Utilization of a Novel Scoring System in Predicting 30-day Mortality in Acute Pulmonary Embolism, the CLOT-5 Pilot Study.

OBJECTIVES: To construct a new scoring system utilizing biomarkers, vitals, and imaging data to predict 30-day mortality in acute pulmonary embolism (PE). BACKGROUND: Acute PE, a well-known manifestation of venous thromboembolic disease, is responsible for over 100,000 deaths worldwide yearly. Contemporary management algorithms rely on a multidisciplinary approach to care via PE response teams (PERT) in the identification of low, intermediate, and high-risk patients. The PESI and sPESI scores have been used as cornerstones of the triage process in assigning risk of 30-day mortality for patients presenting with acute PE; however, the specificity of these scoring systems has often come into question. METHODS: This study retrospectively analyzed 488 patients with acute PE who were managed at a tertiary care institution with either conservative therapy consisting of low molecular weight or unfractionated heparin, advanced therapies consisting of catheter directed therapies, aspiration thrombectomy, or a combination of these therapies, or surgical embolectomy. The CLOT-5 score was designed to include vital signs, biomarkers, and imaging data to predict 30-day mortality in patients presenting with acute PE. RESULTS: The CLOT-5 score had an area under the curve (AUC) of 0.901 with a standard error of 0.29, while the PESI and sPESI scores had an AUC and standard errors of 0.793 ±- 0.43 and 0.728 ± 0.55, respectively. CONCLUSIONS: When incorporated into the management algorithms of national PERT programs, the CLOT-5 score may allow for rapid and comprehensive assessment of patients with acute PE at high risk for clinical decompensation, leading to early escalation of care where appropriate.

Diastolic dysfunction and clinical outcomes after transcatheter or surgical aortic valve replacement in patients with atypical aortic valve stenosis.

BACKGROUND: Diastolic dysfunction is a predictor of poor outcomes in many cardiovascular conditions. At present, it is unclear whether diastolic dysfunction predicts adverse outcomes in patients with atypical aortic stenosis who undergo aortic valve replacement (AVR). METHODS: Five hundred and twenty-three patients who underwent transcatheter AVR (TAVR) (n = 303) and surgical AVR (SAVR) (n = 220) at a single institution were included in our analysis. Baseline left and right heart invasive hemodynamics were assessed. Baseline transthoracic echocardiograms were reviewed to determine aortic stenosis subtype and parameters of diastolic dysfunction. Aortic stenosis subtype was categorized as typical (normal flow, high-gradient) aortic stenosis, classical, low-flow, low-gradient (cLFLG) aortic stenosis, and paradoxical, low-flow, low-gradient (pLFLG) aortic stenosis. Cox proportional hazard models were utilized to examine the relation between invasive hemodynamic or echocardiographic variables of diastolic dysfunction, aortic stenosis subtype, and all-cause mortality. Propensity-score analysis was performed to study the relation between aortic stenosis subtype and the composite outcome [death/cerebrovascular accident (CVA)]. RESULTS: The median STS risk was 5.3 and 2.5% for TAVR and SAVR patients, respectively. Relative to patients with typical aortic stenosis, patients with atypical (cLFLG and pLFLG) aortic stenosis displayed a significantly higher prevalence of diastolic dysfunction (LVEDP ≥ 20mmHg, PCWP ≥ 20mmHg, echo grade II or III diastolic dysfunction, and echo-PCWP ≥ 20mmHg) and, independently of AVR treatment modality, had a significantly increased risk of death. In propensity-score analysis, patients with atypical aortic stenosis had higher rates of death/CVA than typical aortic stenosis patients, independently of diastolic dysfunction and AVR treatment modality. CONCLUSION: We demonstrate the novel observation that compared with patients with typical aortic stenosis, patients with atypical aortic stenosis have a higher burden of diastolic dysfunction. We corroborate the worse outcomes previously reported in atypical versus typical aortic stenosis and demonstrate, for the first time, that this observation is independent of AVR treatment modality. Furthermore, the presence of diastolic dysfunction does not independently predict outcome in atypical aortic stenosis regardless of treatment type, suggesting that other factors are responsible for adverse clinical outcomes in this higher risk cohort.

Pulmonary Cement Embolism After Vertebroplasty.

Pulmonary cement embolism (PCE) is a known complication that can occur in the setting of vertebroplasty. The majority of these cases are asymptomatic and found incidentally on imaging. There are no current management recommendations regarding PCE. We present a case of a patient who underwent vertebroplasty complicated by a symptomatic sub-massive PCE.

Impact of late gadolinium enhancement extent, location, and pattern on ventricular tachycardia and major adverse cardiac events in patients with ischemic vs. non-ischemic cardiomyopathy.

Background: Left ventricular late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) has been associated with increased risk for life-threatening ventricular tachyarrhythmias. The differences in association between LGE characteristics and prognosis in patients with ischemic (ICM) vs. non-ischemic (NICM) cardiomyopathy is incompletely understood. Methods: A total of 168 consecutive patients who underwent CMR imaging with either ICM or NICM were included in our study. LGE extent, location and pattern were examined for association to the primary endpoint of ventricular tachycardia (VT) and secondary endpoint of major adverse cardiac events (MACE). Results: Of 68 (41%) patients with ICM and 97 (59%) patients with NICM, median LGE mass was 15% (IQR 9-28) for the ICM group and 10% (IQR 6-15) for the NICM group. On multivariate analysis for both groups, LGE characteristics were prognostic while LVEF was not. In patients with ICM, septal and apical segment LGE, and involvement of multiple walls predicted both endpoints on multivariate analysis. LGE extent (≥median) and inferior wall LGE independently predicted the primary endpoint. In patients with NICM, anterior, inferior and apical segment LGE, and involvement of multiple walls predicted both endpoints on multivariate analysis. LGE extent (≥median, number of LGE segments, LGE stratified per 5% increase) and midwall LGE were independent predictors of the primary endpoint. Conclusions: Although LGE was an independent predictor of prognosis in both groups, LGE extent, location, and pattern characteristics were more powerful correlates to worse outcomes in patients with NICM than ICM.

