Publications by authors named "Khalid Sawalha"

25 Publications

  • Page 1 of 1

Ipsilateral Vocal Cord Paralysis After Acute Anterior Ischemic Stroke.

Perm J 2020 Dec;25

Department of Neurology, The New Mexico University Health Sciences Center, Albuquerque, NM.

Introduction: The vocal cord is innervated by the recurrent laryngeal nerve and the superior laryngeal nerve, which are branches of the vagus nerve. The nucleus ambiguous is a motor nucleus of the vagus nerve and it is located in the medulla. It receives supratentorial upper motor regulatory fibers. Commonly, this regulation is bilaterally represented in the brain. Less commonly, it is contralaterally represented. This case describes a rare presentation.

Case Presentation: We present a female patient in her early sixties with a past medical history significant for hypertension who presented with acute right-sided weakness and expressive aphasia (National Institutes of Health Stroke Scale = 20). Computed tomography (CT)-head was unremarkable but she was outside the window for chemical thrombolytic therapy. CT-angiogram revealed occlusion of the left extracranial and intracranial internal carotid artery and, thus, she was deemed not a candidate for mechanical thrombectomy. CT-perfusion scans (Rapid software) showed a large penumbra within the respective vascular territory affected including the operculum and the insula. The core infarction was relatively small and located in the left basal ganglia. After inducing therapeutic hypertension, the patient's aphasia improved. Surprisingly, this unmasked a moderate to severe hypophonic voice. The patient underwent flexible fiberoptic laryngoscopy which showed a paralyzed left vocal cord but without signs of inflammation.

Conclusion: Our case is a rare case of transient ipsilateral vocal cord paralysis associated with anterior unilateral cerebral ischemia. The paralysis resolved with improvement of the cerebral ischemic penumbra.
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http://dx.doi.org/10.7812/TPP/20.104DOI Listing
December 2020

CK-MB Elevation in Mild Hypothermia: What We Did and We Should Have Done.

J Investig Med High Impact Case Rep 2021 Jan-Dec;9:2324709621995335

White River Health System, Batesville, AR, USA.

An 88-year-old male patient with a past medical history of hypertension and gastroesophageal disease presented with nausea, vomiting, and hypothermia. He was admitted for further testing, which revealed elevated creatine kinase and its MB isoenzyme (CK-MB) and troponin with no significant electrocardiogram changes. He denied cardiac symptoms or any previous cardiac history. The patient was treated with fluids and antibiotics in which improvement in his symptoms was noted. In this article, we share this rare case of hypothermia associated with elevation of CK-MB.
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http://dx.doi.org/10.1177/2324709621995335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7894683PMC
February 2021

Acute Respiratory Failure From Hypermagnesemia Requiring Prolonged Mechanical Ventilation.

J Investig Med High Impact Case Rep 2020 Jan-Dec;8:2324709620984898

White River Health System, Batesville, AR, USA.

Electrolyte abnormalities are an underrecognized cause of respiratory failure in the intensive care unit. One such abnormality is a relatively rare phenomenon of hypermagnesemia resulting in paralysis. A 73-year-old Caucasian male patient presented to the emergency department with diffuse abdominal pain of 2-day duration. He received magnesium citrate and gastrointestinal cocktail for his constipation after initial imaging showed constipation. In view of acute worsening, follow-up computed tomography of the abdomen was done, which showed free air in upper abdomen along with free fluid. Hence, he was taken for emergent laparotomy with repair of pyloric ulcer perforation with omental patch. Post procedure course was complicated by sepsis, acute kidney injury, and respiratory failure with hypoxemia and hypercapnia. On physical examination the patient had flaccid paralysis in all his extremities along with absent brain stem reflexes. Extensive workup including imaging of brain failed to reveal diagnosis. On postoperative day 1, the patient was noted to have magnesium level of 9.2 mg/dL (1.6-2.3 mg/dL), which was thought to be cause of flaccid paralysis and respiratory failure. In view of his acute oliguric kidney injury, he was initiated on intermittent hemodialysis, until his magnesium levels were back to its physiologic limits. His paralysis gradually improved over next 48 to 72 hours and he was liberated from ventilator successfully.
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http://dx.doi.org/10.1177/2324709620984898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783877PMC
December 2020

An Unusual Cause of an Intraperitoneal Bleed: Bleeding Hepatic Artery Pseudoaneurysm Due to an Eroding Cholecystitis.

J Investig Med High Impact Case Rep 2020 Jan-Dec;8:2324709620982431

White River Health System, Batesville, AR, USA.

