Search

IntroductionFemale patients, patients from racial minorities, and patient with low socioeconomic status have been noted to have less access to catheter ablation for atrial fibrillation.MethodsThis is a cross-sectional, retrospective study using a large population database (Explorys) to evaluate the gender, racial and socioeconomic differences in access of catheter ablation therapy in patient with atrial fibrillation.ResultsA total of 2.2 million patients were identified as having atrial fibrillation and 62,760 underwent ablation. Females had ablation in 2.1% of cases while males received ablation in 3.4% of cases. Caucasians had ablation in 3.3% of cases, African Americans in 1.5% of cases and other minorities in 1.2% of cases. Individuals on medicaid underwent ablation in 1.6% of cases, individuals on medicare and private insurance had higher rates (2.8 and 2.9%, respectively). Logistic regression showed that female patients (OR 0.608, CI 0.597–0.618, p < 0.0001), patients who are African American (OR 0.483, CI 0.465–0.502, p < 0.0001), or from other racial minorities (OR 0.343, CI 0.332–0.355, p < 0.0001) were less likely to undergo ablation. Patient with medicare (OR 1.444, CI 1.37–1.522, p < 0.0001) and private insurance (OR 1.572, CI 1.491–1.658, p < 0.0001) were more likely to undergo ablation.ConclusionFemale gender, racial minorities, low socioeconomic status are all associated with lower rates of catheter ablation in management of atrial fibrillation.

Background Atrial fibrillation (AF) is associated with anatomical and electrical remodeling. Some patients with AF have concomitant sick sinus syndrome and may need permanent pacemaker (PPM) implantation. Association between catheter ablation of AF timing and need for PPM in sick sinus syndrome has not been assessed. Methods and Results We used pooled electronic health data to perform retrospective cross‐sectional analysis of 66, 595 patients with AF and sick sinus syndrome to assess the need of PPM implantation temporally, with AF performed divided into earlier within 5 years (group 1), 5 to 10 years (group 2), or beyond 10 years (group 3) of diagnosis. PPM implantation was lowest among those who had catheter ablation within 5 years of sick sinus syndrome diagnosis: group 1 versus group 2 (18.15% versus 27.21%) and group 1 versus group 3 (18.15% versus 27.22%). Interestingly, there was no difference in risk of PPM between group 2 and group 3 (27.21% versus 27.22%; odds ratio [OR], 1.00 [95% CI, 0.85–1.20]). Conclusions Even after controlling known risk factors that increase the need for pacemaker implantation, timing of AF ablation was the strongest predictor for need for PPM. Patients adjusted OR of PPM was lower if patients had catheter ablation within 5 years of diagnosis compared with later than 5 years (adjusted OR, 0.64 [95% CI, 0.59–0.70]).

Background Inflammatory bowel disease (IBD) has been associated with an increased risk of cardiovascular events, but the risk of cerebrovascular accidents (CVA) remains unknown. Hypercoagulability and systemic inflammation are two proposed mechanisms by which the presence of IBD might lead to the development of CVA. Objective To assess the risk of CVA in patients with IBD compared to those without IBD with known traditional risk factors for CVA. Methods We reviewed data from a large commercial database (Explorys, IBM) that aggregated records from 26 health-care systems nationwide. Using systemized nomenclature of medicine - clinical terms, we identified adult patients diagnosed with IBD (ulcerative colitis or Crohn's disease) between September 1994 and September 2019. We then examined the risk of CVA in these patients. Known risk factors such as age ≥65 -years old, diabetes mellitus (DM), hypertension (HTN), female gender, atrial fibrillation (Afib) were collected. A univariate binary logistic model was constructed using CVA as the dependent variable and other variables as independent variables. To adjust for possible confounding, a multivariable model adjusting for all covariates was created to test for CVA. Results A total of 52,176,550 patients were included in this analysis, and 261,890 had IBD. The prevalence of CVA was higher in IBD patients compared to non-IBD patients (6.24% versus 0.48%, p

To examine echocardiographic parameters correlation with clinical severity indices, Alveolar- arterial gradient (A-a gradient), oxygenation index and clinical outcomes in newborns with persistent pulmonary hypertension of the newborn (PPHN). Retrospective cohort study of 67 subjects,35 weeks' gestation with the diagnosis of PPHN admitted to the University of Kentucky neonatal intensive care unit (NICU) between September 2014 and December 2016. High left ventricular end-systolic eccentricity index (EIs) correlates with the overall clinical severity of PPHN as it is associated with higher A-a gradient and oxygenation index (P = 0.0003 and P0.0001, respectively). Elevated EIs was also predictive for the use of inhaled nitric oxide and extracorporeal membrane oxygenation (P = 0.0004 and P0.0001, respectively). EIs value of1.38 provides cutoff value as an objective marker for the need for extracorporeal membrane oxygenation. EIs can be used to assess clinical severity and outcomes and should be reported routinely. Further studies are warranted to confirm these results.

