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Distinct Aspects of Left Ventricular Mechanical Function Are Differentially Associated With Cardiovascular Outcomes and All-Cause Mortality in the Community. - Journal of the American Heart Association
There are few data relating novel measures of left ventricular (LV) mechanical function to cardiovascular disease (CVD) outcomes in the community. Whether distinct components of LV mechanical function provide information regarding risk for different CVD outcomes is unclear.We used speckle tracking echocardiography to quantify distinct components of LV mechanical function (measured as LV strain in multiple planes) in 2831 Framingham Offspring Study participants (mean age, 66 years; 57% women, 97% with LV fractional shortening >0.29). Participants were followed for 6.0Â±1.2 years for onset of 69 coronary heart disease (CHD), 71 heart failure (HF), and 199 mortality events. Adjusting for CVD risk factors, longitudinal LV strain appeared associated with incident CHD (hazards ratio [HR] per SD increment, 1.29; 95% confidence interval [CI], 1.00-1.67; P=0.05), whereas circumferential and radial strain were not (P>0.37 for both); however, the association of longitudinal strain with CHD was nonsignificant after Bonferroni correction. By contrast, circumferential strain was a significant predictor of incident HF (HR per SD increment, 1.79; 95% CI, 1.35-2.37; P<0.0001). Decrements in circumferential, radial, and longitudinal strain measures were related to all-cause mortality (P<0.008 for all). Results remained similar in multivariable models adjusting additionally for the conventional echocardiographic measures of LV mass and fractional shortening.In our large, community-based sample, distinct components of LV mechanical function were associated with specific CVD outcomes. Additional studies are needed to replicate these findings and investigate the prognostic and therapeutic utility of these novel measures of LV mechanical function.Â© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.
Burden of Invasive Staphylococcus aureus Infections in Hospitalized Infants. - JAMA pediatrics
Staphylococcus aureus is a frequent cause of infection in hospitalized infants. These infections are associated with increased mortality and morbidity and longer hospital stays, but data on the burden of S aureus disease in hospitalized infants are limited.To compare demographics and mortality of infants with invasive methicillin-resistant S aureus (MRSA) and methicillin-susceptible S aureus (MSSA), to determine the annual proportion of S aureus infections that were MRSA, and to contrast the risk of death after an invasive MRSA infection with the risk after an invasive MSSA infection.Multicenter retrospective study of a large, nationally representative cohort at 348 neonatal intensive care units managed by the Pediatrix Medical Group. Participants were 3888 infants with an invasive S aureus infection who were discharged from calendar year 1997 through calendar year 2012.Invasive S aureus infection.The incidence of invasive S aureus infections, as well as infant characteristics and mortality after MRSA or MSSA infection.The 3888 infants had 3978 invasive S aureus infections (2868 MSSA and 1110 MRSA). The incidence of invasive S aureus infection was 44.8 infections per 10â€¯000 infants. The yearly proportion of invasive infections caused by MRSA increased from calendar year 1997 through calendar year 2006 and has moderately decreased since then. Infants with invasive MRSA or MSSA infections had similar gestational ages and birth weights. Invasive MRSA infections occurred more often at a younger postnatal age. For infants with available mortality data, more infants with invasive MSSA infections (nâ€‰=â€‰237) died before hospital discharge than infants with invasive MRSA infections (nâ€‰=â€‰110). The proportions of infants who died after invasive MSSA and MRSA infections were similar at 237 of 2474 (9.6%) and 110 of 926 (11.9%), respectively (Pâ€‰=â€‰.05). The adjusted risk of death before hospital discharge was similar after invasive MSSA and MRSA infections (risk ratio, 1.19; 95% CI, 0.96-1.49). The risks of death at 7 and 30 days after invasive infection were similar between infants with invasive MSSA infection and infants with invasive MRSA infection.Infant mortality after invasive MRSA and MSSA infections is similar, but MSSA causes more infections and more deaths in infants than MRSA. Measures to prevent S aureus infection should include MSSA in addition to MRSA.
