Assessing the Efficacy of RADPAD Protection Drape in Reducing Radiation Exposure to Operators in the Cardiac Catheterization Laboratory: A Systematic Review and Meta-Analysis.

One of the leading environmental hazards, ionizing radiation, is linked to several detrimental health consequences in the body. RADPAD (Worldwide Innovations & Technologies, Inc., Kansas City, Kansas) is a sterile, lead-free, lightweight, disposable radiation protection shield. We conducted a systematic review and meta-analysis to determine the effectiveness of RADPAD protection drapes in the cardiac catheterization lab and how they can aid interventional cardiologists in becoming subjected to less scatter radiation. PubMed, Embase, and Google Scholar were searched for studies discussing the efficacy of RADPAD protection drapes in reducing radiation exposure to operators in the cardiac catheterization laboratory. A random-effects model was used to pool odds ratios (ORs) and 95% confidence intervals (CIs) for endpoints: primary operator exposure dose, dose area product (DAP), relative exposure, and screening time. Our analysis included 892 patients from six studies. Compared to the No-RADPAD group, primary operator exposure dose (E) was significantly lower in the RADPAD group (OR: -0.9, 95% CI: -1.36 to -0.43, I2 = 80.5%, p = 0.0001). DAP was comparable between both groups (OR: 0.008, 95% CI: -0.12 to -0.14, I2 = 0%, p = 0.9066). There was no difference in the relative exposure (E/DAP) (OR: -0.47, 95% CI: -0.96 to 0.02, I2 = 0%, p = 0.90) and screening time (OR: 0.13, 95% CI: 0.08 to 0.35, I2 = 0%, p = 0.22) between the two groups. The interventional cardiology laboratory is exposed to significantly less scatter radiation during procedures owing to the RADPAD protective drape. Consequently, all catheterization laboratories could be advised to employ RADPAD protective drapes.

Short-Term Outcomes of Cardiac Arrhythmias Among COVID-19 Patients: A Propensity Matched National Study.

The risk of arrhythmia is high in patients with COVID-19. The current literature is limited in understanding the clinical impact of arrhythmias and the extent of healthcare utilization in COVID-19 patients. The Nationwide In-patient Sample Database (NIS) from 2019 to 2020 was queried to identify COVID-19 patients who developed arrhythmias vs those without. Multivariate regression for adjusted odds ratios (aOR) and propensity score matching (PSM) were done to compare outcomes among both cohorts. A total of 1,664,240 patients (weighted) were hospitalized with COVID-19 infection, 380,915 (22.89%) of whom were diagnosed with an arrhythmia. After propensity matching COVID-19 with arrhythmias had higher rates of in-hospital mortality (22.4% vs 13.5%, P < 0.001), acute kidney injury (PSM 39.4% vs 35.7%, P < 0.001), acute heart failure (AHF) (18.2% vs 12.6%, P < 0.001), acute stroke (0.76% vs 0.57%, P < 0.001), cardiogenic shock (1.38% vs 0.5%, P < 0.001), cardiac arrest (5.26% vs 2.3%, P < 0.001) acute myocardial infarction (AMI) (12.8% vs 7.8%, P < 0.001), intracerebral hemorrhage (0.63% vs 0.45%, P < 0.001), major bleeding (2.6% vs 1.8%, P < 0.001) and endotracheal intubation (17.04% vs 10.17% < 0.001) compared to arrhythmias without COVID-19. This cohort also had lower odds of receiving interventions such as cardiac pacing (aOR 0.15 95% Cl 0.13-0.189 P < 0.001), cardioversion (aOR 0.43 95% CI 0.40-0.46, P < 0.001), and defibrillator (aOR 0.087 95% Cl 0.061-0.124, P < 0.001) compared to arrhythmia patients without COVID-19. Cardiac arrhythmias associated with COVID-19 resulted in longer length of hospital stay and higher total costs of hospitalizations. Arrhythmias associated with COVID-19 had worse clinical outcomes with an increased rate of in-hospital mortality, longer length of hospital stay, and higher total cost. These patients also had lower odds of receiving interventions during the index hospitalization.

Meta-Analysis of Efficacy and Safety of Intravenous Iron in Patients With Iron Deficiency and Heart Failure With Reduced Ejection Fraction.

