A Case of Trauma-Related Angioedema of the Airway in a Patient on an Angiotensin Receptor Blocker.

BACKGROUND Angioedema is non-pitting edema that occurs in the deep layers of the skin and subcutaneous tissue due to vascular leakage of plasma resulting from 1 of 2 major pathophysiological processes: mast cell-mediated angioedema and bradykinin-mediated angioedema. While it is a well-recognized adverse reaction of angiotensin-converting enzyme inhibitors, the association of angioedema with angiotensin receptor blockers is relatively less studied. Direct local trauma, although rarely, has been suggested to induce angioedema under certain conditions. We present a unique case of direct, local, trauma-related angioedema in a patient on an angiotensin receptor blocker. CASE REPORT The patient, an 83-year-old woman on telmisartan for hypertension, hit her neck against the edge of a chair during a fall. Shortly thereafter, she developed progressive airway compromise due to airway angioedema, as noted on direct laryngoscopy. A contrast CT scan of the neck also noted edema of the periglottic and supraglottic regions. She required intravenous corticosteroid administration and intubation in the emergency room and was successfully extubated 3 days after admission. She had no prior history of angioedema or allergy. We hypothesize that increased levels of circulatory bradykinin in the setting of telmisartan, combined with a local release of bradykinin from trauma, was the main pathophysiologic cause of the angioedema. CONCLUSIONS This case report highlights the rare and often forgotten adverse reaction of angioedema with use of angiotensin receptor blockers and confirms the finding of local trauma as a possible trigger.

The impact of comorbidities and sociodemographic predictors on pneumococcal vaccination coverage in adults with coronary heart disease.

Aim: Coronary heart disease (CHD) increases the risk of adverse outcomes from invasive pneumococcal disease. Methods: Using the 2020 and 2021 data from the national health interview survey, we identified adults with CHD. Chi-square analysis and logistic regression were used to examine factors that influence vaccination status. Results: There were 2675 participants aged 41 and above with CHD. Participants were predominantly white people (82.5%) and males (60.1%). The odds of receiving the pneumococcal vaccine increased with stepwise increase in comorbidities from 1 to 2 and from 2 to 3. Among individuals with ≥2 comorbidities, black people were less likely to be vaccinated compared with white people. Conclusion: Pneumococcal vaccine uptake among adults with CHD is determined by cumulative comorbidities and ethnicity.

Recurrent thromboembolism due to direct oral anticoagulation interruption postpericardial window for a hemopericardium.

We present a female patient with a history of systolic heart failure with an ejection fraction of 25-30%, and unprovoked pulmonary embolism on extended anticoagulation therapy with rivaroxaban who underwent a pericardial window for cardiac tamponade due to hemopericardium in the setting of direct oral anticoagulant (DOAC). The rivaroxaban was held following the pericardial window, and she experienced another episode of pulmonary embolism before the rivaroxaban could be restarted. Currently, there are no guidelines on when to restart anticoagulation postpericardial window for DOAC-associated hemopericardium. Studies are needed to help solve this dilemma.

We present a female patient with a history of systolic heart failure which means their left ventricle was unable to pump blood efficiently. They also have a history of an unprovoked disruption in the flow of blood in the pulmonary arteries or its branches, known as a pulmonary embolism. The patient was on direct oral anticoagulation medication to thin their blood, promoting efficient blood flow and minimizing the risk of clots and blockages. While on this medication, the patient developed a significant collection of blood around the heart, so the medication was withheld and the blood collection was drained. She developed another episode of pulmonary embolism before the medication could be restarted. Healthcare providers need guidance on when to restart anticoagulation medications in these types of patients.

Cannabinoid Hyperemesis Syndrome in a 23-Year-Old Woman with Uncontrolled Type 1 Diabetes Mellitus.

