History Of Cerebral Vascular Accident Research Articles

An Unusual Manifestation of Elevated Liver Enzymes and Architecture

Question: A 68-year-old woman with a past medical history of cerebral vascular accident and chronic kidney disease underwent an outpatient anorectal examination under anesthesia for evaluation of a 6-month history of rectal bleeding and constipation. She was found to have a rectal mass involving the posterior vaginal wall. Biopsy specimens from the rectal and vaginal lesions showed invasive squamous cell carcinoma (SCC) with venous invasion (Figures A and B). The carcinoma was p16+ representing a high-risk human papilloma virus–induced SCC (Figure C). Computed tomography of the chest, abdomen, and pelvis showed the vaginal mass and a nodular liver suggestive of cirrhosis. With regard to the patient’s risk factors for liver disease, the patient had remote social alcohol consumption in her 20s without a history of intravenous drug use, family history of liver disease, autoimmune diseases, or hepatitis. In preparation for palliative chemotherapy, blood work was obtained, which was pertinent for white blood cell count of 8.8 103/μL, hemoglobin of 12.7 g/dL, platelets 257 103/μL, aspartate aminotransferase 127 U/L, alanine aminotransferase 65 U/L, alkaline phosphatase 1133 U/L, bilirubin 4.8 mg/dL, prothrombin time of 15.3 seconds, and international normalized ratio of 1.2. Serologic work-up was unremarkable for viral, autoimmune, or metabolic etiologies of liver disease, so magnetic resonance cholangiopancreatography was obtained (Figure D). Subsequently, the patient underwent transjugular hepatic hemodynamic pressure measurements with results as follows: right atrial pressure = 7 mm Hg, free hepatic vein pressure = 15 mm Hg, wedged hepatic vein pressure = 27 mm Hg, and corrected sinusoidal pressure = 12 mm Hg, followed by nontargeted liver biopsy (Figure E).

Self-limited thrombotic thrombocytopenic purpura.

Our team is presenting a patient who is a 57-year -old woman with a past medical history of cerebral vascular accident. The patient presented to the emergency department with symptoms of fever, right upper quadrant pain, and emesis. Initial diagnostic studies revealed thrombocytopenia with acute kidney injury, fever, and leukocytosis. After initiation of treatment for sepsis, the patient developed a hemolytic anemia, which resolved with administration of methylprednisolone. Labs subsequently revealed ADAMTS-13 activity of 4% with positive inhibitor, which confirmed the diagnosis of thrombotic thrombocytopenic purpura (TTP) after the patient's discharge. On retrospective analysis, the case represents a unique and rapid clinical recovery from TTP without administration of therapeutic plasma exchange, rituximab, or caplacizumab.

470: PREDICTION SCORING FOR PRIMARY RESISTANCE IN GRAM-NEGATIVE BACTEREMIA WITHIN A LARGE HEALTH SYSTEM

Introduction: Resistant Gram-negative organisms complicate successful treatment of infectious diseases in critically ill patients as common antibiotic agents are ineffective. Knowledge of risk factors associated with antimicrobial resistant Gram-negative infections is necessary to select appropriate antibiotic agents as culture results are not available immediately. The primary objective was to identify risk factors associated with primary resistance of selected Gram-negative bacteria isolated from blood and establish a scoring method to predict primary resistance. Methods: A total of 378 cases from 390 isolates were analyzed within the Banner health system. Fifty susceptible cases were identified for each of the following organisms: Pseudomonas aeruginosa (Ps), Escherichia coli (EC), Klebsiella pneumoniae (KP), and Enterobacter cloacae (Ent. c). The number of nonsusceptible cases were 50 for EC and KP, 27 for Ent. c and 50 for Ps. Results: The presence of chronic kidney disease (CKD), peripheral vascular disease (PVD), connective tissue disease (CTD), hemi/paraplegia, ventilator use, central vascular access, transfer from long term care facility, admission from outpatient parenteral antibiotic therapy, receiving chemotherapy, history of cerebral vascular accident, diabetes with complication and history of infection within the previous 6 months were strongly associated with resistance. A logistic regression model was developed for predicting primary resistance. An individual with no risk factors for primary resistance would have a predicted probability of resistance of 27%. Further analysis of these factors is required to remove any correlation bias and to develop a prediction scoring system to determine primary resistance. Conclusions: To conclude, this study was able to identify certain risk factors to be statistically significant (p< 0.05) to determine primary resistance which will help develop a prediction scoring system that will aid in appropriate antibiotic selection for the treatment of selected Gram-negative bacteremia infections.

