United States

Introduction 
Rocuronium-induced anaphylaxis (RIA): 
 Estimated to occur in between 1 in 3,500 &amp; 1 in 20,000 cases.
 90% of cases occur at induction of anesthesia.
 Neuromuscular blocking drugs are thought to be responsible for between 60-70% of anesthesia-induced reactions, with rocuronium being the most implicated.
Sugammadex: 
 Synthetic modified gamma-cyclodextrin derivative.
 The physiological rationale in RIA: Sugammadex incompletely encapsulates rocuronium, preventing the rocuronium epitope from binding IgE. Hence, the Severity of anaphylaxis should be ameliorated. 

Methods: 
Screen process:
We did a systematic review and looked at published case reports. 
We used mesh terms “ anaphylaxis, allergy, or hypersensitivity” and “ Rocuronium, Zemuron, or Esmeron.” 
We looked into Ovid Meline, Embase, and Web of Science. After the screening process, we found 356 published case reports. 
We divided them into two groups, Group A RIA and Group B Sugammdex use in RIA. 
We looked at baseline patient characteristics, ASA severity, the incidence of complications, duration of hypotension, discharge disposition, and mortality. 

Results: 
Baseline patient characteristics: 
All patients of RIA and RIA with sugammadex were ≤60 years old 52% and 73%.
Female sex was more common in the RIA with sugammadex (67%) rather than in RIA alone (58%). 
Almost three-quarters of the RAI group had ASA classification of (1-2) compared to two-thirds of the RIA with the sugammadex group. 
Dose of Sugammadex: 
Dose of sugammdex was ≤4mg kg (25%), &gt;4mg kg (29%), ≤500mg (25%) and &gt;500mg (21%). 
Complications: 
RIA with sugammdex was associated with lower tachycardia (54% vs 78%), rash (39% vs 78%), complications (0% vs 20%) and ICU admission (61% vs 91%) rather than RIA alone (p &lt;0.05). 
However, no differences were detected in bronchospasm or high peak airway pressure, epinephrine infusion, length of hypotension, and mortality (p &gt;0.05). 

Recommendations: 
Early recognition and treatment of anaphylactic shock.
Epinephrine is still the mainstay of treatment. 
Consider using sugammadex in case of suspected RIA.
We recommend a 16 mg/kg dose.
We recommend using sugammadex in case of cardiac arrest or refractory anaphylaxis as evidence of NNT to avoid organ dysfunction is 7 and potential evidence of mortality benefit. 

References: 
Simons FE, Ardusso LR, Bilò MB, El-Gamal YM, Ledford DK, Ring J, et al. World Allergy Organization. World Allergy Organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011;4:13–37. 
Harper NJ, Dixon T, Dugué P, Edgar DM, Fay A, Gooi HC, et al. Working Party of the Association of Anaesthetists of Great Britain and Ireland. Suspected anaphylactic reactions associated with anaesthesia. Anaesthesia. 2009;64:199–211. 
McDonnell NJ, Pavy TJ, Green LK, Platt PR. Sugammadex in the management of rocuronium-induced anaphylaxis. Br J Anaesth. 2011;106:199–201. 
Mertes PM, Laxenaire MC, GERAP [Anaphylactic and anaphylactoid reactions occurring during anaesthesia in France. Seventh epidemiologic survey (January 2001-December 2002)] Ann Fr Anesth Reanim. 2004;23:1133–43. French. 



AMA Research Challenge 2022

Rocuronium-Induced Anaphylaxis, Systematic review, and current opinion

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Charles Lopresto, DO

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Introduction 
Rocuronium-induced anaphylaxis (RIA): 
 Estimated to occur in between 1 in 3,500 & 1 in 20,000 cases.
 90% of cases occur at induction of anesthesia.
 Neuromuscular blocking drugs are thought to be responsible for between 60-70% of anesthesia-induced reactions, with rocuronium being the most implicated.
Sugammadex: 
 Synthetic modified gamma-cyclodextrin derivative.
 The physiological rationale in RIA: Sugammadex incompletely encapsulates rocuronium, preventing the rocuronium epitope from binding IgE. Hence, the Severity of anaphylaxis should be ameliorated. 

