The Fruit and Veggies for Kidney Health Study: A Prospective Randomized Trial.

Rationale & Objective: Providing fruits and vegetables (F&Vs) to health care system patients with elevated urine albumin-creatinine ratio (ACR) reduced ACR, slowed chronic kidney disease (CKD) progression and reduced cardiovascular disease (CVD) risk factors in previous studies. This study evaluated a community-based strategy in lower-income populations to identify African Americans with elevated ACR before health care system involvement and sustain them in a 6-month F&V protocol with (F&V + Cook) and without (F&V Only) cooking instructions, with the hypothesis that adjuvant cooking instructions with F&Vs would further reduce ACR. Study Design: Prospective, randomized, parallel 2-arm design. Setting & Participants: African American adults with ACR >10 mg/g creatinine randomized to 1 of 2 study arms. Interventions: Two cups/day of F&Vs with or without cooking instructions in participants followed 6 months. Outcomes: Participants sustaining the F&V protocol and between-group indicators of CVD risk, kidney injury, and dietary intake at 6 weeks and 6 months. Results: A total of 142 African American adults (mean age, 57.0 years; ACR, 27.4 mg/g; body mass index, 34.4; 24.9% CKD 1; 24.8% CKD 2; 50.4% CKD 3; 55% female) randomized to F&V Only (n=72) or F&V + Cook (n=70), and 71% were retained at 6 months. Participants received 90% of available F&V pick-ups over 6 weeks and 69% over 6 months. In the adjusted model, 6-month ACR was 31% lower for F&V + Cook than F&V Only (P = 0.02). Net 6-week F&V intake significantly increased and biometric variables improved for participants combined into a single group. Limitations: Small sample size, low-baseline ACR, and potential nonresponse bias for 24-hour dietary recall measure. Conclusions: These data support the feasibility of identifying community-dwelling African Americans with ACR indicating elevated CVD and CKD risk and sustaining a F&V protocol shown to improve kidney outcomes and CVD risk factors and provides preliminary evidence that cooking instructions adjuvant to F&Vs are needed to lower ACR. Funding: National Institute on Diabetes, Digestive, and Kidney Diseases grant "Reducing chronic kidney disease burden in an underserved population" (R21DK113440). Trial Registration: NCT03832166. Plain-Language Summary: African Americans, particularly those in low-income communities, have increased rates of chronic kidney disease (CKD) with worsening outcomes over time. Giving fruits and vegetables to individuals with CKD identified in health care systems was previously shown to reduce kidney damage, measured by urine protein albumin, and slow kidney function decline. We recruited African Americans in low-income communities with increased urine albumin levels. They received fruits and vegetables for 6 months, and we tested whether added cooking instructions further reduced urine albumin levels. Most participants continued to receive fruits and vegetables throughout the 6 months. Those given cooking instructions had lower urine albumin levels after 6 months, indicating decreased kidney damage. Providing cooking instructions with fruits and vegetables appears to lessen kidney damage more than just fruits and vegetables alone.

Marginal ulcers and associated risk factors after Roux-en-Y gastric bypass.

As the prevalence of morbid obesity continues to climb in America, so does the popularity of the Roux-en-Y gastric bypass (RYGB) to achieve weight loss goals; however, a long-term risk of RYGB is marginal ulceration, which requires urgent surgery if perforated. We sought to identify characteristics associated with elective vs urgent presentation for marginal ulcer following RYGB. Retrospective data for consecutive cases with marginal ulcers that required surgical intervention from May 2016 to February 2021 were queried from our institution's bariatric database, and differences in patient characteristics and clinical course were assessed according to presentation. Forty-three patients underwent surgery for marginal ulcer during the study timeframe. Twenty-four (56%) patients presented electively and were treated with resection of the gastroenterostomy and reanastomosis; the remaining 19 (44%) presented urgently with perforation and were treated with omental patch repair. Demographics, comorbidities, and medications were similar between groups. Patients with urgent presentations were less likely to have bleeds (0% vs. 33%, P = 0.0056) and strictures (16% vs. 46%, P = 0.0368), but were more likely to require admission to the intensive care unit (32% vs. 4%, P = 0.0325) and have a longer median length of stay (2 vs. 5 days, P < 0.0001). Bariatric surgeons must properly counsel patients about the risk of marginal ulcer development to prevent dangerous perforation, intensive care unit stays, and long hospitalizations.

