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Common Variable Immunodeficiency Associated With Noninfectious Pulmonary Complications and Its Treatment: Beyond Immunoglobulin Therapy
No full textCommon variable immunodeficiency (CVID) is a type of primary immunodeficiency that presents as a heterogenous disorder characterized by hypogammaglobinemia, poor response to vaccines, recurrent sinopulmonary infections, and can have noninfectious systemic manifestations. We performed a single-center, retrospective, observational study of five patients with noninfectious complications of CVID. All patients had CVID as defined by the European Society of Immunodeficiencies criteria and had received intravenous immunoglobulin therapy. There were multiple pulmonary manifestations of CVID including frequent pneumonias, bronchiectasis, granulomatous lung disease, and pulmonary hypertension. All our patients were treated with pulmonary vasodilators for severe precapillary pulmonary hypertension along with individualized immunosuppression regimen for interstitial lung disease. Despite treatment for interstitial lung disease and PH, their conditions worsened over 2-3 years with all patients progressing toward organ transplant evaluation. Idiopathic thrombocytopenia and non-cirrhotic portal hypertension were common, with three patients probably suffering from nodular regenerative hyperplasia. Noninfectious complications of CVID can affect different organs and progress despite advanced therapies. Single or multiorgan transplantation is a treatment option for patients with end-stage organ involvement refractory to medical therapy
Factor V Serves as an Early Biomarker for Graft Loss After Liver Transplant: A Prospective Evaluation
No full textBACKGROUND: Low post-operative day (POD) 1 Factor V has been retrospectively associated with graft loss after liver transplantation when stratified by a cutoff of 0.36 U/mL. We aimed to validate this prospectively.
METHODS: Patients transplanted at Toronto General Hospital were recruited (May 2018-March 2021). Factor V measurements were obtained on POD1-3, 5, and 7. Graft and patient survival at 3, 6, and 12 months were primary and secondary outcomes, respectively. We identified an optimal cutoff through receiver operating characteristic (ROC) analysis and the Youden index. Kaplan-Meier method and Log-rank tests were used to assess/compare survival.
RESULTS: One hundred and twenty-nine patients were included. One hundred and eight had Factor V \u3e0.36 and 21 had ≤ 0.36 U/mL. This cutoff was predictive of 6- and 12-month graft survival and 12-month patient survival. With an optimal cutoff of 0.46 U/mL on POD1, 87 patients had Factor V \u3e0.46 and 42 had ≤ 0.46 U/mL. Three-, 6-, and 12-month graft survival rates were 100%, 98.8%, and 98.8%, for patients with Factor V \u3e0.46 U/mL, and 92.9%, 87.7%, and 87.7% for Factor V ≤ 0.46 U/mL. Similarly, 3-, 6-, and 12-month patient survival rates were 98.8%, 96.4%, and 95.0% for patients with Factor V \u3e0.46 U/mL, and 92.9%, 88.0%, and 82.9% for Factor V ≤ 0.46 U/mL. Stratification below the novel cutoff was associated with decreased graft survival at months 3 (p = 0.012), 6 (p = 0.006), and 12 (p = 0.006), and decreased patient survival at 12 months (p = 0.022).
CONCLUSIONS: Factor V serves as an early biomarker for graft loss, with an optimal predictive cutoff of 0.46 U/mL in this prospective population. Validation of this new cutoff is necessary
Preoperative smoking cessation improves carotid endarterectomy outcomes in asymptomatic carotid stenosis patients
No full textOBJECTIVE: Smoking cessation has been suggested as having the potential to improve the outcomes of carotid endarterectomy (CEA) and mitigate the risk of long-term stroke in patients with asymptomatic carotid stenosis (ACS). This study aims to compare the perioperative and long-term outcomes of CEA in patients with ACS across different smoking status groups.
