Self-driven bronchoscopy simulation training in medical students led to improvements in bronchial anatomy knowledge and bronchoscopy skills. Further investigation is under way to determine the impact of bronchoscopy simulation training on future specialty interest and long-term skills retention.
A nine-year-old female crossbred dog was presented with tetraplegia following a fall. No vertebral abnormalities were detectable on plain radiographs of the cervical spine. Magnetic resonance imaging scans revealed absence of extraparenchymal compression and an area of oedema within the cervical spinal cord, suggesting a favourable prognosis. Following nursing care and physiotherapy, the dog recovered the ability to walk, although mild neurological deficits persisted in the left limbs.
WHAT THIS PAPER ADDSIn this single institution retrospective analysis of patients with asymptomatic internal carotid artery stenosis identified on duplex ultrasound as moderate to severe (70%e80%) from 2003 to 2018. There was a low rate (5.3%) of stroke/transient ischaemic attack without documented progression of stenosis, but there was a high rate (24.1%) of stenosis progression, as well as a 16.3% mortality rate at five years. The data reinforce the need to follow these patients closely, and patients at a higher risk of death, in particular, may benefit the least from intervention.Objective: Treatment of asymptomatic internal carotid artery (ICA) stenosis, particularly for moderate to severe (70%e80%) disease, is controversial. The goal was to assess the clinical course of patients with moderate to severe carotid stenosis. Methods: A single institution retrospective analysis of patients with asymptomatic ICA stenosis identified on duplex ultrasound as moderate to severe (70%e80%) from 2003 to 2018 were analysed. Duplex criteria for 70%e80% stenosis was a systolic velocity of !325 cm/s or an ICA:common carotid artery ratio of !4, and an end diastolic velocity of <140 cm/s. Asymptomatic status was defined as no stroke/transient ischaemic attack (TIA) within six months of index duplex. Primary outcomes were progression of stenosis to >80%, ipsilateral stroke/TIA without documented progression, and death. Results: In total, 206 carotid arteries were identified in 182 patients meeting the inclusion criteria. Mean patient age was 71.5 years, 57.7% were male, and 67% were white. There were 19 stenoses removed from analysis except for survival analysis as they initially underwent carotid endarterectomy or carotid artery stent based on surgeon/patient preference. Documented progression occurred in 24.1% of stenoses. There were 5.3% of stenoses associated with an ipsilateral stroke/TIA without documented progression, which occurred at a mean of 26.4 months. KaplaneMeier analysis demonstrated a 60.3% five year freedom from stenosis progression, 92.5% five year freedom from stroke/TIA without documented progression, and 83.7% five year survival. Risk factors associated with stroke/TIA without documented progression at five years were atrial fibrillation (hazard ratio [HR] 14.87, 95% confidence interval [CI] 2.72e81.16; p ¼ .002) and clopidogrel use at index duplex (HR 6.19, 95% CI 1.33e28.83; p ¼ .020). Risk factors associated with death at five years were end stage renal disease (HR 9.67, 95% CI 2.05e45.6; p ¼ .004), atrial fibrillation (HR 7.55, 95% CI 2.48e23; p < .001), prior head/neck radiation (HR 6.37, 95% CI 1.39e29.31; p ¼ .017), non-obese patients (HR 5.49, 95% CI 1.52e20; p ¼ .009), and non-aspirin use at index duplex (HR 3.05, 95% CI 1.12e8.33; p ¼ .030). Conclusion: Patients with asymptomatic moderate to severe carotid stenosis had a low rate of stroke/TIA without documented progression. However, there was a high rate of stenosis progression reinforcing the need to follow these patients closely.
Introduction: In single-ventricle patients undergoing bi-directional Glenn (BDG), 36-59% have angiographically detectable aorto-pulmonary collateral (APC) flow. However, predictors, hemodynamic and clinical outcomes are unknown. Hypothesis: We hypothesize that (a) shunt type, hemodynamic findings at the pre-Glenn catheterization predict pre-BDG APC burden and (b) APC burden at BDG catheterization may predict post BDG death/transplantation, pulmonary artery (PA) or APC intervention. Methods: Retrospective cohort study of patients following Norwood Procedure for single ventricle anatomy. Covariates included demographics; clinical and hemodynamic at Pre-BDG catheterization. APC burden at pre-BDG catheterization was assessed dichotomously by a single reader (moderate/severe vs. none/mild). Logistic regression was used to identify predictors of APC burden and Cox regression for time to clinical outcomes. Results: Among 104 patients, 89.4% (n=93/104) underwent pre-BDG catherization, of which 55% (n=51/93) had APC intervention and 91% (n=85/93) progressed to BDG. Post-BDG, 60% (n=51/85) had no/mild and 40% (n=34/85) had moderate/severe APC burden. Within 36 months, APC intervention occurred in 74% (n=69/63) with no difference between groups (84% vs. 79%, Logrank 0.75). Predictors of APC burden were male sex (OR 3.59; 95% CI 1.18-10.98), older age at BDG (1.02 per year; 1.01-1.04), PA saturations (1.80;1.18-2.75), and Qp:Qs ratio (OR 1.23 per 0.10 unit increase;1.08-1.41). APC burden is not predictive of death/transplantation or future APC intervention but may show a trend towards future PA intervention (HR 2.11, 95% CI 0.98-4.52, p=0.056)(Figure 1). Sano shunt is a predictor of APC intervention following BDG (HR 2.07, 95%CI 1.09-3.90, p=0.03). Conclusions: Moderate or severe APC burden was present in 40% after stage I Norwood and QP:QS is a strong predictor for APC burden; patients with moderate/severe APC’s may be at higher risk of PA interventions.
