Utility of Combined Echocardiography and Lung Ultrasound for Coronavirus Disease-19 Intensive Care Unit Patients: Case Series

BACKGROUND: A little evidence existed for ultrasound evaluation of coronavirus disease (COVID)-19 patients. AIM: We aimed to present combined transthoracic echocardiography and lung ultrasound in 17 COVID-19 patients in the intensive care unit (ICU). METHODS: Patients were on age 57 + 14 years, 9 on mechanical ventilation and 8 on oxygen support, with average 1.2 comorbidities per patient. Ultrasound was performed by a single experienced sonographer and an assistant. RESULTS: Impaired left ventricular ejection fraction (EF) was found in 2 patients (pts) of them (11.8%) and diastolic dysfunction in 7 (41.2%), which was significantly higher in those ones with comorbidities. In 2 pts (11.8%), the presence of pulmonary hypertension with enlarged right ventricle was found. Later one pulmonary thromboembolism was confirmed in them with computed tomography angio. B-lines were found in 8 pts (47.1%), finding that was significantly higher in pts on mechanical ventilation, but not in relation with decreased EF. In one pt (0.6%), pleural effusion was found, but in none of them lung consolidation. CONCLUSIONS: Our findings revealed that combined echocardiography and lung ultrasound in COVID-19 ICU pts have been an accurate method for diagnosing right and left ventricular function and should be a useful one for guiding of their treatment and prognosis

Вентрикуларна фибрилација по ендоскопска ретроградна холангиопанкреатографија кај пациент со вграден уред за лево вентрикуларна асистенција – приказ на случај

Congestive heart failure is a growing global health problem. Left ventricular assist device (LVAD) is a method used to extend the life of patients with congestive heart failure as a definitive treatment or to “bypass” the period until heart transplantation. Ventricular arrhythmias in patients with LVAD are not uncommon. The aim of this paper is to present the case of a patient with an already implanted LVAD and the need for appropriate interdisciplinary medical treatment. Case report: We present the case of a 54-year old patient, A. D., with implanted LVAD - HeartMate 3 due to severe congestive heart failure. The patient was admitted with jaundice at the PHIU Clinic for Gastroenterohepatology with performed endoscopic retrograde cholangiopancreatography (ERCP)) procedure and a stent was placed in the choledochus duct. Immeasurable blood pressure and pulse were recorded in this patient. The ECG was approaching VF (ventricular fibrillation) and it was all asymptomatic by the patient.  LVAD mechanical pump leads to continuous blood flow, which means that patients with LVAD not infrequently have no pulse or measurable blood pressure. Also, in patients with LVAD, ECG pulses are with electrical disturbances. VF and ventricular tachycardia (VT) are ventricular arrhythmias that are often seen on ECG in patients with implanted LVAD. Usually these arrhythmias occur with unknown duration and terminate spontaneously. Conclusion: Patients with LVAD are prone to cardiac arrhythmias. The continuous development of medical devices leads to a continuous educational and clinical approach to patients.                                                                        Конгестивната срцева слабост е растечки глобален здравствен проблем. Уредот за лево вентрикуларна асистенција (LVAD) се користи за продолжување на животот на пациентите со конгестивна срцева слабост како дефинитивен третман или за премостување на периодот до трансплантација на срце. Вентрикуларните аритмии кај пациентите со LVAD не се невообичаени. Целта на овој труд е да се прикаже случајот на пациент со веќе вграден LVAD и потребата од соодветен интердисциплинарен медицински третман. Приказ на случај: Ви претставуваме случај на 54-годишен пациент, А. Д., со вграден LVAD - HeartMate 3 поради тешка конгестивна срцева слабост. Пациентот е примен со иктерус на ЈЗУ Клиниката за гастроентерохепатологија по што е извршена ендоскопска ретроградна холангиопанкреатографија (ERCP)) и е поставен стент во холедохусниот канал. Кај овој пациент е регистрирано немерлив крвен притисок и пулс. На ЕКГ е регистрирана VF вентрикуларна фибрилација (VF) и сето тоа беше асимптоматски од страна на пациентот. Механичката пумпа на LVAD води до континуиран проток на крв, што значи дека пациентите со LVAD не ретко немаат пулс или мерлив крвен притисок. Исто така, кај пациентите со LVAD, ЕКГ импулсите се со електрични нарушувања. VF и вентрикуларна тахикардија (VT) се вентрикуларни аритмии кои често се гледаат на ЕКГ кај пациентите со имплантиран LVAD. Најчесто овие аритмии се јавуваат со непознато времетраење и спонтано завршуваат. Заклучок: Пациентите со ЛВАД се склони кон срцеви аритмии. Континуираниот развој на медицинските помагала води кон континуиран едукативен и клинички пристап во третманот на пациентите