Cytotoxic and targeted therapy for treatment of pseudomyogenic hemangioendothelioma. - Clinical sarcoma research
Pseudomyogenic hemangioendothelioma (PMH) is a recently described, indolent vascular tumor that usually presents in the distal extremities. PMH typically has a multi-focal presentation and can involve several tissue planes including the dermis, subcutis, muscle, and bone. This soft tissue tumor predominantly affects men between 20 and 50Â years of age. PMH tumors typically are resected but frequently recur locally; thus, more efficacious treatment options are needed. Herein, we report two cases of patients with PMH who were treated with systemic therapy. To the best of our knowledge, our report is the first to describe a response of PMH either to gemcitabine/taxane cytotoxic chemotherapy or to a mammalian target of rapamycin inhibitor. In the first case, a 45-year-old man with PMH of the right ilium was treated with gemcitabine plus docetaxel. Although chemotherapy was ultimately halted owing to gemcitabine-induced pulmonary toxicity, positron emission tomography-computer tomography scans taken after three cycles of gemcitabine plus docetaxel illustrated a noticeable response to the regimen. In the second case, a 22-year-old man with PMH of the right distal femur and metastases in the left ilium showed no response to gemcitabine plus docetaxel therapy, but underwent surgical resection after cisplatin and doxorubicin resulted in stable disease. DNA sequencing of his tumor revealed the presence of a tuberous sclerosis 1 (TSC1) mutation, so daily everolimus, which inhibits mammalian target of rapamycin, was started. Two months after beginning everolimus, the patient underwent magnetic resonance imaging of the pelvis, which revealed mild shrinkage of PMH metastases in the left iliac bone. Despite the apparent heterogeneity of response to gemcitabine/taxane chemotherapy in our two patients, these two cases indicate that gemcitabine/taxane and mammalian target of rapamycin inhibitor may serve as systemic treatment options for PMH and warrant further investigation.
Deep organ space infection after emergency bowel resection and anastomosis: The anatomic site does not matter. - The journal of trauma and acute care surgery
Deep organ space infection (DOSI) is a serious complication after emergency bowel resection and anastomosis. The aim of this study was to identify the incidence and risk factors for the development of DOSI.National Surgical Quality Improvement Program database study including patients who underwent large bowel or small bowel resection and primary anastomosis. The incidence, outcomes, and risk factors for DOSI were evaluated using univariate and multivariate analyses.A total of 87,562 patients underwent small bowel, large bowel, or rectal resection and anastomosis. Of these, 14,942 (17.1%) underwent emergency operations and formed the study population. The overall mortality rate in emergency operations was 12.5%, and the rate of DOSI was 5.6%. A total of 18.0% required ventilatory support in more than 48 hours, and 16.0% required reoperation. Predictors of DOSI included age, steroid use, sepsis or septic shock on admission, severe wound contamination, and advanced American Society of Anesthesiologists classification. The anatomic location of resection and anastomosis was not significantly associated with DOSI.Patients undergoing emergency bowel resection and anastomosis have a high mortality, risk of DOSI, and systemic complications. Independent predictors of DOSI include wound and American Society of Anesthesiologists classification, sepsis or septic shock on admission, and steroid use. The anatomic location of resection and anastomosis was not significantly associated with DOSI.Epidemiologic/prognostic study, level III.
Isolated blunt severe traumatic brain injury in Bern, Switzerland, and the USA: a matched cohort study. - The journal of trauma and acute care surgery
The ideal prehospital management of patients with severe traumatic brain injury (TBI) including the impact of endotracheal intubation (ETI) and physicians on scene is unclear. Prehospital management differs substantially in Switzerland and the USA: in Switzerland there is usually a physician on scene who may provide ETI and other advanced life support procedures, whereas in the USA prehospital management (including ETI) is performed by paramedics.Retrospective cohort-matched study of patients with isolated blunt severe TBI (head AIS 4-5) and no major extracranial injuries, utilizing Bern University Hospital data from the Swiss PEBITA (TBI-specific) database and the US National Trauma Data Bank (NTDB) 2009-2010. A 1:4 cohort matching of Bern and US patients was performed. Matching criteria were sex, age (+/-10 years), exact field GCS, exact head AIS, and injury type (subdural hematoma, epidural hematoma, intraparenchymal hemorrhage, intraventricular hemorrhage, brain edema/swelling, brain stem injury). The matched cohorts were compared with univariable analysis (Fisher's exact and Mann-Whitney U test).Matching of the Bern (n=128) and US cohort (n=86'375) resulted in 355 matched cases (71 Bern and 284 US). Bern patients had significantly longer scene times (median 23.0 vs. 9.0 min., p<0.001), and more frequent prehospital ETI (31.0 vs 18.7%, p=0.034) and air transportation (39.4 vs 19.4%, p<0.001). No significant difference in procedures (craniotomy/craniectomy, ICP-monitoring, tracheotomy), Intensive Care Unit (ICU) and total hospital length of stay (LOS), ventilator days, and in-hospital mortality (14.1 vs 15.8%, p=0.855) was found between the two cohorts.Taking into account the limitation that patient- and injury-related factors, but not in-hospital treatment variables were matched, the more frequent prehospital ETI and presence of a physician on scene in the Swiss cohort compared to the US cohort had no significant effect on outcomes, including ICU and total hospital LOS, ventilator days, and in-hospital mortality.Level IV, therapeutic study.