BACKGROUND Patients with type 1 diabetes mellitus may experience gastrointestinal symptoms, including those suggestive of diabetic gastroparesis. Cannabinoid hyperemesis syndrome (CHS) includes nausea, vomiting, and abdominal pain in the setting of chronic cannabinoid use. This report presents a case of CHS in a 23-year-old woman with uncontrolled type 1 diabetes mellitus. CASE REPORT A 23-year-old woman with chronically uncontrolled type 1 diabetes mellitus had been presenting monthly at the emergency department for the last 2 years, for acute bouts of intractable nausea and vomiting, occasionally with abdominal pain. Given her history of uncontrolled diabetes, she had been managed for diabetic gastroparesis with prokinetics. A gastric emptying study 6 months prior to admission was normal, and the patient had had multiple unremarkable abdominal computed tomography imaging scans. On this admission, she benefitted from supportive management with only temporary improvement of symptoms. On further questioning, she reported consistent use of cannabis for the last few years, and regression of acute vomiting with hot baths at home. With counseling, she ceased cannabis for 2 months and was symptom-free during this period. CONCLUSIONS This report has shown the importance of taking a comprehensive drug history in all patients, including in patients with type 1 diabetes, and is a reminder that cannabinoid use can cause severe nausea, vomiting, and abdominal pain in this patient group.

The impact of multiple regions of pain and work-life balance among healthcare workers.

BACKGROUND: Although the association of chronic pain (CP) with a poor work-life balance has been well studied, the interaction effect of multiple pain sites on work-life balance is unknown. OBJECTIVE: To evaluate the most prevalent CP site among healthcare workers, the demographic characteristics of the individuals with the predominant pain type, and to assess the interaction of multiple pain sites on work-life balance. METHODS: Using data from the National Health Interview Survey, 2,458 healthcare works were identified for this study. The independent variables were chronic low back and hip pain. The dependent variables were (1) if pain affected their family or significant other, (2) if pain limited their life or work activities, and (3) Usually working >35 hours/week. Multiple logistic regression and an interaction analysis were used to analyze the impact of different pain sites on work-life balance. RESULTS: Among healthcare workers, chronic low back pain was more prevalent than chronic hip pain (69.4% vs 61.4%, p-value<0.001). Respondents with chronic low back pain were mostly 40 - 64 years of age (49.6%), females (71.2%), white (77.6%), married (55.5%), had no college degree (85.4%), earn greater than $75,000 (50.0%). In the interaction analysis, in the presence of chronic hip pain, those with chronic low back pain had an AOR of 2.20 (1.05 - 4.64), p-value 0.038 of chronic low back pain affecting their family and significant others, and an AOR of 2.18 (1.17- 4.05), p-value 0.014 of chronic low back pain affecting their life or work. CONCLUSION: Chronic low back pain was more prevalent than chronic hip pain among healthcare workers. Together both pain sites had a significant impact on the work-life balance of this population. Further studies should assess other dimensions of work-life balance and chronic pain.

Endovascular Venous Interventions - A State-of-the-Art Review.

Venous vascular diseases are an important clinical entity estimated to affect several million people worldwide. Deep vein thrombosis (DVT) is a common venous disease with a population variable prevalence of 122 to 160 persons per 100,000 per year, whereas pulmonary embolism (PE) affects up to 60 to 70 per 100 000 and carries much higher mortality. Chronic venous diseases, which cause symptoms like leg swelling, heaviness, pain, and discomfort, are most prevalent in the elderly and significantly impact their quality of life. Some estimate that chronic vascular diseases account for up to 2% of healthcare budgets in Western countries. Treating venous vascular disease includes using systemic anticoagulation and interventional therapies in some patient subsets. In this comprehensive review, we discuss endovascular treatment modalities in the management of venous vascular diseases.

"The Spiked Helmet sign": A harbinger of impending barotrauma.

The 'spiked helmet sign' (SHS) is an electrocardiographic finding associated with critical illness and a high risk of death; It is likened to ST-elevation, leading to harmful coronary imaging despite lack of apparent myocardial infarction. We describe the case of SHS secondary to high ventilation pressures in the setting of Acute Respiratory Distress Syndrome (ARDS) in a critically ill patient who subsequently developed barotrauma.