Comparison of Echocardiographic and Catheter Mean Gradient to Assess Stenosis After Transcatheter Aortic Valve Implantation.

Discordance exists between Doppler-derived and left heart catheterization (LHC)-derived mean gradient (MG) in transcatheter aortic valve implantation (TAVI). We compared echocardiographic parameters of prosthetic valve stenosis and LHC-derived MG in new TAVIs. In a retrospective, single-center study, intraoperative transesophageal echocardiogram (TEE)-derived MG, LHC-derived MG, and acceleration time (AT) were obtained before and after TAVI in 362 patients. Discharge MG, AT, and Doppler velocity index (DVI) using transthoracic echocardiogram (TTE) were also obtained. MG ≥10 mm Hg was defined as abnormal. During native valve assessment with pre-TAVI TEE and pre-TAVI LHC, Pearson correlation coefficient revealed a nearly perfect linear relation between both methods' MGs (r = 0.97, p <0.0001). Intraoperatively, after TAVI, Spearman correlation coefficient revealed a weak-to-moderate relation between post-TAVI TEE and LHC MGs (r = 0.33, p <0.0001). Significant differences were observed in categorizations between post-TAVI TEE MG and post-TAVI AT (McNemar test p = 0.0003) and between post-TAVI TEE MG and post-TAVI LHC MG (signed-rank test p <0.0001), with TEE MG more likely to misclassify a patient as abnormal. At discharge, 30% of patients had abnormal TTE MG, whereas 0% and 0.8% of patients had abnormal DVI and AT, respectively. Discharge TTE MG was not associated with death or hospitalization for heart failure at a median follow-up of 862 days. Post-TAVI Doppler-derived MG by intraoperative TEE was higher than LHC, despite being virtually identical before implantation. At discharge, patients were more likely to be classified as abnormal using MG than DVI and AT. Elevated MG at discharge was not associated with death or hospitalization for heart failure.

Daily Oxygenation Support for Patients Hospitalized With SARS-CoV-2 in an Integrated Health System.

BACKGROUND: Many COVID-19 studies are constructed to report hospitalization outcomes, with few large multi-center population-based reports on the time course of intra-hospitalization characteristics, including daily oxygenation support requirements. Comprehensive epidemiologic profiles of oxygenation methods used by day and by week during hospitalization across all severities are important to illustrate the clinical and economic burden of COVID-19 hospitalizations. METHODS: This was a retrospective, multi-center observational cohort study of 15,361 consecutive hospitalizations of patients with COVID-19 at 25 adult acute care hospitals in Texas participating in the Society of Critical Care Medicine Discovery Viral Respiratory Illness Universal Study COVID-19 registry. RESULTS: At initial hospitalization, the majority required nasal cannula (44.0%), with an increasing proportion of invasive mechanical ventilation in the first week and particularly the weeks to follow. After 4 weeks of acute illness, 69.9% of adults hospitalized with COVID-19 required intermediate (eg, high-flow nasal cannula, noninvasive ventilation) or advanced respiratory support (ie, invasive mechanical ventilation), with similar proportions that extended to hospitalizations that lasted ≥ 6 weeks. CONCLUSIONS: Data representation of intra-hospital processes of care drawn from hospitals with varied size, teaching and trauma designations is important to presenting a balanced perspective of care delivery mechanisms employed, such as daily oxygen method utilization.

Heart transplant Recipients' perspectives on invasive versus Non-invasive graft failure surveillance Methods.

BACKGROUND: Heart transplant recipients must regularly be assessed for graft rejection; however, endomyocardial biopsy (EMB), can be stressful, painful, and inconvenient. AlloMap® is the only commercially available non-invasive test for graft rejection. Current guidelines include AlloMap® testing in low-risk patients OBJECTIVES: To examine the patients' perspective, this study compared patients' experiences of AlloMap® and EMB surveillance at our center. METHODS: We enrolled consecutive heart transplant recipients who were to undergo routine EMB and AlloMap® testing (on different visits) to quantify their anxiety on the GAD-7 scale and their pain level on the Polyclinic Pain Scale. We assessed paired differences of anxiety and pain within patients according to surveillance method. RESULTS: We studied 43 participants (median age 60.5[54, 66] years; 35(81%) men; 27(63%) Caucasian). The median GAD-7 scores were 1[0, 4] and 2[0, 5] prior to EMB and AlloMap®, respectively (paired difference: 0[-1, 1],P = 0.323). The median pain scores were 1[0, 1] and 0[0, 0] for EMB and AlloMap®, respectively. Patients experienced less pain with AlloMap® testing compared to EMB (EMB-AlloMap;1[0, 1],P = 0.006). Seven (16%) participants experienced a total of 9 adverse events (pain, bruising, bleeding, swelling) from EMB vs 2(5%) participants who experienced a total of 3 adverse events (pain, bruising) from AlloMap®(P = 0.059). CONCLUSION: Heart transplant recipients had less pain and fewer adverse events while undergoing graft rejection surveillance with AlloMap® testing compared to EMB. An additional benefit of AlloMap® testing is that it may be performed at home and reduce these high-risk patients' infectious exposures.

