Search

Background: Excessive perioperative bleeding is associated with major complications in cardiac surgery, resulting in increased morbidity, mortality, and cost., Methods: An international expert panel was convened to develop consensus statements on the control of bleeding and management of transfusion and to suggest key quality metrics for cardiac surgical bleeding. The panel reviewed relevant literature from the previous 10 years and used a modified RAND Delphi methodology to achieve consensus., Results: The panel developed 30 consensus statements in 8 categories, including prioritizing control of bleeding, prechest closure checklists, and the need for additional quality indicators beyond reexploration rate, such as time to reexploration. Consensus was also reached on the need for a universal definition of excessive bleeding, the use of antifibrinolytics, optimal cessation of antithrombotic agents, and preoperative risk scoring based on patient and procedural factors to identify those at greatest risk of excessive bleeding. Furthermore, an objective bleeding scale is needed based on the volume and rapidity of blood loss accompanied by viscoelastic management algorithms and standardized, patient-centered blood management strategies reflecting an interdisciplinary approach to quality improvement., Conclusions: Prioritizing the timely control and management of bleeding is essential to improving patient outcomes in cardiac surgery. To this end, a cardiac surgical bleeding quality metric that is more comprehensive than reexploration rate alone is needed. Similarly, interdisciplinary quality initiatives that seek to implement enhanced quality indicators will likely lead to improved patient care and outcomes., Competing Interests: Disclosures All authors report that financial support for the consensus project was provided by SABM via a grant received from Baxter. Rawn Salenger reports a relationship with Edwards Lifesciences Corporation that includes: consulting or advisory and speaking and lecture fees; with Terumo Medical Corp that includes: consulting or advisory and speaking and lecture fees; with AtriCure Inc that includes: consulting or advisory and speaking and lecture fees; with La Jolla Pharmaceutical Company that includes: consulting or advisory and speaking and lecture fees; with Encare that includes: consulting or advisory and speaking and lecture fees; and with Zimmer Biomet that includes: consulting or advisory and speaking and lecture fees. Rakesh C. Arora reports a relationship with Edwards Lifesciences Corporation that includes: consulting or advisory; with HLS Therapeutics Inc that includes: consulting or advisory; and with Renibus Therapeutics, Inc that includes: consulting or advisory. Daniel T. Engelman reports a relationship with Edwards Lifesciences Corporation that includes: consulting or advisory; with Renibus Therapeutics, Inc that includes: consulting or advisory; with Alexion that includes: consulting or advisory; with CardioRenal Systems that includes: consulting or advisory; with Genentech that includes: consulting or advisory; with Medela Inc that includes: consulting or advisory; with Arthrex Inc that includes: consulting or advisory; with BioPorto Diagnostics Inc that includes: consulting or advisory; and with AtriCure Inc that includes: consulting or advisory. Caroline Evans reports a relationship with Pharmacosmos UK Ltd that includes: consulting or advisory and speaking and lecture fees; with Pfizer that includes: consulting or advisory and speaking and lecture fees; with Royal College of Anaesthetists Centre for Perioperative Care Guidelines on Anaemia that includes: consulting or advisory; and with British Society of Haematology Guidelines on Preoperative Anaemia that includes: consulting or advisory. Michael C. Grant reports a relationship with ERAS Cardiac Society that includes: board membership. Vicki Morton reports a relationship with ERAS Cardiac Society that includes: board membership; and with Edwards Lifesciences Corporation that includes: speaking and lecture fees. Sherri Ozawa reports a relationship with Accumen Inc that includes: employment; with CSL Vifor that includes: consulting or advisory; with CSL Behring that includes: consulting or advisory; with Werfen that includes: speaking and lecture fees; and with SABM that includes: board membership. Jacob Raphael reports a relationship with Octapharma that includes: consulting or advisory. Linda Shore-Lesserson reports a relationship with CSL Behring that includes: consulting or advisory; and with Vifor Pharma Inc that includes: consulting or advisory. Pierre Tibi reports a relationship with Accumen that includes: consulting or advisory; with HemoSonics LLC that includes: speaking and lecture fees; and with Baxter that includes: speaking and lecture fees. Aryeh Shander reports a relationship with CSL Vifor that includes: consulting or advisory; with Pharmacosmos A/S that includes: consulting or advisory; with Accumen that includes: consulting or advisory; with I-Sep that includes: consulting or advisory; with Grifols Inc that includes: consulting or advisory; with Lindis Corp that includes: consulting or advisory; with Octapharma that includes: consulting or advisory; with Masimo Corporation that includes: consulting or advisory; with HbO(2) Therapeutics LLC that includes: consulting or advisory; a consulting or advisory role was also taken when acting as an expert witness in a class action litigation process. The other authors have no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest None declared.