An 80-year-old male patient presented with sepsis secondary to infected central line which was placed for native aortic valve endocarditis. He also had melena and abdominal pain prior to his presentation. Abdominal computed tomography (CT) was done, which showed cholelithiasis. Esophagogastroduodenoscopy was also done with no source of bleeding identified. Later, he developed hemodynamic instability requiring aggressive fluid resuscitation and multiple packed blood cell transfusions. In view of his hemodynamic instability, a repeat abdominal CT scan showed air droplets within the gallbladder pneumobilia, ascites, diverticulosis, and a bleeding infrahepatic hematoma measuring 6 × 10 cm, which was not on his prior scan 2 days prior. A mesenteric arteriogram was performed that identified an aneurysm of the right hepatic artery with no active bleeding; therefore, it was coiled. Due to his continued clinical decompensation, he underwent an urgent open cholecystectomy, in which serosanguineous fluid, cholecystocolic fistula, and old clot related to his previous bleed were encountered. However, control of bleeding was difficult, and the patient expired. We report this case of right hepatic artery aneurysm that we believe its etiology was related to eroding cholecystitis.
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http://dx.doi.org/10.1177/2324709620982431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758654PMC
December 2020

Iatrogenic Right Atrial Thrombus Complicated by Pulmonary Embolism: Management and Outcomes.

Curr Cardiol Rev 2020 Nov 24. Epub 2020 Nov 24.

University of Massachusetts Medical School-Baystate, Springfield, MA,. United States.

Right atrial thrombus can originate from distal venous sources or can be iatrogenic secondary to placement of central venous catheters, atrial devices, or surgeries. One of the most common complications of central venous catheters (CVCs) is thromboembolism, which can be either fixed to the right atrium or can be free-floating. Device-related right atrial thrombosis (RAT) can result in catheter occlusion, vascular occlusion, infection, and pulmonary embolism. The true incidence of these complications is unknown because the diagnosis may not be considered in asymptomatic patients and might be missed by transthoracic echocardiography (TTE). In this literature review, we discuss iatrogenic etiologies of RAT that is complicated by pulmonary embolism. We highlight the importance of maintaining a high index of suspicion of iatrogenic RAT, possible complications, and its management.
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http://dx.doi.org/10.2174/1573403X16999201124201632DOI Listing
November 2020

COVID-19-Induced Acute Bilateral Optic Neuritis.

J Investig Med High Impact Case Rep 2020 Jan-Dec;8:2324709620976018

White River Health System, Batesville, AK, USA.

A 44-year-old male patient with no past medical history presented 2 weeks after seropositive coronavirus disease 2019 (COVID-19) infection with vision problems suggestive of optic neuritis. Radiological testing showed findings suspicious for acute bilateral optic neuritis. The patient had also anti-MOG antibodies. Whether this was an optic neuritis due to COVID-19, MOG antibody disease, or an activation of MOG antibody disease by COVID-19 is discussed in this case.
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http://dx.doi.org/10.1177/2324709620976018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705770PMC
December 2020

Concurring hypertrophic cardiomyopathy and takotsubo cardiomyopathy: Assessment and management.

Heart Lung 2020 Oct 31. Epub 2020 Oct 31.

Department of Cardiology, UMMS-Baystate Medical Center, Springfield, MA, USA.

The prevalence of takotsubo cardiomyopathy (TCM) has been on the rise, but co-occurrence with hypertrophic cardiomyopathy (HOCM) remains rare. Although presenting patient demographics were similar to those in TCM, the potential for hemodynamic compromise was significantly compounded by the presence of underlying HOCM. Management was similar to standalone TCM, although use of inotropic agents and mechanical support appears to be more prevalent. Despite the increased potential for complications and the paucity of data regarding management, outcomes appear to be mostly favorable in both the hospitalization period and at follow-up. Interestingly, despite a new diagnosis of HOCM in about half the cases described, which signifies no significant left ventricular outflow tract (LVOT) gradient prior to TCM, half of those patients had a persistently elevated LVOT gradient after resolution of TCM. This poses a question of whether or not TCM can predispose to LVOT obstruction in HOCM patients even after its resolution.
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http://dx.doi.org/10.1016/j.hrtlng.2020.10.006DOI Listing
October 2020

It Is Just a Rash They Said! Acute Skin Manifestation in a Patient With Vasculitis in Rural Hospitals.

J Investig Med High Impact Case Rep 2020 Jan-Dec;8:2324709620966446

White River Health System, Batesville, AR, USA.

A 76-year-old Caucasian male with a history of rheumatoid arthritis, Raynaud's phenomenon, pulmonary embolism on warfarin, and a previous amputation of his left partial ring and fifth finger presented with acute onset of rash in bilateral lower extremities. He was recently started on trimethoprim-sulfamethoxazole due to concern for cellulitis. Differential diagnosis for acute-onset rash with the patient's history presented as a challenge to the internist, as the differential is broad. Our case goes through the differential diagnosis to contrast the different presentations of rash in a patient with vasculitis. Ultimately skin biopsy in conjunction with a past positive cryoglobulinemic level helped confirm the diagnosis of cutaneous vasculitis, following which he was started on appropriate treatment and recovered.
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http://dx.doi.org/10.1177/2324709620966446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585880PMC
October 2020

Lorazepam timing for acute convulsive seizure control (LoTASC).

Seizure 2020 Dec 6;83:41-47. Epub 2020 Oct 6.

