Search

Luai Madanat,1 Melinda Sager,1 Daniel O’Connor,1 Bijaya Thapa,1 Nishant Aggarwal,1 Bipin Ghimire,1 Carl Lauter,1– 4 Gabriel N Maine,5,6 Matthew Sims,1,2,4 Alexandra Halalau1,4 1Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA; 2Infectious Diseases, William Beaumont Hospital, Royal Oak, MI, USA; 3Allergy and Immunology, William Beaumont Hospital, Royal Oak, MI, USA; 4Oakland University William Beaumont School of Medicine, Rochester, MI, USA; 5Pathology and Laboratory Medicine, William Beaumont Hospital, Royal Oak, MI, USA; 6Pathology, Oakland University William Beaumont School of Medicine, Rochester, MI, USACorrespondence: Luai Madanat, Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA, Tel +1 248-551-3000, Email Luai.madanat@beaumont.orgBackground: Antibody levels against SARS-CoV-2 can be used as an indicator of recent or past vaccination or infection. However, the prognostic value of antibodies targeting the receptor binding protein (anti-RBD) in hospitalized patients is not widely reported.Purpose: Determine prognostic impact of SARS-CoV-2 antibody quantification at the time of admission on clinical outcomes in hospitalized COVID-19 patients.Methods: We conducted a pilot observational study on patients hospitalized with SARS-CoV-2 infection to determine the prognostic impact of antibody quantitation within the first two days of admission. Anti-nucleocapsid IgG (anti-N) and Anti-RBD levels were measured. Anti-RBD level of 500 AU/mL was used as a cutoff to stratify patients. Spearman’s rank Coefficient (rs) was used to demonstrate association.Results: Of the 26 patients included, those who were vaccinated more frequently tested positive for Anti-RBD (100% vs 46.2%, P = 0.005) with higher median titer level (623 vs 0, P = 0.011) compared to unvaccinated patients. Anti-N positivity was more frequently seen in unvaccinated patients (53.9% vs 7.7%, P = 0.03). Anti-RBD levels > 500 were associated with lower overall hospital length of stay (LOS)(5 vs 10 days, P = 0.046). The analysis employing a Spearman Rank coefficient demonstrated a strong negative correlation between anti-S titer and LOS (rs=− .515, p = 0.007) and a moderate negative correlation with oxygen needs (rs =− .401, p = 0.042).Conclusion: Anti-RBD IgG levels were associated with lower LOS and oxygen needs during hospitalization. Further studies are needed to determine if levels on admission can be used as a prognostic indicator.Keywords: SARS-CoV-2, anti-RBD IgG, anti-nucleocapsid IgG, hospitalized patients, prognosis, outcomes

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide, and its prevalence is expanding owing to advanced age and higher rates of chronic heart disease.1 The standard treatment for stroke reduction in patients with nonvalvular AF is anticoagulation. However, alternative therapy may be advisable in a certain subset of patients, owing to either previous failure of oral anticoagulation or presence of contraindications to anticoagulation.1 The left atrial appendage has been identified as the primary site of thrombus formation in more than 90% of patients with AF.2 The PLAATO3 study in 2002 was the first to demonstrate the use of a device to occlude the left atrial appendage for stroke reduction in patients with AF and provided the fundamental ground for future development in that field. Since its publication several percutaneous left atrial appendage occlusion (LAAO) devices have been developed and tested, including the Watchman, Amulet, and LARIAT, among others.4 The Watchman (Boston Scientific, Marlborough, MA) is the most extensively studied and is the only FDA-approved percutaneous LAAO device currently available in the United States.5 More than 100,000 devices have been implanted since it gained its approval in 2015.6 LAAO devices are approved for use in patients with nonvalvular AF who are not candidates for long-term coagulation with comparable outcomes in terms of risk of stroke, bleeding, and cardiovascular complications.7,8 Percutaneous LAAO has also been used in patients with recurrent cardioembolic stroke while on oral anticoagulation.9 Implantation of any intracardiac device carries the risk of device thrombosis and infection. However, risk of LAAO device infection is low owing to complete endothelialization. Currently, there are no guidelines regarding prophylaxis of bacterial endocarditis with Watchman device placement. Similarly, management of LAAO device infections remains uncertain, with no clear guidelines. We report a case of a 74-year-old man with Watchman device infection that was managed conservatively with a long course of antibiotics without the need for surgical extraction. Key Teaching Points • Left atrial appendage occlusion devices, despite endothelialization, can carry a late risk of device-related infective endocarditis. • Review of literature suggests role of transesophageal echocardiogram in the diagnosis of left atrial appendage occlusion device infections. • While surgical extraction has been previously described, we report a case of successful antibiotic suppression at 6-month follow-up.

Abstract: In-stent restenosis (ISR) is a recognized complication following percutaneous coronary intervention in which the luminal diameter is narrowed through neointimal hyperplasia and vessel remodeling. Although rates of ISR have decreased in most recent years owing to newer generation drug-eluting stents, thinner struts, and better intravascular imaging modalities, ISR remains a prevalent dilemma that proves to be challenging to manage. Several factors have been proposed to contribute to ISR formation, including mechanical stent characteristics, technical factors during the coronary intervention, and biological aspects of drug-eluting stents. Presentation of ISR can range from asymptomatic to late myocardial infarction and could be difficult to differentiate from acute thrombus formation. No definite guidelines are present on the management of ISR. In this review, we will discuss the mechanisms underlying ISR and provide insight into patient-related and procedural risk factors contributing to ISR, in addition to highlighting common treatment approaches utilized in the management of ISR.

