Search

We present the case of a woman who developed presumed spontaneous coronary artery dissection of a septal branch. She later developed high-grade atrioventricular block that led to a diagnosis of cardiac sarcoidosis involving the interventricular septum. This case illustrates a rare and challenging presentation of cardiac sarcoidosis. (Level of Difficulty: Beginner.), Central Illustration

Objectives: To characterize the impact of obesity on disease severity in patients with coronavirus disease 2019. Design: This was a retrospective cohort study designed to evaluate the association between body mass index and risk of severe disease in patients with coronavirus disease 2019. Data were abstracted from the electronic health record. The primary endpoint was a composite of intubation or death. Setting: Two hospitals in Massachusetts (one quaternary referral center and one affiliated community hospital). Patients: Consecutive patients hospitalized with confirmed coronavirus disease 2019 admitted between March 13, 2020, and April 3, 2020. Interventions: None. Measurements and Main Results: A total of 305 patients were included in this study. We stratified patients by body mass index category: < 25 kg/m2 (54 patients, 18%), ≥ 25 kg/m2 to < 30 kg/m2 (124 patients, 41%), ≥ 30 kg/m2 to < 35 kg/m2 (58 patients, 19%), and ≥ 35 kg/m2 (69 patients, 23%). In total, 128 patients (42%) had a primary endpoint (119 patients [39%] were intubated and nine died [3%] without intubation). Sixty-five patients (51%) with body mass index greater than or equal to 30 kg/m2 were intubated or died. Adjusted Cox models demonstrated that body mass index greater than or equal to 30 kg/m2 was associated with a 2.3-fold increased risk of intubation or death (95% CI, 1.2–4.3) compared with individuals with body mass index less than 25 kg/m2. Diabetes was also independently associated with risk of intubation or death (hazard ratio, 1.8; 95% CI, 1.2–2.7). Fifty-six out of 127 patients (44%) with body mass index greater than or equal to 30 kg/m2 had diabetes, and the combination of both diabetes and body mass index greater than or equal to 30 kg/m2 was associated with a 4.5-fold increased risk of intubation or death (95% CI, 2.0–10.2) compared with patients without diabetes and body mass index less than 25 kg/m2. Conclusions: Among consecutive patients hospitalized with coronavirus disease 2019, obesity was an independent risk factor for intubation or death.

Background Experimental studies support a link between obesity and pulmonary hypertension (PH), yet clinical studies have been limited. This study sought to determine the association of obesity and pulmonary hemodynamic measures and mortality in PH. Methods and Results We examined patients undergoing right‐sided heart catherization (2005–2016) in a hospital‐based cohort. Multivariable regression models tested associations of body mass index and pulmonary vascular hemodynamics, with PH defined as mean pulmonary artery pressure >20 mm Hg, and further subclassified into precapillary, postcapillary, and mixed PH. Multivariable Cox models were used to examine the effect of PH and obesity on mortality. Among 8940 patients (mean age, 62 years; 40% women), 52% of nonobese and 69% of obese individuals had evidence of PH. Higher body mass index was independently associated with greater odds of overall PH (odds ratio, 1.34; 95% CI, 1.29–1.40; P P P P P P for interaction=0.02). Conclusions Obesity is independently associated with PH. PH is associated with greater mortality; this is modified by obesity such that obese patients with precapillary PH have lower mortality compared with nonobese counterparts. Further studies are needed to elucidate mechanisms underlying obesity‐related PH.

