Trends in Utilization and Outcomes of Pulmonary Artery Catheterization in Heart Failure With and Without Cardiogenic Shock

BackgroundThe pulmonary artery catheter (PAC) has been used in a wide range of critically ill patients. It is not indicated for routine care of heart failure (HF), but its role in cardiogenic shock (CS) has not been clarified.Methods and ResultsWe conducted a retrospective cohort study with the use of the National Inpatient Sample and identified a total of 9,431,944 adult patients admitted from 2004 to 2014 with the primary diagnosis of HF (n = 8,516,528) or who developed CS (n = 915,416) during the index hospitalization. Overall, patients with PAC had increased hospital costs, length of stay, and mechanical circulatory support use. In patients with HF, PAC use was associated with higher mortality (9.9% vs 3.3%, OR 3.96; P < .001) but the excess of mortality declined over time. In those with CS, PAC was associated with lower mortality (35.1% vs 39.2%, OR 0.91; P < .001) and in-hospital cardiac arrest (14.9% vs 18.3%, OR 0.77; P < .001); this paradox persisted after propensity score matching.ConclusionsThe use of PAC in CS has decreased from 2004 to 2014, although its use is now associated with improved outcomes, which may reflect better selection of patients or better use of the information to guide therapies. Our data provide reassurance that PAC use in this population is an appropriate strategy.     

Weight loss and lifestyle interventions for obstructive sleep apnoea in adults: Systematic review and meta‐analysis

Lifestyle interventions addressing diet, exercise‐training, sleep hygiene, and/or tobacco/alcohol cessation are recommended in the management of obstructive sleep apnoea (OSA). Yet their effectiveness on this condition still requires further research. This systematic review and meta‐analysis was aimed at establishing (a) the effectiveness of lifestyle interventions on apnoea‐hypopnoea index (AHI), oxygen desaturation index (ODI), excessive daytime sleepiness (EDS), and secondary OSA measures among adults, and (b) which intervention characteristics may drive the greatest improvements. A systematic search of studies was conducted using CINAHL, ProQuest, Psicodoc, Scopus, and Web of Science, from inception to April 2018. Standardized mean differences were calculated using the inverse variance method and random‐effects models. The meta‐analyses of 13 randomized controlled trials and 22 uncontrolled before‐and‐after studies (1420 participants) revealed significant reductions on AHI (d = ?0.61 and ?0.46, respectively), ODI (d = ?0.61 and ?0.46) and EDS (d = ?0.41 and ?0.49). Secondary OSA outcomes were also improved after interventions. However, effectiveness of interventions differed depending on their components, OSA severity, and gender. Thus, until future research further supports the differential effectiveness among lifestyle interventions on OSA, those addressing weight loss through diet and exercise‐training may be the most effective treatments for male patients with moderate‐severe OSA.     

Spontaneous generation and survival of blood dendritic cells in mononuclear cell culture without exogenous cytokines

Studies on purified blood dendritic cells (DCs) are hampered by poor viability in tissue culture. We, therefore, attempted to study some of the interactions/relationships between DCs and other blood cells by culturing unseparated peripheral blood mononuclear cell (PBMC) preparations in vitro. Flow cytometric techniques were used to undertake a phenotypic and functional analysis of DCs within the cultured PBMC population. We discovered that both the CD11c(+) and CD11c(-) CD123(hi) DC subsets maintained their viability throughout the 3-day culture period, without the addition of exogenous cytokines. This viability was accompanied by progressive up-regulation of the surface costimulatory (CD40, CD80, CD86) and activation (CMRF-44, CMRF-56, CD83) molecules. The survival and apparent production of DCs in PBMC culture (without exogenous cytokines) and that of sorted DCs (with cytokines) were evaluated and compared by using TruCOUNT analysis. Absolute DC counts increased (for CD123(hi) and CD11c(+) subsets) after overnight culture of PBMCs. Single-cell lineage depletion experiments demonstrated the rapid and spontaneous emergence of "new" in vitro generated DCs from CD14(+)/CD16(+) PBMC radioresistant precursors, additional to the preexisting ex vivo DC population. Unlike monocyte-derived DCs, blood DCs increased dextran uptake with culture and activation. Finally, DCs obtained after culture of PBMCs for 3 days were as effective as freshly isolated DCs in stimulating an allogeneic mixed leukocyte reaction.     