A 3-year analysis of the impact of COVID-19 pandemic on NSTEMI incidence, clinical characteristics, management, and outcomes.

OBJECTIVE: The COVID-19 pandemic has been associated with decreased incidence of acute coronary syndrome with worsened outcomes. Few studies have addressed the effects beyond the initial phases of the pandemic. This study elucidated the incidence, clinical characteristics, management, and outcomes of NSTEMI at a tertiary referral center from sample time periods of 2019-2022. METHODS: This study included consecutive NSTEMI patients from March 14-May 9, 2019-2022. Variables included baseline characteristics, clinical features on arrival, management strategy, time parameters, and adverse outcomes. The primary outcome was defined as death, heart failure requiring diuretics, and/or sustained ventricular arrhythmia. RESULTS: This study comprised 250 patients of whom 181 who were admitted during the COVID-19 outbreak. Baseline characteristics were similar among groups. There was a reduction in door-to-angiography time from 29 h in 2019 to 19 h in 2020 [p = 0.01] and 20 h in 2021 [p = 0.02]. PCI intervention increased from 31.8% in 2019% to 50.0% in 2020 [p = 0.05] and 54.7% in 2021 [p < 0.01]. Median length-of-stay (LOS) was reduced from 3 days in 2019 to 2 days in 2020 [p = 0.03]. There was no significant change in outcomes in COVID-19 cohorts compared to control year. CONCLUSIONS: NSTEMI patients during the first 2 years of the COVID-19 pandemic were associated with reduced door-to-angiography times and increased percutaneous coronary intervention (PCI), and patients in year one were associated with reduced LOS. This study suggests that NSTEMI may be managed more efficiently thus reducing hospital bed utilization and potential costs.

The top 100 cited articles on spontaneous coronary artery dissection: a bibliometric analysis.

Aim: This study identifies the most cited papers on spontaneous coronary artery dissection and evaluates their focus and the characteristics of the current literature. Methods: The Web of Science database was queried for publications between 1971 and 2021. The articles were ranked from the most to the least citations, and each was reviewed by two authors. Results: The total citations ranged from 44 to 457, with a median (interquartile range) citation of 78.5 (60-140). Females were 28% of the first authors, about half the papers (52/100) were published in the last decade, most were observational studies (78/100) and the rest were nonoriginal studies. The impact factor of the journal weakly correlated with the number of citations (r [98] = 0.24; p = 0.018). Conclusion: Efforts are needed to encourage female authorship and increase the quality of articles in this subject area.

This study characterizes articles on spontaneous coronary artery dissection with the most interactions. This was achieved by searching an online database for all such articles. We were particularly interested in publications between 1971 and 2021. These articles had a citation count ranging from 44 to 457. Females were underrepresented in the list of first authors of these articles, and most of these articles were published within the last decade and were observational studies. There was a weak positive relationship between the impact factor of the journals these articles were published in and the citation count. Efforts are needed to encourage female authorship and increase the quality of articles in this subject area.

The association between health information technology and influenza vaccine uptake among adults with heart disease.

Aim: Assess the association of health information technology (HIT) on influenza vaccine (IV) uptake among adults with heart disease. Methods: The association of four different uses of HIT - (1) look up health information, (2) schedule medical appointments, (3) refill prescriptions online and (4) communicate with healthcare providers on IV uptake - was analyzed using multiple logistic regression. Results: Adults with heart disease who use the internet to look up information (adjusted odds ratio [AOR] = 1.48, 95% CI: 1.39-1.59; p < 0.001), fill up prescription (AOR = 1.87, 95% CI: 1.69-2.06; p < 0.001), and communicate with a healthcare provider (AOR = 1.95, 95% CI: 1.23-3.10; p = 0.005) had a higher uptake of IV unlike those who did not. Conclusion: Using the internet in patient-healthcare system engagement via HIT was associated with increase IV uptake. Future studies should assess the impact of population-level variables on this relationship.

