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Critical care cardiology refers to the practice focus of and subspecialty training for the comprehensive management of life-threatening cardiovascular diseases and comorbid conditions that require advanced critical care in an intensive care unit. The development of coronary care units is often credited for a dramatic decline in mortality rates after acute myocardial infarction throughout the 1960s. As the underlying patient population became progressively sicker, changes in organizational structure, staffing, care delivery, and training paradigms lagged. The coronary care unit gradually evolved from a focus on rapid resuscitation from ventricular arrhythmias in acute myocardial infarction into a comprehensive cardiac intensive care unit designed to care for the sickest patients with cardiovascular disease. Over the past decade, the cardiac intensive care unit has continued to transform with an aging population, increased clinical acuity, burgeoning cardiac and noncardiac comorbidities, technologic advances in cardiovascular interventions, and increased use of temporary mechanical circulatory support devices. Herein, we provide an update and contemporary expert perspective on the organizational structure, staffing, and care delivery in the cardiac intensive care unit; examine the challenges and opportunities present in the education and training of the next generation of physicians for critical care cardiology; and explore quality improvement initiatives and scientific investigation, including multicenter registry initiatives and randomized clinical trials, that may change clinical practice, care delivery, and the research landscape in this rapidly evolving discipline.

There are limited data on volume-outcome relationships in acute myocardial infarction (AMI) with cardiogenic shock (CS).

Purpose: Studies on outcomes related to endovascular treatment (EVT) in advanced stages of chronic kidney disease (CKD) and end-stage renal disease (ESRD) among hospitalizations with acute limb ischemia (ALI) are limited.Methods: The Nationwide Inpatient Sample was quarried from October 2015 to December 2017 to identify the hospitalizations with ALI and undergoing EVT. The study population was subdivided into 3 groups based on their CKD stages: group 1 (No CKD, stage I, stage II), group 2 (CKD stage III, stage IV), and group 3 (CKD stage V and ESRD). The primary outcome was all-cause in-hospital mortality.Results: A total of 51 995 hospitalizations with ALI undergoing EVT were identified. The in-hospital mortality was significantly higher in group 2 (OR = 1.17; 95% CI 1.04 – 1.32, p=0.009) and group 3 (OR = 3.18; 95% CI 2.74–3.69, p<0.0001) compared with group 1. Odds of minor amputation, vascular complication, atherectomy, and blood transfusion were higher among groups 2 and 3 compared with group 1. Group 2 had higher odds of access site hemorrhage compared with groups 1 and 3, whereas group 3 had higher odds of major amputation, postprocedural infection, and postoperative hemorrhage compared with groups 1 and 2. Besides, groups 2 and 3 had lower odds of discharge to home compared with group 1. Finally, the length of hospital stay and cost of care was significantly higher with the advancing CKD stages.Conclusion: Advanced CKD stages and ESRD are associated with higher mortality, worse in-hospital outcomes and higher resource utilization among ALI hospitalizations undergoing EVT.Clinical Impact Current guidelines are not clear for the optimum first line treatment of acute limb ischemia, especially in patients with advanced kidney disease as compared to normal/mild kidney disease patients. We found that advanced kidney disease is a significant risk factor for worse in-hospital morbidity and mortality. Furthermore, patients with acute limb ischemia and advanced kidney disease is associated with significantly higher resource utilization as compared to patients with normal/mild kidney disease. This study suggests shared decision making between treating physician and patients when considering endovascular therapy for the treatment of acute limb ischemia in patients with advanced kidney disease.

Postoperative atrial fibrillation (POAF) is associated with increased morbidity and mortality. Epicardial injection of botulinum toxin may suppress POAF.

For high-risk patients with aortic arch pathology, hybrid aortic arch repair with simultaneous or staged thoracic endovascular repair of the descending aorta may be a viable alternative to open repair. However, data on postintervention aortic remodeling remain limited. We report the short-term outcomes of remodeling of the thoracoabdominal aorta after hybrid arch repair + thoracic endovascular repair.

Studies reporting cardiogenic shock (CS) outcomes in women are scarce.

There are limited data on in-hospital cardiac arrest (IHCA) complicating non-ST-segment-elevation myocardial infarction (NSTEMI) based on management strategy.

