Single-Dose Calcium Channel Blocker Toxicity in a Patient With Severe Liver Disease.

Calcium channel blockers (CCBs) are commonly used in the management of multiple diseases, including hypertension, arrhythmia, and vasospastic disorder. Nimodipine, a dihydropyridine CCB, has demonstrated utility in preserving hearing following vestibular schwannoma resection surgery. Due to its widespread use, CCB overdose is common. This case report presents a unique case of CCB toxicity in a 56-year-old female with end-stage liver dysfunction. The patient developed vasodilatory shock after receiving a single dose of prophylactic nimodipine following vestibular schwannoma surgery. The primary objective of this report is to highlight the unique risk for CCB toxicity that exists for patients with advanced liver disease who receive nimodipine in the perioperative setting.

Characteristics and Outcomes of Adults With Congenital Heart Disease in the Cardiac Intensive Care Unit.

Background: Little is known regarding the characteristics, treatment patterns, and outcomes in patients with adult congenital heart disease (ACHD) admitted to cardiac intensive care units (CICUs). Objectives: The authors sought to better define the contemporary epidemiology, treatment patterns, and outcomes of ACHD admissions in the CICU. Methods: The Critical Care Cardiology Trials Network is a multicenter network of CICUs in North America. Participating centers contributed prospective data from consecutive admissions during 2-month annual snapshots from 2017 to 2022. We analyzed characteristics and outcomes of admissions with ACHD compared with those without ACHD. Multivariable logistic regression was used to assess mortality in ACHD vs non-ACHD admissions. Results: Of 23,299 CICU admissions across 42 sites, there were 441 (1.9%) ACHD admissions. Shunt lesions were most common (46.1%), followed by right-sided lesions (29.5%) and complex lesions (28.7%). ACHD admissions were younger (median age 46 vs 67 years) than non-ACHD admissions. ACHD admissions were more commonly for heart failure (21.3% vs 15.7%, P < 0.001), general medical problems (15.6% vs 6.0%, P < 0.001), and atrial arrhythmias (8.6% vs 4.9%, P < 0.001). ACHD admissions had a higher median presenting Sequential Organ Failure Assessment score (5.0 vs 3.0, P < 0.001). Total hospital stay was longer for ACHD admissions (8.2 vs 5.9 days, P < 0.01), though in-hospital mortality was not different (12.7% vs 13.6%; age- and sex-adjusted OR: 1.19 [95% CI: 0.89-1.59], P = 0.239). Conclusions: This study illustrates the unique aspects of the ACHD CICU admission. Further investigation into the best approach to manage specific ACHD-related CICU admissions, such as cardiogenic shock and acute respiratory failure, is warranted.

Prognostic significance of haemodynamic parameters in patients with cardiogenic shock.

AIMS: Invasive haemodynamic assessment with a pulmonary artery catheter is often used to guide the management of patients with cardiogenic shock (CS) and may provide important prognostic information. We aimed to assess prognostic associations and relationships to end-organ dysfunction of presenting haemodynamic parameters in CS. METHODS AND RESULTS: The Critical Care Cardiology Trials Network is an investigator-initiated multicenter registry of cardiac intensive care units (CICUs) in North America coordinated by the TIMI Study Group. Patients with CS (2018-2022) who underwent invasive haemodynamic assessment within 24 h of CICU admission were included. Associations of haemodynamic parameters with in-hospital mortality were assessed using logistic regression, and associations with presenting serum lactate were assessed using least squares means regression. Sensitivity analyses were performed excluding patients on temporary mechanical circulatory support and adjusted for vasoactive-inotropic score. Among the 3603 admissions with CS, 1473 had haemodynamic data collected within 24 h of CICU admission. The median cardiac index was 1.9 (25th-75th percentile, 1.6-2.4) L/min/m2 and mean arterial pressure (MAP) was 74 (66-86) mmHg. Parameters associated with mortality included low MAP, low systolic blood pressure, low systemic vascular resistance, elevated right atrial pressure (RAP), elevated RAP/pulmonary capillary wedge pressure ratio, and low pulmonary artery pulsatility index. These associations were generally consistent when controlling for the intensity of background pharmacologic and mechanical haemodynamic support. These parameters were also associated with higher presenting serum lactate. CONCLUSION: In a contemporary CS population, presenting haemodynamic parameters reflecting decreased systemic arterial tone and right ventricular dysfunction are associated with adverse outcomes and systemic hypoperfusion.

