Treatment of Critical Bleeds in Patients With Immune Thrombocytopenia: A Systematic Review.

Objectives: Evidence-based protocols for managing bleeding emergencies in patients with immune thrombocytopenia (ITP) are lacking. We conducted a systematic review of treatments for critical bleeding in patients with ITP.

Methods: We included all study designs and extracted data in aggregate or individually for patients who received one or more interventions and for whom any of the following outcomes were reported: platelet count response, bleeding, disability, or death.

How to manage ITP with life-threatening bleeding.

While immune thrombocytopenia often presents with mild bleeding manifestations or surprising findings of thrombocytopenia on routine complete blood counts in patients without symptoms, some patients can present with new thrombocytopenia and life-threatening bleeding. Emergent assessment and treatment are needed to prevent substantial morbidity and even mortality. These patients present to the emergency room with bleeding, and hematologists are subsequently consulted.

Cardiac device-induced right to left shunt causing significant hypoxemia: A case report and review of literature.

We describe a patient where a pacemaker lead induced tricuspid valve changes that caused a right to left shunt through a preexisting patent foramen ovale resulting in significant hypoxemia. This event occurred years after the pacemaker had been placed. Surgical closure of the patent foramen ovale resolved the patient's hypoxemia and dyspnea.

Definition of a critical bleed in patients with immune thrombocytopenia: Communication from the ISTH SSC Subcommittee on Platelet Immunology.

Background: Immune thrombocytopenia (ITP) is an autoimmune disease characterized by low platelet counts and increased risk of bleeding. In preparation for an upcoming guideline, the ITP Emergency Management Guideline Panel, including clinical experts in hematology, emergency medicine, research methodology, and patient representatives, identified the need for a standardized definition of a critical ITP bleed. The goal of the definition was to distinguish critical bleeds from bleeds that may not require urgent treatment, typically in the context of severe thrombocytopenia.

Systems-based hematology: highlighting successes and next steps.

Systems-based hematology is dedicated to improving care delivery for patients with blood disorders. First defined by the American Society of Hematology in 2015, the idea of a systems-based hematologist arose from evolving pressures in the health care system and increasing recognition of opportunities to optimize the quality and cost effectiveness of hematologic care. In this review, we begin with a proposed framework to formalize the discussion of the range of initiatives within systems-based hematology.

Worsening Mitral Stenosis Due to Post-transcatheter Aortic Valve Replacement Improvement of Concomitant Aortic Insufficiency.

Transcatheter aortic valve replacement (TAVR) has become an alternative to surgical treatment in severe aortic valve stenosis, with expanding indications and rapidly growing number of performed procedures. Poor opposition of TAVR prosthesis to the aortic root causes paravalvular leak, while mitral regurgitation and stenosis have been associated with valve implantation low in the left ventricular outflow tract (LVOT). We report an unusual case of a patient with combined severe aortic stenosis and moderate aortic insufficiency who underwent elective TAVR, which resulted in significant increase of a pre-existing mitral valve gradient.

Successful percutaneous coronary intervention significantly improves coronary sinus blood flow as assessed by transthoracic echocardiography.

Background: Transthoracic echocardiography (TTE) has been used to assess coronary sinus blood flow (CSBF), which reflects total coronary arterial blood flow. Successful angioplasty is expected to improve coronary arterial blood flow. Changes in CSBF after percutaneous coronary intervention (PCI), as assessed by TTE, have not been systematically evaluated.

Revascularization options in stable coronary artery disease: it is not how to revascularize, it is whether and when to revascularize.

Patients with acute coronary syndromes and severe multivessel or left main coronary artery disease have better outcomes when prompt revascularization is performed in addition to optimal medical therapy (OMT). However, in patients with stable ischemic heart disease, randomized strategy trials have revealed equipoise between initial strategies of OMT alone and OMT plus revascularization. Conducted in diverse stable ischemic heart disease patient populations and throughout the spectrum of atherosclerotic and ischemic burden, the RITA-2, MASS II, COURAGE, BARI 2D and FAME 2 trials demonstrate that OMT alone and OMT plus revascularization yield similar outcomes with respect to mortality and myocardial infarction.

Disseminated intravascular coagulation with congestive heart failure and left ventricular thrombus: a case report with literature review of 7 cases.