Anemia, renal impairment and in-hospital mortality, in acute worsening chronic heart failure patients

Aim of the study: To analyze the impact of anemia and renal impairment on in-hospital mortality(IHD), in patients with acute worsening chronic heart failure. Methods: 232 randomly selected patients with symptoms of HF were retrospectively analyzed. Analyzed variables: gender, age, risk factors and co-morbidities: HTA, HLP, DM, COPD, CAD, PVD, CVD, anemia(defined as Hgb ≤10mg/dl), renal failure. Measured variables: systolic and diastolic BP, Hgb, sodium, BUN, creatinine, length of hospital stay and IHD. Comparative analysis was performed between patients with in-hospital mortality(IHD) and survivors, as a function of anemia and renal impairment. Statistical analysis: descriptive and comparative analysis, t-test, Chi square, univariate (binary logistic and linear regression and multivariate linear regression(stepwise backward). Results: Mean age 69.6±11.4, 102(44%)females and 130(56%) males, with females being significantly older 72.6±12.5 vs. 67.7±10.2(p=0.002), with significantly higher SBP, DBP and sodium level (p=0.003; 0.002 and 0.028 respectively), and males having HTA more often OR 1.3; p=0.017. Mean hospital stay was 6.8±5.8 days, with significant difference between IHD and non IHD group(7.9±4.5 vs. 3.8±7.9; p=0.000), with the highest mortality during the first (37.3%) and second hospital day (44.1%). 44 pts.(19%) had anemia, 31(13.4%) had known Chronic Renal Failure(CRF), and 59(25.4%) had IHD. Anemia was significantly associated with IHD (Chi square 6,36, sig 0.012, Exp B 2.48, sig 0.010), meaning pts. with anemia had 2,5 times greater risk for IHD. CRF per se, was not associated with IHD. Univariate linear regression identified creatinine(R square .032, beta .180, sig 0.006), and BUN(R square .034, beta .184, sig 0.005), as predictors of IHD. Multivariate stepwise regression model(anemia, HRF, Hgb, BUN, creatinine, sodium) at step 3(mean square .799, sig 0.002), identified two independent predictors Hgb(beta -.148, sig 0.028), and BUN(beta .163, sig 0.055). Multivariate model that included other known predictors of IHD(EF%, SBP, DBP, HRF, CAD, anemia, Hgb, BUN, creatinine, sodium) at step 8(mean square 1.537, sig 0.000), identified four independent predictors: EF%(beta -.204, sig 0.002), SBP(beta -.130, sig 0.052) as markers of systolic dysfunction and again anemia(Exp B 2.2.06, sig 0.041), and BUN(beta .200, sig 0.002). Conclusion: Anemia and renal impairment are well known comorbidities associated with HF that have great impact on course of HF. We confirmed that anemia and BUN, are significantly independent predictors of in hospital mortality in acute worsening CHF