Trends and Outcomes in Cardiac Arrest Among Heart Failure Admissions.

There is limited large, national data investigating the prevalence, characteristics, and outcomes of cardiac arrest (CA) in patients hospitalized for heart failure (HF). The goal of this study was to examine the characteristics, trends, and outcomes of HF hospitalizations complicated by in-hospital CA. We used the National Inpatient Sample to identify all primary HF admissions from 2016 to 2019. Cohorts were built based on the presence of a codiagnosis of CA. Diagnoses were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. Associations with CA were then analyzed using multivariate logistic regression. We identified a total of 4,905,564 HF admissions, 56,170 (1.1%) of which had CA. Hospitalizations complicated by CA were significantly more likely to be male, to have coronary artery disease, renal disease, and less likely to be White (p <0.001, all). Age <65 (odds ratio [OR] 1.18, p <0.001), renal disease (OR 2.41, p <0.001), and coronary artery disease (OR 1.26, p <0.001) had higher odds of CA while female gender (OR 0.84, confidence interval [CI] 0.83 to 0.86, p <0.001) or HFpEF (OR 0.49, CI 0.48 to 0.50, p <0.001) had lower odds of CA. Patients with CA had higher inpatient mortality (CA 54.2% vs no CA 2.1%, p <0.001), which persisted after multivariate adjustment (OR 64.8, CI 63.5 to 66.0, p <0.001). CA occurs in >1 in 1,000 HF hospitalizations and remains a prominent and serious event associated with a high mortality. Further research is needed to examine long-term outcomes and mechanical circulatory support utilization with more granularity in HF patients with in-hospital CA.

Characteristics, therapies, and outcomes of In-Hospital vs Out-of-Hospital cardiac arrest in patients presenting to cardiac intensive care units: From the critical care Cardiology trials network (CCCTN).

BACKGROUND: Cardiac arrest (CA) is a common reason for admission to the cardiac intensive care unit (CICU), though the relative burden of morbidity, mortality, and resource use between admissions with in-hospital (IH) and out-of-hospital (OH) CA is unknown. We compared characteristics, care patterns, and outcomes of admissions to contemporary CICUs after IHCA or OHCA. METHODS: The Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs in the US and Canada. Participating centers contributed data from consecutive admissions during 2-month annual snapshots from 2017 to 2021. We analyzed characteristics and outcomes of admissions by IHCA vs OHCA. RESULTS: We analyzed 2,075 admissions across 29 centers (50.3% IHCA, 49.7% OHCA). Admissions with IHCA were older (median 66 vs 62 years), more commonly had coronary disease (38.3% vs 29.7%), atrial fibrillation (26.7% vs 15.6%), and heart failure (36.3% vs 22.1%), and were less commonly comatose on CICU arrival (34.2% vs 71.7%), p < 0.001 for all. IHCA admissions had lower lactate (median 4.3 vs 5.9) but greater utilization of invasive hemodynamics (34.3% vs 23.6%), mechanical circulatory support (28.4% vs 16.8%), and renal replacement therapy (15.5% vs 9.4%); p < 0.001 for all. Comatose IHCA patients underwent targeted temperature management less frequently than OHCA patients (63.3% vs 84.9%, p < 0.001). IHCA admissions had lower unadjusted CICU (30.8% vs 39.0%, p < 0.001) and in-hospital mortality (36.1% vs 44.1%, p < 0.001). CONCLUSION: Despite a greater burden of comorbidities, CICU admissions after IHCA have lower lactate, greater invasive therapy utilization, and lower crude mortality than admissions after OHCA.

Society for Cardiovascular Magnetic Resonance 2021 cases of SCMR and COVID-19 case collection series.

