Management of intermediate and high risk acute pulmonary embolism (PE) is challenging. The role of multidisciplinary teams for the care of these patients is emerging. Herein, we report our experience with a pulmonary embolism response team (PERT). We conducted a retrospective chart review on all patients admitted to the Cleveland Clinic main campus who required activation of the (PERT) from October 1, 2014 to September 1, 2016. We extracted data pertaining to clinical presentation, bleeding complications, and pre- and post-discharge imaging. Patients were classified as low, intermediate or high risk PE. Descriptive and continuous variables were collected and analyzed. There were 134 PERT activations. PE was confirmed by CT-PA in 118 patients. Fifteen (13%) patients were classified as low risk, 80 (68%) intermediate risk PE and 23 (19%) high risk PE. Fourteen (12%) patients were treated with catheter directed rtPA, 6 (5%) received full dose (100 mg rtPA), 16 (13%) received systemic half-dose (50 mg rtPA), 6 (5%) underwent a surgical embolectomy and 4 (3%) underwent mechanical thrombectomy. 65 (55%) patients received anticoagulation only, and 8 (7%) patients were managed conservatively without any anticoagulation or advanced therapy. 11 (9%) patients died while during the hospitalization. Fourteen patients had major bleeding events. There were no bleeding events among patients who received systemic low dose or full dose rtPA. A multidisciplinary approach to cases of intermediate risk and high risk PE can be implemented successfully. We saw a relatively low rate of bleeding events with use of rtPA.

Background Literature regarding the effect of Roux-en-Y gastric bypass (RYGBP) on vitamin D level shows contradictory findings. Our goal was to determine preoperatively vitamin D levels, to evaluate the efficacy of therapeutic and prophylactic doses of vitamin D and to assess the relationship of 25-OH vitamin D level and body mass index (BMI). Methods We conducted a retrospective cross-sectional study of 72 patients who underwent RYGBP from Results Our study demonstrated that 80% of the obese patients undergoing RYGBP had serum 25-OH vitamin D levels of less than 32 ng/ml. Postoperative data show that 45% of these patients continue being vitamin D insufficient despite the treatment. We demonstrated that a statistically significant inverse correlation between BMI and 25-OH vitamin D levels (r=0.464, p=0.01) exists. Conclusion Our finding strongly supports the need for aggressive monitoring of vitamin D levels for long-term prevention of complications of vitamin D deficiency in gastric bypass patients. Identifying the factors that predict patient's responses to vitamin D supplementation requires larger-scale studies and further analysis of these tendencies suggested by our findings.

Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic arterial disease that can affect any artery but most commonly affects the renal, carotid, and vertebral arteries, predisposing to stenosis, aneurysm, dissection, and/or tortuosity. 1-3 While headache is a common symptom reported by patients with FMD, little is known about this relationship. 4,5 The etiology of FMD is not known, nor is it understood why such a high percentage of patients with FMD experience headaches. 6 In addition to FMD, patients with associated vascular abnormalities, such as intracranial aneurysm and cervical carotid and vertebral artery dissection, also commonly experience headache. 5,7,8 The aim of this study was to report the frequency and characteristics of headache in a cohort of patients enrolled in the United States Registry for FMD and to identify clinical factors associated with the presence of this symptom. From 2009 through 2016, 1433 adult patients 18 years of age and older were enrolled in the Registry. Eligibility for enrollment was determined by site investigators based on identifying the characteristic appearance of multifocal or focal FMD from vascular imaging in at least one vascular bed. 2,5 Eligible subjects provided written informed consent. Demographic and clinical data, family history, headache-related variables, presenting signs and symptoms at the time of FMD diagnosis, and medications taken at the time of enrollment were recorded. An assessment of headache at initial Registry enrollment included query for presence of headache, type of headache (migraine or other), frequency of headache, whether headache was associated with menses, and whether headache(s) required suppressive medication. The Institutional Review Board (IRB) at the University of Michigan, the Data Coordinating Center for the US Registry of FMD, approved this study (HUM00022250). In addition, all participating sites in the Registry obtained individual institutional IRB approval. Patients were categorized into two groups: those with and those without reported headaches at the time of Registry enrollment. Univariate analysis was conducted by comparing demographics, past medical history, symptoms and signs at time of FMD diagnosis, arterial bed involvement, and family history between the two groups using Student's

Background Fibromuscular dysplasia (FMD) is a nonatherosclerotic arterial disease that has a variable presentation including pulsatile tinnitus (PT). The frequency and characteristics of PT in FMD are not well understood. The objective of this study was to evaluate the frequency of PT in FMD and compare characteristics between patients with and without PT. Methods and Results Data were queried from the US Registry for FMD from 2009 to 2020. The primary outcomes were frequency of PT among the FMD population and prevalence of baseline characteristics, signs/symptoms, and vascular bed involvement in patients with and without PT. Of 2613 patients with FMD who were included in the analysis, 972 (37.2%) reported PT. Univariable analysis and multivariable logistic regression were performed to explore factors associated with PT. Compared with those without PT, patients with PT were more likely to have involvement of the extracranial carotid artery (90.0% versus 78.6%; odds ratio, 1.49; P =0.005) and to have higher prevalence of other neurovascular signs/symptoms including headache (82.5% versus 62.7%; odds ratio, 1.82; P <0.001), dizziness (44.9% versus 22.9%; odds ratio, 2.01; P <0.001), and cervical bruit (37.5% versus 15.8%; odds ratio, 2.73; P <0.001) compared with those without PT. Conclusions PT is common among patients with FMD. Patients with FMD who present with PT have higher rates of neurovascular signs/symptoms, cervical bruit, and involvement of the extracranial carotid arteries. The coexistence of the 2 conditions should be recognized, and providers who evaluate patients with PT should be aware of FMD as a potential cause.

Introduction. —Deep vein thrombosis should be considered as one of the differential causes of unilateral lower-extremity swelling. When the lower-extremity venous duplex ultrasound is negative for a deep vein thrombosis and a proximal occlusion is suspected, investigation should be completed with interrogation of the pelvic veins. Case Report. —We describe a 66-year-old man with a history of rectal carcinoma treated with chemotherapy, radiation, and proctosigmoidectomy who presented to the vascular laboratory with left lower-extremity swelling and erythema. A lower-extremity venous duplex was performed with a Phillips iU22 9–3 MHZ linear transducer, which revealed monophasic flow in the distal left external iliac vein with normal compression images. Further evaluation with a 5–1 MHZ curved array probe revealed a velocity shift within the external iliac vein consistent with iliac vein stenosis. A venogram confirmed a critical stenosis in the mid left external iliac vein with associated thrombus. The patient underwent mechanical thrombectomy and placement of 10 by 40 mm Smart stent. Post-interventional venogram demonstrated excellent antegrade flow and no evidence of residual thrombus. Discussion. —If left untreated, venous stenosis may predispose the patient to persistent lower extremity swelling, venous thrombosis, and venous stasis ulcers. Because of the underlying anatomic defect, symptoms may not improve with conservative management, including anticoagulation. Several diagnostic modalities can be considered for diagnosis of the venous stenosis, including venous duplex ultrasound, magnetic resonance venography, computed tomography with venous phase, venography, and intravascular ultrasound. Conclusion. —Cost considerations makes venous duplex a valuable, noninvasive, first-line method to investigate suspected venous stenosis.