Left Ventricular Global Longitudinal Strain in Patients With COVID-19 Infection.

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, is an ongoing pandemic that has affected millions globally. Many infected patients have been noted to have cardiovascular damage. Prior to the development of clinical symptoms, the use of transthoracic echocardiography, specifically with measurements of left ventricular global longitudinal strain (LVGLS), may provide an additional prognostic marker for patients infected with COVID-19. We sought to determine whether patients with COVID-19 and reduced LVGLS have an increased risk for mortality. The mean LVGLS was determined to be significantly lower in the non-survivors compared to the survivors (-11.6 ± 1.8 vs -15.4 ± 0.74, p<0.05). It should be noted, however, that even those that survived were found to have reduced LVGLS (<-18.5%). A multivariate logistic regression analysis was also performed that demonstrated a relationship between reduced LVGLS and an increased risk for mortality. Overall, our data indicate that COVID-19 patients may have subclinical left ventricular dysfunction, and that critically ill patients may have a greater decline in cardiac dysfunction.

Impact of early cholecystectomy on the readmission rate in patients with acute gallstone cholangitis: a retrospective single-centre study.

BACKGROUND AND AIMS: The pathogenesis of acute cholangitis (AC) occurs with biliary obstruction followed by bacterial growth in the bile duct. The leading cause of AC is obstructing gallstones. There have been conflicting theories about the optimal timing for cholecystectomy following AC. The aim of this study is to assess the impact of early cholecystectomy on the 30-day readmission rate, 30-day mortality, 90-day readmission rate and the length of hospital stay. METHODS: This retrospective study was performed between January 2015 and January 2021 in a high-volume tertiary referral teaching hospital. Included patients were 18 years or older with a definitive diagnosis of acute gallstone cholangitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) with complete clearance of the bile duct as an index procedure. We divided the patients into two groups: patients who underwent ERCP alone and those who underwent ERCP with laparoscopic cholecystectomy (LC) on the same admission (ERCP+LC). Data were extracted from electronic medical records. The primary endpoint of the study was the 30-day readmission rate. RESULTS: A total of 114 patients with AC met the inclusion criteria of the study. The ERCP+LC group had significantly lower rates of 30-day readmission (2.2% vs 42.6%, p<0.001), 90-day readmission (2.2% vs 30.9%, p<0.001) and 30-day mortality (2.2% vs 16.2%, p=0.017) when compared with the ERCP group. In a multivariate logistic regression analysis, patients in the ERCP+LC group had 90% lower odds of 30-day readmission compared with patients who did not undergo LC during admission (OR=0.1, 95% CI (0.032 to 0.313), p<0.001). CONCLUSION: Performing LC on same day admission was associated with a decrease in 30-day and 90-day readmission rate as well as 30-day mortality.

The Role of Magnesium in the Management of Atrial Fibrillation with Rapid Ventricular Rate.

BACKGROUND: Atrial fibrillation is currently managed with a variety of rate controlling and antiarrhythmic agents. Often, magnesium is used as adjunctive therapy, however, the benefit it provides in managing Afib with RVR has been debated. This study aimed to determine if IV MgSO4 administration in conjunction with standard therapy provides any synergistic effect in acute and prolonged control of Afib with RVR. METHODS: This was a retrospective study involving ninety patients with episodes of Afib with RVR during their hospitalization. The treatment group included those that had received magnesium (n=32) along with standard management and the control group (n=58) received only standard management. Heart rates at different time intervals were collected. Dose dependent effects of IV MgSO4 on heart rates were also evaluated. RESULTS: Patients that received magnesium had a lower mean heart rate (85 BPM versus 96 BPM, P<0.05) 24 hours after onset of the episode. Also, in the last 16 hours of observation, it appeared that administration of higher levels of magnesium resulted in statistically lower heart rates. In the group of patients that received 2 grams of magnesium, the mean heart rate at 8 hours was 103.4 beats/min and 84.8 beats/min at 24 hours (p<0.01). This same trend was not seen in patients that received 1 gram of magnesium or in the control group. CONCLUSIONS: Overall, the use of IV MgSO4 as an adjunctive treatment permitted normalization of the heart rate progressively that continued to at least 24 hours.

