Hewittabrahamsen7051

The technique of the eversion carotid endarterectomy (ECEA), as an alternative to the conventional endarterectomy with primary or patch angioplasty, is an established technique for managing internal carotid artery stenoses and recently its application has been upgraded through the European Society for Vascular Surgery guidelines (Recommendation 55 Class 1, Level A). However, the typical eversion method has been associated with postoperative hypertension due to loss of the baroreceptor reflex; the standard oblique transection at the bulb performed in the eversion endarterectomy interrupts either the baroreceptor sensoring tissue, which is mostly located in the adventitia at the medial portion of the proximal internal carotid artery, or even the proper Hering nerve, a branch of the glossopharyngeal nerve. These actions deregulate the natural negative feedback of the carotid baroreceptor. Guided by the anatomical location of the baroreceptor sensor we have elaborated a slight modification of the classical ECEA ttients who underwent typical ECEA had significantly higher postoperative blood pressure values compared with those who underwent me-ECEA. Actually, the mean postoperative SBP was 172.67 ± 24.59 mm Hg in the typical ECEA group compared with 160.86 ± 12.83 mm Hg in the me-ECEA group ( p  = 0.023). The mean diastolic blood pressure in the ECEA group was 65.42 ± 11.39 mm Hg compared with 58.06 ± 9.06 mm Hg in the me-ECEA group ( p  = 0.009). Our proposed me-ECEA technique seems to be related to lower rates of postoperative hypertension compared with the typical ECEA, probably due to the sparing of the main mass of the baroreceptor apparatus; this improved modification (me-ECEA) of the typical eversion procedure could represent an alternative ECEA technique with its inherent advantages. © Thieme Medical Publishers.Background  Routine performance measures of primary percutaneous coronary intervention (PCI) within an ST-segment elevation myocardial infarction (STEMI) network are needed to improve care. Objective  We evaluated the door-in to door-out (DI-DO) delays at the initial hospitals in STEMI patients as a routine performance measure of the metropolitan STEMI network. Patients and Methods  We retrospectively analyzed the DI-DO time from 1,076 patients with acute STEMI who were transferred by ground ambulance to a primary PCI center for primary PCI between 4 October 2014 and 1 April 2019. Correlation analysis between DI-DO times and total ischemia time was performed using Spearman's test. Logistic regression analyses were used to find variables associated with a longer DI-DO time. Results  Median DI-DO time was 180 minutes (25th percentile to 75th percentile 120-252 minutes). DI-DO time showed a positive correlation with total ischemia time ( r  = 0.4, p   120 minutes (odds ratio 1.55, 95% confidence interval 1.03 to 2.33, p  = 0.03). Conclusion  The DI-DO time reported in this study has not reached the guideline recommendation. To improve the overall performance of primary PCI in the region, interventions aimed at improving the DI-DO time at the initial hospitals and specific threat for women patients with STEMI are possibly the best efforts in improving the total ischemia time. © Thieme Medical Publishers.Left atrial-femoral artery (LA-FA) bypass with a centrifugal pump and no oxygenator is commonly used for descending and thoracoabdominal aortic (DTAA) operations, mitigating the deleterious effects of cross-clamping. We present our initial experience performing DTAA replacement under LA-FA (left-to-left) cardiopulmonary bypass (CPB) with an oxygenator. DTAA replacement under LA-FA bypass with an oxygenator was performed in 14 consecutive patients (CPB group). The pulmonary vein and femoral artery (or distal aorta) were cannulated and the full CPB machine were used, including oxygenator, roller pump, pump suckers, and kinetically enhanced drainage. The CPB group was compared with 50 consecutive patients who underwent DTAA replacement utilizing traditional LA-FA bypass without an oxygenator (LA-FA group). Perioperative data were collected and statistical analyses were performed. All CPB patients maintained superb cardiopulmonary stability. The pump sucker permitted immediate salvage and return of shed blood. Superb oxygenation was maintained at all times. High-dose full CPB heparin was reversed without difficulty. The CPB group required markedly fewer blood transfusions than the LA-FA group (2.21 vs. 5.88 units, p   less then  0.004). The 30-day mortality rate was 7.1% ( n  = 1) and there were no paraplegia cases in the CPB group versus 7 (14%) deaths and 3 (6%) paraplegia cases in the LA-FA group. Traditional LA-FA bypass without an oxygenator avoids high-dose heparin. In the present era, heparin reversal is more secure. Our experience finds that the novel application of LA-FA CPB with an oxygenator is safe and suggests improved hemodynamics (immediate return of shed blood) and a hemostatic advantage (avoidance of loss of coagulation factors in the cell saver). © Thieme Medical Publishers.Infective endocarditis retains high morbidity and mortality rates despite recent advances in diagnostics, pharmacotherapy, and surgical intervention. Risk stratification in endocarditis patients, including blood-culture negative endocarditis, is crucial in deciding the optimal management strategy; however, the studies investigating risk stratification in these patients were lacking despite the difference with blood-culture positive endocarditis. The aim of this study is to identify risk factors associated with in-hospital mortality in blood-culture negative infective endocarditis patients. A