Severe Congestive Heart Failure Research Articles

A RARE CASE OF PRIMARY CARDIAC MYXOFIBROSARCOMA

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Primary cardiac myxofibrosarcoma is a rare malignancy of mesenchymal origin which is associated with poor prognosis. Patients are generally asymptomatic in the earlier stages, however can present with life threatening hemodynamic instability. CASE PRESENTATION: Patient is a 25-year-old Caucasian male with history of asthma who presented with sudden onset of unresponsiveness, refractory shock and extensive bilateral pulmonary infiltrates. He was treated for bronchitis and pneumonia as outpatient on and off for two months prior to presentation. A transthoracic echocardiography showed large rounded mobile mass (5.5 cm by 4.5 cm) in left atrial cavity which was attached to anterior mitral leaflet causing severe mitral stenosis. CT showed extensive bilateral pulmonary consolidations. The patient was not deemed a candidate for surgical resection of the atrial mass. In the light of grave prognosis and failed aggressive medical therapy, family opted for comfort care measures. Autopsy of the left atrial mass showed low grade primary cardiac atrial myxofibrosarcoma. DISCUSSION: Myxofibrosarcoma most commonly occurs in the extremities but rarely can be seen in the heart. Primary cardiac myxofibrosarcoma is seen in the left atrium about 75% of the time [1]. Prognosis is poor because of its invasive nature and poor response to therapy including radiation, resection and chemotherapy [2]. Patients tend to be asymptomatic in the earlier stages. Clinical presentation is usually due to mass effect from the tumor. Tumor specifically located in the left atrium can cause obstruction of the mitral valve which manifests as symptoms of functional mitral stenosis leading to symptoms associated with heart failure. It can produce “tumor plop” (sound from tumor bounding around in the heart) and murmur similar to the mid-diastolic rumble of mitral stenosis [3]. This case is significant not only because of rarity of primary myxofibrosarcoma but also the clinical presentation and acute decompensation. Per our literature review, there are no reports of primary cardiac myxofibrosarcoma that presented with acute respiratory distress syndrome (ARDS). Our patient’s acute decompensation is likely synergistic result of cardiogenic shock from functional mitral stenosis (tumor mass effect) as well as underlying septic shock from pneumonia. CONCLUSIONS: Primary cardiac myxofibrosarcoma is a rare tumor which is usually detected when there are apparent hemodynamic changes form the mass effect, at which time treatment is limited given its extensive spread. Palliative care is generally the final outcome. Reference #1: Ujihira, Kosuke et al. “A case report of primary cardiac myxofibrosarcoma presenting with severe congestive heart failure” Journal of cardiothoracic surgery vol. 11,1 95. 7 Jul. 2016. Reference #2: Lazaros GA, et al. Primary myxofibrosarcoma of the left atrium: case report and review of the literature. Angiology. 2008;59(5):632–635. Reference #3: Vaideeswar, P. Butany, JW. (Feb 2008). "Benign cardiac tumors of the pluripotent mesenchyme". Semin Diagn Pathol. 25 (1): 20–8. DISCLOSURES: No relevant relationships by Bishal Bhandari, source=Web Response No relevant relationships by Cameron Koester, source=Web Response No relevant relationships by Abhishek Kalidas Kulkarni, source=Web Response No relevant relationships by Manjari Regmi, source=Web Response

Long-Term Single-Center Outcomes of Patients With Chronic Renal Dialysis Undergoing Cardiac Surgery

The prevalence of dialysis-dependent chronic renal failure (DD-CRF) is growing worldwide. Such patients are exposed to a higher cardiovascular risk because of severe calcification and congestive heart failure caused by volume overload, with poor outcomes. This study aimed to evaluate outcomes of patients with DD-CRF who were undergoing cardiac surgery in a single institution (West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany). A retrospective evaluation of 241 consecutive patients who presented with DD-CRF and were undergoing cardiac-surgery between January 2000 and December 2017 was conducted. End points were major adverse cardiac and cerebrovascular events and long-term survival. Additionally, Cox regression multivariate analysis was performed to detect independent predictors of mortality. Follow-up was 98.3% complete through August2018. The mean age of the study cohort was 63 ± 12.2 years, and 65.1% of these patients were male. Congestive heart failure (CHF) was present in 41.5% of patients, 30.7% had a previous myocardial infarction, 9.1% had previous cardiac surgery, and 22.4% needed urgent or emergency surgery. These patients underwent isolated coronary artery bypass grafting (44.8%), isolated procedures other than coronary artery bypass grafting (17.8%), or concomitant procedures (37.3%). Early outcomes reported in-hospital mortality in 10.4%, low cardiac output syndrome in 7.1%, and stroke in 2.1% of patients, respectively. Overall mortality was recorded in 61% of patients at last follow-up. Cox regression multivariate analysis reported age 60 years or older (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.62 to 3.45; P < .001) and CHF (HR, 1.95; 95% CI, 1.37 to 2.78; P < .001) as positive predictors of death and subsequent kidney transplantation (HR, 0.35; 95% CI, 0.20 to 0.59; P < .001) as a negative predictor of death. Cardiac surgery in patients with DD-CRF is associated with high morbidity and mortality. Interestingly, overall mortality was mainly not cardiac related, and older patients or those who presented with CHF had the worst life expectancy. However, subsequent kidney transplantation positively affected long-term survival in these patients.

