Publications by authors named "Leonidas Palaiodimos"

32 Publications

Effect of Hydroxychloroquine on QTc in Patients Diagnosed with COVID-19: A Systematic Review and Meta-Analysis.

J Cardiovasc Dev Dis 2021 May 13;8(5). Epub 2021 May 13.

Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA.

Background: Hydroxychloroquine or chloroquine with or without the concomitant use of azithromycin have been widely used to treat patients with SARS-CoV-2 infection, based on early in vitro studies, despite their potential to prolong the QTc interval of patients.

Objective: This is a systematic review and metanalysis designed to assess the effect of hydroxychloroquine with or without the addition of azithromycin on the QTc of hospitalized patients with COVID-19.

Materials And Methods: PubMed, Scopus, Cochrane and MedRxiv databases were reviewed. A random effect model meta-analysis was used, and I-square was used to assess the heterogeneity. The prespecified endpoints were ΔQTc, QTc prolongation > 500 ms and ΔQTc > 60 ms.

Results: A total of 18 studies and 7179 patients met the inclusion criteria and were included in this systematic review and meta-analysis. The use of hydroxychloroquine with or without the addition of azithromycin was associated with increased QTc when used as part of the management of patients with SARS-CoV-2 infection. The combination therapy with hydroxychloroquine plus azithromycin was also associated with statistically significant increases in QTc. Moreover, the use of hydroxychloroquine alone, azithromycin alone, or the combination of the two was associated with increased numbers of patients that developed QTc prolongation > 500 ms.

Conclusion: This systematic review and metanalysis revealed that the use of hydroxychloroquine alone or in conjunction with azithromycin was linked to an increase in the QTc interval of hospitalized patients with SARS-CoV-2 infection that received these agents.
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http://dx.doi.org/10.3390/jcdd8050055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8152730PMC
May 2021

Assessment of the Association of COPD and Asthma with In-Hospital Mortality in Patients with COVID-19. A Systematic Review, Meta-Analysis, and Meta-Regression Analysis.

J Clin Med 2021 May 13;10(10). Epub 2021 May 13.

Albert Einstein College of Medicine, Bronx, NY 10461, USA.

Together, chronic obstructive pulmonary disease (COPD) and asthma account for the most common non-infectious respiratory pathologies. Conflicting preliminary studies have shown varied effect for COPD and asthma as prognostic factors for mortality in coronavirus disease 2019 (COVID-19). The aim of this study was to explore the association of COPD and asthma with in-hospital mortality in patients with COVID-19 by systematically reviewing and synthesizing with a meta-analysis the available observational studies. MEDLINE, Scopus, and medRxiv databases were reviewed. A random-effects model meta-analysis was used, and I-square was utilized to assess for heterogeneity. In-hospital mortality was defined as the primary endpoint. Sensitivity and meta-regression analyses were performed. Thirty studies with 21,309 patients were included in this meta-analysis (1465 with COPD and 633 with asthma). Hospitalized COVID-19 patients with COPD had higher risk of death compared to those without COPD (OR: 2.29; 95% CI: 1.79-2.93; I 59.6%). No significant difference in in-hospital mortality was seen in patients with and without asthma (OR: 0.87; 95% CI: 0.68-1.10; I 0.0%). The likelihood of death was significantly higher in patients with COPD that were hospitalized with COVID-19 compared to patients without COPD. Further studies are needed to assess whether this association is independent or not. No significant difference was demonstrated in COVID-19-related mortality between patients with and without asthma.
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http://dx.doi.org/10.3390/jcm10102087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8152460PMC
May 2021

Dabigatran, rivaroxaban, and apixaban are superior to warfarin in Asian patients with non-valvular atrial fibrillation: An updated meta-analysis.

World J Cardiol 2021 Apr;13(4):82-94

Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, United States.

Background: Most of the randomized clinical trials that led to the wide use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with atrial fibrillation (AF) originated from western countries.

Aim: To systematically review and quantitatively synthesize the real-world data regarding the efficacy and safety of dabigatran, rivaroxaban, and apixaban compared to warfarin for stroke prevention in Asian patients with non-valvular AF.

Methods: Medline, Cochrane, and ClinicalTrial.gov databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. The primary outcome was ischemic stroke. The secondary outcomes were all-cause mortality, major bleeding, intracranial hemorrhage, and gastrointestinal bleeding.

Results: Twelve studies from East Asia or Southeast Asia and 441450 patients were included. Dabigatran, rivaroxaban, and apixaban were associated with a significant reduction in the incidence of ischemic stroke [hazard ratio (HR) = 0.78, 95% confidence interval (CI): 0.65-0.94; HR = 0.79, 95%CI: 0.74-0.85, HR = 0.70, 95%CI: 0.62-0.78; respectively], all-cause mortality (HR = 0.68, 95%CI: 0.56-0.83; HR = 0.66, 95%CI: 0.52-0.84; HR = 0.66, 95%CI: 0.49-0.90; respectively), and major bleeding (HR = 0.61, 95%CI: 0.54-0.69; HR = 0.70, 95%CI: 0.54-0.90; HR = 0.58, 95%CI: 0.43-0.78; respectively) compared to warfarin.

