Cardiac Amyloidosis: A Contemporary Review of Medical and Surgical Therapy.

Amyloidosis is a systemic disease initiated by deposition of misfolded proteins in the extracellular space, due to which multiple organs may be affected concomitantly. Cardiac amyloidosis, however, remains a major cause of morbidity and mortality in this population due to infiltrative /restrictive cardiomyopathy. This review attempts to focus on contemporary medical and surgical therapies for the different types of cardiac amyloidosis. Amyloidosis affecting the heart are predominantly of the transthyretin type (acquired in the older or genetic in the younger patients), and the monoclonal immunoglobulin light chain (AL) type which is solely acquired. A rare form of secondary amyloidosis AA type can also affect the heart due to excessive production and accumulation of the acute-phase protein called Serum Amyloid A" (SAA) in the setting of chronic inflammation, cancers or autoinflammatory disease. More commonly AA amyloidosis is seen in the liver and kidney. Other rare types are Apo A1 and Isolated Atrial Amyloidosis (AANF). Medical therapies have made important strides in the clinical management of the two common types of cardiac amyloidosis. Surgical therapies such as mechanical circulatory support and cardiac transplantation should be considered in appropriate patients. Future research using AI driven algorithms for early diagnosis and treatment as well as development of newer genetic engineering technologies will drive improvements in diagnosis, treatment and patient outcomes.

NT-proBNP and D-Dimer in acute decompensated heart failure: assessment of diagnostic accuracy and correlation with echocardiographic parameters.

PURPOSE: Abnormalities in coagulation and inflammation exist in heart failure. This study compares the diagnostic accuracy of NT-proBNP and D-Dimer and the correlation of these biomarkers with echocardiographic parameters in acute decompensated heart failure. METHODS: A retrospective cross-sectional/observational study was performed using 162 patients with acute decompensated heart failure and 253 age-matched controls. Patients were ruled out for a pulmonary embolus by CT or VQ scans. The study protocol was approved by Institutional Review Board, Lubbock, TX. Correlation of NT-proBNP and D-Dimer values was done with echocardiographic parameters. Statistical significance was assumed at p < 0.05. RESULTS: D-Dimer showed a positive correlation with NT-proBNP (r = 0.665, p = 001). The AUC for NT-proBNP, D-Dimer and a combination of D-Dimer plus NT-proBNP were 0.963, 0.928 and 0.982 respectively. The AUC value for D-Dimer versus the combination of D-Dimer and NT-roBNP was not significant (p = 0.21). Correlation of NT-proBNP was significant with the echocardiographic parameters but D-Dimer did not significantly correlate with any of the echocardiographic parameters studied. CONCLUSIONS: Comparison of the AUC values for D-Dimer versus the combination of D-Dimer and NT-proBNP showed no significance suggestive of comparable diagnostic accuracy in the study population. The lack of correlation between D-Dimer and echocardiographic parameters suggests an independent pathophysiological mechanism underlying upregulation of D-Dimer in acute decompensated heart failure. Further systematic studies are needed to define mechanism of D-Dimer increase in heart failure.

Cardiovascular Changes in Menopause.

Menopause is associated with changes consistent with cardiovascular aging. The effects of cardiac disease are multifaceted, affecting endothelial function, coronary artery physiology and metabolic dysfunction leading to structural changes in the coronary anatomy. A systematic review of literature from 1986 to 2019 was conducted using PubMed and Google Scholar. The search was directed to retrieve papers that addressed the changes in cardiovascular physiology in menopause and the current therapies available to treat cardiovascular manifestations of menopause. The metabolic and clinical factors secondary to menopause, such as dyslipidemia, insulin resistance, fat redistribution and systemic hypertension, contribute to the accelerated risk for cardiovascular aging and disease. Atherosclerosis appears to be the end result of the interaction between cardiovascular risk factors and their accentuation during the perimenopausal period. Additionally, complex interactions between oxidative stress and levels of L-arginine and ADMA may also influence endothelial dysfunction in menopause. The increased cardiovascular risk in menopause stems from the exaggerated effects of changing physiology on the cardiovascular system affecting peripheral, cardiac and cerebrovascular beds. The differential effects of menopause on cardiovascular disease at the subclinical, biochemical and molecular levels form the highlights of this review.

