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Introduction: Acromegaly is an uncommon pituitary disorder with an incidence of six per million persons. While hypertension is often encountered in these patients, heart failure rarely is seen with an incidence rate under 10%. We describe a case of an individual who was diagnosed with acromegaly after an acute exacerbation of heart failure with subsequent management requiring an LVAD to perform Transsphenoidal Surgery (TSS). Case Description: 37-year-old male otherwise healthy initially presented to an emergency room and was found to be in acute heart failure exacerbation. Concerning acromegaly features included macrognathia, enlarged hands and feet, swollen phalanges, widened spacing of teeth, and frontal bossing. IGF-1 level was found 455 ng/mL. MRI showed a 10mm macroadenoma. A right heart catheterization showed elevated filling pressures. Cardiac MRI showed no defects or enhancement. Endomyocardial biopsy showed no inflammatory infiltrates or evidence of infiltrative diseases. Patient had an ejection fraction of 15% corroborated by cardiac MRI along with the presence of aortic root dilatation and mitral regurgitation. The patient started on 0.5mg of Cabergoline twice weekly and 120mg weekly Lanreotide injections. Patient stabilized with plans for further close monitoring and outpatient neurosurgical evaluation. The COVID-19 pandemic and insurance gaps led the patient to spend two years off his medicines and he was unable to be seen by his medical team. Patient was seen by our system after recurrent hospitalizations for heart failure at our sister hospital, AICD was unable to be placed due to the patient's anatomy, he was placed on wearable cardiac defibrillator and required milrinone infusion for progression to end-stage heart failure with cardiac cachexia. At our institution, the patient was evaluated for Orthotopic Heart Transplant (OHT) but due to active GH secreting macroadenoma there was concern for OHT failure without TSS. Decision was made to utilize LVAD as Bridge-to-Transplant for OHT so the patient could be stabilized and safely undergo TSS. The patient tolerated surgeries well and is currently on the active transplant list. Discussion(s): Heart failure is an uncommon presentation of severe acromegaly requiring multidisciplinary management. We describe a case of a patient who initially presented with heart failure too unstable for surgery. Due to the COVID-19 pandemic the patient's disease progressed resulting in end-stage heart failure requiring LVAD placement for further treatment. We would like to draw attention to the use of LVAD placement in acromegalic patients who develop severe cardiovascular disease who are not candidates for OHT.Copyright © 2023
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INTRODUCTION: Neutrophil lymphocyte ratio (NLR) is elevated in response to stressful stimuli and has been shown to be associated with poor prognosis in both benign & malignant disorders. Literature regarding NLR as a prognostic marker in COVID19 are limited. Our study was aimed to investigate the relationship between NLR & survival outcomes in patients hospitalized with Coronavirus disease 2019 (COVID19). METHODS: Ours was a single center, retrospective observational study, which included 472 nasopharyngeal swab SARS-CoV-2 RT-PCR positive patients. NLR was derived from the admission complete blood count & was divided into 5 sub-groups as (0-0.99, 1-2.99, 3-9.99, 10-19.99, >20). Demographics, comorbid conditions, and outcomes such as need for mechanical ventilation, length of stay and inpatient mortality were assessed. Statistics were performed using STATA. Significance was assigned at p<0.05. RESULTS: The mean age was 71.16 years in NLR >10 group as compared to 60.3 years in patients with normal NLR 1-2.99. Male patients were found to have much higher NLR than females (65.12% vs 34.88% in NLR 10-19.99, 64.86% vs 35.14% in NLR>20;p-value: 0.05). Among comorbidities, COPD patients were found to have higher NLR (18.92% of NLR>20 vs 10.71% of NLR 1-2.99;p-value:0.02). Rate of endotracheal intubation and need for mechanical ventilation was significantly higher with increasing NLR (0% vs 7% vs 14% vs 17% vs 32%;p-value: 0.03). Inpatient mortality was significantly higher in patients who had NLR>20 (70.27% of NLR>20 vs 16.07% of NLR 1-3 p-value <0.0001). On multivariate regression, patients with NLR>20 had 4 times higher odds of mortality;however, the p-value was not significant (4.07±2.78 p-value: 0.175). CONCLUSIONS: Increasing NLR in COVID19 patients is associated with increased ICU admission, intubation & inpatient mortality. Further studies are warranted to establish NLR, which is readily available & inexpensive, as a potential prognostic indicator in COIVD19 patients.
