Nature,frequency, and predictors of secondary procedures after endovascular repair of abdominal aortic aneurysm

OBJECTIVES: Endovascular stent grafting offers a potentially less invasive option for treatment of abdominal aortic aneurysm. Clinical benefit has been demonstrated with respect to early parameters such as blood transfusion, return of gastrointestinal function, and length of hospital stay. Endovascular repair, however, has been criticized on the basis of inferior long-term outcome. Secondary procedures may be necessary to address durability issues such as migration, high-pressure endoleak, graft limb thrombosis, and degeneration of the stent-fabric structure itself, issues that may compromise the primary goal of aneurysm repair, protection from rupture. METHODS: Between 1996 and 2002, 703 patients underwent endovascular treatment of infrarenal abdominal aortic aneurysm at The Cleveland Clinic Foundation. During this time, five devices were used: Ancure, AneuRx, Excluder, Talent, and Zenith. Outcome was assessed with physical examination, lower extremity arterial studies, plain abdominal radiography, and computed tomography at discharge, at 1, 6, and 12 months postoperatively, and annually thereafter. Secondary procedures were defined as any procedure, exclusive of diagnostic angiography, performed after stent graft implantation, directed at treatment of aneurysm-related events. Multivariable statistical techniques for censored data (Cox proportional hazards modeling) were used to determine baseline parameters associated with need for secondary procedures over follow-up, with calculation of hazards ratio (HR) and 95% confidence interval (CI). RESULTS: Patient follow-up averaged 12.2 +/- 11.7 months. Patient survival was 90% +/- 1.4% at 1 year, 78% +/- 2.6% at 2 years, and 70% +/- 3.8% at 3 years. Aneurysm rupture occurred in 3 patients (0.4%), accounting for rupture risk of 1.4% over the first 2 years of follow-up (Kaplan-Meier method). Overall, 128 secondary procedures were required in 104 patients (15%), with a cumulative risk of 12% +/- 1.5% at 1 year, 24% +/- 2.8% at 2 years, and 35% +/- 4.4% at 3 years after stent graft implantation. Among the secondary procedures, new stent grafts and extensions were placed in 34 patients (27%), embolization of endoleak was performed in 33 patients (26%), and open surgical conversion was undertaken in 11 patients (9%). Periprocedural mortality of secondary procedures was 8% overall, but was 18% for patients undergoing open surgical conversion. Multivariable modeling identified the date the procedure was performed (HR, 1.53 per 3-month period of study; CI, 1.22-1.92; P <.001) and aneurysm size (HR, 1.35 per centimeter of minor axis; CI, 1.13-1.60; P <.001) as independent predictors of need for secondary procedures. CONCLUSIONS: Current endovascular devices are associated with a relatively high rate of complications over mid-term follow-up, culminating in frequent need for secondary remedial procedures. With strict follow-up imaging compliance, however, risk for rupture and aneurysm-related death remain exceedingly low. Newer technology may achieve improved durability and a lower requirement for secondary procedures, while maintaining the minimally invasive nature of presently available devices.     

Comparison of Epworth Sleepiness Scale scores by patients with obstructive sleep apnea and their bed partners

OBJECTIVES: In some patients with obstructive sleep apnea (OSA), Epworth Sleepiness Scale scores (ESS) do not reflect the severity of disease. In many cases, bed partners (BPs) report more severe hypersomnia on the part of the patient than the patient him/herself. The purpose of this study was to assess the agreement between patients and BPs on ESS scores and to compare patients and BPs on the correlation between ESS and the severity of OSA. METHODS: ESS scores were estimated by patients and their BPs and their scores were compared. The correlation between the ESS and the apnea-hypopnea index, arousal index, minimum oxygen desaturation, and body mass index of the patient was estimated and compared between the patient and BP. RESULTS: ESS scores of the patient and BP were similar in their correlation with polysomnographic variables. BPs tended to give slightly higher ESS scores than the patient. CONCLUSIONS: ESS scores as estimated by BPs of patients with OSA did not correlate more positively with polysomnographic variables of OSA severity than scores estimated by affected patients.     

Bone marrow derived elements and resident microglia in brain inflammation

Infection of the central nervous (CNS) system by the human immunodeficiency virus (HIV) depends on the migration of infected hematogenous cells into the brain. We thus used quantitative light and electron microscopic immunocytochemistry to study the homing and turnover of bone marrow derived cells in the CNS in radiation bone marrow chimeras under normal conditions and in experimental autoimmune encephalomyelitis (EAE) as an experimental model of brain inflammation. Our studies suggest the following conclusions. First, the central nervous system is continuously patrolled by a small number of T-lymphocytes and monocytes. Meningeal and perivascular monocytes are slowly replaced by hematogenous cells under normal conditions, and this turnover is accelerated in the course of inflammation. In contrast, resident microglia represent a very stable cell pool, which in adult animals is only exceptionally replaced by hematogenous cells, even after recovery from severe brain inflammation. Second, although in bone-marrow-chimeric animals resident microglia, astrocytes, and ependymal cells are not able to present antigen to Lewis T-lymphocytes, the inflammatory reaction in EAE is qualitatively and quantitatively similar in these animals compared to fully histocompatible Lewis rats. Finally, resident microglia express the macrophage activation antigen ED1. Thus, microglia cells appear to function as effector cells in EAE lesions.     

