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European Heart Journal. Case Reports Jun 2024Delayed coronary obstruction (DCO) is a rare but potentially life-threatening complication after transcatheter aortic valve implantation (TAVI) mostly affecting the left...
BACKGROUND
Delayed coronary obstruction (DCO) is a rare but potentially life-threatening complication after transcatheter aortic valve implantation (TAVI) mostly affecting the left main coronary artery (LMCA) and often caused by prosthesis endothelialization or thrombus formations. Herein, we report an unusual case of a delayed LMCA-obstruction caused by a calcium nodule, which was diagnosed 4 months after TAVI due to recurrent ventricular tachycardia (VT) episodes.
CASE SUMMARY
A 73-year-old patient was readmitted to an external hospital with syncope three months after TAVI. Fast VT could be induced in electrophysiological examination, why the patient received a two-chamber implantable cardioverter defibrillator (ICD). However, after 1 month the patient was readmitted to our department with another syncope. Implantable cardioverter defibrillator records revealed multiple fast VT episodes (200-220 b.p.m.). In addition, the patient reported new-onset exertional dyspnoea (New York Class Association Stage III) and elevated high-sensitive cardiac troponin of 115 ng/L. Due to the symptoms and laboratory markers indicating potential myocardial ischaemia, a cardiac computed tomography angiography (CCTA) was performed. Cardiac computed tomography angiography revealed obstruction of the LMCA likely caused by calcium shift during TAVI. After CCTA-guided percutaneous coronary intervention, patient's course remained uneventful.
DISCUSSION
The present case report highlights the role of CCTA as a powerful non-invasive diagnostic tool in complex settings after TAVI. Delayed coronary obstruction as a procedural complication can occur after TAVI and manifest with various symptoms, including new-onset or recurrent VTs, like in the present case. Cardiac computed tomography angiography provided accurate assessment of the implanted prosthesis and detection of DCO, thus guiding the subsequent PCI.
PubMed: 38947146
DOI: 10.1093/ehjcr/ytae300 -
Cureus Jun 2024Psoriasis is a chronic immune-mediated disease affecting the skin, nails, and/or joints. It is associated with systemic inflammation and may also be linked to an... (Review)
Review
Psoriasis is a chronic immune-mediated disease affecting the skin, nails, and/or joints. It is associated with systemic inflammation and may also be linked to an increased risk of atherosclerotic cardiovascular disease (ASCVD). The objectives of this study were to determine the overall risk of ASCVD in patients with psoriasis and to evaluate the risk according to ASCVD type and the severity of psoriasis. This was a systematic review and meta-analysis of observational studies reporting the association between psoriasis and one or more of the clinical types of ASCVD. We searched Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, Excerpta Medica Database (EMBASE), Scopus, Bielefeld Academic Search Engine (BASE), and Google Scholar for relevant studies in the English language from the beginning of their records to July 2023. Study selection and data extraction were conducted by four independent reviewers. A total of 21 observational studies (three cross-sectional, one case-control, and 17 cohort) were included in this review, representing a total of 778,049 patients with psoriasis and 16,881,765 control subjects without psoriasis. The included studies had varying degrees of covariate adjustment, and thus, their findings may have been subject to residual confounding. All the meta-analyses used the adjusted effect sizes and were based on the random-effects model. However, the cohort studies were analysed separately from the non-cohort studies (the case-control and cross-sectional studies). There was a significant association between psoriasis and ASCVD (cohort studies: hazard ratio (HR), 1.21; 95% confidence interval (CI), 1.14 to 1.28; I = 63%; p < 0.001; non-cohort studies: odds ratio (OR), 1.60; 95% CI, 1.34 to 1.92; I = 31%; p = 0.23). Psoriasis was also significantly associated with myocardial infarction (cohort studies: HR, 1.20; 95% CI, 1.10 to 1.31; I = 60%; p < 0.001; non-cohort studies: OR, 1.57; 95% CI, 1.15 to 2.15; I = 74%; p = 0.05), coronary artery disease (cohort studies: HR, 1.20; 95% CI, 1.13 to 1.28; I = 67%; p < 0.001; non-cohort studies: OR, 1.60; 95% CI, 1.34 to 1.92; I = 31%; p = 0.23), aortic aneurysm (HR, 1.45; 95% CI, 1.04 to 2.02; I = 67%; p = 0.08) but not with ischaemic stroke (HR, 1.14; 95% CI, 0.96 to 1.36; I = 44%; p = 0.17). Pooled analysis in terms of the severity of psoriasis showed that both mild (cohort studies: HR, 1.17; 95% CI, 1.08 to 1.26; I = 74%; p < 0.001; non-cohort studies: OR, 1.54; 95% CI, 1.25 to 1.90; I = 0%; p = 0.50) and severe (cohort studies: HR, 1.43; 95% CI, 1.23 to 1.65; I = 65%; p < 0.001; non-cohort studies: OR, 1.65; 95% CI, 1.29 to 2.12; I = 25%; p = 0.26) psoriasis were significantly associated with ASCVD. Psoriasis (including mild and severe disease) is associated with an increased risk of ASCVD, including coronary artery disease (CAD) and aortic aneurysm (AA). ASCVD risk assessment and prevention should be prioritised in all adult psoriasis patients. Future observational studies investigating the association between psoriasis and ASCVD should conduct a more comprehensive adjustment of covariates.
