Background Continuous-flow left ventricular assist devices (LVAD) are increasingly being used in patients with end-stage heart failure and have largely replaced older generation pulsatile devices. ...While significant rates of infection have been reported in patients with pulsatile device support, incidence and outcomes of this complication for the continuous-flow device patients remain unknown. Methods Between June 2005 and August 2009, 81 patients were implanted with continuous-flow LVADs at Washington University School of Medicine either as bridge to transplantation or as destination therapy. Outcomes of this study included incidence of postimplantation infection, types of infection, microbiologic profile, and association of postimplantation infections with clinical endpoints. Results Forty-two patients (51.9%) had at least one type of infection on continuous-flow LVAD support with a mean follow-up period of 9.2 ± 9.2 months. Patients who had an infection on LVAD support had a significantly prolonged hospital stay (37.9 ± 32.0 versus 20.7 ± 23.0 days, p = 0.008) and a trend toward increased mortality (33.1% versus 18.7% at 2 years, respectively, log rank p = 0.102) compared with patients who did not. Subgroup analysis revealed that postimplantation sepsis was significantly associated with increased mortality in the continuous-flow LVAD cohort (61.9% versus 18.0% at 2 years, respectively, in septic and nonseptic patients, log rank p = 0.001). The majority of the sepsis cases occurred before hospital discharge, whereas most of the device related infections occurred after discharge. Resistant Staphylococcus and Pseudomonas species were the most common pathogens leading to device- and nondevice-related local infections. Development of driveline or pocket infection had no effect on survival in patients with continuous-flow assist device support ( p = 0.193). Conclusions Even though better clinical outcomes have been achieved with the newer generation continuous-flow devices, infection complications—in particular sepsis—are still a major risk for patients with continuous-flow LVAD implantation. Prevention strategies with aggressive medical and surgical management of infections may increase survival and decrease morbidity among continuous-flow LVAD patients.
Chronic kidney disease (CKD) is an important global public health problem that is associated with adverse health outcomes and high health care costs. Effective and cost-effective treatments are ...available for slowing the progression of CKD and preventing its complications, including cardiovascular disease. Although wealthy nations have highly structured schemes in place to support the care of people with kidney failure, less consideration has been given to health systems and policy for the much larger population of people with non–dialysis-dependent CKD. Further, how to integrate such strategies with national and international initiatives for control of other chronic noncommunicable diseases (NCDs) merits attention. We synthesized the various approaches to CKD control across 17 European countries and present our findings according to the key domains suggested by the World Health Organization framework for NCD control. This report identifies opportunities to strengthen CKD-relevant health systems and explores potential mechanisms to capitalize on these opportunities. Across the 17 countries studied, we found a number of common barriers to the care of people with non–dialysis-dependent CKD: limited work force capacity, the nearly complete absence of mechanisms for disease surveillance, lack of a coordinated CKD care strategy, poor integration of CKD care with other NCD control initiatives, and low awareness of the significance of CKD. These common challenges faced by diverse health systems reflect the need for international cooperation to strengthen health systems and policies for CKD care.
Abstract Background Robotic intraperitoneal mesh placement (rIPOM) has recently emerged as an alternative to laparoscopic intraperitoneal mesh placement (LapIPOM) for minimally invasive incisional ...hernia repair. We aimed to compare LapIPOM to rIPOM in terms of hospital length of stay (LOS) and 30-day postoperative complications in patients undergoing incisional hernia repair within the Americas Hernia Society Quality Collaborative (AHSQC) Study Design Propensity score analysis was used to compare matched groups of patients within the AHSQC undergoing LapIPOM versus rIPOM. The primary outcome measure was hospital LOS, and secondary outcomes were 30-day wound events. Results 454 (71.9%) patients underwent LapIPOM and 177 (28.1%) underwent rIPOM. The laparoscopic group had an increased median LOS (1 vs 0 days; interquartile range (IQR) 3.00; p<0.001). The risk of surgical site occurrence (SSO) was higher in the LapIPOM group vs the rIPOM group (14% vs 5%; p=0.001), however SSO requiring procedural intervention (SSOPI) was similar between the groups (1% vs 0%; p=1). Operative time greater than 2 hours was more common in the rIPOM group (47% vs 31%; p<0.05). Conclusion Despite longer operative times using the rIPOM approach, patients undergoing rIPOM had a significantly shorter LOS than LapIPOM without additional risk of wound morbidity requiring intervention. Further studies are necessary to identify the best candidates for the rIPOM approach.
