Recurrences of atrial fibrillation in patients with heart failure without reduced ejection fraction: a role for CA125

Background Atrial fibrillation (AF) and heart failure (HF) without reduced ejection fraction often occur together, and their combination is associated with increased morbidity and mortality compared with each disorder alone. Sinus rhythm maintenance seems to be beneficial but challenging in these patients. Purpose We studied the possible value of CA125 to predict recurrences in patients with persistent AF and HF without reduced ejection fraction who underwent electrical cardioversion (ECV). Methods We designed a prospective cohort study by consecutively including all the patients who underwent ECV in our hospital with symptomatic persistent non-valvular AF and a concomitant diagnosis of HF without reduced ejection fraction. We excluded patients with clinical instability or ejection fraction <40%. We defined HF as the presence of diastolic dysfunction in echo (left atrium indexed volume >34 ml/m2 or e/e' >8) or ejection fraction between 40 and 50%. We followed-up them during 6 months for detecting AF recurrences with an ECG-Holter 3 months after ECV and an ECG at 6th month. We considered a recurrence as any AF documentation in ECG or ECG-Holter after the ECV. A peripheral blood sample was extracted just before ECV and CA125 was determined. Kaplan-Meyer analysis was used to study the possible relationship between CA125 plasmatic levels, dichotomized according to the median value, and AF recurrence. Results We included 95 patients with a medium age of 64±9 years old. Of them, 31 (32.6%) were women, 14 (14.7%) had diabetes and 56 (58.9%) hypertension. The medium ejection fraction was 58.14±10.27% and the median CA125 was 10.98±8.97 U/ml. We detected 54 (57.4%) recurrences in 6 months. In patients with AF recurrences, CA125 values were higher than in patients who maintained sinus rhythm (19.28±29.11 U/ml vs. 14.98±17.02 U/ml). CA125 was significantly related with AF recurrences (log-rank 5.37; p=0.021). Conclusions In our sample of patients with persistent AF and HF without reduced ejection fraction, CA125 plasmatic levels are related with AF recurrences after ECV. CA125 has been associated with the clinical severity of HF and the symptoms and signs of fluid congestion. This probably means more ventricular and atrial myocardial damage that might predispose to AF. Sinus rhythm maintenance is specially challenging in patients with HF so those with higher levels of CA125 probably need a closer surveillance and a more aggressive rhythm control. FUNDunding Acknowledgement Type of funding sources: None.

A case of prenatally diagnosed prune belly syndrome variant and congenital pouch colon in the United States: A case report

Background: Prune belly syndrome (PBS) and congenital pouch colon (CPC) are rare congenital syndromes with a low incidence in the United States (U.S.) with most CPC cases being from India. In this case report, we describe, to the best of our knowledge, the first PBS variant and CPC patient in the U.S. Case Presentation: A 30-year-old G2P0010 woman was referred to a tertiary center after an 18-week ultrasound showed a fetal abdominal mass. A prenatal MRI showed a dilated loop of bowel containing a mixture of urine and meconium, oligohydramnios, and a protuberant abdominal wall. Born at 37 weeks, the child’s physical exam was notable for a distended abdomen with thin abdominal musculature, non-palpable bilateral testes, no anal opening, and flat buttocks. Intra-operatively, a dilated cecum/ascending colon was noted with an abrupt change in caliber at the transverse colon, bilateral enlarged ureters, a left testis at the internal ring and no visualized right testis. A colostomy and mucous fistula were created 5 cm from the sigmoid pouch. Conclusion: While most reported cases of CPC undergo single stage repair (one operation) at 1 day of life, our patient underwent the first procedure of a staged repair at 16 hours of life given his clinical instability at the time as well as his unknown urological anatomy in the setting of urinary obstruction. This case demonstrates the importance of fetal imaging, multidisciplinary approach at a tertiary care center, and reinforces a staged repair when necessary.