METHODS: All patients receiving an elective CEA for ACS between 2013 and 2023 were identified in the Vascular Quality Initiative (VQI). Patients with an ipsilateral carotid stenosis \u3c70% and those receiving a concomitant coronary artery bypass graft were excluded. Patients were then classified according to their smoking status: never smokers, former smokers (defined as those who have stopped smoking more than 30 days prior to their operation), and current smokers. Patient characteristics and outcomes were compared using the χ(2) or Fischer exact test as appropriate for categorical variables and the analysis of variance or Kruskal-Wallis test as appropriate for continuous variables. Cox regression analysis was used to study the association between smoking status and the primary outcomes of long-term stroke and major adverse cardiac events (MACE) defined as the composite outcome of stroke, myocardial infarction, and/or mortality.
RESULTS: A total of 77,664 patients received a CEA for ACS, of which 19,416 patients (25%) were never smokers, 39,374 patients (51%) were former smokers, and 18,874 patients (24%) were current smokers. Patients in the three groups had similar rates of perioperative stroke (P = .79), myocardial infarction (P = .07), mortality (P = .23), and MACE (P = .17). At 18-month follow-up, former and never smokers had similar rates of stroke (former 0.9% vs never 0.8%; P = .92), with former smokers exhibiting a lower stroke risk than current smokers (former 0.9% vs current 1.5%; P = .001). At 18 months, former smokers had a significantly lower rate of MACE compared with current smokers (former 11.8% vs current 13.2%; P = .03), but a higher rate compared with never smokers (former 11.8% vs never 8.7%; P \u3c .001). On multivariate Cox regression analysis, compared with current smokers, former smokers were independently associated with a lower risk of stroke (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.53-0.87; P = .002), mortality (HR, 0.79; 95% CI, 0.74-0.84; P \u3c .001), and MACE (HR, 0.77; 95% CI, 0.70-0.83; P \u3c .001). No difference in long-term stroke risk was observed between former and never smokers (HR, 1.06; 95% CI, 0.82-1.38; P = .65).
CONCLUSIONS: This study demonstrates that preoperative smoking cessation in patients with ACS significantly reduces the risk of stroke, mortality, and MACE following CEA compared with continued smoking, aligning their outcomes more closely with those of never smokers. Optimizing patients with ACS prior to surgery should include smoking cessation counseling. Vascular surgeons play a critical role in encouraging smoking cessation, as their guidance can significantly improve patient outcomes following CEA
Surgical options for advanced renal cell carcinoma
No full textDetection of advanced renal cell carcinoma (RCC) is not uncommon, although there has been a stage migration due to frequent use of abdominal imaging allowing early detection of renal masses. Since open IVC thrombectomy was introduced in 1972, minimally invasive approaches such as laparoscopic approach, hand-assisted approach and robotic approach have been adopted. While robotic surgery has potential benefits to improve perioperative outcomes, and our experience with robotic surgery has grown significantly over the last decade, open surgery at an academic center remains the standard of care in this setting. In the setting of metastatic RCC, cytoreductive nephrectomies have been discussed for many years but their indications are unclearly defined, although cytoreductive nephrectomy can be considered in patients with disease largely limited to the kidney or on-going or impending symptomatic disease. Significant advances have been made in systematic therapy for RCC which will eventually lead to the evolution of neoadjuvant and adjuvant therapy in patients with advanced RCC. The surgical management of advanced RCC is a major and complex undertaking but has shown to be feasible and effective
Premature Ventricular Contractions As A Predictive Marker For Cardiac Events In Stable Heart Failure Patients