AbstractA 36-year-old pregnant woman with a prior history of depression and recent gunshot wounds presented with sudden deterioration in her mental status. Clinical examination revealed psychosis, hallucinations, and lack of orientation, with an otherwise normal neurological and cardiorespiratory examination. Computed tomographic scan of her head was normal, and she was diagnosed with acute psychosis and excited delirium. She did not respond to supraphysiologic dosages of antipsychotic therapy and needed physical restraints for combativeness and agitation. Her cerebrospinal fluid analysis was negative for an infectious etiology, but was positive for anti-N-methyl-D-aspartate receptor encephalitis antibodies. Abdominal imaging revealed a right-sided ovarian cyst. Subsequently she underwent right-sided oophorectomy. Postoperatively the patient continued to have intermittent episodes of agitation requiring antipsychotic medications. Later, she was safely transitioned to home care with family support.

Sepsis is a multisystem disease process, which constitutes a significant public health challenge and is associated with high morbidity and mortality. Among other systems, sepsis is known to affect the cardiovascular system, which may manifest as myocardial injury, arrhythmias, refractory shock, and/or septic cardiomyopathy. Septic cardiomyopathy is defined as the reversible systolic and/or diastolic dysfunction of one or both ventricles. Left ventricle dysfunction has been extensively studied in the past, and its prognostic role in patients with sepsis is well documented. However, there is relatively scarce literature on right ventricle (RV) dysfunction and its role. Given the importance of timely detection of septic cardiomyopathy and its bearing on prognosis of patients, the role of RV dysfunction has come into renewed focus. Hence, through this review, we sought to describe the pathophysiology of RV dysfunction in sepsis and what have we learnt so far about its multifactorial nature. We also elucidate the roles of different biomarkers for its detection and prognosis, along with appropriate management of such patient population.

A recently published randomized control trial showed different results with suture-based vascular closure device (VCD) than plug-based VCD in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR). The learning curve for MANTA device is steep, while the learning curve for suture based VCD is shallow as the devices are quite different. In this meta-analysis, we have compared suture-based (ProGlide and Prostar XL) vs plug-based VCDs (MANTA).

AbstractIntroductionRates of injection-drug use associated infective endocarditis (IDU-IE) are rising, and most patients with IDU-IE do not receive addiction care during hospitalization. We sought to characterize cardiac surgeons’ practices and attitudes toward patients with IDU-IE due to their integral role treating them.MethodsThis is a survey of 201 cardiac surgeons in the U.S who were asked about the addiction care they engage for patients with IDU-IE along with questions pertaining to stigma against people who use drugs (PWUD). Descriptive statistics and multivariable logistic regression were used to identify patterns in surgeons’ practices and determine associations between attitudes toward substance use disorder (SUD) and beliefs about medications for opioid use disorder (MOUD).ResultsA minority of surgeons have access to specialty addiction services (35%) in their hospital, but when available 93% consult them for patients with IDU-IE. A quarter of surgeons reported thinking that SUD is a choice and do not believe MOUD have a role in reducing IDU-IE recurrence. Conversely, 69% of surgeons agreed with the disease model of addiction and were four times more likely to believe that MOUD has a role in reducing IDU-IE recurrence (aOR 4.09, 95% CI 1.8–9.27, p = 0.001).ConclusionAccess to addiction specialists is limited in most hospital settings, but when available, most surgeons report consulting them and supporting MOUD. However, a significant proportion of surgeons hold non-evidence-based attitudes toward SUD and PWUD. This suggests that lack of education and stigma may affect the care of patients with IDU-IE, highlighting the need for education about, and destigmatization of addiction within health systems.

Sex differences have diversely affected cardiac diseases. Little is known whether these differences impact outcomes of catheter ablation of ventricular tachycardia (VT).

Cardiogenic shock (CS) and cardiac arrest (CA) are the most life-threatening complications of acute myocardial infarction. Although there is a significant overlap in the pathophysiology with approximately half the patients with CS experiencing a CA and approximately two-thirds of patients with CA developing CS, comprehensive guideline recommendations for management of CA + CS are lacking. This paper summarizes the current evidence on the incidence, pathophysiology, and short- and long-term outcomes of patients with acute myocardial infarction complicated by concomitant CA + CS. We discuss the hemodynamic factors and unique challenges that need to be accounted for while developing treatment strategies for these patients. A summary of expert-based step-by-step recommendations to the approach and treatment of these patients, both in the field before admission and in-hospital management, are presented.

