History Of Arterial Disease Research Articles

Predictors of exercise capacity following septal myectomy in patients with hypertrophic cardiomyopathy.

Patients with hypertrophic obstructive cardiomyopathy (HOCM) have impaired exercise capacity. The gold standard therapy for patients with HOCM is septal myectomy surgery; however, changes in maximum oxygen uptake (VO2peak) following myectomy are variable, with VO2peak decreasing in some patients. Therefore, we evaluated changes in VO2peak following surgical myectomy to determine clinical predictors of those exhibiting decreased VO2peak post-myectomy. HOCM patients (N = 295) who performed symptom limited cardiopulmonary exercise testing prior to and following surgical myectomy were included for analysis. The VO2peak non-responder group (n = 128) was defined as <0% change in VO2peak from pre- to post-myectomy. Step-wise regression models using demographics, clinical, and physiologic characteristics were created to determine predictors of hypertrophic cardiomyopathy patients in the VO2peak non-responder group. Independent predictors of the VO2peak non-responder group included higher pre-myectomy VO2peak (% predicted), older age, women, history of dyslipidemia, lack of cardiac rehabilitation enrollment, and lower body mass index (all p < 0.03). Forty-three (14.6%) patients reached the primary end-point of all-cause mortality during a median follow up of 11.25 years (interquartile range 6.94 to 16.40). After adjustment for age, sex, beta-blocker use, coronary artery disease history, and body mass index, the VO2peak non-responder group had greater risk of death compared with the VO2peak responder group (adjusted hazard ratio: 1.77, 95% confidence interval: 1.06-3.34, p = 0.01). This large hypertrophic cardiomyopathy cohort demonstrated that demographic (i.e. female sex), lack of cardiac rehabilitation enrollment, and cardiovascular risk factors (i.e. history of dyslipidemia) are predictive of those patients that did not exhibit increases in VO2peak following septal myectomy surgery.

Safety of duplex ultrasound-assisted transulnar versus transradial arterial access for invasive coronary procedures: A search for safe alternative access

Background: Transulnar approach (TUA) was comparable to the transradial approach (TRA) in terms of efficacy and safety in the presence of extensive operator experience in the TUA. Without adequate experience, there was an increase in time, and number of punctures, to successful access. Objectives: The aim of the study was to compare the in-hospital safety of duplex ultrasound (DUS) assisted TUA to those of DUS-assisted TRA. Methods: All patients had preprocedural DUS assessment. Patients who needed urgent procedures (e.g., ST-elevation myocardial infarction) or had a history of upper extremity arterial disease were excluded. The patients were randomized into TUA or TRA arms. The primary endpoint was a composite of in-hospital vascular access complications (bleeding, limb ischemia, local pain, spasm, and need for crossover). The timing to successful puncture, total number of punctures, total procedural time, fluoroscopy time, amount of contrast, and radiation dose were compared between the two arms as well. Results: A total of 104 patients were randomized into TUA (n = 50) or TRA (n = 54) arms. There was no statistically significant difference between both arms in terms of the primary endpoint (TUA vs. TRA: 37.5% vs. 28.6% respectively, P = 0.33). Apart from an increase in the incidence of access site pain (28% vs. 7%, respectively, P = 0.006), there was no statistically significant difference between the two approaches in terms of time to successful access, number of punctures, total procedural time, fluoroscopy time, or contrast and radiation doses. There was no clinically detectable limb ischemia in both arms on 30-day follow-up. Conclusions: This study demonstrated that there was no difference in safety between DUS-assisted TRA and TUA. In the presence of DUS, TUA becomes a viable alternative arterial access even with the lack of previous TUA experience. More prolonged follow-up is needed to exclude late subclinical events related to the TUA.

Effectiveness of Buerger-Allen Exercise on Lower Extremity Perfusion and Peripheral Neuropathy Symptoms among Patients with Diabetes Mellitus.

Background:Buerger-Allen Exercise (BAE) promote Lower Extremity Perfusion (LEP) via the wound healing process and reduce Peripheral Neuropathy Symptoms (PNS) among Diabetes Mellitus (DM) patients. We study the efficacy of BAE on LEP and PNS among patients with DM.Materials and Methods:This quasi-experimental study was conducted prospectively from July to October 2017. Fifty DM patients between the ages of 30 and 75 from both genders were selected using a purposive sampling technique and were assessed for LEP with a manual Ankle-Brachial Index (ABI) scale and assessed for PNS with Michigan Neuropathy Screening Instrument (MNSI). The BAE was demonstrated for 4 consecutive days. The intervention was repeated five times per day for each patient and the posttest was conducted 5th day using the same tools.Results:The majority (n = 75, 75%) were 60–69 age group and 98% had education till primary school. 62% had diabetes and 20% of them had a history of peripheral arterial disease. 50% of participants had mildly impaired perfusion during pretest whereas abnormal neuropathy was seen in more than 70% cases which decreased posttest. A significant difference in PNS was seen after the implementation of BAE in both right LEP (t48 = 6.81, p < 0.001) and left LEP t48= 5.21, p < 0.001).Conclusions:BAE has to be taught to the patients with DM in improving the level of LEP and can be encouraged to practice in the hospital and home care setup.