Conclusion: Dabigatran, rivaroxaban, and apixaban appear to be superior to warfarin in both efficacy and safety in Asians with non-valvular AF.
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http://dx.doi.org/10.4330/wjc.v13.i4.82DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8069517PMC
April 2021

BMI and pneumonia outcomes in critically ill COVID-19 patients: an international multicenter study.

Obesity (Silver Spring) 2021 May 9. Epub 2021 May 9.

Intensive Care Unit, Centre hospitalier de Dunkerque, 59240, Dunkerque.

Background: Previous studies unveiled a relation between the severity of COVID-19 pneumonia and obesity. The aims of this multicenter retrospective cohort study were to disentangle the association of BMI and associated metabolic risk factors (diabetes, hypertension, hyperlipidemia, current smoking) in critically ill patients with COVID-19.

Methods: This multicenter retrospective cohort study enrolled patients admitted in intensive care for COVID-19, in 21 centers (Europe, Israel, USA) between 02/19/2020 and 05/19/2020. Primary and secondary outcomes were the need for invasive mechanical ventilation (IMV), and 28-day mortality.

Results: A total of 1,461 patients were enrolled, median(IQR) age was 64 years (40.9-72.0); 73.2% males; BMI 28.1 kg/m (25.4-32.3); 1,080 patients (73.9%) required IMV; the 28-day mortality estimate was 36.1% (95%CI, 33.0-39.5). Adjusted mixed logistic regression model showed a significant linear relation between BMI and IMV: OR 1.27 (95%CI, 1.12-1.45) per 5 kg/m . Adjusted Cox proportional hazards regression model showed a significant association between BMI and mortality, which was only increased in obesity class III (≥40 kg/m ) (HR 1.68 (95%CI 1.06-2.64).

Conclusion: In critically ill COVID-19 patients, we observed a linear association between BMI and the need for IMV, independent of other metabolic risk factors, and a non-linear association between BMI and mortality risk. (NCT04391738).
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http://dx.doi.org/10.1002/oby.23223DOI Listing
May 2021

Sex-specific impact of severe obesity in the outcomes of hospitalized patients with COVID-19: a large retrospective study from the Bronx, New York.

Eur J Clin Microbiol Infect Dis 2021 May 6. Epub 2021 May 6.

Albert Einstein College of Medicine, Bronx, NY, USA.

It has been demonstrated that obesity is an independent risk factor for worse outcomes in patients with COVID-19. Our objectives were to investigate which classes of obesity are associated with higher in-hospital mortality and to assess the association between obesity and systemic inflammation. This was a retrospective study which included consecutive hospitalized patients with COVID-19 in a tertiary center. Three thousand five hundred thirty patients were included in this analysis (female sex: 1579, median age: 65 years). The median body mass index (BMI) was 28.8 kg/m. In the overall cohort, a J-shaped association between BMI and in-hospital mortality was depicted. In the subgroup of men, BMI 35-39.9 kg/m and BMI ≥40 kg/m were found to have significant association with higher in-hospital mortality, while only BMI ≥40 kg/m was found significant in the subgroup of women. No significant association between BMI and IL-6 was noted. Obesity classes II and III in men and obesity class III in women were independently associated with higher in-hospital mortality in patients with COVID-19. The male population with severe obesity was the one that mainly drove this association. No significant association between BMI and IL-6 was noted.
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http://dx.doi.org/10.1007/s10096-021-04260-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8101338PMC
May 2021

Vitamin D Status Is Associated With In-Hospital Mortality and Mechanical Ventilation: A Cohort of COVID-19 Hospitalized Patients.

Mayo Clin Proc 2021 04 9;96(4):875-886. Epub 2021 Jan 9.

Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA; Section of Endocrinology, VA Boston Healthcare System, Harvard Medical School, Boston, MA. Electronic address:

Objective: To explore the possible associations of serum 25-hydroxyvitamin D [25(OH)D] concentration with coronavirus disease 2019 (COVID-19) in-hospital mortality and need for invasive mechanical ventilation.

Patients And Methods: A retrospective, observational, cohort study was conducted at 2 tertiary academic medical centers in Boston and New York. Eligible participants were hospitalized adult patients with laboratory-confirmed COVID-19 between February 1, 2020, and May 15, 2020. Demographic and clinical characteristics, comorbidities, medications, and disease-related outcomes were extracted from electronic medical records.

Results: The final analysis included 144 patients with confirmed COVID-19 (median age, 66 years; 64 [44.4%] male). Overall mortality was 18%, whereas patients with 25(OH)D levels of 30 ng/mL (to convert to nmol/L, multiply by 2.496) and higher had lower rates of mortality compared with those with 25(OH)D levels below 30 ng/mL (9.2% vs 25.3%; P=.02). In the adjusted multivariable analyses, 25(OH)D as a continuous variable was independently significantly associated with lower in-hospital mortality (odds ratio, 0.94; 95% CI, 0.90 to 0.98; P=.007) and need for invasive mechanical ventilation (odds ratio, 0.96; 95% CI, 0.93 to 0.99; P=.01). Similar data were obtained when 25(OH)D was studied as a continuous variable after logarithm transformation and as a dichotomous (<30 ng/mL vs ≥30 ng/mL) or ordinal variable (quintiles) in the multivariable analyses.