Iron deficiency is an independent risk factor for heart failure (HF) exacerbation. We aim to study the safety and efficacy of intravenous (IV) iron therapy in patients with HF with reduced ejection fraction (HFrEF). A literature search was conducted on MEDLINE (Embase and PubMed) using a systematic search strategy by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) until October 2022. CRAN-R software (The R Foundation for Statistical Computing, Vienna, Austria) was used for statistical analysis. The quality assessment was performed using the Cochrane Risk of Bias and Newcastle-Ottawa Scale. We included 12 studies with a total of 4,376 patients (IV iron n = 1,985 [45.3%]; standard of care [SOC] n = 2,391 [54.6%]). The mean age was 70.37 ± 8.14 years and 71.75 ± 7.01 years in the IV iron and SOC groups, respectively. There was no significant difference in all-cause mortality and cardiovascular mortality (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.74 to 1.04, p <0.15). However, HF readmissions were significantly lower in the IV iron group (RR 0.73, 95% CI 0.56 to 0.96, p = 0.026). Non-HF cardiac readmissions were not significantly different between the IV iron and SOC groups (RR 0.92, 95% CI 0.82 to 1.02, p = 0.12). In terms of safety, there was a similar rate of infection-related adverse events in both arms (RR 0.86, 95% CI 0.74 to 1, p = 0.05). IV iron therapy in patients with HFrEF is safe and shows a significant reduction in HF hospitalizations compared with SOC. There was no difference in the rate of infection-related adverse events. The changing landscape of HFrEF pharmacotherapy in the last decade may warrant a re-demonstration of the benefit of IV iron with current SOC. The cost-effectiveness of IV iron use also needs further study.

Study to Assess Level of Preoperative Anxiety in Patients Scheduled for Surgery.

BACKGROUND: Pre-operative anxiety is unpleasant state of tension or uneasiness that results from patient doubt and fear before an operation. This study aims at assessing level of state and trait anxiety and other associated factors among preoperative patient. METHODS: A descriptive cross-sectional study was done among 195 patients above 18 years of age planned for elective surgery the following day in different departments in tertiary care center. State and Trait Anxiety Inventory and self-designed semi structured pro-forma was used to assess anxiety and patient particulars respectively. RESULTS: There were 195 patients in study among which 93(47.7%) underwent major surgery and 102 (52.3%) underwent minor surgery. The mean State Anxiety Score was 45.89±12.502. The mean Trait Anxiety Score was 43.17±9.342. State and Trait anxiety differed significantly in male and female patients. Trait Anxiety was associated with education and marital status. CONCLUSIONS: There was no significant difference in anxiety level in patient undergoing major and minor surgery. Male and female patients differed significantly in both State and Trait Anxiety.

Severe Case of Oral Baclofen Withdrawal Resulting in Mechanical Ventilation.

Abrupt baclofen withdrawal may be life-threatening with varied neuropsychiatric manifestations. We present a case of baclofen withdrawal necessitating intubation. A 58-year-old female with a history of undiagnosed muscle spasticity presented with worsening extremities tremors, paresthesia, and weakness for 2 days. Initial vitals included temperature 103 F, tachycardia, hypertension, and tachypnea. Examination revealed coarse tremors of all extremities. Inflammatory markers, blood, and urine culture were negative. Head and spine imaging were non-diagnostic. Meningitis and seizure were ruled out. She continued worsening with hallucinations, hyperpyrexia, ocular clonus, and profound muscle rigidity. The patient was intubated for respiratory distress and transferred to intensive care unit (ICU). Further history revealed running out of oral baclofen 3 days ago. Baclofen was restarted with symptomatic improvement. The patient was extubated after 2 days and discharged to a rehabilitation facility. Oral or intrathecal baclofen is thought to inhibit spinal nerves reducing muscle spasm and pain. Abrupt stoppage causes activation of dopamine and noradrenergic receptors causing muscle spasms, tremors, hyperpyrexia, delusions, hallucination, and delirium. Severe cases can mimic meningoencephalitis, seizure disorder, or neuroleptic malignant syndrome. Symptoms usually develop in 1 to 3 days of cessation and can be life-threatening if unrecognized timely. Treatment includes supportive therapy, re-administration of baclofen, or use of benzodiazepines, propofol, dexmedetomidine; however, no specific guidelines have been established. To the knowledge of the authors, this is the first case of oral baclofen withdrawal requiring intubation. We found only 3 reported cases of intrathecal baclofen withdrawal necessitating intubation.

