Abstract Background Cryoballoon ablation of atrial fibrillation (AF) involves successful electrical pulmonary vein isolation (PVI). Pulmonary vein (PV) ostial occlusion with cryoballoon is ...classically assessed using PV angiography. A pressure-guided technique to assess ostial occlusion has been evaluated in small cohorts with mixed results. We evaluated the efficacy of this pressure-guided PVI technique and its impact on reducing contrast and fluoroscopy time as compared to the traditional approach. Methods We evaluated patients with paroxysmal AF, who underwent cryoballoon PVI. Patients prior to January 20th, 2013 underwent confirmation of PV occlusion by angiography only. Patients ablated after this time had PV occlusion initially determined by pressure monitoring and further confirmed by contrast injection into the PV in most cases (Pressure-guided PVI). Differences in the volume of contrast used and fluoroscopy time were evaluated. Results 46 patients had pressure-guided PVI and29 patients had occlusion of PV confirmed by angiography alone. Pressure-guided PVI was 99.5% successful in ablating AF, which was non-inferior to traditional method of PV isolation. This technique used an average of 8 cc of contrast and 21.5 min of fluoroscopy time, which was significantly less than the contrast amount used, and fluoroscopy time with angiographic isolation of PV. Conclusion Pressure-guided PVI is an effective method for cryoablation of AF. This method not only significantly reduces the volume of contrast used but also decreases the fluoroscopy without compromising the success of PVI.
Background Our aim was to determine the prevalence of platelet dysfunction using an end point of assembly into a stable thrombus after severe injury. Although the current debate on acute traumatic ...coagulopathy has focused on the consumption or inhibition of coagulation factors, the question of early platelet dysfunction in this setting remains unclear. Study Design Prospective platelet function in assembly and stability of the thrombus was determined within 30 minutes of injury using whole blood samples from trauma patients at the point of care using thrombelastography-based platelet functional analysis. Results There were 51 patients in the study. There were significant differences in the platelet response between trauma patients and healthy volunteers, such that there was impaired aggregation to these agonists. In trauma patients, the median ADP inhibition of platelet function was 86.1% (interquartile range IQR 38.6% to 97.7%) compared with 4.2 % (IQR 0 to 18.2%) in healthy volunteers. After trauma, the impairment of platelet function in response to arachidonic acid was 44.9% (IQR 26.6% to 59.3%) compared with 0.5% (IQR 0 to 3.02%) in volunteers (Wilcoxon nonparametric test, p < 0.0001 for both tests). Conclusions In this study, we show that platelet dysfunction is manifest after major trauma and before substantial fluid or blood administration. These data suggest a potential role for early platelet transfusion in severely injured patients at risk for postinjury coagulopathy.
ACR Appropriateness Criteria Head Trauma Shetty, Vilaas S., MD; Reis, Martin N., MD; Aulino, Joseph M., MD ...
Journal of the American College of Radiology,
06/2016, Letnik:
13, Številka:
6
Journal Article
Recenzirano
Abstract Neuroimaging plays an important role in the management of head trauma. Several guidelines have been published for identifying which patients can avoid neuroimaging. Noncontrast head CT is ...the most appropriate initial examination in patients with minor or mild acute closed head injury who require neuroimaging as well as patients with moderate to severe acute closed head injury. In short-term follow-up neuroimaging of acute traumatic brain injury, CT and MRI may have complementary roles. In subacute to chronic traumatic brain injury, MRI is the most appropriate initial examination, though CT may have a complementary role in select circumstances. Advanced neuroimaging techniques are areas of active research but are not considered routine clinical practice at this time. In suspected intracranial vascular injury, CT angiography or venography or MR angiography or venography is the most appropriate imaging study. In suspected posttraumatic cerebrospinal fluid leak, high-resolution noncontrast skull base CT is the most appropriate initial imaging study to identify the source, with cisternography reserved for problem solving. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Background Expert panels of colorectal surgeons consistently rank anastomotic leak as among the most important quality metrics for colectomies. Nonetheless, most administrative and clinical databases ...do not collect data on anastomotic leaks and rely on reported organ space surgical site infections (OSI) as a proxy for identifying anastomotic leaks. This study questions the validity of using OSI as a surrogate for anastomotic leak. Methods The Upstate New York Surgical Quality Initiative (UNYSQI) is a collaboration of 12 hospitals that prospectively collects colectomy-specific metrics, including anastomotic leak, in addition to standard National Surgical Quality Improvement Program (NSQIP) data, including OSIs. Cases with an organ space infection and/or anastomotic leak were selected from the 2010–2011 UNYSQI database. Patient characteristics and outcomes were compared for cases with organ space infections and anastomotic leaks. Results Overall, 3% of colectomies had a reported organ space infection and 4% had an anastomotic leak. Among cases having anastomotic leaks, only 25% were also coded as having an organ space infection, leaving 75% of anastomotic leaks not captured by the NSQIP database (κ = 0.272; P ≤ .001). Conclusion Organ space infection is a poor surrogate for anastomotic leak, resulting in grossly underestimated leak rates and seemingly represents different postoperative courses. Procedure-specific quality measures for colorectal surgery should include data collection on anastomotic leaks to provide accurate data for use in improving patient care.
Imaging plays an essential role in identifying intracranial injury in patients with traumatic brain injury (TBI). The goals of imaging include (1) detecting injuries that may require immediate ...surgical or procedural intervention, (2) detecting injuries that may benefit from early medical therapy or vigilant neurologic supervision, and (3) determining the prognosis of patients to tailor rehabilitative therapy or help with family counseling and discharge planning. In this article, the authors perform a review of the evidence on the utility of various imaging techniques in patients presenting with TBI to provide guidance for evidence-based, clinical imaging protocols. The intent of this article is to suggest practical imaging recommendations for patients presenting with TBI across different practice settings and to simultaneously provide the rationale and background evidence supporting their use. These recommendations should ultimately assist referring physicians faced with the task of ordering appropriate imaging tests in particular patients with TBI for whom they are providing care. These recommendations should also help radiologists advise their clinical colleagues on appropriate imaging utilization for patients with TBI.
