Hybrid approach to postmyocardial infarction ventricular septal defect repair.

Postinfarction ventricular septal rupture is a rare and devastating complication of myocardial infarction. Despite attempts at acute surgical and percutaneous defect closure, morbidity and mortality remain high. Herein, we describe a hybrid surgical and catheter-based approach to defect closure in a 63-year-old woman with postinfarction ventricular septal rupture and cardiogenic shock.

Tricuspid valve-in-valve jailing right ventricular lead is not free of risk.

Transcatheter tricuspid valve in valve (TViV) is increasingly performed on patients with degenerated bioprosthetic valves and elevated surgical risk. Jailing a right ventricular (RV) pacer lead at the time of TViV implantation has been achieved without causing lead dysfunction; however, device-related complications that require lead extraction raise the need for better periprocedural strategies for TViV, in pacer-dependent patients. We describe a case of device pocket infection with incomplete lead extraction, due to a jailed RV lead at the time of TViV.

Arterial Blood Pressure at Liver Transplant Evaluation Predicts Renal Histology in Candidates With Renal Dysfunction.

Renal dysfunction is common in liver transplantation (LT) candidates, but differentiating between reversible and irreversible renal injury can be difficult. Kidney biopsy might be helpful in differentiating reversible from irreversible renal injury, but it is associated with significant complications. We aimed to identify pre-LT predictors of potentially reversible renal injury using histological information obtained on pre-LT renal biopsy. Data on 128 LT candidates who underwent pre-LT kidney biopsy were retrospectively collected and correlated with renal histological findings. Indications for kidney biopsy were iothalamate glomerular filtration rate (iGFR) ≤40 mL/minute, proteinuria >500 mg/day, and/or hematuria. According to the biopsy diagnosis, patients were grouped into the following categories: normal (n = 13); acute tubular necrosis (ATN; n = 25); membranoproliferative glomerulonephritis (n = 19); minimal histological changes (n = 24); and advanced interstitial fibrosis (IF) and glomerulosclerosis (GS) (n = 47). Compared with patients having advanced IF/GS, patients with normal biopsies and those with ATN had lower systolic blood pressure (SBP) and diastolic blood pressure (DBP) and higher international normalized ratio and total bilirubin levels (<0.05 for all). Both SBP and DBP directly correlated with the degree of IF and GS (R = 0.3, P ≤ 0.02 for all). SBP ≤90 mm Hg was 100% sensitive and 98% specific in correlating with normal biopsies or ATN, whereas SBP ≥140 mm Hg was 22% sensitive and 90% specific in correlating with advanced IF/GS. Model for End-Stage Liver Disease score, serum creatinine, iGFR, urinary sodium excretion, and renal size did not correlate with biopsy diagnosis or degree of IF or GS. In conclusion, SBP at the time of LT evaluation correlates with renal histology, and it should be included along with other clinical and laboratory markers in the decision-making process to list patients with renal dysfunction for LT alone versus simultaneous liver-kidney transplantation.

Serum Electrolyte Levels and Outcomes in Patients Hospitalized with Hepatic Encephalopathy.

INTRODUCTION AND AIMS: Serum electrolyte derangements are common in patients with decompensated cirrhosis hospitalized for hepatic encephalopathy. There are limited data describing the association between electrolyte levels and outcomes in hepatic encephalopathy. We assessed the association between initial serum electrolyte values and outcomes in patients with hepatic encephalopathy. MATERIAL AND METHODS: A total of 385 consecutive patients hospitalized with encephalopathy were included in the study. Baseline electrolyte levels (sodium, potassium, chloride, bicarbonate, calcium and phosphorus) were measured at the time of admission and assessed for association with outcomes, which included survival, admission to the intensive care unit, requirement for mechanical ventilation, and length of hospital stay. P-values ≤ 0.0083 were considered significant after adjustment for multiple testing. RESULTS: In unadjusted analysis, significant associations were identified regarding both bicarbonate and phosphorus (admission to intensive care unit), and calcium (mechanical ventilation); however these findings weakened and no longer approached statistical significance when adjusting for confounding variables. No other significant associations between serum electrolyte measurements and outcomes were observed. CONCLUSIONS: Our findings suggest that in patients hospitalized with encephalopathy, serum electrolyte measurements are not strong predictors of patient outcome.

A multidisciplinary approach to reducing alarm fatigue and cost through appropriate use of cardiac telemetry.

