Detection of viral genome in rejecting cardiac transplant patients has been reported, with coxsackievirus and adenovirus causing premature graft failure. Recently, parvovirus B19 (PVB19) genome in ...myocardial samples has been increasingly reported, but its role in cardiac pathology and effect on transplant graft survival are unknown. The objectives of this study were to determine if changes in the viruses identified in the myocardium represent an epidemiologic shift in viral myocardial disease and whether PVB19 adversely affects transplant graft survival.
From September 2002 to December 2005, nested polymerase chain reaction was used to evaluate endomyocardial biopsy specimens for 99 children (aged 3 weeks-18 years) with heart transplants for the presence of viral genome. Cellular rejection was assessed by histology of specimens. Transplant coronary artery disease (TCAD) was diagnosed by coronary angiography or histopathology.
Specimens from 700 biopsies were evaluated from 99 patients; 121 specimens had viral genome, with 100 (82.6%) positive for PVB19, 24 for Epstein-Barr virus (EBV; 7 positive for PVB19 and EBV), 3 for CMV, and 1 for adenovirus. Presence of PVB19 genome did not correlate with rejection score, nor did a higher viral copy number. Early development of advanced TCAD (p < 0.001) occurred in 20 children with persistent PVB19 infection (> 6 months).
PVB19 is currently the predominant virus detected in heart transplant surveillance biopsy specimens, possibly representing an epidemiologic shift. Cellular rejection does not correlate with the presence or quantity of PVB19 genome in the myocardium, but children with chronic PVB19 infection have increased risk for earlier TCAD, supporting the hypothesis that PVB19 negatively affects graft survival.
Advance knowledge about changes in multiple dimensions of health related quality of life (HRQoL) among older adults receiving long-term services and supports (LTSS) over time and across settings.
A ...prospective, observational, longitudinal cohort design.
Nursing homes (NHs), assisted living facilities (ALFs), community.
A total of 470 older adults who were first-time recipients of LTSS.
Single-item quality-of-life measure assessed every 3 months over 2 years. HRQoL domains of emotional status, functional status, and social support were measured using standardized instruments.
Multivariable mixed effects model with time varying covariates revealed that quality-of-life ratings decreased over time (P < .001). Quality-of-life ratings were higher among enrollees with fewer depressive symptoms (P < .001), higher general physical function (P < .001), enhanced emotional well-being (P < .001), and greater social support (P = .004). Ratings also were higher among those with increased deficits in activities of daily living (P = .02). Ratings were highest among enrollees who received LTSS from ALFs, followed by NHs, then home and community-based services (H&CBS), but only findings between ALFs and H&CBS were statistically significant (P < .001). Finally, ratings tended to decrease over time among enrollees with greater cognitive impairment and increase over time among enrollees with less cognitive impairment (P < .001).
Findings advance knowledge regarding what is arguably the most important outcome of elderly LTSS recipients: quality of life. Understanding associations between multiple HRQoL domains and quality of life over time and directly from LTSS recipients represents a critical step in enhancing care processes and outcomes of this vulnerable population.
Background A severe shortage of available donor organs has created an impetus to use extended criteria organs for heart transplantation. Although such attempts increase donor organ availability, they ...may result in an adverse donor-recipient risk profile. The TransMedics Organ Care System (OCS) (TransMedics, Inc, Boston) allows preservation of the donor heart by perfusing the organ at 34°C in a beating state, potentially reducing the detrimental effect of cold storage and providing additional assessment options. We describe a single-center experience with the OCS in high-risk heart transplant procedures. Methods Thirty hearts were preserved using the OCS between February 2013 and January 2014, 26 of which (86.7%) were transplanted. Procedures were classified as high risk based on (1) donor factors, ie, transport time more than 2.5 hours with estimated ischemic time longer than 4 hours, left ventricular ejection fraction (LVEF) less than 50%, left ventricular hypertrophy (LVH), donor cardiac arrest, alcohol/drug abuse, coronary artery disease or (2) recipient factors, ie, mechanical circulatory support or elevated pulmonary vascular resistance (PVR), or both. Results Donor and recipient age was 37 ± 12 years and 43 ± 13 years, respectively. Allograft cold ischemia time was 85 ± 17 minutes and OCS perfusion time was 284 ± 90 minutes. The median intensive care unit stay was 6 days. One death (3.8%) was observed over the follow-up: 257 ± 116 (109–445 days). There was preserved allograft function in 92% of patients, with a mean LVEF of 64% ± 5%. Conclusions Use of the OCS is associated with markedly improved short-term outcomes and transplant activity by allowing use of organs previously not considered suitable for transplantation or selection of higher risk recipients, or both.