Conclusion: Among patients admitted with laboratory-confirmed COVID-19, 25(OH)D levels were inversely associated with in-hospital mortality and the need for invasive mechanical ventilation. Further observational studies are needed to confirm these findings, and randomized clinical trials must be conducted to assess the role of vitamin D administration in improving the morbidity and mortality of COVID-19.
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http://dx.doi.org/10.1016/j.mayocp.2021.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834253PMC
April 2021

Early and Significant Reduction in C-Reactive Protein Levels After Corticosteroid Therapy Is Associated With Reduced Mortality in Patients With COVID-19.

J Hosp Med 2021 03;16(3):142-148

Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York.

Background: Corticosteroids may be beneficial in a subset of patients with coronavirus disease 2019 (COVID-19), but predictors of therapeutic response remain unknown. C-reactive protein (CRP) is a routinely measured biomarker, and reduction in its levels after initiation of therapy may predict inpatient mortality.

Methods: In this retrospective cohort study, the charts of patients who were admitted to Montefiore Medical Center between March 10, 2020, and May 2, 2020 for the management of COVID-19 were examined. Of all patients who met inclusion criteria, patients who received corticosteroid treatment were categorized as CRP responders (≥50% CRP level reduction) and CRP nonresponders (<50% CRP level reduction) based on change in CRP within 72 hours of corticosteroid treatment initiation. The outcomes of interest were two-fold: (1) CRP response after treatment with corticosteroid, and (2) differences in mortality among patients with CRP response compared those without.

Results: Of 2,707 patients admitted during the study period, 324 received corticosteroid treatment. Of patients who received corticosteroid treatment, CRP responders had reduced risk of death compared with risk among CRP nonresponders (25.2% vs 47.8%; unadjusted odds ratio [OR], 0.37; 95% CI, 0.21-0.65; P <.001). This effect remained strong and significant after adjustment for potential confounders (adjusted OR, 0.27; 95% CI, 0.14-0.54; P <.001).

Conclusion: Reduction in CRP by 50% or more within 72 hours of initiating corticosteroid therapy potentially predicts inpatient mortality. This may serve as an early biomarker of response to corticosteroid therapy in patients with COVID-19.
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http://dx.doi.org/10.12788/jhm.3560DOI Listing
March 2021

Venous thromboembolism in the era of COVID-19.

Phlebology 2021 Mar 10;36(2):91-99. Epub 2020 Sep 10.

Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, USA.

Coronavirus disease 2019 (COVID-19) does not only affect the respiratory system but appears to be a systemic disease. Venous thromboembolism is a common manifestation in hospitalized patients with COVID-19 with a reported incidence that is significantly higher compared to other acute viral infections. The pathophysiology mechanisms have not been fully explored and autopsy studies might enhance our understanding on this topic. Microthrombi formation occurs mainly in the pulmonary vasculature but can also occur in other organs. The high inflammatory burden related to COVID-19 seems to be associated with the coexisting coagulopathy. Concomitant manifestations of COVID-19, such as severe pneumonia, which has similar clinical presentation with pulmonary embolism (PE), and barriers related to strict isolation protocols are the two main reasons why PE diagnosis might be more challenging in patients with COVID-19. Medical societies have published guidance reports suggesting the administration of prophylactic anticoagulant therapy in hospitalized patients with COVID-19, but several questions regarding the optimal acute and long-term treatment of these patients remain unanswered.
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http://dx.doi.org/10.1177/0268355520955083DOI Listing
March 2021

Diabetes is associated with increased risk for in-hospital mortality in patients with COVID-19: a systematic review and meta-analysis comprising 18,506 patients.

Hormones (Athens) 2021 Jun 29;20(2):305-314. Epub 2020 Oct 29.

Albert Einstein College of Medicine, 1400 Pelham Parkway South, Bronx, NY, 10461, USA.

Purpose: Infectious diseases are more frequent and can be associated with worse outcomes in patients with diabetes. The aim of this study was to systematically review and conduct a meta-analysis of the available observational studies reporting the effect of diabetes on mortality among hospitalized patients with COVID-19.

Methods: The Medline, Embase, Google Scholar, and medRxiv databases were reviewed for identification of eligible studies. A random effects model meta-analysis was used, and I was utilized to assess the heterogeneity. In-hospital mortality was defined as the endpoint. Sensitivity, subgroup, and meta-regression analyses were performed.

Results: A total of 18,506 patients were included in this meta-analysis (3713 diabetics and 14,793 non-diabetics). Patients with diabetes were associated with a higher risk of death compared with patients without diabetes (OR 1.65; 95% CI 1.35-1.96; I 77.4%). The heterogeneity was high. A study-level meta-regression analysis was performed for all the important covariates, and no significant interactions were found between the covariates and the outcome of mortality.

Conclusion: This meta-analysis shows that that the likelihood of death seems to be higher in diabetic patients hospitalized with COVID-19 compared with non-diabetic patients. Further studies are needed to assess whether this association is independent or not, as well as to investigate the role of adequate glycemic control prior to infection with COVID-19.
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http://dx.doi.org/10.1007/s42000-020-00246-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595056PMC
June 2021

Comprehensive review of hemolysis in ventricular assist devices.