The Ohio State University, Wexner Medical Center, Department of Neurology, United States. Electronic address:

Introduction: Guidelines specify early administration of benzodiazepines (BZD) for the management of convulsive status epilepticus. The distinction between acute convulsive seizure and status epilepticus can be misconstrued resulting in BZD administration prior to a patient meeting criteria of status epilepticus. Early BZD administration may theoretically lead to systemic vital instability. Our study aims to assess if administering lorazepam, for convulsive seizures <5 min, causes vital instability.

Methods: This is a retrospective study analyzing patients who presented with a seizure lasting <5 min between 2011 and 2016. Continuous variables of lorazepam receivers versus non- receivers were analyzed using t-test for parametric and Mann-Whitney U test for nonparametric data. Categorical variables were analyzed using Chi-Square Test. Subsequently, subjects were analyzed through univariate and multivariate regression models to determine predictors of vital instability.

Results: Out of 1052 subjects initially screened, 165 were included. Of these, 91 (55 %) received lorazepam, and 74 (45 %) did not. Through univariate and multivariate analyses, there was a significantly higher incidence of vital instability (defined as receipt of a vasopressor or intubation) in patients who received lorazepam (OR = 6.76, 95 % CI = 1.48, 30.95) (p = 0.014). This was dose-dependent (p < 0.0001). It was responsible for 22.5 % of the vital instability. Lorazepam administration significantly prolonged the intensive care unit (ICU) length of stay (0 days [IQR 0 - 0] vs [IQR 0-2.3]; p = 0.038).

Conclusion: Our study suggests that lorazepam administration for acute convulsive seizures not meeting convulsive status epilepticus criteria may lead to iatrogenic vital instability and need for ICU admission.
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http://dx.doi.org/10.1016/j.seizure.2020.09.024DOI Listing
December 2020

Impact of chronic kidney disease on in-hospital outcomes and readmission rate after edge-to-edge transcatheter mitral valve repair.

Catheter Cardiovasc Interv 2021 Mar 15;97(4):E569-E579. Epub 2020 Aug 15.

Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois.

Background: Transcatheter mitral valve repair (TMVR) is a treatment option for patients with 3+ or greater mitral regurgitation who cannot undergo mitral valve surgery. Outcomes in patients with chronic kidney disease (CKD) and end stage renal disease (ESRD) are unclear. We sought to evaluate the TMVR in-hospital outcomes, readmission rates and its impact on kidney function.

Methods: Data from 2016 National Readmission Database was used to obtain all patients who underwent TMVR. Patients were classified by their CKD status: no CKD, CKD, or ESRD. The primary outcomes were: in-hospital mortality, 30- and 90-day readmission rate, and change in CKD status on readmission. Multivariable logistic regression analysis was used to assess in-hospital, readmission outcomes and kidney function stage.

Results: A total of 4,645 patients were assessed (mean age 78.5 ± 10.3 years). In-hospital mortality was higher in patients with CKD (4.0%, odds ratio [OR]:2.01 [95% CI, confidence interval: 1.27-3.18]) and ESRD (6.6%, OR: 6.38 [95% CI: 1.49-27.36]) compared with non-CKD (2.4%). 30-day readmission rate was higher in ESRD versus non-CKD patients (17.8% vs. 10.4%, OR: 2.24 [95% CI: 1.30-3.87]) as was 90-day readmission (41.2% vs. 21% OR: 2.51 [95% CI:1.70-3.72]). Kidney function improved in 25% of patients with CKD stage 3 and in 50% with CKD stage 4-5 at 30-and 90-day readmission. Incidence of AKI, major bleeding, and respiratory failure were higher in CKD group.

Conclusions: Patients with CKD and ESRD have worse outcomes and higher readmission rate after TMVR. In patients who were readmitted after TMVR, renal function improved in some patients, suggesting that TMVR could potentially improve CKD stage.
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http://dx.doi.org/10.1002/ccd.29188DOI Listing
March 2021

Role of Non-Perfusion Factors in Mildly Symptomatic Large Vessel Occlusion Stroke.

J Stroke Cerebrovasc Dis 2020 Oct 30;29(10):105172. Epub 2020 Jul 30.

The Ohio State University Wexner Medical Center, Department of Neurology, 410 W 10th Ave, Columbus, USA.

Introduction: Uncertainty regarding reperfusion of mildly-symptomatic (minor) large vessel occlusion (LVO)-strokes exists. Recently, benefits from reperfusion were suggested. However, there is still no strong data to support this. Furthermore, a proportion of those patients don't improve even after non-hemorrhagic reperfusion. Our study evaluated whether or not non-perfusion factors account for such persistent deconditioning.

Methods: Patients with identified minor LVO-strokes (NIHSS ≤ 8) from our stroke alert registry between January-2016 and May-2018 were included. Variables/ predictors of outcome were tested using univariate/multivariate logistic and linear regression analyses. Three month-modified ranking scale (mRS) was used to differentiate between favorable (mRS = 0-2) and unfavorable outcomes (mRS = 3-6).

Results: Eighty-one patients were included. Significant differences between the two outcome groups regarding admission-NIHSS and discharge-NIHSS existed (OR = 0.47, 0.49 / p = 0.0005, <0.0001 respectively).The two groups had matching perfusion measures. In the poor outcome group, discharge-NIHSS was unchanged from the admission-NIHSS while in the good outcome group, discharge-NIHSS significantly improved.

