An interactive, online decision aid assessing patient goals and preferences for treatment of aortic stenosis to support physician-led shared decision-making: Early feasibility pilot study.

BACKGROUND: Guidelines recommend shared decision making when choosing treatment for severe aortic stenosis but implementation has lagged. We assessed the feasibility and impact of a novel decision aid for severe aortic stenosis at point-of-care. METHODS: This prospective multi-site pilot cohort study included adults with severe aortic stenosis and their clinicians. Patients were referred by their heart team when scheduled to discuss treatment options. Outcomes included shared decision-making processes, communication quality, decision-making confidence, decisional conflict, knowledge, stage of decision making, decision quality, and perceptions of the tool. Patients were assessed at baseline (T0), after using the intervention (T1), and after the clinical encounter (T2); clinicians were assessed at T2. Before the encounter, patients reviewed the intervention, Aortic Valve Improved Treatment Approaches (AVITA), an interactive, online decision aid. AVITA presents options, frames decisions, clarifies patient goals and values, and generates a summary to use with clinicians during the encounter. RESULTS: 30 patients (9 women [30.0%]; mean [SD] age 70.4 years [11.0]) and 14 clinicians (4 women [28.6%], 7 cardiothoracic surgeons [50%]) comprised 28 clinical encounters Most patients [85.7%] and clinicians [84.6%] endorsed AVITA. Patients reported AVITA easy to use [89.3%] and helped them choose treatment [95.5%]. Clinicians reported the AVITA summary helped them understand their patients' values [80.8%] and make values-aligned recommendations [61.5%]. Patient knowledge significantly improved at T1 and T2 (p = 0.004). Decisional conflict, decision-making stage, and decision quality improved at T2 (p = 0.0001, 0.0005, and 0.083, respectively). Most patients [60%] changed treatment preference between T0 and T2. Initial treatment preferences were associated with low knowledge, high decisional conflict, and poor decision quality; final preferences were associated with high knowledge, low conflict, and high quality. CONCLUSIONS: AVITA was endorsed by patients and clinicians, easy to use, improved shared decision-making quality and helped patients and clinicians arrive at a treatment that reflected patients' values. TRIAL REGISTRATION: Trial ID: NCT04755426, Clinicaltrials.gov/ct2/show/NCT04755426.

What matters most to patients with severe aortic stenosis when choosing treatment? Framing the conversation for shared decision making.

BACKGROUND: Guidelines recommend including the patient's values and preferences when choosing treatment for severe aortic stenosis (sAS). However, little is known about what matters most to patients as they develop treatment preferences. Our objective was to identify, prioritize, and organize patient-reported goals and features of treatment for sAS. METHODS: This multi-center mixed-methods study conducted structured focus groups using the nominal group technique to identify patients' most important treatment goals and features. Patients separately rated and grouped those items using card sorting techniques. Multidimensional scaling and hierarchical cluster analyses generated a cognitive map and clusters. RESULTS: 51 adults with sAS and 3 caregivers with experience choosing treatment (age 36-92 years) were included. Participants were referred from multiple health centers across the U.S. and online. Eight nominal group meetings generated 32 unique treatment goals and 46 treatment features, which were grouped into 10 clusters of goals and 11 clusters of features. The most important clusters were: 1) trust in the healthcare team, 2) having good information about options, and 3) long-term outlook. Other clusters addressed the need for and urgency of treatment, being independent and active, overall health, quality of life, family and friends, recovery, homecare, and the process of decision-making. CONCLUSIONS: These patient-reported items addressed the impact of the treatment decision on the lives of patients and their families from the time of decision-making through recovery, homecare, and beyond. Many attributes had not been previously reported for sAS. The goals and features that patients' value, and the relative importance that they attach to them, differ from those reported in clinical trials and vary substantially from one individual to another. These findings are being used to design a shared decision-making tool to help patients and their clinicians choose a treatment that aligns with the patients' priorities. TRIAL REGISTRATION: ClinicalTrials.gov, Trial ID: NCT04755426, Trial URL https://clinicaltrials.gov/ct2/show/NCT04755426.