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INTRODUCTION: The host immune responses try to confront Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with all the potential cells and cytokines. Eventually, natural killer cells and T cells become exhausted, decreasing their counts, leading to lymphopenia. This study aims to assess the clinical utility of the absolute lymphocyte count (ALC) at admission in predicting outcome in patients with COVID-19. METHODS: Ours was a single-center, retrospective observational study, which included 463 nasopharyngeal swabs SARS-CoV-2 RT-PCR positive patients. Absolute lymphocyte count was retrieved from the admission complete blood count & was divided into 3 sub-groups (<500, <1000, and >1000 cells/μL). Demographics, comorbid conditions, and outcomes such as the need for mechanical ventilation, length of stay, and inpatient mortality were assessed. Statistics were performed using STATA. Significance was assigned at p<0.05. RESULTS: 13.82% of patients had ALC count<500, 44.71% had <1000 and 41.25% had more than 1000. Mean age in ALC group<500 was higher (71±1 years vs 65± 1.1 years in ALC group <1000 and 59.9+/-1.3 in ALC group >1000). Profound lymphopenia (<500 cells/μL) was more common in males compared to females (71.88 % vs 28% p value 0.01). ALC count <500, was associated with higher rate of non-invasive (45.31% vs 26.56% for ALC <1000, p-value: 0.01) as well as invasive ventilation (26.5% with ALC <500 vs 19% with ALC <1000 vs 10.4% with ALC with >1000;p-value: 0.01). Inpatient mortality was significantly higher in cohort with ALC <500 (51.56% with ALC <500 vs 33.3% with ALC <1000 vs 24.08% with ALC >1000;p-value 0.05). On multivariate regression, ALC was not a independent predictor of mortality (ALC<500, OR: 1.56±0.75, p-value: 0.44). CONCLUSIONS: Lymphopenia at admission in COVID19 patients is associated with an increased need for non-invasive & invasive ventilation & inpatient mortality. Currently, clinical trials assessing GM-CSF as a possible therapeutic option is underway.
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INTRODUCTION: Coronavirus disease 2019 (COVID- 19) caused by the SARS-CoV-2 virus has emerged as one of the greatest challenges to humanity in recent history. Older people have shown to have poor outcomes in recent studies. Our study looks at the characters and outcomes in patients of different age groups admitted to our center. METHODS: Our study is a single-center, retrospective, observational study of 471 COVID-19 patients (confirmed with a positive nasopharyngeal swab for SARS-CoV2 RT PCR) admitted to our hospital. Patients were divided into 3 groups based on Age (0-45 years, 46-65 years, and >65 years). Demographic characteristics and in-hospital outcomes were compared between these groups. STATA was used to perform statistics. Statistical significance was assigned at p=<0.05. RESULTS: 471 patients were included in the study of which 79 (16.77%), 159 (33.76%), and 233 (49.47%) belonged to the age group of 0-45 years (Group A), 46- 65 years (Group B) and >65 years (Group C) respectively. On comparison of pre-existing comorbidities, patients in group B and group C had a higher incidence of baseline comorbidities (Diabetes, Hypertension, Heart failure, COPD rates were 33.96% vs 43.1%, 55.35% vs 81.12%, 9.01% vs 20.59%, 2.5% vs 11.21% respectively). On comparing in-hospital outcomes, the mean time to mechanical ventilation from admission was 3.25 (±1.31) days, 2.42 (±0.68) days and 2.75 (±0.53) days for group A, B and C respectively. 74 (15.71%) patients required intubation during hospitalization of which 7.5%, 32.5%, and 60% belonged to groups A, B, and C respectively. The overall mortality rate among intubated patients was 90.54% among which 8.15%, 31.08%, and 60.81% belonged to groups A, B, and C respectively. The inhospital mortality rate was 32.48% of which 3.27%, 17.65%, and 79.08% belonged to groups A, B, and C respectively. In-hospital mortality rate for group A, B and C were 6.33%, 16.98% and 51.93% respectively (p <0.0001). However, on multivariate regression analysis, age was not an independent predictor of in-hospital mortality for any age group. CONCLUSIONS: Patients >65 years of age have higher co-morbidities and worse in-hospital outcomes. However, age is not an independent predictor of mortality and each patient should be evaluated individually while making an important treatment decision.