Conclusion: Admission and discharge NIHSS are independent predictors of outcome in patients with minor-LVO strokes. Unchanged discharge-NIHSS predicts worse outcomes while improved discharge-NIHSS predicts good outcomes. Unchanged NIHSS in the poor outcome group was independent of the perfusion parameters. In literature, complement activation and pro-inflammatory responses to ischemia might account for the progression of stroke symptoms in major-strokes. Our study concludes similar phenomena might be present in minor-strokes. Therefore, discharge-NIHSS may be useful as a clinical marker for future therapies.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105172DOI Listing
October 2020

Hemopericardium in a Sirolimus-Treated Renal Transplant Patient.

Cureus 2020 Aug 1;12(8):e9508. Epub 2020 Aug 1.

Cardiovascular Medicine, University of Massachusetts Medical School Baystate, Massachusetts, USA.

Sirolimus is an immunosuppressant frequently prescribed to prevent graft-vs-host disease in renal transplant patients. Pericardial effusion is recognized as a rare and potentially lethal side effect of this medication. Hemopericardium, specifically, is an even rarer complication that has yet to be reported in the literature. We report the first case of sirolimus-induced hemopericardium in a renal transplant patient.
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http://dx.doi.org/10.7759/cureus.9508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458718PMC
August 2020

Systematic Review of COVID-19 Related Myocarditis: Insights on Management and Outcome.

Cardiovasc Revasc Med 2021 02 18;23:107-113. Epub 2020 Aug 18.

Department of Cardiology, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA, United States of America.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also referred to as COVID-19, was declared a pandemic by the World Health Organization in March 2020. The manifestations of COVID-19 are widely variable and range from asymptomatic infection to multi-organ failure and death. Like other viral illnesses, acute myocarditis has been reported to be associated with COVID-19 infection. However, guidelines for the diagnosis of COVID-19 myocarditis have not been established.

Methods: Using a combination of search terms in the PubMed/Medline, Ovid Medline and the Cochrane Library databases and manual searches on Google Scholar and the bibliographies of articles identified, we reviewed all cases reported in the English language citing myocarditis associated with COVID-19 infection.

Results: Fourteen records comprising a total of fourteen cases that report myocarditis/myopericarditis secondary to COVID-19 infection were identified. There was a male predominance (58%), with the median age of the cases described being 50.4 years. The majority of patients did not have a previously identified comorbid condition (50%), but of those with a past medical history, hypertension was most prevalent (33%). Electrocardiogram findings were variable, and troponin was elevated in 91% of cases. Echocardiography was performed in 83% of cases reduced function was identified in 60%. Endotracheal intubation was performed in the majority of cases. Glucocorticoids were most commonly used in treatment of myocarditis (58%). Majority of patients survived to discharge (81%) and 85% of those that received steroids survived to discharge.

Conclusion: Guidelines for diagnosis and management of COVID-19 myocarditis have not been established and our knowledge on management is rapidly changing. The use of glucocorticoids and other agents including IL-6 inhibitors, IVIG and colchicine in COVID-19 myocarditis is debatable. In our review, there appears to be favorable outcomes related to myocarditis treated with steroid therapy. However, until larger scale studies are conducted, treatment approaches have to be made on an individualized case-by-case basis.
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http://dx.doi.org/10.1016/j.carrev.2020.08.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434380PMC
February 2021

Outcomes of MitraClip placement in patients with liver cirrhosis.

Cardiovasc Revasc Med 2020 Aug 12. Epub 2020 Aug 12.

Department of Cardiology, University of Massachusetts Medical School- Baystate Medical Center, Springfield, MA, United States of America.

Introduction: Liver cirrhosis is associated with increased morbidity and mortality. Many preoperative risk assessment tools do not take into account the presence or degree of liver cirrhosis prior to surgery. Over recent years, percutaneous mitral valve repair using MitraClip has emerged as an option for patients at high risk of surgical intervention. However, the safety, efficacy and outcomes of this procedure in patients with liver cirrhosis have not yet been evaluated.

Methods: This is a retrospective cohort study using the 2013-2017 National Inpatient Sample database of adults who were hospitalized for MitraClip repair of mitral valve. All patients were divided into patients with cirrhosis and those without cirrhosis. The primary outcome was all-cause mortality in patient with cirrhosis who underwent MitraClip. The secondary outcomes were to assess length of stay (LOS) and total hospital cost per year in cirrhotic patients compared to non-cirrhotic patients.

Results: In-hospital mortality was higher in cirrhosis group compared to non-cirrhosis however not statistically significant (8.1% vs 3.2%, OR: 2.59 [95% CI: 0.47-14.28, p-value 0.27). Additionally, neither of the secondary outcomes, LOS and total cost, were found to be statistically significant. However, the incidence of cardiogenic shock was significantly higher in the cirrhosis group 13.3% versus 3.9% (p-value 0.032).

