Clinical Outcomes With the Use of Prophylactic Versus Therapeutic Anticoagulation in Coronavirus Disease 2019.

OBJECTIVES: To determine the impact of anticoagulation on inhospital mortality among coronavirus disease 2019-positive patients with the a priori hypothesis that there would be a lower risk of inhospital mortality with use of preemptive therapeutic over prophylactic dose enoxaparin or heparin. DESIGN SETTING: Retrospective cohort study from April 1, 2020, to April 25, 2020. The date of final follow-up was June 12, 2020 Two large, acute-care hospitals in Western Connecticut. PATIENTS: Five hundred and one inpatients were identified after discharge as 18 years or older and positive for severe acute respiratory syndrome coronavirus 2. The final sample size included 374 patients after applying exclusion criteria. Demographic variables were collected via hospital billing inquiries, whereas the clinical variables were abstracted from patients' medical records. EXPOSURE: Preemptive enoxaparin or heparin at a therapeutic or prophylactic dose. MAIN RESULTS: When comparing treatments through multivariable analysis, risk of inhospital mortality was 2.3 times greater in patients receiving preemptive therapeutic anticoagulation (95% CI = 1.0-4.9; p = 0.04). Additionally, the average treatment effects were higher (ß = 0.11, p = 0.01) in the therapeutic group. CONCLUSIONS: An increase in inhospital mortality was observed among patients on preemptive therapeutic anticoagulation. Thus, in the management of coronavirus disease 2019 and its complications, we recommend further research and cautious use of preemptive therapeutic over prophylactic anticoagulation.

A Complicated Case of Triple Valve Infective Endocarditis in an IV Drug User with a Bicuspid Aortic Valve Requiring Three Separate Salvage Operations: A Case Report and Literature Review.

Infective endocarditis (IE) is an infection of the endocardium that involves valves and adjacent mural endocardium or a septal defect. Local complications include severe valvular insufficiency, which may lead to intractable congestive heart failure and myocardial abscesses. If left untreated, IE is generally fatal. Diagnosing IE can be straightforward in patients with the typical oslerian manifestations such as bacteremia, evidence of active valvulitis, peripheral emboli, and immunologic vascular phenomena. In the acute course, however, the classic peripheral stigmata may be few or absent, particularly among intravenous drug abuse (IVDA) patients in whom IE is often due to a S. aureus infection of right-sided heart valves. We present a complicated case of a very aggressive native aortic valve MSSA (methicillin sensitive Staphylococcus aureus) IE in a young adult male with a past medical history of bicuspid aortic valve and IV drug abuse. His clinical course was complicated by aortic valve destruction and development of third-degree AV block, as well as an aorto-left atrial fistula requiring emergent operation for AV replacement and patch repair. The patient required two reoperations for recurrent endocarditis and its complications.

Neanderthal and Denisova genetic affinities with contemporary humans: introgression versus common ancestral polymorphisms.

Analyses of the genetic relationships among modern humans, Neanderthals and Denisovans have suggested that 1-4% of the non-Sub-Saharan African gene pool may be Neanderthal derived, while 6-8% of the Melanesian gene pool may be the product of admixture between the Denisovans and the direct ancestors of Melanesians. In the present study, we analyzed single nucleotide polymorphism (SNP) diversity among a worldwide collection of contemporary human populations with respect to the genetic constitution of these two archaic hominins and Pan troglodytes (chimpanzee). We partitioned SNPs into subsets, including those that are derived in both archaic lineages, those that are ancestral in both archaic lineages and those that are only derived in one archaic lineage. By doing this, we have conducted separate examinations of subsets of mutations with higher probabilities of divergent phylogenetic origins. While previous investigations have excluded SNPs from common ancestors in principal component analyses, we included common ancestral SNPs in our analyses to visualize the relative placement of the Neanderthal and Denisova among human populations. To assess the genetic similarities among the various hominin lineages, we performed genetic structure analyses to provide a comparison of genetic patterns found within contemporary human genomes that may have archaic or common ancestral roots. Our results indicate that 3.6% of the Neanderthal genome is shared with roughly 65.4% of the average European gene pool, which clinally diminishes with distance from Europe. Our results suggest that Neanderthal genetic associations with contemporary non-Sub-Saharan African populations, as well as the genetic affinities observed between Denisovans and Melanesians most likely result from the retention of ancient mutations in these populations.