Effects of vorapaxar on clot characteristics, coagulation, inflammation, and platelet and endothelial function in patients treated with mono‐ and dual‐antiplatelet therapy

BackgroundVorapaxar is indicated with standard antiplatelet therapy (APT) in patients with a history of myocardial infarction (MI) or peripheral arterial disease (PAD). ObjectivesTo evaluate the comparative effects of vorapaxar on platelet‐fibrin clot characteristics (PFCC), coagulation, inflammation, and platelet and endothelial function during treatment with daily 81 mg aspirin (A), 75 mg clopidogrel (C), both (C + A), or neither. MethodsThrombelastography, conventional platelet aggregation (PA), ex vivo endothelial function by ENDOPAT, coagulation, platelet activation/inflammation marked by urinary 11‐dehydrothromboxane B2 (UTxB2) and safety were determined in patients who were APT naïve (n = 21), on C (n = 8), on A (n = 29), and on A + C (n = 23) during 1 month of vorapaxar therapy and 1 month of offset. ResultsVorapaxar had no effect on PFCC, ADP‐ or collagen‐induced PA, thrombin time, fibrinogen, PT, PTT, von Willebrand factor (vWF), D‐dimer, or endothelial function (P > .05 in all groups). Inhibition of SFLLRN (PAR‐1 activating peptide)‐stimulated PA by vorapaxar was accelerated by A + C at 2 hours (P < .05 versus other groups) with nearly complete inhibition by 30 days that persisted through 30 days after discontinuation in all groups (P < .001). SFLLRN‐induced PA during offset was lower in APT patients versus APT‐naïve patients (P < .05). Inhibition of UTxB2 was observed in APT‐naive patients treated with vorapaxar (P < .05). Minor bleeding was only observed in C‐treated patients. ConclusionVorapaxar had no influence on PFCC measured by thrombelastography, coagulation, or endothelial function irrespective of APT. Inhibition of protease activated receptor (PAR)‐1 mediated platelet aggregation by vorapaxar was accelerated by A + C and offset was prolonged by concomitant APT. Vorapaxar‐induced anti‐inflammatory effects were observed in non‐aspirin‐treated patients.

Risk Factors of Postoperative Intestinal Ischemia After Abdominal Aortic Aneurysm Repair

Introduction - Intestinal ischemia remains a complication following abdominal aortic aneurysm (AAA) repair associated with a high mortality.1-6 The influence of possible risk factors for developing postoperative intestinal ischemia needs clarification. We sought to define predictors as well as the related mortality and to form a prediction model with the predictiors found. Methods - A nationwide population-based cohort study of 9433 patients who underwent an AAA operation between 2014 and 2016 was conducted. Potential risk factors were determined by reviewing prior studies and univariate analysis. With logistic regression analysis independent predictors of intestinal ischemia were established. These variables were used to form a prediction model. Results - Intestinal ischemia occurred in 267 patients (2.8%). Rupture of AAA was the most important predictor of developing intestinal ischemia (odds ratio [OR], 5.9, 95% confidence interval [CI]4.4-8.0), followed by having a suprarenal AAA (OR 3.4; CI 1.1-10.6). Associated procedural factors were open repair (OR 2.8; 95%CI 1.9-4.2), blood loss >1L (OR 3.6; 95%CI 1.7-7.5) and prolonged operating time (OR 2.0; 95%CI 1.4-2.8). Patient characteristics included having peripheral arterial disease (OR 2.4; 95%CI 1.3-4.4), female gender (OR 1.7; 95%CI 1.2-2.4), renal insufficiency (OR 1.7; 1.3-2.2) and pulmonary history (OR 1.6; 95%CI 1.2-2.2). Age <68 proved to be a protective factor (OR 0.5; 95%CI 0.4-0.8). Associated mortality was higher in patients with intestinal ischemia versus patients without (50.6% vs 5.1%, p<.001). A prediction model with an excellent AUC=0.878 (95% CI 0.860-0.896) could be formed. Conclusion - The prediction model can be used to identify patients at high risk for developing intestinal ischemia and possibly lower the mortality risk.

Diagnostic Accuracy of History and Physical Examination for Predicting Major Adverse Cardiac Events Within 30Days in Patients With Acute Chest Pain.

