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Objective There is a paucity of data on how race affects the clinical presentation and short-term outcome among hospitalized patients with SARS-CoV-2, the 2019 coronavirus (COVID-19). Methods Hospitalized patients ≥ 18 years, testing positive for COVID-19 from March 13, 2020 to May 13, 2020 in a United States (U.S.) integrated healthcare system with multiple facilities in two states were evaluated. We documented racial differences in clinical presentation, disposition, and in-hospital outcomes for hospitalized patients with COIVD-19. Multivariable regression analysis was utilized to evaluate independent predictors of outcomes by race. Results During the study period, 3678 patients tested positive for COVID-19, among which 866 were hospitalized (55.4% self-identified as Caucasian, 29.5% as Black, 3.3% as Hispanics, and 4.7% as other racial groups). Hospitalization rates were highest for Black patients (36.6%), followed by other (28.3%), Caucasian patients (24.4%), then Hispanic patients (10.7%) (p

Severe COVID-19 illness is associated with intense inflammation, leading to high rates of thrombotic complications that increase morbidity and mortality. Markedly elevated levels of D-dimer with normal fibrinogen levels are the hallmark laboratory findings of severe COVID-19- associated coagulopathy. Prophylaxis against venous thromboembolism is paramount for all hospitalized patients, with more aggressive prophylaxis and screening recommended for patients with D-dimer levels above 3.0 μg/mL. Point-of-care ultrasonography is the imaging method of choice for patients at high risk, as it entails minimal risk of exposing providers to the virus.

Multi-month dispensing (MMD) is a patient-centered approach in which stable patients receive medicine refills of three months or more. In this pre-post longitudinal study, we determined hypertension and HIV treatment outcomes in a cohort of hypertensive PLHIV at baseline and 12 months of receiving integrated MMD. At each clinical encounter, one healthcare provider attended to both hypertension and HIV needs of each patient in an HIV clinic. Among the 1,082 patients who received MMD, the mean age was 51 (SD = 9) years and 677 (63%) were female. At the start of MMD, 1,071(98.9%) patients had achieved HIV viral suppression, and 767 (73.5%) had achieved hypertension control. Mean blood pressure reduced from 135/87 (SD = 15.6/15.2) mmHg at the start of MMD to 132/86 (SD = 15.2/10.5) mmHg at 12 months (p p = 0.01) without a significant difference in the proportion of patients with HIV viral suppression at baseline and at 12 months, 98.9% vs 99.0% (p = 0.65). Patients who received MMD with elevated systolic blood pressure at baseline were less likely to have controlled blood pressure at 12 months (OR-0.9, 95% CI, 0.90,0.92). Overall, 1,043 (96.4%) patients were retained at 12 months. Integrated MMD for stable hypertensive PLHIV improved hypertension control and sustained optimal HIV viral suppression and retention of patients in care. Therefore, it is feasible to provide integrated MMD for both hypertension and HIV treatment and achieve dual control in the setting of sub-Saharan Africa.

Severe COVID-19 illness is associated with intense inflammation, leading to high rates of thrombotic complications that increase morbidity and mortality. Markedly elevated levels of D-dimer with normal fibrinogen levels are the hallmark laboratory findings of severe COVID-19-associated coagulopathy. Prophylaxis against venous thromboembolism is paramount for all hospitalized patients with COVID-19, with more aggressive prophylaxis and screening recommended for critically ill patients with D-dimer levels above 3.0 μg/mL. Point-of-care ultrasonography is the imaging method of choice for patients at high risk, as it entails minimal risk of exposing providers to the virus.