Introduction Rates of injection-drug use associated infective endocarditis (IDU-IE) are rising, and most patients with IDU-IE do not receive addiction care during hospitalization. We sought to characterize cardiac surgeons’ practices and attitudes toward patients with IDU-IE due to their integral role treating them.Methods This is a survey of 201 cardiac surgeons in the U.S who were asked about the addiction care they engage for patients with IDU-IE along with questions pertaining to stigma against people who use drugs (PWUD). Descriptive statistics and multivariable logistic regression were used to identify patterns in surgeons’ practices and determine associations between attitudes toward substance use disorder (SUD) and beliefs about medications for opioid use disorder (MOUD).Results A minority of surgeons have access to specialty addiction services (35%) in their hospital, but when available 93% consult them for patients with IDU-IE. A quarter of surgeons reported thinking that SUD is a choice and do not believe MOUD have a role in reducing IDU-IE recurrence. Conversely, 69% of surgeons agreed with the disease model of addiction and were four times more likely to believe that MOUD has a role in reducing IDU-IE recurrence (aOR 4.09, 95% CI 1.8–9.27, p= 0.001).Conclusion Access to addiction specialists is limited in most hospital settings, but when available, most surgeons report consulting them and supporting MOUD. However, a significant proportion of surgeons hold non-evidence-based attitudes toward SUD and PWUD. This suggests that lack of education and stigma may affect the care of patients with IDU-IE, highlighting the need for education about, and destigmatization of addiction within health systems.

Restoration of lymphatic drainage across the bronchial anastomosis after lung transplantation requires several weeks. As donor antigen and antigen presenting cell trafficking via lymphatics into graft-draining lymph nodes is an important component of the alloresponse, alternative pathways must exist that account for rapid rejection after pulmonary transplantation. Here, we describe a novel allorecognition pathway mediated through donor extracellular vesicle (EV) trafficking to mediastinal lymph nodes via the pleural space. Pleural fluid collected early after lung transplantation in rats and humans contains donor-specific EVs. In a fully MHC mismatched rat model of lung transplantation, we demonstrate EVs carrying donor antigen preferentially accumulate in mediastinal lymph nodes and colocalize with MHC II expressing cells within 4 h of engraftment. Injection of allogeneic EVs into pleural space of syngeneic lung transplant recipients confirmed their selective trafficking to mediastinal lymph nodes and resulted in activation of T cells in mediastinal, but not peripheral lymph nodes. Thus, we have uncovered an alternative pathway of donor antigen trafficking where pulmonary EVs released into the pleural space traffic to locoregional lymph nodes via pleural lymphatics. This pathway obviates the need for restoration of lymphatics across the bronchial anastomosis for trafficking of donor antigen to draining lymph nodes.

Injection drug use-related infective endocarditis (IDU-IE) is a complex disease with increasing incidence. Although universally recognized that IDU-IE requires antibiotics and often requires cardiac surgery, most patients do not receive addiction treatment which substantially increases their risk of recurrent IDU-IE from drug use recurrence. Accordingly, a multidisciplinary approach integrating addiction treatment may benefit patients with IDU-IE. We describe the format and structure of a team called the Multidisciplinary Endocarditis Evaluation Team (MEET) whose purpose is to optimize, formalize, and standardize the care of patients with IDUIE. Given the complexity of IDU-IE, MEET is comprised of addiction medicine, anesthesia, cardiology, cardiac surgery, infectious disease, case management, nursing, and social work. MEET strived to be acceptable to patients and families to support their preferences and values. MEET focused treatment of IDU-IE on the patient’s medical and surgical needs with attention to the patients’ underlying substance use disorder as an essential component.

