Fairfield Medical Center

Percutaneous coronary intervention (PCI) in high-risk patients based on anatomy (left main disease, multivessel disease, calcification), comorbidities (advanced age, frailty, renal dysfunction, valvular heart disease), and adverse hemodynamics (decreased left ventricle ejection fraction, poor cardiac output, relative hypotension) 1 poses a significant challenge for interventional cardiologists.Although generally well tolerated, alterations in coronary perfusion during PCI in high-risk patients can limit quality and completeness of revascularization, potentially leading to worse short-term and long-term outcomes.Use of mechanical circulatory support (MCS) devices can minimize hemodynamic compromise and enable optimal completion of PCI. 2 In contemporary practice, there are 2 MCS devices that are primarily used and widely available: percutaneous ventricular assist device (PVAD) and intra-aortic balloon pump (IABP).The use of IABP in high-risk PCI has not been shown to improve patient outcomes, 3 and a randomized trial comparing PVAD and IABP for high-risk PCI did not show any differences in short-term outcomes. 4This comparison, however, was not sufficiently powered to examine intermediate-term outcomes and did not account for the learning curve associated with PVAD use, 5 and a per-protocol analysis did show a trend toward reduction in major adverse events at 90 days with the use of PVAD. 6espite limited randomized trial data, IABP is still commonly used, and there has been an increase in the use of PVAD for PCI in high-risk patients in recent years. 3n this issue of JSCAI, Shah et al 7,8 present 2 articles examining the use of PVAD and IABP for high-risk PCI. 7,8In the research letter, 8 the authors highlight limitations in comparing outcomes among patients receiving PVAD-and IABP-supported PCI using observational data.The authors highlight that in real-world use, there is no equipoise in device selection for high-risk PCI.Rather, there appears to be preferential use of PVAD for very high-risk patients and IABP for patients at a relatively lower risk.This is illustrated in the propensity score

From 2019-2023, the United States Food and Drug Administration has cleared 9 novel obstructive sleep apnea-detecting wearables for home sleep apnea testing, with many now commercially available for sleep clinicians to integrate into their clinical practices. To help clinicians comprehend these devices and their functionalities, we meticulously reviewed their operating mechanisms, sensors, algorithms, data output, and related performance evaluation literature. We collected information from PubMed, United States Food and Drug Administration clearance documents, ClinicalTrials.gov, and web sources, with direct industry input whenever feasible. In this "device-centered" review, we broadly categorized these wearables into 2 main groups: those that primarily harness photoplethysmography data and those that do not. The former include the peripheral arterial tonometry-based devices. The latter was further broken down into 2 key subgroups: acoustic-based and respiratory effort-based devices. We provided a performance evaluation literature review and objectively compared device-derived metrics and specifications pertinent to sleep clinicians. Detailed demographics of study populations, exclusion criteria, and pivotal statistical analyses of the key validation studies are summarized. In the foreseeable future, these novel obstructive sleep apnea-detecting wearables may emerge as primary diagnostic tools for patients at risk for moderate-to-severe obstructive sleep apnea without significant comorbidities. While more devices are anticipated to join this category, there remains a critical need for cross-device comparison studies as well as independent performance evaluation and outcome research in diverse populations. Now is the moment for sleep clinicians to immerse themselves in understanding these emerging tools to ensure our patient-centered care is improved through the appropriate implementation and utilization of these novel sleep technologies. Chiang AA, Jerkins E, Holfinger S, etal. OSA diagnosis goes wearable: are the latest devices ready to shine? J Clin Sleep Med. 2024;20(11):1823-1838.

Background. SMARCA4-deficient undifferentiated tumors are rare and pose a diagnostic challenge. This study delves into the intricate diagnostic terrain of SMARCA4-deficient undifferentiated tumors, providing insights into their diverse clinical presentations and diagnostic approaches. Case Presentation. A 69-year-old heavy-smoker man with adalimumab-treated rheumatoid arthritis presented with multiple lesions. A CT scan revealed a spiculated lung mass, enlarged mediastinal lymph nodes, and hepatic lesions. A whole-body FDG-PET/CT scan revealed heterogeneous hypermetabolic lesions in the lung, liver, and bone. Initial two core needle liver biopsies and a left upper lobe lung wedge resection initially indicated steatohepatitis and granulomatous formation with no evidence of malignancy. Several months later, the patient returned with left-sided flank pain and significant weight loss. CT scan identified a thigh mass, adrenal lesion, and extensive multiple skeletal lesions. A biopsy of the thigh mass revealed an extensively necrotic, epithelioid-to-spindled cell neoplasm with positive staining for pan keratin, focal staining for CD56, and a loss of nuclear expression of SMARCA4. A final diagnosis of SMARCA4-deficient undifferentiated tumor was rendered. Unfortunately, the patient's condition deteriorated, and he died a few weeks after receiving the final diagnosis. Conclusion. SMARCA4-deficient undifferentiated tumors have emerged as recent subjects of medical study, distinguished by their unique morphology and SMARCA4-deficient immunohistochemistry. These tumors present diverse clinical manifestations, affecting multiple organ systems. This report underscores the diagnostic complexities associated with complex clinical presentation and highlights the importance of multidisciplinary collaboration in addressing challenging clinical scenarios, particularly among heavy smoker male patients and intricate radiological presentations.

Objective: This study aims to analyze COVID-19 hospitalization and death rate in the Asian population of a predominantly Asian-serving multi-hospital system (ASMHS).Methods: The COVID-19 patient information was collected electronically from March 1 to November 12, 2020, including demographics, insurance, mortality, ICU admissions, and length of stay (LOS). Demographic characteristics were compared with the county-level and national data. A comparison of hospital LOS between Asians and non-Asians was conducted.Results: The prevalence ratio of deaths in Asians at ASMHS was 1.29, which was 53% higher than the county and 77% higher than the nation. The ICU admission for ASMHS Asian patients was 11.8% compared to 5.6% for non-Asian. Overall Asians and Asians aged > 65 had significantly longer LOS than non-Asians (p < .001).Conclusions: High prevalence ratio of deaths was noted in ASMHS’s Asian patients which may be related to older age, higher ICU rate, and longer LOS.

There are limited data on morbidity and mortality in severely anemic patients for whom blood transfusion is not an option, with most data coming only from surgical patients and no data on the rate of myocardial ischemia associated with severe anemia. We sought to determine rates of all-cause mortality and myocardial ischemia in severely anemic hospitalized patients declining transfusion. With institutional review board approval, we conducted a retrospective review of all hospital admissions for adult blood refusal patients between January 2004 and September 2015 at a single institution. Severe anemia was defined as hemoglobin (Hb) level of not more than 8.0g/dL at any time during hospital admission. Outcomes measured included all-cause mortality within 30 days of nadir Hb and myocardial ischemia as defined by abnormal troponin (>0.10 ng/mL). We studied the association of patient's nadir Hb with outcomes via multivariable repeated measures generalized estimating equations (GEEs). Of 1306 blood refusal patients with hospital admissions during the study period, 263 had at least one admission with Hb level of not more than 8.0g/dL. The rate of all-cause mortality within 30 days was 19.8%, and the multivariable GEE model indicated a 55% increase in odds of mortality per 1 g/dL decrease in nadir Hb (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.25-1.91; p<0.0001). Rate of myocardial ischemia was 10.5% and in the multivariable model risk increased with decreasing nadir Hb (per 1 g/dL decrease; OR, 1.42; 95% CI, 1.07-1.90; p = 0.016). Severe anemia is associated with increased myocardial ischemia and mortality in patients declining transfusion, with risk increasing with decreasing nadir Hb.