After deep venous thrombosis (DVT), many patients have impaired quality of life (QOL). We aimed to assess whether pharmacomechanical catheter-directed thrombolysis (PCDT) improves short-term or long-term QOL in patients with proximal DVT and whether QOL is related to extent of DVT.The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial was an assessor-blinded randomized trial that compared PCDT with no PCDT in patients with DVT of the femoral, common femoral, or iliac veins. QOL was assessed at baseline and 1 month, 6 months, 12 months, 18 months, and 24 months using the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) disease-specific QOL measure and the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary general QOL measures. Change in QOL scores from baseline to assessment time were compared in the PCDT and no PCDT treatment groups overall and in the iliofemoral DVT and femoral-popliteal DVT subgroups.Of 692 ATTRACT patients, 691 were analyzed (mean age, 53 years; 62% male; 57% iliofemoral DVT). VEINES-QOL change scores were greater (ie, better) in PCDT vs no PCDT from baseline to 1 month (difference, 5.7; P = .0006) and from baseline to 6 months (5.1; P = .0029) but not for other intervals. SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 2.4; P = .01) but not for other intervals. Among iliofemoral DVT patients, VEINES-QOL change scores from baseline to all assessments were greater in the PCDT vs no PCDT group; this was statistically significant in the intention-to-treat analysis at 1 month (difference, 10.0; P .0001) and 6 months (8.8; P .0001) and in the per-protocol analysis at 18 months (difference, 5.8; P = .0086) and 24 months (difference, 6.6; P = .0067). SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 3.2; P = .0010) but not for other intervals. In contrast, in femoral-popliteal DVT patients, change scores from baseline to all assessments were similar in the PCDT and no PCDT groups.Among patients with proximal DVT, PCDT leads to greater improvement in disease-specific QOL than no PCDT at 1 month and 6 months but not later. In patients with iliofemoral DVT, PCDT led to greater improvement in disease-specific QOL during 24 months.

Management of intermediate and high risk acute pulmonary embolism (PE) is challenging. The role of multidisciplinary teams for the care of these patients is emerging. Herein, we report our experience with a pulmonary embolism response team (PERT). We conducted a retrospective chart review on all patients admitted to the Cleveland Clinic main campus who required activation of the (PERT) from October 1, 2014 to September 1, 2016. We extracted data pertaining to clinical presentation, bleeding complications, and pre- and post-discharge imaging. Patients were classified as low, intermediate or high risk PE. Descriptive and continuous variables were collected and analyzed. There were 134 PERT activations. PE was confirmed by CT-PA in 118 patients. Fifteen (13%) patients were classified as low risk, 80 (68%) intermediate risk PE and 23 (19%) high risk PE. Fourteen (12%) patients were treated with catheter directed rtPA, 6 (5%) received full dose (100 mg rtPA), 16 (13%) received systemic half-dose (50 mg rtPA), 6 (5%) underwent a surgical embolectomy and 4 (3%) underwent mechanical thrombectomy. 65 (55%) patients received anticoagulation only, and 8 (7%) patients were managed conservatively without any anticoagulation or advanced therapy. 11 (9%) patients died while during the hospitalization. Fourteen patients had major bleeding events. There were no bleeding events among patients who received systemic low dose or full dose rtPA. A multidisciplinary approach to cases of intermediate risk and high risk PE can be implemented successfully. We saw a relatively low rate of bleeding events with use of rtPA.

Widely used flushing and in-situ destruction based remediation techniques (i.e. pump-and treat, enhanced-solubilization, and chemical oxidation/reduction) for sites contaminated by nonaqueous phase liquid (NAPL) contaminant sources have been shown to be ineffective at complete mass removal and reducing aqueous-phase contaminant of concern (COC) concentrations to levels suitable for site closure. A remediation method was developed to reduce the aqueous solubility and mass-flux of COCs within NAPL through the in-situ creation of a NAPL mixture source-zone. In contrast to remediation techniques that rely on the rapid removal of contaminant mass, this technique relies on the stabilization of difficult-to-access NAPL sources to reduce COC mass flux to groundwater. A specific amount (volume) of relatively insoluble n-hexadecane (HEXDEC) or vegetable oil (VO) was injected into a trichloroethene (TCE) contaminant source-zone through a bench-scale flow cell port (i.e. well) to form a NAPL mixture of targeted mole fraction (TCE:HEXDEC or TCE:VO). NAPL-aqueous phase batch tests were conducted prior to the flow-cell experiments to evaluate the effects of various NAPL mixture ratios on equilibrium aqueous-phase concentrations of TCE to design optimal NAPL (HEXDEC or VO) injection volumes for the flow-cell experiments. The NAPL-stabilization flow-cell experiments initiated and sustained significant reductions in COC concentration and mass flux due to a combination of both reduced relative permeability (increased NAPL-saturation) and via modification of NAPL composition (decreased TCE mole fraction). Variations in remediation performance (i.e. impacts on TCE concentration and mass flux reduction) between the different HEXDEC injection volumes were relatively minor, and therefore inconsistent with Raoult's Law predictions. This phenomenon likely resulted from non-uniform mixing of the injected HEXDEC with TCE in the source-zone. VO injection caused TCE concentrations and mass-flux to decrease more rapidly than with HEXDEC injections. This phenomenon occurred because the injected VO was observed to mix more uniformly with TCE in the source-zone due to a lower mobilization potential. The relative lower density differences (buoyancy effects) between VO and the flushing solution (water) was the primary factor contributing to the lower mobilization potential for VO. Overall, this study indicated that the delivery of HEXDEC or VO into the toxic TCE source-zone was effective in significantly reducing contaminant aqueous-phase concentration and mass-flux. However, the effectiveness of this in-situ NAPL stabilization technique depends on source delivery, uniform mixing of amendment, and that the amendment remains immobilized within and around the NAPL contaminant source.

