Impact of preprocedural left ventricular systolic function on the safety and durability of percutaneous coronary intervention

BACKGROUND

Percutaneous coronary intervention (PCI) is considered less safe in patients with reduced ejection fraction (EF), an impression based on older data. Whether the safety and durability of contemporary PCI are different in patients with reduced EF compared with normal EF patients is unknown.

METHODS

Patients from the BIOFLOW II, IV and V clinical trials were grouped as normal EF (≥50%) and reduced EF (30%-50%). Using multivariable logistic regression and cox proportional hazards regression, we determined relations of EF category with procedural safety (a composite of cardiac death, myocardial infarction, stroke and urgent coronary artery bypass grafting within 30 days of PCI) and target lesion failure (TLF; comprising cardiac death, target vessel myocardial infarction, target vessel revascularization within 1 year of PCI) respectively. In sensitivity analyses, we regrouped patients into EF < 45% and ≥55% and repeated the aforementioned analyses.

RESULTS

In 1685 patients with normal EF (mean age 65 years; 27% women; mean EF 61%) and 259 with low EF (mean age 64 years; 17% women; mean EF 41%), 101 safety and 148 TLF events occurred. Compared with patients in the normal EF group, those with reduced EF had neither a statistically significant higher proportion of safety events, nor a higher multivariable-adjusted risk for such events. Similarly, patients with reduced EF and normal EF did not differ in terms of TLF event proportions or multivariable-adjusted risk for TLF. The results were similar in sensitivity analyses with EF groups redefined to create a 10% between-group EF separation.

CONCLUSION

PCI safety and durability outcomes are similar in patients with mild-moderately reduced EF and normal EF.

Physical Activity in Cardiac Implantable Electronic Device Recipients During the COVID-19 Pandemic

OBJECTIVE

To characterize the physical activity (PA) level in patients with a cardiac implantable electronic device (CIED) during the coronavirus disease 2019 (COVID-19) pandemic and compare PA level during the pandemic in 2020 with the year 2019.

METHODS

We performed a retrospective analysis of PA activity in individuals implanted with a CIED enrolled in the BIOTRONIK CERTITUDE Registry. Mean daily and weekly PA from January to August 2020 was compared with 2019.

RESULTS

A total of 21,660 individuals met eligibility criteria, with mean age of 72.6±11.6 years, and 12,411 (57.3)% were males. A significant decline in daily PA was noted following the pandemic declaration in 2020, with a maximum mean reduction of -24.5±36.3 minutes (P<.0001) observed in April 2020 compared with 2019. PA in 2020 increased from April to May (120.6±67.4 to 129.2±70.9 min/d). PA was lower for all months in 2020 compared with 2019. The decrease in PA was observed in all prespecified groups based on age, sex, type of device, and region of the country.

CONCLUSION

After the declaration of the coronavirus disease 2019 pandemic, a significant decline in daily PA was observed in individuals with a CIED. Future investigation to establish the impact of this reduction on short and long-term cardiovascular outcomes is required.

The Safety of High-Dose Intranasal Fentanyl in the Pediatric Emergency Department

OBJECTIVES

This study aimed to determine if the use of intranasal (IN) fentanyl in the pediatric emergency department of 2 to 5 μg/kg at doses greater than 100 μg is associated with adverse events in pediatric patients.

METHODS

We performed a retrospective chart review of patients receiving IN fentanyl at an urban, tertiary care emergency department in Memphis, TN, from January 1, 2011, to December 31, 2017. All adverse events documented through the hospital's voluntary safety reporting system involving IN fentanyl were reviewed to determine patient outcomes.

RESULTS

A total of 3205 patients received greater than 100 μg of IN fentanyl during the study period from 2011 to 2017. The average (SD) patient age was 13.7 (2.65) years, ranging from 5 to 18 years. The mean (SD) initial dose was 162 (30) μg ranging from 102 to 265 μg (2 doses were given greater than 200 μg in the study period). Initial average (SD) dose for weight was 2.62 (0.5) μg/kg. A total of 13 adverse events were documented, with only 3 occurring at doses greater than 100 μg. No patients required the reversal agent naloxone or invasive respiratory support.

