A retrospective analysis of bleeding risk with rivaroxaban, enoxaparin, and aspirin following total joint arthroplasty or revision.

STUDY OBJECTIVE: Rivaroxaban, enoxaparin, and aspirin are commonly used medications for thromboprophylaxis following lower extremity joint arthroplasty or revision. Previous research has demonstrated efficacy in preventing venous thromboembolism with each medication, however, the comparative risk of bleeding between them remains poorly understood. The aim of this study was to compare the odds of bleeding between rivaroxaban, enoxaparin, and aspirin following lower extremity joint arthroplasty or revision. DESIGN: This is a 3-year retrospective cohort study. SETTING: Data were obtained from 148 facilities across 55 states and territories of the United States. PATIENTS: This study included 85,938 patients who underwent hip or knee arthroplasty or revision. INTERVENTION: Patients received enoxaparin, rivaroxaban, or aspirin as monotherapy for thromboprophylaxis. MEASUREMENTS: The primary outcome was all bleeding, classified as major or minor bleeding, occurring in the 40 days following surgery. The secondary outcome was venous thromboembolism. MAIN RESULTS: Among 85,938 patients, 10,465 received rivaroxaban, 14,047 received enoxaparin, and 61,426 received aspirin. Bleeding occurred in 126 (1.20%) patients with rivaroxaban, 253 (1.80%) with enoxaparin, and 611 (0.99%) with aspirin. There was a significant increase in odds of bleeding in the enoxaparin compared to aspirin group odds ratio (OR) 1.18, 95% confidence interval (CI) 1.01-1.38, p = 0.042), and a trend toward increased odds of bleeding in rivaroxaban compared to aspirin group (OR 1.21, 95% CI 0.99-1.47, p = 0.058) and rivaroxaban compared to enoxaparin (OR 1.03, 95% CI 0.82-1.28, p = 0.827). Odds of venous thromboembolism were not statistically significant between all three study medications. CONCLUSIONS: Among rivaroxaban, enoxaparin, and aspirin used for thromboprophylaxis in knee and hip arthroplasty or revision, aspirin had significantly decreased odds of bleeding complications compared to enoxaparin. Although not statistically significant, aspirin also had a trend toward decreased odds of bleeding complications compared to rivaroxaban. Our study results suggest that aspirin is a safer alternative for use in postoperative thromboprophylaxis following lower extremity joint arthroplasty or revision.

A Retrospective Analysis Comparing Post-Operative Bleeding with Various Doses of Aspirin after Lower Extremity Joint Arthroplasty or Revision.

STUDY OBJECTIVE: Previous studies have shown that aspirin is noninferior to other anticoagulation therapies in preventing postoperative venous thromboembolism following lower extremity arthroplasty or revision; however, its optimal dosing for this indication is less clear. This study aims to compare the odds of bleeding between different aspirin dosages following lower extremity joint arthroplasty or revision. DESIGN: This is a 3-year retrospective multi-center cohort study across the United States and its territories. SETTING: This study included patients admitted for total hip or knee arthroplasty or revision and were treated with prophylactic aspirin. PATIENTS, INTERVENTION, MEASUREMENTS: Patients were assigned to groups based on a total daily aspirin dose of 81, 162, 325, or 650 mg. Data were analyzed for postsurgical bleeding and thromboembolism events occurring during the initial admission and up to 40 days following surgery. Other exploratory variables included type of surgery, hip or knee arthroplasty, length of stay, and patient demographic data. MAIN RESULTS: Among 53,848 patients receiving aspirin, 3922 received a total daily dose of 81 mg, 19,341 received a total daily dose of 162 mg, 5256 received a total daily dose of 325 mg, and 25,329 received a total daily dose of 650 mg. Bleeding occurred in 466 (0.87%) patients and venous thromboembolism (VTE) in 209 patients (0.39%). The odds of bleeding were compared using logistic regression, with the 650-mg dose as the reference group. None were statistically significant for bleeding between all studied aspirin doses: 81 mg (OR 1.12, 95% CI 0.83-1.51, p = 0.451), 162 mg (OR 0.83, 95% CI 0.67-1.03, p = 0.097), and 325 mg (OR 0.83, 95% CI 0.59-1.13, p = 0.245). The odds of VTE were also not statistically significant: 81 mg (OR 0.71, 95% CI 0.40-1.17, p = 0.181), 162 mg (OR 0.75 95% CI 0.54-1.03, p = 0.072), and 325 mg (OR 1.00, 95% CI 0.64-1.53, p = 0.989). CONCLUSIONS: There were no significant differences in the odds of bleeding or venous thromboembolism among all studied aspirin dosages in patients receiving aspirin for thromboprophylaxis following lower extremity joint arthroplasty or revision.

