Radiofrequency modified maze procedure for chronic atrial fibrillation

Background We studied the effectiveness of Radiofrequency (RF) modified maze in early and late restoration of sinus rhythm in patients with rheumatic heart disease (RHD). Methods We studied 84 patients with RHD over 23.6±12.5 months after the RF modified maze and another group of 64 patients over six months after valvular surgery alone (the Non-Maze group). Any thromboembolic episodes and NYHA class of the patient were recorded. The short term survivors in sinus rhythm, underwent stress test and echocardiography for atrial transport function at 3–6 months after surgery. Results In the Maze group, sinus rhythm was restored in 60/70 patients (85.71%) immediately and sustained in 55/70 patients (78.57%) over the follow-up as against an immediate conversion rate of 5.3% (5/53 patients, p<0.001) in the Non-maze group. The additional Cardiopulmonary (CP) bypass time (p=0.13) and cross clamp time (p=0.511) needed for maze is not statistically significant. Left atrial (LA) transport function was preserved in 41/51 patients (80.4%) and Right atrial (RA) transport function in 51/51 patients (100%). Stress test showed good chronotropic response in all the 41 patients in whom it was performed. In the Maze group one patient presented with acute valve thrombosis and subsequently, succumbed to it. In the non maze group 3/55 patients (5.66%) were hospitalized for stroke. No patient needed permanent pacemaker nor was sinus node dysfunction seen. The immediate postoperative morbidity and mortality was comparable in the two groups. Conclusions The RF modified maze is safe, effective and brief without any additional risk. It restores sinus rhythm in the majority, however there is an attrition in some.     

Impact of Cognition on Burn Inpatient Rehabilitation Outcomes

Background

A significant proportion of burn injury patients are admitted to inpatient rehabilitation facilities (IRFs). There is increasing interest in the use of functional variables, such as cognition, in predicting IRF outcomes. Cognitive impairment is an important cause of disability in the burn injury population, yet its relationship to IRF outcomes has not been studied.

Surface Modification of Biomedical MgCa4.5 and MgCa4.5Gd0.5 Alloys by Micro-Arc Oxidation

The aim of this work was to characterize the structure and corrosion properties of the MgCa_4.5(Gd_0.5) alloys surface treated by the micro-arc oxidation (MAO) process. The MgCa_4.5 and MgCa_4.5Gd_0.5 alloy samples were processed by MAO in an electrolyte composed of NaOH (10 g/dm³), NaF (10 g/dm³), NaH₂PO₄ (5 g/dm³), Na₂SiO₂·5H₂O (10 g/dm³) and water. Two different voltages (120 V and 140 V) were used in the MAO process. The alloys protected by an oxide layer formed in the MAO were then the subject of corrosion resistance tests in an environment simulating the human body (Ringer’s solution). After the experiments, the resulting samples were investigated using SEM, XPS and EDS techniques. The addition of Gd affected the fragmentation of the coating structure, thereby increasing the specific surface; higher voltages during the MAO process increased the number and size of surface pores. Corrosion tests showed that the MgCa_4.5Gd_0.5 alloys were characterized by low polarization resistances and high corrosion current densities. The studies indicated the disadvantageous influence of gadolinium on the corrosion resistance of MgCa_4.5 alloys. The immersion tests confirmed lower corrosion resistance of MgCa_4.5Gd_0.5 alloys compared to the referenced MgCa_4.5 ones. The MgCa_4.5 alloy with the MAO coating established at voltage 140 V demonstrated the best anticorrosion properties.     

Extensive Mongolian Spots with Autosomal Dominant Inheritance

Background

Mongolian spots are benign skin markings at birth which fade and disappear as the child grows. Often persistent extensive Mongolian spots are associated with inborn error of metabolism. We report thirteen people of the single family manifested with extensive Mongolian spots showing autosomal dominant inheritance.

Case Presentation

A one day old female child, product of second degree consanguineous marriage, born by normal vaginal delivery with history of meconium stained amniotic fluid and birth asphyxia. On examination the child showed extensive bluish discoloration of the body involving trunk and extremities in both anterior and posterior aspects associated with bluish discoloration of the tongue. A detailed family history revealed most of the family members manifested with extensive bluish discoloration of the body soon after birth which faded in the first few years of life and completely disappeared by puberty. Thus it was diagnosed to be extensive Mongolian spots with an autosomal dominant inheritance.