Male Disadvantage in Oxidative Stress-Associated Complications of Prematurity: A Systematic Review, Meta-Analysis and Meta-Regression

A widely accepted concept is that boys are more susceptible than girls to oxidative stress-related complications of prematurity, including bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), and periventricular leukomalacia (PVL). We aimed to quantify the effect size of this male disadvantage by performing a systematic review and meta-analysis of cohort studies exploring the association between sex and complications of prematurity. Risk ratios (RRs) and 95% CIs were calculated by a random-effects model. Of 1365 potentially relevant studies, 41 met the inclusion criteria (625,680 infants). Male sex was associated with decreased risk of hypertensive disorders of pregnancy, fetal distress, and C-section, but increased risk of low Apgar score, intubation at birth, respiratory distress, surfactant use, pneumothorax, postnatal steroids, late onset sepsis, any NEC, NEC > stage 1 (RR 1.12, CI 1.06–1.18), any IVH, severe IVH (RR 1.28, CI 1.22–1.34), severe IVH or PVL, any BPD, moderate/severe BPD (RR 1.23, CI 1.18–1.27), severe ROP (RR 1.14, CI 1.07–1.22), and mortality (RR 1.23, CI 1.16–1.30). In conclusion, preterm boys have higher clinical instability and greater need for invasive interventions than preterm girls. This leads to a male disadvantage in mortality and short-term complications of prematurity.

Oral antibiotic treatment of exacerbation of COPD. Beyond COVID-19

COPD (chronic obstructive pulmonary disease) includes patients with chronic bronchitis and / or emphysema who have in common the presence of a chronic and progressive airflow obstruction, with symptoms of dyspnea and whose natural history is modified by acute episodes of exacerbations. Exacerbation (EACOPD) is defined as an acute episode of clinical instability characterized by a sustained worsening of respiratory symptoms. It is necessary to distinguish a new EACOPD from a previous treatment failure or a relapse. EACOPD become more frequent and intense over time, deteriorating lung function and quality of life. The diagnosis of EACOPD consists of 3 essential steps: a) differential diagnosis; b) establish the severity, and c) identify its etiology. The main cause of exacerbations is infection, both bacterial and viral. Antibiotics are especially indicated in severe EACOPD and the presence of purulent sputum. Beta-lactams (amoxicillin-clavulanate and cefditoren) and fluoroquinolones (levofloxacin) are the most widely used antimicrobials. This review updates the problem of acute exacerbation with infectious origin from the perspective of etiology, antimicrobial resistance, microbiological studies, risk stratification, and antimicrobial management. The risk, prognosis and characteristics of COPD patients who develop COVID19 are analyzed.

Examining the Short-Term Natural History of Developmental Dysplasia of the Hip in Infancy: A Systematic Review

Background This study was an update on the AAOS clinical practice guideline’s analysis of the natural history of developmental dysplasia of the hip (DDH). The objective was to delineate the natural history of clinical instability or radiologic abnormalities of the hip in infants by identifying the proportion of cases that resolved without treatment compared to cases that progressed and/or required treatment. Methods We performed a literature search of PUBMED to identify studies which evaluated the natural history of DDH. We used the same search strategy as that utilized in the previous AAOS guidelines, updated to include articles published between September 2013 and May 2021. We assessed the quality of included articles using the Oxford Centre for Evidence-Based Medicine level of evidence and reported study demographics and outcomes using summary statistics. Results Twenty-four articles met our eligibility criteria. Most included studies were retrospective (14/24), investigated either the incidence of DDH (8/24) or assessed screening programs (7/24). The most prevalent study population followed were Graf 2A hips (7/24). Most studies were low quality with level of evidence 3 (13/24) or 4 (7/24). Sample sizes ranged from 9 to 3251. Twenty studies reported the number of cases resolved over the follow-up period with a mean rate of 84.3% (95% confidence interval 76.1, 92.6). Conclusion We found most mild-to-moderate DDH can resolve without treatment in early infancy, especially in physiologically immature (Graf 2A) hips. More high-quality evidence is needed to properly assess the natural history of DDH as only one included study was a randomized trial.