Background: Coagulation abnormalities can accompany acute congestive heart failure (CHF). However, disseminated intravascular coagulation (DIC) is rarely documented in such patients. DIC is characterized by generalized excessive activation of coagulation pathways followed by their depletion with secondary activation of anticoagulation and fibrinolysis.

Accuracy of capsule colonoscopy in detecting colorectal polyps in a screening population.

Background & Aims: Capsule colonoscopy is a minimally invasive imaging method. We measured the accuracy of this technology in detecting polyps 6 mm or larger in an average-risk screening population.

Methods: In a prospective study, asymptomatic subjects (n = 884) underwent capsule colonoscopy followed by conventional colonoscopy (the reference) several weeks later, with an endoscopist blinded to capsule results, at 10 centers in the United States and 6 centers in Israel from June 2011 through April 2012.

Effects of obesity and subsequent weight reduction on left ventricular function.

Obesity is reaching epidemic proportions in the United States. Obesity adversely affects the circulatory system with resultant endothelial dysfunction, which promotes systemic hypertension, coronary artery disease, and vascular calcification. It is believed that the release of adipokines is responsible for this effect.

Effect of comorbidities and medications on left ventricular mass regression after bariatric surgery.

Hypertension, diabetes, and obesity frequently coexist and significantly contribute to cardiovascular morbidity and mortality. Weight loss in obese individuals has been associated with improved blood pressure control and regression in left ventricular (LV) hypertrophy. The authors investigated the impact of comorbidity and medication on clinical and echocardiographic parameters after weight loss in obese patients.

The impact of weight loss on cardiac structure and function in obese patients.

Background: Obesity frequently results in structural and physiologic changes in the cardiovascular system. Whether weight reduction leads to reversal of these changes is not well-established. This investigation sought to identify the effect of a weight reduction program on right and left ventricular structure and function.

Myocardial performance index correlates with right ventricular ejection fraction measured by nuclear ventriculography.

Background: Assessment of right ventricular (RV) ejection fraction (EF) by two-dimensional echocardiography (2D ECHO) is practical but limited because of complex geometry of the RV. Techniques used for accurate measurement of RV EF are invasive or costly. However, derivation of 2D ECHO Doppler parameters to estimate RV function could be useful and inexpensive.

Ability of prospective assessment of personality profiles to predict the practice specialty of medical students.

Medical practice encompasses a diverse spectrum of specialties. Factors that impact selection of clinical disciplines by young physicians may have recently evolved associated with changes in medical school demographics. We assessed whether physicians gravitate to certain practice specialties due to preexisting personality traits.

Lung cancer immunotherapy.

Recent insights into anti-tumor immunotherapy have led to a wave of clinical trials involving immunotherapy for lung cancer. Vaccines have evolved from nonspecific immune stimulants, like Bacillus Calmette-Guerin (BCG), to much more specific and potent strategies, some of which generate active immune responses against tumor-associated antigens. Understanding the mechanisms of anti-tumor immunity and identifying target antigens will likely improve these therapeutic strategies and provide them with a niche in the future of lung cancer therapy.

African Americans with LVH demonstrate depressed sensitivity of the coronary microcirculation to stimulated relaxation.

Excess coronary heart disease morbidity and mortality among African Americans remains an important yet unexplained public health problem. We hypothesized that adverse outcome is in part due to intrinsic or acquired abnormalities in coronary endothelial function and vasoreactivity. We compared dose-response curves relating changes in coronary blood flow and epicardial diameter to graded infusions of acetylcholine in 50 African American and 65 white subjects with hypertensive left ventricular hypertrophy (LVH) and normal coronary arteries.

The presence of African American race predicts improvement in coronary endothelial function after supplementary L-arginine.

Objectives: The purpose of our study was to determine if the presence of African American ethnicity modulates improvement in coronary vascular endothelial function after supplementary L-arginine.

Background: Endothelial dysfunction is an early stage in the development of coronary atherosclerosis and has been implicated in the pathogenesis of hypertension and cardiomyopathy. Amelioration of endothelial dysfunction has been demonstrated in patients with established coronary atherosclerosis or with risk factors in response to infusion of L-arginine, the precursor of nitric oxide.