Recurrent short-to-shield phenomenon requiring LVAD exchange: a rare complication.

Left ventricular assist device (LVAD) therapy is a common alternative approach for a patient with end-stage heart failure with HeartMate II (HM II) being one of the most common LVAD implants. The short-to-shield (STS) phenomenon is an uncommon drive-line (DL) dysfunction resulted from broken insulator causing an underlying wire to contact a metallic shield in a DL. This leads to a short circuit and a pump stoppage. We reported a case of 66-year-old man status post-implantation of HM II who presented with STS phenomenon. A tear at the distal end of the DL was found, and the patient underwent replacement of the extracorporeal part of DL twice. After the second repair, the pump functioned normally when tested in the hospital but the STS occurred again at home. The patient then underwent LVAD replacement surgery and insulation breach was found at one of the wires in intracorporeal part of the DL. After the surgery, the patient sustained recurrent episodes of STS and had to undergo a third extracorporeal DL repair surgery. Analysis of the removed DL confirmed an insulation breach. The STS has been resolved since then. Our case is unique as it is very rare to sustain another episode of STS shortly after a pump exchange. It also shows that the occurrence of STS can be intermittent and the area of insulation breach can be different from the area of the visualized tear. As a result, closed monitoring after DL repair must be strictly implemented.

Is there seasonality in hospitalizations for major depressive disorder in Canada?

Abstract Background Canada, a temperate country with four defined seasons incurs an annual productivity loss of over $30 billion on major depressive disorder (MDD); however it remains unknown whether inpatient hospitalization for MDD exhibits seasonal variations. Objective Our study objective was to determine if there are seasonal variations in hospitalization rates for MDD in Canada. Methods We used time series analysis to determine monthly rates of hospitalizations for MDD from 2006 - 2013, on data from population level health-administrative databases in Ontario, Canada. We also stratified analysis by gender and three age groups: 18 to 39, 40 to 65 and those over 65. We compared demographic and comorbidity profiles of patients admitted in April, August and December to elucidate if patient characteristics differed by season of admission. Results We identified a total of 130,336 admissions for MDD for 95,439 unique patients. Baseline characteristics of the patients were similar across seasons. We did not detect significant seasonality of hospitalizations for MDD across any of the gender or age subgroups. Discussion Our results question the popularly held belief that hospitalizations for MDD vary with seasons. These findings highlight the need for uniform hospital resource allocation for MDD throughout the year in Canada.

Irrigation and Debridement Before a 2-Stage Revision Total Knee Arthroplasty Does Not Increase Risk of Failure.

BACKGROUND: Studies have suggested that the success of 2-stage revision total knee arthroplasty (rTKA) may be compromised by a prior failed irrigation and debridement (I&D). The purpose of this study was to use 2 large state inpatient databases to compare the 2-stage rTKA failure rates for those patients with and without a prior I&D. METHODS: This retrospective, longitudinal study used inpatient discharge data from the State Inpatient Database of 2 states (California and New York) from 2005 to 2011. A combination of International Classification of Diseases, Ninth Revision, diagnosis and procedure codes was used to identify rTKA patients and compare failure rates for rTKA patients with and without prior I&D. The primary outcome was failure of the staged revision, which was defined as subsequent surgery due to infection within 4 years of the 2-stage rTKA. RESULTS: Of the 750 patients who underwent 2-stage rTKA, 57 had undergone a prior I&D. In all, 126 patients failed rTKA. After 4 years, the estimated failure rate was 8.7% (95% confidence interval [CI], 1.9%-16.9%) in the group with prior I&D and 17.5% (95% CI, 14.7%-20.4%) in the group without prior I&D. After adjusting for sex, race, insurance, median household income, and comorbidities, the hazard ratio for the group with a failed I&D was 0.49 (P = .122; 95% CI, 0.20-1.20), which indicated a lower risk of failure compared to the group without prior I&D. CONCLUSION: These findings indicate that the failure rate of 2-stage rTKA is not increased by prior failed I&D.

Few modifiable factors predict readmission following radical cystectomy.