Calculation of Mitral Valve Area by Continuity Equation Using Velocity-Time Integral From Mitral Valve Orifices After Mitral Clip.

BACKGROUND: This study investigates the hemodynamics of a dual-orifice mitral valve after mitral valve clip closure (MVCC) in patients with functional and nonfunctional mitral regurgitation (MR). If inflow velocity-time integral (VTi) of both orifices is equal, then the standard continuity equation can be applied to calculate the total mitral valve area (MVA). METHODS AND RESULTS: Adults undergoing MVCC placement were prospectively enrolled. With transesophageal echocardiography (TEE), the vena contracta (VC) of the medial and lateral mitral valve (MV) orifices were determined using color-flow Doppler and dual MV orifice areas were calculated. Valve orifices were classified as large vs small based on VC diameters. Continuous-wave Doppler measurements from both orifices were obtained. Forty-nine patients with severe MR (functional, n = 18) were enrolled. The VTi, mean gradient, peak gradient, and mean velocity of the larger vs smaller orifice were not significantly different, irrespective of MR etiology (P=nonsignificant). There was no difference in these parameters between large and small orifice regardless of MR mechanism (P=nonsignificant). There were no differences in the means of MVA as derived from either large or small VTi-derived and VC-derived areas (P=nonsignificant). CONCLUSIONS: Mitral valve inflow hemodynamics were the same regardless of the size differences between the large and small orifices. Therefore, total MVA can be calculated using the continuity equation in patients irrespective of MR mechanism. This allows for a derivation of total MVA at the time of MVCC placement to evaluate for mitral stenosis.

Associations between Cortical Thickness and Metamemory in Alzheimer's Disease.

Metacognitive deficits affect Alzheimer's disease (AD) patient safety and increase caregiver burden. The brain areas that support metacognition are not well understood. 112 participants from the Imaging and Genetic Biomarkers for AD (ImaGene) study underwent comprehensive cognitive testing and brain magnetic resonance imaging. A performance-prediction paradigm was used to evaluate metacognitive abilities for California Verbal Learning Test-II learning (CVLT-II 1-5) and delayed recall (CVLT-II DR); Visual Reproduction-I immediate recall (VR-I Copy) and Visual Reproduction-II delayed recall (VR-II DR); Rey-Osterrieth Complex Figure Copy (Rey-O Copy) and delayed recall (Rey-O DR). Vertex-wise multivariable regression of cortical thickness was performed using metacognitive scores as predictors while controlling for age, sex, education, and intracranial volume. Subjects who overestimated CVLT-II DR in prediction showed cortical atrophy, most pronounced in the bilateral temporal and left greater than right (L > R) frontal cortices. Overestimation of CVLT-II 1-5 prediction and DR performance in postdiction showed L > R associations with medial, inferior and lateral temporal and left posterior cingulate cortical atrophy. Overconfident prediction of VR-I Copy performance was associated with right greater than left medial, inferior and lateral temporal, lateral parietal, anterior and posterior cingulate and lateral frontal cortical atrophy. Underestimation of Rey-O Copy performance in prediction was associated with atrophy localizing to the temporal and cingulate areas, and in postdiction, with diffuse cortical atrophy. Impaired metacognition was associated to cortical atrophy. Our results indicate that poor insight into one's cognitive abilities is a pervasive neurodegenerative feature associated with AD across the cognitive spectrum.

Guía de práctica clínica para el tratamiento de la leucemia linfocítica crónica: guía para profesionales de la salud / Clinical practice guideline for the treatment of chronic lymphocytic leukemia: a guide for health care professionals

La leucemia linfocítica crónica (LLC) es una neoplasia caracterizada por la proliferación y acumulación clonal de células B maduras, que típicamente co-expresan los antígenos de superficie CD5 ­ CD23, dentro de la sangre, la médula ósea, los ganglios linfáticos, el bazo y otros tejidos . Esta patología es considerada el tipo de leucemia más común en personas adultas en países occidentales, y se considera una enfermedad de adultos mayores, con una mediana de edad al diagnóstico de 70 años .

