bluuebunny/crossref_metadata_2025 huggingface dataset:
Ethical issues in cardiac arrest and acute cardiac care: a European perspective
Authors: Vincent Jean-Louis
Published: December 2016

The respiratory system is key to the management of patients with respiratory, as well as haemodynamic, compromise and should be monitored. The ventilator is more than just a machine that delivers gas; it is a true respiratory system monitoring device, allowing the measurement of airway pressures and intrinsic positive end-expiratory pressure and the plotting of pressure/volume curves. For effective and reliable monitoring, it is necessary to keep in mind the physiology, such as the alveolar gas equation, heart-lung interactions, the equation of movement, etc. Monitoring the respiratory system enables adaptation of not only respiratory management, but also haemodynamic management.
Cardiac magnetic resonance in the intensive and cardiac care unit
Authors: Schwitter Juerg , Bremerich Jens
Published: December 2016

Current applications of cardiac magnetic resonance offer a wide spectrum of indications in the setting of acute cardiac care. In particular, cardiac magnetic resonance is helpful for the differential diagnosis of chest pain by the detection of ischaemia, myocardial stunning, myocarditis, and pericarditis. Also, Takotsubo cardiomyopathy and acute aortic diseases can be evaluated by cardiac magnetic resonance and are important differential diagnoses in patients with acute chest pain. In patients with restricted windows for echocardiography, according to guidelines, cardiac magnetic resonance is the method of choice to evaluate complications of an acute myocardial infarction. In an acute myocardial infarction, cardiac magnetic resonance allows for a unique characterization of myocardial damage by quantifying necrosis, microvascular obstruction, oedema (i.e. area at risk), and haemorrhage. These features will help us to understand better the pathophysiological events during infarction and will also allow us to assess new treatment strategies in acute myocardial infarction. To which extent the information on tissue damage will guide patient management is not yet clear, and further research, e.g. in the setting of the European Cardiovascular MR registry, is ongoing to address this issue. Recent studies also demonstrated the possiblity to reduce costs in the management of acute coronary syndromes when cardiac magnetic resonance is integrated into the routine work-up. In the near future, applications of cardiac magnetic resonance will continue to expand in the acute cardiac care units, as manufacturers are now strongly focusing on this aspect of user-friendliness. Finally, in the next decade or so, magnetic resonance imaging of other nuclei, such as fluorine and carbon, might become a reality in clinics, which would allow for metabolic and targeted molecular imaging with excellent sensitivity and specificity.
Portable (short-term) mechanical circulatory support
Authors: Price Susanna , Vranckx Pascal
Published: December 2016

Mechanical circulatory support can be used to resuscitate patients, as a stabilizing measure for angiography and prompt revascularization, or to buy time until more definite measures can be taken. In addition, there is experimental evidence that ventricular unloading of the left ventricle can significantly reduce the infarct size. Different systems for mechanical circulatory support are available to the medical community. Treatment options for mechanical circulatory support must be tailored to each patient in order to maximize the potential benefits and minimize the risk of detrimental effects. Intra-aortic balloon pumping is still the most widely used mechanical circulatory support therapy. The relative ease and speed with which this device can be applied to patients with a rapidly deteriorating haemodynamic picture have led to its widespread use as a first-line intervention among critically unstable patients. Where intra-aortic balloon pumping is inadequate, an immediate triage to a more advanced percutaneous (short-term) mechanical circulatory support may be warranted. Despite their extensive use, the utility of mechanical circulatory support devices in acute heart failure syndromes and cardiogenic shock remains uncertain. This chapter concentrates on the application of mechanical circulatory support relevant to the interventional cardiologist and cardiac intensive care physician.
Nutrition support in acute cardiac care
Authors: Casaer Michael P , Van den Berghe Greet
Published: December 2016

Malnutrition in cardiac and critical illness is associated with a compromised clinical outcome. The aim of nutrition therapy is to prevent these complications and particularly to attenuate lean tissue wasting and the loss of muscle force and of physical function. During the last decade, several well-powered randomized controlled nutrition trials have been performed. Their results challenge the existing nutrition practices in critically ill patients. Enhancing the nutritional intake and the administration of specialized formulations failed to evoke clinical benefit. Some interventions even provoked an increased mortality or a delayed recovery. These unexpected new findings might be, in part, caused by an important leap forward in the methodological quality in the recent trials. Perhaps reversing early catabolism in the critically ill patient by nutrition or anabolic interventions is impossible or even inappropriate. Nutrients effectively suppress the catabolic intracellular autophagy pathway. But autophagy is crucial for cellular integrity and function during metabolic stress, and consequently its inhibition early in critical illness might be deleterious. Evidence from large nutrition trials, particularly in acute cardiac illness, is scarce. Nutrition therapy is therefore focused on avoiding iatrogenic harm. Some enteral nutrition is administered if possible and eventually temporary hypocaloric feeding is tolerated. Above all, the refeeding syndrome and other nutrition-related complications should be prevented. There is no indication for early parenteral nutrition, increased protein doses, specific amino acids, or modified lipids in critical illness.
The use of biomarkers for acute cardiovascular disease
Authors: Jaffe Allan S
Published: December 2016

