BACKGROUND: The optimal approach to implementing telemedicine hypertension management in the United States is unknown. METHODS: We examined telemedicine hypertension management versus the effect of usual clinic-based care on blood pressure (BP) and patient/clinician-related heterogeneity in a systematic review/meta-analysis. We searched United States-based randomized trials from Medline, Embase, CENTRAL, CINAHL, PsycINFO, Compendex, Web of Science Core Collection, Scopus, and 2 trial registries. We used trial-level differences in BP and its control rate at ≥6 months using random-effects models. We examined heterogeneity in univariable metaregression and in prespecified subgroups (clinicians leading pharmacotherapy [physician/nonphysician], self-management support [pharmacist/nurse], White versus non-White patient predominant trials [>50% patients/trial], diabetes predominant trials [≥25% patients/trial], and White patient predominant but not diabetes predominant trials versus both non-White and diabetes patient predominant trials]. RESULTS: Thirteen, 11, and 7 trials were eligible for systolic and diastolic BP difference and BP control, respectively. Differences in systolic and diastolic BP and BP control rate were −7.3 mm Hg (95% CI, −9.4 to −5.2), −2.7 mm Hg (−4.0 to −1.5), and 10.1% (0.4%–19.9%), respectively, favoring telemedicine. Greater BP reduction occurred in trials where nonphysicians led pharmacotherapy, pharmacists provided self-management support, White patient predominant trials, and White patient predominant but not diabetes predominant trials, with no difference by diabetes predominant trials. CONCLUSIONS: Telemedicine hypertension management is more effective than clinic-based care in the United States, particularly when nonphysicians lead pharmacotherapy and pharmacists provide self-management support. Non-White patient predominant trials achieved less BP reduction. Equity-conscious, locally informed adaptation of telemedicine interventions is needed before wider implementation.

Introduction: Left atrial appendage (LAA) harbors approximately 90% of thrombi in non-valvular atrial fibrillation (AF) for which an anticoagulant (AC) is indicated to prevent cardio-embolic stroke. Alternatively, the benefits of LAA occlusion (LAAO) devices to those patients who encounter life-threating bleeding with AC are also well established. However, the LAAO device comes with the risk of device related thrombus (DRT), which is a real challenge. Case: A 68 year-old-male with history of chronic AF on apixaban and recurrent ischemic and hemorrhagic stroke was evaluated for LAAO device placement procedure. Initially, when the patient was not taking AC, he had an ischemic stroke likely cardio-embolic source, which necessitated the initiation of apixaban. Unfortunately, while he was taking apixaban, he had a right thalamic bleed causing persistent left sided paresis. Subsequently, AC was held for 6 months and he underwent watchman device placement. He remained on apixaban for 45 days post procedure and was continued on aspirin only. After 10 months, on routine cardiac computerized tomographic arteriography (CTA), a large filling defect measuring 1.7 x 1.4 cm on the left atrial side of the watchman device was seen (Figure 1A) which was confirmed with transesophageal echocardiogram. Then, he was re-started on apixaban for a short period of time, which culminated him to have a right temporal bleed. After holding AC for 3 months, repeat CTA showed persistent filling defect suggestive of DRT (Figure 1B). Therefore, AC was permanently discontinued and patient was evaluated for DRT removal procedure. Utilizing a shared decision model, the option of mechanical thrombectomy with cerebral protection device (CPD) was chosen to mitigate the risk of embolic stroke. Post procedure, he was continued on apixaban 2.5 mg twice daily for 3 months and then aspirin forever. Subsequent surveillance CTA did not show DRT (Figures 1C and D). Patient has remained asymptomatic thereafter. Conclusion: 3-7% of patients with Watchman device suffer from DRT. Life threatening bleeding from AC further complicates the management of such patients. Mechanical thrombectomy with CPD is an established procedure for the removal of intra-arterial or intravenous thrombus. However, the feasibility of the routine use of mechanical thrombectomy with CPD for persistent DRT in-patient like ours is yet to be studied in detail.

