Usefulness of Live/Real Time Three‐Dimensional Transthoracic Echocardiography in Evaluation of Prosthetic Valve Function

We studied 31 patients with prosthetic valves (PVs) using two‐dimensional and three‐dimensional transthorathic echocardiography (2DTTE and 3DTTE, respectively) in order to determine whether 3DTTE provides an incremental value on top of 2DTTE in the evaluation of these patients. With 3DTTE both leaflets of the St. Jude mechanical PV can be visualized simultaneously, thereby increasing the diagnostic confidence in excluding valvular abnormalities and overcoming the well‐known limitations of 2DTTE in the examination of PVs, which heavily relies on Doppler. Three‐dimensional transthorathic echocardiography provides a more comprehensive evaluation of PV regurgitation than 2DTTE with its ability to more precisely quantify PV regurgitation, in determining the mechanism causing regurgitation, and in localizing the regurgitant defect. Furthermore, 3DTTE is superior in identifying, quantifying, and localizing PV thrombi and vegetations, in addition to the unique feature of providing a look inside mass lesions by serial sectioning. These preliminary results suggest the superiority of 3DTTE over 2DTTE in the evaluation of PVs and that it provides incremental knowledge to the echocardiographer. (ECHOCARDIOGRAPHY, Volume 26, November 2009)     

The Balanced Scorecard: a strategic management system for multi-sector collaboration and strategy implementation

This article illustrates the application of the Balanced Scorecard, a method more commonly associated with the business world, to a nonprofit multisector National Women's Health Quality Initiative (NWHQI). The article delineates the following multiple uses of the Balanced Scorecard for the NWHQI effort: Set NWHQI strategy and structure. Provide the framework and principles to implement NWHQI's strategy. Develop a measurement system to assess the progress and success of NWHQI's strategy. Serve as a collaboration mechanism for multisector stakeholders. Advance women's health knowledge base. This article concludes by sharing key insights regarding the utility of the Balanced Scorecard to promote the success of this nationwide women's health quality initiative.     

Applying the balanced scorecard in healthcare provider organizations

Several innovative healthcare executives have recently introduced a new business strategy implementation tool: the Balanced Scorecard. The scorecard's measurement and management system provides the following potential benefits to healthcare organizations: It aligns the organization around a more market-oriented, customer-focused strategy It facilitates, monitors, and assesses the implementation of the strategy It provides a communication and collaboration mechanism It assigns accountability for performance at all levels of the organization It provides continual feedback on the strategy and promotes adjustments to marketplace and regulatory changes. We surveyed executives in nine provider organizations that were implementing the Balanced Scorecard. We asked about the following issues relating to its implementation and effect: 1. The role of the Balanced Scorecard in relation to a well-defined vision, mission, and strategy 2. The motivation for adopting the Balanced Scorecard 3. The difference between the Balanced Scorecard and other measurement systems 4. The process followed to develop and implement the Balanced Scorecard 5. The challenges and barriers during the development and implementation process 6. The benefits gained by the organization from adoption and use. The executives reported that the Balanced Scorecard strategy implementation and performance management tool could be successfully applied in the healthcare sector, enabling organizations to improve their competitive market positioning, financial results, and customer satisfaction. This article concludes with guidelines for other healthcare provider organizations to capture the benefits of the Balanced Scorecard performance management system.     