Purpose: Physician turnover is costly to health care systems and affects patient experience due to discontinuity of care. This study aimed to assess the frequency of turnover by ophthalmologists and identify physician and practice characteristics associated with turnover., Design: Retrospective cross-sectional study., Participants: Actively practicing United States ophthalmologists included in the Centers for Medicare and Medicaid Services Physician Compare and Physician and Other Supplier Public Use File between 2014 and 2021., Methods: We collected data for each ophthalmologist that was associated with practice/institution and then calculated the rate of turnover both annually in each year window and cumulatively as the total proportion from 2014 to 2021. Multivariable logistic regression analysis was used to identify physician and practice characteristics associated with turnover. We also evaluated turnover characteristics surrounding the Coronavirus disease 2019 (COVID-19) pandemic., Main Outcome Measures: Ophthalmologist turnover, defined as a change of an ophthalmologist's National Provider Identifier practice affiliation from one year to the next., Results: Of 13 264 ophthalmologists affiliated with 3306 unique practices, 34.1% separated from at least 1 practice between 2014 and 2021. Annual turnover ranged from 3.7% (2017) to 19.4% (2018), with an average rate of 9.4%. Factors associated with increased turnover included solo practice (adjusted odds ratio [aOR], 9.59), university affiliation (aOR, 1.55), practice location in the Northeast (aOR, 1.39), and practice size of 2 to 4 members (aOR, 1.21; P < 0.05 for all). Factors associated with decreased turnover included male gender (aOR, 0.87) and more than 5 years of practice: 6 to 10 years (aOR, 0.63), 11 to 19 years (aOR, 0.54), 20 to 29 years (aOR, 0.36), and ≥ 30 years (aOR, 0.18; P < 0.05 for all). In the initial year (2020) of the COVID-19 pandemic, annual turnover increased from 7.8% to 11.0%, then decreased to 8.7% in the postvaccine period (2021)., Conclusions: One-third of United States ophthalmologists separated from at least 1 practice from 2014 through 2021. Turnover patterns differed by various physician and practice characteristics, which may be used to develop future strategies for workforce stability. Because administrative data cannot solely determine reasons for turnover, further investigation is warranted given the potential clinical and financial implications., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the effect of cost of living on general surgery resident salaries and identify factors associated with greater incomes and availability of housing stipends., Design: Retrospective cross-sectional analysis of Fellowship and Residency Electronic Interactive Database (FREIDA), institutional websites, and Doximity. Program characteristics were compared through Kruskal-Wallis tests, ANOVA, and χ 2 tests. Multivariable linear mixed modeling and multivariable logistic regression were utilized to determine factors associated with higher salary and availability of housing stipend, respectively., Setting: Three-hundred fifty-one general surgery residency programs in the United States., Participants: Three-hundred-seven general surgery residency programs with available salary data for the 2022 to 2023 academic year., Results: The average postgraduate year 1 resident annual salary was $59,906.00 (standard deviation [SD] ± $5051.97). After adjustment for the cost of living, the average annual income surplus was $22,428.42 (SD ± $4848.64). Cost of living and resident remuneration varied substantially across regions (p < 0.001). Annual income surplus was the highest for programs in the Northeast when compared to other regions (p < 0.001). Resident annual income increased by $510 (95% confidence interval [CI] $430-$590) for each $1000 increase in the cost of living and $150 (95% CI $80-$210) for each 10-rank increase in Doximity general surgery program reputation ranking. An increased cost of living was associated with a higher likelihood of housing stipend availability (odds ratio 1.17, 95% CI 1.07-1.28)., Conclusions: General surgery residents are inadequately compensated for the cost of living, indicating the potential for increased compensation to alleviate economic strain of surgical trainees. As financial stress can have implications for mental and physical well-being, further discussion of current resident salaries and benefits is warranted., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative option for high-risk myeloid malignancies. Post-transplant cyclophosphamide (PT-Cy) has proven to be effective for graft versus host disease (GVHD) prophylaxis. Given that graft-versus-tumor (GVT) effect plays a major role in reducing the risk of disease