Methods: 
Screen process:
We did a systematic review and looked at published case reports. 
We used mesh terms “ anaphylaxis, allergy, or hypersensitivity” and “ Rocuronium, Zemuron, or Esmeron.” 
We looked into Ovid Meline, Embase, and Web of Science. After the screening process, we found 356 published case reports. 
We divided them into two groups, Group A RIA and Group B Sugammdex use in RIA. 
We looked at baseline patient characteristics, ASA severity, the incidence of complications, duration of hypotension, discharge disposition, and mortality. 

Results: 
Baseline patient characteristics: 
All patients of RIA and RIA with sugammadex were ≤60 years old 52% and 73%.
Female sex was more common in the RIA with sugammadex (67%) rather than in RIA alone (58%). 
Almost three-quarters of the RAI group had ASA classification of (1-2) compared to two-thirds of the RIA with the sugammadex group. 
Dose of Sugammadex: 
Dose of sugammdex was ≤4mg kg (25%), >4mg kg (29%), ≤500mg (25%) and >500mg (21%). 
Complications: 
RIA with sugammdex was associated with lower tachycardia (54% vs 78%), rash (39% vs 78%), complications (0% vs 20%) and ICU admission (61% vs 91%) rather than RIA alone (p <0.05). 
However, no differences were detected in bronchospasm or high peak airway pressure, epinephrine infusion, length of hypotension, and mortality (p >0.05). 

Recommendations: 
Early recognition and treatment of anaphylactic shock.
Epinephrine is still the mainstay of treatment. 
Consider using sugammadex in case of suspected RIA.
We recommend a 16 mg/kg dose.
We recommend using sugammadex in case of cardiac arrest or refractory anaphylaxis as evidence of NNT to avoid organ dysfunction is 7 and potential evidence of mortality benefit. 

References: 
Simons FE, Ardusso LR, Bilò MB, El-Gamal YM, Ledford DK, Ring J, et al. World Allergy Organization. World Allergy Organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011;4:13–37. 
Harper NJ, Dixon T, Dugué P, Edgar DM, Fay A, Gooi HC, et al. Working Party of the Association of Anaesthetists of Great Britain and Ireland. Suspected anaphylactic reactions associated with anaesthesia. Anaesthesia. 2009;64:199–211. 
McDonnell NJ, Pavy TJ, Green LK, Platt PR. Sugammadex in the management of rocuronium-induced anaphylaxis. Br J Anaesth. 2011;106:199–201. 
Mertes PM, Laxenaire MC, GERAP [Anaphylactic and anaphylactoid reactions occurring during anaesthesia in France. Seventh epidemiologic survey (January 2001-December 2002)] Ann Fr Anesth Reanim. 2004;23:1133–43. French.

poster

Background: Surgery provides an excellent opportunity for smokers to quit. Our prior work showed that many smokers scheduled for surgery are willing to “quit for a bit” (from the morning of surgery until at least one week after surgery), even if not ready to contemplate sustained abstinence (“quit for good”). This project aimed to develop, and pilot test an innovative tobacco use intervention to help surgical patients who smoke to maintain at least short-term perioperative abstinence.
Methods: An existing SMS message library used to promote sustained abstinence (“quit for good”) was modified to target “quitting for a bit” by emphasizing the benefits of smoking cessation to surgery. Numerous opportunities for patients to provide responses to queries were provided. Current smokers seen in a preoperative evaluation clinic were stratified according to the intended duration of perioperative abstinence and randomized within each stratum to receive either the “quit for a bit” intervention or the conventional “quit for good” intervention. The primary outcomes were a treatment engagement index calculated as the proportion of response opportunities completed by subjects, and the proportion of subjects who continued using the SMS service at study completion (30 days). Secondary outcomes were self-reported smoking status and satisfaction with the service.
Results: The engagement index did not differ between groups (median [25th, 75th] of 23.7 [8.8, 46.0] for “quit for a bit” group (n=48) and 22.2 [4.8, 46.0] for “quit for good” group (n=50), p= 0.74), nor did the proportion of patients continuing SMS use after study completion (33% and 28%, respectively). Abstinence outcomes on the morning of surgery, 7, and 30 days after surgery did not differ between groups. Satisfaction with the programs was high in both groups and did not differ. There was no significant interaction between intended abstinence duration and any outcome, i.e., alignment of intent with intervention did not affect efficacy.
Conclusion: Tobacco use treatment delivered via SMS was feasible and well-utilized by surgical patients. Tailoring an SMS intervention to focus on the benefits of short-term abstinence in surgical patients did not increase engagement in treatment or perioperative abstinence rates.

