Henna Kalsi

Predicting left atrial thrombi in atrial fibrillation

BACKGROUND The aim of the study was to determine whether CHADS(2) score is predictive of left atrial appendage thrombus (LAAT) in nonvalvular atrial fibrillation (AF). Strategies for effective stroke prevention in AF require tools capable of identifying those patients at greatest risk for embolization of LAAT and most likely to benefit from warfarin. Nearly half of strokes in AF are due to noncardioembolic mechanisms for which antiplatelet therapy would be more appropriate. Previous attempts to develop such tools have been limited by including patients without proven cardioembolism. METHODS Nonanticoagulated, nonvalvular AF patients with (cases) or without (controls) LAAT by transesophageal echocardiography were identified using Mayo Clinic Echocardiography and Cardioversion Unit Databases (Rochester, MN). Type and duration of AF, CHADS(2) score, and echocardiography measures were compared to determine variables predictive of LAAT. RESULTS The CHADS(2) score was significantly higher for cases (n = 110, mean +/- SD 2.8 +/- 1.6) compared to controls (n = 387, 1.6 +/- 1.3). By multivariate analysis, independent predictors of LAAT included heart failure (HR 5.78, P < 0001), prior stroke/transient ischemic attack (HR 3.94, P < .0001), diabetes mellitus (HR 1.98, P = .015), permanent AF (HR 3.02, P < .05), AF duration (HR 2.24, P < .05), and spontaneous echocardiographic contrast (HR 4.35, P = .005). Using these elements, a new scoring system provided cleaner case-control separation (C-index 0.90) and higher predictive power compared to CHADS(2) (C-index 0.71). CONCLUSIONS The CHADS(2) score predicts the presence of LAAT in AF patients. Some, but not all, variables within this score are predictive of LAAT. By including only echo and clinical variables predictive of LAAT, our novel scoring system better identified those AF patients at greatest cardioembolic risk.

The association of active cancer with venous thromboembolism location: a population-based study.

OBJECTIVE To test active cancer for an association with venous thromboembolism (VTE) location. PATIENTS AND METHODS Using the resources of the Rochester Epidemiology Project, we identified all Olmsted County, MN, residents with incident VTE during the 35-year period 1966-2000 (N = 3385). We restricted analyses to residents with objectively diagnosed VTE during the 17-year period from January 1, 1984, to December 31, 2000 (N = 1599). For each patient, we reviewed the complete medical records in the community for patient age, gender, and most recent body mass index at VTE onset; VTE event type and location; and previously identified independent VTE risk factors (ie, surgery, hospitalization for acute medical illness, active cancer, leg paresis, superficial venous thrombosis, and varicose veins). Using logistic regression we tested active cancer for an association with each of 4 symptomatic VTE locations (arm or intra-abdominal deep venous thrombosis [DVT], intra-abdominal DVT, pulmonary embolism, and bilateral leg DVT), adjusted for age, gender, body mass index, and other VTE risk factors. RESULTS In multivariate analyses, active cancer was independently associated with arm or intra-abdominal DVT (odds ratio [OR], 1.76; P = .01), intra-abdominal DVT (OR, 2.22; P = .004), and bilateral leg DVT (OR, 2.09; P = .02), but not pulmonary embolism (OR, 0.93). CONCLUSION Active cancer is associated with VTE location. Location of VTE may be useful in decision making regarding cancer screening.

Severe case and literature review of primary erythromelalgia: novel SCN9A gene mutation.

Erythromelalgia is a rare clinical syndrome characterized by intermittent heat, redness, swelling and pain more commonly affecting the lower extremities. Symptoms are mostly aggravated by warmth and are eased by a cold temperature. In some cases, symptoms can be very severe and disabling. Erythromelalgia can be classified as either familial or sporadic, with the familial form inherited in an autosomal dominant manner. Recently, there has been a lot of progress in studying Na(v)1.7 sodium channels (expressed mostly in the sympathetic and nociceptive small-diameter sensory neurons of the dorsal root ganglion) and different mutations affecting the encoding SCN9A gene that leads to channelopathies responsible for some disorders, including primary erythromelalgia. We present a severe case of progressive primary erythromelalgia caused by a new de novo heterozygous missense mutation (c.2623C>G) of the SCN9A gene which substitutes glutamine 875 by glutamic acid (p.Q875E). To our knowledge, this mutation has not been previously reported in the literature. We also provided a short literature review about erythromelalgia and Na(v) sodium channelopathies.