Abstract: Cardiotoxicity from chemotherapy regimens has been long reported. However, the understanding of cardiac side effects of biological therapies is rapidly evolving. With cancer patients achieving higher life expectancy due to the use of personalized medicine and novel targeted anticancer agents, the occurrence of cardiotoxicity is becoming more significant. Novel biological therapies include anti-HER2 antibodies, tyrosine kinase inhibitors, bruton kinase inhibitors, antivascular endothelial growth factors, proteasome inhibitors, immunomodulator drugs, and immune checkpoint inhibitors. Potential cardiovascular toxicities linked to these anticancer agents include hypertension, arrhythmias, QT prolongation, myocardial ischemia and infarction, left ventricular dysfunction, congestive heart failure, and thromboembolism. Cardiac biomarkers, electrocardiography, echocardiography and magnetic resonance imaging are common diagnostic modalities used for early detection of these complications and timely intervention. This review discusses the various types of cardiotoxicities caused by novel anticancer biologic agents, their molecular and pathophysiological mechanisms, risk factors, and diagnostic and management strategies that can be used to prevent, minimize, and treat them.

Background Congestive heart failure (CHF) readmissions are associated with substantial financial and medical implications. We performed a descriptive study to determine demographic, clinical, and behavioral factors associated with 30-day readmission. Materials and methods Patients hospitalized with CHF at William Beaumont Hospital in Royal Oak, MI, from March 2019-May 2019 were studied. Response to heart failure knowledge and self-care questionnaires along with the patients’ demographic and clinical factors were collected. Thirty-day readmission to any of the eight hospitals in the Beaumont Health System was documented. Results One-hundred ninety-six (196) patients were included. The all-cause 30-day readmission rate was 23%. A numerical higher rate of readmissions was observed among males (23.7% vs 22.2%), current smokers (27.3% vs 22.9%), and patients with peripheral vascular disease (PVD; 28.9% vs 21.2%), diabetes mellitus (DM; 26.4% vs 18.9%), hypertension (HTN; 26.4% vs 10%), coronary artery disease (CAD; 24.6% vs 19%), and prior history of cerebrovascular accident (CVA; 28.9% vs 21.2%) (p>0.05). Reduced left ventricular ejection fraction (LVEF) was associated with higher readmissions (24.4% vs 20.5%, p=0.801). Patients with the highest reported questionnaire scores corresponding to better heart failure knowledge and self-care behaviors at home were readmitted at a similar rate compared to those scoring in the lowest interval (25%, p=0.681). Conclusion Though statistically insignificant due to the limitations of sample size, a higher percentage of readmissions was observed in male patients, current smokers, reduced LVEF, and higher comorbidity burden. Better reported patient self-care behavior, medication compliance, and heart failure knowledge did not correlate with reduced readmission rates. While the impact of medical comorbidities on 30-day readmissions is better established, the role of socioeconomic factors remains unclear and might suggest a focus for future work.

The use of nasopharyngeal (NP) swab sampling for the detection of various respiratory pathogens has been a standard procedure in medicine for many years. While this is a fairly common procedure, there has been a significant increase in utilization recently due to the SARS-CoV-2 pandemic. We describe a case of a 40-year-old SARS-CoV-2 positive patient with no prior cardiac history who developed asystole while an NP swab was being used to obtain a sample for a SARS-CoV-2 assay. Return of normal sinus rhythm was achieved with chest compressions alone. The incident was deemed to have been an exaggerated vagal response to intranasal stimulation; better known as the trigeminocardiac reflex. This is the first reported case describing asystole during use of an NP swab. This case occurred in a patient with no known cardiac disease and highlights the potential importance of the arrhythmogenic nature of COVID-19 that could potentiate the vagal response in susceptible individuals undergoing NP sampling.

We report a case of a 91-year-old Caucasian woman with a history of chronic lymphocytic leukaemia who developed acute hypoxic respiratory failure (AHRF) requiring intubation for less than 24 hours after receiving rasburicase. Laboratory workup was significant for methemoglobinemia and acute anaemia, and blood film demonstrated evidence of oxidative haemolysis with bite cells. The patient was given a presumptive diagnosis of glucose-6-phosphate dehydrogenase (G6PD) deficiency and was managed conservatively with successful resolution of AHRF and stabilisation of haemoglobin level. Seven days after admission, she passed away due to subsequent complications; hence, follow-up G6PD level could not be obtained. Haemolytic anaemia and methemoglobinemia in the setting of recent rasburicase administration should raise clinical suspicion for G6PD deficiency. In non-emergent cases, patients should be screened prior to receiving rasburicase regardless of risk factors. Because rasburicase is often needed emergently, patients at high risk of tumour lysis syndrome should be screened early for G6PD deficiency.