Case Report: Conjunctival Infestation with Thelazia gulosa: A Novel Agent of Human Thelaziasis in the United States.

We report a case of thelaziasis in a 26-year-old female, acquired in Oregon. A total of 14 worms were removed from the patient's left eye and were morphologically identified as being Thelazia gulosa. Until now, only two species of Thelazia have been implicated in causing human disease, Thelazia callipaeda in Asia and Europe and occasional reports of Thelazia californiensis from the United States of America. Here, we describe a third, previously unreported parasite of humans, T. gulosa (the cattle eyeworm) as an agent of human thelaziasis and the first reported case of human thelaziasis in North America in over two decades.

The Impact of Changes in Medicare's Physician Payment System on Critical Care.

In 2015 President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) which repealed the Sustainable Growth Rate (SGR) mechanism for Medicare physician reimbursement and mandated that CMS develop alternative payment methodologies to "reward health care providers for giving better care not more just more care." MACRA makes 3 major changes to Medicare reimbursements: (1) it ends the SGR formula; (2) it establishes a new framework to reward physicians based on performance and health outcomes rather than volume; and (3) it aims to combine existing quality reporting programs into one streamlined system. Beginning in 2019, physicians must enter one of two new tracks for payment: the Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). SCCM has a unique opportunity as the largest multidisciplinary critical care organization to comment upon and, ideally, to help develop the new physician payment models specifically for critical care services. The time is now for SCCM and its individual members to become involved in the process.

Effect of circadian variability in frequency of premature ventricular complexes on left ventricular function.

BACKGROUND: Frequent idiopathic premature ventricular complexes (PVCs) can result in a reversible form of cardiomyopathy. OBJECTIVE: The purpose of this study was to assess the impact of variability in PVC frequency throughout the day on PVC-induced cardiomyopathy. METHODS: The subjects of this study were 107 consecutive patients (58 men [54%]; mean age 49.7 ± 15.0 years; left ventricular ejection fraction 50.4% ± 11.4%) referred for ablation of frequent PVCs. All patients underwent 24-hour Holter monitoring before the ablation procedure. The circadian variation in PVC burden was determined and correlated with the presence or absence of cardiomyopathy. RESULTS: A total of 43 patients (40%) had cardiomyopathy. Patients with cardiomyopathy had an ejection fraction of 38.4% ± 6.9%, a higher PVC burden (28.5% ± 11.5% vs 19.5% ± 10.5%; P = .0001), less variability in circadian PVC distribution (coefficient of variation hourly: 31.5% ± 21% vs 59.8% ± 32.4%; P = .0001), and more frequent interpolated PVCs (20 patients [47%] vs 15 patients [23%]; P = 0.022), and were more frequently asymptomatic than patients without cardiomyopathy (56% vs 19%; P = .0001). In multivariate analysis, consistency in PVC burden throughout the day was an independent predictor of PVC-induced cardiomyopathy (odds ratio 16.3; 95% confidence interval 1.7-155.3; p = 0.015). CONCLUSION: In patients with frequent PVCs, consistency in hourly PVC frequency throughout the day is an independent predictor of PVC-induced cardiomyopathy.

Outcome of percutaneous coronary intervention following recent surgery.

Outcome data regarding postoperative acute coronary syndrome treated with percutaneous coronary intervention (PCI) are limited. The objective of this study was to determine clinical outcomes of patients undergoing PCI within 7 days after a surgical procedure. We assessed outcomes of 517 patients who underwent PCI within 7 days after a surgery across 44 hospitals from January 2010 to December 2011 from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry. Patients with postoperative PCI were compared with all other patients with PCI using propensity-matched analysis. Of the 65,175 patients who underwent PCI within the study period, 517 patients had undergone surgery within the previous 7 days. In unadjusted analysis, patients with postsurgical PCI had higher in-hospital mortality (6.96% vs 1.33%), stroke (0.96% vs 0.26%), bleeding events (6.96% vs 2.6%), heart failure (6.96% vs 2.36%), and cardiogenic shock (7.16% vs 1.95%). After propensity matching, mortality remained higher in postsurgical patients (6.5% vs 3.96%, odds ratio 1.7 [1.1 to 2.6], p = 0.02). The odds of mortality were especially high among patients who would otherwise be considered low risk (<1% of predicted mortality in a nonsurgical setting) in whom a recent surgery was strongly associated with death (odds ratio 5.7, p = 0.02). In conclusion, PCI performed within 7 days after a surgical procedure is associated with an increased risk of early mortality. Although some of this increased risk is related to an adverse clinical profile, higher mortality is also observed in patients otherwise considered low risk for PCI.