SMS 2 QUIT: A randomized clinical trial to promote perioperative smoking cessation using short message services.

Percutaneous electrical nerve field stimulation (PENFS) is a minimally invasive therapy that involves electrodes placed on the ear through needle arrays to stimulate the auricular branches of the cranial nerves. We hypothesize that PENFS can decrease pain in fibromyalgia through stimulation of the auricular branch of the vagus nerve. We previously published data suggesting a neuromodulatory effect of PENFS in fibromyalgia1, and here we seek to further explore the potential vagal mechanisms. This was a randomized, controlled, open label investigation conducted in a government hospital. Twenty-one veterans with fibromyalgia were randomized to receive either standard therapy or ST with auricular PENFS (ST+PENFS). Seed-based connectivity using a vagal nucleus seed was assessed and correlated to pain scores using the CONN toolbox. Functional connectivity between the vagal nucleus and several clusters in the cuneus and lingual gyri predicted greater decreases in pain for the PENFS treatment group, relative to the standard-care control group. Our results further suggest that connectivity to the vagal nucleus may be predictive of treatment response in fibromyalgia. Future directions include extracting heart rate variability data to further assess the potential effects of PENFS on vagal nerve modulation for pain treatment.

Vagal Nucleus Connectivity Predicts Percutaneous Electrical Nerve Field Stimulation Treatment Response in Veterans with Fibromyalgia

Introduction:
Alcoholic cardiomyopathy (AC) results due to the consumption of high levels of alcohol on a long-term basis. Its prevalence varies and ranges from 4 to 40 percent. Although AC makes up approximately 4% of all cardiomyopathies, it is the second most common cause of dilated cardiomyopathy. We herein explore the outcomes of percutaneous coronary intervention (PCI) among patients with AC.

Methods:
This is a cross-sectional study of the National Inpatient Sample (NIS) for hospital discharges in the United States between 2012 to 2014. We identified the number of patients with a primary or secondary diagnosis of AC using the ICD-9 code of 4.255. Using the ICD-9 code for PCI (00.66, 36.01, 36.02, 36.05, 36.06, 36.07, 17.55), we identified patients diagnosed with AC who underwent a PCI (AC/PCI). Hospital length of stay (LOS), death, cost of hospitalization, and cardiovascular outcomes, including atrial fibrillation (AF) and Ventricular fibrillation (VF) were compared between patients with and without AC who underwent a PCI.

Results:
A total of 2,488,293 PCIs were performed between 2012 to 2014. Of these, there were a total of 161 admissions for alcoholic cardiomyopathy. The patients with AC/PCI were likely to stay longer in the hospital, with an average stay of 6.6 days (SD = 6.2) compared to patients without AC undergoing PCI -3.7 days (SD = 5.0) (p=0.0001). The mean hospital charge for patients with AC/PCI was $120,225 (SD=101,044), while that of those without AC who underwent PCI was $87,936 (SD=83,947) (p=0.0001). A higher death rate during hospitalization, 3.7%, was recorded in the AC/PCI category vs. 2.3% in patients without AC who underwent PCI (p=0.0001). Patients with AC/PCI had a higher prevalence of AF (30.4%) than VF (7.5%).