To evaluate the association between use of the internet to interact with the healthcare system and the likelihood of taking the flu shot among adults with heart disease. We were interested in how using the internet to communicate with a health provider, look up health information, schedule medical appointments, and refill a prescription increase influenza vaccine (IV) uptake. Only use of the the internet to look up information, fill up prescription, and communicate with a healthcare provider were associated with an increase uptake of the vaccine. Using the internet to engage the healthcare system was associated with an increase of IV uptake. Further research should evaluate the effect of insurance and socioeconomic status on this relationship.

Venous Thromboembolism Prophylaxis in Inflammatory Bowel Disease: A Two-year Retrospective Study of Patients Presenting With Inflammatory Bowel Disease to a Community Hospital.

Objective We set out to determine the rate of pharmacological venous thromboembolism (VTE) prophylaxis among patients admitted with inflammatory bowel disease (IBD) and indirectly compare it to national trends. We also assessed the demographic and clinical correlates for non-prescription of pharmacologic VTE prophylaxis among IBD patients with and without a flare. Methods We extracted data from 123 patients admitted to our facility with IBD from September 2018 to August 2020 retrospectively. Out of this cohort, 26 patients were excluded and 96 were included in our analysis. Baseline characteristics were analyzed using descriptive statistics. Multiple logistic regression was used to evaluate the correlates of pharmacological VTE prophylaxis use in individuals with IBD and to analyze the predictors of VTE prophylaxis use in patients with IBD flares. Results Out of the 96 patients with IBD included in this study, 61 (63.5%) presented with an IBD flare, and among those with a flare, 26/61 (42.6%) received VTE prophylaxis. IBD patients aged ≥ 65 years and of Black race were less likely to be placed on pharmacological VTE prophylaxis (adjusted odds ratio (AOR) 0.20, 95% CI (0.06 - 0.70), p-value 0.012) and (AOR 0.16, 95% CI (0.05 - 0.50), p-value 0.002) respectively. Among those with a flare, the presence of bright red bleeding per rectum was associated with a low rate of pharmacologic VTE use (AOR 0.01, 95% CI (0.00 -1.78), p-value 0.001). Overall the rate of VTE prophylaxis use in the IBD patient cohort was 56.3% and this was irrespective of flare status. Conclusion Our study showed the low rate of pharmacologic VTE prophylaxis use in IBD patients at this center and this finding was in line with national trends. Interestingly age and the race of patients played a major role in the decision to provide pharmacological VTE prophylaxis but the reason for this finding was not explored by our study. A larger multi-center study is needed to further evaluate these relationships.

Prevalence and Outcomes in STEMI Patients Without Standard Modifiable Cardiovascular Risk Factors: A National Inpatient Sample Analysis.

To evaluate the in-hospital mortality and acute STEMI-related complications in a SMuRF-less STEMI population compared with a SMuRF STEMI population in the United States. The National Inpatient Sample (NIS) Database (2005-2014) was analyzed to identify patients with STEMI using ICD-9. Patients were grouped into SMuRF and SMuRF-less based on the presence of ≥1 SMuRF risk factor. The primary outcomes were the prevalence and in-hospital mortality of SMuRF-less patients. Secondary outcomes were rates of in-hospital complications in STEMI patients. A total of 434,111 STEMI patients were identified with 318,281 (73.4%) and 115,830 (26.6%) patients in the SMuRF and SMuRF-less categories, respectively. In multivariable logistic regression analysis, SMuRF-less patients had a higher in-hospital mortality rate (odds ratio [OR]: 1.670; 95% confidence interval [CI]: 1.620-1.722) and acute renal failure (OR: 1.724; 95% CI: 1.662-1.787). SMuRF-less STEMI patients have higher odds of in-hospital mortality and in-hospital STEMI-related complications compared with SMuRF STEMI patients.