Background Hypertrophic cardiomyopathy is estimated to affect 1 out of every 500 adults in the USA. One of its main complications is left ventricular outflow obstruction, which may require surgical septal myectomy in severe cases. We report a rare complication of postoperative septal akinesis leading to thrombus formation presenting as an acute ischaemic stroke. Case summary A 48-year-old woman presented with acute stroke 2 years after surgical septal myectomy for hypertrophic obstructive cardiomyopathy. Diagnostic workup identified an intraventricular thrombus arising in the left ventricular outflow tract (LVOT). After comprehensive evaluation, it was determined that the thrombus development was a complication of the prior septal myectomy causing focal septal akinesis. Treatment with anticoagulation resulted in improvement of neurological symptoms and resolution of the intraventricular thrombus. Discussion This case illustrates the rarity and unusual presentation of an intracardiac thrombus that arises from septal myectomy site. A thrombus arising in the LVOT, which is characterized by high gradient laminar flow, is highly unusual. This suggests microscopic and macroscopic alteration in the ventricular septal wall structure, as evident by the septal wall akinesis seen on echocardiography. Recognition of this complication is critical to the selection of appropriate anticoagulation as secondary stroke prevention in these patients.

Radiofrequency catheter ablation (RFCA) is an effective treatment for arrhythmias. The effects of RFCA on cardiovascular implantable electronic devices (CIED) function have varied. We aim to study the effect of RFCA on device parameters and clinical outcomes in patients with CIED. We conducted a single-center retrospective cohort study between 2011 and 2018. Generator and lead parameters were compared pre- and post-ablation using paired sample t-test. The median follow-up interval for documentation of procedure-related complications and clinical outcomes was 8 weeks. We identified 119 eligible patients; whose mean age was 64.5 ± 11.91 years and 22 (18.4%) were females. Types of CIED include single-chamber implantable cardioverter defibrillators (8.93%), dual-chamber implantable cardioverter defibrillators (41.96%), and either dual-chamber or biventricular pacemakers (44.54%). Arrhythmias for which patients underwent RFCA include atrial fibrillation/atrial tachycardia (15.22%), atrial flutter (38.14%), atrioventricular node reentrant tachycardia (13.56%), and premature ventricular complex or ventricular tachycardia (20.34%). No statistically significant difference was observed in pre- and post-ablation: (1) atrial sensing thresholds, pacing thresholds, lead impedance; (2) right ventricle sensing and pacing thresholds; and (3) left ventricle pacing threshold and impedance. A decrease in right ventricle impedance after ablation (549.77 ± 173 ohm vs 507.40 ± 129.0 ohm, P-value0.004) was observed. Zero complications or deaths were observed. In this single-center study, RFCA did not significantly impact CIED function and was not associated with short-term complications. However longer follow-up is required to confirm these findings.

Takotsubo cardiomyopathy (TCM) is characteristically associated with left ventricular apical ballooning and regional wall motion abnormalities that predispose to the formation of left ventricular (LV) thrombi and subsequent thromboembolic events (VTE). There is limited data about the risk factors of developing stroke in the absence of LV thrombi in patients with TCM. Identify risk factors that predispose patients with TCM to develop VTE and stroke. We retrospectively reviewed all patients admitted with a primary diagnosis of stress induced or Takotsubo cardiomyopathy at a large tertiary care center from 2005 to 2019. Patients who met the echocardiographic criteria of TCM, had resolution of WMA on repeat echocardiogram, did not have coronary artery disease if angiography was performed and survived for3 months after index presentation were included in the analysis. Patients were followed for up to a period of 1 year. Multivariate analysis was performed to identify predictors of thromboembolism. Among the 400 patients who presented with TCM, 146 patients were included in the analysis. A total of 13 patients (8.9%) had documented thromboembolic events. Patients with VTE more often had Atrial fibrillation (30.8% vs 6.8%, P = 0.018), higher LV mass (224.5g vs 184g, P = 0.04), lower EF on presentation (31.5% vs 40%, P = 0.011) and were less likely to have undergone coronary angiography following diagnosis (23.1% vs 54.9%, P = 0.04). On multivariate analysis, atrial fibrillation (OR 9.15, CI 1.15-72.70) and low ejection fraction on admission (OR 0.88, CI 0.81-0.97) were independent risk factors for the development of VTE. Atrial fibrillation and low ejection fraction on presentation were associated with higher risk of developing thromboembolic events in patients with TCM.