Understanding the proper use of biomarkers requires clinicians to appreciate some critical pre-analytic and analytic issues, as well as how to use the markers properly. The bene?ts of such an approach will not only facilitate the care of patients today, but will also prepare clinicians to understand and embrace the new generation of markers that is coming and that will continue to make this area transformational for cardiology. Two fundamental concepts underlie the clinical use of biomarkers: First, biomarkers should always be used in conjunction with all other clinical information. Second, in order to maximize their diagnostic and prognostic use, biomarkers should be interpreted as quantitative variables. For example, a cardiac troponin level which is 50 times the upper limit of normal has a much higher positive predictive value for the presence of an acute myocardial infarction, compared to a level just above the upper limit of normal.
Mechanical complications of myocardial infarction
Authors: López-Sendón José , López de Sá Esteban
Published: December 2016

Mechanical complications after an acute infarction include different forms of heart rupture, including free wall rupture, interventricular septal rupture, and papillary muscle rupture. Its incidence decreased dramatically with the widespread use of reperfusion therapies but may occur in 2–3% of ST-elevation myocardial infarction patients, and mortality is very high if not properly diagnosed, as surgery is the only effective treatment. Echocardiography is the most important tool for diagnosis that should be suspected in patients with hypotension, heart failure, or recurrent chest pain. Awareness and well-established protocols are crucial for an early diagnosis. Modern imaging techniques permit a more reliable and direct identification of left ventricular free wall rupture, which is almost impossible to identify with conventional echocardiography. Mitral regurgitation, secondary to papillary muscle ischaemia or necrosis or left ventricular dilatation and remodelling, without papillary muscle rupture, is frequent after myocardial infarction and is considered as an independent risk factor for outcomes. Revascularization to control ischaemia and surgical repair should be considered in all patients with severe or symptomatic mitral regurgitation in the absence of severe left ventricular dysfunction. Other mechanical complications include true aneurysms and thrombus formation in the left ventricle. Again, these complications have decreased with the use of early reperfusion therapies and, for thrombus formation, with aggressive antithrombotic treatment. In a single large randomized trial (STICH), surgical remodelling of the left ventricle failed to demonstrate a significant improvement in outcomes, although it still may be an option in selected patients.
Cardiac complications in trauma
Authors: Demetriades Demetrios , Kobayashi Leslie , Lam Lydia
Published: December 2016

Post-traumatic cardiac complications may occur after penetrating or blunt injuries to the heart or may follow severe extracardiac injuries. The majority of victims with penetrating injuries to the heart die at the scene and do not reach hospital care. For those patients who reach hospital care, an immediate operation, sometimes in the emergency room, cardiac injury repair, and cardiopulmonary resuscitation provide the only possibility of survival. Many patients develop perioperative cardiac complications such as acute cardiac failure, cardiac arrhythmias, coronary air embolism, and myocardial infarction. Some survivors develop post-operative functional abnormalities or anatomical defects, which may not manifest during the early post-operative period. It is essential that all survivors undergo detailed early and late cardiac evaluations. Blunt cardiac trauma encompasses a wide spectrum of injuries that includes asymptomatic myocardial contusion, arrhythmias, or cardiogenic shock to full-thickness cardiac rupture and death. Clinical examination, electrocardiograms, troponin measurements, and echocardiography are the cornerstone of diagnosis and monitoring of these patients. Lastly, some serious extracardiac traumatic conditions, such as traumatic pneumonectomy and severe traumatic brain injury, may result in cardiac complications. This may include tachyarrhythmias, cardiogenic shock, electrocardiographic changes, troponin elevations, heart failure, and cardiac arrest.
Pulmonary embolism
Authors: Torbicki Adam , Kurzyna Marcin , Konstantinides Stavros
Published: December 2016

Pulmonary embolism is usually a consequence of deep vein thrombosis, and together the two conditions are known as venous thromboembolism. Non-thromboembolic causes of pulmonary embolism are rare. Pulmonary thromboembolism is a potentially life-threatening disease, if left untreated. This is due to a natural tendency towards early recurrence of pulmonary emboli which may lead to fatal right ventricular failure. In more severe cases, secondary right ventricular failure may result from myocardial ischaemia and injury caused by systemic hypotension and adrenergic overstimulation. Clinical presentation of pulmonary embolism is non-specific and may include dyspnoea, chest pain, haemoptysis, syncope, hypotension, and shock. Patients with suggestive history, symptoms, and signs require an immediate triage which determines further management strategy. Computerized tomographic angiography has become the mainstay of diagnosis. However, depending on the clinical presentation, treatment decisions may also be made based on results from other tests. In particular, in high-risk patients with persistent hypotension or shock, bedside echocardiography may be the only available test to identify patients in need of primary thrombolysis, surgical embolectomy, or percutaneous intervention which will stabilize the systemic cardiac output. For most normotensive patients, anticoagulation is sufficient as initial treatment. However, in the presence of signs of right ventricular dysfunction and myocardial injury monitoring is recommended to allow prompt rescue reperfusion therapy in case of haemodynamic decompensation.
Acute cognitive disorders: recognition and management of delirium in the cardiovascular intensive care unit
Authors: McPherson John , Giuseffi Jennifer , Wagner Chad , Ely E Wesley
Published: December 2016