Genetic and Pharmacological Modulation of Akt1 for Improving Ovarian Graft Revascularization in a Mouse Model. - Biology of reproduction
Ovarian tissue cryopreservation and transplantation is one of a few available treatments for fertility preservation in women diagnosed with cancer. Rapid revascularization is essential for reducing hypoxic damage after grafting and protecting the primordial follicles reserve. Using a mouse model of heterotopic ovarian graft transplantation, we have delineated the role of endothelial Akt1 expression using longitudinal MRI follow-up to quantify angiogenic response. Endothelial Akt1 activation in ovarian grafts promoted angiogenesis to support the graft during post-transplantation hypoxic period. Similarly, simvastatin therapy activated Akt1 at the transplantation site and improved the revascularization and vascular support of ovarian grafts. These results serve as an important first step towards pharmacological intervention to improve revascularization of ovarian grafts and restoration of fertility in cancer survivors. The pro angiogenic effects reported here may extend beyond improving ovarian graft reception in fertility preservation and could potentially be used for different organ or tissue transplantation.Copyright 2015 by The Society for the Study of Reproduction.
Minimally Invasive Gynecologic Surgery for Benign Conditions: Progress and Challenges. - Obstetrical & gynecological survey
The objective of this review is to evaluate the progress made in laparoscopic and hysteroscopic gynecologic surgery and address challenges still faced by surgeons using minimally invasive techniques to improve the care of women with noncancerous gynecologic problems.Relevant literature was reviewed and evidence-based arguments put forward in the article for the progress that has been made and the deficiencies that still exist.In the last 2 decades, enormous progress has been made in providing minimally invasive surgical options for women with gynecologic diseases. The progress has been especially striking in the performance of hysterectomy, the most common major surgery performed on nonpregnant women. The recent controversy over power morcellation has revealed a poor understanding of the literature concerning leiomyosarcoma leading to confusion and consequently denial of minimally invasive surgical options for many women. Hysteroscopic surgery has been evolving rapidly with the development of hysteroscopic morcellator, global endometrial ablation systems, and hysteroscopic tubal sterilization.Although huge advances have been made in minimally invasive gynecologic surgery, high-quality evidence from well-designed clinical trials is lacking for many of the new technologies. Accurate estimates regarding the risk of occult leiomyosarcoma are also lacking. Additional research is urgently needed to address these deficiencies.
Pediatric Urinary Retention in the Emergency Department: AÂ Concerning Symptom with Etiology Outside the Bladder. - The Journal of emergency medicine
Urinary retention in an otherwise healthy adolescent is a concerning symptom, in which etiology can range from an extracystic mass to central nervous system involvement (CNS). One possibility is acute disseminated encephalomyelitis (ADEM), a rare inflammatory autoimmune disease that affects the CNS via demyelination. The disease usually is preceded by an acute viral infection, and commonly presents with multifocal neurological deficits. The diagnosis for ADEM is made based on clinical presentation, correlating with findings characterized on magnetic resonance imaging (MRI) in the CNS.Our case involves a 16-year-old boy who presented to the Emergency Department (ED) with urinary retention. The patient was an otherwise healthy adolescent who was experiencing intermittent fevers for 1Â week, and was found to be monospot positive when seen by his pediatrician. When presenting to the ED, the patient's primary complaint was urinary retention, which he experienced acutely in the middle of the night. Due to the suspicious nature of the patient's symptoms and history of present illness, the patient received a thorough workup including magnetic resonance imaging (MRI) of the patient's brain and spinal cord, which demonstrated findings consistent with ADEM. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: There is very little literature describing a case of ADEM in the ED where the primary manifesting symptom was urinary retention. In addition, it is important that clinicians address acute urinary retention in an otherwise healthy adolescent as a red flag, with the need to rule out concerning etiology.Copyright Â© 2015 Elsevier Inc. All rights reserved.
