mortality. The secondary outcomes were differences in B-type natriuretic peptide level (BNP), length of stay, and readmission rates between the two groups. RESULTS: Nearly half of the patients in the Cohort had troponin level elevation. Troponin level elevation was significantly associated with higher 30-day (4.8% vs. 0.6%, P=0.014), 1-year (12.2% vs. 4.6%, P=0.009), and 2-year mortality (13.8% vs. 5.1%, P=0.005) when compared to a normal troponin level. Troponin level elevation was an independent predictor of mortality after adjusting for clinical and laboratory risk factors seen in HFpEF decompensation. Additionally, BNP level >287 pg/mL, age, and history of atrial fibrillation were identified as statistically significant predictors of mortality. CONCLUSIONS: Troponin level elevation, in hospitalized patients with HFpEF decompensation, was associated with higher short-, intermediate-, and long-term mortality.

A Rare Case of Embolic ST-Elevation Myocardial Infarction in an Adult Patient With Repaired Hypoplastic Left Heart Syndrome.

A 24-year-old male with past medical history of hypoplastic left heart syndrome and staged reconstructive surgery in infancy culminating in the Fontan circulation presented to the hospital with a chief complaint of chest pain described as an "elephant sitting" on his chest. Initial 12-lead electrocardiogram revealed 2-mm ST segment elevation in inferior leads, 3-mm ST-segment elevation in anterolateral precordial leads V3 and V4, and 2-mm ST-segment elevation in V5 and V6, with right axis deviation. He was transported emergently to the cardiac catheterization laboratory where coronary angiography revealed complete occlusion of multiple anomalous branches of the right coronary system with hazy appearance suggesting the presence of thrombotic material. An aspiration catheter was used successfully to reestablish TIMI grade III flow. The patient was treated with aspirin, brilinta (ticagrelor), and anticoagulation with vitamin K antagonism to prevent recurrent thromboembolic complications.

Left ventricular noncompaction diagnosed following Graves' disease.

Isolated left ventricular noncompaction (LVNC) is a rare genetic cardiomyopathy. Clinical manifestations are variable; patients may present with heart failure symptoms, arrhythmias, and systemic thromboembolism. However, it can also be asymptomatic. When asymptomatic, LVNC can manifest later in life after the onset of another unrelated condition. We report a case of LVNC which was diagnosed following a hyperthyroid state secondary to Graves' disease. The association of LVNC with other noncardiac abnormalities including neurological, hematological, and endocrine abnormalities including hypothyroidism has been described in isolated case reports before. To the best of our knowledge, this is the first reported case of LVNC diagnosed following exacerbation in contractile dysfunction triggered by Graves' disease.

Mural thrombus in the normal-appearing descending thoracic aorta of a chronic smoker.

Thrombus formation in an atherosclerotic or aneurysmal descending thoracic aorta is a well-described, frequently encountered vascular condition. In comparison, thrombus formation in a normal-appearing descending thoracic aorta is reported far less often. We describe the case of a 46-year-old woman who had splenic and renal infarctions secondary to embolic showers from a large, mobile thrombus in a morphologically normal proximal descending thoracic aorta. After the patient underwent anticoagulation, stent-grafting, and surgical bypass to correct an arterial blockage caused by the stent-graft, she resumed a relatively normal life. In contrast with other cases of a thrombotic but normal-appearing descending thoracic aorta, this patient had no known malignancy or systemic coagulative disorders; her sole risk factor was chronic smoking. We discuss our patient's case and review the relevant medical literature, focusing on the effect of smoking on coagulation physiology.

Association between smoking and chronic kidney disease: a case control study.

BACKGROUND: The progression of chronic kidney disease (CKD) remains one of the main challenges in clinical nephrology. Therefore, identifying the pathophysiological mechanisms and the independent preventable risk factors helps in decreasing the number of patients suffering end stage renal disease and slowing its progression. METHODS: Smoking data was analyzed in patients with CKD throughout 2005-2009. One hundred and ninety-eight patients who had recently been diagnosed with stage three CKD or higher according to the National Kidney Foundation (NKF) 2002 Classification were studied. The control group was randomly selected and then matched with the case subjects using a computerized randomization technique. The relative risk was estimated by computing odds ratio (OR) by using multinomial logistic regression in SPSS ® for Windows between the two groups. RESULTS: Smoking significantly increases the risk of CKD (OR = 1.6, p = 0.009, 95% CI = 1.12-2.29). When compared to nonsmokers, current smokers have an increased risk of having CKD (OR = 1.63 p = 0.02, 95% CI = 1.08-2.45), while former smokers did not have a statistically significant difference. The risk increased with high cumulative quantity (OR among smokers with > 30 pack-years was 2.6, p = 0.00, 95% CI = 1.53-4.41). Smoking increased the risk of CKD the most for those classified as hypertensive nephropathy (OR = 2.85, p = 0.01, 95% CI = 1.27-6.39) and diabetic nephropathy (2.24, p = 0.005, 95% CI = 1.27-3.96). No statistically significant difference in risk was found for glomerulonephritis patients or any other causes. CONCLUSION: This study suggests that heavy cigarette smoking increases the risk of CKD overall and particularly for CKD classified as hypertensive nephropathy and diabetic nephropathy.