The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus.

BACKGROUND: Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM. METHODS: Through a retrospective records review, we identified patients with a well-established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1-10 Likert scale, both before and 30 minutes after the injection. RESULTS: Eighty-eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= -6 to -3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P < .0001). CONCLUSION: The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk.

Intracranial hemorrhage in the setting of posterior reversible encephalopathy syndrome: two case reports and a review.

Posterior reversible encephalopathy syndrome (PRES) is clinically characterized by seizures, changes in vision, altered mental status, and headache, with associated radiologic changes on brain imaging. Intraparenchymal hemorrhage is a rare complication of PRES and an atypical initial presentation of this condition. In this report, we discuss two patients who presented with multifocal cerebral hemorrhages that were later attributed to PRES. We further expand on the pathophysiology, management, and prognosis on patients with hemorrhagic PRES. Increased awareness of this complication of PRES is important in guiding prognostication and treatment.

Morbidity and Mortality of Congestive Heart Failure in Trauma Patients.

BACKGROUND: Cardiovascular morbidity and mortality in heart failure (HF) patients comprise a major health and economic burden, especially when readmission rate and length of stay (LOS) are considered. With increasing average life expectancy, HF prevalence continues to rise. Diseases such as diabetes mellitus, hypertension and ischemic heart disease continue to be the leading causes of HF. Current data suggest that HF is the most common cause for hospital admission in patients older than 65 years. OBJECTIVE: In this study, we sought out to compare the 30-day readmission rate in trauma patients who have a preexisting history of HF to those who do not have a history of HF. Additionally, we emphasized the effect of different cardiac variables in the HF group such as the pathophysiology of HF (HF with preserved ejection fraction [HFpEF] versus HF with reduced ejection fraction [HFrEF]) and the etiology of HFrEF (ischemic versus nonischemic). METHODS: A retrospective chart analysis of 8,137 patients who were admitted to our hospital between 2005 and 2013 secondary to trauma with an Injury Severity Score <30. Data were extracted using International Classification of Diseases, Ninth Revision codes. Neurotrauma patients were excluded. RESULTS: Of 8,137 trauma patients, 334 had preexisting HF, of which 169 had HFpEF while 165 had HFrEF). Of the 165 HFrEF cases, 121 were ischemic in etiology versus 44 nonischemic. Of 334 HF patients, 81 patients (24%) were readmitted within 30 days versus 1,068 (14%) of the non-HF patients (95% CI: 1.52-2.25, relative risk: 1.85, P < 0.0001). Of the 81 readmitted HF patients, 64 had HFpEF while 35 had HFrEF. There was no statistical significance observed in any of the endpoints in the HFpEF versus HFrEF groups. Mortality, 30-day readmission and LOS were all significantly higher in the ischemic versus nonischemic HFrEF group. CONCLUSIONS: In our trauma population, HF patients had a significantly higher 30-day readmission rate when compared to non-HF patients. The pathophysiology of HF (HFpEF versus HFrEF) did not seem to play a role. However, after subgroup analysis of the HFrEF group based on etiology, all endpoints including mortality, readmission and LOS were significantly higher in the ischemic HFrEF subgroup rendering this entity higher importance when treating trauma patients with preexisting HF.

Risk factors for coronary artery disease and acute coronary syndrome in patients ≤40 years old.

OBJECTIVE: In this study, we assessed the risk factor profile in premature coronary artery disease (CAD) and acute coronary syndrome for adults ≤40 years old. METHODS: A retrospective chart analysis of 397 patients ≤40 years old admitted from 2005 to 2014 for chest pain and who underwent coronary arteriography. RESULTS: Of 397 patients that had undergone coronary arteriography, 54% had CAD while 46% had normal coronary arteries. When compared with patients with normal coronary arteries, patients with CAD were more likely to smoke tobacco, have dyslipidemia, be diabetic, have BMI >30 kg/m(2), have a family history of premature CAD and be male in gender. CONCLUSION: Healthcare intervention in the general population through screening, counseling and education regarding the risk factors is warranted to reduce premature CAD.

