Primary localized cutaneous lichen myxedematosus with light chain-restricted plasma cells: A distinct variant of the localized form of lichen myxedematosus.

Lichen myxedematosus (LM) is a chronic cutaneous mucinosis that can present as a localized skin lesion or as a generalized systemic disease termed scleromyxedema. The differential diagnosis is determined by a combination of clinical presentation, serological studies, and histopathological examination. Currently, well-established and accepted histopathological features to distinguish localized LM from scleromyxedema have not been elucidated. Our recent publication, together with a retrospective literature review, suggests that the presence of groups of light chain-restricted plasma cells represents a distinct histopathological clue for the diagnosis of localized LM. In this report, we provide two additional cases of localized LM with lambda light chain-restricted plasma cells, together with clinical and histopathological findings that are similar to our previous publication. These cases support our theory that the light chain-restricted plasmacytic microenvironment is primarily attributed to the pathogenesis of localized LM. Therefore, we consider these cases to constitute a clinically and pathologically new variant of localized LM and name it primary localized cutaneous LM with light chain-restricted plasma cells.

Relationships between socioeconomic status and cardiovascular outcomes in patients with complete heart block.

BACKGROUND: Literature illustrates an association between adverse outcomes and lower socioeconomic status (SES) in patients with critical cardiovascular presentations; however. limited data exist on complete heart block (CHB) outcomes in the context of SES. OBJECTIVES: The purpose of this study was to assess the association of SES (using zip code income quartiles) with the outcomes of CHB cases. METHODS: We queried the 2016-2019 Nationwide Inpatient Sample and identified CHB as the primary diagnosis. We compared in-hospital outcomes based on zip code mean income quartiles (≤2 [< $59,000] vs ≥3). The primary outcome was mortality. Secondary outcomes included total and early permanent pacemaker (PPM) and temporary pacemaker (TPM) use, cardiogenic shock, palliative care involvement, mechanical ventilation use, length of stay (LOS), and total charges. Multivariable regression models were used to adjust for potential confounders. RESULTS: Of 150,265 CHB hospitalizations, 76,635 (51%) involved patients with a lower income quartile. Lower quartiles were associated with lower odds of early PPM use (adjusted odds ratio [aOR] 0.86; 95% confidence interval [CI] 0.81-0.90) and higher odds of in-hospital mortality (aOR 1.23; 95% CI 1.05-1.46), total TPM use (aOR 1.08; 95% CI 1.02-1.14), palliative care (aOR 1.2; 95% CI 1.02-1.43), mechanical ventilation use (aOR 1.11; 95% CI 1.01-1.23), cardiogenic shock (aOR 1.15; 95% CI 1.01-1.31), and longer LOS (4 days vs 3.6 days; P <.001) compared to patients in higher quartiles. CONCLUSION: Patients with lower income admitted for CHB were less likely to receive an early PPM and had higher adverse outcomes compared to patients with higher income.

Temporary-permanent pacemakers are associated with better clinical and safety outcomes compared to balloon-tipped temporary pacemakers.

BACKGROUND: Balloon Tipped Temporary Pacemakers (BTTP) are the most used temporary pacemakers; however, they are associated with a risk of dislodgement and thromboembolism. Recently, Temporary Permanent Pacemakers (TPPM) have been increasingly used. Evidence of outcomes with TPPM compared to BTTP remains scarce. METHODS: Retrospective, chart review study evaluating all patients who underwent temporary pacemaker placement between 2014 and 2022 (N = 126) in the cardiac catheterization laboratory (CCL) at a level 1 trauma center. Primary outcome of this study is to evaluate the safety profile of TPPM versus BTTP. Secondary objectives include patient ambulation and healthcare utilization in patients with temporary pacemakers. RESULTS: Both groups had similar baseline characteristics distribution including gender, race, and age at temporary pacemaker insertion (p > .05). Subclavian vein was the most common site of access for the TPPM cohort (89.0%) versus the femoral vein in the BTTP group (65.1%). Ambulation was only possible in the TPPM group (55.6%, p < .001). Lead dislodgement, venous thromboembolism, local hematoma, and access site infections were less frequently encountered in the TPPM group (OR = 0.23 [95% CI (0.10-0.67), p < .001]). Within the subgroup of patients with TPPM, 36.6% of the patients were monitored outside the ICU setting. There was no significant difference in the pacemaker-related adverse events among patients with TPPM based on their in-hospital setting. CONCLUSION: TPPM is associated with a more favorable safety profile compared to BTTP. They are also associated with earlier patient ambulation and reduced healthcare utilization.

Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

STUDY OBJECTIVE: Ventricular paced rhythm is thought to obscure the electrocardiographic diagnosis of acute coronary occlusion myocardial infarction. Our primary aim was to compare the sensitivity of the modified Sgarbossa criteria (MSC) to that of the original Sgarbossa criteria for the diagnosis of occlusion myocardial infarction in patients with ventricular paced rhythm. METHODS: In this retrospective case-control investigation, we studied adult patients with ventricular paced rhythm and symptoms of acute coronary syndrome who presented in an emergency manner to 16 international cardiac referral centers between January 2008 and January 2018. The occlusion myocardial infarction group was defined angiographically as thrombolysis in myocardial infarction grade 0 to 1 flow or angiographic evidence of coronary thrombosis and peak cardiac troponin I ≥10.0 ng/mL or troponin T ≥1.0 ng/mL. There were 2 control groups: the "non-occlusion myocardial infarction-angio" group consisted of patients who underwent coronary angiography for presumed type I myocardial infarction but did not meet the definition of occlusion myocardial infarction; the "no occlusion myocardial infarction" control group consisted of randomly selected emergency department patients without occlusion myocardial infarction. RESULTS: There were 59 occlusion myocardial infarction, 90 non-occlusion myocardial infarction-angio, and 102 no occlusion myocardial infarction subjects (mean age, 72.0 years; 168 [66.9%] men). For the diagnosis of occlusion myocardial infarction, the MSC were more sensitive than the original Sgarbossa criteria (sensitivity 81% [95% confidence interval [CI] 69 to 90] versus 56% [95% CI 42 to 69]). Adding concordant ST-depression in V4 to V6 to the MSC yielded 86% (95% CI 75 to 94) sensitivity. For the no occlusion myocardial infarction control group of ED patients, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 96% (95% CI 90 to 99) versus 97% (95% CI 92 to 99); negative likelihood ratio (LR) 0.19 (95% CI 0.11 to 0.33) versus 0.45 (95% CI 0.34 to 0.65); and positive LR 21 (95% CI 7.9 to 55) versus 19 (95% CI 6.1 to 59). For the non-occlusion myocardial infarction-angio control group, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 84% (95% CI 76 to 91) versus 90% (95% CI 82 to 95); negative LR 0.22 (95% CI 0.13 to 0.38) versus 0.49 (95% CI 0.35 to 0.66); and positive LR 5.2 (95% CI 3.2 to 8.6) versus 5.6 (95% CI 2.9 to 11). CONCLUSION: For the diagnosis of occlusion myocardial infarction in the presence of ventricular paced rhythm, the MSC were more sensitive than the original Sgarbossa criteria; specificity was high for both rules. The MSC may contribute to clinical decisionmaking for patients with ventricular paced rhythm.

Atropine-Induced Ventricular Asystole During a Dobutamine Stress Test.

Dobutamine stress echocardiography is a safe diagnostic test with low incidence of serious complications. Atropine has been shown to reduce test duration without increasing the rate of complications. We present a case of a 52-year-old man with end stage renal disease who experienced syncope due to ventricular asystole after atropine administration during a dobutamine stress test. The underlying pathophysiology is discussed.

Determinants of empiric transfusion in gastrointestinal bleeding in the emergency department.