BACKGROUND: Alarm fatigue (AF) is a distressing factor for staff and patients in the hospital. Using cardiac telemetry (CT) without clinical indications can create unnecessary alarms, and increase AF and cost of healthcare. We sought to reduce AF and cost associated with CT monitoring. METHODS: After implementing a new protocol for CT placement, data were collected on telemetry orders, alarms and bed cost for 13 weeks from 1 January 2015 through 31 March 2015. We also retrospectively collected data on the same variables for the 13 weeks prior to the intervention. A survey was administered to nurses to assess past and present perceptions of AF. Interventions included protocol creation and education for participants. RESULTS: At baseline, 77% of patients were monitored with CT. A total of 145 (31%) order discrepancies were discovered during data collection, of which 72% had no indication for CT, so CT was discontinued. The other 28% had indications, so orders were placed. A total of 8336 alarms were recorded during 4 weeks of data collection, of which 333 (4%) were classified as true actionable alarms. Postintervention data showed 67% CT assignment with 10% reduction in CT usage, with no increase in mortality (p<0.001 and >0.05, respectively). A 42% cost reduction was achieved after adjusting the patient status. Nurses reported 27% perceived reduction in AF. One-year follow-up revealed that 69% of patients were being monitored by CT, and the rate of order discrepancies due to lack of indication was 9%. CONCLUSION: All hospital units may benefit from the protocols created during this study. If applied appropriately, these protocols can lead to reduced AF and cost per episode of care.

Safety of ultra-low contrast coronary angiography in patients with acute kidney injury.

BACKGROUND: Ultra-low contrast administration during coronary angiography has been previously shown to be feasible and safe among patients with stable chronic kidney disease. In the present study, we investigate the safety of ultra-low contrast coronary angiography in patients with pre-existing acute kidney injury (AKI). METHODS: The study was a retrospective single-center evaluation of hospitalized patients who had AKI and required coronary angiography. Ultra-low contrast use was defined as ≤18 mL of contrast media. RESULTS: The cohort consisted of a case series of eight inpatients with AKI who required coronary angiography. The mean age was 57 (±16) years and half were females. All patients had chronic kidney disease with a mean baseline estimated glomerular filtration rate of 34 (±17) mL/min/1.73 m2. The mean creatinine before angiography was 3 (±1) mg/dL and volume of contrast administered was 14 (±4) mL. One patient had a 0.1 mg/dL increase in creatinine during admission, and no patients had further AKI up to 1-week postprocedure. CONCLUSIONS: The current data suggest that ultra-low contrast coronary angiography can be safely performed in patients with pre-existing AKI The study should be viewed as hypothesis-generating due to its small sample size. A larger cohort is required to validate the results.

Percutaneous debulking of tricuspid valve infective endocarditis vegetations using a large bore manual aspiration device - AlphaVac.

Most infectious endocarditis patients can be managed medically. However, non-responders to antibiotics and ongoing sequelae such as septic emboli, may require mechanical interventions. AngioVac (Angiodynamics, Latham, NY, USA) is a percutaneous aspiration device used for removal of thrombi, emboli, masses, and vegetations. Main drawbacks are the requirement for a perfusionist, two large-bore accesses, and meticulous de-airing. These drawbacks make the procedure more time-consuming and possibly increase the risk of complications. AlphaVac (Angiodynamics) omits the motor element, thereby overcoming several of the limitations. In the current report, we describe two cases of percutaneous aspiration of tricuspid valve vegetations using AlphaVac. Learning objective: To consider manual percutaneous aspiration of infective valvular vegetations using the AlphaVac cannula in case of insufficient response to antibiotics or for prevention of emboli.

Acute Unilateral Vision Loss Due to Optic Neuropathy in a Patient with Systemic Lupus Erythematosus.

BACKGROUND Systemic lupus erythematosus (SLE) causes sight-threatening, ophthalmologic problems that are frequently challenging to manage. Optic neuropathy is a rare ophthalmological complication of SLE that can progress to total bilateral vision loss if not identified and treated rapidly. We describe a patient with SLE who presented with an acute, painless unilateral optic neuropathy who subsequently experienced partial recovery of vision when treated with high-dose intravenous corticosteroids. CASE REPORT A 44-year-old female with known SLE presented with 4 days of painless, complete, and gradual vision loss in the right eye. Initial ophthalmologic examination revealed no light perception, afferent pupil defect, 4+ optic disc swelling, and 1+ venous tortuosity of the right eye. No hemorrhage or exudates were noted. Diagnostic workup revealed a lupus flare with elevated inflammatory markers including elevated anti-nuclear antibody, anti-ds-DNA antibody, anti-Sm antibody, and anti-phospholipid IgG antibody. The diagnosis of optic neuropathy was clinically established, and the patient was treated with high-dose intravenous corticosteroids. Her vision improved, and she was transitioned to oral corticosteroids with eventual significant improvement in her vision. CONCLUSIONS Optic neuropathy is a rare and devastating ophthalmologic complication of SLE. The diagnosis can be made by linking key clinical findings on ophthalmologic examination with positive serological studies. If treated rapidly with immunosuppressive therapy, the vision loss can be reversed, and permanent blindness avoided. Although this rare complication is generally bilateral in nature, clinician must also be aware of unilateral disease and treat patients accordingly.

