Laval Hospital Research Articles

The laval questionnaire: a new instrument to measure quality of life in morbid obesity

BackgroundOur recent review of the literature uncovered eleven obesity-specific quality of life questionnaires, all with incomplete demonstration of their measurement properties. Our objective was to validate a new self-administered questionnaire specific to morbid obesity to be used in clinical trials. The study was carried out at the bariatric surgery clinic of Laval Hospital, Quebec City, Canada.MethodsThis study followed our description of health-related quality of life in morbid obesity from which we constructed the Laval Questionnaire. Its construct validity and responsiveness were tested by comparing the baseline and changes at 1-year follow-up in 6 domain scores (symptoms, activity/mobility, personal hygiene/clothing, emotions, social interactions, sexual life) with those of questionnaires measuring related constructs (SF-36, Impact of Weight on Quality of Life-Lite, Rosenberg Self-Esteem Scale and Beck Depression Inventory-II).Results112 patients (67 who got bariatric surgery, 45 who remained on the waiting list during the study period) participated in this study. The analysis of the discriminative function of the questionnaire showed moderate-to-high correlations between the scores in each domain of our instrument and the corresponding questionnaires. The analysis of its evaluative function showed (1) significant differences in score changes between patients with bariatric surgery and those without, and (2) moderate-to-high correlations between the changes in scores in the new instrument and the changes in the corresponding questionnaires. Most of these correlations met the a priori predictions we had made regarding their direction and magnitude.ConclusionThe Laval Questionnaire is a valid measure of health-related quality of life in patients with morbid obesity and is responsive to treatment-induced changes.

Modified and Newly Designed Right-sided Double-lumen Endobronchial Tubes Are Complementary

University Heart and Lung Institute at Laval Hospital, Quebec City, Quebec, Canada. jean.bussieres@anr.ulaval.caWe read with great interest the case report1on the application of a newly designed right-sided, double-lumen endobronchial tube (R-DLT) in patients with a very short right mainstem bronchus.However, in citing our work2on the improvement of the endobronchial positioning of the R-DLT, Hagihira et al. stated that we modified the design of the bronchial cuff and that these changes seem to offer little improvement. This statement is inconsistent with our published manuscript which demonstrates, on a randomized series of 80 patients, that the modified enlarged area of the lateral orifice (and not the bronchial cuff as stated by Hagihira et al. ) improve the success rate of final positioning from 74 to 97% with a P < 0.0109. These two new versions of the R-DLT are not intended to solve the same problem, but the final objective, improvement of the use of R-DLT, is similar.We thank Dr. Hagihira for this interesting case report. While this new R-DLT may become a useful tool for thoracic anesthesiologists, we would first encourage them to validate its use with a randomized study.University Heart and Lung Institute at Laval Hospital, Quebec City, Quebec, Canada. jean.bussieres@anr.ulaval.ca

Abstract 3237: The Economic Impact of Same-Day Discharge after Transradial Percutaneous Coronary Intervention and a Single Bolus of Abciximab; an Analysis from the EASY Trial

Background: In patients presenting with an acute coronary syndrome, same-day home discharge (SDD) after an uncomplicated transradial percutaneous coronary intervention (PCI) performed under a single bolus of abciximab was found clinically non-inferior to the usual overnight hospitalization (OH) and an abciximab bolus followed by a 12h infusion. Objective: To estimate post-PCI health resources cost of trial subjects, and, using cost-minimization, immediate and short-term economic impact of same-day home discharge. Method: A total of 1005 patients were randomized to either the SDD group (n =504) or the OH (n = 501). As randomization was post-procedure, and PCI resource use showed minimal and non-significant differences, a post-PCI cost analysis was conducted. A hospital-based perspective was used. Detailed per patient information of healthcare resources used immediately post-PCI up to hospital discharge were prospectively collected. Costs were estimated based on 2006 Laval Hospital unit prices, and 2006 costs from the Centre Hospitalier de l’université de Montréal (CHUM) hospital costing system (direct and indirect costs). In addition, patient-reported resources for a period of 30 days post-discharge were examined. Results: Per hour post-PCI hospital costs were estimated as $113, based on average 2006 cost for all patients hospitalized for angioplasty plus stent (DRG 112) at the CHUM ($5716), net of estimated PCI-related cost ($1131), and divided by average post PCI length-of-stay of subjects. SDD patients stayed an average of 8.9 hours (95%CI from 8.2 to 9.5) post-PCI, compared to 26.5 hours (25.2–27.8) for OH patients. Mean estimated post-PCI hospital costs (including abciximab infusion when used, other medications, nursing time, meals, etc..) were $1004 ($929–$1079) in the SDD group versus $3117 ($2975–$3260) in the OH group, saving, on average, $2113 per patient (p<0.001). Within 30 days of discharge, only 50 patients were rehospitalized, 29 after SD discharge and 21 after OH (p=0.26). Conclusion: Same-day home discharge after an uncomplicated transradial PCI and a single bolus of abciximab resulted in a 68% relative saving in post PCI costs. In our trial, SDD of 504 patients saved over 1 million dollars to the hospital.

