To evaluate the role of the capnography head-up tilt test (CHUTT) in the diagnosis of syncope in pediatric patients.
The CHUTT is a head-up tilt test with concomitant capnometry. Hyperventilation on ...CHUTT was diagnosed when the patient's end-tidal carbon dioxide pressure (ETPCO2) was </=25 mm Hg. Hyperventilation syncope was diagnosed when three criteria were met: loss of consciousness, ETPCO2 </=25 mm Hg, and no significant drop in blood pressure. The cohort included 65 consecutive children and adolescents (mean age, 14.2 years) who were assessed for syncope by routine investigations and CHUTT.
The cause of the syncope was established in 67% of cases: cardioinhibitory reaction in 17%, vasodepressor in 20%, psychogenic in 22%, and mixed neurally mediated-psychogenic in 8% of the patients. The history indicated a cause of syncope in 40%, the CHUTT in 49%, and a combination of the history and positive CHUTT in 66% of patients. Neither the patients' clinical data nor values of the blood pressure, heart rate, respiratory rate, and ETPCO2 measured during recumbency predicted which patients would manifest hyperventilation or hyperventilation syncope on tilt.
The CHUTT contributes substantially to the diagnosis of syncope in pediatric patients. The CHUTT advances the understanding of the pathophysiological mechanisms of syncope and enables the physician to reassure the patient regarding the essentially benign nature of the condition. Because it is not possible to predict which patients would develop a hyperventilation syncope on the standard tilt test, the modification of this procedure by measuring the ETPCO2 for the assessment of children with syncope should be considered.
The AngioVac (Angiodynamics) system is indicated for the removal of right-sided venous soft thrombi and emboli. This is the first report that demonstrates the AngioVac system can be extended to the ...extraction of right-sided cardiac tumors, in the current case, a pulmonary valve papillary fibroelastoma infected with Streptococcus salivarius and Rothia species. (Level of Difficulty: Advanced.)
Display omitted
Background In a dynamic health care system, strong leadership has never been more important for surgeons. Little is known about how to design and conduct effectively a leadership program specifically ...for surgeons. We sought to evaluate critically a Leadership Development Program for practicing surgeons by exploring how the program's strengths and weaknesses affected the surgeons' development as physician-leaders. Methods At a large academic institution, we conducted semistructured interviews with 21 surgical faculty members who applied voluntarily, were selected, and completed a newly created Leadership Development Program in December 2012. Interview transcripts underwent qualitative descriptive analysis with thematic coding based on grounded theory. Themes were extracted regarding surgeons’ evaluations of the program on their development as physician-leaders. Results After completing the program, surgeons reported personal improvements in the following 4 areas: self-empowerment to lead, self-awareness, team-building skills, and knowledge in business and leadership. Surgeons felt “more confident about stepping up as a leader” and more aware of “how others view me and my interactions.” They described a stronger grasp on “giving feedback” as well as a better understanding of “business/organizational issues.” Overall, surgeon-participants reported positive impacts of the program on their day-to-day work activities and general career perspective as well as on their long-term career development plans. Surgeons also recommended areas where the program could potentially be improved. Conclusion These interviews detailed self-reported improvements in leadership knowledge and capabilities for practicing surgeons who completed a Leadership Development Program. A curriculum designed specifically for surgeons may enable future programs to equip surgeons better for important leadership roles in a complex health care environment.
Abstract Background Short and intermediate term wear rates for highly cross-linked polyethylene (HCLPE) liners in total hip arthroplasty are significantly lower than published rates for traditional ...polyethylene liners. The aim of this study was to report the longest-to-date follow up of for a specific HCLPE liner. Methods A series of 35 total hip arthroplasties using a specific HCLPE liner were reviewed. AP radiographs were reviewed for femoral head penetration, the presence of femoral and/or acetabular osteolysis, long term survival, total wear and wear rates in all patients. Results The average patient age at time of surgery was 70 years with an average follow up of 10 years (118 months, range 7.2 to 13.4` years). The mean wear rate in our cohort was 0.07 mm/year. Total wear was 0.71 mm over the study period. No hips showed evidence of osteolysis in any zones. Survivorship at latest follow up was 100% with all cause revision as an end point. Conclusions The wear rate of HCLPE liners continues to be lower than published wear rates for traditional polyethylene and continues to reaffirm the acceptably low wear rates using HCLPE acetabular liner in primary total hip arthroplasty
Dynamic thin-section computed tomography (CT) was used to evaluate renal cell carcinoma in 80 patients. The lesion was correctly staged with CT in 90% of patients. With use of the dynamic technique, ...the ipsilateral renal vein was depicted in 99% of patients. Extension of the tumor to the renal vein or the inferior vena cava was correctly detected in 18 of 19 patients. Actual depiction of tumor thrombus was a far more accurate indicator of renal vein invasion than was the identification of isolated renal vein enlargement. Dynamic thin-section CT of the kidney should be considered the routine method for comparison studies with other newer cross-sectional techniques in the evaluation of renal cell carcinoma.