Conclusion:
Alcohol abuse increases the disease burden and continues to be a public health concern. Despite the decreased prevalence compared to their non-AC/PCI counterparts, the AC/PCI group had poorer hospital outcomes. Further studies are needed to explore the burden of long-term alcohol consumption on cardiovascular disease treatment outcomes.

Alcohol and Heart Health; A Public Health Concern

Assessing Time in Therapeutic Range (TTR): Is remote anticoagulation management as effective as in-person care?

Abstract Title: Catheter ablation for atrial fibrillation: a national study of demographics & socioeconomic factors.

Background: Atrial fibrillation(AF) is the most commonly diagnosed cardiac arrhythmia. With a worldwide prevalence of >33 million, it poses a significant economic burden and serious cardiovascular morbidity and mortality. Catheter ablation(CA) has proven to be an important curative treatment for paroxysmal, persistent, and permanent AF.

Methods: This retrospective study acquired data from the NIS between January,2007 and December,2017. Primary and secondary diagnosis of non-valvular atrial fibrillation were identified using ICD-9 and 10-CM codes. Chi square and unpaired t test were used to evaluate socio-demographic disparities.

Results: From 35,906,946 patients with NVAF, 343641(0.96%) underwent catheter ablation. Patients who underwent CA were mostly in the age group of 50-75 years(63.67%) vs <50 years(8.63%) vs >75 years(27.71%). The majority of patients undergoing CA were men(61.6%) and was more common amongst White race(86.17%) vs Native American(0.58%) vs Black(7.31%). Patients with a median household income falling in 76th-100th percentile(28%) were the majority to have the procedure. Most of the patients had medicare insurance(59.5%) vs Medicaid(4.06%) vs private insurance(32.71%). CA was performed more often during weekdays(89.54%) vs weekends(10.46%) and frequently done as a non-elective procedure(51.41%) vs elective(48.59%). It was more frequent in urban teaching hospitals(73.14%) vs urban non teaching(24.1%) and was more common in the South region(39.57%) vs West region(19.33%). Co-morbidity comparison between the cohorts with vs without CA include hypertension(67.4% vs 75.52%), diabetes(24.53% vs 33.8%), CHF(33.4%
vs 42.45%), alcohol use(2.12% vs 3.17%), tobacco use(7.38% vs 7.72%), and drug abuse(1.02% vs 1.37%). p value was noted to be <0.0001 for above comparisons. In regression analysis, age>50 years(OR-1.59,1.52-1.66,P<0.0001), native-Americans (OR1.39,1.24-1.55,p<0.0001), patients with private insurance(OR-1.307,1.28-1.33,p<0.0001) and high income group(OR-1.154,1.12-1.18,p<0.0001) were associated with higher odds of utilization of catheter ablation.

Conclusion: There is a significant racial and sex disparity in patients undergoing CA for NVAF that mandates further investigation. These results are important when interpreting the characteristics of the patients, so future trials can be made to decrease the high burden of NVAF through CA. Study’s limitation is insufficient data on disease severity and cardiovascular
diagnostic test variables for accurately predicting the factors associated with under utilization.

Catheter ablation for atrial fibrillation: a nationwide study of demographics and socioeconomic factors.

Clinical Characteristics and Outcome of Patients with Left Ventricular Thrombus After ST-segment Elevation Myocardial Infarction: A Single-Center Retrospective Study

1Ngoda Manongi, MD MS., 2Emmanuel Moustakakis, MD., 2Sijun Kim, DO. 
1 Department of Internal Medicine, New York Presbyterian Queens
2 Division of Cardiology, New York Presbyterian Queens

Abstract

Background: Left ventricular thrombus (LVT) can occur in the setting of an ST-elevation myocardial infarction (STEMI). This is a single-center retrospective study to evaluate the clinical characteristics and outcome of patients who develop LVT as a complication of STEMI to help identify at-risk patients for early diagnosis and treatment.