Factors associated with early 14-day unplanned hospital readmission: a matched case–control study

Background/Purpose Early unplanned hospital readmissions are burdensome health care events and indicate low care quality. Identifying at-risk patients enables timely intervention. This study identified predictors for 14-day unplanned readmission. Methods We conducted a retrospective, matched, case–control study between September 1, 2018, and August 31, 2019, in an 1193-bed university hospital. Adult patients aged ≥ 20 years and readmitted for the same or related diagnosis within 14 days of discharge after initial admission (index admission) were included as cases. Cases were 1:1 matched for the disease-related group at index admission, age, and discharge date to controls. Variables were extracted from the hospital’s electronic health records. Results In total, 300 cases and 300 controls were analyzed. Six factors were independently associated with unplanned readmission within 14 days: previous admissions within 6 months (OR = 3.09; 95 % CI = 1.79–5.34, p < 0.001), number of diagnoses in the past year (OR = 1.07; 95 % CI = 1.01–1.13, p = 0.019), Malnutrition Universal Screening Tool score (OR = 1.46; 95 % CI = 1.04–2.05, p = 0.03), systolic blood pressure (OR = 0.98; 95 % CI = 0.97–0.99, p = 0.01) and ear temperature within 24 h before discharge (OR = 2.49; 95 % CI = 1.34–4.64, p = 0.004), and discharge with a nasogastric tube (OR = 0.13; 95 % CI = 0.03–0.60, p = 0.009). Conclusions Factors presented at admission (frequent prior hospitalizations, multimorbidity, and malnutrition) along with factors presented at discharge (clinical instability and the absence of a nasogastric tube) were associated with increased risk of early 14-day unplanned readmission.

CUERPO EXTRAÑO PUNZANTE LOCALIZADO EN APÉNDICE CECAL, DE DOS MESES DE EVOLUCIÓN. EXTRACCIÓN POR COLONOSCOPIA - INFORME DE CASO.

Introduction Ingestion of foreign bodies implies a 35% risk of possible complications, which are associated with their type (blunt or sharp) and their size. Although in most of them, it is expected that they pass along the gastrointestinal tract without difficulty or complications, the management will depend on the characteristics of the swallowed object, time of evolution and symptoms of the patient. Case description We present the clinical case of a 58-year-old female patient with a recent gastric bypass surgical history, who accidentally ingested a piece of dental equipment two months earlier during a dental procedure, remaining asymptomatic until she came to our office. In radiographic controls for confirmation, location and evolution, the presence of a 2 cm sharp object was evidenced, apparently located in the cecal appendix, which does not progress distally. For the management, initial expectant management was proposed, which was completed with therapeutic colonoscopy for its extraction, the technique recommends that the sharp object should be grasped by the pointed end, distal to the wall, which reduces the risk of perforation related to the procedure or damage of the mucosa during extraction, the case is completed with successful resolution and without complications. Conclusion Less invasive therapeutic management such as colonoscopy should be considered first line in this type of case, when there are no signs or radiological findings of perforation or clinical instability, due to its low incidence of complications and a high success rate.

Association of the mobility level of critically ill adult patients with the success of extubation: protocol for a cohort study

IntroductionSeveral factors contribute to the reduction of the mobility in ICU), such as the use of sedatives, severity, invasive devices, acute clinical instability, lack of resources, the culture of immobility, architectural barriers and the own weakness developed in the ICU. The need for ventilatory support is common in most of patients, and weaning from mechanical ventilation (MV) is an arduous process that requires the commitment of the entire team. Instruments that objectively assess the mobility of patients admitted to the ICU can be useful to identify the existence or not of an association between mobility and prognosis.ObjectiveTo estimate the association between the level of mobility and successful extubation.Methods and analysisProspective cohort study with the beginning of follow-up when the patient completes 24 hours of invasive MV in the ICU and ends on the date the patient’s hospital discharge. Adult patients (≥18 years old) admitted to the ICU will be included in the first invasive MV event in this hospitalisation. Patients should be independently able to mobilise before current hospital admission. Predictor variables will be collected (age, sex, body mass index, Simplified Acute Physiological Score III (SAPS III), ICU admission type: clinic, elective or emergency surgery postoperative, Charlson Index, number of physiotherapists per patient in each ICU, use of sedation, vasoactive drugs and neuromuscular blocker, ICU mobility scale, time of invasive MV, ICU admission and hospital admission, and outcome. The primary outcome is the result of extubation (success or failure).Ethics and disseminationThis study was approved by the Ethics Committee, certificate number 92878218.1.0000.5505. The protocol was registered on the Registro Brasileiro de Ensaios Clínicos (ReBEC) (registration number RBR-8k4f68). The results will be published in specialised journals and disseminated to the medical society and the general public.