relapse, the application of PT-Cy must balance the risk of relapse. Mixed chimerism (MC) refers to a state of concurrent presence of recipient and donor cells post allo-HSCT which may precede relapse disease., Objective: We investigated the impact of PT-Cy on early MC (EMC) and disease relapse in patients with a myeloid malignancy post allo-HSCT., Study Design: This retrospective single-center study included patients that underwent allo-HSCT between 2015 and 2021. Patient and disease characteristics were collected from the electronic health records. EMC was defined as <95% donor cells at day 90-120 post allo-HSCT., Results: A total of 144 patient that received an allo-HSCT were included in the study. One hundred and eight (75%) patients received PT-Cy as part of the GVHD prophylaxis regimen. The majority underwent allo-HSCT for acute myeloid leukemia (62%) or myelodysplastic syndrome (31%). Sixty-five percent received allo-HSCT from a matched unrelated donor transplant and 65% received a myeloablative conditioning regimen. A lower rate of chronic GVHD (p = 0.03) and a higher rate of EMC (p = 0.04) were observed in patients that received PT-Cy. PT-Cy was not associated with overall survival (OS) and relapse-free survival (RFS). Multivariable analysis identified measurable residual disease status (p = 0.003), hematopoietic cell transplantation-specific comorbidity index (p = 0.012) and chronic GVHD (p = 0.006) as independent prognostic variables for OS. AML-adverse risk (p = 0.004) and EMC (p = 0.018) were independently prognostic for RFS. While EMC overall was not significantly associated with higher risk of relapse, EMC was associated with shorter RFS within adverse-risk AML patients., Conclusion: Our study shows that PT-Cy was associated with an increased risk of EMC. The predictive value of EMC for relapse remains unclear and may depend on the underlying disease, which should be validated in a larger cohort., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Introduction: Medical centers have dramatically increased the use of magnetic resonance imaging (MRI). At 2 large academic tertiary care centers in New York City, nearly half of inpatient MRI orders took more than 12 h to complete, delaying patient discharge and increasing avoidable hospital days. We posited that transitioning inpatient MRIs to outpatient facilities, when safe and appropriate, could reduce inpatient MRI orders and avoidable hospital days., Methods: We manually reviewed 59 inpatient MRI orders delayed on the estimated date of discharge (EDD). These orders were often delayed due to no standard process to escalate orders for medical reasons or no system to coordinate outpatient orders. We developed a revised workflow involving an automation platform that flagged inpatient MRI orders requested within 24 h of the EDD and emailed the care team to request a second review of the order. The care team reconsidered whether the order was (1) required for discharge, (2) non-urgent and could be converted to an outpatient order, or (3) unnecessary and could be canceled., Results: Over 9 months, the automation platform flagged 618 inpatient MRI orders, of which 53.9% (333/618) were reviewed by the care team. Among the orders, 24.0% (80/333) of reviewed orders and 12.9% (80/618) of all orders were transitioned to either outpatient or canceled orders. These transitioned orders were associated with 267 fewer avoidable hospital days and a cost savings of $199,194., Conclusion: A standardized process and second review of inpatient MRI orders on the EDD can reduce inappropriate orders and more effectively use inpatient imaging resources., Precis: A standardized workflow and automation platform encouraged a second review of inpatient MRI orders to reduce inappropriate orders, avoidable hospital days, and hospital costs., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Aortic root evaluation is conventionally based on 2-dimensional measurements at a single phase of the cardiac cycle. This work presents an image analysis method for assessing dynamic 3-dimensional changes in the aortic root of minimally calcified bicuspid aortic valves (BAVs) with and without moderate to severe aortic regurgitation., Methods: The aortic root was segmented over the full cardiac cycle in 3-dimensional transesophageal echocardiographic images acquired from 19 patients with minimally calcified BAVs and from 16 patients with physiologically normal tricuspid aortic valves (TAVs). The size and dynamics of the aortic root were assessed using the following image-derived measurements: absolute mean root volume and mean area at the level of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction, as well as normalized root volume change and normalized area change of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction over the cardiac cycle., Results: Normalized volume change over the cardiac cycle was significantly greater in BAV roots with moderate to severe regurgitation than in normal TAV roots and in BAV roots with no or mild regurgitation. Aortic root dynamics were most significantly different at the mid-level of the sinuses of Valsalva in BAVs with moderate to severe regurgitation than in competent TAVs and BAVs., Conclusions: Echocardiographic reconstruction of the aortic root demonstrates significant differences in dynamics of BAV roots with moderate to severe regurgitation relative to physiologically normal TAVs and competent BAVs. This finding may have implications for risk of future dilatation, dissection, or rupture, which warrant further investigation., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Left ventricular assist devices (LVAD) are increasingly used for durable mechanical circulatory support in advanced heart failure. While LVAD therapy provides substantial improvement in mortality and quality of life, long-term therapy confers increased risk for device complications. We evaluated if cardiac computed tomography (CCT) improves the detection of cardiomechanical complications among patients with LVAD and suspected device malfunction., Methods: In this study, we compared the diagnostic performance of CCT and transthoracic echocardiography (TTE) for the identification of cardiomechanical LVAD complications, including thrombus or neointimal hyperplasia, inflow cannula malposition with dynamic obstruction, fixed outflow obstruction, device infection, and severe aortic regurgitation. Complications were confirmed with surgical evaluation, pathologic assessment, or response to therapeutic intervention., Results: Among 58 LVAD patients, who underwent CCT and TTE for suspected LVAD dysfunction, there were 49 confirmed cardiomechanical LVAD complications among 43 (74.1%) patients. The most common LVAD complication was thrombus or neointimal hyperplasia (65.3%), followed by dynamic obstruction (26.5%). Individually, CCT identified 29 of the 49 (59.2%) confirmed LVAD cardiomechanical complications, whereas TTE alone identified a complication in 11 cases (22.4%). However, diagnostic performance was greatest when the two modalities were used in combination, yielding a sensitivity of 67%, specificity of 93%, PPV of 97%, NPV of 47% and diagnostic accuracy of 73%., Conclusion: The novel and complementary use of CCT with TTE for the evaluation of suspected device malfunction improves the accurate identification of cardiomechanical LVAD complication compared to either modality alone., Competing Interests: Declaration of competing interest Priyesh Patel's research fellowship was funded by T32 HL007101. Chetan B. Patel is a consultant for Medtronic and Abbott. All other authors have no relevant disclosures or competing interests., (Copyright © 2020 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Ivosidenib (AG-120) and enasidenib (AG-221) are targeted oral inhibitors of the mutant isocitrate dehydrogenase (mIDH) 1 and 2 enzymes, respectively. Given their effectiveness as single agents in mIDH1/2 relapsed or refractory acute myeloid leukemia (AML), this phase 1 study evaluated the safety and efficacy of ivosidenib or enasidenib combined with intensive chemotherapy in patients with newly diagnosed mIDH1/2 AML. Ivosidenib 500 mg once daily and enasidenib 100 mg once daily were well tolerated in this setting, with safety profiles generally consistent with those of induction and consolidation chemotherapy alone. The frequency of IDH differentiation syndrome was low, as expected given the concurrent administration of cytotoxic chemotherapy. In patients receiving ivosidenib, the frequency and grades of QT interval prolongation were similar to those observed with ivosidenib monotherapy. Increases in total bilirubin were more frequently observed in patients treated with enasidenib, consistent with this inhibitor's known potential to inhibit UGT1A1, but did not appear to have significant clinical consequences. In patients receiving ivosidenib (n = 60) or enasidenib (n = 91), end-of-induction complete remission (CR) rates were 55% and 47%, respectively, and CR/CR with incomplete neutrophil or platelet recovery (CR/CRi/CRp) rates were 72% and 63%, respectively. In patients with a best overall response of CR/CRi/CRp, 16/41 (39%) receiving ivosidenib had IDH1 mutation clearance and 15/64 (23%) receiving enasidenib had IDH2 mutation clearance by digital polymerase chain reaction; furthermore, 16/20 (80%) and 10/16 (63%), respectively, became negative for measurable residual disease by multiparameter flow cytometry. This trial was registered at www.clinicaltrials.gov as #NCT02632708., (© 2021 by The American Society of Hematology.)