Serum Sodium Profile of Congestive Heart Failure Patients and its Impact on Their Outcome at Discharge.

IntroductionPatients with congestive heart failure (CHF) readily present with electrolyte imbalance which commonly includes deficiencies of sodium, potassium, and magnesium. Hyponatremia occurs in advanced stages of CHF and is associated with adverse disease outcome-longer hospital stay, severity of CHF, and increased risk of mortality.MethodsIn this observational, single-center, prospective, case-control study adult patients admitted with clinical diagnosis of CHF were included after informed consent. Their demographic, clinical, and biochemical profile was attained. Patients with low serum sodium (hyponatremia) were grouped as "cases" and patients with normal serum sodium profile (normonatremia) were grouped as "controls". Factors associated with both groups and their hospital outcome were compared. SPSS for Windows version 16 (SPSS Inc., Chicago, IL, USA) was utilized.ResultsHyponatremia (serum sodium <135 mmol/L) was present in 58/189 (30.7%) patients admitted with CHF. Younger patients with non-ischemic CHF, and history of previous diagnosis, treatment, and hospitalization due to CHF were more likely to be affected. Diabetic nephropathy, chronic kidney disease, salt-restricted diet, drugs including furosemide, spironolactone, and angiotensin-converting enzyme inhibitors, low serum potassium, and reduced GFR were also related to hyponatremia. Hyponatremic CHF patients showed adverse hospital outcome on all parameters including higher death rate (12% vs. 0.8%), longer duration of hospital day, and deranged blood pressures and severe CHF at the time of discharge.ConclusionHyponatremic CHF patients are associated with prolonged hospital stay, more severe form of CHF, and deranged blood pressures. Overall, hyponatremia is an indirect clinical indicator of circulatory dysfunction and should guide a clinician for closer observation as outcomes could be poor. These patients also have higher in-hospital mortality risk.

Adductor pollicis muscle and nutritional status in heart failure patients: Is there an association?

Adductor pollicis muscle thickness (APMT) has been used as a simple index for muscle mass for the assessment of nutritional status among hospitalized patients to identify malnutrition. The aim of this study was to evaluate the association between APMT and nutritional status in clinical patients diagnosed with congestive heart failure (CHF). APMT was measured in 500 patients with CHF on the dominant side. Nutritional status was assessed means of by the Subjective Global Assessment (SGA). Functional classification was performed according to guidelines provided by the New York Heart Association (NYHA), which establishes four categories of CHF severity. Poisson regression was used to verify the association of APMT, malnutrition, and severity of CHF. P ≤ 0.05 was considered statistically significant. The malnutrition prevalence varied from 1.5% in patients with functional class I CHF to 96.2% in patients classified as functional class IV (P ≤ 0.001). In both sexes, APMT values were significantly lower in patients who were malnourished (P< 0.001). The proportion of patients with CHF and malnutrition was higher among women than men (47.2 versus 37.4%, P = 0.027). Malnutrition was slightly more common among patients ≥60 y of age compared with other age groups (48.3%, P ≤ 0.001). APMT is a significant protective factor for malnutrition even after controlling for sex, age, body mass index, and CHF functional class. Malnutrition is highly prevalent among patients with CHF and is associated with functional class. APMT may be used as a simple index for muscle mass for the assessment of nutritional status in these patient populations, and is also associated with malnutrition in these patients, even after controlling for other risk factors.