Conclusion: Patients with liver cirrhosis who underwent MitraClip repair of MV were at higher risk of developing cardiogenic shock, without any significant increase in in-hospital mortality, LOS or total cost. However, this study showed a trend toward higher rates of mortality, requirement of blood transfusion, mechanical ventilation, length of stay, and cost of care in cirrhosis patients.
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http://dx.doi.org/10.1016/j.carrev.2020.08.014DOI Listing
August 2020

An Unusual Case of Drug-Induced Thrombocytopenia.

J Investig Med High Impact Case Rep 2020 Jan-Dec;8:2324709620947891

White River Health System, Batesville, AR, USA.

Drug-induced thrombocytopenia (DIT) is a differential diagnosis for consideration when acute thrombocytopenia is encountered in the outpatient or inpatient setting. The mechanism of thrombocytopenia induced by different antiplatelet therapies varies. DIT may occur due to antibody formation following the exposure to a drug, or naturally occurring preexisting antibodies may produce rapid-onset thrombocytopenia when a drug molecule binds to a platelet receptor inducing a conformational change thus rendering it to be an antigen target for naturally occurring antibodies. A 66-year-old female with history of hypertension presented with non-ST elevation myocardial infarction, had drug eluting stent placed in first obtuse marginal artery of left circumflex coronary artery. Started on antiplatelet medications aspirin 81 mg, ticagrelor 90 mg (which was later transitioned to clopidogrel 75 mg), as well as tirofiban 12.5 mg (for 12 hours only). Tirofiban is a GP IIb/IIIa antagonist, other drugs in this class have been documented to induce thrombocytopenia as well, but rates for tirofiban appear to be the highest, the reason is unclear. These antibodies are thought to be either naturally occurring or induced from conformational changes to GP IIb/IIIa binding site after binding to the GP IIb/IIIa receptor, binding of these drugs to the receptor precipitates an epitope much more specific for platelet surface antigens. Tirofiban and clopidogrel/ticagrelor can cause thrombocytopenia, but onset in this case is unusual: acute antibody reaction would be expected within hours, not delayed 30 hours after starting antiplatelet medication, and nonacute reaction would present 1 to 2 weeks out.
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http://dx.doi.org/10.1177/2324709620947891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430073PMC
August 2020

The Efficacy of Intravenous Insulin Infusion in the Management of Hypertriglyceridemia-Induced Pancreatitis in a Rural Community Hospital.

J Investig Med High Impact Case Rep 2020 Jan-Dec;8:2324709620940492

White River Health System, Batesville, AR, USA.

A 28-year-old female presented to the emergency room with epigastric pain, nausea, and vomiting; her lipase was elevated, and computed tomography of abdomen showed evidence of acute pancreatitis. Her past medical history was significant for poorly controlled insulin requiring type 2 diabetes mellitus and 2 previous admissions for hypertriglyceridemia-induced pancreatitis. Due to the severity of her pancreatitis presentation, she was admitted to the intensive care unit. She received aggressive intravenous fluid hydration and was started on an insulin drip. Apheresis was strongly considered given the degree of her hypertriglyceridemia (11 602 mg/dL), but there was no timely access to this treatment option. She, however, significantly improved with insulin therapy alone. Her triglyceride levels decreased rather quickly to 4783 mg/dL within 24 hours and by the fourth day of admission were comfortably <1000 mg/dL with insulin infusion along with clinical improvement. She was discharged on niacin and insulin therapy along with her home medications of statin and fenofibrate.
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http://dx.doi.org/10.1177/2324709620940492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7350394PMC
July 2020

Cardiogenic shock in autoimmune rheumatologic diseases: an insight on etiologies, management, and treatment outcomes.

Heart Fail Rev 2020 Jun 20. Epub 2020 Jun 20.

Heart and Vascular Institute, West Virginian University, 1 Medical Center Dr., Morgantown, WV, 26505, USA.

Autoimmune rheumatological disorders are known to have an increased risk for cardiovascular diseases including coronary artery disease (CAD), myocarditis, pericarditis, valvulopathy, and in consequence cardiogenic shock. Data on cardiogenic shock in rheumatological diseases are scarce; however, several reports have highlighted this specific entity. We sought to review the available literature and highlight major outcomes and the management approaches in each disease. Systematic literature search, including PubMed, Ovid/Medline, Cochrane Library, and Web of Science, was conducted between January 2000 and December 2009. We reviewed all cases reporting cardiogenic shock with rheumatologic conditions, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Takayasu's arteritis (TA), granulomatosis with polyangiitis (GPA), giant cell arteritis (GCA), and antiphospholipid syndrome (APS). We selected 45 papers reporting a total of 48 cases. Mean age was 39 ± 7.3 years and 68.8% were females. Most common rheumatologic conditions associated with cardiogenic shock were SLE (31%), GPA (23%), TA (14.6%), APA (10.4%), and RA (8.3%). Cardiogenic shock was found to be caused by eosinophilic myocarditis in 58% of cases, CAD in 19% of cases, and valvulopathy in 6% of cases. Most patient required high-dose steroids and second immunosuppressant therapy. Mechanical circulatory supported was required in 23 cases, IABP in 16 cases, and ECMO in 12 cases. Complete recovery occurred in 37 patients while 9 patients died and 2 required heart transplant. Responsible for two-thirds of cases, eosinophilic myocarditis should be suspected in young cardiogenic shock patients with underlying rheumatologic conditions. Lupus and GPA are the two most common conditions.
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http://dx.doi.org/10.1007/s10741-020-09990-4DOI Listing
June 2020

Spontaneous Biliary Pericardial Tamponade: A Case Report and Literature Review.

