Heparin-induced thrombocytopenia (HIT) is an immune-mediated thrombocytopenia resulting from prior heparin exposure. It can be associated with limb- or life-threatening thrombotic events. Patients ...undergoing any vascular procedures including endovascular procedures that require heparin administration are at risk. There is very little reported in the literature with regards to thrombosis associated with HIT after endovascular aortic aneurysm repair. All reported cases of HIT thrombosis presented as acute arterial lower limb ischemia or deep vein thrombosis. In this report, we present a case of HIT complicated by stent graft thrombosis and bowel ischemia.
A clinical decision support system (CDSS) is a computer program that applies a set of rules to data stored in electronic health records to offer actionable recommendations. We aimed to establish ...whether a CDSS that supports detection of immunological treatment failure among patients with HIV taking antiretroviral therapy (ART) would improve appropriate and timely action.
We did this prospective, cluster randomised controlled trial in adults and children (aged ≥18 months) who were eligible for, and receiving, ART at HIV clinics in Siaya County, western Kenya. Health facilities were randomly assigned (1:1), via block randomisation (block size of two) with a computer-generated random number sequence, to use electronic health records either alone (control) or with CDSS (intervention). Facilities were matched by type and by number of patients enrolled in HIV care. The primary outcome measure was the difference between groups in the proportion of patients who experienced immunological treatment failure and had a documented clinical action. We used generalised linear mixed models with random effects to analyse clustered data. This trial is registered with ClinicalTrials.gov, number NCT01634802.
Between Sept 1, 2012, and Jan 31, 2014, 13 clinics, comprising 41,062 patients, were randomly assigned to the control group (n=6) or the intervention group (n=7). Data collection at each site took 12 months. Among patients eligible for ART, 10,358 (99%) of 10,478 patients were receiving ART at control sites and 10,991 (99%) of 11,028 patients were receiving ART at intervention sites. Of these patients, 1125 (11%) in the control group and 1342 (12%) in the intervention group had immunological treatment failure, of whom 332 (30%) and 727 (54%), respectively, received appropriate action. The likelihood of clinicians taking appropriate action on treatment failure was higher with CDSS alerts than with no decision support system (adjusted odds ratio 3·18, 95% CI 1·02-9·87).
CDSS significantly improved the likelihood of appropriate and timely action on immunological treatment failure. We expect our findings will be generalisable to virological monitoring of patients with HIV receiving ART once countries implement the 2015 WHO recommendation to scale up viral load monitoring.
US President's Emergency Plan for AIDS Relief (PEPFAR), through the US Centers for Disease Control and Prevention.
Objective To review the treatment of blunt thoracic aortic injuries (BAI) at a single institution over the past 12 years and compare pre-, peri-, and postoperative variables and outcomes of both open ...(OR) and thoracic endovascular (TEVAR) repair of these injuries. Methods All cases of confirmed BAI from 1994 to present were included in this retrospective review. Data collected included demographic data, injury severity score, Glasgow coma score, arrival hemodynamic variables, and associated injuries. Operative data included: type of procedure (OR or TEVAR), duration of procedure, need for and amount of blood transfused, use of anticoagulation, type of anesthesia, and service performing the procedure. Outcomes evaluated were: death, paraplegia, length of stay, days ventilated, and procedure related complications. Specific to EVAR; access, stent graft type and number, presence of endoleak and long-term clinical and radiologic follow-up were evaluated. Results Thirty cases of blunt thoracic aortic injury were identified. Two patients received no treatment and died, 28 patients were treated (OR 16, TEVAR 12) and included for comparison. There were no significant differences between groups with respect to preoperative variables with the exception of significantly more associated intra-abdominal injuries in the TEVAR group ( P = .03). Five patients in the OR group (31.2%) died in the perioperative period. There were no deaths in the TEVAR group ( P =.05). One OR patient (6.25%) suffered postoperative paraplegia. No paraplegia occurred in the TEVAR group. Intraoperative variables were similar between groups with the exception of mean units of blood transfused (OR 8.5 units, vs TEVAR 0.2 units, P = .002). Ten patients in the OR group either died or had a procedure related complication compared with none in the TEVAR group ( P = .001). There was no difference in length of stay or length of mechanical ventilation between the groups. There were no procedure or device related complications in the TEVAR group during follow-up (mean 15.3 months, range 1 to 53.5 months). Conclusions Endovascular repair of BAI results in significantly less combined mortality and morbidity when compared to OR. Significantly less blood is needed intraoperatively in the TEVAR group. No complications from stent graft insertion have been observed during follow-up. Endovascular repair is replacing open repair as the treatment of choice for BAI at our institution.
Abstract Background Although many studies of heart failure therapies test improvements of patient condition in terms of mean changes of quality of life (QoL) or exercise tolerance (ET) measures, it ...is of increasing interest to quantify the proportion of patients that “respond” to therapy and understand factors predicting response. These questions can be address through the use of a “responder analysis,” in which the proportion of patients in whom a measure of QoL or ET improves by a minimum amount is determined. Here, we review the principles of a “responder analysis.” Methods and Results We used data from published studies of cardiac resynchronization therapy to model the results of a responder analysis and original data from a recent study of cardiac contractility modulation to illustrate the many facets of such an analysis that need to be understood and investigated further. Some of these areas include: understanding how to choose criteria for response; how to deal with differing results obtained with different measures of response; and how to deal with potentially conflicting information provided by a responder analysis and the more standard comparison of mean changes. Conclusions Additional prospective studies will help advance understanding the optimal way to use responder analyses in heart failure trials.
In this report, we describe a technique that could potentially be used for both prevention and treatment of spinal cord ischemia (SCI) in endovascular repair of thoracoabdominal aneurysms. This ...technique involves using a specially designed endograft with side branches (paraplegia prevention branches PPBs), which are left patent to perfuse the aneurysmal sac and any associated lumbar or intercostal arteries in the early postoperative period. The use of PPBs with this technique is feasible and allows for a temporary controlled endoleak that may be useful for preventing or reversing spinal cord injury. This technique may be considered as an adjunct to the more standard perioperative physiological manipulations such as permissive hypertension and spinal fluid drainage.
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