Falls in people with dementia

Falls and concomitant injuries are common problems among large groups of the elderly population, leading to immobility and mortality. These problems are even more pronounced among people suffering from dementia. This thesis targets fall risk factors for people with dementia in institutions. The overall aim of this thesis was to investigate risk factors for falls, predisposing as well as related to circumstances surrounding falls, and to do this as efficiently as possible. In a prospective cohort study including residents of residential care facilities with and without dementia, the fall rate was higher for those with dementia, the crude incidence rate ratio (IRR) was 2.55 (95% CI 1.60–4.08) and the adjusted IRR was 3.79 (95% CI 1.95–7.36). In the group of people suffering from dementia, including 103 residents, a total of 197 falls resulted in 11 fractures during the 6-months follow-up period. From the same baseline measurements 26% and 55%, respectively, of the variation in falls could be explained in the group of residents with and without dementia. Fall predictors significantly and independently associated with an increased risk of falls in the group of people suffering from dementia were the category “man walking with an aid” and the use of more than four drugs. In a prospective cohort study, including 204 patients in a psychogeriatric ward, a total of 244 falls resulted in 14 fractures. Fall predictors significantly and independently associated with an increased risk of falls were male sex, failure to copy a design, use of clomethiazole, and walking difficulties. Treatment with statins was associated with a reduced risk of falls. With these fall predictors in the negative binomial regression (Nbreg) model, 48% of the variation in falls was explained. The data from the psychogeriatric ward were also analysed with the use of partial least squares regression (PLS) and regression tree to be compared with the results of the Nbreg analysis. PLS and regression tree are techniques based on combinations of variables. They both showed similar patterns, that a combination of a more severe level of dementia, behavioral complications and medication related to these complications is associated with an increased fall rate. Thirty-two percent and 38%, respectively, of the variation in fall rate were explained in the PLS and regression tree analysis. The circumstances surrounding the falls in the psychogeriatric ward were analysed. It was found that the fall rate was equally high during the night and the day. A large proportion of the falls was sustained in the patients’ own room and a small proportion of the falls was witnessed by the staff. This pattern was even more pronounced during the night. The proportion of diurnal rhythm disturbances and activity disturbances was higher for falls at night than for falls during the day. Circumstances associated with an increased risk of falls, as shown by a short time to first fall, were anxiety, darkness, not wearing any shoes and, for women, urinary tract infection. The proportion of urinary tract infection was also higher in connection to falls sustained by women than to falls sustained by men. This thesis confirms that people suffering from dementia are prone to fall. Walking difficulties, male sex and impaired visual perception are factors that should be considered in the work of reducing falls among people suffering from dementia. Furthermore, falls at night, behavioral complications and medication related to these complications should also be considered in this work, especially as the dementia disease progresses. A larger portion of the variation of the outcome variable was explained by the Nbreg model than the regression tree and PLS. However, these statistical methods, based on combinations of variables, gave a complementary perspective on how the fall predictors were related to falls

Early rehospitalizations in patients treated for acute coronary syndrome - can we identify predictors?

