Search

Background: Heart transplantation (HT) is the treatment of choice for many patients with end-stage heart failure who remain symptomatic despite optimal medical therapy, but no study has looked directly into functional improvement of HT patients after an inpatient rehabilitation program.Objective: To determine functional improvement in HT patients who completed an inpatient rehabilitation program.Design: Retrospective study.Setting: An inpatient rehabilitation facility (IRF) associated with a tertiary care hospital.Patients: Seventeen patients admitted between March 2011 and September 2014 after HT.Methods: Demographic, clinical, and functional data (admission and discharge Functional Independence Measure [FIM] scores) were recorded. Change in FIM scores and FIM efficiency (change in FIM score/length of stay) were analyzed. FIM outcomes for HT patients were compared with regional and national averages for patients undergoing an inpatient rehabilitation program for cardiac debility. As a secondary outcome, we evaluated whether body mass index of HT patients had an impact on FIM gains in an IRF. Individual FIM items were analyzed for trends. Results are reported as mean ± SD.Results: Twelve male and 5 female patients with mean age of 61.2 ± 4.5 years were identified. Three patients were readmitted to acute hospital because of complications. For those 14 patients who completed the IRF stay, the mean admission and discharge motor FIM were 51.5 (±14.6) and 74.7 (±12.0), respectively. The mean admission and discharge cognition FIM were 30.9 (±3.2) and 32.9 (±1.7), respectively. The mean total FIM gain was 26.9 ± 13.3 (P < .05). The mean FIM efficiency was 3.2 (±2.0). After admission to an IRF, 82% were discharged home with statistically significant improvement in their functional ability. In addition, all individual FIM items improved from admission to discharge. There was positive relationship between body mass index and FIM gain but this was not statistically significant.Conclusions: An inpatient rehabilitation program appears to positively impact optimal outcomes (functional recovery and discharge to home) for selected patients with HT and is comparable with regional and national FIM gain and efficiency for patients admitted to IRFs with other cardiac conditions. [ABSTRACT FROM AUTHOR]

Background: Appropriate thromboprophylaxis for patients with atrial fibrillation (AF) remains a national challenge.Methods: We hypothesized that provision of decision support in the form of an Atrial Fibrillation Decision Support Tool (AFDST) would improve thromboprophylaxis for AF patients. We conducted a cluster randomized trial involving 15 primary care practices and 1,493 adults with nonvalvular AF in an integrated health care system between April 2014 and February 2015. Physicians in the intervention group received patient-level treatment recommendations made by the AFDST. Our primary outcome was the proportion of patients with antithrombotic therapy that was discordant from AFDST recommendation.Results: Treatment was discordant in 42% of 801 patients in the intervention group. Physicians reviewed reports for 240 patients. Among these patients, thromboprophylaxis was discordant in 63%, decreasing to 59% 1 year later (P = .02). In nonstratified analyses, changes in discordant care were not significantly different between the intervention group and control groups. In multivariate regression models, assignment to the intervention group resulted in a nonsignificant trend toward decreased discordance (P = .29), and being a patient of a resident physician (P = .02) and a higher HAS-BLED score predicted decreased discordance (P = .03), whereas female gender (P = .01) and a higher CHADSVASc score (P = .10) predicted increased discordance.Conclusions: Among patients whose physicians reviewed recommendations of the decision support tool discordant therapy decreased significantly over 1 year. However, in nonstratified analyses, the intervention did not result in significant improvements in discordant antithrombotic therapy. [ABSTRACT FROM AUTHOR]

