Pexy of intraperitoneal LVAD driveline to relieve small bowel obstruction.

BACKGROUND: Left ventricular assist device (LVAD) implantation is a lifesaving intervention in advanced heart failure. However, LVAD is not without complication. In this case, an inadvertent intraperitoneal driveline caused small bowel obstruction, subsequently requiring pexy of the driveline to the abdominal wall to avoid future complications. CASE PRESENTATION: A 37-year-old male with worsening, nonischemic, dilated cardiomyopathy underwent LVAD implantation. Postoperative day (POD) 15 he developed small bowel obstruction, and abdominal exploration showed transition point at an inadvertently placed intraperitoneal LVAD driveline. The patient was LVAD-dependent precluding removal, so the driveline was secured to the anterior abdominal wall. He subsequently improved and was discharged. CONCLUSIONS: While LVAD is increasingly common for heart failure patients, the tunneled driveline may inadvertently enter the peritoneal cavity where it can cause significant morbidity. In this case, we propose securing the driveline to the abdominal wall to prevent complications when LVAD removal is not an option.

Don't call me crazy! Delirium occurs outside of the intensive care unit.

INTRODUCTION: Delirium has been well studied among patients in the intensive care unit (ICU); however, data beyond the ICU is limited. The purpose of this study is to prospectively evaluate the incidence and associated risk factors for delirium in noncritical care areas (NCCA). METHODS: After institutional review board approval, a prospective cohort study was conducted at our urban Level I Trauma Center from December 2015 to February 2016. All patients admitted to the designated study area by a trauma surgeon were included. The Confusion Assessment Method (CAM) was administered every 12 hours until discharge. Delirious patients (CAM+) were administered the CAM-S to quantify the severity of delirium. Demographics, laboratory data, and inpatient medication lists were analyzed. RESULTS: Of 148 participants, 12 (8%) were CAM+ and 136 (92%) were CAM-. The average CAM-S of CAM+ patients was 7 ± 3. Included patients were aged 52 ± 20 years and 45% were men. Of patients 65 years or older, 9 (21%) were CAM+. Medications associated with delirium were: albuterol (p = 0.01), atorvastatin (p = 0.01), duloxetine (p = 0.04), sertraline (p = 0.04), folic acid (p = 0.01), thiamine (p = 0.01), vitamin D (p < 0.001), haloperidol (p = 0.04), metoprolol (p = 0.02), and vancomycin (p = 0.02). Abnormal laboratory values associated with delirium included: Albumin (p = 0.03; odds ratio [OR], 7.94, 95% confidence interval [CI], 1.1-63.20), Calcium (p = 0.01; OR, 4.95; 95% CI, 1.5-16.7), Sodium (p = 0.04; OR, 3.91; 95% CI, 1.13-13.5), hematocrit (p = 0.04), and mean corpuscular hemoglobin concentration (p < 0.05; OR, 5.29; 95% CI, 1.19-23.46). CONCLUSIONS: Our study demonstrated an 8% incidence of delirium overall in NCCA, increasing to 21% in patients 65 years or older. Many risk factors identified among NCCA patients are consistent with the ICU literature; however, our CAM+ patients had additional risk factors which have not been previously associated with the development of delirium. Screening of NCCA patients for delirium should be considered. LEVEL OF EVIDENCE: Prognostic and Epidemological, level IV.

Leaf surface traits and water storage retention affect photosynthetic responses to leaf surface wetness among wet tropical forest and semiarid savanna plants.