The association of glycemic control and fall risk in diabetic elderly: a cross-sectional study in Hong Kong

BackgroundMany foreign studies investigated glycemic control and fall risk. However, there was insufficient study on this topic in Hong Kong. This study aims to find out the association of glycemic control and fall risk in the diabetic elderly in a general outpatient clinic in the North District of Hong Kong. Their frequency of falls and other associated risk factors of fall were also studied.MethodsA cross-sectional questionnaire survey was conducted on 442 diabetic patients aged 65 years-old or above with regular follow-up in a general outpatient clinic. Main outcome measure was the number of falls in the past one year from the interview date. Recurrent falls was defined as two or more falls in the past one year from the interview date. Subjects were asked about experience of hypoglycemic symptoms. HbA1c level, chronic illness, retinopathy etc. were obtained through computerized medical record review. Chi square test and logistic regression were used to assess the association between outcomes and the explanatory variables.ResultsIn the past one year, 23.3% participants experienced at least one fall and 8.6% had recurrent falls. Hypoglycemic symptoms, and lower visual acuity < 0.6 were significantly associated with fall (OR 2.42, p = 0.007 and OR 1.75, p = 0.038 respectively). Age 75–79 years-old had a higher likelihood of fall than the 65–69 age group (OR 2.23, p = 0.044). Patients with HbA1c 7.0–7.4% had a lower risk of recurrent falls when compared to those with intensive control (OR 0.32, p = 0.044). Other risk factors that increased risk of recurrent falls were hypoglycemic symptoms (OR 6.64, p < 0.001) and history of cerebral vascular accident (OR 4.24, p = 0.003).ConclusionsHypoglycemic symptoms had a very strong association with falls. Less stringent HbA1c control reduced the risk of recurrent falls. Healthcare professionals need to take a more proactive approach in enquiring about hypoglycemia. There should be individualized diabetic treatment target for the diabetic elderly.

Beneficial Xultophy Treatment from Medical and Social Points of View

The case is a 65-year-old male who has been treated for Type 2 diabetes mellitus (T2DM) for 26 years. He has no previous history of cerebral vascular accident (CVA) or coronary heart disease (CHD). He has been treated on insulin therapy, and recently his glucose variability became worse due to the irregular lifestyle. Then, diabetic treatment was changed to Xultophy, which consists of insulin degludec and liraglutide. Providing 16 units of Xultophy brought him a satisfactory daily profile of blood glucose, which seemed to be lower doses compared with the ordinary standard amount. Treatment of Xultophy seems to be effective and some discussion would be described from several points of view.

Outcomes of Infants and Children with Stage 1 Single Ventricle Implanted with Ventricular Assist Devices: An Analysis of the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Registry

<h3>Purpose</h3> Ventricular assist device (VAD) use in patients with congenital heart disease is increasing. Data on VAD outcomes in infants/children with stage 1 single ventricle (SV) are limited. Our study aims to characterize the outcomes of this population using multi-center registry data. <h3>Methods</h3> We examined the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry for outcomes of stage 1 SV patients undergoing VAD implantation between March 2018 - June 2020. ACTION data are collected from 30 centers, and major adverse events undergo central adjudication using pre-specified event definitions. Clinical characteristics, major adverse events, and survival are reported. <h3>Results</h3> During the study period, 27 stage 1 SV patients underwent VAD implant with median age of 1 month (range 0.1-44), weight 3.7kg (2.4-17), and BSA 0.24 m² (0.18-0.65). Pre-implant comorbidities were frequent: ventilator support (85%), ECMO (37%), history of cerebral vascular accident (CVA, 30%), and pre-implant dialysis (18.5%). Device strategy included paracorporeal continuous-flow VAD in 11 patients, paracorporeal pulsatile VAD (12), and multiple devices (4). Concomitant surgical procedure was performed in 4 patients. Median support duration was 56 days (2-271). A positive clinical outcome, defined as transplant, weaned, or alive on device was obtained in 59%, with 12 patients transplanted while 11 died on device (Fig 1). Adverse events on VAD support included neurologic dysfunction (18.5%, with n=2 CVA), bleeding (22%), infection (48%), renal dysfunction (15%), and device malfunction (4%). <h3>Conclusion</h3> Stage 1 SV patients undergoing VAD support have frequent and severe pre-implant comorbidities, which likely contributed to the significant morbidity and mortality post-implant. A variety of device types and surgical strategies are employed by centers to support this challenging physiology.