The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). "Cases of SCMR" is a case series hosted on the SCMR website ( https://www.scmr.org ) that demonstrates the utility and importance of CMR in the clinical diagnosis and management of cardiovascular disease. The COVID-19 Case Collection highlights the impact of coronavirus disease 2019 (COVID-19) on the heart as demonstrated on CMR. Each case in series consists of the clinical presentation and the role of CMR in diagnosis and guiding clinical management. The cases are all instructive and helpful in the approach to patient management. We present a digital archive of the 2021 Cases of SCMR and the 2020 and 2021 COVID-19 Case Collection series of nine cases as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar literature search engine.

The Clinical Significance of Apneas Versus Hypopneas: Is There Really a Difference?

Introduction Obstructive sleep apnea is diagnosed by identifying obstructive apneas and hypopneas, but no study has shown that it is necessary to distinguish these events from each other. Our goal was to analyze results from polysomnograms to determine if adverse health outcomes were more likely in patients with higher apnea indices relative to their hypopnea indices. Our hypothesis was that scoring apneas separately from hypopneas has no predictive value. Methods A retrospective case series was performed for consecutive diagnostic and split-night polysomnograms with apnea-hypopnea indices greater than five per hour. Clinical data reviewed included the presence of cardiovascular diseases, hypertension, depression, and migraine. Both univariate and multivariate analyses were performed to look for correlations between polysomnographic indices and the comorbidities. Results Three hundred fifty-one records were included. Univariate analysis showed no significant difference between the apnea index (AI) and hypopnea index (HI) based on the presence of any of the comorbidities. Multivariate logistic regression also indicated no significant association between indices and comorbidities, aside from one statistically significant correlation between a higher HI and depression. Conclusions Clinical comorbidities are no more likely in patients with higher apnea indices than hypopnea indices. While apneas are considered a more severe form of obstruction, this distinction does not have any known clinically predictive value. This finding raises the question as to whether scoring hypopneas and apneas as different events on polysomnograms is necessary or helpful. Scoring apneas and hypopneas as "obstructions" could save resources and increase inter-scorer reliability.

Ethylene Glycol Toxicity in the Setting of Recurrent Ingestion: A Case Report and Literature Review.

Ethylene glycol (EG) poisoning is a toxicologic emergency requiring high clinical suspicion and early diagnosis to prevent life-threatening complications. Direct EG quantification methods involve cumbersome and time-consuming laboratory tests of limited utility in the emergency setting. Accordingly, the osmolal gap is frequently employed as a surrogate screening method in cases of suspected toxic alcohol poisoning. However, the osmolal gap has several inherent limitations to be considered when used as a diagnostic tool for EG toxicity. Although many of these limitations are widely acknowledged, the clinical finding of a normal serum osmolal gap in the setting of recurrent toxic alcohol exposure is an observation that has remained largely unexplored. The purpose of this case report is to characterize the accelerated osmolal gap to anion gap conversion that may occur in the setting of chronic toxic alcohol abuse.

Predictors of moderate to severe obstructive sleep apnea: identification of sex differences.

PURPOSE: Home sleep apnea tests are recommended only for patients at high risk of moderate to severe obstructive sleep apnea (OSA, apnea-hypopnea index [AHI] ≥ 15/h). We evaluated 14 factors known to be associated with OSA and identified sex differences in predictors of moderate to severe OSA. METHODS: Retrospective analysis was done on 545 subjects who completed sleep questionnaires and underwent diagnostic polysomnogram at a tertiary sleep center. Univariate and multivariate analysis was conducted separately in males and females to determine which variables were independent predictors of moderate to severe OSA. RESULTS: Overall, physical traits were stronger predictors in both males and females. For each sex, only 3 variables were found to be independently predictive of moderate to severe OSA. In order of predictive strength, this included body mass index (BMI) ≥ 38 kg/m2 (aOR 5.80, p < 0.001), neck circumference (NC) ≥ 17 in. (aOR 2.52, p = 0.002), and Epworth sleepiness scale (ESS) ≥ 13 (aOR 2.22, p = 0.015) for males and age ≥ 50 years (aOR 4.19, p < 0.001), NC ≥ 14.5 in. (aOR 3.13, p = 0.003), and report of morning headaches (aOR 2.00, p = 0.039) for females. Applying the Bonferroni correction, BMI and NC remained significant for males, and age and NC remained significant for females. CONCLUSIONS: In a subject population referred for sleep evaluation at a tertiary care center only a few variables are independently predictive of moderate to severe OSA, and these variables differed between males and females. Only BMI, NC, and a high ESS were independently predictive of moderate to severe OSA in males, whereas age, NC, and morning headaches were independently predictive in females.