Is troponin I useful for predicting in-hospital risk for unstable angina patients in a community hospital? Results of a prospective study

INTRODUCTION AND OBJECTIVES: Before including troponin I detection in the daily practice of our hospital we performed a prospective study to determine its real usefulness and to establish the best cut-off point. METHODS: We studied 82 consecutive patients admitted with unstable angina to a community hospital. Troponin I was determined (> 10 h after chest pain). Patients were referred to a tertiary hospital for catheterization/revascularization if clinical events developed. RESULTS: Twenty-five patients (31%) suffered events during admission: recurrent angina in 23 cases (28%); heart failure in 5 (6%); exitus in 3 (4%); myocardial infarction in 1 (1%). The cut-off point for troponin I that best predicted events was 0.1 ng/ml. Patients with troponin I > 0.1 (34 patients, 42%) experienced more events [47 vs. 19%; OR = 3.8 (1.4-10.4); p = 0.01] and had higher rates of recurrent angina (42 vs. 19%), heart failure (12 vs. 2%) and exitus (9 vs 0%). Patients with ECG changes and troponin I > 0.1 showed a significantly higher percentage of events (63%) than those with ECG changes alone (23%) or troponin I > 0.1 alone (15%) or those without ECG changes and troponin I < 0.1 (17%) (p < 0.0001). CONCLUSIONS: Troponin I elevation is useful for predicting in-hospital risk for unstable angina patients admitted to a community hospital. A low cut-off value (0.1 ng/ml) predicts events. The association of ECG changes and high troponin I identifies a population at very high risk; however, the absence of both variables in patients with a diagnosis of unstable angina does not preclude the development of events.     

Bleeding and recurrent thrombosis in definite antiphospholipid syndrome: analysis of a series of 66 patients treated with oral anticoagulation to a target international normalized ratio of 3.5

BACKGROUND: Prolonged anticoagulation is the treatment of choice for patients with thrombosis and the antiphospholipid syndrome. However, there is still debate about the optimum intensity of anticoagulation. METHODS: The study included 66 patients with antiphospholipid syndrome (Sapporo criteria) and previous thrombosis. All were receiving oral anticoagulation to a target international normalized ratio of 3.5. Every patient was individually interviewed to recall major bleeding and thrombotic episodes during the previous 12 months. RESULTS: Patients were mainly women and white. The rate of major bleeding was 6 cases per 100 patient-years (95% confidence interval [CI] 1.6-15.0). The rate of intracranial bleed was 1.5 per 100 patient-years (95% CI, 0.04-8.4). None of the bleeding episodes was fatal. The rate of thrombotic recurrences was 9.1 cases per 100 patient-years (95% CI, 3.3-19.6). Most recurrences took place in the same vascular bed as the original thrombosis. Age, time receiving anticoagulant therapy, primary vs secondary antiphospholipid syndrome, positivity for anticardiolipin antibodies, positivity for lupus anticoagulant, previous arterial thrombosis, previous stroke, previous venous thrombosis, and previous thrombocytopenia were not predictive of bleeding events. However, the risk of thrombotic recurrences was independently higher in patients who were receiving anticoagulation for longer periods. CONCLUSIONS: The risk of intracranial and fatal bleeding in patients with definite antiphospholipid syndrome and previous thrombosis treated with oral anticoagulation to a target international normalized ratio of 3.5 is similar than in groups of patients treated to lower target ratios. The risk of thrombotic recurrences, even during anticoagulation, was high. Most recurrences took place in the same territory as original thromboses.     