Delirium is the most common acute cognitive disorder seen in critically ill patients in the cardiovascular intensive care unit. It is defined as a disturbance of consciousness and cognition that develops suddenly and fluctuates over time. Delirious patients can become hyperactive, hypoactive, or both. The occurrence of delirium during hospitalization is associated with increased in-hospital and long-term morbidity and mortality. The cause of delirium is multifactorial and may include imbalances in neurotransmitters, inflammatory mediators, metabolic disturbances, impaired sleep, and the use of sedatives and analgesics. Patients with advanced age, dementia, chronic illness, extensive vascular disease, and low cardiac output are at particular risk of developing delirium. Specialized bedside assessment tools are now available to rapidly diagnose delirium, even in mechanically ventilated patients. Increased awareness of delirium risk factors, in addition to non-pharmacological and pharmacological treatments for delirium, can be effective in reducing the incidence of delirium in cardiac patients and in minimizing adverse outcomes, once delirium occurs.
Perioperative cardiac care of the high-risk non-cardiac patient
Authors: Balik Martin
Published: December 2016

Non-cardiac surgery conveys a cardiac risk related to the status of the patient’s cardiovascular system. Cardiac-related risk of surgery can be assessed by integrating the risk and urgency of the procedure with cardiovascular risk factors, which include age, ischaemic heart disease, heart failure, stroke, diabetes mellitus, chronic obstructive pulmonary disease, and renal dysfunction. An individual assessment can include simple multivariate scoring systems, developed with the aim of evaluating cardiac risk prior to non-cardiac surgery. Patient assessment can be extended for indicated additional tests. The indications for further cardiac testing and treatments are the same as in the non-operative setting, but their timing is dependent on the urgency of surgery, and patient-specific and surgical risk factors. A delay in surgery, due to the use of both non-invasive and invasive preoperative testing, should be limited to those circumstances in which the results of such tests will clearly affect patient management. In high-risk patients, the result of the cardiac assessment helps to choose adequate perioperative monitoring and to indicate for an intensive care unit stay perioperatively. Chronic medications can be adjusted, according to the current knowledge on perioperative management. Drugs with the potential to reduce the incidence of post-operative cardiac events and mortality include beta-blockers, statins, and aspirin. Chronic platelet anti-aggregation and anticoagulation therapies have to be adapted by weighing the risk of bleeding against the risk of thrombotic complications.
Perioperative management of the high-risk surgical patient: cardiac surgery
Authors: Ranucci Marco , Castelvecchio Serenella , Ballotta Andrea
Published: December 2016

During the last decade, as a result of continually improving surgical strategy and the technology which supports it (e.g. anaesthesia), cardiac surgery is offered to patients with advanced age and those with increasingly complex co-existing conditions that were previously considered to be contraindications. In addition, an increasing number of patients have previously undergone angioplasty, thereby delaying their initial coronary artery bypass graft surgery to a more advanced age. In general, candidates for cardiac surgery may now be not only older than in the past, but also more likely to have health problems such as hypertension and diabetes. Risk stratification may help to identify ‘the’ high-risk patient: ‘pre-warned is pre-armed’. In high-risk cardiac surgery patients, the surgical treatment options and perioperative care must be tailored to each patient, in order to optimize the benefits and minimize the risk of detrimental effects. The preoperative anticoagulation practice is an important aspect, balancing the risk between ischaemic and bleeding complications. New antiplatelet agents and oral anticoagulants have been recently delivered, and their role in patients scheduled for heart surgery is an additional important issue.
Colonization With Vancomycin-Resistant Enterococci and Risk for Bloodstream Infection Among Patients With Malignancy: A Systematic Review and Meta-Analysis
Authors: Alevizakos Michail , Gaitanidis Apostolos , Nasioudis Dimitrios , Tori Katerina , Flokas Myrto Eleni , Mylonakis Eleftherios
Published: December 2016

Background

Vancomycin-resistant enterococci (VRE) cause severe infections among patients with malignancy, and these infections are usually preceded by gastrointestinal colonization.

Methods

We searched the PubMed and EMBASE databases (up to May 26, 2016) to identify studies that reported data on VRE gastrointestinal colonization among patients with solid or hematologic malignancy.

Results

Thirty-four studies, reporting data on 8391 patients with malignancy, were included in our analysis. The pooled prevalence of VRE colonization in this population was 20% (95% confidence interval [CI], 14%–26%). Among patients with hematologic malignancy, 24% (95% CI, 16%–34%) were colonized with VRE, whereas no studies reported data solely on patients with solid malignancy. Patients with acute leukemia were at higher risk for VRE colonization (risk ratio [RR] = 1.95; 95% CI, 1.17–3.26). Vancomycin use or hospitalization within 3 months were associated with increased colonization risk (RR = 1.92, 95% CI = 1.06–3.45 and RR = 4.68, 95% CI = 1.66–13.21, respectively). Among the different geographic regions, VRE colonization rate was 21% in North America (95% CI, 13%–31%), 20% in Europe (95% CI, 9%–34%), 23% in Asia (95% CI, 13%–38%), and 4% in Oceania (95% CI, 2%–6%). More importantly, colonized patients were 24.15 (95% CI, 10.27–56.79) times more likely to develop a bloodstream infection due to VRE than noncolonized patients.