Background: The trend of telemedicine is exponentially increasing worldwide due to the coronavirus disease (COVID-19) pandemic. However, patient satisfaction is always a concern regarding the use of telemedicine. Introduction: The aim of this study is to evaluate the perception and satisfaction level of patients toward the use of telemedicine during the pandemic of COVID-19 among Pakistani population. Materials and Methods: The survey questionnaires were distributed to 251 patients who received telemedicine consultation in any of three specializations: orthopedic, ophthalmology, and general medicine. The questionnaire contains 15 questions that covered four categories of patient satisfaction: interpersonal communication, caring, care delivery, and proficiency. Descriptive and analytical statistics were obtained by analyzing data using SPSS software version 20. Results: A total of 251 patients responded to the telemedicine questionnaire. Overall, 61.35% patients reported that they did not need any support for using technology during consultation and 96.41% of the patient population reported that telemedicine saved their travel time. It was found that gender, education, and age were significantly associated with the ease in technology with the p-value 0.012, 0.004 and

Background The novel coronavirus disease (COVID-19) emerged from China in 2019 and rapidly spread worldwide. Patients with metabolic comorbid conditions are more susceptible to infection by COVID-19. Metabolic syndrome is a constellation of interlinked metabolic risk factors that predispose patients to increased risk of complications. Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of metabolic syndrome and non-alcoholic steatohepatitis (NASH) is the aggressive form of NAFLD. Objective The aim of this study is to determine the relationship between metabolic syndrome components and the risk of COVID-19. Methods We reviewed data from a large commercial database (Explorys IBM) that aggregates electronic health records from 26 large nationwide healthcare systems. Using systemized nomenclature of clinical medical terms (SNOMED-CT), we identified adults with the diagnosis of metabolic syndrome and its individual components from 1999-2019. We included patients with the diagnosis of COVID-19 from December 2019 to May 2020. Comorbidities known to be associated with COVID-19 and metabolic syndrome such as obesity, diabetes mellitus, dyslipidemia, smoking, male gender, African American, and hypertension were collected. Univariable and multivariable analyses were performed to investigate whether metabolic syndrome or its individual components are independently associated with the risk of COVID-19. Results Out of 61.4 million active adult patients in the database, 8,885 (0.01%) had documented COVID-19. The cumulative incidence of COVID-19 was higher if metabolic syndrome was the primary diagnosis (0.10% vs 0.01% %, OR 7.00 [6.11–8.01]). The adjusted odds (aOR) of having COVID-19 was higher in patients if they were African Americans (OR 7.45 [7.14- 7.77]), hypertensive (aOR 2.53 [2.40 - 2.68]), obese (aOR 2.20 [2.10 2.32]), diabetic (aOR 1.41 [1.33- 1.48]) hyperlipidemic (OR 1.70 [1.56-1.74]) or diagnosed with NASH (OR 4.93 [4.05- 6.00]). There was a slight decrease in adjusted odds of having COVID-19 in males as compared to females (aOR 0.88 [0.84- 0.92]). Conclusion The incidence of COVID-19 in patients with metabolic syndrome is high. Among all comorbid metabolic conditions, NASH had the strongest association with COVID-19., Highlights • In the United States, the incidence of COVID-19 among patients with metabolic syndrome or its components is high. • Among all metabolic comorbid conditions, non-alcoholic steatohepatitis (NASH) the more aggressive form of non-alcoholic fatty liver disease (NAFLD) is associated with the highest risk of COVID-19. • African Americans are disproportionately affected by COVID-19.