The cornerstones in the assessment of emergency department (ED) patients with suspected acute coronary syndrome (ACS) are patient history and physical examination, electrocardiogram, and cardiac troponins. Although there are several prior studies on this subject, they have in some cases produced inconsistent results. The aim of this study was to evaluate the diagnostic and prognostic accuracy of elements of patient history and the physical examination in ED chest pain patients for predicting major adverse cardiac events (MACE) within 30days. This was a prospective observational study that included 1167 ED patients with nontraumatic chest pain. We collected clinical data during the initial ED assessment of the patients. Our primary outcome was 30-day MACE. Pain radiating to both arms increased the probability of 30-day MACE (positive likelihood ratio [LR+] 2.7), whereas episodic chest pain lasting seconds (LR+ 0.0) and >24h (LR+ 0.1) markedly decreased the risk. In the physical examination, pulmonary rales (LR+ 3.0) increased the risk of 30-day MACE, while pain reproduced by palpation (LR+ 0.3) decreased the risk. Among cardiac risk factors, a history of diabetes (LR+ 3.0) and peripheral arterial disease (LR+ 2.7) were the most predictive factors. No clinical findings reliably ruled in 30-day MACE, whereas episodic chest pain lasting seconds and pain lasting more than 24h markedly decreased the risk of 30-day MACE. Consequently, these two findings can be adjuncts in ruling out 30-day MACE.

Real-World Rates and Management of Thrombocytopenia Due to Cancer Treatment in Advanced/Metastatic Female Genitourinary Malignancies

OBJECTIVES Thrombocytopenia is a common, potentially treatment-limiting hematologic side effect in cancer treatment (Kuter DJ, 2018). This is particularly true for female genitourinary (fGU) cancers, such as ovarian and endometrial, where treatment involves agents such as platinum-based agents, taxanes, PARP inhibitors, and gemcitabine (Lord R et al., 2018; Berek JS et al., 2018; Cassidy CA et al., 2001; Ten Berg MJ et al., 2001; Mahner S., 2015). Evidence has shown that dose reduction can be an effective way to address thrombocytopenia and avoid discontinuation of treatment (Lord R et al., 2018; Berek JS et al., 2018). In this study, we explore the use of RWD to understand real-world rates of thrombocytopenia in fGU cancer, including rates of occurrence, management and impacts on chemotherapy treatment, dose reduction, and discontinuation. METHODS Analyses were conducted on nationally representative insurance claims database and Electronic Medical Records (EMR). Inclusion criteria of adult fGU cancer patients with prior exposures to gemcitabine, platinum-based agents, taxanes, or PARP inhibitor with 1-month continuous enrollment (or activity, for EMR) were applied. Thrombocytopenia post-treatment exposure was identified using ICD codes. Baseline descriptive characteristics and subsequent dosing changes were assessed. Results were also stratified for the top 2 fGU malignancies present in the data, ovarian and endometrial cancer (approximately two-fifths and one-third respectively). Factors associated with thrombocytopenia were assessed using logistic regression modeling and ensemble predictive model approaches (e.g., XG Boost). Covariates for regression modeling included patient demographics, pre-existing medical conditions, drug exposures and lab test procedures. Model performance was assessed using Receiver-Operating Characteristic (ROC) scores). RESULTS Thrombocytopenia incidence ranged from 10-15%, with approximately 6% of cases diagnosed within the first 60 days of therapy. Early onset of thrombocytopenia (within 30 days of initiating therapy) occurred in less than 5% of patients and increased to 13% after more than 90 days. A significant proportion of patients with thrombocytopenia showed evidence of treatment discontinuation, with relatively few showing evidence of dose reduction in chemotherapy. Of patients with TCP, up to 15% of patients were prescribed corticosteroids and less than 10% of patients required platelet transfusion. ROC scores for ensemble model approaches were on the order of 85-90%. Factors associated with development of TCP included age, history of arterial disease, and concomitant GI malignancy. CONCLUSION Thrombocytopenia is a common condition in ovarian and endometrial cancer, leading to treatment discontinuation in a high proportion of patients. Given relatively low rates of chemotherapy dose titration in TCP patients, there is an opportunity to improve management of this hematologic complication and enable patients to remain on chemotherapy. Predictive model findings, while preliminary, also suggest opportunity to proactively identify patients with high risk of developing TCP, thereby facilitating earlier identification and pre-emptive treatment modification. Disclosures Ransom: Medidata Solutions: Employment. Galaznik:Medidata Solutions: Employment. Rusli:Medidata Solutions: Employment. Lempernesse:Medidata Solutions: Employment. Berger:Medidata Solutions: Consultancy.

What Proportion of Patients Admitted with Stroke or Transient Ischemic Attack May Be Suitable for Newer Cholesterol-Lowering Treatment?