A prospective observational study on impact of epinephrine administration route on acute myocardial infarction patients with cardiac arrest in the catheterization laboratory (iCPR study).

BACKGROUND: Epinephrine is routinely utilized in cardiac arrest; however, it is unclear if the route of administration affects outcomes in acute myocardial infarction patients with cardiac arrest. OBJECTIVES: To compare the efficacy of epinephrine administered via the peripheral intravenous (IV), central IV, and intracoronary (IC) routes. METHODS: Prospective two-center pilot cohort study of acute myocardial infarction patients who suffered cardiac arrest in the cardiac catheterization laboratory during percutaneous coronary intervention. We compared the outcomes of patients who received epinephrine via peripheral IV, central IV, or IC. RESULTS: 158 participants were enrolled, 48 (30.4%), 50 (31.6%), and 60 (38.0%) in the central IV, IC, and peripheral IV arms, respectively. Peripheral IV epinephrine administration route was associated with lower odds of achieving return of spontaneous circulation (ROSC, odds ratio = 0.14, 95% confidence interval = 0.05-0.36, p < 0.0001) compared with central IV and IC administration. (There was no difference between central IV and IC routes; p = 0.9343.) The odds of stent thrombosis were significantly higher with the IC route (IC vs. peripheral IV OR = 4.6, 95% CI = 1.5-14.3, p = 0.0094; IC vs. central IV OR = 6.0, 95% CI = 1.9-19.2, p = 0.0025). Post-ROSC neurologic outcomes were better for central IV and IC routes when compared with peripheral IV. CONCLUSION: Epinephrine administration via central IV and IC routes was associated with a higher rate of ROSC and better neurologic outcomes compared with peripheral IV administration. IC administration was associated with a higher risk of stent thrombosis. Trial registration This trial is registered at NCT05253937 .

Usefulness of Statins as Secondary Prevention Against Recurrent and Terminal Major Adverse Cardiovascular Events.

Clinical guidelines recommend statins for patients with atherosclerotic cardiovascular disease (ASCVD), but many remain untreated. The goal of this study was to assess the impact of statin use on recurrent major adverse cardiovascular events (MACE). This study used medical records and insurance claims from 4 health care systems in the United States. Eligible adults who survived an ASCVD hospitalization from September 2013 to September 2014 were followed for 1 year. A multivariable extended Cox model examined the outcome of time-to-first MACE, then a multivariable joint marginal model investigated the association between post-index statin use and nonfatal and fatal MACE. There were 8,168 subjects in this study; 3,866 filled a statin prescription ≤90 days before the index ASCVD event (47.33%) and 4,152 filled a statin prescription after the index ASCVD event (50.83%). These post-index statin users were younger, with more co-morbidities. There were 763 events (315/763, 41.3% terminal) experienced by 686 (8.4%) patients. The adjusted overall MACE risk reduction was 18% (HR 0.82, 95% CI 0.70 to 0.95, p = 0.007) and was more substantial in the first 180 days (HR 0.72, 95% CI 0.60 to 0.86, p <0.001). There was a nonsignificant 19% reduction in the number of nonfatal MACE (rate ratio 0.81, 95% CI 0.49 to 1.32, p = 0.394) and a 65% reduction in the risk of all-cause death (HR 0.35, 95% CI 0.22 to 0.56, p <0.001). In conclusion, we found a modest increase in statin use after an ASCVD event, with nearly half of the patients untreated. The primary benefit of statin use was protection against early death. Statin use had the greatest impact in the first 6 months after an ASCVD event; therefore, it is crucial for patients to quickly adhere to this therapy.

Inpatient hospitalisation and mortality rate trends from 2004 to 2014 in the USA: a propensity score-matched case-control study of hyperkalaemia.