Pulmonary arterial response to Angiostrongylus vasorum in naturally infected dogs: echocardiographic findings in two cases

BackgroundAngiostrongylus vasorum is a nematode living in the pulmonary arteries of canids. Infected dogs develop severe pulmonary lesions which can potentially lead to pulmonary hypertension (PH). However, reports of PH in natural infected dogs are scant. One of the possible causes of the low prevalence of PH in A. vasorum-infected dogs could be the establishment of large diameter intrapulmonary arteriovenous anastomoses (IPAVAs), which attenuate pulmonary vascular resistance, thus reducing the pulmonary arterial pressure. The present report describes the pulmonary arterial pressure (PAP) response to A. vasorum natural infection in two dogs, assessed by echocardiography and by the saline contrast echocardiographic test (SCE).ResultsBoth dogs showed clinical signs of respiratory disease. At presentation, case 1 did not show echocardiographic signs of PH and the SCE test was positive proving the presence of IPAVAs. However, at the follow-up visit, despite A. vasorum infection resolution, the same dog showed PH and the SCE test resulted negative, which ruled out the presence of IPAVAs. Case 2 suffered from severe pulmonary arterial hypertension and right-side congestive heart failure since the day of presentation. Saline contrast echocardiography was negative both at the time of presentation and at the follow-up visit.ConclusionsIn the two cases described above, the PH was not associated with IPAVAs. During A. vasorum infection, IPAVAs recruitment mechanism is able to contrast the rise of PAP until a certain level. It probably represents an initial escape mechanism of PH that, over time, exhausts its compensatory capacities allowing PAP to rise and to be detectable on echocardiography.

SAT-592 Amiodarone-Induced Cure Of Graves' Disease

INTRODUCTION While amiodarone-induced thyrotoxicosis is known to potentially exacerbate latent subclinical hyperthyroidism, we describe a rare case of amiodarone-induced hypothyroidism in a patient with longstanding subclinical hyperthyroidism secondary to Graves disease. CASE The patient is a 66-year-old woman with longstanding subclinical hyperthyroidism due to Graves’ disease and non-toxic multi-nodular goiter. Her mild Graves’ disease was diagnosed nine years back when she presented with hyperthyroidism, negative thyrotropin receptor antibodies (TRAb), and homogenously increased radioactive iodine uptake. The thyroid sonogram and RAI scan had shown bilateral nontoxic nodules, with benign fine needle aspiration cytology. She was intermittently and successfully treated with methimazole 2.5 mg daily, and had no interest in receiving Radioactive Iodine therapy. Her course over the subsequent years was significant for diagnosis of breast cancer treated with lumpectomy and paclitaxel-adriamycin, complicated by the onset of severe congestive heart failure and permanent atrial fibrillation, for which she was started on oral Amiodarone 200mg twice a day. Her serum TSH subsequently increased from baseline 4.53 mcIU/mL (normal 0.73-4.60 mcIU/mL) to 6.04 mIU/L at 6 weeks. Amiodarone dose was tapered to a daily dose and later discontinued because of a prolonged QT on electrocardiogram. Repeat thyroid testing at six months showed a markedly elevated TSH at 66.32 mcIU/mL (normal 0.73-4.60 mcIU/mL) with a serum T4 of less than 0.25 ng/dl (normal 0.58-1.64 ng/dl). TRAb and thyroid peroxidase antibodies remained negative. So with a provisional diagnosis of amiodarone-induced hypothyroidism, methimazole was discontinued and levothyroxine 25 mcg daily started. A follow-up testing one month later showed a TSH of 11.5 mcIU/mL and serum T4 of 0.72 ng/dl. DISCUSSION Amiodarone, through its high iodine content, has been associated with hypothyroidism as well as hyperthyroidism in both normal and dysfunctional thyroid glands. It typically induces thyrotoxicosis in autonomously functioning thyroid glands by stimulating excessive thyroid hormone biosynthesis in response to iodine load, whereas it typically induces hypothyroidism in patients with underlying autoimmune thyroiditis likely because of failure to escape Wolf-Chaikoff effect. Our patient illustrates a very rare and interesting permanent cure of Graves’ disease followed by hypothyroidism after amiodarone exposure.

Left Ventricular Assist Device Artifact in EEG

ABSTRACTLeft ventricular assist devices are increasingly used as therapy for patients with severe congestive heart failure. These patients typically receive care in the intensive care unit when EEG monitoring is necessary. Identification of artifacts created by these devices is important for accurate EEG diagnosis, thus avoiding unnecessary therapies that may result in complications or require intubation of the patient. This report describes a case of a patient with altered mental status and history of congestive heart failure with a left ventricular assist device who developed seizures following left subdural hematoma and emergent evacuation. While being treated for seizures, the EEG showed a diffuse continuous and regular delta, predominant on the left that mirrored the electrocardiogram (EKG) rhythm strip and appeared to indicate an external artifact. Moving the amplifier farther away from the heart and repositioning the patient resolved the artifact. It is important to recognize potential sources of interference and artifacts when these devices are involved. This case illustrates how clinicians can prevent administration of unneeded therapies to these patients.