Chronic lymphocytic leukemia (CLL) is a neoplasm characterized by the proliferation and clonal accumulation of mature B cells, which typically co-express the CD5 - CD23 surface antigens, within the blood, bone marrow, lymph nodes, spleen and other tissues. This pathology is considered the most common type of leukemia in adults in Western countries, and is considered a disease of older adults, with a median age at diagnosis of 70 years.

Guía de práctica clínica para el tratamiento de la leucemia linfocítica crónica / Clinical practice guideline for the treatment of chronic lymphocytic leukemia

La guía está dirigida al personal clínico asistencial especializado que brinda tratamiento a los pacientes con diagnóstico de LLC, en el contexto del SGSSS colombiano. Incluye a los siguientes profesionales potenciales: Hematólogos y Hematólogos-oncólogos. También está dirigida a los centros asistenciales que brindan cuidado a los pacientes con diagnóstico de LLC y a quienes toman decisiones administrativas, tanto en el medio hospitalario como en las aseguradoras, pagadores del gasto en la salud y en la generación de políticas de salud. Finalmente, las recomendaciones pueden ser de interés para pacientes con LLC, sus familiares y cuidadores. Se considera pertinente aclarar que la guía ofrecerá recomendaciones específicas frente a las preguntas definidas, y excede el alcance de esta, definir las competencias profesionales del equipo involucrado en el manejo de esta patología.

The guide is aimed at specialized clinical care personnel who provide treatment to patients diagnosed with CLL, in the context of the Colombian SGSSS. It includes the following potential professionals: hematologists and hematologist-oncologists. It is also addressed to health care centers that provide care to patients diagnosed with CLL and to administrative decision makers, both in the hospital environment and in the insurance companies, health care payers and health policy makers. Finally, the recommendations may be of interest to CLL patients, their families and caregivers. It is considered pertinent to clarify that the guide will offer specific recommendations in response to the questions defined, and it is beyond the scope of this guide to define the professional competencies of the team involved in the management of this pathology.

Barriers to Optimal Acute Management of Stroke: Perspective of a Stroke Center in Mexico City.

Background: Stroke is a leading cause of death and disability worldwide, particularly in low- and middle-income countries. We aimed to identify the main barriers to optimal acute management of stroke in a referral center. Methods: Demographic data was collected from patients assessed with acute stroke in the emergency department of the Instituto Nacional de Neurología y Neurocirugía (INNN) from January to June 2019. Additionally, a telephone interview was conducted with patients/primary caregiver to know which they considered the main reason for the delay in arrival at INNN since the onset of stroke. Results: 116 patients were assessed [age 65 ± 15 years, 67 (57.8%) men]. Patients consulted other facilities prior to arrival at INNN in 59 (50.9%) cases (range of hospitals visited 1-4), 83 (71.6%) arrived in a private car, with prenotification in only 4 (3.4%) of the total sample. The mean onset-to-door time was 17 h (45 min-10 days). Telephone interviews were done in 61 patients/primary caregivers, stating that they consider the multiple evaluations in other facilities [n = 26/61 (42.6%)] as the main reason for delay in arrival at the ED, followed by ignorance of stroke symptoms and treatment urgency [n = 21/61 (34.4%)]. Conclusion: In this small, retrospective, single center study, the main prehospital barrier to optimal acute management of stroke in a developing country is multiple medical evaluations prior to the patient's transport to a specialized stroke hospital, who mostly arrived in a private car and without prenotification. These barriers can be overcome by strengthening public education and improving patient transfer networks and telemedicine.

Acute Heart Failure Due to Aluminum Phosphide Poisoning.

Aluminum phosphide (ALP) is a pesticide agent and infrequent culprit of accidental poisoning. We present a case of severe reversible cardiomyopathy and left ventricular apical thrombus in a patient who worked as an exterminator and had ALP poisoning.

Foix-Chavany-Marie Syndrome as a Manifestation of Unilateral Opercular Stroke.