Background: In single-ventricle patients undergoing staged-bidirectional Glenn, 36–59% have aorto-pulmonary collateral flow, but risk factors and clinical outcomes are unknown. We hypothesise that shunt type and catheter haemodynamics may predict pre-bidirectional Glenn aorto-pulmonary collateral burden, which may predict death/transplantation, pulmonary artery or aorto-pulmonary collateral intervention. Methods: Retrospective cohort study of patients undergoing a Norwood procedure for single-ventricle anatomy. Covariates included clinical and haemodynamic characteristics up to/including pre-bidirectional Glenn catheterisation and aorto-pulmonary collateral burden at pre-bidirectional Glenn catheterisation. Multivariable models used to evaluate relationships between risk factors and outcomes. Results: From January 2011 to March 2016, 104 patients underwent Norwood intervention. Male sex (odds ratio 3.36, 95% confidence interval 1.17–11.4), age at pre-bidirectional Glenn assessment (2.12, 1.33–3.39 per month), and pulmonary to systemic flow ratio (1.23, 1.08–1.41 per 0.1 unit) were associated with aorto-pulmonary collateral burden. Aorto-pulmonary collateral burden was not associated with death/transplantation (hazard ratio 1.19, 95% confidence interval 0.37–3.85), pulmonary artery (sub-hazard ratio 1.38, 0.32–2.61), or aorto-pulmonary collateral interventions (sub-hazard ratio 1.11, 0.21–5.76). Longer post-Norwood length of stay was associated with greater risk of death/transplantation (hazard ratio 1.22 per week, 95% confidence interval 1.08–1.38), but lower risk of aorto-pulmonary collateral intervention (sub-hazard ratio 0.86 per week, 95% confidence interval 0.75–0.98). Time to pre-bidirectional Glenn catheterisation was associated with lower risk of pulmonary artery (sub-hazard ratio 0.80 per month, 95% confidence interval 0.65–0.98) and aorto-pulmonary collateral intervention (sub-hazard ratio 0.79, 0.63–0.99). Probability of moderate/severe aorto-pulmonary collateral burden increased with left-to-right shunt (22.5% at <1.0, 57.6% at >1.4) and the age at pre-bidirectional Glenn catheterisation (10.6% at <2 months, 56.9% at >5 months). Conclusions: Aorto-pulmonary collateral burden is common after Norwood procedure and increases as age at bidirectional Glenn increases. As expected, higher pulmonary to systemic flow ratio is a marker for greater aorto-pulmonary collateral burden pre-bi-directional Glenn; aorto-pulmonary collateral burden does not confer risk of death/transplantation or pulmonary artery intervention.
ovarian vein transposition. This video details the ovarian vein transposition procedure and highlights that ovarian vein transposition is an excellent alternative for the treatment of Nutcracker syndrome.
did not change across the different age groups. The rates of in-hospital stroke/death after TCAR were 1.4% in patients 70 years or younger vs1.9% in those 71 to 79 years and 1.5% in those 80 years and older (P ¼ .55). A comparison of TCAR with CEA across different age groups showed no significant differences in outcomes, and no interaction was noted between treatment and age (Table ). When compared with TFCAS, no differences were noted between TCAR and TFCAS in patients less than 80 years of age. However, in patients 80 years and older, TCAR was associated with a 72% reduction in stroke risk (4.7% vs 1.0%,; odds ratio [OR], 0.28; 95% confidence interval [CI], 0.12-0.65; P < .01), a 65% reduction in risk of stroke/death (4.6% vs 1.5%; OR, 0.35; 95% CI, 0.20-0.62; P < .001), and 76% reduction in the risk of stroke/death/myocardial infarction (5.3% vs 2.5%; OR, 0.24; 95% CI, 0.12-0.47; P < .001) compared with TFCAS.
Objectives: We reviewed a consecutive series of patients who had arteriovenous fistula (AVF) placement in advance of starting hemodialysis and sought to determine what factors were associated with failure of the AVF to be ready for use, which required patients to start dialysis with a tunneled dialysis catheter (TDC).Methods: We analyzed all patients who had an AVF placed at our institution from 2013 to 2018 using data from the Vascular Quality Initiative database and retrospective chart review. The primary study group included patients who had an AVF placed in advance of needing hemodialysis. Patients were categorized as "Success": AVF placement with hemodialysis initiated using the AVF or "Failure": AVF placement with hemodialysis initiated using a TDC.Results: Of the 46 patients reviewed, 26 (56.5%) were classified as "Failure." Preoperative factors associated with failure included: uremia (5% of success group vs 26.9% of failure group; P ¼ .031), uremic males (37.5% of uremic male patients failed vs 0% of uremic females; P ¼ .007), history of coronary artery disease among males (success, 8.33% vs fail, 50%; P ¼ .04), and history of percutaneous coronary intervention among males (fail male, 25% vs fail female, 0%; P ¼ .030).Conclusions: In our series of patients referred for AVF placement prior to starting dialysis, we noted an unexpectedly high rate of hemodialysis initiation with a TDC. This study suggests that patientrelated factors such as uremia and a history of coronary artery disease or intervention may be associated with failure of the AVF to be ready for hemodialysis. Further work building from findings in this study may help with patient selection decisions to minimize the need to initiate hemodialysis with a TDC.
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