Novel Use of Seraph-100™ Blood Purification Therapy in Heat Stroke.

The Seraph-100™ is a purification filter that blunts cytokine storm, providing a more favorable environment to establish immune homeostasis. We present a novel case of compassionate use of Seraph filter in a young, healthy active duty service member with heat injury-induced massive inflammatory response. The patient is a previously healthy 26-year-old male with altered mental status, tachycardia, fever to 40.3 °C, and hypotension after losing consciousness during a 4-mile run. He had a history of one heat injury in college and took no medications or supplements. Initial workup demonstrated hemoconcentration, leukocytosis, and hyperkalemia. He was intubated, received isotonic crystalloid fluid, and was admitted to the intensive care unit. The patient developed vasopressor-resistant shock and multiorgan failure with rhabdomyolysis requiring continuous renal replacement therapy. The addition of the Seraph resulted in improved hemodynamic stability, decreased inflammatory markers, and improved organ function. Approximately 1 week after the final Seraph treatment, the patient had an abrupt massive lower gastrointestinal bleed and was transitioned to comfort care by family. We present the novel use of Seraph in the setting of multiorgan failure and hyperinflammatory state due to heat injury. The patient's vasopressor refractory distributive shock was believed to be secondary to heat stroke-induced massive inflammatory response, leading to a trial of Seraph therapy. This case demonstrates that the Seraph filter has the potential to improve hemodynamic instability and reduce cytokine storm in nonsepsis patients.

Urea(lly) Got Me: An Uncommon Etiology of Peripartum Liver Failure.

A 23-year-old woman presented 4 days postpartum for agitation and confusion, with initial evaluation consistent with acute fatty liver of pregnancy (AFLP). Later in her course, an amino acid panel was highly suggestive of citrullinemia type 1. She was started on arginine supplementation and glycerol phenylbutyrate and evaluated for a liver transplant. After starting the medication and diet modification, her liver failure resolved, and she was safely discharged. Urea cycle disorders may mimic AFLP with liver enzyme elevation, delirium, and hyperammonemia, but unlike AFLP, patients with urea cycle disorders will typically not recover without dietary modifications and/or medication.

Racial and gender differences of cervical vertebral maturation staging between African Americans versus Caucasian patients of various age groups: A retrospective study.

BACKGROUND AND OBJECTIVE: The primary purpose of this study was to compare CVM staging between African American (AA) and Caucasian (CC) subjects, grouped based on gender. The secondary objectives were to conduct a CVM comparison of (1) male vs. female subjects, grouped based on their race, and (2) AA vs. CC subjects, categorized based on their age group. MATERIALS AND METHODS: All patients between 8-18 years of age (University of XXX), meeting the criteria, were included between the period of the year 2007 to 2020. Three blinded independent evaluators analysed the lateral cephalograms for a 6-stage CVM system (CS1 to CS6) as described by McNamara and Franchi. Samples were divided based on race, gender, and age to conduct the statistical analysis for racial and gender comparisons. RESULTS: Out of the initial 1,300 lateral cephalograms, 1,276 with the mean age: 12.7 years SD 2.5 years, and median CVM: 4 (IQR: 25% percentile- 2 and 75% percentile- 4) were included. Gender-specific racial age comparison showed no significant differences for male subjects for most of the CVM stages (P>0.05). Overall and race-specific gender comparison of age showed significant differences for almost all CVM stages (P<0.05). No significant difference of CVM was found on racial comparison for overall, females (P=0.6131) or males (P=0.0825) subjects. On age-specific racial comparison, AA girls (8-10 years) were skeletally more mature than CC girls (P=0.0143); over 14-year-old CC girls (P<0.0001) and over 16-year-old CC boys (P=0.0008), being skeletally more mature than AA boys of the same age. CONCLUSIONS: There was no significant difference between AA and CC subjects on gender-specific comparisons for most of the CVM stages. A significant difference of age was observed for most of the CVM stage between male and female subjects on race-specific comparisons. Female patients were ahead in skeletal maturity as compared to males for each CVM stage. The CVM for 8-12-year-old AA females was significantly higher than that of the CC females, whereas the CVM for>14-year-old CC females was significantly higher than AA females.

Opioid Use and Morbidities during Left Ventricular Assist Device Support.