PubMed: 38947134
DOI: 10.7759/cureus.63379 -
Research Square Jun 2024Vancomycin, an antibiotic with activity against Methicillin-resistant Staphylococcus aureus (MRSA), is frequently included in empiric treatment for community-acquired...
Vancomycin, an antibiotic with activity against Methicillin-resistant Staphylococcus aureus (MRSA), is frequently included in empiric treatment for community-acquired pneumonia (CAP) despite the fact that MRSA is rarely implicated in CAP. Conducting polymerase chain reaction (PCR) testing on nasal swabs to identify the presence of MRSA colonization has been proposed as an antimicrobial stewardship intervention to reduce the use of vancomycin. Observational studies have shown reductions in vancomycin use after implementation of MRSA colonization testing, and this approach has been adopted by CAP guidelines. However, the ability of this intervention to safely reduce vancomycin use has yet to be tested in a randomized controlled trial. STOP-Vanc is a pragmatic, prospective, single center, non-blinded randomized trial. Adult patients with suspicion for CAP who are receiving vancomycin and admitted to the Medical Intensive Care Unit at Vanderbilt University Medical Center will be screened for eligibility. Eligible patients will be enrolled and randomized in a 1:1 ratio to either receive MRSA nasal swab PCR testing in addition to usual care (intervention group), or usual care alone (control group). PCR testing results will be transmitted through the electronic health record to the treating clinicians. Primary providers of intervention group patients with negative swab results will also receive a page providing clinical guidance recommending discontinuation of vancomycin. The primary outcome will be vancomycin-free hours alive, defined as the number of hours alive and free of the use of vancomycin within the first seven days following trial enrollment estimated using a proportional odds ratio model. Secondary outcomes include 30-day all-cause mortality and time alive off vancomycin. STOP-Vanc will provide the first randomized controlled trial data regarding the use of MRSA nasal swab PCR testing to guide antibiotic de-escalation. This study will provide important information regarding the effect of MRSA PCR testing and antimicrobial stewardship guidance on clinical outcomes in an intensive care unit setting. This trial was registered on ClinicalTrials.gov on February 22, 2024. (ClinicalTrials.gov identifier: NCT06272994).
PubMed: 38947088
DOI: 10.21203/rs.3.rs-4365928/v1 -
Research Square Jun 2024Nirmatrelvir/ritonavir (NM/r) is a safe and effective oral antiviral therapeutic used for treatment of mild-to-moderate COVID-19. Case reports described a clinical...
Nirmatrelvir/ritonavir (NM/r) is a safe and effective oral antiviral therapeutic used for treatment of mild-to-moderate COVID-19. Case reports described a clinical rebound syndrome whereby individuals experience a relapse of symptoms shortly after completing successful treatment. There is a lack of information on frequency of COVID-19 rebound after NM/r in routine clinical care, contributing factors, and clinical outcomes. : We reviewed electronic medical records to verify COVID-19 diagnosis, symptoms, and treatment with NM/r from January-June 2022. We defined COVID-19 clinical rebound as clear improvement in symptoms followed by recurrence or worsening of symptoms within 30 days of a five-day course of NM/r. We studied 268 adults with median age 57 (IQR 47, 68), 80% White race, 85% non-Hispanic ethnicity, 55% female, 80% vaccinated and boosted against SARS-CoV-2, and 68% with any co-morbidity. Sixteen (6.0%) of studied patients were determined to have COVID-19 clinical rebound. The median time from starting NM/r to rebound was 11 days (IQR 9, 13). Notable demographic and clinical factors with higher proportion (not statistically significant) among COVID-19 rebound patients were female sex (75% rebound vs 54.5% no rebound), Black race (12.5% rebound vs 4.9% no rebound), presence of at least one co-morbidity (81.3% rebound vs 67.5% no rebound), and lack of prior SARS-CoV-2 infection (100% rebound vs 92.9% no rebound). Only one patient (6.25%) was hospitalized after COVID-19 rebound. COVID-19 clinical rebound after treatment with NM/r is mild with favorable outcomes and more common than previously reported from real-world clinical care studies.
