Recurrent Aortic Thromboembolism Associated With TET2 Mutation in Chronic Myelomonocytic Leukemia

Ten-eleven translocation 2 (TET2) plays a pivotal role in epigenetic regulation, cell differentiation, and the inflammatory response. It also mediates the transcriptional regulation for inflammatory cytokines, particularly interleukin-6. While loss-of-function mutation in TET2 has been associated with hematological malignancies, it has been increasingly recognized to cause atherosclerotic disease. The increased atherogenicity is thought to be the result of increased production of pro-inflammatory interleukin-1β cytokines following activation of NLRP3 inflammasomes. We present a unique case of recurrent atherothrombosis in an elderly man who was diagnosed with chronic myelomonocytic leukemia in the setting of TET2 mutation.

Can Untrained Patients Perform Their Own Skin and Soft Tissue Ultrasound Examination by Teleguidance?

Objectives: This pilot study aims to determine if patients untrained in performing ultrasound can self-scan to obtain images under remote clinician teleguidance during a simulated telehealth encounter. This study also seeks to describe the patients' comfort level and barriers to performing an ultrasound examination on themselves using a handheld ultrasound device. Methods: This was a single center prospective observational cohort study conducted over a 4-month period in 2021. Patients were eligible if they had no prior training in the use of ultrasound and in the use of teleguidance. They voluntarily consented to participate at a single ambulatory internal medicine clinic. Results: 20 participants were enrolled and underwent teleguidance to ultrasound their own skin and soft tissues at the antecubital fossae. Six second video clips were evaluated by 2 subject matter experts using the Point of Care Ultrasound Image Quality scale. A score >7 was considered adequate for diagnostic interpretation. The average score was 10.15/14, with a minimum score of 5/14, and maximum score of 14/14 and a standard deviation (SD) of 2.39 using a two tailed Z-score. Setting alpha at 0.05 the 95% CI was (5.47-14.83). Conclusion: In a pilot study of 20 participants with no ultrasound experience, untrained healthy volunteers were able to perform technically acceptable and interpretable ultrasound scans using teleguidance by a trained clinician.

The role of hemodialysis access duplex ultrasound for evaluation of patency and access surveillance

The rise in prevalence of end stage renal disease (ESRD) and the impact on health care resulted in increasing focus on delivery of vascular access. Hemodialysis vascular access is the most common renal replacement therapy method. The vascular access types include arteriovenous fistula, arteriovenous graft, and tunneled central venous catheters. Vascular access function remains an important outcome measure with significant impact on morbidity and health care cost. The survival and quality of life of patients on hemodialysis is dependent on the adequacy of dialysis through proper vascular access. Early detection of failure to mature vascular access, stenosis, thrombosis, and aneurysm or pseudoaneurysm formation remains crucial. Ultrasound can help identify complications, even though ultrasound evaluation of the arteriovenous access is less well defined. Some published vascular access guidelines support ultrasound for detecting stenosis. The evolution of ultrasound has improved throughout the years, both multi parametric top-line systems and hand-held systems. Ultrasound evaluation is inexpensive, rapid, noninvasive, and repeatable, it is a powerful tool used for early diagnosis. The ultrasound image quality still depends on the skill of the operator. Careful attention to technical details is needed and avoidance of several diagnostic pitfalls is necessary. This review is focused on the role of ultrasound for hemodialysis access surveillance, evaluation of maturation, detection of access complications, and aid with cannulation.

Left Main Coronary Artery Interventions

The management of left main coronary artery (LMCA) disease has evolved over the past two decades. Historically, coronary artery bypass grafting (CABG) surgery has been the gold standard for the treatment of LMCA disease. However, with the advancements in percutaneous coronary interventions (PCIs) and stent technology, PCI in select patients has achieved comparable outcomes to CABG. As such, this has led to changes in the American College of Cardiology and European Society of Cardiology guidelines, which recommend that PCI might be an alternative to CABG in select patients. In this review article, we describe the historical perspective and early experience with coronary interventions of LMCA disease, landmark clinical trials and their effect on guidelines, and the role of intravascular imaging in the management of LMCA lesions.

Peripheral Vascular Disease in Women: Therapeutic Options in 2019

PURPOSE OF REVIEW

In recent years, there have been advances in the prevention, management, and control of peripheral vascular disease (PVD). There is a trend towards aggressive risk factor modification, noninvasive screening, and endovascular revascularization with surgical approaches reserved only for select cases. This article reviews the different management strategies ranging from pharmacotherapy, revascularization, and rehabilitation with an emphasis on the response of women to these therapies.

RECENT FINDINGS

Overall, the representation of women in the majority of the published data in this arena remains poor. Studies examining medical therapy and endovascular and surgical revascularization were not designed to address sex disparities. Nevertheless, we dissect these therapies and their relevant randomized trials. The paucity of data investigating the response of women to the different management options makes it difficult to make any evidence-based recommendations. This not only applies to the type of intervention, but also the appropriate timing and risks entailed.