Renin-Angiotensin Blockade Reduces Readmission for Acute Chest Syndrome in Sickle Cell Disease.

Rationale Acute chest syndrome (ACS) is a life-threatening complication of sickle cell disease (SCD). Current treatment is supportive-supplemental oxygen, transfusions, and antibiotics. Prevention of ACS may reduce morbidity and mortality in patients with SCD. Acute chest syndrome appears similar to pulmonary fat embolism (PFE), a complication of severe skeletal trauma or orthopedic procedures from pulmonary micro-vessel blockage by bone marrow fat. Vascular obstruction and bone marrow necrosis occur in PFE and ACS.  Pulmonary fat embolism rat models have shown that angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) mitigate damage in PFE. These medications could work similarly in ACS. We hypothesize that time to readmission after one hospitalization for ACS will be reduced in patients taking ACEI or ARB compared to patients who are not. Methods This is a retrospective cohort study. Inclusion criteria are adults (18 to 100 years) with sickle cell anaemia (HbSS), hemoglobin SC (HbSC) disease, sickle cell thalassemia (HbSßThal), hospitalized with ACS over 16 years (January 1, 2000, to March 31, 2016); patients who take and don't take ACEI or ARB. Children (<18 years old), elderly adults (>100 years old), pregnant patients, and patients with sickle cell trait were excluded. Data was collected from the Health Facts database, which contains de-identified information from the electronic medical records of hospitals in which Cerner© has a data use agreement. Kaplan-Meier estimates explored a time-to-event model of ACS readmission. Multivariable analysis (age, gender, smoking history) was conducted using Cox proportional hazards regression. Results were reported around a 95% confidence interval. Results There were 6972 patients in total. Of which, 9.6% (n = 667) reported taking ACEI or ARB. Results for the covariates were: average age of 38 years old; 63% female (n = 4366/6969); 16% smokers (n = 1132). Readmission rates were higher for patients not taking ACEI/ARB than those who did: 0.44 (95% CI 0.43, 0.46) versus 0.28 (95% CI 0.24, 0.31) at one year, and 0.56 (95% CI 0.55, 0.58) versus 0.33 (95% CI 0.29, 0.37) at two years. Age had the strongest effect on readmission rates for patients taking ACEI/ARB (adjusted hazards ratio 0.78 [95% CI 0.68, 0.91]). Conclusion Patients with SCD who reported taking ACEI or ARB had lower readmission rates for ACS; age was the strongest covariate. Our results may have a significant impact on the prevention of ACS. Prospective studies comparing ACEI or ARB therapy versus placebo are needed to confirm this preventative effect.

Gastroesophageal Reflux Disease-Associated Chronic Cough: A Population-Based Analysis of Patient Presentations in the United States.

Gastroesophageal reflux disease is an extremely prevalent illness in the United States; however, clinicians report that its association with chronic cough is often overlooked and undiagnosed. We used the CERNER Health Facts® database to analyze the statistical prevalence. Our findings indicate that there is a minority of patients who are untreated for this common complaint. We propose considering this on the differential diagnosis and following current treatment guidelines with proton pump inhibitors to effectively treat this complaint.

The Use of Direct Oral Anticoagulants in the Management of Venous Thromboembolism in Patients With Obesity.

Introduction The use of direct oral anticoagulants (DOACs) has gained significant traction given the lack of therapeutic monitoring and the need for anticoagulant bridging. There is a paucity of data on their effectiveness in obese patients with venous thromboembolism (VTE). Preliminary subgroup and pharmacokinetic analyses suggest reduced efficacy in those with a bodyweight >120 kg or body mass index (BMI) ≥40 kg per m2 and it is currently not recommended that these agents be used as first-line agents. We aimed to assess the rate of VTE recurrence in obese patients diagnosed with VTE and treated with DOAC therapy. Methods We utilized the Health Facts Center National Data Warehouse (Cerner) to perform a retrospective analysis of patients with VTE (acute deep venous thrombosis (DVT) or pulmonary embolism) that presented to the hospital between 2010 and 2016 and were managed with DOACs. The cohort of patients diagnosed with DVT or PE were identified using International Classification of Disease (ICD-9-CM, ICD-10-CM). Patients were divided into two groups based on their weight: 1) weight <120 kg or 2) weight>120 kg. Six-month VTE recurrence rates were recorded. Summary and univariate statistics were performed. Results A total of 18,147 patients with a mean (±SD) age of 62 (17) years were included; 48% (n=8732) were male. A total of 2,419 (13%) patients weighed >120 kg while the rest (N=15,728, 87%) weighed <120 kg. There were significantly more female patients weighing<120 kg (54% vs 42%, p<0.0001); otherwise, there was no significant difference in age or tobacco use between both groups (p>0.05). There was no significant difference in six-month readmission rates for VTE recurrence in patients that weighed <120 kg (34%) in comparison with patients >120 kg (36%) (p=0.08). Conclusion Our study suggests that the use of DOACs in obese patients is equally efficacious with similar VTE recurrence rates in comparison with non-obese patients. This study paves the way for prospective multi-institutional randomized control trials to further reinforce the safe use of such agents in this patient population.

Risk Factors for Returning to the Operating Room for a Second Surgery After Midurethral Sling for Stress Urinary Incontinence.

OBJECTIVES: The objective of this study was to identify risk factors for having to return to the operating room for a second surgery after midurethral sling (MUS). METHODS: We used a case-control design. Cases return to operating room were a composite of 6 surgical complications or recurrent stress urinary incontinence because we believed that women would consider return to the operating room (OR) a similar MUS-related complication regardless of indication. Cases were obtained from Cerner Health Facts database, including 213 hospitals, using current procedural technology codes 57288 (repeat sling), 57287 (sling revision), and 53500 (urethrolysis) for procedures after index MUS. Controls no return to OR were randomly selected in 4:1 ratio from the remaining slings without these procedures. Multivariable regression analysis included all variables with P < 0.10 on univariable analysis. RESULTS: Between January 1, 2010, and December 31, 2016, 1247 patients returned to the OR of 17,953 patients who underwent initial MUS (6.9%). After adjusting for confounders, white race (OR, 1.47 [1.20-1.81]), lack of concomitant prolapse surgery (OR, 1.37 [1.18-1.59]), immunosuppressant drugs (OR, 1.27 [1.12-1.45]), and blood thinner use (OR, 1.38 [1.18-1.62]) significantly impacted the odds for returning to the OR. Anticholinergic use and smoking tobacco or marijuana, although significant on univariable analysis, were no longer significant after adjusting for confounders. CONCLUSIONS: The rate of a second surgery after MUS using a composite outcome, over a 7-year period including multiple diagnoses, is 6.9%. White race, using immunosuppressant drugs, using blood thinners, and not having concomitant prolapse surgery are all risk factors for having second surgery after MUS.