Percutaneous coronary interventions in octogenarians in the American College of Cardiology-National Cardiovascular Data Registry: development of a nomogram predictive of in-hospital mortality

OBJECTIVES: We sought to evaluate the results of percutaneous coronary intervention (PCI) in elderly patients in contemporary practice. BACKGROUND: Prior studies of PCI in the elderly population demonstrate increased in-hospital mortality, but these studies are limited by small population size. METHODS: Using the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) of 100,253 patients, the in-hospital outcomes in all 8,828 PCI procedures performed on octogenarians were evaluated. Patients underwent PCI between 1998 and 2000 at over 145 participating centers. RESULTS: The mean age was 83.72 +/- 3.02 years, with female preponderance (53%). The PCI was considered angiographically successful in 93%, stents were placed in 75%, and the post-PCI length of stay was 3.3 +/- 5.1 days. Overall in-hospital mortality was 3.77% but was only 1.35% in PCI without recent myocardial infarction (MI) within one week (p < 0.0001). Patients having PCI within 6 h of the onset of their MI had an increase in mortality tenfold (13.79%) compared with patients without a recent MI (p < 0.0001). All groups that were defined based on time of PCI after MI onset up to seven days had increased mortality (all p < 0.0001). Older age (odds ratio [OR] of 1.03 per incremental year), depressed ejection fraction (EF) (OR 0.69 per 10 points for EF <60%), and time of PCI after MI onset (<6 h, OR 6.87; 6 to 24 h, OR 5.66; 24 h to one week, OR 2.93) were most strongly predictive of outcome by multivariate analysis. The predicted mortality from the multivariate model correlated well with the observed in-hospital mortality up to 20% mortality. A 254-point nomogram was constructed employing the logistic model using a weighted point system. CONCLUSIONS: In patients > or = 80 years old, PCI has good success and acceptable mortality. The presence of an acute or recent MI substantially increases the risk of in-hospital death.     

Effects of etomidate on vasopressor use in patients with sepsis or severe sepsis: A propensity-matched analysis

Purpose

The safety of single-bolus etomidate to facilitate intubation in septic patients is controversial due to its potential to suppress adrenal steroidogenesis. The purpose of this study was to evaluate the effects of etomidate on the development of shock when used as an induction agent to facilitate intubation in septic patients.

Methods

A multicenter, retrospective, propensity-matched cohort study comparing patients with sepsis or severe sepsis who either received etomidate or did not receive etomidate for intubation was conducted. The primary outcome was the difference in the need for vasopressor support within 72 hours after intubation. Secondary outcomes included the use of multiple vasopressors, intensive care unit length of stay, and in-hospital mortality.

Results

A total of 411 patients were analyzed. Eighty-three patients were matched by propensity score. There was no difference in the matched cohort in regards to vasopressor use within 72 hours of intubation (odds ratio, 0.95; 95% confidence interval, 0.52-1.76; P = .88). Furthermore, there were no significant differences observed with regard to secondary outcomes, including in-hospital mortality (P = .76).

Conclusions

The use of etomidate for intubation in septic patients did not increase vasopressor requirements within 72 hours after intubation.     

Ineffectiveness of colchicine for the prevention of restenosis after coronary angioplasty.

