Patent foramen ovale closure in patients with transient ischemia attack/stroke

Paradoxical embolism through a patent foramen ovale (PFO) has been recognized as a potential cause of transient ischemia attack (TIA) and stroke especially in younger patients. The therapeutic options are medical treatment (antiaggregation or anticoagulation) with an annual recurrence rate of 3% to 4% for stroke or TIA, surgical PFO closure, or catheter closure. Randomized studies are ongoing; however, the results will not be available soon. Since August 1994, we have attempted catheter closure of a PFO in 281 patients (age 17 to 79 years, mean 46.8 +/- 13.2) with paradoxical embolism. Of these, 184 patients had at least one embolic stroke, 112 patients at least one TIA, and 15 patients at least one peripheral embolism. The diameter of the PFO, measured with a balloon catheter, ranged from 3 mm to 24 mm with a mean of 10 +/- 3.5 mm. Implantation of the occluder was technically successful in all patients (two attempts in four patients). Seven different devices were used: 26 Sideris buttoned, 11 ASDOS, 19 Angel Wings, 98 PFO-Star, 37 Cardioseal-Starflex, 57 Amplatzer and, 33 Helex devices. One patient suffered from septicemia and subsequently died. In 2 patients, device embolization occurred during or after the procedure (1 Sideris, 1 PFO-Star; catheter retrieval successful). Thirty-seven patients had other minor complications without long-term sequelae: atrial fibrillation within the first weeks after implantation in five patients, asymptomatic thrombus on the device at routine transesophageal echocardiogram (TEE) in 7 patients (1 Angel Wings, 1 ASDOS, 1 CardioSeal, 4 PFO-Star), and device frame fracture in 25 patients (2 Sideris, 4 ASDOS, 1 Angel Wings, 1 CardioSeal, 17 PFO-Star). No complications occurred with the newer devices (Amplatzer and Helex). A residual shunt after 6 months was found in 5.5% of the patients who had completed their 6-month TEE follow-up. In two patients, a second occluder was implanted because of a residual shunt. During a follow-up period of 1 month to 71 months (mean 12 +/- 16 months, 268 patient years), a recurrence of an embolic event (seven TIA, two stroke) occurred in eight patients. None of these occurred with the newer devices (Amplatzer, Helex). Freedom from recurrence of the combined end point of TIA, ischemic stroke, and peripheral embolism was 95.7% (95% CI: 89.0%-98.4%) at 1 year and 94.1% (95% CI: 80.1-98.4%) at 3 years. Catheter PFO closure is a technically simple procedure. With the newer devices and increasing experience, the success rate has improved and the complication rate has decreased. The advantage of the procedure is that closing the defect means a causal treatment. However, catheter closure of PFO despite a very low morbidity has inherent potential risks like any other interventional procedure. Furthermore, selection of patients who definitely have PFO as the cause of their cerebral event has not been defined. For these reasons, further studies are warranted.     

Motivations of Persons with Psychiatric Disabilities to Work in Mental Health Peer Services: A Qualitative Study Using Self-Determination Theory

Introduction Individuals with psychiatric disabilities have low rates of employment and occupational rehabilitation success. Mental health peer services are a new occupational modality that opened a promising occupational path: persons with serious mental illnesses employed to provide support to others with psychiatric conditions. However challenges to successful peer work exist. Work motivation is central to understanding and supporting peer workers, yet little is known about sources of motivation to work as mental health peer providers. The aim of this study was to identify what drives individuals to mental health peer work using self determination theory (SDT). Methods Motivations of 31 mental health peer workers were explored as part of a larger study. A theory driven approach was employed to emerging qualitative data using SDT concepts: external motivation and internally regulated motivations derived from basic needs (autonomy, competence, relatedness). Results External motivations included generic occupational goals and getting away from negative work experiences. Internal motivations corresponded with SDT basic needs: autonomy met-needs was reflected in having freedom to disclose and finding that work accords with personal values; competence met-needs was reflected in using personal experience as a resource to help others; and relatedness met-needs were reflected in having opportunity to connect intimately and reciprocate with consumers. Conclusion This study identified external and internal motivations of persons with psychiatric disabilities to work as peer providers—a novel occupation in mental health. Employing personal experience and enabling peer contact emerge as major motivational tenets of mental health peer work. According to SDT instrumental occupational goals are considered more external than satisfaction of basic psychological needs. The study demonstrates the applicability of SDT in the design of autonomy supported environments to promote work engagement and sustenance of mental health peer providers.     

A Randomized Trial of Complications of Peripherally and Centrally Inserted Central Lines in the Neuro-Intensive Care Unit: Results of the NSPVC Trial

Neurocritical Care - The objective of this study was to compare the relative number of complications from peripherally inserted central venous catheters (PICC) and centrally inserted central venous...     

The COVID-19 Pandemic as a Threat Multiplier for Childhood Health Disparities: Evidence from St. Louis,MO

The COVID-19 pandemic has highlighted socioeconomic and racial health disparities in the USA. In this study, we examined the COVID-19 pandemic as a threat multiplier for childhood health disparities by evaluating health behavior changes among urban St. Louis, MO, children (ages 6–14) during the COVID-19 pandemic. From 27 October to 10 December 2020, 122 parents/guardians reported on their children’s health behaviors (Eating, Sleeping, Physical activity, Time outside, Time with friends in-person, Time with friends remotely, Time using media for educational proposes, Time using media for non-educational proposes, and Social connectedness) prior to and during the COVID-19 pandemic. We ran K-means cluster analyses to identify distinct health behavior cluster profiles. Relative risks were determined to evaluate behavioral differences between the two clusters. Two distinct cluster profiles were identified: a High Impact profile (n = 49) and a Moderate Impact profile (n = 73). Children in the High Impact cluster had a greater risk of being diagnosed with COVID-19, developed worsened eating habits (RR = 2.10; 95% CI = 1.50–2.93), spent less time sleeping, and spent less time outdoors (RR = 1.55; 95% CI = 1.03–2.43) than the Moderate Impact cluster. The High Impact cluster was more likely to include Black children and children from single-adult households than the Moderate Impact cluster (both p < 0.05). Our findings suggest that the COVID-19 pandemic may be a threat multiplier for childhood health disparities. Further research is needed to better understand the long-term effects of the COVID-19 pandemic on children’s health.     

Antimicrobial Therapy of Experimental Enterococcal Endocarditis

The successful therapy of enterococcal endocarditis requires prolonged administration of synergistic antibiotic combinations. Controversy has arisen regarding optimal therapy (i) when the organism possesses high-level streptomycin resistance, and (ii) when the patient is allergic to penicillin. This study examines these questions in vitro and in a rabbit model of enterococcal endocarditis. The combination of penicillin with either streptomycin or gentamicin increased the rate of bacterial killing in vitro and in vivo when compared with penicillin alone (P < 0.05) when the test strain was relatively susceptible to streptomycin (minimal inhibitory concentration, 128 mug/ml). Only the combination of penicillin and gentamicin was consistently more effective than penicillin alone (P < 0.01) when the test strain was highly resistant to streptomycin (minimal inhibitory concentration > 150,000 mug/ml). The combination of vancomycin and streptomycin was more rapidly bactericidal than vancomycin alone in vitro and in the animal model against the streptomycin-susceptible strain (P < 0.01). The relative rate of in vitro bacterial killing by various antibiotics and combinations was predictive of the efficacy of these drugs in eradicating enterococci from cardiac vegetation in experimental endocarditis.