Incidence and Risk Factor Analysis for Gastrointestinal Bleeding and Pump Thrombosis in Left Ventricular Assist Device Recipients.

Left ventricular assist devices (LVADs) are associated with hemostatic complications. We describe the incidence and risk factors for gastrointestinal bleeding (GIB) and pump thrombosis (PT) to optimize patient selection/management. An IRB-approved retrospective review of first LVAD implants between October 1, 2011 and September 30, 2013 at a single center was conducted. Endpoints included epidemiological and risk factor analyses for GIB and PT. Descriptive statistics, chi-squared, and t-tests were used. Sixty-four patients received continuous-flow LVADs. The 12-month incidence of GIB and PT was 23.4% and 12.5%. Time to first GIB was 72.6 days (9-160). The 1-, 3-, and 6-month rate of PT was 1.6%, 6.25%, and 12.5%, respectively. All PT required pump exchange. Females (50% vs. 16%, P = 0.026) and patients without antiplatelet therapy (12.5% vs. 50%, P = 0.046) were at increased risk of PT. No pre-implant comorbidities were associated with PT. Infection was not identified as a risk factor in our cohort (25% vs. 51.8%, P = 0.156). Mean INR preceding event was not different from nonevent patients (2.1 vs. 2.24, P = 0.24). Regarding biomarkers preceding event, elevated plasma free hemoglobin (pfHg) did not reach significance (75% vs. 58%, P = 0.383) while lactate dehydrogenase was elevated significantly (744 vs. 298, P < 0.001). Receiver operating characteristic (ROC) analysis demonstrated that an LDH of >500 was highly sensitive and specific for PT. No pre-implant factors were associated with GIB. Post-implant risk factors for GIB included infection (80% vs. 38.8%, P = 0.005) and infrequent elevations in pfHg (13.3% vs. 63.3%, P < 0.001). Increased pump speed as a GIB risk factor was confirmed (HeartMate II 9560 rpm vs. 9490 rpm, P < 0.001; HeartWare 2949 rpm vs. 2710 rpm, P < 0.001). Anticoagulation/antiplatelet therapy did not affect GIB: mean INR preceding event was not different from nonevent patients (2.21 vs. 2.27, P = 0.67) and antiplatelet use was not different (46.7% vs. 46.9%, P = 0.985). LVADs are associated with early hemostatic-related morbidity. Few pre-implantation risk factors were elucidated; however, post-implantation factors including antiplatelet therapy, infection, and pump speed were identified.

Impact of parenteral nutrition guideline implementation on growth of very low-birth-weight infants in a neonatal intensive care unit.

BACKGROUND: In preterm neonates, parenteral nutrition (PN) is utilized to provide adequate energy and maintain the expected growth rate of a fetus. To optimize growth, our institution implemented comprehensive guidelines for prescribing PN. This study compared the effect of this change on growth outcomes of very low-birth-weight (VLBW) infants at 28 days' postnatal age (PNA). METHODS: Neonates <1250 g who received PN for >7 days were divided into preimplementation and postimplementation cohorts based on date of birth. The primary objective was to compare the average weight velocity (g/kg/day) of neonates at 28 days' PNA. Secondary objectives included identifying the average number of days to regain birth weight and comparing the percentage of infants above the 10th percentile for weight for age at 28 days with those at baseline. RESULTS: There were 204 neonates in cohort 1 (before implementation) and 176 neonates in cohort 2 (after). No difference in weight velocity was identified (12.9 ± 5.2 vs 12.1 ± 4.9 g/kg/day; P = .177). No difference was detected in days to regain birth weight (9.2 ± 4.6 vs 9.9 ± 4.7; P = .909) or in the percentage of patients above the 10th percentile for weight for age (birth: 85.3% vs 83.5% [P = .634]; 28 days: 73% vs 64.8% [P = .082]). CONCLUSION: No difference was observed in the weight velocity of VLBW neonates <1250 g at birth when using the implemented guideline for PN prescription writing at our institution.

Successful Surgical Management of Aortic Arch Thrombosis in the Neonate.

Spontaneous thrombosis in the aortic arch is a rare finding in the neonate. Often the thrombosis is initially interpreted as arch obstruction secondary to coarctation or interrupted aortic arch. Thus the obstruction is mechanical with no structural abnormality. We describe 2 newborns with coarctation and extensive thrombosis within the aortic arch. We report their successful surgical management, with a brief review of the literature and pertinent management principles.

Narcissism and United States' culture: The view from home and around the world.

The issue of Americans' levels of narcissism is subject to lively debate. The focus of the present research is on the perception of national character (PNC) of Americans as a group. In Study 1, American adults (N = 100) rated Americans as significantly more narcissistic than they perceived themselves and acquaintances. In Study 2, this finding was replicated with American college students (N = 322). PNC ratings of personality traits and externalizing behaviors revealed that Americans were perceived as disagreeable and antisocial as well. In Study 3, we examined the broader characteristics associated with PNC ratings (N = 183). Americans rated the typical American as average on a variety of characteristics (e.g., wealth, education, health, likability) and PNC ratings of narcissism were largely unrelated to these ratings. In Study 4 (N = 1,202) Americans rated PNCs for different prespecified groups of Americans; as expected, PNC ratings of narcissism differed by gender, age, and occupational status such that American males, younger Americans, and Americans working in high-visibility and status occupations were seen as more narcissistic. In Study 5 (N = 733), citizens of 4 other world regions (Basque Country, China, England, Turkey) rated members of their own region as more narcissistic than they perceived themselves, but the effect sizes were smaller than those found in the case of Americans' perceptions of Americans. Additionally, members of these other regions rated Americans as more narcissistic than members of their own region. Finally, in Study 6, participants from around the world (N = 377) rated Americans as more narcissistic, extraverted, and antagonistic than members of their own countries. We discuss the role that America's position as a global economic and military power, paired with a culture that creates and reifies celebrity figures, may play in leading to perceptions of Americans as considerably narcissistic.