Kratom-Induced Acute Respiratory Distress Syndrome (ARDS).

The alkaloid derivatives of Mitragyna speciosa, commonly known as kratom, pose a threat to society due to its potential for abuse, adverse reactions and tendency to be used as self-medication for opioid withdrawal, pain and mood disorders. A number of deaths have been reported along with complications such as respiratory depression, cardiopulmonary arrest, torsade de pointes and seizures. Its various effects and potential are yet to be fully studied. We describe the case of a healthy young male who presented with progressive respiratory failure requiring mechanical ventilation. Imaging revealed multifocal lung infiltrates while extensive infectious and cardiac work-up was negative. Based on the clinical course, a diagnosis of acute respiratory distress syndrome (ARDS) caused by kratom was made. The patient showed gradual clinical improvement and was weaned off supplemental oxygen. This case highlights yet another adverse reaction to kratom and the growing threat posed by its use. LEARNING POINTS: Kratom is a herbal supplement with opioid-like effects at high doses and stimulant effects at low doses.It is most commonly used to self-treat opioid withdrawal, mood disorders and pain.Acute respiratory distress syndrome (ARDS) is one of the adverse effects of kratom, which also include kratom withdrawal syndrome, seizures, rhabdomyolysis, torsades de pointes and sudden death.Kratom has growing abuse potential; the FDA is acting to prevent its use and recommends healthcare professionals voluntarily report any adverse reactions.

Direct and indirect economic burden associated with rotator cuff tears and repairs in the US.

OBJECTIVE: This retrospective study examined treatment characteristics and the economic burden associated with rotator cuff tears (RCT) and rotator cuff repairs (RCR). Additionally, this study aimed to explore the economic implications associated with delayed surgical intervention. METHODS: Adult RCT patients meeting eligibility criteria were identified from 1/1/2013-6/30/2017 using the IBM Watson Health MarketScan Commercial database. Patients with incident RCR within 12 months post-index and 12 months continuous enrollment after the RCR date were also analyzed. Early surgery was defined as RCR within 6 months and 1 month from the partial-thickness tear and full-thickness tear diagnoses, respectively. Patient characteristics, all-cause direct costs (plan paid and patient out-of-pocket), RCT-related costs, pre-surgical costs, post-surgical costs, and healthcare resource utilization were reported by RCT type. Attributable indirect costs, absenteeism and short-term disability (STD), were also estimated. RESULTS: 102,488 RCT patients were identified (partial-thickness tears: 46,856 [45.7%]; full-thickness tears: 55,632 [54.3%]). Fifty per cent RCT patients underwent RCR within 12-months of diagnosis. Full-thickness RCT patients had an average total baseline (one year pre-diagnosis) and post-index costs of $17,096 and $32,110, respectively. Similarly, partial thickness patients had baseline costs of $16,385 and post-index costs of $27,017. Mean all-cause annual post-surgery costs were $34,086 for patients with partial-thickness tears and $34,249 for patients with full-thickness tears, of which 40% and 38% of costs were RCT-related, respectively. Productivity losses due to absenteeism and STD in the 12-month post-surgery period averaged $5843 and $4493, respectively, for partial-thickness tear patients and $5770 and $4382, respectively, for full-thickness tear patients. Average additional spending per delayed surgical patient between diagnosis and surgery was $8524 and $3213 (both p <0.001) for partial- and full-thickness tear patients, respectively. CONCLUSIONS: This exploratory analysis indicates considerable RCT and RCR economic burden to the healthcare system. High healthcare utilization and costs highlight the importance of efficiently managing patients with RCT diagnosis. Data also suggest that early surgical intervention may be economically beneficial if surgical intervention is anticipated post-RCT.

Optimal In Situ Fenestration Technique With Laser Perforation and Balloon Dilation for Aortic Stent-Grafts.