The top 50 most cited articles on cardiac tumors: a bibliometric analysis.

Aim: We evaluated the characteristics of the top 50 most cited articles on cardiac tumors using bibliometric analysis. Method: Independent reviewers queried the Web of Science database for articles within the past 50 years. Results: Most articles were published between 1991 and 2016, 18% (9/50) of the first authors were women, 52% (26/50) of the articles were focused on cardiac imaging in addition to other aspects of cardiac tumors and only 61.5% (16/26) of these were focused purely on cardiac imaging. A journal's impact factor and the number of citations of an article were positively correlated, r(48) = 0.24, p = 0.048. Conclusion: This study presents insight into the top 50 most cited articles on cardiac tumors and provides guidance for future research.

We assessed the authorship characteristics, types of articles, and the relationship between the citation counts of the articles, and the academic importance of the journal in which the top 50 articles were published. Two authors searched separately an online database for the top 50 articles published. The top 50 articles were published between 1991 and 2016, two in five first authors were women, most of the articles were on cardiac imaging, and an article was more likely to be cited if it was published in a journal with a high academic importance. This study shows us that few women are authors in this academic area and researchers should explore other aspects of cardiac tumors.

The Role of Health Information Technology in Pneumococcal Vaccination Uptake Among Adults with Heart Disease.

Background:Health information technology (HIT) may influence pneumococcal vaccination uptake in high-risk populations. This study assessed the association of HIT utilization on pneumococcal vaccine (PCV) uptake among adults ≥40 years with heart disease.Methods:This was a cross-sectional study of 2,134 individuals representing 16,813,593 United States adults ≥40 years with heart disease using the National Health Interview Survey data. The independent variables were use of the Internet to (1) look up health information, (2) fill a prescription, and (3) schedule a medical appointment, and use of an e-mail (4) communicate with a health care provider. The dependent variable was PCV uptake. Chi-square analysis was used to evaluate group differences, and a multiple logistic regression was used to analyze the association between HIT utilization and PCV uptake.Results:Those who use the Internet to fill up a prescription and to communicate with their health care provider were more likely to take up the PCV (adjusted odds ratio [AOR] 1.56; 95% confidence interval [CI] 1.03-2.37, p = 0.035) and (AOR 1.95; 95% CI 1.23-3.10, p = 0.005) respectively. Compared with those who did not use HIT in any form, those who used HIT in at least three or four forms had a higher PCV uptake (AORs 1.93; 95% CI 1.19-3.13, p = 0.008) and (AOR 2.33 95% CI 1.22-4.47, p = 0.011) respectively.Conclusion:Our analysis shows a positive association of HIT utilization and PCV uptake. It further stresses the importance of electronic health in preventive medicine. This implies that HIT can be used purposively in other aspects of preventive health. Larger studies should evaluate the relationship between different uses of HIT and the uptake of different vaccines.

COVID-19 associated collapsing glomerulopathy presenting as acute kidney injury on chronic kidney disease: a case report and review of the literature.

Traditionally collapsing glomerulopathy (CG) is associated with medications, autoimmune disease, viral infection and the APOL1 gene variant seen in blacks/African Americans. Most reported cases of acute kidney injury (AKI) in COVID-19 infected individuals have been in individuals without prior CKD. In this report, we present a 49-year-old African American female with a past medical history of chronic kidney disease (CKD) stage 4, hypertension, type 2 diabetes mellitus, recent COVID-19 infection, and a repeat positive blood test for COVID-19 more than 21 days after the initial result, who presented with an AKI on CKD. Renal biopsy revealed a collapsing glomerulopathy. She was started on hemodialysis and did not receive immunosuppressive therapy due to the advanced scaring seen on the renal biopsy. Concerning the pathophysiology of COVID-19-associated CG, researchers have postulated different mechanisms such as a direct cytopathic effect of the virus on podocytes, immune dysregulation, and fluid imbalance. This is one of a few cases of AKI on CKD due to CG related to COVID-19. The mechanism of CG was, however, unclear. Currently, there is no specific interventions to prevent the development of CG in patients with COVID-19 infection. Further studies should investigate measures to prevent the development of CG.