Restoration of lymphatic drainage across the bronchial anastomosis after lung transplantation requires several weeks. As donor antigen and antigen presenting cell trafficking via lymphatics into graft‐draining lymph nodes is an important component of the alloresponse, alternative pathways must exist that account for rapid rejection after pulmonary transplantation. Here, we describe a novel allorecognition pathway mediated through donor extracellular vesicle (EV) trafficking to mediastinal lymph nodes via the pleural space. Pleural fluid collected early after lung transplantation in rats and humans contains donor‐specific EVs. In a fully MHC mismatched rat model of lung transplantation, we demonstrate EVs carrying donor antigen preferentially accumulate in mediastinal lymph nodes and colocalize with MHC II expressing cells within 4 h of engraftment. Injection of allogeneic EVs into pleural space of syngeneic lung transplant recipients confirmed their selective trafficking to mediastinal lymph nodes and resulted in activation of T cells in mediastinal, but not peripheral lymph nodes. Thus, we have uncovered an alternative pathway of donor antigen trafficking where pulmonary EVs released into the pleural space traffic to locoregional lymph nodes via pleural lymphatics. This pathway obviates the need for restoration of lymphatics across the bronchial anastomosis for trafficking of donor antigen to draining lymph nodes. Following lung transplantation, donor‐specific extracellular vesicles traffic to locoregional mediastinal lymph nodes via the pleural space where they co‐localize with MHC‐II expressing cells and promote T cell responses via the semi‐direct or indirect pathway, obviating the need for intact afferent lymphatics for donor antigen trafficking across the bronchial anastomosis.

Supplemental Digital Content is available in the text.Refractory ventricular tachycardia (VT) and electrical storm are frequently associated with hemodynamic compromise requiring mechanical support. This study sought to review the current literature on the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for hemodynamic support during VT ablation. This was a systematic review of all published literature from 2000 to 2019 evaluating patients with VT undergoing ablation with VA-ECMO support. Studies that reported mortality, safety, and efficacy outcomes in adult (>18 years) patients were included. The primary outcome was short-term mortality (intensive care unit stay, hospital stay, or ≤30 days). The literature search identified 4,802 citations during the study period, of which seven studies comprising 867 patients met the inclusion criteria. Periprocedural VA-ECMO was used in 129 (15%) patients and all were placed peripherally. Average inducible VTs were 2–3 per procedure and ablation time varied between 34 mins and 4.7 hours. Median ages were between 61 and 68 years with 93% males. Median duration of VA-ECMO varied between 140 minutes and 6 days. Short-term mortality was 15% (19 patients), with the most frequent causes being refractory VT, cardiac arrest, and acute heart failure. All-cause mortality at the longest follow-up was 25%. Major bleeding, vascular/access complications, limb ischemia, stroke, and acute kidney injury were reported with varying frequency of 1–6%. In conclusion, VA-ECMO is used infrequently for hemodynamic support for VT ablation. Further data on patient selection, procedural optimization, and clinical outcomes are needed to evaluate the efficacy of this strategy.

To evaluate outcomes by sex in older adults with cardiogenic shock complicating acute myocardial infarction (AMI-CS).

Supplemental Digital Content is available in the text.There are contrasting data on concomitant Impella device in cardiogenic shock patients treated with venoarterial extracorporeal membrane oxygenation (VA ECMO) (ECPELLA). This study sought to compare early mortality in patients with cardiogenic shock treated with ECPELLA in comparison to VA ECMO alone. We reviewed the published literature from 2000 to 2018 for randomized, cohort, case-control, and case series studies evaluating adult patients requiring VA ECMO for cardiogenic shock. Five retrospective observational studies, representing 425 patients, were included. Venoarterial extracorporeal membrane oxygenation with concomitant Impella strategy was used in 27% of the patients. Median age across studies varied between 51 and 63 years with 59–88% patients being male. Use of ECPELLA was associated with higher weaning from VA ECMO and bridging to permanent ventricular assist device or cardiac transplant in three and four studies, respectively. The studies showed moderate heterogeneity with possible publication bias. The two studies that accounted for differences in baseline characteristics between treatment groups reported lower 30 day mortality with ECPELLA versusVA ECMO. The remaining three studies did not adjust for potential confounding and were at high risk for selection bias. In conclusion, ECPELLA is being increasingly used as a strategy in patients with cardiogenic shock. Additional large, high-quality studies are needed to evaluate clinical outcomes with ECPELLA.

To evaluate the outcomes, safety, and efficacy of dual antiplatelet therapy (DAPT) with newer P2Y12inhibitors compared with clopidogrel in patients with acute myocardial infarction (AMI) complicated by cardiac arrest (CA) or cardiogenic shock (CS).