INTRODUCTION: We sought to determine the patient and provider-related factors associated with readmission after radical cystectomy (RC) for bladder cancer. In this era of healthcare reform, hospital performance measures, such as readmission, are beginning to affect provider reimbursement. Given its high readmission rate, RC could be a target for quality improvement. METHODS: We reviewed bladder cancer patients who underwent RC in California's State Inpatient Database (2005-2009) of the Healthcare Cost and Utilization Project. We examined patient-(e.g., race, discharge disposition) and provider-related factors (e.g., volume) and evaluated their association with 30-day readmission. Multivariable logistic regression was used to examine associations of interest. RESULTS: Overall, 22.8% (n = 833) of the 3649 patients who underwent RC were readmitted within 30 days. Regarding disposition, 34.8%, 50.8%, and 12.2% were discharged home, home with home healthcare, and to a post-acute care facility (PACF), respectively. Within 30 days, 20.3%, 20.9%, and 42.3% were discharged home, home with home healthcare, and to a PACF were readmitted, respectively. African Americans (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.07-2.50), having ≥2 comorbidities (OR 1.42, 95% CI 1.06-1.91), receiving a neobladder (OR 1.45, 95% CI 1.09-1.93), and discharged to a PACF (OR 3.79, 95% CI 2.88-4.98) were independent factors associated with readmission. Hospital stays ≥15 days were associated with less readmission (OR 0.43, 95% CI 0.27-0.67, p = 0.0002). Procedure volume was not associated with complication, in-hospital mortality, or readmission. CONCLUSIONS: About one-fifth of patients undergoing RC are readmitted. Patients who are discharged to a PACF, African American, and who have more extensive comorbidities tend to experience more readmissions. Increased efforts with care coordination among these patients may help reduce readmissions.

Neoplastic and non-neoplastic complications of solid organ transplantation in patients with preexisting monoclonal gammopathy of undetermined significance.

Monoclonal gammopathy of undetermined significance (MGUS) occurs in 3-7% of the elderly population, with higher prevalence in renal failure patients, and is associated with a 25-fold increased lifetime risk for plasma cell myeloma (PCM), also known as multiple myeloma. Using the California State Inpatient, Emergency Department, and Ambulatory Surgery Databases components of the Healthcare Cost and Utilization Project (HCUP), we sought to determine whether patients with MGUS who undergo solid organ allograft (n = 22,062) are at increased adjusted relative risk (aRR) for hematologic malignancy and other complications. Among solid organ transplant patients, patients with preexisting MGUS had higher aRR of PCM (aRR 19.46; 95% CI 7.05, 53.73; p < 0.001), venous thromboembolic events (aRR 1.66; 95% CI 1.15, 2.41; p = 0.007), and infection (aRR 1.24; 95% CI 1.06, 1.45; p = 0.007). However, when comparing MGUS patients with and without solid organ transplant, there was decreased aRR for PCM with transplant (aRR 0.34; 95% CI 0.13, 0.88; p = 0.027), and increased venous thromboembolic events (aRR 2.33; 95% CI 1.58, 3.44; p < 0.001) and infectious risks (aRR 1.44; 95% CI 1.23, 1.70; p < 0.001). While MGUS increased the risk of PCM overall following solid organ transplantation, there was lower risk of PCM development compared to MGUS patients who did not receive a transplant. MGUS should not preclude solid organ transplant.

Trends in blood utilization in United States cardiac surgical patients.

BACKGROUND: We sought to determine whether publication of blood conservation guidelines by the Society of Thoracic Surgeons in 2007 influenced transfusion rates and to understand how patient- and hospital-level factors influenced blood product usage. STUDY DESIGN AND METHODS: We identified 4,465,016 patients in the Nationwide Inpatient Sample database who underwent cardiac operations between 1999 and 2010 (3,202,404 before the guidelines and 1,262,612 after). Hierarchical linear modeling was used to account for hospital- and patient-level clustering. RESULTS: Transfusion rates of blood products increased from 13% in 1999 to a peak of 34% in 2010. Use of all blood components increased over the study period. Aortic aneurysm repair had the highest transfusion rate with 54% of patients receiving products in 2010. In coronary artery bypass grafting, the number of patients receiving blood products increased from 12% in 1999 to 32% in 2010. Patients undergoing valvular operations had a transfusion rate of 15% in 1999, increasing to 36% in 2010. Patients undergoing combined operations had an increase from 13% to 40% over 11 years. Risk factors for transfusion were anemia (odds ratio [OR], 2.05; 95% confidence interval [CI], 2.01-2.09), coagulopathy (OR, 1.54; 95% CI, 1.51-1.57), diabetes (OR, 1.32; 95% CI, 1.28-1.36), renal failure (OR, 1.29; 95% CI, 1.26-1.32), and liver disease (OR, 1.23; 95% CI, 1.16-1.31). Compared to the Northeast, the risk for transfusion was significantly lower in the Midwest; higher-volume hospitals used fewer blood products than lower-volume centers. Cell salvage usage remained below 5% across all years. CONCLUSION: Independent of patient- and hospital-level factors, blood product utilization continues to increase for all cardiac operations despite publication of blood conservation guidelines in 2007.

