Internal and emergency medicine
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Size threshold for aortic surgery in bicuspid aortic valve (BAV) is debated. Connective tissue disorders (CTDs) are claimed as a clinical turning point, suggesting early surgery in BAV patients with CTD. Thus, we aimed at developing a score to detect high risk of carrying CTDs in consecutive BAVs from primary care. ⋯ We selected traits with high statistical difference between MFS and BAV easily obtainable by cardiologists and primary-care internists: mitral valve prolapse, myopia ≥ 3DO, pectus carenatum, pes planus, wrist and thumb signs, and difference between aortic size at root and ascending aorta ≥ 4 mm. Clustering of ≥ 3 of these manifestations were more frequent in Marfan patients than in BAVs (71.4% vs 6.1%, p < 0.0001) resulting into an Odds Ratio to be affected by MFS of 38.3 (95% confidence intervals 14.8-99.3, p < 0.0001). We propose a score assembling simple clinical and echocardiographic variables resulting in an appropriate referral pattern of BAVs from a primary-care setting to a tertiary center to evaluate the presence of a potential, major CTD.
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Observational Study
Prognostic stratification in septic patients with overt and cryptic shock by speckle tracking echocardiography.
We evaluated the prevalence and prognostic value of left (LV) and right (RV) ventricular systolic dysfunction in the presence of overt and cryptic shock. In this prospective study, between October 2012 and June 2019, we enrolled 354 patients with sepsis, 41% with shock, among those admitted to the Emergency Department High-Dependency Unit. Patients were grouped based on the presence of shock, or by the presence of lactate levels ≥ (LAC +) or < 2 mmol/L (LAC-) evaluated within the first 24 h. ⋯ In patients without shock, as well as in those LAC-, LV dysfunction was associated with increased day-28 mortality rate (78% vs 57% in non-survivors and survivors without shock and 74% vs 53% in non-survivors and survivors LAC-, all p < 0.01). LV (RR 2.26, 95% CI 1.37-3.74) and RV systolic dysfunction (RR 1.85, 95% CI 1.22-2.81) were associated with increased 28-day mortality rate in addition and independent to LAC + (RR 1.81, 95% CI 1.15-2.84). In conclusion, LV and RV ventricular dysfunction were independently associated with an increased mortality rate, altogether with the presence of cryptic shock.
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Pacemaker implantation can be complicated by ventricular perforation. We present a case of diaphragmatic stimulation induced by right ventricular pacemaker lead perforation.
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Observational Study
New indices of arterial stiffness correlate with disease severity and mid-term prognosis in acute decompensated heart failure.
Arterial stiffness has been implicated in pathophysiology of heart failure (HF) since it is involved in the ventricular-vascular coupling. Recently, new indices obtained by a cuff oscillometric technique, the arterial velocity pulse index (AVI) for the stiffness of central arteries and the arterial pressure volume index (API) for the stiffness of peripheral arteries have been developed and validated. However, the AVI and API measurement has not been attempted in HF population. ⋯ Apart from the level of NT-proBNP, the AVI at discharge of ≥ 26 showed a trend of being associated with the composite outcome (HR 2.747, 95% CI 1.411-5.349, P < 0.001 for univariate analysis; HR 1.864, 95% CI 0.892-3.893, P = 0.09761 for multivariate analysis). New noninvasive arterial stiffness indices as the AVI and API reflected severity of illness and midterm prognosis in admitted HF patients. Further studies are warranted for understanding its mechanisms and developing clinical applications.
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Proton pump inhibitors (PPI)-related hypomagnesemia is a potentially life-threatening adverse event first described in 2006. PPIs are widely used in the general population. Information regarding prevalence and risk factors is scarce. ⋯ Adult patients with long-term use of PPIs have a high prevalence of hypomagnesemia. Increasing age, female sex, concomitant use of drugs that impair tubular function and chronic kidney disease may enhance this phenomenon. Anemia, hyponatremia and malignant bone compromise were associated factors with PPIs-related hypomagnesemia.