Single-Operator Left atrial appendage Occlusion utilizing Conscious sedation TEE, Lack of Outpatient pre-imaging, and Same-day Expedited discharge (SOLO-CLOSE): A comparison with conventional approach.

BACKGROUND: Left atrial appendage occlusion (LAAO) with WATCHMAN currently requires preprocedural imaging, general anesthesia, and inpatient overnight admission. We sought to facilitate simplification of LAAO. AIMS: We describe and compare SOLO-CLOSE (single-operator LAA occlusion utilizing conscious sedation TEE, lack of outpatient pre-imaging, and same-day expedited discharge) with the conventional approach (CA). METHODS: A single-center retrospective analysis of 163 patients undergoing LAAO between January 2017 and April 2022 was conducted. The SOLO-CLOSE protocol was enacted on December 1, 2020. Before this date, we utilized the CA. The primary efficacy endpoint was defined as successful LAAO with ≤5 mm peri-device leak at time of closure. The primary safety endpoint was the composite incidence of all-cause deaths, any cerebrovascular accident (CVA), device embolization, pericardial effusion, or major postprocedure bleeding within 7 days of the index procedure. Procedure times, 7-day readmission rates, and cost analytics were collected as well. RESULTS: Baseline characteristics were similar in both cohorts. Congestive heart failure (37.5% vs. 11.1%) and malignancy (28.8% vs. 12.5%) were higher in SOLO-CLOSE. Median CHA2D2SVASc score was 5 in both cohorts. The primary efficacy endpoint was met 100% in both cohorts. Primary safety endpoint was similar between cohorts (p = 0.078). Mean procedure time was 30 min shorter in SOLO-CLOSE (p < 0.01). Seven-day readmissions for SOLO-CLOSE was zero. After SOLO-CLOSE implementation, there was a 188% increase in positive contribution margin per case. CONCLUSIONS: The SOLO-CLOSE methodology offers similar efficacy and safety when compared to the CA, while improving clinical efficiency, reducing procedural times, and increasing economic benefit.

Guillain-Barré syndrome after aortic, tricuspid, and mitral valve surgery.

Guillain-Barré syndrome incidence within 8 weeks of a surgical procedure appears to be more common than previously thought. GBS following open-heart surgery is exceedingly rare, perhaps underdiagnosed or underreported given surveillance data incidence. Clinicians should be keenly aware of this association and quickly consider a GBS diagnosis.

Rapidly progressive dyspnea in gastrointestinal stromal tumor (GIST) with imatinib cardiac toxicity.

Gastrointestinal stromal tumors (GISTs) are rare and current estimates range from 4,000 to 6,000 number of GIST cases in the USA annually. Imatinib, a tyrosine kinase inhibitor, has shown a survival benefit in GISTs, and the presence of KIT mutation status is predictive of response. The current case discusses rapidly progressive dyspnea and heart failure in an elderly male with metastatic GIST who was started on imatinib. Although reported as a rare and sporadic side effect of imatinib, the current case illustrates rapidity and the clinical significance of cardiotoxicity, with onset at 2 weeks. Cases of imatinib-induced cardiotoxicity can range from being mild ventricular dysfunction to overt heart failure. Prior to starting imatinib, our patient had a history of hypertension. He subsequently ended up developing heart failure as acknowledged by the echocardiogram (ECHO). In general, elderly with preexisting cardiovascular comorbidity are at greater risk. The goal in such situations is immediate discontinuation or reduction of the imatinib dosage. The case prompts for awareness of imatinib cardiotoxicity. Moreover, a pretreatment cardiac assessment along with monitoring throughout therapy is therefore advisable. Also, imatinib-induced cardiotoxicity should be differentiated from imatinib-associated fluid retention, in which ECHO findings can be normal. This case report raises the concern for accelerated cardiotoxicity profile of imatinib. Further prospective studies with multidisciplinary input are needed to establish this association further.

Idiopathic pulmonary vein thrombosis?

Idiopathic pulmonary vein thrombosis (PVT) is a rare disease which is likely under-diagnosed because of nebulous presentations. Accurate diagnosis is essential to prevent complications.