INTRODUCTION: Foix-Chavany-Marie syndrome (FCMS) is a type of pseudobulbar palsy that affects facio-pharyngo-glosso-masticatory muscles. MATERIALS AND METHODS: A 62-year-old man was admitted to the emergency department after 9 hours of acute dysarthria and dysphagia. MRI showed restricted diffusion in the right operculum on diffusion-weighted imaging (DWI). No thrombolytic therapy was given. The patient had a history of mechanical aortic valve replacement under anticoagulation with a vitamin K antagonist. Work-up demonstrated suboptimal levels of INR. Due to severe dysphagia during hospitalization, a percutaneous endoscopic gastrostomy (PEG) was performed. RESULTS: The patient was discharged 5 days later, with a modified Rankin scale (mRs) score of 3, and secondary stroke prevention. He had achieved an excellent functional outcome (mRs 1) at 6-month follow-up. CONCLUSION: Our patient had a satisfactory recovery due to prompt diagnosis, secondary stroke prevention, and compliance with treatment. LEARNING POINTS: In the presence of acute dysarthria and dysphagia, Foix-Chavany-Marie syndrome (FCMS) should be considered.FCMS may occur in the presence of unilateral opercular stroke.Swallowing and speech therapy play an essential role in rehabilitation after the acute setting.

The Impact of Environmental Factors on the Mortality of Patients With Chronic Heart Failure.

Outcomes of acute heart failure hospitalizations are worse during the winter than the rest of the year. Seasonality data are more limited for outcomes in chronic heart failure and the effect of environmental variables is unknown. In this population-level study, we merged 20-year data for 555,324 patients with heart failure from the national Veterans Administration database with data on climate from the National Oceanic and Atmospheric Administration and air pollutants by the Environmental Protection Agency. The outcome was the all-cause mortality rate, stratified by geographical location and each month. The impact of environmental factors was assessed through Pearson's correlation and multiple regression with a family-wise α = 0.05. The monthly all-cause mortality was 13.9% higher in the winter than the summer, regardless of gender, age group, and heart failure etiology. Winter season, lower temperatures, and higher concentrations of nitrogen dioxide were associated with a higher mortality rate in multivariate analysis of the overall population. Different environmental factors were associated in regions with similar patterns of temperature and precipitation. The only environmental factor associated with the mortality rate of patients dwelling in large urban centers was the air quality index. In conclusion, the mortality in chronic heart failure exhibits a seasonal pattern, regardless of latitude or climate. In this group of patients, particularly those of male gender, a higher mortality was associated with environmental factors and incorporating these factors in treatment plans and recommendations could have a favorable cost-benefit ratio.

Transcatheter edge-to-edge mitral valve repair for annuloplasty ring dehiscence: The peri-ring approach.

Recurrent severe primary mitral regurgitation from annuloplasty ring dehiscence is very rare and is associated with adverse outcomes. We present a case where transcatheter edge-to-edge mitral repair with MitraClip was used in high surgical risk patient using a peri-ring approach due to unfavorable anatomy for a conventional intra-ring approach.

Brugada Phenocopy: A Case of Incessant Ventricular Tachycardia in a Patient with Tricyclic Antidepressant Overdose.

Brugada electrocardiographic pattern, or Brugada phenocopy (BrP), can be found in conditions other than Brugada syndrome. We present the case of a 34-year-old woman who was found convulsing at home followed by ventricular tachycardia (VT) cardiac arrest upon arrival to the emergency department. Electrical direct cardioversion led to a return of spontaneous circulation, and she was started on intravenous amiodarone. The patient had four additional episodes of pulseless VT that returned to sinus rhythm with electrical cardioversion. A subsequent electrocardiogram taken in sinus rhythm revealed a right bundle branch block pattern with a coved ST segment elevation and inverted T waves in leads V1 and V2, suggestive of BrP type 1. Further inquiry revealed that an empty bottle of nortriptyline was found at her home. Nortriptyline intoxication was subsequently confirmed by a serum level of 1581 ng/mL. Treatments with intravenous sodium bicarbonate resolved the BrP, and she fully recovered with supportive care. Intoxication with drugs that inhibit cardiac sodium channels, such as nortriptyline, can trigger a BrP in otherwise normal individuals. Nortriptyline and other tricyclic antidepressants (TCAs) are used to treat chronic pain, depression, and other conditions but have dose-related side effects and can lead to fatal overdose. Intoxication by these TCAs should be on the differential when a BrP is observed.