Methods: In this retrospective single center study, we identified patients diagnosed with STEMI admitted to NewYork-Presbyterian Queens between December 2015 and December 2020 using electronic medical record. Transthoracic echocardiogram (TTE) was used to assess the presence of LV thrombus. Demographic data, choice of anticoagulation (AC), use of concomitant antiplatelet agents were collected and reviewed. Clinical outcomes following initiation of AC included bleeding events, stroke, systemic embolism, echocardiographic resolution of LV thrombus, and all-cause mortality. 
Results: Among the 545 patients admitted with STEMI, 14 patients (2.6%) had LVT. The left anterior descending artery was the culprit vessel in all of these cases. The median time from admission to diagnosis using echocardiography was 48 hours (range: 3-74) and the mean LV ejection fraction was 34% (range: 20-45%). Ultrasound enhancing agent was used in all patients. Ten patients (71%) had symptom onset more than 24 hours prior to presentation. Therapeutic anticoagulation was started with heparin and bridged to VKA in 10 patients (71%) and DOAC in 3 patients (21%). One patient did not receive anticoagulation due to bleeding concerns. One patient suffered a stroke shortly after initiating DOAC. Major bleeding event occurred in 1 patient. Follow-up echo was available at six months in 7 patients and showed resolution of LVT in all patients with a mean LV ejection fraction of 42% (range: 25-60%). The median length of hospital stay was 7 days (range 4-21 days). 
Conclusions: The incidence of LVT following STEMI between December 2015 and December 2020 was 2.6%. A high index of suspicion for LVT is needed in patients who have a delayed presentation of STEMI and involve the left anterior descending artery. TTE using ultrasound enhancing agent is important to accurately make the diagnosis.

Clinical Characteristics and Outcome of Patients with Left Ventricular Thrombus After ST-segment Elevation Myocardial Infarction: A Single-Center Retrospective Study

Background: Asymptomatic aortic stenosis management is not only a daily practice challenge but also an area of clinical research controversy. As evidence on conservative versus early aortic valve replacement (AVR) is debatable, we conducted a systematic review and meta-analysis to compare the efficacy of conservative versus AVR in asymptomatic aortic stenosis (AS).

Methods: Electronic databases were systematically searched to identify any observational or interventional studies that compared the effects of conservative management versus AVR on all causes, cardiovascular, non-cardiovascular mortality. Pooled risk ratios (RR) and their 95% confidence intervals (CI) were calculated using random-effects models.

Results: A total of 6216 patients were included from 12 studies (observational=10, and randomized clinical trial=2) with a mean follow-up duration of 5 years. When compared to early AVR, conservative management has statistically significant higher risk of all cause (RR: 0.36, 95%CI [0.32 to 0.46], p<0.00001), cardiovascular (RR: 0.32, 95%CI [0.24 to 0.41], p<0.00001), and non-cardiovascular mortality with (RR: 0.30, 95%CI [0.12 to 0.73], p=0.008). Regarding other complications, conservative treatment showed significant higher risk in sudden cardiac death (RR: 0.46, 95%CI [0.30-0.71], p=0.0005), yet no difference over AVR in stroke, myocardial infarction (RR: 0.86, 95% CI [0.35 to 2.13], p=0.75) and (RR: 0.54, 95% CI [0.19 to 1.53], p=0.25), respectively. 

Conclusion: Patients with asymptomatic aortic valve stenosis, managed with early AVR, have a lower risk of all-cause, cardiovascular, and non-cardiovascular mortality when compared to conservative management.

Conservative management versus early aortic valve replacement for treatment of asymptomatic aortic stenosis: a systematic review & meta-analysis

Background: Atrial fibrillation (AF) is a common postoperative complication after 
coronary artery bypass surgery (CABG). Studies have shown a higher incidence 
of postoperative AF in White patients than in Black patients. This retrospective 
cross-sectional study aims to characterize the incidence and risk factors for 
postoperative AF in Middle Eastern and Black patients compared to White 
patients. 

Methods: Adult patients were included if they had undergone CABG between 
January 2014 and December 2021. Baseline demographics and perioperative 
data were collected. Patients’ race designations were based on self-identification 
in the electronic health records. Univariate and multivariable analyses were 
conducted to identify predictors of postoperative AF. 

