Trends and In-Hospital Outcomes of Patients Admitted with ST Elevation Myocardial Infarction and Chronic Total Occlusions: Insights from a National Database.

Chronic total occlusion (CTO) is seen in a minority of ST-elevation myocardial infarction (STEMI) patients and is implicated in poor outcomes due to "double jeopardy." There is no large national data evaluating the trend and outcomes of STEMI patients who have a CTO (STEMI-CTO). We analyzed the Nationwide In-patients sample database from 2008 to 2011 and compared the trends, clinical characteristics, and in-hospital outcomes of STEMI patients with and without CTO. An increasing trend of CTO was seen in STEMI patients from 2008 to 2011. STEMI-CTO patients were younger, more likely develop cardiogenic shock, undergo percutaneous coronary intervention and thrombolysis. In this large, contemporary, national database, we also found that STEMI-CTO patients were more likely to have iatrogenic cardiac & vascular complications and undergo percutaneous mechanical circulatory support. We did not find significant difference in in-hospital deaths between STEMI-CTO patients and those without CTO.

Therapeutic Hypothermia Is Associated With a Decrease in All-cause Mortality in Cardiac Arrest Due to Shockable Rhythm.

BACKGROUND: The benefits of therapeutic hypothermia (TH) in comatose patients postcardiac arrest remain uncertain. While some studies have shown benefit, others have shown equivocal results. We pooled data from randomized controlled trials to better study the outcomes of TH. METHODS: Electronic research databases were queried up till September 21, 2021. Randomized controlled trials comparing TH (32-34 °C) with control (normothermia or temperature ≥36 °C) in comatose postcardiac arrest patients were included. RESULTS: The study included 10 randomized controlled trials with 3988 subjects (1999 in the TH arm and 1989 in the control arm). There was no difference in all-cause mortality between TH and control (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.66-1.05; P = 0.08; I2 = 41%). There was no difference in the odds of poor neurological outcomes (OR, 0.78; 95% CI, 0.61-1.01; P = 0.07; I2 = 43%). Subgroup analysis showed a decrease in all-cause mortality and poor neurological outcomes with TH in shockable rhythms (OR, 0.55; 95% CI, 0.37-0.80; P = 1.00; I2 = 0% and OR, 0.48; 95% CI, 0.32-0.72; P = 0.92; I2 = 0%, respectively). CONCLUSIONS: TH may be beneficial in reducing mortality and poor neurological outcomes in comatose postcardiac arrest patients with shockable rhythms.

Sub-acute Onset of Guillain-Barré Syndrome Post-mRNA-1273 Vaccination: a Case Report.

Ever since the start of the pandemic, SARS-CoV-2 has taken the lives of millions of people around the globe. Several COVID-19 vaccines have been developed with rapidity to prevent acquiring COVID-19 infection, hospitalizations, and deaths. The routine side effects of these vaccines are commonly known and non-severe. Few serious side effects such as thrombosis with thrombocytopenia syndrome (TTS) and Guillain-Barré syndrome (GBS) are increasingly reported particularly after inoculation with ChAdOx1 nCoV-19 (Oxford/AstraZeneca) and Ad26.COV 2.S (Johnson & Johnson's Janssen). Rare cases of GBS after BNT162b2 (Pfizer-BioNTech), an mRNA vaccine, are also reported. However, the true association of these cases to COVID-19 continues to be unclear and the safety of these vaccines continues to be great in preventing deaths from COVID-19 infection. We report a case of middle-aged female who had a gradual onset of lower extremity weakness with a nadir of symptoms reached 10 and 12 weeks after the onset. This protracted course (sub-acute) is atypical for a "classical" GBS. The presence of an antecedent event, autonomic symptoms such as hypotension, and the need for ventilator support favored the diagnosis of GBS than chronic inflammatory demyelinating polyneuropathy (CIDP). This is the first known case to be reported of sub-acute onset of Guillain-Barré syndrome after receiving the mRNA-1273 vaccine. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s42399-022-01124-1.

Sleep duration, baseline cardiovascular risk, inflammation and incident cardiovascular mortality in ambulatory U.S. Adults: National health and nutrition examination survey.