Prevalence of peripheral arterial disease in subjects at moderate cardiovascular risk: Greek results of the PANDORA study.

INTRODUCTION: Peripheral arterial disease (PAD) is a form of atherosclerotic disease that confers a cardiovascular (CV) risk equivalent to that of coronary heart disease. Despite its association with high CV risk, PAD is potentially underdiagnosed. The primary objective of the study was to assess the prevalence of asymptomatic PAD through measurement of the ankle-brachial index (ABI) in subjects at moderate CV risk. Secondary objectives included the assessment of the prevalence of CV risk factors and lifestyle habits in the total population and in subjects with or without PAD, as well as the identification of factors associated with PAD. METHODS: PANDORA (NCT00689377) was a cross-sectional study conducted in 6 European countries. The study required a single visit in which males aged 45 or females 55 years, with at least 1 additional risk factor, but no overt CV disease or diabetes, underwent ABI measurement. Data on patient demographics, vital signs, CV risk factors, lipid levels and current treatment were recorded. RESULTS: Eight hundred forty subjects (789 evaluable) were enrolled by 120 office-based physicians across Greece. Age was 62.1 ± 9.1 years and body-mass index 29.6 ± 4.3 kg/m(2); 61.2% of the subjects were male, 47% were smokers, and 73.5% hypertensive. The prevalence of asymptomatic PAD, defined as ABI0.90, was 28.0% (95% CI: 24.88-31.14). In logistic regression analysis, hypertension (OR: 2.48, 95% CI: 1.58-3.89, p<0.0001), low high-density lipoprotein cholesterol (OR: 2.27, 95% CI: 1.55-3.32, p<0.0001), and divorced marital status (OR: 2.63, 95% CI: 1.14-6.07, p=0.023), were found to be strong determinants for PAD. CONCLUSIONS: Asymptomatic PAD was highly prevalent in subjects with moderate CV risk treated by officebased physicians in Greece. ABI measurement is a significant tool for identifying subjects at higher risk who may require earlier and possibly more aggressive intervention.

The PANDORA study: peripheral arterial disease in patients with non-high cardiovascular risk.

Few studies are available with sufficient sample size to accurately describe the prevalence of low ankle-brachial index (ABI) in patients at 'non-high' cardiovascular (CV) risk. The aim of this study was to evaluate the prevalence of asymptomatic peripheral arterial disease (PAD), as determined by using ABI, in this patient population. A non-interventional, cross-sectional, pan-European study was conducted in patients with ≥1 CV risk factor in addition to age, evaluating the prevalence of asymptomatic PAD (ABI ≤ 0.90). Secondary objectives included assessing the prevalence and treatment of CV risk factors. Patients were consecutively recruited during scheduled visits to the physician's office, or were randomly selected by the physician from a list of eligible patients. Patients with diabetes were excluded as this condition was deemed to be a secondary prevention risk. 10,287 patients were enrolled (9,816 evaluable: mean age 64.3 years; 53.5% male). Prevalence of asymptomatic PAD was 17.8% (99% CI 16.84-18.83). Factors significantly associated with asymptomatic PAD included hypertension, age, alcohol intake, family history of coronary heart disease, low levels of high-density lipoprotein-cholesterol, and smoking (p < 0.0001). Patients treated with statins were significantly less likely to have asymptomatic PAD than those who were not (odds ratio 0.62; 95% CI 0.50-0.76; p < 0.0001). Asymptomatic PAD was highly prevalent in patients with non-high CV risk, the majority of whom would not typically be candidates for ABI assessment. These patients should be carefully screened, and ABI measured, so that therapeutic interventions known to diminish their increased CV risk may be offered.

Prevalence of peripheral arterial disease in patients at non-high cardiovascular risk. Rationale and design of the PANDORA study.