Objective: Post COVID-19 disease pulmonary complications are generally expected among the hospitalized or elderly patients with multiple comorbidities given the gravity of the disease among such patients. However, non-hospitalized patients with less severe symptoms from COVID-19 disease have also been experiencing signif-icant morbidity and difficulty functioning their activities of daily living. Therefore, we aim to characterize post COVID-19 pulmonary complications (symptomatology, clinical and radiological findings) in patients who did not require hospitalization but had significant outpatient visits secondary to COVID-19 sequelae. Methods: This is a two part cross-sectional study based on a retrospective chart review. Patients with COVID-19 disease not requiring hospitalization but followed up at pulmonology clinic with respiratory symptoms were analyzed twice in an interval of 12 months. 23 patients in first cross-section group (followed up from December 2019 to June 2021) and 53 patients in second group (followed up from June 2021 to July 2022) were included in the analyses. Differences in mean and percentage of baseline characteristics and clinical outcomes between the two groups are analyzed using unpaired t -tests and Chi-squared tests respectively. Post COVID-19 disease symptoms are classified in to 3 different groups (mild, moderate and severe) based on duration of symptoms and presence or absence of hypoxia. Results: Dyspnea on exertion (DOE) was the common compliant in majority of patients in both cross-section groups (43.5% vs 56.6%). Mean age in years were 33 and 50 in first and second cross-section groups respectively. Majority of the patients had mild and moderate symptoms in both groups (43.5% vs 9.4%, P = 0.0007; 43.5% vs 83%, P = 0.005). Mean duration of symptoms in first cross-section group was 3.8 whereas 10.5 months (P = 0.0001) in second cross-section group. Conclusion: Our study outlines the burden of post COVID-19 disease pulmonary complications in patient group where these complications are less expected. Strategies for the implementation of multidisciplinary post COVID-19 care clinic along with mass vaccination awareness campaigns in rural US should be prioritized to mit-igate this existing burden. ?? 2023 Published by Elsevier Inc.

INTRODUCTION: Acute uvular edema, uvulitis, and uvular necrosis are rare complications of COVID-19 infection (1).Here, we report a case of acute uvular edema/uvulitis followed by uvular necrosis following an asymptomatic COVID-19 infection. CASE PRESENTATION:A 71-year-old female presented to the ED with complaints of sensation of lump, sore throat, and difficulty swallowing, 3 days after left total knee replacement surgery done under spinal anesthesia.On physical examination, the patient was noted to have a markedly enlarged erythematous uvula with whitish patches (Figure 1).A stridor was heard on forced inspiration.Laboratory studies showed normal leukocytes, elevated C reactive protein and positive COVID-19 PCR.Patient was hemodynamically stable with unremarkable vitals.Computerized tomography of neck revealed mucosal edema of the uvula with no localized abscess.The next day, the patient expectorated a pink flesh-like chunk while brushing her teeth which was identified as the lower pole of the uvula.She reported immediate resolution of her symptoms after expectoration of uvular tissue.Eventually, the patient was discharged home with a course of clindamycin and nystatin swish and swallow.DISCUSSION: Uvulitis is a rare manifestation of COVID-19 (1).Cases of uvular enlargement often associated with pharyngitis or epiglottitis have been reported earlier but not related to COVID-19.Uvular angioedema has also been reported post-Pfizer covid vaccine (2).Possible causes of uvulitis are infections, trauma, allergies, inhalation or ingestion of certain chemicals.However, uvulitis is a clinical diagnosis and other associated diseases of epiglottitis and retropharyngeal abscess should be ruled out which was done in our case.The possible pathophysiology of uvular edema is likely the persistent irritation to the tissue secondary to COVID infection leading to erythema and necrosis which might have happened in our case.CONCLUSIONS: Acute uvular edema/uvulitis and/or uvular necrosis should be suspected in patients presenting with a sore throat, dysphagia, odynophagia and respiratory compromise after a recent COVID-19 infection.Patient education along with physician awareness and early employment of treatment measures can help decrease the incidence, prompt diagnosis and management, and reduce the patient discomfort and adverse outcomes.