CONCLUSIONS

To our knowledge, this is the first study using doses greater than 100 μg of IN fentanyl in a pediatric population. Our results indicate that fentanyl can be safely administered at doses of greater than 100 μg without any clinically significant adverse outcomes observed for 7 years of use. It is our hope that this information will increase utilization of IN fentanyl for treatment of acute pain in emergency departments and in the prehospital setting.

The use of computed tomography versus clinical acumen in diagnosing appendicitis in children: A two-institution international study

BACKGROUND

Appendicitis in children can be diagnosed utilizing clinical and laboratory findings, with the assistance of ultrasound (US) and/or computed tomography (CT). However, repeated exposure to ionizing radiation increases the lifetime risk of cancer. We compared the work-up of suspected appendicitis between a children's hospital in the United States (USA) and one in Spain to identify differences in imaging use and associated outcomes.

METHODS

A two-institution retrospective review was performed for surgical consultations of suspected appendicitis from 2015-2017. We compared imaging use, the utilization of overnight observation, and diagnostic accuracy rates between the two centers.

RESULTS

A total of 1,952 children were evaluated. Among the 1,288 in the USA center, 754(58.5%) underwent CT during their evaluation. The most common imaging modality was US only (39.9%), then CT only (39.3%), CT+US (19.3%), and no imaging (i.e. only clinical acumen) (1.6%). In Spain, only 19 (2.9%) of 664 children underwent CT compared to the USA (p < 0.0001). Only clinical acumen was the most common modality employed (48.6%), followed by US only (48.5%), US+CT (2.4%), and CT only (0.5%). In the USA, 16.8% were observed overnight, 2.3% of whom received no imaging. In Spain, 33.4% were observed overnight, 32.4% of whom had no imaging (p < 0.0001). The accuracy rates for diagnosing appendicitis in the USA and Spain centers were 94.7% and 95.1%, respectively.

CONCLUSION

Use of clinical acumen and/or US have similar clinical outcomes and similar accuracy rates compared to heavy reliance on CT imaging for diagnosing appendicitis, with associated decrease in radiation exposure. The disparate diagnostic approach of the two centers may reflect that physical examination is a dying art in North America.

LEVEL OF EVIDENCE

III.

Utilization and programming of an automatic MRI recognition feature for cardiac rhythm management devices

Background

Cardiac implantable electronic devices (CIED)—ie, pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy devices—have recently been designed to allow for patients to safely undergo magnetic resonance imaging (MRI) when specific programming is implemented. MRI AutoDetect is a feature that automatically switches CIED’s programming into and out of an MR safe mode when exposed to an MRI environment.

Objective

The purpose was to analyze de-identified daily remote transmission data to characterize the utilization of the MRI AutoDetect feature.

Methods

Home Monitoring transmission data collected from MRI AutoDetect–capable devices were retrospectively analyzed to determine the workflow and usage in patients experiencing an MRI using the MRI AutoDetect feature.

Results

Among 48,756 capable systems, 2197 devices underwent an MRI using the MRI AutoDetect feature. In these 2197 devices, the MRI AutoDetect feature was used a total of 2806 times with an average MRI exposure of 40.83 minutes. The majority (88.9%) of MRI exposures occurred on the same day as the MRI AutoDetect programming. A same day post-MRI exposure follow-up device interrogation was performed 8.6% of the time. A device-related complaint occurred within 30 days of the MRI exposure in 0.25% of MRI exposures using MRI AutoDetect but with no adverse clinical outcome.

Conclusion

As a result of automation in device programming, the MRI AutoDetect feature eliminated post-MRI device reprogramming in 91.4% of MRI exposures and, while less frequent, allowed for pre-MRI interrogations prior to the day of the MRI exposure—reducing resource utilization and creating workflow flexibility.

Shunt Failure-The First 30 Days

BACKGROUND

Incontrovertible predictors of shunt malfunction remain elusive.

OBJECTIVE

To determine predictors of shunt failure within 30 d of index surgery.

METHODS

This was a single-center retrospective cohort study from January 2010 through November 2016. Using a ventricular shunt surgery research database, clinical and procedural variables were procured. An "index surgery" was defined as implantation of a new shunt or revision or augmentation of an existing shunt system. The primary outcome was shunt failure of any kind within the first 30 days of index surgery. Bivariate models were created, followed by a final multivariable logistic regression model using a backward-forward selection procedure.