Background: Liver fibrosis stage determines the risk of morbidity and mortality from chronic hepatitis C virus (HCV) infection. The majority of HCV-infected patients are underserved and have other comorbid conditions that lead to more progressive liver disease such as cirrhosis and hepatocellular carcinoma. Safety net hospitals are the prime location to treat these patients. Direct acting antiviral (DAA) agents are highly effective in virus eradication.Aim: We aimed to evaluate the effect of treatment with DAAs on FIB-4 index.Methods: We identified 343 patients who initiated HCV treatment with DAAs from 2016 to 2018 and achieved a sustained virologic response (SVR) in Metrohealth Medical Center, a safety net hospital system. We compared the severity of hepatic fibrosis before and 1 year after SVR was attained. We evaluated whether the presence of other comorbid conditions influenced liver fibrosis regression. All analyses were performed using SAS software.Results: There was a statistically significant drop in mean FIB-4 score from baseline to post-SVR (3.47 ± 2.84 vs. 2.28 ± 1.60, P < 0.001). One hundred seventeen patients had baseline FIB-4 scores ≥3.25, 56% had FIB-4 scores

Purpose: The aim of meniscal scaffolds is to fill the defect, allow regeneration of meniscal-like tissues, and to prevent long-term risk of cartilage wear and tear. The aim of this study was to evaluate clinical results after two years and magnetic resonance imaging (MRI) results a year after implantation of a meniscal scaffold. Methods: Fifteen patients were recruited into a prospective, single-arm, single-center study, and treated with meniscal scaffolds as a result of segmental meniscal defect due to previous partial meniscectomy. Patients were evaluated using functional knee scores used pre-operatively and 6, 12, and 24 months postoperatively. The radiological outcome was assessed using MRI at 12 months by evaluating scaffold size, morphology, and intensity according to the Genovese grading system. Cartilage assessment was completed according to The International Cartilage Repair Society (ICRS) score. Results: All patients completed a follow-up of 24 months. A statistically significant increase in mean levels of all functional scores was present in all patients. On the MRI, all but one of the patients presented an incorporated meniscal implant. In most of the patients (73%), the meniscal implant was a Genovese type III. Type II and III signal intensities were present in all scaffolds when compared with the residual meniscal tissue. A stable cartilage (ICRS) status was observed in 80% of the patients compared with the pre-operative cartilage scores. Conclusion: In our case series of patients treated with the meniscal scaffold implant, we observed good clinical results at a two year follow-up. Furthermore, MRI findings suggest that meniscal scaffolds might have a beneficial effect on articular cartilage.

Background We hypothesized that the torn anterior cruciate ligament (ACL) demonstrates a great healing response after initial trauma and has competent cells leading to the healing but differs in its response based on the type of tear and duration of injury. This study aimed to evaluate the histological and cellular responses to the injured ACL. Methods Fifty-two tissue samples from the ACL were harvested from patients undergoing arthroscopy. Detailed histological and cellular examinations were performed for ligament angiogenesis, fibrocytes, and synovial tissue infiltration. We compared the cellular response to injury in partially and completely ruptured ACLs. The duration of ACL injury and its response to cellular characteristics were also examined. Immunohistochemical studies using cluster of differentiation 34 (CD34) staining was used to evaluate endothelial cells and fibrocytes. Results We found a significantly higher density of synovial and ligament angiogenesis and fibrocytes at the torn end of ACL (Mann–Whitney, P < 0.050). Numerous fibrocytes were identified in complete ACL tears versus partial tears (Mann–Whitney = 0.020). Increased cellular proliferation was identified at the ruptured end of ACL remnant (Kruskal–Wallis, P < 0.050). The cellular proliferation of ruptured ACL decreased after 12 months. Conclusions Based on our findings of the time-dependent decrease in the cellular response at the torn ends of the ACL, we recommend early intervention, preservation of the ACL remnant, and primary ACL repair or augmented reconstruction.

Drug-induced thrombocytopenia requires a high suspicion for diagnosis and a broad investigation to exclude other etiologies of low platelets. Cessation of the offending agent often results in recovery of platelet counts. Many medications are known to cause a degree of thrombocytopenia. We present a rare case of severe thrombocytopenia associated with administration of azithromycin.