BackgroundProtein convertase subtilisin–kexin type 9 (PCSK9) inhibitors effectively clear low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C). We evaluated stroke admissions potentially eligible for more intensive cholesterol treatment. MethodsRetrospective analysis of consecutive admissions to a hyperacute stroke unit over 5 months in 2017. Records were individually searched. Data were collected on diagnosis, risk factors, and stroke work-up. European Society of Cardiology and European Atherosclerosis Society guidelines for the management of dyslipidaemias were used for screening patients eligible for PCSK9 inhibitors. ResultsOf 650 patient admissions: 351 (54%) had acute ischemic stroke or transient ischemic attack (TIA), 80 (12%) hemorrhage, and 219 (34%) mimic syndromes. Patients with hemorrhage (n = 80), mimic syndromes (n = 219), and absent LDL-C, or non-HDL-C testing (n = 27) were subsequently excluded. 324 patients with acute ischemic stroke and TIA were further screened for PCSK9-inhibitor treatment eligibility. Forty-one (13%) patients with LDL-C greater than or equal to 1.8mmol/L (≥70 mg/dL) on maximal tolerated statin dose and with concomitant “very high vascular risk” were identified. “Very high vascular risk” was defined as a documented history of cardiovascular disease and/or peripheral arterial disease. Of 41 patients eligible for PCSK9 inhibitors, median age was 82 years (range 53-96); median vascular risk factors were 2 (range 1-5); 7 (17%) had TIA; 13 (31%) had history of preceding cerebrovascular events, 13 (31%) diabetes mellitus, 17 (42%) cardioembolic events, 9 (22%) lacunar syndrome, 11 (22%) symptomatic internal carotid artery stenosis (n = 9 were >70%), and 4 (10%) undetermined aetiology. Eighty-three percent patients eligible for PCSK9 inhibitors also had non-HDL-C values greater than or equal to 2.6 mmol/L. ConclusionsUp to 13% of unselected acute ischemic stroke or TIA patients admitted to a hyper-acute stroke unit were potentially suitable for more intensive cholesterol treatment. Our data may act as a useful guide for sample size selection in future stroke trials testing PCSK9 inhibitors.

Prolonged Peripheral Hypoperfusion Promotes Neuroprotection in Ischemic Stroke.

ObjectivesSublethal, transient occlusion of peripheral vessels, called remote ischemic preconditioning (RIPC), induces a neuroprotective state against brain infarction. Recent studies suggest chronic hypoperfusion in patients with peripheral vascular disease (PVD) has analogous effects. We hypothesized a positive correlation between the severity of chronic hypoperfusion and the extent of neuroprotection. To determine if this correlation exists, we compared stroke volumes and clinical measures of modified ranking scale (mRS) and National Institute of Health Stroke Scale (NIHSS) between cases with and without PVD, subgrouping PVD cases by ankle-brachial-index (ABI) values.Patients and methodsCases of ischemic stroke with and without PVD were sampled retrospectively from a local institutional data base. Charts were manually reviewed for demographics (age, sex, ethnicity), comorbidities (diabetes, hypertension, hyperlipidemia, coronary artery disease, smoking, and stroke history), clinical measures (admission NIHSS, prior mRS, three-month mRS, and survival) and stroke volumes in each case. Those diagnosed with PVD and ABI indicating active disease were grouped as PVD cases; those not diagnosed with PVD or having ABI indicating absence of disease were used as controls. PVD cases were subgrouped by disease severity per ABI values: mild (ABI 0.8-0.9), moderate (ABI 0.5-0.9) and severe (ABI < 0.5). Data were analyzed in R using adjusted logarithmic-multivariate models. Adjusted cox proportional hazards models were used to estimate associations between survival and PVD.ResultsA total of 105 patients, 50 PVD cases and 55 controls, were collected. Mean age was 72.54 years, 51.4% were males and 48.6% females, and 94% were Caucasian. There were 17 mild, 22 moderate, and 11 severe cases of PVD. A higher incidence of comorbidities was present in PVD cases. The mean admission NIHSS was 4.44 and did not differ significantly between groups. Stroke volumes were significantly lower (p = .021) in PVD cases (4.39 ± 8.97 ml) compared to controls (19.33 ± 44.31 ml). There was also a significant difference (p = .04) between volumes of mild (3.86 ± 5.47 ml) and severe (0.63 ± 0.76 ml) PVD cases. There were significant differences (p = .012) in the incidence of good outcomes in moderate to severe PVD cases (100%) compared to controls (83.3%). There was no difference in survival between groups (p = .538).ConclusionIncreasing degrees of hypoperfusion related to PVD have a potential neuroprotective effect in acute ischemic stroke quantified by lower stroke volumes and better clinical outcomes at three months as seen in other preclinical models of RIPC.

Characteristics of Acute Cerebral Infarction in Patients with Familial Hypercholesterolemia

Background The patients with familial hypercholesterolemia (FH) suffer from early onset atherosclerotic vascular disease due to high level of cholesterol and subsequent vascular inflammation, especially in the form of coronary artery disease. We investigated the clinical characteristics of FH associated cerebral infarction and its possible mechanism. Methods Between January 2014 and May 2017, acute cerebral infarction patients who admitted to Chung-Ang University Hospital were reviewed from stroke registry and the diagnosis of FH was made based on the Dutch Lipid Clinic Network Diagnostic Criteria for FH. We reviewed their initial laboratory and brain imaging information, prescribed medication and followed lipid profile after discharge. Stroke mechanism was determined based on Trial of ORG 10172 in Acute Stroke Treatment classification. Results Among 1,401 acute cerebral infarction or transient ischemic attack patients, one probable and three possible FH stroke patients were detected. All the patients denied of previous coronary artery disease history and initial lipid panel revealed high levels of total cholesterol (378±75 mg/dL) and low-density lipoprotein-cholesterol (238±56 mg/dL). Stroke mechanisms were heterogeneous, including one atherosclerotic, two vertebral artery dissection cases and one coagulation disorder. All the patients were combined with noticeable degree of intracranial atherosclerosis and were maintained with statin treatment. Conclusions This study illustrates diverse stroke mechanism among stroke patients with FH. Further research is required to disclose exact incidence of FH among stroke population and effective treatment strategy. Key Words: Familial hypercholesterolemia, Stroke, Atherosclerosis