Remote ischemic preconditioning immediately before percutaneous coronary intervention does not impact myocardial necrosis, inflammatory response, and circulating endothelial progenitor cell counts: a single center randomized sham controlled trial.

AIMS: Percutaneous coronary intervention (PCI) is frequently accompanied by myocardial injury. The present study was performed to determine whether remote ischemic preconditioning (IP) induces cardioprotection during PCI. METHODS: We enrolled 95 patients requiring nonemergency PCI for stable disease or unstable angina into this prospective clinical trial. Patients were randomized to either remote IP (induced by three 3-min cycles of blood pressure cuff inflations to 200 mm Hg around the upper arm, followed by 3-min of reperfusion n = 47) or sham control (n = 48) immediately preceding PCI. The primary outcome measure was the frequency of post-PCI myonecrosis, defined as a peak postprocedural cTnT T ≥ 0.03 ng/dL. Secondary outcome measures were the change in plasma high-sensitivity C-reactive protein (hsCRP) levels following PCI and in endothelial progenitor cells (EPC) counts following IP. RESULTS: There was no difference in the primary endpoint of the frequency of PCI related myonecrosis which occurred in 22 (47%) and 19 (40%) patients in the remote IP and control groups, respectively, P = 0.42. There was significant increase in hsCRP post-PCI in both groups (P < 0.001), but there was no difference between the groups (median %change in hsCRP 46% vs. 54%, P = 0.73). There was no significant change in circulating early (CD34 -/CD133+/KDR+), intermediate (CD34+/CD133+/KDR+), or late (CD34+/CD133-/KDR+) EPC in the two groups immediately following IP. The composite rate of death, myocardial infarction, and target lesion revascularization at 1 year was 14.1% versus 13.7% (P = 0.90). CONCLUSIONS: Our study indicates that remote IP immediately before PCI does not induce cardioprotection in low to moderate risk patients.

Drug-Eluting Stents Versus Bare Metal Stents in Saphenous Vein Graft Intervention.

Percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) is associated with higher adverse event rates, lower procedural success, and inferior longterm patency rates compared with native vessel PCI. The ability to comply with dual antiplatelet therapy, and whether the patient will need an interruption in dual antiplatelet therapy, should be considered when deciding whether to implant a drug-eluting stent (DES) or bare metal stent (BMS) in an SVG. DES should be used for SVG PCI because they seem to reduce target vessel revascularization. This article reviews the evolution and contemporary evidence regarding use of DES versus BMS in SVG PCI.

Left anterior descending artery length and coronary atherosclerosis in apical ballooning syndrome (Takotsubo/stress induced cardiomyopathy).

BACKGROUND: A proposed etiology of apical ballooning syndrome (ABS) is a spontaneously aborted anterior myocardial infarction (MI) in patients with a long "wrap around" left anterior descending artery (LAD) rather than it being a unique cardiomyopathy. The aim of this study was to evaluate whether patients with ABS have a higher frequency of "wrap around" LAD. METHODS: A retrospective analysis of the coronary anatomy and presence of coronary artery disease (CAD) by angiography was performed among 97 ABS patients, and compared to a matched control group with anterior ST-elevation MI. LAD length was graded: type 1--does not supply the left ventricular (LV) apex, type 2--the LAD and right coronary both supply the apex, type 3--supplies the entire apex, and type 4--supplies the apex and >25% of the inferior wall (wrap around). RESULTS: ABS patients had lower ejection fractions at presentation (41% ± 14% vs 47% ± 13%, p=0.001). There was no difference in the frequency of the 4 types of LAD between ABS (7%, 11%, 55%, 27%) and controls (3%, 13%, 51%, 33%), p=0.45. In ABS, there was no difference in the mean LV ejection fraction (32.7%, 38.8%, 42.9%, 41.1%, respectively, p=0.39), or wall motion score index at presentation in the 4 LAD groups. The prevalence of angiographic CAD in ABS was 84%. CONCLUSIONS: ABS patients do not have a higher frequency of "wrap around" LAD. This fact, together with a greater magnitude of LV dysfunction at presentation, supports that cardiomyopathy is not due to spontaneously aborted anterior MI.