No full textIntroduction: Even though premature ventricular contractions (PVCs) are often viewed as harmless, recent studies show that a πρεχεδινγ PVC beat might be inefficient. It suggests that even a moderate number of PVCs could reduce contractile efficiency and elevate event risk. Yet, the prevalence of moderate to high PVCs (\u3e5%) in stable heart failure (HF) patients and the association between PVC percentage and cardiac event risk in stable HF patients are still unclear. Aim: This study aimed to quantify HF patients with \u3e5% PVCs and to evaluate the predictive power of PVCs for cardiac events. Methods: Our study retrospectively reviewed 651 HF patients from Amsterdam UMC (AUMC) with LVEF \u3c 40% or NTproBNP \u3e 600 pg/ml, and 180 HF patients from Henry Ford Hospital (HFH) with LVEF \u3c 40%. We employed a multivariable Cox regression model to evaluate predictors of cardiac events, such as all-cause mortality, VT/VF and/or ICD shocks, and cardiac arrest, selecting variables with p \u3c 0.05 from univariable analysis. For survival models, numeric variables not fitting a normal distribution were transformed into categorical variables using ROC-derived thresholds. Results: In AUMC and HFH cohorts, the median age was 64 years, with 43.5% and 50% females, respectively. Approximately, 9-11% of patients in both cohorts had more than 5% PVCs. In AUMC cohort, individuals in the top three PVC deciles faced significantly higher event risk than lower deciles (Figure 1). Based on univariable analysis, four predictors, including PVC %, NT-proBNP, occurrences of bi/trigeminy, and NSVT were selected for inclusion in the multivariable survival model. Thresholds of 0.5% for PVCs and 6000 pg/ml for NTproBNP were used. PVCs greater than 0.5% were significantly linked to an increased risk of cardiac events, exhibiting hazard ratios (HR) greater than two across all models with significant p-values, and slightly outperforming NSVT in predictive strength. (Table 1) Conclusions: Our analysis across two independent cohorts reveals that 9-11% of stable HF patients exhibit a notable PVC burden (\u3e5% of total beats), even with adequate treatment. In AUMC cohort, PVC burden exceeding 0.5%, equal to about 3-4 beats per minute, is significantly associated with increased cardiac event risk, suggesting PVC\u27s predictive power may rival that of NSVTs
Quality of Life Predictors in Patients with Acute Lower Limb Ischemia Quality of Life in Acute Limb Ischemia
No full textBACKGROUND: While existing literature has established factors associated with improved health-related quality of life (HRQOL) in patients with chronic limb-threatening ischemia, similar work has not been done in individuals with acute lower limb ischemia (ALLI). This study aims to identify the factors associated with HRQOL in patients presenting with ALLI.
METHODS: Using a prospectively collected registry, all patients who received treatment for ALLI between May 2016 and July 2023 at a quaternary medical center were identified and invited to complete two HRQOL questionnaires: the Vascular Quality of Life Questionnaire-6 (VascuQoL-6) and the EuroQol 5-Dimension 5-Level (EQ-5D-5L). Simple linear regression followed by multivariate analysis using multiple linear regression were used to determine the patient variables independently associated with HRQOL.
RESULTS: Of the 216 eligible patients treated for ALLI during the study period, 47 (20%) of patients with a mean age of 58 ± 10 years completed the HRQOL questionnaires. Questionnaires were completed at a median time of 16.5 months after the episode of ALLI. On multiple linear regression, higher age was associated with higher VascuQoL-6 (P = 0.037) and EQ-5D-5L (P = 0.041) scores, while hypertension and nonambulatory status were significant predictors of lower VascuQoL-6 (P = 0.006, P = 0.013) and EQ-5D-5L (P = 0.009, P = 0.026) scores. Any ambulation had a significantly higher HRQOL compared to nonambulatory status, but no significant HRQOL difference was observed between patients with any type of ambulation (unhindered ambulation, ambulation with pain, and ambulation using a prosthesis).
CONCLUSIONS: This study demonstrates that the ability to ambulate after ALLI, and not amputation per se, is an important predictor of HRQOL. As such, early rehabilitation strategies should be a focus of post-ALLI care. Further exploration of factors that shape HRQOL after ALLI is needed
Impact of moderate or severe mitral and tricuspid valves regurgitation after transcatheter aortic valve replacement
No full textBACKGROUND: Tricuspid regurgitation (TR) and mitral regurgitation (MR) are common valvular conditions encountered in patients undergoing transcatheter aortic valve replacement (TAVR). This retrospective study investigates the impact of moderate or severe TR and MR on all-cause mortality in 1-year post-TAVR patients.