INTRODUCTION: The interplay between sleep duration and inflammation on the baseline and incident cardiovascular (CV) risk is unknown. We sought to evaluate the association between sleep duration, C-reactive protein (CRP), baseline CV risk, and incident CV mortality. METHODS: We used data from the National Health and Nutrition Examination Survey 2005-2010 linked with the cause of death data from the National Center for Health Statistics for adults aged ≥18 years. The associations between self-reported sleep duration and CRP, 10-year atherosclerotic CV disease risk score (ASCVD) and CV mortality were assessed using Linear, Poisson and Cox proportional hazard modeling as appropriate. RESULTS: There were 17,635 eligible participants with a median age of 46 years (interquartile range [IQR] 31, 63). Among them, 51.3% were women and 46.9% were non-Hispanic Whites. Over a median follow-up of 7.5 years (IQR 6.0, 9.1), 350 CV deaths occurred at an incident rate of 2.7 per 1000-person years (IQR 2.4, 3.0). We observed a U-shaped associations between sleep duration and incident CV mortality rate (P-trend=0.011), sleep duration and 10-year ASCVD risk (P-trend <0.001), as well as sleep duration and CRP (P-trend <0.001). A self-reported sleep duration of 6-7 hours appeared most optimal. We observed that those participants who reported <6 or >7 hours of sleep had higher risk of CV death attributable to inflammation after accounting for confounders. CONCLUSIONS: There was a U-shaped relationship of incident CV mortality, 10-year ASCVD risk, and CRP with sleep duration. These findings suggest an interplay between sleep duration, inflammation, and CV risk.

Relative Predictive Value of Circulating Immune Markers in US Adults Without Cardiovascular Disease: Implications for Risk Reclassification.

OBJECTIVE: To investigate the relative predictive value of circulating immune cell markers for cardiovascular mortality in ambulatory adults without cardiovascular disease. METHODS: We analyzed data of participants enrolled in the National Health and Nutrition Examination Survey from January 1, 1999, to December 31, 2010, with the total leukocyte count within a normal range (4000-11,000 cells/µL [to convert to cells ×109/L, multiply by 0.001]) and without cardiovascular disease. The relative predictive value of circulating immune cell markers measured at enrollment-including total leukocyte count, absolute neutrophil count, absolute lymphocyte count, absolute monocyte count, monocyte-lymphocyte ratio (MLR), neutrophil-lymphocyte ratio, and C-reactive protein-for cardiovascular mortality was evaluated. The marker with the best predictive value was added to the 10-year atherosclerotic cardiovascular disease (ASCVD) risk score to estimate net risk reclassification indices for 10-year cardiovascular mortality. RESULTS: Among 21,599 participants eligible for this analysis, the median age was 47 years (interquartile range, 34-63 years); 10,651 (49.2%) participants were women, and 10,713 (49.5%) were self-reported non-Hispanic white. During a median follow-up of 9.6 years (interquartile range, 6.8-13.1 years), there were 627 cardiovascular deaths. MLR had the best predictive value for cardiovascular mortality. The addition of elevated MLR (≥0.3) to the 10-year ASCVD risk score improved the classification by 2.7%±1.4% (P=.04). Elevated MLR had better predictive value than C-reactive protein and several components of the 10-year ASCVD risk score. CONCLUSION: Among ambulatory US adults without preexisting cardiovascular disease, we found that MLR had the best predictive value for cardiovascular mortality among circulating immune markers. The addition of MLR to the 10-year risk score significantly improved the risk classification of participants.

Mucormycosis in COVID-19: A systematic review of literature.