Clinical trials demonstrated that women treated for breast cancer with anthracycline or trastuzumab are at increased risk for heart failure and/or cardiomyopathy (HF/CM), but the generalizability of ...these findings is unknown. We estimated real-world adjuvant anthracycline and trastuzumab use and their associations with incident HF/CM.
We conducted a population-based, retrospective cohort study of 12,500 women diagnosed with incident, invasive breast cancer from January 1, 1999 through December 31, 2007, at eight integrated Cancer Research Network health systems. Using administrative procedure and pharmacy codes, we identified anthracycline, trastuzumab, and other chemotherapy use. We identified incident HF/CM following chemotherapy initiation and assessed risk of HF/CM with time-varying chemotherapy exposures vs no chemotherapy. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) with adjustment for age at diagnosis, stage, Cancer Research Network site, year of diagnosis, radiation therapy, and comorbidities.
Among 12 500 women (mean age = 60 years, range = 22-99 years), 29.6% received anthracycline alone, 0.9% received trastuzumab alone, 3.5% received anthracycline plus trastuzumab, 19.5% received other chemotherapy, and 46.5% received no chemotherapy. Anthracycline and trastuzumab recipients were younger, with fewer comorbidities than recipients of other chemotherapy or none. Compared with no chemotherapy, the risk of HF/CM was higher in patients treated with anthracycline alone (adjusted HR = 1.40, 95% CI = 1.11 to 1.76), although the increased risk was similar to other chemotherapy (adjusted HR = 1.49, 95% CI = 1.25 to 1.77); the risk was highly increased in patients treated with trastuzumab alone (adjusted HR = 4.12, 95% CI = 2.30 to 7.42) or anthracycline plus trastuzumab (adjusted HR = 7.19, 95% CI = 5.00 to 10.35).
Anthracycline and trastuzumab were primarily used in younger, healthier women and associated with increased HF/CM risk compared with no chemotherapy. This population-based observational study complements findings from clinical trials on cancer treatment safety.
Background:
Post-acute home health-care (HHC) services provide a unique opportunity to train and support family caregivers of older adults returning home after a hospitalization. To enhance ...family-focused training and support strategies, we must first understand caregivers’ experiences.
Objective:
To explore caregivers’ experiences regarding training and support for managing older adults’ physical functioning (PF) needs in the post-acute HHC setting.
Method:
We conducted a qualitative descriptive study using semi-structured telephone interviews of 20 family caregivers. Interviews were recorded, transcribed, and analyzed using conventional content analysis.
Results:
We identified the following primary categories: facilitators to learning (eg, past experience, learning methods), barriers to learning (eg, learning on their own, communication, timing/logistics, preferred information and timing of information delivery), and interactions with HHC providers (eg, positive/negative interactions, provider training and knowledge).
Conclusion:
Caregivers were responsive to learning strategies to manage older adults’ PF needs and, importantly, voiced ideas to improve family-focused training and support. HHC providers can use these findings to tailor training and support of family caregivers in the post-acute HHC setting.
