Multiple Myeloma as the Underlying Cause of Thrombotic Microangiopathy Leading to Acute Kidney Injury: Revisiting a Very Rare Entity

Thrombotic microangiopathy (TMA) describes a pathological process of microvascular thrombosis, consumptive thrombocytopenia, and microangiopathic hemolytic anemia, leading to end-organ ischemia and infarction, affecting particularly the kidney and brain. TMA is a pathological feature of a number of clinical disorders including thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and atypical hemolytic uremic syndrome. Rare but important, TMA may also occur in malignancy, connective tissue disease, malignant hypertension, and renal transplantation (rejection or drug toxicity). We present a very rare case where the patient developed acute kidney injury from TMA but found to have multiple myeloma as the possible underlying etiology

Utilization of extracorporeal membrane oxygenation during the COVID-19 pandemic.

The ongoing outbreak of severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2, or coronavirus disease 2019 (COVID-19)] was declared a pandemic by the World Health Organization on March 11, 2020. Worldwide, more than 65 million people have been infected with this SARS-CoV-2 virus, and over 1.5 million people have died due to the viral illness. Although a tremendous amount of medical progress has been made since its inception, there continues to be ongoing research regarding the pathophysiology, treatments, and vaccines. While a vast majority of those infected develop only mild to moderate symptoms, about 5% of people have severe forms of infection resulting in respiratory failure, myocarditis, septic shock, or multi-organ failure. Despite maximal cardiopulmonary support and invasive mechanical ventilation, mortality remains high. Extracorporeal membrane oxygenation (ECMO) remains a valid treatment option when maximal conventional strategies fail. Utilization of ECMO in the pandemic is challenging from both resource allocation and ethical standpoints. This article reviews the rationale behind its use, current status of utilization, and future considerations for ECMO in critically ill COVID-19 patients

Landscape heterogeneity affects diurnal raptor communities in a sub-tropical region of northwestern Himalayas, India.

Raptors are highly sensitive to environmental and human-induced changes. In addition, several species of raptors exist in considerably small numbers. It is thus critical to conserve raptors and their habitats across relatively larger landscapes. We examined the diurnal raptor assemblages and seasonality in a subtropical habitat in India's northwestern Himalayas. Quantitative data on diurnal birds of prey and their habitat features across six distinct habitat types were collected from 33 sample sites. We observed 3,434 individuals of 28 diurnal raptors belonging to two orders and three families during a two-year survey from December 2016 to November 2018. A significant variation in bird species richness and abundance was found across habitats and seasons, with farmlands and winters being the most diverse and speciose. The generalized linear model, used to determine raptor community responses, indicated that elevation and proximity to dumping sites significantly affected the raptor abundance. The non-metric multidimensional scaling (NMDS) revealed significant differences in raptor assemblages across the habitat types. The study concluded that raptors' persistence is largely determined by their preference for favourable feeding, roosting, and nesting opportunities. The presence of protected and habitat-exclusive species validates the high conservation importance of these ecosystems, particularly the forest patches and farmlands, necessitating robust conservation and management measures in this part of northwestern Himalaya

Outcomes and Contemporary Trends in Surgical vs Transcatheter Aortic Valve Replacement in Patients with Chronic Obstructive Pulmonary Disease

Background: Chronic obstructive lung disease (COPD) is a common morbidity among patients referred for aortic valve replacement. The objective of the present study is to assess trends and outcomes of COPD patients undergoing either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) for severe aortic stenosis. Methods: We analyzed the National Inpatient Sample database from January 2012 to December 2017 using the International Classification of Diseases, 9th and 10th Revision Clinical Modifications to identify all patients with COPD aged ≥50 years who underwent either TAVR or SAVR for aortic stenosis. To account for potential bias, 1:1 propensity-matched analysis was performed. Logistic regression was used for predictors of mortality in the cohort. Linear regression was used for trend analysis. Results: Of the total of 95,555 cases, 40,080 underwent TAVR whereas 49,985 underwent SAVR. In-hospital mortality for the propensity-matched cohorts was higher in the SAVR cohort compared to the TAVR group (4.6% vs. 2.5%; p \u3c 0.001). Respiratory complications were also higher in the SAVR group (7.5% vs. 3.7%; p \u3c 0.001) but were less likely to have a permanent pacemaker placement (5.3% vs. 10.8%, p \u3c 0.001). Length of stay (11.8 days [standard deviation (SD), 8.8] vs. 6.4 days [SD, 6.8]) and cost of stay ($244,657 [SD,$183,333] vs. $229,524 [SD,$146,994]) were favorable toward TAVR as compared to SAVR. In-hospital mortality has declined over the study period in the TAVR group from 4.8% to 1.5%. Conclusion: TAVR has more favorable in-hospital outcomes in patients with COPD compared to SAVR