World J Cardiol 2020 Jul;12(7):334-341

Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, United States.

Ventricular assist devices (VADs) have played an important role in altering the natural history of end-stage heart failure. Low-grade hemolysis has been traditionally described in patients with VADs, indicating effective device functionality. However, clinically significant hemolysis could be crucial in terms of prognosis, calling for prompt therapeutic actions. The absence of solid and widely approved diagnostic criteria for clinically significant hemolysis, render the utilization of hemolysis laboratory markers challenging. Hemolysis incidence varies (5%-18%) depending on definition and among different VAD generations, being slightly higher in continuous-flow devices than in pulsatile devices. Increased shear stress of red blood cells and underlying device thrombosis appear to be the main pathogenetic pathways. No certain algorithm is available for the management of hemolysis in patients with VADs, while close clinical and laboratory monitoring remains the cornerstone of management. Imaging examinations such as echocardiography ramp test or computed tomography scan could play a role in revealing the underlying cause. Treatment should be strictly personalized, including either pharmacological (antithrombotic treatment) or surgical interventions.
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http://dx.doi.org/10.4330/wjc.v12.i7.334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415236PMC
July 2020

Predictors of vertigo in the emergency department: The preved study.

J Stroke Cerebrovasc Dis 2020 Sep 25;29(9):105043. Epub 2020 Jun 25.

NYC Health+Hospitals/Jacobi, Albert Einstein College of Medicine, Bronx, NY, USA. Electronic address:

Background And Purpose: Acute vertigo (sense of motion) can be the sole manifestation of a posterior circulation stroke, and often gets missed in the emergency department (ED). The studies for evaluation of central vertigo have focused on physical exam findings, which require expertise and may not be suitable for rapid triage by a nurse in ED or by paramedics.

Methods: This cross sectional study included retrospective chart review of patients 18 years of age and older who presented to the Adult ED with acute dizziness or vertigo during the calendar year 2017. All the patients with a diagnosis of central or peripheral vertigo were included in the final analysis. Sensitivity, specificity, Likelihood Ratio of positive result (LR (+)) and Likelihood Ratio of negative result (LR (-)) for central and peripheral vertigo were calculated for risk factors, symptoms and physical examination features. Chi-squared test and univariate logistic regression were used to evaluate statistical correlation and to calculate the prevalence odds ratio (POR).

Results: Two hundred and forty nine out of 505 (49.3%) patients presenting with dizziness had vertigo. Of these, 14 had central vertigo and 163 had peripheral vertigo. Statistically significant variables were: constant symptoms of vertigo (p 0.000- POR 8.7, 95% confidence interval (CI) 2.3-33.1), no change in symptoms with head movement (p 0.000- POR 10.2, 95% CI 3.0-35.4), dysmetria (p 0.000- POR 56.8, 95% CI 5.8-557.1), and unsteady gait (p 0.000- POR 13.3, 95% CI 3.3-54.3). The sensitivity and specificity to detect central vertigo were 100% and 66.4% respectively if the patient had either unsteady gait, constant symptoms, or no change in symptoms with head movement, [VAIN triad (Vertigo- Ataxia, Incessant, or Non-positional)].

Conclusions: We suggest that triage with VAIN triad can be used to design prospective studies to develop a triage algorithm for the detection of central vertigo in the ED.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105043DOI Listing
September 2020

Practices and Barriers in Sexual History Taking: A Cross-Sectional Study in a Public Adult Primary Care Clinic.

J Sex Med 2020 08 28;17(8):1509-1519. Epub 2020 Jun 28.

Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

Background: Surveys report low frequencies of sexual history (SH) obtained in primary care. Sexually transmitted infections incidence can be reduced with timely screening. It is important to determine whether providers obtain thorough SH and to identify needs for improvement.

Aim: To evaluate the frequency and depth of SH taking in primary care.

Methods: In this cross-sectional cohort study, 1,017 primary care visits were reviewed (1,017 adult patients, female 55.26%). 417 patients were seen by male providers and 600 patients were seen by female providers. Multivariate ordered and logit models were deployed.

Main Outcome Measures: The primary outcome measures included SH taking rates and completeness based on the 5 P model as described by the Centers for Disease Control and Prevention.

Results: All components of SH were explored in 1.08% of visits. Partial SH was obtained in 33.92% of visits. No SH was taken in the majority of visits (65%). SH was more likely to be taken from female patients than from male patients (P < .001), and was less likely to be obtained from older patients as compared to younger individuals (P < .001). There was no significant difference in SH taking between male and female providers (P = .753). The provider title and the level of training were found to be independent predictors of SH taking (P < .001).

Clinical Implications: The results of this study highlight an unmet need for more comprehensive and consistent SH taking amongst providers, particularly in high-risk settings, so that SH can be used as a valuable tool in preventive care.

Strengths & Limitations: To the best of our knowledge, this is the largest study to date examining SH taking in the primary care setting. Limitations include the retrospective study design, lack of generalizability to other hospitals, and inconsistencies in available data.