Coronavirus disease 2019 (COVID-19) is an acute viral illness caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Opportunistic infections such as mucormycosis have been reported among COVID-19 patients particularly in South Asian countries during the second wave of this pandemic. It is necessary to re-evaluate any changes in traditional risk factors associated with mucormycosis such as diabetes mellitus, organ transplant, etc in the precedent of ongoing COVID-19 pandemic. We conducted a systematic review using electronic databases. A total of 115 COVID-19 patients who were diagnosed with mucormycosis were included in this study. Diabetes mellitus was the most common co-morbidity with 77.1%, followed by hypertension (29.5%) and renal disease (14.3%). 55.2% of the patients had received dexamethasone for COVID-19 infection. Ten patients (11.5%) had received tocilizumab. Sinuses were the most common site of mucormycosis among COVID-19 patients at 79.4% with maxillary sinus (47.4%) being most commonly infected. Orbits were the second most prevalent site at 56.7% and lungs were infected with mucor at 11.3%. The mean duration between the diagnosis of COVID-19 infection and mucormycosis was 16.15 days (range 2-90 days). Cavernous sinus was either infiltrated or encased in 14 patients (14.4%). Cerebral involvement was seen in terms of abscess, infarcts, or edema in 12 patients (12.4%). Only 76 patients had data on the outcomes, out of which 37 (48.7%) patients had died. Diabetes mellitus is still the most common co-morbidity similar to non-COVID-19 patients. More than 90% of the patients with COVID-19 infection had received steroids. Complications such as cavernous sinus thrombosis, cerebral infarcts, abscesses were common. Indiscriminate use of steroids in patients needs to be avoided and focus needs to be put on tight blood sugar control in diabetic patients. Studies are needed to confirm the role of the SARS-CoV-2 virus in causing immune dysfunction and mucormycosis.

A Case Report on Adult-Onset Still's Disease Successfully Treated With Tocilizumab: A Brief Review on its Safety and Efficacy.

Adult-onset Still's disease (AOSD) is a rare autoimmune disease of unknown etiology with systemic inflammatory manifestations consisting of a triad of fevers, evanescent skin rash, and arthritis. Although steroids are the first line of therapy, about 20%-30% of patients are refractory, intolerant, and or relapse during tapering or upon discontinuation of steroids. There are no clinical guidelines in treating such patients and treatment in these patients is challenging. Previously used biological agents have limited efficacy and hence there is a need for new therapies. Tocilizumab (TCZ), an interleukin (IL)-6 receptor antibody has been used with a clinical benefit and has shown to decrease the dose of steroids in patients with adult-onset still disease. The aim of this case report is to highlight the use of tocilizumab in relapsing and steroid intolerant cases of AOSD. The use of this drug in patients with AOSD is currently off-label. Randomized control studies can provide additional information that offers better visibility in treating AOSD patients who are steroid-resistant or intolerant. The rarity of disease possesses additional challenges in conducting these studies.

A Review of the Diagnostic Use of Fine-needle Aspiration Cytology for Tuberculosis Epididymo-orchitis: To Do or Not to Do.

Isolated tuberculous epididymo-orchitis is a rare manifestation of the vast extrapulmonary tuberculosis (EPTB) disease spectrum, especially in developed nations, making it prone to delayed diagnosis or misdiagnosis and inadvertent orchiectomy. Several observational studies and case reports have been reported with the successful use of fine-needle aspiration cytology (FNAC) in diagnosing tuberculosis orchitis, thus avoiding inadvertent orchiectomy. Because tuberculous epididymo-orchitis can mimic testicular neoplasm, the use of FNAC is not prevalent in developed countries for fear of the seeding of tumor cells and there is a lack of consensus on the use of FNAC for diagnostic purposes in such patients. We report a case of a 27-year-old man with an atypical presentation of genitourinary tuberculosis (TB) and its management. The case report also reviews the literature to discuss the available evidence and tries to answer the long-standing question on the role of FNAC in the diagnosis of tuberculous epididymo-orchitis. The currently available literature has demonstrated the safety and efficacy of FNAC in diagnosing TB epididymo-orchitis and, based on our review, the benefits of differentiating TB epididymo-orchitis from testicular malignancy using FNAC exceeds its minimal risk and must be considered to minimize clinical diagnosis error and unnecessary orchiectomy in low-risk patients.

A Case Report on Pituitary Apoplexy Presenting as Acute Kidney Injury.

Pituitary apoplexy is characterized by the acute ischemic or hemorrhagic infarction of the pituitary gland. Acute kidney injury is a less recognized complication associated with pituitary apoplexy but occasionally can be a presenting condition in patients with pituitary apoplexy. Here we discuss the case of a patient who presented with significant volume depletion, admitted with acute kidney injury, and was later diagnosed with pituitary apoplexy.