Coronary chronic total occlusions (CTOs) are frequently identified during coronary angiography and remain the most challenging lesion group to treat. Patients with CTOs are frequently left ...unrevascularized due to perceptions of high failure rates and technical complexity even if they have symptoms of coronary disease or ischemia. In this review, the authors describe a North American contemporary approach for percutaneous coronary interventions for CTO. Two guide catheters are placed to facilitate seamless transition between antegrade wire–based, antegrade dissection re-entry–based, and retrograde (wire or dissection re-entry) techniques, the “hybrid” interventional strategy. After dual coronary injection is performed, 4 angiographic parameters are assessed: 1) clear understanding of location of the proximal cap using angiography or intravascular ultrasonography; 2) lesion length; 3) presence of branches, as well as size and quality of the target vessel at the distal cap; and 4) suitability of collaterals for retrograde techniques. On the basis of these 4 characteristics, an initial strategy and rank order hierarchy for technical approaches is established. Radiation exposure, contrast utilization, and procedure time are monitored throughout the procedure, and thresholds are established for intraprocedural strategy conversion to maximize safety, efficiency, and effectiveness.
Introduction: Systemic inflammation may be one of the mechanisms mediating the association between ambient air pollution and cardiovascular morbidity and mortality. Interleukin-6 (IL-6) and ...fibrinogen are biomarkers of systemic inflammation that are independent risk factors for cardiovascular disease. Objective: We investigated the association between ambient air pollution and systemic inflammation using baseline measurements of IL-6 and fibrinogen from controlled human exposure studies. Methods: In this retrospective analysis we used repeated-measures data in 45 nonsmoking subjects. Hourly and daily moving averages were calculated for ozone, nitrogen dioxide, sulfur dioxide, and particulate matter ≤ 2.5 µm in aerodynamic diameter ($PM_{2.5}$). Linear mixed-model regression determined the effects of the pollutants on systemic IL-6 and fibrinogen. Effect modification by season was considered. RESULTS: We observed a positive association between IL-6 and O₃ 0.31 SD per O₃ interquartile range (IQR); 95% confidence interval (CI), 0.08-0.54 and between IL-6 and SO₃ (0.25 SD per SO₂ IQR; 95% CI, 0.06-0.43). We observed the strongest effects using 4-day moving averages. Responses to pollutants varied by season and tended to be higher in the summer, particularly for O₃ and$PM_{2.5}$. Fibrinogen was not associated with pollution. Conclusions: This study demonstrates a significant association between ambient pollutant levels and baseline levels of systemic IL-6. These findings have potential implications for controlled human exposure studies. Future research should consider whether ambient pollution exposure before chamber exposure modifies IL-6 response.
OBJECTIVE:The aim of this study was to assess the impact of a new workers’ compensation medical assessment model on loss of earnings (LOE) benefits duration.
METHODS:A medical assessment model was ...introduced incorporating return to work planning and inclusion of the workerʼs treating physician. Impact of the program on LOE benefit duration was assessed using a quasi-experimental pre–post study design. Cox PH multivariable regression was adjusted for age, gender, injury severity, time to referral, and industry.
RESULTS:The study population comprised 3146 workers1794 assessed pre-intervention and 1574 assessed after introduction of the new model. There was a significant reduction in LOE benefit duration for workers assessed in the new model (hazard ratio 1.33, 95% confidence interval 1.23–1.43).
CONCLUSIONS:The probability of being off LOE benefits for workers assessed in the new program was 33% greater than for workers assessed in the prior program.
A young woman concerned about mercury Kales, Stefanos N; Thompson, Aaron M S
Canadian Medical Association journal (CMAJ),
2016-Feb-02, 2016-02-02, 20160202, Letnik:
188, Številka:
2
Journal Article
Recenzirano
Odprti dostop
The patient should be asked about potential sources of elemental, inorganic and organic mercury (Appendix 1, available at www.cmaj.ca/lookup/ suppl/doi:10.1503/cmaj.150669/-/DC1).1 A dietary history ...documenting the types and amount of fish consumed (especially large predatory fish, such as tuna, swordfish and shark) will provide information on potential exposure to organic mercury (methylmercury). Dental amalgam releases small amounts of elemental mercury vapour. Therefore, the physician should inquire about the number and integrity of the patient's fillings, her chewing habits and bruxism. In the occupational history, the physician should inquire about working with or around processes involving mercury.1 Inadvertent inhalation of mercury vapour from broken instrumentation or fluorescent light bulbs is another potential, albeit infrequent, source of exposure to elemental mercury.1 Patients may also come into contact with inorganic mercury salts through topical antiseptics on disrupted skin or other tissues. Testing is generally not indicated but may be considered in cases of high consumption of large predatory fish or exposure to mercury vapour (inadvertent or occupational) (Box 1).6 If such testing is clinically indicated, it is prudent to order measurement of both blood and urine mercury levels. Blood mercury primarily reflects methylmercury (from consumption of fish), whereas urine mercury corrected for creatinine concentration primarily reflects exposure to elemental and inorganic mercury.7 Unconventional testing methods (e.g., commercial hair analysis, urine mercury challenge or "provoked" testing using a chelator) should be avoided.8 Before ordering a mercury test, the physician should explain to the patient that laboratory reference ranges are population averages and do not reflect toxicity thresholds. Blood mercury levels are usually less than 25 nmol/L (5 µg/L) among those who eat little fish, whereas levels up to 100 nmol/L (20 µg/L) may be seen in people who eat fish four to seven times a week. Urine mercury levels are also generally below 25 nmol/L (5 µg/L).9 In con- trast, documented clinical toxicity is associated with levels greater than 500 nmol/L (100 µg/L) in urine and 1000 nmol/L (200 µg/L) in blood.10 For prenatal exposure, prospective cohort studies have suggested that the risk of subtle neurocognitive effects may start at maternal blood mercury levels as low as 200 nmol/L (40 µg/L),9 although guidance values are much lower because of the application of safety factors.