An Unusual Case of Stridor: Severe Tracheal Narrowing Secondary to Esophageal Food Impaction.

Foreign body impaction (FBI) in the esophagus has the potential to be a serious condition with a high mortality rate. Although the majority of foreign bodies trapped within the esophagus pass spontaneously, some do require endoscopic intervention. This case discusses a 95-year-old-female with a history of cerebral vascular accident who presented with acute onset respiratory distress with inspiratory stridor. The patient denied any episodes of choking or foreign body sensation. Further imaging revealed a large food bolus within the esophagus with extensive tracheal narrowing. The patient was diagnosed promptly and successfully managed endoscopically. This case presentation emphasizes the need to maintain a high index of clinical suspicion for FBI in high-risk populations, especially when the patient’s history makes it unlikely. In the setting of respiratory complications, airway protection remains a priority, but an accurate diagnosis with timely intervention is paramount.

Ischemic stroke following neck dissection in the elderly.

Objective:Despite the known association of perioperative stroke with perioperative mortality, the prevalence of stroke following neck dissection in elderly patients remains unclear. This study compared the incidence of neck dissection-associated perioperative stroke in elderly and younger patients.Materials and Methods:Totally, 1057 patients receiving neck dissection for head and neck cancers between June 2012 and July 2016 were reviewed at a single center. The patients were divided into elderly (age ≥65 years, n = 177) and younger (age <65 years, n = 880) groups (mean age: 72.3 ± 6.1 and 53.3 ± 7.6, respectively). Patient, anthropometric, and clinical characteristics including diagnoses, comorbidities, length of hospitalization, and incidence of perioperative stroke were compared.Results:Younger patients were more likely to be male (P = 0.001) and to have received radiotherapy (P = 0.013). The prevalence of predisposing factors was higher in the elderly, including history of cerebral vascular accident (P = 0.002), hypertension (P < 0.001), diabetes (P < 0.001), and coronary artery disease (P < 0.001). Elderly patients also had longer hospitalizations (P < 0.001) for which previous radiotherapy was identified as a risk factor (adjusted odds ratio = 3.79, P = 0.0078). Postoperative ischemic stroke was diagnosed in two elderly patients (1.1%), whereas no ischemic strokes occurred in the younger group (P = 0.028). The overall incidence of perioperative stroke was 0.19%.Conclusion:The incidence of perioperative stroke was higher in the elderly than in the younger group. Furthermore, the prevalence of ischemic stroke in elderly patients associated with neck dissection was higher than that previously reported in the aged population after general head and neck operations, highlighting an increased risk of stroke in elderly patients receiving extensive neck surgery.

Patent foramen ovale and neurologic events in patients undergoing liver transplantation.

Patent foramen ovale (PFO) is present in approximately 20% of individuals. During liver transplantation (LT), intra-operative transesophageal echocardiography can observe transient intra-cardiac shunting of atheromatous debris via a PFO. Closure of PFOs prior to LT has thus been suggested as a potential treatment to reduce peri-operative cerebral vascular accident (CVA). The objective of this study was to assess if the presence of PFO is associated with CVA in patients undergoing LT. Three hundred fifty-eight patients undergoing LT at a single academic institution were included. All patients underwent standardized cardiac evaluation including a detailed cardiovascular history and physical examination, electrocardiogram and transthoracic echocardiogram. Five patients were excluded because of poor transthoracic echocardiographic image quality, and three patients were excluded because of PFO closure prior to LT, yielding a study population of 350 patients. Medical records were reviewed to determine demographics, echocardiographic findings and outcome following LT. Major adverse cardiovascular events, myocardial infarction, CVA and death were collected. Mean age was 53.4 ± 10.2 years; 61% male and 5% of patients had a prior history of CVA. Alcohol and hepatitis C were the most common etiologies for liver disease. Forty-six patients (13.1%) were diagnosed with PFO prior to LT. In-hospital CVA occurred in 6 patients (1.7%). The prevalence of a CVA was not significantly higher in patients with PFO compared to patients without PFO, 2.2% vs 1.6%, p = 0.57. In-hospital mortality was similar in patients with PFO compared to patients without PFO, 4.4% and 5.3%, p = 1.0. The presence of a PFO in patients undergoing LT is not associated with postoperative CVA. Prophylactic closure of PFOs, in the absence of other indications, does not appear to be warranted in patients undergoing LT.

