Agarwal, Anjali

The efficacy and safety of extracorporeal membrane oxygenation (ECMO) support during transcatheter aortic valve replacement (TAVR) remains unknown. We conducted a meta-analysis to compare benefit and risk of ECMO in TAVR patients. Bibliographic databases were searched from inception to January 1, 2024. Included studies involved patients ≥18 years old undergoing TAVR and using ECMO emergently or prophylactically. Mortality and procedure success were primary outcomes. Peri- or postoperative complications were the secondary outcomes. We identified 11 observational studies, including 2,275 participants (415 ECMO and 1,860 non-ECMO). The unadjusted mortality risk in ECMO-supported patient was higher than non-ECMO patients (odds ratio [OR] 1.73). The mortality unadjusted risk remained high (OR 3.89) and statistically significant for prophylactic ECMO. Prophylactic ECMO had lower mortality risk compared with emergent ECMO (OR 0.17). Extracorporeal membrane oxygenation-supported patients had lower procedural success rate (OR 0.10). Extracorporeal membrane oxygenation patients undergoing TAVR had significantly increased risk of bleeding (OR 3.32), renal failure (OR 2.38), postoperative myocardial infarction (OR 1.89), and stroke (OR 2.32) compared with non-ECMO patients. Clinical results are not improved by ECMO support in patients with high-risk TAVR. Prophylactic ECMO outperforms emergent. Overall, ECMO support increases mortality and postoperative complications. Transcatheter aortic valve replacement outcomes may improve with prophylactic ECMO in high-risk situations.

AbstractPrimary care physicians (PCPs) are commonly approached with concerns involving patient genetics. This is a challenge because most PCPs lack expertise in genetic testing compared to their genetic counselor counterparts. Currently, the recommended best practice is to refer patients for genetic testing based on cancer‐related family history questionnaires with a genetic counseling referral to discuss their results and any implications. However, the extent to which PCPs are using these questionnaires for this purpose remains poorly understood. In this cross‐sectional study, PCPs were presented with the American Cancer Society's seven recommended family history questions to determine the percentage who consider each to be an indicator for referral to a genetics specialist. Questionnaires were completed by 88 of 260 attending PCPs at a national primary care review conference. The main outcome was the percentage of PCPs who identified each question as a trigger for genetic testing. Secondary outcomes included correlations with years of practice, genetics training, and methods used to obtain patient family history. Only two of the seven questions were considered triggers by most PCPs (range, 76–83%). The remaining five had lower percentages (range, 22–55%). Years of practice did not influence the number of triggers identified (Spearman correlation coefficient test: r = 0.05, p = 0.68). Few PCPs (3.4%) felt they had good to excellent genetics training during residency. Only 44.3% had genetics specialists available for referral. Overall, low percentages of PCPs consider the American Cancer Society questions to be triggers for genetic testing referrals. Furthermore, many do not have a genetics specialist or counselor available for referral. Addressing these concerns may help PCPs understand the basics of genetic testing and use standardized questionnaires to make appropriate referrals to genetic specialists, thereby reducing inappropriate referrals and improving appointment access to this precious resource for those who truly need it.

Introduction: Family health history can be a valuable indicator of risk to develop certain cancers. Unfortunately, patient self-reported family history often contains inaccuracies, which might change recommendations for cancer screening. We endeavored to understand the difference between a patient’s self-reported family history and their electronic medical record (EMR) family history. One aim of this study was to determine if family history information contained in the EMR differs from patient-reported family history collected using a focused questionnaire. Methods: We created the Hereditary Cancer Questionnaire (HCQ) based on current guidelines and distributed to 314 patients in the Department of Family Medicine waiting room June 20 to August 1, 2018. The survey queried patients about specific cancers within their biological family to assess their risk of an inherited cancer syndrome. We used the questionnaire responses as a baseline when comparing family histories in the medical record. Results: Agreement between the EMR and the questionnaire data decreased as the patients’ risk for familial cancer increased. Meaning that the more significant a patient’s family cancer history, the less likely it was to be recorded accurately and consistently in the EMR. Patients with low-risk levels, or fewer instances of cancer in the family, had more consistencies between the EMR and the questionnaire. Conclusions: Given that physicians often make recommendations on incomplete information that is in the EMR, patients might not receive individualized preventive care based on a more complete family cancer history. This is especially true for individuals with more complicated and significant family history of cancer. An improved method of collecting family history, including increasing patient engagement, may help to decrease this disparity.