Conclusions

A substantial VRE colonization burden exists among patients with malignancy, and colonization greatly increases the risk for subsequent VRE bloodstream infection. Adherence to antimicrobial stewardship is needed, and a re-evaluation of the use of vancomycin as empiric therapy in this patient population may be warranted.
The Impact of an Academy of Medical Educators on the Culture of an American Health Sciences Campus
Authors: Corral Janet , Guiton Gretchen , Aagaard Eva
Published: December 2016

Purpose

During the last two decades in the United States, academies of medical educators (AMEs) have proliferated as formal organizations within faculties of health professions education to recognize teaching excellence, support faculty development, and encourage scholarly activity. AMEs have been effective at rewarding faculty for educational excellence and providing faculty development. However, the impact of an AME on campus culture remains unclear.

Method

A qualitative case study asked, How has an AME shaped organizational culture? The authors investigated the University of Colorado health sciences campus AME given its clear mandate to impact organizational culture. The authors interviewed a purposeful sample of 26 AME members and non-AME campus faculty and educational leaders during the 2014–2015 academic year. Two reviewers employed content analysis to code the transcripts.

Results

The AME has positively impacted organizational culture by being a symbol of institutional commitment to the educational mission, and by asserting education as an evidence-based practice. At the faculty member level, the AME’s impact includes creating a home and community for educators to network. Individual faculty influence departments and programs across campus through teaching and interpersonal connections. However, the AME has not impacted all of campus, due to only reaching self-identified educators, and the siloed nature of departments on campus.

Conclusions

Although limited to a single campus and an early established AME, this study contributes significant insight by describing how an AME as a structural unit impacts individual faculty members, who in turn impact organizational campus culture regarding the educational mission.
Middle Range Theory
Authors: Liehr Patricia , Smith Mary Jane
Published: December 2016

This replication and critique addresses ongoing development and use of middle range theory since considering this body of nursing knowledge 18 years ago. Middle range theory is appreciated as essential to the structure of nursing knowledge. Nine middle range theories that demonstrate ongoing use by the theory authors are analyzed using the criteria of theory name, theory generation, disciplinary perspective, theory model, practice use and research use. Critique conclusions indicate the importance of staying with the theory over time, naming and development consistent with the disciplinary perspective, movement to an empirical level, and bringing middle range theory to the interdisciplinary table.
Determining Optimal Route of Hysterectomy for Benign Indications
Authors: Schmitt Jennifer J. , Carranza Leon Daniel A. , Occhino John A. , Weaver Amy L. , Dowdy Sean C. , Bakkum-Gamez Jamie N. , Pasupathy Kalyan S. , Gebhart John B.
Published: December 2016

OBJECTIVE:

To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy.

METHODS:

A retrospective postrobot cohort of benign hysterectomies (2009–2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded the laparoscopic hysterectomy route. A prerobot cohort (2004–2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated.

RESULTS:

Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the prerobot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the postrobot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%) robot-assisted; and 136 (11.4%) abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when a vaginal approach was expected. Robotic hysterectomies had longer operations (141 compared with 59 minutes, P<.001) and higher rates of surgical site infection (4.7% compared with 0.2%, P<.001) and urinary tract infection (8.1% compared with 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated $800,000 in hospital costs over 5 years.

CONCLUSION:

When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.
Implementing Immediate Postpartum Long-Acting Reversible Contraception Programs
Authors: Hofler Lisa G. , Cordes Sarah , Cwiak Carrie A. , Goedken Peggy , Jamieson Denise J. , Kottke Melissa
Published: December 2016

OBJECTIVE:

To understand the most important steps required to implement immediate postpartum long-acting reversible contraception (LARC) programs in different Georgia hospitals and the barriers to implementing such a program.

METHODS:

This was a qualitative study. We interviewed 32 key personnel from 10 Georgia hospitals working to establish immediate postpartum LARC programs. Data were analyzed using directed qualitative content analysis principles. We used the Stages of Implementation to organize participant-identified key steps for immediate postpartum LARC into an implementation guide. We compared this guide to hospitals' implementation experiences.

RESULTS:

At the completion of the study, LARC was available for immediate postpartum placement at 7 of 10 study hospitals. Participants identified common themes for the implementation experience: team member identification and ongoing communication, payer preparedness challenges, interdependent department-specific tasks, and piloting with continuing improvements. Participants expressed a need for anticipatory guidance throughout the process. Key first steps to immediate postpartum LARC program implementation were identifying project champions, creating an implementation team that included all relevant departments, obtaining financial reassurance, and ensuring hospital administration awareness of the project. Potential barriers included lack of knowledge about immediate postpartum LARC, financial concerns, and competing clinical and administrative priorities. Hospitals that were successful at implementing immediate postpartum LARC programs did so by prioritizing clear communication and multidisciplinary teamwork. Although the implementation guide reflects a comprehensive assessment of the steps to implementing immediate postpartum LARC programs, not all hospitals required every step to succeed.