METHODS: Consecutive patients who underwent TAVR at the 3 academic tertiary care centers in our health system between 2012 and 2018 were identified. Patients were stratified into 2 groups based on valvular regurgitation severity: moderate/severe MR vs no/mild MR, and moderate/severe TR vs no/mild TR. Primary outcome was all-cause mortality at 1-year and 5-year follow up, and secondary outcome was in-hospital death. Logistic regression analysis was conducted to assess the relationship between moderate/severe MR or TR and all-cause mortality at 1-year and 5-year follow-up.
RESULTS: We included a total of 1,071 patients who underwent TAVR with mean age 80.9 ± 8.6 years, 97% white, and 58.3% males. Moderate or severe MR group included 52 (4.88%) patients while mild or no MR group included 1,015 (95.12%) patients. There was no significant difference between both groups in TAVR procedure success rate (100% vs 97.83%, P = .283), in-hospital mortality (0 vs 1.08%, P = .450), or mortality at 1-year follow up (15.38% vs 14.09%, P = .794). At 5-year follow up, moderate/severe MR group had higher mortality (61.4% vs 49.5%, P = .046). In multivariable logistic regression analysis, moderate or severe MR did not show significant correlation with all-cause mortality at 1-year and 5-year follow up. Moderate or severe TR group included 86 (8.03%) patients while mild or no TR group included 985 (91.97%) patients. There was no difference between both groups in TAVR procedure success (98.8% vs 97.9%, P = .54) or in-hospital mortality (0% vs 1.1%, P = .33). At 1-year follow up, patients with moderate or severe TR had higher mortality (26.7% vs 13.2%, P = .001) compared to patients with mild or no TR. Same finding was noted with extended follow up at 5-years (68.3% vs 48.7%, P \u3c .001). In multivariable cox regression analysis, moderate/severe TR was associated with higher all-cause mortality at 1-year (OR 1.94, 95% CI [01.09, 3.44], P = .023) and at 5-year (OR 1.46, 95% CI [1.092, 1.952], P = .011) follow up. Patients with combined moderate/severe MR and TR have even higher mortality compared to either moderate/severe valve regurgitation alone or mild/no valve regurgitation at 5-year follow up.
CONCLUSION: At long term follow up, moderate/severe TR, but not MR, is associated with higher mortality in patients underwent TAVR. Combined moderate/severe TR and MR had even worse mortality. Careful assessment of multivalvular heart disease prior to the procedure is warranted
Safety and complications associated with the use of protamine in percutaneous coronary intervention
No full textOBJECTIVES: There is a paucity of data on the use of protamine after PCI. The purpose of this study was to assess the incidence of thrombotic complications of protamine after high-risk PCI.
METHODS: The authors conducted a retrospective analysis of 168 patients. All patients received protamine intra- or immediately post-index PCI. Baseline characteristics and procedural characteristics including heparin dosing, protamine dosing, and bleeding and thrombotic complications were evaluated. The primary outcome was the incidence of acute stent thrombosis (ST), subacute ST, and \u27other\u27 thrombotic complications. Secondary outcomes included mortality within 24 hours and within 30 days of the index procedure.
RESULTS: A total of 168 patients were included. The majority of patients received dual anti-platelet therapy prior to the index procedure (85%). The average procedure time was 202 ± 103 minutes, and an average of 2.59 (± 1.38) stents were deployed. An average protamine dose of 32mg was administered, and the median dose was 20mg (IQR 20). Seventy-three (43%) had a coronary perforation and five (3%) had access site related bleeding requiring transfusion. Four (2%) patients had acute ST, no patients experienced subacute ST, and 2 (1%) patients developed non-coronary arterial thrombosis. Eight (5%) died within 24 hours of their PCI and 14 (8%) patients died within 30 days after PCI.