PURPOSE: Mortality associated with COVID-19 disease is multifactorial.Various COVID-19 related mortality risk factors may differ as per the geographical distribution, health care settings, patient population and socio-economic factors.It is very important to understand the underlying driving forces for COVID-19 related in-hospital mortality (IHM) in the particular area to formulate the appropriate implementation strategies.Assessment of such factors associated with COVID-19 mortality may guide the health care professionals in making decisions for the better patient outcomes.Therefore, we aim to examine the characteristics and clinical outcomes of COVID-19 patients in intensive care unit (ICU) in a rural academic hospital.Additionally, we believe that our study results may help in making implementation strategies at primary care level, focusing on the modifiable risk factors associated with COVID-19 IHM.METHODS: This is a retrospective study of the COVID-19 patients managed in ICU of a rural academic hospital in a health professional shortage area (HPSA).Among 278 eligible patients, 89 patients expired during the treatment and are included in expired group (EG) whereas, 179 patients are included in non-expired group (NEG).Differences in mean and percentage of baseline characteristics and clinical outcomes between the two groups were analyzed using unpaired t-tests and Chi-squared tests respectively.Institutional review board of Cayuga Medical Center exempted this study from the review.RESULTS: A higher number of elderly patients were found in the EG as compared to NEG (mean age 72 vs 65, P¼0.0008).Majority of the patients were male (59.6% vs 56%), White (58.5% vs 51.4%) and obese (mean body mass index 29.3vs 31.5 kg/m2) in EG and NEG respectively.Cardiovascular disease (CVD) risks like current smoking status (17% vs 5.6%, P¼0.003), diabetes mellitus (DM) (45% vs 30.2%,P¼0.02), hypertension (HTN) (72% vs 58.7%, P¼0.04), coronary artery diseases (CAD) (38.2% vs 23.5%, P¼0.01) and Atrial fibrillation (27% vs 16.2%, P¼0.04) were found in higher proportion among EG as compared to NEG.Only 2.2% vs 4% had ST segment elevation myocardial infarction, 1% vs 4.5% had non-ST segment elevation myocardial infarction and 2.2% vs 6.7% underwent cardiac catheterization between the two groups with no statistical significance.Mean length of hospital stay were 4 vs 5.5 days (P¼0.05),ICU stay were 7.6 vs 4.7 days (P¼0.0002) and mechanical ventilator use were 2.3 vs 1 day (P¼0.02)between the two groups.34.8% patients in EG and 10% in NEG required intubation and mechanical ventilation (P¼<0.0001). CONCLUSIONS:Our study outlines the plausible association of CVD risk factors with COVID-19 IHM.Incorporation of Telemedicine (TM) based CVD management approach along with the post COVID-19 care clinic may play a promising role at primary care level especially in HPSA like ours.Such CVD conscious implementation strategies may help in mitigating the fatal but preventable COVID-19 outcomes.CLINICAL IMPLICATIONS: Implementation of robust primary prevention strategies for modifiable CVD risks like HTN, CAD, DM, smoking status may help in mitigating the fatal outcomes of COVID-19 disease.Appropriate formulation and assessment of feasibility of TM based CVD management strategies along with COVID-19 care clinic is a real need.

