Pulmonary embolism (PE) is a rare yet serious postoperative complication for lung transplant recipients (LTRs). The association between timing and severity of PE and the development of chronic ...allograft lung dysfunction (CLAD) has not been described.
A single-center, retrospective cohort analysis of first LTRs included bilateral or single lung transplants and excluded multiorgan transplants and retransplants. PEs were confirmed by computed tomography angiography or ventilation/perfusion (VQ) scans. Infarctions were confirmed on computed tomography angiography by a trained physician. The PE severity was defined by the Pulmonary Embolism Severity Index (PESI) score, a 30-d post-PE mortality risk calculator, and stratified by low I and II (0-85), intermediate III and IV (85-125), and high V (>125). PE and PESI were analyzed in the outcomes of overall survival, graft failure, and chronic lung allograft dysfunction (CLAD).
We identified 57 of 928 patients (6.14%) who had at least 1 PE in the LTR cohort with a median follow-up of 1623 d. In the subset with PE, the median PESI score was 85 (75.8-96.5). Most of the PESI scores (32/56 available) were in the low-risk category. In the CLAD analysis, there were 49 LTRs who had a PE and 16 LTRs (33%) had infarction. When treating PE as time-dependent and adjusting for covariates, PE was significantly associated with death (hazard ratio HR 1.8; 95% confidence interval CI, 1.3-2.5), as well as increased risk of graft failure, defined as retransplant, CLAD, or death (HR 1.8; 95% CI, 1.3-2.5), and CLAD (HR 1.7; 95% CI, 1.2-2.4). Infarction was not associated with CLAD or death. The PESI risk category was not a significant predictor of death or CLAD.
PE is associated with decreased survival and increased hazard of developing CLAD. PESI score was not a reliable predictor of CLAD or death in this lung transplant cohort.
The scar of patients with left ventricular (LV) nonischemic cardiomyopathy (NICM) and ventricular tachycardia (VT) typically originates at or near the mitral annulus and extends a variable distance ...toward the apex.
To determine whether electrocardiograms of VT with LV apical exit sites would identify patients with larger scars extending a greater distance from the base toward the apex and decreased heart transplant/left ventricular assist device (LVAD)-free survival.
Consecutive patients with LV NICM undergoing VT ablation between May 2008 and April 2011 were studied. All electrocardiograms of spontaneous and induced VT were analyzed. Apical VT was defined as left bundle branch morphology with precordial transition ≥ V5 or right bundle branch morphology with precordial transition ≤ V3. Scar percentage was defined as the area of low voltage divided by the total surface area.
Thirty-two of 76 patients had 1 or more apical VTs. Those with apical VTs had larger percentage of endocardial and epicardial bipolar scars (14.9% vs 8.1%, P = .01, and 15.5% vs 5.5%, P = .03, respectively), scar that, although originating from the periannular region (94.7% of the patients), was more likely to extend apically beyond the basal half (48.3% vs 24.4%, P = .05 endocardial, and 85.7% vs 25.9%, P = .07 epicardial), and worse transplant/LVAD-free survival during a mean follow-up of 332 days (P = .006).
Patients with NICM and apical VTs have larger voltage abnormality extending as contiguous or patchy "scar" from the base further toward the apex and worse transplant/LVAD-free survival. Particular attention should be paid to optimal heart failure management in these patients, with more guarded prognosis.
The aim of this study was to determine (1) the patient-preferred timing characteristics of a system for online patient access to radiologic reports and (2) patient resource needs and preferences ...after exposure to reports.
Adult outpatients from a single imaging center completed researcher-administered electronic questionnaires. Participants were exposed to 3 simulated clinical scenarios and asked to answer questions on the basis of what they thought they would do in each. Scenarios included symptomatology and written radiology reports that were nearly normal, seriously abnormal, and indeterminate, with reports containing typical medical terminology. Participants were asked about preferred timing for online access to reports, communication methods, educational resources, and alternative formats. McNemar's test correlated proportions and generalized estimating equations were used to evaluate responses.
Participants (n = 53) most often preferred immediate access to reports: 32 (60.2%) for the nearly normal scenario, 25 (47.2%) for the seriously abnormal scenario, and 24 (45.3%) for the indeterminate scenario. Three-day delayed access was next most commonly preferred: 15 (28.3%), 19 (35.8%), and 19 (35.8%), respectively. Forty-two participants (79.2%) preferred the portal method of notification over ways they have historically gotten results, with an increased proportion being satisfied with it overall (P < .04). Most would use a variety of educational resources and found alternative lay language conclusions and hyperlinks helpful.