Curr Cardiol Rev 2020 Jun 11. Epub 2020 Jun 11.

State University of New York: Downstate Medical Center, Brooklyn, NY. United States.

Background: Biliary pericardial tamponade (BPT) is a rare form of pericardial tamponade, characterized by yellowish-greenish pericardial fluid upon pericardiocentesis. Historically, BPT reported to occur in the setting of an associated pericardio-biliary fistula. However, BPT in the absence of a detectable fistula is extremely rare.

Case Presentation: A 75-year-old Hispanic male presenting with dyspnea and diagnosed with cardiac tamponade. Subsequent pericardiocentesis revealed biliary pericardial fluid (bilirubin of 7.6 mg/dl). Patient underwent extensive workup to identify a potential fistula between hepatobiliary system and the pericardial space, which was non-revealing. The mechanism of bile entry into the pericardial space remains to be unidentified.

Literature Review: A total of six previously published BPT were identified: all were males, mean age of 53.3 years (range: 31-73). Mortality was reported in two out of the six cases. The underlying etiology for pericardial tamponade varied across the cases: incidental pericardio-biliary fistula, traumatic pericardial injury, and presence of associated malignancy. - Conclusion: Biliary pericardial tamponade is a rare form of tamponade that warrants a prompt workup (e.g., Hepatobiliary Iminodiacetic Acid - HIDA scan) for an iatrogenic vs. traumatic pericardio-biliary fistula. As a first case in the literature, our case exhibits a biliary tamponade in the absence of an identifiable fistula.
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http://dx.doi.org/10.2174/1573403X16666200611132045DOI Listing
June 2020

Readmissions Rates After Myocardial Infarction for Gastrointestinal Bleeding: A National Perspective.

Dig Dis Sci 2021 Mar 20;66(3):751-759. Epub 2020 May 20.

Department of Gastroenterology, UMMS-Baystate Medical Center, Springfield, MA, USA.

Background And Aims: Gastrointestinal (GI) bleeding is one most common complications of acute myocardial infarction (AMI). We aimed to determine the incidence, in-hospital outcomes, associated healthcare burden and predictors of GI bleeding within 30 days after AMI.

Methods: Data were extracted from Nationwide Readmission Database 2010-2014. Patients were included if they had a primary diagnosis of ST or non-ST elevation myocardial infarction. Exclusion criteria were admissioned in December, aged less than 18 years and a diagnosis of type-2 MI. The primary outcome was 30-day readmission with upper or lower GI bleeding. Secondary outcomes were in-hospital mortality, etiology of bleeding, in-hospital complications, procedures, length of stay, and total hospitalization charges. Independent predictors of readmission were identified using multivariate logistic regression analysis.

Results: Out of the 3,520,241 patients discharged with ACS, 10,018 (0.3%) were readmitted with GI bleeding within 30 days of discharge. 60% had lower GI bleeding. Most common sources suspected were GI cancers in 17% and hemorrhoidal bleeding in 10%. In hospital mortality rate for readmission was 3.6%. Independent predictors of readmission were age, Charlson comorbidity score, history of chronic kidney disease, GI tumor, inflammatory bowel disease and artificial heart valve. Type of treatment for AMI had no impact on readmission. Patients readmitted had higher rates of shock (adjusted odds ratio, 1.48, 95% CI 1.01-3.72).

Conclusions: In the first nationwide study, 30-day incidence of GI bleeding after AMI is 0.3%. GI bleeding complicating AMI carries a substantial in-hospital mortality and cost of care.
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http://dx.doi.org/10.1007/s10620-020-06315-1DOI Listing
March 2021

Impact of cardiovascular comorbidities on inpatient mortality in patients hospitalized with neutropenic fever.

Support Care Cancer 2021 Jan 14;29(1):509-513. Epub 2020 May 14.

Department of Hematology/Oncology, Saint Francis Cancer Center, Hartford, CT, 06105, USA.

Introduction: Concomitant cardiovascular comorbidities in patients with cancer are not uncommon. There is limited data on the impact of cardiovascular comorbidities on in-hospital mortality in patients admitted with neutropenic fever.

Methods: This is a retrospective cohort study using the 2016 NIS database of adults (> 18 years old) hospitalized for neutropenic fever as the primary diagnosis. The primary outcome studied is all-cause mortality in patients with neutropenic fever. ICD-10-CM codes were used to identify cardiovascular risk factors including smoking; hyperlipidemia; peripheral vascular diseases; hypertension; history of cerebrovascular disease or transient ischemic attack; and cardiovascular morbidities including atrial fibrillation, coronary artery disease, and congestive heart failure. Multivariate linear regression analysis was used to adjust for cofounders.

