2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery Hillis, L. David, MD, FACC; Smith, Peter K., MD, FACC; Anderson, Jeffrey L., MD, FACC, FAHA ...
Journal of the American College of Cardiology,
12/2011, Letnik:
58, Številka:
24
Journal Article
Hypothesis and background The purpose of this study was to compare the accuracy of patient-specific guides for total shoulder arthroplasty (TSA) with traditional instrumentation in arthritic cadaver ...shoulders. We hypothesized that the patient-specific guides would place components more accurately than standard instrumentation. Materials and methods Seventy cadaver shoulders with radiographically confirmed arthritis were randomized in equal groups to 5 surgeons of varying experience levels who were not involved in development of the patient-specific guidance system. Specimens were then randomized to patient-specific guides based off of computed tomography scanning, standard instrumentation, and anatomic TSA or reverse TSA. Variances in version or inclination of more than 10° and more than 4 mm in starting point were considered indications of significant component malposition. Results TSA glenoid components placed with patient-specific guides averaged 5° of deviation from the intended position in version and 3° in inclination; those with standard instrumentation averaged 8° of deviation in version and 7° in inclination. These differences were significant for version ( P = .04) and inclination ( P = .01). Multivariate analysis of variance to compare the overall accuracy for the entire cohort (TSA and reverse TSA) revealed patient-specific guides to be significantly more accurate ( P = .01) for the combined vectors of version and inclination. Patient-specific guides also had fewer instances of significant component malposition than standard instrumentation did. Conclusion Patient-specific targeting guides were more accurate than traditional instrumentation and had fewer instances of component malposition for glenoid component placement in this multi-surgeon cadaver study of arthritic shoulders. Long-term clinical studies are needed to determine if these improvements produce improved functional outcomes.
Background While female sexual dysfunction is a frequent occurrence, characteristics in infertile women are not well delineated. Furthermore, the impact of infertility etiology on the characteristics ...in women with differing androgen levels observed in women with polycystic ovary syndrome and unexplained infertility has not been assessed. Objective The objective of the study was to determine the characteristics of sexual dysfunction in women with polycystic ovary syndrome and unexplained infertility. Study Design A secondary data analysis was performed on 2 of Eunice Kennedy Shriver National Institute of Child Health and Human Development Cooperative Reproductive Medicine Networks clinical trials: Pregnancy in Polycystic Ovary Syndrome Study II and Assessment of Multiple Intrauterine Gestations From Ovarian Stimulation. Both protocols assessed female sexual function using the Female Sexual Function Inventory and the Female Sexual Distress Scale. Results Women with polycystic ovary syndrome had higher weight and body mass index than women with unexplained infertility (each P < .001), greater phenotypic (Ferriman-Gallwey hirsutism score, sebum score, and acne score; each P < .001), and hormonal (testosterone, free testosterone, and dehydroepiandrosterone; each P < .001) evidence of androgen excess. Sexual function scores, as assessed by the Female Sexual Function Inventory, were nearly identical. The Female Sexual Distress Scale total score was higher in women with polycystic ovary syndrome. The mean Female Sexual Function Inventory total score increased slightly as the free androgen index increased, mainly as a result of the desire subscore. This association was more pronounced in the women with unexplained infertility. Conclusion Reproductive-age women with infertility associated with polycystic ovary syndrome and unexplained infertility, despite phenotypic and biochemical differences in androgenic manifestations, do not manifest clinically significant differences in sexual function.
Orthostatic changes in systolic blood pressure (SBP) impact cardiovascular outcomes. In this study, we aimed to determine the pattern of orthostatic systolic pressure changes in participants enrolled ...in the SBP Intervention Trial (SPRINT) at their baseline visit before randomization and sought to understand clinical factors predictive of these changes. Of the 9323 participants enrolled in SPRINT, 8662 had complete data for these analyses. The SBP after 1 minute of standing was subtracted from the mean value of the three preceding seated SBP values. At the baseline visit, medical history, medications, anthropometric measures, and standard laboratory testing were undertaken. The mean age of SPRINT participants was 68 years, two-thirds were male, with 30% black, 11% Hispanic, and 55% Caucasian. The spectrum of SBP changes on standing demonstrated that increases in SBP were as common as declines, and about 5% of participants had an increase, and 5% had a decrease of >20 mm Hg in SBP upon standing. Female sex, taller height, more advanced kidney disease, current smoking, and several drug classes were associated with larger declines in BP upon standing, while black race, higher blood levels of glucose and sodium, and heavier weight were associated with more positive values of the change in BP upon standing. Our cross-sectional results show a significant spectrum of orthostatic SBP changes, reflecting known (eg, age) and less well-known (eg, kidney function) relationships that may be important considerations in determining the optimal target blood pressure in long-term outcomes of older hypertensive patients.
Abstract A total of 290 consecutive patients who underwent total hip and total knee arthroplasty were prospectively entered into a clinical anticoagulation trial using a 10-day course of Lovenox with ...the American College of Chest Physicians-1A guidelines. Major complications occurred in 9% of patients; symptomatic deep vein thrombosis occurred in 9 (3.8%) patients, and nonfatal pulmonary embolism in 3 (1.3%) patients. Complications included 4.7% readmissions, 3.4% return to the operating room for wound incision and drainage, 5.1% prolonged hospitalization (wound drainage), and 3.4% injection site complications. Wound drainage of more than 7 days was predictive of readmission and wound reoperation. A body mass index of more than 35 was predictive of prolonged wound drainage. Return to the operating room for wound complications occurred 3× more frequently with the use of Lovenox than in our previous study using warfarin. Surgical site complications requiring readmission or reoperation should be considered “major” complications.