PubMed: 38947049
DOI: 10.21203/rs.3.rs-4497916/v1 -
MedRxiv : the Preprint Server For... Jun 2024Prediabetes, a high-risk state for developing diabetes, affects more than 1 in 3 adults nationally. However, <5% of people with prediabetes are receiving any treatment...
BACKGROUND
Prediabetes, a high-risk state for developing diabetes, affects more than 1 in 3 adults nationally. However, <5% of people with prediabetes are receiving any treatment for prediabetes. Prior intervention studies for increasing prediabetes treatment uptake have largely focused on individual barriers with few multi-level interventions that address clinician- and system-level barriers.
OBJECTIVE
To measure the effectiveness of a multi-level intervention on uptake of prediabetes treatment in a primary care clinic.
DESIGN
Pragmatic study of the START (Screen, Test, Act, Refer and Treat) Diabetes Prevention intervention.
PARTICIPANTS
The START Diabetes Prevention intervention was implemented in a suburban primary care clinic outside of Baltimore compared to a control clinic in the same area over a 12-month period.
INTERVENTION
START Diabetes Prevention intervention included a structured workflow, shared decision-making resources and electronic health record clinical decision support tools.
MAIN MEASURES
Uptake of prediabetes treatment, defined as Diabetes Prevention Program referral, metformin prescription and/or medical nutrition referral within 30 days of any PCC visit.
KEY RESULTS
We demonstrated greater uptake of preventive treatment among patients with prediabetes in the intervention clinic vs. control clinic receiving usual care (11.6% vs. 6.7%, p<0.001). More patients in the intervention vs. control clinic reported their PCC discussed prediabetes with them (60% vs. 48%, p=0.002) and more felt overall that they understood what their doctor was telling them about prediabetes and that their opinion was valued. The START Diabetes Prevention Strategy had greater acceptability and usefulness to PCCs at the study end compared to baseline.
CONCLUSIONS
A low-touch multi-level intervention is effective in increasing prediabetes treatment uptake. The intervention was also acceptable and feasible for clinicians, and enhanced patient understanding and discussions of prediabetes with their clinicians.
PubMed: 38947005
DOI: 10.1101/2024.06.10.24308653 -
MedRxiv : the Preprint Server For... Jun 2024Auditory processing disorder (APD) has been studied in both research and clinic settings, but the relation between the two has not been addressed. In a longitudinal...
PURPOSE
Auditory processing disorder (APD) has been studied in both research and clinic settings, but the relation between the two has not been addressed. In a longitudinal research study (SICLiD), we found that children with clinically normal audiometry who had caregiver-reported listening difficulties (LiD), with or without clinically assessed APD, performed poorly on both listening and cognitive tests. Specific questions asked here were, for the children with LiD, what other neurodevelopmental clinical conditions were identified, what interventions were used by different clinical providers, and how clinical practice was predicted by research results.
METHODS
Study setting was a large, research-led, tertiary pediatric hospital. Electronic medical records of 74 children aged 6-13 years, recruited into SICLiD and assigned to an LiD group based on a validated and reliable caregiver report (ECLiPS), were independently reviewed. Focus was on clinical assessments and interventions following appointments provided in the Hospital Divisions of Audiology, Occupational Therapy, Psychology (Developmental and Behavioral Pediatrics), and Speech-Language Pathology (SLP), prior to participation in SICLiD. Descriptive statistics on clinical encounters, identified conditions, and interventions were compared with quantitative, standardized performance on SICLiD assessments of listening and cognitive function. SICLiD z-scores were compared for participants with and without each clinical condition using univariate and logistic prediction analyses.
