Maharaj Singh

Access Site Complications After Peripheral Vascular Interventions Incidence, Predictors, and Outcomes

Background—Access site hematomas and pseudoaneurysms are the most frequent complications of peripheral vascular intervention (PVI); however, their incidence and risk factors remain unclear. Methods and Results—We retrospectively analyzed data from the multicenter Vascular Quality Initiative on 22 226 patients who underwent 27 048 PVI from August 2007 to May 2013. Primary end points included incidence and predictors of access site complications (ASCs), length of postprocedural hospitalization, discharge status, and 30-day and 1-year mortality. ASC complicated 936 procedures (3.5%). Of these, 74.4% were minor complications, 9.7% were moderate requiring transfusion, 5.4% were moderate requiring thrombin injection, and 10.5% were severe requiring surgery. Predictors of ASC were age >75 years, female sex, white race, no prior PVI, nonfemoral arterial access site, >6-Fr sheath size, thrombolytics, arterial dissection, fluoroscopy time >30 minutes, nonuse of vascular closure device, bedridden preoperative ambulatory status, and urgent indication. Mean hospitalization was longer after procedures complicated by ASC (1.2±1.6 versus 1.9±1.9 days; range, 0–7 days; P=0.002). Severity of ASC correlated with higher rates of discharge to rehabilitation/nursing facilities compared with home discharge. Patients with severe ASC had higher 30-day mortality (6.1% versus 1.4%; P<0.001), and those with moderate ASC requiring transfusion had elevated 1-year mortality (12.1% versus 5.7%; P<0.001). Conclusions—Several factors independently predict ASC after PVI. Appropriate use of antithrombotic therapies and vascular closure device in patients at increased risk of ASC may improve post-PVI outcomes.

Risk factors of trastuzumab-induced cardiotoxicity in breast cancer: A meta-analysis

Background:Trastuzumab targets the human epidermal growth factor receptor 2 oncogene and in combination with first-line therapy results in significantly improved survival outcomes and has thus become standard of care in both adjuvant and metastatic settings. While it is estimated that 1% to 4% of patients treated with trastuzumab will develop heart failure and ∼10% will experience a reduction in left ventricular ejection fraction (LVEF), the patient risk factors associated with trastuzumab-induced cardiotoxicity (TIC) are unclear. This meta-analysis aims to consolidate previously published data to identify the risk factors most likely leading to TIC. Methods:A search of the MEDLINE literature database using the keywords trastuzumab/Herceptin, risk factors, outcomes, cardiac, cardiotoxicity, cardiomyopathy, LVEF, and chemotherapy was performed. Only prospective/retrospective human studies were included, with additional studies excluded if they reported baseline LVEF > 68%, a cohort of <50 patients, or results that were not stratified based on cardiotoxic events. Pooled odds ratio (OR) and 95% confidence interval (CI) for each potential risk factor were calculated, with heterogeneity of data and samples explored using random-effects modeling. Results:Data were collected from 17 articles, capturing 6527 patients. Hypertension (OR 1.61, 95% CI 1.14–2.26; P < 0.01), diabetes (OR 1.62; 95% CI 1.10–2.38; P < 0.02), previous anthracycline use (OR 2.14; 95% CI 1.17–3.92; P < 0.02), and older age (P = 0.013) were all shown to be associated with TIC. Conclusion:Cardiac performance should be closely monitored in women treated with trastuzumab. Recognizing potential risk factors along with careful attention to symptoms/LVEF measurements could minimize the occurrence of TIC in this population.

Can the Electronic Health Record Identify Vulnerable Older Adults in Need of a Palliative Care Assessment in the Hospital Setting

vides useful information that a significant portion of PN use was inappropriate in elderly adults, and the finding underlines the importance of audit and evaluation of nutritional status by a nutritional support team. Half of PN support in the present work was using Kabiven because it can be infused through a peripheral line, whereas TPN requires a central venous catheter for infusion, the use of which may carry the risk of infection in elderly adults. Therefore, Kabiven was preferred as PN support to avoid TPN-associated central line infection. In conclusion, physicians and nutritional support teams should carefully evaluate the indication for PN in elderly adults to avoid the inappropriate use of PN.

Does expression of estrogen receptor, progesterone receptor, and HER2 in atypical breast lesions predict a subsequent clinically significant event?