The genomic landscape of TERT promoter wildtype-IDH wildtype glioblastoma.

The majority of glioblastomas can be classified into molecular subgroups based on mutations in the TERT promoter (TERTp) and isocitrate dehydrogenase 1 or 2 (IDH). These molecular subgroups utilize distinct genetic mechanisms of telomere maintenance, either TERTp mutation leading to telomerase activation or ATRX-mutation leading to an alternative lengthening of telomeres phenotype (ALT). However, about 20% of glioblastomas lack alterations in TERTp and IDH. These tumors, designated TERTpWT-IDHWT glioblastomas, do not have well-established genetic biomarkers or defined mechanisms of telomere maintenance. Here we report the genetic landscape of TERTpWT-IDHWT glioblastoma and identify SMARCAL1 inactivating mutations as a novel genetic mechanism of ALT. Furthermore, we identify a novel mechanism of telomerase activation in glioblastomas that occurs via chromosomal rearrangements upstream of TERT. Collectively, our findings define novel molecular subgroups of glioblastoma, including a telomerase-positive subgroup driven by TERT-structural rearrangements (IDHWT-TERTSV), and an ALT-positive subgroup (IDHWT-ALT) with mutations in ATRX or SMARCAL1.

Race as a predictor of postoperative hospital readmission after spine surgery.

Hospital readmission after surgery results in a substantial economic burden, and several recent studies have investigated the impact of race and ethnicity on hospital readmission rates, with the goal to identify hospitals and patients with high readmission risk. This single-institution, retrospective cohort study assesses the impact of race, along with other risk factors, on 30-day readmission rates following spinal surgery. This study is a single-institution retrospective cohort study with accrual from January 1, 2008, to December 31, 2010. Inclusion criteria included adult patients who underwent anterior and/or posterior spinal surgery. The primary aim of this study was to assess the impact of patient race and other risk factors for postoperative hospital readmission within 30days following spine surgery. A total of 1346 patients (654 male, 692 female) were included in the study. Overall, 159 patients (11.8%) were readmitted in the 30days following their surgery. Multivariate logistic regression found significant risk factors for 30-day readmission, including Black race (OR: 2.20, C.I. 95% (1.04, 4.64)) and total length of stay greater than 7days (OR: 4.73, C.I. 95% (1.72, 12.98)). Cervical surgery was associated with decreased odds of readmission (OR: 0.27, C.I. 95% (0.08, 0.91)). Our study demonstrates that race and length of hospital stay influence the incidence of 30-day readmission rates after spinal surgery. Studies such as ours will aid in identifying patients with postoperative readmission risk and help elucidate the underlying factors that may be contributing to disparities in readmission after surgery.

The Influence of the Menstrual Phases on Polysomnography.

PURPOSE:  The primary objective of this study is to determine how the phases of the menstrual cycle influence the results of polysomnography (PSG). METHODS:  Twenty-eight adult subjects who reported regular menstrual periods, last menstrual period (LMP) within 26 days of their PSG, no exogenous hormone use, no history of polycystic ovarian syndrome, and who were scheduled for diagnostic PSG at Boston Medical satisfied inclusion criteria for the study. These subjects were divided into a Follicular Cohort (days 0-13 of the cycle) or Luteal Cohort (days 14-26 of the cycle), and a one-way analysis using a t-test was performed to test the hypothesis that the follicular phase confers protection against obstructive sleep apnea (OSA). A likelihood-ratio chi-square test was also applied to assess for a statistically significant association between menstrual stage and the presence of moderate-to-severe sleep apnea (apnea-hypopnea index (AHI) > 15/h). Thus, the statistical analysis was performed using AHI as both a continuous and a categorical outcome. RESULTS:  The mean AHI for patients in the Follicular Cohort (6.1/h) was significantly lower than the Luteal Cohort (14.3/h, p = 0.033). In the Follicular Cohort, 12% of patients had moderate to severe OSA. In the Luteal Cohort, 46% of patients had moderate to severe OSA (p = 0.045). CONCLUSIONS:  Subjects undergoing PSG during the follicular phase have significantly lower AHIs than those in the luteal phase. Thus, the timing of PSG acquisition for regularly menstruating women should be considered when interpreting results.