COVID-19 pericarditis mimicking an acute myocardial infarction: a case report and review of literature.

The novel coronavirus disease (Covid-19) continues to spread all over the world with acute respiratory distress syndrome and multiorgan failure being a significant cause of morbidity and mortality. The involvement of the cardiovascular system is associated with increased mortality and there have been various manifestations reported in the literature. We present a case of a patient requiring intensive care unit (ICU) admission for acute respiratory distress syndrome from Covid-19 who developed ST elevations in inferior leads in electrocardiogram (ECG) and elevated troponins. The changes resolved in serial ECG accompanied by normalization of blood troponin levels. His subsequent echocardiogram did not reveal any abnormalities in wall motion or heart function leading to a diagnosis of focal pericarditis mimicking an acute myocardial infarction. We also present a review of literature on various cardiac manifestations reported so far in cases of Covid-19.

Nasopharyngeal Swab for COVID-19 Test Necessitating Mechanical Ventilation and Tracheostomy.

We present the first-ever reported case of massive epistaxis following nasopharyngeal (NP) swabbing requiring intubation and tracheostomy. A 67-year-old male with a mechanical aortic valve on warfarin presented from a nursing home to the emergency department with hypoxia. NP swab for coronavirus disease 2019 (COVID-19) was obtained, immediately followed by significant epistaxis. Patient desaturated to low 80s requiring intubation for airway protection and hypoxemic respiratory failure. Anterior nasal packing was performed. The COVID-19 test resulted negative. Extubation was unsuccessful on days four and nine. The patient subsequently underwent tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. The patient was transferred to sub-acute rehabilitation with a tracheostomy tube on minimal ventilator support. The World Health Organization (WHO) has recommended obtaining an NP swab in COVID-19 suspects to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using reverse transcriptase polymerase chain reaction (PCR).A study found that NP swabbing was associated with epistaxis in approximately 5-10% of the cases. Nursing home populations are at higher risk for COVID-19 and also reported to have increased use of oral anticoagulation for chronic atrial fibrillation with other co-morbidities (high CHADVASc score) which may increase bleeding risk with NP swabbing. Less invasive methods such as salivary and mid-turbinate sampling, nasal swab or saliva can be a better alternative sample for detecting SARS-CoV-2 as recommended by the Centers for Disease Control and Prevention (CDC) and suggested by FDA. Positive PCR testing beyond nine days of illness is likely due to persistent dead virus particles and thus repeat testing is not suggested. Obtaining a history of bleeding diathesis, use of oral anticoagulants and consideration of NP anatomy is advised before swabbing. This case report raises the concern against inadvertent NP swabbing in cases with a low pretest probability of COVID-19 infection with higher bleeding risk.

Factitious Disorder Masquerading as a Life-Threatening Anaphylaxis.

Factitious disorder is a psychiatric disorder in which sufferers intentionally fabricate physical or psychological symptoms in order to assume the role of the patient, without any obvious gain. We present a case of a 23-year-old female with chronic urticaria who presented with dyspnea, dysphasia, mild generalized erythema, abdominal cramps, and headache. She was tachypneic and hypotensive. This was her third admission with similar symptoms within the last 7 months. Tryptase, complement, anti-SM/RNP, Sjogren, Scl-70, C3, and C4 were negative. Computed tomography-guided bone marrow biopsy showed no mast cells. Flow cytometry did not show any immunophenotypic reaction. Other possible differentials including pregnancy, autoimmune disorders, and infections including hepatitis, thyroid disorder, and age-related malignancies were ruled out. After a thorough review, malingering disorder was ruled out, but we noticed the patient's intent of assuming a sick role. Later, the patient was diagnosed with major depressive disorder. Factitious anaphylaxis can present with multiple presentations including a life-threatening condition that mimics true anaphylaxis. A better approach would be thorough clinical evaluation and early multidisciplinary involvement. This case highlights the importance of further evidence-based studies in factitious disorder to decrease the disease burden and reduce the health care cost.

Atypical presentation of an elderly male with autoimmune encephalitis: anti-LG1 limbic encephalitis.