CONCLUSION:

Hospital teams report that implementing immediate postpartum LARC programs involves multiple departments and a number of important steps to consider. A stage-based approach to implementation, and a standardized guide detailing these steps, may provide the necessary structure for the complex process of implementing immediate postpartum LARC programs in the hospital setting.
Maternal Morbidity After Previable Prelabor Rupture of Membranes
Authors: Dotters-Katz Sarah K. , Panzer Alexis , Grace Matthew R. , Smid Marcela C. , Keku J. Adeolu , Vladutiu Catherine J. , Boggess Kim A. , Manuck Tracy A.
Published: December 2016

OBJECTIVE:

To identify risk factors for maternal morbidity after previable prelabor rupture of membranes (PROM).

METHODS:

We conducted a case–control study of singleton and twin pregnancies complicated by previable PROM (14.0–22.9 weeks of gestation) at a single tertiary care referral institution, 2000–2015. Pregnancies complicated by fetal anomalies, previable PROM within 2 weeks of chorionic villus sampling or amniocentesis, and those with contraindications to expectant management (eg, chorioamnionitis) were excluded. Cases were women with the primary outcome of composite maternal morbidity (defined as having at one or more of the following: sepsis, intensive care unit admission, acute renal insufficiency, uterine curettage, hysterectomy, deep vein thrombosis, pulmonary embolus, blood transfusion, readmission, or maternal death). Controls were women without the primary composite morbidity. Bivariate analysis compared demographic, clinical, and management characteristics of women in the case group and those in the control group. Multivariable logistic regression models were developed to quantify the association between maternal characteristics and composite severe maternal morbidity.

RESULTS:

During the study period, 174 women presented with by previable PROM and were candidates for expectant management. Sixty-five (37%) women opted for immediate delivery; 109 (63%) elected expectant management. Twenty-five of 174 (14%) experienced one or more components of the composite maternal morbidity (cases) and were compared with 149 (86%) women in the control group. Women in the case group were more not more likely to elect expectant management (68% compared with 59%, P=.40), but were more likely to be aged 35 years or older (40% compared with 14%, P=.002) or to be carrying twins (52% compared with 16%, P<.01). In the regression model, twin gestation and age 35 years or older were both significantly associated with increased odds of composite maternal morbidity (odds ratio [OR] 5.62, 95% confidence interval [CI] 2.21–14.3 and OR 4.00, 95% CI 1.48–10.8, respectively).

CONCLUSION:

Antenatal counseling of women with previable PROM should include that one in seven women experience significant morbidity. Although expectant management was not associated with increased risk in this cohort, women with twins or those aged 35 years or older were at substantially increased risk.
Effect of Spirogyra neglecta on the early stages of 1, 2-dimethylhydrazine-induced colon carcinogenesis in rats
Authors: Taya Sirinya , Thumvijit Tarika , Chewonarin Teera , Punvittayagul Charatda , Wongpoomchai Rawiwan
Published: December 2016

This study focused on the chemopreventive effects of Spirogyra neglecta extract (SNE) and dried S. neglecta mixed diet on the early stages of 1,2-dimethylhydrazine (DMH)-induced colon carcinogenesis in rats. Male Wistar rats were injected with DMH to initiate aberrant crypt foci (ACF) formation. In the initiation stage, SNE significantly decreased the number of ACF in the colon of DMH-treated rats. Rats that received a low dose of SNE showed enhanced activity of several detoxifying and antioxidant enzymes. In the postinitiation stage, a low dose of SNE significantly decreased the number of ACF in the colon of DMH-treated rats. It significantly reduced the number of proliferating cell nuclear antigen-positive cells and increased the number of apoptotic cells in colonic crypts. S. neglecta thus inhibited the development of the early stages of DMH-induced colon carcinogenesis in rats by modulation of xenobiotic metabolizing enzymes and inhibition of cell proliferation as well as induction of apoptosis.
Incidence trends and clinical–pathological characteristics of invasive cutaneous melanoma from 1980 to 2010 in the Canton of Zurich, Switzerland
Authors: Minini Remo , Rohrmann Sabine , Braun Ralph , Korol Dimitri , Dehler Silvia
Published: December 2016

The aims of this paper are to describe the incidence trends of invasive cutaneous melanoma in the Canton of Zurich and to evaluate clinical and pathological factors such as cancer subtype, localization, age and Breslow thickness. A retrospective analysis was carried out with data from the population-based Cancer Registry of Zurich and Zug located in Zurich. A total of 8469 cases in 8034 different patients of invasive cutaneous melanoma were registered for the period 1980–2010 in the Canton of Zurich. Incidence trends were age standardized to the European standard population. Joinpoint regression was used to compute changes in incidence and mortality rates, measured as the annual percent change (APC). The most common subtypes of cutaneous melanoma were superficial spreading melanoma (SSM, 41.1%), followed by nodular melanoma (16.5%), lentigo maligna melanoma (13.5%), acral-lentiginous melanoma (5.0%) and other types of melanoma (2.8%); 21.1% were melanoma not otherwise specified. The trunk was the most frequent location (30.8%), followed by the lower limb and hip (26.4%) and the upper limb and shoulder (22.8%). Statistically significantly increasing incidence trends were observed for both men (APC=3.0%) and women (APC=2.1%). Incidences of SSM and melanoma not otherwise specified were the histological subtypes for which a significant increase in incidence was observed (APC for the period 1980–2010=3.2% for both). In terms of Breslow thickness, thin melanomas (0.01–1.00 mm) showed an increasing incidence. The incidence of melanoma increased in both men and women between 1980 and 2010. In terms of the different subtypes and Breslow thickness, increasing incidences of the SSM and of thin melanomas (0.01–1.00 mm) were observed. These observations are in agreement with other studies from Southern and Western Switzerland as well as other European countries and the USA.
Avoiding Radical Surgery in Elderly Patients With Rectal Cancer Is Cost-Effective
Authors: Rao Christopher , Sun Myint Arthur , Athanasiou Thanos , Faiz Omar , Martin Antony Paul , Collins Brendan , Smith Fraser McLean
Published: December 2016