BACKGROUND: Lower extremity peripheral arterial disease (PAD) is a marker of widespread atherosclerosis. Individuals with PAD, most of whom do not show typical PAD symptoms ('asymptomatic' patients), are at increased risk of cardiovascular ischaemic events. American College of Cardiology/American Heart Association guidelines recommend that individuals with asymptomatic lower extremity PAD should be identified by measurement of ankle-brachial index (ABI). However, despite its associated risk, PAD remains under-recognised by clinicians and the general population and office-based ABI detection is still poorly-known and under-used in clinical practice. The Prevalence of peripheral Arterial disease in patients with a non-high cardiovascular disease risk, with No overt vascular Diseases nOR diAbetes mellitus (PANDORA) study has a primary aim of assessing the prevalence of lower extremity PAD through ABI measurement, in patients at non-high cardiovascular risk, with no overt cardiovascular diseases (including symptomatic PAD), or diabetes mellitus. Secondary objectives include documenting the prevalence and treatment of cardiovascular risk factors and the characteristics of both patients and physicians as possible determinants for PAD under-diagnosis. METHODS/DESIGN: PANDORA is a non-interventional, cross-sectional, pan-European study. It includes approximately 1,000 primary care participating sites, across six European countries (Belgium, France, Greece, Italy, The Netherlands, Switzerland). Investigator and patient questionnaires will be used to collect both right and left ABI values at rest, presence of cardiovascular disease risk factors, current pharmacological treatment, and determinants for PAD under-diagnosis. DISCUSSION: The PANDORA study will provide important data to estimate the prevalence of asymptomatic PAD in a population otherwise classified at low or intermediate risk on the basis of current risk scores in a primary care setting. TRIAL REGISTRATION NUMBER: Clinical Trials.gov Identifier: NCT00689377.

Does timing of dialysis in patients with ESRD and acute myocardial infarcts affect morbidity or mortality?

BACKGROUND AND OBJECTIVES: Patients with ESRD have an increased incidence of coronary events with a relatively higher risk for mortality after acute myocardial infarction (AMI). We evaluated whether it is safer to delay dialysis in AMI or if delay poses separate risks. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a retrospective review of 131 long-term hemodialysis patients who had AMI and were admitted between 1997 and 2005 at three New York City municipal hospitals. Patients were separated into three groups on the basis of time between cardiac symptoms and first dialysis (<24 h, 24 to 48 h, and >48 h). RESULTS: A total of 17 (13%) patients died, 10 (59%) of whom had either hypotension or an arrhythmia during their first cardiac care unit dialysis. Although these groups were comparable in acuity and cardiac status, there were no findings of increased morbidity (26, 36, and 20%, respectively) or mortality (11, 18, and 13%, respectively), despite differences in the timing of each group's dialysis. We found that previous cardiac disease, predialysis K+, DeltaK+ after dialysis, and APACHE scores were significantly higher in patients with peridialysis morbidity. CONCLUSIONS: We conclude that there is no increased morbidity with early dialysis in AMI, but rather close attention needs to be paid to the rate of decrease in serum potassium in patients with ESRD and their level of acuity when undergoing dialysis.

Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure.

BACKGROUND: Fractional excretion of sodium (FENa) has been used in the diagnosis of acute renal failure (ARF) to distinguish between the two main causes of ARF, prerenal state and acute tubular necrosis (ATN). However, many patients with prerenal disorders receive diuretics, which decrease sodium reabsorption and thus increase FENa. In contrast, the fractional excretion of urea nitrogen (FEUN) is primarily dependent on passive forces and is therefore less influenced by diuretic therapy. METHODS: To test the hypothesis that FEUN might be more useful in evaluating ARF, we prospectively compared FEUN with FENa during 102 episodes of ARF due to either prerenal azotemia or ATN. RESULTS: Patients were divided into three groups: those with prerenal azotemia (N = 50), those with prerenal azotemia treated with diuretics (N = 27), and those with ATN (N = 25). FENa was low only in the patients with untreated plain prerenal azotemia while it was high in both the prerenal with diuretics and the ATN groups. FEUN was essentially identical in the two pre-renal groups (27.9 +/- 2.4% vs. 24.5 +/- 2.3%), and very different from the FEUN found in ATN (58.6 +/- 3.6%, P < 0.0001). While 92% of the patients with prerenal azotemia had a FENa <1%, only 48% of those patients with prerenal and diuretic therapy had such a low FENa. By contrast 89% of this latter group had a FEUN <35%. CONCLUSIONS: Low FEUN (

Screening for microalbuminuria simplified by urine specific gravity.