Abstract Background High-flex (HF) total knee arthroplasties are modified posterior-stabilized (PS) implants designed to accommodate greater flexion. Methods We examined differences between HF and PS ...retrieved tibial inserts with regard to polyethylene surface damage. Twenty HF inserts from each of 3 manufacturers were matched using patient demographics with 20 PS inserts from the same manufacturers. Ranges of motion between matched patients were not different. Results Based on subjective damage scores, no differences were detected between HF and PS groups. Differences were found, however, among manufacturers, consistent with design approaches taken for PS and HF implants. Conclusion In our series, high flexion did not influence damage, although this was likely influenced by the fact that few HF patients in our study had larger range of motions than their PS counterparts.
Abstract Objective The presentation and electrocardiographic (ECG) characteristics of transient left ventricular apical ballooning syndrome (TLVABS) can be similar to that of anterior ST-segment ...elevation myocardial infarction (STEMI). We tested the hypothesis that the ECG on presentation could reliably differentiate these syndromes. Subjects and Methods Between January 1, 2002 and July 31, 2004, we identified 18 consecutive patients with TLVABS who were matched with 36 subjects presenting with acute anterior STEMI due to atherothrombotic left anterior descending coronary artery occlusion. Results All patients with TLVABS were women (mean age, 72.0 ± 13.1 years). The heart rate, PR interval, QRS duration, and corrected QT interval were similar between groups. Distribution of ST elevation was similar, but patients with anterior STEMI exhibited greater ST elevation. Regressive partitioning analysis indicated that the combination of ST elevation in lead V2 of less than 1.75 mm and ST-segment elevation in lead V3 of less than 2.5 mm was a suggestive predictor of TLVABS (sensitivity, 67%; specificity, 94%). Conditional logistic regression indicated that the formula: (3 × ST-elevation lead V2 ) + (ST-elevation V3 ) + (2 × ST-elevation V5 ) allowed possible discrimination between TLVABS and anterior STEMI with an optimal cutoff level of less than 11.5 mm for TLVABS (sensitivity, 94%; specificity, 72%). Patients with TLVABS were less likely to have concurrent ST-segment depression (6% vs 44%; P = .003). Conclusions Women presenting with TLVABS have similar ECG findings to patients with anterior infarct but with less-prominent ST-segment elevation in the anterior precordial ECG leads. These ECG findings are relatively subtle and do not have sufficient predictive value to allow reliable emergency differentiation of these syndromes.
Statin therapy has recently been shown to decrease adverse perioperative events in patients undergoing vascular surgery. The potential beneficial effect of lipid-lowering therapy in patients ...undergoing coronary artery bypass grafting (CABG) is not well known. This was an observational analysis of 4,739 patients who underwent first-time isolated CABG at a single institution from 1995 to 2001. Patients were categorized into 2 groups based on treatment with a lipid-lowering agent within 30 days before surgery. Univariate and multivariate analyses were used to determine the association between lipid-lowering therapy and survival to hospital discharge. Patients in the lipid-lowering group (n = 2,334) tended to be younger (mean age 66 ± 10 vs 68 ± 10 years), were more likely to be diabetic (31% vs 28%), and on β blockers (77% vs 70%) than patients in the nonlipid-lowering group (n = 2,405). In-hospital mortality was significantly lower in the lipid-lowering group than in the nonlipid-lowering therapy group (1.4% vs 2.2%, odds ratio 0.62, 95% confidence interval 0.40 to 0.96, p = 0.03). A multivariable model demonstrated a loss of statistical significance for the effect of lipid-lowering therapy on in-hospital mortality (adjusted odds ratio 0.83, 95% confidence interval 0.5 to 1.37, p = 0.46). In conclusion, preoperative use of lipid-lowering therapy in patients undergoing CABG appears safe and is associated with improved survival to hospital discharge compared with patients not receiving lipid-lowering therapy. However, patient risk factors and other cardioprotective medication use associated with the use of preoperative lipid-lowering therapy appear to explain the association with improved survival.
Cost Effectiveness of Childhood Obesity Interventions Gortmaker, Steven L., PhD; Long, Michael W., ScD; Resch, Stephen C., PhD ...
American journal of preventive medicine,
July 2015, Letnik:
49, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Introduction The childhood obesity epidemic continues in the U.S., and fiscal crises are leading policymakers to ask not only whether an intervention works but also whether it offers value for money. ...However, cost-effectiveness analyses have been limited. This paper discusses methods and outcomes of four childhood obesity interventions: (1) sugar-sweetened beverage excise tax (SSB); (2) eliminating tax subsidy of TV advertising to children (TV AD); (3) early care and education policy change (ECE); and (4) active physical education (Active PE). Methods Cost-effectiveness models of nationwide implementation of interventions were estimated for a simulated cohort representative of the 2015 U.S. population over 10 years (2015–2025). A societal perspective was used; future outcomes were discounted at 3%. Data were analyzed in 2014. Effectiveness, implementation, and equity issues were reviewed. Results Population reach varied widely, and cost per BMI change ranged from $1.16 (TV AD) to $401 (Active PE). At 10 years, assuming maintenance of the intervention effect, three interventions would save net costs, with SSB and TV AD saving $55 and $38 for every dollar spent. The SSB intervention would avert disability-adjusted life years, and both SSB and TV AD would increase quality-adjusted life years. Both SSB ($12.5 billion) and TV AD ($80 million) would produce yearly tax revenue. Conclusions The cost effectiveness of these preventive interventions is greater than that seen for published clinical interventions to treat obesity. Cost-effectiveness evaluations of childhood obesity interventions can provide decision makers with information demonstrating best value for the money.
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