The use of opioids during left ventricular assist device (LVAD) support is increasing, but the implication remains unknown. We investigated the association between the use of opioid and morbidities during LVAD supports. We retrospectively reviewed the clinical data of patients who received LVAD between 2014 and 2017, which were stratified by the use of opioid at post-LVAD 3 months. Among 136 patients, 77 (57%) were in the opioid group. Hemoglobin and albumin were lower, and C-reactive protein was higher at baseline and 3 months later in the opioid group (P < 0.05 for all). The opioid group displayed worse hemodynamics, with higher pulmonary capillary wedge pressure and central venous pressure (P < 0.05 for both). Furthermore, the opioid group had higher incidences of gastrointestinal bleeding (31% versus 17%, P = 0.043) and sepsis (30% versus 13%, P = 0.036) during the 1 year observational period, whereas survivals were not stratified by the use of opioid (83% versus 90%, P = 0.27). Opioid use was associated with morbidities accompanied by poor hemodynamics during LVAD supports. The detailed causality of opioid use on morbidities remains a future concern.

Effect of tobacco smoking on outcomes after left ventricular assist device implantation.

Despite the well-established correlation between the tobacco use and cardiovascular disease, little is known about postoperative outcomes following the left ventricular assist device (LVAD) implantation. We aimed to elucidate the effect of tobacco smoking on post-LVAD implant outcomes. Patients who received LVADs from 2013 to 2018 were retrospectively characterized as current, former, or never smokers at the time of implant. We examined 1-year survival, total hospital readmissions, and specific hospital readmissions for LVAD-related adverse events based on patient's smoking status. Of the enrolled patients (n = 292), 55% were former smokers, 33% were never smokers, and 11% were current smokers. The majority of patients were African-American (48%) with a median age of 58 years. Never smokers were younger and less likely to be Caucasian compared to former or current smokers (P < .05, for both). The category of former smokers had statistically comparable total readmission rates with never smokers (2.49 vs. 2.13 event/year), whereas current smokers had significantly higher rates compared to never smokers (2.81 events/year, P < .05), with odds ratio 2.12 (95% CI = 1.35-3.32) adjusted for age and Caucasian race for >5 times of total readmissions per year. The rates of driveline infection, stroke, and hemolysis were statistically comparable between the never smokers and former smokers, while current smokers had significantly higher rates compared to never smokers (P < .05 for all).

Robotic-Assisted Total Pericardiectomy for Acute Relapsing Pericarditis: A Case Report.

Acute, relapsing pericarditis is an uncommon potential complication of any cardiothoracic intervention. If medical management fails to mitigate recurrent symptoms, robotic total pericardiectomy can be performed as a definitive therapeutic option. A 33-year-old woman had severely symptomatic, persistent pericarditis, which began 3 weeks after pacemaker placement for tachy-brady syndrome. After failure of pharmacologic treatment, a robot-assisted total pericardiectomy was performed with a drastic improvement in symptoms. Considering that this case of pericarditis was inflammatory (nonconstrictive), a radical excisional approach to all the pericardium was undertaken in order to prevent relapse of symptoms. A bilateral endoscopic off-pump robot-assisted approach was used to completely and fully excise both the anterior and posterior pericardium. In conclusion, we present a case of acute relapsing pericarditis in a very symptomatic patient who failed medical therapy and underwent a robotic totally endoscopic radical pericardiectomy with excellent results. We believe that this technique allows for total pericardiectomy using the least invasive approach and should be considered in the management of this rare but potentially debilitating condition.

Robotic-Assisted Third-Time Redo Mitral Valve Replacement.

Robotic-assisted approaches in cardiac surgery are becoming an increasingly common form of minimally invasive surgery. Recent literature has shown robotic-assisted techniques to be superior to traditional sternotomy in infection rates, bleeding, length of hospital stay, and postoperative quality of life. Although there are growing numbers of centers performing robotic mitral valve (MV) surgery, this approach is usually reserved for first-time MV repair. This case report describes a patient with two previous MV surgical procedures complicated by a late paravalvular leak that was unsuccessfully treated with four Amplatzer devices (AGA Medical, Inc, Plymouth, MN). A successful, totally endoscopic, robotic-assisted, third-time reoperative MV replacement was performed in this challenging patient.