INTRODUCTION: Current guidelines for the management of GI bleeding (GIB) recommend restrictive transfusion triggers unless patients have shock or specific comorbidities. However, these studies may not be applicable to Emergency Department (ED) patients. Factors determining transfusion decisions in the ED are poorly understood. We compared baseline characteristics and outcomes between ED patients with GI bleeding transfused at lower or higher empiric hemoglobin levels. METHODS: Single center, retrospective analysis of hospital records from a large tertiary care center of ED patients diagnosed with GIB who underwent red blood cell transfusion in the ED. A pre-transfusion hemoglobin cutoff of 7 g/dl was used to divide patients into restrictive and empirically transfused groups. Demographics, mortality, hospital length-of-stay, and mortality risk estimates were compared between groups. RESULTS: 175 patients met inclusion criteria, with 120 restrictive patients (68.5%) and 55 liberal patients (31.4%). The sample was 49.7% male, with mean age 67.2 years, similar between groups. Patients in the empiric transfusion group had more acute emergency severity index scores (2.09 vs. 2.3). No difference was found between groups in triage vital signs, pre-endoscopy Rockall scores or mortality estimates, or length of stay. Most common reasons for empiric transfusion from chart review were hypotension and witnessed large hemorrhage. CONCLUSIONS: Patients that were empirically transfused had similar presentations to patients meeting restrictive guidelines, based on review of triage data. Transfusions above restrictive thresholds occurred frequently in our population. Additional studies are required to clarify appropriate criteria to guide transfusions for GIB in the ED.

Methadone and the QTc Interval: Paucity of Clinically Significant Factors in a Retrospective Cohort.

OBJECTIVE: Methadone is associated with prolongation of the electrocardiographic QTc interval. QTc prolongation may be linked to cardiac dysrhythmia and sudden cardiac death. The rate of these events is unknown in methadone-maintained patients. METHODS: This retrospective cohort study of 749 patients with opioid use disorder receiving methadone maintenance therapy through a single safety-net hospital, queried the electronic health record for electrocardiogram results, demographics, methadone dose, and diagnostic codes consistent with cardiac conduction disorder (International Classification of Disease, Ninth Revision [ICD-9] 426) and cardiac dysrhythmia (ICD-9 427). Factors associated with QTc interval were explored; Cox proportional-hazards regression models were used to analyze time to an event that may predispose to sudden cardiac death. RESULTS: One hundred thirty-four patients had an electrocardiogram while on methadone, 404 while off methadone, and 211 both while on and off methadone. Mean QTc interval while on methadone (436 ms, SD 36) was significantly greater than while off methadone (423 ms, SD 33). Age and methadone dose were weakly associated with increased QTc interval (P < 0.01 and P < 0.0005, respectively, adjusted R = 0.05). There were 44 ICD-9 426 and 427 events over 7064 patient-years (6.3 events/1000 patient-yrs). Having a QTc greater than sex-specific cut-off values was significantly associated with time to event (hazard ratio 3.32, 95% confidence interval 1.25-8.81), but being on methadone was not. CONCLUSIONS: Methadone is associated with QTc prolongation in a nonclinically significant dose-related manner. Cardiac events were rare and the sudden cardiac death rate was below that of the general population. Current recommendations for cardiac risk assessment in methadone-maintained patients should be reconsidered.

What's in a Name? Utilization of the Innominate Vein for Pacemaker Lead Placement in the Setting of Persistent Left Superior Vena Cava.

Persistent left superior vena cava (PLSVC) represents the most common thoracic venous anomaly and is an important clinical entity for cardiologists and electrophysiologists, among others. In approximately 30% of cases, a bridging innominate vein connects the left superior vena cava to the right. The present report highlights the value of defining the venous anatomy with a case of dual-chamber pacemaker implantation in the PLSVC with the right ventricular lead placed via the innominate vein. Pertinent considerations for device implantation in the setting of this anomaly are discussed and relevant venography reviewed.

Cardiac pauses in competitive athletes: a systematic review examining the basis of current practice recommendations.