Incidence of ARDS in an adult population of northeast Ohio

STUDY OBJECTIVES: To assess the incidence of the ARDS in a well-defined adult population. DESIGN: Kaiser Permanente of northeast Ohio, a health maintenance organization, uses the Cleveland Clinic Foundation as its only tertiary care center. In an ongoing prospective assessment in the Cleveland Clinic ICUs, we identified adult Kaiser Permanente patients with ARDS between 1996 and 1999. ARDS was defined according to the 1994 American-European Consensus Conference criteria. The denominator in the incidence calculation was the adult members of Kaiser Permanente of each year of the study period, and the numerator was the new adult ARDS patients in this particular year. The cause of ARDS, the mortality, and the cause of death were retrospectively identified, as well as other characteristics of the study population. RESULTS: ARDS was diagnosed in 66 patients during the 3-year study period. The incidence per 100,000 population was 11.4 in 1996, 19.8 in 1997, and 14.4 in 1998; the overall incidence was 15.3/100,000/yr. The mean PaO(2)/fraction of inspired oxygen (+/- SD) was 110.8 +/- 37.8, the mean APACHE II was 23.4 +/- 6.9, and the mean ICU stay was 12.0 +/- 9.5 days. The most common cause of ARDS was direct lung injury (75.8%), and the most common cause of death was septic shock (53.8%). CONCLUSION: The incidence of ARDS in an adult population in northeast Ohio was 15.3/100,000/yr, a number that is slightly higher but comparable to recent estimates reported by other researchers.     

Impact of physician specialty on the cost of nonvariceal upper GI bleeding care

OBJECTIVE: Upper GI bleeding (UGIB) is a common medical emergency that leads to a high consumption of medical resources and costs. We aimed to analyze the influence of physician specialty on the costs of nonvariceal UGIB care. METHODS: We retrospectively assessed 350 nonvariceal UGIB episodes that were primarily cared for by gastroenterologists (n = 142), internists (n = 67), or surgeons (n = 141). Gastroenterologists followed evidence-based clinical protocols that included early endoscopy and early hospital discharge for uncomplicated bleeding. A risk score system was used to control for severity of illness. Linear regression analyses were performed to find out predictors of costs and the influence of specialist care on length of stay (LOS). RESULTS: The overall mean hospital cost was significantly lower in patients cared for by gastroenterologists (EUR 1,630) than in those managed by internists (EUR 3,745, p < 0.001) or surgeons (EUR 2,513, p < 0.05). The mean LOS was the variable with highest influence on total cost. Patients cared for by gastroenterologists had a mean LOS significantly shorter (7.3 days) than that of those treated by internists (16.2 days, p < 0.001) or surgeons (11 days, p < 0.001). Hospital costs and LOS differences were maintained when adjusting for severity of illness. In caring for low risk patients, nongastroenterologists had a higher probability of having a hospital stay longer than 4 days (odds ratio = 18.4, Cl = 4.6-73.6, p < 0.001). CONCLUSION: The implementation of specific evidence-based protocols by gastroenterologists reduces length of hospital stay and saves medical costs in patients with nonvariceal UGIB, especially those at low risk.     

A retrospective analysis of patients with gallbladder cancer treated with radical resection versus cholecystectomy plus external radiotherapy

BACKGROUND/AIMS: To compare patients with gallbladder cancer treated with radical resection and regional lymphadenectomy (RR-RL) versus simple cholecystectomy and adjuvant external radiotherapy (SC-ERT) and determine outcome. METHODOLOGY: Presentation, operative data, complications and survival were examined in 137 patients. In particular, the 45 patients treated with RR-RL or SC-ERT. RESULTS: Twenty-five had SC-ERT and 20 had a RR-RL. There were no epidemiological differences between groups. Resection of segments IV-b and V and en bloc dissection of regional lymph nodes was the most frequently used procedure (75%). The morbidity and mortality of the radical procedure were 25% and 10%. The morbidity of SC-ERT was 16%. All patients with Nevin I are alive. For lesions Nevin II and Nevin III RR-RL offered a 100% 5-year survival rate and SC-ERT had a 62% and 39% 5-year survival rate respectively. For lesions Nevin IV and V there was no difference in long-term survival. CONCLUSIONS: RR-RL is better than SC-ERT in patients with Nevin II and III lesions because it improves survival rate. SC-ERT can be recommended as an alternative treatment. For more advanced lesions further trials are needed.     