LVAD Use in the Treatment of End-Stage Heart Failure

Circulatory failure, developing at a certain stage of the course of most heart diseases, is a progressive process, associated with high morbidity and mortality. The effectiveness of generally accepted conservative and resynchronizing therapy for disease progression is relatively low. Mortality of patients with clinically severe congestive heart failure (CHF) reaches 26-29% within a one year after diagnosis. Thus, heart transplantation is the main option for patients with endstage heart failure. About 5,000 heart transplants are performed annually in the world, with 95% of them occurring in North America and Western Europe. But even in countries with a high level of transplantation activity, donor organs of the required quality are still sorely lacking. In such a situation, the main alternative to transplantation may be the use of artificial heart ventricles usually called as ventricular assist device (VAD). In the long run, VAD therapy can serve as a tool for healing (“bridge to recovery”), as a tool of awaiting of further transplantation (“bridge to transplantation”), or as a destination therapy. The article presents the experience of using VAD (in the form of left ventricular bypass) in five patients with end-stage CHF. In order to replace the function of the heart LV, a miniature implant system for auxiliary blood circulation INCOR VAD (Berlin Heart GmbH, Berlin, Germany) was used. Our experience from 5 cases has successfully demonstrated that the implantation of a system for long-term mechanical support of the heart to patients with progressive heart failure can be an effective method of treatment that can safely extend the waiting time for heart transplantation.

Vein of Galen Aneurysmal Malformation and High-output Cardiac Failure in a Newborn

Background: Vein of Galen aneurysm (VGA) is the most common form of symptomatic cerebrovascular malformation in neonates. It develops in a fetus in the first trimester of pregnancy due to unknown reasons, but it is likely to have a genetic etiology. The prognosis of VGA is usually poor, particularly in newborns with heart failure due to high-flow intracerebral shunt. Surgery and endovascular embolization are partially successful treatments for controlling congestive heart failure and pulmonary hypertension. Case report: In this article, we present the case of a 3600-gram, full-term, female neonate hospitalized with respiratory distress and severe heart failure. The neonate was the second child of a 28-year-old mother. After echocardiography and brain sonography, she was diagnosed with the vein of Galen malformation. The case had severe and persistent congestive heart failure and refractory pulmonary hypertension. Conclusion: It is important to perform the auscultation of fontanel in newborns and consider VGA as a differential diagnosis in the neonates with congestive heart failure.

OUTCOMES OF NON-SURGICAL PATIENTS WITH SEVERE TRICUSPID REGURGITATION AND CONGESTIVE HEART FAILURE

A significant number of patients with severe tricuspid regurgitation (TR) and congestive heart failure do not undergo corrective surgery and are medically managed. We sought to assess their characteristics and outcomes and compare them to those who underwent tricuspid valve surgery (TVS). This was

Admission characteristics predictive of in-hospital death from hospital-acquired sepsis: A comparison to community-acquired sepsis

PurposeHealthcare associated (HA) sepsis is associated with increased resource utilization and mortality compared with community acquired (CA) sepsis. The purpose of this study was to identify independent predictors of in-hospital mortality from HA-sepsis. Materials and methodsRetrospective study of adult patients admitted with HA or CA-sepsis. Predictors were identified using logistic regression. ResultsThere were 3917 sepsis encounters, of which 3186 were CA and 731 were HA. History of stroke (83/731, 11%) and myocardial infarction (70/731, 10%) were higher in HA than CA-sepsis (stroke: 258/3186, 8%, p = .005; myocardial infarction: 213/3186, 7%, p = .007). HA-sepsis patients required more mechanical ventilation (153/731, 21%) than CA-patients (218/3186, 7%, p < .001) and had a higher rate of vasopressor use (334/731, 46%) than CA patients (832/3186, 26%, p < .001). The HA group had longer ICU lengths of stay (LOS) than CA patients did at 9 days and 2.8 days, respectively (p < .0001). Moderate to severe liver disease (OR = 27, 95%CI 1.4, 513, p = .031) and congestive heart failure (CHF, 5.81, 95% CI 1.3, 26, p = .025) were predictive of in-hospital mortality from HA-sepsis. ConclusionsLiver disease and CHF were independent predictors of in-hospital mortality in HA-sepsis. HA-sepsis patients had increased prevalence of previous stroke, myocardial infarction, and liver disease.