Plant diseases are a vital risk to crop yield and early detection of plant diseases remains a complex task for the farmers due to the similar appearance in color, shape, and texture. In this work, authors have proposed an automatic plant disease detection technique using deep ensemble neural networks (DENN). Transfer learning is employed to fine-tune the pre-trained models. Data augmentation techniques include image enhancement, rotation, scaling, and translation are applied to overcome overfitting. This paper presents a detailed taxonomy on the performance of different pre-trained neural networks and presents the performance of a weighted ensemble of those models relevant to plant leaf disease detection. Further, the performance of the proposed work is evaluated on publicly available plant village dataset, which comprises of 38 classes collected from 14 crops. The performance of DENN outperform state-of-the-art pre-trained models such as ResNet 50 & 101, InceptionV3, DenseNet 121 & 201, MobileNetV3, and NasNet. Performance evaluation of the proposed model demonstrates that effective in categorizing various types of plant diseases that comparatively outperform pre-trained models.

ABSTRACTBackgroundWe aimed to determine the optimal range of discharge serum magnesium in hospitalized patients by evaluating one-year mortality risk according to discharge serum magnesium.MethodsThis was a single-center cohort study of hospitalized adult patients who survived until hospital discharge. We classified discharge serum magnesium, defined as the last serum magnesium within 48 hours of hospital discharge, into ≤1.6, 1.7–1.8, 1.9–2.0, 2.1–2.2, and ≥2.3 mg/dL. We assessed one-year mortality risk after hospital discharge based on discharge serum magnesium, using discharge magnesium of 2.1–2.2 mg/dL as the reference group.ResultsOf 39,193 eligible patients, 8%, 23%, 34%, 23%, and 12% had a serum magnesium of ≤1.6, 1.7–1.8, 1.9–2.0, 2.1–2.2, and ≥2.3 mg/dL, respectively, at hospital discharge. After the adjustment for several confounders, discharge serum magnesium of ≤1.6, 1.7–1.8, and ≥2.3 mg/dL were associated with higher one-year mortality with hazard ratio of 1.35 (95% CI 1.21–1.50), 1.14 (95% CI 1.06–1.24), and 1.17 (95% CI 1.07–1.28), respectively, compared to discharge serum magnesium of 2.1–2.2 mg/dL. There was no significant difference in one-year mortality between patients with discharge serum magnesium of 1.9–2.0 and 2.1–2.2 mg/dL.ConclusionThe optimal range of serum magnesium at discharge was 1.9–2.2 mg/dL. Both hypomagnesemia and hypermagnesemia at discharge were associated with higher one-year mortality.

BackgroundWe aimed to report the incidence of hospital-acquired hypophosphataemia and hyperphosphataemia along with their associated in-hospital mortality.MethodsWe included 15 869 adult patients hospitalised at a tertiary medical referral centre from January 2009 to December 2013, who had normal serum phosphate levels at admission and at least two serum phosphate measurements during their hospitalisation. The normal range of serum phosphate was defined as 2.5–4.2 mg/dL. In-hospital serum phosphate levels were categorised based on the occurrence of hospital-acquired hypophosphataemia and hyperphosphataemia. We analysed the association of hospital-acquired hypophosphataemia and hyperphosphataemia with in-hospital mortality using multivariable logistic regression.ResultsFifty-three per cent (n=8464) of the patients developed new serum phosphate derangements during their hospitalisation. The incidence of hospital-acquired hypophosphataemia and hyperphosphataemia was 35% and 27%, respectively. Hospital-acquired hypophosphataemia and hyperphosphataemia were associated with odds ratio (OR) of 1.56 and 2.60 for in-hospital mortality, respectively (p value<0.001 for both). Compared with patients with persistently normal in-hospital phosphate levels, patients with hospital-acquired hypophosphataemia only (OR 1.64), hospital-acquired hyperphosphataemia only (OR 2.74) and both hospital-acquired hypophosphataemia and hyperphosphataemia (ie, phosphate fluctuations; OR 4.00) were significantly associated with increased in-hospital mortality (all p values <0.001).ConclusionHospital-acquired serum phosphate derangements affect approximately half of the hospitalised patients and are associated with increased in-hospital mortality rate.