Conclusion: The SH taking rates in primary care clinics are globally low with a variation depending on the provider position or level of training, provider gender, and patient age. Palaiodimos L, Herman HS, Wood E, et al. Practices and Barriers in Sexual History Taking: A Cross-Sectional Study in a Public Adult Primary Care Clinic. J Sex Med 2020;17:1509-1519.
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http://dx.doi.org/10.1016/j.jsxm.2020.05.004DOI Listing
August 2020

Severe obesity, increasing age and male sex are independently associated with worse in-hospital outcomes, and higher in-hospital mortality, in a cohort of patients with COVID-19 in the Bronx, New York.

Metabolism 2020 07 16;108:154262. Epub 2020 May 16.

Section of Endocrinology, VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA.

Background & Aims: New York is the current epicenter of Coronavirus disease 2019 (COVID-19) pandemic. The underrepresented minorities, where the prevalence of obesity is higher, appear to be affected disproportionately. Our objectives were to assess the characteristics and early outcomes of patients hospitalized with COVID-19 in the Bronx and investigate whether obesity is associated with worse outcomes independently from age, gender and other comorbidities.

Methods: This retrospective study included the first 200 patients admitted to a tertiary medical center with COVID-19. The electronic medical records were reviewed at least three weeks after admission. The primary endpoint was in-hospital mortality.

Results: 200 patients were included (female sex: 102, African American: 102). The median BMI was 30 kg/m. The median age was 64 years. Hypertension (76%), hyperlipidemia (46.2%), and diabetes (39.5%) were the three most common comorbidities. Fever (86%), cough (76.5%), and dyspnea (68%) were the three most common symptoms. 24% died during hospitalization (BMI < 25 kg/m: 31.6%, BMI 25-34 kg/m: 17.2%, BMI ≥ 35 kg/m: 34.8%, p = 0.03). Increasing age (analyzed in quartiles), male sex, BMI ≥ 35 kg/m (reference: BMI 25-34 kg/m), heart failure, CAD, and CKD or ESRD were found to have a significant univariate association with mortality. The multivariate analysis demonstrated that BMI ≥ 35 kg/m (reference: BMI 25-34 kg/m, OR: 3.78; 95% CI: 1.45-9.83; p = 0.006), male sex (OR: 2.74; 95% CI: 1.25-5.98; p = 0.011) and increasing age (analyzed in quartiles, OR: 1.73; 95% CI: 1.13-2.63; p = 0.011) were independently associated with higher in-hospital mortality. Similarly, age, male sex, BMI ≥ 35 kg/m and current or prior smoking were significant predictors for increasing oxygenation requirements in the multivariate analysis, while male sex, age and BMI ≥ 35 kg/m were significant predictors in the multivariate analysis for the outcome of intubation.

Conclusions: In this cohort of hospitalized patients with COVID-19 in a minority-predominant population, severe obesity, increasing age, and male sex were independently associated with higher in-hospital mortality and in general worse in-hospital outcomes.
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http://dx.doi.org/10.1016/j.metabol.2020.154262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228874PMC
July 2020

Derotational Subtrochanteric Osteotomy and External Fixation for the Treatment of Neurogenic Hip Dislocation in Children with Cerebral Palsy: Could This Be a Viable Method of Treatment?

Cureus 2020 Mar 27;12(3):e7437. Epub 2020 Mar 27.

Orthopaedics, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, GRC.

Purpose The treatment of painful and chronic dislocated hip in children with severe cerebral palsy (CP) is particularly demanding and controversial. Numerous surgical techniques have been described, and their outcomes vary a lot. The purpose of the present study is to evaluate a new method, which combines varus derotational subtrochanteric osteotomy (VDSO) and external osteosynthesis: (VDSOEO). Methods Six non-ambulatory children with spastic quadriplegia and chronic dislocated painful hips were treated. The technique involved a small incision on the subtrochanteric site of the osteotomy, followed by retention with a single-sided external osteosynthesis with rotational correction capability [swiveling clamp (SC)] for the reduction of the femur head in the acetabulum, and finally by the osteotomy. Hardware was removed without a second intervention four-six months postoperatively and after the osteotomy was healed. Evaluation of the method was based on clinical, functional, and radiological criteria. Results  Four patients achieved improved radiological scores. Two patients demonstrated resubluxation during the period of the osteotomy's healing process. However, no patients experienced pain, and all were able to sit post-surgery, while caregivers reported improved capacity for nursing care. Conclusions It is our strong belief that this approach can improve the quality of life in children with severe CP and painful and chronic dislocated hips. It is a viable and definitely less invasive procedure than classic pelvic or femur osteotomies.
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http://dx.doi.org/10.7759/cureus.7437DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186101PMC
March 2020

Combination of low-dose glucocorticosteroids and mineralocorticoids as adjunct therapy for adult patients with septic shock: A systematic review and meta-analysis of randomized trials and observational studies.

Avicenna J Med 2019 Oct-Dec;9(4):134-142. Epub 2019 Oct 3.

Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.

Background: The role of the combination of glucocorticosteroids and mineralocorticosteroids in treating septic shock is not well-defined. The aim of this study was to perform a systematic review and meta-analysis of the randomized controlled trials and observational studies assessing the effect of low-dose hydrocortisone and fludrocortisone on patients with septic shock.