Invasive screening for lower extremity peripheral artery disease: Killing two birds with one stone?

Objectives There is substantial evidence that the majority of cases of lower extremity peripheral artery disease are undetected. As a result, there is great interest in the detection of lower extremity peripheral artery disease through routine screening. However, routine screening of lower extremity peripheral artery disease is still debated. Methods In our cross-sectional study, we included 200 consecutive patients with symptoms suggestive of angina who were undergoing coronary angiography. Irrespective of intermittent claudication, we subsequently performed peripheral angiography to detect lower extremity peripheral artery disease. The predictors of lower extremity peripheral artery disease were analyzed, and the diagnostic utility of these predictors and their combinations were determined. Additionally, the determinants of the amount of radio-opaque material used and peripheral fluoroscopy time were investigated. Results The overall prevalence of lower extremity peripheral disease was 16%. Being older than 65 years, having coronary artery disease and smoking history remained significant predictors after adjusting for other well-known parameters. Having the combination of age ≥65 and smoking was associated with a positive predictive value of 50% (likelihood ratio 5.06), and having all of the predictors was associated with a positive predictive value of 100% (likelihood ratio &gt;1000). Conclusions Routine screening for lower extremity peripheral disease patients undergoing coronary angiography may be useful in selected patients.

A Rare Case of Lower Limb Gangrene Following Anterior Exenteration in a Previously Irradiated Pelvis

Limb-threatening ischemia following arterial thrombosis in a patient with no known history of arterial disease or vascular injury following surgery is difficult to explain. This case report illustrates a rare complication of arterial thrombosis leading to limb gangrene in a patient with recurrent carcinoma cervix who underwent anterior exenteration. A 43-year-old woman irradiated 10 years back for FIGO stage IIA carcinoma cervix presented with recurrence. Since the workup revealed localized disease, surgery was planned. Under general anesthesia with an epidural catheter in situ, patient was placed in lithotomy position and abdomen opened through a lower vertical midline incision. As the lesion was adherent to urinary bladder, a decision was made to do anterior exenteration with uretero-colostomy. The surgery lasted for 7 h, and patient was placed in head-low position for more than 3 h to assist small-bowel packing. Postoperatively, patient developed ischemia of right lower leg with documented thrombosis of right common femoral artery. As the arterial embolectomy failed and gangrene had set in, the limb was amputated on the fourth postoperative day. At the time of this write up, the patient has completed 5 years of disease-free status. She is rehabilitated with the below-knee prosthesis and is mobile. Prolonged lithotomy positioning in the presence of a prior history of radiation may be associated with arterial thrombosis which can threaten limb perfusion, which if not diagnosed and treated early can result in limb gangrene.

3149 Ulcerative Colitis in an Octogenarian: A Diagnostic and Therapeutic Challenge

INTRODUCTION: Individuals aged &gt;60 years contribute to 10%-15% of inflammatory bowel disease diagnoses with merely 10% of them being over 80 years of age. Older-onset ulcerative colitis (UC) is more common than Crohn's disease, with a male preponderance. Compared to younger patients, UC in the elderly manifests more as proctitis, has a subtler presentation with lesser bleeding, diarrhea, and abdominal pain, and a lower risk of relapse, but with increased severity. Till date, literature regarding UC in the octogenarian age group is limited to a handful of case reports. CASE DESCRIPTION/METHODS: An 81-year-old-male, non-smoker, with a history of coronary artery disease and family history significant for systemic lupus erythematosus, presented with moderate to severe, dull, periumbilical abdominal pain of one-month duration, associated with mucoid diarrhea, intermittent high-grade fever, anorexia, and unintentional weight loss. He denied any nausea, vomiting, blood in vomit or stools, icterus or pruritus. He did not report any history of high-risk behavior or recent travel. His examination was unremarkable except periumbilical and diffuse lower abdominal tenderness. Laboratory evaluation was notable for leucocytosis (13.5 K/ul), hyponatremia (128 mEq/L) and hypokalemia (3.1 mEq/L). U/S abdomen showed intestinal distension and a trial of opioid receptor agonists and probiotics was initiated for a probable diagnosis of irritable bowel syndrome, which failed to show clinical improvement. Treatment with broad-spectrum antibiotics, based on CT findings suggestive of colitis, led to partial symptomatic relief. Colonoscopy was performed following a recurrence of symptoms that revealed multiple areas of ulcerations and a biopsy confirmed the diagnosis of UC. The patient received guideline-directed medical therapy with 5-aminosalicylates and corticosteroids, which led to clinical improvement, and since then, the patient has been in remission. DISCUSSION: The unique pathophysiology, clinical manifestations and disease course of UC in the elderly add to its diagnostic challenge. Additionally, the scarcity of literature regarding treatment guidelines and lack of clarity of appropriate clinical endpoints (objective vs.symptom control) limits evidence-based decision in this population with a higher hospitalization and mortality rate. Consequently, a high degree of suspicion needs to be maintained in the aging population presenting with clinical features of colitis to ensure prompt treatment and limit complications.

