Persistent Prothrombotic State in a Patient With Alström Syndrome.

We present the case of a patient with Alström syndrome who was found to have evidence of a prothrombotic state on autopsy after sudden cardiac death. To the best of our knowledge, this case of persistent prothrombotic milieu is the first described in a patient with Alström syndrome.

Aortic cusp perforation during rotational atherectomy: a case report.

Background: Rotational atherectomy has become increasingly utilised over the past decade. Although a relatively safe procedure in appropriately trained physicians' hands, there are a number of recognised complications. Case summary: We describe the case of a 64-year-old female who presented with chest pain and was diagnosed with non-ST-segment elevation acute coronary syndrome. A transthoracic echocardiogram (TTE) showed normal biventricular function and no valve disease. Invasive coronary angiogram was performed which revealed a severely calcified ostial right coronary artery (RCA) disease which was felt to be the culprit of the presentation. Balloon dilatation was unsuccessful, therefore, rotational atherectomy with an Amplatz left 0.75 guide and a 1.5 mm rota-burr was utilised and improved calcium burden. This was complicated by ostial dissection, treated with stenting. A TTE following the procedure revealed moderate aortic regurgitation (AR). The patient was discharged as she remained asymptomatic. An outpatient transoesophageal echocardiogram performed eight months later showed evidence of severe eccentric AR. Cardiac magnetic resonance imaging confirmed severe AR with left ventricular dilatation. Repeat angiogram 10 months after index procedure revealed in-stent restenosis, and the patient was accepted by heart multidisciplinary team for aortic valve replacement and grafting of RCA. Discussion: As the field of rotational atherectomy continues to expand, we propose that novel complications such as reported in this case may become recognised. Finally, we stress the importance of multi-modality imaging in the investigation and timely planning of interventions in the management of these patients.

Hemorrhagic Ascites Is Associated With Reduced Survival in Cirrhosis: A Systematic Review and Meta-Analysis.

Background: Hemorrhagic ascites is characterized as red blood cell count greater than 10,000/mm3. In cirrhosis, ascites is an event of decompensation, and associated with poor prognosis. However, significance of hemorrhagic ascites is unclear. We conducted a systematic review and meta-analysis to evaluate the significance of hemorrhagic ascites in cirrhotic patients. Methods: We conducted a systematic search in Embase, MEDLINE, Cochrane Central Register of Controlled Trials, the World Health Organization (WHO) International Clinical Trial Registry, and Web of Science Core Collection to identify studies till March 2021, which, in patients with cirrhosis, compared outcomes amongst those with hemorrhagic ascites to those with non-hemorrhagic ascites. The primary outcome was 3-year mortality, and secondary outcomes were acute kidney injury (AKI), hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP) and portal vein thrombosis (PVT). Results: Four studies, with 2,058 cirrhosis patients, were included. Among these, 1,488 patients had non-hemorrhagic ascites and 570 had hemorrhagic ascites. We observed no significant differences in AKI (odds ratio (OR) = 2.55; confidence interval (CI): 0.58 - 11.24), HE (OR = 2.52; CI: 0.70 - 9.05), SBP (OR = 1.66; CI: 0.12 - 22.83) and PVT (OR = 0.99; CI: 0.71 - 1.39). Intensive care unit (ICU) stay was significantly higher in patients with hemorrhagic ascites compared to those with non-hemorrhagic ascites (OR = 1.79; CI: 1.37 - 2.36; I2 = 56%). Pooled 3-year mortality was significantly higher in those with hemorrhagic (72.5% (CI: 68.2-76.4%)) when compared to non-hemorrhagic ascites (57.9% (CI: 55.2-60.6%)) (OR = 2.17; CI: 1.71 - 2.74) with low heterogeneity (I2 = 15%). Conclusions: In patients with cirrhosis, hemorrhagic ascites is a poor prognostic marker, which is associated with increased ICU stay and mortality. Prospective studies are needed to further evaluate significance of hemorrhagic ascites in patients with cirrhosis.

A Quality Improvement Process to Increase and Sustain a Peritoneal Dialysis Programme in the United Kingdom.

INTRODUCTION: Peritoneal dialysis (PD) remains underutilised in the West. The proportion of patients in the UK starting renal replacement therapy (RRT) with PD fell from 7.2% in 2011 to 6.0% in 2016. At our centre, 8.4% of dialysis patients received PD in April 2014. Evidence suggests that home dialysis improves patient clinical outcomes; therefore, a target was agreed to achieve 25% of dialysis patients receiving PD by 2018. METHODS: A rapid improvement process was introduced, as a quality improvement tool, to increase and sustain the PD programme. With multidisciplinary team support for PD growth, a nephrologist was trained to insert PD catheters. Nurses were trained to provide patients with balanced pre-dialysis information and discuss alternative dialysis modalities with haemodialysis (HD) patients. The "Acceptance, Choice and Empowerment" project raised awareness of home therapy choices, using a peer educator model specifically for ethnic minority patients. Lean methodologies were used to ensure continuous quality improvement. RESULTS: PD uptake increased from 37 to 84 patients, giving a PD penetration increase from 8.4% to 19.1% between April 2014 and March 2018. Catheter insertions increased from 94 at the end of QI Period 1 to 185 at the end of QI Period 2, representing a 97% increase, with the medical/surgical split remaining stable. Peritonitis rates remained stable, and PD drop off to HD reduced from 52% to 41% during the same period. CONCLUSIONS: By implementing a rapid improvement process and embedding a quality improvement programme, the number of incidents and prevalent PD patients increased and was sustained.