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IMPORTANCE: Intravascular microaxial left ventricular assist device (LVAD) compared with intra-aortic balloon pump (IABP) has been associated with increased risk of mortality and bleeding among patients with acute myocardial infarction (AMI) and cardiogenic shock (CS) undergoing percutaneous coronary intervention (PCI). However, evidence on the association of device therapy with a broader array of clinical outcomes, including data on long-term outcomes and cost, is limited. OBJECTIVE: To examine the association between intravascular LVAD or IABP use and clinical outcomes and cost in patients with AMI complicated by CS. DESIGN, SETTING, AND PARTICIPANTS: This retrospective propensity-matched cohort study used administrative claims data for commercially insured patients from 14 states across the US. Patients included in the analysis underwent PCI for AMI complicated by CS from January 1, 2015, to April 30, 2020. Data analysis was performed from April to November 2021. EXPOSURES: Use of either an intravascular LVAD or IABP. MAIN OUTCOMES AND MEASURES: The primary outcomes were mortality, stroke, severe bleeding, repeat revascularization, kidney replacement therapy (KRT), and total health care costs during the index admission. Clinical outcomes and cost were also assessed at 30 days and 1 year. RESULTS: Among 3077 patients undergoing PCI for AMI complicated by CS, the mean (SD) age was 65.2 (12.5) years, and 986 (32.0%) had cardiac arrest. Among 817 propensity-matched pairs, intravascular LVAD use was associated with significantly higher in-hospital (36.2% vs 25.8%; odds ratio [OR], 1.63; 95% CI, 1.32-2.02), 30-day (40.1% vs 28.3%; OR, 1.71; 95% CI, 1.37-2.13), and 1-year mortality (58.9% vs 45.0%; hazard ratio [HR], 1.44; 95% CI, 1.21-1.71) compared with IABP. At 30 days, intravascular LVAD use was associated with significantly higher bleeding (19.1% vs 14.5%; OR, 1.35; 95% CI, 1.04-1.76), KRT (12.2% vs 7.0%; OR, 1.88; 95% CI, 1.30-2.73), and mean cost (+$51 680; 95% CI, $31 488-$75 178). At 1 year, the association of intravascular LVAD use with bleeding (29.7% vs 24.3%; HR, 1.36; 95% CI, 1.05-1.75), KRT (18.1% vs 10.9%; HR, 1.95; 95% CI, 1.35-2.83), and mean cost (+$46 609; 95% CI, $22 126-$75 461) persisted. CONCLUSIONS AND RELEVANCE: In this propensity-matched analysis of patients undergoing PCI for AMI complicated by CS, intravascular LVAD use was associated with increased short-term and 1-year risk of mortality, bleeding, KRT, and cost compared with IABP. There is an urgent need for additional evidence surrounding the optimal management of patients with AMI complicated by CS.

Introduction:Recent reports have demonstrated an association between Impella compared to IABP use with increased risk for short-term clinical outcomes, including stroke, bleeding, and mortality among patients with AMI and cardiogenic shock (CS) undergoing PCI. Data on long-term outcomes and cost are limited.Methods:This retrospective study analyzed administrative claims data from a large commercially insured population from 14 states. Patients undergoing PCI for AMI complicated by CS from 7/1/14 to 4/30/20 were included. Those who had both devices or other mechanical circulatory support were excluded. We performed a 1:1 propensity score-matched analysis in patients receiving an Impella versus IABP. The primary outcome was mortality, and secondary outcomes were stroke, bleeding, repeat revascularization, incident dialysis, and cost at 30-days and 1-year follow-up.Results:Of the 3,347 patients undergoing PCI for AMI complicated by CS, the mean (SD) age was 65.4 (12.5) years, 71% were men, and 32% had a cardiac arrest. Among 820 propensity-matched pairs, at 30-days use of the Impella was associated with a significantly higher mortality (Odds ratio [OR] 1.91; 95% Confidence interval [CI]: 1.54-2.37, P<0.001), incident dialysis (OR 1.55; 95% CI:1.10-2.18, P=0.01), and mean difference in cost ($40,869, Interquartile range: $20,829-$64,200, P<0.001) compared to IABP (Figure). Incident stroke, bleeding, and repeat revascularization were not different between groups (P>0.05). At 1-year, mortality (Hazard ratio [HR] 1.58, 95% CI: 1.33-1.87, P<0.001) and incident dialysis (HR 1.70, 95% CI: 1.25-2.30, P=0.001) remained higher in Impella.Conclusions:In patients undergoing PCI for AMI complicated by CS, use of Impella was associated with an increased 30-day and 1-year mortality, dialysis, and cost compared to IABP. There is need for additional evidence surrounding the optimal management of patients with AMI and CS undergoing PCI.