Use and abuse of fecal occult blood tests: a community hospital experience.

BACKGROUND: The Fecal Occult Blood Test (FOBT) is one of the diagnostic modalities indicated for screening patients for Colorectal Cancer (CRC). Despite being approved only for screening for CRC, numerous studies in the past have illustrated misuse of the FOBT. We examined utilization of the FOBT for patients admitted to a community teaching hospital. METHODS: The study was conducted at Saint Joseph Hospital, Chicago USA. A retrospective review of Electronic Medical Records (EMRs) of patients admitted from January 2016 to December 2017 was performed. RESULTS: We reviewed the EMRs of 729 patients who received the stool testing for occult blood (FOBT). All tests (100%) were carried out for purposes other than CRC screening. Anemia (38%) was the most common reason documented for carrying out the FOBT. Further, 88% of the tests were ordered on patients who either did not fulfill CRC screening criteria or had other contraindications for testing. Usage of contraindicated medication was the most important factor (58% of patients) that made the candidates ineligible for testing. A total 73 Colonoscopies were ordered for patients who received the test inappropriately with a resulting low yield (0.47%) of CRC diagnosis. CONCLUSION: The stool occult blood test continues to be utilized for reasons other than CRC screening. Majority of patients who underwent the test were not suitable candidates due to the presence of contraindications for testing. Unsuitable FOBT testing led to further unnecessary investigations.

Sphingolipids metabolism in the salivary glands of rats with obesity and streptozotocin induced diabetes.

Diabetes is considered a major public health problem affecting millions of individuals worldwide. Remarkably, scientific reports regarding salivary glands sphingolipid metabolism in diabetes are virtually non-existent. This is odd given the well-established link between the both in other tissues (e.g., skeletal muscles, liver) and the key role of these glands in oral health preservation. The aim of this paper is to examine sphingolipids metabolism in the salivary glands in (pre)diabetes (evoked by high fat diet feeding or streptozotocin). Wistar rats were allocated into three groups: control, HFD-, or STZ-diabetes. The content of major sphingolipid classes in the parotid (PSG) and submandibular (SMSG) glands was assessed via chromatography. Additionally, Western blot analyses were employed for the evaluation of key sphingolipid signaling pathway enzyme levels. No changes in ceramide content in the PSG were found, whereas an increase in ceramide concentration for SMSG of the STZ group was observed. This was accompanied by an elevation in SPT1 level. Probably also sphingomyelin hydrolysis was increased in the SMSG of the STZ-diabetic rats, since we observed a significant drop in the amount of SM. PSG and SMSG respond differently to (pre)diabetes, with clearer pattern presented by the later gland. An activation of sphingomyelin signaling pathway was observed in the course of STZ-diabetes, that is, metabolic condition with rapid onset/progression. Whereas, chronic HFD lead to an inhibition of sphingomyelin signaling pathway in the salivary glands (manifested in an inhibition of ceramide de novo synthesis and accumulation of S1P).

Usefulness of Mean Platelet Volume to Predict Significant Coronary Artery Disease in Patients With Non-ST-Elevation Acute Coronary Syndromes.

Acute coronary syndrome (ACS) is characterized by unstable plaque with thrombotic process involving central role of platelets. The diagnosis and prediction of significant coronary artery disease (CAD) in non-ST-elevation ACS (NSTE-ACS) can be challenging. The central role of platelets in acute atherothrombosis in NSTE-ACS spurred appreciable interest in the diagnostic and predictive role of platelet activity. Mean platelet volume (MPV) is one of the most promising laboratory markers in patients with CAD. This retrospective study was designed to investigate the diagnostic and predictive value of high MPV levels in patients with NSTE-ACS with significant CAD. A total of 213 patients (men 53%, mean age 61 ± 12.3 years) with NSTE-ACS were enrolled from 2011 to 2016 from 2 teaching hospitals. Patients' demographic, laboratory, and angiographic data were collected. Significant CAD was defined as ≥70% stenosis in at least 1 major coronary artery. Patients with high MPV (MPV ≥9 fl) had more significant CAD (55% vs 35%, p = 0.005), lower platelet count (204 ± 59 × 1,000/µl vs 246 ± 56 × 1,000/µl, p = 0.001), and higher HbA1c (6.9 vs 6.4, p = 0.02). Patients with significant CAD had higher MPV level (9.2 ± 1.07 vs 8.6 ± 1.03 fl, p = 0.001), higher MPV/platelet ratio (0.46 vs 0.40, p = 0.01), older age (64.5 ± 11 vs 59.2 ± 12 years, p = 0.02), and lower high-density lipoprotein level (42 ± 12 vs 47 ± 16, p = 0.01). Multivariate analysis showed that increased age, high MPV, high troponin, and low high-density lipoprotein levels were associated with significant CAD. Patients with high MPV along with high troponin level demonstrated a 4.8-fold increased risk for significant CAD compared to those with normal MPV and high troponin (odds ratio 4.8, 95% confidence interval 1.31 to 17.6, p = 0.001). In conclusion, considering high MPV in the context of elevated troponin level increases the predictive value of screening for significant CAD, and this result may help determine who is most likely to benefit from cardiac catheterization.