RESULTS

Our dataset contained 655 unique patients with a total of 1206 operations. The median age for the cohort at the time of first shunt surgery was 4.6 yr (range, 0-28; first and third quartile, .37 and 11.8, respectively). The 30-day failure rates were 12.4% when analyzing the first-index operation only (81/655), and 15.7% when analyzing all-index operations (189/1206). Small or slit ventricles at the time of index surgery and prior ventricular shunt operations were found to be significant covariates in both the "first-index" (P < .01 and P = .05, respectively) and "all-index" (P = .02 and P < .01, respectively) multivariable models. Intraventricular hemorrhage at the time of index surgery was an additional predictor in the all-index model (P = .01).

CONCLUSION

This study demonstrates that only 3 variables are predictive of 30-day shunt failure when following established variable selection procedures, 2 of which are potentially under direct control of the surgeon.

Novel two-lead cardiac resynchronization therapy system provides equivalent CRT responses with less complications than a conventional three-lead system: Results from the QP ExCELs lead registry

Introduction

The novel two‐lead cardiac resynchronization therapy (CRT)‐DX system utilizes a floating atrial dipole on the implantable cardioverter‐defibrillator lead, and when implanted with a left ventricular (LV) lead, offers a two‐lead CRT system with AV synchrony. This study compared complication rates and CRT response among subjects implanted with a two‐lead CRT‐DX system to those subjects implanted with a standard three‐lead CRT‐D system.

Methods and Results

A total of 240 subjects from the Sentus QP—Extended CRT Evaluation with Quadripolar Left Ventricular Leads postapproval study were selected to identify 120 matched pairs based on similar demographic characteristics using a Greedy algorithm. The complication‐free rate was evaluated as the primary endpoint. All‐cause mortality, heart failure hospitalizations, device diagnostic data, New York Heart Association (NYHA) class improvement, and defibrillator therapy were evaluated from clinical data, in‐office interrogations, and remote monitoring throughout the follow‐up period. Complication‐free survival favored the CRT‐DX group with 92.5% without a major complication compared to 85.0% in the CRT‐D cohort (P = .0495; 95% confidence interval: 0.1%‐14.9%) over a mean follow‐up of 1.3 and 1.4 years, respectively. Incidence of all‐cause mortality, heart failure hospitalizations, NYHA changes at 6 months postimplant, and percent of LV pacing during CRT therapy were similar in both device cohorts. Inappropriate shocks were more frequent in the CRT‐D cohort with 5.8% of subjects receiving an inappropriate shock vs 0.8% in the CRT‐DX cohort.

Conclusion

The results of this subanalysis demonstrate that the CRT‐DX system can provide similar CRT responses and significantly fewer complications when compared to a similar cohort with a conventional three‐lead CRT‐D system.

Factors Associated With Return Visits at 7 Days After Hospital Discharge

OBJECTIVE

To identify variables associated with return visits to the hospital within 7 days after discharge.

METHODS

We performed a retrospective study of 7-day revisits and readmissions between October 2012 and September 2015 using the Pediatric Health Information System database supplemented by electronic medical record data from a tertiary-care children's hospital. We examined factors associated with revisits among the top 10 most frequent indications for hospitalization using generalized estimating equations.

RESULTS

There were 736 (4.2%) revisits and 416 (2.3%) readmissions within 7 days. Predictors of 7-day revisits and readmissions included age, length of hospital stay, and presence of a chronic medical condition. In addition, insurance status was associated with risk of revisits and race was associated with risk of readmissions in the bivariate analysis.

CONCLUSIONS

In this study, we identified patient characteristics that may be associated with a higher risk of early return to the emergency department and/or readmissions. Early identification of this at-risk group of patients may provide opportunities for intervention and enhanced care coordination at discharge.

Reducing Time to Pain Medication Administration for Pediatric Patients with Long Bone Fractures in the Emergency Department

Introduction

Pain management is a critical aspect of effective long bone fracture treatment. Pediatric patients frequently report suboptimal pain management, which is an area of growing public concern. The purpose of this quality improvement project was to develop a protocol with the goal to administer pain medication to children presenting with suspected long bone fractures ≤47 minutes of emergency department arrival.