Incidence of Compartment Syndrome of the Arm in a Large Series of Transradial Approach for Coronary Procedures

Despite the fact that transradial approach is widely used, literature on this devastating complication after transradial approach is scarce. Pubmed review from 1992 to 2007 includes only 5 isolated reports. In one small series with 250 patients, an incidence of 0.4% is suggested. We conducted a retrospective review of the transradial cases in Laval Hospital from 1994 to September 2007 (51,296 procedures) to know the incidence of compartment syndrome of the arm (CSA) and compare it with the literature. In our institution CSA occurred in 2 of the 51,296 transradial procedures (0.004%). Both of them were in female patients with low BSA (1.7 and 1.5 m(2)) who received either an excess of unfractioned heparin during the procedure or uncorrected low-molecular-weight heparin after the procedure. Both of them underwent fasciotomy of the forearm. Recovery was complete in one patient. The other patient required skin graft and developed a partial Volkmann contracture at follow-up. This low incidence is due to a high index of suspicion when swelling or pain in the arm used for the procedure is noted and to the immediate application of a specific protocol. This protocol initiated by the nursing personnel consists of inflation of a tensiometer cuff at the point of pain or swelling. Cuff is inflated during at least 15 minutes up to 10-15 mmHg below the systolic pressure to allow distal pulsatile flow to the hand or forearm (monitored with oxymetry/plethismography) so the bleeding stops and diffuses to decrease the pressure within the forearm. Usually, two periods of 15 min of inflation are required to control bleeding. Incidence of CSA is very low at our institution. A high suspicion with any complaint of pain and swelling in the arm and a proper management of anticoagulation especially in the postprocedure period with great emphasis in patients with low BSA or low creatinine clearance are the key points. Implantation of an immediate specific nursing protocol is required.

Adjuvant Chemotherapy in Resected Lung Cancer: Two-Year Experience in a University Hospital

Randomized trials have confirmed the benefits of adjuvant chemotherapy in improving survival in resected early-stage non-small-cell lung cancer (NSCLC). The extent to which these results have translated into clinical practice is unknown. To examine the referral pattern of patients with resected lung cancer to adjuvant chemotherapy, and to compare compliance and toxicities with current literature. A retrospective analysis of all patients who underwent a surgical resection for lung cancer at Laval Hospital (Quebec City, Quebec) from March 2004 to January 2006 was conducted. A total of 258 patients underwent surgery. Seven patients were excluded because of early postoperative death, and two patients were excluded because of incomplete data. Data from 249 patients were analyzed (94% NSCLC). Fifty per cent were referred to medical oncology for consideration of adjuvant chemotherapy, including 37 of 61 patients with stage II NSCLC. One hundred patients received chemotherapy. No significant difference in age, sex, comorbidities and surgical procedures was observed between those who received chemotherapy and those who did not. Chemotherapy was initiated 47 days (median) after the surgery and consisted mainly of cisplatin-vinorelbine (38%), cisplatin-etoposide (22%) and carboplatin-paclitaxel (20%). Sixty-six per cent of the patients completed all four cycles. Grade 3 or 4 toxicities consisted mainly of fatigue (23%) and cytopenia (40%). No death was registered; 15% had to be hospitalized because of adverse effects. Although adjuvant chemotherapy is gaining acceptance in clinical practice, more patients should be referred to medical oncology following surgical resection. Compliance and toxicity are similar to or better than those described in published randomized trials.