D-dimer predicts pulmonary embolism after low-risk spine surgery.

Introduction Pulmonary embolism (PE) is a risk of mortality following spine surgery. Many studies have demonstrated that deep venous thrombosis (DVT) may affect and actually advance to PE, but few studies have shown how venous thromboembolism (VTE), including PE and DVT, affect blood markers after spine surgery. In this study, we examined changes in blood markers with PE or DVT after low-risk spine surgery, namely cervical laminoplasty or lumbar laminectomy. Methods Seventy-two spine surgery patients were studied. A 16-row multidetector computed tomography was performed before and 3 d after the surgery. Patients with a history of cerebral vascular accident or arterial thrombotic episode or pre-surgical asymptomatic PE or DVT were excluded. Plasma levels of soluble fibrin monomer complex, D-dimer, plasminogen activator inhibitor type-1 (PAI-1), and white blood cell and platelet counts were measured preoperatively and postoperatively at days 1, 3, and 7. Results No patient developed symptomatic post-surgical VTE. Six patients with asymptomatic PE and six with asymptomatic DVT were detected post-surgery, including one patient with both. D-dimer postoperatively at days 3 and 7 was significantly higher in the post-op PE group than in the no-PE group. PAI-1 preoperatively was significantly higher in the DVT and VTE groups than in the no-DVT and no-VTE groups. Conclusions Elevated D-dimer at postoperative days 3 and 7 is a predictive factor for the early diagnosis of PE after spine surgery. Moreover, elevated PAI-1 preoperatively is a predictive factor for the early diagnosis of DVT and VTE. Consequently, PE may occur through a pathway other than DVT.

Real-World Clinical Characteristics and Treatment Patterns of Individuals Aged 80 and Older with Nonvalvular Atrial Fibrillation: Results from the ReAl-life Multicenter Survey Evaluating Stroke Study.

To compare the clinical characteristics of and use of oral anticoagulant (OAC) therapy in individuals aged 80 and older with atrial fibrillation (AF) with those of individuals younger than 80 with AF in clinical practice. Observational study. The ReAl-life Multicenter Survey Evaluating Stroke prevention strategies in Turkey trial (NCT02344901), a national observational registry. Turkish adults with nonvalvular AF (NVAF). Age data were collected at the time of entry into the registry and the octogenarian subgroup included all patients aged ≥ 80 years. We compared background and management in octogenarian with non-octogenarian AF patients. Fifty-seven cardiology units enrolled 6,273 individuals in 3months. Participants aged 80 and older (n=1,170) were more likely to be female (60.7% vs 54.7%, P<.001) and had a higher prevalence of persistant or permanent AF, comorbidities, history of cerebral vascular accident, and major bleeding. As a consequence of having more comorbidities, Congestive heart failure; Hypertension; Aged 75 and older; Diabetes Mellitus; prior stroke, transient ischemic attack, or thromboembolism; Vascular disease; Aged 65 to 74; female Sex (CHA2 DS2 VASc) (4.32±1.35 vs 3.04±1.54, P<.001) and Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalized ratio, Elderly, Drugs or alcohol (HAS-BLED) (2.14±1.05 vs 1.54±1.05, P<.001) scores were higher in those aged 80 and older. The mean time in therapeutic range of individuals who were taking warfarin was lower in those aged 80 and older (45.9±27.9) than in those younger than 80 (54.7±24.9%, P<.001). Anticoagulant therapy was prescribed for 74.8% of participants younger than 80% and 63% of those aged 80 and older (P<.001). Higher CHA2 DS2 VASc score and lower HAS-BLED score were independent predictors of OAC prescription in participants aged 80 and older. Nearly one-fifth of individuals with NVAF in this real-world sample were aged 80 and older. Participants aged 80 and older were more likely to be female and have more comorbidities than those who were younger than 80. Those aged 80 and older with AF were less likely to receive anticoagulants than those who were younger than 80, but having more comorbidities and other individual-level characteristics may explain this difference. When they were prescribed OACs, participants aged 80 and older had poorer quality of anticoagulation than those who were younger, suggesting opportunities for improvement.