OBJECTIVE: To assess the precipitating factors, clinical course, and treatment of 11 cases of severe intraocular infections of radionecrosis after pterygium excision in an attempt to minimize the devastating ocular sequelae. DESIGN AND SETTING: From the database of cases of radionecrosis at Royal Perth (Australia) Hospital and Lions Eye Institute, Perth, we identified 11 cases of severe intraocular infection complicating radionecrosis. We reviewed the case notes and the available radiotherapy records (n=8). PATIENTS: Eleven patients admitted during an 8-year period. RESULTS: Mean (±SD) dose of radiotherapy was 22.7±1.0 Gy and mean latency period, 14.45±2.5 years. Among the six proven bacterial cases, Pseudomonas was identified in four, Staphylococcus aureus in one, and Streptococcus pneumoniae was involved in one bilateral case. Among the four fungal cases, Petriellidium boydii was indicated in two, and Fusarium and Scedosporium inflatum in one each. The condition may remain undiagnosed for some time and mimic a posterior scleritis, serous retinal detachment, or pseudotumor. INTERVENTIONS: Early débridement and culture; close microbiological assistance; and systemic antimicrobials for a prolonged period. Perforation or incipient perforation necessitated penetrating keratoplasties in seven patients and repeated keratoplasties in three. MAIN OUTCOME MEASURES: The use of radiotherapy following pterygium excision should be limited and only low doses used. Ulcer beds and calcific plaques at sites of radionecrosis should not be directly covered without first performing adequate sterilization. Removal of plaques may precipitate sepsis; ulcer beds and plaques harbor infective agents. CONCLUSION: Severe radionecrosis may expose a patient to a lifelong risk of intraocular sepsis and profound visual morbidity. Conjunctival autografting is a safer method to reduce recurrence rate after pterygium excision.

The angiogenic agent erucamide (cis-13-docosenamide), incorporated into a polymeric biomaterial (Elvax® 40P, a copolymer of ethylene and vinyl acetate), was used to determine whether angiogenesis can be increased in the regenerating skeletal muscle, and whether the enhanced revascularization improves the new muscle formation. The angiogenic nature of this lipid was confirmed in a rat cornea-micropocket assay, prior to insertion of small strips of the polymer containing either 3 μg, 30 μg, 300 μg erucamide or only polymer as a control into the mid-region of crush-injured tibialis anterior (TA) muscles of forty-five adult male BALB/c mice. All TA muscles were sampled ten days after injury and analyzed morphometrically. Statistical analyses of the mean blood vessel area density in lesions from twelve perfused TA muscles (three from each of the erucamide-treated or control group), revealed a dose-dependent angiogenic effect of erucamide: a dosage of 3 μg increased mean blood vessel area density to 5.1% compared to 2.0% in controls, due to numerous large caliber, thin-walled vessels, whereas the mean vessel area density in both the 30-μg (3.5%) and 300-μg (1.5%) doses were similar to controls. However, at all three doses tested, erucamide did not significantly alter the degree of new muscle formation, connective tissue deposition, or removal of necrotic debris.

Is gardening a health hazard?Legionella longbeachae, a potential cause of pneumonia, has been found in Australian potting media. However, further research is needed to determine its clinical relevance in this situation. This did not stop the popular media linking two deaths fromLegionella infection in Queensland to potting mix exposure.

Although socioeconomically disadvantaged children have an increased risk of asthma, the association between early-childhood antibiotics and the incidence of asthma among such children has had limited study.

IN REPLY We are grateful to Dr Alfonso for his comments. Reynolds and Alfonso1 highlight the importance of cryotherapy, lamellar or penetrating corneoscleral grafts, in addition to antimicrobial treatment in infectious keratoscleritis.Surgery did indeed play a major role in our patients.2 In 11 patients, seven had full-thickness penetrating keratoplasties either for incipient or frank perforation or to control overwhelming infection. A graft would have been performed in another patient had he not declined. Three patients required further grafts since infection failed to be eradicated. These were three fungal cases in which an initial graft was necessary for frank perforation but before adequate antifungal therapy. The chronicity of these fungal cases was particularly troublesome, and as we point out,2 viable fungal elements were still present in tissue from two patients despite grafting and 3 and 6 months antifungal treatment, respectively.We received communication from several ophthalmologists with