Cardiac arrest in seronegative idiopathic inflammatory myopathy: a case report.

Background: Idiopathic inflammatory myopathies (IIMs) are autoimmune diseases that are characterized by muscle injury. These disorders can cause cardiomyopathy and heart failure, myocarditis, and arrhythmias. However, only a few cases of cardiac arrest as a result of IIMs have been previously reported. Case summary: A 46-year-old male presented with an out-of-hospital ventricular fibrillation cardiac arrest. A diagnosis of IIM had been made through a muscle biopsy performed 2 years before presentation. The patient had a positive anti-nuclear antibody but negative myositis-specific antibodies. His initial symptoms of IIM were mild and consisted of myalgias. His only cardiac symptoms were minor palpitations that occurred 3 years prior to the cardiac arrest, with a negative Holter monitor test result at that time. His cardiac catheterization was normal. He was suspected to have myocarditis, and a rheumatologist was consulted, following which the patient was initiated on intravenous immunoglobulin (IVIG). Cardiac magnetic resonance imaging demonstrated evidence of chronic myocarditis and an ejection fraction of 44%. He was initiated on goal-directed medical therapy for heart failure. A VVI implantable cardioverter defibrillator was implanted for secondary prevention. He was discharged and prescribed additional immunosuppression including further IVIG infusions, prednisone taper and rituximab infusions. Discussion: Our case demonstrates that cardiac arrest in IIM is not only plausible, but can be the first major cardiac manifestation of the disease. When a diagnosis of IIM is made, patients require a thorough assessment of cardiac symptomatology and a low threshold for additional cardiac investigations.

A unique presentation of Pulmonary Langerhans Cell Histiocytosis.

Pulmonary Langerhans Cell Histiocytosis (PLCH) is a diffuse lung disease that primarily affects young adults, with cigarette smoking playing a significant role in developing the disease. Patients with PLCH present with characteristic CT chest findings of small irregular nodules and upper zone cysts. Previously, larger nodules greater than 10 mm and cavitation have only been reported a few times in the literature. We describe the case of a 69-year-old male who presented with dyspnea, non-productive cough and weight loss, who was found to have multiple cavitary nodules on CT imaging of the chest. Histopathologic sampling of the lung revealed Langerhans cells which stained positive for S100 and CD1a, consistent with a diagnosis of PLCH. The patient was counselled to quit smoking as the mainstay of treatment. In 3-month follow-up his symptoms had largely resolved, with evidence of decreased nodule size on repeat CT imaging.

A Systematic Review of Economic Evaluations in Vascular Surgery.

BACKGROUND: With increasing healthcare costs and the emergence of new technologies in vascular surgery, economic evaluations play a critical role in informing decision-making that optimizes patient outcomes while minimizing per capita costs. The objective of this systematic review is to describe all English published economic evaluations in vascular surgery and to identify any significant gaps in the literature. METHODS: We conducted a comprehensive English literature review of EMBASE, MEDLINE, The Cochrane Library, Ovid Health Star, and Business Source Complete from inception until December 1, 2018. Two independent reviewers screened articles for eligibility using predetermined inclusion criteria and subsequently extracted data. Articles were included if they compared 2 or more vascular surgery interventions using either a partial economic evaluation (cost analysis) or full economic evaluation (cost-utility, cost-benefit, and/or cost-effectiveness analysis). Data extracted included publishing journal, date of publication, country of origin of authors, type of economic evaluation, and domain of vascular surgery. RESULTS: A total of 234 papers were included in the analysis. The majority of the papers included only a cost analysis (183, 78%), and there were only 51 papers that conducted a full economic analysis (22%). The 51 papers conducted a total of 69 economic analyses. This consisted of 32 cost-effectiveness analyses, 29 cost-utility analyses, and 8 cost-benefit analyses. The most common domains studied were aneurysmal disease (89, 38%) and peripheral vascular disease (50, 21%). Economic evaluations were commonly published in the Journal of Vascular Surgery (83, 35%) and Annals of Vascular Surgery (32, 14%), with most study authors located in the United States (127, 54%). There was a trend of economic evaluations being published more frequently in recent years. CONCLUSIONS: The majority of vascular surgery economic evaluations used only a cost analysis, rather than a full economic evaluation, which may not be ideal in pursuing interventions that simultaneously optimize cost and patient outcomes. The literature is lacking in full economic evaluations-a trend persistent in other surgical specialties-and there is a need for full economic evaluations to be conducted in the field of vascular surgery.

Level of clinical evidence presented at the Society for Vascular Surgery Annual Meeting during a 5-year period (2012-2016).

