Multidisciplinary management of ventilator weaning and tracheostomies for COVID-19 patients at a major NYC public hospital: A blueprint for other institutions.

At the height of the coronavirus pandemic in New York City, at our hospital (NYC Health/Hospitals-Elmhurst) 95% of inpatients tested positive for COVID-19 and it operated at 500% surge ICU capacity-one of the greatest impacted centers in the nation. In the face of this we established a systematic multidisciplinary approach to manage ventilated ICU patients and select those appropriate for tracheostomy. Members from Pulmonary Critical Care, Anesthesiology, Surgery, Ethics, and Otolaryngology, created a protocolized way to assess all ICU patients in our hospital and, if deemed appropriate, help them towards weaning or tracheostomy and subsequent discharge. Given the climbing COVID numbers throughout the nation, and once again in NY, we believe sharing our protocol and brief outcomes will be very helpful for hospitals who are struggling with what we did, as it may serve as a blueprint for these institutions.

Coronary artery disease in patients with body mass index ≥30 kg/m(2): a retrospective chart analysis.

OBJECTIVE: In this study, we evaluated obesity as a single risk factor for coronary artery disease (CAD), along with the synergistic effect of obesity and other risk factors. METHODS: A retrospective study of 7,567 patients admitted to hospital for chest pain from 2005 to 2014 and underwent cardiac catheterization. Patients were divided into two groups: obese and normal with body mass index (BMI) calculated as ≥30 kg/m(2) and <25, respectively. We assessed the modifiable and non-modifiable risk factors in obese patients and the degree of CAD. RESULTS: Of the 7,567 patients who underwent cardiac catheterization, 414 (5.5%) had a BMI ≥30. Of 414 obese patients, 332 (80%) had evidence of CAD. Obese patients displayed evidence of CAD at the age of 57 versus 63.3 in non-obese patients (p<0.001). Of the 332 patients with CAD and obesity, 55.4% had obstructive CAD versus 44.6% with non-obstructive CAD. In obese patients with CAD, male gender and history of smoking were major risk factors for development of obstructive CAD (p=0.001 and 0.01, respectively) while dyslipidemia was a major risk factor for non-obstructive CAD (p=0.01). Additionally, obese patients with more than one risk factor developed obstructive CAD compared to non-obstructive CAD (p=0.003). CONCLUSION: Having a BMI ≥30 appears to be a risk factor for early development of CAD. Severity of CAD in obese patients is depicted on non-modifiable and modifiable risk factors such as the male gender and smoking or greater than one risk factor, respectively.

Morbidity and mortality of infective endocarditis in a hospital system in New York City serving a diverse urban population.

Infective endocarditis (IE) is a severe illness associated with significant morbidity and mortality. The primary purpose of this study was to evaluate morbidity and mortality of IE in a hospital serving the most diverse area in New York City. An analysis of 209 patients admitted to the hospital from 2000 to 2012 who were found to have IE based on modified Duke criteria. Among the 209 patients with IE, 188 (88.8%) had native heart valves and 21 (11.2%) had prosthetic valves. Of the patients with native heart valves, 3.7% had coronary artery bypass graft, 4.3% were active drug users, 6.3% had permanent pacemakers, 12.2% had a history of IE, 25.7% were diabetic, 17% had end-stage renal disease (ESRD), 9% had congestive heart failure, 8% had abnormal heart valves, and 13.8% had an unknown etiology. Mortality rates of the patients with prosthetic heart valves were 27.7% compared to 8.11% in patients with native heart valves (OR 3, p<0.0001). Since we identified diabetes mellitus and ESRD to be significant risk factors in our population, we isolated and compared characteristics of patients with and without IE. IE among patients with diabetes mellitus was 23% compared with 13.8% in the control group (p=0.016). Cases of IE in patients with ESRD were 15.3%, compared with 4% in the control group (p<0.0001). We identified an overall mortality rate of 20.1% in patients with IE, a readmission rate within 30 days of discharge of 21.5%, and an average age of 59 years. Among 209 patients, 107 were males and 102 females. The most common organisms identified were Staphylococcus aureus (43.7%), viridans streptococci (17%) followed by Enterococcus (14.7%). Despite appropriate treatment, high rates of morbidity and mortality remained, with a higher impact in patients greater than 50 years of age. Such discoveries raise the importance of controlling and monitoring risk factors for IE.

Serum vitamin D levels correlate to coronary artery disease severity: a retrospective chart analysis.

