Caged-in: Successful percutaneous closure of left atrial appendage with Watchman-FLX in the presence of proximal thrombus

Percutaneous mechanical closure of the left atrial appendage (LAA) is a valuable stroke prevention strategy in patients with atrial fibrillation and contraindication to oral anticoagulation. LAA thrombus is a common finding in patients with atrial fibrillation and frequently fails to resolve despite therapeutic anticoagulation. In this scenario, LAA occlusion device implant is generally discouraged due to the high risk of thrombus dislodgement and embolization; however, alternative management options are limited. We report the first case of a successful LAA occlusion device (Watchman-FLX) implant in the presence of a proximal thrombus.     

Update on magnetic resonance cholangiopancreatography

MRCP is a useful tool in the diagnosis of a wide variety of pathologic entities including congenital anomalies, biliary obstruction and stricture, biliary calculi, pancreatitis, neoplasms, and trauma. ERCP and MRCP both have important roles in the management of patients with suspected pancreaticobiliary disease. Knowledge of the advantages and disadvantages of each technique is needed to determine the appropriate work-up of patients with these pathologies.     

Inflammatory markers, D-dimer, pro-thrombotic factors, and physical activity levels in patients with peripheral arterial disease

Men and women with lower extremity peripheral arterial disease (PAD) have reduced physical activity levels compared with persons without PAD. We describe associations between physical activity levels with D-dimer, pro-coagulant factors, and inflammatory markers in patients with PAD. Participants were 188 patients with PAD identified from non-invasive vascular laboratories. Physical activity was measured over 7 days with a vertical accelerometer. We measured the ankle-brachial index (ABI) and levels of D-dimer, C-reactive protein (CRP), fibrinogen, serum amyloid A (SAA), prothrombin 1.2, t-PA antigen, PAI-1, and the t-PA antigen/PAI-1 ratio. Adjusting for age, sex, race, body mass index, ABI, comorbidities, smoking, total cholesterol/HDL ratio and statin use (for CRP only), we found significant inverse linear associations between physical activity levels and log D-dimer (p = 0.002), log CRP (p < 0.001), fibrinogen (p = 0.014), and log SAA (p = 0.012). There were no significant associations between physical activity levels and other blood factors. In an analysis adjusting for all blood factors simultaneously along with known and potential confounders, log D-dimer was the only blood factor associated significantly with physical activity levels (p = 0.036). Based on these findings, future studies should assess whether interventions to increase physical activity in patients with PAD reduce levels of D-dimer and inflammatory markers.     

Maximizing the healthcare environment: A systematic review exploring the potential of computer technology to promote self-management of chronic illness in healthcare settings

Objective

The aim of this systematic review is to investigate the effectiveness of using computers to deliver patient self-management programs (PSMPs) to patients with chronic illness in health supported settings.

Methods

We included randomized controlled trials (RCTs), where the experimental intervention was compared either with an equivalent ‘standard’ PSMP delivered by staff, usual care or no intervention and reported data either on clinical or behavioral outcomes. We conducted a narrative synthesis, incorporating a small quantitative analysis to enable comparisons across studies.

Results

A total of 11 studies met the inclusion criteria. There was insufficient evidence to determine whether computer-based PSMPs were superior to standard programs. However, it appeared that these interventions were effective when compared to no intervention. Interventions incorporating behavior change techniques beyond the provision of information appeared more effective than those that did not.

Conclusion

Evidence from the current review, whilst limited, suggests that computer-based PSMPs, delivered in health-supported settings, show potential for changing health behaviors and improving clinical outcomes in patients with chronic illness.Practice Implications: Although the approach shows promise, it is premature to recommend the integration of these interventions into clinical practice. However, more well designed trials are warranted to test their efficacy and cost-benefit.     

Female Gender and Diabetes Mellitus Increase the Risk of Recurrence after Laparoscopic Incisional Hernia Repair

Background

Laparoscopic hernia repair is used widely for the repair of incisional hernias. Few case studies have focussed on purely ‘incisional’ hernias. This multicentre series represents a collaborative effort and employed statistical analyses to provide insight into the factors predisposing to recurrence of incisional hernia after laparoscopic repair. A specific hypothesis (ie, laterality of hernias as well as proximity to the xyphoid process and pubic symphysis predisposes to recurrence) was also tested.

Methods

This was a retrospective study of all laparoscopic incisional hernias undertaken in six centres from 1 January 2004 to 31 December 2010. It comprised a comprehensive review of case notes and a follow-up using a structured telephone questionnaire. Patient demographics, previous medical/surgical history, surgical procedure, postoperative recovery, and perceived effect on quality of life were recorded. Repairs undertaken for primary ventral hernias were excluded. A logistic regression analysis was then fitted with recurrence as the primary outcome.

Results

A total of 186 cases (91 females) were identified. Median follow-up was 42 months. Telephone interviews were answered by 115/186 (62%) of subjects. Logistic regression analyses suggested that only female sex (odds ratio (OR) 3.53; 95% confidence interval (CI) 1.39–8.97) and diabetes mellitus (3.54; 1–12.56) significantly increased the risk of recurrence. Position of the defect had no statistical effect.

Conclusions

These data suggest an increased risk of recurrence after laparoscopic incisional hernia repair in females and subjects with diabetes mellitus. These data will help inform surgeons and patients when considering laparoscopic management of incisional hernias. We recommend a centrally hosted, prospectively maintained national/international database to carry out additional research.     

Recognizing and improving patient nonadherence to statin therapy

Despite landmark trials demonstrating the benefits of statin therapy for lipid lowering and in the primary and secondary prevention of acute coronary events, many patients do not adhere to medication regimens. Although incremental gains have been made in lowering the absolute levels of total serum cholesterol in the general population, only one third of treated patients are achieving their lipid goals, with fewer than 20% of patients with cardiovascular disease at their target lipid goals. Only half of patients continue taking statins prescribed to them at 6 months, and only 30% to 40% continue taking them at 1 year. Predictors of poor adherence to statins are described, such as female gender and low socioeconomic status. Approaches that are physician focused and patient centered, such as frequent follow-up and serum lipid testing and better education of patients about cardiovascular disease, are suggested to offset a major impediment to achieving the full therapeutic outcomes promised by clinical trials.