Aim: Aim of this study is to analyse the epidemiology, treatment modalities and complications faced in management of mandibular condylar fractures by surgical and conservative treatment, over period of five years at our centre., Material and Method: Data of patients who were diagnosed with condylar fractures of mandible from 2013 to 2018 was collected, and were evaluated on the basis of Etiology, fracture pattern, age, sex, associated injuries, treatment modalities and complications., Results: The sample size of 82 patients (total 204), 67 male (81.71%) and 15 female (18.29%) (Male: female = 4.5:1), commonly affected 21-40 years age group. RTA is the most common cause (67.07). Subcondylar fractures were significantly related to RTA under influence of alcohol (48.5%). Total 55 (67%) were treated conservatively and (30.59%) of this belonged to MacLennan I. MacLennan II and III were mostly treated surgically with retromandibular approach being the most common., Conclusion: The principal factors which determine the treatment plan are the level of the fracture and the degree of displacement. Most of undisplaced fractures can be managed by closed non surgical treatment. Open reduction is justified mostly in adults with undisplaced or displaced fractures associated with Malocclusion and patients requiring immediate function. Even after these guidelines many other factors like Medical condition, Patient acceptance & Cost can be a deciding factor., (© 2020 Craniofacial Research Foundation. Published by Elsevier B.V. All rights reserved.)

Endocardial transvenous permanent pacemakers (TVPs) are a mainstay within cardiology and used to treat a range of bradyarrhythmias. However, their use is associated with potential complications both at the time of implantation and longer term. The concept of a leadless pacemaker, where a self-contained device is placed within the right ventricle, has obvious attractions. Two leadless systems have been developed, though only one is currently available. Results from clinical trials have been promising but a number of hurdles need to be circumvented before leadless devices can usurp TVPs. At present, use is restricted to specialist centres, for a limited indication and for patients in whom conventional implantation is contraindicated. This article provides a contemporary critique of design types, evidence base and existing limitations of this nascent technology., Competing Interests: Declaration of competing interest All authors have none to declare., (Copyright © 2019 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

More than 2,400 continuous-flow left ventricular assist devices (LVADs) are implanted each year in the United States alone. Both the number of patients living with LVADs and the life expectancy of these patients are increasing. As a result, patients with LVADs are increasingly encountered by non-LVAD specialists who do not have training in managing advanced heart failure for general medical care, cardiovascular procedures, and other subspecialty care. An understanding of the initial evaluation and management of patients with LVADs is now an essential skill for many health care providers. In this State-of-the-Art Review, we discuss current LVAD technology, summarize our clinical experience with LVADs, and review the current data for the medical management of patients living with LVADs., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Degenerative mitral valve disease is associated with variable and complex defects in valve morphology. Three-dimensional echocardiography (3DE) has shown promise in aiding preoperative planning for patients with this disease but to date has not been as transformative as initially predicted. The clinical usefulness of 3DE has been limited by the laborious methods currently required to extract quantitative data from the images., Methods: To maximize the utility of 3DE for preoperative valve evaluation, this work describes an automated 3DE image analysis method for generating models of the mitral valve that are well suited for both qualitative and quantitative assessment. The method is unique in that it captures detailed alterations in mitral leaflet and annular morphology and produces image-derived models with locally varying leaflet thickness. The method is evaluated on midsystolic transesophageal 3DE images acquired from 22 subjects with myxomatous degeneration and from 22 subjects with normal mitral valve