Materials And Methods: MEDLINE, Scopus, and Cochrane databases were reviewed. A random effect model meta-analysis was used and -square was used to assess the heterogeneity. Short-term mortality was chosen as our primary end point. A subgroup analysis was performed including only the randomized controlled trials.

Results: A total of 10,550 patients were included in this meta-analysis. Administration of the steroid combination was associated with improved short-term mortality (odds ratio, 0.78, confidence interval, 0.64-0.96), intensive care unit mortality, and shock reversal, without increase in steroid-related side effects, such as secondary infection or gastrointestinal hemorrhage.

Conclusion: This systematic review and meta-analysis showed that use of the combination of glucocorticosteroids and mineralocorticosteroids has a beneficial impact on short-term mortality, intensive care unit mortality, and shock reversal, without increasing the incidence of gastrointestinal hemorrhage or superinfection in patients with septic shock, when used as an adjunct treatment to the established standard of care.
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http://dx.doi.org/10.4103/ajm.AJM_97_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6796303PMC
October 2019

Transcatheter Closure of Patent Foramen Ovale: Randomized Trial Update.

Interv Cardiol Clin 2019 10 27;8(4):341-356. Epub 2019 Jul 27.

Division of Cardiology, Department of Medicine, Virginia Commonwealth University, 1101 East Marshall Street, Richmond, VA 23298, USA.

A patent foramen ovale (PFO) is found in about one-quarter of all adults, but the prevalence increases to approximately half of those with a history of a so-called cryptogenic stroke. The true efficacy of PFO closure for prevention of recurrent paradoxical embolism has been debated for years, as the early 3 randomized trials did not show a statistically significant benefit of PFO closure over standard-of-care medical therapy. However, 3 recent randomized trials along with the long-term follow-up data from the largest early trial demonstrated superiority of device closure for secondary stroke prevention.
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http://dx.doi.org/10.1016/j.iccl.2019.05.002DOI Listing
October 2019

Questions on Percutaneous Patent Foramen Ovale Closure for Secondary Stroke Prevention: The Heads of the Lernaean Hydra.

Cardiology 2019 17;144(1-2):50-52. Epub 2019 Jul 17.

Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.

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http://dx.doi.org/10.1159/000501231DOI Listing
November 2019

A Rare Case of Pseudo-atrial Flutter Waves in a Patient with Essential Tremor.

Cureus 2019 Jan 21;11(1):e3934. Epub 2019 Jan 21.

Cardiology, 424 General Military Hospital, Thessaloniki, GRC.

High-frequency muscle tremor can mimic atrial flutter. Unnecessary therapies and aggressive interventions may have devastating consequences in these cases. We present a case of a patient with global pseudo-atrial flutter waves in the setting of essential tremor strictly confined to the arms. Two-dimensional transthoracic echocardiography (2D TTE) was used to discriminate normal sinus rhythm from pseudo-atrial flutter waves.
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http://dx.doi.org/10.7759/cureus.3934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6430307PMC
January 2019

The best DEFENSE for high-risk patent foramen ovale: An updated meta-analysis of six randomized trials.

Arch Cardiovasc Dis 2019 Mar 26;112(3):150-152. Epub 2018 Dec 26.

Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 10461 NY, USA.

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http://dx.doi.org/10.1016/j.acvd.2018.06.001DOI Listing
March 2019

Reversal of Novel Anticoagulants in Emergent Surgery and Trauma: A Comprehensive Review and Proposed Management Algorithm.

Curr Pharm Des 2018 ;24(38):4540-4553

First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece.

Non-vitamin K oral anticoagulants (NOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban, are increasingly used for thromboembolism prevention. Contrary to older anticoagulants, such as coumadin, when antidotes existed and were broadly used in cases of emergent surgery and bleeding, antidotes for NOACs have not been developed until recently. Moreover, the monitoring of NOAC's anticoagulant effect varies across different hospital settings and the absence of a single test that can accurately predict the degree of anticoagulation achieved increases the uncertainty. These uncertainties often result in management dilemmas for clinicians when patients who are on NOACs need a reversal of anticoagulation. Until recently, available antidotes for NOACs included only prothrombin complex concentrate (PCC), activated prothrombin complex concentrate (aPCC) and recombinant activated factor VII and the less optimal fresh frozen plasma (FFP). Recently though, novel antidotes for NOACs have been developed, including idarucizumab, which is a monoclonal antibody fragment that binds dabigatran, and andexanet alfa, a modified decoy form of the activated factor X (FXa) that binds FXa inhibitors and AT III. Another option, ciraparantag, which is a small molecule that binds to heparin, thrombin inhibitors and FXa inhibitors, is still in phase I development. In this review, we summarize the current evidence and present the available bypassing and novel reversal agents. Finally, we propose an algorithm for the management of patients who take NOACs and present to the emergency department with either trauma and active bleeding or need for emergent surgery.
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http://dx.doi.org/10.2174/1381612825666181226150629DOI Listing
November 2019

The predictive value of baseline pulmonary hypertension in early and long term cardiac and all-cause mortality after transcatheter aortic valve implantation for patients with severe aortic valve stenosis: A systematic review and meta-analysis.