Methods

A multidisciplinary team developed a standardized protocol for pain management of patients presenting with musculoskeletal pain utilizing acetaminophen as the first-line agent under a nurse-initiated order. Following education and implementation, weekly reports generated using the International Classification of Diseases codes of fractures were reviewed to assess compliance with the protocol. This study evaluates the frequency of a second pain medication administration and reduction in vital signs and pain scores.

Results

Implementation of a pain management protocol reduced median time to pain medication administration to 26 minutes. Overall, 63% (n = 638) of patients required a second pain medication. Of these, 66.5% (348/523) who initially received acetaminophen and 59.7% (286/479) who initially received an opioid required a second pain medication. No significant changes in pre and posttreatment vital signs were found between groups. Patients who initially received opioids experienced a greater reduction in posttreatment pain scores.

Conclusions

Using a standardized pain management protocol in combination with comprehensive education effectively reduces median time to pain medication administration in pediatric patients with long bone fractures. Acetaminophen is a rapid and effective first-line agent for managing pain in this population.

Platelet Transfusions in the PICU: Does Disease Severity Matter?

OBJECTIVES

Pediatric intensivists frequently prescribe platelet transfusions to critically ill children, but there are limited data on platelet transfusion practice and platelet transfusion-related outcomes in the PICU. In this study, we evaluated the current platelet transfusion practice and platelet transfusion-related outcomes in the PICU.

DESIGN

Institutional review board-approved, retrospective cohort study from January 2010 to March 2016.

SETTING

Tertiary-level PICU.

PATIENTS

Children less than 19 years old who received platelet transfusions in the PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Thirty-six percent (1,547/4,339) of platelet transfusions in the institution were given to 2.4% of PICU patients (232/9,659). The patients who received a platelet transfusion (platelet transfusions, n = 232) compared with those who did not receive platelets (no platelet transfusions, n = 9,427) were younger, had similar gender distribution, had a higher median Pediatric Risk of Mortality-3 score, and stayed longer in the PICU. Fifty percent of platelet transfusions were prescribed prophylactically for thrombocytopenia to patients without extracorporeal membrane oxygenation support. The mortality was higher for platelet transfusions group (30% vs 2.3%) with an 18 times increased unadjusted odds of mortality when compared with no platelet transfusion group (odds ratio, 18.2; 95% CI, 13.3-24.8; p < 0.0001). In a multiple logistic regression analysis, the predicted probability of dying for platelet transfusion group compared with no platelet transfusion group depended on the median Pediatric Risk of Mortality-3 score. Patients who received platelet transfusion versus no platelet transfusion have increased odds of dying at lower median Pediatric Risk of Mortality-3 scores, but decreased odds of dying at higher median Pediatric Risk of Mortality-3 scores.

CONCLUSIONS

This PICU cohort demonstrates that the odds or predicted probability of dying change in patients who received platelet transfusions based on underlying disease severity measured by Pediatric Risk of Mortality-3 score compared with patients who did not receive platelet transfusions. A large, prospective trial is required to confirm this association and determine whether to consider underlying disease severity in estimating risks and benefits of prophylactic platelet transfusions in critically ill children.

Abstract P6-04-10: Components of cap-independent translation as novel targets in breast cancer

Background: The majority of cellular mRNAs are translated in a cap-dependent manner, involving ribosome assembly at 5’ 7-methylguanylate cap structures followed by scanning and initiation at a favorable AUG codon. Alternatively, mRNA structural elements termed internal ribosome entry sites (IRESs) facilitate translation in a cap-independent manner, and have been identified in mRNAs encoding many canonical cellular oncogenes, including c-MYC, c-SRC, XIAP, Aurora-A kinase, and IGF1R. IRES trans-activating factors (ITAFs) are accessory proteins that augment or inhibit translation mediated by specific IRES sequences, via binding to IRES structures and/ or other translational machinery. In addition, conversion of ribosomal RNA (rRNA) uracil bases to pseudouracil enhances IRES-mediated translation.

