Upstate University Hospital

Introduction: Patients with ischemic stroke of unknown origin may be indicated for long-term insertable cardiac monitoring (ICM) for potential AF. It has been proposed that stroke pathways incorporating a Heart-Brain collaborative approach may improve triaging for appropriate monitoring and prevent loss to follow-up, however little is known about in-hospital patient pathways and associated monitoring utilization in real-world practice. Methods: Patients with ischemic stroke hospitalization during 2020-2023 were identified in the U.S. Medicare Fee-for-service database, with index date assigned as the date of hospitalization. Those with a claim for AF, mechanical heart valve or bacterial endocarditis during index hospitalization were excluded to refine to those more likely to have stroke of unknown origin. Patients were assigned to cohorts based on the physician specialties documented in the claim: Neurology Only, Cardiology Only, or Both Neuro/Card. Those with other or unclassifiable specialties were excluded from the analysis. Patients were followed for 12 months post-hospitalization. Outcome variables included index length of stay (LOS), ICM insertion, and follow-up cardiology visit in patient discharged without a consult. Results: Of 112,436 stroke hospitalizations meeting criteria, 79,603 (70.8%) saw Neurology Only, 29,409 (26.2%) saw Cardiology Only, and 3,424 (3.0%) saw Both (Table 1). ICM implant during stroke hospitalization was observed in a higher proportion of patients with a team approach including Both Neuro/Card (45.2% of patients vs. 28.9% Card Only or 2.3% Neuro Only, p<0.001 both comparisons). Among patients with Neuro/Card, adding ICM implant was not associated with longer LOS (mean 6.0 vs. 6.3 days) (Table 2). Likewise, adding another specialty consultation was not associated with longer LOS (6.0 days vs. 8.2 Neuro Only or 6.1 Card Only). In patients discharged without cardiology, time to consult was 112(94) days. Of patients who receive ICM, those with Both Card/Neuro or Card Only received the device earlier than Neuro Only (mean 7.9-9.1 vs. 73.6 days) and were >2x more likely to be implanted before discharge vs. later in follow-up (92-94% vs. 41%). Conclusions: Heart-brain collaboration in the inpatient stroke setting was associated with increased rate of ICM and did not appear to extend LOS. These data suggest that a multidisciplinary approach in ischemic stroke may help ensure timely evaluation for potential cardiac monitoring for AF.

Introduction Antidysrhythmic medications are commonly prescribed, but there is little information on the incidence of adverse effects following an inadvertent extra dose of these medications. This poses a challenge to poison centers when trying to decide which patients need to be sent to a healthcare facility for monitoring. Methods A retrospective data review of cases reported to a regional poison center between January 1, 2012 and December 31, 2022 was performed. Cases were included if the exposure was a double dose or less of the patient’s own antidysrhythmic medication, the exposure was unintentional or a result of therapeutic error, and the antidysrhythmic(s) belonged to Vaughan Williams Class I or III. Cases were included even if other medications were included in the therapeutic error. Descriptive data were collected on cases meeting the inclusion criteria. Results One hundred and sixty-two exposures were included. Of these, only 49 were monitored in a healthcare facility for which coded outcomes were available. Of these, the majority had no or minor effects (83.7%). Two of the exposures developed hypotension, but both also involved either a beta-adrenoceptor blocking drug or a calcium-channel blocker. Of the 25 cases that only included an antidysrhythmic, adverse effects were even less common, with 92.0% having no or only minor effects. Discussion In this small cohort, adverse events were uncommon with inadvertent extra dose antidysrhythmic exposures. However, serious outcomes have been reported in other studies. It appears adverse events are less common if the extra dose exposure does not involve other cardioactive medications. Conclusions Extra-dose exposures of some antidysrhythmics belonging to Vaughan Williams Class I or III were generally well tolerated, but more data are needed to determine whether certain patients can be safely monitored at home. For example, only three cases involved Class IA drugs. Based on our findings, patients who reportedly ingest an extra dose of an antidysrhythmic plus another cardioactive medication should be evaluated at a healthcare facility.

BackgroundGlucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a popular first-line treatment option in managing Type 2 Diabetes Mellitus (T2DM) with cardiovascular co morbidities. Studies have established the benefit of GLP-1 RAs in improving cardiovascular (CV) outcomes in patients with T2DM. However, the impact of GLP-1 RAs on mortality and cardiovascular outcomes in patients with T2DM and Heart failure with reduced ejection fraction (HFrEF) remains uncertain.MethodsThis retrospective cohort study employed an active-comparator new-user design using the TriNetX Research Network database. Patients aged 18 years or older with T2DM and left ventricular ejection fraction of ≤40 % were identified for inclusion. Patients were classified into two groups: GLP-1 RAs users versus dipeptidyl peptidase 4 inhibitor (DPP4i) users. Propensity score matching (1:1) was conducted based on demographics, body mass index, comorbidities, glycated hemoglobin levels, medications and socioeconomic factors resulting in a matched cohort of 26,196 patients. Outcomes analyzed included all-cause mortality, acute myocardial infarction, cerebrovascular accident, and all-cause hospitalization.ResultsThe GLP-1 RA user group demonstrated a reduced hazard ratio (HR, 95 % confidence interval) over 5 years compared with the DPP4i user group for all-cause mortality (0.62, 0.59–0.66, P < 0.001), all-cause hospitalization (0.71, 0.69–0.73, P < 0.001), acute myocardial infarction (0.87, 0.82–0.92, P < 0.001), heart failure exacerbation (0.83, 0.81–0.86, P < 0.001) and cerebrovascular accidents (0.85, 0.80–0.92, P < 0.001).ConclusionIn patients with T2DM and HFrEF, GLP-1 RA therapy shows potential beneficial effects in reducing CV events over 5 years compared to control (DPP4i) group.

Peripheral artery disease (PAD) is associated with a high risk of cardiovascular events. While glucagon-like peptide-1 receptor agonists (GLP-1RAs) have demonstrated cardiovascular benefit in patients with diabetes, their role in patients with PAD without diabetes is not well understood. This study aimed to assess the impact of GLP-1RA therapy on cardiovascular outcomes in nondiabetic PAD patients. We conducted a retrospective cohort study using the TriNetX U.S. collaborative network, identifying adults aged 18-89 with PAD and no history of diabetes from January 2014 to January 2024. Patients treated with GLP-1RAs were compared with untreated counterparts. A 1:1 greedy nearest neighbor propensity score matching was performed to balance baseline characteristics. The primary outcomes were 3-point major adverse cardiovascular events (MACE) defined as nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death, all-cause mortality; major adverse limb events (MALE) defined as limb-threatening ischemia, revascularization procedures, or major amputation. Cox regression and Kaplan-Meier analysis were used to assess outcomes over a 5-year follow-up period. After matching, 13,555 patients remained in each group with well-balanced covariates. GLP-1RA use was associated with lower risk of MACE (hazard ratio (HR): 0.61; 95% confidence interval (CI): 0.57-0.66; p < 0.001), all-cause mortality (HR: 0.40; 95% CI: 0.35-0.46; p < 0.001), and MALE (HR: 0.22; 95% CI: 0.17-0.28; p < 0.001). In a sensitivity analysis focusing on semaglutide use initiated post-2021, the benefits remained robust for both MACE (HR: 0.55; 95% CI: 0.50-0.60) and all-cause mortality (HR: 0.303; 95% CI: 0.25-0.36). In this large real-world cohort, GLP-1RA therapy was associated with significantly reduced cardiovascular and limb-related events in nondiabetic patients with PAD. These findings support the potential role of GLP-1RAs in cardiovascular risk reduction beyond diabetes and highlight the need for prospective randomized trials in this population.

Abstract The treatment of scaphoid nonunions remains a challenge, with multiple surgical techniques described. The purpose of this retrospective study was to evaluate the union rates in patients undergoing treatment of scaphoid nonunion with a single headless compression screw and the risk factors associated with failure to achieve union.Using the CPT code for the repair of a scaphoid nonunion (25440), 167 patients were identified as having operative repair of a scaphoid fracture nonunion using headless compression screw fixation performed at a single institution between the years of 2002 and 2024. All patients were followed clinically and with serial radiographic analysis postoperatively to determine if union was achieved. The primary outcome of fracture union was analyzed for each patient. Demographics of individual patients, fracture characteristics, and different autograft types were collected as a secondary analysis to evaluate for risk factors for scaphoid nonunion repair failure.The overall union rate was 75.5% (126/167). Female patients trended toward a higher rate of union following repair compared with male patients, although statistical significance was not fully met (p = 0.07). Age, time from injury to surgery, fracture location, bone graft source, bone graft type, avascular necrosis, tobacco use, and workers' compensation did not demonstrate a significant impact on union rates. No difference was found in the union rate of scaphoid nonunion repairs based on the graft harvest location or graft type.Fixation with headless compression screws and autologous bone graft is a reliable, effective method for treating scaphoid nonunions, with union rates similar to those previously reported. Female patients trended toward having a higher rate of union following repair, although statistical significance was not reached.Therapeutic Level IV.

ABSTRACTCholangiocarcinoma is a rare gastrointestinal malignancy with an annual incidence of 0.3 to 6 cases per 100,000, and, usually, it is reported as adenocarcinoma in about 95% of the cases. It can develop as a result of combination of genetic predispositions and various risk factors like but not limited to choledochal cysts, cholelithiasis/choledocholithiasis, yet its diagnosis is challenging due to difficulties in obtaining tissue for diagnosis. In this study, we present a challenging case in diagnosis that reveals undifferentiated carcinoma with osteoclast-like giant cells in the perihilar region of the bile duct.