Conclusion

Knowledge about the natural history of extensive Mongolian spots, their inheritance and association with certain metabolic diseases mainly IEM and Mucopolysaccharidosis aids in the diagnosis and in order to improve the patient''s prognosis.     

Failure to weigh patients in hospital: a medication safety risk

Often patients are not weighed in hospital. Failure to weigh patients prescribed renally excreted drugs may correlate to adverse drug events. We carried out a cross-sectional study of patients prescribed common renally excreted drugs (heparin, enoxaparin and gentamicin), admitted to two wards at Royal North Shore Hospital, Sydney over 3 months. Of all patients surveyed, 28% (22/78) in the orthopaedic ward and 22% (27/124) in the medical ward were weighed. Among those prescribed therapeutic doses of the study drugs, 25% (3/12) in the orthopaedic ward and 27% (7/26) in the medical ward were weighed. Patients prescribed therapeutic anticoagulation who were not weighed experienced more haemorrhagic complications than patients who were weighed (P = 0.03). Patients prescribed renally excreted drugs in hospital are frequently not weighed. This is associated with reduced medication safety.     

Optimizing the management of acute ischaemic stroke: a review of the utilization of intravenous recombinant tissue plasminogen activator (tPA)

What is known and Objective:  Thrombolysis using intravenous tissue plasminogen activator (tPA) is the only available evidence‐based treatment for acute ischaemic stroke; however, its current utilization is very low. Therefore, the aim of this article is to review the literature regarding the use of intravenous tPA for the treatment of acute ischaemic stroke. The review will also compare utilization rates of thrombolysis in different centres across the world and identify key reasons for the underutilization of thrombolysis in stroke. Methods:  MEDLINE, EMBASE, International Pharmaceutical Abstracts (IPA) and Google Scholar were searched for relevant original articles, review papers and other publications over the publication period 1995–2012. Results and Discussion:  The National Institute of Neurological Disorders and Stroke (NINDS) (1995, N = 624 patients) and ECASS III (2008, N = 821 patients) are two pivotal randomized controlled trials providing evidence for the use of intravenous tPA within 3 h or 3–4·5 h from stroke onset, respectively. Both trials have shown that tPA administration decreases disability at 90 days from stroke. Furthermore, a recent pooled analysis of randomized controlled trials (2010, N = 3670 patients) supports these results, highlighting that early stroke treatment is associated with better outcomes, especially when treatment is started within 90 min of stroke onset (but suggesting that the benefit could be afforded within a 4·5‐h time window). Three major observational trials, STARS (2000, N = 389 patients), CASES (2005, N = 1135 patients) and SITS‐MOST (2007, N = 6483 patients), have reported acceptable safety and efficacy in clinical practice. However, only a small proportion of acute ischaemic stroke patients receive tPA in clinical practice, because of the limited availability of tPA‐utilizing sites and suboptimal use of tPA in sites where it is available. What is new and Conclusion:  tPA reduces disability in stroke patients. Moreover, acceptable safety has been demonstrated in routine clinical practice. However, tPA is significantly underutilized, and specific efforts are needed to encourage appropriate implementation of the stroke treatment guidelines to optimize the use of this important therapy.     

Development of a Computerised Antithrombotic Risk Assessment Tool (CARAT) to optimise therapy in older persons with atrial fibrillation

Aim: To develop and evaluate a novel Computerised Antithrombotic Risk Assessment Tool (CARAT) to aid clinicians' decision making regarding the risk–benefit of antithrombotic therapy in older patients. Methods: CARAT was developed in an iterative process involving multidisciplinary feedback and computerisation of previously trialled algorithms. Hospital‐based clinicians then applied the tool to patient cases, to evaluate its usability. Results: Overall, 94% of clinicians (n= 27 yielding 216 responses) were satisfied with CARAT's format. Most (72%) clinician responses agreed with CARAT recommendations; over two‐thirds agreed with estimates of stroke and bleeding risk. However, geriatricians were 3.5 times more likely to disagree with CARAT recommendations than cardiologists, particularly in cases of high fall risk. Overall, 63% responded that CARAT was at least ‘somewhat useful’ for clinical practice; 22% indicating it was ‘very useful’. Conclusion: CARAT has potential as a useful decision‐support tool to assist clinicians in decision making regarding appropriate antithrombotic therapy in older patients.