Abstract P244: Utility or Futility of Echocardiography in Determining Cardiac Causes of CVA

Background: Current guidelines recommend that all patients who are suspected to have a cardio-embolic cause for their cerebral vascular accident (CVA) should receive an echocardiogram. However, there are no clear risk stratification tools to help clinicians identify patients at high risk for having cardio-embolic stroke. As a result, echocardiograms appear to be over utilized and may have a low yield in routine clinical practice. Methods: In our single center study we included patients who were &gt;18 years old and had been admitted from November 2015 to February 2016 to our hospital with an admission diagnosis of Cerebral Vascular Accident (CVA) using ICD-9 code 434.91. Multivariable logistic regression was used to identify factors associated with a greater likelihood of having an echocardiogram ordered as a part of the diagnostic workup. Results: Among 347 patients who were admitted with a diagnosis of CVA, echocardiogram was ordered in 259 (74.6%) patients. In patients who underwent echocardiography, only 3/259 (0.01%) had abnormal findings (e.g., Patent foramen ovale or intracardiac vegetations) that might suggest a cardio-embolic source for their CVA. In the adjusted analyses we found that factors like age, previous history of CVA, findings of atrial fibrillation on electrocardiogram (p-values &gt; 0.05), were not significantly associated with the decision for ordering echocardiograms. Conclusions: Our study shows a low yield of echocardiography to determine an embolic cause in patients who were admitted to the hospital with diagnosis of CVA. Furthermore, no patient-level variables were associated with the likelihood of having an echocardiogram ordered. This may suggest that providers’ decisions to order echocardiograms is random rather than systematic, which itself stems from lack of clear recommendations for clinicians in when to order this test. More clear guidelines in this matter will be helpful to ensure appropriate utilization of this modality in CVA patients.

Predictors of quality of life in patients with heart failure

To understand quality of life (QOL) and the effects of sociodemographics, disease severity, physical symptoms (dyspnea and fatigue), and depression on QOL of heart failure (HF) patients in Taiwan. Adult HF patients with history of cerebral vascular accident, myocardial infarction within the previous 6 months, major diseases, concurrent cancers, and coexisting terminal diseases, cognitive impairments, or residence in institutions, were excluded in this study. Quality of life, physical symptoms, and depression were measured by the Minnesota Living with Heart Failure Questionnaire, Pulmonary Function Status and Dyspnea Questionnaire, and Brief Symptom Inventory depression subscale, respectively. Hierarchical regression analyses were used to examine the correlations of demographics, disease severity, physical symptoms, and depression with QOL in HF patients. One hundred and thirty-three HF patients (64.2 ± 12.7 years, 78.2% male, 36.1% NYHA III/IV) were recruited in the study. In the final regression model, age, duration of HF, physical symptoms, and depression had a significant impact on global QOL, ultimately accounting for 37.6% of the variance of QOL. Age, duration of HF, physical symptoms, and depression are important predictors of QOL in HF patients. Interventions targeting physical symptoms and depression are expected to improve QOL of HF patients.

Risk factors of community-onset urinary tract infections caused by plasmid-mediated AmpC β-lactamase-producing Enterobacteriaceae

The AmpC β-lactamase (AmpC)-producing Enterobacteriaceae emerged worldwide. This study was conducted to determine the risk factors of community-onset urinary tract infections (UTIs) caused by plasmid-mediated AmpC-producing Enterobacteriaceae. Patients who were diagnosed as community-onset UTIs caused by Enterobacteriaceae in a tertiary-care teaching hospital from December 2010 to January 2012 were included. Extended-spectrum β-lactamase (ESBL)-producing isolates were excluded. We identified plasmid-mediated AmpC-producing Enterobacteriaceae both phenotypically (by disk potentiation test and double-disk synergy test) and genotypically (by Multiplex polymerase chain reaction (PCR) assay). The demographic data, clinical characteristics, and risk factors of acquisition were described. Among the 323 non-ESBL-producing Enterobacteriaceae identified in community-onset UTIs, 50 isolates were phenotypically positive for AmpC. Escherichia coli was the most common AmpC-producing organism (60%), followed by Klebsiella pneumonia (8%), and Enterobacter cloacae and Proteus mirabilis (6% for each species). The independent risk factors for acquisition of AmpC-producing Enterobacteriaceae included prior history of cerebral vascular accident [odds ratio (OR) = 2.014; 95% confidence interval (CI) = 1.007-4.031; p = 0.0048], and prior use of fluoroquinolones (OR = 4.049; 95% CI = 1.759-9.319; p = 0.001) and cephamycin (OR = 9.683; 95% CI = 2.007-45.135; p = 0.004). AmpC-producing isolates were multidrug resistant. Carbapenems, cefepime, and piperacillin/tazobactam had the best in vitro efficacy. The most commonly identified plasmid-mediated AmpC gene was bla(CIT), followed by bla(DHA)/bla(EBC), and bla(MOx). For community-onset UTIs, AmpC-producing Enterobacteriaceae should be suspected in those with prior history of cerebral vascular accident and prior use of antimicrobials. To treat these multiple-resistant isolates, carbapenems, cefepime, and piperacillin/tazobactam may be considered.