The top 100 Twitter influencers in cardiology.

IMPORTANCE: Twitter represents a growing aspect of the social media experience and is a widely used tool for public education in the 21st century. In the last few years, there has been concern about the dissemination of false health information on social media. It is therefore important that we assess the influencers of this health information in the field of cardiology. OBJECTIVE: We sought to identify the top 100 Twitter influencers within cardiology, characterize them, and examine the relationship between their social media activity and academic influence. DESIGN: Twitter topic scores for the topic search "cardiology" were queried on May 01, 2020 using the Right Relevance application programming interface (API). Based on their scores, the top 100 influencers were identified. Among the cardiologists, their academic h-indices were acquired from Scopus and these scores were compared to the Twitter topic scores. RESULT: We found out that 88/100 (88%) of the top 100 social media influencers on Twitter were cardiologists. Of these, 63/88 (72%) were males and they practiced mostly in the United States with 50/87 (57%) practicing primarily in an academic hospital. There was a moderately positive correlation between the h-index and the Twitter topic score, r = +0.32 (p-value 0.002). CONCLUSION: Our study highlights that the top ranked cardiology social media influencers on Twitter are board-certified male cardiologists practicing in academic settings in the US. The most influential on Twitter have a moderate influence in academia. Further research should evaluate the relationship between other academic indices and social media influence.

Contained Rupture of a Small Mycotic Abdominal Aneurysm in a Patient With Infective Endocarditis.

A contained ruptured mycotic abdominal aneurysm is one of the complications of infective endocarditis. It is a complication that physicians should entertain when patients with infective endocarditis present with a complaint of back pain. This case report aims to increase the awareness of the possibility of a rupture of a small size abdominal mycotic aneurysm. This is a 36-year-old female with a history of intravenous (IV) drug use and infective endocarditis secondary to methicillin-sensitive Staphylococcus aureus presented with acute right-sided lower back pain. Work-up revealed a contained ruptured 2.5 cm mycotic abdominal aneurysm. She had an open surgical repair of the abdominal aorta followed by a mitral valve replacement a week later and she was discharged home on antibiotics and an anticoagulant. Untreated, a mycotic aneurysm can expand quickly and has a higher likelihood of rupturing as compared to an atherosclerotic abdominal aortic aneurysm. A contained ruptured mycotic abdominal aneurysm can lead to a dramatic hemodynamic compromise when it becomes uncontained, hence it is prudent that it is acted after it is diagnosed. Most authors recommend prompt surgery for all patients irrespective of the size of the aneurysm. Younger age is a factor to consider in choosing a repair approach despite the complications associated with both open surgical and endovascular repair.

Pleural and Pericardial Infection Due to Cutibacterium acnes in a Splenectomized Patient: A Case Report of an Underreported Systemic Infection.

Infectious pericarditis does not always present with all the classic findings. Some of the traditional signs of fever, pleuritic chest pain, and frictional rub may be missing. This presents a diagnostic challenge, thus clinical suspicion is important. The most common cause of infectious pericarditis is viral. However, bacterial pericarditis may occur with severe complications such as constrictive pericarditis, pericardial effusion, cardiac tamponade, left ventricular pseudoaneurysm, and aortic mycotic aneurysm. The purpose of this presentation is to increase awareness of Cutibacterium acnes (C. acnes) as a cause of bacterial pericarditis. This case report highlights C. acnes as a prevalent cause of both pleural and pericardial infections. The diagnosis can be challenging, considering that this bacterium is difficult to isolate, slow growing, and causes indolent illness. Prolonged incubation time may be required. In addition to the more traditional causes of bacterial pericarditis, namely Staphylococcus and Streptococcus species, C acnes appears to play an important role. It should not be considered a contaminant as it may require further investigation.