morphology., Results: Relative to manual image analysis, the automated method accurately represents both normal and complex leaflet geometries with a mean boundary displacement error on the order of one image voxel. A detailed quantitative analysis of the valves is presented and reveals statistically significant differences between normal and myxomatous valves with respect to numerous aspects of annular and leaflet geometry., Conclusions: This work demonstrates a successful methodology for the relatively rapid quantitative description of the complex mitral valve distortions associated with myxomatous degeneration. The methodology has the potential to significantly improve surgical planning for patients with complex mitral valve disease., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Diabetes mellitus (DM) is an established adverse prognostic factor in patients sustaining myocardial infarction (MI). However, its impact on long-term survival remains less clear. The aim of this observational study was to quantify lifetime mortality and years of life lost after MI in patients with and without DM., Methods: In 1995, 2153 individuals with MI were recruited from 20 adjacent hospitals within Yorkshire, UK. Median survival, all-cause mortality at 20 years and lost years of life when compared to actuarial predictions were compared in patients with and without DM. Landmark analyses were conducted to define the ongoing impact of DM beyond specified time points., Results: 13% (279/2153) had known DM. They experienced higher mortality at 30 days (33.1% vs 24.6%; p<0.0001) and at 20 years (84.9% vs 75.7%; p<0.0001). Overall, there was a 48% increased risk of death (p<0.0001), which persisted after adjustment for potential confounders. There was no interaction between DM and prior MI in predicting mortality (p=0.67). Median survival decreased by 3.3 years (p<0.0001). The adverse impact of DM persisted in sequential landmark analyses at 1, 5 and 10 years. Presence of DM conferred 2 extra years of life lost when compared with actuarial predictions (8 vs 6 years; p<0.0001)., Conclusions: DM remains an independent adverse prognostic factor in the long-term after MI. Persistently diverging survival curves support enduring efforts to reduce mortality late after MI., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Tachycardia-induced cardiomyopathy (TIC) carries significant risk of morbidity and mortality, although full recovery is possible. Little is known about the myocardial recovery pattern., Objective: The purpose of this study was to determine the time course and predictors of myocardial recovery in pediatric TIC., Methods: An international multicenter study of pediatric TIC was conducted. Children ≤18 years with incessant tachyarrhythmia, cardiac dysfunction (left ventricular ejection fraction [LVEF] <50%), and left ventricular (LV) dilation (left ventricular end-diastolic dimension [LVEDD] z-score ≥2) were included. Children with congenital heart disease or suspected primary cardiomyopathy were excluded. Primary end-points were time to LV systolic functional recovery (LVEF ≥55%) and normal LV size (LVEDD z-score <2)., Results: Eighty-one children from 17 centers met inclusion criteria: median age 4.0 years (range 0.0-17.5 years) and baseline LVEF 28% (interquartile range 19-39). The most common arrhythmias were ectopic atrial tachycardia (59%), permanent junctional reciprocating tachycardia (23%), and ventricular tachycardia (7%). Thirteen required extracorporeal membrane oxygenation (n = 11) or ventricular assist device (n = 2) support. Median time to recovery was 51 days for LVEF and 71 days for LVEDD. Two (4%) underwent heart transplantation, and 1 died (1%). Multivariate predictors of LV systolic functional recovery were age (hazard ratio [HR] 0.61, P = .040), standardized tachycardia rate (HR 1.16, P = .015), mechanical circulatory support (HR 2.61, P = .044), and LVEF (HR 1.33 per 10% increase, p=0.005). For normalization of LV size, only baseline LVEDD (HR 0.86, P = .008) was predictive., Conclusion: Pediatric TIC resolves in a predictable fashion. Factors associated with faster recovery include younger age, higher presenting heart rate, use of mechanical circulatory support, and higher LVEF, whereas only smaller baseline LV size predicts reverse remodeling. This knowledge may be useful for clinical evaluation and follow-up of affected children., (Published by Elsevier Inc.)