We measured the serum levels of myoglobin, total creatine kinase (CK), and the CK myocardial (CK-MB), muscle (CK-MM), and brain (CK-BB) isoenzymes in 37 subjects treated with statins and 43 ...nonstatin-treated controls running the 2011 Boston Marathon. Venous blood samples were obtained the day before (PRE) and within 1 hour (FINISH) and 24 hours after (POST) the race. The hematocrit and hemoglobin values were used to adjust for changes in the plasma volume. The CK distribution was normalized using log transformation before analysis. The exercise-related increase in CK 24 hours after exercise, adjusted for changes in plasma volume, was greater in the statin users (PRE to POST 133 ± 15 to 1,104 ± 150 U/L) than in the controls (PRE to POST 125 ± 12 to 813 ± 137 U/L; p = 0.03 for comparison). The increase in CK-MB 24 hours after exercise was also greater in the statin users (PRE to POST 1.1 ± 3.9 to 8.9 ± 7.0 U/L) than in the controls (PRE to POST 0.0 ± 0.0 to 4.2 ± 5.0 U/L; p <0.05 for comparison). However, the increases in muscle myoglobin did not differ at any point between the 2 groups. Increases in CK at both FINISH and POST race measurements were directly related to age in the statin users ( r2 = 0.13 and r2 = 0.14, respectively; p <0.05) but not in the controls ( r2 = 0.02 and r2 = 0.00, respectively; p >0.42), suggesting that susceptibility to exercise-induced muscle injury with statins increases with age. In conclusion, our results show that statins increase exercise-related muscle injury.
Abstract Purpose Teamwork is essential for ensuring the quality and safety of health care delivery in the intensive care unit (ICU). This article addresses what we know about teamwork, team tasks, ...and team improvement strategies in the ICU to identify the strengths and limitations of the existing knowledge base to guide future research. Methods A keyword search of the PubMed database was conducted in February 2013. Keyword combinations focused on 3 areas: (1) teamwork, (2) the ICU, and (3) training/quality improvement interventions. All studies that investigated teamwork, team tasks, or team interventions within the ICU (ie, intradepartment) were selected for inclusion. Results Teamwork has been investigated across an array of research contexts and task types. The terminology used to describe team factors varied considerably across studies. The most common team tasks involved strategy and goal formulation. Team training and structured protocols were the most widely implemented quality improvement strategies. Conclusions Team research is burgeoning in the ICU, yet low-hanging fruit remains that can further advance the science of teams in the ICU if addressed. Constructs must be defined, and theoretical frameworks should be referenced. The functional characteristics of tasks should also be reported to help determine the extent to which study results might generalize to other contexts of work.
Our purpose was to use 3-dimensional (3D) surface photography to quantitatively measure breast cosmesis within the framework of a randomized clinical trial of conventionally fractionated (CF) and ...hypofractionated (HF) whole breast irradiation (WBI); to identify how 3D measurements are associated with patient- and physician-reported cosmesis; and to determine whether objective measures of breast symmetry varied by WBI treatment arm or transforming growth factor β 1 (TGFβ1) status.
From 2011 to 2014, 287 women age ≥40 with ductal carcinoma in situ or early-stage invasive breast cancer were enrolled in a multicenter trial and randomized to HF-WBI or CF-WBI with a boost. Three-dimensional surface photography was performed at 3 years posttreatment. Patient-reported cosmetic outcomes were recorded with the Breast Cancer Treatment Outcome Scale. Physician-reported cosmetic outcomes were assessed by the Radiation Therapy Oncology Group scale. Volume ratios and 6 quantitative measures of breast symmetry, termed F1-6C, were calculated using the breast contour and fiducial points assessed on 3D surface images. Associations between all metrics, patient- and physician-reported cosmesis, treatment arm, and TGFβ1 genotype were performed using the Kruskal-Wallis test and multivariable logistic regression models.
Among 77 (39 CF-WBI and 38 HF-WBI) evaluable patients, both patient- and physician-reported cosmetic outcomes were significantly associated with the F1C vertical symmetry measure (both P < .05). Higher dichotomized F1C and volumetric symmetry measures were associated with improved patient- and physician-reported cosmesis on multivariable logistic regression (both P ≤ .05). There were no statistically significant differences in vertical symmetry or volume measures between treatment arms. Increased F6C horizontal symmetry was observed in the CF-WBI arm (P = .05). Patients with the TGFβ1 C-509T variant allele had lower F2C vertical symmetry measures (P = .02).