2670 A Highly Lethal Case of Gastric Pneumatosis

INTRODUCTION: While gas can accumulate in the intestinal wall at multiple sites, the stomach is the rarest site because of its acidity and very efficient mucosal barrier. In has been proposed in one retrospective study that 46% of their cases involved the colon, 27% the small bowel, 14% in whom the whole gastrointestinal tract was infected including the portal venous system, 7% the small bowel with the colon, and only 5% the stomach as in our case. CASE DESCRIPTION/METHODS: An 83 year old male with history of coronary artery disease, diabetes mellitus, bullous pemphigoid and smoking history presented for shortness of breath over one week. Patient was tachypnic and using accessory muscles on exam. During his hospital course, he had abdominal pain. CT Scan showed fluid filled distal esophagus, distended stomach, air-fluid levels and peripheral lucencies concerning for intramural gas. Nasogastric tube put out a large amount of red emesis after which he expired. DISCUSSION: There are two distinct pathological processes involved in air within the lumen of the stomach which is termed gastrointestinal pneumatosis. The first type is called gastric emphysema which often has a benign course and constitutes 9% of all gastrointestinal pneumatosis cases. Gastric emphysema is classified as traumatic, pulmonary or obstructive types. There have only been 5 recorded cases of gastric emphysema with a pulmonary etiology and four of those cases were secondary to bullous emphysema. The second type is emphysematous gastritis which involves gas forming organisms including Pseudomonas aeruginosa, Candida albicans, and Staphylococcus aureus. The risk factors for this dangerous type of gastrointestinal pneumatosis include a history of abdominal surgery or manipulation, bowel infarction/ischemia, immunosuppression which include disease processes including diabetes, alcohol abuse or corrosive material ingestion. There is a mortality of 16% in those receiving surgical treatment versus 6% who received only conservative treatment. In stable patients, improvement in clinical condition or emphysema resolution within 3 days occurs with nasogastric catheter decompression as attempted in our case. This becomes important in identifying between gastric emphysema, a relatively benign course, or emphysematous gastritis, which has a poor prognosis. As time becomes an increasingly prognostic factor for these individuals, differentiation in treatments based on type could lead to faster implementation which could ultimately help to prevent demise.

Factors in ProGlide® Vascular Closure Failure in Sheath Arteriotomies Greater than 16 French

The ProGlide® vascular closure device (Abbott Vascular, Redwood City, CA, USA) is approved for the closure of arterial punctures (typically 5-21 Fr sheath; maximum outer diameter, 26 Fr). However, a failure rate of about 2-8% is reported. This study was conducted to analyse factors predisposing to failure when the devices were used for the closure of large hole (16-26 Fr) arteriotomies, and to determine the predictive cut off values of predisposing factors. In this retrospective study, the ProGlide® device was used to achieve vascular access site closure in 458 patients undergoing repair of abdominal aortic aneurysm, thoracic aortic aneurysm, type B aortic dissection, or transcatheter aortic valve implantation. The primary endpoint was device failure, defined as inability to achieve common femoral artery (CFA) closure; successful repair, development of acute lower limb ischaemia and haemodynamic compromise; or delayed pseudoaneurysm formation during the follow up period, requiring open repair. Overall, ProGlide® failure occurred in 7.6% of cases. Factors that predisposed to failure included a history of peripheral arterial disease (PAD) (p<.001), the presence of CFA calcification (p<.001), the depth of the skin puncture site≥33mm (p<.001), body mass index (BMI) of ≥28.7kg/m2 (p<.001), and use of sheath size≥19 Fr (p<.001). Factors such as BMI, history of PAD, the presence of CFA calcification, the depth of the skin puncture site, and sheath size are significantly associated with ProGlide® failure. Hence, careful patient and device selection and operating procedure are paramount to achieve successful outcomes.

