McLaren Macomb

Tandem lesions (TLs) are a subtype of acute ischemic stroke, which involve an extracranial carotid lesion (ie, severe carotid stenosis ≥70%) with large vessel occlusion. While large vessel occlusion has a standard approach with mechanical thrombectomy (MT), the best practice for intervention of the carotid lesion is not well-established. Utilizing data from the ASSIST registry, we investigated the differences in clinical and procedural outcomes between acute versus nonacute stenting. The ASSIST registry (an international acute ischemic stroke MT prospective study) was utilized to identify the subgroup of patients with acute ischemic stroke secondary to TL who received MT. The TLs were grouped by MT+acute carotid stenting (CAS) versus MT+acute carotid nonstenting. The demographics and clinical outcomes (90-day modified Rankin Scale score) were compared between TL and non-TL groups, and between MT+CAS and MT+acute carotid nonstenting. Multivariable analyses were performed to determine independent predictors of clinical outcomes. A total of 183 of 1270 (14.4%) TLs were identified in the ASSIST registry. MT+CAS was performed in 83 of 183 (45.4%) subjects, and 100 of 183 (54.6%) received MT+acute carotid nonstenting. There are no significant differences at baseline between the 2 groups in the National Institutes of Health Stroke Scale score, Alberta Stroke Program Early Computed Tomography Score, or target vessel. Achieving a modified Rankin Scale score of 0 to 2 at 90 days was 70.9% in the MT+CAS group versus 48.9% in the MT+acute carotid nonstenting group (P=0.001), with a modified Rankin Scale score of 0 to 2 being significantly associated with the MT+CAS group in multivariable analysis (odds ratio, 2.14 [95% CI, 1.01-4.51]). There was no significant difference in mortality or symptomatic intracerebral hemorrhage between the groups. In acute ischemic stroke, secondary to TLs treatment with thrombectomy and acute carotid stenting is associated with improved 90-day functional outcome without an increase in symptomatic intracerebral hemorrhage compared with no acute stenting approach. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03845491.

Pure primary gastric squamous cell carcinoma (PGSCC) is a notably rare gastric malignancy. We present the case of a 51-year-old woman with advanced gastric squamous cell carcinoma characterized by a 7.6 cm necrotic mass invading the proximal stomach, liver metastasis, and lymphadenopathy at diagnosis. Despite the lack of standardized treatment protocols, we review tumor markers and potential management strategies, including surgical and chemotherapeutic interventions. The rarity and aggressive nature of PGSCC necessitates further research to develop effective detection and treatment methods to improve patient prognosis and survival outcomes.

Introduction Cardiac rehabilitation (CR) is an underutilized resource in patients with ischemic heart disease, despite being a Class IA recommendation. In this study, a multidisciplinary quality improvement (QI) team aimed to improve CR referrals by standardizing the ordering process at our hospital system. Method By using a collaborative approach involving the electronic medical record (EMR), medical provider education, and hospital protocols, our two-hospital healthcare system was able to successfully identify barriers to CR referral rates and implement interventions for these barriers. All physicians and medical providers, including ancillary staff, were educated on the EMR order sets to improve compliance by using automated order sets in the EMR. The CR referral order in the EMR included a statement regarding the application of evidence-based medicine, and a computerized provider order entry was included as a reminder to the ordering provider. The use of EMR was monitored monthly by the QI committee. Chi-square test and odds ratios were obtained for statistical analysis. Results Through provider-EMR education and patient education on discharge, CR referral rates significantly improved from 51.2 to 87.1% (p = 0.0001) in a 12-month period. The study included 1,499 patients in total. The improvement was statistically significant regardless of patient gender, race, or insurance coverage. Additionally, subgroup analysis in this study found that prior to standardization of the ordering process, African American patients were significantly less likely to be referred to CR compared to Caucasian patients. (51.2% vs. 41.0%, p=0.01). There was no statistically significant difference in the likelihood of CR referral between Caucasian and African American patients following the intervention (84.0% vs. 78.0%, p = 0.166). Conclusion This study shows that CR is an underutilized resource and that effective QI initiatives may not only increase CR referral rates but also close the gap between racial inequities in referral rates. Future research with multi-center randomized control trials is needed to further enhance its external generalizability to other institutions.

Surgically repaired tetralogy of Fallot (TOF) is a congenital heart disease with a cumulative survival rate of 72% in the 4th decade of life in longitudinal single-cohort studies. Debate surrounds conservative versus surgical management in adults with TOF once pulmonary regurgitation occurs. A 73-year-old male with surgically corrected TOF presented with heart failure symptoms. He underwent ToF repair with a classic right Blalock-Taussig shunt at 2years of age with transannular patching at 18years of age. Echocardiography revealed elevated right ventricular systolic pressures, severe right ventricular dilatation, and pulmonary regurgitation. Our patient's new-onset right-sided heart failure was managed medically with diuresis. He received a new pulmonic valve via percutaneous approach on a later planned hospitalization with resolution of symptoms and improved tricuspid regurgitation. It is a class I recommendation for pulmonic valve intervention once greater than moderate PR occurs; however, medical optimization should take place first. Following adequate RV load optimization, our patient underwent successful transcatheter pulmonic valve implantation with resolution of symptoms and cessation of diuretic.