The use of continuous-flow left ventricular assist devices (CF-LVADs) has revolutionized the landscape of mechanical circulatory support for patients with heart failure. Clinical trials are already testing the next generation of CF-LVADs. In this study, our objective was to review our long-term experience with the current generation of CF-LVADs, specifically, the HeartMate (HM) II (Thoratec Corp, Pleasanton, CA). In this single-center retrospective analysis, we evaluated the records of 278 consecutive patients who underwent a total of 302 HM II placements from June 2005 through June 2014. We excluded 11 patients from our final study group, who had previously undergone placement of a HM XVE that failed. We divided the remaining 267 patients into 3 equal groups of 89 patients each, by time period: group 1, June 2005 through May 2009; group 2, June 2009 through January 2012; and group 3, February 2012 through June 2014. To examine differences in survival between our 3 groups, we used time-to-event analysis, including the Kaplan-Meier method. To examine secondary outcomes (including stroke, hemolysis, gastrointestinal bleeding, pump thrombus, and transplant), we used one-way analysis of variance. For our final study group of 267 patients, the total follow-up time was 479.01 patient-years (median, 469 days). The mean age of patients was 57 years; 81.4% were male. In all, 209 (78.9%) patients underwent HM II placement as a bridge to transplant; 58 (21.1%), as destination therapy (DT). The overall survival rate was 94% at 30 days, 77% at 1 year, 65% at 2 years, 60% at 3 years, 50% at 4 years, and 48% at 5 years. In bridge to transplant patients, the survival rate was 78% at 1 year and 66% at 2 years; in DT patients, 70% and 60%. In group 1 patients, the survival rate was 94% at 30 days, 64% at 1 year, and 48% at 2 years; in group 2, 93%, 88%, and 76%; and in group 3, 94%, 77%, and 73% (P = 0.003). In the later years of our study period, from June 2009 onwards (ie, in groups 2 and 3), we noted a statistically significant increase in HM II placement as DT, a reduction of driveline infections, increasing pump exchange, increasing hemolysis, a reduced frequency of transplants, and an improved survival rate (as compared with the earlier group 1). The HM II has favorably influenced the outcomes of patients with end-stage heart failure, yet major complications still limit their survival. Improving compatibility between the pump and the individual host patient, enhancing anticoagulation strategies, and developing a totally implantable pump might further reduce complications thereby improving survival times and allowing CF-LVAD placement to be a true long-term alternative to a heart transplant. [ABSTRACT FROM AUTHOR]

Corresponding Author [ABSTRACT FROM AUTHOR]

Background Left ventricular assist devices (LVADs) are increasingly used in patients with heart failure. To study the impact of stroke on clinical outcomes after continuous-flow (CF-) LVAD implantation, we evaluated our single-center experience. Methods From 2006 to 2013, we implanted the HeartMate II CF-LVAD in 230 patients. We used standard statistical methods to evaluate our results. Results Of our study group, 185 patients (80.4%) received the CF-LVAD as a bridge to transplantation. Strokes occurred in a total of 39 patients (17%), an incidence rate of 0.064 strokes per person-year: 19 (48.7%) were embolic, and 20 (51.3%) were hemorrhagic. The stroke-free rate at 6 months after HeartMate II implantation was 92.6%, at 12 months, 89.6%, and at 24 months, 86.1%. Baseline demographic characteristics did not differ significantly, except that stroke patients had a lower incidence of coronary artery disease ( p = 0.004) and prior cardiac surgery ( p = 0.001). We noted a trend toward an increased risk of stroke in patients with CF-LVAD–related infections ( p = 0.053). The survival rate in stroke (versus stroke-free) patients at 6 months was 84.6% (versus 84.2%); at 12 months, 71.8% (versus 81.6%); and at 24 months, 53.9% (versus 74.7%; p = 0.0019). During a median follow-up time of 761 days, mortality risk in stroke patients was 2.01 times that of stroke-free patients (hazard ratio = 2.01; p = 0.004). Conclusions Stroke while on CF-LVAD support was associated with significant mortality. To reduce the risk of stroke, it is essential to further elucidate risk factors, to optimize anticoagulation, and to further understand the impact of LVAD-related infections. [ABSTRACT FROM AUTHOR]

In recent years, outbreaks of methanol poisoning from the consumption of tainted alcohol have claimed umpteen lives around the world. Low wages in developing countries have forced consumers to turn to cheaper, unregulated, and often toxic brews. In Kenya, the most common surrogate alcohol is known as “chang’aa” and has caused numerous instances of methanol poisoning. Though once prohibited, the Kenyan government legalized and attempted to regulate the brew in 2010. Five years later, toxic brews are still an issue. To understand how consumption patterns and legal ramifications affect the brewing of chang’aa, three brewers and ten consumers were interviewed. In addition, the brewing process was carefully studied over several days. Improper brewing techniques, unsafe brewer additives, and unclean equipment were noted as possible methods of methanol contamination. From these case studies, opportunities for the redefinition of government standards and development of inexpensive methanol detection techniques are identified. [ABSTRACT FROM AUTHOR]

Sickle cell disease is a group of disorders, the majority of which are detected through state newborn screening programs. There is limited knowledge of disease prevalence in the U.S. population. We report 20 years of case finding and laboratory data for sickle cell disease and trait to assist in: planning for health services delivery; providing data for researchers; aiding in tracking health outcome trends; and assessing sickle gene prevalence in the newborn population. During the 20-year period, there were 39,422 confirmed cases of sickle cell disease among 76,527,627 newborn births screened (1:1941) and 1,107,875 laboratory reports of probable sickle trait among 73,951,175 newborn births screened (1:67). The highest sickle cell disease incidence during the 20 years was in the District of Columbia (1:437) followed by Mississippi (1:683) and South Carolina (1:771). For sickle cell trait, the highest incidences were in the District of Columbia (1:22), Mississippi (1:26), and South Carolina (1:31). [ABSTRACT FROM AUTHOR]