Hypothyroidism and the risk of lower extremity arterial disease

Background: Although an independent association between hypothyroidism and coronary artery disease has been demonstrated, few studies have examined the association between hypo-thyroidism and peripheral arterial disease. In the current study, we test the hypothesis that there is an independent association between hypothyroidism and lower extremity arterial disease. Methods: We retrospectively compared the prevalence of hypothyroidism in patients who had infra-inguinal arterial bypass surgery over a 6-year period with that of a control group of surgical patients who had pure cardiac valve surgery during the same time period. Both unadjusted and adjusted odds ratios were calculated to estimate the association between hypothyroidism and lower extremity arterial disease. Results: A total of 614 cases and 529 control subjects had surgery during the study period. When comparing all subjects, there was no association between hypothyroidism and lower extremity arterial disease (unadjusted odds ratio 0.88; 95% confidence intervals [CI]: 0.61-1.28). However, gender was found to be a significant effect modifier (P \u3c 0.001), and gender-stratified analyses were subsequently performed. In men, there was a positive independent association between hypothyroidism and lower extremity arterial disease (adjusted odds ratio 2.65; 95% CI: 1.19-5.89), whereas in women there was a negative independent association (adjusted odds ratio 0.22; 95% CI: 0.11-0.46). Conclusions: Gender is a significant effect modifier for the association between hypothyroidism and lower extremity arterial disease. The association is positive in men and negative in women. Future prospective studies that evaluate hypothyroidism as a risk factor for peripheral arterial disease should consider gender stratification in order to corroborate this finding. © 2010 Mazzeffi et al, publisher and licensee Dove Medical Press Ltd

Case Report Asystole after Orthotopic Lung Transplantation: Examining the Interaction of Cardiac Denervation and Dexmedetomidine

Dexmedetomidine is an α 2 -receptor agonist commonly used for sedation and analgesia in ICU patients. Dexmedetomidine is known to provide sympatholysis and also to have direct atrioventricular and sinoatrial node inhibitory effects. In rare instances, orthotopic lung transplantation has been associated with disruption of autonomic innervation of the heart. The combination of this autonomic disruption and dexmedetomidine may be associated with severe bradycardia and/or asystole. Since orthotopic lung transplant patients with parasympathetic denervation will not respond with increased heart rate to anticholinergic therapy, bradyarrhythmias must be recognized and promptly treated with direct acting beta agonists to avoid asystolic cardiac events

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification

Socioeconomic position is not associated with 30-day or 1-year mortality in demographically diverse vascular surgery patients

Objectives: Disparities in outcomes after surgical procedures have been attributed to race, sex, use of private insurance, and socioeconomic position (SEP). The purpose of this study was to determine the impact of SEP on mortality after lower-extremity bypass (LEB) surgery in a diverse patient population with extremes of SEP. Design: Analysis of an electronic medical database. Setting: A tertiary care hospital in a demographically diverse section of a large metropolitan area. Participants: Six hundred nine (158 white men, 156 nonwhite men, 100 white women, and 195 non-white women) patients undergoing infrarenal lower-extremity arterial bypass surgery from July 1, 2002, to December 31, 2007. Measurements and Results: SEP was estimated using data from the 2000 US Census. The effects of race, sex, various comorbidities, the Revised Cardiac Risk Index, American Society of Anesthesiologists physical status, use of private insurance, indication for bypass surgery, and SEP on all-cause mortality was analyzed. SEP differed significantly among the 4 race-sex groups, with white men having the highest position (mean = 2.38) and non-white men having the lowest position (mean = -3.02). There was no statistically significant association in 30-day mortality among race-sex groups or with SEP. One-year mortality differed significantly between men and women for the entire cohort (13.7% and 24.1%, respectively; p \u3c 0.01) but not among race groups or SEP. Conclusions: Disparities in SEP are not associated with short- or long-term mortality after LEB surgery. Other comorbid risk factors are more important when determining outcomes and should be the focus of interventions to improve outcomes. © 2012 Elsevier Inc. All rights reserved

Hypothyroidism and the risk of lower extremity arterial disease

Michael A Mazzeffi1, Hung-Mo Lin1, Brigid C Flynn1, Thomas L O’Connell2, David E DeLaet31Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY, USA; 2Division of Endocrinology, Department of Medicine, University of North Carolina, Chapel Hill, NC , USA; 3Division of General Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY, USABackground: Although an independent association between hypothyroidism and coronary artery disease has been demonstrated, few studies have examined the association between hypothyroidism and peripheral arterial disease. In the current study, we test the hypothesis that there is an independent association between hypothyroidism and lower extremity arterial disease.Methods: We retrospectively compared the prevalence of hypothyroidism in patients who had infra-inguinal arterial bypass surgery over a 6-year period with that of a control group of surgical patients who had pure cardiac valve surgery during the same time period. Both unadjusted and adjusted odds ratios were calculated to estimate the association between hypothyroidism and lower extremity arterial disease.Results: A total of 614 cases and 529 control subjects had surgery during the study period. When comparing all subjects, there was no association between hypothyroidism and lower extremity arterial disease (unadjusted odds ratio 0.88; 95% confidence intervals [CI]: 0.61–1.28). However, gender was found to be a significant effect modifier (P < 0.001), and gender-stratified analyses were subsequently performed. In men, there was a positive independent association between hypothyroidism and lower extremity arterial disease (adjusted odds ratio 2.65; 95% CI: 1.19–5.89), whereas in women there was a negative independent association (adjusted odds ratio 0.22; 95% CI: 0.11–0.46).Conclusions: Gender is a significant effect modifier for the association between hypothyroidism and lower extremity arterial disease. The association is positive in men and negative in women. Future prospective studies that evaluate hypothyroidism as a risk factor for peripheral arterial disease should consider gender stratification in order to corroborate this finding.Keywords: hypothyroidism, cardiovascular, peripheral arterial disease, vascular bypass, gende