Ischemic, genetic and pharmacological origins of cardiac arrhythmias: The contribution of the Quebec Heart Institute

Research in the field of basic electrophysiology at the Quebec Heart Institute (Laval Hospital, Quebec City, Quebec) has evolved since its beginning in the 1990s. Interests were focused on cardiac arrhythmias induced by drugs, allelic variants and metabolic factors produced during ischemia. The results have contributed to the creation of new standards in drug development, more specifically, testing all new drugs for their potential effects on cardiac potassium currents, which could produce life-threatening proarrhythmic effects. In a French-Canadian population, three heterozygous single nucleotide polymorphisms in hK(v)1.5, a gene encoding for a major atrial repolarizing current, were found. These variants affect the expression level of the hK(v)1.5 channel and change the inactivation process in the presence of its accessory beta subunit. Because these effects could shorten atrial action potential, their presence was tested in postcoronary bypass patients and a higher prevalence was found in patients with postoperative atrial fibrillation. Finally, three potentially proarrhythmic factors characteristic of ischemia were identified: pH decrease; oxygen free radicals, which both increase the flow of K(+) ions through human ether-a-go-go-related gene and hK(v)1.5, producing a reduction in action potential duration, frequently leading to cardiac arrhythmias; and lysophosphatidylcholine, a metabolite involved in the production of cardiac arrhythmias early during ischemia that was shown to be a major cause of electrical uncoupling. Over the past decade, the Quebec Heart Institute has provided a significant amount of original data in the field of basic cardiac electrophysiology, specifically concerning arrhythmias originating from pharmacological agents, genetic background and cardiac ischemia.

Catheter ablation for cardiac arrhythmias: A 14-year experience with 5330 consecutive patients at the Quebec Heart Institute, Laval Hospital

Catheter ablation is a curative treatment with excellent success and minimal complication rates for patients with supraventricular or ventricular arrhythmias. The acute outcomes and complications of all catheter ablation procedures for supraventricular and ventricular arrhythmias performed at the Quebec Heart Institute (Sainte-Foy, Quebec) during a 14-year period from January 1, 1993, to December 31, 2006, were prospectively assessed. The ablation procedures were classified according to the arrhythmias induced using standard electrophysiological techniques and definitions. Immediate success and complication rates were prospectively included in the database. A total of 5330 patients had catheter ablation performed at the Institute during the period assessed. The mean (+/- SD) age of patients was 50 +/- 18 years (range four to 97 years), and 2340 patients (44%) were men. Most of the patients were younger than 75 years (group 1), and 487 (9%) were 75 years of age and older (group 2). Indications for ablations were as follows: atrioventricular nodal re-entry tachycardia (AVNRT) in 2263 patients, accessory pathways in 1147 patients, atrioventricular node ablation in 803 patients, typical atrial flutter in 377 patients and atrial tachycardia in 160 patients; 580 patients had other ablation procedures. The overall success rates were 81% for atrial tachycardia, 92% for accessory pathways or flutter, and 99% for AVNRT or atrioventricular node ablation. There was no difference in the success rates of the younger (group 1) and older (group 2) patients. Seventy-seven patients (1.4%) had complications, including 11 major events (myocardial infarction in one patient, pulmonary embolism in three patients and permanent pacemaker in seven patients). In patients undergoing AVNRT ablation, two had a permanent pacemaker implanted immediately after the procedure and three had a permanent pacemaker implanted at follow-up. The results confirm that radiofrequency ablation is safe and effective, supporting ablation therapy as a first-line therapy for the majority of patients with cardiac arrhythmias.

The Quebec Heart Institute: 50 years of excellence in cardiology

The Quebec Heart Institute was established in 1957 at the Laval Hospital in Sainte-Foy, Quebec. Since then, clinical and research activities have made this Institute one of the largest tertiary care cardiology centres in Canada. With its vast catchment area of more than 3,000,000 people, the Institute has developed a strong collaboration with referral physicians centred on clinical, teaching and research interests. The Institute pioneered several aspects of cardiac surgery, invasive cardiology, echocardiography, basic research and, more recently, a network of researchers and clinicians working in the field of 'metabolic cardiology'. The first 50 years of the Quebec Heart Institute are depicted in this overview, which will also introduce this special supplement to The Canadian Journal of Cardiology.

Cardiovascular magnetic resonance for the clinical cardiologist

Cardiovascular magnetic resonance is a noninvasive imaging modality that provides superior anatomical and functional information in the absence of ionizing radiation. The cardiovascular magnetic resonance imaging program has been active at the Quebec Heart Institute at Laval Hospital for two years, now providing advanced imaging studies to over 42 referral centres from eastern and central Quebec as well as providing training for national and international fellows. The program benefits from the collborative work of cardiologists and radiologists, who both bring to the table their unique expertise. The following text reviews current clinical applications useful in the daily practice of the cardiovascular specialist.