Purpose: To analyze early rehospitalization rate (defined as 90 days after the acute event) in patients with ACS, and to identify predictors of risk for readmission. Methods:463 randomly selected patients with ACS,were retrospectively analyzed.Analyzed variables:type of ACS(STEMI/NSTEMI/APNS),location of MI,gender,age,risk factors:HTA,HLP,DM,COPD,CAD,PVD,CVD,EF,type of treatment(PCI vs. noninvasive),extensiveness of coronary disease,GRACE and TIMI risk score, type of morbidity,and reason for rehospitalization.Comparative analysis was performed between patients with early rehospitalisation and others.Statistical analysis:t-test,Chi square,univariate and multivariate linear regression. Results:463 patients were enrolled:68.9% males mean age 60.4±10.9, and 31.1% females mean age 64.94±12.0(p 0.000).MI type:STEMI 75.8%,NSTEMI 11.2%,APNS 13%; MI location:40.2% anterior,39,7% inferior,3% lateral and 3.7% multiple locations(p 0.000).Risk profile:15.3% HCAD,27% HF,62% HTA,28.1% DM,5.8% PVD,2.6% COPD.Mean BMI was 27±2.9,mean SBP 138.8±28.5mmHg,mean HR 84.3±24.2,mean EF (in 208 pts.) 50.2±10.4%, mean GRACE score(in 72 pts.) was 148.9±60.6,mean TIMI score(in 263 pts.) was 3.9±2.3. 87.5% were treated with PCI procedure, with mean disease’s CA 1.84(range 1-5), median 1(p 0.000). Hospital morbidity was present in 16% of pts.,6.9% minor, 3% major bleeding complications, 2.4% acute HF, 1.9% pericardial effusion, and 1.1% early stent thrombosis.Early rehospitalization rate was 6.3% (29/463):14 ischemic/trombotic events;9 acute heart failures, 3 malignant arrhythmias, and three fatal events. Univariate predictors of RH: HR(R square 0.014, p 0.014, beta .116, r -.217, p 0.002);EF(%) (R square 0.055, p 0.001, beta -.234, r -.231, p 0.001).HTA was significantly associated with reduced hospitalization risk (Chi square 4.28, p 0.039, exp B .405, p 0.054),diabetes(Chi square 10.04, p 0.002, exp B 3.45, p 0.001), PVD (expB 2.85, p 0.070),early in-hospital morbidity(expB 2.12, p 0.084),and NSTEMI pts. had OR 1.3, and APNS pts. OR 1.16 for rehospitalization(higher but not significantly in comparison to STEMI pts.). Multivariate model with variables that were found significantly associated with HR, identified two strong independent predictors of early rehospitalization(mean square.424, sig 0.000),EF(beta -.220, p 0.001),and diabetes(t 2.52, p 0.012) Conclusions:LV systolic dysfunction was again proven to be a strong predictor of clinical outcome in terms of early hospital readmission in ACS patients no matter how they were treated for ACS, and diabetes was the single strong independent predictor-risk factor for this event

Diabetes in acute coronary syndrome patients: do we see only the tip of the iceberg?

Aim of the study: To analyse the influence of glycoregulation in pts. with known or newly detected diabetes, on in-hospital morbidity/mortality in patients with acute coronary syndrome. Methods: randomly selected ACS patients were analysed for: stress glycaemia, HgbA1c, risk profile, lipid profile, SINTAX score, TIMI flow, LV function and in-hospital morbidity/mortality. We comparatively analysed pts. based on the level of HgbA1c (⩾ 6,5% vs 6.5%). Mean values of HgbA1c and stress glycaemia were as follows: NonD - 5.19±0.56 and 6.82±1.87; PD - 5.99±0.19 and 8.32±3.17; ND - 8.19±1.15 and 17.68.19±1.15; CD - 5.79±0.55 and 8.89±4.38; and UD - 9.36±1.33 and 16.23±6.24; (ANOVA p >0.000). No significant difference was found between NonD and CD pts., and between ND and UD (high in the last two), but there was significant difference in HgbA1c (p0.000, Kappa agreement (0.516; sig p>0.000). TG levels were increased only in UD, and ND groups: 1.93±1.06, and 2.36±1.22, (ANOVA p=0.026, Tukey test ND vs NonD p=0.050; and vs PD p=0.016), without significant difference in other lipid fractions. Mean SINTAX score was 15.45±8.2, without significant inter-gorup differences. TIMI flow before PCI significantly differed across the groups, the lowest being in ND - 0.14±0.36 and PD - 1.13±1.42 pts. (group value 1.37±1.42; ANOVA p=0.001; Tukey test: NonD vs ND 0.000; and 0.043 vs CD). Mean EF was 51.51±8.5, without significant inter-group difference. 29 in-hospital events in 22 (19%) patients were registered: 7.7% arrhythmias, 6.9% heart failure, 3.4% GIT bleedings, and 2.6% CVI. In-hospital mortality was 4.3%. In multivariate logistic regression analysis, ejection fraction, stress glycaemia, and HgbA1c were identified as independent predictors of in-hospital outcome. Conclusion: High prevalence of unknown diabetes in ACS patients exists, leading to worse CAD, even in comparison with pts with known, well controlled diabetes. Stress glycaemia, HgbA1c and ejection fraction are independent predictors of in-hospital morbidity/mortality

Acute heart failure in the context of acute coronary syndrome (a case report)

RVMI is associated with acute STEMI myocardial infarction of the inferior wall of the left ventricle, and occurs in 30 to 50 percent of such cases