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INTRODUCTION: Systemic inflammation elicited by a cytokine storm is considered a hallmark of coronavirus disease 2019 (COVID-19). This study aims to assess the clinical utility of the lymphocyte-to-C-reactive protein (CRP) ratio (LCR), typically used for gastric & colorectal cancer prognostication. METHODS: Ours was a single center, retrospective observational study, which included 321 nasopharyngeal swab SARS-CoV-2 RT-PCR positive patients. LCR was derived from the admission complete blood count & was divided into 2 sub-groups (<99.99 vs >100). Demographics, comorbid conditions, and outcomes such as need for mechanical ventilation, length of stay and inpatient mortality were assessed. Statistics were performed using STATA. Significance was assigned at p<0.05. RESULTS: LCR <99.99 group had more elderly patients as compared to LCR >100 group (67.74% vs 54.01% of patients >60 years of age). Male patients were found to have lower LCR than females (60.75% vs 39.25% with LCR <99.99;p-value: 0.03). Among comorbidities, patients with history of cancer were found to have higher LCR (7.53% of LCR <99.99 vs 13.24% of LCR >100;p-value:0.03). Lower LCR was associated with higher rate of non-invasive (36.56% with LCR <99.99 vs 19.12% with LCR >100;p-value: 0.01) as well as invasive ventilation (17.74% with LCR <99.99 vs 11.76 with LCR >100;p-value: 0.01). Inpatient mortality was significantly higher in patients who had LCR <99.99 (39.25% with LCR <99.99 vs 22.63% with LCR >100;p-value <0.03). On multivariate regression, patients with LCR <99.99 had 2 times higher odds of mortality;however, this finding did not reach statistical significance. (2.27± 0.81 p-value: 0.15). CONCLUSIONS: Decreasing LCR in COVID19 patients is associated with increased need for non-invasive & invasive ventilation & inpatient mortality. Further studies are warranted to establish LCR, which is readily available & inexpensive, as a potential prognostic indicator in COIVD19 patients.
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INTRODUCTION: Coronavirus disease 2019 (COVID-19) is a multisystem infection caused by SARS-CoV-2 Virus. Recent studies have demonstrated poor outcomes in patients with diabetes mellitus (DM). We sought to assess the in-hospital outcomes of COVID19 patients with DM at our centre. METHODS: Ours was a single centre, retrospective, observational study of 470 COVID-19 patients admitted to our hospital. We divided these patients into 2 groups;those with DM and those without. We compared demographic characteristics, comorbid conditions, and in-hospital outcomes between the two groups. Statistics were performed using STATA. Statistical significance was assigned at p<0.05. RESULTS: Out of the 470 patients included in the study, 35.53% of patients had DM. Mean age of patients with and without DM was 68.35years±1.08 vs 61.71±1.05years respectively. 8.72% of patients were on pharmacological therapy. The diabetic cohort had a higher prevalence of hypertension, heart failure compared to the non-diabetic cohort (88.02 vs49.5% p-value:0.004, 22.9% vs 9.31% p-value: 0.04). Other comorbidities such as OSA, CKD, COPD, Asthma were comparable between both groups. The DM group had a higher level of inflammatory markers during the course of hospitalisation (D-dimer 3802.68± 1499 vs 3448.13 ±1139, CRP: 12.60±0.76 vs 11.85±0.60, ESR: 73.66±10.41 vs 58.04±7.10). The DM group had a significantly higher need for mechanical ventilation (18.56% vs 13.29%, p<0.03), and subsequent in-hospital mortality (43.35% vs 25.74% p<0.05). On multivariate regression, diabetics had 2.64 higher odds of in-hospital mortality, however, the p-value was not significant (Write ODDS Ratio and Confidence interval p-value: 0.116). CONCLUSIONS: Overall inpatient mortality was higher in patients with DM, likely driven by an increased need for mechanical ventilation. Our study positively adds to the existing literature that DM is a significant risk factor for higher morbidity and mortality in COVID-19 patients.