While it is reasonable to predict that photosynthetic rates are inhibited while leaves are wet, leaf gas exchange measurements during wet conditions are challenging to obtain due to equipment limitations and the complexity of canopy-atmosphere interactions in forested environments. Thus, the objective of this study was to evaluate responses of seven tropical and three semiarid savanna plant species to simulated leaf wetness and test the hypotheses that (i) leaf wetness reduces photosynthetic rates (Anet), (ii) leaf traits explain different responses among species and (iii) leaves from wet environments are better adapted for wet leaf conditions than those from drier environments. The two sites were a tropical rainforest in northern Costa Rica with ~4200 mm annual rainfall and a savanna in central Texas with ~1100 mm. Gas exchange measurements were collected under dry and wet conditions on five sun-exposed leaf replicates from each species. Additional measurements included leaf wetness duration and stomatal density. We found that Anet responses varied greatly among species, but all plants maintained a baseline of activity under wet leaf conditions, suggesting that abaxial leaf Anet was a significant percentage of total leaf Anet for amphistomatous species. Among tropical species, Anet responses immediately after wetting ranged from -31% (Senna alata (L.) Roxb.) to +21% (Zamia skinneri Warsz. Ex. A. Dietr.), while all savanna species declined (up to -48%). After 10 min of drying, most species recovered Anet towards the observed status prior to wetting or surpassed it, with the exception of Quercus stellata Wangenh., a savanna species, which remained 13% below Anet dry. The combination of leaf wetness duration and leaf traits, such as stomatal density, trichomes or wax, most likely influenced Anet responses positively or negatively. There was also overlap between leaf traits and Anet responses of savanna and tropical plants. It is possible that these species converge on a relatively conservative response to wetness, each for divergent purposes (cooling, avoiding stomatal occlusion, or by several unique means of rapid drying). A better understanding of leaf wetness inhibiting photosynthesis is vital for accurate modeling of growth in forested environments; however, species adapted for wet environments may possess compensatory traits that mitigate these effects.

Risky business? Investigating outcomes of patients undergoing urgent laparoscopic appendectomy on antithrombotic therapy.

INTRODUCTION: The literature regarding outcomes in patients on irreversible antithrombotic therapy (IAT) undergoing urgent laparoscopic appendectomy is limited. The aim of this multicenter retrospective study was to examine the impact of prehospital IAT on outcomes in this population. METHODS: From 2010 to 2014, seven institutions from the Southwest Surgical Multicenter Trials (SWSC MCT) group conducted a retrospective study to evaluate the clinical course of all patients on IAT who underwent urgent/emergent laparoscopic appendectomy. The IAT+ group was subdivided into IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix). These groups were matched 1:1 to controls. The primary outcomes were estimated blood loss (EBL) and transfusion requirement. Secondary outcomes included infections (SSI - Surgical Site Infection, DSI - Deep Space Infection, and OSI - Organ Space Infection), hospital length of stay (HLOS), complications, 30-day readmissions, and mortality. RESULTS: Out of the 2903 patients included in the study, 287 IAT+ patients were identified and matched in a 1:1 ratio to 287 IAT-patients. In the IAT+ vs IAT-analysis, no significant differences in EBL (p = 1.0), transfusion requirement during the preoperative (p = 0.5), intraoperative (p = 0.3) or postoperative periods (p = 0.5), infectious complications (SSI; p = 1.0, DSI; p = 1.0, and OSI; p = 0.1), overall complications (p = 0.3), HLOS (p = 0.7), 30-day readmission (p = 0.3), or mortality (p = 0.1) were noted. Similarly, outcomes in the IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix) subgroups failed to demonstrate any significant differences when compared to controls. CONCLUSIONS: Our analysis suggests that IAT is not associated with worse outcomes in urgent/emergent laparoscopic appendectomy. Prehospital use of IAT should not be used to delay laparoscopic appendectomy.

Delirium in the ICU: What About the Floor?

Delirium was first described in the 1800s as acute, fluctuating confusion. Recent studies note an incidence of 15% in adult intensive care unit patients. Here we present the first prospective study to evaluate the incidence and risk factors for delirium in patients admitted to the trauma surgeon (TS) in non-critical care areas (NCCAs). Patients 18 years or older admitted to any TS in the designated NCCA were evaluated and consented for participation over a 3-month period. Participants were screened with the Confusion Assessment Method (CAM) every 12 hr. Those positive for delirium (CAM+) were administered the CAM-Severity. In addition, 69 other previously identified risk factors were evaluated. Over 3 months, 148 patients were evaluated, 12 of whom were CAM+ (8%). Of patients 65 years or older, 21% screened positive for delirium. Age, education level, presence of Foley catheter, respiratory distress, orthopedic operation, and lack of ambulation were risk factors associated with delirium (p < .05). Among all TS patients in the NCCA, we found delirium to be present in 8%. Our nurses identified a 21% incidence of delirium in patients 65 years or older. Given this significant incidence, screening at-risk patients in the NCCA should be considered.

Prevalence and Causes of Paralysis-United States, 2013.