Some outpatients want immediate online access to complete, written radiologic reports and would use multiple resources to understand report contents. Effects of immediate access on provider workflow and on anxiety and autonomy among a diverse population of patients still need to be studied.
Background Ischemic stroke patients benefit most from intravenous thrombolysis when they receive the treatment as quickly as possible after symptom onset. Hospitals participating in the Georgia ...Coverdell Acute Stroke Registry reduced the time from patient arrival to administration of intravenous tissue plasminogen activator. This study evaluates the benefit of reducing door-to-treatment (DTT) time as measured by hospital length of stay (LOS). Methods Data from 3154 ischemic stroke patients treated with intravenous thrombolysis from 2007 to 2013 were analyzed. The impact of door-to-treatment time on patients' length of hospital stay, discharge disposition, ambulatory status at discharge, and bleeding complications was assessed, controlling for patient-, hospital- and event-related characteristics. Results Patients who received intravenous thrombolysis within 30 minutes of hospital arrival had a 19% shorter (95% confidence interval CI: 2%-32%, P value = .04) hospital LOS than those treated for more than 120 minutes after arrival. Patients treated within 60 minutes of arrival were 27% more likely (odds ratio = 1.28, 95% CI: 1.06-1.56, P = .01) to have a better discharge disposition than patients treated after 60 minutes of arrival while having a similar rate of bleeding complications. Conclusions Shortening the door-to-treatment time is associated with a decrease in patient LOS and better patient outcomes. Hospitals should be encouraged to measure, monitor, and reduce DTT time progressively for a better patient outcome.
Background Acute normovolemic hemodilution (ANH) decreases transfusion rates but adds to the complexity of anesthetic management during hepatectomy. A randomized controlled trial was conducted to ...determine if selecting patients for ANH using a transfusion nomogram improves management and resource use compared with selection using extent of resection. Study Design One hundred fourteen patients undergoing partial hepatectomy were randomized to a clinical arm (ANH used for resection of ≥3 liver segments) or a nomogram arm (ANH used for predicted probability of transfusion ≥50% based on a previously validated nomogram). The primary end point was appropriate management, defined as avoidance of ANH in patients at low risk or use of ANH in patients at high risk for allogeneic red blood cell transfusions. Results Between September 2009 and May 2011, 58 patients were randomized to the clinical arm and 56 to the nomogram arm. Demographics, diagnoses, extent of resection, blood loss, and incidence and grade of complications did not differ between the 2 groups. There were no differences in perioperative transfusions or laboratory values. Nomogram-based allocation did not change appropriate management overall (80% vs 76% in the clinical arm; p = 0.65), but did result in comparable perioperative outcomes and a trend toward decreased ANH use (30% vs 47%; p = 0.09), particularly in low blood loss (estimated blood loss ≤400 mL) cases (12% vs 25%; p = 0.04). Conclusions Although allocation of intraoperative management using a transfusion nomogram did not improve appropriate management overall, it more effectively identified low blood loss cases and reduced ANH use in patients least likely to benefit.
Right ventricular infarction can precipitate severe right-to-left shunting and refractory hypoxia from a previously dormant patent foramen ovale. Right ventricle mechanical circulatory support and ...patent foramen ovale closure can play a crucial role in the treatment of hypoxia and right ventricular recovery. We report a case of successful percutaneous patent foramen ovale closure on right ventricle mechanical circulatory support in a patient with right ventricular shock. (Level of Difficulty: Intermediate.)
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Right ventricular infarction can precipitate severe right-to-left shunting and refractory hypoxia from a previously dormant patent foramen ovale. Right…
The literature defining and addressing teamwork and communication is abundant; however, few studies have analyzed the relationship between measures of teamwork and communication and quantifiable ...outcomes. The objectives of this review are: (1) to identify studies addressing teamwork and communication in the operating room in relation to discrete measures of outcome, (2) to create a classification of studies of the relationship between teamwork and communication and outcomes, (3) to assess the implications of these studies, (4) to explore the methodological challenges of teamwork and communication studies in the perioperative setting, and (5) to suggest future research directions.studies in the perioperative setting, and (5) to suggest future research directions.