Colchicine, an antimitogenic agent, has shown promise in preventing restenosis after coronary angioplasty in experimental animal models. A prospective trial was conducted involving 197 patients randomized in a 2:1 fashion to treatment with oral colchicine, 0.6 mg twice daily (130 patients), or placebo (67 patients) for 6 months after elective coronary angioplasty. Treatment in all patients began between 12 h before angioplasty and 24 h after angioplasty. Compliance monitoring revealed that 96% of all prescribed pills were ingested. Demographic characteristics were similar in colchicine- and placebo-treated groups. A mean of 2.7 lesions/patient were dilated. Side effects resulted in a 6.9% dropout rate in the colchicine-treated patients. Complete quantitative angiographic follow-up was obtained in 145 patients (74%) with 393 dilated lesions. Quantitative angiographic measurements were obtained in two orthogonal views at baseline before angioplasty and immediately and at 6 months after angioplasty. The quantitative mean lumen diameter stenosis before angioplasty was 67% both in the 152 lesions in the placebo-treated group and in the 241 lesions in the colchicine-treated group; this value was reduced to 24% immediately after angioplasty in the lesions in both treatment groups. At the 6-month angiogram, lesions had restenosed to 47% lumen diameter narrowing in the placebo-treated group compared with 46% in the colchicine-treated group (p = NS). Forty-one percent of colchicine-treated patients developed restenosis in at least one lesion compared with 45% of the placebo-treated group (p = NS). In conclusion, colchicine was ineffective for preventing restenosis after coronary angioplasty.     

Acute cytoreduction techniques in the early treatment of hyperleukocytosis associated with childhood hematologic malignancies

Early and effective cytoreduction for high peripheral white blood cell counts in pediatric patients with acute leukemia may be helpful in preventing complications secondary to hyperviscosity. It also may be a useful adjunct to systemic chemotherapy. As an alternative to automated apheresis for this purpose, manual exchange transfusion is efficacious and does not require hemapheresis instrumentation and disposables and the related special staff. Two patients, a neonate with acute myeloblastic leukemia and a white blood cell count of 422.2 k/microliter as well as a 2 1/2-year-old with an admission diagnosis of acute promyelocytic leukemia and a white blood cell count of 617.4 k/microliter, underwent manual exchange hemotherapy for acute cytoreduction. The procedures were tolerated well, and significant leukocyte removal was achieved, with the respective leukocyte reductions being 81.1 and 68.7%. The techniques available for pediatric cytoreduction are compared, with emphasis on their efficiency and safety and appropriateness for very small children.     

Using intact nerve to bridge peripheral nerve defects: an alternative to the use of nerve grafts

This preliminary study was conducted to determine whether a regenerating peripheral nerve in a rat model can use the epineurium of an intact nerve to bridge a nerve gap defect. To create the intact nerve bridge a 1-cm segment of the peroneal nerve is resected leaving a gap defect. The proximal and distal peroneal nerve stumps are sutured 1-cm apart, in an end-to-side fashion, to the epineurium of the intact tibial nerve. The following experimental groups were used (n = 12): group A, immediate primary repair of resected segment; group B, intact nerve bridge technique; group C, nerve autograft; and group D, gap in situ control. Evaluation 12 weeks after surgery included measurement of the tibialis anterior muscle contraction force, axonal counting, wet weight of the tibialis anterior muscle, and histologic examination. The results of this animal study support 3 main conclusions: regenerating axons can use the epineurium of an intact nerve to bridge a gap in nerve continuity; when using functional recovery to assess regeneration, there is no significant difference between standard nerve autografts and the intact nerve bridge technique; and based on histologic examination, the intact nerve bridge technique does not injure the intact tibial nerve used to bridge the gap defect. Taken together, the results of this preliminary animal study suggest that the intact nerve bridge technique may be a potential alternative to standard nerve autografts in appropriate circumstances. Further investigation in a higher animal model is warranted before considering clinical application of the intact nerve bridge technique.     

Reasons for Lack of Diagnostic Colonoscopy After Positive Result on Fecal Immunochemical Test in a Safety-Net Health System

Background

Effective colorectal cancer screening depends on timely diagnostic evaluation in patients with abnormal results on fecal immunochemical tests (FITs). Although prior studies suggest low rates of follow-up colonoscopy, there is little information among patients in safety-net health systems and few data characterizing reasons for low follow-up rates. This study aimed to characterize factors contributing to lack of follow-up colonoscopy in a racially diverse and socioeconomically disadvantaged cohort of patients with abnormal results on FIT (“abnormal FIT” for brevity) receiving care in an integrated safety-net health system.