Long-term survival and functional capacity in cardiac surgery patients after prolonged intensive care

OBJECTIVE: To determine whether hospital discharge alone represents a good outcome for patients who had prolonged intensive care after cardiac surgery by studying their postdischarge survival and functional outcome. The secondary objective is to estimate the proportion of intensive care unit (ICU) resources used by the long-stay (> or = 10 initial consecutive ICU days) patients and to identify preoperative patient characteristics that are associated with a prolonged ICU stay and hospital and long-term survival. DESIGN: Inception cohort study. SETTING: The Cleveland Clinic Foundation, a tertiary care, academic teaching institution. PATIENTS: Cardiac surgery patients with an initial ICU stay of 10 or more consecutive days. INTERVENTIONS: Data were collected daily during hospitalization on every adult who underwent coronary artery bypass graft and/or valve surgery at one institution in 1993. Discharged patients who spent >10 initial consecutive days in the ICU after surgery were contacted by telephone to determine vital status and functional capacity using the Duke Activity Status Index. Total ICU and total hospital direct costs were obtained for each patient. MEASUREMENTS AND MAIN RESULTS: The primary outcome measurements were ICU length of stay, hospital mortality, after-surgery and postdischarge mortality and functional capacity, and relative resource utilization. Of the 2,618 cardiac surgery patients who met the inclusion criteria, 142 (5.4%) had an initial ICU length of stay of 10 or more consecutive days. Of these, 47 (33.1%) died in the hospital. Ninety-four of the 95 discharged patients were followed up (median follow-up, 30.6 months), and 44 of the 94 (46.8%) died during the follow-up period. The median Duke Activity Status Index for the 50 survivors was 26 out of a possible 58.2. The 142 long-stay patients used 50% of the total ICU days and 48% of the total ICU direct cost for all 2,618 patients. CONCLUSIONS: Many survivors of prolonged intensive care die soon after hospital discharge and many longer term survivors have a poor functional state. Therefore, hospital discharge is an incomplete measure of outcome for these patients, and longer follow-up is more appropriate. The relatively small number of patients who require prolonged intensive care consumes a disproportionate amount of the total ICU and total hospital direct cost.     

Design and evaluation of the StartingTogether App for home visits in preventive child health care

Background

The StartingTogether program (in Dutch SamenStarten) is a family-centred method for early identification of social-emotional and behavioural problems in young children. Nurses in preventive child health care find it challenging to: determine family issues and need for care; provide education; refer to social services; increase parent empowerment. To mitigate these challenges, we developed and evaluated the StartingTogether App, offering nurses and parents conversational support, tailored education and information on social services.

Methods

A mixed method design, consisting of a qualitative evaluation of the StartingTogether App, with group discussions with nurses (N?=?14) and a pilot test (N?=?5), and a randomized controlled trial, evaluating the effectiveness of the app. Nurses (N?=?33) made home visits to parents (N?=?194), in teams with or without the app. Nurses were surveyed on the challenges experienced during visits. Parents (N?=?166) were surveyed on their satisfaction with health care and app. Nurses were interviewed on the benefits and barriers to use the app.

Results

Parents with the StartingTogether App were more satisfied with the visits than parents without (p?=?.002). Parents with a high educational level were more satisfied with the visits than the parents with a low educational level. With the app, their satisfaction level was similar (p?<?.001). Nurses using the app felt more equipped to communicate with parents (p?=?.012) and experienced that parents were more knowledgeable and skilled (p?=?.001). Parents felt that with the app the nurse was more polite (p?=?.02), listened more carefully (p?=?.03), and had more time (p?=?.02). Nurses with the app gave parents more opportunity to ask questions (p?=?.001) and gave clearer answers (p?<?.001). The qualitative evaluation indicated that some nurses needed extra time to develop the habit of using the app.

Conclusions

The StartingTogether App contributes to parents’ satisfaction with home visits. An interaction effect between parents’ educational level and rating of home visits indicated that the app has an additional value for parents with a lower educational level. Applying mobile applications, such as the StartingTogether App, potentially has a positive effect on communication between nurses and parents about the family situation in relation to parent empowerment and the child’s development.

Trial registration

The study is registered with ISRCTN under the number ISRCTN12491485, on August 23, 2018. Retrospectively registered.