Appropriately testing patients with intermediate risk for coronary artery disease: how well are we doing?

BACKGROUND: Cardiovascular risk assessment and stratification of stable coronary artery disease represents a pivotal component of coronary artery disease management. The introduction of risk stratification tools has advanced the detection of patients with intermediate to high risk for coronary artery events. These patients will ultimately undergo non-invasive and invasive cardiovascular testing. OBJECTIVE: To synthesise evidence illustrating risk stratification tools and non-invasive testing for patients with intermediate risk for coronary artery disease and suggest a simple method for clinicians to follow prior to ordering non-invasive cardiovascular testing. STUDY SELECTION: Literature review of PubMed and MEDLINE Central on studies and evidence highlighting the appropriate use criteria for radionuclide myocardial perfusion imaging. FINDINGS AND CONCLUSIONS: Overtestingusing myocardial perfusion imaging is well documented in several studies in the literature. Few studies highlighted the importance of the appropriate use criteria for radionuclide myocardial perfusion imaging, which can reduce unnecessary testing in patients with suspected coronary artery disease. Herein, we propose 'Simple Steps to Follow' to be considered by clinicians prior to ordering radionuclide myocardial perfusion imaging. The target audience of this article is internal and family medicine primary care physicians and other non-cardiologist physicians.

Recurrent Syncope, a Clue in Amyloid Cardiomyopathy.

Infiltrative cardiomyopathies include a variety of disorders that lead to myocardial thickening resulting in a constellation of clinical manifestations and eventually heart failure that could be the first clue to reach the diagnosis. Among the more described infiltrative diseases of the heart is amyloid cardiomyopathy. The disease usually presents with subtle, nonspecific symptoms. Herein, we illustrate a case of recurrent syncope as the initial presenting symptom for systemic amyloid with polyneuropathy and cardiomyopathy as a cause of syncope. The article illustrates the role of advanced cardiac imaging in the diagnosis of the disease with a focused literature review. We also highlight the role of early, shared decision-making between patient, family, and medical team in the management of cardiac amyloidosis.

Collapsing glomerulopathy in systemic lupus erythematosus.

Collapsing glomerulopathy (CG) is a rare disease that can be associated with multiple other disorders. It usually leads to poor prognosis with a high percentage of patients progressing to end-stage renal disease. In this article, we illustrate a clinical case of CG associated with systemic lupus erythematosus that had a prompt response to mycophenolate and prednisone. The condition started after sudden cessation of the already established mycophenolate treatment regimen. The patient then presented with acute kidney injury due to kidney biopsy-proven CG. In that circumstance, we hypothesised that mycophenolate may play a role in prevention and development of CG.

Pacemaker Placement in Patients with Stroke-Mediated Autonomic Dysregulation.

Lateral medullary syndrome (LMS) is an ischemic disease of the medulla oblongata, which involves the territory of the posterior inferior cerebellar artery. Lateral medullary syndrome is often missed as the cause of autonomic dysregulation in patients with recent brain stem stroke. Due to the location of the baroreceptor regulatory center in the lateral medulla oblongata, patients with LMS occasionally have autonomic dysregulation-associated clinical manifestations. We report a case of LMS-associated autonomic dysregulation. The case presented as sinus arrest and syncope, requiring permanent pacemaker placement. A dual-chamber pacemaker was placed, after failure of conservative measures to alleviate the patient's symptoms. Our case shows the importance of recognizing LMS as a potential cause for life-threatening arrhythmias, heart block, and symptomatic bradycardia. Placement of permanent pacemaker may be necessary in some patients with LMS presenting with syncope, secondary to sinus arrest.

Revisiting propafenone toxicity.

Propafenone is a Vaughan Williams class 1c antiarrhythmic medication widely used for treatment of arrhythmias. Although the long-term safety of propafenone use has not been established, it is commonly used for treatment of atrial fibrillation in patients with no structural heart disease. Propafenone is well known as pill-in-the-pocket treatment for its effect in terminating paroxysmal episodes of atrial fibrillation. Herein, we discuss an unusual adverse reaction to propafenone in a patient who presented with symptomatic bradycardia and hypotension. The aim of this article is to increase physician awareness for propafenone toxicity and its management, with a focused literature review on propafenone pharmacotherapy.