Background Predicting refractory coagulopathy early in resuscitation of injured patients may decrease a leading cause of preventable death. We hypothesized that clot strength (G) measured by ...point-of-care rapid thrombelastography (r-TEG) on arrival in the emergency department can predict massive transfusion (MT) and coagulation-related mortality (MT-death). Methods Trauma alerts/activations from May 2008 to September 2010 were reviewed. The variables included the following: age, sex, injury severity score (ISS), systolic blood pressure (SBP), base deficit (BD), traditional coagulation tests (international normalized ratio (INR, partial thromboplastin time PTT), TEG-derived G, and blood products transfused within the first 6 hours. Independent predictors of 2 outcomes (MT ≥10 packed red blood cells units/6 h and MT-related death) were identified using logistic regression. The individual predictive values of BD, INR, PTT, and G were assessed comparing the areas under the receiver operating characteristic curves (AUC ROC), while adjusting for age, ISS, and SBP. Results Among the 80 study patients, 48% required MT, and 21% died of MT-related complications. INR, ISS, and G were independent predictors of MT, whereas age, ISS, SBP, and G were independently associated with MT-death. The predictive power for outcome MT did not differ among INR (adjusted AUC ROC = 0.92), PTT (AUC ROC = 0.90, P = .41), or G (AUC ROC = 0.89, P = .39). For outcome MT-death, G had the greatest adjusted AUC ROC (0.93) compared with the AUC ROC for BD (0.87, P = .05), INR (0.88, P = .11), and PTT (0.89; P = .19). Conclusion These data suggest that the point-of-care TEG parameter clot strength (G) provides consistent, independent prediction of MT and MT-death early in the resuscitation of injured patients.
A 17 year-old man presented to the emergency department with signs and symptoms of a peritonsillar abscess. His trismus was sopronounced that it was too difficult to drain the abscess under dynamic ...ultrasound guidance. It was suggested that localization of the abscess with ultrasound be used concurrently with video laryngoscopy. The ultrasound was used to localize the abscess and visualize its depth. The laryngoscope was then used to visualize the exact spot, where the ultrasound probe characterized the abscess. The probe was then removed, and a needle attached to a syringe was used in its place. Drainage was facilitated using the video laryngoscope in the oral cavity. Seven milliliters of pus was removed, and the patient drastically improved after the procedure.
Objectives We sought to describe the prevalence of restrictive lung function in structural congenital heart disease and to determine the effect of cardiothoracic surgical intervention. Methods The ...data from a retrospective review of the spirometry findings from pediatric patients with structural congenital heart disease were compared with the data from 220 matched controls. Restrictive lung function was defined as a forced vital capacity of <80%, with a preserved ratio of the forced expiratory volume in the first second to forced vital capacity of >80%. Results Of the children with congenital heart disease, 20% met the criteria for restrictive lung function compared with 13.2% of the controls ( P = .03). The prevalence in those with congenital heart disease without a surgical history was similar to that of the controls (odds ratio, 0.62; 95% confidence interval, 0.34-1.13). Restrictive lung function was more likely if surgical intervention had occurred within the first year of life (odds ratio, 1.96; 95% confidence interval, 1.08-3.55; P < .0001). Those who had undergone both sternotomy and thoracotomy had a greater prevalence of restrictive lung function than those who had undergone sternotomy or thoracotomy alone (54.2% vs 25.6% and 23.5%, respectively; P < .0001). The prevalence of restrictive lung function increased significantly with each additional surgical intervention (odds ratio, 1.61; 95% confidence interval, 1.29-2.01; P < .0001). Conclusions Restrictive lung function was more prevalent in those with congenital heart disease after cardiothoracic surgical intervention than in the controls or patients without surgical intervention. The prevalence was also greater with surgical intervention at an earlier age. The risk was equivalent when sternotomy alone was compared with thoracotomy alone but was significantly greater when both sternotomy and thoracotomy were performed. The risk increased with each additional surgery performed.
Electrocardiographic screening of intercollegiate athletes is controversial because the costs and yield are not well defined. Both the American Heart Association (AHA) and the European Society of ...Cardiology (ESC) have different criteria for screening, partly because the populations being screened are different.
The purpose of this study was to determine the cost and yield of a 5-year ECG screening program at a United States Division I college.
At the University of Virginia, all 1,473 competitive athletes over the course of 5 years were screened with history and physical and with ECGs using ESC guidelines with follow-up testing as dictated by clinical symptoms and ECG findings.
History and physical alone uncovered five significant cardiac abnormalities. ECGs were abnormal in 275 (19%), resulting in 359 additional tests. Additional testing confirmed eight significant cardiac abnormalities that were not found by history and physical: 1 bicuspid aortic valve, 4 rapidly conducting accessory pathways, 1 long QT patient, 1 with frequent premature ventricular contractions and low ejection fraction, and 1 with frequent premature ventricular contractions but normal ejection fraction. No cases of hypertrophic cardiomyopathy were found. Total cost of the program was US $894,870. Cost of history and physical screening alone was $343,725 or $68,745 per finding. The marginal cost of adding ECG screening, including resulting tests and procedures. was US$551,145 or US$68,893 per additional finding.
ECG screening of U.S. college athletes can uncover significant cardiac pathology not discovered by history and physical alone. Although ECG screening also results in many false positives resulting in additional tests, the overall cost per diagnosis of adding ECG screening is similar to that of history and physical screening alone.
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