34 Background: Atypical ductal hyperplasia (ADH) and atypical lobular hyperplasia (ALH) increase breast cancer risk 3-5 fold. Risk reduction strategies include intense radiographic surveillance, medical, or surgical prophylaxis, all with associated side effects. Thus, identifying predictors of future breast cancer associated with atypia would limit aggressive treatment to only those patients at highest risk for disease progression. Given that lifetime estrogen exposure is a risk factor for breast cancer, and human epidermal growth factor receptor-2 (HER2) gene amplification is linked to breast pathogenesis, we tested whether expression patterns of estrogen receptor (ER), progesterone receptor (PR), and HER2 at initial diagnosis of atypia predicted a subsequent clinically significant event (SCSE), defined as another occurrence of atypia, in situ, or invasive carcinoma. METHODS Patients with an initial diagnosis of ADH and/or ALH were retrospectively identified. 19 women who developed a SCSE (cases) were matched to 45 women with no SCSE for at least 5 years after the diagnosis of atypia (controls). Archived tissue from cases and controls were subjected to ER, PR, and HER2 immunohistochemistry. ER and PR were reported using Allred score (0 to 8). HER2 was reported as negative (0-1+), equivocal (2+) or positive (3+). Atypia with HER2 (2+) or (3+) scores were subject to SISH to confirm gene amplification. RESULTS There was no significant difference in expression of ER (mean Allred: cases = 7.26 ± 0.35; controls = 6.91 ± 0.43) or PR (mean Allred: cases = 6.95 ± 0.43; controls = 6.57 ± 0.34). >90% of both cases and controls were HER2 negative (0-1+). Longitudinal assessment of ER, PR, and HER2 in patients who developed a SCSE revealed that three of 19 cases presented with HER2 overexpression; however SISH analysis revealed no gene amplification. Interestingly, ER/PR expression decreased in three of seven patients with atypia who later developed an invasive malignancy. CONCLUSIONS ER and PR expression do not predict a SCSE after an initial diagnosis of breast atypia. HER2 does not appear to be a useful marker for risk prediction of a SCSE, as HER2 overexpression was not identified in any of our cases.

Bivalirudin versus unfractionated heparin during peripheral vascular interventions: A Propensity-matched Study.

This study aimed to compare the association of access site complications and the use of unfractionated heparin versus bivalirudin during subinguinal peripheral vascular intervention.

Impact of the Heart WATCH Program on Patients at Risk of Developing Metabolic Syndrome, Prediabetes or Cardiovascular Disease

Methods Our institution’s Heart WATCH program consists of screening sessions with a multidisciplinary team (physician/nurse, nutritionist and psychologist), a minimum of three visits with a nurse practitioner and weekly follow-up phone calls for a 14-week period. Sociodemographic variables were obtained at initial visit. Biometric testing indices and self-reported clinical and behavioral health measures were recorded pre- and postintervention, and compared using paired t-tests or McNemar’s test as appropriate. Results Heart WATCH enrolled 242 women from November 2006 to April 2014, and 193 (80%) completed all phases of the 14-week lifestyle intervention. Postintervention, participants demonstrated improved health status in all areas and improved significantly in the following areas: diet/nutrition (P=0.014), exercise (P<0.001), stress (P<0.0001), quality of life (P=0.003), weight (P<0.0001), waist circumference (P=0.01) and total cholesterol (P=0.019). Clinically meaningful improvements were realized by participants who moved to a healthier classification in a number of vital signs and blood panel indices. Conclusions These findings suggest the “elevated risk profile” for women with components of metabolic syndrome can be reversed through a lifestyle program focused on reducing risk factors associated with cardiovascular disease and prediabetes. Future research is needed to determine mechanisms of risk reduction as well as optimal patient-centered and culturally appropriate approaches to weight management. (J Patient-Centered Res Rev. 2015;2:56-63.)

The beneficial effect of weight reduction on adverse cardiovascular outcomes following bariatric surgery is attenuated in patients with obstructive sleep apnea

Weight loss after bariatric surgery is associated with reduction in adverse cardiovascular outcomes; however, the impact of obstructive sleep apnea (OSA) on reduction of cardiovascular outcomes after bariatric surgery in morbidly obese patients is not known. We retrospectively assessed differences in cardiovascular events after laparoscopic adjustable gastric banding (LAGB)-induced weight loss in patients with and without OSA before and after propensity score matching for age, sex, body mass index (BMI), and major comorbidities between the two groups and determined predictors of poor outcomes. OSA was present in 222 out of 830 patients (27 per cent) who underwent LAGB between 2001 and 2011. Despite a similar reduction in BMI (20.0 and 20.8 per cent), a significantly higher percentage of cardiovascular events were observed in patients with than without OSA (35.6 vs 6.9 per cent; p < 0.001) at 3 years (mean follow-up 6.0 ± 3.2; range: 0.5 to 13 years). The differences in the cumulative endpoint of new onset stroke, heart failure, myocardial infarction, venous thrombosis, and pulmonary embolism between the OSA and non-OSA groups were maintained after propensity matching. Patients with OSA treated with continuous positive airway pressure (CPAP) during sleep [n = 66] had lower cardiovascular event rates at 30 months compared with those not treated (p < 0.041). OSA (hazard ratio: 6.92, 95% CI: 3.39-14.13, p < 0.001) remained an independent predictor of cardiovascular events after multivariate analysis. Thus, patients with OSA, despite a similar initial weight loss after LAGB, had a higher incidence of cardiovascular events compared with a propensity-matched group without OSA. Treatment with CPAP appears to reduce such events.

