Late thrombosis of Gore Cardioform septal occluder device in a patient with history of patent foramen ovale closure.

Patent foramen ovale (PFO) is a flaplike opening in the fossa ovalis; between the septum primum and secundum. It is highly prevalent with approximately 25% of the population having a PFO. It is usually asymptomatic but can rarely cause paradoxical embolism leading to stroke and/or significant right to left shunting causing hypoxia. The complications of PFO closure with a percutaneous device include embolization, cardiac perforation, and thrombosis. These are all early complications. We describe the case of a patient with a history of PFO closure who had device thrombosis 3 years after implantation. Management includes anticoagulation with warfarin. Repeat cardiac imaging to document the resolution of thrombosis is recommended.

Is Concomitant Mitral Stenosis Associated With Worse Outcomes in Patients Who Underwent TAVR? Insights from a National Database.

Concomitant mitral stenosis (MS) is present in 10% to 15% of all patients who underwent transcatheter aortic valve replacement (TAVR). Our aim is to assess outcomes of TAVR in patients with MS using a national database. The Nationwide Inpatient Sample database was used to identify patients who underwent TAVR from 2015 to 2020. We created 2 groups, patients with and those without MS. We then compared baseline characteristics, demographics, and in-hospital outcomes of the groups. Primary outcomes were in-hospital mortality, acute respiratory failure, and pacemaker placement. Secondary outcomes were length of stay and in-hospital costs. Our study indicates that patients with MS had greater incidence of acute respiratory failure (8.8% vs 4.89%, p = 0.001), complete heart block (13.54% vs 9.36%, p = 0.01), and permanent pacemaker placement (8.03% vs 6.03%, p = 0.05). In-hospital mortality was greater in the MS group; however, it was not statistically significant (1.32% vs 1.53%, p = 0.679).

Disparities in Acute Coronary Syndrome Outcomes in Individuals With Intellectual Disabilities: A Propensity-Matched Analysis of National Inpatient Sample.

BACKGROUND: Individuals with intellectual disabilities (IDs) are at similar risk of acute coronary syndrome (ACS) as compared to general population. However, there is a paucity of real-world data evaluating outcomes of ACS in this population. We sought to study ACS outcomes in individuals with IDs using a large national database. METHODS: Adult admissions with a primary diagnosis of ACS were identified from the national inpatient sample of years 2016-2019. Cohort was stratified according to presence of IDs. A 1 to 1 nearest neighbor propensity score matching using 16 patient variables. Outcomes evaluated were in-hospital mortality, coronary angiography (CA), timing of CA (early [day 0] vs. late [>day0]), and revascularization. RESULTS: A total of 5110 admissions (2555 in each group) were included in our matched cohort. IDs admissions had higher rates of in-hospital mortality (9 % vs. 4 %, aOR: 2.84, 95 % CI [1.66-4.86], P < 0.001), and were less likely to receive CA (52 % vs. 71 %, aOR: 0.44, 95 % CI [0.34-0.58], P < 0.001) and revascularization (33 % vs. 52 %, aOR: 0.45, 95 % CI [0.35-0.58], P < 0.001). In-Hospital mortality was higher in the ID admissions whether invasive coronary treatment (CA or revascularization) was performed (6 % vs. 3 %, aOR: 2.34, 95 % CI [1.09-5.06], P = 0.03) or not (13 % vs. 5 %, aOR: 2.56, 95 % CI [1.14-5.78], P = 0.023). CONCLUSION: Significant disparities exist in ACS outcomes and management in individuals with IDs. More research is needed to understand the reasons for these disparities and develop interventions to improve quality of care in this population.

Advances in viral oncolytics for treatment of multiple myeloma - a focused review.

INTRODUCTION: Oncolytic viruses are genetically engineered viruses that target myeloma-affected cells by detecting specific cell surface receptors (CD46, CD138), causing cell death by activating the signaling pathway to induce apoptosis or by immune-mediated cellular destruction. AREAS COVERED: This article summarizes oncolytic virotherapy advancements such as the therapeutic use of viruses by targeting cell surface proteins of myeloma cells as well as the carriers to deliver viruses to the target tissues safely. The major classes of viruses that have been studied for this include measles, myxoma, adenovirus, reovirus, vaccinia, vesicular-stomatitis virus, coxsackie, and others. The measles virus acts as oncolytic viral therapy by binding to the CD46 receptors on the myeloma cells to utilize its surface H protein. These H-protein and CD46 interactions lead to cellular syncytia formation resulting in cellular apoptosis. Vesicular-stomatitis virus acts by downregulation of anti-apoptotic factors (Mcl-2, BCL-2). Based upon the published literature searches till December 2020, we have summarized the data supporting the advances in viral oncolytic for the treatment of MM. EXPERT OPINION: Oncolytic virotherapy is an experimental approach in multiple myeloma (MM); many issues need to be addressed for safe viral delivery to the target tissue.

