Introductionː Postoperative cognitive dysfunction has long-term consequences of increased mortality, loss of autonomy, and prolonged hospitalization. We sought to determine whether exposing patients ...to modafinil may attenuate or prevent this devastating syndrome from affecting the elderly postoperatively.Methodsː Adults aged 65 and older and American Society of Anesthesiologists (ASA) I-III physical status scheduled for elective noncardiac/non-neurosurgical surgery were included. Subjects were tested with the Trail Making Test (TMT) and Rey Auditory Visual Learning Test (RAVLT) preoperatively as well as in the immediate postoperative period, at 1 week, and at 3 months. After baseline testing, patients were randomized into three groups: 0) placebo pre and post-procedure; 1) modafinil only pre-procedure and placebo post-procedure; and 2) modafinil pre and post-procedure. A nonsurgical control group was also utilized.Resultsː Seventy-six subjects completed the trial 3 months post-surgery. The baseline RAVLT obtained was analyzed with 2-way ANOVA with repeated measures and showed improvement in learning in all groups (p = 0.03). At 1-week post-surgery, Group 0 subjects demonstrated no learning improvement in the RAVLT. However, there was a significant improvement in learning in both groups that received modafinil (p<0.01), and in the nonsurgical controls (p<0.01). This learning benefit normalized at 3 months.Conclusionː In this prospective, double-blind, placebo-controlled trial, we found that patients who received modafinil showed improvement in the RAVLT at 1 week. However, this learning benefit normalized at 3 months. Further study should examine dose effect, timing, and route of administration to determine if the effect can be enhanced and if in fact, wakefulness is improved post-surgically.
Prosthetic valve endocarditis (PVE) is an uncommon complication after heart valve replacement surgery that can result in increased morbidity and mortality. Current guidelines for management of PVE ...recommend antibiotic therapy followed by surgical valve replacement. The number of aortic valve replacements is expected to rise in the coming years with the expanded indications for use of transcatheter aortic valve replacement (TAVR) in patients with low, intermediate, and high surgical risk, as well as in patients with a failed aortic bioprosthetic valve. Current guidelines do not address the use of valve-in-valve (ViV) TAVR for management of PVE in patients who are at high risk for surgical intervention. The authors present a case of a patient with aortic valve PVE after surgical aortic valve replacement (SAVR); he was treated with valve-in-valve (ViV) TAVR due to the high surgical risk. The patient was discharged, but he returned to the hospital with PVE and valve dehiscence 14 months after ViV TAVR, after which he successfully underwent re-operative SAVR.
Introduction Management of post-operative pain after cardiac surgery continues to be a challenge; inadequate management of pain can lead to increased morbidity, impaired physical function with ...potential delay in recovery, increased perioperative and chronic opioid consumption, increased cost of care, and a decreased quality of life. This study aimed to evaluate the effect of adding buprenorphine and magnesium to bupivacaine for superficial parasternal intercostal plane blocks (SPIB) on pain and opioid consumption in the first 24 hours after coronary artery bypass grafting (CABG). Methods Patients undergoing CABG were divided into the following four groups: saline SPIB, SPIB with bupivacaine (BPVC), SPIB with bupivacaine and buprenorphine (BPVC+BPRN), and SPIB with bupivacaine, buprenorphine, and magnesium (BPVC+BPRN+MG). The primary outcomes were pain scores and opioid consumption after SPIB; the secondary outcomes were post-operative nausea and vomiting, time to extubation, and length of stay (LOS) in the intensive care unit and hospital. Results One hundred thirty-four eligible patients undergoing CABG were randomized to either the saline (n=27), BPVC (n=20), BPVC+BPRN (n=24), or BPVC+BPRN+MG (n=29) group. All of the intervention groups combined (BPVC, BPVC+BPRN, and BPVC+BPRN+MG) had decreased pain scores and decreased opioid consumption when compared to the saline group; although not statistically significant, visual analog scale (VAS) scores trended downward at most time points with BPVC versus saline, BPVC+BPRN versus BPVC, and BPVC+BPRN+MG versus BPVC+BPRN. There was no difference among the study groups in the incidence of post-operative nausea and/or vomiting (PONV), time to extubation, hospital LOS, and ICU LOS. Conclusion In this prospective, double-blind, placebo-controlled trial, we found that SPIB with local anesthetic is effective at reducing VAS scores and opioid consumption after CABG. Further study is needed to determine whether the addition of adjuvants can further improve pain control and opioid consumption.