Ultra-cold neutrons (UCN), neutrons with energies low enough to be confined by the Fermi potential in material bottles, are playing an increasing role in measurements of fundamental properties of the ...neutron. The ability to manipulate UCN with material guides and bottles, magnetic fields, and gravity can lead to experiments with lower systematic errors than have been obtained in experiments with cold neutron beams. The UCN densities provided by existing reactor sources limit these experiments. The promise of much higher densities from solid deuterium sources has led to proposed facilities coupled to both reactor and spallation neutron sources. In this Letter we report on the performance of a prototype spallation neutron-driven solid deuterium source. This source produced bottled UCN densities of 145±7 UCN/cm3, about three times greater than the largest bottled UCN densities previously reported. These results indicate that a production UCN source with substantially higher densities should be possible.
Objectives This study sought to evaluate the outcome and prevalence of viral endomyocardial infection after cardiac transplantation. Background Viral myocardial infection causes heart failure, but ...its role after cardiac transplantation is unclear. We hypothesized that viral infection of the cardiac allograft reduces graft survival. Methods Between June 1999 and November 2004, 94 pediatric cardiac transplant patients were screened for the presence of viral genome in serial endomyocardial biopsies (EMBs) using polymerase chain reaction (PCR) assays. Graft loss, advanced transplant coronary artery disease (TCAD), and acute rejection (AR) were compared in the PCR-positive (n = 37) and PCR-negative (n = 57) groups, using time-dependent Kaplan-Meier and Cox regression analyses. From November 2002 to November 2004, intravenous immunoglobulin therapy (IVIG) was administered to patients with PCR-positive EMBs. The outcomes of the IVIG-treated, PCR-positive patients (n = 20) were compared with IVIG-untreated, PCR-positive patients (n = 17). Results Viral genomes were detected in EMBs from 37 (39%) patients; parvovirus B19, adenovirus, and Epstein-Barr virus (EBV) were the most common. The PCR-positive group (n = 37, 25% graft loss at 2.4 years) had decreased graft survival (p < 0.001) compared with the PCR-negative group (n = 57, 25% graft loss at 8.7 years) and developed advanced TCAD prematurely (p = 0.001). The number of AR episodes was similar in both groups. On multivariate analysis, presence of viral genome was an independent risk factor for graft loss (relative risk: 4.2, p = 0.015). The time to advanced TCAD after becoming PCR-positive was longer in the IVIG-treated patients (p = 0.03) with a trend toward improved graft survival (p = 0.06). Conclusions Viral endomyocardial infection is an independent predictor of graft loss in pediatric cardiac transplant recipients. This effect appears to be mediated through premature development of advanced TCAD. IVIG therapy in this subgroup may improve survival and merits further investigation.
Importantly, many pain mitigation interventions can be offered for little or no cost. Even for those with costs, the costs may be offset by avoiding the costs of subsequent harm from unmitigated pain ...and fear, including the negative impact on health outcomes due to vaccine hesitancy and noncompliance with other health care interventions, and the costs for treatment of needle fears that have developed due to poorly managed pain. Performance metrics can include clinical indicators (e.g., pain intensity, fear intensity), process indicators (e.g., use of pain interventions, compliance with vaccination) and conceptual indicators (e.g., knowledge, satisfaction). Appendix 5 (available at www.cmaj.ca/lookup/suppl/ doi:10.1503/cmaj.150391/-/DC1) and a global vaccine safety research network (https://brighton collaboration.org)26 offer some sample tools for assessing pain and related outcomes, and documenting pain interventions used. Data are needed on the painfulness of different vaccines (including their route of administration), aspects of vaccine injection technique (e.g., speed of injection and injection in a single limb for multiple vaccine injections), and vaccine formulations and delivery systems that minimize pain. Given the potential role of memory for pain and fear in subsequent experiences of pain,27 research is needed to examine the efficacy of interventions for memory reframing. Studies on the impact of pain interventions on future pain and vaccine compliance are also warranted to show the long-term impact of pain