Association of autosomal dominant polycystic kidney disease with cardiovascular disease: a US-National Inpatient Perspective.

PURPOSE: Data on the epidemiology of cardiovascular diseases (CVD) in patients with autosomal dominant polycystic kidney disease (ADPKD) are limited. In this study, we assess the prevalence of CVD in patients with ADPKD and evaluate associations between these two entities. METHODS: Using the National Inpatient Sample database, we identified 71,531 hospitalizations among adults aged ≥ 18 years with ADPKD, from 2006 to 2014 and collected relevant clinical data. RESULTS: The prevalence of CVD in the study population was 42.6%. The most common CVD were ischemic heart diseases (19.3%), arrhythmias (14.2%), and heart failure (13.1%). The prevalence of CVD increased with the severity of renal dysfunction (RD). We found an increase in hospitalizations of patients with ADPKD and CVD over the years (ptrend < 0.01), irrespective of the degree of RD. CVD was the greatest independent predictor of mortality in these patients (OR: 3.23; 95% CI 2.38-4.38 [p < 0.001]). In a propensity matched model of hospitalizations of patients with CKD with and without ADPKD, there was a significant increase in the prevalence of atrial fibrillation/flutter (AF), pulmonary hypertension (PHN), non-ischemic cardiomyopathy (NICM), and hemorrhagic stroke among patients with ADPKD when compared to patients with similar degree of RD without ADPKD. CONCLUSIONS: The prevalence of CVD is high among patients with ADPKD, and the most important risk factor associated with CVD is severity of RD. We found an increase in the trend of hospitalizations of patients with ADPKD associated with increased risk of AF, PHN, NICM, and hemorrhagic stroke. History of CVD is the strongest predictor of mortality among patients with ADPKD.

Approach to echocardiography in ARDS patients in the prone position: A systematic review.

Echocardiography is commonly utilized in patients with acute respiratory distress syndrome (ARDS) for assessment of cardiac function, volume status, and the potential development of acute cor pulmonale. In severe ARDS, prone positioning is frequently used, which imposes technical challenges during transthoracic echocardiography (TTE) image acquisition. Moreover, prone positioning can affect cardiopulmonary function in ways that are reflected on the echocardiographic findings in this position. Historically, a transesophageal approach was recommended when a patient is prone, with few studies reporting utility of TTE in this setting. However, recent publications have begun to address this knowledge gap. This review explores recent literature addressing the use of TTE in prone patients with ARDS, with a special focus on the cardiopulmonary effects of proning and potential solutions to the technical difficulties that arise in this position.

Unmasking pulmonary hypertension following tricuspid valve replacement.

In this Viewpoint, we highlight a possible hemodynamic problem arising following tricuspid valve replacement (TVR) in patients with severe chronic tricuspid regurgitation, represented by "unmasking" of pulmonary hypertension (PH) following the surgery. We share an observation that should alert cardiologists to the fact that this increasingly utilized surgery is not risk free, and careful assessment of the right ventricular function and pulmonary circulation preoperatively is extremely important, especially in patients with preexisting risk factors for PH, since TVR may lead to a sudden increase in right ventricular afterload.

Gender Differences in Outcomes After Implantation of Left Ventricular Assist Devices.

BACKGROUND: Left ventricular assist device (LVAD) implantation has historically been underutilized in women compared with men. It was hypothesized that the introduction of continuous-flow LVADs would lead to more LVAD implantations in women and possibly narrow the gender gap. METHODS: Patients who underwent LVAD implantation between 2009 and 2014 were identified using the national inpatient sample. RESULTS: A total of 3511 patients (17,251 when weighted) underwent LVAD implantation in the United States between 2009 and 2014. Mean age was 56 years and there were 817 women in the study sample (23.32%). LVAD implantations in women doubled from 2009 to 2014, but men continued to receive LVAD 3 times more than women. Inpatient mortality after LVAD placement was similar between men and women (13.42% women vs 12.85% men; odds ratio, 1.05; P = .16). Most common complications after LVAD implantation in both genders included acute kidney injury, bleeding requiring blood transfusion, and postoperative sepsis. There were no gender-specific differences in the incidence of periprocedural complications, including postoperative cardiac tamponade, postoperative thromboembolism, or sepsis. In addition, no significant difference was found in length of stay and median hospitalization cost. The use of extracorporeal membrane oxygenation did not differ between men and women. Subgroup analysis in patients older than 65 years of age showed higher in-hospital mortality but no differences between genders. CONCLUSIONS: The number of women undergoing LVAD implantation has increased with the introduction of continuous-flow LVADs, but a gender gap still exists. Most major in-hospital outcomes after LVAD implantation are similar between genders.

Impact of Chronic Thrombocytopenia on Outcomes After Transcatheter Valvular Intervention and Cardiac Devices Implantation (From a National Inpatient Sample).