The established benefits of cooling along with development of sophisticated methods to safely and precisely induce, maintain, monitor, and reverse hypothermia have led to the development of targeted temperature management (TTM). Early trials in human subjects showed that hypothermia conferred better neurological outcomes when compared to normothermia among survivors of cardiac arrest, leading to guidelines recommending targeted hypothermia in this patient population. Multiple studies have sought to explore and compare the benefit of hypothermia in various subgroups of patients, such as survivors of out-of-hospital cardiac arrest versus in-hospital cardiac arrest, and survivors of an initial shockable versus non-shockable rhythm. Larger and more recent trials have shown no statistically significant difference in neurological outcomes between patients with targeted hypothermia and targeted normothermia; further, aggressive cooling is associated with a higher incidence of multiple systemic complications. Based on this data, temporal trends have leaned towards using a lenient temperature target in more recent times. Current guidelines recommend selecting and maintaining a constant target temperature between 32 and 36 °C for those patients in whom TTM is used (strong recommendation, moderate-quality evidence), as soon as possible after return of spontaneous circulation is achieved and airway, breathing (including mechanical ventilation), and circulation are stabilized. The comparative benefit of lower (32–34 °C) versus higher (36 °C) temperatures remains unknown, and further research may help elucidate this. Any survivor of cardiac arrest who is comatose (defined as unarousable unresponsiveness to external stimuli) should be considered as a candidate for TTM regardless of the initial presenting rhythm, and the decision to opt for targeted hypothermia versus targeted normothermia should be made on a case-by-case basis.

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Cardiogenic shock (CS) is associated with hemodynamic compromise and end-organ hypoperfusion due to a primary cardiac etiology. In addition to vasoactive medications, percutaneous mechanical circulatory support (MCS) devices offer the ability to support the hemodynamics and prevent acute organ failure. Despite the wide array of available MCS devices for CS, there are limited data on the complications from these devices. In this review, we seek to summarize the complications of MCS devices in the contemporary era. Using a systems-based approach, this review covers domains of hematological, neurological, vascular, infectious, mechanical, and miscellaneous complications. These data are intended to provide a balanced narrative and aid in risk–benefit decision-making in this acutely ill population.

ABSTRACTObjective: Acute kidney injury (AKI) is associated with higher morbidity and mortality in cardiac arrest (CA). There are limited contemporary data on the incidence and outcomes of AKI in CA.Methods: We comprehensively searched the databases of MEDLINE, EMBASE, PUBMED, and the Cochrane from inception to November 2020. Observational studies that reported the incidence of AKI in CA survivors were included. Data from each study were combined using the random effects to calculate pooled incidence and risk ratios with 95% confidence intervals (CIs). The primary outcome was short-term mortality and secondary outcomes included long-term mortality, incidence of AKI, and use of renal replacement therapy (RRT). Subgroup and meta-regression analyses were performed to explore heterogeneity.Main results: A total of 25 observational studies comprising 8,165 patients were included. The incidence of AKI in CA survivors was 40.3% (range 32.9–47.8%). In stage 3 AKI, one-fourth of patients required RRT. AKI was associated with an increased risk of both short-term (OR 2.27 [95% CI 1.74–2.96]; p< 0.001) and long-term mortality (OR 1.51 [95% CI 1.93–3.25]; p< 0.001). Meta-regression and subgroup analyses did not suggest any effect of hypothermia on incidence of AKI.Conclusion: AKI complicates the care of 40% of CA survivors and is associated with significantly increased short- and long-term mortality.

ABSTRACTBackgroundThis study aimed to 1) determine the incidence of acute kidney injury (AKI), 2) identify risk factors for AKI, and 3) evaluate the impact of AKI on in-hospital outcomes in hospitalized patients for methanol intoxication.MethodsWe searched the National Inpatient Sample Database for hospitalized patients from 2003 to 2014 with a primary diagnosis of methanol intoxication. We excluded patients with end-stage kidney disease. We identified the AKI using a discharge diagnosis code. We compared clinical characteristics, in-hospital treatment, outcomes, and resource use between AKI and non-AKI patients.ResultsA total of 603 hospital admissions for methanol intoxication were analyzed. AKI developed in 135 (22.4%) admissions. Anemia (OR 3.43 p < 0.001), hypertension (OR 1.86; p = 0.02), volume depletion (OR 3.46; p = 0.001), sepsis (OR 6.91; p < 0.001), rhabdomyolysis (OR 6.25; p = 0.003), and acute pancreatitis (OR 5.30; p = 0.004) were independent risk factors for AKI development. AKI was significantly associated with increased risk of in-hospital mortality and organ failure. AKI patients needed more mechanical ventilation, and extracorporeal therapy, had longer length of hospital stay, and higher hospitalization costs.ConclusionOver one-fifth of methanol intoxication patients developed AKI during hospitalization. AKI was associated with higher morbidity, mortality, and resource utilization.