Presented is a case series of duplex ultrasound examination for evaluation of the hypothenar ulnar artery. Because of its superficial location, the distal ulnar artery is well characterized by duplex ultrasound. Aneurysm, thrombosis, and ectasia are the most common abnormal findings. The study is a single-center database query of all arterial duplex examinations performed from January 1, 2000 through December 31, 2006, and containing the words ulnar artery. A total of 2766 upper-extremity arterial duplex scans were queried yielding 155 scans meeting the search criteria. A total of 9 ulnar arteries were interrogated into the hypothenar area of the hand. Seven of them were abnormal, and 2 were follow-up studies of a patient who had undergone repair of bilateral ulnar artery aneurysms. Reported symptoms include pain, digital lesions, pallor or a pulsatile mass. Of the 7 abnormal ulnar arteries, 3 arteries were aneurysmal (diameter greater than 1.5 times the proximal segment), and 3 were ectatic (increase in diameter less than 1.5 times the proximal segment). Two arteries were tortuous, and one was occluded. All but one patient was a past or present smoker. All abnormalities were attributed to occupational repetitive trauma and one patient experienced a single traumatic event. The mean patient age was 42 years (median 37) and all were male. Of the 3 aneurysms, the largest was 17 mm and was associated with mural thrombus and a biphasic Doppler signal. The other 2 aneurysms were 5.0 and 6.9 mm with mural thrombus and triphasic Doppler signals. One patient underwent successful thrombolysis, 3 patients were followed conservatively, and 2 of the aneurysms and one of the thrombosed arteries were surgically repaired. Although abnormal findings of the distal ulnar artery are rare, they may be well visualized and characterized with duplex ultrasound. Duplex ultrasound is an ideal diagnostic modality for evaluation and follow-up of distal ulnar artery abnormalities in experienced vascular laboratories.

Introduction Pseudoaneurysm of the superficial temporal artery is rare and most often the result of blunt trauma to the head. Thomas Bartholin first observed and reported on this phenomenon in 1740. Case Report Presented is the case of an 18-year-old man referred for the evaluation of a pulsatile mass over the left temple that developed after an altercation occurring in the preceding 2 months. Methods Duplex ultrasound examination was performed with the use of a Philips IU22 (Bothell, WA) with a 17–5 MHz linear transducer. Results Fusiform dilation of the frontal branch of the superficial temporal artery was noted, measuring 0.6 × 0.8 cm and containing echogenic material. The proximal segment of the artery measured 0.2 × 0.2 cm. A follow-up scan was performed 6 weeks later demonstrating enlargement of the aneurysm to 0.6 × 1.2 cm with additional homogeneous thrombus. The aneurysm was resected, followed by suture ligation of the inflow and outflow arteries. Pathologic description was consistent with a dilated segment of artery filled with organizing granulating tissue and focal areas of thrombosis. The wall of the aneurysm consisted of fibrous tissue only, with no evidence of a muscular layer. No evidence of inflammatory infiltrate or giant cells was identified. Conclusions Aneurysms may be saccular or fusiform and may be true or false. Aneurysmal dilation is identified when a vessel measures 1.5 times the diameter of the proximal segment. A true aneurysm will involve all layers of the vessel wall, whereas a false aneurysm (pseudoaneurysm) is identified when less than all layers of the vessel wall are involved. Aneurysms resulting from a single traumatic event, such as the one described in the present case report, are most often pseudoaneurysms. The superficial temporal artery and its branches are readily and accurately evaluated and characterized by duplex ultrasound.

