Novel use of the GuideLiner catheter to minimize contrast use during PCI in a patient with chronic kidney disease.

The GuideLiner catheter (Vascular Solutions, Minneapolis, MN) is a rapid-exchange "mother and child" guide extension that increases support in complex percutaneous coronary intervention (PCI). While this device was primarily designed to facilitate balloon and stent delivery, we describe the use of this device to reduce contrast volume through sub-selective visualization in a patient with chronic kidney disease (CKD) undergoing PCI of the left coronary system.

Utility of Suprasternal Transinnominate Artery for Alternate Access in Transcatheter Aortic Valve Replacement.

OBJECTIVE: Despite advancements in transcatheter aortic valve replacement (TAVR) technology, alternate access strategies are still required when transfemoral access is unsuitable. In these often anatomically complex group of patients, we sought to evaluate the safety and feasibility of suprasternal transinnominate (TI) artery access for TAVR. METHODS: At our institution, 652 patients underwent TAVR from November 2011 through February 2020. Of these, 23 patients underwent TI TAVR via a 5-cm suprasternal incision without special instrumentation. Outcomes of interest were technical considerations, postoperative complications, and perioperative recovery in relation to established access strategies. RESULTS: The mean Society of Thoracic Surgeons risk score was 8.6 ± 4.2 and the average age was 75 ± 8. All patients underwent TI TAVR using a self-expanding (12), or balloon-expandable (11) transcatheter heart valve. Average postoperative stay was 2 ± 0.7 days (range 2 to 4) with most 20/23 (87%) being discharged to home. There was no 30-day mortality or readmission. There was 1 access-site complication and 1 cerebrovascular accident within 30 days, both intraoperative, with excellent recovery. All patients had either trivial (19) or mild (4) aortic regurgitation on 30-day echocardiography. CONCLUSIONS: TAVR via suprasternal TI access is feasible, safe, provides satisfactory perioperative recovery and adds to the options when patients require alternate access. Further data would be optimal to validate this single-center experience.

Use of Social Media at Cardiovascular Congresses: Opportunities for Education and Dissemination.

Social Media includes different forms of online communication from Twitter, Facebook, Instagram, LinkedIn, podcasts, YouTube etc. and has advanced how information is exchanged. A notable use is engaging on Twitter at medical conferences, both for those attending the conference and the global audience who are not able to attend. It is also increasingly used as an educational tool similar to e-learning. The objective of this paper is to: 1) highlight the impact of using Twitter at cardiovascular congresses as an interactive platform for active learning as compared to passively listening to a presentation; 2) present perspectives from not only clinicians, researchers but also patients on how this information is interpreted; 3) provide recommendations for conference organizers for best practice live tweeting to share the information and knowledge beyond those in attendance; with potential for not only engagement but also educating our global community.

Emerging drug therapies for the management of acute decompensated heart failure.

The mortality and morbidity of patients with heart failure (HF) remains unacceptably high despite current advances in medical therapies. In recent years, rapid growth in understanding the pathophysiology of heart failure has allowed for insights into many potential new therapeutic strategies. Yet until now, despite sound biological basis for efficacy and success in early-phase studies, novel agents have not stood up to the scrutiny of late-phase clinical trials. This review will examine the key emerging therapies for acute decompensated heart failure (ADHF), in light of available pathophysiological and clinical evidence. Several new agents for ADHF use novel mechanisms of action that focus on new treatment targets, such as those providing anti-ischemic and anti-stunning effects, blocking vasopressin receptors, blocking endothelin-1 receptors, or endogenous cardiac neurohormones and B-type natriuretic peptide (BNP).

The renal patient with cardiovascular disease--no longer a simple plumbing problem.

The clinical syndrome of chronic kidney disease (CKD) with coronary artery disease (CAD) is a clinical challenge. The risk of cardiovascular disease in patients with renal impairment appears to be far greater than in the general population. Despite the high prevalence of CKD related to cardiovascular disease (CVD), it remains understudied. Most of the current research comes from small community-based studies and retrospective reviews, assuming that patients with CKD will similarly benefit from treatments as patients with normal renal function. Most of the current clinical trials have excluded patients with CKD even though they represent a group of people at high risk for cardiovascular (CV) complications. CKD is associated with adverse CV outcomes and higher mortality even after adjustment for conventional risk factors. Declining renal function portends increasing CV risk and may be explained by several other factors that are being investigated, including inflammation, decreased vascular compliance, homocysteine, albuminuria and dyslipidemia. In addition, there is a lack of appropriate intervention in patients with CKD, despite established awareness of their high cardiovascular risk.