PURPOSE: To evaluate the response of various stent-grafts after laser fenestration and dilation with noncompliant balloons to determine the optimal therapeutic combination for this treatment technique. MATERIALS AND METHODS: Five aortic stent-grafts were evaluated ex vivo: the Bolton RelayPlus, Jotec E-vita Thoracic 3G, Medtronic Valiant, Cook Zenith Alpha, and Vascutek Anaconda. Small holes were created using an excimer laser with the grafts submerged in saline. Five rows of 5 fenestrations were created, 4 holes in each row were dilated once with a 6-, 8-, 10-, or 12-mm-diameter noncompliant balloon to the specified nominal pressure (one hole served as the control). The saline solution from each stent-graft was collected and qualitatively analyzed for debris. The fenestrations were evaluated under light and scanning electron microscopes. The maximum diameter and area for each fenestration were measured. The direction and length of tears were assessed. RESULTS: The fenestration was feasible and reproducible in all the stent-grafts. The mean area of fenestration ranged from 7.63±1.63 to 14.75±0.73 mm2 when using balloons of 6- and 8-mm diameter, respectively. The 10- and 12-mm-diameter balloons caused a significant increase in area, variability, and tearing. The Anaconda graft tended to tear in the weft direction, while the other devices tore in the warp direction when using the 10- and 12-mm-diameter balloons. Dilation of the RelayPlus and Anaconda grafts with 6- and 8-mm-diameter balloons provided minimal tearing and precise fenestrations. Melted fiber remnants were observed after filtration of the saline solution for all devices. CONCLUSION: Laser fenestration and dilation with noncompliant balloons is a relatively simple and reproducible option for revascularization in urgent, complex aortic endovascular repairs. In our model, large balloons (ie, >10 mm) increased the destruction and tearing of the fabric. The maximum dilation recommended is 6 to 8 mm to avoid significant tears. Development of stent-grafts or novel fabrics designed explicitly for fenestration is needed to reduce potential complications.

Unusual Early Recovery of a Critical COVID-19 Patient After Administration of Intravenous Vitamin C.

BACKGROUND Coronavirus disease 2019 (COVID-19) continues to spread, with confirmed cases now in more than 200 countries. Thus far there are no proven therapeutic options to treat COVID-19. We report a case of COVID-19 with acute respiratory distress syndrome who was treated with high-dose vitamin C infusion and was the first case to have early recovery from the disease at our institute. CASE REPORT A 74-year-old woman with no recent sick contacts or travel history presented with fever, cough, and shortness of breath. Her vital signs were normal except for oxygen saturation of 87% and bilateral rhonchi on lung auscultation. Chest radiography revealed air space opacity in the right upper lobe, suspicious for pneumonia. A nasopharyngeal swab for severe acute respiratory syndrome coronavirus-2 came back positive while the patient was in the airborne-isolation unit. Laboratory data showed lymphopenia and elevated lactate dehydrogenase, ferritin, and interleukin-6. The patient was initially started on oral hydroxychloroquine and azithromycin. On day 6, she developed ARDS and septic shock, for which mechanical ventilation and pressor support were started, along with infusion of high-dose intravenous vitamin C. The patient improved clinically and was able to be taken off mechanical ventilation within 5 days. CONCLUSIONS This report highlights the potential benefits of high-dose intravenous vitamin C in critically ill COVID-19 patients in terms of rapid recovery and shortened length of mechanical ventilation and ICU stay. Further studies will elaborate on the efficacy of intravenous vitamin C in critically ill COVID-19.

Laser Fenestration of Aortic Stent-Grafts Followed by Noncompliant vs Cutting Balloon Dilation: A Scanning Electron Microscopy Study.

PURPOSE: To examine the effects of in situ laser fenestration and subsequent balloon dilation (noncompliant vs cutting) on the graft fabric of 4 aortic stent-graft models. METHOD: In an in vitro setup, the Zenith TX2, Talent, Endurant, and Anaconda aortic stent-grafts (all made of polyester graft material) were subjected to laser fenestration with a 2.3-mm-diameter probe at low and high energy in a physiologic saline solution followed by balloon dilation of the hole. For the first series of tests, 6-mm-diameter noncompliant balloons were used and replaced for the second series by 6-mm-diameter cutting balloons. Each procedure was performed 5 times (5 fenestrations per balloon type). The fenestrations were examined visually and with light and scanning electron microscopy. RESULTS: Each fenestration demonstrated various degrees of fraying and/or tearing regardless of the device. The monofilament twill weave of the Talent endograft tore in the warp direction up to 7.09±0.46 mm at high energy compared with 2.41±0.26 mm for the Endurant multifilament device. The fenestrations of the 3 endografts with multifilament weave (Zenith, Anaconda, and Endurant) showed more fraying; fenestration areas in the multifilament Endurant were >10 mm2 at low and high energy. The fenestrations were free of melted fibers, but minor blackening of the filaments was observed in all devices. Overall, the cutting balloons resulted in worse tearing and damage. Of note, the edges of the dilated laser-formed fenestrations of the Talent and the Endurant grafts demonstrated evidence of additional shredded yarns. CONCLUSION: In situ fenestration does not cause any melting of the polyester; however, the observed structural damage to the fabric construction must be carefully considered. Cutting balloons caused various levels of tearing compared to the noncompliant balloons and cannot be recommended for use in this application. Rather, noncompliant balloons should be employed, but only with endografts constructed from multifilament yarns. The use of in situ fenestration must be restricted to urgent and emergent cases until long-term durability can be determined.