AIMS: It is generally recommended that individuals aspiring to competitive sports should undergo pre-participation cardiovascular assessment, particularly including arrhythmia risk evaluation. In regard to bradyarrhythmias, the 36th Bethesda Conference suggested that asymptomatic cardiac pauses ≤3 s are 'probably of no significance', whereas longer 'symptomatic' pauses may be abnormal. This study focused on assessing the evidence for the '3 s' threshold. METHODS: A systematic literature search was undertaken including Embase (1980-) and Ovid Medline (1950-). The following MeSH terms were used in the database searches: Cardiac.mp & pause.mp. Additionally, pertinent publications found by review of citation lists of identified publications were examined. Individuals with reversible causes of bradyarrhythmia (e.g. drugs) were excluded. RESULTS: The study population comprised 194 individuals with cardiac pauses of 1.35-30 s. In 120 athletes, specific records for pause durations were provided, but it was not always clear whether pauses occurred at rest. Among these 120 athletes, 106 had pauses ≤3 s, of whom 92 were asymptomatic and 14 were symptomatic. Fourteen athletes had pauses >3 s, of whom nine were asymptomatic and five were symptomatic. There were no deaths during follow-up (7.46 ± 5.1 years). With respect to symptoms, the ≤3 s threshold had a low-positive predictive value (35.7%) and low sensitivity (26.3%), but good negative predictive value (86.7%) and specificity (91%). CONCLUSION: While the evidence is not incontrovertible, the 3 s pause threshold does not adequately discriminate between potentially asymptomatic and symptomatic competitive athletes, and alone should not be used to exclude potential competitors.

Risk of new-onset atrial fibrillation and stroke after radiofrequency ablation of isolated, typical atrial flutter.

BACKGROUND: Radiofrequency ablation (RFA) is considered a curative procedure for typical atrial flutter (AFL); however, patients remain at risk for developing new atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to determine the incidence and predictors of new-onset AF and stroke after RFA of isolated AFL in a multicenter cohort. METHODS: The study included 315 consecutive patients who underwent successful RFA of isolated, typical AFL from 2006 to 2013 at 4 community and teaching hospitals. Patients with any history of AF prior to RFA were excluded. RESULTS: During 2.5 ± 1.8 years of follow-up after RFA, 80 patients (25%) developed new AF. In multivariate analysis, after adjusting for baseline medical therapy, obstructive sleep apnea and left atrial enlargement were independently associated with the development of new AF. Presence of a cardiac implantable electronic device (CIED) was associated with a 3.6-fold (95% confidence interval 1.9-6.6, P <.0001) increase in the likelihood of AF detection. New AF was detected in 48% of patients with CIED and 35% of those who underwent Holter ECG vs 19% of those with clinical follow-up only (P <.0001). Anticoagulation was stopped in 58% patients an average of 3.3 ± 4.8 months after RFA. Stroke occurred in 3 patients (1%) during the follow-up period. CONCLUSION: New AF occurs in ≥25% of patients after RFA of isolated typical AFL, but stroke is relatively rare. Obstructive sleep apnea and left atrial enlargement are risk factors for AF. The presence of a CIED significantly enhances the likelihood of detecting new AF, demonstrating the importance of arrhythmia surveillance after RFA of AFL.

Transvenous phrenic nerve stimulation for the treatment of central sleep apnoea in heart failure.

AIMS: Periodic breathing with central sleep apnoea (CSA) is common in heart failure patients and is associated with poor quality of life and increased risk of morbidity and mortality. We conducted a prospective, non-randomized, acute study to determine the feasibility of using unilateral transvenous phrenic nerve stimulation for the treatment of CSA in heart failure patients. METHODS AND RESULTS: Thirty-one patients from six centres underwent attempted transvenous lead placement. Of these, 16 qualified to undergo two successive nights of polysomnography-one night with and one night without phrenic nerve stimulation. Comparisons were made between the two nights using the following indices: apnoea-hypopnoea index (AHI), central apnoea index (CAI), obstructive apnoea index (OAI), hypopnoea index, arousal index, and 4% oxygen desaturation index (ODI4%). Patients underwent phrenic nerve stimulation from either the right brachiocephalic vein (n = 8) or the left brachiocephalic or pericardiophrenic vein (n = 8). Therapy period was (mean ± SD) 251 ± 71 min. Stimulation resulted in significant improvement in the AHI [median (inter-quartile range); 45 (39-59) vs. 23 (12-27) events/h, P = 0.002], CAI [27 (11-38) vs. 1 (0-5) events/h, P≤ 0.001], arousal index [32 (20-42) vs. 12 (9-27) events/h, P = 0.001], and ODI4% [31 (22-36) vs. 14 (7-20) events/h, P = 0.002]. No significant changes occurred in the OAI or hypopnoea index. Two adverse events occurred (lead thrombus and episode of ventricular tachycardia), though neither was directly related to phrenic nerve stimulation therapy. CONCLUSION: Unilateral transvenous phrenic nerve stimulation significantly reduces episodes of CSA and restores a more natural breathing pattern in patients with heart failure. This approach may represent a novel therapy for CSA and warrants further study.