Methods: Analysis of publically available microarray datasets of breast cancer and normal breast tissue clinical specimens revealed that expression of several ITAFs is upregulated at the mRNA level in malignant tissues compared to normal controls. mRNAs encoding the ITAFs polypyrimidine tract binding protein 1 (PTBP1), splicing factor proline/ glutamine rich (SFPQ), poly-RC binding protein 2 (PCBP2), and interleukin enhancer binding factor 2 (ILF2, also NF45) were significantly upregulated (p &lt; 0.05), as well as mRNA encoding the dyskeratosis congenita 1 (DKC1) rRNA-modifying enzyme. Independent analysis of an 855 human breast tumor dataset revealed that high mRNA expression of DKC1 and ILF2 are enriched in basal-like breast tumors compared to other intrinsic subtypes (t-test, p&lt;0.01). Kaplan-Meier analyses revealed that high expression of DKC1 or ILF2 mRNAs were both significantly associated with decreased relapse-free survival duration (p = 0.0007 and p = 0.002, respectively).

To investigate the biological impact of ITAF and DKC1 silencing, PTBP1, PCBP2, SFPQ, and DKC1 knockdown was accomplished using pGIPZ and pTRIPZ lentiviral shRNA vectors. Silencing of these genes and concomitant reduction in protein levels (measured by western blot) led to significant proliferation impairment in MDA-MB-231, MDA-MB-436, and MCF7 breast cancer cells in culture, using Alamar Blue assay. In addition, 4T1 mouse mammary carcinoma cells express DKC1, PTBP1 and SFPQ, and may serve as a useful model in immunocompetent mice.

Conclusions and future directions: Future experiments will include investigation of protein-level expression in archival human specimens using immunohistochemistry, as well as investigation of the effects of ITAF/ DKC1 silencing in human xenografts using NOD/ SCID mice. Based on their increased expression in malignant breast tissues and activity in translation of oncoproteins, cellular ITAF genes and DKC1 gene may represent novel therapeutic targets for intervention. In particular, the increased expression of DKC1 enzyme and ILF2 in basal-like breast cancers implies a possible therapeutic opportunity in triple-negative breast cancers.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-04-10.

The effect of gabapentin on neuropathic pain

OBJECTIVE

To evaluate the effects of gabapentin on pain scores and opiate use.

DESIGN

Retrospective review of patients charts who received gabapentin for at least 30 days. Data were collected concerning patients' diagnosis, current drug use, concurrent drug use, gabapentin dose, pain scores, and patient-reported side effects. Patients were divided into three groups based on their pain diagnosis; low back, neuropathic, and myofascial pain. The neuropathic group was subdivided into postherpetic neuralgia, diabetic neuropathy, sympathetically maintained pain, and phantom pain.

SETTING

Two tertiary referral teaching hospitals in southeastern Michigan.

RESULTS

A total of 122 charts were reviewed and included in this study. A significant decrease in pain scores with gabapentin was seen in the neuropathic pain group (paired t-test, p < .0001) but not in the low back pain group. Of the neuropathic pain group, patients with postherpetic neuralgia had the greatest decrease in pain scores. Ten patients showed a > 75% decrease in pain scores, of these: nine had a direct nerve injury, and one had postherpetic neuralgia. Opiate use was unchanged in all groups. Patients who were taking opiates had significantly less benefit with gabapentin use in terms of pain score. Patient-reported side effects were similar to those reported in a nonchronic pain population.

CONCLUSION

Gabapentin may be a useful adjunct for treating neuropathic pain with a minimum of side effects. Particular advantage may be gained with the use of this drug for postherpetic neuralgia and direct peripheral nerve injuries.

On being a mentor to nurse practitioner students: the preceptor-student relationship

This article explores the identity of NPs as clinical practice preceptors and mentors for NP students, including the inherent conflict created for preceptors by these overlapping role expectations. Also examined is the nurse practitioner-student relationship with phases of the relationship between student and preceptor/mentor presented. Issues related to student and preceptor role development and personal characteristics of both impacting on the relationship are identified. Implications for client health outcomes, educational programs, students, preceptors and nursing researchers are discussed.

A simple process for controlling operating room specialized inventory

As with any new system, success would not exist without team efforts. Cooperation from the materiel service department played an important role in its success. Prompt purchase orders and a prompt delivery system are a must when PAR levels are kept at a minimum. The new manual inventory system became an efficient and effective alternative to controlling products within the surgery department at Tampa General Hospital. And now for automation!