Determining patient risk factors associated with accelerated growth of popliteal artery aneurysms.

OBJECTIVE: The objective of this study was to determine the natural progression of popliteal artery aneurysms (PAAs) and clinical variables associated with their accelerated growth. METHODS: Retrospective chart review of 224 patients with encounters between January 2008 and May 2016 and with at least one PAA was conducted. From this group, 65 asymptomatic patients had either unilateral (n = 43) or bilateral (n = 22) PAAs that were observed for at least 1 year of medical management before intervention. We divided these aneurysms into two groups based on whether their overall growth rate was above or below the eventual mean. Aneurysm diameter was taken from duplex ultrasound and computed tomography angiography. RESULTS: There were 87 aneurysms evaluated among 65 patients. Mean age at diagnosis was 70.9 years (standard deviation [SD], 9.39 years), and 64 patients were male (98%); 50 (77%) were white and 7 (11%) were African American. The average body mass index was 27.69 (SD, 4.90). At or before initial diagnosis, 61 (94%) patients had a concomitant lower extremity or abdominal aortic aneurysm; 51 (78%) patients were current or former smokers; and 16 (25%) had atrial fibrillation. The average growth rate of all aneurysms was 1.22 mm/y (SD, 1.93 mm). The mean surveillance time from initial diagnosis to last follow-up or intervention was 3.12 years (SD, 1.66 years). Of 87 aneurysms, 25 (29%) were repaired; 18 (21%) were repaired because of size criteria, 2 (2%) because of symptom criteria (claudication or acute limb ischemia), and 5 (6%) because of both criteria. During our study window, 62 aneurysms (71%) remained asymptomatic or did not undergo an intervention. The mean initial diameter at diagnosis was 16.9 mm (SD, 5.32 mm). Within the study, 50 (57%) aneurysms presented with or developed mural thrombus. Univariate analysis identified larger initial diameter (19.2 vs 14.7 mm; P = .020), atrial fibrillation (35% vs 16%; P = .042), and mural thrombus (38% vs 20%; P < .001) as predictors of diameter expansion greater than the mean. Multivariable analysis of the significant univariate factors determined that only initial diameter (odds ratio, 5.53; P = .007) and the presence or development of mural thrombus (odds ratio, 4.00; P = .008) maintained significance. CONCLUSIONS: Patients presenting with a PAA at 20 mm or >20 mm in diameter, presence of luminal thrombus, or atrial fibrillation may need to be observed at more frequent scanning intervals than those without these risk factors. Further studies are required to validate these predictive growth factors.

Predicting opportunities to increase utilization of laparoscopy for colon cancer.