OBJECTIVE: During the past decades, there has been an increasing emphasis on the use of high-quality evidence to inform clinical decision-making. The purpose of our study was to assess trends in the level of evidence (LOE) of abstracts presented at the Vascular Annual Meeting from 2012 to 2016. METHODS: All Vascular Annual Meeting abstracts for 2012 to 2016 were obtained through the Journal of Vascular Surgery. Two reviewers independently screened abstracts for eligibility. Research with a nonclinical focus was excluded from the study. Data extracted from eligible abstracts included study type (therapeutic, prognostic, diagnostic), study size, country of academic institution of primary author, presentation type, and whether the sample was recruited or from a database. Abstracts were assigned an LOE using the 2011 Oxford Centre for Evidence-Based Medicine classification scheme based on study design (eg, case series, randomized controlled trial). A χ2 test and analysis of variance test were conducted to assess nonrandom changes in LOE during the study period. RESULTS: Of the 1403 abstracts screened, 1147 were included. Inter-rater agreement was high (κ value for abstract screening was 0.93; κ value for data extraction was 0.89). Therapeutic studies were the most common study type (58%), followed by prognostic studies (37%), then diagnostic studies (5%). The majority of abstracts (75.0%) were submitted from North American institutions. Overall, 0.35% of the presentations were level I evidence, 3.1% level II, 52.8% level III, 38.0% level IV, and 5.7% level V. The average LOE per year fluctuated between 3.54 and 3.32, with a mean LOE of 3.45. The proportion of high-quality evidence (level I and level II) increased in the years 2015 and 2016, representing 78% of all level I and level II abstracts presented in the 5-year period. A χ2 test between LOE and year yielded a P value of .0084, indicating significant nonrandom change in LOE between 2012 and 2016. The majority of high LOE research was presented in poster sessions (37.5%), plenary sessions (27.5%), and international forum sessions/talks (25%) at the meeting. CONCLUSIONS: Overall, average LOE remained relatively consistent between 2012 and 2016, with most abstracts classified as level III or level IV. There was a gradual, albeit minor, increase in the proportion of level I and level II evidence in 2015 and 2016, potentially indicating the increasing commitment to producing and disseminating high-level research in vascular surgery. Furthermore, a lack of a classification tool specific to vascular surgery research occasionally presented a challenge in assigning LOE, perhaps indicating a need for such a tool in this specialty.

Bridging the Gap between Gut Microbial Dysbiosis and Cardiovascular Diseases.

The human gut is heavily colonized by a community of microbiota, primarily bacteria, that exists in a symbiotic relationship with the host and plays a critical role in maintaining host homeostasis. The consumption of a high-fat (HF) diet has been shown to induce gut dysbiosis and reduce intestinal integrity. Recent studies have revealed that dysbiosis contributes to the progression of cardiovascular diseases (CVDs) by promoting two major CVD risk factors-atherosclerosis and hypertension. Imbalances in host-microbial interaction impair homeostatic mechanisms that regulate health and can activate multiple pathways leading to CVD risk factor progression. Dysbiosis has been implicated in the development of atherosclerosis through metabolism-independent and metabolite-dependent pathways. This review will illustrate how these pathways contribute to the various stages of atherosclerotic plaque progression. In addition, dysbiosis can promote hypertension through vascular fibrosis and an alteration of vascular tone. As CVD is the number one cause of death globally, investigating the gut microbiota as a locus of intervention presents a novel and clinically relevant avenue for future research, with vast therapeutic potential.

Evaluating the Effectiveness of Internal Iliac Artery Branched Endovascular Stent Grafts.

BACKGROUND: The aim of this study is to describe our institutional experience using iliac branch grafts (IBGs) in aortoiliac aneurysm repair. METHODS: From October 2009 to April 2016, 41 consecutive patients (all men), mean age 71.7 years (range 55-87), underwent IBG implantation. Abdominal aortic aneurysm with common iliac artery involvement (n = 21) or bilateral common iliac artery aneurysms (n = 20) were indications. Computed tomography was used to evaluate patency and postoperative endoleaks within 1 month of implantation and after 1 year. RESULTS: A total of 42 IBGs were deployed in 41 patients successfully. One hundred percent of grafts implanted were patent at 1 month and at annual follow-up. There was 1 mortality at 30 days, due to acute renal failure. Sixteen type II and 1 type Ib endoleaks were found, for which 3 reinterventions were performed and the remainder treated conservatively. Five patients had complications which required reintervention. CONCLUSIONS: IBG placement has excellent short-term outcomes and potential to limit buttock claudication in the treatment of abdominal aortic aneurysms involving the iliac arteries.