Results: A total of 1686 patients were included (median age 67 years, 27% were 
females). There was a total of 1169 White, 440 Black, and 77 Middle Eastern patients. 
The overall incidence of postoperative AF was 40%. We observed a lower incidence 
of postoperative AF in Middle Eastern (32%, OR 0.59, 95% CI 0.36-0.97, P = 0.034) 
and Black patients (28%, OR 0.47, 95% CI 0.37-0.60, P = <0.001) as compared to 
White patients (45%). Other variables associated with postoperative AF on the 
univariate analysis included female gender, pre-operative AF, age, chronic kidney 
disease, left atrial size, obstructive sleep apnea, pre-operative AV nodal blockade, 
concomitant valvular surgery, and moderative-severe valvular disease. On 
multivariable analysis, the Middle Eastern race was associated with a lower incidence 
of postoperative AF with a trend towards significance (OR 0.60 95% CI 0.34-1.07, P 
0.081), whereas the Black race continued to be significantly associated with a lower 
incidence of postoperative AF (OR 0.59 95% CI 0.44-0.79, P <0.001). Other variables 
that continued to be significantly associated with postoperative AF included age ≥65 
years (OR 1.44 P 0.007), female gender (OR 0.63 P 0.002), left atrial size index >32 
ml/kg (OR 1.64 P 0.005), moderate-severe aortic stenosis (OR 1.88 P 0.005), 
preoperative AF (OR 4.55 P 0.005), and AV nodal blockade (OR 0.632 P 0.019). 

Conclusion: We report a lower prevalence of postoperative AF in Middle Eastern 
and Black patients. Further studies are needed to investigate the underlying 
associations between racial and ethnic categories and AF post CABG.

Effect of Race on the incidence of atrial fibrillation post-coronaryartery bypass surgery in a Middle Eastern Community in the United States

Introduction: Heart failure is a growing public health problem with an estimated prevalence of 4-5 million American population. Despite significant advances in heart failure management, the mortality remains high. This study aspires to investigate the risk factors that are associated with mortality in hospitalized heart failure patients.
Methods: We utilized the 2019 National Inpatient Sample (NIS) dataset sponsored by the Agency for Healthcare Research and Quality (AHRQ) under the Healthcare Cost and Utilization Project (HCUP). Patients with Heart Failure (HF) were identified using Clinical Classifications Software Refined (CCSR) for International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Variable of interest include hypertension, diabetes, dyslipidemia, peripheral vascular disease, nicotine use and sleep apnea. Clinical outcomes include HF hospitalizations and effect of different variable on HF mortality. 
Results: A weighted total of 5,675,784 HF related hospitalizations were recorded in the year 2019. A total of 3907455(68.9%) had hypertension, 2080710(36%) had diabetes and 3081445 (54%) had dyslipidemia . 651035(11%) had a comorbidity of peripheral arterial disease, 1542990 (27.1%) were nicotine dependent, and 991150 (17.4%) had sleep apnea. The mortality rate per 10,000 HF hospitalizations were analyzed. There were 7047 deaths due to hypertension as compared to 2953 in non-hypertensive population, 2368 deaths due to diabetes as compared to 2122 deaths in patients without diabetes. The Mortality rate was 4502 in patients with dyslipidemia as compared to 4234 in patients without dyslipidemia. Peripheral arterial disease (PAD) lead to 2434 death as compared to 2183 death in patients without PAD. The mortality rate 4649 deaths due to nicotine use as compared to 4278 in patients who do not use nicotine and 4580 was due to sleep apnea as compared to 4336 death in patients with no sleep apnea. 
Conclusion: Heart failure lead to significant number of hospitalization in the United States in year 2019. Among all studied factors, hypertension was found to be associated with highest mortality risk. This study guides the importance of strict blood pressure control in significantly decreasing mortality associated with heart failure. 





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Rocuronium-Induced Anaphylaxis, Systematic review, and current opinion

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