Hon Lee

Acute gastroduodenal perforations associated with use of crack

Crack, the free-base form of cocaine, was introduced as an illicit street drug in 1986. Since then, we have noted a significant increase in acute gastroduodenal perforations. Between 1982 and 1986, we treated 11 patients with such perforations. This represents a constant occurrence rate of 6% of hospital admissions for peptic ulcer disease. Since 1986 we have treated 16 patients with gastroduodenal perforation, which yields an occurrence rate of 16%. Nine of the 16 patients had a close temporal relationship between the use of crack and the onset of their perforation. This group was younger and disproportionately comprised of male patients. These findings led us to believe that there may be a pathogenic relationship between the use of crack and acute gastroduodenal perforation, and the clinician should be aware of the various potential complications of this new drug. This relationship also raises questions about the exact pathophysiology of peptic ulcer disease.

Coronary artery bypass grafting and percutaneous coronary intervention in patients with end-stage renal disease

OBJECTIVES To determine the relative risks of long-term mortality between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) among patients with end-stage renal disease (ESRD). METHODS We identified 1015 patients with ESRD who underwent coronary revascularization between 1996 and 2008 within Kaiser Permanente Northern California. We obtained clinical variables from health plan databases, state death certificates and social security administration files. Our primary and secondary outcomes, respectively, were all-cause mortality and repeat revascularization. Our primary predictor was CABG compared with PCI. We used a Cox proportional hazards model for multivariable analyses. RESULTS The mean age of CABG and PCI patients was similar (64.7 ± 10.6 and 63.4 ± 9.3, respectively, P = 0.06). The CABG group had a higher proportion of diabetics (P = 0.045), and higher nitrate use (P = 0.01). Adjusted for age, gender, race, year of index revascularization, number of vessels intervened, duration of dialysis and baseline comorbidities, patients referred for CABG during the first year had a hazard ratio (HR) of 1.16 [95% confidence interval (CI), 0.80-1.67] for mortality compared with PCI. During Years 1-5, the HR was 0.91 (95% CI, 0.63-1.33) with an overall HR of 0.73 (95% CI, 0.43-1.22). The sub-HR as calculated by the Fine-Gray competing risk model was 0.51 (95% CI, 0.31-0.85). CONCLUSIONS As there are no randomized clinical trials in this area, our observational study adds to the growing body of literature that suggests a significant decrease in repeat revascularization with CABG and at least equivalency in long-term mortality with CABG when compared with PCI in ESRD patients.

Multimorbidity is strongly associated with long-term but not short-term mortality after cardiac valve replacement

BACKGROUND The presence of multimorbidity is known to be related to adverse clinical outcomes. However, its association with mortality in patients undergoing cardiac valve replacement is not known. METHODS Multimorbidity (as a continuous variable) was characterized in adults receiving cardiac valve replacement surgery between 2008 and 2012 within Kaiser Permanente Northern California based on information from health plan electronic health records. Our primary outcome was 3-year all-cause mortality after surgery. We used Cox proportional hazards regression to evaluate the independent association of each additional comorbidity with mortality. RESULTS Among 3686 eligible patients, mean age was 67.9±13.5years and median comorbidity burden was 3 (IQR: 2). The presence of most individual comorbidities except hypertension and hyperlipidemia did not occur in isolation. The unadjusted annual incidence (per 100 person-years) of death increased with higher comorbidity burden: ≤1: 4.61 (95% CI: 3.29-6.45), 2-3: 13.7 (95% CI: 11.9-15.8), 4-5: 23.6 (95% CI: 20.6-26.9), and ≥6: 43.4(95% CI: 34.6-54.4). Advancing age, diabetes mellitus, cerebrovascular accident, heart failure, lung disease, urgent status and use of aldosterone-receptor antagonists were independently associated with an increased risk of mortality. In multivariable analyses, each additional comorbidity was significantly associated with an increased risk of long-term (adjusted hazard ratio (HR) 1.30, 95% CI: 1.22-1.39) but not short-term mortality (HR 0.92, 95% CI: 0.80-1.07). CONCLUSIONS Our study demonstrated that multimorbidity in patients undergoing cardiac valve replacement is significantly associated with long-term but not short-term mortality.

Analysis of mitral valve replacement outcomes is enhanced by meaningful clinical use of electronic health records.

OBJECTIVE Cardiac surgical mortality has improved during the last decade despite the aging of the population. An integrated US health plan developed a heart valve registry to track outcomes and complications of heart valve operations. This database was used for longitudinal evaluation of mitral valve (MV) outcomes from 1999 to 2008 at four affiliated hospitals. METHODS We identified 3130 patients in the Apollo database who underwent 3180 initial MV procedures. Internal administrative and Social Security Administration databases were merged to determine survival rates. Electronic health records were searched to ascertain demographics, comorbidities, and postoperative complications. Cox regression was used to evaluate mean survival and identify risk factors. RESULTS The procedures included 1160 mechanical valve replacements, 1159 tissue valve replacements, and 861 annuloplasties. The mean age of patients undergoing these procedures was 58 ± 11 years, 69 ± 12 years, and 62 ± 12 years, respectively. Mean survival was 8.9 ± 0.1 years for mechanical valve replacement, 7.0 ± 0.1 years for tissue valve replacement, and 7.7 ± 0.1 years for annuloplasty. Early in the study, there was a preference for implanting mechanical MVs. Beginning in 2003, more patients received tissue valve replacements rather than mechanical valves. Over time, there was an increasing trend of annuloplasty. Cox regression analysis identified the following risk factors for increased ten-year mortality: tissue valve implantation; advanced age; female sex; nonelective, nonisolated procedure; diabetes; postoperative use of banked blood products; previous cardiovascular intervention; dialysis; and longer perfusion time. Hospital location, reoperation, preoperative anticoagulation, and cardiogenic shock were not statistically significant risk factors. CONCLUSIONS When controlling for other risk factors, we observed a lower long-term survival rate for tissue valve replacement compared with mechanical valve replacement. Integrating electronic health records with existing electronic databases provided near-real-time analysis of longitudinal cardiac surgical outcomes.

Right Heart Bullet Embolus: A Model for Management — Case Report

Bullet embolism to the right heart from a distal vein is a rare event. Its diagnosis requires a high index of suspicion and use of various radiographic modalities. The many complications associated with a retained intracardiac foreign body argue strongly for its retrieval.