Andrew Tseng

The Evolving Treatment of Peripheral Arterial Disease through Guideline-Directed Recommendations

Peripheral arterial disease (PAD) refers to partial or complete occlusion of one or more non-coronary arteries that leads to compromised blood flow and ischemia. Numerous processes are involved in arterial stenosis, however, atherosclerosis remains the most common etiology. PAD constitutes a major health economic problem, and it is estimated that over 200 million people around the world suffer from PAD, with at least 20% having some degree of claudication. The purpose of this review is to compare and contrast the guidelines on PAD published in 2005, 2011 and 2016 in terms of new recommendations and level of evidence for practicing clinicians.

Clinical Review of the Pharmacogenomics of Direct Oral Anticoagulants

PurposeThere is growing interest in the use of pharmacogenomics to optimize the safety and efficacy of anticoagulation therapy. While the pharmacogenomics of warfarin have been well-studied, the pharmacogenomics of direct oral anticoagulants (DOACs) continue to be a fledgling, but growing, field of interest. We present a pertinent clinical review of the present state of research on the pharmacogenomics of DOACs.Methods and ResultsThe present article is a review of pertinent clinical and scientific research on the pharmacogenomics of DOACs between January 2008 and December 2017 using MEDLINE and the United States National Institutes of Health Clinical Trials Registry. Many studies have identified single-nucleotide polymorphisms (SNPs) in genes responsible for DOAC metabolism that impacted serum DOAC concentration but had uncertain clinical significance.ConclusionsAs such, there is currently no strong evidence for the use of pharmacogenomic testing in optimizing the safety and efficacy of DOAC therapy. Nonetheless, genes of interest have been identified for each DOAC that may be of potential clinical utility. Further research is currently underway to elucidate the value of pharmacogenomics in this increasingly prescribed therapy.

Pain Relief as a Primary Treatment Goal: at What Point does Functioning and Well-Being Become more Important? a Case Study of an Adolescent with Debilitating Chronic Pain

BACKGROUND Pediatric chronic pain is a common problem with significant economic implications and devastating consequences on quality of life. The present report describes a case involving a 15-year-old girl with severe and debilitating chronic pain. RESULTS Before her referral to a pain rehabilitation program, the patient saw numerous specialists who treated her with an aggressive medical regimen and two spinal cord stimulators. She was then referred for intensive interdisciplinary treatment and, after three weeks of rehabilitation, she reported clinically significant changes in anxiety, pain catastrophizing and functional disability. The patient was successfully titrated off all of her opioid medications and, eventually, both neurostimulator implants were removed. DISCUSSION Interdisciplinary pain rehabilitation is a useful treatment for patients with chronic pain. With its primary emphasis on functional restoration as opposed to strictly pain reduction, patients can regain a higher quality of life with reduced pain and fewer medications, surgeries and hospitalizations.

Is it actionable? An Evaluation of the Rapid PCR-Based Blood Culture Identification Panel on the Management of Gram-Positive and Gram-Negative Blood Stream Infection

Background There is growing interest in the use of rapid blood culture identification (BCID) panels in antimicrobial stewardship programs (ASP). While many studies have looked at its clinical and economic utility, its comparative utility in gram-positive and gram-negative blood stream infections (BSI) have not been as well characterized. Methods The study was a quasi-experimental retrospective study at the Mayo Clinic in Phoenix, Arizona. All adult patients with positive blood cultures before BCID implementation (June 2015 to December 2015) and after BCID implementation (June 2016 to December 2016) were included. The outcomes of interest included: time to first appropriate antibiotic escalation, time to first appropriate antibiotic de-escalation, time to organism identification, LOS, infectious disease consultation, discharge disposition, and in-hospital mortality. Results In total, 203 patients were included in this study. There was a significant difference in the time to organism identification between pre- and post-BCID cohorts (27.1h vs. 3.3h, p<0.0001). BCID did not significantly reduce the time to first appropriate antimicrobial escalation or de-escalation for either GP-BSIs or GN-BSIs. Providers were more likely to escalate antimicrobial therapy in GP-BSIs after gram stain and more likely to de-escalate therapy in GN-BSIs after susceptibilities. While there were no significant differences in changes in antimicrobial therapy after organism identification by BCID, over a quarter of providers (28.1%) made changes after organism identification. Conclusions While BCID significantly reduced the time to identification for both GP-BSIs and GN-BSIs, BCID did not reduce the time to first appropriate antimicrobial escalation and de-escalation.

Anticoagulation in Behçet related intrathoracic vasculitis

Behçet disease is a rare multisystem condition associated with HLA-B51 positivity that commonly afflicts individuals of Turkish or Middle Eastern descent, less than 10% of whom have pulmonary involvement. Behçet-related pulmonary vasculitis is an uncommon and heterogeneous group of conditions, often with associated pulmonary artery thrombus formation. These microthrombi can result in a misdiagnosis of acute pulmonary embolism. Anticoagulation therapy can be difficult, as blood thinners increase the risk of pulmonary hemorrhage without affording the same benefits as in pulmonary embolism management. We present two cases of pulmonary vasculitis in the context of Behçets syndrome, one in a Native American man with associated superior vena cava syndrome and pericarditis, with an increased risk of hemorrhagic pericardial effusion, and the other in an African American man with acute hypoxic respiratory failure with an increased risk of alveolar hemorrhage. We describe their management and the balancing act surrounding anticoagulation therapy in Behcet-related pulmonary vasculitis.

PROSPECTIVE CRYOBALLOON DOSING STUDY BASED ON TIME-TO-ISOLATION

Background: Cryoballoon ablation is an effective treatment for Paroxysmal Atrial Fibrillation (PAF). Optimal dosing of the second-generation cryoballoon (CB2; Arctic Front AdvanceTM, Medtronic Inc) is still unclear. Time-to-effect (TTE) is the physiologic end-point when acute pulmonary vein signals

Real-world incidence of efficacy and safety outcomes in patients on direct oral anticoagulants with left ventricular systolic dysfunction at a tertiary referral center

Patients with heart failure (HF) have increased risk for thromboembolic events. Real‐world incidences of efficacy and safety outcomes of direct oral anticoagulants (DOACs) in patients with left ventricular systolic dysfunction (LVSD) are of growing clinical interest.

CAN STRAIN ECHOCARDIOGRAPHY PREDICT REJECTION IN HEART TRANSPLANT RECIPIENTS WITH NORMAL EJECTION FRACTION

Rejection is prevalent in heart transplant (HTX) recipients and its diagnosis with noninvasive tools has been difficult. The aim of this study was to determine if 2-dimensional speckle tracking echocardiography (2D-STE) can be used to predict rejection in HTX recipients with normal left ventricular