Multiple brain abscesses caused by Cladophialophora bantianum: a challenging case.

Cladophialophora bantianum, a dematiaceous fungus with dark pigmented hyphae, is a rare cause of central nervous system (CNS) infection. This aggressive mold has a high mortality rate, primarily related to its poor response to currently available antifungal therapy. In this article, we report a 74-year-old immunocompromised man who presented with left-sided weakness, sensory deficit, and an abnormal magnetic resonance imaging (MRI) of the brain, which showed multiple ring-enhancing cerebral lesions. The largest lesion measured 4.6 x 3.9 centimeters and was located within the parietal region. He underwent a stereotactic needle biopsy, revealing a pigmented fungus which subsequently grew Cladophialophora bantiana. The patient failed initial monotherapy with liposomal amphotericin B. Later in the patient's hospital course, Flucytosine and voriconazole were added but there was no significant change in the size of the lesions on a repeat brain MRI performed one month into therapy. Surgical resection of the largest lesion was performed. Nevertheless, he continued to deteriorate and therapy was withheld per family request.

Monitoring quality of flexible endoscope disinfection by microbiologic surveillance cultures.

BACKGROUND: The purpose of this study is to assess the adequacy of currently approved high-level disinfection (HLD) for flexible endoscopes, by reviewing retrospectively the results of environmental cultures on the endoscopes, which were ready to use. METHODS: Cultures of all of our gastrointestinal endoscopes that were ready for use were sent to the laboratory for environmental cultures. Thirty milliliters of sterile water was passed through the biopsy channel of the endoscopes and the flushed water was collected in a sterile container. The specimen was plated onto blood agar, incubated at 37C, and examined for growth at 24 and 48 hours. RESULTS: Cultures were positive during the initial part of the study repeatedly with the same organism; the source of contamination was traced to be the source water and scope cleaner, after they were suspected and sent for cultures. In addition to Pseudomonas, there was contamination of the endoscopes with Micrococcus and Staphylococcus during the study period. CONCLUSIONS: Using environmental cultures for monitoring effectiveness of standard reprocessing procedures on a regular basis in clinical practice is not only inexpensive but also valuable to identify the source of possible contamination and rectify reprocessing methods to prevent transmission of infection secondary to endoscopy.

Intestinal spirochetosis: a poorly understood infection causing chronic diarrhea.

A young man with chronic diarrhea for many years underwent extensive evaluation. Finally, based on multiple colonic mucosal biopsies from near-normal appearing mucosa, the cause was elucidated to be spirochetosis. This is an enigmatic condition where the spirochetes seem to attach to the epithelial lining of the small and large bowel, without significant underlying inflammation. Because of this reason, there is controversy whether it is a true diarrheal pathogen. Suggested treatments are discussed.

Diagnostic and therapeutic difficulties in retroperitoneal abscess.

Abscesses developing within the retroperitoneal spaces are complicated and serious infections. These abscesses present insidiously, leading to considerable mortality and morbidity. A high clinical suspicion can help diagnose and treat this potentially fatal illness. Computed axial tomography is the best diagnostic modality for retroperitoneal abscess. Computed tomographic scan is useful, not only for diagnosing the retroperitoneal abscess, but can be used for therapeutic drainage of abscesses in high-surgical-risk patients. We present an illustrative case of retroperitoneal abscess and discuss the pathogenesis of retroperitoneal abscess, diagnosis, and treatment.

Endometriosis of the pancreas presenting as a cystic pancreatic neoplasm with possible metastasis.

The authors report a case of endometriosis that presented as a cystic mass in the tail of the pancreas, leading to extensive evaluation and ultimately a major surgical resection. The diagnosis was made by histopathological evaluation, revealing endometrial glands and stroma in the wall of the mass with hemorrhagic fluid in the cystic lumen, compatible with pancreatic involvement by an endometrial cyst.