Metabolomics study in severe extracranial carotid artery stenosis

BackgroundSignificant genetic association has been found in patients with severe carotid artery stenosis (CAS). The present study wished to investigate if metabolites may also act as biomarkers for CAS.MethodsConsecutive patients with at least one carotid artery stenosis > = 60% on cerebral angiography were prospectively recruited from May 2007 to January 2016. Normal controls were recruited from outpatient clinic who had no stroke and coronary artery disease (CAD) history, and the brain magnetic resonance or computed tomographic angiography showed bilateral CAS < 30%. Risk factor profile, clinical characteristics, age, and clinical features were recorded. All subjects were male, and none had diabetes. 1H-NMR spectroscopy-based metabolomics analysis was carried out for plasma samples.ResultsTotally, 130 male subjects were recruited. Age had no significant difference between the controls and CAS group (60.2 ± 5.9 vs. 63.3 ± 6.0, p = 0.050). The CAS group had significantly higher frequency of CAD, hypertension, smoking and alcohol but lower body mass index than the controls (p < 0.05). The laboratory tests showed CAS group had significantly higher level of homocysteine but lower levels of cholesterol, high-density lipoprotein and hemoglobin than the controls (p < 0.05). The 1H-NMR based plasma metabolomics analysis indicated that choline was significantly lower in CAS patients. The VIP values of lipids were greater than 1.0, which were considered significantly different.ConclusionsOur results suggest homocysteine, choline and lipids in association with traditional risk factors may be involved in the pathogenesis of CAS. Diet adjustment to control homocysteine, choline and lipids may be helpful for the prevention of CAS.

Risk factors and role of low molecular weight heparin in obstetric complications among women with inherited thrombophilia – a cohort study

IntroductionAlthough there is a vast literature regarding the association between inherited thrombophilia, obstetric complications and the effect of low molecular weight heparin (LMWH), these are controversial and we have not found publications related to additional risk factors other than thrombophilia.Our objectives were to assess the prevalence of miscarriage, placenta-mediated pregnancy complications and fetal loss in pregnant women with IT, establishing associated risk factors and the effect of LMWH. Materials and methodsA retrospective cohort of pregnant women with IT was formed. Risk factors considered were: high-risk IT, age ≥35 years, body mass index ≥25 and ≥30, assisted reproductive technology, antiphospholipid antibodies, autoimmune disease, first-degree family history of obstetric complications and personal history of venous or arterial thromboembolic disease, the outcomes being M, FL and PMPC. Results and conclusionsData from 250 pregnancies in 88 women were obtained.There were 112 (45%) Ms, 13 (5.2%) FLs and 25 (10%) PMPCs.High-risk IT was associated with FL (OR=4.96; 95% CI, 1.42–17.3). Antiphospholipid antibodies and family history of obstetric complications were associated with PMPC (OR=7.12; 95% CI, 1.89–26.74, OR=3.88; 95% CI, 1.18–12.78, respectively). The LMWH presented a benefit in the combined outcome (any obstetric complication, OR=0.25; 95% CI, 0.12–0.54) and M (OR=0.41; 95% CI, 0.20–0.82).We conclude that obstetric complications are common in women with IT. Antiphospholipid antibodies, family history of obstetric complications and high-risk IT might be additional risk factors. The LMWH has an apparent protective effect against obstetric complications, which is consistent with some previous studies.

Paclitaxel-Coated Balloons and Eluting Stents: Is There a Mortality Risk in Patients With Peripheral Artery Disease?

Paclitaxel drug-coated balloons and drug-eluting stents became commercially available for the treatment of intermittent claudication in 2015 and 2012, respectively. Both devices demonstrated superiority in limb revascularization compared with non-paclitaxel-coated devices and were rapidly accepted into clinical practice. In a recent systematic review and study-level meta-analysis, Katsanos et al reported a late all-cause mortality signal for patients in the drug-coated balloon and drug-eluting stent arms of randomized clinical trials for both devices. As a result of this safety signal, Vascular InterVentional Advances Physicians (VIVA), a not-for-profit 501c(3) organization, convened the Vascular Leaders Forum on March 1 and 2, 2019, in Washington, DC, to initiate an open and collaborative process of investigation into this finding. The Vascular Leaders Forum brought together 100 stakeholders, including an international group of representatives of cardiovascular medicine, interventional radiology, vascular medicine, and vascular surgery; oncologists; basic scientists; the Food and Drug Administration; the Centers for Medicare and Medicaid Services; and commercial manufacturers of these products. The Vascular Leaders Forum reviewed the natural history of peripheral arterial disease, the use of paclitaxel in peripheral arterial disease and other conditions, the harm signal noted by Katsanos et al, the impact of the methods chosen by Katsanos et al, possible mechanisms of harm, the role of the Food and Drug Administration in a setting like this one, and guidance for clinicians taking care of patients with symptomatic peripheral arterial disease. This document integrates the most current data to help establish an appropriate path forward to understand the risks and benefits associated with these technologies while ensuring the best treatment paradigm for patients.

