Tracheal agenesis: a rare disease with unique airway considerations

IMPLICATIONS: Abnormal tracheal development causes a spectrum of life-threatening anomalies. We report a newborn with tracheal agenesis and a common "esophagotrachea." Ventilation was achieved first by face mask then with an endotracheal tube. In this report, we describe the types of tracheal agenesis and discuss initial airway management.     

VENOUS THROMBOEMBOLISM, FACTOR V LEIDEN, AND METHYLENETETRAHYDROFOLATE REDUCTASE IN A SICKLE CELL ANEMIA PATIENT

Vaso-occlusive crisis is the most common cause of morbidity in patients with sickle cell anemia (SCA). Central nervous system involvement that leads to hemiplegia is the most frequent neurological complication in those patients. Peripheral deep venous thromboembolism was not reported in SCA patients. Activated protein C resistance is associated with an increased risk of thrombophilia. The authors report an SCA patient with recurrent cerebrovascular accident and deep venous thrombosis. Activated protein C resistance due to factor V Leiden heterozygous and heterozygocity for the methylenetetrahydrofolate reductase were diagnosed and suspected to be the risk factors that contribute to the development of the deep vein thrombosis in this SCA patient.     

Hospital productivity: The role of efficiency drivers

A major feature of health‐care systems is substantial variation in hospital productivity. Hospital productivity varies widely across countries. The presence of such variation suggests potential areas for improvement, which can substantially lower health‐care costs. This research aims to investigate factors that may explain variations in hospital productivity by constructing a longitudinal data (panel) on English NHS hospital trusts. It also seeks to explore possible interactions among the factors in a data–driven manner. We employ unbiased panel regression tree techniques from the machine‐learning literature to explore the complex interactive structure of the data. We next use econometric panel regression to deal with individual hospital effects to identify some of the determinants of hospital productivity. The findings point to the significance of efficiency‐enhancing mechanisms for hospital productivity, including measures to reduce the length of stay, increase day case (outpatient) surgery rate, and to minimize errors. Further, such measures are shaped by more fundamental factors such as the availability of human capital and management practices. Our results underscore the importance of within‐hospital efficiency‐enhancing mechanisms to cost‐adjusted hospital productivity. Improving hospital operational processes will enhance productivity. At a deeper level, human capital and management practices are likely to be most critical.     

Surgical management of pediatric hepatocellular carcinoma: An analysis of the National Cancer Database

PurposeThis study evaluates overall survival (OS) between liver transplantation (LT) and liver resection (LR), while assessing the effect of margin status, in children with hepatocellular carcinoma (HCC).MethodsThe National Cancer Database was queried (2004–2015) for children (< 18 years) with non-metastatic HCC undergoing surgery.ResultsOne hundred six children with HCC treated surgically (LT 34, LR 72) were identified. For T1 stage, no difference in OS was observed for LT vs. margin-negative liver resection [LR(?)] (log-rank, p = 0.47). For T2/T3/T4 stage, no difference in OS was observed for LT vs. LR(?) (log-rank, p = 0.08); both subgroups exhibited superior OS vs. margin-positive liver resection [LR(+)] (log-rank, LT vs. LR(+): p = 0.001 and LR(?) vs. LR(+): p = 0.04). On multivariable Cox regression: (i) histology (fibrolamellar vs. not) and T stage (T1 vs. T2/T3/T4) were not associated with OS (both p = 0.06), (ii) chemotherapy and size > 5 cm were not associated with OS (both p ≥ 0.42), (iii) when compared to LT, both LR(?) (p = 0.03) and LR(+) (p = 0.001) were associated with increased likelihood of mortality.ConclusionAlthough margin-negative resection may be obtained with LT or LR, early LT consultation is warranted for children at high risk of LR(+) regardless of Milan criteria due to the negative impact of LR(+) on OS.Type of studyRetrospective cohort study.Level of evidenceIII     

Safety,usability, and performance of a wireless left atrial pressure monitoring system in patients with heart failure: the VECTOR-HF trial

Aims

In heart failure (HF), implantable haemodynamic monitoring devices have been shown to optimize therapy, anticipating clinical decompensation and preventing hospitalization. Direct left-sided haemodynamic sensors offer theoretical benefits beyond pulmonary artery pressure monitoring systems. We evaluated the safety, usability, and performance of a novel left atrial pressure (LAP) monitoring system in HF patients.

Methods and results

The VECTOR-HF study (NCT03775161) was a first-in-human, prospective, multicentre, single-arm, clinical trial enrolling 30 patients with HF. The device consisted of an interatrial positioned leadless sensor, able to transmit LAP data wirelessly. After 3 months, a right heart catheterization was performed to correlate mean pulmonary capillary wedge pressure (PCWP) with simultaneous mean LAP obtained from the device. Remote LAP measurements were then used to guide patient management. The miniaturized device was successfully implanted in all 30 patients, without acute major adverse cardiac and neurological events (MACNE). At 3 months, freedom from short-term MACNE was 97%. Agreement between sensor-calculated LAP and PCWP was consistent, with a mean difference of −0.22 ± 4.92 mmHg, the correlation coefficient and the Lin's concordance correlation coefficient values were equal to 0.79 (p < 0.0001) and 0.776 (95% confidence interval 0.582–0.886), respectively. Preliminary experience with V-LAP-based HF management was associated with significant improvements in New York Heart Association (NYHA) functional class (32% of patients reached NYHA class II at 6 months, p < 0.005; 60% of patients at 12 months, p < 0.005) and 6-min walk test distance (from 244.59 ± 119.59 m at baseline to 311.78 ± 129.88 m after 6 months, p < 0.05, and 343.95 ± 146.15 m after 12 months, p < 0.05).

Conclusion

The V-LAP™ monitoring system proved to be generally safe and provided a good correlation with invasive PCWP. Initial evidence also suggests possible improvement in HF clinical symptoms.     

Progress of medical students after open admission or admission based on knowledge tests

Medical Education 2010: 44 : 205–214 Context Although admission to university in Austria is generally open for applicants who have successfully completed secondary school, in some areas of study, including human medicine and dentistry, the selection of students by additional criteria has become legally possible as a result of a decision by the European Court in 2005. We studied the impact of this important change on the temporal pattern of medical students’ progress through the study programme. Methods All 2532 regular students admitted to the diploma programme in human medicine at the Medical University of Graz during the academic years 2002/03–2007/08 were included in the analysis. Non‐parametric and semi‐parametric survival analysis techniques were employed to compare the time required to complete the first two study semesters (first part of the curriculum) before and after the implementation of admission tests. Temporal patterns of dropout before this goal was achieved were also investigated. Sex, age and nationality of students were assessed as potential confounding variables. Results The cumulative probability of study success was dramatically better in selected students versus those who were admitted openly (P < 0.0001). Whereas only 20.1–26.4% of openly admitted students completed the first two study semesters within the scheduled time of 1 year, this percentage rose to 75.6–91.9% for those selected by admission tests. Similarly, the cumulative probability for dropping out of study was also significantly lower in selected students (P < 0.0001). By univariate as well as multivariate techniques, student nationality, age and sex were also identified as partly significant, albeit weak, predictors. Discussion The analysis convincingly demonstrates that, by contrast with open admission, performance‐based selection of medical students significantly raises the probability of successful study progress. Additionally, the proportion of dropouts is significantly reduced. Thus, admission tests save considerable costs, in terms of both student time and public resources.