BACKGROUND:

Radical surgery is associated with significant perioperative mortality in elderly and comorbid populations. Emerging data suggest for patients with a clinical complete response after neoadjuvant chemoradiotherapy that a watch-and-wait approach may provide equivalent survival and oncological outcomes.

OBJECTIVE:

The purpose of this study was to compare the cost-effectiveness of watch and wait and radical surgery for patients with rectal cancer after a clinical complete response following chemoradiotherapy.

DESIGN:

Decision analytical modeling and a Markov simulation were used to model long-term costs, quality-adjusted life-years, and cost-effectiveness after watch and wait and radical surgery. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters.

SETTINGS:

A third-party payer perspective was adopted.

PATIENTS:

Patients included in the study were a 60-year–old male cohort with no comorbidities, 80-year–old male cohorts with no comorbidities, and 80-year–old male cohorts with significant comorbidities.

INTERVENTIONS:

Radical surgery and watch-and-wait approaches were studied.

MAIN OUTCOME MEASURES:

Incremental cost, effectiveness, and cost-effectiveness ratio over the entire lifetime of the hypothetical patient cohorts were measured.

RESULTS:

Watch and wait was more effective (60-year–old male cohort with no comorbidities = 0.63 quality-adjusted life-years (95% CI, 2.48–3.65 quality-adjusted life-years); 80-year–old male cohort with no comorbidities = 0.56 quality-adjusted life-years (95% CI, 0.52–1.59 quality-adjusted life-years); 80-year–old male cohort with significant comorbidities = 0.72 quality-adjusted life-years (95% CI, 0.34–1.76 quality-adjusted life-years)) and less costly (60-year–old male cohort with no comorbidities = $11,332.35 (95% CI, $668.50–$23,970.20); 80-year–old male cohort with no comorbidities = $8783.93 (95% CI, $2504.26–$21,900.66); 80-year–old male cohort with significant comorbidities = $10,206.01 (95% CI, $2762.014–$24,135.31)) independent of patient cohort age and comorbidity. Consequently, watch and wait was more cost-effective with a high degree of certainty (range, 69.6%–89.2%) at a threshold of $50,000/quality-adjusted life-year.

LIMITATIONS:

Long-term outcomes were derived from modeled cohorts. Analysis was performed for a United Kingdom third-party payer perspective, limiting generalizability to other healthcare contexts.

CONCLUSIONS:

Watch and wait is likely to be cost-effective compared with radical surgery. These findings strongly support the discussion of organ-preserving strategies with suitable patients.
Omission of Adjuvant Chemotherapy Is Associated With Increased Mortality in Patients With T3N0 Colon Cancer With Inadequate Lymph Node Harvest
Authors: Wells Katerina O. , Hawkins Alexander T. , Krishnamurthy Devi M. , Dharmarajan Sekhar , Glasgow Sean C. , Hunt Steven R. , Mutch Matthew G. , Wise Paul , Silviera Matthew L.
Published: December 2016

BACKGROUND:

Adjuvant chemotherapy for T3N0 colon cancer is controversial. National guidelines recommend its use in patients with stage II with high-risk features, including lymph node harvest of less than 12, yet this treatment is underused.

OBJECTIVE:

The purpose of this study was to demonstrate that the use of adjuvant chemotherapy in patients with T3N0 adenocarcinoma with inadequate lymph node harvest is beneficial.

DESIGN:

This was a retrospective population-based study of patients with resected T3N0 adenocarcinoma of the colon.

SETTINGS:

The National Cancer Database was queried from 2003 to 2012.

PATIENTS:

A total of 134,567 patients with T3N0 colon cancer were included in this analysis.

MAIN OUTCOME MEASURES:

The use of chemotherapy, short-term outcomes, and overall survival was evaluated. Clinicopathologic factors associated with omission of chemotherapy were also analyzed.