Basiliximab and heart transplantation in Hispanics: the experience in Puerto Rico.

BACKGROUND: Induction immunotherapy in addition to standard triple therapy at the time of cardiac transplantation with cytolytic antibodies has been used in recipients with pre transplant renal impairment, and to prevent rejection. Recently, anti-interlukin-2 receptor monoclonal antibodies have been used for these purposes. A retrospective study of 58 heart transplant recipients was conducted to assess the effect of basiliximab, a chimeric anti-interlukin-2 receptor monoclonal antibody on biopsy proven acute rejection, serum creatinine, creatinine clearance, hospitalizations due to infection and mortality one year after transplantation. METHODS: A total of 58 heart transplant patient's charts were reviewed. All patients received triple immunosuppressive therapy with cyclosporine or tacrolimus, mycophenolate mofetil and prednisone post transplant. Basiliximab 20 mg on day 0 and day 4 was administered as induction therapy in a subgroup of patients. Both groups had similar pre transplant characteristics. Analysis was performed at intervals of 0-17 weeks, 18-34 weeks, 35-52 weeks, and one year overall. The incidence of acute rejection episodes, post-transplant renal function, patient survival and hospitalizations due to infection was analyzed. RESULTS: Twenty-seven patients received induction therapy with basiliximab and 31 patients did not. Basiliximab induction helped reduce acute rejection overall during the first year, with 22 episodes of rejection in the induction group, and 67 episodes in the no induction group. In the 0-17 weeks following transplantation there were 20 reported rejection episodes in the induction group versus 58 rejection episodes in the no-induction group, demonstrating also reduction of rejection by induction in this group. Basiliximab induction group had preserved renal function, with higher creatinine clearance at 1 year when compared to the no induction group. There were no differences between groups in terms of hospitalizations due to infections or mortality. CONCLUSION: Induction therapy with basiliximab significantly reduced the number of acute rejection within the first year after heart transplantation, without a negative impact on patient's renal function, risk of infection or mortality.

Constrictive pericarditis.

Constrictive pericarditis is a rare but severely disabling consequence of the chronic inflammation of the pericardium, leading to an impaired filling of the ventricles and reduced ventricular function. Patients complain about fatigue, peripheral edema, breathlessness and abdominal swelling; signs and symptoms of right-sided heart failure. Besides history and physical examination, diagnostic studies aid in the diagnosis, including electrocardiogram, chest x-ray, echocardiogram, chest CT and/or MRI, and hemodynamic measurements. Medical management with diuretics and salt restriction is useful for symptomatic relief of fluid overload and peripheral edema, but patients ultimately become refractory. Although conservative treatment may alleviate the patient's symptoms, pericardiectomy remains the onlydefinitive treatment for the disease. An interesting and representative case of constrictive pericarditis is presented in this article.

Uneventful pregnancy and delivery in a patient with idiopathic pulmonary hypertension: a case report.