Background An observational study in veterans showed that a novel water method (water infusion in lieu of air insufflation) enhanced cecal intubation and willingness to undergo a repeat scheduled ...unsedated colonoscopy. Objective To confirm these beneficial effects and significant attenuation of discomfort in a randomized, controlled trial (RCT). Design Prospective RCT, intent-to-treat analysis. Setting Veterans Affairs ambulatory care facility. Patients Veterans undergoing scheduled unsedated colonoscopy. Interventions During insertion, the water and traditional air methods were compared. Main Outcome Measurements Discomfort and procedure-related outcomes. Results Eighty-two veterans were randomized to the air (n = 40) or water (n = 42) method. Cecal intubation (78% vs 98%) and willingness to repeat (78% vs 93%) were significantly better with the water method ( P < .05; Fisher exact test). The mean (standard deviation) of maximum discomfort (0 = none, 10 = most severe) during colonoscopy was 5.5 (3.0) versus 3.6 (2.1) P = .002 (Student t test), and the median overall discomfort after colonoscopy was 3 versus 2, P = .052 (Mann-Whitney U test), respectively. The method, but not patient characteristics, was a predictor of discomfort ( t = −1.998, P = .049, R2 = 0.074). The odds ratio for failed cecal intubation was 2.09 (95% CI, 1.49-2.93) for the air group. Fair/poor previous experience increased the risk of failed cecal intubation in the air group only. The water method numerically increased adenoma yield. Limitations Single site, small number of elderly men, unblinded examiner, possibility of unblinded subjects, restricted generalizability. Conclusions The RCT data confirmed that the water method significantly enhanced cecal intubation and willingness to undergo a repeat colonoscopy. The decrease in maximum discomfort was significant; the decrease in overall discomfort approached significance. The method, but not patient characteristics, was a predictor of discomfort. (Clinical trial registration number NCT00747084 ).
Pleuropulmonary blastoma is a rare and highly aggressive pulmonary malignancy in children. Clinically, the malignancy is often mistaken for symptoms of respiratory tract infection or pneumothorax. ...The neoplasm is histologically characterized by primitive blastema and a malignant mesenchymal stroma that demonstrates multidirectional differentiation. The patients with PPB are managed by multimodal therapy. We present a report of 3 cases of histopathologically diagnosed pleuropulmonary blastoma. The patients presented with chief complaints of difficulty in breathing, cough, fever and chest pain. Radiographs of the patients showed partial to complete opacification of hemithorax. Contrast enhanced computed tomography scans revealed large well defined heterogenously enhancing solid mass lesions in the hemithorax. Knowledge of types, imaging findings, staging and association with other tumors is crucial for correct diagnosis of pleuropulmonary blastoma and subsequent adequate management.
Background The objective of this study was to assess the long-term effects of the CorCap Cardiac Support Device (CSD; Acorn Cardiovascular, Inc, St. Paul, MN) on left ventricular (LV) structure and ...function in patients with heart failure. Cardiac support devices, which reduce LV wall stress, have been shown to promote reverse remodeling in three different experimental models of heart failure. However, long-term effects in patients with heart failure have not been reported. Methods We enrolled 300 patients with heart failure in the Acorn Randomized Trial, as previously reported (Ann Thorac Surg 2007;84:1226–35). Echocardiograms were obtained every six months until the last patient was followed for one year, and then annually thereafter. Standard measurements of LV volumes, ejection fraction, and sphericity index were made by a Core laboratory at the Mayo Clinic who were blinded to treatment assignment. Results Patients treated with the CorCap Cardiac Support Device had significant reductions in LV end diastolic volume (average difference 18.8 mL; p = 0.005) and LV end systolic volume (average difference 15.6 mL; p = 0.013) compared with the control group. Sphericity index was significantly increased in the treatment group (average difference 0.045 units; p = 0.018). These changes were maintained over three years of follow-up. The improvements in LV size and shape were observed when the CorCap was implanted concomitantly with mitral value surgery or by itself. Conclusions These results demonstrate that the CorCap Cardiac Support Device has a long-term beneficial impact on LV size and shape in patients with heart failure.
Background Pilot studies using a novel water method to perform screening colonoscopy allowed patients to complete colonoscopy without sedation medications and also significantly increased the cecal ...intubation success rate. Objective To perform a randomized, controlled trial comparing air insufflation (conventional method) and water infusion in lieu of air insufflation(study method) colonoscopy in minimally sedated patients. Hypothesis Compared with the conventional method, patients examined by the study method had lower pain scores and required less medication but had a similar cecal intubation rate and willingness to undergo colonoscopy in the future. Setting Outpatient colonoscopy in a single Veterans Affairs hospital. Methods After informed consent and standard bowel preparation, patients received premedications administered as 0.5-increments of fentanyl (25 μg) and 0.5-increments of Versed (midazolam) (1 mg) plus 50 mg of diphenhydramine. The conventional and the study methods for colonoscopy were implemented as previously described. Additional pain medications were administered at the patients' request. Main Outcome Measurements Increments of medications, pain scores, cecal intubation, and willingness to repeat colonoscopy. Results Increments of medications used before reaching the cecum (1.6 ± 0.2 vs 2.4 ± 0.2, P < .0027), total increments used (1.8 ± 0.2 vs 2.5 ± 0.2, P < .014), and the maximum pain scores (1.3 ± 0.3 vs 4.1 ± 0.6, P < .0002) were significantly lower with the water method. Cecal intubation rate (100%) and willingness to undergo a repeat colonoscopy (96%) were similar. Limitations Single Veterans Affairs hospital, older male population. Conclusion Water infusion in lieu of air insufflation is superior to air insufflation during colonoscopy in the minimally sedated patients ( ClinicalTrials.gov Identifier NCT00785889 ).