The goals of cross-product reuse in a software product line (SPL) are to mitigate production costs and improve the quality. In addition to reuse across products, due to the evolutionary development ...process, a SPL also exhibits reuse across releases. In this paper, we empirically explore how the two types of reuse—reuse across products and reuse across releases—affect the quality of a SPL and our ability to accurately predict fault proneness. We measure the quality in terms of post-release faults and consider different levels of reuse across products (i.e., common, high-reuse variation, low-reuse variation, and single-use packages), over multiple releases. Assessment results showed that quality improved for common, low-reuse variation, and single-use packages as they evolved across releases. Surprisingly, within each release, among preexisting (‘old’) packages, the cross-product reuse did not affect the change and fault proneness. Cross-product predictions based on pre-release data accurately ranked the packages according to their post-release faults and predicted the 20 % most faulty packages. The predictions benefited from data available for other products in the product line, with models producing better results (1) when making predictions on smaller products (consisting mostly of common packages) rather than on larger products and (2) when trained on larger products rather than on smaller products.
There is a discrepancy between the marked reduction in adverse events with statins and their modest effect on atheroma regression. We hypothesized that, in a Western population, high-dose ...atorvastatin will result in alterations in coronary atheroma composition, phenotype, and microvascular function.
Serial coronary radiofrequency intravascular ultrasound (VH-IVUS), coronary flow reserve (CFR), and hyperemic microvascular resistance (HMR) were performed at baseline and after 6 months of treatment with 80 mg atorvastatin in 20 patients with moderate coronary artery disease (CAD). For each VH-IVUS frame (n = 2249), changes in total plaque atheroma, composition, and phenotype (pathological intimal thickening, fibrotic plaque, fibroatheroma), and serial remodeling were assessed.
Total serum cholesterol decreased from 186.0 mg/dL (interquartile range IQR, 168.0 to 212.5 mg/dL) to 139.0 mg/dL (IQR, 124.3 to 151.3 mg/dL). Percent atheroma volume did not change significantly (-0.5% IQR, -2.8% to 3.7%; P=.90) and serial remodeling analysis demonstrated 40% constrictive, 24% incomplete, and 36% expansive patterns. There was a trend toward lower percent fibrous tissue (-3.47 ± 1.78%; P=.07) and percent fibro-fatty tissue (-2.52 ± 1.24%; P=.06) and increase in percent necrotic core (+2.74 ± 1.65%; P=.11) and percent dense calcium (+1.99 ± 0.81; P=.02), which translated into significantly less pathological intimal thickening (4% vs 12%; P<.0001) and more fibroatheromas (67% vs 57%; P<.0001) at follow-up compared to baseline. There were modest non-significant improvements in CFR (+0.26 IQR, -0.37 to 0.76; P=.23) and HMR (-0.22 IQR, -0.56 to 0.28; P=.12).
In this pilot study of Western patients with moderate CAD, high-dose atorvastatin resulted in alterations in coronary atheroma composition with corresponding changes in plaque phenotype and modest improvement in coronary microvascular function.
Spontaneous coronary artery dissection (SCAD) is a well-known but infrequent cause of acute coronary syndrome (ACS), and often goes unrecognized. Although management of SCAD is, at times, ...controversial, when a patient presents with ACS, percutaneous coronary intervention (PCI) is frequently necessary. We present a patient with ST-segment elevation myocardial infarction (STEMI) with SCAD that illustrates two important points: use of intracoronary optical coherence tomography to guide PCI, and histologic assessment to provide a unique insight into the etiology of SCAD. Following the case, we briefly review the important aspects of the pathophysiology, epidemiology, diagnosis, and interventional management of SCAD.
Hyperkalemia is a common electrolyte disorder associated with life-threatening cardiac arrhythmias and increased mortality. Patients at greatest risk for hyperkalemia include those with diabetes and ...those with impaired renal function in whom a defect in the excretion of renal potassium may already exist. Hyperkalemia is likely to become more common clinically because angiotensin receptor blockers and angiotensin-converting enzyme inhibitors are increasingly being used in higher doses and are thought to confer cardiovascular and renal protection. Until recently, options for treating hyperkalemia were limited to the use of thiazide and loop diuretics and sodium polystyrene sulfonate. Newer options such as sodium zirconium cyclosilicate will allow for the safe and effective treatment of hyperkalemia while maintaining patients on prescribed renin-angiotensin-aldosterone system inhibitors.