A case of asymptomatic pancytopenia with clinical features of hemolysis as a presentation of pernicious anemia.

Pernicious anemia is an autoimmune disease with a variety of clinical presentations. We describe a case of pernicious anemia presenting with pancytopenia with hemolytic features. Further workup revealed very low vitamin B12 levels and elevated methylmalonic acid. It is important for a general internist to identify pernicious anemia as one of the cause of pancytopenia and hemolytic anemia to avoid extensive workup. Pernicious anemia can present strictly with hematological abnormalities without neurological problems or vice versa as in our case.

Catastrophic chest pain: blinded by cardiopulmonary disease.

A 53-year-old man with a history of diabetic foot ulcer, osteomyelitis, coronary artery disease, hypertension and hyperlipidaemia, presented with chest pain of 3 weeks duration. Eleven days earlier, the patient had had a drug-eluting stent (DES) placed in a branch of the right coronary artery (RCA) after similar chest pain, leading to the findings of a positive nuclear stress test. Since discharge, he was not compliant with taking clopidegrel (Plavix), a concern for in-stent thrombosis with recurrent myocardial ischaemia; but work up was negative and medications were restarted. Within 24 h of admission, he developed bilateral flaccid leg weakness, urine retention and loss of sensation from the umbilicus level down. MRI revealed a T4-T6 epidural abscess. Emergent decompression laminectomy and abscess drainage was completed. Neurological symptoms improved hours after surgery with complete resolution of sensory deficits. Cultures grew Streptococcus sp., treated with intravenous nafcillin for 8 weeks. He regained leg strength with continued improvement seen in rehabilitation.

Traumatic intracranial hemorrhage correlates with preinjury brain atrophy, but not with antithrombotic agent use: a retrospective study.

BACKGROUND: The impact of antithrombotic agents (warfarin, clopidogrel, ASA) on traumatic brain injury outcomes is highly controversial. Although cerebral atrophy is speculated as a risk for acute intracranial hemorrhage, there is no objective literature evidence. MATERIALS AND METHODS: This is a retrospective, consecutive investigation of patients with signs of external head trauma and age ≥60 years. Outcomes were correlated with antithrombotic-agent status, coagulation test results, admission neurologic function, and CT-based cerebral atrophy dimensions. RESULTS: Of 198 consecutive patients, 36% were antithrombotic-negative and 64% antithrombotic-positive. ASA patients had higher arachidonic acid inhibition (p = 0.04) and warfarin patients had higher INR (p<0.001), compared to antithrombotic-negative patients. Antithrombotic-positive intracranial hemorrhage rate (38.9%) was similar to the antithrombotic-negative rate (31.9%; p = 0.3285). Coagulopathy was not present on the ten standard coagulation, thromboelastography, and platelet mapping tests with intracranial hemorrhage and results were similar to those without hemorrhage (p≥0.1354). Hemorrhagic-neurologic complication (intracranial hemorrhage progression, need for craniotomy, neurologic deterioration, or death) rates were similar for antithrombotic-negative (6.9%) and antithrombotic-positive (8.7%; p = 0.6574) patients. The hemorrhagic-neurologic complication rate was increased when admission major neurologic dysfunction was present (63.2% versus 2.2%; RR = 28.3; p<0.001). Age correlated inversely with brain parenchymal width (p<0.001) and positively with lateral ventricular width (p = 0.047) and cortical atrophy (p<0.001). Intracranial hemorrhage correlated with cortical atrophy (p<0.001) and ventricular width (p<0.001). CONCLUSIONS: Intracranial hemorrhage is not associated with antithrombotic agent use. Intracranial hemorrhage patients have no demonstrable coagulopathy. The association of preinjury brain atrophy with acute intracranial hemorrhage is a novel finding. Contrary to antithrombotic agent status, admission neurologic abnormality is a predictor of adverse post-admission outcomes. Study findings indicate that effective hemostasis is maintained with antithrombotic therapy.

Accessory cardiac bronchus.