We present 4 patients, 4 months to 10 years of age, with thoracic outlet syndrome. All were referred to the brachial plexus clinic. Three patients were diagnosed with vascular thoracic outlet syndrome after clinical evaluation and diagnostic imaging. Three had a cervical rib and 1 had an anomalous first rib. All patients were treated surgically through a supraclavicular approach and had resolution of the symptoms. No postoperative complications were noted., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The rising use of antiplatelet therapy for primary prevention and secondary prevention of cardiovascular and cerebrovascular events poses a dilemma for physicians in the perioperative period. The proven benefits of aspirin in preventing further thrombotic events in patients with prior ACS or stroke make it difficult to withdraw this therapy. The risk of hypercoagulability associated with surgery is also independent of antiplatelet withdrawal, but adds to the rebound effect of platelet responsiveness. Therefore, aspirin should be continued whenever feasible. Similarly, the use of thienopyridines such as clopidogrel, especially for the prevention of stent thrombosis, should be maintained for at least the recommended time frame, if not longer. It is recognized that maintaining antiplatelet therapy is also not without risk, as bleeding complications have been well documented. Unfortunately, current perioperative guidelines do not often provide a simple solution for management. Therefore, the risk of bleeding has to be weighed against the risk of thrombosis, and decisions should be made with all providers caring for the patient on an individual basis.

Introduction: Keloids scars are challenging problems facing many reconstructive surgeons and have proven to be resistant to many treatments. This is evident by the broad range of treatments available and implemented with inconsistent results. We reviewed our experience to better define the disorder and to evaluate the impact of specific treatment options as related to our patient population., Methods: After obtaining Institutional Review Board approval, we examined the medical records of pediatric patients who were evaluated at our pediatric burn center between 2000 to 2008. All study subjects were identified as having keloid scars confirmed by clinical evaluation (raised scar extending beyond the margins of the original wound [1,2]). Treatments included excision and grafting [split thickness autograft (STAG) or full thickness autograft (FTAG)], excision and grafting with steroid injection, excision and primary closure, or excision and primary closure with steroid injection. Patients were included only if there was follow-up of 12 months or greater., Results: One hundred and ten subjects with a diagnosis of a keloid scar were identified. Twenty-six were treated with excision and skin grafting and 8 were treated with a steroid and surgery regimen. Of the patients treated with surgery and steroids, the treatment varied from an intra-operative injection to post-operative injections at 6-week intervals. The number of injections was determined by the administering surgeon and varied from one to three. Clinical end points were determined by the administering surgeon and included: (1) no further improvement in scar maturation or (2) absence of improvement. Recurrence was defined as return of a raised scar consistent with a keloid scar. The recurrence rate was 87.5% for patients treated with surgery and steroids and 80.0% for surgery only. This difference was not statistically significant., Conclusions: Our data demonstrate that steroids do not significantly decrease recurrence in pediatric burn related keloids as compared to previously published series involving non-burn related keloids [3,5]. This further emphasizes that burn related keloids respond differently to conventional treatments that have proven successful in keloid scars from other mechanisms of injury. A consistent and effective treatment algorithm should be implemented in treating keloid scars from burn wounds., (Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.)