The determination of dextromethorphan in canine plasma is used to demonstrate the high throughput bioanalytical approach of automated dilute-and-shoot (DAS) sample preparation followed by a 1 min isocratic liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis. Dilute-and-shoot preparation is commonly used for the determination of drugs in several biological matrices such as urine and saliva, but is not typically used with plasma samples because the amount of protein present in plasma can lead to a variety of problems including column failure. As a result, plasma sample preparation usually removes protein by precipitation, extraction or filtration; however, the dilute-and-shoot approach solubilizes proteins throughout the chromatographic portion of the assay. The attributes of this approach are compared with a previously validated liquid/liquid extraction procedure for determination of dextromethorphan in plasma. Accuracy and precision of both methods are similar. The lower limit of quantitation (LLOQ) of the dilute-and-shoot approach is much higher at 2 ng/ml versus 5 pg/ml with the liquid/liquid extraction; however, the sample throughput of the preparation portion of the dilute-and-shoot approach is more than 50-fold greater. The ruggedness of the dilute-and-shoot method was thoroughly investigated because of the problems traditionally associated with the direct injection of diluted plasma onto an LC-MS/MS instrument. With the optimal conditions, greater than 1000 injections of diluted plasma have been successfully performed on a single column in less than 19 h making this technique an excellent approach for the rapid preparation and high throughput of plasma samples containing drug levels in the ng/ml range or higher. Application of this methodology to measure the levels of dextromethorphan in canine plasma to evaluate drug delivery from various formulations is also presented.

Anticoagulant medications are beneficial for a range of conditions and indications including prevention of stroke and peripheral arterial embolism in patients with atrial fibrillation, prevention of complications from thrombosis of mechanical heart valves, prevention of venous thromboembolism (VTE) in postoperative and immobilized medically ill patients, for individuals with acute coronary syndrome (ACS) and for the treatment of VTE. The first oral anticoagulant medication was approved by the US Food and Drug Administration (FDA) in 1954 and had remained the only available and approved oral agent until October of 2010. Over the decades warfarin has prevented an immeasurable number of potential devastating fatal and nonfatal thrombotic and embolic events with an overall good safety profile. While complications occur, most importantly hemorrhagic, for the vast majority of patients this is a rare occurrence. Despite excellent efficacy and safety, for a number of reasons there has been significant interest in development of new, safe alternatives, which until recently was an elusive goal. The most important drawbacks of warfarin include a delayed onset of action, the need for frequent monitoring with dose adjustments, a plethora of drug–drug and drug–food interactions, and its reputation for being thought of as a “rat poison.” The new oral anticoagulants have the benefit of more predictable pharmacokinetics, a rapid onset of action, no need for routine laboratory monitoring, fixed dosing regimens, and fewer drug–drug and drug–food interactions. By the same token, there may be times when monitoring anticoagulant activity is necessary, which creates a challenge as the new anticoagulants do not all have the same effect on routine laboratory assays most physicians are familiar with. Additionally, there may be circumstances in which rapid reversal of anticoagulant activity is needed, presenting another more significant challenge in the setting of life-threatening bleeding or need for emergent surgery. Three new drugs, Dabigatran, Rivaroxaban, and Apixaban, have been approved by the US FDA for multiple indications beginning in 2010 to the present and there are others in development. They work through direct reversible or irreversible inhibition of either factor IIa or factor X. Their onset of action is rapid, within 1–3 h because they do not rely on inhibiting future coagulation factor production as seen with warfarin. Furthermore, they have relatively short elimination half-lives, ranging from 4 to 17 h in patients with normal renal function, relative to warfarin with an elimination half-life of 20–60 h. These features have both positive and potentially negative implications. On the positive side, the rapid onset of action and the short elimination half-life mean the need for complicated bridging instructions with parental anticoagulants may no longer be necessary. On the negative side, this means that unlike warfarin even a single missed dose can result in subtherapeutic anticoagulant levels with the potential for subsequent thromboembolic complications. Metabolism and elimination are more dependent on renal clearance for the new oral anticoagulants (although apixaban is less dependent on renal mechanisms relative to dabigatran and rivaroxaban) compared with 100 % liver metabolism seen with warfarin (Poulsen et al. Drugs 72:1739–1753, 2012). This underscores the importance of checking renal function prior to prescribing these medications and monitoring for changes in renal function. While there are some notable drug–drug interactions, they are far less when compared to warfarin and there are no drug–food interactions. Table 16.1 summarizes the key features of the newer oral anticoagulants discussed in this chapter.