Accessory cardiac bronchus is a poorly recognized, usually asymptomatic, congenital abnormality of the bronchial tree. Recognition of bronchial anomalies is important since they are associated with clinical complications including recurrent episodes of infection, hemoptysis, and in some cases malignancy.

Over diagnosis of chronic obstructive pulmonary disease in an underserved patient population.

INTRODUCTION: While cross-national studies have documented rates of chronic obstructive pulmonary disease (COPD) misdiagnosis among patients in primary care, US studies are scarce. Studies investigating diagnosis among uninsured patients are lacking. OBJECTIVE: The purpose of this study is to identify patients who are over diagnosed and thus, mistreated, for COPD in a federally qualified health center. METHODS: A descriptive study was conducted for a retrospective cohort from February 2011 to June 2012. Spirometry was performed by trained personnel following American Thoracic Society recommendations. Patients were referred for spirometry to confirm previous COPD diagnosis or to assess uncontrolled COPD symptoms. Airway obstruction was defined as a forced expiratory volume in the first second of expiration (FEV1) to forced vital capacity ratio less than 0.7. Reversibility was defined as a postbronchodilator increase in FEV1 greater than 200 mL and greater than 12%. RESULTS: Eighty patients treated for a previous diagnosis of COPD (n = 72) or on anticholinergic inhalers (n = 8) with no COPD diagnosis were evaluated. The average age was 52.9 years; 71% were uninsured. Only 17.5% (14/80) of patients reported previous spirometry. Spirometry revealed that 42.5% had no obstruction, 22.5% had reversible obstruction, and 35% had non-reversible obstruction. CONCLUSION: Symptoms and smoking history are insufficient to diagnose COPD. Prevalence of COPD over diagnosis among uninsured patient populations may be higher than previously reported. Confirming previous COPD diagnosis with spirometry is essential to avoid unnecessary and potentially harmful treatment.

Hepatic abscess associated with Salmonella serotype B in a chronic alcoholic patient.

BACKGROUND: Hepatic abscess secondary to Salmonella is extremely rare in the United States and other Western countries. METHODS: A 43-year-old Caucasian man, with a history of chronic alcohol abuse, was admitted to the hospital for intermittent abdominal pain, fever and diarrhea. Clinical, radiological and laboratory results were analyzed. Medical literature in PubMed pertaining to similar cases was reviewed. RESULTS: Stool culture was positive for Salmonella serotype B and a CT scan of the abdomen with contrast was consistent with a solitary hepatic abscess. Appropriate intravenous antibiotics followed by oral maintenance therapy for six weeks resulted in a complete clinical recovery and radiographic resolution. CONCLUSIONS: The cause of Salmonella hepatic abscess in our patient was most likely associated with decreased mucosal resistance to the bacteria, seeding of infection via transient portal bacteremia and loss of host immunity. Our case highlights the fact that appropriate antibiotic alone is sufficient in the management of a solitary hepatic abscess less than 3-5 cm.

Giant bullae emphysema.

Bullous lung disease, a variant of the emphysematous process, can come in different forms and presentations, both histologically and radiographically. Giant bulla (GB) is the rarest form of bullous lung disease. Onset of disease to duration to symptoms is unclear. Presenting symptoms include cough, chest pain, and progressive dyspnea. Differentiating between other cystic lung diseases or developmental/congenital anomalies is vital. While most patients with bullous lung disease can be managed medically, those with giant bulla should be referred for careful surgical evaluation. The authors describe GB, highlight the role of imaging, and discuss the evaluation and pathophysiology of this rare presentation.

Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters.