Renal gene expression in embryonic and newborn diabetic mice

Several novel genes that are upregulated in diabetic kidneys have been identified. Recently, transforming growth factor beta driven secreted proteins, i.e., connective tissue growth factor and gremlin (bone morphogenetic protein 2), have been identified, and their expression has been correlated with the tissue changes seen in diabetic nephropathy in the adult population. However, there are very few studies reported in the literature that describe the gene expression in the diabetic state during embryonic and neonatal life. It is well known that exposure to glucose or its epimer, i.e., mannose, induces marked dysmorphogenesis of the embryonic metanephros in an organ culture system. These changes are associated with ATP depletion and marked apoptosis, suggesting an oxidant stress in the induction of dysmorphogenesis of the embryonic metanephros. In view of the glucose-induced changes in the fetal metanephros, a diabetic state was induced by the administration of streptozotocin during pregnancy, and newborn mouse kidneys were processed for suppression subtractive hybridization-PCR. In addition, a diabetic state was induced in newborn diabetic mice, and after 1 week their kidneys were harvested and subjected to representational difference analysis of cDNA. Four novel genes with upregulated mRNA expression were identified. They included: (1) a translocase inner mitochondrial membrane 44 that is involved in the ATP-dependent import of preproteins from the cytosol into the mitochondrial matrix; (2) a kidney-specific aldo-keto reductase that utilizes NADPH and NADH as cofactors in the reduction of aromatic aldehydes and aldohexoses; (3) Rap1b, a Ras-related small GTP-binding protein that behaves as a GTPase and cycles between GTP-bound (active) and GDP-bound (inactive) states associated with conformational change, and (4) a fusion protein of ubiquitin polypeptide and ribosomal protein L40 (UbA(52) or ubiquitin/60) that is intimately involved in the ubiquitin-dependent proteasome pathway related to the accelerated degradation of proteins under various stress conditions, such as those seen in patients with cancer and diabetes mellitus.     

Pseudoaneurysm of anterior tibial artery following tibial nailing: a case report

Interlocking nailing is a widely accepted and performed treatment for tibial shaft fractures. The addition of percutaneously placed transfixation screws increases the stabilisation provided by intramedullary nailing; however, the technical complexity associated with the procedure has introduced new potential complications. We report a pseudoaneurysm of the anterior tibial artery caused by a proximal interlocking screw after intramedullary nailing surgery to repair a tibial shaft fracture. The patient experienced complete relief of symptoms following removal of the nail and the screws, excision of the proximal fibula, resection of the pseudoaneurysm, and ligation of the anterior tibial artery. We recommend the oblique placement of the proximal interlocking screws to prevent this rare complication.     

Accuracy of the precordial V-Quick patch in persons with cardiac or pulmonary disease

The aim of this study was to demonstrate the equivalence of 12-Lead Electrocardiograms (EKG) obtained with the new V-Quick patch and traditional tab-style electrodes. Using a within-subject design, a convenience sample of 100 subjects with either cardiac or pulmonary disease underwent two 12-lead EKGs, one with the traditional tab-style electrodes and one with the precordial patch. Computer-generated measurements of waveform axes and amplitude were obtained for both EKGs. Comparison of mean and 95% confidence intervals revealed no significant differences in Q, R or S wave amplitude across the six precordial leads. Furthermore, a four-factor ANOVA found no significant difference (p > 0.05) in the Q, R and S wave amplitude between the type of electrode, gender and type of disease. A subset of 29 EKGs read by three experts found intra- (.90) and inter-rater (.84) reliability to be strong. In conclusion, the precordial V-Quick patch provided equivalent EKGs to those obtained using standard tab-style electrodes.     

Future therapies for heart failure

The treatment of heart failure has changed as the understanding of the disease evolves. Heart failure remains the only cardiovascular disease that continues to rise in both incidence and prevalence, despite recent advances in treating symptoms and thwarting disease progression. Many opportunities exist for improving patient outcomes with pharmaceutical agents and technologies available now or in the near future. This article discusses recently approved drugs and devices and clinical trials that may affect the management of this challenging disease.     

Alterations in Adrenergic Receptor Signaling in Heart Failure

In the failing heart, several changes occur in cardiac adrenergic receptor-signal transduction pathways. The most striking of these changes occur in -ARs, and of the changes in -adrenergic receptors, 1-receptor down-regulation is the most prominent. Other changes include uncoupling of 2-adrenergic receptors and increased activity of the inhibitory G-protein, Gi. Most of these changes appear to be related to increased activity of the adrenergic nervous system, i.e. increased exposure to norepinephrine. Antagonists of the adrenergic nervous system improve left ventricular function and outcome in patients with heart failure. This fact supports the notion that activation of these neurohormonal systems exerts a net long-term detrimental effect on the natural history of chronic heart failure and that myocardial adrenergic desensitization phenomena are at least partially adaptive in the setting of left ventricular dysfunction.