RESULTS:

Inadequate lymph node harvest was observed in 23.3% of patients, and this rate decreased over the study period from 46.8% in 2003 to 12.5% in 2012 (p < 0.0001). Overall 5-year survival for patients with T3N0 cancer was 66.8%. Inadequate lymph node harvest among these patients was associated with lower overall 5-year survival (58.7% vs 69.8%; p < 0.001). The use of adjuvant chemotherapy among patients with T3N0 cancer after inadequate lymph node harvest was only 16.7%. In a multivariable analysis, factors associated with failure to receive chemotherapy included advanced age (OR = 0.44 (95% CI, 0.43–0.45)), increased comorbidities (OR = 0.7 (95% CI, 0.66–0.76)), and postoperative readmission (OR = 0.78 (95% CI, 0.67–0.91)). Patients with inadequate lymph node harvest who received adjuvant chemotherapy had improved 5-year survival (chemotherapy, 78.4% vs no chemotherapy, 54.7%; p < 0.001). Even when controlling for all of the significant variables, the administration of chemotherapy remained a predictor of decreased mortality (HR = 0.57 (95% CI, 0.54–0.60); p < 0.001).

LIMITATIONS:

This study was limited by its retrospective, population-based design.

CONCLUSIONS:

Patients with T3N0 colon cancer with inadequate lymph node harvest who receive adjuvant chemotherapy have increased overall survival. Despite this survival benefit, a fraction of these patients receive adjuvant chemotherapy. Barriers to chemotherapy are multifactorial.
Preoperative Immunonutrition and Elective Colorectal Resection Outcomes
Authors: Thornblade Lucas W. , Varghese Thomas K. , Shi Xu , Johnson Eric K. , Bastawrous Amir , Billingham Richard P. , Thirlby Richard , Fichera Alessandro , Flum David R.
Published: December 2016

BACKGROUND:

Randomized controlled trials demonstrate the efficacy of arginine-enriched nutritional supplements (immunonutrition) in reducing complications after surgery. The effectiveness of preoperative immunonutrition has not been evaluated in a community setting.

OBJECTIVE:

This study aims to determine whether immunonutrition before elective colorectal surgery improves outcomes in the community at large.

DESIGN:

This is a prospective cohort study with a propensity score–matched comparative effectiveness evaluation.

SETTINGS:

This study was conducted in Washington State hospitals in the Surgical Care Outcomes Assessment Program from 2012 to 2015.

PATIENTS:

Adults undergoing elective colorectal surgery were selected.

INTERVENTIONS:

Surgeons used a preoperative checklist that recommended that patients take oral immunonutrition (237 mL, 3 times daily) for 5 days before elective colorectal resection.

MAIN OUTCOME MEASURES:

Serious adverse events (infection, anastomotic leak, reoperation, and death) and prolonged length of stay were the primary outcomes measured.

RESULTS:

Three thousand three hundred seventy-five patients (mean age 59.9 ± 15.2 years, 56% female) underwent elective colorectal surgery. Patients receiving immunonutrition more commonly were in a higher ASA class (III–V, 44% vs 38%; p = 0.01) or required an ostomy (18% vs 14%; p = 0.02). The rate of serious adverse events was 6.8% vs 8.3% (p = 0.25) and the rate of prolonged length of stay was 13.8% vs 17.3% (p = 0.04) in those who did and did not receive immunonutrition. After propensity score matching, covariates were similar among 960 patients. Although differences in serious adverse events were nonsignificant (relative risk, 0.76; 95% CI, 0.49–1.16), prolonged length of stay (relative risk, 0.77; 95% CI, 0.58–1.01 p = 0.05) was lower in those receiving immunonutrition.

LIMITATIONS:

Patient compliance with the intervention was not measured. Residual confounding, including surgeon-level heterogeneity, may influence estimates of the effect of immunonutrition.

CONCLUSIONS:

Reductions in prolonged length of stay, likely related to fewer complications, support the use of immunonutrition in quality improvement initiatives related to elective colorectal surgery. This population-based study supports previous trials of immunonutrition, but shows a lower magnitude of benefit, perhaps related to compliance or a lower rate of adverse events, highlighting the value of community-based assessments of comparative effectiveness.
Periorbital Syringomas Treated With an Externally Used 1,444 nm Neodymium-Doped Yttrium Aluminum Garnet Laser
Authors: Kim Jun Young , Lee Jae Won , Chung Kee Yang
Published: December 2016

BACKGROUND

The 1,444 nm wavelength is also well absorbed in water making it a possible setting for treatment of cystic lesions such as eccrine hydrocystomas and syringomas.

OBJECTIVE

The authors aimed to investigate the efficacy of an externally used 1,444 nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser for the treatment of periorbital syringomas.

METHODS AND MATERIALS

Nineteen patients with periorbital syringomas were treated twice with the externally used 1,444 nm Nd:YAG laser at 2-month intervals. Laser fluences were delivered to each papule with pulse energy of 160 mJ, 1.6 W of power, and at a 10 Hz pulse rate. Clinical improvement and patient satisfaction were assessed at 2 and 6 months after each treatment. Side effects were also examined.

RESULTS

Clinical improvement of >50% was observed in 68.4% of individuals at 2 months after first treatment (2FT) and in all patients at 6 months after second treatment (6ST). Patient satisfaction of no less than “satisfied” was recorded for 63.2% of patients at 2FT, and in 89.5% of patients at 6ST. Erythema was observed in 63.2% of patients but only at 2FT.

