Arshad Javed

Medicare Readmission Penalties in Detroit

The Affordable Care Act stipulates that hospitals will be subject to readmission penalties. Hospitals in Detroit, a city in bankruptcy, were subject to high readmission penalties in 2013 and 2014. Such penalties may compound poverty and disparities in the city.

Meta-Analysis Comparing Patent Foramen Ovale Closure Versus Medical Therapy to Prevent Recurrent Cryptogenic Stroke

New evidence suggests that closure of a patent foramen ovale (PFO) plus medical therapy (MT; antiplatelet or anticoagulation) is superior to MT alone to prevent recurrent cryptogenic stroke. We performed a meta-analysis of randomized controlled trials that compared PFO closure plus MT with MT alone in patients with cryptogenic stroke. The efficacy end points were recurrent stroke, transient ischemia attack, and death. The safety end points were major bleeding and newly detected atrial fibrillation. Trials were pooled using random effects and fixed effects models. A trial sequential analysis was performed to assess if the current evidence is sufficient. Risk ratios (RR) were calculated for pooled estimates of risk. Five randomized controlled trials (3,440 patients) were included. Mean follow-up was 4.1 years. PFO closure reduced the risk of recurrent stroke by 58% (RR 0.42, 95% CI 0.20 to 0.91, p = 0.03). The number needed to treat was 38. The cumulative Z-line crossed the trial sequential boundary, suggesting there is adequate evidence to conclude that PFO closure reduces the risk of recurrent stroke by 60%. PFO closure did not reduce the risk of transient ischemia attack (RR 0.78, 95% CI 0.53 to 1.15, p = 0.21), mortality (RR 0.74, 95% CI 0.35 to 1.60, p = 0.45), or major bleeding (RR 0.96, 95% CI 0.42 to 2.20, p = 0.93); it did increase the risk of atrial fibrillation (RR 4.69, 95% CI 2.17 to 10.12, p <0.0001).

Aortic valve myxoma at the extreme age: a review of literature

Primary cardiac tumours are a rare finding, with cardiac myxoma and fibroelastoma representing the majority of these tumours. Cardiac myxomas are most commonly found in the left atrium but are rarely found with attachment to the cardiac valves. The authors describe a case of aortic myxoma found in an 81-year-old man presented with peripheral arterial disease. CT angiogram of the thorax was performed to find the source of emboli and it showed a mass attached to the aortic valve and protruding into the aorta. Details of the location and texture were studied on transoesophageal echocardiography. Preoperative coronary angiography showed coronary artery disease and the patient underwent successful coronary artery bypass grafting and simultaneous resection of the mass. Histopathology revealed the mass as a myxoma.

NOVEL ECHOCARDIOGRAPHIC VARIABLES IN THE DIAGNOSIS OF ACUTE PULMONARY EMBOLISM

Background: The contemporary role of echocardiography in the diagnostic algorithm for acute pulmonary embolism (APE) is largely supportive. This pilot study explored the utility of novel echocardiographic variables for the diagnosis of APE. Methods: A retrospective analysis of massive/sub-massive

Ultrasound Assisted Catheter Directed Thrombolysis in the Management of a Right Atrial Thrombus: A New Weapon in the Armamentarium?

Catheter related thrombosis (CRT) is a commonly encountered entity fraught with substantial risk for mortality secondary to various complications including pulmonary embolism (PE), tricuspid regurgitation, endocarditis, right sided heart failure, and cardiogenic and septic shock. CRT carries a mortality rate of 18% in hemodialysis patients and more than 40% in nonhemodialysis patients. Management strategies include systemic anticoagulation, systemic thrombolysis, surgical evacuation, and percutaneous retrieval with no established guidelines. Ultrasound assisted catheter directed thrombolysis emerges as promising modality with a relatively lower risk of hemorrhage compared to systemic thrombolysis. We report a case of a 75-year-old man with dialysis catheter related thrombosis without PE for which ultrasound assisted catheter directed thrombolysis was used successfully as an alternative therapy.

Splenule disguised as pancreatic mass: elucidated with SPECT liver-spleen scintigraphy.

Splenules are congenital foci of healthy splenic tissue that are separate from the main body but are structurally identical to the spleen, derived from mesenchymal buds on the left side of the mesogastrium and commonly seen in or near the tail of the pancreas. We report a case of a 58-year-old male who was found to have a pancreatic tail mass on contrast-enhanced abdominal CT, which was similarly disguised as a pancreatic tail mass on both magnetic resonance cholangiopancreatography and abdominal MRI. A liver spleen scintigraph with Tc sulfur colloid later proved the mass to be a splenule.

Innocent left ventricular outflow tract membrane masquerading as vegetation

Innocent left ventricular outflow tract (LVOT) membranes are a rare entity and found incidentally on echocardiography. The authors report a case of innocent LVOT membrane in a patient who was admitted with ischaemic stroke. Initial transthoracic echocardiography showed a possible valvular vegetation which was thought to be the cause of embolic stroke. Anticoagulation with coumadin and antibiotics were started. Subsequent Transesophageal echocardiography showed that it was more consistent with innocent LVOT membrane and not vegetation. Anticoagulation and antibiotics were discontinued, and on a follow-up over 5 years later, the membrane was stable in size and location without any complications.