Beneficial effects of antioxidant vitamins on the stenotic kidney

Renal artery stenosis (RAS) may lead to renal injury, partly mediated through increased oxidative stress. However, the potential effects of chronic oral antioxidant intervention on the stenotic kidney remain unknown. This study was designed to test the hypothesis that chronic antioxidant vitamin supplementation in RAS would preserve renal function and structure. Single-kidney hemodynamics and function were quantified in vivo in pigs using electron-beam CT after 12 weeks of unilateral RAS (n=7), a similar degree of RAS orally supplemented with vitamins C (1 g) and E (100 IU/kg) (RAS+Vitamins, n=7), or controls (normal, n=7). Renal tissue was studied ex vivo using Western blotting and immunohistochemistry. Mean arterial pressure was similarly elevated in both RAS groups, while ischemic renal volume and glomerular filtration rate were similarly reduced. Renal blood flow was decreased in RAS compared with normal (326.5+/-99.9 versus 553.4+/-48.7 mL/min, respectively, P=0.01), but preserved in RAS+Vitamins (485.2+/-104.1 mL/min, P=0.3 versus normal). The marked increase in the expression of the NADPH-oxidase subunits p47phox and p67phox, nitrotyrosine, endothelial and inducible nitric oxide synthase, and nuclear factor-kappaB observed in RAS (P<0.05 versus normal) was normalized in RAS+Vitamins (P>0.1). Furthermore, trichrome staining and the expression of transforming growth factor-beta and tissue inhibitor of matrix-metalloproteinase-1 were also decreased in RAS+Vitamins. In conclusion, chronic blockade of the oxidative stress pathway in RAS using antioxidant vitamins improved renal hemodynamics and decreased oxidative stress, inflammation, and fibrosis in the ischemic kidney. These observations underscore the involvement of oxidative stress in renal injury in RAS and support a role for antioxidant vitamins in preserving the ischemic kidney.     

Additive value of low-dose dobutamine to technetium-99m sestamibi-gated single-photon emission computed tomography for prediction of wall motion improvement in patients undergoing coronary artery bypass graft

BACKGROUND: The two most useful methods for myocardial viability assessment are perfusion imaging and dobutamine echocardiography. HYPOTHESIS: The present study investigated the additive value of a new method, dobutamine technetium 99m (99mTc)-sestamibi-gated single-photon emission computed tomography (SPECT), which combines these two modalities, to the prediction of wall motion improvement after revascularization. METHODS: Fifty-five consecutive patients with ischemic cardiomyopathy, who were referred for viability evaluation, underwent resting and dobutamine (dose, 5-10 microkg/kg/min) gated SPECT with 99mTc-sestamibi. Of these patients, 36 underwent coronary artery bypass graft (CABG) within 1 month of the study and 32 had repeat resting gated SPECT within 1 year. Global and regional wall motion, wall thickness, and perfusion were simultaneously analyzed at rest and after dobutamine using the 20-segment model; the sestamibi uptake and wall motion response to dobutamine of each segment were rated quantitatively. Based on these findings, the segments were categorized as normal, viable, or nonviable. The predictive values for wall motion improvement were assessed by perfusion, using cutoffs of 50 and 60% of sestamibi uptake, and thereafter by the addition of dobutamine response in the segments that were rated nonviable. RESULTS: Of the 1,080 myocardial segments studied, 906 (84%) had abnormal wall motion and were analyzed for viability. Concordance between perfusion and wall motion response to dobutamine was 60% with the 50% cutoff of sestamibi uptake, and increased to 65% with the 60% sestamibi cutoff (p < 0.04). The respective predictive values of wall motion improvement using the 50 and 60% cutoff points were as follows: sensitivity 93 and 70%, respectively, (p < 0.01); specificity 59 and 86% (p < 0.001), respectively; accuracy 77% for both. The addition of the wall motion response to dobutamine to the assessment of the nonviable segments by perfusion (60% cutoff) increased the sensitivity from 70 to 85% (p = 0.001) and the negative predictive value from 70 to 81% (p = 0.009); the positive predictive value remained high (86 vs. 82%). No additive value of wall motion response to dobutamine was demonstrated for nonviable segments by perfusion with a 50% cutoff. CONCLUSION: Dobutamine sestamibi-gated SPECT is a feasible method for the analysis of myocardial perfusion, function, and contractile reserve of individual myocardial segments in patients with ischemic cardiomyopathy. Viability assessment based on a threshold of 60% uptake of sestamibi, with the addition of the wall motion response to dobutamine in the nonviable segments, seems to yield better predictive values for wall motion improvement after CABG.