CONCLUSION

Externally used 1,444 nm Nd:YAG laser treatment may represent an effective and safe approach for the treatment of periorbital syringomas, resulting in good satisfaction and minimal side effects.
Further delineation between typical and atypical dopamine uptake inhibitors: effects on food-maintained behavior and food consumption
Authors: Slezak Jonathan M. , Desai Rajeev I. , Katz Jonathan L.
Published: December 2016

The present studies compared the acute effects of benztropine analogs (4-Cl-BZT, JHW 007, AHN 1-055), which are atypical dopamine uptake inhibitors, with those of the standard dopamine uptake inhibitors GBR 12909 and cocaine, on the reinforcing efficacy of food and food intake in male Sprague-Dawley rats. Repeated drug effects of JHW 007 on food intake were also determined. The number of ratios completed under a progressive-ratio schedule of food delivery was used as an index of reinforcing efficacy. Food intake was determined by measuring powdered laboratory-chow consumption during daily 40 min food-availability time periods. Under the progressive-ratio schedule, cocaine and GBR 12909 dose-dependently increased the number of ratios completed. JHW 007 decreased ratios completed, whereas neither 4-Cl-BZT nor AHN 1-055 increased ratios completed with a magnitude that approximated any of the increases produced by cocaine or GBR 12909. Acute administration of each drug dose-dependently decreased food intake; however, the benztropine analogs were more potent than cocaine and GBR 12909. A reduction in food intake emerged after repeated administration of a low dose of JHW 007. Future studies that compare JHW 007 with standard anorectic drugs (e.g. phentermine) and continue investigation of the repeated drug effects under similar experimental procedures are clearly warranted.
An Automated Expanded Polytetrafluoroethylene Suturing and Coaxial Fastener System for Mitral Chordae Replacement: Strength, Feasibility, and Healing
Authors: Lee Candice Y. , Wong Joshua K. , Sauer Jude S. , Gorea Heather R. , Martellaro Angelo J. , Sifain Andrew R. , Knight Peter A.
Published: December 2016

Objective

Mitral valve (MV) chordae replacements can be technically challenging. Technology that remotely delivers and accurately secures artificial chordae may reduce the learning curve and improve the reliability of MV repairs.

Methods

The technology involved two devices: a remote suturing device for delivery of expanded polytetrafluoroethylene (ePTFE) suture to the papillary muscle and a Coaxial titanium suture fastener (TF) device with integrated saline infusion for real-time determination of chordae length during fixation. A mechanical model simulating MV chordae tension in a beating heart quantified the durability of 120 coaxially fastened ePTFE sutures using TF over time. Investigation of the technology was performed in ex vivo porcine, ovine, and in situ cadaver hearts, whereas live-tissue testing was conducted in a survivor ovine model. Mitral valve repair procedures involved the iatrogenic induction of mitral regurgitation by the resection of one to two native MV chordae, followed by implantation of ePTFE suture using the technology. Epicardial echocardiography, saline infusion testing, and histologic analysis evaluated MV competence, repair integrity, and long-term healing.

Results

Durability testing of ePTFE suture secured with TF demonstrated no degradation of TF pull-apart forces of for 440 million cycles. Mitral valve repairs using the technology were performed in eight sheep; four demonstrating proof of concept and four survived for an average of 6.5 months after completion of the procedure. At reoperation, echocardiography demonstrated trace to no mitral regurgitation with near complete endothelialization of the TF and artificial chordae.

Conclusions

This technology successfully enabled the implantation of artificial chordae while providing real-time adjustment of chordae length during MV repair. These results encourage further investigation of its use clinically.
Strategies to Improve the Efficacy of Epicardial Linear Ablation on the Beating Heart
Authors: Watanabe Yoshiyuki , Schill Matthew R. , Kazui Toshinobu , Melby Spencer J. , Schuessler Richard B. , Damiano Ralph J.
Published: December 2016

Objective

Creating transmural linear lesions on the beating heart is an important component of minimally invasive surgical ablation for atrial fibrillation. Animal studies have shown poor efficacy for surface bipolar radiofrequency ablation (RFA). Clinicians have developed strategies including multiple device applications and vena caval occlusion (VCO) to improve ablation efficacy. These techniques were evaluated in an acute porcine model.

Methods

In the first experiment, an RFA device was used to perform two 40-second epicardial ablations on the right atrium of six pigs. Ablations were performed with and without VCO. Ultrasonic flow probes were used to verify VCO. In the second experiment, an RFA device was used to perform two 40-second epicardial ablations at six locations on the left and right atria of six pigs. All animals were sacrificed. The hearts were removed and stained with 2,3,5-triphenyltetrazolium chloride. Sections were examined using digital photography.

Results

With VCO, 42 (81%) of 52 sections were transmural; without VCO on the RA, only 12 (24%) of 50 sections were transmural (P < 0.01). In thick (>2 mm) tissue, 10 (59%) of 17 VCO sections were transmural compared with only two (8%) of 24 with normal caval blood flow. Compared with a single ablation, multiple device applications improved transmurality on the LA but not the RA (92% vs 71%, P < 0.05).

Conclusions

In an acute animal model, VCO improved the efficacy of beating-heart RFA on the RA. Multiple device applications improved the efficacy of RFA on the LA.