Background: Diagnosis of coronary artery disease (CAD) in China with coronary angiography (CA) can be challenging because of high disease prevalence and limited resources. Coronary computed tomography angiography (CTA) may provide an opportunity to minimize invasive diagnostic procedures among intermediate-risk patients indicated for CA and increase patient access to diagnosis of CAD in a cost-effective manner., Objective: This study was conducted to evaluate the potential costs and efficiency of using CTA in combination with CA to optimize diagnosis and care of patients with suspected CAD in China., Methods: We conducted a cost-consequences analysis from the perspective of Fuwai Hospital in Beijing. We developed a decision-analytic model that compared a diagnostic strategy of CA only with a strategy of CTA in combination with CA for patients with intermediate pretest probability of significant CAD and indicated for CA., Results: In the base-case analysis, use of CTA in combination with CA led to a cost-savings of US $597 per patient evaluated compared with the CA-only diagnostic strategy. The hospital cost per angiography-confirmed diagnosis of CAD was US $8,103 for CTA followed by CA compared with US $9,148 for CA only. The unit cost of CA, and CTA sensitivity were the most influential parameters on the results. The range of cost savings associated with use of CTA followed by CA was US $768 - US $461 per patient over a CAD prevalence range of 14% - 59%., Conclusion: The results of our study suggest that CTA implementation in China for intermediate-risk patients indicated for CA may optimize the patient population that undergoes invasive CA procedures and may provide cost savings for Chinese hospitals.

Objective: The goal of this analysis was to evaluate the impact of gout, a painful inflammatory arthritis condition, on an employed population's health-related work absence and objectively measured productivity output., Methods: Payroll, demographic, medical, pharmaceutical, sick leave, short- and long-term disability, and workers' compensation data were collected from multiple large employers with employees widely dispersed across the United States. Data were collected during the time period of 2001 to 2004 from approximately 300,000 employees. Objective productivity output data were also available for a subset of employees (captured electronically in the form of units of work processed per person). T-tests and chi-square tests were used to compare demographic data. Two-stage multivariate regression models were used to compare annual work absence and at-work productivity between employees with and without gout, while controlling for group differences in demographics, salary, other work-related variables, and comorbidities (using the Charlson Comorbidity Index)., Results: The annual prevalence of gout was 4.7 per 1000 employees from 2001 to 2004. Employees with gout had 4.56 more annual absence days for all categories of health-related work absence than those without gout. Objective productivity (units of work processed) results were only available for a small subsample of employees (86 with gout and 27,472 without gout). Employees with gout processed 3.51% fewer units per hour worked and 2.38% fewer units per year than employees without gout (nonsignificant at P = 0.49 and P = 0.78, respectively)., Conclusion: This study suggests that gout has a substantial impact on work absence and may also negatively impact productivity.

Objective: To investigate the effectiveness of statin therapy and to compare the effectiveness results of this study with the reported efficacy of the corresponding data from randomized clinical trials in a moderate-to-high risk coronary heart disease (CHD) managed care population., Methods: Subjects, > or = 18 years old, with a new hyperlipidemia diagnosis or a new prescription claim for a lipid-lowering medication (LLM) between January 1, 1999 and March 31, 2001 were followed for 12 months. Subjects were classified into six medication categories of LLM use based partly on efficacy levels on package inserts. CHD risk factors were measured in the 24-month period prior, and subjects were required to have an established CHD or a CHD-related condition, or have two or more CHD risk factors., Results: The study population consisted of 39,124 hyperlipidemic subjects with moderate-to-high CHD risk; 22,048 (56.4%) were untreated with LLMs. Absolute mean low-density lipoprotein cholesterol (LDL-C) reductions ranged from a 32 mg/dL decrease in the low-efficacy groups to a 57 mg/dL decrease in the high efficacy statin group; percent reductions ranged from a 19% reduction from baseline to a 32% reduction from baseline, respectively. Less than half of subjects (47%) reached LDL goals set forth by NCEP Adult Treatment Panel (ATP III) guidelines, however, the rate of reaching goal increased as statin efficacy increased., Conclusions: While a dose-response relationship was observed, the effectiveness of statin therapy was less than stated in package labeling and only 72% of the users of the highest efficacy statins reached their ATP III goal. LLM use was inconsistent with that recommended by the NCEP ATP III CHD risk assessment. Hyperlipidemia treatment in the managed care setting remains in need of improvement.