Nonadherence to cardiovascular medications such as statins is a common, important problem. Clinicians currently rely on intuition to identify medication nonadherence. The visit-to-visit variability ...(VVV) of low-density lipoprotein (LDL) cholesterol might represent an opportunity to identify statin nonadherence with greater accuracy. We examined the clinical and pharmacy data from 782 members of the Boston Medical Center Health Plan, seen at either the Boston Medical Center or its affiliated community health centers, who were taking statins and had ≥3 LDL cholesterol measurements from 2008 to 2011. The LDL cholesterol VVV (defined by the within-patient SD) was categorized into quintiles. Multivariate logistic regression models were generated with statin nonadherence (defined by the standard 80% pharmacy refill-based medication possession ratio threshold) as the dependent variable. The proportion of statin nonadherence increased across the quintiles of LDL cholesterol VVV (64.3%, 71.2%, 89.2%, 92.3%, 91.7%). Higher quintiles of LDL cholesterol VVV had a strong positive association with statin nonadherence, with an adjusted odds ratio of 3.4 (95% confidence interval 1.7 to 7.1) in the highest versus lowest quintile of LDL cholesterol VVV. The age- and gender-adjusted model had poor discrimination (C-statistic 0.62, 95% confidence interval 0.57 to 0.67), but the final adjusted model (age, gender, race, mean LDL cholesterol) demonstrated good discrimination (C-statistic 0.75, 95% confidence interval 0.71 to 0.79) between the adherent and nonadherent patients. In conclusion, the VVV of LDL cholesterol demonstrated a strong association with statin nonadherence in a clinic setting. Furthermore, a VVV of LDL cholesterol-based model had good discrimination characteristics for statin nonadherence. Research is needed to validate and generalize these findings to other populations and biomarkers.
Hypothermia for spinal cord injury Kwon, Brian K., MD, PhD, FRCSC; Mann, Cody, BSc; Sohn, Hong Moon, MD, PhD ...
The spine journal,
11/2008, Letnik:
8, Številka:
6
Journal Article
Recenzirano
Abstract Background context Interest in systemic and local hypothermia extends back over many decades, and both have been investigated as potential neuroprotective interventions in a number of ...clinical settings, including traumatic brain injury, stroke, cardiac arrest, and both intracranial and thoracoabdominal aortic aneurysm surgery. The recent use of systemic hypothermia in an injured National Football League football player has focused a great deal of attention on the potential use of hypothermia in acute spinal cord injury. Purpose To provide spinal clinicians with an overview of the biological rationale for using hypothermia, the past studies and current clinical applications of hypothermia, and the basic science studies and clinical reports of the use of hypothermia in acute traumatic spinal cord injury. Study design/setting A review of the English literature on hypothermia was performed, starting with the original clinical description of the use of systemic hypothermia in 1940. Pertinent basic science and clinical articles were identified using PubMed and the bibliographies of the articles. Methods Each article was reviewed to provide a concise description of hypothermia's biological rationale, current clinical applications, complications, and experience as a neuroprotective intervention in spinal cord injury. Results Hypothermia has a multitude of physiologic effects. From a neuroprotective standpoint, hypothermia slows basic enzymatic activity, reduces the cell's energy requirements, and thus maintains Adenosine Triphosphate (ATP) concentrations. As such, systemic hypothermia has been shown to be neuroprotective in patients after cardiac arrest, although its benefit in other clinical settings such as traumatic brain injury, stroke, and intracranial aneurysm surgery has not been demonstrated. Animal studies of local and systemic hypothermia in traumatic spinal cord injury models have produced mixed results. Local hypothermia was actively studied in the 1970s in human acute traumatic spinal cord injury, but no case series of this intervention has been published since 1984. No peer-reviewed clinical literature could be found, which describes the application of systemic hypothermia in acute traumatic spinal cord injury. Conclusions Animal studies of acute traumatic spinal cord injury have not revealed a consistent neuroprotective benefit to either systemic or local hypothermia. Human studies of local hypothermia after acute traumatic spinal cord injury have not been published for over two decades. No peer-reviewed studies describing the use of systemic hypothermia in this setting could be found. Although a cogent biological rationale may exist for the use of local or systemic hypothermia in acute traumatic spinal cord injury, there is little scientific literature currently available to substantiate the clinical use of either in human patients.
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