OBJECTIVES: To estimate the prevalence and causes of functional paralysis in the United States. METHODS: We used the 2013 US Paralysis Prevalence & Health Disparities Survey to estimate the prevalence of paralysis, its causes, associated sociodemographic characteristics, and health effects among this population. RESULTS: Nearly 5.4 million persons live with paralysis. Most persons with paralysis were younger than 65 years (72.1%), female (51.7%), White (71.4%), high school graduates (64.8%), married or living with a partner (47.4%), and unable to work (41.8%). Stroke is the leading cause of paralysis, affecting 33.7% of the population with paralysis, followed by spinal cord injury (27.3%), multiple sclerosis (18.6%), and cerebral palsy (8.3%). CONCLUSIONS: According to the functional definition, persons living with paralysis represent a large segment of the US population, and two thirds of them are between ages 18 and 64 years. Targeted health promotion that uses inclusion strategies to account for functional limitations related to paralysis can be undertaken in partnership with state and local health departments.

Adults aging 'with' and 'into' paralysis: Epidemiological analyses of demography and health.

BACKGROUND: Survival for many individuals with paralysis is increasing, making this population a larger subset of the aging population (Molton, & Jensen, 2010). Yet little is known about the demographics and health of this population (Freedman, 2014). OBJECTIVE: This study is one of the first evaluations of the differences in etiology, sociodemographic and health characteristics (i.e., health status, chronic, and secondary and medical conditions) of adults aging with versus into disability. METHODS: A cross sectional epidemiological study was performed using secondary data from a nationally representative sample of adults with paralysis. The National Paralysis Survey is a random digit-dial survey of over 70,000 households. Weighted descriptive and regression analyses were conducted. RESULTS: Eighty percent of those aging with paralysis had disabilities for 40+ years. They showed significantly better self-reported health status, and a trend for more secondary and medical conditions. Those aging into paralysis had more chronic diseases. CONCLUSIONS: Differences are evident between those aging with vs. into paralysis. These findings suggest that differentiating subgroups of older adults with disabilities by onset of disability makes disability and health information more actionable for programs and policies. Additional studies to explore the intersection of aging and disability onset across adulthood could increase our understanding of the dynamics of aging in persons with early and later onset disabilities.

Using the international classification of functioning, disability and health to expand understanding of paralysis in the United States through improved surveillance.

BACKGROUND: Surveillance on paralysis prevalence has been conceptually and methodologically challenging. Numerous methods have been used to approximate population-level paralysis prevalence estimates leading to widely divergent prevalence estimates. OBJECTIVE/HYPOTHESES: To describe three phases in use of the International Classification of Functioning, Disability and Health (ICF) as a framework and planning tool for defining paralysis and developing public health surveillance of this condition. METHODS: Description of the surveillance methodology covers four steps: an assessment of prior data collection efforts that included a review of existing surveys, registries and other data collection efforts designed to capture both case definitions in use and prevalence of paralysis; use of a consensus conference of experts to develop a case definition of paralysis based on the ICF rather than medical diagnostic criteria; explanation of use of the ICF framework for domains of interest to develop, cognitively test, validate and administer a brief self-report questionnaire for telephone administration on a population; and development and administration of a Paralysis Prevalence and Health Disparities Survey that used content mapping to back code items from existing national surveys to operationalize key domains. RESULTS: ICF coding led to a national population-based survey of paralysis that produced accurate estimates of prevalence and identification of factors related to the health of people in the U.S. living with paralysis. CONCLUSIONS: The ICF can be a useful tool for developing valid and reliable surveillance strategies targeting subgroups of individuals with functional disabilities such as people with paralysis and others.

The psychosocial impact of Hurricane Katrina on persons with disabilities and independent living center staff living on the American Gulf Coast.

OBJECTIVES: To determine the impact of Hurricane Katrina on the psychosocial health of people with disabilities and on the ability of people with disabilities in the affected area to live independently. PARTICIPANTS: Transcribed conversations were analyzed for 56 survivors of Hurricane Katrina on the American Gulf Coast, all of whom were persons with disabilities or persons working with them. METHOD: Semi-structured interviews were conducted either individually or in focus groups with participants. Qualitative analysis was undertaken using hermeneutic techniques. RESULTS: Six major themes emerged: faith, incredulousness, blaming others or oneself, family adaptation and resiliency, and work and professional responsibility. CONCLUSIONS: The resiliency of persons with disabilities to adapt to disasters can be better understood through factors such as these, providing an effective barometer of social capital that can help societies prepare for future disasters among those most vulnerable.