To evaluate the impact of chronic thrombocytopenia (cTCP) on outcomes of transcatheter valvular procedures such as aortic valve implantation (TAVI), MitraClip, permanent pacemaker (PPM), implantable-cardioverter defibrillator (ICD), cardiac resynchronization therapy (CRT), left atrial appendage closure, and pericardiocentesis. Impact of cTCP on clinical outcomes following TAVI, Mitraclip, PPM, ICD, CRT, left atrial appendage closure, and pericardiocentesis procedures is not well described. Utilizing the National Inpatient Sample and (ICD-9-CM) procedural codes, we evaluated patients (age ≥18 years) who underwent these procedures, from January 1, 2009 to December 31, 2014, with or without cTCP as a chronic condition variable indicator. Propensity score matching model implemented to derive 2 matched groups. Propensity score matching created 47,292 and 47,351 hospitalizations matched pairs with and without cTCP, respectively. Patients with cTCP were older (mean age, 74.27 vs 72.26 years; absolute standardized differences [ASD] = 15.6) and less likely to be female (36.76% vs 43.74%, ASD = -14.31). They experienced higher in-hospital mortality (3.0% vs 2.0%; odds ratio [OR], 1.53; 95% confidence interval [CI], 1.27 to 1.83) and higher odds of vascular injury requiring surgery (2.63% vs 1.10%; OR, 2.43; 95% CI, 1.93 to 3.05). Postoperative hematoma and bleeding were 2-fold higher (4.57% vs 2.24%; OR, 2.08; 95% CI, 1.77 to 2.45) and 3-fold higher (6.34% vs 2.45%; OR, 2.69; 95% CI, 2.31 to 3.13) respectively among cTCP patients. They had greater health-care cost ($47,163 vs $35,763, p <0.0001) and longer hospital stay (mean 9.26 days vs 6.84 days, p <0.0001). In conclusion, cTCP patients had higher risk of complications after TAVI, MitraClip, PPM, ICD, CRT, left atrial appendage closure, and pericardiocentesis, including a 1.5-fold increased risk of in-hospital mortality.

Rare case of implantable cardioverter defibrillator infection caused by Stenotrophomonas maltophilia and Pantoea calida.

Despite the numerous advancements in cardiac implantable electronic defibrillator (CIED) designs and implantation techniques, device-related infections continue to represent significant morbidity and mortality. Although Gram-positive bacteria remain the most commonly reported organisms, various other bacterial families have been reported. We describe a 61-year-old patient with a history of non-ischaemic cardiomyopathy who presented with implantable cardioverter defibrillator pocket infection due to Stenotrophomonas maltophilia and Pantoea calida that developed a few days following the device generator replacement. Early device explantation, tissue sampling and initiation of sensitivity-directed antibiotics are necessary steps for early diagnosis and management of such CIED-related infections. S. maltophilia and P. calida should be added to the expanding list of the causative organisms behind CIED-related infections. Our case and available literature demonstrated excellent sensitivity of these two organisms to sulfamethoxazole-trimethoprim treatment.

Prosthetic Aortic Valve Endocarditis in a Patient With Birt-Hogg-Dube Syndrome due to Lactobacillus paracasei.

Various causative organisms and predisposing factors were implicated in the pathogenic process behind prosthetic valve endocarditis. Lactobacillus paracasei, a classic constituent of probiotics, rarely causes infections in humans and was reported only in few case reports. The use of probiotics was hypothesized to be a risk factor for these infections; however, no causative relationship could be drawn. We describe a 75-year-old woman with history of Birt-Hogg-Dube syndrome and bioprosthetic aortic valve replacement who presented with worsening dyspnea was found to have Lactobacillus paracasei bacteremia and evidence of bacterial vegetations noted on transesophageal echocardiography (TEE) along with evidence of severe aortic insufficiency. Based on antibiotics sensitivity profile, she was treated with penicillin and gentamycin, which resulted in bacterial clearance on repeat blood cultures, and the patient was transferred to a different facility to undergo replacement of the prosthetic aortic valve. Although Lactobacillus paracasei is rarely involved in human infections, it should be suspected in patients with underlying structural heart/valvular disease, recent antibiotic exposure or recent probiotic use who are presenting with evidence of infective endocarditis. Combination antibiotics including beta lactams, aminoglycosides and clindamycin are suggested treatment of choice for this organism.

Hypothermia-triggered biventricular Takotsubo cardiomyopathy: the octopus that survived the polar vortex.

Takotsubo cardiomyopathy (TTC) is most commonly characterised by transient apical ballooning in response to physical or emotional stress without significant coronary artery disease (CAD). Various physical and emotional factors can trigger TTC. We report a case of hypothermia-induced biventricular TTC in an 84-year-old man admitted with a core body temperature of 29.8°C, followed by quick recovery of systolic function and resolution of wall motion abnormality after discharge. TTC should be suspected in hypothermic patients presenting with evidence of new onset heart failure and be added to the expanding list of factors triggering TTC. Similar to TTC induced by various other factors, hypothermia-induced TTC also carries a favourable prognosis with relatively quick recovery of wall motion abnormalities.

Apical Ballooning of Takotsubo Cardiomyopathy in a Patient with Non-ST Elevation Myocardial Infarction Due to Right Coronary Artery Stenosis: The Trapped Octopus Got a Heart Attack.

