Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fibrillation with ST-elevation acute myocardial infarction

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST-elevation acute myocardial infarction (STEMI). In comatose survivors of cardiac arrest, mild induced hypothermia (MIH) improves neurological recovery. In the present study, we investigated feasibility and safety of combining primary PCI and MIH in comatose survivors of ventricular fibrillation with signs of STEMI after reestablishment of spontaneous circulation. Forty consecutive patients undergoing primary PCI and MIH from November 1, 2003 to December 31, 2005 were compared to 32 consecutive patients who underwent primary PCI but no MIH between January 1, 2000 and November 1, 2003. There were no significant differences between the MIH and no MIH groups in general characteristics, cardiac arrest circumstances and angiographic features. Except for decreases in heart rate during hypothermia interval, there was no difference between the MIH and no MIH groups in arterial pressure, peak arterial lactate (5.1 mmol/l versus 5.7 mmol/l; p = .56), need for vasopressors (65% versus 53%; p = .44), inotropes (48% versus 59%; p = .44), aortic balloon counterpulsation (20% versus 22%; p = .92), repeat cardioversion/defibrillation (30% versus 34%; p=.89) and use of antiarrhythmics (33% versus 53%; p = .13). There was also no difference in inspired oxygen requirements during mechanical ventilation and in renal function. Hospital survival with cerebral performance category 1 and 2 was significantly better in MIH group (55% versus 16%; p=.001). Our preliminary experience indicates that primary PCI and MIH are feasible and may be combined safely in comatose survivors of ventricular fibrillation with signs of STEMI. Such a strategy may improve survival with good neurological recovery.     

Tibial and Fibular Mid-Shaft Bone Traits in Young and Older Sprinters and Non-Athletic Men

High impact loading is known to prevent some of the age-related bone loss but its effects on the density distribution of cortical bone are relatively unknown. This study examined the effects of age and habitual sprinting on tibial and fibular mid-shaft bone traits (structural, cortical radial and polar bone mineral density distributions). Data from 67 habitual male sprinters aged 19–39 and 65–84 years, and 60 non-athletic men (referents) aged 21–39 and 65–80 years are reported. Tibial and fibular mid-shaft bone traits (strength strain index SSI, cortical density CoD, and polar and radial cortical density distributions) were assessed with peripheral quantitative computed tomography. Analysis of covariance (ANCOVA) adjusted for height and body mass indicated that the sprinters had 21 % greater tibial SSI (P < 0.001) compared to the referents, with no group × age-group interaction (P = 0.54). At the fibula no group difference or group × age-group interaction was identified (P = 0.12–0.81). For tibial radial density distribution ANCOVA indicated no group × radial division (P = 0.50) or group × age-group × division interaction (P = 0.63), whereas an age × radial division interaction was observed (P < 0.001). For polar density distribution, no age-group × polar sector (P = 0.21), group × polar sector (P = 0.46), or group × age-group × polar sector interactions were detected (P = 0.15). Habitual sprint training appears to maintain tibial bone strength, but not radial cortical density distribution into older age. Fibular bone strength appeared unaffected by habitual sprinting.     

Results of a Surgeon-Directed Quality Improvement Project on Breast Cancer Surgery Outcomes in South-Central Ontario

Background

Gaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario.

Methods

Surgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005–2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region.

Results

Over 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons.

Conclusions

This surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.