Systemic inflammatory response can be associated with clinically significant and, at times, refractory hypotension. Despite the lack of uniform definitions, this condition is frequently called ...vasoplegia or vasoplegic syndrome (VS), and is thought to be due to dysregulation of endothelial homeostasis and subsequent endothelial dysfunction secondary to direct and indirect effects of multiple inflammatory mediators. Vasoplegia has been observed in all age groups and in various clinical settings, such as anaphylaxis (including protamine reaction), sepsis, hemorrhagic shock, hemodialysis, and cardiac surgery. Among mechanisms thought to be contributory to VS, the nitric oxide (NO)/cyclic guanosine monophosphate (cGMP) pathway appears to play a prominent role. In search of effective treatment for vasoplegia, methylene blue (MB), an inhibitor of nitric oxide synthase (NOS) and guanylate cyclase (GC), has been found to improve the refractory hypotension associated with endothelial dysfunction of VS. There is evidence that MB may indeed be effective in improving systemic hemodynamics in the setting of vasoplegia, with reportedly few side effects. This review describes the current state of clinical and experimental knowledge relating to MB use in the setting of VS, highlighting the potential risks and benefits of therapeutic MB administration in refractory hypotensive states.
Clinical trials comparing thrombectomy devices with conventional percutaneous coronary interventions (PCI) in patients with acute ST elevation myocardial infarction (STEMI) have produced conflicting ...results. The objective of our study was to systematically evaluate currently available data comparing thrombectomy followed by PCI with conventional PCI alone in patients with acute STEMI.
Seventeen randomized trials (n = 3,909 patients) of thrombectomy versus PCI were included in this meta-analysis. We calculated the summary odds ratios for mortality, stroke, post procedural myocardial blush grade (MBG), thrombolysis in myocardial infarction (TIMI) grade flow, and post procedural ST segment resolution (STR) using random-effects and fixed-effects models.
There was no difference in risk of 30-day mortality (44/1914 vs. 50/1907, OR 0.84, 95% CI 0.54-1.29, P = 0.42) among patients randomized to thrombectomy, compared with conventional PCI. Thrombectomy was associated with a significantly greater likelihood of TIMI 3 flow (1616/1826 vs. 1533/1806, OR 1.41, P = 0.007), MBG 3 (730/1526 vs. 486/1513, OR 2.42, P < 0.001), STR (923/1500 vs. 715/1494, OR 2.30, P < 0.001), and with a higher risk of stroke (14/1403 vs. 3/1413, OR 2.88, 95% CI 1.06-7.85, P = 0.04). Outcomes differed significantly between different device classes with a trend towards lower mortality with manual aspiration thrombectomy (MAT) (21/949 vs.36/953, OR 0.59, 95% CI 0.35-1.01, P = 0.05), whereas mechanical devices showed a trend towards higher mortality (20/416 vs.10/418, OR 2.07, 95% CI 0.95-4.48, P = 0.07).
Thrombectomy devices appear to improve markers of myocardial perfusion in patients undergoing primary PCI, with no difference in overall 30-day mortality but an increased likelihood of stroke. The clinical benefits of thrombectomy appear to be influenced by the device type with a trend towards survival benefit with MAT and worsening outcome with mechanical devices.
This collection of Michael Grossman's most important papers adds essential background and depth to his work on economic determinants of public health. Each of the book's four sections includes an ...introduction that contextualizes the issues and addresses the larger stakes of his work. An afterword discusses the significance of Grossman's approach for subsequent research on health economics, as well as the work others have done to advance and extend his innovative perspective.Determinants of Healthexplains how the economic choices people make influence health and health behaviors. It begins with a section on the theoretical underpinnings and empirical results of Grossman's groundbreaking health economics model, first introduced in the 1970s, followed by essays on the relationship between health and schooling; determinants of infant health, with a special emphasis on public policies and programs; and the economics of unhealthy behaviors. Grossman treats health as a form of human capital. He shows that public policies and programs that determine the price and availability of key inputs have critical effects on outcomes ranging from birth weight and infant mortality to cigarette smoking, alcohol abuse, illegal drug use, and obesity. Grossman's approach has led to a major stream of literature in the field, sparking contributions by the world's leading health economists, including Joseph Newhouse, Jonathan Gruber, Amy Finkelstein, Michael Greenstone, and David Cutler. His clarity on the role that economics play in people's good and bad health choices is immensely valuable to the debate over how we legislate and spend on health.
The role of Emergency Medicine Physicians (EMP) in the care of trauma patients in North America has evolved since the advent of the specialty in the late 1980's. The evolution of this role in the ...context of the overall demands of the specialty and accreditation requirements of North American trauma centers will be discussed. Limited available data published in the literature examining the role of EMP's in trauma care will be reviewed with respect to its implications for an expanded role for EMPs in trauma care. Two training models currently in the early stages of development have been proposed to address needs for increased manpower in trauma and the critical care of trauma patients. The available information regarding these models will be reviewed along with the implications for improving the care of trauma patients in both Europe and North America.