The BRASH syndrome, a synergistic arrhythmia phenomenon.

BRASH syndrome is a relatively novel clinical entity with profound bradycardia secondary to simultaneous metabolic derangement and drug toxicity. The syndrome is a clinical pentad of bradycardia, acute kidney injury, use of atrioventricular nodal blocking agents, shock, and hyperkalemia. It is widely underrecognized with selectively few reports, mainly in the elderly population. We present a 43-year-old woman on two oral atrioventricular blocking agents who presented with 1 week of increasing lethargy with rapid deterioration into cardiac arrest with subsequent shock postresuscitation. She was found to have hyperkalemia, metabolic acidosis, and acute kidney injury on arrival. Her initial electrocardiogram was remarkable for sinus arrest and junctional bradycardia. She was treated with a temporary pacemaker, renal replacement therapy, and potassium-lowering agents, with subsequent improvement resulting in conversion to normal sinus rhythm.

Complication of Late Presenting STEMI Due to Avoidance of Medical Care During the COVID-19 Pandemic.

Patients are avoiding hospitals for fear of contracting severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). We are witnessing a re-emergence of rare complications of myocardial infarctions (MI) due to delayed revascularization. Herein, we describe a case of hemorrhagic pericarditis from thrombolytics administered to a patient with late presenting MI. (Level of Difficulty: Beginner.).

Cardiac Lymphoma Presenting with Recurrent STEMI.

The incidence of primary cardiac tumors is exceedingly rare, whereas secondary cardiac tumors are more common in the global population. Cardiac involvement is seen in approximately 18% of patients with non-Hodgkin's lymphoma at the time of autopsy. Clinical manifestations of cardiac involvement are subtle and often go unrecognized until advanced stages of the disease. We present a rare case of metastatic cardiac lymphoma that presented as an ST-segment elevation myocardial infarction complicated by left ventricular free wall rupture and cardiogenic shock due to transmural myocardial necrosis from malignant cell infiltration.

Percutaneous Coil Embolization for Symptomatic Coronary Fistula: Pre-Operative Cardiovascular Optimization Before Renal Transplantation.

Pre-operative optimization of cardiovascular conditions in patients awaiting renal transplantation significantly improves post-transplantation cardiac complications. We describe a case of symptomatic coronary fistula treated with percutaneous coil embolization in a young adult awaiting renal transplantation. (Level of Difficulty: Advanced.).

Hemofilia adquirida A y B como manifestación inicial de linfoma no Hodgkin. Reporte de un caso y revisión de la literatura / Acquired Hemophilia A and B as an initial manifestation of Non-Hodgkin Lymphoma. Case report and literature review

Resumen La hemofilia adquirida es una complicación rara y potencialmente fatal en pacientes con neoplasias hematológicas (desórdenes linfoproliferativos) o tumores sólidos. Presentamos una paciente de 75 años de sexo femenino con antecedente de hipertensión arterial y anemia ferropénica que ingresa a urgencias por cuadro de dolor abdominal generalizado tipo cólico, asociado a episodios eméticos de contenido alimentario y deposiciones melénicas. Dentro de los estudios iniciales se encontraron: tiempos de coagulación prolongados, prueba de mezclas de aPTT con evidencia de anticoagulante circulante específico, factor IX, 0% y factor VIII, 0% con inhibidores de factor VIII y IX en 180 UB y 130 UB respectivamente. Se consideró que la paciente cursaba con hemofilia adquirida A y B con realización de estudios de extensión diagnosticándose linfoma no Hodgkin marginal esplénico.

Abstract Acquired hemophilia is a potentially fatal rare complication of patients with hematological malignancies (usually lymphoproliferative disorders) or solid tumors. We report a 75-year female patient with a history of arterial hypertension and iron deficiency anemia. Log in to the emergency department complaining of generalized cramping abdominal pain associated with emetic episodes and melenic stools. In initial studies found prothrombin time (PT) 19 seconds control: 11 seconds, INR 1.8 and activated partial thromboplastin time (aPTT) 45 seconds, control: 29 seconds. Mixing aPTT study with normal plasma was performed suggesting specific anticoagulation factor. Other tests were performed: Factor IX 0%, factor VIII and 0%. Factor VIII inhibitor: 180 UB, factor IX inhibitor: 130 UB. It was considered acquired hemophilia A and B and was studying with extension studies found a splenic marginal non Hodgkin lymphoma.

