Pulmonary Hypertension with “Normal” Pulmonary Vascular Resistance

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The Role of Palliative Care Consultation in Withdrawal of Life-Sustaining Treatment among ICU Patients Receiving Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO): A Retrospective Case-Control Study

Background: Extracorporeal membrane oxygenation (ECMO) has extended the survivability of critically ill patients beyond their unsupported prognosis and has widened the timeframe for making an informed decision about the goal of care. However, an extended time window for survival does not necessarily translate into a better outcome and the sustaining treatment is ultimately withdrawn in many patients. Emerging evidence has implicated the determining role of palliative care consult (PCC) in direction of the care that critically ill patients receive. Objective: To evaluate the impact of PCC in withdrawal of life-sustaining treatment (WOLST) among critically ill patients, who were placed on venovenous ECMO (VV-ECMO) at the intensive care unit (ICU) of a tertiary care hospital. Methods: In a retrospective observational study, electronic medical records of 750 patients admitted to the ICU of our hospital between January 1, 2015, and October 31, 2021, were reviewed. Data was collected for patients on VV-ECMO, for whom WOLST was withdrawn during the ICU stay. Clinical characteristics and the underlying reasons for WOLST were compared between those who received PCC (PCC group) and those who did not (non-PCC group). Results: A total of 95 patients were included in our analysis, 63 in the PCC group and 32 in the non-PCC group. The average age of the study population was 48.8 ± 12.6 years, and 64.2% were male. There was no statistically significant difference between the two groups in terms of demographics or clinical characteristics at the time of ICU admission. The average duration of ICU stay and VV-ECMO were 14.1 ± 19.9 days and 9.4 ± 16.6 days, respectively. The number of PCC visits was correlated with the length of ICU stay. The average duration of ICU stay (40.3 ± 33.2 days vs 27.8 ± 19.3 days, P = .05) and ECMO treatment (31.9 ± 27 days vs 18.6 ± 16.1 days, P = .01) were significantly longer in patients receiving PCC than those not receiving PCC. However, the frequency of life sustaining measures or the underlying reasons for WOLST did not significantly differ between the two groups (P \u3e .05). Conclusion: Among ICU patients requiring ECMO support, longer duration of ICU stay and treatment with a higher number of life-sustaining measures seemed to be correlated with the number of PCC visits. The underlying reasons for WOLST seem not to be affected by PCC

The Role of Palliative Care Consultation in Withdrawal of Life-Sustaining Treatment among ICU Patients Receiving Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO): A Retrospective Case-Control Study

Background: Extracorporeal membrane oxygenation (ECMO) has extended the survivability of critically ill patients beyond their unsupported prognosis and has widened the timeframe for making an informed decision about the goal of care. However, an extended time window for survival does not necessarily translate into a better outcome and the sustaining treatment is ultimately withdrawn in many patients. Emerging evidence has implicated the determining role of palliative care consult (PCC) in direction of the care that critically ill patients receive. Objective: To evaluate the impact of PCC in withdrawal of life-sustaining treatment (WOLST) among critically ill patients, who were placed on venovenous ECMO (VV-ECMO) at the intensive care unit (ICU) of a tertiary care hospital. Methods: In a retrospective observational study, electronic medical records of 750 patients admitted to the ICU of our hospital between January 1, 2015, and October 31, 2021, were reviewed. Data was collected for patients on VV-ECMO, for whom WOLST was withdrawn during the ICU stay. Clinical characteristics and the underlying reasons for WOLST were compared between those who received PCC (PCC group) and those who did not (non-PCC group). Results: A total of 95 patients were included in our analysis, 63 in the PCC group and 32 in the non-PCC group. The average age of the study population was 48.8 ± 12.6 years, and 64.2% were male. There was no statistically significant difference between the two groups in terms of demographics or clinical characteristics at the time of ICU admission. The average duration of ICU stay and VV-ECMO were 14.1 ± 19.9 days and 9.4 ± 16.6 days, respectively. The number of PCC visits was correlated with the length of ICU stay. The average duration of ICU stay (40.3 ± 33.2 days vs 27.8 ± 19.3 days, P = .05) and ECMO treatment (31.9 ± 27 days vs 18.6 ± 16.1 days, P = .01) were significantly longer in patients receiving PCC than those not receiving PCC. However, the frequency of life sustaining measures or the underlying reasons for WOLST did not significantly differ between the two groups (P \u3e .05). Conclusion: Among ICU patients requiring ECMO support, longer duration of ICU stay and treatment with a higher number of life-sustaining measures seemed to be correlated with the number of PCC visits. The underlying reasons for WOLST seem not to be affected by PCC

Immune Response to SARS-CoV-2 Vaccine among Heart Transplant Recipients: A Systematic Review