Results: A total of 28,060 patients were admitted with neutropenic fever in 2016. Average age was 43.9 ± 1.7 years, and 49.3% were females. Among the cases identified, 205 patients died during hospitalization with an overall in-hospital mortality of 0.7%. Atrial fibrillation was independently associated with higher in-hospital mortality (odds ratio [OR] 3.01; CI 1.38 to 6.57; p = 0.005) as was congestive heart failure (OR 3.15; CI 1.08 to 10.14; p = 0.049).

Conclusion: Atrial fibrillation and congestive heart failure were associated with higher inpatient mortality in patients with neutropenic fever. Identifying the risk factors for increased mortality in patients with neutropenic fever is important for risk stratification and guiding clinicians in taking therapeutic decisions in this set of patients.
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http://dx.doi.org/10.1007/s00520-020-05518-6DOI Listing
January 2021

Acute Myocardial Infarction in Systemic Mastocytosis: Case Report With Literature Review on the Role of Inflammatory Process in Acute Coronary Syndrome.

Curr Cardiol Rev 2020 ;16(4):333-337

Department of Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States.

Background: Systemic Mastocytosis (SM) is a disorder of excessive mast cell infiltration in multiple organ tissues. Atherosclerosis is a major risk factor for developing acute coronary syndrome. In addition to lipid accumulation in the arterial wall, inflammation plays an important role in the pathogenesis of plaque rupture and activating the thrombosis cascade. The Mast cells contribution to plaque destabilization has been well established in multiple animal and human studies. In a recent study, SM has been proven to be associated with a higher incidence of acute coronary syndrome even with lower plasma lipids levels. The study showed that 20% of patients with SM had cardiovascular events compared to only 6% in the control group with adjustment to all cardiac risk factors.

Case: We presented a patient with no risk factors for heart disease other than old age and history of SM who developed acute myocardial infarction.

Conclusion: SM can be life-threatening and can result in ACS, anaphylactic reaction, syncope, or cardiac arrest. Clinicians should have a high index of suspicion of acute coronary syndrome (ACS) occurrence in the setting of inflammatory conditions, such as SM and KS, and vice versa, where SM should be considered or ruled out in patients who suffer from anaphylaxis and cardiac arrest or myocardial infarction.
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http://dx.doi.org/10.2174/1573403X16666200331123242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903504PMC
February 2021

Echocardiographic Derived Parameters Association With Long-Term Outcomes After Transcatheter Valve Replacement.

Cardiovasc Revasc Med 2020 08 7;21(8):982-985. Epub 2020 Jan 7.

Heartland Cardiology, Wesley Medical Center, University of Kansas School of Medicine, United States of America.

Background: Transaortic flow, maximum velocity (V max), mean gradient (MG), left ventricular ejection fraction (LVEF), Aortic valve area (AVA) and dimensional index (DI) are important determinants of prognosis in patients with severe aortic stenosis. The specific role of these echocardiography-derived values in predicting prognosis of severe aortic stenosis patients undergoing Transcatheter aortic valve replacement (TAVR) is less defined.

Methods: We identified all severe AS patients who underwent TAVR between 01/2012 and 6/2016. Baseline characteristics, clinical, procedural and one year follow-up data were obtained. Hierarchical logistic regression was used to assess predictors of 1-year mortality after TAVR. Normal flow (NF) was defined as having stroke volume index (SVI) of ≥35 ml/m2; while low Flow (LF) was defined as SVI < 35 ml/m2. High gradient (HG) was defined as mean gradient of ≥40 mmHg; while low gradient (LG) was defined as <40 mmHg.

Results: A total of 399 patients were analyzed. There were no significant differences in baseline characteristics. LVEF less than 35% was associated with higher rate of 1-year mortality (17.6% LVEF <35% vs. 8.9% LVEF≥35%; RR = 2.19; CI 1.05 to 4.54; P = 0.03). There was no difference in 1-year mortality outcomes after TAVR in relation to: Mean Gradient MG, transaortic flow/Stroke Volume Index SVI, DI, V max or AVA.

Conclusion: Low LVEF <35% remains the strongest parameter associated with 1 year mortality after TAVR.
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http://dx.doi.org/10.1016/j.carrev.2019.12.035DOI Listing
August 2020

The Significance of Contrast Density of the Computed Tomography-Angiographic Spot Sign and its Correlation with Hematoma Expansion.

J Stroke Cerebrovasc Dis 2019 Jun 1;28(6):1474-1482. Epub 2019 Apr 1.

The Ohio State University Wexner Medical Center, Department of Neurology - Cerebrovascular and Neurocritical Care Division, Columbus, Ohio, USA.

Background And Purpose: The computed tomography angiographic (CTA) spot sign has been shown to predict hematoma expansion in patients with intracranial hemorrhage (ICH), but the significance of the spot sign density (SSD) and the spot sign ratio (SSR) has not yet been explored.