Adjuvant Role of CT in the Diagnosis of Post-Infarction Left Ventricular Free-Wall Rupture.

Left ventricular free wall rupture is usually a catastrophic mechanical complication of myocardial infarction. Risk factors include advanced age, female gender and absence of prior infarction. The vast majority of patients succumb rapidly due to cardiac tamponade and electromechanical dissociation. Expedited and accurate diagnosis can improve the chances of survival. Echocardiography has been advocated as the gold standard for diagnosis, but other imaging modalities can provide valuable information in these patients. We present the case of a patient who presented with cardiogenic shock, in which the definitive diagnosis of a left ventricular free wall rupture was accomplished by CT scan with intravenous contrast.

Physiological assessment of renal artery stenosis: comparisons of resting with hyperemic renal pressure measurements.

OBJECTIVES: We compared resting and hyperemic pressure gradients induced by intrarenal papaverine for the assessment of renal artery stenosis (RAS). We also investigated the incidence of the QT interval prolongation and ventricular arrhythmias. BACKGROUND: In the coronary circulation, maximal hyperemia is essential in determining the significance of a stenosis. In the renal circulation, the role of maximal hyperemia for the assessment of RAS has not been established. METHODS: In 55 patients with RAS (67 RAS), resting P(d)/P(a) ratio (the ratio between distal renal pressure to the aortic pressure), renal fractional flow reserve (FFR), and resting and hyperemic systolic gradients (RSG and HSG, respectively) were measured with a pressure guidewire. In a subset of 16 patients, renal vein renin activity (RVRA) was measured. RESULTS: HSG was significantly greater than RSG (20 ± 14 mm Hg vs. 9.0 ± 13 mm Hg, respectively; P < 0.001). Renal FFR was significantly lower than baseline P(d)/P(a) ratio (0.91 ± 0.06 vs. 0.94 ± 0.06 vs. respectively; P < 0.001). RVRA increased from 50 ± 66% at rest to 122 ± 112% at hyperemia, P < 0.01. At HSG of 21 mm Hg or renal FFR of 0.90, RVRA increased markedly (120%), but RVRA increased modestly (18%) when RSG was 16 mm Hg or resting P(d)/P(a) ratio was 0.93. The corrected QT intervals at baseline vs. hyperemia were not significantly different (433 ± 26 vs. 436 ± 25 msec, respectively; P = NS); no episodes of ventricular arrhythmias were noted. CONCLUSIONS: Renin production, an index of renal ischemia, was markedly greater at hyperemia than at rest, suggesting that RAS, with either an HSG of 21 mm Hg or a renal FFR of 0.90, can be considered a hemodynamically significant stenosis. Intrarenal papaverine neither prolonged the QT interval nor induced ventricular arrhythmias and the safety of which will need to be corroborated in a large study. © 2010 Wiley-Liss, Inc.

Recipient atrial flutter masquerading as donor flutter in a heart transplant recipient.

Atrial flutter is common after orthotopic heart transplantation. We present the case of a patient who presented with atrial flutter on 12-lead electrocardiogram. On invasive electrophysiologic study, the donor heart was found to be in sinus rhythm and the recipient atrium was in flutter, which was dissociated from the donor.