Clinical features and burden of new onset diabetic foot ulcers post simultaneous pancreas kidney transplantation and kidney only transplantation

BackgroundPatients with diabetes and kidney disease are at risk of diabetes-related foot ulcers (DFU). Whether this risk is modified post simultaneous pancreas-kidney (SPK) or kidney only (KO) transplant is unknown. MethodsWe evaluated the incidence of new onset DFU post SPK and KO transplant in 235 patients with diabetic kidney disease and diabetic neuropathy. In total 90 (51% male) SPK patients and 145 KO (66% male, 26% Type 1 DM) were evaluated in a single centre retrospective study. Median (range) follow up was 6 (3 to 13) years for both cohorts. ResultsWe observed that 16 (17%) of SPK and 22 (15%) KO patients respectively developed a DFU during follow up. In both cohorts a history of peripheral arterial disease [37.5% vs. 4%] and pre-transplant history of DFU were associated with post transplant DFU (p ≪ 0.05).In KO cohort, patients who developed a DFU were more likely to have T1DM than T2DM (29% vs. 10%), p ≪ 0.05. There was no impact of DFU on SPK transplant failure. In contrast patients with DFU post KO transplant had more than five fold increased hazard ratio (HR) of transplant failure as compared to those without DFU independent of other risk factors [HR 5.19 95% CI (2.05 to 13.18) p = 0.001]. ConclusionNearly 1 in 7 patients develop a new onset DFU post KO or SPK transplantation and DFU also significantly increases risk of failure of the transplanted kidney. Our results highlight the need for greater awareness of regular foot examination, DFU prevention and risk evaluation in post-transplant patients. Research in contextEvidence before this studyPatients with diabetes and kidney disease are at enhanced risk of diabetic foot ulcers (DFU). Whether this risk is modified post successful kidney only (KO) or simultaneous pancreas and kidney (SPK) transplantation is unknown. Small case series and studies with short term follow up report varied rates of incidence and are from historical cohorts before the use of modern anti-transplant medications and treatments. Short term studies also suggest that post SPK the resultant normoglycaemia may reverse some features and risk markers of DFU. There are no long term studies on the incidence and impact of diabetic foot ulcers in patients with diabetic kidney disease post SPK or KO transplantation.Added value of this studyWe report the long term follow up results on DFU incidence, clinical features and related impact on transplant viability in 235 patients with diabetic kidney disease and neuropathy post successful SPK and KO transplant at a single centre. We observed that nearly 1 in 7 patients developed a DFU during follow up and that in patients who received KO transplant onset of DFU was associated with more than 5 fold increase of transplant failure.Implications of all the available evidenceOur results highlight the need for greater awareness of regular foot examination, DFU prevention and risk evaluation in post-transplant patients. Despite normoglycaemia post SPK there is a residual burden and risk of DFU. Our work establishes a clinical rationale for further research to explore putative mechanisms that could explain the association between DFU and renal transplant dysfunction.

Predicting asymptomatic coronary artery stenosis by aortic arch plaque in acute ischemic cerebrovascular disease: beyond the cervicocephalic atherosclerosis?

Background:Asymptomatic coronary artery stenosis (ACAS) ≥50% is common in patients with acute ischemic cerebrovascular disease (AICVD), which portends a poor cardiovascular and cerebrovascular prognosis. Identifying ACAS ≥50% early may optimize the clinical management and improve the outcomes of these high-risk AICVD patients. This study aimed to investigate whether aortic arch plaque (AAP), an early atherosclerotic manifestation of brain blood-supplying arteries, could be a predictor for ACAS ≥50% in AICVD.Methods:In this cross-sectional study, atherosclerosis of the coronary and brain blood-supplying arteries was simultaneously evaluated using one-step computed tomography angiography (CTA) in AICVD patients without coronary artery disease history. The patients were divided into ACAS ≥50% and non-ACAS ≥50% groups according to whether CTA showed stenosis ≥50% in at least one coronary arterial segment. The AAP characteristics of CTA were depicted from aspects of thickness, extent, and complexity.Results:Among 118 analyzed patients with AICVD, 29/118 (24.6%) patients had ACAS ≥50%, while AAPs were observed in 86/118 (72.9%) patients. Increased AAP thickness per millimeter (adjusted odds ratio [OR]: 1.56, 95% confidence interval [CI]: 1.18–2.05), severe-extent AAP (adjusted OR: 13.66, 95% CI: 2.33–80.15), and presence of complex AAP (adjusted OR: 7.27, 95% CI: 2.30–23.03) were associated with ACAS ≥50% among patients with AICVD, independently of clinical demographics and cervicocephalic atherosclerotic stenosis. The combination of AAP thickness, extent, and complexity predicted ACAS ≥50% with an area under the receiver-operating characteristic curve of 0.78 (95% CI: 0.70–0.85, P < 0.001). All three AAP characteristics provided additional predictive power beyond cervical and intracranial atherosclerotic stenosis for ACAS ≥50% in AICVD (all P < 0.05).Conclusions:Thicker, severe-extent, and complex AAP were significant markers of the concomitant ACAS ≥50% in AICVD, possibly superior to the indicative value of cervical and intracranial atherosclerotic stenosis. As an integral part of atherosclerosis of brain blood-supplying arteries, AAP should not be overlooked in predicting ACAS ≥50% for patients with AICVD.