Introduction: Alcoholic liver disease (ALD) remains the most common type of chronic liver disease in the United States (US) and is a leading cause of morbidity and mortality. Our study aimed to evaluate mortality trends related to ALD in the United States between 1999 and 2020 and identify subpopulations that are disproportionately affected. Methods: We conducted cross-sectional analyses of all ALD-related mortality in the US using death certificate information from the National Vital Statistics System. Age-adjusted mortality rates (AAMR) per 100,000 population were compared among age, sex, racial/ethnic, and geographic subpopulations. Trends in mortality were examined using log-linear regression models to estimate average annual percentage change (AAPC). Results: The study identified 373,302 deaths related to ALD from 1999 to 2020. The AAMR increased from 4.34 (95% confidence interval [CI], 4.26 – 4.42) in 1999 to 7.86 (95% CI, 7.77 – 7.96) in 2020 with an AAPC of +2.7% (95% CI, 2.2 – 3.3, P < 0.001). Males (AAMR: 7.52 [95% CI, 7.49 – 7.55]) had a higher AAMR than females (AAMR: 2.88 [95% CI, 2.86 – 2.90]); however, AAPC was higher in females (AAPC: +4.0% [95% CI, 3.3 – 4.7]) compared to males (AAPC: +2.1% [95% CI, 1.6 – 2.7]). AAMR was highest in adults aged 35 to 64 years (AAMR: 9.95 [95% CI, 9.92 – 9.99]). AAPC was most prominent in individuals < 35 years (AAPC: +7.4% [95% CI, 5.3 – 9.6]). American Indian/Alaska Native (AAMR: 17.33 [95% CI, 17.03 – 17.63]) populations had the highest AAMR, followed by White (AAMR: 5.36 [95% CI, 5.34 – 5.37]), Black (AAMR: 3.64 [95% CI, 3.60 – 3.68]), and Asian/Pacific Islander (AAMR: 1.30 [95% CI, 1.26 – 1.33]) populations. Non-metropolitan (AAMR: 5.47 [95% CI, 5.42 – 5.51]) regions had a higher AAMR compared to metropolitan regions (AAMR: 5.03 [95% CI, 5.01 – 5.05]). Western (AAMR: 8.20 [95% CI, 8.15 – 8.24]) regions had the highest AAMR compared to the other United States census regions. Conclusion: The results of our study reveal a rise in ALD-related deaths from 1999 to 2020, with specific subpopulations in the US being affected at a higher rate. The subgroup analyses show a higher AAMR in men, adults aged 35 to 64 years old, Hispanic populations, and non-metropolitan regions. These findings highlight the pressing necessity for greater awareness and intervention to address the growing burden of ALD mortality in the US (Figure 1).Figure 1.: Mortality Trends Related to Alcoholic Liver Disease in the United States from 1999-2020.
Case Presentation: A 40-year-old male presented with decompensated heart failure and severe pulmonary hypertension (echo-predicted right ventricular systolic pressure 60 mmHg). Right heart catheterization revealed high output heart failure (cardiac index 7.3 L/min/m 2 ), left to right shunt (Qp:Qs 3.6:1), pulmonary hypertension (mean 38 mmHg), and normal pulmonary resistance (1.53 Wood units). Transesophageal echocardiogram revealed a large non-coronary sinus of Valsalva aneurysm with communication to the right atrium (Figure 1a and b). Percutaneous transcatheter closure of the aneurysm was deferred due to large size (3.3 x 4.3 cm), proximity to the right coronary artery, and risk of aneurysm rupture with catheter manipulation (Figure 1c). The patient underwent surgical aneurysm resection and aortic root replacement and recovered well. Discussion: Sinus of Valsalva aneurysms (SVAs) are rare pathologies characterized by expansion of the aortic root wall between the sinotubular junction and the aortic valve annulus and are often associated with connective tissue disorders. SVAs are often diagnosed incidentally on imaging but can present with symptoms if they rupture into nearby cardiac structures, such as an aorto-atrial fistula with left to right shunting, high output heart failure and hemodynamic compromise, as in this case. While transthoracic echocardiogram is the diagnostic modality of choice for most SVAs, multimodality imaging, catheterization, and advanced imaging may also be needed. Surgical repair remains the gold standard of therapy, however treatment with transcatheter device placement has also been successfully performed.