Myelomastocytic Blast Cell Crisis in Resistant Tyrosine Kinase Inhibitor Chronic Myelogenous Leukemia: Case Report and Review of Literature.

We present the clinical case of a 29-year-old male with a diagnosis of chronic myeloid leukemia (CML) in high-risk chronic phase since February 2010. He started treatment with imatinib at a dose of 400 mg obtaining a hematologic response early but without reaching a cytogenetic response in month 18. Then, dasatinib was prescribed. The BCR-ABL transcription level of 58% was documented. It was decided to start treatment with nilotinib but in March 2017 we diagnosed a progression to blast crisis (BC) of myeloid origin with a bone marrow study that documented 72% of blasts with normal karyotype, also very striking, the concomitant skin infiltration, bone lesions of lytic type and hypercalcemia that required the use of zoledronic acid as an emergency. At the end of chemotherapy induction with 7 + 3 (seven days of cytarabine and three days of idarubicin) chemotherapy associated with bosutinib for 14 days and after several infectious complications, we documented a percentage of blasts by flow cytometry of 29% in the bone marrow and the existence of 46% of cells with basophilic characteristics versus mast cells. A basophilic transformation was suspected versus aggressive systemic mastocytosis with a clonal, nonmastocytic hematological disorder. Levels of serum tryptase and mutation D816V C KIT were requested, which were not possible to perform. Treatment with CLAG-M was proposed, however, the patient died early with hyperleukocytosis and severe thrombocytopenia with central nervous system bleeding.

Platelet Count and Mean Platelet Volume at the Time of and After Acute Myocardial Infarction.

Platelet count has been shown to be lower and mean platelet volume (MPV) to be higher in acute myocardial infarction (MI). However, it is not known whether these changes persist post-MI or if these measures are able to distinguish between acute thrombotic and non-thrombotic MI. Platelet count and MPV were measured in 80 subjects with acute MI (thrombotic and non-thrombotic) and stable coronary artery disease (CAD) at cardiac catheterization (acute phase) and at >3-month follow-up (quiescent phase). Subjects were stratified using stringent clinical, biochemical, histological, and angiographic criteria. Outcome measures were compared between groups by analysis of variance. Forty-seven subjects met criteria for acute MI with clearly defined thrombotic (n = 22) and non-thrombotic (n = 12) subsets. Fourteen subjects met criteria for stable CAD. No significant difference was observed in platelet count between subjects with acute MI and stable CAD at the acute or quiescent phase. MPV was higher in acute MI (9.18 ± 1.21) compared to stable CAD (8.13 ± 0.66; P = 0.003) at the acute phase but not at the quiescent phase (8.48 ± 0.58 vs 8.94 ± 1.42; P = 0.19). No difference in platelet count or MPV was detected between thrombotic and non-thrombotic subsets at acute or quiescent phases. The power to detect differences in these measures between thrombotic and non-thrombotic subsets was 58%. Higher MPV at the time of acute MI is not observed by 3 months post-MI (quiescent phase). Platelet count and MPV do not differ in subjects with thrombotic versus non-thrombotic MI. Further investigation is warranted to evaluate the utility of these measures in the diagnosis of acute MI.

Detection of KPC in Acinetobacter spp. in Puerto Rico.

During an island-wide PCR-based surveillance study of beta-lactam resistance in multidrug-resistant (MDR) Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter calcoaceticus-baumannii complex isolates obtained from 17 different hospitals, 10 KPC-positive Acinetobacter isolates were identified. DNA sequencing of the bla(KPC) gene identified KPC-2, -3, and -4 and a novel variant, KPC-10. This is the first report of a KPC-type beta-lactamase identified in Acinetobacter species.