Background Mortality remains unacceptably high among patients hospitalized for acute stroke. Additional knowledge about factors that contribute to mortality after stroke is important for instituting ...therapies to lower mortality. We sought to determine the factors that predict mortality in patients hospitalized for acute stroke. Methods In all, 1477 consecutively admitted patients with acute stroke in 34 hospitals in the state of Georgia participating in the Paul Coverdell Georgia Stroke Registry during a 3-month period (December 1, 2001-February 28, 2002) were identified by retrospective chart review using primary or secondary International Classification of Diseases, Ninth Revision codes. Of patients, 31% were black, 65% were white, and 58% were women. We determined inhospital mortality after admission for acute stroke in this representative group of patients. Results There were 154 (10%) inhospital deaths among the 1477 patients admitted with acute stroke. Univariate analysis showed that mortality was associated with older age ( P = .0008), stroke type ( P = .0051), Glasgow Coma Scale score less than 9 ( P < .0001), decreased serum albumin ( P = .0001), elevated creatinine ( P = .0067), and elevated blood glucose ( P = .0063). In the multivariate analysis, independent risk factors for mortality after acute stroke included older age ( P = .004), stroke type ( P = .0007), Glasgow Coma Scale score less than 9 ( P < .0001), and decreased serum albumin ( P = .0003). There was no relationship between race and inhospital mortality ( P = .9041). In addition, there was no association between independent predictors and race. Conclusion In addition to previously recognized predictors of inhospital mortality, we found hypoalbuminemia to be an independent predictor of mortality in a biracial cohort of patients with acute stroke.
Objective: The purpose of the study was to assess whether there were sex differences in stroke severity, infarct characteristics, symptoms, or the symptoms-deficit relationship at the time of acute ...stroke presentation. Methods: In a prospective study of 505 patients with first-ever ischemic stroke (the Ischemic Stroke Genetics Study), stroke subtype was centrally adjudicated and infarcts were characterized by imaging. Deficits were assessed by National Institutes of Health Stroke Scale (NIHSS) and stroke symptoms were assessed using a structured interview. Kappa statistics were generated to assess agreement between the NIHSS and the structured interview, and a Chi square test was used to assess agreement between the NIHSS and the structured interview by sex. Results: In all, 276 patients (55%) were men and 229 (45%) were women. Ages ranged from 19 to 94 years (median, 65 years). The mean (±SD) NIHSS score of 3.8 (±4.5) for men and 4.3 (±5.2) for women was similar ( P = .15). No sex difference was observed for the symptoms of numbness, visual deficits, or language. Weakness occurred in a greater proportion of women (69%) than men (59%) ( P = .03). Stroke subtype did not differ significantly between sexes ( P = .79). Infarct size and location were similar for each sex. The association between symptoms and neurologic deficits did not differ by sex. Conclusions: We found no sex difference in stroke severity, stroke subtype, or infarct size and location in patients with incident ischemic stroke. A greater proportion of women presented with weakness; however, similar proportions of men and women presented with other traditional stroke symptoms.
Objective Circadian pattern for the onset of acute ischemic stroke has been described; however, data assessing an association between thrombolytic therapy efficacy and circadian rhythm are limited. ...We assessed the relationship between the time of stroke onset and neurologic outcomes after thrombolytic therapy for acute ischemic stroke in the National Institute of Neurological Disorders and Stroke (NINDS) Recombinant Tissue Plasminogen Activator (rt-PA) Stroke Trial. Methods We conducted exploratory, post hoc analysis of 624 patients in the NINDS rt-PA Stroke Trial. Variables assessed included presenting time of day (4- and 6-hour time blocks), outcome variables, stroke subtypes, treatment assignment, and biological markers. Outcome variables included 3-month mortality, clinical outcome at 3 months, intracranial hemorrhage (ICH), computed tomography lesion volume at 3 months, and deterioration at 24 hours. Results The distribution of patients in the time blocks was balanced between the rt-PA and placebo groups. There was not a clear circadian variation in the stroke onset time. There were no associations detected between stroke onset time and clinical outcome, computed tomography lesion volume, and asymptomatic hemorrhage. Patients treated with rt-PA whose stroke onset was between 0401 and 0800 hours had less symptomatic ICH, whereas those who received rt-PA between 0000 and 0400 hours had a 43% incidence of symptomatic ICH. Patients in the placebo group who had stroke onset between 1801 and 2400 hours had lower chances for neurologic deterioration. Patients who had a stroke between 0001 and 0400 hours had the highest fibrinogen concentrations. Conclusions We did not find a circadian pattern to time of day of stroke onset in the patients included in the NINDS rt-PA Stroke Trial. The effect of rt-PA treatment on favorable outcome was independent of time of day of stroke onset. Patients who received rt-PA between 4 and 8 am were less likely to develop symptomatic ICH.
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