The Association of the Pulmonary Artery Pulsatility Index and Right Ventricular Function after Cardiac Surgery

Background. The pulmonary artery pulsatility index (PAPi) has been shown to correlate with right ventricular (RV) failure in patients with cardiac disease. However, the association of PAPi with right ventricular function following cardiac surgery is not yet established. Methods. PAPi and other hemodynamic variables were obtained postoperatively for 959 adult patients undergoing cardiac surgery. The association of post-bypass right ventricular function and other clinical factors to PAPi was evaluated using linear regression. A propensity-score matched cohort for PAPi ≥ 2.00 was used to assess the association of PAPi with postoperative outcomes. Results. 156 patients (16.3%) had post-bypass right ventricular dysfunction defined by visualization on transesophageal echocardiography. There was no difference in postoperative PAPi based on right ventricular function (2.12 vs. 2.00, p=0.21). In our matched cohort (n = 636), PAPi < 2.00 was associated with increased incidence of acute kidney injury (23.0% vs 13.2%, p<0.01) and ventilator time (6.0 hours vs 5.6 hours, p=0.04) but not with 30-day mortality or intensive care unit length of stay. Conclusion. In a general cohort of patients undergoing cardiac surgery, postoperative PAPi was not associated with postcardiopulmonary bypass right ventricular dysfunction. A postoperative PAPi < 2 may be associated with acute kidney injury

Gait Speed Is Not Associated with Vasogenic Shock or Cardiogenic Shock following Cardiac Surgery, but Is Associated with Increased Hospital Length of Stay

Objective. Frailty has been associated with adverse outcomes following cardiac surgery. Gait speed has been validated as a marker of frailty. Slow gait speed has been found to be associated with mortality after cardiac surgery. However, it is unknown why slow gait speed predisposes to cardiac surgical mortality. Design. A retrospective analysis. Participants. Patients undergoing cardiac surgery who had a 5-meter walk test performed preoperatively (n=333 of 1735 total surgical patients) from January 2013 to March 2017. Setting. A tertiary care academic hospital. Measurements and main results. Gait speeds were stratified by tertiles: 1 m/s. There was no difference in the incidence of cardiogenic or vasogenic shock when comparing the gait speed groups. Total hospital length of stay was significantly different among the gait speed groups (p=0.0050). Also, patients in the slowest gait speed tertile had a significant association with need for a postoperative permanent pacemaker (p=0.0298). Conclusion. There was no significant association between gait speed and the incidence of cardiogenic or vasogenic shock after cardiac surgery. Gait speed was associated with increased hospital length of stay and need for a permanent pacemaker after cardiac surgery

Indication for surgery, the revised cardiac risk index, and 1-year mortality

Background: Patients who undergo vascular surgery are at increased risk of perioperative cardiovascular morbidity and mortality. The Revised Cardiac Risk Index (RCRI) is a validated and widely used bedside tool for estimating the risk of a perioperative major adverse myocardial event. We hypothesized that inclusion of the indication for surgery would add independent and prognostic information to the RCRI in predicting all-cause 30-day and 1-year mortality in open infrainguinal vascular surgical procedures. Methods: This was a retrospective study of 603 patients who underwent open infrainguinal bypass vascular surgery between January 2002 and January 2008 at a tertiary care medical center. RCRI and indication for surgery were determined. The primary outcomes of interest were all-cause 30-day mortality (which included all in-hospital mortality, regardless of time) and all-cause 1-year mortality. Results: Overall 30-day mortality was 32 (5.3%). Independent risk factors for early death were RCRI score, being of age ≥80 years, American Society of Anesthesiologists Physical Status classification = 4, and emergency surgery. Overall 1-year mortality, including early deaths, was 114 (18.9%). Indication for surgery, RCRI score, age, American Society of Anesthesiologists Physical Status classification = 4, female sex, and emergency surgery were all independent predictors of 1-year mortality. Conclusions: The RCRI score was associated with both 30-day and 1-year mortality in patients undergoing lower extremity bypass surgery. Indication for surgery was predictive of 1-year mortality but not of 30-day mortality. © 2011 Annals of Vascular Surgery Inc

A Retrospective, Pilot Study of De Novo Antidepressant Medication Initiation in Intensive Care Unit Patients and Post-ICU Depression

Post-ICU Syndromes (PICS) remain a devastating problem for intensive care unit (ICU) survivors. It is currently unknown if de novo initiation of an antidepressant medication during ICU stay decreases the prevalence of post-ICU depression. We performed a retrospective, pilot study evaluating patients who had not previously been on an antidepressant medication and who were started on an antidepressant while in the trauma surgical, cardiothoracic, or medical intensive care unit (ICU). The PHQ-2 depression scale was used to ascertain the presence of depression after ICU discharge and compared this to historical controls. Of 2,988 patients admitted to the ICU, 69 patients had de novo initiation of an antidepressant medication and 27 patients were alive and available for study inclusion. We found the prevalence of depression in these patients to be 26%, which is not statistically different than the prevalence of post-ICU depression in historical controls [95% CI (27.6%, 51.6%)]. De novo initiation of an antidepressant medication did not substantially decrease the prevalence of post-ICU depression in this retrospective, pilot study