Large Free-Floating Intra-Aortic Thrombus

A 56-year-old woman was admitted with chronic chest and back pain with recent exacerbation. Cardiac enzyme levels and ECG were normal. Her history was positive for a patent ductus arteriosus ligation at 13 years of age and a total left mastectomy owing to cancer 4 months earlier. Her son died at 30 years of age as a result of type A aortic dissection. A chest computed …

Times to Treatment in Patients Undergoing Primary Percutaneous Coronary Intervention at Laval Hospital

Background:Current guidelines for ST-elevation myocardial infarction (STEMI) recommend performing primary percutaneous coronary intervention (PCI) within 90 min of hospital arrival. However, recent data suggest that, in a real-world setting, median door-to-balloon (DTB) time is closer to 180 minfor transferred patients with no more than 4 % of patients treated within 90 min. We conducted this retrospective observational study to assess time to treatment in patients undergoing primary PCI at Quebec Heart and Lung Institute (QHLI).
 
 Methods: Consecutive lytic-eligible patients undergoing primary PCI at QHLI for STEMI between April 2004 and March 2004 were included in the present analysis. The primary evaluation was DTB time measured from arrival at the first hospital to first balloon inflation. Clinical outcomes consisted of in-hospital death, reinfarction and bleeding. DTB times and hospital outcomes of patients transferred from referring hospitals were compared to patients presenting directly to QHLI.
 
 Results: During the study period, 203 lytic-eligible patients were treated with primary PCI and included in the present analysis. Sixty-nine patients presented directly to QHLI and 134 were transferred from other Quebec City hospitals. The median DTB time was 114 min in transferred patients, compared with 87 min for patients presenting directly to QHLI [P < 0.001]. DTB time was

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Influence of the menstrual cycle on the timing of acute coronary events in premenopausal women

During their reproductive years, women have a low incidence of coronary artery disease (1,2), which increases markedly 10 to 15 years after menopause (3). It has long been hypothesized that this increased risk is at least in part due to the absence of female hormones, in particular, 17 -estradiol (4). This hypothesis was supported by data from epidemiological studies, which suggested that hormone replacement therapy would protect postmenopausal women from coronary artery disease (5– 8). However, recent placebo-controlled trials designed to test the cardioprotective effects of a regimen of estrogens plus progestin have found no reduction in cardiovascular events or progression of angiographic lesions (9 –12). Nevertheless, acute administration of 17 -estradiol affects the vasculature by modulating the nitric oxide–Larginine pathway (13,14), and improves endothelial function (15) and prolongs the time to ST-segment depression and exercise time, in postmenopausal women with coronary artery disease (16). These data suggest that the acute effects of 17 -estradiol could subside rapidly when levels are low during menses. Therefore, we sought to determine whether premenopausal women would be at greater risk of developing an acute coronary event when blood levels of 17 -estradiol levels are low during the menstrual cycle.

Biliopancreatic Diversion with a New Type of Gastrectomy.

In an attempt to improve the results of biliopancreatic diversion in the treatment of morbid obesity, two aspects of the procedure performed at Laval Hospital were modified to reduce adverse physiological consequences. The distal gastrectomy was replaced by a parietal gastrectomy which preserves vagal continuity along with the lesser curvature, and leaves intact the antro-pyloroduodenal pump. The duodenum was stapled shut and nutrients were diverted through a duodeno-ileal anastomosis. The biliopancreatic diverting intestinal limb was anastomosed to the nutrient ileal limb 100 cm proximal to the ileocaecal valve instead of 50 cm proximal to it, thus doubling the length of the common ileal absorptive segment. Weight loss after either operation was greater than 70% of initial excess weight. Following the new operation, there was a lesser prevalence of side-effects, especially loose stools and malodorous gas, a lesser degree of hypocalcemia and no hypoalbuminemia. The duodenum recanalized at the staple line in 20% of the patients who had the new operation. When data from these patients were excluded, weight loss following the new operation was greater than that seen after the old one. The prevalence of side-effects and the degree of calcium and protein malabsorption remained significantly lower. Weight loss remained satisfactory with a common limb measuring 100 cm. The parietal gastrectomy was not restrictive as shown by the failure to lose further weight when the duodenal stapled diversion failed. Weight loss was thus mainly a function of biliopancreatic diversion, but increased weight loss in the new procedure despite a doubling of the common ileal limb suggests that parietal gastrectomy contributed to weight loss. Because duodenal recanalization can be corrected surgically and now prevented, the modified biliopancreatic bypass is preferred.

INTRAVENOUS DIAZEPAM FOR PSYCHIATRIC REACTIONS FOLLOWING OPEN-HEART SURGERY

Research Center and Department of Anaesthesiology, Institute of Cardiology, Laval Hospital, Quebec, Canada