Inferior Vena Cava Filter Thrombosis in the Postoperative Neurosurgical Setting: Case Report and Review of the Literature.

There are no definitive treatment guidelines for caval-filter thrombosis in the postoperative setting. Clinical management for partial or complete postoperative inferior vena cava (IVC) occlusion relies solely on expert opinion, anecdotal evidence, and small clinical trials. As such, the primary objective of the present report is to offer a complex case of extensive IVC filter occlusion in a neurosurgical patient with past medical history significant for protein C deficiency. The presentation, unique radiological findings, management, and outcome will be discussed. No similar cases of massive IVC-occlusive disease in a thrombophilic patient early in the postoperative course following neurosurgical intervention are documented in the medical literature.

Independent predictors of mortality following spine surgery.

We investigated the effect of preoperative patient demographics and operative factors on mortality in the 30day postoperative period after spine surgery. Postoperative mortality from surgical interventions has significantly decreased with progressive improvement in surgical techniques and patient selection. Well-studied preoperative risk factors include age, obesity, emphysema, clotting disorders, renal failure, and cardiovascular disease. However, the prognostic implications of such risk factors after spine surgery specifically remain unknown. The medical records of all consecutive patients undergoing spine surgery from 2008-2010 at our institution were reviewed. Patient demographics, comorbidities, indication for operation, surgical details, postoperative complications, and mortalities were collected. The association between preoperative demographics or surgical details and postoperative mortality was assessed via logistic regression analysis. All 1344 consecutive patients (1153 elective, 191 emergency) met inclusion criteria for the study; 19 (1.4%) patients died in the 30days following surgery. Multivariable logistic regression found several predictive factors of mortality for all spine surgery patients: operation in the cervical area (odds ratio [OR]: 7.279, 95% confidence interval [CI]: 1.37-42.83, p=0.02), postoperative sepsis (OR: 5.75, 95% CI: 1.16-26.38, p=0.03), operation for neoplastic (OR: 7.68, 95% CI: 1.53-42.71, p=0.01) or traumatic (OR: 13.76, 95% CI: 2.40-88.68, p=0.03) etiology, and age as defined as a continuous variable (OR: 1.05, 95% CI: 1.01-1.10, p=0.03). This study demonstrates predictive factors to help identify and evaluate patients who are at higher risk for mortality from spinal surgery, and potentially devise methods to reduce this risk.

Thoracic Nerve Root Entrapment by Intrathecal Catheter Coiling: Case Report and Review of the Literature.

BACKGROUND: Intrathecal catheter placement has long-term therapeutic benefits in the management of chronic, intractable pain. Despite the diverse clinical applicability and rising prevalence of implantable drug delivery systems in pain medicine, the spectrum of complications associated with intrathecal catheterization remains largely understudied and underreported in the literature. OBJECTIVE: To report a case of thoracic nerve root entrapment resulting from intrathecal catheter migration. STUDY DESIGN: Case report. SETTING: Inpatient hospital service. RESULTS/ CASE REPORT: A 60-year-old man status post implanted intrathecal (IT) catheter for intractable low back pain secondary to failed back surgery syndrome returned to the operating room for removal of IT pump trial catheter after experiencing relapse of preoperative pain and pump occlusion. Initial attempt at ambulatory removal of the catheter was aborted after the patient reported acute onset of lower extremity radiculopathic pain during the extraction. Noncontrast computed tomography (CT) subsequently revealed that the catheter had ascended and coiled around the T10 nerve root. The patient was taken back to the operating room for removal of the catheter under fluoroscopic guidance, with possible laminectomy for direct visualization. Removal was ultimately achieved with slow continuous tension, with complete resolution of the patient's new radicular symptoms. LIMITATIONS: This report describes a single case report. CONCLUSION: This case demonstrates that any existing loops in the intrathecal catheter during initial implantation should be immediately re-addressed, as they can precipitate nerve root entrapment and irritation. Reduction of the loop or extrication of the catheter should be attempted under continuous fluoroscopic guidance to prevent further neurosurgical morbidity.