INTRODUCTION: The novel coronavirus disease (COVID-19) emerged from China in 2019 and rapidly spread worldwide Patients with metabolic comorbid conditions are more susceptible to COVID- 19 Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of metabolic syndrome, with non-alcoholic steatohepatitis (NASH) representing a severe form of NAFLD The aim of this study is to determine the relationship between metabolic syndrome components and the risk of COVID-19 METHODS: We reviewed data from a large commercial database (Explorys IBM) that aggregates electronic health records from 26 large nationwide healthcare systems We identified adult with the diagnosis of metabolic syndrome and its components from 1999 to 2019 Patients with the diagnosis of COVID-19 from December 2019 to May 2020 were identified Comorbidities known to be associated with COVID-19 and metabolic syndrome such as obesity, diabetes mellitus, dyslipidemia, smoking, gender, race, and hypertension were collected Univariable and multivariable analyses were performed to investigate whether metabolic syndrome or its individual components are independently associated with the risk of COVID-19 RESULTS: Out of 61 4 million patients, 8,885 (0 01%) had documented COVID-19 infection Using univariate analysis, patients with metabolic syndrome had a higher cumulative incidence of COVID-19 than those without (0 10% vs 0 01%, OR 7 00 [6 11-8 01) Patients had increased risk if they were diagnosed with hypertension (0 04% vs 0 01%, OR 5 81 [5 57-6 07]), diabetes (0 05% vs 0 01%, OR 4 88 [4 67-5 10]), dyslipidemia (0 04% vs 0 01%, OR 4 22 [4 05-4 40]) or obesity (0 06% vs 0 01%, OR 6 13 [5 86-6 40]) African Americans had a higher risk of COVID-19 (0 07% vs 0 01%, OR 9 20 [8 82-9 59]), but the risk was lower if they were male (0 02% vs 0 01%, OR 0 85 [0 81-0 89]) The overall risk of COVID-19 was the highest in those diagnosed with NASH (0 20% vs 0 01%, OR 14 10 [11 63-17 10]) The adjusted odds (aOR) of having COVID-19 was higher if patients were African American (OR 7 45 [7 14-7 77]), hypertensive (aOR 2 53 [2 40-2 68]), obese (aOR 2 20 [2 10 2 32]), diabetic (aOR 1 41 [1 33-1 48]) had dyslipidemia (OR 1 70 [1 56-1 74]) or NASH (OR 4 93 [4 05-6 00]) The adjusted odds of having COVID-19 was also lower in males compared to females (aOR 0 88 [0 84-0 92]) CONCLUSION: The incidence of COVID-19 in patients with metabolic syndrome is high Among all comorbid metabolic conditions, NASH has the strongest association with COVID-19

Inflammatory bowel disease has been associated with an increased risk of cardiovascular events but its relationship with cerebrovascular events(CVA) is controversial. We sought to explore this relationship using a large US based database. We reviewed data from a large commercial database (Explorys

Understanding of nucleation and growth kinetics of biomimetically deposited hydroxyapatite (HA) on crystalline TiO2 surfaces is important with respect to the application and performance of HA as functional implant coatings. Arc-evaporation was used to deposit TiO2 coatings dominated by anatase phase, rutile phase or their mixtures. Subsequent formation of HA from phosphate buffered saline solution (PBS) was investigated in real-time using in situ quartz crystal microbalance with dissipation technique (QCM-D). Scanning electron microscopy (SEM) and X-ray diffraction (XRD) were employed to characterize the presence, morphology and crystal structure of TiO2 coatings and the formed HA. Increasing temperature of the PBS, increasing flow rate and applying a higher ion concentration in solution were found to accelerate HA nucleation process and hence affect growth kinetics. Lower PBS temperature resulted in the formation of HA coatings with flake-like morphology and increasing HA porosity. All TiO2 coatings under study enabled HA formation at body temperature, while in contrast Ti reference surfaces only supported HA nucleation and growth at elevated temperatures. QCM-D technique is a powerful tool for studying the impact of process parameters during biomimetic coating deposition on coating structure evolution in real time and provides valuable information for understanding, optimizing as well as tailoring the biomimetic HA growth processes.

e15122Background: Quantification of baseline systemic inflammation using readily available peripheral blood-derived inflammatory biomarkers such as CRP has demonstrated prognostic and predictive ut...

Learning points for clinicians Gastrointestinal bleeding occurs in about one-third of patients with Hereditary Hemorrhagic Telangiectasia, however, it contributes less frequently to iron deficiency anemia in patient than unrecognized nasal bleeding. Early recognition with localized management is important. Osler–Weber–Rendu syndrome, also known as Hereditary Hemorrhagic Telangiectasia (HHT), is an autosomal dominant disorder. Telangiectasias and Arterio-Venous Malformations (AVMs) are vascular lesions present in HHT, most commonly causing epistaxis and gastrointestinal bleeding.1 While epistaxis presents as early as childhood, the gastrointestinal manifestations of HHT develop with increasing …

e19060Background: DLBCL is a heterogeneous group of aggressive lymphomas with distinct subtypes, and efforts to identify patients at high risk for treatment failure and poor clinical outcomes are o...