     

Effects of montelukast on subjective and objective outcome measures in preschool asthmatic children

It is well accepted that control of airway inflammation is crucial for overall asthma control. Hence, efficient anti-inflammatory therapy is important for disease control. Therefore, we studied the effect of a treatment with montelukast on subjective and objective measures in preschool asthmatic children with insufficient control of airway inflammation, illustrated by increased fractional exhaled nitric oxide (FeNO). Thirty-one preschool children (2.5-5 years) were included in this study. Children with FeNO > or = 10 ppb at the first visit received montelukast 4 mg as a first line therapy or an add-on therapy to their baseline treatment (group 1). Therapy was not changed at first visit in children with FeNO < 10 ppb (group 2). Symptom scores, FeNO, lung function (forced oscillation, Rrs8Hz) and airway responsiveness to adenosine 5'-monophosphate (AMP) were assessed at visits 1 and 2 eight weeks apart. There was a significant decrease in FeNO (median [interquartile range]; 12.9 [3.7] vs. 7.6 [6.85] ppb, P = 0.011), Rrs8Hz (mean +/- SD; 10.03 +/- 3.1 vs. 8.72 +/- 2.43 hPa.s/L; P = 0.047) and symptom scores (2[2] vs. 1.5[2], P = 0.034) and a significant increase in the provocative AMP dose (2.65 +/- 2.1 vs. 4.54 +/- 1.05; P = 0.015) in group 1 but not in group 2. First line or add-on treatment of oral montelukast in preschool children with mild to moderate asthma and elevated FeNO, decreased levels of FeNO, improved airway responsiveness to AMP, lung function and symptom scores.     

Percutaneous Computed Tomography–guided High-Dose-Rate Brachytherapy Ablation of Breast Cancer Liver Metastases: Initial Experience with 80 Lesions

PurposeTo analyze initial experience with computed tomography–guided high-dose-rate brachytherapy (CT-HDRBT) ablation of breast cancer liver metastases (BCLM).Materials and MethodsBetween January 2008 and December 2010, 37 consecutive women with 80 liver metastases were treated with CT-HDRBT in 56 sessions. Mean age was 58.6 years (range, 34–83 y). Treatment was performed by CT-guided applicator placement and high-dose-rate brachytherapy with an iridium-192 source. The mean radiation dose was 18.57 Gy (standard deviation 2.27). Tumor response was evaluated by gadoxetic acid–enhanced liver magnetic resonance (MR) imaging performed before treatment, 6 weeks after treatment, and every 3 months thereafter.ResultsTwo patients were lost to follow-up; the remaining 35 patients were available for MR imaging evaluation for a mean follow-up time of 11.6 months (range 3–32 mo). Mean tumor diameter was 25.5 mm (range 8–74 mm). Two (2.6%) local recurrences were observed after local tumor control for 10 months and 12 months. Both local progressions were successfully retreated. Distant tumor progression (new metastases or enlargement of nontreated metastases) occurred during the follow-up period in 11 (31.4%) patients. Seven (20%) patients died during the follow-up period. Overall survival ranged from 3–39 months (median 18 months).ConclusionsCT-HDRBT is a safe and effective ablative therapy, providing a high rate of local tumor control in patients with BCLM.     

Hydroxocobalamin Uptake into the Cerebrospinal Fluid after Nasal and Intravenous Delivery in Rats and Humans

The possibility of direct transport of hydroxocobalamin from the nasal cavity into the cerebrospinal fluid (CSF) after nasal administration in rats was investigated and the results were compared with a human study.

Hydroxocobalamin was given to rats (n=8) both intranasally (214 μg/rat) and intravenously (49.5 μg/rat) into the jugular vein using a Vascular Access Port (VAP). Prior to and after drug administration, blood and CSF samples were taken and analysed by radioimmunoassay.

The AUC_CSF/AUC_plasma ratio after nasal delivery does not differ from the ratio after intravenous infusion, indicating that hydroxocobalamin enters the CSF via the blood circulation across the blood–brain barrier (BBB). This same transport route is confirmed by the cumulative AUC-time profiles in CSF and plasma, demonstrating a 30 min delay between plasma absorption and CSF uptake of hydroxocobalamin in rats and in a comparative human study.

The present results in rats show that there is no additional uptake of hydroxocobalamin in the CSF after nasal delivery compared to intravenous administration, which is in accordance with the results found in humans. This indicates a predictive value of the used rat model for the human situation when studying the nose to CSF transport of drugs.     

Object‐location memory in schizophrenia: Interference of symbolic threatening content

Introduction. Monitoring environmental stimuli for their emotional relevance is inherently associated with spatial processing. In schizophrenia, deficits in spatial working memory on one hand, and abnormal emotion processing on the other, have been documented, but these have not been related to each other. In the present study, we investigated whether a specific aspect of spatial memory (i.e., object‐location memory), is impaired in patients with schizophrenia. Moreover, we hypothesised that symbolic threatening content of objects would interfere with spatial processing in patients with schizophrenia but not in healthy controls.

Methods. Spatial memory for symbolic pictorial stimuli was assessed in 40 patients with schizophrenia compared to 41 healthy matched control participants using an object‐relocation task.

Results. Patients with schizophrenia performed worse in relocating objects, independent of overall intellectual ability. More specifically, patients were particularly worse in the relocation of objects with a symbolic threatening content.

Conclusions. These results suggest that a threatening semantic emotional content of schematic stimuli can interfere with spatial processing in schizophrenia. We hypothesise that a disproportional influence of the amygdala on other brain areas, such as the hippocampus, might underlie this specific emotional interference.