Clinical outcomes and disease burden in amyloidosis patients with and without atrial fibrillation⇔insight from the national inpatient sample database

Amyloidosis is a systemic illness that affects multiple organ systems, including the cardiovascular, renal, gastrointestinal, and pulmonary systems. Common manifestations include restrictive cardiomyopathy, arrhythmias, nephrotic syndrome, and gastrointestinal hemorrhage. It is unknown whether coexisting atrial fibrillation (AF) worsens the disease burden and outcomes in patients with systemic amyloidosis. In this study, those with a diagnosis of amyloidosis with and without coexisting AF were identified by querying the Healthcare Cost and Utilization Project—specifically, the National Inpatient Sample for the year 2016—based on International Classification of Diseases, 10th Revision, Clinical Modification codes. During 2016, a total of 2,997 patients were admitted with a diagnosis of amyloidosis, including 918 with concurrent AF. Greater rates of mortality (7.4% vs. 5.6%); heart block (6.8% vs. 2.8%); cardiogenic shock (5% vs. 1.6%); placement of an implantable cardioverter-defibrillator, cardiac resynchronization therapy device, or permanent pacemaker (14.5% vs. 4.5%); renal failure (29% vs. 21%); heart failure (66% vs. 30%); and bleeding complications (5.7% vs. 2.8%) were observed in patients with a diagnosis of amyloidosis and coexisting AF when compared with in patients without AF. Interestingly, patients with amyloidosis without comorbid AF had greater odds of associated stroke relative to those with concurrent AF (7.9% vs. 3.4%). © 2021 Innovations in Cardiac Rhythm ManagementOpen access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Endoscopic Retrograde Cholangiopancreatography (ERCP) in Patients With Liver Cirrhosis: Analysis of Trends and Outcomes From the National Inpatient Sample Database

GOALS: We aimed to assess outcomes of patients with liver cirrhosis who underwent therapeutic or diagnostic endoscopic retrograde cholangiopancreatography (ERCP) to determine whether these patients had different outcomes relative to patients without cirrhosis. BACKGROUND: ERCP is an important procedure for treatment of biliary and pancreatic disease. However, ERCP is relatively technically difficult to perform when compared with procedures such as esophagogastroduodenoscopy or colonoscopy. Little is known about how ERCP use affects patients with liver cirrhosis. STUDY: Using patient records from the National Inpatient Sample (NIS) database, we identified adult patients who underwent ERCP between 2009 and 2014 using International Classification of Disease, Ninth Revision coding and stratified data into 2 groups: patients with liver cirrhosis and those without liver cirrhosis. We compared baseline characteristics and multiple outcomes between groups and compared outcomes of diagnostic versus therapeutic ERCP in patients with cirrhosis. A multivariate regression model was used to estimate the association of cirrhosis with ERCP outcomes. RESULTS: A total of 1,038,258 hospitalizations of patients who underwent ERCP between 2009 and 2014 were identified, of which 31,294 had cirrhosis and 994,681 did not have cirrhosis. Of the patients with cirrhosis, 21,835 (69.8%) received therapeutic ERCP and 9459 (30.2%) received diagnostic ERCP. Patients with cirrhosis had more ERCP-associated hemorrhages (2.5% vs. 1.2%; P\u3c0.0001) compared with noncirrhosis patients but had lower incidence of perforations (0.1% vs. 0.2%; P\u3c0.0001) and post-ERCP pancreatitis (8.6% vs. 7%; P\u3c0.0001). Cholecystitis was the same between groups (2.3% vs. 2.3%; P\u3c0.0001). In patients with cirrhosis, those who received therapeutic ERCP had higher post-ERCP pancreatitis (7.9% vs. 5.1%; P\u3c0.0001) and ERCP-associated hemorrhage (2.7% vs. 2.1%; P\u3c0.0001) but lower incidences of perforation and cholecystitis (0.1% vs. 0.3%; P\u3c0.0001) and cholecystitis (1.9 vs. 3.1%; P\u3c0.0001) compared with those who received diagnostic ERCP. CONCLUSIONS: Use of therapeutic ERCP in patients with liver cirrhosis may lead to higher risk of complications such as pancreatitis and post-procedure hemorrhage, whereas diagnostic ERCP may increase the risk of pancreatitis and cholecystitis in patients with cirrhosis. Comorbidities in cirrhosis patients may increase the risk of post-ERCP complications and mortality; therefore, use of ERCP in cirrhosis patients should be carefully considered, and further studies on this patient population are needed