BACKGROUND
Studies of endovascular renal denervation (RDN) have demonstrated significant blood pressure reduction in eligible patients with resistant hypertension. These trials have used stringent ...inclusion and exclusion criteria in patient enrollment, potentially selecting for a small subset of patients with resistant hypertension. In this study, we examined the changes in estimated prevalence of resistant hypertension when using increasingly stringent definitions of resistant hypertension in a fixed population and assessed the generalizability of RDN when applying study criteria to a community-based hypertensive population.
METHODS
A retrospective chart review was done of hypertensive outpatients. Four increasingly stringent interpretations of the American Heart Association definition of resistant hypertension were used to calculate prevalence estimates. Patients eligible for RDN were identified using criteria from SYMPLICITY HTN-3. Demographic and clinical characteristics were compared.
RESULTS
We identified 1,756 hypertensive outpatients; 55.0% were male, 53.9% were white, and subjects had a mean age of 66.6±12.5 years and a body mass index (BMI) of 30.1±10.7kg/m2. Only 14 (0.8%) were eligible for RDN. Among these patients, 10 (71.4%) were female and all were black, with a mean age of 69.9±8.8 and BMI of 35.7±6.6. Congestive heart failure was more common in patients eligible for RDN.
CONCLUSIONS
Patients eligible for RDN based on published studies represent an exceedingly small proportion of the total hypertensive population. Further studies are necessary to determine if the benefits of RDN can be generalized to a broader range of hypertensive patients than those included in previous trials.
Background and Aim
American Society for Gastrointestinal Endoscopy (ASGE) guidelines have proposed criteria to stratify patients into low, intermediate and high risk of choledocholithiasis. The ...criteria include variables that are readily available in clinical practice. The objective of the present study was to prospectively assess the accuracy of these criteria.
Methods
A prospective observational cohort study was conducted at Beth Israel Deaconess Medical Center. All adult patients referred for endoscopic retrograde cholangiopancreatography (ERCP) with suspected choledocholithiasis were considered for inclusion. ASGE criteria were applied, and each patient was categorized as high, intermediate or low risk for choledocholithiasis. Presence of stone at ERCP served as criteria standard.
Results
During the study period, 402 patients met study inclusion criteria and 336 were reported in the final analysis. Of the 244 patients in the high risk for choledocholithiasis group, 185 were found to have stones at ERCP (75.8%, 95% CI 70.2–80.1%). Of the 92 patients in the intermediate risk for choledocholithiasis group, 45 had stones at ERCP (48.9%, 95% CI 38.8–59.1%); P‐value for difference between groups = 0.001. Diagnostic accuracy for choledocholithiasis in the high‐risk group was 69.05%, and for the intermediate group was 39.95%. Presence of choledocholithiasis on pre‐ERCP imaging (OR: 3.6; 95% CI 2.2–6.0; P < 0.01), and bilirubin >1.8 but <4 mg/dL (OR: 1.69; 95% CI 1.0–2.8; P < 0.04) were the strongest predictors of choledocholithiasis. No additional variable that improved accuracy of ASGE criteria was identified.
Conclusion
ASGE criteria stratify patients by risk for choledocholithiasis and can be used in routine clinical practice.
Handoffs have been shown to be a potential cause of communication failures, leading to possible inefficiencies and patient harm. We noticed that our CA-1 residents were struggling with patient ...handoffs and designed this simulation to improve their handoff skills.
This anesthesiology-specific simulation introduced learners to the perioperative handoff process. We designed it for anesthesiology learners, including junior residents, medical students, and student nurse anesthetists. The simulation centered upon an anesthesiology resident taking care of an ICU patient and handing that patient off to another anesthesiology provider, who took the patient to the OR. We charged learners with reviewing the patient's history and hospital course and giving a complete handoff. We evaluated learners on the completeness and quality of the handoff, as well as on their performance during the session.
Twenty-seven learners participated in this handoff simulation. The participants reported that the simulation improved their understanding of the anesthetic implications of medical conditions and gave them a better understanding of the essential elements of a handoff. Learners also indicated that the debriefing portion of the simulation was effective in filling some of their medical knowledge gaps and improving their handoff skills.
This simulation was found to be an effective educational experience for our CA-1 and CA-3 residents, medical students, and student nurse anesthetists. Feedback was positive from all learners. As a result, this simulation will be implemented in the early learning curriculum for all of our CA-1 residents.
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