Allogenic blood transfusion following total hip arthroplasty: results from the nationwide inpatient sample, 2000 to 2009.

BACKGROUND: The large-scale utilization of allogenic blood transfusion and its associated outcomes have been described in critically ill patients and those undergoing high-risk cardiac surgery but not in patients undergoing elective total hip arthroplasty. The objective of this study was to determine the trends in utilization and outcomes of allogenic blood transfusion in patients undergoing primary total hip arthroplasty in the United States from 2000 to 2009. METHODS: An observational cohort of 2,087,423 patients who underwent primary total hip arthroplasty from 2000 to 2009 was identified in the Nationwide Inpatient Sample. International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 99.03 and 99.04 were used to identify patients who received allogenic blood products during their hospital stay. Risk factors for allogenic transfusions were identified with use of multivariable logistic regression models. We used propensity score matching to estimate the adjusted association between transfusion and surgical outcomes. RESULTS: The rate of allogenic blood transfusion increased from 11.8% in 2000 to 19.0% in 2009. Patient-related risk factors for receiving an allogenic blood transfusion include an older age, female sex, black race, and Medicaid insurance. Hospital-related risk factors include rural location, smaller size, and non-academic status. After adjusting for confounders, allogenic blood transfusion was associated with a longer hospital stay (0.58 ± 0.02 day; p < 0.001), increased costs ($1731 ± $49 [in 2009 U.S. dollars]; p < 0.001), increased rate of discharge to an inpatient facility (odds ratio, 1.28; 95% confidence interval, 1.26 to 1.31), and worse surgical and medical outcomes. In-hospital mortality was not affected by allogenic blood transfusion (odds ratio, 0.97; 95% confidence interval, 0.77 to 1.21). CONCLUSIONS: The increase in allogenic blood transfusion among total hip arthroplasty patients is concerning considering the associated increase in surgical complications and adverse events. The risk factors for transfusion and its impact on costs and inpatient outcomes can potentially be used to enhance patient care through optimizing preoperative discussions and effective utilization of blood-conservation methods.

Primary total knee arthroplasty allogenic transfusion trends, length of stay, and complications: nationwide inpatient sample 2000-2009.

Perioperative blood loss leading to blood transfusion continues to be an issue for total knee arthroplasty (TKA) patients. The US Nationwide Inpatient Sample (NIS) was used to determine annual trends in allogenic blood transfusion rates, and effects of transfusion on in-hospital mortality, length of stay (LOS), costs, discharge disposition, and complications of primary TKA patients. TKA patients between 2000 and 2009 were included (n = 4,544,999) and categorized as: (1) those who received a transfusion of allogenic blood, and (2) those who did not. Transfusion rates increased from 7.7% to 12.2%. For both transfused and not transfused groups, mortality rates and mean LOS declined, while total costs increased. Transfused patients were associated with adjusted odds ratios of in-hospital mortality (AOR 1.16; P = 0.184), 0.71 ± 0.01 days longer LOS (P < 0.0001), and incurred ($1777 ± 36; P < 0.0001) higher total costs per admission.

Analysis of Clostridium difficile infections after cardiac surgery: epidemiologic and economic implications from national data.