BACKGROUND: Despite proven safety and efficacy, rates of minimally invasive approaches for colon cancer remain low in the USA. Given the known benefits, investigating the root causes of underutilization and methods to increase laparoscopy is warranted. Our goal was to develop a predictive model of factors impacting use of laparoscopic surgery for colon cancer. METHODS: The Premier Hospital Database was reviewed for elective colorectal resections for colon cancer (2009-2014). Patients were identified by ICD-9-CM diagnosis code and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes. An adjusted multivariate logistic regression model identified variables predictive of use of laparoscopy for colon cancer. RESULTS: A total of 24,245 patients were included-12,523 (52 %) laparoscopic and 11,722 (48 %) open. General surgeons performed the majority of all procedures (77.99 % open, 71.60 % laparoscopic). Overall use of laparoscopy increased from 48.94 to 52.03 % over the study period (p < 0.0001). Patients with private insurance were more likely to have laparoscopy compared with Medicare patients (adjusted odds ratio (OR) 1.089, 95 % CI [1.004, 1.181], p = 0.0388). Higher volume of surgeons (OR 3.518, 95 % CI [2.796, 4.428], p < 0.0001) and larger hospitals by bed size were more likely to approach colon cancer laparoscopically. Colorectal surgeons were 32 % more likely to approach a case laparoscopically than general surgeons (OR 1.315, 95 % CI [1.222, 1.415], p < 0.0001). Teaching hospitals, hospitals in the Midwest, and hospitals with less than 500 beds were less likely to use laparoscopy. CONCLUSIONS: There are patient, provider, and hospital characteristics that can be identified preoperatively to predict who will undergo surgery for colon cancer using laparoscopy. However, additional patients may be eligible for laparoscopy based on patient-level characteristics. These results have implications for regionalization and increasing teaching of MIS. Recognizing and addressing these variables with training and recruiting could increase use of minimally invasive approaches, with the associated clinical and financial benefits.

Economic burden associated with hospital postadmission dehydration.

BACKGROUND: Development of dehydration after hospital admission can be a measure of quality care, but evidence describing the incidence, economic burden, and outcomes of dehydration in hospitalized patients is lacking. OBJECTIVE: The objective of this study was to compare costs and resource utilization of U.S. patients experiencing postadmission dehydration (PAD) with those who do not in a hospital setting. METHODS: All adult inpatient discharges, excluding those with suspected dehydration present on admission (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes for dehydration: 276.0, 276.1, 276.5), were identified from the Premier database using ICD-9-CM codes. PAD and no-PAD (NPAD) groups were matched on propensity score adjusting for demographics (age, sex, race, medical, elective patients), patient severity (All Patient Refined Diagnosis-Related Groups severity scores), and hospital characteristics (geographic location, bed size, teaching and urban hospital). Costs, length of stay (LOS), and incidence of mortality and catheter-associated urinary tract infection (CAUTI) were compared between groups using the t test for continuous variables and the χ(2) test for categorical variables. RESULTS: In total, 86,398 (2.1%) of all the selected patients experienced PAD. Postmatching mean total costs were significantly higher for the PAD group compared with the NPAD group ($33,945 vs $22,380; P < .0001). Departmental costs were also significantly higher for the PAD group (all P < .0001). Compared with the NPAD group, the PAD group had a higher mean LOS (12.9 vs 8.2 days), a higher incidence of CAUTI (0.6% vs 0.5%), and higher in-hospital mortality (8.6% vs 7.8%) (all P < .05). The results for subgroup analysis also showed significantly higher total cost and longer LOS days for patients with PAD (all P < .05). CONCLUSIONS: The economic burden associated with hospital PAD in medical and surgical patients was substantial.

Antihypertensive drug use and the risk of dementia in patients with diabetes mellitus.

BACKGROUND: Diabetes and hypertension are independent risk factors for dementia, and hypertension may increase this risk in patients with diabetes. It is unclear whether antihypertensive drugs are associated with risk of dementia in these patients. METHODS: A retrospective study using a national cohort of beneficiaries of the Department of Veterans Affairs who have diabetes examined incidence of dementia over a 2-year follow-up period. Multivariate Cox proportional hazards regression model was used to estimate the unique effects of comorbid hypertension and antihypertensive medications on risk of dementia, after adjusting for several potential confounders. RESULTS: In all, 377,838 patients were studied (mean age: 75.53 ± 6.07 years). After adjustments were made for sociodemographic factors, duration of diabetes, comorbidity, and comedications, hypertension was associated with increased risk of developing dementia (hazard ratio [HR] = 1.08; 95% confidence interval [CI] = 1.03, 1.14). Antihypertensive medications decreased risk, ranging from 24% for angiotensin receptor blockers (ARBs) to 4% for ß-blockers. In a stratified analysis of patients without hypertension, angiotensin-converting enzyme inhibitors (HR = 0.81; 95% CI = 0.69, 0.94) and ARBs (HR = 0.55; 95% CI = 0.34, 0.88) continued to show protective effects. CONCLUSIONS: Comorbid hypertension was associated with increased risk of dementia, whereas antihypertensive medications, especially angiotensin-converting enzyme inhibitors and ARBs, were associated with reduced risk, even among patients without hypertension. Consequently, these agents may have potential therapeutic roles in delaying the onset of dementia in patients with diabetes.