Predictors of in-hospital adverse events after endovascular aortic aneurysm repair

BackgroundEndovascular aneurysm repair (EVAR) offered outstanding survival benefit but at the expense of cost, periodic radiographic monitoring, and higher reinterventions rates. Perioperative complications, although rare, can occur after EVAR, contributing to longer hospitalization, higher cost, and significant comorbidity and mortality. Therefore, the aim of this study was to identify the predictors of in-hospital events (IHEs) after elective EVAR. MethodsThe Vascular Quality Initiative database was explored from 2003 to 2017. Patients who had converted to open repair were excluded. IHEs were defined as any in-hospital myocardial infarction, dysrhythmia, congestive heart failure (CHF), stroke, pneumonia, respiratory failure, renal failure, lower extremity ischemia, bowel ischemia, or reoperation. Stepwise backward selection based on the Akaike information criterion statistic was implemented to select the predictors of IHE from the multivariable logistic regression models. Bootstrapping was performed with 1000 replications to internally validate the model and to obtain bias-corrected estimates. Receiver operating characteristic curves (area under the curve [AUC]) and Hosmer-Lemeshow tests were used to assess the discrimination and calibration of the models. ResultsA total of 28,240 patients with full information about IHEs were included. Any IHE took place in 2365 (8.4%) patients. Patients who had an IHE were slightly older (mean age ± standard deviation, 75.6 ± 8.1 years vs 73.3 ± 8.5 years; P < .001]. A higher proportion of women had an IHE (25.6% vs 17.9%; P < .001). Comorbid conditions were more prevalent in patients who developed an IHE (chronic kidney disease, 49.1% vs 33.2%; coronary artery disease, 34.3% vs 29.0%; moderate to severe CHF, 3.9% vs 1.4%; chronic obstructive pulmonary disease, 42.5% vs 31.9%; hypertension, 87.0% vs 83.1%; and diabetes, 18.0% vs 16.1%; all P ≤ .015). An IHE was associated with high in-hospital (5.6% vs 0.03%) and 30-day mortality (6.3% vs 0.3%; both P < .001) and worse 3-year survival beyond the perioperative period (81.1% [79.3%-82.9%] vs 91.1% [90.7%-91.5%]; P < .001). Two models were constructed, one from preoperative factors and the second from preoperative and intraoperative factors. The selected predictors of IHEs were female sex, moderate or severe CHF, chronic kidney disease, coronary artery disease, chronic obstructive pulmonary disease, hypertension, and aneurysm diameter. Intraoperative factors were contrast material volume, operative time, and packed red blood cell transfusion. Nomograms were constructed from the final models. AUC significantly improved after adding intraoperative factors (AUC [95% confidence interval], 0.71 [0.70-0.73] vs 0.65 [0.64-0.66]; P < .001]. ConclusionsIn-hospital adverse events can complicate the perioperative course of EVAR and increase the risk of operative and long-term mortality. Predicting IHEs and identifying their risk factors can potentially mitigate their development in patients at high risk. Predicting IHE risk can have tremendous prognostic value and help disposition planning. This study introduces an internally validated tool to enable vascular surgeons to identify patients' chance of having an IHE.

Correlation between Serum Uric Acid Level and Left Ventricular Ejection Fraction in Patients with Congestive Heart Failure

Background: One of the risk factors of congestive heart failure that still under investigations is hyperuricemia. It’s still debatable whether it’s an independent risk factor or it’s just a consequence of other disorders associated with cardiovascular diseases like hypertension, diabetes and dyslipidemia. Objective: The aim of our study is to elucidate whether in patients with heart failure serum uric acid level correlates with left ventricular ejection fraction supporting the possibility that the detection of progressive hyperuricemia in these patients may be an indicator of deteriorating cardiac function. Methods: We conducted a prospective study that included 124 studied patients and 26 apparently healthy persons at Coronary care unit and Internal Medicine Department at Sohag University Hospitals. Studied populations were classified into; * Group “I”: newly diagnosed heart failure, * Group “II”: decompensated heart failure on regular treatment, * Group “III”: decompensated heart failure but stopped their treatment from three months, Group “IV”: control group, healthy and age-matched subjects. We studied the association between left ventricular ejection fraction, the severity of congestive heart failure and the serum uric acid levels and the well-known conventional risk factors. Results: The main finding was the significantly higher mean serum uric acid levels in patients with congestive heart failure versus apparently healthy persons with “P value = 0.02”. When we adjusted the serum uric acid with other significant risk factors in the univariate analysis which were age, gender and smoking, serum uric acid was an independent risk factor “P value = 0.04”. There was a significant correlation between serum uric acid level and the severity of congestive heart failure “P value 0.35”. High rates of serum uric acid levels were recorded in patients with reduced ejection fraction. A uric acid level of 8.45 mg/dl was found to be the most appropriate cut-off point with the sensitivity 62% and the specificity 78.5%. Conclusion: Higher serum uric acid levels are significantly correlated with the severity of congestive heart failure and left ventricular ejection fraction. Serum uric acid is an independent risk factor for congestive heart failure.