Cardiovasc Revasc Med 2018 Oct - Nov;19(7 Pt B):859-867. Epub 2018 Mar 23.

1st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Background: Transcatheter aortic valve implantation (TAVI) is a safe and effective alternative to surgical aortic valve replacement (SAVR) for the treatment of severe aortic valve stenosis (AS). The impact of concomitant baseline elevated pulmonary artery pressures on outcomes after TAVI has not been established, since different studies used different definitions of pulmonary hypertension (PH).

Objective: To determine the association of PH with early and late cardiac and all-cause mortality after TAVI.

Methods: We performed a meta-analysis of studies comparing patients with elevated pulmonary artery pressures (defined as pulmonary hypertension or not) versus patients without elevated pulmonary artery pressures undergoing TAVI. We first performed stratified analyses based on the different PH cut-off values utilized by the included studies and subsequently pooled the studies irrespective of their cut-off values. We used a random effects model for the meta-analysis and assessed heterogeneity with I-square. Separate meta-analyses were performed for studies reporting outcomes as hazards ratios (HRs) and relative risks (RRs). Subgroup analyses were performed for studies published before and after 2013. Meta-regression analysis in order to assess the effect of chronic obstructive pulmonary disease and mitral regurgitation were performed.

Results: In total 22 studies were included in this systematic review. Among studies presenting results as HR, PH was associated with increased late cardiac mortality (HR: 1.8. 95% CI: 1.3-2.3) and late all-cause mortality (HR: 1.56; 95% CI: 1.1-2). The PH cut-off value that was most likely to be associated with worst outcomes among the different endpoints was pulmonary artery systolic pressure of 60 mm Hg (HR: 1.8; 95% CI: 1.3-2.3; I = 0, for late cardiac mortality and HR: 1.52; 95% CI: 1-2.1; I = 85% for late all-cause mortality).

Conclusion: This systematic review and meta-analysis emphasizes the importance of baseline PH in predicting mortality outcomes after TAVI. Additional studies are needed to clarify the association between elevated baseline pulmonary artery pressures and outcomes after TAVI.
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http://dx.doi.org/10.1016/j.carrev.2018.03.015DOI Listing
August 2019

Extra Oxygen Leads to Bubble Trouble: Portal Vein Gas Embolism from 3% Hydrogen Peroxide Ingestion.

Cureus 2018 Feb 1;10(2):e2136. Epub 2018 Feb 1.

Department of Medicine, Albert Einstein College of Medicine/ Jacobi Medical Center.

Hydrogen peroxide ingestion can cause gastric irritation and gas embolism; however, most reported cases are from the highly concentrated (≥35%) solution used in the industry and data on household-used 3% solution ingestion is scarce. We report a case of a portal vein gas embolism after ingestion of 3% hydrogen peroxide. The patient was managed conservatively with antacids and improved in 48 hours. Endoscopy and hyperbaric treatment were considered but not pursued. This is the fifth reported case of gas embolism after 3% hydrogen peroxide ingestion and stands in line with other reports where the patients improved with conservative management.
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http://dx.doi.org/10.7759/cureus.2136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878092PMC
February 2018

Percutaneous closure of patent foramen ovale vs. medical treatment for patients with history of cryptogenic stroke: A systematic review and meta-analysis of randomized controlled trials.

Cardiovasc Revasc Med 2018 Oct - Nov;19(7 Pt B):852-858. Epub 2018 Mar 2.

Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States.

Background: Patients with history of cryptogenic stroke are more likely to have a patent foramen ovale (PFO) and should be managed with antithrombotic agents, while the alternative option is percutaneous closure of PFOs. Our aim was to perform a meta-analysis of randomized controlled trials (RCTs) comparing percutaneous closure vs. medical treatment for patients with PFO and prior cryptogenic stroke.

Methods: Medline, Scopus and Cochrane databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. New ischemic stroke was defined as the primary endpoint. A sensitivity analysis was performed for Amplatzer device. Subgroup analyses were performed for different patient and PFO characteristics for the composite endpoints as defined by the included RCTs.

Results: In total of 3440 patients were included in this meta-analysis. Closure devices were superior to medical therapy for prevention of recurrent ischemic strokes (HR = 0.29; CI: 0.02-0.56), but were associated with increased risk of new onset of atrial fibrillation (AF) and atrial flutter (RR = 4.67; CI: 2.22-9.81). However, in the sensitivity analysis for Amplatzer device, there was no difference between the two groups in new onset of atrial arrhythmias. Closure devices were superior across all different subgroups when compared to medical treatment with the exception of patients with a small shunt.

Conclusion: This meta-analysis shows that closure devices for patients with PFO and history of cryptogenic stroke can significantly decrease the risk of a new ischemic stroke. The use of Amplatzer device was not associated with increased risk of newly diagnosed atrial arrhythmias.
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http://dx.doi.org/10.1016/j.carrev.2018.02.014DOI Listing
August 2019

Bilateral sphenopalatine ganglion block reduces blood pressure in never treated patients with essential hypertension. A randomized controlled single-blinded study.