INTRODUCTION: A nasogastric tube (NGT) is commonly used for enteral feeding.Its insertion is a benign bedside procedure.Pneumothorax associated with NGT insertion is a rare but serious complication.While COVID-19-related spontaneous pneumothorax has also been reported, the frequency is minimal, and the risk is higher with the severity of the disease.We present a case of pneumothorax as a complication of nasogastric tube insertion in a patient recovering from COVID-19 induced lung damage. CASE PRESENTATION:A 49-year-old female was brought into the emergency department with confusion and shortness of breath, initial chest x-ray showed diffuse ground glass lesions and infiltration along with a positive COVID swab.She was admitted to ICU for hypoxic respiratory distress with COVID-pneumonia.She was started on standard COVID treatment.-Dueto the severity of lung injury she ended up requiring mechanical ventilation.Her recovery was gradual requiring 4 days of mechanical ventilation.The ICU course was lengthy and made her quite weak for appropriate oral intake.After calorie count assessment, it was clear that she will need enteral feeding.A bedside nurse inserted the nasogastric tube per standard protocol to start enteral feeding.The post procedure chest x-ray for NG location confirmation showed a mispositioned nasogastric tube into the right bronchus with extension beyond the margin of right hemithorax and associated hydropneumothorax.Immediately the tube was withdrawn and surgery was consulted.Later on, CT scan of the chest also confirmed hydropneumothorax, requiring chest tube insertion.This whole incident deteriorated her improvement and ultimately she decided to go on comfort care.The patient got transferred to the medical floor with the hospice team where she passed peacefully.DISCUSSION: Although NGT insertion is a simple procedure, the rate of malpositioning can be as high as 15% while the incidence of pneumothorax with insertion is estimated to be around 0.1-1.3%.Risk factors including emphysematous disease, ARDS, excessive force during insertion, and the use of larger diameter tubes can increase the overall incidence.Cases of spontaneous pneumothorax with COVID-19 have also been reported in the literature, underlying etiology may include overdistention of the alveoli with mucous impaction, alveolitis, and the inflamed lung parenchyma (areas of ground glass appearance/GGA) related to COVID-19 disease.Our patient was out of the active disease phase but her chest imaging showed a lot of scarring and GGA that likely contributed to fatal complication.CONCLUSIONS: Pneumothorax associated with NGT insertion is relatively a rare complication.Patients who recovered or are recovering from severe lung damage from covid19 or ARDS are more prone to get pneumothorax with a malpositioned NGT.So special care must be taken when handling the airways of these patients and ideally should be done by experienced staff with a mobile x-ray at the bedside to prevent any delay in diagnosis and management.

Introduction: The social determinants of health (SDoH) are associated with uncontrolled cardiovascular disease (CVD) risk factors and warrant attention. Methods: We describe methods and cross-sectional results of the SDoH screening and referral system at a resident-run primary care clinic at Cayuga Medical Center (total 30 residents ~539 patients seen/month with 12% no shows) starting from Nov 2019. Eight domains of SDoH including food security, utility, housing, childcare, finances, transportation, literacy, and social support were selected based on local county data and focus group discussions. We developed an annual screening tool and referral system integrated into the electronic medical record for any SDoH positive patients to the community health and social workers (CHW/SW), who facilitated access to community resources. Patient education about available community resources, regular follow-up visits with the physician and CHW/SW, and periodic SDoH screening were other key components. Results: Among 741 patients (Hypertension and Diabetes), 607 (82%) patients underwent SDoH screening (Table). 200 (33%) patients had at least one domain of SDoH (SDoH +) and received SDoH interventions whereas, 407 (67%) did not have any SDoH. The three most common SDoH were lack of social support (61%), transportation (35%) and finance issues (25%). Patients in the SDoH+ group were younger, with higher percentage of non-White race/ethnicity, unemployment, disability, living alone, current smokers, illicit substance use, anxiety, depression, obesity, and opioid use with statistical significance. However, there were no significant differences in CVD risk factors like SBP (138.3 vs 138.4 mmHg), DBP (84 vs 83 mmHg), HbA1c (6.4 vs 6.2) and LDL-c (103.7 vs 101.5 mg/dL). Conclusions: In addition to controlling standard CVD risk factors, implementation of SDoH routine screening and referral system in a primary care clinic may help in mitigating CVD burden as seen in our study.

INTRODUCTION:Anaplasmosis is a known tick-related illness caused by an intracellular bacterium Anaplasma phagocytophilum.The common presentation includes myalgias, fever, leukopenia, and thrombocytopenia.Complications like myocarditis, encephalitis, and pneumonitis are rare and are usually in immunocompromised patients.We present a case of anaplasmosis-related respiratory failure requiring mechanical ventilation in an immunocompetent patient.