Effects of milrinone on inflammatory response-related gene expressions in cultured rat cardiomyocytes.

Congestive heart failure (CHF) is defined as a cardiac dysfunction leading to low cardiac output and inadequate tissue perfusion. Intravenous positive inotropes are used to increase myocardial contractility in hospitalized patients with advanced heart failure. Milrinone is a phosphodiesterase Ⅲ inhibitor and used most commonly for inotropic effect. The well-known PROMISE study investigated the effects of milrinone on mortality in patients with severe CHF, and concluded that long-term therapy with milrinone increased morbidity and mortality among patients with advanced CHF. Previous studies have suggested that phosphodiesterase inhibitors can have potential effects on inflammatory pathways. Hence, we hypothesized that milrinone may alter inflammatory gene expressions in cardiomyocytes, thus leading to adverse clinical outcomes. We used rat cardiomyocyte cell line H9C2 and studied the impact of exposing cardiomyocytes to milrinone (10 μmol/L) for 24 hours on inflammatory gene expressions. RNA extracted from cultured cardiomyocytes was used for whole rat genome gene expression assay (41,000 genes). The following changes in inflammatory response-related gene expressions were discovered. Genes with increased expressions included: THBS2 (+9.98), MMP2 (+3.47), DDIT3 (+2.39), and ADORA3 (+3.5). Genes with decreased expressions were: SPP1 (-5.28) and CD14 (-2.05). We found that the above mentioned gene expression changes seem to indicate that milrinone may hinder the inflammatory process which may potentially lead to adverse clinical outcomes. However, further in vivo and clinical investigations will be needed to illustrate the clinical relevance of these gene expression changes induced by milrinone.

1084. Nocardia Cyriacigeorgica Endocarditis

BackgroundNocardia are beaded, branching Gram-positive rods that are partially acid fast and usually slow growing. Nocardia cyriacigeorgica was first described in 2001, and antimicrobial susceptibility patterns correspond with type VI Nocardia asteroides complex. Nocardia species are not a commonly associated with endocarditis, less than 20 cases to date have been documented. However, when Nocardia endocarditis is identified, the mortality rate is reported to be as high as 41% making antibiotic selection vital in the inpatient and outpatientMethodsA 62-year-old male with a past medical history significant for severe chronic obstructive pulmonary disease (COPD), atrial fibrillation, atrial tachyarrhythmia, and congestive heart failure (CHF) presented to the emergency department (ED) with shortness of breath for 1 week. The patient was initiated on IV diltiazem, meropenem, and eventually required intubation. On hospital day, two blood cultures grew Gram-positive rods, which were eventually identified as aerobic Actinomycete. Culture was sent out for DNA sequencing and N. cyriacigeorgica was identified. Transthoracic echocardiogram showed possible mitral vegetation.ResultsAntimicrobial therapy was initially de-escalated from meropenem to ampicillin, but had to be escalated to ceftriaxone once N. cyriacigeorgica was identified by DNA sequencing. The organism was reported to be susceptible to amikacin, ceftriaxone, linezolid, tobramycin, and trimethoprim/sulfamethoxazole. The patient received 1 week of ceftriaxone therapy inpatient, and was discharged on an additional 3 weeks of ceftriaxone and 6 months of minocycline suppressive therapy.Two months later the patient was re-admitted for N. cyriacigeorgica bacteremia and a pulmonary embolism. During his hospital stay, the patient had a STEMI, but due to multiple comorbidities did not undergo cardiac catheterization. The family elected to withdrawal care, and the patient expired.Conclusion N. cyriacigeorgica is more commonly identified in brain abscesses or skin infections, in the setting of immunosuppression. We report here on an unusual case of N. cyriacigeorgica endocarditis in a patient with COPD. Other than COPD the patient had no known risk factors for N. cyriacigeorgica, including chronic steroid use.Disclosures All authors: No reported disclosures.