Takotsubo cardiomyopathy (TCM) is characterized by apical ballooning with basal preservation in the absence of obstructive coronary artery disease (CAD) that can otherwise explain wall motion abnormalities. However, there is increasing evidence that acute coronary syndromes (ACSs) may coexist with TCM. This report describes a 61-year-old man with a previous medical history of hypertension, diabetes mellitus, and hyperlipidemia, who presented with acute chest pain and associated shortness of breath. He was diagnosed with a non-ST segment myocardial infarction. Echocardiography revealed impaired systolic function with evidence of apical and periapical ballooning of the left ventricle, characteristic of TCM. Coronary angiography revealed evidence of significant luminal stenosis of the right coronary artery (RCA), necessitating intervention with a drug-eluting stent. This patient demonstrated wall motion abnormalities characteristic of TCM beyond the territory of the affected coronary artery suggesting that CAD and TCM can coexist.

Quantitative Readability Assessment of the Internal Medicine Online Patient Information on Annals.org.

Background Approximately 90% of Americans have access to the internet with the majority of people searching online for medical information pertaining to their health, or the health of loved ones. The public relies immensely on online health information to make decisions related to their healthcare. The American Medical Association (AMA) and the National Institute of Health (NIH) recommend that publicly available health-related information be written at the level of the sixth-seventh grade. Materials and methods Patient education materials available to the public on the Annals.org, a website sponsored by the American College of Physicians, were collected. All 89 patient education articles were downloaded from the website and analyzed for their ease of readability. The articles were analyzed utilizing a readability software generating five quantitative readability scores: Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), Gunning Fog Index (GFI), Coleman-Liau Index (CLI), Simple Measure of Gobbledygook (SMOG). All scores, with the exception of FRE, generate a grade level that correlates with the required school-grade level to ensure adequate readability of the information. Results Eighty-nine articles were analyzed generating an average score as follows: FRE 62.8, FKGL 7.0, GFI 8.6, CLI 9.6 and SMOG 9.8. Overall, 87.6% of the articles were written at a level higher than the 7th-grade level, which is recommended by the AMA and NIH. Conclusion In an era of increased reliance on the internet for medical information pertaining to patients' health, materials written at a higher grade than recommended has the potential to negatively impact patients' well-being, in addition to tremendous ramifications on the healthcare system. Potentially redrafting, these articles can prove beneficial to patients who rely on these resources for making healthcare-related decisions.

Sinus Bradycardia and QT Interval Prolongation in West Nile Virus Encephalitis: A Case Report.

Cardiac arrhythmias were reported in cases of West Nile Virus (WNV) encephalitis; however, the underlying pathophysiology remains incompletely understood. We present a 67-year-old male with altered mental status, later diagnosed with WNV encephalitis. Hospital course was complicated by progressive sinus bradycardia and corrected QT (QTc) prolongation. These findings persisted despite the absence of classical causes and resolved only after improvement of the underlying encephalitis. After excluding classical causes, autonomic dysfunction is one of the proposed mechanisms behind cardiac arrhythmias in WNV encephalitis. Resolution of arrhythmias is expected after the improvement of underlying encephalitis and should be taken into consideration before proceeding for pacemaker placement or other cardiac intervention. Furthermore, this case highlights the importance of continuous cardiac monitoring in WNV encephalitis patients.

Comparison of Hospital Outcomes of Transcatheter AorticValve Implantation With Versus Without Hypothyroidism.

Comparative outcomes of transcatheter aortic valve implantation (TAVI) in patients with and without hypothyroidism were not previously reported. This study aimed to appraise the clinical outcomes and impact of hypothyroidism on patients who underwent TAVI. Patients with hypothyroidism who underwent TAVI from 2011 to 2014 were identified in the National Inpatient Sample database using the International Classification of Diseases, ninth Revision, Clinical Modification. The primary outcome was the effect of hypothyroidism on inpatient mortality. Secondary outcomes were the impact of hypothyroidism on post-TAVI complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding. The hypothyroid patients who underwent TAVI had no significant increase in the risk of in-hospital mortality (odds ratio 0.78; 95% confidence interval 0.51 to 1.21, p = 0.282), or most postprocedural complications. However, hypothyroid patients were more likely to develop hemorrhage requiring transfusion (odds ratio 1.36, 95% confidence interval 1.05 to 1.76, p = 0.043). In conclusion, TAVI is a feasible and relatively safe alternative with reasonable in-hospital outcomes in patients with hypothyroidism and severe symptomatic aortic stenosis. However, hypothyroid patients are more likely to require a blood transfusion after TAVI. Additional randomized trials are needed to evaluate TAVR outcomes in hypothyroid patients.

Gemella morbillorum Cryptogenic Brain Abscess: A Case Report and Literature Review.

A case of cryptogenic brain abscess caused by Gemella morbillorum is reported in a 28-year-old immunocompetent man who presented with seizures and hemiparesis. The patient underwent successful stereotactic drainage of the abscess with complete resolution of symptoms and radiographic evidence of resolution. We report the significant pathogenic potential of a normal commensal rarely identified in neurologic infections.