Methods: Using the institutional Neurocritical care and Stroke registry, we retrospectively reviewed patients with ICH from January-2013 to June-2017. We selected patients who had baseline CT-head (CTH), CTA with positive-spot sign within 6 hours of last known well and at least one follow-up CTH within 24 hours. Baseline demographics and variables known to affect hematoma-volume were collected. Hematoma-volumes and SSR were calculated using computer-assisted 3D-volumetric measurement and the average of the surrounding hematoma density divided by the SSD, respectively. The 2-sample t test and the area-under-the-curve (receiver operating characteristic) were used to detect the association between hematoma expansion and outcome at discharge.

Results: A total of 320 patients were reviewed; 22 met the inclusion criteria. Significant hematoma expansion (volume expansion ≥12.5 cc or ≥33% compared to baseline) was noted in 14 (64%) subjects. SSD was significantly higher in subjects with hematoma expansion (216 ± 66) than those without (155 ± 52, P = .036). With a cut-off SSD of ≥150 HU, we had sensitivity of 86% and specificity of 75%. For SSR, lower ratios suggested a trend toward hematoma expansion, although it was not statistically significant (P = .12). There was no significant correlation between SSD or SSR and modified ranking scale at discharge and after 3-6 months.

Conclusion: SSD might be a good predictor of hematoma growth. Although SSR showed a trend toward expansion, results were not statistically significant.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.03.020DOI Listing
June 2019

Role of Magnetic Resonance Imaging in Diagnosis of Motor Neuron Disease: Literature Review and Two Case Illustrations.

Perm J 2019 ;23

Department of Neurology, Ohio State University Wexner Medical Center, Columbus.

Motor neuron diseases (MNDs) are a group of devastating neurologic disorders that cause specific damage to the motor neuron cells. The current diagnosis of MND is based on results of the clinical examination and neurophysiologic studies. The length of time of referral to a neuromuscular neurologist and the lack of validated diagnostic criteria can delay diagnosis. Although the role of imaging is currently most useful in excluding other conditions, several attempts to incorporate neuroimaging in the diagnosis of the disease and assessment of progression have shown promising results.We conducted a literature review via searches in PubMed and The Cochrane Database using multiple relevant terms to the topic. Two cases with a challenging diagnosis of MND are described, with a thorough discussion of how the diagnosis was suggested on the basis of magnetic resonance imaging evidence in each case. Advanced magnetic resonance imaging findings can be useful tools that add to the diagnostic criteria of MNDs, especially in cases where reaching a definitive diagnosis is difficult. Such findings might enable clinicians to reach an early diagnosis that can improve the patient's quality of life and prolong survival.
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http://dx.doi.org/10.7812/TPP/18-131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380476PMC
September 2019

The intraventricular-spot sign: prevalence, significance, and relation to hematoma expansion and outcomes.

J Neurol 2018 Oct 16;265(10):2201-2210. Epub 2018 Jul 16.

Cerebrovascular and Neurocritical Care Division, Department of Neurology, The Ohio State University Wexner Medical Center, 333 West 10 Avenue, Graves Hall, Columbus, OH, 43210, USA.

Background: The presence of the spot sign on computed tomography angiogram (CTA) is considered a sign of active bleeding, and studies have shown it can predict hematoma expansion in intraparenchymal hemorrhage (IPH). The spot sign in intraventricular hemorrhage (IVH) has not been explored yet. The purpose of this study is to estimate the prevalence of the intraventricular-spot sign, and its prediction of hematoma expansion and clinical outcomes.

Methods: We retrieved data of hemorrhagic stroke patients seen at our medical center from January 2013 to January 2018. A total of 321 subjects were filtered for the prevalence analysis (PA). We further excluded 114 subjects without a follow-up CT-head for the hematoma expansion analysis (HEA). Patients were grouped based on the location of hemorrhage into three groups: isolated IPH with the spot sign always in IPH (i-IPH), isolated IVH with the spot sign always in IVH (i-IVH), and combined IPH and IVH which would be further sub-grouped according to the location of the spot sign: in IPH only (IPH+/IVH) and in IVH only (IPH/IVH+). The prevalence, demographics, and incidence of hematoma expansion were compared between the groups using Pearson's chi-square test and Student's t test.

Results: The prevalence of the spot sign was 8, 20, 17, 5% in (i-IPH), (i-IVH), (IPH+/IVH), and (IPH/IVH+) groups, respectively. The rate of hematoma expansion were (42 vs. 13%), (33 vs. 31%), (80 vs. 22%), and (25 vs. 22%) in spot sign positive vs. negative subjects in each group, respectively (p values = 0.023, = 1, <0.001, and = 1).

Conclusion: We studied the prediction of spot sign on hematoma expansion and clinical outcomes in the different subtypes of ICH. Our study showed that spot sign is a good predictor in IPH but not IVH. Despite the rarity of IVH; the prevalence of spot sign was higher in IVH than IPH. This might be due to anatomical and physiological variations.
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http://dx.doi.org/10.1007/s00415-018-8975-8DOI Listing
October 2018