Quantitative 3D image-derived measures revealed comparable cosmetic outcomes with HF-WBI compared with CF-WBI. Our findings suggest that 3D surface imaging may be a more sensitive method for measuring subtle cosmetic changes than global patient- or physician-reported assessments.
Study objective We determine the optimal correction factor for cerebrospinal fluid WBC counts in infants with traumatic lumbar punctures. Methods We performed a secondary analysis of a retrospective ...cohort of infants aged 60 days or younger and with a traumatic lumbar puncture (cerebrospinal fluid RBC count ≥10,000 cells/mm3 ) at 20 participating centers. Cerebrospinal fluid pleocytosis was defined as a cerebrospinal fluid WBC count greater than or equal to 20 cells/mm3 for infants aged 28 days or younger and greater than or equal to 10 cells/mm3 for infants aged 29 to 60 days; bacterial meningitis was defined as growth of pathogenic bacteria from cerebrospinal fluid culture. Using linear regression, we derived a cerebrospinal fluid WBC correction factor and compared the uncorrected with the corrected cerebrospinal fluid WBC count for the detection of bacterial meningitis. Results Of the eligible 20,319 lumbar punctures, 2,880 (14%) were traumatic, and 33 of these patients (1.1%) had bacterial meningitis. The derived cerebrospinal fluid RBCs:WBCs ratio was 877:1 (95% confidence interval CI 805 to 961:1). Compared with the uncorrected cerebrospinal fluid WBC count, the corrected one had lower sensitivity for bacterial meningitis (88% uncorrected versus 67% corrected; difference 21%; 95% CI 10% to 37%) but resulted in fewer infants with cerebrospinal fluid pleocytosis (78% uncorrected versus 33% corrected; difference 45%; 95% CI 43% to 47%). Cerebrospinal fluid WBC count correction resulted in the misclassification of 7 additional infants with bacterial meningitis, who were misclassified as not having cerebrospinal fluid pleocytosis; only 1 of these infants was older than 28 days. Conclusion Correction of the cerebrospinal fluid WBC count substantially reduced the number of infants with cerebrospinal fluid pleocytosis while misclassifying only 1 infant with bacterial meningitis of those aged 29 to 60 days.
Electrospinning is a promising method to construct fused-fiber biomaterial scaffolds for tissue engineering applications, but the efficacy of this approach depends on how substrate topography affects ...cell function. Previously, it has been shown that linear, parallel raised features with length scales of 0.5–2
μm direct cell orientation through the phenomenon of contact guidance, and enhance phenotypic markers of osteoblastic differentiation. To determine how the linear, random raised features produced by electrospinning affect proliferation and differentiation of osteoprogenitor cells, poly(lactic acid) and poly(ethylene glycol)-poly(lactic acid) diblock copolymers were electrospun with mean fiber diameters of 0.14–2.1
μm onto rigid supports. MC3T3-E1 osteoprogenitor cells cultured on fiber surfaces in the absence of osteogenic factors exhibited a lower cell density after 7 and 14 days of culture than cells cultured on spin-coated surfaces, but cell density increased with fiber diameter. However, in the presence of osteogenic factors (2
m
m
β-glycerophosphate, 0.13
m
m l-ascorbate-2-phosphate), cell density after 7 and 14 days of culture on fiber surfaces was comparable to or exceeded spin-coated controls, and alkaline phosphatase activity after 14 days was comparable. Examination of cell morphology revealed that cells grown on fibers had smaller projected areas than those on planar surfaces. However, cells attached to electrospun substrates of 2.1
μm diameter fibers exhibited a higher cell aspect ratio than cells on smooth surfaces. These studies show that topographical factors designed into biomaterial scaffolds can regulate spreading, orientation, and proliferation of osteoblastic cells.
The primary clinical outcome measure for evaluating multiple sclerosis in clinical trials has been Kurtzke's expanded disability status scale (EDSS). New therapies appear to favourably impact the ...course of multiple sclerosis and render continued use of placebo control groups more difficult. Consequently, future trials are likely to compare active treatment groups which will most probably require increased sample sizes in order to detect therapeutic efficacy. Because more responsive outcome measures will be needed for active arm comparison studies, the National Multiple Sclerosis Society's Advisory Committee on Cinical Trials of New Agents in Multiple Sclerosis appointed a Task Force that was charged with developing improved clinical outcome measures. This Task Force acquired contemporary clinical trial and historical multiple sclerosis data for meta-analyses of primary and secondary outcome assessments to provide a basis for recommending a new outcome measure. A composite measure encompassing the major clinical dimensions of arm, leg and cognitive function was identified and termed the multiple sclerosis functional composite (MSFC). The MSFC consists of three objective quantitative tests of neurological function which are easy to administer. Change in this MSFC over the first year of observation predicted subsequent change in the EDSS, suggesting that the MSFC is more sensitive to change than the EDSS. This paper provides details concerning the development and testing of the MSFC.
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