Int J Cardiol 2018 Jan 16;250:233-239. Epub 2017 Oct 16.

2nd Cardiology Department, Medical School, University of Athens, ATTIKON Hospital, Athens, Greece.

Background: Sympathetic fibers connect sphenopalatine ganglion (SPG) with the central nervous system. We aimed to study the effect of SPG block in blood pressure (BP) in never treated patients with stage I-II essential hypertension.

Methods: We performed bilateral SPG block with lidocaine 2% in 33 hypertensive patients (mean age 48±12years, 24 men) and a sham operation with water for injection in 11 patients who served as the control group (mean age 51±12years, 8 men). All patients have been subjected to 24h ambulatory blood pressure monitoring prior and a month after the SBG block in order to estimate any differences in blood pressure parameters. We defined as responders to SBG block those patients with a 24h SBP decrease ≥5mmHg.

Results: We found that 24h and daytime DBP (p=0.02) as well as daytime DBP load (p=0.03) were decreased in the study group a month after SPG block. In addition, a significant response was noted in 12/33 responders (36%) regarding: a. SBP and DBP during overall 24h and daytime (p<0.001) and night-time periods, b. pre-awake and early morning SBP and c. SBP (daytime and night-time) and DBP (daytime) load. No differences regarding BP were found in the sham operation group.

Conclusions: SPG block is a promising, minimally invasive option of BP decrease in hypertensives, probably through SNS modulation. Additionally, due to its anesthetic effect, SPG block might act as a method of selection for those hypertensive patients with an activated SNS before any other invasive antihypertensive procedure.
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http://dx.doi.org/10.1016/j.ijcard.2017.10.042DOI Listing
January 2018

F-FDG PET/CT Imaging of Pulmonary Mucinous Cystadenocarcinoma with Signet Ring Cells.

Nucl Med Mol Imaging 2017 Sep 15;51(3):277-280. Epub 2016 Feb 15.

Department of Nuclear Medicine, 251 Greek Airforce Hospital, Athens, Greece.

A 63-year-old male with a recently diagnosed right lung lesion was referred for staging. F-FDG PET/CT scan revealed a hypodense, cystic-like mass in the right upper lung lobe, which demonstrated low, diffuse F-FDG uptake, likely due to the presence of mucus, as well as intensely hypermetabolic right hilar and right paratracheal lymph nodes. Transbronchial biopsy revealed a primary pulmonary mucinous cystadenocarcinoma with the presence of signet ring cell carcinoma, a co-existence of two rare variants of lung adenocarcinoma. This case report demonstrates the metabolic phenotype along with the radiographic characteristics of this rare tumor and its metastases.
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http://dx.doi.org/10.1007/s13139-016-0402-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5567612PMC
September 2017

The independent association of two "priceless" parameters: Pulse pressure and red cell distribution width in recently diagnosed hypertensive patients.

Hellenic J Cardiol 2016 Nov - Dec;57(6):459-462. Epub 2016 Nov 17.

2(nd) Department of Cardiology Medical School, University of Athens, ATTIKON Hospital, Athens, Greece.

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http://dx.doi.org/10.1016/j.hjc.2016.11.018DOI Listing
January 2018

Infiltration of the sphenopalatine ganglion decreases blood pressure in newly diagnosed and never treated patients with essential hypertension.

Int J Cardiol 2016 Nov 13;223:345-351. Epub 2016 Aug 13.

2nd Cardiology Department, Medical School, University of Athens, Attikon Hospital, Athens, Greece.

Background: Sphenopalatine ganglion (SPG), an extracranial structure, is connected with the central nervous system (CNS) through sympathetic and parasympathetic nerves. We hypothesized that SPG block through sympathetic nerves anesthesia might decrease blood pressure (BP) in recently diagnosed and never treated middle-aged patients with essential hypertension.

Methods: We performed SBG block in 22 hypertensive patients (mean age 45±12years, 15 men). All patients have been subjected to 24hour ambulatory blood pressure monitoring a week prior the procedure as well as in a period of 21-30days after the SBG block in order to estimate differences in 24h average systolic (24h SBP) and diastolic blood pressure (24h DBP), daytime, nighttime, pre-awake and early morning SBP and DBP as well as BP load.

Results: We found that 24h SBP (p=0.001) and 24h DBP (p<0.001), daytime SBP and DBP (p<0.001) as well as daytime SBP and DBP load (p=0.002 and p<0.001, respectively) were decreased in total population at 21-30days after SPG block. In 11/22 responders (24h SBP decrease ≥5mmHg), SBP and DBP were reduced during overall 24h and daytime (p<0.001) and nighttime periods (p=0.01 and p=0.06, respectively) while pre-awake SBP (p=0.09) along with daytime SBP and DBP load (p=0.07 and p=0.06, respectively) were also almost decreased.

Conclusions: SBG block might be a promising, non-invasive, safe, painless and easy to perform therapeutic option of BP decrease. As with renal denervation, SBG should be effective in those hypertensive patients with an activated SNS, so a period of patient selection should precede the application of this procedure.
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http://dx.doi.org/10.1016/j.ijcard.2016.08.230DOI Listing
November 2016