Vasopressin versus norepinephrine in septic shock: a propensity score matched efficiency retrospective cohort study in the VASST coordinating center hospital

PurposeIt is not clear whether vasopressin versus norepinephrine changed mortality in clinical practice in the Vasopressin and Septic Shock Trial (VASST) coordinating center hospital after VASST was published. We tested the hypothesis that vasopressin changed mortality compared to norepinephrine using propensity matching of vasopressin to norepinephrine-treated patients in the VASST coordinating center hospital before (SPH1) and after (SPH2) VASST was published.MethodsVasopressin-treated patients were propensity score matched to norepinephrine-treated patients based on age, APACHE II, respiratory, renal, and hematologic dysfunction, mechanical ventilation status, medical/surgical status, infection site, and norepinephrine dose. The propensity score estimated the probability that a patient would have received vasopressin given baseline characteristics. For sensitivity analysis, we then excluded patients who had underlying severe congestive heart failure. The primary outcome was 28-day mortality.ResultsVasopressin- and norepinephrine-treated patients were similar after matching in SPH1 (pre-VASST); vasopressin-treated patients (n = 158) had a significantly higher mortality than norepinephrine-treated patients (n = 158) (60.8 vs. 46.2%, p = 0.009). In SPH2 after matching, the 28-day mortality rates were not significantly different; 31.2% and 26.9% in the vasopressin (n = 93) and norepinephrine (n = 93) groups, respectively (p = 0.518). The day 1 vasopressin dose in SPH1 vs. SPH2 was 0.036 units/min (SD 0.009) vs. 0.032 units/min (SD 0.005), p = 0.001, significantly lower in SPH2 after VASST.ConclusionsBefore VASST, vasopressin use was associated with increased mortality compared to norepinephrine in the VASST coordinating center hospital. After VASST, there was no difference in mortality between vasopressin- and norepinephrine-treated patients. This may be the first retrospective propensity-matched cohort study of a sepsis treatment in a center that had previously coordinated a large pivotal randomized controlled trial of that treatment and could be a useful approach for other sepsis therapies.Trial registrationRegistration: ISRCTN94845869

Impact of Event Severity on Hospital Rankings Based on Heart Failure Readmission Rates.

The Medicare Readmissions Reduction Program penalizes hospitals with higher than expected readmission rates after discharge for congestive heart failure (CHF). This exploratory study analyzed whether categorizing readmissions by event severity might have implications for the program. The authors used the 5% MedPAR (Medicare Provider and Analysis Review) data for 2008 to 2014 and ranked 1820 hospitals based on all readmissions, readmissions for CHF, short-stay CHF readmissions, and readmissions for severe CHF with evidence of cardiogenic shock. Ranking hospitals based on severe CHF readmissions changes their relative rank order significantly compared to counting all readmissions. If confirmed in the full Medicare data, the finding could inform the design of the Readmission Reduction Program.

Icodextrin-associated generalized exfoliative skin rash in a CAPD patient: a case-report

BackgroundIcodextrin is a starch-derived, water soluble glucose polymer, which is used as an alternative to glucose in order to enhance dialytic fluid removal in peritoneal dialysis patients. Although the safety and efficacy of icodextrin is well-established, its use in everyday clinical practice has been associated with the appearance of skin rashes and other related skin reactions.Case presentationHerein, we report the rare case of a 91-year-old woman with a history of severe congestive heart failure, who initiated continuous ambulatory peritoneal dialysis with icodextrin-based dialysate solutions and 15 days after the initial exposure to icodextrin developed a generalized maculopapular and exfoliative skin rash extending over the back, torso and extremities. Discontinuation of icodextrin and oral therapy with low-dose methyl-prednisolone with quick dose tapering improved the skin lesions within the following days.ConclusionsThis case report highlights that skin hypersensitivity is a rare icodextrin-related adverse event that should be suspected in patients manifesting skin reactions typically within a few days or weeks after the initial exposure.

Rates of Mortality in Lumbar Spine Surgery and Factors Associated With Its Occurrence Over a 10-Year Period: A Study of 803,949 Patients in the Nationwide Inpatient Sample.