Surgical Treatment of Primary Cardiac Sarcomas: Review of a Single-Institution Experience. - The Annals of thoracic surgery
Primary cardiac sarcomas are rare, aggressive, and usually lethal. Surgical management protocols are not defined because of the lack of extensive experience in treating these patients. In this study, we reviewed our outcomes with primary cardiac sarcoma, and we make recommendations regarding management.Review of the Houston Methodist Hospital cardiac tumor database from 1990 to 2015 (25 years) yielded 131 primary cardiac evaluations of possible cardiac sarcoma. From these we identified 95 patients who underwent surgical excision. A computer search of cardiac sarcomas yielded 131 tumors that were coded as primary cardiac sarcoma or possible primary cardiac sarcoma. Retrospective data collection and clinical outcomes were evaluated for all 95 patients. Medical records and follow-up material were requested for all patients through clinic visits and contacting the physician of the patient, the hospital record department, and the cardiac tumor board after previous approval. The procedures were performed using an institutional review board-approved cardiac tumor protocol, and the patients gave full consent.All 95 patients were diagnosed as having primary cardiac sarcoma by histologic appearance. Age ranged from 15 to 84 years at the time of presentation (mean, 44 years). Male patients made up 57% of the sample. The most common site for the cardiac sarcoma was the right atrium (37 patients) followed by the left atrium (31 patients). Postoperative 1-year mortality was 35% (33 patients). The most common tumor histologic type was angiosarcoma (40%) followed by spindle cell sarcoma (11%).Primary cardiac sarcoma is a rare but lethal disease. Surgical intervention is associated with acceptable surgical mortality in this high-risk group of patients.Copyright Â© 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Measurement methods to assess diastasis of the rectus abdominis muscle (DRAM): A systematic review of their measurement properties and meta-analytic reliability generalisation. - Manual therapy
Systematic literature review.Diastasis of the rectus abdominis muscle (DRAM) has been linked with low back pain, abdominal and pelvic dysfunction. Measurement is used to either screen or to monitor DRAM width. Determining which methods are suitable for screening and monitoring DRAM is of clinical value.To identify the best methods to screen for DRAM presence and monitor DRAM width.AMED, Embase, Medline, PubMed and CINAHL databases were searched for measurement property studies of DRAM measurement methods. Population characteristics, measurement methods/procedures and measurement information were extracted from included studies. Quality of all studies was evaluated using 'quality rating criteria'. When possible, reliability generalisation was conducted to provide combined reliability estimations.Thirteen studies evaluated measurement properties of the 'finger width'-method, tape measure, calipers, ultrasound, CT and MRI. Ultrasound was most evaluated. Methodological quality of these studies varied widely. Pearson's correlations of rÂ =Â 0.66-0.79 were found between calipers and ultrasound measurements. Calipers and ultrasound had Intraclass Correlation Coefficients (ICC) of 0.78-0.97 for test-retest, inter- and intra-rater reliability. The 'finger width'-method had weighted Kappa's of 0.73-0.77 for test-retest reliability, but moderate agreement (63%; weighted KappaÂ =Â 0.53) between raters. Comparing calipers and ultrasound, low measurement error was found (above the umbilicus), and the methods had good agreement (83%; weighted KappaÂ =Â 0.66) for discriminative purposes.The available information support ultrasound and calipers as adequate methods to assess DRAM. For other methods limited measurement information of low to moderate quality is available and further evaluation of their measurement properties is required.Copyright Â© 2015 Elsevier Ltd. All rights reserved.
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