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Background:Currently, there are no guidelines regarding the optimal daily timing of inpatient warfarin administration. Objective:The purpose of this study was to determine whether dosing warfarin in the morning will have a significant impact on therapeutic international normalized ratio (INR) achievement compared with evening administration in mechanical mitral valve patients initiated on warfarin following cardiac surgery. Methods:This was a single-center, pre- and post-retrospective cohort conducted between 2014 and 2018. One-hundred fifty-four adult patients who underwent a mechanical mitral valve replacement or alternative cardiac surgery with a history of a mechanical mitral valve were enrolled. The primary outcome was achievement of therapeutic INR at any time point after initiation of warfarin. Pre-intervention administration timing was 6 pmand post-intervention timing was 10 am. Results:Baseline characteristics including age, sex, and race were similar between the 2 groups (P= NS for each characteristic). Therapeutic INR achievement was significantly improved at all time points following 10 amwarfarin administration compared with 6 pm(hazard ratio = 1.69; P= .005). Mean time-to-therapeutic INR was 7.37 days in the post-intervention group and 8.39 days in the pre-intervention group (P= .073). There were no significant differences in INR >4, bleeding, or thrombotic complications between groups. Conclusion and Relevance:This retrospective analysis suggests that there may be a postoperative benefit in therapeutic INR achievement in mechanical valve patients when dosing warfarin in the morning compared with evening administration. Large-scale studies should be conducted to further elucidate the potential benefit across more heterogeneous populations.

Background: A sound understanding of pelvic anatomy is essential for training in obstetrics and gynaecology (OBGYN) and for practising in the field post-qualification. There is a growing concern that surgery residents have an inadequate knowledge of anatomy and little confidence in their approach to the subject.Objective: This study aims to explain the use of an anatomy workshop to deliver a unique and self-designed innovative instruction method that employs cutting-edge resources to enhance OBGYN residents’ comprehension of clinical anatomy and to discuss why this approach works.Methodology: The workshop emphasised the clinical and surgical anatomy of the female pelvis using 3-D virtual dissections, relevant plastinated specimens and also bony pelvic models that had been developed in house. Anatomists and OBGYN consultants facilitated the workshop. The students’ knowledge of anatomy and their perceptions of the subject were evaluated by pre- and post-tests and a five-point Likert scale, respectively. A mixed methods analysis was applied.Results: Of the 42 participants, 26 (61.9%) completed both the pre- and post-test. The overall difference (mean percentage) between the pre- and post-test performance was 25.41%. There was a significant difference in the residents’ knowledge of anatomy between the pre- and post-workshop (p<0.05). Participants (n=10) provided positive feedback on the workshop content, teaching tools, learning activities and educators. They recommended that the workshop should be held at least once a year (70%), and particularly during the first year of residency (90%).Conclusion: The active learning workshop enabled by multidisciplinary teaching and the innovative tools employed resulted in improved outcomes in knowledge of anatomy, confidence and learning satisfaction. Reintroduction of anatomy concepts during OBGYN residency training is needed to improve surgical training and patient care.

There is a lack of research comparing procedural outcomes of surgical ablation (SA) and catheter ablation (CA) among patients with heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF). The main objective was to compare the short‐term procedural outcomes of SA and CA in patients with HFrEF. We used the national inpatient sample to identify hospitalizations over 18 years with HFrEF hospitalization and AF, and undergoing SA and CA from 2016 to 2017. Furthermore, the clinical outcomes of SA vs CA in AF stratified as nonparoxysmal and paroxysmal were analyzed. A total of 1,770 HFrEF hospitalizations with AF who underwent SA and 1,620 HFrEF hospitalizations with AF who underwent CA were included in the analysis. Hospitalizations with CA had higher baseline comorbidities. The in‐hospital mortality among HFrEF with AF undergoing SA as compared with CA was similar (2.8% vs 1.9%, respectively, adjusted P‐value 0.09). Hospitalizations with SA had a significantly longer length of hospital stay, a higher percentage of postprocedural, and cardiac complications. In HFrEF hospitalizations with nonparoxysmal AF, SA as compared with CA was associated with a higher percentage of in‐hospital mortality (2.4% vs 1%, adjusted P‐value <.05), a longer length of stay, a higher cost of treatment, and a higher percentage of cardiac complications. CA is associated with lower in‐hospital adverse procedural outcomes as compared with SA among HFrEF hospitalizations with AF. Further research with freedom from AF as one of the outcome is needed between two groups for HFrEF. Catheter ablation is associated with lower in‐hospital procedural outcomes as compared to surgical ablation among heart failure with reduced ejection fraction hospitalizations. The recurrence of atrial fibrillation, long‐term safety, efficacy, and quality of life associated with surgical and catheter ablation remain to be determined in this population.