CONCLUSIONS: In our cohort, administration of protamine was well tolerated in the majority of patients, however, 3.6% of patients did experience coronary or peripheral arterial thrombosis warranting caution when using protamine in these challenging scenarios
Circle of Willis Variants and Their Association with Outcome after Successful Revascularization of Anterior Large Vessel Occlusion
No full textBACKGROUND AND PURPOSE: Leptomeningeal collaterals have been associated with better outcomes in large-vessel stroke, but little is known about how the Circle of Willis (CoW) collaterals affect stroke outcomes. We aimed to determine the relationship between three anatomically distinct CoW subtypes and 90-day outcomes in acute ischemic stroke patients after successful revascularization via endovascular thrombectomy (EVT).
MATERIALS AND METHODS: We performed a retrospective analysis of patients treated with successful EVT for large-vessel occlusion at a comprehensive stroke center between May 2016 and November 2023. The CoW anatomy was trichotomized using baseline computed tomography angiography as follows: (I) complete CoW (C-CoW), (II) non-isolating incomplete CoW (NI-CoW), and (III) isolating incomplete CoW (I-CoW). Chi-squared and logistic regression analyses were utilized to determine the association of the CoW subtype with two co-primary outcomes: the 90-day modified Rankin Scale and 90-day mortality.
RESULTS: A total of 465 patients were included in the analysis. Multivariable logistic regression analysis demonstrated a significant association between I-CoW and 90-day mRS compared to NI-CoW [OR (95% CI), 1.83 (1.08-3.09); p=0.02]. Additionally, I-CoW anatomy was associated with a higher 90-day mortality than C-CoW [OR (95%CI), 2.58 (1.01-6.60); p=0.04] and NI-CoW [OR (95% CI), 1.89 (1.13-3.18); p=0.01].
CONCLUSIONS: CoW variants are associated with functional and mortality outcomes in patients treated with endovascular thrombectomy for anterior circulation large vessel occlusion. Further research is needed to determine how CoW vessel anatomy may impact clinical assessment, triage, and treatment in acute ischemic stroke.
ABBREVIATIONS: CoW = Circle of Willis; EVT = endovascular thrombectomy; C-CoW = complete Circle of Willis; NI-CoW = non-isolating incomplete Circle of Willis; I-CoW = isolating Circle of Willis; AIS = acute ischemic stroke; LVO = large vessel occlusion; ACom = anterior communicating artery; PCom = posterior communicating artery; Tan CS = Tan collateral scores; ACA = anterior cerebral artery; PCA = posterior cerebral artery
Fishhook Injuries and Antibiotic Prescribing Patterns: A Retrospective Analysis
No full textINTRODUCTION: Fishhook injuries are a common occurrence among anglers. There are no guidelines for prophylactic antibiotic use after fishhook removal. This study analyzed the management of embedded fishhooks, prophylactic antibiotic use, and complication rate at a Michigan county emergency department to observe whether antibiotic use changes patient outcome. Commentary on a freshwater pathogen (Aeromonas hydrophila) is also included.
METHODS: Cases were obtained through a retrospective chart review of patients seen for fishhook injury between 2016 and 2022. We analyzed age, sex, relevant medical history, type of fishhook, site preparation, removal technique, antibiotic use, return visit within 30 days, and complications.
RESULTS: Fifty-one patients with fishhooks injuries were identified. Mean age was 48±17 y. Forty-three patients were male (84%), and 8 were female (16%). Hook site varied, with most occurring in the finger/thumb (78.4%) and scalp (5.9%). One case involved the ear cartilage. The most common removal technique was the advance and cut method (52.9%). Four patients had an immunocompromising condition (eg, diabetes). Oral antibiotics were prescribed to 26 patients (51%) on discharge. Prophylactic antibiotic choice varied-cephalexin predominated (61.5%). There were no wound infections or complications in cases where the fishhook was removed during the emergency department encounter (50 of 51). One case involved a delayed presentation, abscess formation, and outpatient hand surgery referral.
CONCLUSIONS: In this small observational study, antibiotic prophylaxis for freshwater-associated fishhook injury did not change outcome regardless of fishhook location or presence of an immunocompromising condition. Further controlled studies are needed to determine the validity of these findings