Studies that have investigated prism adaptation (PA) effects on symptoms of visuospatial neglect have primarily used neuropsychological tests as outcome measures. An important question that remains to be answered is whether PA effects translate into improvements in patients' daily life activities. In the present review, we examined systematically the evidence for the effect of PA treatment on daily life activities in patients with neglect. Two authors independently assessed the methodological quality of 25 intervention and 1 follow-up studies using validated scales. PA effects were evaluated for reading/writing, activities of daily living (ADL) direct tests, ADL questionnaires, and navigation tests. Studies were evaluated as being of excellent (n = 1), good (n = 12), fair (n = 10), or poor (n = 3) quality. Among the 26 articles, a total of 32 measurements showed significant PA effects (one measurement from a study of excellent quality, 17 from studies of good quality, 10 from studies of fair quality, four from studies of poor quality), whereas non-significant effects were found in 15 measurements (two from a study of excellent quality, three from studies of good quality, eight from studies of fair quality, two from studies of poor quality). There is some evidence suggesting that PA can improve daily functioning, particularly as measured by reading/writing and ADL direct tests. The impact of several variables on PA effects should be investigated further including sample heterogeneity and time since injury.

We evaluated the measurement of tissue oxygen content (StO(2)) by continuous near-infrared spectroscopy (NIRS) during and following cardiopulmonary resuscitation (CPR) and compared the changes in StO(2) and end-tidal carbon dioxide (ETCO(2)) as a measure of return of spontaneous circulation (ROSC) or rearrest.This was a case series of five patients who experienced out-of hospital cardiac arrest. Patients included those who had already experienced ROSC, who were being transported to the hospital, or who were likely to have a reasonable amount of time remaining in the resuscitation efforts. Patients were continuously monitored from the scene using continuous ETCO(2) monitoring and a NIRS StO(2) monitor until they reached the hospital. The ETCO(2) and StO(2) values were continuously recorded and analyzed for comparison of the time points when patients were clinically identified to have ROSC or rearrest.Four of five patients had StO(2) and EtCO(2) recorded during an episode of CPR and all were monitored during the postarrest period. Three patients experienced rearrest en route to the hospital. Downward trends were noted in StO(2) prior to each rearrest, and rapid increases were noted after ROSC. The StO(2) data showed less variance than the ETCO(2) data in the periarrest period.This preliminary study in humans demonstrates that StO(2) dynamically changes during periods of hemodynamic instability in postarrest patients. These data suggest that a decline in StO(2) level may correlate with rearrest and may be useful as a tool to predict rearrest in post-cardiac arrest patients. A rapid increase in StO(2) was also seen upon ROSC and may be a better method of identifying ROSC during CPR than pauses for pulse checks or ETCO(2) monitoring.

To determine the association between poor sleep quality, fatigue, and self-reported safety outcomes among emergency medical services (EMS) workers.We used convenience sampling of EMS agencies and a cross-sectional survey design. We administered the 19-item Pittsburgh Sleep Quality Index (PSQI), 11-item Chalder Fatigue Questionnaire (CFQ), and 44-item EMS Safety Inventory (EMS-SI) to measure sleep quality, fatigue, and safety outcomes, respectively. We used a consensus process to develop the EMS-SI, which was designed to capture three composite measurements of EMS worker injury, medical errors and adverse events (AEs), and safety-compromising behaviors. We used hierarchical logistic regression to test the association between poor sleep quality, fatigue, and three composite measures of EMS worker safety outcomes.We received 547 surveys from 30 EMS agencies (a 35.6% mean agency response rate). The mean PSQI score exceeded the benchmark for poor sleep (6.9, 95% confidence interval [CI] 6.6, 7.2). More than half of the respondents were classified as fatigued (55%, 95% CI 50.7, 59.3). Eighteen percent of the respondents reported an injury (17.8%, 95% CI 13.5, 22.1), 41% reported a medical error or AE (41.1%, 95% CI 36.8, 45.4), and 90% reported a safety-compromising behavior (89.6%, 95% CI 87, 92). After controlling for confounding, we identified 1.9 greater odds of injury (95% CI 1.1, 3.3), 2.2 greater odds of medical error or AE (95% CI 1.4, 3.3), and 3.6 greater odds of safety-compromising behavior (95% CI 1.5, 8.3) among fatigued respondents versus nonfatigued respondents.In this sample of EMS workers, poor sleep quality and fatigue are common. We provide preliminary evidence of an association between sleep quality, fatigue, and safety outcomes.