Nanotechnology-based strategies for combating toxicity and resistance in melanoma therapy.

Drug toxicity and resistance remain formidable challenges in cancer treatment and represent an area of increasing attention in the case of melanoma. Nanotechnology represents a paradigm-shifting field with the potential to mitigate drug resistance while improving drug delivery and minimizing toxicity. Recent clinical and pre-clinical studies have demonstrated how a diverse array of nanoparticles may be harnessed to circumvent known mechanisms of drug resistance in melanoma to improve therapeutic efficacy. In this review, we discuss known mechanisms of resistance to various melanoma therapies and possible nanotechnology-based strategies that could be used to overcome these barriers and improve the pharmacologic arsenal available to combat advanced stage melanoma.

Image-guided percutaneous internal fixation of sacral fracture.

Percutaneous iliosacral screw placement is a technically challenging procedure with a significant complication profile for misplaced screws. The use of stereotactic image guidance has been shown to provide superior accuracy in the placement of spinal instrumentation. Here, the authors describe a novel application of O-arm technology (Medtronic Sofamor Danek, Memphis, TN, USA) to help safely place iliosacral screws for the treatment of a traumatic sacral fracture.

Risk Assessment and Characterization of 30-Day Perioperative Myocardial Infarction Following Spine Surgery: A Retrospective Analysis of 1346 Consecutive Adult Patients.

STUDY DESIGN: A retrospective review. OBJECTIVE: The aim of the study was to perform a risk assessment of 30-day perioperative myocardial infarction (MI) for spine surgery patients. SUMMARY OF BACKGROUND DATA: There is an increased emphasis to reduce complications and improve outcomes after spinal surgery. One of the more devastating perioperative complications of spinal surgery is MI. METHODS: We evaluated all medical records of 1346 consecutive patients who underwent spinal surgery at a single institution from 2008 to 2010 for incidence of MI within 30 days of surgery and documented all demographic, preoperative, and operative variables. Associations between postoperative MI and individual risk factors were determined using logistic regression analysis. Patients were stratified into emergent and elective groups and a similar analysis was performed. RESULTS: Overall, 22 patients (1.6%) had 30-day perioperative MI, 14 patients (1.2%) undergoing elective surgery, and 8 patients (4.2%) after emergent surgery (P = 0.047). Three (13.6%) patients experienced 30-day mortality and an additional 3 (13.6%) patients experienced mortality within 1 year. Multivariate logistic regression determined that age more than 65 years, atrial fibrillation, hypertension, prior MI, anticoagulant use, low albumin, length of stay more than 7 days, intraoperative transfusion, trauma etiology, baseline creatinine more than 1  mg/dL, and at least 2 levels of spinal fusion were predictive of postoperative MI. For patients undergoing emergent surgery, age more than 65 years was associated with an increased risk of postoperative MI. When stratified by elective surgery, we found that age more than 65, postoperative stay more than 7 days, intraoperative blood transfusion, baseline creatinine more than 1  mg/dL, and fusion of more than 1 level were associated with an increased risk of MI. CONCLUSION: The present study demonstrates a low incidence of MI after elective surgery with a higher incidence after emergent spine surgery and identifies patient factors predictive of postoperative MI. LEVEL OF EVIDENCE: 3.

Traumatic atlanto-occipital dissociation presenting as locked-in syndrome.

We present an unusual presentation of unstable atlanto-occipital dissociation as locked-in syndrome. Traumatic atlanto-occipital dissociation is a severe injury that accounts for 15-20% of all fatal cervical spinal injuries. A disruption occurs between the tectorial ligaments connecting the occipital condyle to the superior articulating facets of the atlas, resulting in anterior, longitudinal, or posterior translation, and it may be associated with Type III odontoid fractures. Furthermore, the dissociation may be complete (atlanto-occipital dislocation) or incomplete (atlanto-occipital subluxation), with neurologic findings ranging from normal to complete quadriplegia with respiratory compromise.