INTRODUCTION: Corynebacterium species are facultative anaerobic gram-positive bacilli of normal skin flora.They are often considered as blood culture contaminants due to their low pathogenicity [1].Among, various species, Corynebacterium diphtheriae, and non-diphtheriae species (Corynebacterium striatum and Corynebacterium jeikeium) are well known pathogens which may account for 3% cases of infective endocarditis (IE) especially among those with prosthetic heart valves or structural heart diseases.However, various other species of non-diphtheriae Corynebacterium causing prosthetic valve or even native valve IE have been reported infrequently [2].Therefore, in the context of emerging infections, the propensity of non-diphtheriae Corynebacterium causing severe sepsis and native valve IE should not be overlooked. CASE PRESENTATION:A 74-year-old female with history of heart failure with preserved ejection fraction and atrial fibrillation presented with right wrist and knee pain.She was in sepsis likely due to right wrist cellulitis and right knee septic arthritis for which she underwent multiple episodes of joint washout procedures.She was empirically started on Piperacillin-Tazobactam after initial blood cultures revealed gram-positive bacteria.Final blood culture revealed Corynebacterium afermentans.Repeat blood cultures persistently revealed C. afermentans which were underestimated initially as contaminants.Despite receiving appropriate antibiotics for a week, patient remained septic which prompted us to look for IE.Trans-esophageal echocardiogram (TEE) revealed a 0.9 mm x 0.7 mm vegetation on the ventricular side of the posteromedial leaflet of the native mitral valve.Her clinical condition did not improve with Piperacillin-Tazobactam. Subsequently, C. afermentans was found to be resistant to Piperacillin-Tazobactam as per the final sensitivity analysis results due to which she was started on Vancomycin for six weeks.She was eventually diagnosed with native valve IE due to C. afermentans and she made a full recovery with six weeks of Vancomycin.DISCUSSION: In general, Corynebacterium species are known to be the common skin contaminants.Among various species, C. afermentans is an uncommon species that has been rarely found to cause native valve IE.However, in our patient, an uncommon species of common skin contaminants turned out to be a culprit for sepsis with native valve IE, resistant to Piperacillin-Tazobactam.This added another pathogen in the list of uncommon causes of IE.Diagnostically, it is extremely difficult to determine the various species of Corynebacterium and still there is very insufficient data about differentiating a true infection versus a skin contamination [3].In this context, it is very challenging to assess the likelihood of genuine infection or even IE in such patients with Corynebacterium bacteremia.However, the clinical scenario of sepsis with any Corynebacterium species should always raise a suspicion for IE even for those patients who do not have prosthetic heart valves. CONCLUSIONS:It is extremely important to test for IE in all the patients with sepsis and Corynebacterium bacteremia, particularly when not responding well to appropriate antibiotics.It is a high time to remove the tag of "contaminants" for Corynebacterium species unless proved otherwise.

Introduction: The most common causes of myopericarditis are Coxsackie B followed by Coxsackie A, Echovirus, and Poliovirus. However, Epstein Barr Virus (EBV) may uncommonly cause myopericarditis and can mimic acute coronary syndrome (ACS). Case: A 19-year-old healthy non-smoker male presented with acute onset of central, positional chest pain preceded by a 5 day-long course of viral prodromal symptoms including sore throat. EKG showed inferolateral ST segment elevations (Figure 1). HS-Troponin T was markedly elevated (initial; 988, 1 hour; 1171). He was started on ibuprofen and colchicine for suspected myopericarditis. TTE showed LVEF 50% with borderline mild posterior and lateral wall hypokinesis with no pericardial effusion (Figure 1). Although, the presentation and PR depression were consistent with pericarditis, focal wall motion abnormality led to consideration of right or circumflex CAD such as coronary dissection. This was ruled out by coronary angiogram (Figure 2). Cardiac MRI demonstrated the epicardial pattern of gadolinium enhancement consistent with myopericarditis (Figure 2). Subsequently, patient tested positive for IgG (6.4) and IgM (3.2) [normal range 0.8 to 1.1] against EBV Capsid Antigens with unremarkable remaining viral panel results. His symptoms improved significantly with ibuprofen and colchicine. He was also treated with metoprolol succinate and lisinopril due to reduced ejection fraction. Conclusions: Cardiac complications from EBV infection are uncommon. Sometimes, the EKG with pericarditis can mimic ACS warranting an invasive test. Therefore, clinicians must maintain a high level of suspicion for myopericarditis resulting from EBV.