The rate of mortality in surgical procedures involving the lumbar spine has historically been low, and as a result, there has been difficulty providing accurate quantitative mortality rates to patients in the preoperative planning phase. Awareness of these mortality rates is essential in reducing postoperative complications and improving outcomes. Additionally, mortality rates can be influenced by procedure type and patient profile, including demographics and comorbidities. The purpose of this study is to assess rates and risk factors associated with mortality in surgical procedures involving the lumbar spine using a large national database. The Nationwide Inpatient Sample database was reviewed from 2003 to 2012. A total of 803,949 patients age 18 years or older were identified by ICD-9CM procedure codes for spinal fusion or decompression of the lumbar spine. Mortality was stratified based on type of procedure (simple or complex fusion, decompression), patient demographics and comorbidities, and in-hospital complications. Binary logistic regression was used to identify the risk of death while controlling for comorbidities, race, sex, and procedure performed. Significance was defined as P < .05 differences relative to the overall cohort. Mortality for all patients requiring surgery of the lumbar spine was 0.13%. Mortality based on procedure type was 0.105% for simple fusions, 0.321% for complex fusions, and 0.081% for decompression only. Increased mortality was observed demographically in patients who were male (odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.51-2.03), black (OR: 1.40; CI: 1.10-1.79), ages 65-74 (OR: 1.46; CI: 1.25-1.70), and age 75+ (OR: 2.70; CI: 2.30-3.17). Comorbidities associated with the greatest increase in mortality were mild (OR: 10.04; CI: 7.76-13.01) and severe (OR: 26.47; CI: 16.03-43.70) liver disease and congestive heart failure (OR: 4.57; CI: 3.77-5.53). The complications with the highest mortality rates were shock (OR: 20.67; CI: 13.89-30.56) and pulmonary embolism (OR: 20.15; CI: 14.01-29.00). From 2003 to 2012, the overall mortality rate in 803,949 lumbar spine surgery patients was 0.13%. Risk factors that were significantly associated with increased mortality rates were male gender, black race, and ages 65-74 and 75+. Comorbidities associated with an increased mortality rate were mild and severe liver disease and congestive heart failure. Inpatient complications with the highest mortality rates were shock and pulmonary embolism. These findings can be helpful to surgeons providing preoperative counseling for patients considering elective lumbar procedures and for allocating resources to treat and prevent perioperative complications leading to mortality. 3.

Correlation between Serum Uric Acid level and Left Ventricular Ejection Fraction in Patients with Congestive Heart Failure

Background: One of the risk factors of congestive heart failure that still under investigations is hyperuricemia. It's still debatable whether it's an independent risk factor or it's just a consequence of other disorders associated with cardiovascular diseases like hypertension, diabetes and dyslipidemia. Objective: The aim of our study is to elucidate whether in patients with heart failure serum uric acid level correlated with left ventricular ejection fraction supporting the possibility that the detection of progressive hyperuricemia in these patients may be an indicator of deteriorating cardiac function. Methods: We conducted a prospective study that included 124 studied patients and 26 apparently healthy persons at Coronary care unit and Internal Medicine Department at Sohag University Hospitals. All studied populations were classified into four groups; v Group I patients being newly diagnosed heart failure, v Group II patients decompensated heart failure on regular treatment, v Group III patients decompensated heart failure but stopped their treatment from three months, v Group IV control group selected to our study healthy and age-matched subjects from 30 to 70 years old . Then we studied the association between left ventricular ejection fraction, the severity of congestive heart failure and the serum uric acid levels and the well-known conventional risk factor that include age, sex, BMI, positive family history, smoking, hypertension, diabetes and dyslipidemia then through logistic regression analysis we tried to identify the independent predictors of coronary artery diseases. Results: The mean finding in our study is the significant higher mean ± SD serum uric acid levels in patients with congestive heart failure (8.43±2.95) versus apparently healthy persons (5.55±1.48) with P value = .02. When we adjusted the serum uric acid with others significant factors in the univariate analysis which were age, gender and smoking, serum uric acid was an independent risk factor P value = .04. Another interesting finding is significant correlation between serum uric acid level and the severity of congestive heart failure P value<0.001,correlation coefficient=.35, where, that high rates of serum uric acid levels were recorded in patients with severe congestive heart failure. The gold finding is significant correlation between serum uric acid level and left ventricular ejection fraction P value<0.001, correlation coefficient=.35, where, that high rates of serum uric acid levels were recorded in patients with reduced ejection fraction. According to ROC analysis a uric acid level of 8.45 mg/dl was found to be the most appropriate cut-off point with the sensitivitv 62% and the specificity 75%. Conclusion: Higher serum uric acid levels are significantly correlated with the severity of congestive heart failure and left ventricular ejection fraction, as follows, the mean finding in our study is the significant higher mean ± SD serum uric acid levels in patients with congestive heart failure (8.43±2.95) versus apparently healthy persons (5.55±1.48) with P value = .02. When we adjusted the serum uric acid with others significant factors in the univariate analysis which were age, gender and smoking, serum uric acid was an independent risk factor P value = .04.