Morbidity and mortality of infective endocarditis in a hospital system in New York City serving a diverse urban population.

Infective endocarditis (IE) is a severe illness associated with significant morbidity and mortality. The primary purpose of this study was to evaluate morbidity and mortality of IE in a hospital serving the most diverse area in New York City. An analysis of 209 patients admitted to the hospital from 2000 to 2012 who were found to have IE based on modified Duke criteria. Among the 209 patients with IE, 188 (88.8%) had native heart valves and 21 (11.2%) had prosthetic valves. Of the patients with native heart valves, 3.7% had coronary artery bypass graft, 4.3% were active drug users, 6.3% had permanent pacemakers, 12.2% had a history of IE, 25.7% were diabetic, 17% had end-stage renal disease (ESRD), 9% had congestive heart failure, 8% had abnormal heart valves, and 13.8% had an unknown etiology. Mortality rates of the patients with prosthetic heart valves were 27.7% compared to 8.11% in patients with native heart valves (OR 3, p<0.0001). Since we identified diabetes mellitus and ESRD to be significant risk factors in our population, we isolated and compared characteristics of patients with and without IE. IE among patients with diabetes mellitus was 23% compared with 13.8% in the control group (p=0.016). Cases of IE in patients with ESRD were 15.3%, compared with 4% in the control group (p<0.0001). We identified an overall mortality rate of 20.1% in patients with IE, a readmission rate within 30 days of discharge of 21.5%, and an average age of 59 years. Among 209 patients, 107 were males and 102 females. The most common organisms identified were Staphylococcus aureus (43.7%), viridans streptococci (17%) followed by Enterococcus (14.7%). Despite appropriate treatment, high rates of morbidity and mortality remained, with a higher impact in patients greater than 50 years of age. Such discoveries raise the importance of controlling and monitoring risk factors for IE.

A perspective on sympathetic renal denervation in chronic congestive heart failure.

Medical therapy has indisputably been the mainstay of management for chronic congestive heart failure. However, a significant percentage of patients continue to experience worsening heart failure (HF) symptoms despite treatment with multiple therapeutic agents. Recently, catheter-based interventional strategies that interrupt the renal sympathetic nervous system have shown promising results in providing better symptom control in patients with HF. In this article, we will review the pathophysiology of HF for better understanding of the interplay between the cardiovascular system and the kidney. Subsequently, we will briefly discuss pivotal renal denervation (RDN) therapy trials in patients with resistant hypertension and then present the available evidence on the role of RDN in HF therapy.

Coronary Artery Disease in Young Adults.

Coronary heart disease (CHD) sustains a significant negative impact on hospital admissions and deaths worldwide. The prevalence of CHD in young adults is difficult to establish accurately, as these asymptomatic patients typically do not undergo diagnostic studies. In this article, the authors will focus on young adults with CHD emphasizing common and uncommon risk factors, current management and review of previous studies.

Statin-mediated low-density lipoprotein lowering in chronic congestive heart failure.

Many theories and clinical trials have attempted to address the effect of low-density lipoprotein (LDL) lowering in chronic congestive heart failure (CHF). The current evidence suggests that there is no convincing reason for administering statins to patients with nonischemic heart failure. Although they do not reduce the mortality rate, statins reduce LDL cholesterol and may provide some benefit to patients with ischemic heart failure. In contrast, some authors believe that statin therapy may actually worsen outcomes in patients with CHF, especially if there is excessive reduction in LDL cholesterol. This review discusses the theories attempting to link the adverse effects of statin-mediated LDL lowering in CHF to increased levels of endotoxin or reduced levels of coenzyme Q10. In addition, the 2 largest randomized, double-blind, placebo-controlled clinical trials (CORONA and GISSI-HF) were discussed. It is clear that more trials are needed to definitely ascertain the effect of statins on CHF.