Nodular pulmonary amyloidosis: a complex disease with malignancy association.

Pulmonary amyloidosis is a rare disease that incorporates deposition of amyloid microfibril material in the lung parenchyma. The condition generally presents as an indolent subacute-to-chronic pulmonary disease and requires tissue biopsy to establish the diagnosis. Nodular pulmonary amyloidosis, a subtype of pulmonary amyloidosis, is characterised by special radiographic and pathological features. While the disease can be associated with inflammatory conditions; its association with mucosal-associated lymphoid tissue (MALT lymphoma) is unusual and carries management challenges. Herein, we illustrate a case study of nodular pulmonary amyloidosis associated with underlying MALT lymphoma in a patient with known systemic lupus erythematosus. The aim of this article is to share the management experience of this complex condition with the medical community and to conduct an up-to-date literature review on nodular pulmonary amyloidosis.

Renal cell carcinoma with isolated breast metastasis.

Renal cell carcinoma (RCC) is a highly prevalent disease worldwide with many cases being metastasised to various organs during the time of initial presentation. Metastatic RCC to the breast is a rare entity and can mimic primary breast carcinoma. In this article, we present a 63-year-old Caucasian woman presented with a breast mass that was detected by screening mammography and found to have a biopsy proven grade-II clear RCC in the breast tissue. Despite the high incidence and prevalence of primary breast cancer, metastasis from extramammary should be suspected in patients with a prior history of other cancers. In this brief literature review, we also highlight the survival benefit from surgery and close follow-up in selected group of patients with metastatic, metachronous and solitary RCC.

Central Line Proficiency Test Outcomes after Simulation Training versus Traditional Training to Competence.

RATIONALE: Studies have shown the importance of simulation-based training on the outcomes of central venous catheter (CVC) insertion by trainees. OBJECTIVES: To compare the performance of internal medicine trainees who underwent standardized simulation training of CVC insertion with that of internal medicine trainees who had traditional CVC training and were already deemed competent to perform the procedure during a proficiency evaluation using a training mannequin. METHODS: Trainees who perform CVC insertion were enrolled in the institutional Central Line Workshop, which includes both an online and an experiential simulation component. The training is followed by a certification station proficiency assessment. Residents and fellows previously certified competent to perform CVC placement without supervision completed the online module, but they could opt out of the experiential component and proceed directly to the evaluation. RESULTS: Forty-eight trainees participated in the study. Twenty-one (44%), 15 (31%), 6 (13%), 1 (2%), 2 (4%), and 3 (6%) were in postgraduate year 1 (PGY1), PGY2, PGY3, PGY4, PGY5, and PGY6, respectively. Twenty-nine completed the hands-on instruction, 28 (97%) of whom successfully passed the simulation-based assessment on their first attempt. Nineteen trainees previously credentialed to perform CVC placement without supervision opted out of the simulation-based experiential training. Of these, five (26%) failed in their first attempt (P = 0.02 vs. trainees who completed the simulation training). CONCLUSIONS: Standardized simulation-based training can improve CVC insertion proficiency, even among trainees with previous experience sufficient to have been deemed competent in the procedure. Improved performance at simulation-based testing may translate to improved outcomes of CVC placement by trainees.

Assessing the performance and satisfaction of medical residents utilizing standardized patient versus mannequin-simulated training.

BACKGROUND: Conducting simulations of rapidly decompensating patients are a key part of internal medicine (IM) residency training. Traditionally, mannequins have been the simulation tool used in these scenarios. OBJECTIVE: To compare IM residents' performance and assess realism in specific-simulated decompensating patient scenarios using standardized patients (SPs) as compared to mannequin. METHODS: Nineteen IM residents were randomized to undergo simulations using either a mannequin or an SP. Each resident in the two groups underwent four different simulation scenarios (calcium channel blocker overdose, severe sepsis, severe asthma exacerbation, and acute bacterial meningitis). Residents completed pretest and post-test evaluations as well as a questionnaire to assess the reality perception (realism score). RESULTS: Nine residents completed mannequin-based scenarios, whereas 10 completed SP-based scenarios. Improvement in the post-test scores was seen in both groups. However, there were significantly higher post-test scores achieved with SP simulations in three out of the four scenarios (P=0.01). When compared with the mannequin group, the SP simulation group showed a significantly higher average realism score (P=0.002). CONCLUSIONS: Applying SP-based specific-simulation scenarios in IM residency training may result in better performance and a higher sense of a realistic experience by medical residents.