Idiopathic pulmonary hypertension is a rare disease characterized by sustained elevation of the pulmonary artery pressure and pulmonary vascular resistance, normal pulmonary artery wedge pressure, in the absence of a known cause. Prior reports suggest a very high maternal mortality in patients with idiopathic pulmonary hypertension undergoing pregnancy, and for that the recommendation has been avoidance of pregnancy (or termination if the patient is already pregnant). On the other hand, there have been multiple reports of patients with idiopathic pulmonary hypertension sustaining pregnancy and labor without major complications. This case report illustrates the course of pregnancy and labor in a patient diagnosed with idiopathic pulmonary hypertension. At age 24, the patient started with symptoms of shortness of breath and chest pain, and upon evaluation she was found with moderately severe idiopathic pulmonary hypertension. One year and 8 months later the patient becomes pregnant, and begins follow up with gynecology and cardiology. During this time the patient was asymptomatic, and did not have any clinical evidence of pulmonary hypertension. The risks of pregnancy were discussed with the patient, and she decided to continue pregnancy. She had an uneventful pregnancy, complicated only by preterm labor at 34 weeks and 5 days of gestation. She had spontaneous labor and delivered vaginally a healthy baby boy, weighting 4 pounds and 12 ounces. No invasive monitoring was used. The mother and the baby were discharged home 48 hours postpartum. Seven months later the patient returned for evaluation, presenting evidence of severe pulmonary hypertension. She has been followed up ever since by a cardiologist and currently is stable but symptomatic. This report adds to the amount of evidence that suggests that pregnancy and labor in a patient with idiopathic pulmonary hypertension may have a better outcome than previously reported. The decision of undertaking and/or continuing pregnancy in a patient with idiopathic pulmonary hypertension relies ultimately on the patient's choice, but should be done on an individual basis after careful evaluation of the risks. Finally, the need of close follow up with a multidisciplinary team is mandatory in the patient with idiopathic pulmonary hypertension that wishes to undergo pregnancy.

Primary pulmonary hypertension and pregnancy.

Primary pulmonary hypertension (PPH) is a disorder intrinsic to the pulmonary vascular bed characterized by sustained elevation in pulmonary artery pressure and pulmonary vascular resistance with normal pulmonary artery wedge pressure, in the absence of a known cause. Cardiovascular disorders are the most common cause of morbidity and mortality in pregnant women. Risk is so great with some cardiovascular abnor-malities that recommendation of avoidance or interruption of pregnancy is supportable, one of these conditions is pulmonary hypertension. In this article two patients with primary pulmonary hypertension who sustained two pregnancies each are described. Both patients had uneventful pregnancies and deliveries, with all neonates surviving. When evaluating primary pulmonary hypertension and pregnancy, early studies reported a maternal mortality rate as high as 50%. More recent studies report a maternal mortality of 30%. In this article, cases of primary pulmonary hypertension undergoing pregnancy from 1978 to 2005 were reviewed, revealing a 22% maternal mortality for the total number of pregnancies. Despite advances in treatment, primary pulmonary hypertension continues to carry considerable maternal morbidity and mortality, and prevention of pregnancy is still the main recommendation. Early diagnosis and treatment is critical and a multi-disciplinary approach is required when dealing with a patient with PPH who desires to continue pregnancy.

Bullous pemphigoid: course of the disease. A study of 25 patients.

Different studies on the course of bullous pemphigoid have suggested that there may be significant variations in the survival of these patients based on their ethnicity or region of origin. Because of the lack of studies on patients with bullous pemphigoid in the Caribbean, specifically in Puerto Rico, a retrospective analysis about the outcome of patients with this disease in the region was performed. Twenty-five (25) patients were included in this study. The patients were diagnosed as bullous pemphigoid by clinical, histopathologic and immunopathologic assessment. Medical records were reviewed and those patients that were alive were contacted and examined on a follow up visit. Nine were men and sixteen were women; the age at the time of the diagnosis ranged from 54 to 90 year-old (mean 72); 13 were alive after at least 5 years of follow-up and 12 had died. The age at the moment of death ranged from 67 to 95 year-old (mean 83). Of those patients living, 85% were in remission, while 15% had active disease. In general, patients had a disease of mild severity, but, still, 68% of them received systemic corticosteroid therapy. Five of patients had to be admitted due to disease; two of them died while at the hospital. This data suggests that bullous pemphigoid in Puerto Ricans is a disease with a relatively benign course, but which can be fatal in the elderly, especially, if it requires admission to the hospital and the patient receives high doses of systemic corticosteroids.