This study aimed to assess inpatient prevalence, characteristics, outcomes, and resource utilization of hospitalization for methanol intoxication in the United States.

ABSTRACTBackgroundGoodpasture’s syndrome is a rare and life-threatening autoimmune disease. While Goodpasture’s syndrome is well described in Caucasian and Asian populations, its prevalence and outcomes among African American and Hispanic populations are unclear. We conducted this study to assess the impacts of race on hospital outcomes among patients with Goodpasture’s syndrome.MethodsThe National Inpatient Sample database was used to identify hospitalized patients with a principal diagnosis of Goodpasture’s syndrome from 2003 to 2014. Goodpasture’s syndrome patients were grouped based on their race. The differences in-hospital supportive care for organ failure and outcomes between Caucasian, African American, and Hispanic Goodpasture’s syndrome patients were assessed using logistic regression analysis.ResultsNine hundred and sixty-four patients were hospitalized with a primary diagnosis of Goodpasture’s syndrome. Of these, 786 were included in the analysis: 622 (79%) were Caucasian, 73 (9%) were African American, and 91 (12%) were Hispanic. Hispanics had significantly lower use of plasmapheresis. The use for mechanical ventilation, noninvasive ventilation support, and renal replacement therapy in African Americans and Hispanics were comparable to Caucasians. There was no significant difference in organ failure, sepsis, and in-hospital mortality between African Americans and Caucasians. In contrast, Hispanics had higher in-hospital mortality than Caucasians but similar risk of organ failure and sepsis.ConclusionAfrican American and Hispanic populations account for 9% and 12% of hospitalizations for Goodpasture’s syndrome, respectively. While there is no significant difference in in-hospital mortality between African Americans and Caucasians, Hispanics with Goodpasture’s syndrome carry a higher in-hospital mortality compared to Caucasians.

Pulmonary arterial hypertension (PAH) is a progressive disease associated with significant morbidity and mortality. Despite the negative impact of PAH on quality of life and survival, data on use of specialty palliative care services (PCS) is scarce.

Background: Post-operative atrial fibrillation is a complication with high morbidity. In patients on prior-to-admission beta-blockers, early post-operative beta-blockade reduces atrial fibrillation risk; however, this benefit is not studied in hemodynamically unstable patients requiring vasopressors.

ABSTRACTBackgroundThe objective of this study was to evaluate the predictors and associated outcomes of rhabdomyolysis in admitted patients for heat stroke in the United States.MethodsThe National Inpatient Sample was utilized to identify hospitalized patients with a primary diagnosis of heat stroke from the years 2003–2014. Rhabdomyolysis was identified using hospital diagnosis code. We compared the clinical characteristics, in-hospital treatment, complications, outcomes, and resource utilization between patients with and without rhabdomyolysis.ResultsA total of 3,372 hospital admissions for heat stroke were studied. Of these, rhabdomyolysis occurred in 1049 (31%) admissions. The risk factors for rhabdomyolysis were age 20–39 years, male sex, African American race, history of alcohol drinking, whereas age ≥60 years, smoking, history of diabetes mellitus, and hypertension were associated with lower risk of rhabdomyolysis. Patients with rhabdomyolysis had greater requirements for mechanical ventilation, blood component transfusion, and renal replacement therapy. Rhabdomyolysis was significantly associated with increased risk of hyponatremia, hypernatremia, hyperkalemia, hypocalcemia, serum phosphorus and magnesium derangement, metabolic acidosis, sepsis, ventricular arrhythmia or cardiac arrest, renal failure, respiratory failure, liver failure, neurological failure, hematologic failure, and in-hospital mortality. Length of hospital stay and hospitalization cost were higher when rhabdomyolysis occurred during hospital stay.ConclusionRhabdomyolysis occurred in about one-third of hospitalized patients for heat stroke and was associated with increased morbidity, mortality, and resource utilization.