OBJECTIVE: To study the trends of hyperkalaemia in USA inpatient hospitalisation records with heart failure (HF), chronic kidney disease (CKD), acute kidney injury (AKI) and/or type II diabetes mellitus (T2DM) from 2004 to 2014 with respect to prevalence and inpatient mortality. DESIGN: Observational cross-sectional and propensity score-matched case-control study. SETTING: The National Inpatient Sample (representing up to 97% of inpatient hospital discharge records in the USA) from 2004 to 2014 PARTICIPANTS: 120 513 483 (±2 312 391) adult inpatient hospitalisation records with HF, CKD/end-stage renal disease (ESRD), AKI and/or T2DM. EXPOSURE: Hyperkalaemia, defined as the presence of an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of '276.7' in any of the first 15 diagnostic codes. PRIMARY AND SECONDARY OUTCOME MEASURES: The outcomes of interest are the annual rates of hyperkalaemia prevalence and inpatient mortality. RESULTS: Among 120 513 483 (±2 312 391) adult inpatient hospitalisations with HF, CKD/ESRD, AKI and/or T2DM, we found a 28.9% relative increase of hyperkalaemia prevalence from 4.94% in 2004 to 6.37% in 2014 (p<0.001). Hyperkalaemia was associated with an average of 4 percentage points higher rate of inpatient mortality (1.71 post-matching, p<0.0001). Inpatient mortality rates decreased from 11.49%±0.17% to 6.43%±0.08% and 9.67%±0.13% to 5.05%±0.07% for matched cases with and without hyperkalaemia, respectively (p<0.001). CONCLUSIONS: Hyperkalaemia prevalence increased over time and was associated with greater inpatient mortality, even after accounting for presentation characteristics. We detected a decreasing trend in inpatient mortality risk, regardless of hyperkalaemia presence.

Integrating Population Health Strategies into Primary Care: Impact on Outcomes and Hospital Use for Low-Income Adults.

Objective: Our objectives were two-fold: 1) To evaluate the benefits of population health strategies focused on social determinants of health and integrated into the primary care medical home (PCMH) and 2) to determine how these strategies impact diabetes and cardiovascular disease outcomes among a low-income, primarily minority community. We also investigated associations between these outcomes and emergency department (ED) and inpatient (IP) use and costs. Design: Retrospective cohort. Setting: Community-based PCMH: Baylor Scott & White Health and Wellness Center (BSW HWC). Patients/Participants: All patients who attended at least two primary care visits at BSW HWC within a 12-month time span from 2011-2015. Methods: Outcomes for patients participating in PCMH only (PCMH) as compared to PCMH plus population health services (PCMH+PoPH) were compared using electronic health record data. Main Outcomes: Diastolic and systolic blood pressure, hemoglobin A1c, ED visits and costs, and IP hospitalizations and costs were examined. Results: From 2011-2015, 445 patients (age=46±12 years, 63% African American, 61% female, 69.5% uninsured) were included. Adjusted regression analyses indicated PCMH+PoPH had greater improvement in diabetes outcomes (prediabetes HbA1c= -.65[SE=.32], P=.04; diabetes HbA1c= -.74 [SE=.37], P<.05) and 37% lower ED costs than the PCMH group (P=.01). Worsening chronic disease risk factors was associated with 39% higher expected ED visits (P<.01), whereas improved chronic disease risk was associated with 32% fewer ED visits (P=.04). Conclusions: Integrating population health services into the PCMH can improve chronic disease outcomes, and impact hospital utilization and cost in un- or under-insured populations.

A comparison of risk scores' long-term predictive abilities for patients diagnosed with ST elevation myocardial infarction who underwent early percutaneous coronary intervention.

Objective. To compare the long-term (5 year) prognostic values of commonly used risk scores on major adverse cardiovascular events (MACE) in a cohort of patients who underwent primary PCI for STEMI. Design. We created a composite endpoint of MACE, defined as the occurrence of any of the following events within 5 years: ischemic or hemorrhagic stroke, target vessel revascularization, nonfatal myocardial infarction, cardiovascular death. We dichotomized risk scores into high risk and not high risk according to the literature's pre-existing cutoffs as follows: GRACE score >127 = high risk, SYNTAX I score ≥33 = high risk, SYNTAX II ≥32 high risk, TIMI >8 = high risk. We utilized the area under the receiver operating characteristic curve (AUC) as the metric for predictive ability. Results. There were 768 patients in this study and 416 (54.2%), 209 (27.2%), 511 (66.5%), and 74 (9.6%) were at high risk according to the GRACE, SYNTAX I, SYNTAX II, and TIMI scores, respectively. The AUCs for 5-year MACE were 0.54 (95% confidence interval (CI): 0.49-0.59, p = .0947), 0.79 (95% CI: 0.75-0.83, p < .0001), 0.58 (95% CI: 0.54-0.62, p = .0004), and 0.5 (95% CI: 0.48-0.53, p = .7259), respectively. Conclusion. SYNTAX I score was superior in predicting MACE in patients with STEMI and a high burden of CAD. Utilizing the basal SYNTAX I score in STEMI patients with significant non-culprit CAD may improve risk stratification, decision-making, and outcomes.