INTRODUCTION: We present a case of an elderly male with anti-LG1 limbic encephalitis involving hypothalamus presenting with acute changes in mental status and persistent hyperthermia. CASE REPORT: A 74-year-old male presented to the hospital with fever and chills. He had also been evaluated by his PCP for changes in his mental status, trouble remembering things, and following directions while driving. A lumbar puncture was performed, and empiric meningitis coverage was initiated. His LP results were not suggestive for any infectious process. An MRI showed bilateral hippocampal edema. As an infectious workup was non-revealing and other causes were ruled out, with the concern for paraneoplastic or autoimmune encephalitis, patient was started on high dose steroids and plasma exchange while results of antibodies for autoimmune and paraneoplastic encephalitis were awaited. After plasmapheresis and a course of steroids, the patient's mental status began to slowly improve. He was discharged from the hospital and on subsequent neurology office visit, his serum autoimmune encephalitis panel returned positive for anti-LGI 1 antibodies. Further management consisted of outpatient rituximab infusion. DISCUSSION: Diagnosis of limbic encephalitis can be challenging and can present with symptoms of limbic dysfunction. A modest index of suspicion of limbic encephalitis should be kept in adults with altered mental changes. Early recognition and initiation of therapy can be crucial in the management of patients with autoimmune encephalitis and can prevent permanent cognitive impairment and damage.

Mediterranean diet and the risk of chronic kidney disease: A systematic review and meta-analysis.

OBJECTIVE: Mediterranean diet has been shown to be associated with lower risk of cardiovascular disease. However, its association with chronic kidney disease (CKD) remains inconclusive as the results were not consistent among population-based studies. This study aims to assess the association between Mediterranean diet adherence and CKD prevention. METHODS: We performed a systematic review and meta-analysis of studies describing the risk for CKD in community-dwelling subjects ≥18 years of age. Mediterranean diet adherence was assessed by standardized food frequency questionnaires. The search was conducted through MEDLINE, EMBASE and Cochrane Library. RESULTS: Of 168 citations, a total of nine (n = 19 151) and four studies (n = 8467) were included in the systematic review and meta-analysis, respectively. Only studies adopting Mediterranean Diet Scale (MDS) were included in the analysis. The mean score was 3.8 ± 0.3 points. With the mean follow-up duration of 20.6 ± 7.0 years, the pooled odds ratio (OR) for CKD was 0.901 (95% confidence interval [CI] 0.868-0.935) for each 1-point increment of MDS. The incidence of CKD was 0.026 events per person-year (95% CI 0.008-0.045). Moreover, male sex was associated with the incidence of CKD in an adjusted meta-regression analysis. In contrast, there was no significant association between age, black race, smoking, diabetes, hypertension estimated glomerular filtration rate and total daily energy intake vs CKD incidence. CONCLUSION: Adherence to Mediterranean diet by a 1-point increment of MDS was associated with 10% lower risk of CKD. However, there were insufficient data on patients with pre-existing CKD or dialysis.

Treatment outcomes of bumetanide continuous infusion: A systematic review and meta-analysis.

The clinical use of continuous bumetanide infusion for acute heart failure and volume overload is common. However, there is not enough supporting evidence for the use of continuous bumetanide infusion. Thus, we conducted this systematic review and meta-analysis aiming to describe the treatment outcomes of continuous bumetanide infusion. We searched Ovid MEDLINE, EMBASE and the Cochrane Library for eligible publications. Inclusion criteria were patients age ≥18 years with bumetanide infusion for heart failure, acute kidney injury (AKI) or volume overload. From 1564 citations, three studies (n = 94 patients) were included in the systematic review and meta-analysis. The mean dose of bumetanide was 1.08 ± 0.43 mg/hour with a mean treatment duration of 45.09 ± 10.12 hours. Mean urine output in response to continuous bumetanide infusion was 1.88 mL/kg/hour (95% confidence interval [CI], 1.72-2.05). The incidence of AKI with continuous bumetanide infusion was 24.7% (95% CI, 8.2-54.6). By using Pearson's correlation coefficient, increasing doses of bumetanide were correlated with increased urine output (P = .026) and increased incidence of AKI (P < .01). There was no correlation between increasing urine output and the incidence of AKI (P = .739). In conclusion, with available evidence, continuous bumetanide infusion may be used in the treatment of acute heart failure or volume overload with close monitoring for new-onset or worsening AKI.