BACKGROUND: The albumin-to-creatinine ratio and the 24-hour urine collection to measure microalbuminuria are inconvenient and expensive. The newer rapid and less expensive dipstick methods for screening of microalbuminuria estimate only albumin and are subject to errors caused by variation in volume. We determined the relation between urine-specific gravity (Usg) and urine creatinine (Ucr) so that Ucr can be derived from Usg to correct for albumin concentration in the urine which is influenced by urine volume. METHODS: We randomly included 42 consecutive patients from the primary care clinic, and 34 patients from the diabetic clinic. RESULTS: We found that a very good correlation existed between Usg and Ucr in the 42 patients from the primary care clinic (Ucr = 11.4 x Usg -11,509, r = 0.83, p < 0.001). Patients from the diabetic clinic who had well-controlled blood sugar (n = 21) showed a similar trend (Ucr = 10.82 x Usg -10,882, r = 0.87, p < 0.001). However, this was not the case with uncontrolled diabetics (Ucr = 2.53 x Usg -2,513, r = 0.26, NS). Using simple arithmetic, we derived a simplified formula where Ucr can be predicted from Usg. Using multiple regression to incorporate the urinary glucose level by dipstick, a more generic formula was obtained for estimating urinary creatinine. CONCLUSION: Usg can be used instead of Ucr to normalize for the varied urine concentration while screening for microalbuminuria. Poorly controlled diabetics should be screened after their blood sugars are well controlled or use the more generic formula that incorporates urinary glucose. Thus, by measuring spot urine albumin and specific gravity by dipsticks one gets an easy, immediate and accurate estimation of microalbuminuria in an office setting.

Massive and disproportionate elevation of blood urea nitrogen in acute azotemia.

In renal failure, blood urea nitrogen and serum creatinine usually rise in tandem; the normal BUN: Cr ratio is 10-15: 1. Disproportionate rises in BUN: Cr (> 20: 1) often imply pre-renal azotemia but may be caused by increased protein catabolism or an excessive protein load. In this study we looked at intensive care patients who acutely developed markedly increased BUN (> or = 100 mg/dL) with only modest elevation of Cr (< or = 5 mg/dL) for possible causes of the disproportionate azotemia. There were 19 such cases collected over 6 months, nine women and ten men, with mean age 69.2 +/- 4.4 years (13/19 > 75 years). Peak BUN was 156 +/- 11 mg/dL; peak Cr 4.3 +/- 0.5 mg/dL. Eleven patients expired. Mean serum albumin at the time of consultation was 2.7 +/- 0.2 g/dL; mean total lymphocyte count 1.0 +/- 0.1/mm3. Of possible factors causing the azotemia, nine patients had documented hypovolemia; eight had congestive heart failure; six were in septic or hypovolemic shock, and two received high-dose steroids. As contributing factors, eight patients had Salb < 2.5 g/dL; eight were given a high protein intake > 100 g/d; two had HIV, and two others had gastrointestinal bleeding. Infection was present in 14 patients; seven had sepsis (bacteremia with hypotension). All patients had at least one of these factors present and 16/19 had two or more. Fractional Na excretion was < 1% (consistent with pre-renal azotemia) in only four of the 11 patients in whom it was measured. We conclude that severely disproportionate BUN : Cr is frequently multifactorial and is most common in the elderly, perhaps due to their lower muscle mass, and in ICU patients given a high protein intake. It is often not indicative of uncomplicated renal hypoperfusion, although low renal perfusion (hypovolemia, shock, or heart failure) is common. Mortality is high due to the severe illnesses, especially infection, worsened by decreased renal function and hypercatabolic state.