Usefulness of Combined Renin-Angiotensin System Inhibitors and Diuretic Treatment In Patients Hospitalized with COVID-19.

Antecedent use of renin-angiotensin system inhibitors (RASi) prevents clinical deterioration and protects against cardiovascular/thrombotic complications of COVID-19, for indicated patients. Uncertainty exists regarding treatment continuation throughout infection and doing so with concomitant medications. Hence, the purpose of this study is to evaluate the differential effect of RASi continuation in patients hospitalized with COVID-19 according to diuretic use. We used the Coracle registry, which contains data of hospitalized patients with COVID-19 from 4 regions of Italy. We used Firth logistic regression for adult (>50 years) cases with admission on/after February 22, 2020, with a known discharge status as of April 1, 2020. There were 286 patients in this analysis; 100 patients (35.0%) continued RASi and 186 (65%) discontinued. There were 98 patients treated with a diuretic; 51 (52%) of those continued RASi. The in-hospital mortality rates in patients treated with a diuretic and continued versus discontinued RASi were 8% versus 26% (p = 0.0179). There were 188 patients not treated with a diuretic; 49 (26%) of those continued RASi. The in-hospital mortality rates in patients not treated with a diuretic and continued versus discontinued RASi were 16% versus 9% (p = 0.1827). After accounting for age, cardiovascular disease, and laboratory values, continuing RASi decreased the risk of mortality by approximately 77% (odds ratio 0.23, 95% confidence interval 0.06 to 0.95, p = 0.0419) for patients treated with diuretics, but did not alter the risk in patients treated with RASi alone. Continuing RASi in patients concomitantly treated with diuretics was associated with reduced in-hospital mortality.

Arrhythmias and Intraventricular Conduction Disturbances in Patients Hospitalized With Coronavirus Disease 2019.

Cardiac arrhythmias have been observed in patients hospitalized with coronavirus disease (COVID-19). Most analyses of rhythm disturbances to date include cases of sinus tachycardia, which may not accurately reflect true cardiac dysfunction. Furthermore, limited data exist regarding the development of conduction disturbances in patients hospitalized with COVID-19. Hence, we performed a retrospective review and compared characteristics and outcomes for patients with versus without incident arrhythmia, excluding sinus tachycardia, as well as between those with versus without incident conduction disturbances. There were 27 of 173 patients (16%) hospitalized with COVID-19 who developed a new arrhythmia. Incident arrhythmias were associated with an increased risk of intensive care unit admission (59% vs 31%, p = 0.0045), intubation (56% vs 20%, p <0.0001), and inpatient death (41% vs 10%, p = 0.0002) without an associated increase in risk of decompensated heart failure or other cardiac issues. New conduction disturbances were found in 13 patients (8%). Incident arrhythmias in patients hospitalized with COVID-19 are associated with an increased risk of mortality, likely reflective of underlying COVID-19 disease severity more than intrinsic cardiac dysfunction. Conduction disturbances occurred less commonly and were not associated with adverse patient outcomes.

Contrast-associated acute kidney injury following peripheral angiography.

Contrast-associated acute kidney injury (CA-AKI) is a well-known complication following angiography. Peripheral angiograms have been delayed or canceled for fear of worsening renal function leading to dialysis dependence. With the emergence of preventive measures, it is hypothesized that the risk of CA-AKI may be lower than previously observed. We performed a retrospective chart review of a single surgeon's 118 cases who underwent angiographic procedures from September 2019 through August 2020, recording patient characteristics and serum creatinine values. This cohort was comprised of 65 (55%) men and had a median age of 69 years [quartile 1 = 60, quartile 3 = 75]; 55 (47%) had diabetes mellitus and the median estimated glomerular filtration rate was 64 [45, 84] mL/min/1.73 m2. We observed a statistically significant decrease in paired serum creatinine (-0.02 mg/dL) following the procedure, and only 4 patients (3.4%) developed CA-AKI, with older age and elevated baseline creatinine being associated with reduced kidney function. We did not detect an adverse relationship between contrast volume and CA-AKI. While CA-AKI continues to be a concern for patients who require peripheral angiographic procedures, this study found the overall risk to be low. This may be partly attributable to the use of pre- and postprocedure hydration protocols and lower contrast volumes.