How Do COVID-19 Inpatients in the Denver Metropolitan Area Measure Up?

BACKGROUND: Inpatient data for COVID-19 (SARS-CoV-2) afflicted inpatients remain sparse. Data are needed to create accurate projections for resource consumption as the pandemic continues. Published reports of inpatient data have come from China, Italy, Singapore, and both the East and West coasts of the United States. OBJECTIVE: The objective is to present our inpatient experience with COVID-19. Design, Setting, and Participants. This is a retrospective study of 681 patients with laboratory-confirmed COVID-19 from six hospitals in the Denver metropolitan area admitted between February 18 and April 30, 2020. Clinical outcomes of patients discharged or expired by April 30, 2020, were analyzed. Main Outcomes. We compiled patient demographics, length of stay, number of patients transferred to or admitted to the ICU, ICU length of stay, mechanical ventilation requirements, and mortality rates. RESULTS: Of the 890 patients with laboratory-confirmed COVID-19, 681 had discharged and were included in this analysis. We observed 100% survival of the 0-18 age group (n = 2), 97% survival of the 19-30 age group, 95% survival of the 31-64 age group, 79% survival of the 65-84 age group, and 75% survival of the 85 and older age group. Our total inpatient mortality was 13% (91 patients), rising to 29% (59 patients) for those requiring ICU care. CONCLUSIONS: Compared to similar reports from other metropolitan areas, our analysis of discharged or expired COVID-19 patients from six major hospitals in the Denver metropolitan area revealed a lower mortality. This includes the subset of patients admitted to the ICU regardless of the need for intubation. A lower ICU length of stay was also observed.

Flash Pulmonary Edema: A Case and Review of Left Ventricular Non-Compaction Cardiomyopathy.

Description Left ventricular non-compaction cardiomyopathy is an uncommon type of cardiomyopathy caused by malformation of the myocardium during embryogenesis. This results in trabeculations within the ventricular wall that can affect the left and, less commonly, right ventricles. Presentation ranges from clinically asymptomatic to life-threatening arrhythmias. It is a rare and relatively unknown form of cardiomyopathy, though thought to be underdiagnosed. Prevalence is increasing due to improvements in imaging and awareness. Management is similar to that of other cardiomyopathies including angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers, beta-blockers, diuretics, automatic implantable cardioverter defibrillator placement and cardiac transplantation. We present a case of a 38-year-old, otherwise healthy, Indian male who presented with flash pulmonary edema and was found to have left ventricular non-compaction cardiomyopathy. This report includes a review of left ventricular non-compaction cardiomyopathy.

Meningococcemia Masquerading as a Nonspecific Flu-Like Syndrome.

Neisseria meningitidis is a cause of bacterial meningitis and meningococcemia worldwide. Rarely, it causes invasive disease with significant lifelong sequela if survived. Early clinical recognition is key as meningococcemia is an easily treatable disease, yet mortality is 50% if it is left untreated. In this case review, we present a classic case of meningococcemia, with an atypical presentation.

Unusual primary syphilis: Presentation of a likely case with a review of the stages of acquired syphilis, its differential diagnoses, management, and current recommendations.

Syphilis is an ancient disease that has re-emerged in the last decade. It is prevalent among men who have sex with men and has increased in incidence with certain ethnic groups. It usually presents as primary or secondary syphilis and can progress to tertiary syphilis if not treated. Primary syphilis will classically manifest as a single, painless ulcer with smooth, clean, and raised borders on the genitals or less often on the oral mucosa. Unusual primary syphilis cases have been reported and can be easily misdiagnosed with a resulting delay of treatment. Secondary syphilis is a systemic disease, wherein the treponemes have disseminated to various organ systems, typically presenting with characteristic mucocutaneous lesions. Tertiary syphilis has a higher rate of morbidity and mortality; as such, the aim of this article is to provide the readers with tools to recognize early syphilis and prevent its progression to late stages. In this review, we present a likely case of unusual primary syphilis mimicking herpes progenitalis as well as a compilation of all atypical cases of primary syphilis from 1973 to 2015. We will also review the differential diagnosis, management, and recommendations for each stage of syphilis.