retrospective cohort study was conducted at National Cardiovascular Center Harapan Kita, Jakarta in blood-culture negative infective endocarditis patients from 2013 to 2015. Patient characteristics, clinical parameters, echocardiographic parameters, and clinical complications were collected from medical records and hospital information systems. There were 146 patients that satisfy the inclusion and exclusion criteria out of 162 patients with blood-culture infective endocarditis. The in-hospital mortality rate was 13.5%. On bivariate analyses, factors that were related to in-hospital mortality include New York Heart Association (NYHA) class III and IV heart failure ( p  = 0.007), history of hypertension ( p  = 0.021), stroke during hospitalization ( p   less then  0.001), the decline in renal function ( p   less then  0.001), and surgery ( p  = 0.028). Variables that were independently associated with mortality upon multivariate analysis were heart failure NYHA functional class III and IV (OR 7.56, p  = 0.011), worsening kidney function (OR 10.23, p   less then  0.001), and stroke during hospitalization (OR 8.92, p  = 0.001). Presence of heart failure with NYHA functional class III and IV, worsening kidney function, and stroke during hospitalization were independently associated with in-hospital mortality in blood-culture infective endocarditis patients. © Thieme Medical Publishers.The causal linkage between triglycerides and coronary artery disease has been controversial. Most of the trials hitherto have shown marginal or no beneficial effects of reduction of triglycerides (with fibrates) on top of low-density lipoprotein (LDL) reduction. But a significant residual cardiovascular risk remains even after use of high dose of statins. Omega-3 fatty acids have been shown to reduce triglyceride levels and some old trials have shown the benefits of fish oils in reducing cardiovascular events. However, barring a few trials most of the large trials of omega-3 fatty acids are negative. Recently, few large trials have been conducted to see the effects of high dose omega-3 fatty acids on cardiovascular outcomes and some of them have shown promising results on top of LDL reduction. © Thieme Medical Publishers.Background The implementation of evidence-based practices (EBPs) in community settings appears to result in reduced benefit relative to controlled trials. This difference in outcomes may be attributable in part to engagement challenges therapists encounter when delivering EBPs to low-income ethnic minority youth and families. Objective The current study sought to identify therapist, client, and session characteristics associated with therapist-reported engagement challenges in therapy sessions, as well the associations between two types of client engagement challenges and therapists' self-reported ability to deliver the EBP in sessions within a system-driven implementation in public children's mental health services. Method One hundred and three therapists reported on two types of engagement challenges-Limited Client Engagement and Expressed Client Concerns-in 702 sessions with 274 clients. Results Results indicated that therapists reported a higher frequency of Limited Client Engagement in sessions with male clients and in sessions where the youth was present, and by therapists with smaller caseloads. No variables significantly predicted Expressed Client Concerns. buy AG-1478 Both types of engagement challenges were negatively associated with therapists' report of their ability to carry out intended activities in the same session. Conclusions Findings suggest that therapists may benefit from learning strategies to address these two distinct types of engagement challenges encountered in implementation of EBPs with diverse families in community settings.Pain adversely affects the quality of life in cancer patients. Although conventional oral analgesics and co-analgesics manage 80%-90% of pain, interventional pain management techniques may be useful in the management of cancer pain refractory to opioid analgesia or in patients unable to tolerate systemic opioids. Herein, we report three cases depicting the successful role of erector spinae plane block in our palliative care unit for the management of different chronic cancer pain. Copyright © 2020 Indian Journal of Palliative Care.Glossopharyngeal nerve (GPN) block is used for pain management in patients' head and neck malignancy. The GPN is a mixed nerve containing both motor and sensory fibers. The usual approaches for GPN blocks are usually topical, intraoral, or peristyloid. Topical anesthesia may be difficult in patients with limited mouth opening or when there is inflammation in the area of interest. Intraoral and peristyloid approaches have risk of inadvertent neurovascular injection. The intraoral technique may lead to long-lasting oropharyngeal discomfort. Hence, GPN block is done at the pharyngeal wall level for pain relief. Copyright © 2020 Indian Journal of Palliative Care.Prolonged and neglected use of an intravenous (IV) line could be limb- and life-threatening. In many terminally sick cancer patients of rural India, pain management is a major concern. It is a very common practice by local practitioners to give IV fluids and pain medications in such patients. Where IV access is difficult, a secure venous cannula is kept in situ for long periods to administer pain medicines and fluids. This article tries to highlight the dangers a neglected IV line poses to limb and life and tries to stress on the importance of a subcutaneous route for pain medication administration in terminally ill palliative patients. Copyright © 2020 Indian Journal of Palliative Care.