Clinical aspects of ischemia with no obstructive coronary artery disease (INOCA).

Ischemia with no obstructive coronary arteries (INOCA) is defined as patients with evidence of myocardial ischemia without obstructive coronary artery disease. About 3-4 million people in the United States have INOCA, more commonly affecting women, and carries adverse morbidity, mortality, and relatively high healthcare costs. The pathophysiology of INOCA appears to be multi-factorial with a variety of contributing mechanisms. Diagnosis of INOCA is suggested by non-invasive or invasive testing consistent with myocardial ischemia. Due to the high prevalence of coronary risk factors and atherosclerosis in the INOCA population, current treatment strategies target angina, coronary atherosclerosis, and atherosclerotic risk factors, as well as burgeoning treatment of coronary microvascular dysfunction (CMD). Ongoing clinical trials are assessing different options.

Comparison of clinical characteristics and outcomes of critically ill adults with SARS-CoV-2 infection during Delta and Omicron variant predominance periods: a single-hospital retrospective cohort study.

INTRODUCTION: Initial reports suggest the B.1.1.529 (Omicron) variant of SARS-CoV-2 causes less severe disease compared with the B.1.617.2 (Delta) variant, though more widespread vaccination contributed to these findings. Little is known about clinical characteristics and outcomes of patients with SARS-CoV-2 infection requiring intensive care during periods of Delta and Omicron variant predominance. AIM: To examine and compare characteristics of critically ill adults with SARS-CoV-2 infection during periods of Delta and Omicron variant predominance. METHODS: We conducted a retrospective cohort study of critically ill adults with SARS-CoV-2 infection at one academic hospital in Los Angeles during Delta (15 July 2021-23 September 2021) and Omicron (21 December 2021-27 January 2022) predominance. Patient characteristics were compared between Delta-period and Omicron-period hospitalisations, overall and stratified by vaccination status. RESULTS: 79 adults required intensive care during the Delta predominance period and 116 during the Omicron predominance period. We found similar proportions of intensive care unit admissions occurring in fully vaccinated patients between the two periods, despite Los Angeles County data revealing an almost 60% increase in the proportion of SARS-CoV-2 hospitalisations occurring in fully vaccinated persons. There was no difference in the need for invasive mechanical ventilation (IMV). Among those who required IMV, the median duration of IMV was shorter overall (Delta=18 days; Omicron=8 days; p=0.006) and among unvaccinated persons (Delta=19 days; Omicron=8.5 days; p=0.018). Among unvaccinated persons, the median intensive care unit length of stay was shorter (Delta=12 days; Omicron=5 days; p=0.037) during Omicron predominance. There was no difference in the proportion of patients who died while hospitalised. CONCLUSIONS: In this single-hospital study, critically ill patients with SARS-CoV-2 infection experienced less severe respiratory disease during Omicron predominance, likely due to reduced variant-specific virulence. Vaccination likely reduced development of critical illness in adults with SARS-CoV-2 infection during Omicron predominance.

Evolution of liver transplant organ allocation policy: Current limitations and future directions.

Since the adoption of the model for end-stage liver disease (MELD) score for organ allocation in 2002, numerous changes to the system of liver allocation and distribution have been made with the goal of decreasing waitlist mortality and minimizing geographic variability in median MELD score at time of transplant without worsening post-transplant outcomes. These changes include the creation and adoption of the MELD-Na score for allocation, Regional Share 15, Regional Share for Status 1, Regional Share 35/National Share 15, and, most recently, the Acuity Circles Distribution Model. However, geographic differences in median MELD at time of transplant remain as well as limits to the MELD score for allocation, as etiology of liver disease and need for transplant changes. Acute-on-chronic liver failure (ACLF) is a subset of liver failure where prevalence is rising and has been shown to have an increased mortality rate and need for transplantation that is under-demonstrated by the MELD score. This underscores the limitations of the MELD score and raises the question of whether MELD is the most accurate, objective allocation system. Alternatives to the MELD score have been proposed and studied, however MELD score remains as the current system used for allocation. This review highlights policy changes since the adoption of the MELD score, addresses limitations of the MELD score, reviews proposed alternatives to MELD, and examines the specific implications of these changes and alternatives for ACLF.

Neurologic Imaging in a Patient with Cirrhosis and Altered Mental Status: To CT or Not to CT.

Hepatic encephalopathy represents a continuum of neuropsychiatric symptoms among patients with end-stage liver disease. When a patient with cirrhosis presents with altered mental status (AMS), routine neurologic imaging is not typically recommended, due to low diagnostic yield. Guidance from the American Association for the Study of Liver Disease states that, on initial presentation, brain imaging is not required unless there are other signs of intracranial pathology, including focal neurologic deficits. We present a case of a 61-year-old female with cirrhosis presenting with AMS without focal deficits, in whom neurological imaging revealed a meningioma and subsequent resection led to symptom improvement.

A case of a pregnant patient with COVID-19 infection treated with emergency c-section and extracorporeal membrane oxygenation.

Coronavirus disease 2019 (COVID-19) causes the development of severe acute respiratory distress syndrome. Pregnant women may be at increased risk for the development of severe disease. We present the case of a pregnant patient who developed respiratory failure due to COVID-19 and rapidly decompensated requiring intubation. Despite mechanical ventilation, the patient's respiratory status continued to worsen. At bedside, cardiothoracic surgeons, obstetricians, intensivists, and neonatologists discussed balancing the risk of COVID-19 and respiratory failure to the patient, premature delivery to the neonate, potential coagulopathy associated with COVID-19, and the need for anticoagulation with mechanical circulatory support. Ultimately, the decision was to proceed with emergency cesarean section delivery in the intensive care unit followed by peri-partum veno-venous extracorporeal membrane oxygenation initiation. The patient and neonate were both discharged home in stable condition.

Myocardial Infarction With Nonobstructive Coronary Arteries.

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is the current term used to describe patients who have a myocardial infarction but have normal, non-obstructed coronary arteries on a coronary angiogram. There is still much debate over the definition, diagnosis, management and treatment of MINOCA. However, MINOCA is not a benign condition; prompt recognition and diagnosis can lead to better management and treatment and thus improve patient outcomes. This review article will update the most recent definition of MINOCA, discuss epidemiology and etiology, and review the diagnostic workup and management options for patients presenting with signs and symptoms of MINOCA.