Typhoons (hurricanes) are a major cause of casualties and damage in the Northwest Pacific Basin. This study used geographical information systems (GIS) software to analyze the tracks of typhoons that ...enter the northern part of the basin and affect Japan. The study area encompassed the northern part of the Northwest Pacific Basin (28°-48° N and 110°-180° E). The primary data for the analysis were from the International Best Track Archive for Climate Stewardship for a sixty-three-year period (1951-2013). Using ArcGIS, we delineated four zones within the study area based on a 300-km buffer around the main Japanese islands. We used this zonal classification to analyze the frequency of typhoons entering each zone, examine the relationship between origin location and zone, and demonstrate how ArcGIS can be used to study the relationship between typhoon tracks and the location and strength of the North Pacific Subtropical High. As few studies have employed GIS software to analyze typhoon tracks over time and space, our goal is to demonstrate how ArcGIS can be used to map and analyze typhoon tracks to better understand the distribution and movement of these dangerous storms in this heavily populated region.
Despite the rapid adoption of transcatheter aortic valve replacement since its approval, the frequency and outcomes of aortic valve reintervention after transcatheter aortic valve replacement are ...poorly understood.
Valve reinterventions, either surgical transcatheter aortic valve explantation or repeat transcatheter aortic valve replacement, between 2012 and 2019 were queried using the Society of Thoracic Surgeons Database and the Transcatheter Valve Therapy Registry through the Michigan Statewide quality collaborative. The reintervention frequency and clinical outcomes including observed-to-expected mortality ratio using Society of Thoracic Surgeons Predicted Risk of Mortality were reviewed.
Among 9694 transcatheter aortic valve replacement recipients, a total of 87 patients (0.90%) received a reintervention, consisting of 34 transcatheter aortic valve explants and 53 repeat transcatheter aortic valve replacement procedures. The transcatheter aortic valve explant group demonstrated a higher Society of Thoracic Surgeons Predicted Risk of Mortality. Reintervention cases increased from 0 in 2012 and 2013 to 26 in 2019. The proportion of transcatheter aortic valve explants among all reinterventions increased and was 65% in 2019. Self-expandable devices had a higher reintervention rate than balloon-expandable devices secondary to a higher transcatheter aortic valve explant frequency (0.58% 23/3957 vs 0.19% 11/5737; P = .001), whereas repeat transcatheter aortic valve replacement rates were similar (0.61% 24/3957 vs 0.51% 29/5737; P = .51). Among patients with transcatheter aortic valve explants, contraindications to repeat transcatheter aortic valve replacement included unfavorable anatomy (75%), need for other cardiac surgery (29%), other structural issues by transcatheter aortic valve device (18%), and endocarditis (12%). For transcatheter aortic valve explant and repeat transcatheter aortic valve replacement, the 30-day mortality was 15% and 2% (P = .032) and the observed-to-expected mortality ratio was 1.8 and 0.3 (P = .018), respectively.
Aortic valve reintervention remains rare but is increasing. The clinical impact of surgical device explantation was substantial, and the proportion of transcatheter aortic valve explants was significantly higher in patients with a self-expandable device.
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An introduction to fluvial geomorphology and paleohydrology in Japan is provided for researchers who are unfamiliar with these topics. Studies by Japanese geomorphologists are reviewed including ...those published only in Japanese-language journals. Emphasis is placed upon the following aspects: (1) abundant sediment yields from steep watersheds subjected to frequent heavy rains despite heavily vegetated conditions, (2) extensive sedimentation in mountain piedmonts and coastal fluvial plains especially during the Holocene, (3) catastrophic hydro-geomorphological events associated with earthquakes and volcanic eruptions, and (4) the impacts of the increased heavy rainfall during the Pleistocene–Holocene transition on the post glacial development of hillslopes and alluvial fans. These geomorphological characteristics differ from those in continental regions, such as Europe and North America, indicating that research on Japanese fluvial systems can contribute a great deal to the understanding of the global variety of fluvial geomorphology. Recent work on paleohydrological reconstruction in Japan is also reviewed.
Objectives: To examine the relationship between the number of rib fractures (RIBFs) and mortality, injury severity, and resource consumption in elderly patients admitted to trauma centers.
Design: ...Thirteen‐year retrospective statewide database analysis.
Setting: Participating trauma centers in Pennsylvania.
Participants: A total of 27,855 trauma patients, including 8,648 elderly patients, admitted to a trauma center with more than one RIBF.
Measurements: Patient demographics, number of RIBFs, Injury Severity Score, complications, patient mortality, preexisting conditions (PECs), and hospital and intensive care unit length of stay.
Results: Mortality for elderly patients (aged≥65) with RIBFs was greater than for patients younger than 65 (20.1% vs 11.4%, P<.001). Mortality rates increased with increasing numbers of RIBFs for both age groups and were always significantly higher in elderly trauma patients. The effect of PECs on patient mortality was inversely related to number of RIBFs and was most pronounced for patients with four or more RIBFs. Seven of 10 complications were more common in elderly patients despite lower mean±standard deviation Injury Severity Score (19.4±13.4 vs 23.2±14.2, P<.001).
Conclusion: Overall trauma‐related mortality is higher in elderly patients with RIBFs than younger patients with RIBFs. Mortality rates rise with increasing number of RIBFs. The number of RIBFs is easy to quantify and may be a useful predictor of overall injury severity and outcome for elderly trauma patients.
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