Patterns of Hepatocellular Carcinoma After Direct Antiviral Agents and Pegylated-Interferon Therapy.

INTRODUCTION:  The impact of direct-acting antiviral agents (DAAs) on the development of hepatocellular carcinoma (HCC) is controversial and a part of the scientific community believes it as a biased interpretation of data. Many studies have reported an aggressive pattern of HCC after DAA use. In this study, we attempted to assess the changes in the pattern of HCC after treatment with DAAs or PI (PEG, pegylated-interferon). METHODS:  A total of 37 HCC patients after DAA treatment and 21 HCC patients after PI treatment were included. The diagnosis of HCC was made and information about demographics, HCC infiltrative pattern, portal vein thrombosis (PVT), time at initial presentation, Child-Turcotte-Pugh (CTP) score, and Barcelona Clinic Liver Cancer (BCLC) stage were compared in the two groups. RESULTS:  The total number of male patients in the DAA group was 62% while either gender was almost equal in PI. The age group of 40-60 was more prevalent in the DAA group while the PI group comprised more patients who were above 60 years. Patients in the DAA group presented after 3.35 years on average while patients in the PI group presented after about seven years. Most of the patients presented with the CTP stage of A. That is true for both groups. For BCLC staging, most of the patients had stage C, which means multiple lesions. At the initial presentation, most of the patients presented with multifocal lesions. CONCLUSION:  Our study found no significant difference in the initial presentation between both groups. However, HCC patients with prior DAA therapy presented early than those with PI therapy.

COVID-19 and Its Psychological Impacts on Healthcare Staff - A Multi-Centric Comparative Cross-Sectional Study.

Background Since the first case of coronavirus disease-19 (COVID-19) in Pakistan was reported in February 2020, the medical and paramedical staff has been working on the frontlines to deal with this disease. They have been facing significant strain and stress due to the pandemic, affecting their social, mental, and personal life. The purpose of this study is to investigate the psychological effects of the COVID-19 pandemic, etiology, personal coping mechanisms, and the strategies that are being adopted to reduce stress by the healthcare workers (HCWs) working in COVID-19 dedicated wards (group 2) and compare it with staff working in other departments but not in COVID-19 wards amid this pandemic (group 1) in various hospitals of Lahore, Pakistan. Methods The comparative cross-sectional study was designed which included doctors, nurses, and allied health professionals from various hospitals of Lahore, Pakistan. A questionnaire was designed which consisted of five sections, and 51 questions. A Chi-square test was used to compare the responses between these two groups. Results The study questionnaire was submitted by 200 participants, 100 responses for each group (see the Appendix). In group 1, HCWs not working in COVID-19 dedicated floors were afraid of getting infected, transmitting the infection to their families and concerned about using personal protective equipment (PPE) improperly. They reported a lack of concentration and tense muscles. The coping mechanisms of this group were exercise, strict precautions at work, and social distancing measures. While HCWs serving in COVID-19 dedicated wards were concerned and afraid of putting their families at risk by working in the high-risk environment; the major stresses in this group were: lack of knowledge about proper strategies for treatment, they faced insecurity due to physical and verbal violence by caretakers of COVID-19 patients, and lack of concentration. The coping mechanism was the support of their families and taking strict precautions, with self-isolation if required, to avoid any disease transmission to their families. The proposed strategies to be implemented included teaching skills for self-rescue as well as the implementation of policies at the administrative level to reduce working hours and frequent shift rotation. Conclusion The COVID-19 outbreak posed a great deal of mental stress among HCWs working on the COVID-19 floor as well as those serving in other departments of the hospital. The HCWs from group 1 were most afraid of getting infected and putting family members at risk, experienced tense muscles and lack of concentration, coped their stress by exercise and being more vigilant, and suggested the strategies of teaching skills for self-rescue and better community awareness. While the staff from the second group were most afraid of being the source of infection and violence from the caretakers of patients, experienced tense muscles, used family support, and strict isolation measures as coping mechanisms and suggested the strategies of self-rescue and increase in wages of directly exposed healthcare workers to deal with such pandemics in future in a better way.