Tracking Blood Pressure Control Performance and Process Metrics in 25 US Health Systems: The PCORnet Blood Pressure Control Laboratory.

Background The National Patient-Centered Clinical Research Network Blood Pressure Control Laboratory Surveillance System was established to identify opportunities for blood pressure (BP) control improvement and to provide a mechanism for tracking improvement longitudinally. Methods and Results We conducted a serial cross-sectional study with queries against standardized electronic health record data in the National Patient-Centered Clinical Research Network (PCORnet) common data model returned by 25 participating US health systems. Queries produced BP control metrics for adults with well-documented hypertension and a recent encounter at the health system for a series of 1-year measurement periods for each quarter of available data from January 2017 to March 2020. Aggregate weighted results are presented overall and by race and ethnicity. The most recent measurement period includes data from 1 737 995 patients, and 11 956 509 patient-years were included in the trend analysis. Overall, 15% were Black, 52% women, and 28% had diabetes. BP control (<140/90 mm Hg) was observed in 62% (range, 44%-74%) but varied by race and ethnicity, with the lowest BP control among Black patients at 57% (odds ratio, 0.79; 95% CI, 0.66-0.94). A new class of antihypertensive medication (medication intensification) was prescribed in just 12% (range, 0.6%-25%) of patient visits where BP was uncontrolled. However, when medication intensification occurred, there was a large decrease in systolic BP (≈15 mm Hg; range, 5-18 mm Hg). Conclusions Major opportunities exist for improving BP control and reducing disparities, especially through consistent medication intensification when BP is uncontrolled. These data demonstrate substantial room for improvement and opportunities to close health equity gaps.

Nomenclature for Kidney Function from KDIGO: Shortcomings of Terminology Oversimplification.

The recent Kidney Disease: Improving Global Outcomes (KDIGO) consensus conference proposed a universal nomenclature calling for "Kidney Disease" (KD) to be applied to every form of kidney dysfunction, regardless of etiology. We recognize that the estimated glomerular filtration rate and urine albumin:creatinine ratio are limited in their application to the broad spectrum of KD. However, there are additional in vitro and advanced diagnostic options that can help identify the underlying cause of KD and inform about prognosis and management. While the overarching benefit of generalizing KD as a medical problem lies with screening and detection, the downsides attributable to a nonexact diagnosis (i.e., unclear prognosis and management strategy) are considerable. Finally, the terms "acute kidney injury" and "worsening renal function" are currently used interchangeably by nephrologists and cardiologists alike, and a universal adoption of one term will likely be a sizeable challenge. To be of greater benefit, we propose KD be used as a starting point and that the etiology and other epigenetic determinants of illness continue to be evaluated and characterized.

Flecainide toxicity late after liver transplantation.

Flecainide is an antiarrhythmic agent indicated for patients with supraventricular arrhythmias without ischemic or structural heart disease. Flecainide toxicity is a rare condition in which patients may present with bradycardia, widening of QRS, PR prolongation, ventricular tachycardia, syncope, malaise, dizziness, visual disturbance, nausea, vomiting, and/or lethargy. It carries an associated mortality rate of approximately 10%. Herein, we describe the course of a patient who experienced flecainide toxicity in the setting of renal and liver failure.

Role of endothelial cell receptors in the context of SARS-CoV-2 infection (COVID-19).

Endothelial cell (EC) dysfunction contributes to COVID-19-associated vascular inflammation and coagulopathy, and the angiotensin-converting enzyme 2 (ACE2) receptor plays a role in EC dysfunction in COVID-19. To expand the understanding of the role of the ACE2 receptor relative to EC dysfunction, this review addresses (1) tissue distribution of the ACE2 protein and its mRNA expression in humans, (2) susceptibility of the capillary ECs to SARS-CoV-2 infection, and (3) the role of EC dysfunction relevant to ACE2 and nuclear factor-κB in COVID-19.