RESULTS
Most (86%) of the children with LiD had been evaluated by at least one clinical service. Overall, 24 assessment categories related to LiD, including APD, were identified. Most common conditions were attention (32%), language (28%), hearing (18%), anxiety (16%), and autism spectrum (6%) disorders. Performance on SICLiD measures varied significantly between providers, conditions, and interventions. Significant relationships between SICLiD and clinical conditions were mostly caregiver-reported items from the ECLiPS or the Children's Communication Checklist (CCC-2). Other significant correlations were scarce, but included the SCAN composite score, which predicted clinical language and attention, but not other auditory abilities or APD. SICLiD data combined with caregiver reports provided reliable predictions of all clinical conditions except APD.
CONCLUSIONS
The variety of disciplines, assessments, conditions and interventions revealed here supports previous studies showing that LiD and APD are multifaceted problems of neurodevelopment. Comparisons between clinical- and research-based assessments suggest a diagnostic path that prioritizes caregiver reports and selected psychometric tests for screening and diagnostic purposes.
PubMed: 38946985
DOI: 10.1101/2024.06.12.24308837 -
MedRxiv : the Preprint Server For... Jun 2024Propranolol, a non-selective beta-blocker, is commonly used for migraine prevention, but its impact on stroke risk among migraine patients remains controversial. Using...
BACKGROUND
Propranolol, a non-selective beta-blocker, is commonly used for migraine prevention, but its impact on stroke risk among migraine patients remains controversial. Using two large electronic health records-based datasets, we examined stroke risk differences between migraine patients with- and without- documented use of propranolol.
METHODS
This retrospective case-control study utilized EHR data from the Vanderbilt University Medical Center (VUMC) and the All of Us Research Program. Migraine patients were first identified based on the International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria using diagnosis codes. Among these patients, cases were defined as those with a primary diagnosis of stroke following the first diagnosis of migraine, while controls had no stroke after their first migraine diagnosis. Logistic regression models, adjusted for potential factors associated with stroke risk, assessed the association between propranolol use and stroke risk, stratified by sex and migraine subtype. A Cox proportional hazards regression model was used to estimate the hazard ratio (HR) for stroke risk at 1, 2, 5, and 10 years from baseline.
RESULTS
In the VUMC database, 378 cases and 15,209 controls were identified, while the All of Us database included 267 cases and 6,579 controls. Propranolol significantly reduced stroke risk in female migraine patients (VUMC: OR=0.52, p=0.006; All of Us: OR=0.39, =0.007), but not in males. The effect was more pronounced for ischemic stroke and in females with migraines without aura (MO) (VUMC: OR=0.60, p=0.014; All of Us: OR=0.28, p=0.006). The Cox model showed lower stroke rates in propranolol-treated female migraine patients at 1, 2, 5, and 10 years (VUMC: HR=0.06-0.55, p=0.0018-0.085; All of Us: HR=0.23, p=0.045 at 10 years).
CONCLUSIONS
Propranolol is associated with a significant reduction in stroke risk, particularly ischemic stroke, among female migraine without aura patients. These findings suggest that propranolol may benefit stroke prevention in high-risk populations.
PubMed: 38946982
DOI: 10.1101/2024.06.11.24308801 -
Health Science Reports Jul 2024Ovarian cancer is a common type of cancer and a leading cause of death in women. Therefore, accurate and fast prediction of ovarian tumors is crucial. One of the...
PURPOSE
Ovarian cancer is a common type of cancer and a leading cause of death in women. Therefore, accurate and fast prediction of ovarian tumors is crucial. One of the appropriate and precise methods for predicting and diagnosing this cancer is to build a model based on artificial intelligence methods. These methods provide a tool for predicting ovarian cancer according to the characteristics and conditions of each person.
METHOD
In this study, a data set included records related to 171 cases of benign ovarian tumors, and 178 records related to cases of ovarian cancer were analyzed. The data set contains the records of blood test results and tumor markers of the patients. After data preprocessing, including removing outliers and replacing missing values, the weight of the effective factors was determined using information gain indices and the Gini index. In the next step, predictive models were created using random forest (RF), support vector machine (SVM), decision trees (DT), and artificial neural network (ANN) models. The performance of these models was evaluated using the 10-fold cross-validation method using the indicators of specificity, sensitivity, accuracy, and the area under the receiver operating characteristic curve. Finally, by comparing the performance of the models, the best predictive model of ovarian cancer was selected.
RESULTS
The most important predictive factors were HE4, CA125, and NEU. The RF model was identified as the best predictive model, with an accuracy of more than 86%. The predictive accuracy of DT, SVM, and ANN models was estimated as 82.91%, 85.25%, and 79.35%, respectively. Various artificial intelligence (AI) tools can be used with high accuracy and sensitivity in predicting ovarian cancer.