PURPOSE: To identify clinically important risk factors associated with upper extremity venous thrombosis following peripherally inserted central venous catheters (PICC). METHODS: A retrospective case control study of 400 consecutive patients with and without upper extremity venous thrombosis post-PICC insertion was performed. Patient data included demographics, body mass index (BMI), ethnicity, site of insertion, size and lumen of catheter, internal length, infusate, and co-morbidities, such as diabetes mellitus, congestive heart failure, and renal failure. Additional risk factors analyzed were active cancer, any history of cancer, recent trauma, smoking, a history of prior deep vein thrombosis, and recent surgery, defined as surgery within three months prior to PICC insertion. RESULTS: The prevalence of trauma, renal failure, and infusion with antibiotics and total parenteral nutrition (TPN) was higher among patients exhibiting upper extremity venous thrombosis (UEVT), when compared to controls. Patients developing UEVT were also more likely to have PICC line placement in a basilic vein and less likely to have brachial vein placement (P<.001). Left-sided PICC line sites also posed a greater risk (P=.026). The rate of standard DVT prophylaxis with low molecular weight heparin and unfractionated heparin and the use of warfarin was similar in both groups. Average length of hospital stay was almost double among patients developing UEVT, 19.5 days, when compared to patients undergoing PICC line insertion without thrombosis, 10.8 days (t=6.98, P<.001). CONCLUSIONS: In multivariate analysis, trauma, renal failure, left-sided catheters, basilic placement, TPN, and infusion with antibiotics, specifically vancomycin, were significant risk factors for UEVT associated with PICC insertion. Prophylaxis with low molecular weight heparin, unfractionated heparin or use of warfarin did not prevent the development of venous thrombosis in patients with PICCs. Length of hospital stay and cost are markedly increased in patients who develop PICC-associated upper extremity venous thrombosis.

Impact and costs of targeted recruitment of minorities to the National Lung Screening Trial.

BACKGROUND: To promote results in the National Lung Screening Trial (NLST) that are generalizable across the entire US population, a subset of NLST sites developed dedicated strategies for minority recruitment. PURPOSE: To report the effects of targeted strategies on the accrual of underrepresented groups, to describe participant characteristics, and to estimate the costs of targeted enrollment. METHODS: The 2002-2004 Tobacco Use Supplement was used to estimate eligible proportions of racial and ethnic categories. Strategic planning included meetings/conferences with key stakeholders and minority organizations. Potential institutions were selected based upon regional racial/ethnic diversity and proven success in recruitment of underrepresented groups. Seven institutions submitted targeted recruitment strategies with budgets. Accrual by racial/ethnic category was tracked for each institution. Cost estimates were based on itemized receipts for minority strategies relative to minority accrual. RESULTS: Of 18,842 participants enrolled, 1576 (8.4%) were minority participants. The seven institutions with targeted recruitment strategies accounted for 1223 (77.6%) of all minority participants enrolled. While there was a significant increase in the rate of minority accrual pre-implementation to post-implementation for the institutions with targeted recruitment (9.3% vs. 15.2%, p < 0.0001), there was no significant difference for the institutions without (3.5% vs. 3.8%, p = 0.46). Minority enrollees at the seven institutions tended to have less than a high school education, be economically disadvantaged, and were more often uninsured. These socio-demographic differences persisted at the seven institutions even after adjusting for race and ethnicity. The success of different strategies varied by institution, and no one strategy was successful across all institutions. Costs for implementation were also highly variable, ranging from $146 to $749 per minority enrollee. LIMITATIONS: Data on minority recruitment processes were not consistently kept at the individual institutions. In addition, participant responses via newspaper advertisements and the efforts of minority staff hired by the institutions could not be coded on Case Report Forms. CONCLUSIONS: Strategic efforts were associated with significant increases in minority enrollment. The greatest successes require that a priori goals be established based on eligible racial/ethnic proportions; the historical performance of sites in minority accrual should factor into the selection of sites; recruitment planning must begin well in advance of trial launch; and there must be endorsement by prominent representatives of the racial groups of interest.

Streptococcus sanguinis brain abscess as complication of subclinical endocarditis: emphasizing the importance of prompt diagnosis.

A 19-year-old male patient was diagnosed with S. sanguinis brain abscess of unknown etiopathology as a complication of subclinical endocarditis. While viridans streptococci are implicated in dental seeding to the heart, S. sanguinis brain abscesses are rare. Six previous cases of S. sanguinis brain abscess in the literature reported dental procedures and maxillofacial trauma. In our patient, there was no obvious source of infective endocarditis preceding the development of brain abscess. This demonstrates the importance of prompt diagnosis and initiation of antimicrobial therapy given the potential for long-term sequelae such as focal deficits and seizures.