Introduction: White matter hyperintensities (WMH) is the most prominent neuroimaging feature of small vessel disease (SVD). SVD is thought to be a result of arteriolosclerosis, chronic hypoperfusion of white matter, selective oligodendrocyte death and degeneration of myelinated fibers. The risk of ischemic stroke is significantly increased with the presence of WMH. The presence of intracranial collaterals is a strong predictor of salvageable neurological function in acute stroke; however, the factors affecting the ability to recruit collaterals are poorly understood. We wanted to study if the presence and severity of small vessel white matter disease had an adverse effect on cerebral collateral flow in acute embolic large vessel stroke. Methods: We identified a consecutive series of adult subjects with acute embolic large vessel strokes confirmed on CT angiography (CTA) from a 10-year institutional database. Patients without a brain MRI within six months of CTA were excluded. Collateral scores of the affected hemisphere were calculated on CTA using the modified Tan scale (0-4) by two independent trained reviewers and confirmed by a neuroradiologist. The WMH was quantified using the Fazekas scale (0-3) incorporating both deep and periventricular components. Areas of restricted diffusion on brain MRI in the peri-stroke period were eliminated from the assessment of Fazekas score. Spearman’s correlation tests were performed for the association between collateral scores and WMH. Results: A total of 234 patients (mean age 70±14 years, 47% [110/234] women) satisfied the inclusion criteria. The prevalence of periventricular and deep WMH was 83% and 87% respectively. Aging had a significant impact on periventricular WMH (r=0.48, p <0.001) and deep WMH (r=0.47, p <0.001). However, collateral scores exhibited no statistically significant relationship with the presence or severity of periventricular scores (r=0.08, p=0.17) or deep WMH scores (r=0.01, p=0.77). Conclusions: Our results indicate that the presence of SVD does not affect cerebral collateral flow. The vascular niche and risk factors of SVD appear to be distinct from that of intracranial vessels responsible for collateral reperfusion of ischemic territory in acute large vessel embolic stroke.

Postobstructive pulmonary edema (POPE) also known as negative pressure pulmonary edema (NPPE) is an underdiagnosed entity in clinical practice and can lead to life-threatening hypoxemia. A 64-year-old male patient’s perioperative course was complicated by acute hypoxemic respiratory failure, after extubation following general anesthesia, following the excision of the right vocal cord papilloma. His chest X-ray showed features of pulmonary edema, EKG showed dynamic ST-T changes in the lateral leads, and echocardiography showed evidence of regional motion abnormalities. His coronaries were normal on the immediate angiogram. He was managed with lung protective mechanical ventilation strategy, diuretics, and fluid restriction. His respiratory status improved, and trachea was extubated after 10 hours of intensive care unit (ICU) stay. The case illustrates the various differentials of immediate postoperative flash pulmonary edema and ensuing appropriate management strategy.

Although no consensus exists on whether extracorporeal membrane oxygenation (ECMO) support is an indication for solid-organ transplantation other than heart and lung, this practice continues to be limited. We present a case of a 55-year-old man who was placed on venoarterial ECMO (VA-ECMO) during orthotopic heart transplantation (OHT) because of acute graft failure. Twenty-four hours later, the patient underwent deceased-donor renal transplantation (DDRT) while on VA-ECMO and had no complications. On post-DDRT day 2 (post-OHT day 3), the patient was successfully decannulated from VA-ECMO and ultimately discharged home. This case highlights the potential successful use of ECMO support during solid-organ transplantation other than heart and lung and the importance of trained providers and tailored anticoagulation. To the authors’ knowledge, this is the first report of perioperative ECMO use during kidney transplantation after recent heart transplantation.

Infections caused by the Bartonella species are responsible for the human diseases collectively called ‘bartonellosis’. The clinically important human infections are mostly caused by the three species (eg, B. bacilliformis, B. quintana and B. henselae) of Bartonella out of the many progressively increasing identified species. Bartonella henselae transmitted by the arthropod vector, fleas, after cat bite is responsible for the rare multisystem cat scratch disease in humans. We present an extremely rare case of B. henselae contracted presumably through a red ant bite. The patient had a prolonged hospital stay for persistent encephalopathy due to delay in diagnosis and initiation of antimicrobial therapy. His hospital course was complicated by two episodes of pulseless electrical activity cardiac arrest related to pulmonary embolism. However, he recovered to his baseline status in the hospital with timely administration of systemic anticoagulation and antimicrobials. He was discharged home with no neurological deficits.