Is carotid artery screening obligatory in young patients undergoing coronary artery bypass grafting?

Background Postoperative complications from the Central Nervous System after Coronary Artery Bypass Grafting Operations (CABG) can range from transient neurologic or psychological changes to massive brain infarction and irreversible coma. The risk of stoke after CABG is approximately 2%. Multiple mechanisms such as brain hypoperfusion during or after the operation, carotid stenosis and embolization can lead to these complications. Methods 635 patients with risk factors for Cerebral Vascular Accident (CVA) such as history of stroke, peripheral vascular disease (PVD) and age over 65 years old compared to 331 patients 65 years old, history of CVA, history of PVD. All patients had a preoperative carotid triplex. For practical reasons the Carotid Artery Stenosis was defund as significant> 50-75% and severe > 75%. EuroSCORE I calculated as well for all patients in order to calculate the postoperative mortality score. Results From the low risk group (311 patients), 33 (10%) were found to have significant carotid stenosis and 5 had severe stenosis and underwent Carotid endarterectomy and CABG at the same time. None of them suffered from postoperative stroke and one patient died due to chest infection. From the high-risk group (635 patients) 15 (2,36%) developed transient neurologic symptoms and 6 (0,94%) developed severe postoperative stroke and 2 (0,31%) died. Conclusion Because of the catastrophic neurological complications in patients undergo Coronary Artery Bypass operations even if they are low risk patients for CVA we suggest to have a preoperative carotid triplex in order to find asymptomatic lesions and take all the perioperative precautions. That will improve the outcome and will reduce more the morbidity and mortality.

ANALYSIS OF DRUG THERAPY FOR ACUTE CEREBRAL INFARCTION AT HUE CENTRAL HOSPITAL FROM AUGUST 2010 TO JUNE 2011

Objectives: The cerebral infarction is a complex clinical emergency and the application of guidelines of treatment in each health establishment varies. The study was conducted with two main objectives: (1) Identify the profile of patients and (2) Analyze the drug therapy in patients with acute cerebral infarction. Materials and Methods: A prospective, descriptive study of 94 in patients with acute cerebral infarction treated at the Hue Central Hospital from 08/2010 to 06/2011 was conducted; Results: the mean age was 68.6 ± 15.5 years (range 16-101), 73.4% had hypertension at admission, the most commonly risk factors included pre-existing hypertensions (59.6%), cardiovascular diseases (28.7%) and a history of cerebral vascular accident or TIA (26.6%). Four groups of drugs used the most frequently were: neuroprotective drugs (95.8%), antibiotics (85.1%), vitamins - minerals (84.0%), drugs for peptic ulcer prophylaxis (74.5%). A total of three cases of ADR were reported. 86.2% of patients received potential drug-drug interaction pairs and the mean number of drug-drug interaction pairs per patient was 4.9 ± 2.4. Conclusions: The treatment of patients with cerebral infarction was complex, often has to combine many different classes of drugs, some have narrow therapeutic ranges, which were indicated in patients with multiple pathologies that increased the risk of drug-related problems. It is necessary to monitor closely the drug therapeutics.