Fibrin D-Dimer Concentration, Deep Vein Thrombosis Symptom Duration, and Venous Thrombus Volume

Introduction: To determine the relationship between fibrin D-dimer levels, symptom duration, and thrombus volume, consecutive patients with incident deep venous thrombosis (DVT) were evaluated. Methods: In a cross-sectional study design, patient symptom onset was determined by careful patient questioning. Venous thrombosis was confirmed by compression duplex ultrasonography. Thrombus volume was estimated based on patient’s femur length using a forensic anthropology method. Fibrin D-dimer was measured by latex immunoassay. Results: 72 consecutive patients with confirmed leg DVT agreed to participate. The median symptom duration at the time of diagnosis was 10 days. The median D-dimer concentration was 1050 ng/dL. The median thrombus volume was 12.92 cm3. D-Dimer levels correlated with estimated thrombus volume (P < .0006 CI 0.12-0.41; R2 adjusted = .15) but not symptom duration, patient’s age, or gender. Conclusions: Despite varying symptom duration prior to diagnosis, fibrin D-dimer remains a sensitive measure of venous thrombosis and correlates with thrombus volume.

Care of the Adult Hodgkin Lymphoma Survivor

Of those individuals diagnosed with Hodgkin lymphoma, 85% will survive and may be affected by residual effects of their cancer and its therapy (chemotherapy, radiation therapy, stem cell transplantation). Hodgkin lymphoma survivors are at risk of developing secondary malignancies, cardiovascular disease, pulmonary disease, thyroid disease, infertility, premature menopause, chronic fatigue, and psychosocial issues. These conditions usually have a long latency and therefore present years or decades after Hodgkin lymphoma treatment, when the patients care is being managed by a primary care provider. This review summarizes these unique potential medical and psychologic sequelae of Hodgkin lymphoma, and provides screening and management recommendations.

Predicting superficial venous incompetence with strain gauge plethysmography

Background With currently available effective interventional methods to treat superficial venous insufficiency, it becomes particularly important to have a simple and reliable method to evaluate the location and severity of venous reflux. To date, there are few studies that evaluated plethysmography with and without tourniquet application to differentiate superficial from deep venous incompetence. Objectives To determine if strain gauge plethysmography (SGP) with and without tourniquet application can be used to distinguish between the superficial and deep venous components of venous incompetence. Methods We conducted a prospective study using SGP with and without tourniquet application and duplex ultrasound (duplex US) to assess the severity and location of venous incompetence in 62 patients (85 limbs, 42 women, with an age range of 32–81 years) referred to our vascular laboratory for haemodynamic evaluation. Based on duplex US results, patients were diagnosed with superficial (SVI), deep and superficial (mixed) and deep vein incompetence (DVI). Results Mixed incompetence was the most common type. Twenty-three out of 33 limbs in the SVI group normalized their refill rate (RR) with tourniquet application (69.6%). Normalization of the RR with tourniquet application was less common in the mixed (n: 17 out of 40, 42.5%) and DVI (n: 2 out of 6, 33.3%) groups. Conclusion SGP with tourniquet application is a simple and fast technique that can identify patients with SVI, based on RR improvement, who probably would benefit more from ablation procedures. Further studies evaluating impact of SGP with tourniquet test results on clinical outcome of SVI invasive treatment are warranted

Peripheral Arterial Diseases

Peripheral vascular diseases are common, and are associated with major morbidity and mortality, and yet they continue to receive less intense clinical attention than coronary artery or myocardial disease. The term peripheral vascular disease has been used historically to denote the noncardiac arterial occlusive diseases. This traditional term is best applied to describe the global set of pathophysiologic syndromes that affect the arterial, venous, and lymphatic circulations. Precision in medicine is based on precision of terminology. The distinct and diverse vascular syndromes encompass many etiologies and natural histories, as well as differing diagnostic and treatment pathways. Thus, use of a more specific nomenclature is required. The arterial diseases include those disorders that cause either fixed obstruction or abnormal vascular reactivity of the arteries supplying a given tissue; the obstruction impairs blood delivery and can produce ischemia. Venous diseases occur in response to processes that impede normal venous function, including all noncardiac causes of venous hypertension. These disorders include venous valvular incompetence and venous hypertension, deep venous thrombosis, pulmonary embolism, postphlebitic syndrome, and varicose veins.

Aneurysms of the Peripheral Arteries

Aneurysms of the aorta, both in the thorax and abdominal segments, have been well studied. This is in part due to relatively easy access for examination, the high rate of incidence, and noninvasive imaging techniques that are readily available in most places. There is little data on systemic arterial aneurysm incidence, natural history or treatment that was obtained in a prospective or randomized method. In sharp contrast, systemic aneurysms are for the most part rare and therefore less likely to be imaged, let alone studied.1 The literature available is primarily retrospective series, literature reviews, and case reports. While accurate and well written, a great many questions are left open for systematic study. With these limitations in mind, this chapter should be read critically and applied to patient care with conservative creativity