BACKGROUND: Heart transplant (HTX) recipients are at a significantly higher risk of adverse clinical outcomes, due to chronic immunosuppression and co-existence of other chronic conditions, when contracting the SARS-CoV-2 infection. Although vaccination against SARS-CoV-2 is currently the most promising measure for the prevention of severe Coronavirus Disease 2019 (COVID-19) among solid organ transplant recipients, the extent of immune response and its protective efficacy among patients receiving HTX has not been sufficiently studied. METHODS: We performed a systematic review of the literature by inquiring PubMed/Medline to identify original studies among HTX recipients, who had received at least one dose of the SARS-CoV-2 vaccine. Data on the measured humoral or cellular immune response was collected from all the eligible studies. Factors associated with a poor immune response were further investigated within these studies. RESULTS: A total of 12 studies comprising 563 HTX recipients were included. The average age of the study participants was 60.8 years. Sixty four percent of the study population were male. Ninety percent of the patients had received an mRNA vaccine (Pfizer/ BNT162b2 or Moderna/mRNA-1273). A positive immune response to SARS-CoV-2 vaccine was variably reported in 0% to 100% of the patients. Older age (\u3e 65 years), vaccine dose (first, second, or third), time since HTX to the first dose of the vaccine, the time interval between the latest dose of the vaccine and measurement of the immune response, and the type of immunosuppressive regimen were all indicated as potential determinants of a robust immune response to the SARS-CoV-2 vaccination. CONCLUSION: HTX recipients demonstrate a weaker immune response to the vaccination against SARS-CoV-2 compared to the general population. Older age, anti-metabolite agents such as mycophenolate mofetil, and vaccination during the first year following the HTX have been indicated as potential determinants of a poor immune response

Anticoagulation and bleeding risk in patients with COVID-19

BACKGROUND: There is no current standardized approach to anticoagulation in patients with Coronavirus Disease 2019 (COVID-19) while potential bleeding risks remain. Our study characterizes the patterns of anticoagulation use in COVID-19 patients and the risk of related bleeding. METHODS: This is a single center retrospective analysis of 355 adult patients with confirmed diagnosis of COVID-19 from March 1 to May 31, 2020. Chi-square was used to analyze the relationship between degree of anticoagulant dose and bleeding events by site. Multivariable logistic regression was used to look at factors associated with inpatient death. RESULTS: 61% of patients were being treated with prophylactic doses of anticoagulation, while 7% and 29% were being treated with sub-therapeutic and therapeutic anticoagulation (TA) doses respectively. In 44% of patients, we found that the decision to escalate the dose of anticoagulation was based on laboratory values characterizing the severity of COVID-19 such as rising D-dimer levels. There were significantly higher rates of bleeding from non-CNS/non-GI sites (p = 0.039) and from any bleeding site overall (p = 0.019) with TA. TA was associated with significantly higher rates of inpatient death (41.6% vs 15.3% p \u3c 0.0001) compared to those without. All patients who developed CNS hemorrhage died p = 0.011. After multivariable logistic regression, only age OR 1.04 95% CI (1.01 to 1.07) p = 0.008 and therapeutic anticoagulation was associated with inpatient mortality OR 6.16 95% CI (2.96 to 12.83) p ≤ 0.0001. CONCLUSION: The use of TA was significantly associated with increased risk of bleeding. Bleeding in turn exhibited trends towards higher inpatient death among patients with COVID-19. These findings should be interpreted with caution and larger more controlled studies are needed to verify the net effects of anticoagulation in patients with COVID-19

Copy Number Networks to Guide Combinatorial Therapy of Cancer and Proliferative Disorders

Interaction networks can be charted by seeking gene pairs that are amplified and/or deleted in tandem, even when located at a distance on the genome. Our experience with radiation hybrid (RH) panels, a library of cell clones that have been used for genetic mapping, have shown this tool can pinpoint statistically significant patterns of co-inherited gene pairs. In fact, we were able to identify gene pairs specifically associated with the mechanism of cell survival at single gene resolution. Further, the RH network can be used to provide single gene specificity for cancer networks constructed from correlated copy number alterations (CNAs). In a survival network for glioblastoma, we found that the epidermal growth factor receptor (EGFR) oncogene interacted with 46 genes. Of these genes, ten (22%) happened to be targets for existing drugs. Here, we highlight the potential of CNA networks to guide combinatorial drug treatment in cancer, autoimmunity and atherosclerosis

Targeting heart failure with preserved ejection fraction: current status and future prospects

Manreet Kanwar, Claire Walter, Megan Clarke, Maria Patarroyo-Aponte Department of Cardiology, Allegheny General Hospital, Pittsburgh, PA, USA Abstract: Heart failure with preserved ejection fraction (HFpEF) portrays a significant burden in terms of prevalence, morbidity, mortality, and health care costs. There is a lack of consensus on the basic pathophysiology, definition, and therapeutic targets for therapy for this syndrome. To date, there are no approved therapies available for reducing mortality or hospitalization for these patients. Several clinical trials have recently started to try and bridge this major gap. There is an urgent need to focus on drug and device development for HFpEF as well as to understand HFpEF pathophysiology. Keywords: HFpEF therapies, diastolic dysfunctio