Multi-vessel disease including the brachiocephalic artery remains a relatively rare finding in atherosclerotic disease when compared to stenosis of other major vasculature. Its management presents many difficulties. Endovascular intervention is a highly preferred choice of therapy in these patients although it is dependent on operator experience. We present a case of left common carotid and brachiocephalic arterial stenosis in a patient who presented with neurological alterations that was treated with endovascular stenting. Technical difficulty was encountered during intervention but was successful.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, impacting approximately 6.1 million adults in the United States, with projections to increase two-fold by 2030. AF significantly increases the risk of stroke and other adverse cardiovascular events, leading to increased morbidity and mortality. The 2023 ACC/AHA/ACCP/HRS guidelines present a paradigm shift in AF management, moving from a duration-based classification to a more comprehensive, patient-centered approach. This includes a novel AF classification system that emphasizes early detection and intervention, including risk factors and lifestyle modification tailored to each patient’s risk profile. Moreover, the recommendations advocate for a multidisciplinary care model, ensuring coordinated management involving primary care providers and specialists. Primary care providers play a crucial role in initiating risk factor management and lifestyle interventions, even before the development of AF. This review aims to thoroughly examine the guidelines for the diagnosis and management of AF and equip general internists with the necessary insights to navigate the evolving landscape of AF care effectively.
Although the COVID-19 pandemic was a surprise for many, this was anticipated by many public health officials. Organizations have long warned of the potential of a viral outbreak, however many of these organizations were eventually defunded, or ignored. As we know, COVID-19 is a highly transmissible virus with the potential for life-threatening outcomes, while also capable of dismantling economic and healthcare infrastructure. The first case of COVID-19 in the United States was confirmed on January 20, 2020, and now the US leads in the highest number of confirmed cases globally. On March 11, 2020, the World Health Organization (WHO) declared the coronavirus a pandemic (1). The initial response to COVID-19 was inefficient and consisted of strict testing requirements that severely underestimated the prevalence of the disease, setting the US back months from containing the spread. This pandemic has magnified the weakness of the current healthcare system in the US and has identified areas that are in need of improvement. In this article, we describe inefficiencies that have been brought to light by this global pandemic while comparing similar points seen in other countries outside of the United States. Greater efforts are warranted to improve the current healthcare system and to potentially prevent the spread of future outbreaks within the United States.
Disseminated coccidioidomycosis is associated with significant morbidity and mortality. Involvement of the meninges is often fatal if untreated, typically requiring lifelong antifungal therapy and neurosurgical intervention. We present the case of a young male without any known immunocompromising conditions who opted exclusively for medical management of newly diagnosed coccidioidomycosis meningitis with communicating hydrocephalus and discuss the controversy associated with this approach. This case highlights the importance of shared decision-making between patient and clinician, even if the plan diverges from available guidelines. Furthermore, we discuss clinical considerations in approaching the close outpatient monitoring of patients with central nervous system coccidioidomycosis with hydrocephalus.
Background Healthcare coverage has been shown to have implications in the prevalence of coronary artery disease. We explore the impact of lack of healthcare coverage on ischemic heart disease (IHD) mortality in the US. Methods We obtained county-level IHD mortality and healthcare coverage data from the CDC databases for a total of 3,119 US counties. The age-adjusted prevalence of current lack of health insurance among individuals aged 18 to 64 years were obtained for the years 2018 and 2019 and were placed into four quartiles. First (Q1) and fourth quartile (Q4) had the least and highest age-adjusted prevalence of adults without health insurance, respectively. IHD mortality rates, adjusted for age through the direct method, were obtained for the same years and compared among quartiles. Ordinary least squares (OLS) regression for each demographic variable was conducted with the quartiles as an ordinal predictor variable and the age-adjusted mortality rate as the outcome variable. Results We identified a total of 172,942 deaths related to ischemic heart disease between 2018 and 2019. Overall AAMR was higher in Q4 (92.79 [95% CI, 92.35–93.23]) compared to Q1 (83.14 [95% CI, 82.74–83.54]), accounting for 9.65 excess deaths per 100,000 person-years ( slope = 3.47, p = 0.09). Mortality rates in Q4 for males (126.20 [95% CI, 125.42–126.98] and females (65.57 [95% CI, 65.08–66.05]) were higher compared to Q1 (115.72 [95% CI, 114.99–116.44] and 57.48 [95% CI, 57.04–57.91], respectively), accounting for 10.48 and 8.09 excess deaths per 100,000 person-years for males and females, respectively. Similar trends were seen among Hispanic and non-Hispanic populations. Northeastern, Southern, and Western regions had higher AAMR within Q4 compared to Q1, with higher prevalence of current lack of health insurance accounting for 49.2, 8.15, and 29.04 excess deaths per 100,000 person-years, respectively. Conclusion A higher prevalence of adults without healthcare coverage may be associated with increased IHD mortality rates. Our results serve as a hypothesis-generating platform for future research in this area.