Risk analysis of urgent coronary artery bypass grafting

We analyzed the risk factors of morbidity and mortality associated with urgent coronary artery bypass grafting (CABG) for impending myocardial infarcton. Among 1,428 consecutive patients who underwent isolated on-pump CABG between 1992 and 1998, a total of 126 were urgent cases. Their inhospital and long-term data were analyzed by the Kaplan-Meier method or logistic model. The mean number of grafts performed during urgent CABG was 3.2, and arterial reconstruction was performed in 117 (93.9%) cases. Major postoperative complicatons occurred in 64 cases (50.8%), and there were 9 inhospital deaths (7.1%). Significant predictor of inhospital death, identified by multivariate analysis, was a history of cerebral vascular accident. During a mean follow-up period of 3.1 years, there was a total of 7 remote deaths giving an actuarial 5-year survival rate of 93.5% (excluding inhospital deaths). Remote cardiac events occurred in 23 patients, giving an actuarial 5-year event-free rate of 74.8%. Multivariate logistic regression analysis found that risk factors influencing cardiac events were poor left ventricular function, preoperative renal dysfunction, postoperative use of intra-aortic balloon pumping, and postoperative induction of dialysis, while those influencing survival were previous myocardial infarction. Comparing elective CABG performed in the same period, the inhospital mortality of urgent cases was 33.8 times higher. Among hospital-survivors, patients after urgent CABG demonstrated fair long-term survival and future development of cardiac events. All efforts to achieve complete revascularization and frequent use of the internal mammary artery may contribute to improving the long-term results; however, careful management is necessary for patients with poor cardiac function.

The identification of older nursing home residents vulnerable for deterioration of grade 1 pressure ulcers

The objective of this study was to identify prognostic factors associated with the development of pressure ulcer lesions (grade 2-4) in nursing home patients with non-blanchable erythema. No studies could be found that identify risk factors for further development of pressure ulcer in patients with non-blanchable erythema. For some patients with non-blanchable erythema, standard preventive measures do not suffice to prevent pressure ulcers from deterioration. Identifying these patients beforehand can considerably contribute to the efficiency of pressure ulcer prevention. Secondary data analyses of a previously conducted randomised controlled trial were performed. Eighty-four wards of 16 Belgian nursing homes participated in the study. In total, 235 nursing home residents with a grade 1 pressure ulcer (non-blanchable erythema) were included. All the residents received standard preventive care. Potential prognostic factors were collected using a standardised form. The incidence of pressure ulcers was recorded according to the European pressure ulcer classification system. The cumulative pressure ulcer incidence was 18.7% (44/235). Hypotension (relative risk = 3.42, 95% CI = 1.56-7.49), a history of a cerebral vascular accident (relative risk = 1.94, 95% CI = 1.10-3.70) and contractures (relative risk = 2.02, 95% CI 1.03-3.95) were identified as independent predictive factors for developing pressure ulcers. Remarkably, being urinary incontinent decreased the risk of developing a pressure ulcer by 76%. In nursing home residents with non-blanchable erythema, hypotension, contractures, and a history of cerebral vascular accident were independent risk factors for the development of pressure ulcer lesions. Patients with non-blanchable erythema who have hypotension, contractures or a history of cerebral vascular accident are in need of more intensive preventive measures. Identifying these patients can contribute considerably to a more efficient pressure ulcer prevention policy, resulting in a lower pressure ulcer lesion incidence and in lower costs.

A descriptive evaluation of unfractionated heparin use during pregnancy

The mainstay of oral anticoagulant therapy, warfarin sodium, crosses the placenta during pregnancy and may cause fetal complications. Unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) do not cross the placenta and have demonstrated utility in the prevention and treatment of thrombosis during pregnancy. The purpose of this study was to review treatment strategy, indication, and maternal and fetal outcomes in anticoagulated pregnancies at Kaiser Permanente Colorado. We identified 103 pregnancies in 93 mothers prescribed an anticoagulant during a pregnancy occurring between January 1, 1998 and March 31, 2005. The majority of patients were treated with UFH (89.3%). Indications for anticoagulation included venous thromboembolism (VTE) prophylaxis (53.4%), history of pregnancy loss (29.1%), acute VTE (16.5%), and history of cerebral vascular accident (CVA) (1.0%). There were no maternal deaths. Fetal demise occurred in 8 pregnancies (7.8%) at a median 14 weeks gestation (range 7-22 weeks). No fetal demise occurred in pregnancies treated for acute VTE or history of CVA. There were two occurrences of pulmonary embolism (1.9%) and two hemorrhagic events requiring transfusion (1.9%). Maternal and fetal adverse events were infrequent in our population of anticoagulated pregnancies. UFH remains a viable option among more expensive LMWH products.

Instructions for Obtaining Journal CME Credit

Instructions for Obtaining Journal CME Credit