OBJECTIVES: Clostridium difficile infections (CDIs) have increased during the past 2 decades, especially among cardiac surgical patients, who share many of the comorbidity risk factors for CDI. Our objectives were to use a large national database to identify the regional-, hospital-, patient-, and procedure-level risk factors for CDI; and determine mortality, resource usage, and cost of CDIs in cardiac surgery. METHODS: Using the Nationwide Inpatient Sample database, we identified 349,122 patients who had undergone coronary artery bypass, valve, or thoracic-aortic surgery from 2004 to 2008. Of these, 2581 (0.75%) had been diagnosed with CDI. Multivariable regression analysis and the propensity method were used for risk adjustment. RESULTS: Compared with the West, CDIs were more likely to occur in the Northeast (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.12-1.47) and Midwest (OR, 1.27, 95% CI, 1.11-1.46) and less likely in the South (OR, 0.80; 95% CI, 0.70-0.90). Medium-size hospitals (OR, 0.88; 95% CI, 0.78-0.99) had a lower risk of CDI than did large hospitals. Older age (>75 years; OR, 2.59; 95% CI, 1.93-3.49), longer preoperative length of stay (OR, 1.51; 95% CI, 1.43-1.60), Medicare (OR, 1.21; 95% CI, 1.05-1.39) and Medicaid (OR, 1.60; 95% CI, 1.31-1.96) coverage, and more comorbidities were associated with CDI. Among the matched pairs, patients with CDIs had greater mortality (302 [12%] vs 187 [7.2%], P<.001), a longer median length of stay (21 vs 11 days, P<.001), and greater median hospital charges ($193,330 vs $112,245, P<.001). The cumulative incremental cost of CDIs was an estimated $212 million annually. CONCLUSIONS: Our results have shown that CDI is associated with increased morbidity and resource usage. Additional work is needed to better understand the complex interplay among regional-, hospital-, and patient-level factors.

Enforcement of Ohio's Smoke Free Workplace Law through the lens of public health practice.

OBJECTIVES: Little is known about whether public health (PH) enforcement of Ohio's 2007 Smoke Free Workplace Law (SFWPL) is associated with department (agency) characteristics, practice, or state reimbursement to local PH agencies for enforcement. We used mixed methods to determine practice patterns, perceptions, and opinions among the PH workforce involved in enforcement to identify agency and workforce associations. METHODS: Focus groups and phone interviews (n=13) provided comments and identified issues in developing an online survey targeting PH workers through e-mail recruitment (433 addresses). RESULTS: A total of 171 PH workers responded to the survey. Of Ohio's 88 counties, 81 (43% rural and 57% urban) were represented. More urban than rural agencies agreed that SFWPL enforcement was worth the effort and cost (80% vs. 61%, p=0.021). The State Attorney General's collection of large outstanding fines was perceived as unreliable. An estimated 77% of agencies lose money on enforcement annually; 18% broke even, 56% attributed a financial loss to uncollected fines, and 63% occasionally or never fully recovered fines. About half of agency leaders (49%) felt that state reimbursements were inadequate to cover inspection costs. Rural agencies (59%) indicated they would be more likely than urban agencies (40%) to drop enforcement if reimbursements ended (p=0.0070). Prioritization of SFWPL vs. routine code enforcement differed between rural and urban agencies. CONCLUSIONS: These findings demonstrate the importance of increasing state health department financial support of local enforcement activities and improving collection of fines for noncompliance. Otherwise, many PH agencies, especially rural ones, will opt out, thereby increasing the state's burden to enforce SFWPL and challenging widespread public support for the law.

Bisphosphonate-related osteonecrosis of the jaw: historical, ethical, and legal issues associated with prescribing.

The long-term effects of many drugs are unknown. Established risks are communicated to patients who participate in clinical trials during the informed consent process. However, unknown and unanticipated side effects of medications may occur years after treatment. Patients with metastatic bone cancer experience an imbalance between tumor cells and the bone marrow microenvironment. Increased cytokine release, osteoclastic activity, and uncoupled osteoblastic activity lead to weakened bone structure and osteolytic lesions. The bisphosphonates are a class of drugs available in IV and oral formulations to treat and prevent bone loss and decrease the risk of skeletal-related events. Intravenous bisphosphonates such as zoledronic acid and pamidronate disodium are approved by the US Food and Drug Administration for the treatment of bone pain and hypercalcemia of malignancy and the prevention of painful bone fractures in patients with metastatic bone cancer. Oral bisphosphonates such as alendronate, risedronate, and etidronate are used to reduce the risk of skeletal fractures in patients with osteoporosis and in breast cancer. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a rare but painful complication of treatment characterized by infection, exposed bone, and poor wound healing. In this article, we discuss BRONJ and identify past, present, and future ethical and legal issues surrounding bisphosphonate administration.