CONCLUSION
Therefore, the use of these tools can help specialists and patients with early, easier, and less expensive diagnosis of ovarian cancer. Future studies can leverage AI to integrate image data with serum biomarkers, thereby facilitating the creation of novel models and advancing the diagnosis and treatment of ovarian cancer.
PubMed: 38946777
DOI: 10.1002/hsr2.2203 -
The Australasian Journal of Dermatology Jul 2024In comparison with TNF-α inhibitors, anti-IL-17A agents are considered to have a lower risk of active tuberculosis (TB) or latent TB infection (LTBI) reactivation.
Evaluation of serial QuantiFERON-TB Gold in tube test results and tuberculosis infection status in patients with psoriasis receiving anti-IL-17 treatment (secukinumab and ixekizumab): Real-world data from a tuberculosis-endemic country.
BACKGROUND
In comparison with TNF-α inhibitors, anti-IL-17A agents are considered to have a lower risk of active tuberculosis (TB) or latent TB infection (LTBI) reactivation.
METHODS
In this study, we aimed to evaluate the TB infection status and serial QuantiFERON-TB-Gold in tube test (QFT) results of psoriasis patients using IL-17 inhibitors (secukinumab [SEC] and ixekizumab [IXE]) in a real-world setting from a tuberculosis-endemic country. Patients who used an anti-IL-17 agent for at least 3 months in our follow-up were included in the study. Patients' clinical and demographic features, baseline QFT results and latest QFT results (if any), and TB infection status were noted from the past medical records.
RESULTS
A total of 717 patients, of whom 333 (46.4%) were female, were included in the study. The cumulative exposure time to an anti-IL-17 agent was 14,147 patient-months, 9743 patient-months for SEC and 4404 patient-months for IXE. Also, 459 (SEC = 305/IXE = 154) patients used an anti-IL-17 agent for ≥ 12 months. Of these, 125 had positive baseline QFT results. In all, 334 had negative baseline QFT results. The latest QFT result of 309 was also negative (persistent seronegative group). During follow-up, the QFT results of 10 patients changed from negative to positive (positive seroconversion group). Seven of them were using SEC and three were using IXE, respectively. No case of active TB infection was detected.
CONCLUSION
In our study, the positive seroconversion rate of 10/334 seems high, but this did not translate to active disease. However, closer monitoring may be required, especially in patients with advanced age, the presence of PsA, long disease duration and long anti-IL-17 treatment duration.
PubMed: 38946637
DOI: 10.1111/ajd.14340 -
Vector Borne and Zoonotic Diseases... Jul 2024Tick-borne relapsing fever (TBRF) caused by is an endemic disease in Israel and highly prevalent in military personnel. Prevention among the Israel Defense Force...
Tick-borne relapsing fever (TBRF) caused by is an endemic disease in Israel and highly prevalent in military personnel. Prevention among the Israel Defense Force soldiers is based on increased awareness mainly in hyperendemic areas and selective postexposure prophylaxis with doxycycline. In this study, we report the presence of a suspected outbreak of TBRF in four soldiers who spent 30 h inside a deserted bunker. Clinical data on TBRF suspected cases were retrieved from clinical records, soft ticks were collected using carbon dioxide (CO) traps and their DNA was extracted and analysed by PCR and nucleotide sequencing. Environmental conditions such as relative humidity, air temperature, wind speed, and type of soil, as well as presence or absence of animal traces inside the bunkers were documented. TBRF-like clinical symptoms in the patients included: tick bite scars, fever (37.5-39.2°C), rash, tachycardia, hypotension, myalgia, cough, headache, cervical lymphadenopathy and nausea. Microscopic search for in blood smears was performed in three patients and was negative. Out of the 255 ticks collected from the bunker, 198 were analyzed and 2 (1%) were infected with . To determine if tick infestation in military bunkers is a common phenomenon, we surveyed nine additional military bunkers located in four different geographical areas for the presence of soft ticks. Only one additional bunker was infested with two ticks, both negative for . Presence of earth that probably helped sustain a relatively big tick population was observed on the floor in the highly infested bunker. Environmental treatment with lambda-cyhalothrin at 9.7% was performed and showed efficacy with no ticks recovered in the infested bunker 124 days after intervention. This study shows that military bunkers may harbor soft ticks infected with and entrance into bunkers should be considered as a risk for acquiring this infection like entrance into natural caves and archeological ruins.
PubMed: 38946628
DOI: 10.1089/vbz.2024.0041