Risk factors for dementia in patients over 65 with diabetes.

OBJECTIVE: This study identified factors in patients with diabetes associated with risk of developing dementia. RESEARCH DESIGN AND METHODS: This retrospective, longitudinal study used a national cohort of US Veterans with diabetes 65 years or older to examine incidence of dementia over 2 years. A multivariable Cox regression model was used to estimate risk of developing dementia associated with sociodemographic factors, use of diabetes medications, and duration of diabetes. RESULTS: In all, 377,838 patients (average age, 75.53 ± 6.07 years) were studied. Over the 2 year follow-up, 14,580 (3.85%) were diagnosed with dementia. Major risk factors for dementia were age >75 years (75-85 years, hazard ratio [HR] 2.092, 95% confidence interval [CI] 2.017-2.169; ≥85 years, HR 3.468, CI 3.274-3.672), race black versus white, HR 1.218, CI 1.164-1.274), Southern residence (HR = 1.181, CI 1.133-1.232), and diabetes duration (HR for 5 years or more, 1.428, CI 1.357-1.504). There was a reduced HR for dementia with use of an oral hypoglycemic agent (HR 0.940, CI 0.909-0.972) and HMG-CoA reductase inhibitors (HR, 0.875, CI 0.846-0.906). There was no change in HR with insulin use (HR 1.024, CI 0.983-1.067). CONCLUSIONS: Several important factors were identified that are associated with increased dementia risk, and two factors were identified that are associated with reduced risk. It will be important to ascertain whether risk-factor modification reduces the HR for dementia in persons with diabetes, and to further examine effects of medication use for comorbid conditions.

Does use of antihypertensive drugs affect the incidence or progression of dementia? A systematic review.

BACKGROUND: Hypertension appears to contribute to the development of dementia. Antihypertensive drugs may play an important role in altering the incidence or progression of dementia, particularly dementia of the vascular type; however, the neuroprotective effects of these agents in other types of dementia are not well characterized. OBJECTIVES: The main aims of this review were to examine the relationship between use of antihypertensive agents and the incidence and progression of Alzheimer's dementia (AD), vascular dementia (VaD), and unspecified dementia, and to consider whether these agents may be neuroprotective. METHODS: A search of the English-language literature (January 1996-August 2009) was conducted using PubMed, Ovid MEDLINE, EBSCO MEDLINE, and the Cochrane Database of Systematic Reviews for publications mentioning both antihypertensive drugs and dementia. A combination of searches was performed using the following terms: antihypertensive drugs, dementia, cognitive impairment, Alzheimer's dementia, vascular dementia, progression of cognitive impairment, severity of cognitive impairment, severity of dementia, prevalence, and incidence. Searches were also performed using the names of antihypertensive drug classes. The bibliographies of all retrieved articles were reviewed for additional relevant publications. The focus was on randomized controlled trials, cohort studies, and case-control studies, excluding studies in animals, patients aged <45 years, drugs other than antihypertensive agents, and the role in cognition of hormones, receptors, and enzymes. RESULTS: Sixty-five potentially relevant articles were identified from the 536 publications retrieved by the literature search. After application of the exclusion criteria, 12 original studies were included in the review, all published between 1999 and 2008 and most involving patients with AD or VaD. The most frequently studied antihypertensive agents were calcium channel blockers (7 studies), diuretics (6 studies), and angiotensin-converting enzyme (ACE) inhibitors (6 studies). Overall, these medications appeared to be beneficial in dementia, but only ACE inhibitors and diuretics significantly reduced the risk for and progression of dementia in the majority of studies. CONCLUSIONS: Antihypertensive medications-particularly ACE inhibitors and diuretics-may be helpful in reducing the risk for and progression of dementia. Large randomized clinical trials are warranted to further explore the relationship between antihypertensive drugs and dementia.