Racial Disparity Among Women Diagnosed With Invasive Breast Cancer in a Large Integrated Health System

Purpose Reasons for the well-described disparity in outcomes between African American (AA) and non-Hispanic white (NHW) women with invasive breast cancer are unclear, making it difficult to identify solutions. This study examined the effects of demographics, biomarkers, tumor characteristics, cancer stage, morphology, and treatment variables on overall and cancer-free survival in these patient populations. Methods We retrospectively reviewed data for 6231 patients diagnosed with invasive breast cancer throughout an integrated health system from January 2006 through March 2015. Included for analysis were 5023 NHW and 413 AA women. All category and continuous variables in the study were described in the two groups using appropriate statistics. Kaplan-Meier method of survival with log-rank test was used to compare the two racial groups (NHW and AA). Cox proportional hazards regression was used to find hazard ratios for the predictors of survival and recurrence-free survival probability. Propensity probability match method (1:1) was used to match 319 NSW women to 319 similar AA women. Matching was done using all significant predictors, including demographic variables. Results Compared to NHW women, AA women presented with invasive breast cancer at a younger age (P<0.001) and had a higher proportion of stage IV cancers (P<0.001), which were more often infiltrating ductal carcinoma (P<0.003) and poorly differentiated (P<0.001). Within 10-year follow-up, AA women had shorter overall and recurrence-free survival (log-rank P<0.001), were 1.4 times more likely to die (P=0.009), and were twice as likely to have recurrence (P<0.001) than NHW women. In the matched groups, overall survival was similar for AA and NHW (log-rank P=0.0793); however, recurrence-free survival was higher in NHW than in AA women (P=0.047). Conclusions When presenting characteristics of AA and NHW women with invasive breast cancer are matched, disparity in overall mortality and rate of recurrence appears to be reduced or perhaps eliminated, suggesting invasive breast cancers in AA and NHW women respond similarly to treatment. Further study is needed to explore the true effect of biological factors; however, rectifying delivery of and access to care might be expected to mitigate, in large part, the racial disparity currently seen in breast cancer outcomes.

Pomona Large Vessel Occlusion Screening Tool for Prehospital and Emergency Room Settings

Background: Early identification of patients with acute ischemic strokes due to large vessel occlusions (LVO) is critical. We propose a simple risk score model to predict LVO. Method: The proposed scale (Pomona Scale) ranges from 0 to 3 and includes 3 items: gaze deviation, expressive aphasia, and neglect. We reviewed a cohort of all acute stroke activation patients between February 2014 and January 2016. The predictive performance of the Pomona Scale was determined and compared with several National Institutes of Health Stroke Scale (NIHSS) cutoffs (≥4, ≥6, ≥8, and ≥10), the Los Angeles Motor Scale (LAMS), the Cincinnati Prehospital Stroke Severity (CPSS) scale, the Vision Aphasia and Neglect Scale (VAN), and the Prehospital Acute Stroke Severity Scale (PASS). Results: LVO was detected in 94 of 776 acute stroke activations (12%). A Pomona Scale ≥2 had comparable accuracy to predict LVO as the VAN and CPSS scales and higher accuracy than Pomona Scale ≥1, LAMS, PASS, and NIHSS. A Pomona Scale ≥2 had an accuracy (area under the curve) of 0.79, a sensitivity of 0.86, a specificity of 0.70, a positive predictive value of 0.71, and a negative predictive value of 0.97 for the detection of LVO. We also found that the presence of either neglect or gaze deviation alone had comparable accuracy of 0.79 as Pomona Scale ≥2 to detect LVO. Conclusion: The Pomona Scale is a simple and accurate scale to predict LVO. In addition, the presence of either gaze deviation or neglect also suggests the possibility of LVO.

TCT-224 Gastrointestinal Bleed Pre-Transcatheter Aortic Valve Replacement: An Independent Predictor of Mortality

Severe aortic stenosis causes recurrent mucosal bleeds, mainly from angiodysplasias and acquired von Willebrand deficiency (vWD) which is corrected after aortic valve replacement, either transcatheter (TAVR) or surgical (SAVR). Studies have shown major GI bleeding post-TAVR as an independent