BACKGROUND: The pro-atherosclerotic nature of vitamin D deficiency has been shown to increase cardiovascular events. We further emphasized and evaluated the severity of coronary artery disease (CAD) with varying levels of vitamin D in relation to age, gender, ethnicity and baseline confounders. METHODS: A retrospective, single-center study of 9,399 patients admitted between 2005 and 2014 for chest pain who underwent coronary angiography. Patients without a vitamin D level, measured as 25-dihydroxyvitamin D (25[OH]D) were excluded from our study. 25(OH)D deficiency and insufficiency were defined by having serum concentration levels of less than 20 ng/ml and 20 to 29.9 ng/ml, respectively, while normal levels were defined as greater than or equal to 30 ng/ml. We assessed levels of 25(OH)D and extent of coronary disease with coronary angiography as obstructive CAD (left main stenosis of ≥50% or any stenosis of ≥70%), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries (no stenosis >20%). RESULTS: Among 9,399 patients, 1,311 qualified, of which 308 patients (23%) had normal 25(OH)D levels, 552 patients (42%) had 25(OH)D deficiency and 451 patients (35%) had 25(OH)D insufficiency. In an analysis of the extent of coronary disease, we identified 20% of patients having normal coronaries, 55% having obstructive CAD and 25% having non-obstructive CAD. Baseline clinical risk factors and co-morbidities did not differ between the groups. Patients with normal 25(OH)D levels were found to have normal coronaries compared to patients with 25(OH)D deficiency or insufficiency (OR: 7, 95% CI: 5.2 - 9.5, p < 0.0001). Comparing patients with normal 25(OH)D levels, patients with 25(OH)D deficiency or insufficiency (<29 ng/ml), 62% were found to have obstructive CAD (n = 624, OR: 2.9, 95% CI: 2.3-3.7, p < 0.0001) and 25% had non-obstructive CAD (n = 249, OR: 1.5, 95% CI: 1.1-2, p = 0.02). CONCLUSION: Normal coronaries and CAD were shown to correlate with normal and low levels of 25(OH)D, respectively. There is an inverse relationship between the percentage of coronary artery occlusion and serum 25(OH)D concentrations. Vitamin D may provide benefits in risk stratification of patients with CAD and serve as a possible risk factor.

Isolated supra-cardiac partial anomalous pulmonary venous connection causing right heart failure.

Right heart failure (RHF) has been overlooked as left heart failure has predominated. One of the many causes of RHF is partial anomalous pulmonary venous connection (PAPVC), an extremely rare entity in nature. Physicians should consider the unusual causes of RHF after ruling out the common causes.

Avoiding transthoracic echocardiography and transesophageal echocardiography for patients with variable body mass indexes in infective endocarditis.

BACKGROUND: Echocardiography has been a popular modality used to aid in the diagnosis of infective endocarditis (IE) with the modified Duke criteria. We evaluated the necessity between the uses of either a transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) in patients with a body mass index (BMI) greater than or equal to 25 kg/m(2) and less than 25 kg/m(2). METHODS: A single-centered, retrospective study of 198 patients between 2005 and 2012 diagnosed with IE based on modified Duke criteria. Patients, required to be above age 18, had undergone an echocardiogram study and had blood cultures to be included in the study. RESULTS: Among 198 patients, two echocardiographic groups were evaluated as 158 patients obtained a TTE, 143 obtained a TEE, and 103 overlapped with TEE and TTE. Out of these patients, 167 patients were included in the study as 109 (65%) were discovered to have native valve vegetations on TEE and 58 (35%) with TTE. TTE findings were compared with TEE results for true negatives and positives to isolate valvular vegetations. Overall sensitivity of TTE was calculated to be 67% with a specificity of 93%. Patients were further divided into two groups with the first group having a BMI ≥25 kg/m(2) and the subsequent group with a BMI <25 kg/m(2). Patients with a BMI ≥25 kg/m(2) who underwent a TTE study had a sensitivity and specificity of 54 and 92%, respectively. On the contrary, patients with a BMI < 25 kg/m(2) had a TTE sensitivity and specificity of 78 and 95%, respectively. CONCLUSIONS: Patients with a BMI <25 kg/m(2) and a negative TTE should refrain from further diagnostic studies, with TEE strong clinical judgment is warranted. Patients with a BMI ≥ 25 kg/m(2) may proceed directly to TEE as the initial study, possibly avoiding an additional study with a TTE.