interventions. Affiliations: Leslie Dan Faculty of Pharmacy (Taddio), University of Toronto, and The Hospital for Sick Children, Toronto, Ont.; Department of Psychology (C. Meghan McMurtry PhD), University of Guelph, Children's Health Research Institute, and Department of Paediatrics, Western University, London, Ont.; Mount Sinai Hospital (Shah), and Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Rebecca Pillai Riddell PhD), York University, Toronto, Ont.; Departments of Pediatrics (Christine T. Chambers PhD), and Psychology and Neuroscience, Dalhousie University, and Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS; Center for Child Health, Behavior and Development (Melanie Noel PhD), Seattle Children's Research Institute, Seattle, Wash.; Department of Pediatrics (MacDonald), Dalhousie University, IWK Health Centre and Canadian Center for Vaccinology, Halifax, NS; Centre for Effective Practice (Rogers), and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont.; Immunize Canada (Bucci), Canadian Public Health Association, Ottawa, Ont.; Child and Adolescent Health Program Committee (Mousmanis), The College of Family Physicians of Canada, Mississauga, Ont.; Alberta Health Services (Lang), and Cumming School of Medicine, University of Calgary, Calgary, Alta.; Departments of Pediatrics (Scott A. Halperin MD), and Microbiology and Immunology, and Canadian Center for Vaccinology, Dalhousie University, IWK Health Centre, Halifax, NS; College of Pharmacy (Susan Bowles PharmD), Dalhousie University, Halifax, NS; Immunization Programs and Vaccine Preventable Diseases Service (Halpert), BC Centre for Disease Control, Vancouver, BC; Department of Paediatrics (Ipp), The Hospital for Sick Children, and Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Asmundson), Faculty of Arts, University of Regina, Regina, Sask.; Departments of Paediatrics (Michael J. Rieder MD PhD), Physiology and Pharmacology, and Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Canadian Family Advisory Network (Robson), Toronto, Ont.; E.M. Uleryk Consulting (Uleryk), Mississauga, Ont.; Department of Psychology (Martin M. Antony PhD), Ryerson University, Toronto, Ont.; Toronto Public Health (Dubey), Toronto, Ont.; Communicable Disease Control (Hanrahan), Alberta Health Services, Edmonton, Alta.; Bodhi Seed Center for Healing and Conscious Living (Donna Lockett PhD), Milton, Ont.; Department of Emergency Medicine (Scott), IWK Health Centre, Halifax, NS; Science Directorate (Elizabeth Votta Bleeker PhD), Canadian Psychological Association, Ottawa, Ont.
Mechanical device failure can be life-threatening and is becoming increasingly important as left ventricular assist devices (LVADs) are being used for longer periods as a bridge to transplantation ...(period lengthening due to donor shortage) or recovery, or as destination therapy. However, its incidence and clinical management have not been widely studied.
We investigated the incidence and management of major device failure for a total of 102 Thoratec/TCI HeartMate and Thoratec PVAD devices implanted at our institution since 1995.
The cumulative probability of device failure was 6%, 12%, 27% and 64% at 6 months, 1 year, 18 months and 2 years, respectively. Major failure occurred in 8 (7.8%) patients. Four patients presented as emergency cases with vented electric (VE) failure, and 3, with failure due to a seized motor, were supported on the pneumatic driver to explantation, transplantation or device change. Another patient had a ruptured pump diaphragm and was maintained for 12 hours, but died of a Type B aortic dissection. Four patients underwent elective device change, including 2 of a VE pump, 1 with inlet valve regurgitation and fractured power cable at 414 days, and 1 with inlet valve regurgitation at 656 days, all of whom underwent transplantation or explantation. One patient with VE failure was maintained on the pneumatic driver, then underwent Thoratec paracorporeal ventricular assist device (PVAD) implantation and was transplanted. One Thoratec PVAD patient developed LVAD thrombus, underwent pump replacement, and was transplanted. A further patient on the implantable pneumatic (IP) HeartMate developed a pneumoperitoneum due to a leak at the junction of the pneumatic driveline, which was repaired by inserting a new driveline, and underwent heart/kidney transplantation.
Life-threatening mechanical device failure is not uncommon and increases with time, but can be managed successfully in most patients. Improvements in design and manufacture should further enhance outcome with LVADs.
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