Coaching and monetary incentives have been used to modify medical behavior of individuals with several chronic diseases, including asthma. The authors performed a randomized, controlled trial of an ...intervention combining asthma coaching during an emergency department (ED) visit for asthma, and monetary incentive to improve follow-up with primary care providers (PCP).
Subjects were parents of children 2-12 years of age, with Medicaid or no medical insurance, receiving treatment for asthma in the ED. The primary outcome was a verified PCP visit for asthma within two weeks of the index ED visit. All parents received 15 dollars for their time in the ED. Parents in the intervention group were told that they would receive an additional 15 dollars monetary incentive if a PCP visit was completed. The coach engaged in a dialogue with the parent during the ED visit, and discussed the importance and advantages of seeking follow-up care with the child's PCP. All parents received the usual discharge instructions, including advice to see the PCP within three days.
The authors enrolled 92 parents; outcome data were available for 86 (42 controls, 50 intervention). Demographic characteristics were similar in both groups. There was no significant difference in the proportion of patients who had follow-up PCP visits between the intervention (22.0%; 95% confidence interval 95% CI = 11.5% to 36.0%) and control (23.8%; 95% CI = 12.0% to 39.4%) groups (p = 0.99).
An intervention combining asthma coaching during acute ED visits and a monetary incentive to return for a PCP visit does not appear to increase follow-up with the PCP.
Data are conflicting regarding the optimal cutoffs of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) to predict short-term mortality in patients with ...sepsis. We conducted a comprehensive search of several databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus) for English-language reports of studies evaluating adult patients with sepsis, severe sepsis, and septic shock with BNP/NT-proBNP levels and short-term mortality (intensive care unit, in-hospital, 28-day, or 30-day) published from January 1, 2000, to September 5, 2017. The average values in survivors and nonsurvivors were used to estimate the receiver operating characteristic curve (ROC) using a parametric regression model. Thirty-five observational studies (3508 patients) were included (median age, 51-75 years; 12%-74% males; cumulative mortality, 34.2%). A BNP of 622 pg/mL had the greatest discrimination for mortality (sensitivity, 0.695 95% CI, 0.659-0.729; specificity, 0.907 95% CI, 0.810-1.003; area under the ROC, 0.766 95% CI, 0.734-0.797). An NT-proBNP of 4000 pg/mL had the greatest discrimination for mortality (sensitivity, 0.728 95% CI, 0.703-0.753; specificity, 0.789 95% CI, 0.710-0.867; area under the ROC, 0.787 95% CI, 0.766-0.809). In prespecified subgroup analyses, identified BNP/NT-proBNP cutoffs had higher discrimination if specimens were obtained 24 hours or less after admission, in patients with severe sepsis/septic shock, in patients enrolled after 2010, and in studies performed in the United States and Europe. There was inconsistent adjustment for renal function. In this hypothesis-generating analysis, BNP and NT-proBNP cutoffs of 622 pg/mL and 4000 pg/mL optimally predicted short-term mortality in patients with sepsis. The applicability of these results is limited by the heterogeneity of included patient populations.
Aggressive low-density lipoprotein cholesterol (LDL-C)–lowering strategies are recommended for prevention of cardiovascular events in high-risk populations. Guidelines recommend a 30% to 50% ...reduction in at-risk patients even when LDL-C concentrations are between 70 and 130 mg/dl (1.8 to 3.4 mmol/L). However, calculation of LDL-C by the Friedewald equation is the primary laboratory method for routine LDL-C measurement. We compared the accuracy and reproducibility of calculated LDL-C <130 mg/dl (3.4 mmol/L) to LDL-C measured by β quantification (considered the gold standard method) in 15,917 patients with fasting triglyceride concentrations <400 mg/dl (4.5 mmol/L). Both variation and bias of calculated LDL-C increased at lower values of measured LDL-C. The 95% confidence intervals for a calculated LDL-C of 70 mg/dl (1.8 mmol/L) and 30 mg/dl (0.8 mmol/L) were 60 to 86 mg/dl (1.6 to 2.2 mmol/L) and 24 to 60 mg/dl (0.6 to 1.6 mmol/L), respectively. Previous recommendations have emphasized the requirement for a fasting sample with triglycerides <400 mg/dl (4.5 mmol/L) to calculate LDL-C by the Friedewald equation. However, no recommendations have addressed the appropriate lower reportable limit for calculated LDL-C. In conclusion, calculated LDL-C <30 mg/dl (0.8 mmol/L) should not be reported because of significant deviation from the gold standard measured LDL-C results, and caution is advised when using calculated LDL-CF values <70 mg/dl (1.8 mmol/L) to make treatment decisions.
PDF
